Eleven years of experience with the neurologic complications in Korean patients with acute aortic dissection: a retrospective study

Extensive Type A Aortic Arterial Dissection Presenting With Stroke Symptoms: A Case Report

Aortic dissection (AD) is a rare but often lethal condition if not properly and urgently treated. Most often, patients arrive with acute hemodynamic instability and ripping chest agony. The patient's life depends critically on a correct diagnosis made as soon as possible. We describe a 60-year-old man who arrived at the emergency room with symptoms of a brain stroke, including poor consciousness, left-sided weakness, and speech disturbance associated with hemodynamic instability, and chest pain. Thoracic aortic arch dissection was observed on CT angiography (CTA). In addition, CTA revealed that the dissection extends proximally into the left common carotid artery, left subclavian artery, brachiocephalic trunk, and right common carotid artery and distally to the left common iliac artery, coupled with significant stenosis of the left common iliac artery. Proper management of blood pressure (BP) parameters is life-saving for the patient. Since our hospital did not offer cardiothoracic surgery services, the patient was transferred to a different institution, where he received medical care immediately from an expert team and had surgery.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection

Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.

Hotspots and development frontiers of postoperative complications of AD: Bibliometric analysis - a review

The research on the postoperative complications of aortic dissection (AD) has received great attention from scholars all over the world, and the number of research articles in this field has consistently increased year after year. However, no bibliometric reports have been published yet to analyze the scientific output and the current situation in this field. The Bibliometrix R-package, VOSviewer, and CiteSpace software were used to conduct a bibliometric analysis of the hotspots and development frontiers of AD. A total of 1242 articles were retrieved. The USA, China, and Japan had the highest number of publications. The five keywords with the highest frequency were "analysis," "incidence," "acute type," "graft," and "risk factor." The results also indicated that the research in related fields had shifted from surgical treatment and utilizing experience to the evidence-based exploration of risk factors and the construction of prediction models to help better manage postoperative complications of AD. This is the first bibliometric analysis of global publications on the postoperative complications of AD. The current research hotspots focus on three areas: common postoperative complications of AD, exploration of the related risk factors, and management of complications. Future research could focus on identifying risk factors through meta-analysis and using a multicenter database for AD as well as building relevant models to predict the development of complications to better facilitate the clinical management of AD patients.

Hidden Telltale Signs in Hyperacute Ischemic Stroke Caused by Aortic Dissection: A Case Report and Post Hoc Analysis

INTRODUCTION

Rapid identification of hidden telltale signs in hyperacute ischemic stroke caused by aortic dissection (AD) is challenging, mainly owing to the narrow time window for bridging therapy.

CASE REPORT

A 63-year-old man was referred for sudden right-side weakness accompanied by a decreased level of consciousness for almost 1 hour and 37 minutes. He had a history of hypertension. His skin was clammy, and on physical examination, there was involuntary chest thumping in the left upper limb. Hyperacute cerebral infarction was considered after no bleeding was observed on emergency head computed tomography, and intravenous thrombolysis with alteplase was administered immediately after. The patient was then taken to the catheter room, ready for endovascular thrombectomy. Stanford type A AD was found by cerebral angiography before endovascular thrombectomy. The infusion of alteplase was stopped immediately during cerebral angiography, but the patient's blood pressure, heart rate, and blood oxygen were still declining progressively, and the degree of consciousness disturbance deepened. The patient died after the combined but failed rescue attempts of multiple departments.

CONCLUSION

Hyperacute ischemic stroke caused by AD often hides some telltale signs. Clinicians should master basic clinical skills to exclude AD by looking for these telltale signs hidden in hyperacute ischemic stroke to avoid the fatal consequences of intravenous thrombolysis and/or cerebral angiography within the narrow window of time.

