Ongoing Blood Pressure Change in Both Upper Extremities: An Unusual Presentation of Aortic Dissection

doi:10.4236/ijcm.2011.24078

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International Journal of Clinical Medicine, 2011, 2, 463-468

doi:10.4236/ijcm.2011.24078 Published Online September 2011 (http://www.SciRP.org/journal/ijcm)

463

Ongoing Blood Pressure Change in Both Upper

Extremities: An Unusual Presentation of Aortic

Dissection

Hung Yi Chen

Department of Cardiology, Taipei City Hospital-Heping Branch, Chinese Taipei.

Email: [email protected].net, [email protected]

Received May11st, 2011; revised June 29th, 2011; accepted July 30th, 2011.

ABSTRACT

Aortic dissection is a critical condition requiring immediate assessment and management. Patients with this condition

usually present with severe chest pain and high blood pressure. However, because of the variety of presenting symp-

toms and features, it is a challenge to identify th is condition, and patients are frequently misdiagnosed. The potentially

critical course of aortic dissectio n can resu lt in tragedy. We p resent the case of a 46-year-old woman who initia lly pre-

sented with a light headache and sensory loss in her right upper limb. She had a medical history of hypertension with-

out regular medication, and her blood pressure (BP) was 110/67 mmHg on arrival. Four days later, she was sent to the

emergency department again because she experienced transient loss of consciousness lasting for a few minutes. Her BP

was 94/57 mmHg in the right arm and 89/54 in the left arm. She was admitted to the hospital, and the pulses in both

upper limbs were impalpable on the following day. Chest magnetic resonance imaging (MRI) was arranged, and sub-

sequently, aortic dissection was diagnosed. The case presented with unusual characteristics, which increased th e diffi-

culty in immediate correct diagnosis.

Keywords: Aortic Dissection, Blood Press ur e , Pulseless Upper Extremities

1. Introduction

Aortic dissection is a potential fatal condition and early

diagnosis is critical to the prognosis. The management

demands either surgical repair the dissected aorta or

medical reduce arterial shear forces on the torn aortic site.

Early diagnosis with minimal loss of time is the princip le

for prompt management. However, misdiagnosis remains

an unresolved problem because of myriad and unpre-

dictable clinical presentation. Widened mediastinum in a

chest X-ray is a common finding. The initial symptoms

usually present with severe and abrupt chest pain. Physi-

cal examination helpful in diagnosis is unstable blood

pressure. Arterial hypertension is the most frequent pres-

entation. Asymmetric pulses and varying blood pressure

between different upper limbs are another indication of

possible aortic dissection. Hemodynamic instability,

shock, and syncope could be the less common manifesta-

tions in acute aortic dissection. We described a case of

acute aortic dissection presenting with progressive de-

creased blood pressure detected in bilateral upper ex-

tremities. The unusual presentations without typ ical clini-

cal findings obscured the diagnosis. The possibility of

diagnosis should be kept in mind to avoid catastrophe.

2. Case Report

A 46-year-old woman who experienced headache and

right upper limb numbness for 4 hours was admitted to

our emergency department. She denied having any chest,

back, abdominal, arm, or leg pain. She had neither syn-

cope nor dyspnea. No other symptoms were noted at this

time. She had a history of hypertension that was not

treated with regular medication. She was a non-smoker

and had no prior surgeries. No other aspect of her medi-

cal history was significant.

Physical examination revealed that the patient had a

comfortable appearance, and was mild obesity. The pa-

tient’s vital signs were as follows: blood pressure (BP),

110/67 mmHg; pulse rate, 74 beats/min; respiration rate,

18 breaths/min; body temperature, 37˚C. She was alert

and conscious of time, people, and position. Cardiac

auscultation revealed no murmur, gallops, or rubs. The

lung sounds were clear during auscultation. The abdomen

Ongoing Blood Pressure Change in Both Upper Extremities: An Unusual Presentation of Aortic Dissection

464

was soft and non-tender with no masses during palpation.

The results of other physical and neurological examina-

tions were unremark able. Chest radiography showed car-

diomegaly but no other significant findings. The results

of electrocardiography were unremarkable. A brain

computer tomography (CT) scan was performed, but the

result showed no abnormalities. Th e results of laboratory

tests, including a complete blood count and cardiac en-

zyme, glucose, electrolyte, and renal function tests were

normal. After consultation with a neuro logist, a d iagno sis

of cerebrovascular disease was ruled out. The pa tient was

initially recommended treatment for a tension migraine.

After that, she was prescribed a medication and under-

went follow-up at the outpatient department after obser-

vation.

