CDR Walter Reed National Military Medical Center, United States
Introduction: Thoracic aortic aneurysm (TAA) is defined as dilation of the aorta to 4.5 cm or more with a yearly incidence of 5.3 per 100,000 patients. (1,2) Risk factors are older age, male sex, HTN, and CAD. (3) TAA can lead to acute aortic syndrome (AAS) including aortic dissection and intramural aortic hematoma. (1,4) AAS can progress to aortic rupture with a yearly incidence of 1.6 per 100,000 patients with increased risk from greater TAA size and female sex. (1,2,5) These conditions are emergencies with high mortality rates. (6,7) TAAs also present with dysphagia, hoarseness, CHF and respiratory or neurologic complaints. (1,8,9) CT is the recommended imaging exam and treatment consists of surgery or endovascular repair. (1,8) Here, we present a case of AAS and aortic rupture initially presenting as neurological dysfunction.
Description: 90 yo F with history of vascular dementia, 4.6 cm aortic arch TAA, HTN, and carotid atherosclerosis presented to the Emergency Department with progressive ataxia, slurred speech, weakness and lethargy. A hypodensity in her left occipital lobe was found on NCHCT. She quickly transferred to the ICU after her admission for suspected CVA with worsening mental status and new onset afib with RVR. In the ICU, she developed convulsions, hypotension, and tachycardia requiring multiple pressors. An echo demonstrated a large pericardial effusion suspicious for aneurysm rupture. CT revealed a ruptured TAA with hemopericardium, hemothorax, and intramural hemorrhage in the ascending, descending and abdominal aorta. The patient was not a surgical candidate and died during admission.
Discussion: Due to clinical overlap, diagnosis of AAS and aortic rupture may be delayed leading to increased mortality. Our case highlights some of the possible variation in symptomology. Women are less likely to present with abrupt onset of pain and change in pulse/blood pressure on admission, but are 50% more likely to present with altered mental status and coma (10) as in our patient. Women are more likely to have a delayed diagnosis and have worse mortality than men (OR 1.4). (10) Overall, the best treatment for these conditions is early recognition of TAA for outpatient surveillance, medical management of comorbid conditions like HTN, and surgical intervention in a non-emergent setting. (1,8)
