Acute aortic dissection presenting as painless paraplegia: a case report

A 70-year-old Arab man presented to our department because of a sudden inability to walk. He had been well until 1 hour before admission, when he noticed the sudden onset of weakness of his legs with urinary retention. He had no chest, back or leg pain. He had no previous known medical or surgical conditions. His blood pressure was 120/56 mmHg and his pulse was 90 beats/minute. He was afebrile. He had no audible murmurs or rubs. His lungs were clear to auscultation and percussion; however, his peripheral pulses were not checked. Deep tendon reflexes were absent in his legs and he had flaccid paraplegia with no sensory disorder. Distended bladder was also noted. Laboratory investigations eliminated multiple organ failure. Acute low cervical spinal cord compression was initially suspected but spinal magnetic resonance imaging realized in emergency was normal. His clinical condition rapidly worsened 1 day after his admission. He appeared pale, diaphoretic and in extreme distress. His blood pressure was 50 mmHg systolic with a pulse of 130. Despite resuscitation, his blood pressure continued to deteriorate and he experienced cardiopulmonary arrest. Resuscitation was attempted. However, he could not be resuscitated. An autopsy revealed a type A aortic dissection with subsequent separation of the intima and media from the adventitia involving his ascending thoracic aorta with antegrade and retrograde extension. In fact, cardiac tamponade had occurred as the result of intrapericardial rupture. His intercostal and lumbar arteries were affected.

Acute aortic dissection is a catastrophic illness with variable manifestations. It usually manifests as a sudden tearing chest pain radiating to the back [1]. The sudden paraplegia as in our patient can result from interruption of blood flow to the spinal cord especially to crucial zones such as the lower thoracic and lumbar segments and then ischemia of the spinal cord [7]. Aortic dissection revealed by paraplegia is rare [5] and painless acute aortic dissection in which paraplegia is the only presenting symptom is even rarer [6‐12]. This unusual presentation can lead to misdiagnosis of aortic dissection with fatal evolution as in our case. Dissection of the aorta carries a very poor prognosis unless it is treated immediately. Its true incidence is generally underestimated and evidence of dissection is found in one of 400 necropsies [13]. So it is very important to differentiate this condition from other spinal vascular pathologic phenomena that produce paraplegia and are painless and to verify the existence of pulseless femoral arteries [9]. In fact, reversal of paraplegia with surgical intervention [9] as well as conservative management [14] has been described.

Written informed consent was obtained from the patient’s next-of-kin (his son) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.