Related Experiment Video
Updated: Dec 3, 2025
Novel and Innovative Hybrid Technique for Type A Aortic Dissection
Published on: March 28, 2025
Type A Aortic Dissection With Cerebral Malperfusion: New Insights
Shinichi Fukuhara1, Elizabeth L Norton1, Neeraj Chaudhary2
1Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Insights
Internal carotid artery occlusion in type A aortic dissection indicates poor outcomes. Common carotid artery occlusion does not preclude surgery and offers better survival. Prompt neck imaging is recommended for cerebral malperfusion.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Type A aortic dissection with cerebral malperfusion presents significant surgical challenges.
- Craniocervical vessel involvement is critical but under-investigated in surgical literature.
Purpose of the Study:
- To investigate the impact of craniocervical vessel involvement on outcomes in patients with type A aortic dissection and cerebral malperfusion.
Main Methods:
- Retrospective review of medical records and imaging studies for 775 patients with acute type A aortic dissection between 1997 and 2019.
- Analysis of 80 patients (10%) presenting with cerebral malperfusion, focusing on cerebrocervical imaging findings and management strategies.
Main Results:
- Internal carotid artery (ICA) occlusion was present in 24% of patients with available imaging, associated with 100% mortality due to cerebral edema and herniation.
- Common carotid artery (CCA) occlusion without ICA involvement occurred in 62% and had a 79% survival rate to discharge with significantly fewer neurologic deaths.
- In-hospital mortality for all patients was 40%, with 81.3% of deaths being neurology-related.
Conclusions:
- ICA occlusion in type A aortic dissection may predict poor neurologic outcomes irrespective of surgical approach.
- CCA occlusion or coma should not deter surgical candidacy for type A aortic dissection.
- Prompt neck CT angiography is advisable for patients with cerebral malperfusion due to aortic dissection.
Background:
Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature.
Methods:
Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed.
Results:
Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P = .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P < .001), and only 3 (11%) had a neurologic death (P < .001).
Conclusions:
ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.
Related Concept Videos
01:21Aneurysm II: Clinical Manifestations and Diagnostic Studies
01:26Aneurysm III: Interprofessional Care
01:30Aneurysm I: Introduction