Better neurological outcome with early repair of type A aortic dissection with coma

Better neurological outcome with early repair of type A aortic dissection with coma

Early repair of type A aortic dissection complicated by coma has been reported to improve neurological outcome in a study by Takuro Tsukube, Taro Hayashi, Toshihiro Kawahira, Tomonori Haraguchi, Ritsu Matsukawa, Shuichi Kozawa, Kyoichi Ogawa and Yutaka Okita [1]. Of the total 181 patients with aortic dissection treated over a seven year period, 27 presented with coma (Glasgow Coma Scale <11). Twenty one underwent immediate repair. Deep hypothermia with antegrade cerebral perfusion was used for cerebral protection. Post operative therapeutic hypothermia with magnesium treatment was given. Six patients who presented more than 5 hours later was initially treated medically, of which 3 eventually underwent repair.

Repair initiated within five hours of onset of symptoms was found to be superior than a delayed repair in this study. Hospital mortality was fourteen percent in the immediate group while it was sixty seven percent in the delayed group. Eighty six percent had fully recovery of consciousness in the immediate group while it was only 17% in the delayed group.

Neurological recovery was also better with a National Institutes of Health Stroke Scale (NIHSS) score of 31.4±6.6 in the immediate group while it was 28.3±9.5 in the delayed group. The score further improved to 6.4±8.4 and the cumulative survival rate was 71.8% in 3 years with independence in daily activities achieved in 52% (eleven out of twenty one). The authors conclude that immediate repair of dissection is warranted in those with type A aortic dissection and coma for better survival and neurological recovery.

It may be noted that preoperative coma or stroke is an independent predictor of late mortality and was considered a contraindication for surgery. This was because of the potential risk of precipitating hemorrhagic cerebral infarction when systemic anticoagulation is initiated during surgery, and poor long term outcome.

References

1. Takuro Tsukube, Taro Hayashi, Toshihiro Kawahira, Tomonori Haraguchi, Ritsu Matsukawa, Shuichi Kozawa, Kyoichi Ogawa, Yutaka Okita. Neurological Outcomes After Immediate Aortic Repair for Acute Type A Aortic Dissection Complicated by Coma. Circulation. 2011 Sep 13;124(11 Suppl):S163-7.