AORTIC DISSECTION

Learning objectives: The effective thinking logic to rule out or suspect of acute aortic dissection.

Case information: A previously healthy 50-year-old woman was brought to ER because of sudden onset altered mental status (AMS) immediately after defecation. On arrival, she was drowsy and so did not complain any other symptoms. Vital signs were blood pressure 110/50, heart rate 50 (sinus bradycardia), respiratory rate 18, and temperature 36.5. There was conjugate deviation to the left side of the eyes. Other physical findings were unremarkable She was promptly seen by a neurologist and she underwent brain CT and MRI, which revealed no abnormalities. Soon after MRI, her vital signs suddenly collapsed and mental status worsened. Detailed physical examination revealed early diastolic murmur at the aortic area on the chest. Echocardiography showed flaps of aortic valve. She was referred to vascular surgeon for further treatment for acute aortic dissection.

Discussion: In any patients with acute vascular events, acute aortic dissection (AAD) should be ruled out. In our patient, AMS with focal neurologic signs such as conjugate deviation suggest a focal brain lesion rather than diffuse cerebral cortex involvement.  A sudden onset focal brain lesion usually results from acute vascular events. Thus AAD should be ruled out as a cause of these events. AAD can cause various degrees of acute perfusion shutdown for any branches from aorta. In this vignette, diagnostic heuristics were likely to occur when physicians directly proceed to brain MRI looking for a focal neurologic lesion. There might have been more aggressive investigation of a cause of the acute vascular event, including detailed history and physical information.