SHM Converge Scientific Abstract ePoster Gallery-Type a Aortic Dissection Presenting Atypically as Altered Mental Status

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This case describes a 63-year-old woman with hypertension, atrial fibrillation, diabetes, prior strokes with residual left-sided weakness, and chronic kidney disease who presented with altered mental status after a 20-minute loss of consciousness. She had no chest pain, shortness of breath, or other classic anginal symptoms. On exam, she was only oriented to herself and had new left gaze deviation and dysarthria, while her baseline left-sided weakness was unchanged.<br /><br />Initial neurologic workup, including CT head, MRI brain, and EEG, was negative for acute stroke or seizure. Labs showed mild lactic acidosis, elevated creatinine, and rising high-sensitivity troponin, which peaked at 3,414 ng/L. A repeat ECG demonstrated new T-wave inversions, raising concern for non-ST elevation myocardial infarction. She was started on a heparin infusion after cardiology consultation.<br /><br />Further evaluation revealed a moderate pericardial effusion on transthoracic echocardiogram, with preserved ejection fraction and no wall motion abnormalities. A repeat chest x-ray showed a widened mediastinum and pulmonary edema. CT angiography then confirmed a Type A ascending aortic dissection with hemopericardium, prompting immediate discontinuation of heparin. Cardiothoracic surgery recommended non-operative management because of poor prognosis, and the patient was transitioned to hospice care.<br /><br />The discussion emphasizes that Type A aortic dissection is a surgical emergency with potentially fatal complications such as tamponade, rupture, stroke, and myocardial infarction. Although chest pain is the classic presentation, this case highlights an atypical presentation dominated by altered mental status and focal neurologic findings. It underscores the importance of maintaining suspicion for aortic dissection in patients with unexplained neurologic symptoms and possible acute coronary syndrome, especially before starting anticoagulation.

Asset Subtitle

Reshma P. Jadhav

Meta Tag

Author List Aymen Baig, Hunter Stallard, Jack Badawy, Mohammed B. Altaee, Patton McClelland, Reshma P. Jadhav, Sofia Ares Muzquiz, Zack Westenhaver

Category Clinical Vignettes

Concept Type A Aortic Dissection

Concept Surgical Management

Concept Acute Coronary Syndrome

Concept Hemorrhagic Pericardial Effusion

Concept CT Angiography

Distinguished Non-Finalist

Presenter Organization The University of Texas Health Science Center at San Antonio

Presenting Author Reshma P. Jadhav

Track Adult

Keywords

Type A aortic dissection

altered mental status

troponin elevation

non-ST elevation myocardial infarction

heparin infusion

hemopericardium

pericardial effusion

neurologic symptoms

atrial fibrillation

hospice care

Type A Aortic Dissection

Surgical Management

Acute Coronary Syndrome

Hemorrhagic Pericardial Effusion

CT Angiography