A 76‐year‐old woman presented with left lower extremity numbness and weakness for 1 hour. She denied chest or back pain. Vital signs were unremarkable. Neurological examination revealed 0/5 motor strength and decreased pinprick and light touch sensation in the left lower extremity. Vascular examination was remarkable for the absence of a left dorsalis pedis pulse. CT head indicated no acute process. CT thorax and abdomen indicated an aortic dissection from the aortic root into the aortic arch and descending aorta and extending to the superior mesenteric artery, right common carotid artery, left subclavian artery, left common iliac artery, left external iliac artery, and left renal artery. Within 3 hours of initial presentation, the patient died in the emergency department.
If left untreated, acute aortic dissection (AAD) has a mortality rate as high as 1% per hour during the first 48 hours after onset of symptoms. The pathophysiology of aortic dissections is directly related to medial degeneration and repetitive hydrodynamic forces produced by the heart and major vasculature. Once an intimal tear has occurred, the lesion may progress antegrade or retrograde. Left ventricular ejection pressure and velocity determine the extent of aortic medial dissection. The false lumen may compress or obstruct branch vessels of the aorta as it propagates. Many of the clinical manifestations, especially ischemic neuropathy, are attributable to this phenomenon. Although acute onset of severe chest or back pain is the most common presenting symptom, some patients with AAD do not present initially with typical chest or back pain. Therefore, it is important to recognize patients with painless AAD and provide appropriate treatment without delay. Patients with painless AAD have had syncope or stroke. Neurological sequelae of aortic dissection are relatively common and occur in as many as one third of patients. Peripheral neuropathy may result if the dissection involves the iliac arteries. Our case illustrates a painless type A aortic dissection that presented with left lower extremity numbness and weakness due to intimal occlusion of the left common iliac artery and left external iliac artery, which caused distal peripheral nerve ischemia. Making the clinical diagnosis of painless AAD in patients who present with acute neurological symptoms is very difficult and challenging. Therefore, it is imperative to include acute aortic dissection in the differential diagnosis of patients presenting with acute neurological symptoms, and we recommend performing a CT aortic dissection protocol to rule out this devastating condition.
Acute aortic dissection can present atypically without pain. Therefore, it is imperative to include acute aortic dissection in the differential diagnosis of patients who present with acute neurological symptoms to prevent delays in diagnosis and receiving appropriate treatment.
T. Kanluen, none; S. Kanjanauthai, none.
To cite this abstract:Kanjanauthai S, Kanluen T. Painless Acute Aortic Dissection Presenting as Left Lower Extremity Weakness and Numbness. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 153. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/painless-acute-aortic-dissection-presenting-as-left-lower-extremity-weakness-and-numbness/. Accessed September 22, 2019.