Neurovascular syndromes of aortic dissection

Dissecting aneurysm is the most common acute disease of the aorta. Men are more likely than women to develop aortic dissection. One-third of the cases show neurologic manifestations, which may be a clue to early diagnosis. Cerebral, spinal cord and peripheral nerve ischemia can occur. In general, the treatment of choice for dissection originating in the ascending aorta is prompt surgical intervention. Medical therapy to lower elevated blood pressure and to reduce the force of myocardial contractility is sufficient for dissection of the descending aorta.     

Painless aortic dissection presenting with acute ischaemic stroke and multiple organ failure

Acute aortic dissection is an uncommon, life‐threatening catastrophe, and early diagnosis is essential for the best chance of survival. Although acute onset of severe chest or back pain is the most common presenting symptom, some patients might present with atypical symptoms and findings such as acute stroke and mesenteric ischaemia related to the involving arterial segment. Establishing the diagnosis of aortic dissection can be difficult in the presence of atypical symptoms, especially in the absence of pain. Here, we report a case of acute, painless aortic dissection presenting with multiple organ failure and neurological deficits suggesting acute ischaemic stroke.     

Painless aortic dissection presenting as high paraplegia: a case report

Acute aortic dissection is a catastrophic episode that usually presents as a sudden, painful, ripping sensation in the chest or back. Physical findings may include loss of pulses and aortic regurgitation. It is associated with neurologic sequelae in as many as one third of patients. Painless dissection occurs in 5% of patients. We report a case of painless aortic dissection, presenting as acute paraplegia. The patient was a 77-year-old woman who presented with paraplegia, with no chest or back pain. On examination, strength was 5/5 in both upper extremities and 0/5 in both lower extremities. Deep tendon reflexes were absent in her legs. She had no voluntary anal contraction. Sensation was absent from T6 through S5. Computed tomography of the chest revealed a type A dissecting aneurysm. The vascular supply to the spinal cord and the differential diagnosis for new onset paraplegia are discussed.     

Complications arising after thoracic aortic surgery: A case report on an unusual spinal cord infarction. Physiopathological and clinical considerations

Even though new prevention techniques have been developed and are being used during thoraco-abdominal aortic repairs, spinal cord infarction remains a severe and relatively frequent complication of aortic surgery. Infarctions in the territory of the anterior spinal artery are considered the most common. Different clinical pictures related to spinal cord transverse extension wounds are drawn up. In this paper, we present a case report of a subject having presented an isolated motor deficit of the lower limbs and a favorable prognosis, suggesting selective involvement of the anterior horns of the spinal cord subsequent to surgical repair of an aortic dissection. We wish to review the relevant anatomical, clinical and diagnostic characteristics along with current techniques of spinal cord ischemia prevention during and after surgery.     

Man With Sudden Paralysis: Insidious Spinal Cord Infarction due to a Non-Ruptured Abdominal Aortic Aneurysm

Background

Acute infarctions of the spinal cord are rare events characterized by sudden paralysis or sensory deficits below the level of injury. Etiologies include spinal cord trauma, vascular injury, arterial dissection, thromboembolic disease, chronic inflammatory conditions, or mass effect on the spinal cord.

Pain characteristics in disease of heart and aorta

Chest pain or discomfort is one of the cardinal manifestations of thoracic diseases. Fast, accurate diagnosis is essential for patients with angina pectoris, acute myocardial infarction, aortic dissection, ruptured aortic aneurysms, and pulmonary embolisms, which have a high mortality if not treated immediately. In patients with ischemic heart diseases and aortic dissection, an accurate history and a chest roentgenogram can serve as helpful guides to their diagnosis, and ultrasound, computed tomography, and electrocardiography can establish the diagnosis. It is important to suspect cardiovascular emergencies based on quality, duration, and location of pain as well as the presents of hypotension or hypertension, and to start these conditions as soon as possible. Then it is necessary to assess the degree of cardiovascular disability and, if necessary, to introduce patients to cardiovascular specialists.     

