□ ORIGINAL ARTICLE □

Hyper-acute Stroke Patients Associated
with Aortic Dissection
Yasuyuki Iguchi, Kazumi Kimura, Kenichiro Sakai, Noriko Matsumoto,
Junya Aoki, Shinji Yamashita and Kensaku Shibazaki

Abstract
Backgrounds and propose Intravenous thrombolysis using tissue plasminogen activator (tPA) can improve
patient outcomes in acute stroke if administered within 3 hours of onset. However, patients with aortic dissection should avoid tPA therapy due to the possibility of tPA administration inducing rupture of the aortic
dissection. We studied the frequency and clinical characteristics of stroke patients presenting with aortic dissection within 3 hours of onset.
Methods Among stroke patients admitted to our hospital within 3 hours of onset, we examined the frequency of patients presenting with aortic dissection. Next, we examined the clinical characteristics of such
patients, including cases published on PubMed.
Results Among 208 stroke patients presenting within 3 hours of onset, 2 patients (1%) displayed aortic dissection. Carotid duplex ultrasonography could exclude them from tPA therapy. For 19 patients, including 17
published cases from PubMed, median age was 61.0 years, 47% were women, right pulse weakness was seen
in 70%, chest pain in 22%, and lone left hemiparesis in 72%. In 6 patients, carotid ultrasonography showed
arterial dissection due to aortic dissection.
Conclusion Aortic dissection may not be a rare complication in acute stroke within 3 hours of onset. Right
pulse weakness and left hemiparesis are often present. Carotid ultrasonography may be useful in diagnosing
aortic dissection before tPA infusion.
Key words: acute stroke, aortic dissection, carotid duplex ultrasonography, tPA
(Inter Med 49: 543-547, 2010)
(DOI: 10.2169/internalmedicine.49.3026)

Introduction
Recombinant tissue plasminogen activator (tPA) for the
treatment of acute ischemic stroke within 3 hours of onset
requires precise inclusion and exclusion criteria. In particular, patients with a high risk of hemorrhagic complications
should be excluded as candidates for intravenous thrombolysis using tPA (IV-tPA). This is because hemorrhagic complications such as intracerebral hemorrhage and gastrointestinal
bleeding can induce poor outcomes and high mortality rates.
Stanford type A dissection causes ischemic stroke in up to
5-10% of patients by extension of the dissection into the
common carotid arteries, thromboembolism or cerebral hypoperfusion (1). Although both aortic dissection and acute

ischemic stroke are medical emergencies, we occasionally
experience difficulty in diagnosing aortic dissection for patients with acute stroke displaying atypical symptoms and
signs, particularly in those without pain (2). After stroke
physicians have identified aortic dissection as a major contraindication against IV-tPA in the emergency room, urgent
repair of the thoracic aorta should be performed. Indeed, IVtPA should be avoided for stroke patients in the setting of
aortic dissection, given the high risk of aortic rupture. However, especially in the clinical setting, the importance of
rapid and accurate diagnosis for aortic dissection prior to
IV-tPA has still been underestimated and overlooked. The
aim of this study was thus to estimate the frequency of
acute ischemic stroke associated with aortic dissection
within 3 hours of onset in our institute, and to investigate

Department of Stroke Medicine, Kawasaki Medical School, Kurashiki
Received for publication October 16, 2009; Accepted for publication November 24, 2009
Correspondence to Dr. Yasuyuki Iguchi, yigu@med.kawasaki-m.ac.jp

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DOI: 10.2169/internalmedicine.49.3026

the clinical characteristics of acute stroke with aortic dissection based on published articles in the literature.

Methods
Consecutive patients presenting with acute ischemic
stroke within 3 hours of stroke onset between October 2005
and August 2008 were studied. Inclusion and exclusion criteria for IV-tPA were applied in accordance with the Japan
Alteplase Clinical Trial (3). Magnetic resonance imaging
and magnetic resonance angiography were performed in
stroke patients to diagnose cerebral ischemia. Carotid duplex
ultrasonography was performed immediately after hospital
arrival to detect the presence of carotid arterial lesions.
Stroke neurologists determined the National Institutes of
Health Stroke Scale (NIHSS) score on admission.
Concerning a diagnosis of aortic dissection, when stroke
neurologists found 1) hypotension, 2) asymmetrical peripheral pulses in upper and lower extremities, 3) complaint
about chest or back pain, 4) mediastinal widening in chest
roentgenography, and/or 5) intramural hematoma, intimal
flap, false lumen, and/or intra-arterial floating sign on carotid duplex ultrasonography, indicating the presence of carotid arterial dissection, chest CT was performed immediately before IV-tPA.
In addition, all available published case reports on aortic
dissection in acute ischemic stroke patients presenting within
3 hours of onset and appearing eligible for IV-tPA were
identified in the PubMed database using the search terms
“aortic dissection”, “dissecting aneurysm”, “ischemic stroke”
and “cerebral infarction”. We then investigated the clinical
characteristics of previously published cases and those cases
identified in our series. To be included in this review, the
following findings had to be reported: 1) duration from onset to admission, 2) neurological symptoms at presentation,
3) clinical findings suspecting aortic dissection (back pain,
pulse laterality, and hypotension), 4) chest roentgenography
and carotid ultrasonography, 5) administration of IV-tPA and
surgery, and 6) inhospital mortality. This study was conducted in accordance with the Declaration of Helsinki.

