Acute ischemic stroke as a complication of Stanford type A acute aortic dissection: a review and proposed clinical recommendations for urgent diagnosis

Surgical choice for the treatment of partial intestinal ischemic necrosis caused by acute type a aortic dissection combined with malperfusion of superior mesenteric artery

Acute type A aortic dissection is a severe cardiovascular disease characterized by rapid onset and high mortality. Traditionally, urgent open aortic repair is performed after admission to prevent aortic rupture and death. However, when combined with malperfusion syndrome, the low perfusion of the superior mesenteric artery can further lead to intestinal necrosis, significantly impacting the surgery's prognosis and potentially resulting in adverse consequences, bringing. This presents great significant challenges in treatment. Based on recent domestic and international research literature, this paper reviews the mechanism, current treatment approaches, and selection of surgical methods for poor organ perfusion caused by acute type A aortic dissection. The literature review findings suggest that central aortic repair can be employed for the treatment of acute type A aortic dissection with inadequate perfusion of the superior mesenteric artery. The superior mesenteric artery can be windowed and (/or) stented, followed by delayed aortic repair. Priority should be given to revascularization of the superior mesenteric artery, followed by central aortic repair. During central aortic repair, direct blood perfusion should be performed on the distal true lumen of the superior mesenteric artery, leading to resulting in favorable therapeutic outcomes. The research results indicate that even after surgical aortic repair, intestinal ischemic necrosis may still occur. In such cases, prompt laparotomy and necessary necrotic bowel resection are crucial for saving the patient's life.

Therapeutic management of ischemic stroke

Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy.

Clinical outcome of a branch-first approach with a novel continuous whole-brain perfusion strategy for total arch surgery

BACKGROUND

Cerebral protection strategies have been investigated since the introduction of aortic arch surgery and have been modified over the centuries. However, the cerebral protective effects of unilateral and bilateral antegrade cerebral perfusion are similar, with opportunities for further improvement.

METHODS

A total of 30 patients who underwent total arch surgery were enrolled in this study. Patients were assigned to the novel continuous whole-brain or unilateral antegrade cerebral perfusion group according to the cerebral perfusion technique used. Preoperative clinical data and 1-year postoperative follow-up data were collected and analyzed.

RESULTS

There were no significant differences between the two groups in terms of the incidence of permanent neurological deficit, mortality, or therapeutic efficacy. However, the incidence of temporary neurological dysfunction in the novel whole-brain perfusion group was significantly lower than that in the unilateral antegrade cerebral perfusion group.

CONCLUSIONS

In this study, the branch-first approach with a novel whole-brain perfusion strategy had no obvious disadvantages compared with unilateral antegrade cerebral perfusion in terms of cerebral protection and surgical safety. These findings suggest that this new technique is feasible and has application value for total arch surgery.

Endovascular recanalization therapy for patients with acute ischemic stroke with hidden aortic dissection: A case series

Aortic dissection is one of the causes of acute ischemic stroke. Endovascular recanalization therapy (EVT) has emerged as an essential treatment for acute ischemic stroke due to large artery occlusion. However, it is rarely performed in the situation of hidden aortic dissection (AD). Two patients presented to the emergency room with focal neurologic deficits. The first patient was diagnosed with right internal carotid artery (ICA) occlusion. Angiography revealed that the ICA was occluded by the dissection flap. After a stent deployment in the proximal ICA, the antegrade flow was restored. The patient was diagnosed with AD on chest computed tomography (CT) after EVT. For the second patient, intraarterial thrombectomy was performed to treat left middle cerebral artery occlusion. AD was first detected on echocardiography, which was performed after EVT. Herein, we report successful endovascular recanalization therapy performed in two patients with acute ischemic stroke in the situation of undiagnosed aortic dissection. We also reviewed previous case reports and relevant literature.

Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection

Objectives

Acute type A aortic dissection (ATAAD) with severe stenosis or occlusion of the true lumen of aortic arch branch vessels often leads to an increased incidence of severe postsurgical neurological complications and mortality rate. In this study, we aimed to introduce our institutional extra-anatomic revascularization and cannulation strategy with improved postoperative outcomes for better management of patients with cerebral malperfusion in the setting of ATAAD.

Methods

Twenty-eight patients with ATAAD complicated by severe stenosis or occlusion of the aortic arch branch vessels, as noted on combined computed tomography angiography of the aorta and craniocervical artery, between January 2021 and June 2022 were included in this study. Basic patient characteristics, surgical procedures, hospitalization stays, and early follow-up results were analyzed.

Results

The median follow-up duration was 16.5 months (interquartile range: 11.5-20.5), with a 100% completion rate. The 30-day mortality rates was 7.1% (2/28 patients); two patients had multiple cerebral infarctions on preoperative computed tomography and persistent coma. Postoperative transient neurological dysfunction occurred in 10.7% (3/28) of the patients, and no new permanent neurological dysfunction occurred. Of all the patients, 3.6% (1/28) had novel acute renal failure. No other deaths, secondary surgeries, or serious complications occurred during the early follow-up period.

Conclusions

Use of extra-anatomic revascularization and a new cannulation strategy before cardiopulmonary bypass is safe and feasible and may reduce the high incidence of postoperative neurological complications in patients with ATAAD and cerebral malperfusion.

Aortic dissection with epileptic seizure: A case report

BACKGROUND

Aortic dissection (AoD) is a life-threatening disease. Its diversified clinical manifestations, especially the atypical ones, make it difficult to diagnose. The epileptic seizure is a neurological problem caused by various kinds of diseases, but AoD with epileptic seizure as the first symptom is rare.

CASE SUMMARY

A 53-year-old male patient suffered from loss of consciousness for 1 h and tonic-clonic convulsion for 2 min. The patient performed persistent hypomania and chest discomfort for 30 min after admission. He had a history of hypertension without regular antihypertensive drugs, and the results of his bilateral blood pressure varied greatly. Then the electroencephalogram showed the existence of epileptic waves. The thoracic aorta computed tomography angiography showed the appearance of AoD, and it originated at the lower part of the ascending aorta. Finally, the diagnosis was AoD (DeBakey, type I), acute aortic syndrome, hypertension (Grade 3), and secondary epileptic seizure. He was given symptomatic treatment to relieve symptoms and prevent complications. Thereafter, the medical therapy was effective but he refused our surgical advice.

CONCLUSION

The AoD symptoms are varied. When diagnosing the epileptic seizure etiologically, AoD is important to consider by clinical and imaging examinations.

Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review

BACKGROUND

Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.

CASE SUMMARY

A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.

CONCLUSION

Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.

Cerebral infarction and risk factors in acute type A aortic dissection with arch branch extension

OBJECTIVE

Stanford type A aortic dissection (AAD) may affect the supra-aortic arteries, which are associated with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study aimed to investigate cerebral perfusion, the infarction incidence and risk factors in AAD patients.

METHODS

A total of 156 consecutive AAD patients were enrolled and divided into two groups according to whether the aortic arch branches were involved: the affected group (n = 90) and the unaffected group (n = 66). Clinical, echocardiographic/carotid Doppler data and cerebral infarction morbidity were compared between the groups. Independent predictors of 30-day AAD mortality were identified through multivariable Cox regression, and perioperative risk factors were analyzed.

RESULTS

In total, 57.7% of AAD patients had aortic arch branch involvement. Abnormal Doppler waveforms were more common in the affected group (p < 0.05). Regarding intracranial perfusion, the blood flow volumes (BFVs) of the bilateral internal carotid arteries (ICAs) and right vertebral artery (RVA) in the affected group were significantly reduced (p < 0.05). The incidence of cerebral infarction in the affected group was significantly higher than that in the unaffected group (35.6% vs. 19.7%, p = 0.031). Multivariable analysis revealed that age >45 years old, right internal carotid artery (RICA) involvement and reduced left ventricular ejection fraction (LVEF) were significant predictors of perioperative death.