Atypical Presentation of Aortic Dissection in a Young Female and the Utility of Point-of-Care Ultrasound in Identifying Aortic Dissection in the Emergency Department

In the absence of prompt diagnosis and treatment, aortic dissection is an extremely dangerous and often fatal medical condition, of which acute coronary syndrome, stroke, limb ischemia, pulmonary embolism, and acute mesenteric ischemia are all possible manifestations. Neurological manifestations of aortic dissection are often missed at presentation. We report a case of a 23-year-old female without any prior characteristics of connective tissue disorder presenting to the emergency department with headache and right upper limb weakness and the utility of bedside point-of-care ultrasound (POCUS) for diagnosing aortic dissection.

Type A aortic dissection: involvement of carotid artery and impact on cerebral malperfusion

Acute type A aortic dissection is a surgical emergency and management of such pathology can be complex with poor outcomes when there is organ malperfusion. Carotid artery involvement is present in 30% of patients diagnosed with acute type A aortic dissection, and given its emergency and complex nature, there is much controversy regarding the approach, extent of treatment, and timing of the intervention. It is clear that the occurrence of cerebral malperfusion adds an extra layer of complexity to the decision-making framework for treatment. Standardization and validation of the optimal management approach is required, and this should ideally be addressed with large-scale studies. Nonetheless, current literature supports the need for rapid recognition and diagnosis of acute type A aortic dissection with cerebral malperfusion, immediate and extensive surgical repair, and the appropriate use of cerebral perfusion techniques. This paper aims to discuss the current evidence regarding the impact of carotid artery involvement in both the management and outcomes of acute type A aortic dissection.

Risk factors for neurological dysfunctions after surgical repair of acute aortic dissection type A

Introduction

Technical improvement and new operative strategies significantly influence survival and outcomes after the treatment of acute aortic dissection type A (AADA). However, postoperative complications and particularly neurological dysfunctions (ND) are still very common.

Aim

To identify preoperative and intraoperative factors as well as immediate postoperative conditions with an influence on the occurrence of neurological complications of surgical treatment of AADA and accordingly take action to reduce them.

Material and methods

Between January 2013 and December 2018, 240 patients with AADA were emergently surgically treated. All patients were divided into two groups: group I - patients with postoperative ND (subgroup Ia - patients with mild, transient ND and Ib - patients with severe ND) and group II - patients without ND.

Results

Neurological damage after the operation was registered in 87 (39.5%) patients. Thirty (13.6%) patients had mild ND and 57 (25.9%) severe. Presence of preoperative neurological deficit, reduced level of consciousness, supra-aortic vessel dissection, hemodynamic instability, and excessive postoperative bleeding with hypotension are factors with a highly statistically significant association with the occurrence of severe ND. Neurological complications were not identified in 66.7% of patients who were axillary cannulated versus 55.9% of patients cannulated in the other way but the difference did not reach statistical significance (p = 0.1099).

Conclusions

Advanced neuroprotective strategies during surgical treatment of AADA are associated with favorable neurological outcomes, especially in a group of patients with identified risk factors for ND.

Aortic Dissection: An Easily Missed Diagnosis when Pain Doesn't Hold the Stage

Case series

Patients: Male, 73-year-old • Female, 70-year-old

Final Diagnosis: Aortic dissection

Symptoms: Paresis

Medication: —

Clinical Procedure: —

Specialty: Neurology

Cerebrovascular injuries found in acute type B aortic dissections are associated with blood pressure derangements and poor outcome

OBJECTIVE

Cerebrovascular injury (CVI) is a recognized but underappreciated complication of acute type B aortic dissection (ATBAD). This study was performed to determine risk factors for CVI associated with ATBAD and, in particular, the possible contributory role of aggressive anti-impulse therapy.

METHODS

A retrospective review of all patients presenting to a tertiary medical center with an ATBAD between January 2003 and October 2012 was conducted. All CVIs were adjudicated by a vascular neurologist and assigned a probable cause. The initial intensity of anti-impulse therapy was defined as the difference in mean arterial pressure (ΔMAP) from presentation to subsequent admission to the intensive care unit.

