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      Consideration of Two Cases of Ascending Aortic Dissection That Began with Stroke-Like Symptoms

      case-report
      1 , * , 2
      Case Reports in Neurological Medicine
      Hindawi Publishing Corporation

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          Abstract

          We recently experienced two patients with stroke-like symptoms and ascending aortic dissection (AAD) in our outpatient department. Both patients were transferred to our hospital presenting with neurological deficit such as hemiparesis and conjugate deviation. They did not complain from any chest or abdominal pain. Their MRI did not show fresh infarction or main branch occlusion. A chest CT image showed AAD. The former patient was immediately transferred to a tertiary hospital and the latter received conservative management in the cardiovascular department. Discussion. As neither patient was experiencing any pain, we initially diagnosed them with ischemic stroke and began treatment. Fortunately, bleeding complications did not occur. In such cases, problems are caused when intravenous tissue plasminogen activator (t-PA) injection is administered with the aim of reopening the occluded intracranial arteries. In fact, patients with AAD undergoing t-PA injection have been reported to die from bleeding complications without any recognition of the dissection. These findings suggest that confirmation using carotid ultrasound, carotid MR angiography, and a D-dimer test is crucial and should be adopted in emergency departments.

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          The International Registry of Acute Aortic Dissection (IRAD)

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            Association of painless acute aortic dissection with increased mortality.

            To evaluate the clinical characteristics and outcomes of patients with painless acute aortic dissection (AAD). For this study conducted from 1997 to 2001, we searched the International Registry of Acute Aortic Dissection to identify patients with painless AAD (group 1). Their clinical features and in-hospital events were compared with patients who had painful AAD (group 2). Of the 977 patients in the database, 63 (6.4%) had painless AAD, and 914 (93.6%) had painful AAD. Patients in group 1 were older than those in group 2 (mean +/- SD age, 66.6 +/- 13.3 vs 61.9 +/- 14.1 years; P = .01). Type A dissection (involving the ascendIng aorta or the arch) was more frequent in group 1 (74.6% vs 60.9%; P = .03). Syncope (33.9% vs 11.7%; P < .001), congestive heart failure (19.7% vs 3.9%; P < .001), and stroke (11.3% vs 4.7%; P = .03) were more frequent presenting signs in group 1. Diabetes (10.2% vs 4.0%; P = .04), aortic aneurysm (29.5% vs 13.1%; P < .001), and prior cardiovascular surgery (48.1% vs 19.7%; P < .001) were also more common in group 1. In-hospital mortality was higher in group 1 (33.3% vs 23.2%; P = .05), especially due to type B dissection (limited to the descending aorta) (43.8% vs 10.4%; P < .001), and the prevalence of aortic rupture was higher among patients with type B dissection in group 1 (18.8% vs 5.9%; P = .04). Patients with painless AAD had syncope, congestive heart failure, or stroke. Compared with patients who have painful AAD, patients who have painless AAD have higher mortality, especially when AAD is type B.
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              Neurological Symptoms in Aortic Dissection: A Challenge for Neurologists

              Typically, aortic dissection has to be considered in patients with acute thoracic or abdominal pain and accompanying cardiovascular symptoms. Due to these clinical symptoms, neurologists have not been involved in the routine emergency management of aortic dissection. However, transient or permanent neurological symptoms at onset of aortic dissection are not only frequent (17–40% of the patients), but often dramatic and may mask the underlying condition. Especially in pain-free dissection (which occurs in 5–15%) with predominant neurological symptoms diagnosis of aortic dissection can be difficult and delayed. Affecting the outflow of supra-aortal, spinal as well as extremity arteries leads to a variety of neurological symptoms including disturbances of central or peripheral nervous system. Thrombolysis as an emergency stroke therapy without considering aortic dissection may be life-threatening for these patients. Routine chest X-ray and being alert to physical examination findings such as hypotension, asymmetrical pulses or cardiac murmur may reduce risk of delayed diagnosis or misdiagnosis. Neurological symptoms at onset or in the postoperative course of aortic dissection are not necessarily associated with increased mortality.
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                Author and article information

                Journal
                Case Rep Neurol Med
                Case Rep Neurol Med
                CRINM
                Case Reports in Neurological Medicine
                Hindawi Publishing Corporation
                2090-6668
                2090-6676
                2015
                18 January 2015
                : 2015
                : 829756
                Affiliations
                1Department of Neurosurgery, Itoigawa General Hospital, 457-1 Takegahana, Itoigawa, Niigata 941-0006, Japan
                2Department of Neurosurgery, Takaoka City Hospital, 4-1 Takara-machi, Takaoka, Toyama 933-8550, Japan
                Author notes

                Academic Editor: Majaz Moonis

                Article
                10.1155/2015/829756
                4312608
                2f32688d-b903-4837-85ee-00468ea29f6b
                Copyright © 2015 C. Takahashi and T. Sasaki.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 7 November 2014
                : 7 December 2014
                : 26 December 2014
                Categories
                Case Report

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