A Devastating Tear: Atypical Presentation of Aortic Dissection Discovered on Echocardiography

Abstract

Acute aortic dissection (AAD) is a serious medical problem that requires prompt recognition in order to prevent deadly complications. Nevertheless, making the diagnosis can often be challenging. The clinical signs and symptoms of AAD may vary depending on the location of the dissection, leading to subtle differences in the initial patient presentation. Moreover, the classically described signs of blood pressure disparity, pulse deficit, or the presence of a diastolic murmur are often absent. Here, we report a challenging case of AAD in which the patient presented with acute substernal chest pain that resolved after a short period and was associated with hypotension. His bilateral upper and lower extremities were well perfused with symmetrical, palpable pulses. The initial point-of-care ultrasound (POCUS) showed a small pericardial effusion, and a follow-up echocardiogram revealed an ascending aortic flap with aortic root dilation diagnostic of AAD. Our aim is to shed light on the challenge of diagnosing AAD.

Keywords: aortic diseases; atypical presentation; echocardiography; hypotension; pocus; type a aortic dissection; type b aortic dissection.

Figure 1. First electrocardiogram obtained demonstrating normal sinus rhythm with ventricular rate of 60 BPM; left axis deviation and LVH criteria also present.

LVH: left ventricular hypertrophy, BPM: beats per minute

Figure 2. Subsequent electrocardiogram obtained five hours after initial presentation demonstrating sinus bradycardia and a more pronounced T wave inversion in lead II, III, aVF, V4-V6.

Figure 3. Echocardiogram; dilated ascending aorta

Figure 4. Left: Aortic flap noted on parasternal long axis view (green arrow). Right: Parasternal short view on echocardiogram (blue arrow)

Figure 5. Left: Axial view of computed tomography; red arrow showing hemopericardium; Orange arrow indicating dissecting aorta. Right: Sagittal computed tomography section; three red stars mark the dissection line.