Chronic Aortic Dissection in a Young Adult

Background: Acute aortic dissection is a life-threatening disease that is often a diagnostic challenge in the Emergency Department (ED). Patients with acute aortic dissection often have underlying hypertension and atherosclerotic disease, and commonly present with acute-onset severe chest or back pain in their sixth or seventh decades of life. Aortic dissection, however, can also be seen in patients < 40 years old and may present chronically, with symptom duration longer than 2 weeks. Objective: We present an unusual case of chronic aortic dissection in a young patient, followed by a review of the literature on chronic aortic dissections and aortic dissections in young patients. Case Report: We report a case of chronic aortic dissection in a 32-year-old man with a history of untreated hypertension who presented to the ED with palpitations and mild shortness of breath. Conclusion: Acute and chronic thoracic aortic dissections can occur in patients of all ages, as well as in patients with atypical signs and symptoms.     

Aortic dissection presenting as uniocular blindness

A patient presented with uniocular blindness and headache, which was initially suspected to be subarachnoid hemorrhage. The patient had a seven-year history of diabetes mellitus, hypertension and hypothyroidism, as well as a two-year history of congestive cardiac failure with aortic regurgitation. Upon autopsy, the patient was diagnosed with aortic dissection. There are no other known reports of such a presentation. This case demonstrates that aortic dissection can present without any classical features, and hence it is important to consider the possibility of dissection in patients with long-standing hypertension and acute neurologic symptoms associated with pain.     

Spinal Cord Infarction Caused by Non-dissected and Unruptured Thoracoabdominal Aortic Aneurysm with Intraluminal Thrombus

Spinal cord infarction, especially anterior spinal artery syndrome, is a relatively rare disease. We report a case of spinal cord infarction caused by thoracoabdominal aortic aneurysm with intraluminal thrombus. A 52-year-old man presented with sudden onset paraplegia. At first, he was diagnosed with cervical myelopathy due to a C6-7 herniated intervertebral disc, and had an operation for C6-7 discetomy and anterior interbody fusion. Approximately 1 month after the operation, he was transferred to the department of rehabilitation in our hospital. Thoracoabdominal aortic aneurysm with intraluminal thrombus was found incidentally on an enhanced computed tomography scan, and high signal intensities were detected at the anterior horns of gray matter from the T8 to cauda equina level on T2-weighted magnetic resonance imaging. There was no evidence of aortic rupture, dissection, or complete occlusion of the aorta. We diagnosed his case as a spinal cord infarction caused by thoracoabdominal aortic aneurysm with intraluminal thrombus.     

Paralysis: a rare presentation of abdominal aortic aneurysm thrombosis

We report an acute thrombosis of an abdominal aortic aneurysm presenting with paralysis of a lower extremity. The usual presentation of such thrombosis is vascular compromise of the lower extremities. When the thrombus obstructs the artery of Adamkiewicz, the main blood supply to the lower spinal cord, spinal ischemia and paralysis can occur. Mechanisms of aortic occlusion and treatment of aortic thrombosis are briefly outlined.     

Persistent hypertension in young spinal cord injured individuals resulting from aortic repair

The development of persistent hypertension in young, previously healthy paraplegic individuals is unusual; it could be postulated that hypertension is a cardiovascular response peculiar to patients who sustained spinal cord injury after surgical repair of the aorta with trauma-related injuries. In a retrospective study of 712 patients sustaining spinal cord injury during the last decade, seven sustained paraplegia after aortic repair that was necessitated by trauma-related injuries. Despite the low incidence of new-onset hypertension in paraplegic patients, five of the seven developed hypertension, of which three required chronic antihypertensive medications. It is well documented that patients with lesions of the neuraxis above the sixth thoracic segment are prone to the phenomenon of autonomic hyperreflexia. This results from interruption of the baroreceptor reflex and the descending tracts of the spinal cord. There is evidence that the renin-angiotensin system, catecholamines, and receptor-site activity play an important role in the control of blood pressure in spinal cord injured patients. Additional investigation of this rare subgroup of spinal cord injured patients may further illuminate the effect of spinal cord injury on autonomic control of the cardiovascular system.     

