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A sinister cause of anterograde amnesia: painless aortic dissection
American Journal of Emergency Medicine 33 (2015) 989.e5–989.e7
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
A sinister cause of anterograde amnesia: painless aortic dissection☆,☆☆,★ Abstract Aortic dissection is a frequently devastating diagnosis classically associated with severe chest pain. We present a case of painless aortic dissection with anterograde amnesia. An 84-year-old man was brought to the emergency department by ambulance, when his wife noted that he developed acute onset complete loss of short-term memory. Medical history was notable for a 4.5-cm fusiform thoracic aortic root aneurysm. On arrival, he denied pain or syncope. On examination, he was mildly hypotensive (110/59 mm Hg); and there were no murmurs, pulse deficits, or focal neurologic deficits. During his stay, he developed left flank pain. Chest radiography demonstrated subtle mediastinal widening and obscuration of the aortic knob compared with previous films. Computed tomography revealed an extensive intimal flap consistent with an aortic dissection involving the sinus of Valsalva and left renal artery. The patient subsequently developed acute onset chest pain after which he became unresponsive. Echocardiography demonstrated tamponade physiology. The family decided to transition to comfort care measures, and the patient died soon after. We identified 7 other cases in the literature of aortic dissection cases with presentations consistent with transient global amnesia, 5 of which without neurologic deficits and 3 of which without pain. This case highlights the imperative of a thorough history and high index of suspicion for this catastrophic diagnosis in patients with transient global amnesia who otherwise might be expected to have an excellent prognosis and little need for diagnostic work-up. Aortic dissection is an often fatal diagnosis in which blood penetrates through an aortic intimal layer tear. A review of 464 patients included in the multicenter International Registry of Acute Aortic Dissection reported that 443 (95.5%) of these patients presented with chest pain. Among those patients for whom data are available, a majority reported pain which was severe (90.6%), abrupt in onset (84.8%), and tearing or ripping in quality (50.6%). A plurality of patients were hypertensive sysolic blood pressure N150 mm Hg) on presentation (49.0%) [1]. We present an unusual case of aortic dissection in a man with altered mental status and no pain on initial presentation. An 84-year-old man was making phone calls at home, when according to his wife, he began “staring blankly into space.” He was suddenly
☆ Funding sources: None. ☆☆ Conflicts of interest: None. ★ Disclaimers: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, San Antonio, TX; the US Army Medical Department, San Antonio, TX; the US Army Office of the Surgeon General, San Antonio, TX; the Department of the Army Washington, D.C.; the Department of Defense, Washington, D.C.; or the US Government.
0735-6757/Published by Elsevier Inc.
unable to recall any events of the morning, so his wife called emergency medical services. On arrival, emergency medical services noted the patient to be in no apparent distress and without any neurologic deficits by Cincinnati Stroke Test. During transport, he repeatedly asked questions about time and place. Upon arrival to the emergency department, the patient's blood pressure was 110/59 mm Hg, heart rate was 64 beats per minute, respiratory rate was 16 per minute, and oxygen saturation was 97% on room air. Glascow Coma Scale was 15, yet he continued to be disoriented to place and time and exhibited features of anterograde amnesia. He denied any pain or other symptoms. On examination, his heart rate was regular in rate and rhythm without murmurs, rubs or gallops; he had equal bilateral radial pulses; and his neurologic examination was without abnormality including motor, sensory, cerebellar, and gait testing. Regarding medical history, his wife and prior records noted a 4.5-fusiform thoracic aortic root aneurysm. Shortly after arrival, the patient developed mild (2/10) left lower flank pain. Chest radiography was obtained (Fig. 1), which when compared with a recent film (Fig. 2) was notable for mediastinal widening and obscuration of the aortic knob. Computed tomography of the aorta was then obtained, which demonstrated a Stanford A aortic dissection (Fig. 3) with intimal flap involvement of the sinus of Valsalva and left renal artery (Fig. 4). There was no involvement of the carotid arteries. During this period, the patient's systolic blood pressure ranged from 93 to 115 mm Hg, and his heart rate ranged from 48 to 57 beats per minute without pharmacologic intervention. Cardiothoracic surgery was consulted. Upon consultant arrival, the patient reported acute onset of chest pain and shortly after became unresponsive. He was emergently intubated with succinylcholine and etomidate. Ultrasonography of his chest demonstrated tamponade physiology (Fig. 5 and Video available as supplementary material). Given the patient's age and extent of aortic pathology, the decision was made by the family and cardiothoracic surgery to transition to comfort care measures. The patient died soon after. We reviewed the literature for similar reports of patients with aortic dissection presenting with anterograde amnesia. We identified 7 additional cases (Table) [2-7], 5 of which without focal neurologic deficits [2,3,5-7] and 3 of which without pain on initial presentation [4-6]. All but 1 case were Stanford A dissections [6]. These reports uniformly use the term transient global amnesia (TGA) in describing these patients' mental status changes. The definition of TGA remains controversial [8], although generally requires witnessed anterograde amnesia without impairment of consciousness, focal neurologic deficits, recent head trauma, epileptic features, or duration longer than 24 hours [9]. The pathophysiology remains unclear; and possible etiologies include migraine, epilepsy, psychogenic, and vascular. That said, it is interesting to note that TGA patients have a lower subsequent risk of stroke than patients experiencing seizures or transient ischemic attacks, arguing against a strictly ischemic phenomenon [10].
