Preoperative Neurologic Dysfunction in Acute Type A Dissection: Predictor for Neurologic Injury and Impaired Survival

Objectives: In acute type A dissection (AAD), systemic hypotension, true lumen compromise as well as thromboembolism can cause cerebral malperfusion. Aim of this study was to evaluate the impact of neurologic dysfunction at admission on postoperative neurologic outcome and survival.

Methods: A total of 338 patients (mean age 59.3 ± 13.7) underwent immediate surgical repair due to AAD at our institution between 2000 and 2017. Preoperative status evaluated clinically as well as based on lab results and detailed imaging data. Patients were screened and the cohort was divided into two groups based on presence of preoperative neurologic dysfunction (PND)—defined as presence of syncope, seizure, somnolence or coma, dysarthria, amaurosis, paresthesia or paresis.

Results: In total, 50 patients (14.9%) presented at admission with at least one neurologic symptom. In general, patients with PND were in a more severe clinical preoperative state, with higher rates of preoperative intubation (PND+: 34% vs PND-: 10.1%, p = 0.001), malperfusion syndrome (PND+: 42% vs. PND- 20.9%, p = 0.002) and angiographic signs of impaired perfusion or occlusion of the right carotid artery (PND+: 44.7% vs. PND- 12%, p < 0.001). In 5 patients with PND (10%) preoperative CT scan revealed cerebral ischemia. In patients with PND, severe postoperative neurologic injury was detected in 40% (n = 20), ischemic stroke in 15 patients, cerebral edema in 2 patients, spinal cord injury in 2 patients and massive lethal cerebral bleeding in one patients. Multivariate analysis identified preoperative cardiopulmonary resuscitation (OR 10.91, 95% CI 2.314–51.388, p = 0.003), preoperative malperfusion (OR 2.103, 95% CI 1.056–4.188, p = 0.034), and PND (OR 2.915, 95% CI 1.273–6.674, p = 0.011) as predictors for new postoperative neurologic injury. Patients with PND had higher rates of hospital mortality (PND+ 32.7% vs. PND- 15.7%, p = 0.008). Survival analysis showed impaired long-term survival in patients with PND (p = 0.004)

Conclusion: The presence of preoperative neurologic dysfunction emerged as important preoperative predictor for impaired postoperative neurologic outcome in AAD and has dramatic impact on long-term survival.

No conflict of interest has been declared by the author(s).