Reversible Stroke in An Elderly Patient

M. Motaz Baibars MD*, Khalid Alokla MBBS*, Abdul Hamid Alraiyes MD*, M Chadi Alraies MD ¥
* Case Western Reserve University - Case Medical Center – Cleveland, Ohio
¥ Department of Hospital Medicine - Internal Medicine Institute - Cleveland Clinic Foundation - Cleveland, Ohio

•Strokes mainly hemispheric and right-sided.

Learning Objectives
TGA may extinguish important details of the patient’s recent
§Neurological manifestations of aortic
dissection.
§Frequency of permanent neurological
symptoms at onset of aortic dissection
§How to reduce the risk of delayed diagnosis or
misdiagnosis of aortic dissection.
TGA •Syncope occur in 12.7%.
•Hypoxic
encephalopathy presents with confusion to loss of consciousness.
history
including recent severe chest pain. t-PA
IV thrombolytics are fatal in aortic dissection with
stroke or TIA presentation

The Case
80 y/o male with history of hypertension and old
stroke with residual left sided hemiparesis on Frequency Simultaneous occurrence of syncope, seizure, and cerebral, spin
clopidogrel, amlodipine and lisinopril. or
Neurological symptoms at onset of aortic dissection are frequent and dramatic and
may mask the underlying condition. peripheral nerve ischemia point to an underlying spreading vascu
Chief complaint: Right sided numbness and process such as aortic dissection.
weakness for one day.

History of present illness: The patient woke up in

the morning and noticed the right sided weakness
but didn’t call for help till his daughter cam to visit
him in the afternoon and brought him to ED. No
visual symptoms, headache, slurred speech,
vertigo or gait instability. No chest pain, DOE, SOB
or palpitations. The rest of review of system is non-
significant. Chest Pain
only 2/3 of patients with neurological symptoms complained of chest pain, whereas (94.4%) of patients without
PE: Initial vital signs in ED were normal except for
neurological symptoms experienced initial pain.
BP of 173/96. Heart exam declared 2/6 early
diastolic murmur at right second intercostals space
Our patient didn’t have chest pain which was masked
with soft S2. No carotid bruits heard. Neurological by transient LOC orTGA
exam showed decreased pinprick sensation and
4/5 power of bilateral upper and lower extremity,
although right side findings are new with normal
cranial nerves exam.

Hospital course: CBC and BMP were normal.

Head CT revealed no acute event. 2D echo showed
dilatation of the aortic root. Subsequently, CT thorax
with contrast showed type 1 aortic dissection. TEE
Conclusion References
Chest pain the
confirmed and diagnosis
aortic regurgitation
and patientareunderwent
not always cardinal symptom and sign of aortic dissection especially in elderly and high index of suspicion needed as the clinical picture may widely vary. 10 – 15% of ascending disse
should never
dissection be treated
correction with 2thrombolytics.
surgery. days after surgery, 1.Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ: Neurological
symptoms in type A aortic dissections. Stroke 2007; 38: 292–
patient’s right sided numbness and weakness 297.
resolved. 2.Gaul C, Dietrich W, ErbguthFJ Neurological symptoms in aortic
dissection: a challenge for neurologists. Cerebrovasc Dis.
2008;26(1):1-8. Epub 2008 May 30. Review.
3.Pretre R, von Segesser LK: Aortic dissection. Lancet 1997; 349:
1461–1464.