MICTURATION SYNCOPE, A DEATHFUL PEE!

Abstract

Introduction

Acute aortic dissection is among the most dramatic cardiovascular emergencies. Onset is abrupt, and progress is rapid. Diagnosis is challenging when the presentation is atypical. We discuss an older man with micturition syncope diagnosed as an acute thoracoabdominal aortic dissection with cardiac tamponade.

Case description

A 76-years-old man with underlying diabetes and hypertension was brought to Emergency Department after a syncopal attack. The patient developed dizziness immediately after micturition, followed by transient loss of consciousness for 10 minutes. He felt malaise after awake. Clinically, he appeared lethargic but hypotensive with blood pressure 102/60mmHg and a heart rate of 110 beats/min. The examination was unremarkable except for the cool periphery and a poor pulse volume. 

An electrocardiogram showed sinus tachycardia with low QRS voltage. Bedside echocardiography noted pericardial effusion (2.4cm) with the early diastolic collapse of the right ventricle, dilated aortic root (3.6cm) but no intimal flap seen. Chest radiography demonstrated widening mediastinum. CT Angiography of the thoracic and abdomen revealed ascending aortic aneurysm with intramural hematoma (Stanford A) with hemopericardium and infrarenal dissecting abdominal aortic aneurysm. Blood investigation unremarkable.

Bedside pericardiocentesis was performed, followed by rebound hypertension which required labetalol infusion for stabilization. The patient was admitted to Cardiology Care Unit. Unfortunately, he succumbed to death the next day.

Discussion

Micturition syncope is a benign but rare condition. It is caused by neurally mediated parasympathetic nerve over-stimulation, which lead to transient bradycardia and hypotension. However, we need a comprehensive evaluation of all syncope attacks to exclude fatal causes. There is no previous literature that describes micturition syncope as a presentation of aortic dissection. The feasibility of bedside ultrasound allows rapid detection of deathly syncope causes such as aortic dissection and cardiac tamponade despite the atypical presentation.

Conclusion

Acute aortic dissection with cardiac tamponade, while uncommon, can be catastrophic. Our case attempts to highlight the suspicion of atypical presentation. Prompt recognition can be pick-up by emergent besides echocardiography, and appropriate intervention is crucial.