Case Presentation: Patient is a 53 year old African American male with past medical history of hypertension who presented with syncope. He had this episode a total of 3 times, most recently 1 month prior and initial episode 1 year prior. He had resolution of symptoms both times and diagnostic workup did not reveal any findings that would correlate with his symptoms. Patient was admitted and underwent CT head and neck given history of fall which were both negative. Given odd presentation and persistent weakness appreciated on exam, patient did have bilateral weakness with 4/5 strength on exam in upper extremities and had difficulty walking, an MRI head was ordered as well as a carotid ultrasound. Overnight the MRI head showed low turbulent flow into the R MCA territory with multiple infarcts appreciated. CTA Head and neck were ordered and upon review of these; it was determined patient had a Type A Aortic Dissection extending into the aortic arch and neck vessels resulting in marked stenosis of the left proximal common carotid artery true lumen with thrombosis of the false lumen. Dissection flap extends into the innominate artery which is markedly irregular and severely stenotic with thrombosis/occlusion of the right common carotid artery and severe stenosis of the proximal right subclavian artery. CTA chest confirmed dissection after Thoracic surgery was called urgently and patient was placed on esmolol on the floor with the emergency response team and urgently rushed to the operating room.
Discussion: Here we present the difficult diagnostic challenge of syncope and atypical presentation of Type A aortic dissection. We present a patient with hypertensive urgency with blood pressure above 180/89 who’s chief complaint syncope, weakness, and blurry vision. The syncope workup was undertaken, and his symptoms had resolved somewhat but not fully by presentation to the medical team. Syncope typically involves in imaging of the head, ultrasound of the carotids, and thorough history and physical exam. This patient’s exam could not fit a common pattern, and given history weakness and loss of consciousness and hypertension, stroke workup was pursued. Aortic dissections have a fairly typical presentation and syncope has a fairly routine workup. However, 10-15% of aortic dissections present as strokes, and mortality from aortic dissection is approximately 1-2% per hour. It was the vascular abnormalities noted on MRI that led to angiograms of the upper extremity vasculature that correlated with his weakness and pattern of symptoms showing an insult to his carotids resulting in his appearance of stroke like symptoms. This case highlights the importance of correlating imaging, physiology and vascular supply with physical exam findings to find the underlying problem and correcting it to give the patient the optimal chance at recovery.
Conclusions: This case highlights the importance of clinical evaluation in patients. Imaging and routine testing done in syncope routinely do not demonstrate an etiology but successful investigation with history and physical increase the chances of identifying an underlying etiology. In this case, multiple deficits precipitated an MRI looking for a cerebrovascular territory that correlated with his blurry vision, weakness, and his loss of consciousness. Given the presentation of stroke, aortic dissection was urgently pursued. Connecting history with physical and ultimately his multiple MCA infarcts led to angiograms and successful intervention in this patient.