CONCLUSIONS

Aortic arch branch involvement is common in patients with AAD and is associated with reduced cerebral blood flow (especially on the right side) and a higher incidence of cerebral infarction. Age, extension of the RICA dissection and LVEF impairment are independent risk factors for AAD-related death.

[Acute Aortic Dissection: A Life-Threatening Disease Also in Neurological Emergency Medicine]

Acute aortic dissection is rare but life-threatening. The symptoms depend on the localization and reduced perfusion of the downstream organs or limbs and are therefore variable. Neurological symptoms may occur that do not immediately lead to a diagnosis and thus delay the necessary therapy. Knowing the early symptoms and warning signs of aortic dissection is therefore also crucial in neurological emergency care for quickly identifying the affected patients and for providing acute therapy. A misdiagnosis with delayed initiation of therapy can significantly worsen the patient's outcome. This study aims to establish a standardized diagnostic and therapeutic algorithm for suspected acute aortic dissection in neurological emergency care. Close interdisciplinary cooperation is mandatory.

Novel brain computed tomography perfusion for cerebral malperfusion secondary to acute type A aortic dissection

OBJECTIVES

The management of acute type A aortic dissection with malperfusion syndrome remains challenging. To evaluate preoperative condition, symptoms might be subjective and objective evaluation of cerebral artery has not yet been established. For quantitative evaluation, this study focused on brain computed tomography perfusion (CTP), which has been recommended by several guidelines of acute ischaemic stroke.

METHODS

In the last 2 years, 147 patients hospitalized due to acute type A aortic dissection were retrospectively reviewed. Among the 23 (16%) patients with cerebral malperfusion, 14 who underwent brain CTP (6 preoperative and 8 postoperative) were enrolled. CTP parameters, including regional blood flow and time to maximum, were automatically computed using RApid processing of Perfusion and Diffusion software. The median duration from the onset to hospital arrival was 129 (31-659) min.

RESULTS

Among the 6 patients who underwent preoperative CTP, 4 with salvageable ischaemic lesion (penumbra: 8-735 ml) without massive irreversible ischaemic lesion (ischaemic core: 0-31 ml) achieved acceptable neurological outcomes after emergency aortic replacement regardless of preoperative neurological severity. In contrast, 2 patients with an ischaemic core of >50 ml (73, 51 ml) fell into a vegetative state or neurological death due to intracranial haemorrhage. CTP parameters guided postoperative blood pressure augmentation without additional supra-aortic vessel intervention in the 8 patients who underwent postoperative CTP, among whom 6 achieved normal neurological function regardless of common carotid true lumen stenosis severity.

CONCLUSIONS

CTP was able to detect irreversible ischaemic core, guide critical decisions in preoperative patients and aid in determining the blood pressure augmentation for postoperative management focusing on residual brain ischaemia.

Marfan Syndrome with Aortic Root Disease, Severe Heart Failure and Aortic Dissection- Two Case Reports

Marfan syndrome is an uncommon inheritable connective tissue disease which affects the cardiovascular system. This paper presents two cases of Marfan Syndrome with predominant aortic root disease that were seen at the Cardiology Clinic of University of Nigeria Teaching Hospital, Enugu, Nigeria. Their biography, clinical features and echocardiography parameters were captured using structured questionnaire. Both were young males in their 4^th decade of life, and had advanced aortic root diseases which were complicated by left ventricular failure in both, while one of them had aortic dissection and ischemic stroke. Young adult Nigerians with Marfan syndrome presented with advanced aortic root diseases, heart failure, aortic dissection and stroke.

