A Case of Dissecting Aneurysm of the Aorta With Hemiplegia Diagnosed During Life

Abstract

Shennan (1944) in his analysis of 300 cases of dissecting aneurysm of the aorta (up to and including 1932) reported only six correctly diagnosed before death. Among 153 cases reported by Reich (1944), and 12 by Logue, (1943), 36 and 10 respectively were correctly diagnosed. Reviewing these and some other reports, about 49 correct ante-mortem diagnoses have been made among 512 instances of the disease.Differences in the carotid pulses were recorded by Nissim (1946) in one patient. The pulse was reduplicated on the right side and single on the left, without co-existing difference in the intensity of pulsation. He concluded that this was due to the difference in the rate of propogation of the pulse wave through the lumen of the artery and through its dissected coat, where the blood was probably partly clotted.The following case is described because the diagnosis was finally made on the diminished pulsation of-one carotid pulse. This was shown at necropsy to be due to pressure of the aortic aneurysm on the left carotid artery. Case ReportA man, aged 62, was admitted on 6/4/50. Eight days previously he had a sudden attack of cramp-like pain in the centre of the chest, radiating into the back and down the left arm. The pain was very severe for the first 24 hours, and then steadily diminished until his admission to hospital, when he had a feeling of slight constriction only in the centre of the chest and in the small of the back. Four days after the onset of his symptoms he complained of recurring cramps in the calves.In 1947, he had had a sudden attack of dizziness with amblyopia, lasting several days. He was told he had a high blood pressure. In 1948 his vision became blurred for a few days, but apart from these occurrences he had been well.On examination he was of plethoric appearance with a temperature of 99°F. The pulse rate was 90 per minute, with frequent extrasystoles; it was of high tension and equal on the two sides. The blood pressure was 270/160 but no pulsus alternans was detected. The heart was enlarged with a thrusting apex beat in the fifth space, 11 cm. from the mid-line. There was a generalized presystolic gallop rhythm with an apical systolic murmur; an aortic systolic murmur conducted into the neck was followed by a loud aortic second sound. The femoral and dorsalis pedis pulses were equal on palpation. Crepitations were heard at the bases of both lungs. No other abnormal physical signs were found.On 11/4/50 an electrocardiogram showed a left ventricular preponderance, but no evidence of myocardial infarction. An X-ray of the chest showed a large left ventricle and an unfolding aorta with clear lung fields. On 13/4/50, a barium swallow was normal and there was no change in the cardiac or aortic shadows. The Wassermann reaction was negative and the blood urea 84 mg. per cent. The urine contained al-bumen, but no red cells or casts.At this stage it was considered that this was probably a case of coronary thrombosis and he was treated with rest and sedatives only. 279