Case report
A 60-year-old male patient collapsed and was transferred to the next hospital, where he was admitted under the presumed diagnosis of a major stroke due to a new-onset right-sided hemiparesis and motoric aphasia (NIHSS of 12). As the patient was deemed to be in the therapeutic window, he received a systemic thrombolytic therapy. In the subsequent computed tomographic (CT) scan an ATAAD Debakey type I with concomitant bilateral carotid dissection as well as left ICA occlusion up to the intracranial segments was diagnosed (Fig. 1A) and the patient was urgently transferred to our hospital. The patient arrived in a hemodynamic stable condition, but in a comatose state (GCS of 6). A CT perfusion scan of the brain was performed upon arrival in order to evaluate the effects of the thrombolytic therapy, which revealed a persistent major perfusion deficit of almost the complete left-sided cerebral hemisphere (Fig. 1B) . In an interdisciplinary therapy approach it was decided to immediately perform a percutaneous recanalization of the left carotid artery by the interventional neuroradiologists on-site. Hence, three hours after the index event two overlapping 9x50mm carotid stents were placed into the left common carotid artery (CCA) and the ICA via right inguinal access (Fig. 2A) , with the proximal end of the stent placed approximately in 4 cm distance to the aortic arch (Fig. 2B) . Post-interventional CT scan showed restored left hemispheric blood flow and no cranial hemorrhage nor infarct demarcation. Immediately afterwards the patient was transferred to the operating room, where now six hours after the index event surgical repair of ATAAD was performed, including an aortic valve, ascending aorta and partial aortic arch replacement with a biologic valved aortic conduit as well as an additional right coronary artery bypass under 28°C hypothermic circulatory arrest with antegrade brain perfusion via selective cannulation of the truncus brachiocephalicus and the left CCA. During the complete operation non-invasive neuromonitoring via cerebral oximetry showed no side differences nor relevant decrease from initial values.
After the operation the patient showed persistent right-sided hemiparesis with postoperative cranial CT-scan revealing only small ischemic watershed lesions on the left cranial hemisphere. Postoperative course was further complicated by an ischemic colitis with concomitant left-sided hemicolectomy three weeks after the initial operation, most likely caused by a pre-existing stenosis of the visceral arteries. Respiratory weaning was accomplished via tracheostomy and the patient could be transferred to the intermediate care station on the 34th postoperative day, from where he was discharged in cardiopulmonary stable status to a neurologic rehabilitation facility with still persistent but regressive right-sided hemiparesis of the upper extremity as well as motoric aphasia.
Three years later the patient presented himself again at our center due to a cutaneous fistula in the lower third of the sternotomy wound. Patient was in a very good general health status and showed almost full neurological recovery with only persistent weakness of the right arm (modified rankin scale: 1). CT-scan showed a stable aortic repair with a patent carotid stent in the left CCA and ICA (Fig. 3) .