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NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1129-1130

Aortic Dissection Masquerading as Stroke


1 Department of Radiology, KMCH, Coimbatore, Tamil Nadu, India
2 Department of Consultant Neurologist, KMCH, Coimbatore, Tamil Nadu, India

Date of Submission08-Dec-2019
Date of Decision08-Feb-2020
Date of Acceptance14-Jun-2020
Date of Web Publication2-Sep-2021

Correspondence Address:
Shriram Varadharajan
Consultant Neuro-Radiologist, Department of Imaging Sciences and Interventional Radiology, KMCH, Coimbatore - 641 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325300

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How to cite this article:
Nedunchelian M, Patil SB, Kumar E S, Varadharajan S. Aortic Dissection Masquerading as Stroke. Neurol India 2021;69:1129-30

How to cite this URL:
Nedunchelian M, Patil SB, Kumar E S, Varadharajan S. Aortic Dissection Masquerading as Stroke. Neurol India [serial online] 2021 [cited 2021 Sep 28];69:1129-30. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1129/325300




Aortic dissection can easily be missed in patients presenting with neurological symptoms. Transient or permanent neurological symptoms at onset of aortic dissection are seen in 17–40% of the patients and often mask the underlying condition.[1],[2] However, these patients may present with initial symptoms of referred pain of aortic origin giving a potential clue to the diagnosis. Pain of cardiac and aortic origin may radiate to neck, jaw, tooth, arm, and shoulder due to the fact that cardiac visceral afferent fibers and sensory neurons that innervate these areas have a common origin in the spinal dorsal horn. Another cause of referred pain might be stimulation of recurrent branches of vagus nerve around the aortic arch.[3] We present a middle-aged male who presented with abrupt onset of jaw pain and decreased consciousness followed by seizures. Initial MRI with MRA [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d showed scattered bilateral juxta cortical infarcts with involvement of bilateral watershed zones and eccentric wall thickening of aortic arch with suspicious intimal flap extending into right common carotid artery while also showing eccentric thickening (intramural hematoma) along left common carotid artery. Subsequent color doppler USG and CT Angiogram confirmed type A aortic dissection extending into bilateral carotid vessels. Patient worsened clinically within next few days and follow up MRI showed severe progressive bilateral infarcts [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h. Patient eventually expired on day 4 following stroke due to cardiac arrest and could not be resuscitated. Learning points from this are the possibility of dissection in patients presenting with vague chest discomfort or referred pain at various sites at onset of stroke and multi-territorial infarcts including involvement of unilateral or often bilateral watershed regions on imaging. We need to obtain complete vascular imaging covering aortic arch in such patients to look for intimal flaps or eccentric thickening (intramural hematoma). Thus imaging findings in MRI including DWI[4] and non-contrast MRA can provide clues to underlying dissection[5] while additional contrast based vascular imaging (CT angiography) covering aortic arch to vertex is used to confirm the diagnosis.
Figure: 1: (a-h) Initial DWI and ADC (a and b) show scattered bilateral juxta cortical acute infarcts with involvement of watershed regions. MRA (c and d) show intimal flaps in aortic arch with extension into neck vessels (right common carotid) and eccentric thickening in left common carotid (intramural hematoma). Follow up MRI shows progressive infarcts (e) while USG Doppler (f) and CT Angiogram (g and h) confirmed type A aortic dissection extending into bilateral carotid arteries

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Summarizing clinical and imaging clues for dissection in patients presenting with stroke are:

  1. Referred pain of cardiogenic/aortic origin at onset including chest, neck, jaw, or tooth pain.
  2. Multi territorial juxta cortical infarcts in MRI with involvement of watershed regions.
  3. Intimal flap and eccentric wall thickening (intramural hematoma) on vascular imaging.
  4. Progressive infarcts on follow up imaging with deteriorating clinical course.


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There are no conflicts of interest.



 
  References Top

1.
Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological symptoms in type A aortic dissections. Stroke 2007;38:292-7.  Back to cited text no. 1
    
2.
Gaul C, Dietrich W, Erbguth FJ. Neurological symptoms in aortic dissection: A challenge for neurologists. Cerebrovasc Dis 2008;26:1-8.  Back to cited text no. 2
    
3.
Tago M, Furukawa N, Yamaguchi R, Tokushima Y, Aihara H, Yamashita S. Left mandibular pain: A rare initial symptom of acute aortic dissection without coronary obstruction. Int Med 2017;56:1663-5.  Back to cited text no. 3
    
4.
Adam G, Darcourt J, Roques M, Ferrier M, Gramada R, Meluchova Z. Standard diffusion-weighted imaging in the brain can detect cervical internal carotid artery dissections. AJNR Am J Neuroradiol 2020;41:318-22.  Back to cited text no. 4
    
5.
Fernandez E, Nadig R, Mathew T, Sarma GR. Aortic dissection causing embolic stroke. Neurol India 2009;57:689. doi: 10.4103/0028-3886.57784.  Back to cited text no. 5
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