Background. Syncope or new onset focal neurologic deficits are described in as many as one fifth of patients with acute aortic dissection referred for surgery. Coma or stroke caused by involvement of the arch vessels and secondary brain malperfusion is considered a major contraindication for emergency aortic repair. Initial experience with emergency operation in selected patients with acute type A aortic dissection complicated by coma is described. Methods. Five comatose (median Glasgow coma score, 5.5), hemodynamically stable (systolic blood pressure ≥ 100 mm Hg) patients with preserved pupillary reactivity and coma duration of less than 12 hours underwent emergency surgical repair. The ascending aorta was always replaced using profound hypothermic circulatory arrest. Results. There were no operative deaths. No hemorrhagic brain infarction developed postoperatively. Ischemic strokes were documented by radiology in 3 patients, and were always right-sided. Four patients returned to normal life with no neurologic sequelae, whereas 1 patient showed partially recovered left hemiparesis and mild cognitive impairment. Conclusions. Coma may not represent an absolute contraindication for resuscitative surgery in hemodynamically stable patients with acute type A aortic dissection. A larger experience is necessary to draw more definitive conclusions.