Letter to the Editor
Ischaemic stroke secondary to aortic dissection: A diagnostic challenge
Ictus isquémico secundario a disección aórtica: un reto diagnóstico
Read
15178
Timeswas read the article
1221
Total PDF
13957
Total HTML
Share statistics
array:25 [ "pii" => "S2173580818300051" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2016.02.014" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "862" "copyright" => "Sociedad Española de Neurología" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2018;33:192-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1226 "formatos" => array:3 [ "EPUB" => 48 "HTML" => 957 "PDF" => 221 ] ] "Traduccion" => array:1 [ "es" => array:20 [ "pii" => "S0213485316000542" "issn" => "02134853" "doi" => "10.1016/j.nrl.2016.02.001" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "862" "copyright" => "Sociedad Española de Neurología" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2018;33:192-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2453 "formatos" => array:3 [ "EPUB" => 59 "HTML" => 1924 "PDF" => 470 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Ictus isquémico secundario a disección aórtica: un reto diagnóstico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "192" "paginaFinal" => "194" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Ischaemic stroke secondary to aortic dissection: A diagnostic challenge" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1500 "Ancho" => 1500 "Tamanyo" => 182697 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Angio-TC torácica, corte axial (A) y coronal (B), en los que se observa el <span class="elsevierStyleItalic">flap</span> intimal en la aorta ascendente.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Muñiz Castrillo, B. Oyanguren Rodeño, E. de Antonio Sanz, M. González Salaices" "autores" => array:4 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Muñiz Castrillo" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Oyanguren Rodeño" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "de Antonio Sanz" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "González Salaices" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173580818300051" "doi" => "10.1016/j.nrleng.2016.02.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580818300051?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485316000542?idApp=UINPBA00004N" "url" => "/02134853/0000003300000003/v1_201803271020/S0213485316000542/v1_201803271020/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S217358081830004X" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2015.12.020" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "855" "copyright" => "Sociedad Española de Neurología" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2018;33:194-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 779 "formatos" => array:3 [ "EPUB" => 45 "HTML" => 597 "PDF" => 137 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Bilateral papilloedema as the initial manifestation of spinal ependymoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "194" "paginaFinal" => "196" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papiledema bilateral como forma de debut de un ependimoma espinal" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1500 "Ancho" => 1500 "Tamanyo" => 182831 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">T2-weighted sequence showing the ependymoma.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Y. Miranda Bacallado, A. González Hernández, L. Curutchet Mesner, I. Rúa-Figueroa Fernández de Larrinoa" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Miranda Bacallado" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "González Hernández" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Curutchet Mesner" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Rúa-Figueroa Fernández de Larrinoa" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485316000475" "doi" => "10.1016/j.nrl.2015.12.021" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485316000475?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217358081830004X?idApp=UINPBA00004N" "url" => "/21735808/0000003300000003/v1_201804060407/S217358081830004X/v1_201804060407/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2173580818300075" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2017.02.001" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1049" "copyright" => "Sociedad Española de Neurología" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Neurologia. 2018;33:187-91" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1415 "formatos" => array:3 [ "EPUB" => 35 "HTML" => 1109 "PDF" => 271 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Brain disease, connectivity, plasticity and cognitive therapy: A neurological view of mental disorders" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "187" "paginaFinal" => "191" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad cerebral, conectividad, plasticidad y terapia cognitiva. Una visión neurológica del trastorno mental" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1212 "Ancho" => 1675 "Tamanyo" => 175509 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The effects of cognitive stimulation on healthy and injured brains.