Correct!
5. All of the above
Aortic dissection is a medical emergency and can quickly lead to death, even with optimal treatment, as a result of decreased blood supply to other organs, heart failure, and sometimes rupture of the aorta (2). Aortic dissection is relatively rare, occurring at an estimated rate of 2–3.5 per 100,000 people every year. It is more common in males for unknown reasons. Aortic dissection is more common in those with a history of high blood pressure, a known thoracic aortic aneurysm, and in a number of connective tissue diseases that affect blood vessel wall integrity such as Marfan's syndrome and the vascular subtype of Ehlers–Danlos syndrome. Symptoms usually include sudden ripping chest and or abdominal pain. A pulse deficit and mediastinal widening (> 6 cm) are common.
The main complications of ascending aortic dissection include rupture into the pericardium causing tamponade, disruption of the aortic valve ring causing acute aortic insufficiency, and ischemic vascular catastrophe’s involving any of the main arteries. As can be seen in frame A of the CT scan, the patients carotid arteries were threatened. In frame D, the celiac artery can be seen to be perfused via the (tenuous) false lumen.
In this case, the patient had suffered a left MCA- distribution stroke due to dissection of the left carotid artery (later demonstrated by computerized tomography of the brain). This caused his neurological findings and the aphasia/altered consciousness that likely impaired his ability to better describe his chest pain.
The treatment of aortic dissection depends on the part of the aorta involved (2). Surgical treatment is usually required for dissections that involve the aortic arch, while dissections of the part further away from the heart may be treated with blood pressure lowering only. Since the 1990s endovascular aneurysm repair (carried out from inside the blood vessels) has been used in specific cases.
Historically, the first case of aortic dissection described was in the post-mortem examination of King George II of Great Britain in 1760 (3). Surgery for aortic dissection was introduced in the 1950s.
The patient underwent successful emergent graft replacement of his aortic arch. The surgical team acted so quickly that he did not receive beta-blockade to reduce delta pressure / delta time (the rate of change of systolic pressure upstroke) which is typically the cornerstone of medical management of acute aortic dissection. The patient recovered neurological function related to his stroke.
References