Point-of-care ultrasound for stroke patients in the emergency room

Stroke requires rapid determination of the cause to provide timely and appropriate initial management. Various ultrasonographic techniques have been evaluated as ways to determine the cause of stroke; among them, carotid artery ultrasonography is particularly useful since it provides considerable information within a short time period when used to evaluate a specific site. In the emergency room, carotid artery ultrasonography can be used to diagnose internal carotid artery stenosis, predict an occluded vessel, and infer the cause of ischemic stroke. Additionally, carotid artery ultrasonography can diagnose different conditions including subclavian artery steal syndrome, bow hunter's stroke, Takayasu's arteritis, moyamoya disease, and dural arteriovenous fistula. Furthermore, patients with ischemic stroke with a pulse deficit or hypotension must be differentiated from acute type A aortic dissection, which requires emergency surgery; carotid artery ultrasonography can immediately differentiate between the two conditions by identifying the intimal flap of the common carotid artery. The following article provides an overview of carotid artery ultrasonography performed as point-of-care ultrasound in the emergency room in patients with suspected stroke.

The Construction of a Risk Prediction Model Based on Neural Network for Pre-operative Acute Ischemic Stroke in Acute Type A Aortic Dissection Patients

Objective: To establish a pre-operative acute ischemic stroke risk (AIS) prediction model using the deep neural network in patients with acute type A aortic dissection (ATAAD). Methods: Between January 2015 and February 2019, 300 ATAAD patients diagnosed by aorta CTA were analyzed retrospectively. Patients were divided into two groups according to the presence or absence of pre-operative AIS. Pre-operative AIS risk prediction models based on different machine learning algorithm was established with clinical, transthoracic echocardiography (TTE) and CTA imaging characteristics as input. The performance of the difference models was evaluated using the receiver operating characteristic (ROC), precision-recall curve (PRC) and decision curve analysis (DCA). Results: Pre-operative AIS was detected in 86 of 300 patients with ATAAD (28.7%). The cohort was split into a training (211, 70% patients) and validation cohort (89, 30% patients) according to stratified sampling strategy. The constructed deep neural network model had the best performance on the discrimination of AIS group compare with other machine learning model, with an accuracy of 0.934 (95% CI: 0.891-0.963), 0.921 (95% CI: 0.845-0.968), sensitivity of 0.934, 0.960, specificity of 0.933, 0.906, and AUC of 0.982 (95% CI: 0.967-0.997), 0.964 (95% CI: 0.932-0.997) in the training and validation cohort, respectively. Conclusion: The established risk prediction model based on the deep neural network method may have the big potential to evaluate the risk of pre-operative AIS in patients with ATAAD.

Clinical features and risk factors of postoperative in-hospital mortality following surgical repair of Stanford type A acute aortic dissection

Background

To investigate the clinical features of patients with Stanford type A acute aortic dissection (AAD) and analyze the risk factors affecting postoperative in-hospital mortality rate.

Methods

The demographic and clinical data were retrospectively collected and analyzed from 118 AAD patients admitted to the Affiliated Hospital of Hangzhou Normal University from June 2016 to April 2019. All patients underwent surgical treatment and were grouped into death and survival groups. The risk factors affecting postoperative in-hospital death were analyzed using multivariate logistic regression analysis.

Results

The male to female ratio in the patients was 3.8:1 and the mean age was 50.11 ± 9.91 years. The patient’s main comorbidities were hypertension (70.33%) and coronary heart disease (10.17%). The main symptoms included chest pain and back pain (72.89%). The highest incidence of complications was pericardial effusion (48.31%), followed by pleural effusion (22.88%). The mean systolic blood pressure, white blood cell count and D-dimer in the patients were over the ranges of normal people. The incidences of cardiac and renal insufficiency were 18.64% and 16.95% respectively, and the postoperative in-hospital mortality rate was 12.71%. Univariable analysis showed that age, renal insufficiency, cardiac insufficiency, D-dimer level, cardiopulmonary bypass time, operation time, blood transfusion volume and postoperative hemostasis were significant factors leading to the death (P < 0.05). Multivariate logistic regression analysis showed that age > 65, renal insufficiency, cardiopulmonary bypass time ≥ 250 min and postoperative hemostasis were independent risk factors for the death (P < 0.05).

