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Case Reports
. 2025 Aug:133:111600.
doi: 10.1016/j.ijscr.2025.111600. Epub 2025 Jul 2.

The critical role of non-contrast chest CT in avoiding thrombolysis catastrophe: A case of acute aortic dissection masquerading as ischemic stroke

Xiaoyin Huang  1 , Feiyan Chen  2 , Yadong Wu  3
Affiliations
Case Reports

The critical role of non-contrast chest CT in avoiding thrombolysis catastrophe: A case of acute aortic dissection masquerading as ischemic stroke

Xiaoyin Huang et al. Int J Surg Case Rep. 2025 Aug.

Abstract

Introduction and importance: Aortic dissection (AD) complicating acute ischemic stroke poses significant therapeutic challenges, particularly regarding thrombolytic contraindications that may substantially increase mortality risk. This underscores the critical need for expedited differential diagnosis in such clinical scenarios.

Case presentation: An 80-year-old male presented with acute-onset left-sided hemiplegia and unresponsiveness.

Clinical discussion: Initial cerebral neuroimaging demonstrated a substantial ischemic penumbra (136.2 ml Tmax >6 s) in the right middle cerebral artery (MCA) territory, with a core infarction volume of 13.6 ml. Emergency intravenous thrombolysis with alteplase was administered for presumed acute ischemic stroke, followed by mechanical thrombectomy via femoral artery access. Retrospective analysis of preoperative chest Computed tomography (CT) imaging revealed ascending aortic dilation. Subsequent emergency aortic CTA confirmed Stanford Type A dissection extending from the aortic root to the first lumbar vertebral level. Despite comprehensive risk counseling, the patient's family ultimately elected for discharge against medical advice. Telephone follow-up at 30 days post-discharge confirmed patient demise.

Conclusion: This case highlights two critical clinical considerations: Subtle radiographic manifestations of AD in stroke patients may lead to diagnostic delays; the hyper-dense crescent sign on non-contrast cranial CT warrants heightened clinical suspicion for concurrent aortic pathology.

Keywords: Acute aortic dissection; Chest CT; Ischemic stroke; Thrombolysis.

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Conflict of interest statement

Declaration of competing interest The authors declare that there is no conflict of interest for the publication of this article.

Figures

Fig. 1
Fig. 1
(A) Computed tomography perfusion (CTP) scan identified a significant ischemic penumbra (136.2 ml Tmax >6 s) in the right middle cerebral artery (MCA) territory, with a core infarction volume measuring 13.6 ml; (B) Angiographic finding showed complete occlusion of the right middle cerebral artery (MCA) M1 segment (white arrow).
Fig. 2
Fig. 2
Non-contrast chest computed tomography (CT) scan shows eccentric wall thickening with hyper-density (“crescent sign”) (white arrows).
Fig. 3
Fig. 3
Aortic CTA confirmed Stanford Type A dissection extending from the aortic root to the L1 vertebral level.
See this image and copyright information in PMC

References

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