Case presentation
A 68-year-old Chinese female patient presented to the Emergency
Department (ED) 45 minutes after sudden onset of left-sided weakness.
The patient was exercising in the park, then collapsed and was found to
have left-sided weakness and slurred speech. She had a mild headache and
denied all other complaints including chest pain.
Upon arrival to the emergency department, she was afebrile, blood
pressure was 86/62 mmHg, heart rate 61 bpm, respiratory rate 15 bpm and
oxygen saturation 98% on room air. Electrocardiography showed sinus
rhythm, 62 bpm, with no ST changes or T-wave inversions. Her physical
exam showed left hemiparesis, slurred speech, gaze palsy, homonymous
hemianopsia, and hemisensory loss, with a National Institutes of Health
Stroke Scale of 14. Complete blood count and basic metabolic panel were
within normal limits.
Her past medical history was significant for an abdominal aortic
aneurysm repaired with endovascular aneurysmal repair and thoracic
aortic aneurysm. The ascending aorta was 4.5 cm and proximal descending
aorta was 5.4 cm, confirmed by computed tomography angiogram (CTA) one
week prior to this event. No significant trauma, family, or social
history was reported.
Non-contrast computed tomography (CT) of the head and CTA of the head
and neck were obtained (Fig. 1), which showed possible early ischemic
changes in the right insula and a large vessel occlusion in the right
middle cerebral artery. ASPECT score was 9. Furthermore, a thrombus in
the right internal carotid artery and a possible IMH or atherosclerotic
plaque in the aortic arch was found (Fig.1-A).
Initially, the defect in the aortic arch of the head and neck CT was not
recognized. Neurology deemed her a candidate for intravenous tissue
plasminogen activator (tPA) which was started within one hour of symptom
onset. After starting tPA, the radiologist informed the ED team of a
possible IMH in the aortic arch. Close examination of the head and neck
CTA suggested a possible thrombus in the right internal carotid, common
carotid, and aortic arch (Fig.1-A). Our aortic center team was
consulted. tPA was stopped within 20 minutes (25mg, half of the planned
dose, was given). A chest CTA demonstrated a type A IMH involving the
aortic root, ascending aorta, and aortic arch with a significantly
enlarged ascending aorta (5.1cm), aortic arch (4.7 cm) and proximal
descending aorta (5.4 cm). The patient was hemodynamically stable and
would pose a high risk of bleeding or hemorrhagic conversion from tPA,
so surgery was not performed. She was monitored in the intensive care
unit and her neurological condition improved. A follow-up CT scan showed
a decrease in IMH size from 10 mm to 5 mm (Fig. 2-A, B), and
demonstrated no new aortic dissection or expansion. She was discharged 5
days after the onset of stroke. During a follow-up visit in our
outpatient office, she demonstrated complete neurological recovery. The
ascending aorta, aortic arch and proximal descending aorta were dilated
(5.1 cm, 4.7 cm, and 5.4 cm, respectively). Therefore, a decision was
made to proceed with the planned repair of the aorta 6 weeks after the
initial presentation. We performed total arch replacement with a frozen
elephant trunk under deep hypocirculatory arrest at
18oC using retrograde cerebral perfusion. She suffered
no neurologic injuries postoperatively and was discharged on
post-operative day 6 (Fig. 2-C).