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Lubrini, A. Martín-Montes, O. Díez-Ascaso, E. Díez-Tejedor" "autores" => array:4 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Lubrini" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Martín-Montes" ] 2 => array:2 [ "nombre" => "O." "apellidos" => "Díez-Ascaso" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Díez-Tejedor" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485317301433" "doi" => "10.1016/j.nrl.2017.02.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485317301433?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580818300075?idApp=UINPBA00004N" "url" => "/21735808/0000003300000003/v1_201804060407/S2173580818300075/v1_201804060407/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Ischaemic stroke secondary to aortic dissection: A diagnostic challenge" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "192" "paginaFinal" => "194" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Muñiz Castrillo, B. Oyanguren Rodeño, E. de Antonio Sanz, M. González Salaices" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Muñiz Castrillo" "email" => array:1 [ 0 => "sermucas@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Oyanguren Rodeño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "de Antonio Sanz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "González Salaices" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Diagnóstico por Imagen, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ictus isquémico secundario a disección aórtica: un reto diagnóstico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 464 "Ancho" => 1399 "Tamanyo" => 74678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest CT-angiography: axial (A) and coronal (B) planes revealing an intimal flap in the ascending aorta.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Aortic dissection is an infrequent condition associated with a high mortality rate.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> The main risk factor is chronic arterial hypertension, followed by obesity, tobacco use, and connective tissue diseases.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> Aortic dissection typically manifests with sudden, intense chest, abdominal, or interscapular pain.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> The Stanford classification distinguishes 2 types: type A, more frequent and severe, involves the ascending aorta and requires emergency surgery, whereas type B affects the descending aorta.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> Although aortic dissection is a rare cause of ischaemic stroke, it does often present with neurological symptoms.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2–4</span></a> We present the case of a patient with a type A aortic dissection manifesting as ischaemic stroke, and provide a brief literature review.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was an 81-year-old woman with hypertension, type 2 diabetes mellitus, and dyslipidaemia. She had had a lacunar stroke (incomplete left-sided sensorimotor stroke) 3 weeks previously; a thorough neurosonology study and a transthoracic echocardiogram performed during admission revealed no alterations. The patient started antiplatelet therapy. A week before visiting the emergency department, she underwent hip fracture surgery, receiving low molecular weight heparin. The patient was at her home when she suddenly presented diplopia, followed by dysarthria and a low level of consciousness. She arrived at the emergency department 30<span class="elsevierStyleHsp" style=""></span>minutes later; she was haemodynamically stable and had no fever. Although the electrocardiogram showed sinus rhythm, her limbs were cold and her pulse weak. The patient showed no heart murmur or asymmetric pulses. During the initial neurological examination, the patient did not open her eyes either spontaneously or in response to any type of stimulus and did not understand or produce language. She showed anarthria, bilateral absent menace response, normal pupils, roving eye movements, predominantly left-sided flaccid paresis, no plantar response bilaterally, and motor response to painful stimuli in the right limbs only. These findings were suggestive of vertebrobasilar stroke. Following our centre's protocol for managing code stroke patients with suspected large-vessel involvement, we performed baseline CT, CT perfusion, and CT-angiography of the supra-aortic trunks and circle of Willis. An additional neurological examination performed before the imaging study demonstrated the following changes: the patient was conscious and alert, she spoke little but showed no signs of