A Case of Stanford Type A Aortic Dissection Presenting as Syncope and Neurologic Deficits Without Pain: Diagnostic Pitfalls and a Therapeutic Dilemma

Abstract

Acute aortic dissection (AAD) is a true medical emergency that classically presents with sudden severe tearing chest pain that may radiate to the back or with tearing abdominal pain. When it presents atypically without pain, diagnostic delays or misdiagnosis are common, often with devastating consequences. We report the case of a 59-year-old male with uncontrolled hypertension who first presented to an outside emergency department (ED) with multiple collapses and was discharged after assessment. He presented 48 hours later to our ED following collapse and loss of consciousness. The patient was in shock upon arrival. Transient right upper limb weakness and slurring of speech were noted on initial assessment. Acute coronary syndrome (ACS) with cardiogenic shock was suspected on the basis of electrocardiographic (ECG) changes and raised troponin, and ACS treatment was administered. However, bedside echocardiogram performed to assess left ventricular function as part of the ACS work-up suggested Stanford type A AAD, which was confirmed by computed tomogram (CT) of the aorta. Emergency surgical repair of the aorta was performed after transfer to a tertiary hospital, with good postoperative recovery. This case highlights the importance of maintaining a high index of suspicion for aortic dissection in patients presenting with syncope and neurological deficits even in the absence of classical symptoms. Simulation training specifically tailored to scenarios of atypical presentations of AAD may be of benefit to emergency clinicians and help reduce the unacceptably high rate of misdiagnosis.

Keywords: aad; lactate; painless aortic dissection; shock; ste-acs; stroke; type a aortic dissection; ’stanford type a acute aortic dissection.

Figure 1. Transthoracic echocardiogram showing the dissecting flap in the aortic root (black arrow) in keeping with Stanford A dissection.

Figure 2. Dissecting flaps extending into the brachiocephalic and left common carotid arteries (red arrows), which provide a likely explanation for the patient’s neurological symptoms at presentation.

Figure 3. Sagittal view of CT aortogram showing Stanford type A AAD with the dissecting flap extending distally into the descending aorta.

Figure 4. CT aortogram showing dissecting flaps in both the ascending and descending aorta.

Figure 5. Pericardial effusion (black arrow) on CT scan. This was confirmed intraoperatively to be a hemopericardium.