title: Is surgery in acute aortic dissection type A still contraindicated in the presence of preoperative neurological symptoms?
abstract: OBJECTIVE
  Severe neurological deficit (ND) due to acute aortic dissection type A (AADA) was considered a contraindication for surgery because of poor prognosis. Recently, more aggressive indication for surgery despite neurological symptoms has shown acceptable postoperative clinical results. The aim of this study was to evaluate early and mid-term outcomes of patients with AADA presenting with acute ND.
  
  
  METHODS
  Data from 53 patients with new-onset ND who received surgical repair for AADA between 2005 and 2012 at our institution were retrospectively reviewed. ND was defined as focal motor or sensory deficit, hemiplegia, paraplegia, convulsions or coma. Neurological symptoms were evaluated preoperatively using the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS), and at discharge as well as 3-6 months postoperatively using the mRS and National Institutes of Health Stroke Scale. Involvement of carotid arteries was assessed in the pre- and postoperative computed tomography. Logistic regression analysis was performed to detect predictive factors for recovery of ND.
  
  
  RESULTS
  Of the 53 patients, 29 (54.7%) showed complete recovery from focal ND at follow-up. Neurological symptoms persisted in 24 (45.3%) patients, of which 8 (33%) died without neurological assessment at follow-up. Between the two groups (patients with recovery and those with persisting ND), there was no significant difference regarding the duration of hypothermic circulatory arrest (28 ± 14 vs 36 ± 20 min) or severely reduced consciousness (GCS <8). Multivariate analysis showed significant differences for the preoperative mRS between the two groups (P < 0.007). A high preoperative mRS was associated with persistence of neurological symptoms (P < 0.02). Cardiovascular risk factors, age or involvement of supra-aortic branches were not predictive for persistence of ND.
  
  
  CONCLUSIONS
  More than half of our patients recovered completely from ND due to AADA after surgery. Severity of clinical symptoms had a predictive value. Patients suffering from AADA and presenting with ND before surgery should not be excluded from emergency surgery.
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland henriette.most@insel.ch.
authors.forename: Henriette
authors.initials: H
authors.lastname: Most
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Brigitta
authors.initials: B
authors.lastname: Reinhard
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Brigitta
authors.initials: B
authors.lastname: Gahl
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Lars
authors.initials: L
authors.lastname: Englberger
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kadner
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Alberto
authors.initials: A
authors.lastname: Weber
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Jürg
authors.initials: J
authors.lastname: Schmidli
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Thierry P
authors.initials: TP
authors.lastname: Carrel
authors.affiliation: Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
authors.forename: Christoph
authors.initials: C
authors.lastname: Huber
mesh_terms: D000784:Aortic Dissection / Q000150:complications / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000601:surgery*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000150:complications*; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Aortic dissection type A; Coma; Malperfusion; Neurological deficit; Recovery