Conclusions

AAD patients frequently have underlying diseases with pain as the main symptom. Age > 65 years, renal insufficiency, cardiopulmonary bypass time ≥ 250 min and postoperative hemostasis are significantly risk factors for postoperative mortality.

Patient Representation From Structured Electronic Medical Records Based on Embedding Technique: Development and Validation Study

Background

The secondary use of structured electronic medical record (sEMR) data has become a challenge due to the diversity, sparsity, and high dimensionality of the data representation. Constructing an effective representation for sEMR data is becoming more and more crucial for subsequent data applications.

Objective

We aimed to apply the embedding technique used in the natural language processing domain for the sEMR data representation and to explore the feasibility and superiority of the embedding-based feature and patient representations in clinical application.

Methods

The entire training corpus consisted of records of 104,752 hospitalized patients with 13,757 medical concepts of disease diagnoses, physical examinations and procedures, laboratory tests, medications, etc. Each medical concept was embedded into a 200-dimensional real number vector using the Skip-gram algorithm with some adaptive changes from shuffling the medical concepts in a record 20 times. The average of vectors for all medical concepts in a patient record represented the patient. For embedding-based feature representation evaluation, we used the cosine similarities among the medical concept vectors to capture the latent clinical associations among the medical concepts. We further conducted a clustering analysis on stroke patients to evaluate and compare the embedding-based patient representations. The Hopkins statistic, Silhouette index (SI), and Davies-Bouldin index were used for the unsupervised evaluation, and the precision, recall, and F1 score were used for the supervised evaluation.

Results

The dimension of patient representation was reduced from 13,757 to 200 using the embedding-based representation. The average cosine similarity of the selected disease (subarachnoid hemorrhage) and its 15 clinically relevant medical concepts was 0.973. Stroke patients were clustered into two clusters with the highest SI (0.852). Clustering analyses conducted on patients with the embedding representations showed higher applicability (Hopkins statistic 0.931), higher aggregation (SI 0.862), and lower dispersion (Davies-Bouldin index 0.551) than those conducted on patients with reference representation methods. The clustering solutions for patients with the embedding-based representation achieved the highest F1 scores of 0.944 and 0.717 for two clusters.

Conclusions

The feature-level embedding-based representations can reflect the potential clinical associations among medical concepts effectively. The patient-level embedding-based representation is easy to use as continuous input to standard machine learning algorithms and can bring performance improvements. It is expected that the embedding-based representation will be helpful in a wide range of secondary uses of sEMR data.

Exploration of Simplified Intraluminal TEVAR Technique for the Treatment of Aortic Arch Disease

Objective:

The positional relationship between the three branches of the aortic arch was determined in normal people. This study provides data to support the customization of aortic arch stents and simplifies intraluminal treatment.

Methods:

From January 2019 to August 2019, 120 patients who met the inclusion criteria were examined by CT angiography. The ratio of the distance from the midpoint of the three-branch opening onto the anterior wall to the cross-sectional diameter of the aortic arch was calculated. The positional relationship among the three-branch openings was obtained and the data were analyzed statistically.

Results:

The three-branch openings were not in a straight line. The positional relationship among the three-branch openings was divided into four types, which were not statistically different between sex and age (P>0.05).

Conclusion:

By measuring the opening position of the three aortic branches, the positional relationship among the three branches was defined to provide a theoretical basis for the design of intraluminal stents and simplified intracavity thoracic endovascular aortic repair (TEVAR) technology.

Successful treatment of ischemic stroke associated with brachiocephalic artery stenosis using alteplase

Introduction: Brachiocephalic artery stenosis rarely causes right hemispheric infarction with associated left hemiparesis. To date, there have been no reported cases of stroke associated with brachiocephalic artery stenosis that were successfully treated with recombinant tissue-type plasminogen activator (rt-PA), alteplase.