989.e6
M.D. April et al. / American Journal of Emergency Medicine 33 (2015) 989.e5–989.e7
Fig. 1. Chest radiograph upon presentation with mediastinal widening.
Fig. 3. Computed tomography with angiography of the aorta demonstrating an intimal flap and false lumen with involvement of the ascending aorta.
Based on the aforementioned definition, the designation of TGA is questionable for some of these cases given the presence of focal neurologic deficits [4] or patient death before resolution of symptoms could be established (as in our case). Nevertheless, the cases are all arguably consistent with TGA and all of which with adequate observation time reported amnesia resolution within 24 hours. Regarding the cases with focal neurologic deficits, these patients had involvement of the supra-aortic arterial branches. Thus, these deficits may have been due to arterial ischemic processes not necessarily related to the etiology underlying these patients' anterograde amnesia. These cases highlight the importance of considering aortic dissection in patients with TGA who otherwise are expected to have an excellent prognosis and little need for diagnostic work-up. Particularly disconcerting is the absence of pain reported by many of these patients, a feature possibly related to their mental status changes. Colotto et al [7] offer an algorithm endorsing computed tomography angiography for TGA patients in the event of pallor, syncope, pain, hypotension or hypertension, asymmetric extremity blood pressures, fever, leukocytosis,
Fig. 4. Computed tomography with angiograph of the aorta demonstrating hypoenhancement of the left kidney due to intimal tear involving the left renal artery.
Fig. 2. Recent baseline chest radiograph.
Fig. 5. Large, mixed echogenicity pericardial fluid collection, as patient decompensated.
M.D. April et al. / American Journal of Emergency Medicine 33 (2015) 989.e5–989.e7
989.e7
Table Aortic dissection cases presenting with anterograde amnesia reported in the literature Patient
Pain
Syncope
Initial HR
Initial BP
Pulse asymmetry
Murmur
Neuro logical examination
WBC (cells/mm3)
Creatinine (mg/dL)
D-dimer
ECG
X-ray
Survival
Aorta uncoiling Normal Mediastinum wide Normal
No Yes NR
Normal Normal
No Yes
Normal Mediastinum wide
Yes No
(μg/mL)
55 M2
Chest
Yes
80
190/110
NR
SEM
Afocal
NR
NR
NR
Normal
47 M3 47 M4
Lumbar None
No No
60 NR
100/50 NR
Yes NR
SEM NR
Afocal Left weakness
Normal NR
NR NR
NR NR
Normal NR
61 F4
Chest
No
NR
Hypotensive
NR
NR
NR
NR
NR
NR
69 F5 55 M6
None None
No No
55 NR
110/50 123/85
NR No
None None
Right facial paralysis Afocal Afocal
22.4 17.8
1.51 1.49
NR 0.63
64 M7 84MCase
Chest None
No No
NR 64
150/80 110/59
No No
NR None
Afocal Afocal
18 10.4
1.6 1.2
4.61 NR
Normal 1° AV block, PVCs Normal 1° AV block, RBBB
NR
Abbreviations: HR, heart rate; BP, blood pressure; WBC, white blood cells; ECG, electrocardiogram; M, male; F, female; NR, not reported; SEM, systolic ejection murmur; AV, atrioventricular; PVC, premature ventricular contraction; RBBB, right bundle branch block.
