Case Presentation:
A 58‐year‐old woman presented with acute onset of bilateral lower extremity weakness and inability to walk. She described aching pain, “pins and needles,” and numbness over both thighs and buttocks that was worse on exertion. She denied bladder or bowel incontinence, low back pain, fever, or recent trauma. Her medical history was significant for coronary artery disease, with placement of a coronary stent 2 months ago, cerebral aneurysm clipping, hypertension, and tobacco use. She had normal heart and lung sounds. Neurological examination revealed bilateral lower extremity flaccid weakness with 2/5 power on the left and 0/5 on the right, absent knee and ankle reflexes, and decreased rectal tone. Sensation was decreased over both lower extremities, buttocks and lower back, but no truncal sensory level could be delineated. There was no leg edema, and bilateral dorsalis pedis pulses were diminished. Laboratory tests showed a hemoglobin of 8.8 g/dL, creatine kinase 4616 U/L, and troponin 0.47 ng/mL. An urgent neurology evaluation was requested for suspected cord compression. MRI imaging was delayed pending information of her brain clips. However, a thoracolumbar CT revealed an atherosclerotic aorta with a large, partially occluding infrarenal aortic thrombus extending into both common iliac arteries. The patient underwent emergent catheter‐guided aortography and thrombolysis of the acute clot, and successful recanalization of the affected vessels with bilateral aortoiliac stents. An echocardiogram, ordered to rule out emboli, showed a 24 × 11 mm highly mobile, pedunculated left atrial mass. Surgical evaluation showed an atrial myxoma that was successfully excised.
Discussion:
Leriche's syndrome refers to buttock, hip, and thigh claudication in the setting of aortoiliac occlusive disease. Acute aortoiliac occlusion is rare but potentially catastrophic. Most cases are a result of in situ spontaneous thrombosis from plaque rupture in the setting of an atherosclerotic aorta. Embolic aortoiliac occlusion is less common. A few cases of aortic saddle embolism from a cardiac myxoma have been reported. As in this case, patients often present with neurological findings that lead to a neurological evaluation before the vascular cause is recognized. Paresis, sensory loss, and pain are the most common findings in the ischemic limb. Prolonged ischemia results in rhabdomyolysis and ischemic neuritis. Emergent surgical treatment for restoration of blood flow and preservation of limb function are the goals.
Conclusions:
The diagnosis of acute aortoiliac occlusion is challenging. A simple vascular examination is required in all patients presenting with acute neurological deficits. The constellation of buttock and thigh pain, paresis, and diminished peripheral pulses should prompt suspicion for Leriche's syndrome. Early diagnosis and treatment are crucial for an optimal outcome, and as this case highlights, you may need to look to the heart to find Leriche.
Author Disclosure:
S. Nichani, none; S. Flanders, none.