A 55‐year‐old white man without a significant medical history presented to the emergency department (ED) with acute onset of lightheadedness, confusion, and speech difficulty for 2 hours’ duration. Although he was hypotensive, peripheral pulses were equal. The neurological exam was positive for expressive aphasia. A computerized tomography scan of the head ruled out intracranial hemorrhage, and given the National Institute of Health Stroke Scale (NIHSS) score of 6, a thrombolytic agent was administered. Subsequently, carotid ultrasound revealed a 50%–75% stenosis of the right internal and external carotid arteries. Magnetic resonance imaging of the head demonstrated multiple areas of ischemic stroke. A transthoracic echocardiogram (TTE) and transesophageal echocardio‐gram, ordered to exclude cardioembolic etiologies, unexpectedly revealed dissection of the aorta from the aortic root to the abdominal aorta. A chest x‐ray (CXR) revealed mediastinal prominence. On repeat questioning, the patient recollected having transient retrosternal chest discomfort en route to the ED. He underwent successful emergent aortic reconstruction with replacement of the aortic valve and ascending aorta. He was discharged on postoperative day 8, and 2 months later, he did not have any neurological deficits.
Stroke is a clinical diagnosis requiring accuracy and timeliness, especially given the short 3‐hour window for thrombolysis therapy. Standardized stroke scales like NIHSS guide the decision‐making process for emergency physicians administering thrombolysis. Physicians must remember that it offers no role in identifying the etiology of stroke. Our patient is a rare survivor of misdirected thrombolysis that in retrospect would not have been administered after a comprehensive history, physical exam, and bedside imaging studies. Aortic dissection (AD) is a life‐threatening emergency, with a mortality rate of 1%‐2% per hour during the first 48 hours. It can present as acute is‐chemic stroke in 5%‐10% of patients, posing a serious diagnostic dilemma. Thrombolysis is contraindicated in such settings because of fatal cardiac tamponade, aortic rupture, and intracerebral hemorrhage. Current NIHSS guidelines do not recommend CXR, TTE, and carotid ultrasound as part of the initial evaluation of stroke. Emergent CXR and carotid ultrasound before or during thrombolysis have helped to identify AD in patients initially diagnosed with acute ischemic stroke.
In the current era of thrombolysis, physicians should be aware of this atypical presentation of AD and have a high level of suspicion in patients with stroke, particularly in those with impaired consciousness or communication. Rapid bedside imaging studies like CXR, carotid ultrasound, and TTE combined with a comprehensive history and physical exam focusing on chest pain, abdominal pain, bilateral arm blood pressures, and all peripheral pulses can help in earlier recognition of this potentially fatal condition.
V. Ramalingam ‐ none; R. Sinnakirouchenan ‐ none; A. Brasch ‐ none
To cite this abstract:Ramalingam V, Sinnakirouchenan R, Brasch A. A Grave Masquerader!. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 378. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-grave-masquerader/. Accessed May 20, 2019.