Headache as a manifestation of a life-threatening vascular disorder

Headache is a common complaint among patients seeking medical assistance. The differentiation between a primary headache disorder versus headache as a symptom of a serious underlying disease is of crucial importance. Dissections of the carotid or vertebral arteries frequently present with headache and can result in ischemic stroke. Rarely, headache or neck pain is a presenting symptom in patients with spontaneous proximal aortic dissection. We report on a 53-year-old man with a history of migraine with aura, who was admitted to the hospital because of severe frontal headache and neck pain. An anterior chest pain lasting for 10 minutes the day before and a diastolic heart murmur suggested a proximal aortic dissection, which was confirmed by transesophageal echocardiography. Patients with proximal aortic dissection rarely have headache or neck pain, reflecting the low incidence of carotid artery involvement in this disease. However, differentiation between an isolated cervical artery dissection and a proximal aortic dissection extending to the carotid arteries is pivotal, since treatment options are vastly different.     

Headache: an unusual presentation of aortic dissection.

The most common presenting symptom of aortic dissection is chest pain - headache as the initial manifestation is rare. We report a patient with a history of hypertension who presented with severe bifrontal headache, and was found to have an acute aortic dissection in the absence of carotid artery dissection. A discussion of the atypical presentation and possible pathophysiology follows.     

主动脉夹层31例临床分析

目的提高对主动脉夹层临床特点的认识水平,做到早诊断、早治疗。方法分析31例主动脉夹层的病因、诱因、临床表现、诊断、鉴别诊断及治疗。结果主动脉夹层患者中合并高血压者占80%以上,主要首发症状为突发性撕裂样疼痛,增强CT诊断符合率高(100%)。结论以突发胸痛就诊,尤其有高血压者,必须考虑主动脉夹层的诊断,增强CT是确诊主动脉夹层的首选方法,药物治疗的首要问题是稳定高血压和控制心率,手术治疗是彻底治愈的根本方法。     

44例主动脉夹层临床分析

目的 探讨主动脉夹层患者的患病危险因素、临床特征、诊治方法及预后.方法 对我院2005-2008年诊治的44例主动脉夹层患者临床资料进行回顾性分析.结果 主动脉夹层发生的常见病因是高血压.首发表现以胸痛为常见(部分病例以并发症为首发).CT和MRI检查对主动脉夹层的确诊率较超声检查高,但由于超声检查价格便宜,床旁操作方便,故有疑诊患者,可做常规超声检查.主动脉夹层的治疗有内科保守治疗,外科手术治疗和血管内带膜支架治疗.结论 高血压是主动脉夹层的主要危险因素,其临床表现复杂多变,误诊率高.内科治疗时血压控制多需多种降压药物联合应用,然而根据临床分型和病情采取外科手术、介入治疗可降低病死率和改善患者的预后.     

Thoracic aortic dissection in an 18-year-old woman with no risk factors

Spontaneous aortic dissection is a rare, life-threatening cause of chest pain, and has a higher prevalence when traditional risks such as age, hypertension, dyslipidemia, or connective tissue disorders are present. However, even in the absence of risk factors, non-traumatic rupture of an aortic dissection may occur. Most are found in patients over 40 years of age. Younger victims of this disease often also suffer from other conditions such as cystic medial necrosis, connective tissue disorders such as Marfan's syndrome, or vasculitis. We present the case of an 18-year-old, previously healthy woman who was country line dancing when she began to complain of severe, cramping chest and back pain. She was hemodynamically stable on initial presentation but experienced two seizures while in the emergency department and was intubated. Subsequently, her blood pressure dropped and she developed cardiac arrest, and despite vigorous resuscitation that included blood products and emergency department thoracotomy, she was refractory to all attempts. At autopsy she was found to have a spontaneous, non-traumatic rupture of an aortic dissection. This patient had no discernable risk factors for aortic dissection or discoverable cause on necropsy. We present this case to raise awareness among physicians and review other reported cases in the literature of aortic dissection in patients under age 40 years.     