DeBakey Ⅰ型主动脉夹层的围术期处理

目的 探讨DeBakey Ⅰ型主动脉夹层行三分支型主动脉弓腔内覆膜支架手术治疗的围术期处理要点.方法 我院2009年7月至2010年8月应用三分支型主动脉弓腔内覆膜支架手术治疗DeBakey Ⅰ型主动脉夹层患者56例,观察手术时间和术后并发症发生情况.结果 体外循环时间90.0～248.0 min,中位数180.6 min;主动脉阻断时间69.0～180.0 min,中位数108.2 min;停循环时间17.0～37.0 min,中位数22.6 min;术后呼吸机辅助时间16.0～260.0 h,中位数42.8 h;ICU停留时间3.0～23.0 d,中位数6.6 d.54例痊愈出院.术后急性肾功能不全6例,气管切开5例,延迟性心包填塞1例,二次开胸止血3例;截瘫1例,脑出血1例;发生顽固性心律失常5例.死亡2例,1例为急诊手术的大面积急性心肌梗死患者,无法脱离体外循环机;1例术后8 d出现多脏器功能衰竭死亡.结论 DeBakey Ⅰ型主动脉夹层手术创伤大,术前积极控制血压、镇静止痛,术中维持良好的脏器灌注、尽量缩短体外循环及停循环时间,术后密切观察、处理各种并发症是降低并发症发生率及病死率的重要保障.

Abstract：

Objective To investgate the proper perioperative management of Debakey Ⅰ aortic dissection by new type of three branches aortic arch covered stent graft implantation. Methods A total of 56cases with Debakey Ⅰ aortic dissection were enrolled into the study and operated by new type of three branches aortic arch covered stent graft implantation from July 2009 to August 2010. Results The cardiopulmonary bypass time during the operation was 90. 0 -248.0 min( median time 180. 6 ains) ,aortic cross clamp time was 69. 0 - 180. 0 min(median time 108. 2 mins) ,circulation arrest time was 17.0 -37.0 min ( median time 22. 6mins) ,the time using reathing apparatus was 16.0 -260.0 hours (median time 42. 8 hours),ICU residence time was 3.0 -23. 0 days( median time 6. 6 days). Fifty-four patients got well and were discharged. One patient died of multi-organ failure postoperatively and another died of large area of acute myocardial infarction. After the operation, six cases had acute renal failure, five cases had tracheotomy, three cases had reoperation for hemorrhage,one case had retardant pericardial tamponade, one case suffered from spinal cord injury, one had cerebral hemorrhage, and five cases had refractory arrhythmias. Conclusion The new type of three branches aortic arch covered stent graft simplified the procedures of aortic arch operation and lowered the operative risk in treatment of Debakey Ⅰ aortic dissection. Properly control of blood pressure and pain before surgery, shorten circulatory arrest time, maintain good organ perfusion seem to be the key points to improve the prognosis in patients with aortic dissection.     

Sudden cardiac death from structural heart diseases in adults: imaging findings with cardiovascular computed tomography and magnetic resonance

Sudden cardiac death (SCD) is defined as the unexpected natural death from a cardiac cause within an hour of the onset of symptoms in the absence of any other cause. Although such a rapid course of death is mainly attributed to a cardiac arrhythmia, identification of structural heart disease by cardiovascular computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging is important to predict the long-term risk of SCD. In adults, SCD most commonly results from coronary artery diseases, coronary artery anomalies, inherited cardiomyopathies, valvular heart diseases, myocarditis, and aortic dissection with coronary artery involvement or acute aortic regurgitation. This review describes the CCT and CMR findings of structural heart diseases related to SCD, which are essential for radiologists to diagnose or predict.     

Ischemic injury to the spinal cord as a cause of transient paraplegia

Spinal cord ischemia presenting as acute paraplegia is an uncommon occurrence not previously reported in the emergency medicine literature. Paraplegia due to spinal ischemia is seen most commonly after intraoperative aortic manipulation; however, acute hypotension and prolonged cardiopulmonary resuscitation are also reported settings. The differential diagnosis of acute, non-traumatic paraplegia includes mechanical spinal cord compression, acute transverse myelitis, and polyneuritis.     

Seeing the invisible: painless aortic dissection in the emergency setting

Acute dissection of the aorta can be one of the most dramatic cardiovascular emergencies. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterised as ripping or tearing in nature. However, a timely diagnosis can be elusive in the event of an atypical presentation. In this report, the authors present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department.     

