title: Impact of preoperative central neurologic dysfunction on patients undergoing emergency surgery for type A dissection.
abstract: BACKGROUND
  Preoperative central neurologic deficits in the context of acute type A dissection are a complex comorbidity and difficult to handle. The aim this study was to analyze this subgroup of patients by comparing them with neurologically asymptomatic patients with type A dissection. Results may help the surgeon in preoperative risk assessment and thereby aid in the decision-making process.
  
  
  METHODS
  We reviewed the data of patients admitted for acute type A dissection during the period from 1999 to 2010. Associated risk factors, time to surgery from admission, extension of the dissection, localization of central nervous ischemic lesions, and the influence of perioperative brain protective strategies were analyzed in a comparison of preoperative neurologically deficient to nondeficient patients.
  
  
  RESULTS
  Forty-seven (24.5%) of a total of 192 patients had new-onset central neurologic symptoms prior to surgery. Concomitant myocardial infarction (OR 4.9, 95% CI 1.6-15.3, P=0.006), renal failure (OR 5.9, 95% CI 1.1-32.8, P=0.04), dissected carotid arteries (OR 9.2, 95% CI 2.4-34.7, P=0.001), and late admission to surgery at >6 hours after symptom onset (OR 2.7, 95% CI 1.1-6.8, P=0.04) were observed more frequently in neurologically deficient patients. These patients had a higher 30-day in-hospital mortality on univariate analysis (P=0.01) and a higher rate of new postoperative neurologic deficits (OR 9.2, 95% CI 2.4-34.7, P=0.02). Neurologic survivors had an equal hospital stay, and 67% of them had improved symptoms.
  
  
  CONCLUSIONS
  The predominance of neurologic symptoms at admission may be responsible for an initial misdiagnosis. The concurrent central nervous system ischemia and myocardial infarction explains a higher mortality rate and a more extensive "character" of the disease. Neurologically deficient patients are at higher risk of developing new postoperative neurologic symptoms, but prognosis for the neurologic evolution of survivors is generally favorable.
authors.affiliation: Department of Cardiovascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland. Electronic address: lars.niclauss@chuv.ch.
authors.forename: Lars
authors.initials: L
authors.lastname: Niclauss
authors.affiliation: Department of Cardiovascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland.
authors.forename: Dominique
authors.initials: D
authors.lastname: Delay
authors.affiliation: Department of Cardiovascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland.
authors.forename: Enrico
authors.initials: E
authors.lastname: Ferrari
authors.affiliation: Department of Cardiovascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland.
authors.forename: René
authors.initials: R
authors.lastname: Prêtre
mesh_terms: D000784:Aortic Dissection / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D000792:Angiography; D017545:Aortic Aneurysm, Thoracic / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D057234:Preoperative Period; D012189:Retrospective Studies; D018570:Risk Assessment; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D013557:Switzerland / Q000453:epidemiology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014656:Vascular Surgical Procedures