Description

Dissection of the aorta is a life-threatening acute aortic syndrome. Initial symptoms vary; may include chest and back pain, syncope, unconsciousness, and cardiopulmonary arrest. However, some patients may be asymptomatic. Although neurological symptoms such as paraplegia and triplegia as a presentation of aortic dissection are rare, they can make the diagnosis difficult. In our presentation, we report a 70-year-old male patient who presented with a sudden onset of left hemiplegia without chest or back pain.

Introduction to Hemiplegia

Dissection of the aorta is a life-threatening acute aortic syndrome. Initial symptoms vary; may include chest and back pain, syncope, unconsciousness, and cardiopulmonary arrest. However, some patients may be asymptomatic. Although neurological symptoms such as paraplegia and triplegia as a presentation of aortic dissection are rare, they can make the diagnosis difficult. In our presentation, we report a 70-year-old male patient who presented with a sudden onset of left hemiplegia without chest or back pain. He had coronary artery bypass grafting in his medical history. On physical examination, there was no pulse in the lower extremities and the difference in right-left blood pressure was 40 mmHg. Pulmonary computed tomography showed bilateral aortic dissection from the ascending aorta to the common iliac arteries. Paraplegia, although acute aortic dissection with hemiplegia is rare, it should be considered in patients with sudden onset paraplegia who have bilateral pulseless femoral arteries and who do not have chest or back pain. Prompt diagnosis and intervention can prevent morbidity and death. We present a case that was characterized by left hemiplegia at presentation, later developed plegia in the right leg, did not have chest pain, and presented with neurological symptoms of aortic dissection.

Case Report

A 70-year-old male patient was admitted to the emergency department with a sudden onset of loss of strength in his left upper and lower extremities. The patient did not have any symptoms before going to sleep at 21:00. When he woke up at 02:00, he could not move his left arm and leg. He did not have chest, back and leg pain. He had a medical history of coronary artery bypass graft and he did not have a history of medication. On admission to the emergency room, blood pressure was 90/60 mmHg, heart rate was 85/min, respiratory rate His oxygen saturation was 17, 96. There was no acute pathology in her electrocardiogram. In the neurological examination of the patient, his left upper and lower extremities were plegic. In the first stage, wake-up stroke was considered in the patient, and diffusion and fluor Magnetic Resonance Imaging (MRI) were performed. No diffusion restriction was detected. After MRI, the patient developed weakness in the right leg, and the extremity pulses and blood pressure measurements in both extremities were repeated. Pulses could not be detected in both lower extremities, the difference in right-left arm tension was 40 mmHg, and deep tendon reflexes could not be obtained. There was no acute pathology in the computerized tomography of the brain. In computed tomography thoracic angiography, the presence of massive thromboembolism extending from the distal part of the pulmonary trunk to both main pulmonary arteries and to the upper lobe pulmonary artery branch on the right was noted. In addition, an intraluminal dissection flap that starts from the ascending aorta and travels along the thoracic aorta is observed, and the true lumen calturation in the descending thoracic aorta is markedly reduced. At the level of the ascending aorta and aortic arch, the presence of contrasts at the level of the ascending aorta and aortic arch in its false lumen has been noted, and it is significant in favor of ongoing acute dissection. The ascending aorta was reported to have a diameter of approximately 7 cm at its widest point. The patient was taken to emergency operation by cardiovascular surgery.

Acute aortic dissection is the leading cause of death among aortic pathological conditions. In aortic dissection, the vessel layers are variably separated along the length of the aorta. Pain is the most common symptom. Although most patients experience sudden severe pain at the time of dissection, dissection can very rarely be painless. In 2% to 5% of patients, paraplegia develops rapidly as the intercostal arteries are separated from the aortic lumen by dissection. Paraplegia is due to anterior spinal artery ischemia. When the literature on aortic dissection was reviewed, in an article examining 1805 patients, the rate of cases presenting with acute onset paraparesis was 4.2%. Neurological symptoms associated with aortic dissections are usually dramatic and may completely dominate the clinical picture. Spinal cord ischemia due to aortic dissection is a rare syndrome and distal dissection is a rare syndrome. It is more common in aortic dissections. In patients with aortic dissection, spinal cord involvement may be secondary to occlusion of the intercostal and lumbar arteries, the Adamkiewicz artery (arteria radicularis magna), or the thoracic radicular arteries. Our patient presented with left hemiplegia, which initially suggested acute ischemic stroke, and the patient was a candidate for intravenous thrombolytic therapy (t-Pa). However, a diagnosis of aortic dissection was made by pulmonary CT angiography, pulselessness in the lower extremities, difference in blood pressure in the right and left arm. When the literature was reviewed, it was concluded that carotid or vertebral dissection is not an absolute contraindication for intravenous thrombolysis. However, it has also been observed that delaying the emergency operation due to the risk of bleeding in aortic dissection cases given thrombolytic therapy reduces the possibility of survival of the patient. Aortic dissection is difficult to diagnose before t-PA is performed unless the patient has typical chest pain or abnormal findings on laboratory tests. There is no consensus on the optimal timing of major cardiac surgery after thrombolysis, but there are articles in the literature that operations should be delayed for 12-24 hours in cases. Cardiac diseases such as aortic dissection should be ruled out before emergency thrombolysis is performed to treat acute ischemic stroke.