aphasia, she had mild dysarthria, left hemispatial neglect, absent menace response of the left eye, and left-sided hypoaesthesia and faciobrachicrural hemiparesis. Unlike the previous results, these findings were suggestive of ischaemia in the territory of the right middle cerebral artery. The baseline CT scan revealed no signs of hyperacute ischaemia. CT perfusion displayed alterations in the vertebrobasilar territory bilaterally and the territory of the right middle cerebral artery. CT-angiography showed no contrast uptake in the right carotid axis, and partial repletion of the middle cerebral artery with blood flow from the contralateral artery. Only the dural segment of the right vertebral artery was visible (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and C). The left carotid axis, both anterior cerebral arteries, the left middle cerebral artery, and the left vertebral artery appeared to be normal. The basilar artery and both posterior cerebral arteries had filiform stenoses but there was no evidence of dissection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). No posterior communicating arteries were observed. We identified an intimal flap in the aortic arch (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), suggesting aortic arch dissection. A chest and abdomen CT scan confirmed type A aortic dissection with a mural thrombus in the ascending aorta. The dissection reached the brachiocephalic artery, right subclavian artery, and right common carotid artery. The patient died several minutes after the study concluded, 2<span class="elsevierStyleHsp" style=""></span>hours after symptom onset.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Neurological symptoms appear in 17% to 40% of patients with aortic dissection,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a> especially those with type A aortic dissection.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,6</span></a> The most frequent neurological manifestations include ischaemic stroke (6%-32%),<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,5,6</span></a> especially right hemispheric stroke (69.2%-71%),<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3–6</span></a> and in some cases bilateral stroke.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> The predominance of right hemispheric strokes has been linked to the greater proximity between the right carotid axis and the aortic root, which increases the vulnerability of the carotid artery origins to the advancing dissection.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> There are 2 possible pathogenic mechanisms: (1) the dissection may block blood flow through the supra-aortic trunks or advance towards them, or less frequently, (2) a mural thrombus may cause artery-to-artery embolism if it reaches the true lumen.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a> Although pain is the main symptom of aortic dissection, one third of patients with associated ischaemic stroke do not experience pain,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> compared to only 5% to 15% of all patients with aortic dissection.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> The low level of consciousness and speech and language alterations may hinder or prevent detection of this symptom.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,5</span></a> This explains the difficulty of detecting aortic dissections initially manifesting with neurological symptoms and the consequent higher mortality rates (30%) than those seen in other cases of aortic dissection (22.6%).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Several complementary tests are used to diagnose aortic dissection; however, given that aortic dissection rarely causes ischaemic stroke, patients with ischaemic stroke are rarely screened for the condition.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Aortic dissection must be ruled out when the condition is suspected (pain characteristic of the condition or typical signs such as low blood pressure; a weak, asymmetric pulse; and murmur of aortic regurgitation<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,5</span></a>): although stroke is not a contraindication for surgery for type A aortic dissection,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,7</span></a> aortic dissection does contraindicate intravenous fibrinolysis,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5,8</span></a> with a mortality rate of 71% in patients receiving rTPA.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Chest radiography shows mediastinal widening or aortic enlargement in 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> While the sensitivity of transthoracic echocardiography is highly variable (35%-80%), transoesophageal echocardiography has a sensitivity of 98%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Elevated D-dimer concentrations have a high sensitivity yet low specificity for diagnosing aortic dissection; negative results may therefore rule out the condition.