Aortic dissection masquerading as a code stroke: A single-centre cohort study

Abstract

Introduction: Data on the incidence of acute aortic dissection in the code stroke population are scarce. We report estimated incidence, clinical manifestations, treatment and outcomes of patients with an acute aortic dissection in a code stroke cohort from a comprehensive stroke centre. Patients and methods: We used data from a single-centre prospective registry of consecutive adult patients who presented to the emergency department between 2015 and 2018 with neurological deficits suggestive of an acute stroke ('code stroke'). All patients routinely underwent non-contrast computed tomography of the brain and computed tomography-angiography of the aortic arch, cervical and intracranial arteries. Results: Of 2874 code stroke patients, 1563 (54.4%) had acute ischaemia (ischaemic stroke or transient ischaemic attack). Fifteen patients (0.5% of code stroke patients and 0.8% of patients with acute ischaemia) had an acute aortic dissection (all Stanford classification type A). Discerning clinical manifestations were decreased consciousness in 11/15 (73%), pain in 8/15 (53%) and low systolic blood pressure (mean 106 mmHg, SD30). Acute aortic dissection was an incidental finding during computed tomography-angiography in 4/15 (27%). Two out of 15 patients (13%) received intravenous thrombolysis, 9/15 (60%) underwent aortic surgery and 10/15 (67%) died. Of those who survived, 3/5 (60%) had a good functional outcome (modified Rankin Scale 0-2). Discussion and Conclusion: In our comprehensive stroke centre, about 1/200 code stroke patients and 1/125 patients with acute ischaemia had an acute aortic dissection. Multicentre studies are necessary to acquire a more reliable estimate of the incidence of acute aortic dissection in the code stroke population. Given the ramifications of missing this diagnosis, imaging of the entire aortic arch is important in these patients.

Stroke mimics: incidence, aetiology, clinical features and treatment

“…In a recent large series of 2874 code strokes, 15 patients (0.5%) had an aortic dissection. A decrease in level of consciousness, pain and low blood pressure were associated with abnormalities that were helpful in making the correct diagnosis [ 70 ]. Similarly, trauma can result in epidural (see Figure 3 ), subdural and brain haematoma that can at times be difficult to diagnose even with careful imaging.…”

Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke—rationale and study design

“…For certain findings such as endocarditis and aortic dissection, acute phase cardiac CTA likely increases the chance of correct diagnosis and management. 33 However, evidence-based targeted management strategies are not yet available for stroke patients with other cardio-aortic findings such as large (ulcerated) plaques in the aortic arch. 34 The optimal acute phase management of stroke patients with cardiac thrombi is also unclear.…”

Stanford type a aortic dissection with cerebral infarction: a rare case report

“…Whether neurological complications will affect the prognosis of patients with AoD is still controversial. AoD patients need to maintain a low blood pressure to prevent further tearing or even rupture of the dissection, while low blood pressure will reduce stroke hemisphere perfusion and then enlarge the cerebral infarction [15]. Some researchers believe that concurrent ischaemic stroke is a predictor of poor prognosis in patients with AoD [16,17]; however, with early diagnosis of AoD and appropriate surgical treatment, concurrent neurological symptoms have been reported to not be associated with increased mortality [8,18,19].…”