engleski

Aortic arch dissection presenting as cathedral like hemodynamic spectra on transcranial Doppler

Background: In the absence of sudden chest pain, aortic arch dissection remains unrecognized. We report a patient with aortic arch dissection presenting as encephalopathy following comatose state. Case report: The 55 years old patient become suddenly comatose with apnoic crisis and severe hypotension. Glasgow Coma Scale was 6 (1+4 withdraws to pain stimuli on the left+1). Two days before admittance he had chest pain. The history on hypertension was negative. 45 years ago had rheumatic fever. Smoker. Twenty minutes after therapy, blood pressure was stabilized without asymmetry, patient revealed conscious, without lateralization, orientated, but strongly agitated, with strong psychomotor restlessness despite sedation therapy. No cardiac murmurs could be registered. Blood tests were normal, electrocardiography, repeated chest radiography ; brain computerized tomography and electroencephalography were normal. Toxicological analysis was negative. Cerebrospinal analysis was normal. Antiepileptic and sedative therapy was started, but without effect. The sixth day of hospitalization patient becomes dyspnoic accompanied by sweating and restlessness. The seventh day blood pressure could not be measured on the left arm. Carotid color Doppler revealed normal morphologic finding on the carotid arteries, but the hemodynamic spectra was changed with cathedral like appearance, and negative deflection during the diastole. Subclavian steal syndrome in the left vertebral artery was present. Transcranial Doppler revealed the same hemodynamic spectra in the Willis circle. Echocardiography showed the dilatation of the supravalvular aorta with intimal flapping, bicuspid aortic valve with massive aortic regurgitation and pericardial effusion. Chest CT confirmed aortic arch dissection, and patient was transferred to Department of cardiology, compensated after therapy. Control Doppler revealed the similar findings. After one month, neurological and psychiatric examination revealed normal findings. Conclusion: Aortic arch dissection remains usually underdiagnosed. Carotid and Transcranial Doppler should be applied in patients with unusual clinical picture, because spectra may indicate proximal disease.

aortic arch; dissection; TCD

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