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tPA or CTA? A Near Disaster
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A3459 - tPA or CTA? A Near Disaster
Author Block: M. Hamid1, A. Ghani1, B. Lashari1, U. Sarwar1, D. Weisman2; 1Internal Medicine, Abington Jefferson Health, Abington, PA, United States, 2Department of Neurology, Abington Jefferson Health, Abington, PA, United States.
Introduction: Aortic dissection presenting as an ischemic stroke poses a management challenge due to narrow diagnostic and therapeutic time window. We present here a case of Type A Aortic dissection (AD) with the initial presentation as acute stroke.
Case description: A 67-years-old male with no past medical history was brought to the emergency room (ER) as a stroke alert. As per the emergency medical services (EMS), he was painting his bike when he suddenly developed weakness on the left side of the body and became aphasic. His wife witnessed his collapse but was unavailable for the interview.Pertinent vitals in the ER were BP: 142/61 mmHg, Pulse: 54/min, oxygen saturation: 96% on room air, temperature 99°F. On examination, he was drowsy, aphasic but could follow simple commands. Neurologic examination revealed gaze deviation to the right side, left-sided facial palsy, and left-sided hemiplegia, he was moving right sided extremities spontaneously. NIHSS was 24. Cardiovascular examination revealed normal heart sounds. Carotid pulses were difficult to palpate bilaterally. Rest of the physical examination including abdominal and respiratory system was unremarkable. Chest X-ray was normal. CT head was negative for intracranial bleed. As the clinical picture was suggestive of stroke, and the time interval was less than 3 hours from the onset of symptoms, he was considered for thrombolytic therapy but then his wife arrived and recalled he complained of chest pain before collapsing. A careful repeat physical examination revealed minimal to no radial pulse on the left. Considering this information thrombolytics were withheld. An urgent CT angiography of aorta and head/neck was done which showed Type A AD involving both internal carotid arteries(ICAs) with near complete occlusion of right ICA, associated with a large supratentorial infarct on the right. The patient was immediately taken to the operating room and surgical repair was done. After a prolonged hospital course, he was discharged and attained near baseline functional capacity after aggressive rehabilitation.
Conclusion: Type A AD is present in 6% of patients presenting with ischemic stroke. Basic medical skills including comprehensive medical history, thorough physical examination, chest X-ray and a high index of suspicion can help prevent the catastrophic complication of unintended thrombolysis.
Author Block: M. Hamid1, A. Ghani1, B. Lashari1, U. Sarwar1, D. Weisman2; 1Internal Medicine, Abington Jefferson Health, Abington, PA, United States, 2Department of Neurology, Abington Jefferson Health, Abington, PA, United States.
Introduction: Aortic dissection presenting as an ischemic stroke poses a management challenge due to narrow diagnostic and therapeutic time window. We present here a case of Type A Aortic dissection (AD) with the initial presentation as acute stroke.
Case description: A 67-years-old male with no past medical history was brought to the emergency room (ER) as a stroke alert. As per the emergency medical services (EMS), he was painting his bike when he suddenly developed weakness on the left side of the body and became aphasic. His wife witnessed his collapse but was unavailable for the interview.Pertinent vitals in the ER were BP: 142/61 mmHg, Pulse: 54/min, oxygen saturation: 96% on room air, temperature 99°F. On examination, he was drowsy, aphasic but could follow simple commands. Neurologic examination revealed gaze deviation to the right side, left-sided facial palsy, and left-sided hemiplegia, he was moving right sided extremities spontaneously. NIHSS was 24. Cardiovascular examination revealed normal heart sounds. Carotid pulses were difficult to palpate bilaterally. Rest of the physical examination including abdominal and respiratory system was unremarkable. Chest X-ray was normal. CT head was negative for intracranial bleed. As the clinical picture was suggestive of stroke, and the time interval was less than 3 hours from the onset of symptoms, he was considered for thrombolytic therapy but then his wife arrived and recalled he complained of chest pain before collapsing. A careful repeat physical examination revealed minimal to no radial pulse on the left. Considering this information thrombolytics were withheld. An urgent CT angiography of aorta and head/neck was done which showed Type A AD involving both internal carotid arteries(ICAs) with near complete occlusion of right ICA, associated with a large supratentorial infarct on the right. The patient was immediately taken to the operating room and surgical repair was done. After a prolonged hospital course, he was discharged and attained near baseline functional capacity after aggressive rehabilitation.
Conclusion: Type A AD is present in 6% of patients presenting with ischemic stroke. Basic medical skills including comprehensive medical history, thorough physical examination, chest X-ray and a high index of suspicion can help prevent the catastrophic complication of unintended thrombolysis.
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