Neurologic recovery after prolonged circulatory arrest in surgery for aortic dissection

Brain injury manifested by subtle, transient neurologic and neuropsychologic dysfunctions occurs in about a quarter of patients who are subjected to periods of deep hypothermia and circulatory arrest (DHCA). We describe a patient who sustained minimal neurologic damage despite prolonged DHCA.

The patient was a previously healthy 62-year-old woman with acute type A aortic dissection that involved the ascending aorta. During surgery we established retrograde cerebral perfusion and DHCA to provide cerebral protection, and during the procedure the patient underwent 3 separate DHCA periods with a total circulatory arrest time of 91 minutes. Because of tubing damage, retrograde cerebral perfusion was not used during the final period (59 minutes). The patient's head was packed in ice to facilitate maintenance of brain hypothermia. Her average systemic temperature during the third period of circulatory arrest was 22.5 degrees C.

Extensive neuropsychologic testing, which was performed to assess the patient's cognitive functions and abilities at 4-month follow-up, showed an absence of global cognitive decline and only a moderate impairment of attentional capacity. Overall cognitive functioning was within the normal range and did not interfere with everyday activities or quality of life.

Although the total arrest time vastly exceeded the recommended safe period, our patient survived and sustained minimal neurologic damage. The combination of neuroprotective measures used may have contributed to this beneficial outcome.