RESULTS

A total of 112 patients were identified. The average age was 61 years; 64% were male, and 59% were African American. Twenty patients required operative intervention (14 thoracic endovascular aortic repairs and 6 open). CVI occurred in 13 patients (11.6%): 9 were hypoperfusion related (6 diffuse hypoxic brain injuries and 3 watershed infarcts), 2 were procedure related (both thoracic endovascular aortic repairs), 1 was an intracranial hemorrhage on presentation, and 1 was a probable embolic stroke on presentation. CVI patients had demographics and comorbidities comparable to those of the non-CVI patients. CVI was associated with operative intervention (54% vs 13%; P = .002). Thirty-day mortality was significantly higher in CVI patients (54% vs 6%; P < .001). Patients who suffered a hypoperfusion brain injury had a higher MAP on presentation to the emergency department (142 mm Hg vs 120 mm Hg; P = .034) and a significantly greater reduction in MAP (ΔMAP 49 mm Hg vs 15 mm Hg; P < .001) by the time they reached the intensive care unit compared with the non-CVI patients.

CONCLUSIONS

In our series, CVI in ATBAD is more frequent than previously reported and is associated with increased mortality. The most common causes are related to cerebral hypoperfusion. Higher MAP on presentation and greater decline in MAP are associated risk factors for hypoperfusion-related CVI. A less aggressive approach to lowering MAP in ATBAD warrants further study in an attempt to reduce CVI in ATBAD.

An extensive chronic aortic dissection presenting with acute embolic stroke

Herein, we present a rare case of extensive chronic aortic dissection with extension to bilateral subclavian arteries, bilateral common carotid arteries, right internal carotid artery, bilateral proximal external iliac arteries and simultaneous presentation of acute embolic stroke and seizure. The rarity of this case presentation and the presence of neurological features necessitated a high index of clinical suspicion to reach the definitive diagnosis. This study also demonstrates a unique situation requiring correlation between chronic aortic dissection and multi-organ system dysfunction from chronic ischemia.

Painless Acute Aortic Dissection May Present as a Stroke; Risky Markers that Could be Identified on Hospital Arrival

INTRODUCTION

Acute aortic dissection (AAD) is a life-threatening emergency. A small portion of AAD patients presents as an acute stroke without chest pain. A missed or delayed diagnosis of AAD often brings catastrophic outcome. We aimed to identify clinical markers suggestive of the presence of painless AAD in acute stroke patients.

METHODS

From January 2007 through December 2014, painless AAD patients were retrospectively collected from our stroke registry. We expanded the search by reviewing Medline and the Science Citation Index Expanded from 1981 until March 2015. We enrolled 200 consecutive cases of acute ischemic stroke without AAD as the control. Univariate analyses were performed to compare clinical markers, followed by logistic regression to analyze the markers with signifi cant differences.

RESULTS

The AAD group had more female, younger patients and fewer co-morbidities. They more frequently had consciousness disturbances (p < 0.001), were brought to the hospital sooner (p < 0.001), arrived more frequently with impaired consciousness (p = 0.001), hypotension and bradycardia (p < 0.001) and left-sided weakness (70.2%; p < 0.001). In the risk factor analysis, hypotension (OR 48.86, 95% CI 5.70-420.28), bradycardia (OR 8.11, 95% CI 2.71-24.24), initial loss of consciousness (OR 5.27, 95% CI 1.88-14.76), andleft-sided weakness (OR 3.31, 95% CI 1.17-9.40) were observed more frequently in the AAD group.

CONCLUSIONS

Consider to rule out a painless AAD in stroke patients presenting with hypotension, bradycardia, initial loss of consciousness, or left-sided weakness.

Rates of Spinal Cord Infarction After Repair of Aortic Aneurysm or Dissection

BACKGROUND AND PURPOSE

The rate of spinal cord infarction (SCI) after surgical or endovascular repair of an aortic aneurysm or dissection is unclear.