Case Report: An 80-year-old woman presented with left hemiparesis. Brain computed tomography showed no hemorrhage, and computed tomography angiography demonstrated brachiocephalic artery stenosis. Alteplase was administered based on a diagnosis of ischemic stroke. Brain magnetic resonance imaging showed multiple acute infarctions. Thereafter, the blood pressure of the right arm was found to be lower than that of the left arm. The patient’s neurological deficits gradually improved; she was eventually able to walk again and was thus discharged home.

Conclusion: While the combination of left hemiparesis and a decrease in blood pressure in the right arm are well known in patients with stroke associated with Stanford type A aortic dissections, it may also occur in patients with stroke due to brachiocephalic artery stenosis. Unlike stroke associated with Stanford type A aortic dissections, stroke due to brachiocephalic artery stenosis may be treated with alteplase.

MicroRNA microarray analysis to detect biomarkers of aortic dissection from paraffin-embedded tissue samples

OBJECTIVES

The aim of this study was to explore the differential expression profiles of microRNAs (miRNAs) in paraffin-embedded acute aortic dissection (AAD) tissues to find potential biomarkers for this disease.

METHODS

A total of 92 paraffin-embedded tissue specimens were collected from 92 patients with AAD who underwent surgical replacement. Among these specimens, 54 had partial normal aortic segments (smooth intima surface, non-atherosclerotic lesions) in proximal crevasse of aorta. Samples of these segments were taken 1 cm away from aortic lesions as the control group, after eliminating the tunica adventitia tissues. miRNA expression profiles were obtained by miRNA microarray analysis. Differentially expressed miRNAs were found by comparing the AAD group with the control group and were verified by fluorescence real-time quantitative polymerase chain reaction and by fluorescence in situ hybridization.

RESULTS

A total of 71 differentially expressed miRNAs were detected. Twenty-two were up-regulated and 49 were down-regulated. Four up-regulated miRNAs (hsa-miR-636, hsa-miR-142-3p, hsa-miR-425-3p, hsa-miR-191-3p) were selected for validation by real-time fluorescence quantitative polymerase chain reaction and fluorescence in situ hybridization. In the fluorescence real-time quantitative polymerase chain reaction analysis, only hsa-miR-636 showed a statistically significant difference in the AAD versus control comparison (3.3-fold, P = 0.012). The fluorescence in situ hybridization validation showed that the expression level of hsa-miR-636 was significantly increased in the AAD versus control comparison (P < 0.001), with average optical densities of 61.29 ± 16.83 in the AAD group and 9.30 ± 3.98 in the control group.

CONCLUSIONS

Hsa-miR-636 is involved in the pathogenesis of AAD and may be a potential biomarker for this disease.

Stanford type a aortic dissection with cerebral infarction: a rare case report

Background

Aortic dissection (AoD) is a disease with a high mortality rate. Its clinical manifestations are diverse and covert, which makes diagnosis and treatment challenging. Here, we report a very rare case of aortic dissection leading to bilateral cerebral cortex ischaemia and epilepsy.

Case presentation

A 54-year-old man was admitted to the hospital with acute onset of right limb weakness accompanied by slurred speech. He had a history of hypertension as well as tobacco and alcohol use. The patient was found to have aphasia and right hemiplegia on physical examination. No bleeding was seen on the skull CT. Acute cerebral infarction was considered after admission, and rt-PA was administered for intravenous thrombolysis. During intravenous thrombolysis, the patient suddenly developed epilepsy, and diazepam was given immediately by intravenous injection to control the symptoms. Emergency skull diffusion-weighted imaging (DWI) was performed, and the results showed a small, patchy, high signal that was scattered throughout the left brain hemisphere, right frontal parietal lobe and centrum semiovale. Head and neck CT angiography (CTA) was performed; dissection was found in the ascending aorta, aortic arch, bilateral common carotid artery, proximal part of the internal carotid artery, and initial segment of the left external carotid artery. The laceration was located in the upper part of the ascending aorta. AoD complicated by acute cerebral infarction and epilepsy was considered, and the patient was immediately transferred to the cardiovascular surgery specialist hospital for surgical treatment.