elected D-dimer levels, or elevated creatinine. Although undoubtedly nonspecific, the emergency physician may find these criteria useful in ruling out impending aortic catastrophe in patients with TGA. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2014.12.052. Michael D. April, MD, DPhil, MSc⁎ Kurt Fossum, MPAS, PA-C Charles Hounshell, DO, MBA Katherine Stolper, DO Leigh Spear, MD Kevin Semelrath, MD Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium, San Antonio, TX Department of Radiology San Antonio Uniformed Services Health Education Consortium, San Antonio, TX ⁎ Corresponding author. SAMMC, MCHE-EMR, 3551 Roger Brooke Dr JBSA, Fort Sam Houston, TX 78234-6200 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.12.052
References [1] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. [2] Rosenberg GA. Transient global amnesia with a dissecting aortic aneurysm. Arch Neurol 1979;36:255. [3] Bonnet P, Niclot P, Chaussin F, Placide M, Debray MP, Fichelle A. A puzzling case of transient global amnesia. Lancet 2004;364:554–2443. [4] Gaul C, Dietrich W, Tomandl B, Neundorfer B, Erbguth FJ. Aortic dissection presenting with transient global amnesia-like symptoms. Neurology 2004;63:2442–3. [5] Mondon K, Blechet C, Gochard A, Elaroussi D, Fetissof F, Autret A, et al. Transient global amnesia caused by painless aortic dissection. Emerg Med J 2007;24: 63–4. [6] Irioka T, Yamanami A, Yagi Y, Mizusawa H. Aortic dissection as a possible cause of pure transient global amnesia: a case report and literature review. Neurol Sci 2009;30:255–8. [7] Colotto M, Maranghi M, Epifania A, Totaro M, Giura R, Durante C. Unmasking aortic dissection in patients of transient global amnesia: case report and diagnostic algorithm for the emergency department. BMJ Case Reports; 2011[Available online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3062276/. Accessed 12 December 2014]. [8] Brown J. ED evaluation of transient global amnesia. Ann Emerg Med 1997;30:522–6. [9] Hodges JR, Warlow CP. Syndromes of transient amnesia: towards a classification. A study of 153 cases. J Neurol Neurosurg Psychiatry 1990;53:834–43. [10] Mangla A, Navi BB, Layton K, Kamel H. Transient global amnesia and the risk of ischemic stroke. Stroke 2014;45:389–93.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
A sinister cause of anterograde amnesia: painless aortic dissection☆,☆☆,★ Abstract Aortic dissection is a frequently devastating diagnosis classically associated with severe chest pain. We present a case of painless aortic dissection with anterograde amnesia. An 84-year-old man was brought to the emergency department by ambulance, when his wife noted that he developed acute onset complete loss of short-term memory. Medical history was notable for a 4.5-cm fusiform thoracic aortic root aneurysm. On arrival, he denied pain or syncope. On examination, he was mildly hypotensive (110/59 mm Hg); and there were no murmurs, pulse deficits, or focal neurologic deficits. During his stay, he developed left flank pain. Chest radiography demonstrated subtle mediastinal widening and obscuration of the aortic knob compared with previous films. Computed tomography revealed an extensive intimal flap consistent with an aortic dissection involving the sinus of Valsalva and left renal artery. The patient subsequently developed acute onset chest pain after which he became unresponsive. Echocardiography demonstrated tamponade physiology. The family decided to transition to comfort care measures, and the patient died soon after. We identified 7 other cases in the literature of aortic dissection cases with presentations consistent with transient global amnesia, 5 of which without neurologic deficits and 3 of which without pain. This case highlights the imperative of a thorough history and high index of suspicion for this catastrophic diagnosis in patients with transient global amnesia who otherwise might be expected to have an excellent prognosis and little need for diagnostic work-up. Aortic dissection is an often fatal diagnosis in which blood penetrates through an aortic intimal layer tear. A review of 464 patients included in the multicenter International Registry of Acute Aortic Dissection reported that 443 (95.5%) of these patients presented with chest pain. Among those patients for whom data are available, a majority reported pain which was severe (90.6%), abrupt in onset (84.8%), and tearing or ripping in quality (50.6%). A plurality of patients were hypertensive sysolic blood pressure N150 mm Hg) on presentation (49.0%) [1]. We present an unusual case of aortic dissection in a man with altered mental status and no pain on initial presentation. An 84-year-old man was making phone calls at home, when according to his wife, he began “staring blankly into space.” He was suddenly
☆ Funding sources: None. ☆☆ Conflicts of interest: None. ★ Disclaimers: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, San Antonio, TX; the US Army Medical Department, San Antonio, TX; the US Army Office of the Surgeon General, San Antonio, TX; the Department of the Army Washington, D.C.; the Department of Defense, Washington, D.C.; or the US Government.
