85 year-old female with history of depression and osteoarthritis presented with right upper and lower extremity weakness with difficulty ambulating. She also complained of transient substernal non radiating chest tightness which resolved upon arrival to the emergency room. Prior to symptom onset she was moving snow tires at home. Physical exam showed decreased muscle strength in right upper and lower extremity muscle groups. She had absent radial, brachial and femoral pulses on the right side, systolic blood pressure difference >20mm Hg between right and left upper extremities. Electrocardiogram showed normal sinus rhythm without ischemic changes, chest x-ray showed cardiomegaly with mild pulmonary vascular congestion, serial troponins were negative, non-contrast head CT showed no intracranial hemorrhage or infarct. A Transthoracic Echocardiogram raised suspicion for aortic root dissection and false lumen in abdominal aorta. Emergent contrast CT chest and abdomen showed aneurysmal dilation of ascending aorta measuring 5.3 cm, Type A aortic dissection extending from level of aortic valve into infrarenal abdominal aorta. Dissection extended into right brachiocephalic and right subclavian artery. There was evidence of decreased opacification of the right axillary artery consistent with decreased arterial flow to right upper extremity. There was a small pericardial effusion highly suspicious for hemopericardium. Cardiothoracic surgery was emergently consulted but patient declined surgery due to very high surgical risk. She was discharged home under hospice care after a 3 day hospital stay.
Aortic dissection is a life-threatening medical emergency;early recognition is crucial due to high mortality rate. Most cases typically present with severe, tearing chest, abdominal and/or back pain, with hemodynamic instability and organ ischemia due arterial flow compromise. There have been reported cases of aortic dissection presenting as stroke, myocardial infarction, congestive heart failure, syncope, lower extremity weakness, and sometimes with vague chest pain.
In a case series from the International registry of acute aortic dissection (IRAD), a total of 464 patients were reported, 62.3% of whom had type A dissection but only 72.7% complained of chest pain. The classical physical findings such as aortic regurgitation and pulse deficit were noted in only 31.6% and 15.1% respectively. Initial chest x-ray and electrocardiogram were unremarkable in 12.4% and 31.3% respectively. Another study analyzing association of type A aortic dissection and neurological symptoms in 102 patients showed 29% with neurological symptoms and only two-thirds reported chest pain. Neurological symptoms are due to compromised arterial blood flow and hypotension. Neurological symptoms are commonly seen in elderly patients with history of hypertension, diabetes and known aortic aneurysm.
Aortic dissection should be considered in an elderly patient presenting with chest pain and neurological symptoms due to suspected vascular compromise. Appropriate history taking and physical examination is important for accurate diagnosis. Physical exam findings such as absent pulses, blood pressure variations in both extremities should prompt further diagnostic workup for aortic dissection.
To cite this abstract:King A, Ravano E, Ghobrial I. Atypical Chest Pain with Neurological Symptoms. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 567. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/atypical-chest-pain-with-neurological-symptoms/. Accessed January 22, 2020.