Four days later, she was admitted to our emergency

department again because of loss of consciousness. The

episode lasted for 5 minutes in the early morning and

culminated with spontaneous and full recovery. After

recovering clear consciousness, the patient complained of

dizziness and felt faint. At the second examination, her

BP was 94/57 mmHg in the right arm and 89/54 in the

left arm. Her pulse rate was 106 beats/min, respiratory

rate was 20/min, and body temperature was 37˚C. Car-

diac, respiratory, abdominal, and neurological examina-

tions did not reveal further abnormalities, except for

sensory loss in the right upper limb. There were no sig-

nificant changes in her chest radiographs and electrocar-

diographs in comparison with the previous findings. She

was again recommended for admission to the inpatient

unit.

On the following day, her BP was difficult to detect in

the upper arms and both radial arteries were impalpable.

When measured in the lower limbs, her blood pressure

was 190/95 mmHg in the right leg and 198/98 mmHg in

the left leg. The patient did not report any further com-

plaints, and the sensation of numbness in her right upper

limb improved. There was neither further syncope nor

development of other neurological defects. The patient

stated that she was now feeling fine.

Subsequently, sonography and Doppler scan of her

upper extremities were performed under the impression

of peripheral vascular obstruction. The results showed

bilateral patent radial arteries with normal compressibil-

ity. Carotid Doppler was performed, and it revealed in-

creased intimal thickness without marked plaque forma-

tion. In addition, both subclavian arteries were invisible,

the left common carotid artery was co mpletely occluded,

and inverted flow was noted in the left external carotid

artery. Echocardiography showed good left ventricle

contractility. Neither pericardial effusion nor significant

valvular regurgitation was found. Under the impression

of aortoarteritis, chest magnetic reson ance imaging (MRI)

was performed. The results showed aortic dissection with

an intimal flap from the orifice of the left common ca-

rotid artery. The left common caro tid artery and left sub-

clavian artery were almost occluded. A possible intimal

flap in the right innominate artery with high-grade steno-

sis of the right subclavian artery was also demonstrated

(Figure 1). A CT scan was arranged to evaluate the ab-

dominal aorta for surgical management, and the results

showed similar findings. It showed aortic dissectio n fro m

the transverse site, and the dissection extended to the

level of the celiac trunk. There was an intimal flap in the

right innominate artery and a small amount of dense fluid

collected in the pericardial space (Figure 2). The disease

was in progression, and the patient received surgical in-

tervention on the following day. After confirmed the di-

agnosis, surgical repair with aortic aneurysmectomy was

performed and a synthetic graft was interposed between

aortic root and aortic arch. Another two grafts between

ascending aorta graft to right brachiocephalic artery and

to left common carotid artery were placed. Then the

other graft was interposed between ascending aorta and

distal aortic arch. Valvuloplasty with aortic annulus pla-

cation was performed finally. And the patient was dis-

charged after ascending aorta total repair with stable

condition.

3. Discussion

Acute aortic dissection is a potentially fatal condition

requiring immediate assessment and treatment. Immedi-

ate surgical intervention is the treatment of choice for

dissection originating in the ascending aorta, and early

diagnosis is critical to the prognosis. A cute onset of chest

pain is the most common initial presentation. Classical

symptoms include an abrupt, severely painful tearing or

ripping sensation in the chest or substernal area, which

sometimes radiates to infrascapular, mid-back, or ab-

dominal sites. However, pain may be absent or intermit-

tent in aortic dissection, and, because of the myriad and

unpredictable possible clinical presentations, misdiagno-

sis remains an unresolved problem.

The clinical presentation of th is condition may include

symptoms and signs secondary to organ system involve-

ment [1]. The presentations may be diverse and numer-

ous, including neurological, cardiovascular, and gastro-

intestinal manifestations. Neurologic symptoms are fre-

quently associated with thoracic aortic dissection, which

may be a clue to early diagnosis [2]. Although most of

the neurological symptoms are associated with chest pain,

painless aortic dissection may present with neurologic

symptoms. The common neurologic presentations in dis-

secting aortic aneurysm include acute stroke or peripheral

ischemic neuropathy. Among these, stroke is the most

common presentation. Acute stroke may develop when

Ongoing Blood Pressure Change in Both Upper Extremities: An Unusual Presentation of Aortic Dissection

465

Figure 1. Chest magnetic resonance imaging (MRI) showed aortic aneurysm with an obvious intimal flap near the orifice of

the left common carotid artery. The left common carotid artery and left subclavian artery were almost occluded. A possible

intimal flap in the right innominate artery with high-grade stenosis of the right subclavian artery was also demonstrated.

Figure 2. Chest computer tomography (CT) demonstrated an intimal flap near the orifice of the right innominate artery,

which extended into it (arrow). The dissecting aortic aneurysm extended to the descending aorta near the celiac trunk (ar-

owhead). Pericardial effusion was also demonstrated (*). r

Ongoing Blood Pressure Change in Both Upper Extremities: An Unusual Presentation of Aortic Dissection

466

the aortic dissection extends to the innominate artery or

common carotid arteries. Other clinical manifestations,

such as transient cerebral hypoperfusion caused by al-

tered cerebrovascular flow, may present as syncope [3].

