Dissection aortic

Based primarily on the study protocol of the 1995 NINDS rt-PA study.Many centers would also exclude patients with known documented endocarditis or aortic dissection, and those with CT hypoattenuation in more than one third of the middle cerebral artery territory. There are insufficient data to support the use of rt-PA for ischemic stroke in pregnancy or in the pediatric population (age <18 years). 

Suspected aortic dissection Recent major surgery... 

Initial goal is not to achieve a normal BP (except in acute aortic dissection)... 

Esmolol hydrochloride 250-500 mcg/kg/minute IV bolus, then 50-100 mcg/kg/minute by infusion may repeat bolus after 5 minutes or increase infusion to 300 mcg/minute 1-2 minutes 10-30 minutes Hypotension, nausea, asthma, first-degree heart block, heart failure Aortic dissection, perioperative... 

Cardiac Aortic dissection, coronary artery vasospasm, pericarditis, valvular heart disease... 

Suspected aortic dissection associated with stroke... 

Suggested Alternatives for Differential Diagnosis Abdominal aneurysm, aortic dissection, pleural effusion, subarachnoid hemorrhage, superior vena cava syndrome, hantavirus pulmonary syndrome, mediastinitis, fulminate mediastinal tumors pneumonia, gastroenteritis, meningitis, ecthyma, rat bite fever, spider bite, leprosy, plague, tularemia, coccidioidomycosis, diphtheria, glanders, histoplasmosis, psittacosis, typhoid fever, and rickettsial pox. 

Absolute contraindications to fibrinolytic therapy include (1) active internal bleeding (2) previous ICH at anytime (3) ischemic stroke within 3 months (4) known intracranial neoplasm (5) known structural vascular lesion (6) suspected aortic dissection and (7) significant closed head or facial trauma within 3 months. Primary PCI is preferred in these situations. 

Elevated blood pressure should remain untreated in the acute period (first 7 days) after ischemic stroke because of the risk of decreasing cerebral blood flow and worsening symptoms. The pressure should be lowered if it exceeds 220/120 mm Hg or there is evidence of aortic dissection, acute myocardial infarction, pulmonary edema, or hypertensive encephalopathy. If blood pressure is treated in the acute phase, short-acting parenteral agents (e.g., labetalol, nicardipine, nitroprusside) are preferred. 

The major cardiovascuiar manifestations are mitral valve prolapse and ioss of eiasticity of the aortic root, which mayiead to progressive aneurysm andpotentiaiiyfatai aortic dissection. 

Horiuchi K, Takatori A, Inenayo T, Ohta E, Ishii Y, Kyuwa S, Yoshikawa Y. Histopathological studies of aortic dissection in streptozotocin-induced diabetic APA hamsters. Experimental Animals 2005, 54, 363-367. 

Some congenital diseases such as Marfan syndrome or Ehlers Danlos syndrome (type 4) can cause arteriopathies of cranial cervical vessels. In Ehlers Danlos syndrome, elongations, dissections, dilatation and aneurysms, as well as fistula in large and mid-size arteries, are found. Cystic medial necrosis (Ueda et al. 1999) leads to aortic dissections which can include supraaortic vessels (Fig. 5.27)... 

Dissection of the aorta has been reported during cocaine use (82,83). The authors of these two reports noted that all six cases of this rare complication reported in the past 5 years were in men with pre-existing essential hypertension. In a review of emergency visits to a hospital during a 20-year period, 14 of 38 cases of acute aortic dissection involved cocaine use 6 were of type A and 8 of type B (84). Crack cocaine had been smoked in 13 cases and powder cocaine had been snorted in one case. The mean time of onset of chest pain was 12 hours after cocaine use. The chronicity of cocaine use was not known in most of the cases. The cocaine users were typically younger than the non-cocaine users. Chronic untreated hypertension and cigarette smoking were often present. 

Waters DD. Acute aortic dissection related to crack cocaine. Circulation 2002 105(13) 1592-5. 107. 

Riaz K, Forker AD, Garg M, McCullough PA. Atypical presentation of cocaine-induced type A aortic dissection a diagnosis made by transesophageal echocardiography. J 108. Investig Med 2002 50(2) 140-2. 

Palmiere C, Burkhardt S, Staub C, Hallenbarter M, Pizzolato GP, Dettmeyer R, La Harpe R. Thoracic aortic dissection associated with cocaine abuse. Forensic Sci Int 2004 141 137 12. 

Eagle KA, Isselbacher EM, DeSanctis RW International Registry for Aortic Dissection (IRAD) Investigators. Cocaine related aortic dissection in perspective. Circulation 2002 105 1529-30. 

Om A, Porter T, Mohanty PK. Transesophageal echocardio-graphic diagnosis of acute aortic dissection. Complication of cocaine abuse. Am Heart J 1992 123 532-4. 

Extensive aortic dissection with cardiac tamponade and mesenteric ischemia has been attributed to ecstasy (27). 

Since this condition is rare in young adults, diagnosis can be difficult. The authors believed that this was the first case report of aortic dissection secondary to ecstasy. 

Duflou J, Mark A. Aortic dissection after ingestion of ecstasy (MDMA). Am J Forensic Med Pathol 2000 21(3) 261-3. 

Myocardial infarction Aortic dissection Paradoxical embolism (Ch. 6)... 

Chest pain may be indicative of a recent myocardial infarction with complicating stroke, aortic dissection (particularly if the pain is also interscapular) or pulmonary embolism and raises the possibility of paradoxical embolism. 

Both radial pulses should be examined simultaneously since inequality in timing or volume suggests subclavian or iimominate stenosis or occlusion and, importantly, aortic dissection. 

Suspected cardiac source at high risk of recurrent embolism prosthetic mechanical heart valve, endocarditis, aortic dissection, acute coronary syndrome, overt congestive heart failure... 

Innominate or proximal common carotid artery stenosis or occlusion is quite often seen on angiograms in symptomatic patients but, unless very severe, does not influence the decision about endarterectomy for any internal carotid artery stenosis. Although it is possible to bypass such lesions, it is highly doubtful whether this reduces the risk of stroke unless, perhaps, several major neck vessels are involved and the patient has low-flow cerebral or ocular symptoms. This very rare situation can be caused by atheroma, Takayasu s disease or aortic dissection. Clearly, close consultation between physicians and vascular surgeons is needed to sort out, on an individual patient basis, what to do for the best. 

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