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J Thorac Cardiovasc Surg 2003;126:290-291
© 2003 The American Association for Thoracic Surgery

Brief communication

Intentional delay of surgery for acute type A dissection with stroke

^a From the First Department of Surgery, Hirosaki University School of Medicine, Aomori, Japan
^b Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan^b

Received for publication August 23, 2002; accepted for publication September 9, 2002.

^* Address for reprints: Ikuo Fukuda, MD, First Department of Surgery, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562 Japan
ikuofuku{at}cc.hirosaki-u.ac.jp

Dr Fukuda

Since the brain is sensitive to ischemia-reperfusion injury, management of acute aortic dissection with cerebral infarction is controversial.¹ We report on 4 patients with acute aortic dissection complicated by cerebral infarction.

Clinical summary

The clinical course of 4 patients who had simultaneous onset of acute aortic dissection and stroke was reviewed (Table 1). The incidence of cerebral infarction was 8.2% among patients with Stanford type A dissection who were referred for surgery to Tsukuba Medical Center during the past 10 years. Although 1 patient died due to brain herniation, 3 patients successfully underwent reconstruction of the aortic arch in the chronic stage.

View larger version (95K): [in this window] [in a new window]   Figure 1. A, Brain CT of patient 1, revealing multiple low-density areas in the right hemisphere with moderate swelling. B, Aortogram of patient 1, revealing stenosis of the right common carotid artery due to dissection.

PATIENT 3. The patient was a 54-year-old man with left hemiplegia, motor weakness of the right upper extremity, and chest pain. Brain CT revealed cerebral infarction on the right parietal lobe with moderate local brain swelling. Aortography revealed dissection of the aortic arch, brachiocephalic artery, and left common carotid artery. Because motor weakness recovered almost completely, the patient successfully underwent reconstruction of the ascending aorta and the transverse aortic arch on the 41st day without any neurologic complication.

PATIENT 4. The patient was a 47-year-old woman with chest pain, loss of consciousness, and shock. Coronary angiography and aortography revealed dissection of the ascending aorta, transverse aortic arch, and patent coronary arteries. The brain CT revealed right cerebral infarction with swelling of the right hemisphere. Artificial ventilation was necessary for 2 weeks due to severe brain edema. On the 27th day, reconstruction of the ascending aorta and the transverse aortic arch was successfully completed without any deterioration of neurologic function.

Discussion

Involvement of arch branches in acute type A dissection has been reported with varying incidence, ranging from 5% to 46%.^1,2 Surgical mortality and morbidity of patients with cerebral infarction in type A dissection was as high as 31% and 46%, respectively.¹ Reestablishment of flow into the infarcted area of the brain and use of high-dose heparin for extracorporeal circulation induces hemorrhagic infarcts and results in intractable brain edema.³ On the other hand, reversible ischemia due to temporal occlusion of the arch vessels may be observed in patients with acute aortic dissection. Therefore, differentiation between complete cerebral infarction and ischemia is vitally important. Even in irreversible ischemia, brain CT may not show any signs for several hours after occlusion of the artery.³ Piccione and colleagues⁴ reported the usefulness of intentionally delaying surgery for acute aortic dissection with stroke in a patient with Marfan syndrome. Deeb and associates⁵ reported good results with a combination of early percutaneous reperfusion and delay of surgery until the reperfusion injury resolved.⁵

Fann and colleagues² reported that 3 of 7 patients with acute aortic dissection complicated by stroke with persistent severe neurologic deficits died within 4 months (morbidity and mortality 43%). In this study, all patients had cerebral infarction with various degrees of brain edema. Although early reconstruction of the aorta may save the patient from rupture of the aorta, it may exacerbate brain edema and result in death. Appearance of a low-density area in brain CT means breakdown of brain tissue with surrounding edema. The interval between onset and restoration of cerebral blood flow takes several hours even if emergency surgery is conducted. Our patients had acceptable neurologic recovery and operative mortality even with extensive reconstruction of the transverse aortic arch.

In conclusion, intentional delay of surgery and observation with medical treatment is useful for patients who have acute aortic dissection with cerebral infarction.

References

1. Borst HG, Heinemann MK, Stone CD. Malperfusion of arch branches. Borst HG. Surgical treatment of aortic dissection. New York: Churchill Livingstone; 1996. p. 251–254
   
2. Fann J, Sarris G, Miller D, et al. Surgical management of acute aortic dissection complicated by stroke. Circl. 1989;80(Suppl I):I257–263
   
3. Toole JF. Brain infarction: pathophysiology, clinical features, and management. Toole JF, Murros K, Biller J. Cerebrovascular disorders. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 193–232
   
4. Piccione W, Hamilton IN, Najafi H. Intentional delayed repair of acute dissection of the ascending aorta complicated by stroke. J Thorac Cardiovasc Surg. 1995;109:807–808[Free Full Text]
   
5. Deeb GM, Williams DM, Bolling SF, et al. Surgical delay for acute type A dissection with malperfusion. Ann Thorac Surg. 1997;64:1669–1677[Abstract/Free Full Text]
   

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