Neurological symptoms in aortic dissection: a challenge

Síntomas neurológicos en disección de aorta: un desafío

Introduction: aortic dissection should be considered in any patient with sudden chest or abdominal pain and rapid progression to peak pain. Transient or permanent neurological symptoms at onset are not only frequent (17-40%) but may mask the underlying condition, especially in pain-free dissection (5-15%). Objective: to report on a patient with neurological symptoms caused by aortic dissection with no evidence of lesions by neuroimaging. Case report: male patient admitted to a medium complexity hospital in Caldas, Antioquia, Colombia, for presenting neurological manifestations suggestive of cerebrovascular accident. He was referred to a high complexity center in Envigado, Colombia, where aortic dissection was diagnosed by a CT angiogram. Discussion and conclusions: aortic dissection has a broad clinical spectrum and may be deadly if not considered in the presence of neurological symptoms receiving thrombolytic treatment; pain-free dissection is real and constitutes a diagnostic challenge. Neurological symptoms are associated with increased mortality but are not acontraindication for surgery.

1. Black JH, Manning JW. Overview of acute aortic dissection and other acute aortic síndromes [Internet]. UPTODATE; 2020 [Consultado 2020 Jul 22]. Disponible en: https://www.uptodate.com/contents/overview-of-acute-aortic-dissection-and-otheracute-aortic-syndromes
2. Black JH, Manning JW. Clinical features and diagnosis of acute aortic dissection [Internet]. UPTODATE; 2021 [2021 Mar 11]. Disponible en: https://www.uptodate.com/contents/clinical-features-anddiagnosis-of-acute-aortic-dissection?search=Manning%20JW.%20Clinical%20features%20and%20diagnosis%20of%20acute%20aortic%20dissection&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
3. Hollander JE, Chase M. Evaluation of the adult with chest pain in the emergency department [Internet]. UPTODATE; 2020 [Consultado 2020 May 05]. Diponible en: https://www.uptodate.com/contents/evaluation-of-the-adult-with-chestpain-in-the-emergency-department?search=Evaluation%20of%20the%20adult%20with%20chest%20pain%20in%20the%20emergency%20department%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
4. Gómez-Rubioa J, Bárcena-Atalaya AB, Caballero-García FJ. Disección aórtica aguda, lo fundamental de la historia clínica y la exploración física. Medicina de Familia. SEMERGEN. 2014;40(4):228-231.http://dx.doi.org/10.1016/j.semerg.2013.12.011
5. Tapia Ibáñez EX, Paz Cordero DC, Sánchez Calzada A, Ochoa Morales X. Disección aórtica con manifestaciones neurológicas. An Med (Mex). 2018;63(1):59-63.
6. Iluyomade A, Wander P, Shah A, Chikwe J. Neurological manifestations of acute aortic dissection. J Am Coll Cardiol. 2016;67(13 Supplement):1-10.
7. Gaul C, Dietrich W, Joachim Erbguth F. Neurological Symptoms in Aortic Dissection: a challenge for neurologists. Cerebrovasc Dis. 2008;26(1):1-8. doi: 10.1159/000135646
8. Chen CH, Kuan-Ting L. A case report of painless type A aortic dissection with intermittent convulsive syncope as initial presentation. Medicine (Baltimore). 2017;96(17):e6762. doi:10.1097/MD.0000000000006762.
9. Nohe B, Ernemann U, Tepe G, Ritz R, Bail D. Aortic Dissection Mimicking Subarachnoidal Hemorrhage. Anesth Analg. 2005;101(1):233-4, table of contents. doi: 10.1213/01.ANE.0000154190.06408.38.
10. Lee CC, Lee MG, Hsieh R, Porta L, et al. Oral fluoroquinolone and the risk of aortic dissection. J Am Coll Cardiol. 2018;72(12):13691378. doi: 10.1016/j.jacc.2018.06.067
11. Núñez-Gil U, Bautista D, Cerrato E, Salinas P, Varbella F, et al. Incidence, Management, and Immediate- and Long-Term Outcomes After Iatrogenic Aortic Dissection During Diagnostic or Interventional Coronary Procedures. Circulation. Circulation.2015;131(24):2114-9. doi: 10.1161/CIRCULATIONAHA.115.015334
12. Roman MJ, Pugh NL, Hendershot TP, Devereux RB, Dietz H, Holmes K, et al. Aortic Complications Associated With Pregnancy in Marfan Syndrome: The NHLBI National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC). Journal of the American Heart Association. J Am Heart Assoc. 2016;5(8):e004052. doi: 10.1161/JAHA.116.004052
13. Chou AS, Ma WG, Mok SC, Ziganshin BA, Peterss S, et al. Do familial aortic dissections tend to occur at the same age?. Ann Thorac Surg. 2017;103(2):546-550. doi: 10.1016/j.athoracsur.2016.06.007
14. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, et al. Randomized comparison of strategies for type B aortic dissection: The Investigation of stent grafts in aortic dissection (INSTEAD) trial. Circulation. 2009;120(25):2519-28. doi: 10.1161/CIRCULATIONAHA.109.886408
15. Wang W, Wu J, Zhao X, You B, Li C. Type-A aortic dissection manifesting as acute inferior myocardial infarction: 2 case reports. Medicine (Baltimore). 2019;98(43):e17662. doi: 10.1097/MD.0000000000017662
16. Centofanti P, Flocco R, Ceresa F, Attisani M, La Torre M, Weltert L, et al. Is surgery always mandatory for type A aortic dissection?. Ann Thorac Surg. 2006;82(5):1658-63; discussion 1664. doi:10.1016/j.athoracsur.2006.05.065
17. Álvarez-Sabín J, Vázquez J, Sala A, Ortega A, Codina-PuiggrósbA. Manifestaciones neurológicas de los aneurismas disecantesbde aorta. Med Clin (Barc). 1989;92:447-449.
18. Blanco M, Díez-Tejedor E, Larrea JL, Ramírez U. Neurologic complications of type I aortic dissection. Acta Neurol Scand. 1999;99(4):232-235. doi: 10.1111/j.1600-0404.1999.tb07352.x
19. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA.2000;283(7):897-903. doi: 10.1001/jama.283.7.897
20. Blanco M, Díez-Tejedor E, Larrea JL, Ramírez U. Neurologicbcomplications of type I aortic dissection. Acta Neurol Scand. 1999;99(4):232-5. doi: 10.1111/j.1600-0404.1999.tb07352.x
21. Black JH, Burke CR. Surgical and endovascular management of acute type A aortic dissection [Internet]. UPTODATE; 2020 [Consultado 2020 Nov 06]. Disponible en: https://www.uptodate.com/contents/management-of-acute-type-a-aortic-dissection
22. Zamorano JL, Mayordomo L, Evangelista A, San Román JA, Bañuelos C, Gil Aguado M. Guías de práctica clínica de la Sociedad Española de Cardiología enfermedades de la aorta. Rev Esp Cardiol. 2000;53(4):531-541
23. Azizzadeh A, Arbabi CN. Management of chronic type B aortic dissection [Internet]. UPTODATE; 2021 [Consultado 2021 Feb 09]:https://www.uptodate.com/contents/management-of-chronictype-b-aortic-dissection