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Stroke and Outcomes in Patients With Acute Type A Aortic Dissection
Study Questions:
What is the incidence and prognostic importance of stroke in patients with acute type A aortic dissection?
Methods:
This study examined 2,202 patients with acute type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection, and examined the incidence of presenting stroke as well as predictors of stroke and outcomes. Stroke was defined as a loss of neurological function caused by an ischemic event confirmed on computed tomography or magnetic resonance imaging.
Results:
The mean age was 62 ± 14 years, and 68% were male. Presenting stroke was observed in 6.0% of cases (132/2,202). Those with (vs. without) stroke were older (65 ± 12 vs. 61 ± 15 years, p = 0.002), and had greater prevalence of hypertension (86% vs. 71%, p < 0.001). Patients with stroke (vs. without) reported less chest pain (70% vs. 82%, p < 0.001) and back pain (32% vs. 43%, p = 0.02), and had higher rates of syncope (44% vs. 15%, p < 0.001), hemodynamic instability (37% vs. 27%, p = 0.009), and pulse deficit (51% vs. 29%, p < 0.001). No differences between groups were observed on standard testing including electrocardiogram, chest radiograph, or imaging studies, except that arch vessel involvement was more common in patients with a stroke (68% vs. 37%, p < 0.001). Patients with stroke were less likely to have surgical management than those without stroke (74% vs. 85%, p < 0.001), had longer median hospital stays (17.9 vs. 13.3 days, p < 0.001), and had higher rates of in-hospital mortality (42% vs. 24%, p < 0.001), although there was no significant difference in 5-year mortality in patients who survived to discharge (24% vs. 17%, p = 0.30). In patients treated surgically, 5-year survival for those with versus without stroke were 22% and 14%, respectively (p = 0.51), whereas those treated medically had 5-year mortality rates of 100% and 59%, respectively (p = 0.56).
Conclusions:
Stroke is not uncommon in patients with acute type A aortic dissection, and is associated with a markedly higher rate of in-hospital mortality, although no difference was observed in long-term survival among patients surviving to discharge.
Perspective:
This large international multicenter study reported that stroke is not uncommon in patients presenting with acute type A aortic dissection, with an observed 6% incidence. Findings that may be useful to identify patients having a stroke include the lack of chest and back pain, and the presence of syncope, hemodynamic instability, a pulse deficit, and arch vessel involvement. Stroke patients had longer hospitalizations and markedly higher rates of in-hospital mortality, although it is reassuring that among patients surviving to discharge, long-term outcomes are comparable. Patients with stroke had lower rates of surgical repair, which is not surprising, as these patients tend to be sicker and are at higher risk of surgical complications. While there is controversy regarding management and surgical timing in patients with both an acute type A aortic dissection and stroke, patients with a stroke who were treated nonsurgically had a 100% 5-year mortality, suggesting that medical management of patients with both a type A aortic dissection and stroke carries a dreadful prognosis. Future research is needed to determine optimal surgical timing and to identify which of these patients most benefit from surgical repair.
Keywords: Prognosis, Stroke, Hospital Mortality, Tomography, X-Ray Computed, Syncope, Magnetic Resonance Imaging, Hypertension
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