Discussion:
AD and IMH are serious cardiovascular emergencies that classically
present with sudden chest and back pain. However, 15% of patients
report no significant pain [1]. Painless AD/IMH can remain
undetected and the diagnosis can be missed upon initial evaluation.
Furthermore, ischemic stroke is prevalent in 6 % of patients with AD
[2].
In order to prevent misdiagnosis of AD/IMH, a patient’s medical history
and family history should be screened for aortic pathology and a
thorough physical exam including signs of malperfusion on all
extremities should be performed. D-dimer has a high sensitivity and
specificity (100% and 94.8%, respectively) for AD/IMH and can be
measured [5]. Upper mediastinal widening on chest X ray can be a
sign of AD/IMH. Bedside carotid duplex ultrasound to evaluate for
thrombus or carotid artery dissections should also be considered. CTA
should be performed if there is any suspicion of AD/IMH. Our patient’s
head and neck CTA findings, as well as her history of abdominal and
thoracic aortic aneurysm, should have raised the suspicion of aortic
pathology as the cause of her cerebral malperfusion.
Immediate surgical intervention is the gold standard for type A AD and
acceptable outcomes of immediate surgery for type A AD in the setting of
ischemic stroke are reported, but the treatment of type A IMH remains
controversial especially when it is complicated with stroke [6].
Surgery for a Type A IMH is recommended for patients with high risk
features defined as total aortic diameter more than 50 mm, hematoma
thickness more than 11 mm, and ulcer-like projections [7]. Our
patient’s ascending aorta and aortic arch had these risks and if it had
not been for stroke and the administration of tPA, she would have met
criteria for emergent open aortic surgery. TPA significantly increases
the risk of surgical bleeding and operating patients suffering ischemic
stroke have a potential risk of hemorrhagic conversion. Therefore, we
delayed surgery until the patient completely recovered from stroke.