Conclusions

Some aortic dissections have no typical manifestations of chest pain, and the onset is covert. Atypical clinical manifestations of epilepsy secondary to bilateral cerebral hemisphere infarction may appear. AoD with cerebral infarction is a contraindication for intravenous thrombolysis; surgical treatment is the best way to reduce mortality.

Carotid artery stenting before surgery for carotid artery occlusion associated with acute type A aortic dissection: Two case reports

BACKGROUND

We experienced two cases of ischemic stroke resulting from carotid artery occlusion associated with acute type A aortic dissection (ATAAD), in which carotid artery stenting before the surgery for ATAAD resulted in good clinical outcomes.Case 1 description: A 63-year-old woman was hospitalized for conscious disturbance, right hemiparesis, and total aphasia. Computed tomography of the head showed no abnormal findings. Computed tomography angiography showed ATAAD and bilateral common carotid artery occlusion. Surgery was not indicated for ATAAD because of a poor prognosis of ischemic stroke. However, carotid artery stenting of the left common carotid artery occlusion was successfully performed, and her neurological findings improved. The patient underwent hemiarch replacement for ATAAD on the day after carotid artery stenting. Her final modified Rankin Scale was 1. Case 2 Description: A 57-year-old woman was hospitalized for mild left hemiparesis. Magnetic resonance imaging showed right watershed infarction and right common carotid artery occlusion. Computed tomography angiography showed ATAAD. After hospitalization, conscious disturbance appeared and left hemiparesis worsened. Ischemic stroke indicated a poor prognosis for revascularization by surgery for ATAAD. Thus, carotid artery stenting of the right common carotid artery occlusion was performed. The patient's neurological findings improved and she underwent hemiarch replacement for ATAAD at 19 days after carotid artery stenting. Her final modified Rankin Scale was 1.

CONCLUSIONS

In the present cases, although ischemic stroke was serious and precluded surgical indication for ATAAD, carotid artery stenting before surgery for ATAAD resulted in good clinical outcomes. Performing carotid artery stenting before surgery for ATAAD is challenging but achievable, and is a valid treatment option depending on the individual cases.

Aortic Dissection with Haemothorax Mimicking a Stroke

Aortic dissection is a life-threatening clinical emergency and a challenging diagnosis. Depending on its initial location, it may present with several symptoms with the most common being chest pain. We describe the case of a 62-year-old man admitted to the Emergency Department with acute neurological deficits and triaged for the stroke protocol. After unexpected findings on physical examination, other diagnostic hypotheses were evaluated, culminating in the diagnosis of aortic dissection with haemothorax mimicking a stroke.

The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke

Background

Elevated D-dimer levels are a marker of both thrombin formation and fibrinolysis. Currently D-dimer measurement is routinely used for ruling out venous thromboembolism and diagnosis/monitoring of disseminated intravascular coagulation. Recent emerging data suggest that D-dimer may become an important biomarker in ischemic stroke as well as in cardiovascular diseases.

Aims

To outline the clinical utility of D-dimer in work-up and management of ischemic stroke.

Summary

D-dimer measurement is most useful in stroke with active cancer as it can confirm etiologic diagnosis, predict recurrent stroke risk, and aid treatment decision in cancer-associated stroke. In cryptogenic stroke, high D-dimer levels can also provide clues for the cause of stroke as occult cancer and undetected cardiac embolic source as occult atrial fibrillation and may be helpful in treatment decision making of secondary stroke prevention. Serial D-dimer measurements should be further studied to monitor antithrombotic therapy effectiveness in both cardiogenic and cryptogenic etiologies.

Conclusion

Accumulating data suggests the utility of D-dimer test in the management of ischemic stroke, although the evidence is still limited. Future studies would clarify the role of D-dimer measurement in ischemic stroke.