主动脉夹层急诊诊治体会(附11例临床分析)

目的:分析主动脉夹层(AD)的临床特征及诱因,提高急诊确诊率。方法:回顾性分析我院2010年1月-2010年6月AD患者的临床资料。结果:11例AD患者中10例首发症状为疼痛,疼痛部位以胸、腹部为主,并发高血压病史者较多;误诊疾病复杂多样,以急腹症居多,首诊误诊率54.5%;治疗上以内科保守治疗为主。结论:AD首发症状主要为剧烈胸腹疼痛,病死率高,早期及时确诊,降低血压、心率可显著降低病死率。     

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.     

Acute Aortic Dissection With ST Segment Myocardial Infarction Following Masturbation

BackgroundAcute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection.Case ReportA 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival.Why Should an Emergency Physician Be Aware of This?An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis.     

A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review

Cervical artery dissection refers to a tear in the internal carotid or the vertebral artery that results in an intramural haematoma and/or an aneurysmal dilatation. Although cervical artery dissection is thought to occur spontaneously, physical trauma to the neck, especially hyperextension and rotation, has been reported as a trigger. Headache and/or neck pain is the most common initial symptom of cervical artery dissection. Other symptoms include Horner’s syndrome and lower cranial nerve palsy. Both headache and/or neck pain are common symptoms and leading causes of disability, while cervical artery dissection is rare. Patients often consult their general practitioner for headache and/or neck pain, and because manual-therapy interventions can alleviate headache and/or neck pain, many patients seek manual therapists, such as chiropractors and physiotherapists. Cervical mobilization and manipulation are two interventions that manual therapists use. Both interventions have been suspected of being able to trigger cervical artery dissection as an adverse event. The aim of this review is to provide an updated step-by-step risk–benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection.

• Key messages

• Cervical mobilization and/or manipulation have been suspected to be able to trigger cervical artery dissection (CAD). However, these assumptions are based on case studies which are unable to established direct causality.

• The concern relates to the chicken and the egg discussion, i.e. whether the CAD symptoms lead the patient to seek cervical manual-therapy or whether the cervical manual-therapy provoked CAD along with the non-CAD presenting complaint.

• Thus, instead of proving a nearly impossible causality hypothesis, this study provide clinicians with an updated step-by-step risk–benefit assessment strategy tool to (a) facilitate clinicians understanding of CAD, (b) appraise the risk and applicability of cervical manual-therapy, and (c) provide clinicians with adequate tools to better detect and exclude CAD in clinical settings.

     

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.     

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.     

急性主动脉夹层16例临床特点及早期诊断的探讨

目的探讨急性主动脉夹层（AD）患者的易患因素、临床特点及诊断方法,以期提高该疾病的早期诊断水平。方法收集16例急性AD患者的临床资料,对其临床特点、辅助检查资料进行回顾性分析。结果AD患者临床表现多样,胸痛为常见首发症状,高血压是导致AD发生的常见原因。联合应用超声心动图（TTE）、CT和MRI 3种检查方法可以快速明确诊断。结论AD临床表现复杂,掌握其临床特征、保持高度的警惕并及时采取相关的检查是早期发现AD的关键。     

Headache and Neck Pain: The Warning Symptoms of Vertebral Artery Dissection

SYNOPSIS
The clinical features of headache and neck pain in 14 patients with extracranial vertebral artery dissection proven by angiography or magnetic resonance imaging are reported. Pain was always located on the side of the dissected vertebral artery. Whereas eleven patients had head and posterior neck pain, the others had either only posterior neck pain, no change of a chronic pre-existing headache or no pain at all. Pain started suddenly, was of sharp quality and severe intensity, different from any previously experienced headache. Following acute onset, the time course of pain was monophasic with gradual remission of a persistent headache lasting one to three weeks. A delay between onset of head or posterior neck pain and onset of neurologic dysfunction was noted in 12 patients and was less than one day and between one day and three weeks in six each. Report of this distinct type of pain, although non-specific as an isolated symptom, should raise suspicion of an underlying vertebral artery dissection. Early confirmation of this diagnosis and subsequent anticoagulation if dissection does not extend intracranially may help prevent vertebro-basilar ischemic deficits.     

