Case Report

Acute aortic dissection with painless paraplegia: report of 2 cases

Abstract

Acute aortic dissection is often a life-threatening event that usually presents as a sudden, severe, exquisitely painful, ripping sensation in the chest or back. There are a few reports of atypical findings or no pain in the literature. We report 2 patients with painless acute aortic dissection who presented to the emergency department (ED) with sudden onset paraplegia.

Cardiovascular diseases are the major cause of death in most developed countries and in many Developing countries. Aortic diseases contribute to the high overall cardiovascular mortality [1]. Patients who have aortic dissection complain about serious chest pain. Pain is mostly described as tearing, cutting, or shearing in nature. Different symptoms occur because of perfusion defect of the brain, limbs, and visceral organs. Aortic dissection may cause Pericardial tamponade, myocardial ischemia, syncope, and stroke. Paraplegia may occur because of reduced blood flow through intercostal and lumber arteries [2].

Diagnosis of aortic dissection may be difficult if there are atypical symptoms. Atypical symptoms are lack of pain and of neurologic and cardiologic symptoms. Diagnosis of aortic dissection without typical symptoms is very challenging [3]. A 54-year-old male patient was admitted to emergency service at night. His complaint was sudden loss of the ability to walk. There was no history of any significant past illness. He was orientated and cooperated during physical examina- tion. The Glasgow Coma Score was 15. He had no chest or back pain. His vital signs were as follows: blood pressure, 120/80 mm Hg; pulse, 76 beats per minute and regular;

respirations, 22/min; and body temperature, 36.7?C.

On physical examination, cardiac auscultation revealed no murmurs, gallops, or rub. The lungs were clear on auscultation. Right leg was pale; right femoral pulse was decreased. He had motor deficit in the lower extremities, predominantly in the right. Deep tendon reflexes were decreased. He had no pathologic reflexes. Laboratory examination findings were within normal limits. There was no abnormal finding on his 12-lead electrocardiogram. Thoracal and Abdominal computed tomography was per-

formed. Computed tomography revealed aortic dissection from the Ascending aorta until the common iliac arteries bilaterally. There was no rupture (Figs. 1 and 2).

A 54-year-old male patient was transported by an ambulance to emergency service. He had difficulty in standing up and had numbness in lower extremities. He was normal when he woke up that morning. His complaints started after 1 hour. He was conscious, but he was paraplegic during first physical examination. He had no pain in chest, back, or abdomen. In his past medical history, there is hypertension; but he was not routinely using medication. His vital signs were as follows: Blood pressure , 160/90 mm/ Hg; pulse, 92 beats per minute and regular; respiration rate, 20 breaths/min; body temperature, 36.4?C; O₂ saturation with pulse oximetry, 96%. Electrocardiogram result was normal. Muscle strength in both lower extremities was decreased to one fifth. Deep tendon reflexes were also decreased in lower limbs. In computed tomography, there was intimal tear in the descending abdominal aorta at the infrarenal level. In arterial pHase, the left common iliac artery was normal; but the right common iliac artery was not filled with contrast (Fig. 3).

The estimated incidence of aortic dissection is 5 to 30 cases per million people per year [4]. Without intensive treatment, the mortality rate is as high as 80% [5]. Hypertension is a predisposing condition and exists in 70% of patients. More commonly seen in men (at a 2:1 ratio) and in persons in the fifth through seventh decade of life, aortic dissection is a major cause of morbidity in patients with Marfan syndrome and is seen in patients with congenital aortic valve anomalies and coarctation of the aorta and in women during the Third trimester of pregnancy [6]. Classically, acute aortic dissection is described as presenting with a sudden onset of severe chest, back, or abdominal pain that is characterized as ripping or tearing in nature [7]. The severe pain often serves as an alarm to physicians, enabling them to make the correct diagnosis quickly and easily. However, a certain proportion of patients with aortic dissection experience little or no pain at the time of presentation [8,9]. About 10% of aortic dissections are painless and may present with symptoms secondary to complications of the dissection [10]. Syncope and dyspnea secondary to acute aortic valve regurgitation, facial swelling mimicking superior vena cava obstruction, coma, stroke, consumptive coagulo- pathy, gastrointestinal hemorrhage, and aorto-right atrial fistula may also be the immediate manifestations of aortic dissection [11]. A variety of neurologic presentations including inability to

0735-6757/$ – see front matter (C) 2008

631.e4 C. Aktas et al.

Fig. 1 Computed tomography showing aortic dissection from the ascending aorta until the common iliac arteries bilaterally.

walk, intermittent bilateral lower extremity paralysis, progres- sive motor and sensory deficits, unilateral lower extremity numbness, and hoarseness have also been reported [12].

Aortic dissection presenting primarily as paraplegia is rare [5,13]. The reported incidence of neurologic complications ranges from 7.8% to 46.0%, with paraplegia or paraparesis occurring in 1.2% to 8.0% [14]. The sudden onset of weakness and paresthesias as observed in the present case can result from temporary obstruction of the spinal arteries and interruption of blood flow to the spinal cord, especially the watershed zones like the lower thoracic and lumbar segments of the spinal cord [15].

A rare case of painless aortic dissection in which the patient presented with sudden onset of paraplegia is reported. Aortic dissection should be considered in the differential diagnosis of patients who present with paraplegia of acute onset, regardless of whether they complain of pain.

Fig. 2 Computed tomography showing intimal tear in the descending abdominal aorta at the infrarenal level.

Fig. 3 Case 2: Computed tomography showing aortic dissection from the descending abdominal aorta.

Can Aktas MD Department of Emergency Medicine Yeditepe University Hospital

Istanbul, Turkey E-mail address: [email protected]

Orhan Cinar MD

Department of Emergency Medicine

Gulhane Military School

Ankara, Turkey

Didem Ay MD Department of Emergency Medicine Yeditepe University Hospital

Istanbul, Turkey

Bengi Gurses MD Department of Radiology Yeditepe University Hospital

Istanbul, Turkey

Hakan Hasmanoglu

Department of Emergency Medicine

Gulhane Military School

Ankara, Turkey

doi:10.1016/j.ajem.2007.09.020

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