0735-6757/Published by Elsevier Inc.
unable to recall any events of the morning, so his wife called emergency medical services. On arrival, emergency medical services noted the patient to be in no apparent distress and without any neurologic deficits by Cincinnati Stroke Test. During transport, he repeatedly asked questions about time and place. Upon arrival to the emergency department, the patient's blood pressure was 110/59 mm Hg, heart rate was 64 beats per minute, respiratory rate was 16 per minute, and oxygen saturation was 97% on room air. Glascow Coma Scale was 15, yet he continued to be disoriented to place and time and exhibited features of anterograde amnesia. He denied any pain or other symptoms. On examination, his heart rate was regular in rate and rhythm without murmurs, rubs or gallops; he had equal bilateral radial pulses; and his neurologic examination was without abnormality including motor, sensory, cerebellar, and gait testing. Regarding medical history, his wife and prior records noted a 4.5-fusiform thoracic aortic root aneurysm. Shortly after arrival, the patient developed mild (2/10) left lower flank pain. Chest radiography was obtained (Fig. 1), which when compared with a recent film (Fig. 2) was notable for mediastinal widening and obscuration of the aortic knob. Computed tomography of the aorta was then obtained, which demonstrated a Stanford A aortic dissection (Fig. 3) with intimal flap involvement of the sinus of Valsalva and left renal artery (Fig. 4). There was no involvement of the carotid arteries. During this period, the patient's systolic blood pressure ranged from 93 to 115 mm Hg, and his heart rate ranged from 48 to 57 beats per minute without pharmacologic intervention. Cardiothoracic surgery was consulted. Upon consultant arrival, the patient reported acute onset of chest pain and shortly after became unresponsive. He was emergently intubated with succinylcholine and etomidate. Ultrasonography of his chest demonstrated tamponade physiology (Fig. 5 and Video available as supplementary material). Given the patient's age and extent of aortic pathology, the decision was made by the family and cardiothoracic surgery to transition to comfort care measures. The patient died soon after. We reviewed the literature for similar reports of patients with aortic dissection presenting with anterograde amnesia. We identified 7 additional cases (Table) [2-7], 5 of which without focal neurologic deficits [2,3,5-7] and 3 of which without pain on initial presentation [4-6]. All but 1 case were Stanford A dissections [6]. These reports uniformly use the term transient global amnesia (TGA) in describing these patients' mental status changes. The definition of TGA remains controversial [8], although generally requires witnessed anterograde amnesia without impairment of consciousness, focal neurologic deficits, recent head trauma, epileptic features, or duration longer than 24 hours [9]. The pathophysiology remains unclear; and possible etiologies include migraine, epilepsy, psychogenic, and vascular. That said, it is interesting to note that TGA patients have a lower subsequent risk of stroke than patients experiencing seizures or transient ischemic attacks, arguing against a strictly ischemic phenomenon [10].
989.e6
M.D. April et al. / American Journal of Emergency Medicine 33 (2015) 989.e5–989.e7
Fig. 1. Chest radiograph upon presentation with mediastinal widening.
Fig. 3. Computed tomography with angiography of the aorta demonstrating an intimal flap and false lumen with involvement of the ascending aorta.
Based on the aforementioned definition, the designation of TGA is questionable for some of these cases given the presence of focal neurologic deficits [4] or patient death before resolution of symptoms could be established (as in our case). Nevertheless, the cases are all arguably consistent with TGA and all of which with adequate observation time reported amnesia resolution within 24 hours. Regarding the cases with focal neurologic deficits, these patients had involvement of the supra-aortic arterial branches. Thus, these deficits may have been due to arterial ischemic processes not necessarily related to the etiology underlying these patients' anterograde amnesia. These cases highlight the importance of considering aortic dissection in patients with TGA who otherwise are expected to have an excellent prognosis and little need for diagnostic work-up. Particularly disconcerting is the absence of pain reported by many of these patients, a feature possibly related to their mental status changes. Colotto et al [7] offer an algorithm endorsing computed tomography angiography for TGA patients in the event of pallor, syncope, pain, hypotension or hypertension, asymmetric extremity blood pressures, fever, leukocytosis,
Fig. 4. Computed tomography with angiograph of the aorta demonstrating hypoenhancement of the left kidney due to intimal tear involving the left renal artery.
