Acute paraplegia in painless aortic dissection. Rich imaging with poor outcome

Abstract

Study design: Case report. Objective: To describe the clinical and imaging findings of a patient with painless aortic dissection. Setting: University Neurology Department, Thessaloniki, Greece. Patient, Methods, Results: A 46-year-old man was transferred to our Department for emergent evaluation of paraplegia, from the local hospital of the nearby town, where he was admitted complaining from sudden, painless, bilateral leg weakness, 24 h earlier. He presented complete flaccid paraplegia with urinary retention, loss of pain and temperature sensation below the TH7 level and wellpreserved vibration and position sense bilaterally. He had no pain and general physical examination was unremarkable. Chest X-rays first raised the suspicion of an aortic lesion. Thoracic MRI revealed cord dilation, with no enhancement on T1-weighted images (wi) and increased signal on T2-wi at the TH9-TH12 levels, suggesting cord ischemia. At the same MR sequences, the double lumen of the descending aorta indicated dissection in both sagittal and axial images. Later the same day, the patient died, and autopsy verified dissection of the descending aorta up to the aortic valve. Conclusion: The rapid evolution of our case further points out that radiologists, neurologists, as well as internal specialists should be vigilant for this emergency, which despite rich imaging could have a fatal outcome. Case reportA 46-year-old man was admitted to the local hospital of a nearby town, complaining for sudden, painless, bilateral leg weakness while defecating, on October 29. There was no family history of any disease and his past medical history disclosed ankylosing spondyloarthritis (positive HLA B27) diagnosed 20 years ago and hypertension treated for the last 2 years. An urgent brain and lumbar spine CT scan was unremarkable and he was transferred to our Department for further evaluation the next day.Neurologically the patient was alert, fully oriented with normal cranial nerves, upper limbs strength and reflexes. He presented complete flaccid paraplegia with urinary retention, absent plantar and deep tendon reflexes, a spinothalamic thoracic (TH) sensory level at TH7 with loss of pain and temperature sensation below this level, extending over the trunk and both lower limbs. However, he had wellpreserved vibration and position sense bilaterally. He was afebrile and complained of no pain, the electrocardiogram was normal, his arterial blood pressure was 140/80 mm Hg, heart rate 82 min À1 with sinus rhythm and no murmurs or other findings were found on general physical examination.Chest X-rays showed mediastinal enlargement first raising the suspicion of an aortic lesion. Complete blood count and routine serum biochemistry provided normal results, except for increased enzymes LDH 714 U l À1 (normal range 240-480), SGOT 95 U l À1 (range 0-38) and CPK 2866 U l À1 (range 0-190). Emergent lumbar puncture in the lateral decubitus position provided normal cerebrospinal fluid opening pressure (160 mm H 2 O) and cytochemistry (clear, no cells protein 45 mg p...

Misdiagnosis of Aortic Dissection: Experience of 361 Patients

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Aortic Dissection Presenting Primarily as Acute Spinal Cord Damage: A Case Report and Literature Review

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