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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 1  |  Page : 76-77

Aortic dissection presenting as acute stroke: Careful selection of patients for intravenous thrombolysis


1 Department of Neurointervention, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001, India
2 Department of Neurology, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001, India
3 Department of Neurosurgery, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001, India

Date of Submission02-Nov-2012
Date of Decision09-Dec-2012
Date of Acceptance10-Dec-2012
Date of Web Publication4-Mar-2013

Correspondence Address:
Gaurav Goel
Department of Neurointervention, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.108017

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How to cite this article:
Chinchure SD, Goel G, Gupta V, Bansal AR, Singh D, Garg A, Jha AN. Aortic dissection presenting as acute stroke: Careful selection of patients for intravenous thrombolysis. Neurol India 2013;61:76-7

How to cite this URL:
Chinchure SD, Goel G, Gupta V, Bansal AR, Singh D, Garg A, Jha AN. Aortic dissection presenting as acute stroke: Careful selection of patients for intravenous thrombolysis. Neurol India [serial online] 2013 [cited 2020 Feb 28];61:76-7. Available from: http://www.neurologyindia.com/text.asp?2013/61/1/76/108017


Sir,

A 38-year-old male presented with acute onset left hemiparesis and slurring of speech of 3 hours duration. On Admission, National Institute of Health Stroke Scale score was 13 and blood pressure was 100/60 mmHg. Computed tomography (CT) scan brain plain showed no hemorrhage [Figure 1]a. Bolus of intravenous recombinant tissue plasminogen activator (rtPA) was given on CT table awaiting CT perfusion (CTP) and CT angiogram (CTA) of neck and brain. CTP graph showed extreme delay in contrast arrival with no reasonable maps [Figure 1]b. CTA reconstruction images showed normal intracranial vasculature [Figure 1]c and dissection flap extending from the aortic root to innominate artery [Figure 1]d with a clot in right innominate and right common carotid artery [Figure 1]e. Intravenous thrombolysis was stopped immediately. Repeat examination showed near total recovery of the neurological deficit. Patient made good clinical recovery and was taken for aortic surgery after 24 hours.
Figure 1: (a) Noncontrast enhanced CT shows no e/o acute cerebral infarct/intracerebral bleed. (b) CT perfusion graph Shows extreme delay in contrast arrival. This type of graph is usually seen in older patients with severely reduced ejection fraction. (c) CT angiography reconstruction images show normal intracranial vasculature. (d) Dissection flap extending from the aortic root to innominate artery and (e) filling defect-clot in proximal innominate artery

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Aortic artery dissection (AAD) may present as an acute ischemic stroke in 5-10% patients. [1] Extension of the dissection flap to the supra-aortic area with obstruction of the common carotid arteries is implicated as the most common mechanism. [2] Preferential flow changes in right sided vessels in Stanford type A dissection is responsible for predominant left hemiparesis in these patients with aortic dissection. [3],[4] According to Iguchi et al., [3] warning signs for acute stroke with AAD are asymmetrical pulses, hypotension and/or left hemiparesis. Hypotension was the only warning sign in our patient. Patients with AAD mimicking acute myocardial infarction who have been inadvertently treated with IV rtPA have suffered dire complications, including extension of dissection into the pericardium, leading to cardiac tamponade and death. [5] Thrombolysis is contraindicated in acute ischemic stroke caused by AAD because of the risk of fatal intracerebral hemorrhage, aortic rupture, and cardiac tamponade [6] although there are few reports of favorable outcome after IV thrombolysis in AAD. [7] IV Thrombolysis can also delay surgery. To conclude, because of narrow time window for effective IV thrombolysis, underlying etiology causing stroke may not be investigated properly. IV thrombolysis needs careful selection of patient to prevent life threatening complications. Particular attention should be paid to 'red flags' like hypotension and 'left sided' hemiparesis. Ideally CTA may be needed in acute stroke presenting within window period to evaluate for possibility of further intraarterial interventions. We recommend including aortic arch and origins of major neck vessels in CTA in acute stroke protocol as a routine to avoid missing out AAD, which can present as acute stroke.

 
  References Top

1.Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002;122:311-28.  Back to cited text no. 1
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2.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. 2
[PUBMED]    
3.Iguchi Y, Kimura K, Sakai K, Matsumoto N, Aoki J, Yamashita S, et al. Hyper-acute stroke patients associated with aortic dissection. Intern Med 2010;49:543-7.  Back to cited text no. 3
[PUBMED]    
4.Morita S, Shibata M, Nakagawa Y, Yamamoto I, Inokuchi S. Painless acute aortic dissection with a left hemiparesis. Neurocrit Care 2006;4:234-6.  Back to cited text no. 4
[PUBMED]    
5.Kamp TJ, Goldschmidt-Clermont PJ, Brinker JA, Resar JR. Myocardial infarction, aortic dissection, and thrombolytic therapy. Am Heart J 1994;128:1234-7.  Back to cited text no. 5
[PUBMED]    
6.Fessler AJ, Alberts MJ. Stroke treatment with tissue plasminogen activator in the setting of aortic dissection. Neurology 2000;54:1010.  Back to cited text no. 6
[PUBMED]    
7.Ibaraki T, Fukumoto H, Nishimoto Y, Nishimoto M, Suzuki S, Morita H. Surgical management of acute type A aortic dissection with a complaint of disturbance of consciousness; report of a case. Kyobu Geka 2002;55:1053-6.  Back to cited text no. 7
[PUBMED]    


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