The Dissection of Differentials: An Atypical Presentation of Aortic Dissection

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Am J Respir Crit Care Med

Keywords

antihypertensive agent, troponin, acute heart infarction, adult, aortic dissection, aortic root, backache, brain blood flow, carotid stenosis, case report, common carotid artery, computed tomographic angiography, conference abstract, delayed diagnosis, diagnosis, dissection, dizziness, electrocardiogram, electrocardiography, emergency ward, faintness, heart murmur, hemodynamic monitoring, human, hypertension, hypotension, iliac bone, lung embolism, male, mean arterial pressure, mortality rate, oxygen saturation, oxygenation, physical examination, special situation for pharmacovigilance, thorax radiography, transient loss of consciousness, type A aortic dissection, upper limb, vital sign

Abstract

Introduction: The incidence of aortic dissection is reported to be 5 to 30 cases per 1 million people per year. When compared to acute myocardial infarction, whose incidence is 4400 cases per 1 million people per year, it can often be overlooked on the differential. Here, we present a case of an adult male who presented to the Emergency Department (ED) after a pre-syncopal episode and was found to have a delayed diagnosis of Stanford Type A aortic dissection, identified after initial CT angiogram of the chest was non-revealing.Case Presentation: A 66-year-old male presenting to the ED after a syncopal episode. Upon initial evaluation, he was hypotensive with mean arterial pressures in the 50s mmHg. Initial workup involving electrocardiogram (EKG), chest x-ray, CT angiography chest for pulmonary embolism (PE), and CT head without contrast all yielded unremarkable results. The patient was admitted overnight for closer hemodynamic monitoring and a bilateral carotid artery duplex was ordered originally to rule-out carotid artery stenosis, but instead found intimal flap of the right carotid artery. Repeat CT angiography of the chest (with contrast bolus timing for dissection), confirmed a Stanford type A dissection originating at the aortic root, extending to the origin of both common carotid arteries, left subclavian, and down to bilateral common iliac and renal arteries.Discussion: Syncope is a clinical syndrome in which transient loss of consciousness is caused by inadequate cerebral blood flow and oxygenation. Work-up often involves studies including EKG, orthostatic vital signs, and troponin; however, individualized studies should also be performed based on history. Aortic dissection is a life-threatening pathology, commonly presenting with acute tearing chest or back pain, blood pressure differences between upper extremities, hypertension, pulse deficit, heart murmur, focal neurological deficits, and infrequently, syncope. In the absence of prompt diagnosis and treatment, aortic dissection is extremely dangerous with mortality rates ranging from 20-30%. Many atypical presentations have been documented of ascending aortic dissections; however, 10% of individuals are asymptomatic, making the diagnosis even more insidious. Our case emphasizes the importance of keeping a broad differential while completing thorough work-up of the patient's presenting complaint and how pursuing further workup is warranted when clinical suspicion is high. As clinicians, our ability to properly obtain history and complete a physical exam plays a critical role in ordering the most appropriate imaging modality, as even a slight timing difference between imaging may lead to missing a critical diagnosis. (Figure Presented).

Volume

211

Issue

Supplement 1

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