Sudden death and cardiovascular complications in Marfan syndrome: impact of surgical intervention

Marfan syndrome is an autosomal dominant disorder of connective tissue characterized by abnormalities involving the skeletal, ocular, and cardiovascular systems. The cardiovascular complications of the syndrome lead to a reduced life expectancy for affected individuals if left untreated. Major cause of death include acute aortic dissection, aortic rupture, and sudden death, which resulted from congenital vascular fragility. Such life-threatening complications in Marfan syndrome can be managed effectively, by routine aortic imaging, beta-adrenergic blockade, and prophylactic replacement of the aortic root before the diameter exceeds 5.0 to 5.5 mm. Valve preserving aortic root reconstruction yielded improved postoperative quality of life compared with Bentall operation, by reducing late complications related to anticoagulants. It should be carried out before onset of aortic regurgitation for long-term native valve durability.     

SPONTANEOUS CERVICAL EPIDURAL HAEMATOMA

Spontaneous spinal epidural haematoma can occur in the elderly and is a reversible cause of neurological deficit if treated promptly. The diagnosis can be made from a careful history and a simple neurological examination, but it can be confused with myocardial infarct, musculoskeletal pain, vasculitis and acute dissection of an aortic aneurysm. For a favourable outcome, early decompressive laminectomy and evacuation of the haematoma are necessary. We report an unusual case of acute quadriplegia in which prompt diagnosis and early intervention led to almost complete functional recovery with minimal disability.     

Taming the zebra: Unravelling the barriers to diagnosing aortic dissection

Aortic dissection is a lethal cardiovascular emergency that continues to pose a diagnostic dilemma to the emergency physician. The condition is rare, can present atypically and is associated with a cumulative mortality for every hour that passes. While it is a recognised differential of acute chest pain, its prevalence in comparison to other causes often leads to the diagnosis being overlooked. The ED is a busy environment with high patient turnover and varying degrees of complexity and acuity. This increases susceptibility to cognitive bias and error‐producing conditions that can lead to delayed or missed diagnosis. In reported cases where aortic dissection has been missed, clinician awareness of the disease was not the primary issue but failure to respond to clinical cues suggestive of aortic dissection was. To improve patient outcomes for this condition, it is important for clinicians to be aware of pertinent cognitive bias and error‐producing conditions.     

Acute inferior wall myocardial infarction induced by aortic dissection in a young adult with Marfan syndrome: A case report

BACKGROUNDAortic dissection (AD) is an emergent and life-threatening disorder, and its in-hospital mortality was reported to be as high as 24.4%-27.4%. AD can mimic other more common disorders, especially acute myocardial infarction (AMI), in terms of both symptoms and electrocardiogram changes. Reperfusion for patients with AD may result in catastrophic outcomes. Increased awareness of AD can be helpful for early diagnosis, especially among younger patients.CASE SUMMARYWe report a 28-year-old man with acute left side chest pain without cardiovascular risk factors. He was diagnosed with acute inferior ST-segment elevation myocardial infarction (STEMI), which, based on illness history, physical examination, and intraoperative findings, was eventually determined to be type A AD caused by Marfan syndrome. Emergent coronary angiography revealed the anomalous origin of the right coronary artery as well as eccentric stenosis of the proximal segment. Subsequently, computed tomography angiography (CTA) showed intramural thrombosis of the ascending aorta. Finally, the patient was transferred to the cardiovascular surgery department for a Bentall operation. He was discharged 13 d after the operation, and aortic CTA proved a full recovery at the 2-year follow-up.CONCLUSIONIt is essential and challenging to differentiate AD from AMI. Type A AD should be the primary consideration in younger STEMI patients without cardiovascular risk factors but with outstanding features of Marfan syndrome.     

Coexistence of multiple and widespread cardiovascular complications in a patient with Marfan syndrome

Inherited connective tissue diseases such as Marfan syndrome are frequently associated with cardiovascular manifestations. Aortic involvement with dilation and dissection is the most common finding and the major cause of death in Marfan syndrome patients. We report the echocardiographic study of a 53‐year‐old male patient with uncommon coexistence of cardiovascular abnormalities typical of connective tissue disease at first clinical presentation in acute clinical setting: dissection of the descending aorta associated with severe mitral regurgitation due to leaflet flail and massive aortic insufficiency due to ascending aortic enlargement, leading to left ventricular dilation and dysfunction. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013