Hospital: Hospital Ramón y Cajal.
Aut@r o Autores: B. Lumbreras-Fernández, J. Pérez-Templado Ladrón De Guevara, F. González Tello, N.A. Almeida Arostegui, M. Vicente Redondo, A. Vicente Bartulos.
A 71-year-old man with a personal history of COPD, atrial fibrillation and hypertension presented with left hemiparesia, followed by sudden decrease of consciousness (GCS 3) and hemodynamic instability.As the initial diagnosis was acute stroke, a unenhanced CT scan of the brain was performed. There was hypodensity and swelling of the right M3 brain territory, as early signs of ischemia.In the CT-angiography, the right medial (CMA) and posterior cerebral arteries (PCA) (with fetal origin) presented delayed enhancement, by collaterality through the circle of Willis. The perfusion study presented an extensive disturbance in the time-related parameters with decreased flow and volumen in the territory of the right CMA and PCA, related to ischemia, with 20% of penumbra (tissue at risk).Due to these inconsistent findings, we decided to repeat the CT-angiography study of the supra aortic branches (first one was adquiered in a delayed phase time). We identified an intimal flap in the aortic arch, suggesting aortic dissection. It extended towards the right carotid artery causing complete obliteration. The study was completed with CT-angiography of the thoracoabdominal aorta, showing a type A aortic dissection with supra aortic branches and intra-abdominal extension.
Although the most common symptom related to aortic dissection is pain, approximately one third of patients with ischemic stroke do not experience it. Up to 40% of patients with aortic dissections suffer from neurological symptoms, especially in type A, and stroke is the most frequent process involved. It makes the anamnesis more difficult and delay the right diagnosis.
A complete study in stroke should always include supra aortic branches up to the aortic arch to study both of them. The study of the thoracic aorta in an acute stroke is mandatory if a dissection is suspected, even in the absence of chest pain.
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