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).