METHODS

Using administrative claims data, we identified adult patients discharged from nonfederal acute care hospitals in California, New York, and Florida who underwent surgical or endovascular repair of an aortic aneurysm or dissection between 2005 and 2013. Patients with SCI diagnosed before the aortic repair were excluded. Our primary outcome was an SCI during the index hospitalization for aortic repair. Descriptive statistics were used to estimate crude rates of SCI. Analyses were stratified by whether the aneurysm or dissection had ruptured and by type of repair (surgical versus endovascular).

RESULTS

We identified 91 212 patients who had repair of an aortic aneurysm or dissection. SCI occurred in 235 cases (0.26%; 95% confidence interval [CI], 0.22%-0.29%). In patients with ruptured aneurysm or dissection, the rate of SCI was 0.74% (95% CI, 0.60%-0.88%) compared with 0.16% (95% CI, 0.13%-0.19%) with unruptured aneurysm. In secondary analyses, rates of SCI were similar after endovascular repair (0.91%; 95% CI, 0.62%-1.19%) compared with surgical repair (0.68%; 95% CI, 0.53%-0.83%; P=0.147) of ruptured aortic aneurysm or dissection; however, rates of SCI were higher after surgical repair (0.20%; 95% CI, 0.15%-0.25%) versus endovascular repair (0.11%; 95% CI, 0.08%-0.14%; P<0.001) of unruptured aneurysm.

CONCLUSIONS

SCI occurs in ≈1 in 130 patients undergoing aortic dissection or ruptured aortic aneurysm repair and in 1 in 600 patients undergoing unruptured aortic aneurysm repair.

Carotid Artery Dissection and Ischemic Stroke Originating from Localized Aortic Arch Dissection

Aortic dissection is an infrequent but important cause of acute ischemic stroke (AIS), and must not be overlooked because of a possible worse outcome, especially with the use of an intravenous recombinant tissue plasminogen activator. We report a case of left carotid artery dissection and AIS originating from localized aortic arch dissection, pathologically caused by cystic medial necrosis in the tunica media.

Nontraumatic spinal cord ischaemic syndrome

This study presents the clinical features and functional outcomes of eight consecutive patients who were admitted to our institution between 2012 and 2014 with nontraumatic spinal cord infarction (SCI), a rare and devastating condition. We also present a literature review of aetiologies and prognostic factors relevant to our case series. The mean age of our cohort was 64 years and five patients were female. Aortic disease was causative in three, including one patient with biopsy confirmed giant cell arteritis. Fibrocartilaginous embolism was a possible aetiology in two others, anterior spinal artery aneurysm in one, and the cause was undetermined in two patients. American Spinal Injury Association impairment scale (ASIA) scores at nadir (time of maximum severity of signs) were B in three, C in three and D in two patients (all were wheelchair dependent). At last follow-up, ASIA scores were C in one, D in five and E in one patient. One patient died, two remained wheelchair dependent, four required a walking aid or frame and one was mobilising independently. A literature review of 11 patient series of nontraumatic SCI found that prognosis is primarily determined by the severity of motor or sensory involvement, in particular, initial and nadir ASIA A/B scores which strongly correlate with poor outcome. In the majority of series, 40-60% of patients had initial ASIA A/B scores with a similar proportion remaining wheelchair dependent on follow-up. Most patients in our cohort had nadir ASIA C/D scores, which may explain their better outcomes.

Early acute ischaemic stroke in two patients with acute type B aortic dissection: an unusual complication

Aortic thoracic dissection (AD) is a serious cardiovascular disease. According to the Stanford classification; type A involves the ascending aorta and type B the descending distal to the left subclavian artery. Neurological complications secondary to AD are devastating. Ischaemic stroke and hypoxic encephalopathy are early-recognised complications of type A as the arch vessels can be involved AD. Although, late ischaemic stroke had been reported in 1.4-5% of patients with type B dissection, early stroke is very unusual as it cannot be simply explained by AD anatomical pathogenesis. We report two patients who presented with type B AD complicated by early ischaemic strokes. Work-up revealed significant cardiomyopathies in both patients but with left ventricle thrombus in one. In both patients the strokes were felt to be of cardioembolic origin.