Fig. 2. Recent baseline chest radiograph.
Fig. 5. Large, mixed echogenicity pericardial fluid collection, as patient decompensated.
M.D. April et al. / American Journal of Emergency Medicine 33 (2015) 989.e5–989.e7
989.e7
Table Aortic dissection cases presenting with anterograde amnesia reported in the literature Patient
Pain
Syncope
Initial HR
Initial BP
Pulse asymmetry
Murmur
Neuro logical examination
WBC (cells/mm3)
Creatinine (mg/dL)
D-dimer
ECG
X-ray
Survival
Aorta uncoiling Normal Mediastinum wide Normal
No Yes NR
Normal Normal
No Yes
Normal Mediastinum wide
Yes No
(μg/mL)
55 M2
Chest
Yes
80
190/110
NR
SEM
Afocal
NR
NR
NR
Normal
47 M3 47 M4
Lumbar None
No No
60 NR
100/50 NR
Yes NR
SEM NR
Afocal Left weakness
Normal NR
NR NR
NR NR
Normal NR
61 F4
Chest
No
NR
Hypotensive
NR
NR
NR
NR
NR
NR
69 F5 55 M6
None None
No No
55 NR
110/50 123/85
NR No
None None
Right facial paralysis Afocal Afocal
22.4 17.8
1.51 1.49
NR 0.63
64 M7 84MCase
Chest None
No No
NR 64
150/80 110/59
No No
NR None
Afocal Afocal
18 10.4
1.6 1.2
4.61 NR
Normal 1° AV block, PVCs Normal 1° AV block, RBBB
NR
Abbreviations: HR, heart rate; BP, blood pressure; WBC, white blood cells; ECG, electrocardiogram; M, male; F, female; NR, not reported; SEM, systolic ejection murmur; AV, atrioventricular; PVC, premature ventricular contraction; RBBB, right bundle branch block.
elected D-dimer levels, or elevated creatinine. Although undoubtedly nonspecific, the emergency physician may find these criteria useful in ruling out impending aortic catastrophe in patients with TGA. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2014.12.052. Michael D. April, MD, DPhil, MSc⁎ Kurt Fossum, MPAS, PA-C Charles Hounshell, DO, MBA Katherine Stolper, DO Leigh Spear, MD Kevin Semelrath, MD Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium, San Antonio, TX Department of Radiology San Antonio Uniformed Services Health Education Consortium, San Antonio, TX ⁎ Corresponding author. SAMMC, MCHE-EMR, 3551 Roger Brooke Dr JBSA, Fort Sam Houston, TX 78234-6200 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.12.052
References [1] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. [2] Rosenberg GA. Transient global amnesia with a dissecting aortic aneurysm. Arch Neurol 1979;36:255. [3] Bonnet P, Niclot P, Chaussin F, Placide M, Debray MP, Fichelle A. A puzzling case of transient global amnesia. Lancet 2004;364:554–2443. [4] Gaul C, Dietrich W, Tomandl B, Neundorfer B, Erbguth FJ. Aortic dissection presenting with transient global amnesia-like symptoms. Neurology 2004;63:2442–3. [5] Mondon K, Blechet C, Gochard A, Elaroussi D, Fetissof F, Autret A, et al. Transient global amnesia caused by painless aortic dissection. Emerg Med J 2007;24: 63–4. [6] Irioka T, Yamanami A, Yagi Y, Mizusawa H. Aortic dissection as a possible cause of pure transient global amnesia: a case report and literature review. Neurol Sci 2009;30:255–8. [7] Colotto M, Maranghi M, Epifania A, Totaro M, Giura R, Durante C. Unmasking aortic dissection in patients of transient global amnesia: case report and diagnostic algorithm for the emergency department. BMJ Case Reports; 2011[Available online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3062276/. Accessed 12 December 2014]. [8] Brown J. ED evaluation of transient global amnesia. Ann Emerg Med 1997;30:522–6. [9] Hodges JR, Warlow CP. Syndromes of transient amnesia: towards a classification. A study of 153 cases. J Neurol Neurosurg Psychiatry 1990;53:834–43. [10] Mangla A, Navi BB, Layton K, Kamel H. Transient global amnesia and the risk of ischemic stroke. Stroke 2014;45:389–93.