Acute Lower Extremity Paralysis Secondary to Thromboembolic Aortic Occlusion Complicated by Cardiogenic Shock

Abstract

PURPOSE: The diagnosis of thromboembolic acute aortic occlusion is associated with significant morbidity and mortality. Although the primary treatment is embolectomy, improved patient outcomes are realized through early detection and hemodynamic optimization of high risk patients. METHODS: CASE Report RESULTS: A 50 year old man presents with sudden onset of parasthesias, bilateral lower extremity weakness and loss of sensation below the waist accompanied by loss of pulse. Vital signs were stable upon Emergency Department(ED) arrival. CT-Thorax-Angiography revealed complete occlusion of the distal aorta below the inferior mesenteric artery extending to the common iliac bifurcations. An echocardiogram showed an EF of 15%. Vascular Surgery was consulted. On physical exam loss of pulses throughout lower extemities was noted with acrocyanosis indicating a low perfusion state. Metabolic evidence of low perfusion (increased lactate, oliguria, mental status changes) necessitated invasive monitoring which indicated cardiogenic shock in spite of normal vitals signs. Early goal directed therapy (EGDT) prior to surgical intervention corrected the cardiogenic shock. Improving oxygen delivery led improvements in sensation and motor function to his lower limbs. The ScvO2 improved from 27% to72%, lactate normalized from 5.2 to1.0mmol/ L. Following this hemodynamic optimization, he went to the operating room where an open aorto-ilaic-embolectomy along with lower limb fasciotomies to prevent compartment syndrome was performed. Evaluation 13 days after discharge showed complete recovery of lower extremity sensation and ability to ambulate without assistance. CONCLUSIONS: Bilateral lower extremity weakness in the ED has a wide list of differential diagnosis. First intuition would be to assume a neurological cause, but case reports insinuate that bilateral weakness can be the first sign of acute aortic occlusion. Using physical examination and lactate we were able to detect tissue hypoxia beyond the low perfusion to the lower extremities. EGDT and echocardiography identified and reversed cardiogenic shock despite normal vital signs.