As for spinal cord ischemia and peripheral nerve in-

volvement, paraplegia is the most common neurologic

symptom caused by obstruction of spinal arteries; this

symptom has been described in several case reports [4-6].

Spinal cord ischemia and ischemic peripheral neuropa-

thies are more commonly associated with distal aortic

dissection. The aortic dissections in most of these cases

were located in the abdominal aorta and resulted in injury

to the lower extremities. Possible manifestation s of these

injuries include transverse myelitis, progressive myelo-

pathy, anterior spinal cord syndrome, paraplegia, and

qu ad r i p l e g i a [ 6 - 9 ] . Painless di ssecting aorta with isch emic

peripheral neuropathy in upper limbs is very rare and is

often ignored or misdiagnosed. Clinical presentations are

varied and may result in neurologic symptoms, including

paresthesia in the limbs, hoarseness of voice, and Horner

syndrome [10,11]. The possible mechanisms underlying

these symptoms include neuronal ischemia caused by

obstruction of the branch artery, compression caused by

the exp ansion of the false lume n, and leakag e of the aor-

tic dissection aneurysm.

Aortic dissection may also result in symptomatic

ischemia, which most commonly occurs in a lower ex-

tremity [12,13]. Clinicians sho uld co ns ider the possibility

of aortic dissection in patients presenting with abrupt

onset of chest pain and sudden loss of pulse in a lower

extremity. However, the symptomatic ischemia caused

by aortic dissection is not li mited to th e lower ex tremities.

One previous report described a case of acute aortic dis-

section in which the patient experienced numbness and

paleness in the right arm, which was caused by acute

occlusion of the right subclavian artery [14]. The patho-

logic mechanism in that case was similar to that in our

case, but the 2 cases had different clinical manifestations.

In our case, right arm numbness without blood pressure

differentials and without the c linical features of ischemia

obscured the initial diagnosis. The value of different

blood pressure assessed between bilateral upper extremi-

ties believed to be clinically s ignificant is greater than 10

mm Hg in systolic blood pressure [15]. Asymmetric

pulses and varying blood pressures between different

upper limbs are strong indicators of possible aortic dis-

section. Other possible condition included coarctation

aorta involving aortic arch, inflammatory aortitis as

syphilitic aortitis, arotic arch syndrome, supravalvular

aortic stenosis, and subclavian steal syndrome [16-20].

Comparing the blood pressure values in both upper ex-

tremities is important determination in the diagnosis of

pathology involving the aortic arch or upper-extremity

arteries. In fact, asymmetric blood pressures are the most

specific physical signs of aortic dissection and have been

reported in 38% of patients with aortic dissections [21].

Aortic dissection involving both subclavian arteries is

rare, and it is extremely rare when the clinical manifesta-

tion includes absent pulses in both upper extremities and

lacks neurol ogic defects.

Most patients with aortic dissection present with hy-

pertension; however, hemodynamic instability with the

clinical features of circulatory shock may also be a sign

of aortic dissection. Hypotension and shock in acute aor-

tic dissection are secondary to acute severe aortic regur-

gitation, low cardiac output because of cardiac tampo-

nade, aortic rupture, or left ventricular systolic dysfunc-

tion with coronary artery involvement [22,23]. Echocar-

diography did not reveal any special condition in our

case, and this obscured the diagnosis. Fortunately, the

true diagnosis was confirmed by MRI, and a prompt sur-

gical intervention was arranged without any problems.

Emergent surgical repair is indicated to avoid life-

threatening events when aortic dissection involving as-

cending aorta. The standard operation for type A dissec-

tion is to perform an ascending aortic replacement with

open distal hemi-arch anastomosis. Residual aortic an-

eurysm with gradually enlargement in patients who had

previously undergone ascending aortic repair had been

noted [24,25]. Using an open total arch/elephant-trunk

approach or hybrid endovascular approaches provide a

method to compress the false lumen in distal descending

thoracic aorta [26]. Preliminary showed hybrid arch pro-

cedures have benefit in elderly and high risk patients, but,

this benefit is not as pronounced in younger [27-29].

Further outcome data will be necessary in the future. In

our case, after the surgical procedure, she was discharged

under stable condition and kept follow-up at out-patient

department.

4. Conclusions

The case demonstrated the uncommon clinical evolution

of aortic dissection. The most distal intimal tear in a dis-

secting aortic aneurysm where the blood is presumed to

return to the circulation (reentry tears) or multiple intimal

tears without interarms blood pressure differences may

occur in the cases of aortic dissection. Knowledge of the

clinical manifestations and the possible involvement of

aortic arch vessels are the critical factors in diagnosis.

Early blood pressure measurement of other extremities

and image study are indicated to assist the diagnosis of

this condition.

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