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,5</span></a> Aortic dissection is usually diagnosed with MRI-angiography or, even more frequently, with CT-angiography, as this technique is readily available. MRI-angiography has 95% to 100% sensitivity and specificity, whereas CT-angiography has 83% to 94% sensitivity and 87% to 100% specificity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Transthoracic echocardiography of the aorta (Focused Assessment with Sonography in Trauma [FAST])<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> is a fast, non-invasive technique for ruling out the condition when the patient is eligible for intravenous fibrinolysis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patient had no pain and did not exhibit any of the classic signs of aortic dissection. These cases require a high level of suspicion, since systemic manifestations may be scarce or not predominant.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We should also point out the fluctuating nature of the patient's symptoms, with 2 different territories being affected almost immediately. This finding should signal possible aortic dissection since few processes are able to trigger such symptoms.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although neurological symptoms usually appear at the onset of aortic dissection,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> in our case, onset may have occurred 3 weeks previously (chronic dissection<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>), causing the first stroke; antiplatelet therapy following stroke plus low molecular weight heparin administered after surgery may have led to the fatal outcome. The dissection may have gone undetected by transthoracic echocardiography since the study did not focus on the aortic root. The aortic root and arch should therefore be studied in cases of stroke of unknown cause; this will help to rule out not only aortic dissection but also ateromatosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Muñiz Castrillo S, Oyanguren Rodeño B, de Antonio Sanz E, González Salaices M. Ictus isquémico secundario a disección aórtica: un reto diagnóstico. Neurología. 2018;33:192–194.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 531 "Ancho" => 1600 "Tamanyo" => 79900 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT-angiography of the circle of Willis. (A) Axial plane showing partial repletion of the right middle cerebral artery. (B) In a coronal reconstruction of the posterior circulation, only the distal segment of the right vertebral artery is visible; the basilar and posterior cerebral arteries demonstrate filiform stenoses. (C) A coronal reconstruction of the anterior circulation shows lack of repletion of the right internal carotid artery and partial repletion of the right middle cerebral artery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 464 "Ancho" => 1399 "Tamanyo" => 74678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest CT-angiography: axial (A) and coronal (B) planes revealing an intimal flap in the ascending aorta.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of acute aortic dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.A. Nienaber" 1 => "R.E. Clough" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(14)61005-9" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2015" "volumen" => "385" "paginaInicial" => "800" "paginaFinal" => "811" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25662791" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical, diagnostic and management perspectives of aortic dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I.A. Khan" 1 => "C.K. Nair" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2006" "volumen" => "122" "paginaInicial" => "311" "paginaFinal" => "328" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12114376" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurological symptoms in type A aortic dissections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Gaul" 1 => "W. Dietrich" 2 => "I. Friedrich" 3 => "J. Sirch" 4 => "F.J. Erbguth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.STR.0000254594.33408.b1" "Revista" => array:6 [ "tituloSerie" => "Stroke" "fecha" => "2007" "volumen" => "38" "paginaInicial" => "292" "paginaFinal" => "297" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17194878" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurologic symptoms in aortic dissection: a challenge for neurologists" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Gaul" 1 => "W. Diestrich" 2 => "F.J. Erbguth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000135646" "Revista" => array:6 [ "tituloSerie" => "Cerebrovasc Dis" "fecha" => "2008" "volumen" => "26" "paginaInicial" => "1" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18511865" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic dissection as a possible underlying cause of acute ischemic stroke" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Kamouchi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1253/circj.CJ-15-0683" "Revista" => array:6 [ "tituloSerie" => "Circ J" "fecha" => "2015" "volumen" => "79" "paginaInicial" => "1697" "paginaFinal" => "1698" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26155852" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eleven years of experience with the neurological complications in Korean patients with acute aortic dissection: a retrospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Lee" 1 => "K. Kin" 2 => "C. Na" 3 => "S. Oh" 4 => "Y. Kim" 5 => "C. