Article, Emergency Medicine

Putamen hemorrhage occurred simultaneously with Stanford type A acute aortic dissection: a case report

Case Report

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American Journal of Emergency Medicine

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Putamen hemorrhage occurred simultaneously with Stanford Type A acute aortic dissection: a case report?

Abstract

This case report describes a 60-year-old man found unresponsive on the road. He was later admitted to our emergency department (ED) with Consciousness disturbance and decorticate rigidity. computed tomographic imaging revealed coexisting left putamen hemorrhage and Stanford type A acute aortic dissection. Decompressive craniect- omy and hematoma evacuation were performed, but he died during his second hospital day. Morbid anatomy proved aortic dissection from the Ascending aorta to left common iliac artery with pericardial effusion up to 500 mL.

Brain hemorrhage and acute aortic dissection share several risk factors including hypertension and atherosclerosis, but few cases have been reported with brain hemorrhage and aortic dissection occurring simultaneously. Diagnosis for aortic dissection is difficult, especially when the patient has consciousness disturbance because of brain hemorrhage. Consequently, coexistence of these 2 conditions might be missed frequently in emergency settings. Therefore, wider knowledge of this case is important to inform others to suspect and investigate aortic dissection in cases of brain hemorrhage.

A 60-year-old man was found lying, unresponsive, on a sidewalk with vomiting and decorticate rigidity. He was admitted to our emergency department (ED). His medical history, medication, and social history were unknown. Examination revealed markedly elevated blood pressure of 210/140 mm Hg and consciousness disturbance (Glasgow Coma Scale, E1V1M3).

Mediastinal dilation (N 8 cm) was observed in a chest x-ray (Fig. 1), and head computed tomography without contrast revealed left putamen hemorrhage (estimated blood volume of 70 mL) going into the left lateral ventricle and third ventricle leading to Midline shift and hernia cerebri (Fig. 2). We also found simultaneously occurring Stanford type A acute aortic dissection with some pericardial effusion by body CT with contrast (Fig. 3).

In the ED, he was intubated. Mannitol 40 g was started intravenously, with head elevation (15?) to control intracranial pressure. Although standard treatment for Stanford type A acute aortic dissection is emergent surgery, we decided to manage aortic dissection conservatively: extracorporeal circulation devices could not be used because of brain hemorrhage.

We controlled systolic blood pressure to around 130 mm Hg. About 1 hour after his arrival, anisocoria appeared. He was carried to a surgical unit for decompressive craniectomy and hematoma evacuation.

? Source of support: None.

Head CT after surgery revealed whole-Brain hypoxia, and the next morning, about 14 hours after his arrival, he died and morbid anatomy was performed.

Regarding results of morbid anatomy, aortic dissection was visible from the ascending aorta to the left common iliac artery and left Common carotid artery (1 cm from arising). The entry site was located in the descending aorta 3 cm peripheral from the bifurcation of the left subclavian artery. There was also pericardial effusion up to 500 mL secondary to aortic dissection.

Although both brain hemorrhage and acute aortic dissection share several common risk factors including hypertension and atherosclerosis, few cases have been reported with simultaneous occurrence of these 2 conditions. A search of Pubmed and Ichushi-Web (Japan Medical Abstracts Society) using the key words “aortic dissection” and “brain haemorrhage or intracranial haemorrhage or subarachnoid haemor- rhage” produced only 5 reported cases [1-5]. The fact that all reported cases have been from Japan might be related partly to the high frequency of hemorrhagic stroke among Japanese. Four cases [1-4] describe coexistence of Stanford Type B aortic dissection and subarachnoid hemorrhage. No case has been reported for simultaneous occurrence of Stanford type A aortic dissection and brain parenchymal hemorrhage. Some cases of simultaneous occurrence of peripheral artery dissection and brain hemorrhage have also been reported, but they are mostly secondary to systemic vasculitis or Marfan syndrome [6-8].

The sequence of these 2 conditions’ occurrence is unknown in most of these case reports, but the sequence was proved in some cases [1,3], leading to the conclusion that both sequences are possible. Aortic dissection can trigger brain hemorrhage by markedly elevated blood pressure around the aortic arch and sympathetic stimulation because of aortic dissection. In contrast, in our case, the left Internal carotid artery pressure might be extremely low because of arterial dissection expanding into the left common carotid artery. It is, therefore, reasonable to speculate that catecholamine surge after brain hemorrhage had triggered aortic dissection in our case.

Review of 1320 aortic dissection cases’ morbid anatomy [9] reveals that less than 5 cases (0.4%) among 1248 acute aortic dissection cases were complicated by brain hemorrhage. We also reviewed several other studies related to autopsy imaging and morbid anatomy [10-12], but only 1 simultaneously occurring brain hemorrhage and aortic dissection case has been reported [12]. Presumably, this type of co-occurrence is extremely rare, but the precise frequency is difficult to determine. However, considering hypertension as a common risk factor, such cases might be missed in emergency settings without correct diagnosis.

Surgery for Stanford type A acute aortic dissection complicated by brain hemorrhage is usually impossible because extracorporeal pump oxygenation equipment and anticoagulants cannot be used, but making some effort not to miss comorbid aortic dissection is

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Fig. 1. Chest X ray on presentation.

Fig. 3. Chest CT shows aortic dissection.

necessary because such comorbidity can affect the goal of conserva- tive treatment including blood pressure control. Only 1 case has been reported to rescue a patient with Stanford A aortic dissection complicated by brain hemorrhage: aortic arch repair surgery was conducted with extracorporeal circulation plus anticoagulant [5]. In this case, subarachnoid hemorrhage was limited to a superficial area of the brain. The authors inferred that this hemorrhage occurred from an intracranial vein.

In conclusion, making a correct diagnosis of acute aortic dissection is extremely difficult when the patient has consciousness disturbance related to brain hemorrhage unless we suspect it. It is important for ED physicians to know about cases with spontaneously occurring brain hemorrhage and acute aortic dissection. Physicians must suspect acute aortic dissection as a differential diagnosis even after brain hemorrhage is diagnosed.

Fig. 2. Head CT shows putamen hemorrhage.

Tomohiro Sonoo MD Tomoki Wada MD Ryota Inokuchi MD Kensuke Nakamura MD Susumu Nakajima MD Naoki Yahagi MD

Department of Emergency Medicine and Critical care University of Tokyo Hospital, Bunkyo-ku

Tokyo, Japan E-mail addresses: [email protected], [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.01.023

References

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