Vertebral artery dissection onset mimics migraine with aura in a graphic designer

Headache is the most common symptom in patients with cervical artery dissection. This symptom, however, rarely occurs in isolation, and more commonly is associated with other neurological symptoms and signs. Visual symptoms associated with vertebral artery dissection (VD) have also been observed, but do not typically mimic the migraine aura. Here, we report a young patient who presented VD, embolic ischemic lesions, and visual symptoms with the features of aura, followed by migraine headache. The suggestion of VD dissection should be kept in mind in those cases complaining of the first attack of headache that mimics migraine with aura. In these cases, an extensive neuroimaging study is advisable.     

54例主动脉夹层临床分析

目的：探讨主动脉夹层的易患因素、临床特点、诊断方法、治疗厦预后，提高对该病的认识。方法：回顾性分析54倒主动脉夹层分离患者的临床资料。结果：剧烈疼痛是最主要的首发症状（91％）、MRI成像检查诊断准确性最高（100％），药物治疗A型病死率（53％）高于B型（8％）。结论：快速、及时、有效的诊断和治疗是提高生存率的关键。     

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

Background

Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis.

Objectives

To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection.

Case Report

An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation.

Conclusion

Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.     

Pain as the only manifestation of internal carotid artery dissection

Internal carotid artery dissection is a major cause of ischemic stroke in the young. Pain is the leading symptom and is associated with other focal signs such as Horner's syndrome and painful tinnitus or with signs of cerebral or retinal ischemia. We report two patients with angiographically confirmed extracranial internal carotid artery dissection presenting with cephalic pain as the only manifestation. The first patient had a diffuse headache and a latero-cervical pain lasting for 12 days, reminiscent of carotidynia. The second patient experienced an exploding headache suggestive of subarachnoid hemorrhage, which was ruled out by computed tomography of the head and cerebrospinal fluid study. These patients demonstrate that recognition of carotid artery dissection as a cause of carotidynia and headache suggestive of subarachnoid hemorrhage may permit an earlier diagnosis and possibly the prevention of a stroke through the use of anticoagulation.     

Acute thoracic aortic dissection: The basics

With an increasing incidence, aortic dissection is the most common acute illness of the aorta. In the setting of chronic hypertension, with or without other risk factors for aortic dissection, this diagnosis should be considered a diagnostic possibility in patients presenting to the emergency department with acute chest or back pain. Left untreated, about 75% of patients with dissections involving the ascending aorta die within 2 weeks of an acute episode. But with successful initial therapy, the 5-year survival rate increases to 75%. Hence, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome in a majority of the patients. This article reviews acute thoracic aortic dissection, including ED diagnosis and management.     

Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities: a case report

Acute dissection of the aorta can be one of the most dramatic of cardiovascular emergencies. Its symptoms can occur abruptly and progress rapidly. Prompt recognition and appropriate intervention is crucial. However, not all aortic dissections present with classic symptoms of abrupt chest, back, or abdominal pain, and the diagnosis may be missed. A 63-year-old woman presented with transient loss of lower extremity motor and sensory function as the only symptom of an acute thoracoabdominal aortic dissection. Aortic dissection presenting as a transient neurologic syndrome is quite unusual. The sudden onset of weakness and parasthesia can result from the interruption of blood flow to the spinal cord. These symptoms of acute spinal cord ischemia, suggestive of a serious cardiovascular event, must be recognized and thoroughly investigated.     

妊娠合并主动脉夹层6例回顾性分析

目的 探讨妊娠合并主动脉夹层的临床表现、诊断及治疗.方法 选取河南省人民医院于2015年1月至2020年12月收治的妊娠合并主动脉夹层患者6例,对其临床资料、治疗方案和母儿结局进行回顾性分析,探讨不同手术时机对妊娠合并主动脉夹层结局的影响.结果 6例年龄30～38岁,平均32.16岁.发病时间为孕5周至产后1个月,孕早...