Journal of General Internal Medicine

, Volume 22, Issue 9, pp 1370–1372

Ischemic Stroke, Aortic Dissection, and Thrombolytic Therapy—the Importance of Basic Clinical Skills

Case Reports/Clinical Vignettes

Abstract

Aortic dissection masquerading as ischemic stroke is particularly challenging in the era of thrombolysis as a result of narrow diagnostic time window and severe hemorrhagic potential. We describe a case of a 77-year-old patient with a presumed ischemic cerebral infarct, in whom planned treatment with tissue plasminogen activator therapy (TPA) was withheld because of partial spontaneous improvement in his condition. Shortly afterwards, newly elicited clues in the medical history and physical examination led to timely diagnosis and treatment of ascending thoracic aorta dissection, which was the underlying disorder. Analysis of the features of this case and similar previously published cases illustrates the importance of using and mastering basic diagnostic skills.

KEY WORDS

aortic dissection stroke thrombolysis 

References

  1. 1.
    De Sanctis RW, Doroghazi RM, Austen WG, Buckley MJ. Aortic dissection. N Engl J Med. 1987;317:1060–67.CrossRefGoogle Scholar
  2. 2.
    Gerber O, Heyer EJ, Vieux U. Painless dissections of the aorta presenting as acute neurologic syndromes. Stroke. 1986;17:644–47.PubMedGoogle Scholar
  3. 3.
    DeBakey ME, McCollum CH, Crawford ES, et al. Dissection and dissecting aneurysms of the aorta: twenty years follow-up of 527 patients treated surgically. Surgery. 1982;92:1118–34.PubMedGoogle Scholar
  4. 4.
    Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002;122:311–28.PubMedCrossRefGoogle Scholar
  5. 5.
    The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–87.CrossRefGoogle Scholar
  6. 6.
    Kamp TJ, Golschmidt-Clermont PJ, Brinker JA, Resar JR. Myocardial infarction, aortic dissection, and thrombolytic therapy. Am Heart J. 1994;128:1234–37.PubMedCrossRefGoogle Scholar
  7. 7.
    Flemming KD, Brown RD Jr. Acute cerebral infarction caused by aortic dissection: caution in the thrombolytic era. Stroke. 1999;30:477–8.PubMedGoogle Scholar
  8. 8.
    Fessler AJ, Alberts MJ. Stroke treatment with tissue plasminogen activator in the setting of aortic dissection. Neurology. 2000;54:1010.PubMedGoogle Scholar
  9. 9.
    Villa A, Molgora M, Licari S, Omboni E. Acute ischemic stroke, aortic dissection, and thrombolytic therapy. Am J Emerg Med. 2003;21:159–60.PubMedCrossRefGoogle Scholar
  10. 10.
    Wright V, Horvath R, Baird AE. Aortic dissection presenting as acute ischemic stroke. Neurology. 2003;61:581–2.PubMedGoogle Scholar
  11. 11.
    Uchino K, Estrera A, Calleja S, Alexandrov AV, Garami Z. Aortic dissection presenting as an acute ischemic stroke for thrombolysis. J Neuroimaging. 2005;15:281–3.PubMedCrossRefGoogle Scholar
  12. 12.
    Chua CH, Lien LM, Lin CH, Hung CR. Emergency surgical intervention in a patient with delayed diagnosis of aortic dissection presenting with acute ischemic stroke and undergoing thrombolytic therapy. J Thorac Cardiovasc Surg. 2005;130:1222–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Elkind MS, Sacco RL. Stroke risk factors and stroke prevention. Semin Neurol. 1998;18:429–40.PubMedCrossRefGoogle Scholar
  14. 14.
    Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation. 2003;108:628–35.PubMedCrossRefGoogle Scholar
  15. 15.
    Earnest F 4th, Muhm JR, Sheedy PF 2nd. Roentgenographic findings in thoracic aortic dissection. Mayo Clin Proc. 1979;54:43–50.PubMedGoogle Scholar
  16. 16.
    Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part II: therapeutic management and follow-up. Circulation. 2003;108:772–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Tsai TT, Evangelista A, Nienaber CA, et al. Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006;114(1 Suppl):I350–6.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  1. 1.Infectious Diseases, Bnai Zion Medical CenterHaifaIsrael
  2. 2.Radiology DepartmentRambam Medical CenterHaifaIsrael
  3. 3.Neurology DepartmentRambam Medical CenterHaifaIsrael

Personalised recommendations