ShouldWe Operate Unconscious Patients with Acute Aortic Dissection?: Case Report

Survival after acute aortic dissection (AAD) with cerebral malperfusion is a rare condition. We report a case that underwent emergent surgery and survived. A 50-year-old man with history of hypertension was brought to emergency room of a medical center with right hemiplegia and unconsciousness. The patient was transferred to our center 8 hours after the onset of neurological condition.The bedside echocardiography showed AAD with severe aortic insufficiency. Urgent cerebral diffusion magnetic resonance imaging (MRI) was performed to evaluate the cerebral ischemia and revealed focal ischemic regions. The patient underwent emergent cardiac surgery. Aortic incision was made and total transection of the ascending aorta was observed. Aortic valve was tri-leaflet but prolapsing freely into the left ventricle causing severe aortic insufficiency. Suspension of aortic valve and replacing the ascending aorta with tube graft under total circulatory arrest were performed. The procedure and postoperative course was uneventful. The optimal treatment of unconscious patients with AAD has still been controversial. Authors reported exclusion criteria of urgent aortic surgeries. However, there are reports implicating recovery after surgery that was performed more than 6 hours of onset of neurological condition. We think that, unconscious patients with AAD can undergo surgical treatment unless there is no sign of global cerebral ischemia on MRI.