• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Toxicology
    • Trauma
    • Ultrasound
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Acute Aortic Dissection Presenting Exclusively as Lower Extremity Paresthesias

Ryan Gibney, BS*, Jonathan Patane, MD* and Steven Bunch, MD*

*University of California, Irvine, Department of Emergency Medicine, Orange, CA

Correspondence should be addressed to Ryan Gibney, BS at rgibney@uci.edu

DOI: https://doi.org/10.21980/J8NK57 Issue 2:2
Cardiology/VascularVisual EM
No ratings yet.

History of Present Illness:

A 45-year-old male presented with left-lower extremity numbness for 3 hours.  He denied chest pain, shortness of breath, back pain, or pain to his leg.  On physical examination, he was noted to have a normal cardiac exam without murmurs and normal breath sounds, but had no palpable femoral or dorsalis pedis pulse on the left lower extremity. His extremity examination showed normal range of motion, full strength to both lower extremities, but subjective decreased sensation over the entire left lower extremity in all dermatomes.

Significant findings:

Chest x-ray and CT angiogram was performed to evaluate his thoracic and abdominal vasculature. Chest x-ray did not show any significant widening of the mediastinum. The CT angiogram demonstrated an intimal tear along the aortic arch separating a true and false aortic lumen, consistent with an acute aortic dissection. The true lumen (highlighted in blue in images 1-5) can be identified by continuity with an undissected part of the aorta1. While the false lumen (highlighted in red in images 1-5) can be identified by its crescent shape and larger cross-sectional area.1

Discussion:

The classic acute aortic dissection patient presents with sudden onset, tearing chest pain radiating to the back. Inconsistent blood pressure in the extremities is often found, along with diminished or absent peripheral pulses and widened mediastinum on chest x-ray. Painless dissection rarely occurs (6.4% of cases), and is more often found in older patients and is associated with higher mortality.2 Although rare, isolated lower limb findings such as ischemia or paresthesias are noted to occur in about 10% of cases.2 When aortic dissection presents solely with extremity complaints, the diagnosis is often missed.3 Computed tomography angiography is the ideal imaging modality to confirm the diagnosis and classification. Imaging can be obtained in stable patients in conjunction with emergent surgical consultation, pain control, and decreasing the heart rate and blood pressure.  Esmolol is considered the first line agent for decreased both heart rate and blood pressure, simultaneously, to reduce the shear stress of the wall of the dissecting vasculature.4

Topics:

Acute aortic dissection, distal limb ischemia

References:

  1. Castañer E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardó Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical features and complications.Radiographics. 2003; 23: S93-110. doi: 10.1148/rg.23si035507
  2. Park S, Hutchinson S, Mehta R, Isselbacher E, Cooper JV, Fang J, et. al. Association of painless acute aortic dissection with increased mortality. Mayo Clin Proc.2004; 79:125-1257. doi: 10.4065/79.10.1252
  3. Lee C, Chang C, Tsai Y, Wu C. Isolated lower limb ischemia as an unusual presenting symptom of aortic dissection. Cardovasc J Afr.2012;23:13-14.
  4. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266.  doi: 10.1161/CIR.0b013e3181d4739e
Icon

Acute Aortic Dissection - Case Report

1 file(s) 928 KB
Download
Icon

Acute Aortic Dissection - Images

1 file(s) 29.62 MB
Download
Issue 2:2

Reviews:

No ratings yet.

Please rate this





Galeazzi Fracture

05 Apr, 17

Acute Necrotizing Ulcerative Gingivitis (ANUG)

05 Apr, 17
JETem is an online, open access, peer-reviewed journal-repository for EM educators

Most Viewed

  • Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema
  • Anticholinergic Toxicity in the Emergency Department
  • The Suicidal Patient in the Emergency Department Team-Based Learning Activity
  • Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic
  • Acute Chest Syndrome

Visit Our Collaborators

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright © 2016 JETem. All rights reserved.