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2377-13-46" "Revista" => array:5 [ "tituloSerie" => "BMC Neurol" "fecha" => "2013" "volumen" => "13" "paginaInicial" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23692963" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A patient with acute aortic dissection presenting with bilateral stroke, a rare experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O. Kowalska-Brozda" 1 => "M. Brozda" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.pjnns.2015.04.009" "Revista" => array:6 [ "tituloSerie" => "Neurol Neurochir Pol" "fecha" => "2015" "volumen" => "49" "paginaInicial" => "197" "paginaFinal" => "202" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26048610" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety of intravenous thrombolysis for acute ischemic stroke in specific conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Tsivgoulis" 1 => "S. Apostolos" 2 => "A. Alexandrov" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1517/14740338.2015.1032242" "Revista" => array:6 [ "tituloSerie" => "Expert Opin Drug Saf" "fecha" => "2015" "volumen" => "14" "paginaInicial" => "845" "paginaFinal" => "864" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25845759" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735808/0000003300000003/v1_201804060407/S2173580818300051/v1_201804060407/en/main.assets" "Apartado" => array:4 [ "identificador" => "9409" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735808/0000003300000003/v1_201804060407/S2173580818300051/v1_201804060407/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580818300051?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 47 | 0 | 47 |
| 2024 October | 319 | 10 | 329 |
| 2024 September | 341 | 11 | 352 |
| 2024 August | 346 | 9 | 355 |
| 2024 July | 373 | 18 | 391 |
| 2024 June | 357 | 17 | 374 |
| 2024 May | 351 | 27 | 378 |
| 2024 April | 285 | 18 | 303 |
| 2024 March | 305 | 6 | 311 |
| 2024 February | 348 | 20 | 368 |
| 2024 January | 393 | 11 | 404 |
| 2023 December | 290 | 10 | 300 |
| 2023 November | 468 | 23 | 491 |
| 2023 October | 397 | 10 | 407 |
| 2023 September | 300 | 14 | 314 |
| 2023 August | 203 | 7 | 210 |
| 2023 July | 234 | 15 | 249 |
| 2023 June | 193 | 12 | 205 |
| 2023 May | 293 | 20 | 313 |
| 2023 April | 245 | 20 | 265 |
| 2023 March | 249 | 16 | 265 |
| 2023 February | 173 | 18 | 191 |
| 2023 January | 162 | 18 | 180 |
| 2022 December | 175 | 25 | 200 |
| 2022 November | 201 | 23 | 224 |
| 2022 October | 151 | 13 | 164 |
| 2022 September | 1118 | 33 | 1151 |
| 2022 August | 164 | 13 | 177 |
| 2022 July | 94 | 13 | 107 |
| 2022 June | 114 | 17 | 131 |
| 2022 May | 132 | 12 | 144 |
| 2022 April | 178 | 15 | 193 |
| 2022 March | 174 | 12 | 186 |
| 2022 February | 194 | 10 | 204 |
| 2022 January | 217 | 10 | 227 |
| 2021 December | 105 | 15 | 120 |
| 2021 November | 193 | 24 | 217 |
| 2021 October | 196 | 44 | 240 |
| 2021 September | 169 | 23 | 192 |
| 2021 August | 107 | 11 | 118 |
| 2021 July | 112 | 8 | 120 |
| 2021 June | 129 | 19 | 148 |
| 2021 May | 162 | 12 | 174 |
| 2021 April | 396 | 51 | 447 |
| 2021 March | 253 | 28 | 281 |
| 2021 February | 161 | 25 | 186 |
| 2021 January | 193 | 16 | 209 |
| 2020 December | 146 | 16 | 162 |
| 2020 November | 138 | 19 | 157 |
| 2020 October | 82 | 18 | 100 |
| 2020 September | 140 | 19 | 159 |
| 2020 August | 131 | 12 | 143 |
| 2020 July | 131 | 20 | 151 |
| 2020 June | 129 | 27 | 156 |
| 2020 May | 109 | 24 | 133 |
| 2020 April | 90 | 13 | 103 |
| 2020 March | 104 | 24 | 128 |
| 2020 February | 102 | 13 | 115 |
| 2020 January | 89 | 13 | 102 |
| 2019 December | 87 | 13 | 100 |
| 2019 November | 70 | 13 | 83 |
| 2019 October | 53 | 3 | 56 |
| 2019 September | 111 | 9 | 120 |
| 2019 August | 36 | 1 | 37 |
| 2019 July | 30 | 17 | 47 |
| 2019 June | 63 | 32 | 95 |
| 2019 May | 140 | 38 | 178 |
| 2019 April | 77 | 19 | 96 |
| 2019 March | 11 | 5 | 16 |
| 2019 February | 10 | 5 | 15 |
| 2019 January | 8 | 5 | 13 |
| 2018 December | 9 | 4 | 13 |
| 2018 November | 6 | 2 | 8 |
| 2018 October | 17 | 15 | 32 |
| 2018 September | 17 | 4 | 21 |
| 2018 August | 7 | 3 | 10 |
| 2018 July | 12 | 5 | 17 |
| 2018 June | 13 | 3 | 16 |
| 2018 May | 13 | 1 | 14 |
| 2018 April | 14 | 1 | 15 |
| 2018 March | 2 | 2 | 4 |
| 2018 February | 0 | 1 | 1 |
Show all
