Diagnosis of aortic dissection remains elusive despite advances in its diagnostic imaging and treatment, mainly contributed by its diverse clinical presentation. Aortic dissection as a cause of neurological symptoms is often overlooked. Unusual combination of symptoms and signs should raise suspicion of an underlying vascular pathology such as aortic dissection.
We report a case of a previously well 44 year old man presented with sudden onset of right lower limb weakness. However, examination noted no pulse felt over the right leg from level of femoral artery down to dorsalis pedis and feeble left radial pulse. He was admitted for acute limb ischemia and underwent emergency embolectomy. Embolectomy improved flow of the femoral artery but popliteal artery was still unpalpable. He then underwent CT thorax which revealed extensive Stanford Type A aortic dissection involving aortic root until the abdominal aortic bifurcation with superior extension to all aortic arch branches, compression of superior vena cava and left brachiocephalic vein by the dilated aortic root and right renal ischemia from a thrombus at true lumen. Patient succumbed after operative aortic dissection repair.
The occurrence of painless dissection ranges between 5-15%. Neurological symptoms without any pain are observed in 1/3 of patients with Type A aortic dissection1. It is caused by dissection or occlusion of aortic side branches supplying the brain, spinal cord or peripheral nerves. Lower extremity pulse deficit in the absence of peripheral vascular disease are associated with malperfusion syndrome of aortic dissection and found in approximately half of patients with thoraco-abdominal or aortic arch involvement2. Diagnosis of aortic presentation in these cases can be difficult and delayed. Patients with typical features were diagnoses sooner than those without3.
Aortic dissection presented with neurological symptoms is rare. Physician must have high level of suspicion especially in cases with unusual presentation.