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.