Carotid Artery Dissection originated from Asymptomatic Long Segmental Aortic Dissection

Abstract

Background and Rationale: Cerebral arterial dissection is a main cause of young-age stroke, especially frequent in cervical carotid artery and vertebral artery. Cerebral arterial dissection can occur after trauma or spontaneously. In some cases, arterial dissection can be originated from aorta. We report a case of ischemic stroke from ipsilateral carotid artery dissection, which was originated from aortic dissection. Methods: A 59-year old female visit to our emergency department with sudden left sided hemiparesis. Her limbs weakness suddenly started spontaneously with sudden right neck sharp pain. Neck pain were terminated spontaneously 30 minutes after. Neurologic examination on her revealed drowsy mental status, left hemiparesis MRC grade 3, forced right sided eyeball deviation, slurred speech and left facial palsy. Her vital signs were nonspecific findings. And other generalized symptoms were none. Brain MRI revealed multifocal diffusion restriction lesions in left hemisphere, mainly in left middle cerebral artery territory in diffusion weighted images (DWI-MRI). In MRA, double lumen and true lumen narrowing was noticed in from common carotid artery to proximal internal carotid artery. After MRI/A was done, her neurologic symptoms showed mild improvement. Her motor power recovered to MRC grade 4+ and forced eyeball deviation was neutralized. Results: After patient's neurologic symptoms were stabilized, we tried extended-carotid MRA because end point of dissection was not founded in routine MRA. Extended carotid MRA revealed long segmental dissection of carotid artery, which reached to aortic arch with dissecting aneurysm. In series, we performed vascular CT in chest and abdomen in emergency. In CT, focal intimal tear at ascending aorta and double lumen extension from ascending aorta to iliac bifurcation level was noticed, suggesting diffuse aortic dissection. And right renal infarction due to right renal artery involved in dissected false lumen was revealed. But her vital signs and laboratory findings were normal and she complained only focal neurologic symptoms, left sided hemiparesis. For emergency operation of her aortic dissection and renal infarction, she was transferred to other hospital which can perform cardiothoracic surgery. Conclusion: Our patient showed only focal neurologic symptoms and did not complained of any other medical symptoms even though aortic dissection had occurred. Therefore, in carotid arterial dissection, even in spontaneous mode, the possibility of aortic dissection should be considered when long segmental dissection was found in MRA.