Article, Cardiology

Aortic dissection presenting as left leg numbness and paralysis

Case Report

Aortic dissection presenting as left leg numbness and paralysis?

Abstract

We present the case of a 46-year-old man with a Stanford A aortic dissection presenting as left leg numbness and paralysis. There were few indications of dissection on history and physical examination, and the patient was initially seen by an orthopedist for an acute radiculopathy. A complaint of mild chest pain was elicited on repeated questioning and eventually led to the correct diagnosis. The patient underwent extensive stenting and revascularization intraoperatively and was eventually transferred from the intensive care unit to the ward. This case highlights the need for a high level of suspicion required to diagnose aortic dissection and the atypical and painless manner in which a small proportion of aortic dissections can present.

Aortic dissection is a devastating clinical condition that classically presents with ripping or sharp chest pain that can radiate to the back [1,2]. The incidence of acute aortic dissection in the general population is estimated at 2.6 to 3.5 per 100 000 person-years, and patients tend to be men aged 60 to 80 years [1-5]. Early diagnosis and management are crucial. The inciting event in aortic dissection is a tear in the aortic intima that creates a false lumen between the intima and media layers [6]. The dissection can propagate in either direction from the initial tear and can involve various arteries and end organs along its way. Dissection can present painlessly. A recent review of the International Registry of Aortic Dissections showed only 6.3% presenting with Painless dissection [7]. Another International Registry of Aortic Dissections review showed only 3% presenting with spinal cord ischemia and 2% presenting with ischemic peripheral neuropathy [8].

A 46-year-old man presented to the emergency department (ED) with a 1-hour history of lower back pain and left lower leg numbness. He reported a vague history of twisting injury while at work followed by pain and numbness. His blood pressure was 207/105 mm Hg; heart rate, 67 beats/min; and

? Neither of the authors associated with this manuscript received funding for its preparation, and have no conflicts of interest to declare.

respiratory rate, 20 breaths/min. He was afebrile and had a saturation of 92% on room air. His only reported medical history was for hypertension, for which he took Avalide and aspirin, and he reported an allergy to ampicillin. His initial physical examination revealed diffuse numbness and inability to move his lower left leg. X-rays of the lumbar spine showed no acute fracture and multilevel degenerative disk disease.

Given the clinical picture of an acute radiculopathy, an urgent magnetic resonance imaging (MRI) was obtained and an orthopedist was consulted. Their assessment of the patient included decreased sensation in the L1 dermatomal distri- bution and an otherwise normal Neurological examination including reflexes and rectal tone. Examination of peripheral pulses was not commented on by the orthopedist. Upon arrival in the MRI suite and before imaging was obtained, the patient complained of chest pain, and he was transferred back to the ED for an electrocardiogram and assessment. The electrocardiogram showed nonspecific T-wave changes in 1 lead, and the patient was transferred back to MRI. Findings on MRI were consistent with disk protrusion at T12, L4-L5, and L5-S1 with mass effect on the nerve roots. The patient was cleared for discharge by the orthopedist, with analgesia adequate for an acute radiculopathy.

Fig. 1 Chest radiograph of our patient presenting with a Stanford A aortic dissection. Note the widened mediastinum and loss of the aortic knob.

0735-6757/$ – see front matter (C) 2010

1063.e8 Case Report

When the ED physician presented to reassess the patient for discharge, almost 30 hours after his arrival, it was then that a mild component of chest pain was elicited from the history which either preceded or was closely temporally related to the back pain and leg symptoms. This history of chest pain had not been elicited earlier by the local prehospital emergency medical service technicians, the triage nurse or the ED physician who had initially seen the patient. A chest x-ray was completed and is shown below (Fig. 1). Upon review of this x-ray, an emergent computed tomography angiogram of the chest and abdomen was obtained to rule out aortic dissection. Computed tomography angiogram showed a Stanford A aortic dissection arising from the distal Ascending aorta and continuing to the internal iliac arteries. Vessels arising from the false lumen included celiac trunk, hepatic artery, superior and inferior mesenteric arteries, left renal, and right and left iliac arteries. There was no evidence of Bowel ischemia or infarcts to the liver, spleen, or right kidney.

A cardiac surgeon was consulted, and the patient was taken to the operating room shortly after. He underwent prolonged stenting and revascularization with successful reperfusion of his left kidney and left leg and was transferred to the intensive care unit for postoperative management. He was transferred to a surgical floor approximately 2 weeks after admission to the intensive care unit with dense paraplegia below T10.

Our patient presented in a very atypical manner given his initial complaint of left leg numbness and paralysis. Only upon repeated reassessment and questioning did he offer a history of mild chest pain temporally related to the back pain and leg symptoms. This highlights the need for aortic dissection to be included in the differential diagnosis of acute radicular low back pain and the high index of suspicion for the correct diagnosis of aortic dissection. Interestingly, our patient’s intraoperative creatine kinase was 3446 U/L and would subsequently rise to 9216 U/L 2 days later, requiring continuous Venovenous hemofiltration for nephroprotection. This rise in CK was attributed to the ischemic insult to his left leg secondary to occlusion of his left iliac artery, which arose from the false lumen of the aortic dissection.

We present the case of a 46-year-old man with a Stanford A aortic dissection presenting as left leg numbness and

paralysis. There were few indications of dissection on history and physical examination, but a complaint of mild chest pain on repeated questioning eventually led to the correct diagnosis. This case highlights the need for a high level of suspicion required to diagnose aortic dissection.

David Barbic MD, MSc

McGill University Emergency Medicine

Residency Program Royal Victoria Hospital A462, 687 Pine Ave Montreal, QC, Canada H3A 1A1

E-mail address: [email protected]

Will Grad MD, CM

Department of Emergency Medicine Room D10, Sir Mortimer B Davis Jewish General Hospital

3755 Cote Sainte Catherine Road Montreal, QC, Canada H3T 1E2

doi:10.1016/j.ajem.2010.01.034

References

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  5. Clouse WD, Hallett Jr JW, Schaff HV, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneu- rysm rupture. Mayo Clin Proc 2004;79:176.
  6. Spittell PC, Spittell Jr JA, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642.
  7. Park SW, Hutchison S, Mehta RH, et al. Association of painless acute aortic dissection with increased mortality. Mayo Clin Proc 2004;79: 1252.
  8. Suzuki T, Mehta RH, Ince H, et al. Clinical profiles and outcomes of acute Type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation 2003; 108(Suppl 1):II312.

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