Results
In our institute, 208 consecutive ischemic stroke patients
presenting within 3 hours of onset (median age, 73.0 years;
125 men, 83 women) were enrolled. The interval from onset
to hospital was 1.6 hours (range, 1.1-2.2 hours) and median
NIHSS score was 9. Aortic dissection was found in 2 (1%,
95% confident interval; 0.1-3%) of the 208 cases. IV-tPA
was administered for 87 patients (41%).
Case 1
A 72-year-old woman with a history of hypertension felt
disability of the left arm. She was admitted to our emergency room 0.8 hours after onset. Although consciousness
was slightly disturbed, she did not complain of any chest

discomfort or pain. On examination, blood pressure was 83/
34 mmHg. Heart sounds were regular without murmurs and
peripheral arterial pulsations were asymmetrical. Left hemineglect was identified, and her eyes deviated to the right.
Left hemiparesis was seen, with NIHSS score of 18 on admission. Diffusion-weighted magnetic resonance imaging
showed a moderate hyper-intense lesion in the right hemisphere. Chest roentgenography showed no pulmonary edema
or mediastinal widening suggestive of aortic dissection. Carotid ultrasonography revealed an intimal flap in the right
common carotid artery (Fig. 1A). Urgent chest CT showed
type A thoracic aortic dissection (Fig. 1B). As a result, we
completely excluded this patient as a candidate for IV-tPA.
Emergent surgical repair of the dissection was performed,
but she died on hospital day 8.
Case 2
A 72-year-old woman with a history of hypertension was
seen due to the inability to move her left side. She was admitted to our hospital 1.9 hours after onset. In the emergency room, she did not complain of chest pain. Blood pressure was 150/64 mmHg. Left hemiparesis was identified on
admission, with an NIHSS score of 8. Diffusion-weighted
magnetic resonance imaging showed a moderate hyperintense lesion on the right hemisphere. Chest roentgenography showed no pulmonary edema or mediastinal widening.
Verbal communication was lost with loss of consciousness
during transportation from the emergency room to the stroke
care unit. Peripheral arterial pulsations were asymmetrical
and hypotension status was sustained. Carotid ultrasonography revealed the presence of right carotid arterial dissection
with an intimal flap (Fig. 1C). Urgent chest CT showed type
A thoracic aortic dissection (Fig. 1D). The patient was thus
excluded as a candidate for IV-tPA. Although cardiopulmonary resuscitation was performed, she was unable to recover
from cardiac arrest due to shock status and died before going into surgery.
In a literature search using the PubMed database, regarding the review of acute stroke with aortic dissection, we
identified another 17 cases (median age, 61.0 years; 7
women, 10 men). Table 1 shows the clinical features of
acute stroke with aortic dissection including both the present
and published cases (2, 4-15). Nineteen patients (10 men;
median age, 61 years; age range 56 to 72 years) were admitted to hospital within 3 hours of onset (median duration, 0.5
hours; range, 0.45 to 0.8 hours). Of them, 15 (79%) patients
showed loss of consciousness. Interestingly, pain was found
in only 4 patients. Diminished pulsation in the right arm
was documented as a distinctive physical finding in 7 of 10
patients (70%). Right hemiparesis alone was observed in
only 3 of 19 patients (16%) and most (74%) showed leftside weakness. Concerning chest roentgenography, 5 of 12
patients (42%) exhibited enlargement of the mediastinal or
cardiac silhouette. All 6 cases who underwent duplex ultrasonography showed positive findings for presence of carotid
arterial dissection, such as intimal flap in cases 1, 2, 13, and

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DOI: 10.2169/internalmedicine.49.3026

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19, diffuse luminal narrowing of left common carotid artery
in case 3, and proximal right carotid arterial occlusion in
case 10. Surgical retraction and replacement of aortic dissection were done in 11 (58%) patients. IV-tPA was administered in 3 (16%) patients (cases 6, 9, 10). Case 6 became
comatose after IV-tPA. His neurological examination did not
improve and he died 6 days after admission. In case 9, with
an initial NIHSS score of 18, during IV-tPA he complained
of severe back pain. Urgent chest CT showed the type A
aortic dissection, and then emergency operation was performed. After the operation, he regained neurological improvement. One month of postoperatively, he was discharged. Case 10, with an initial NIHSS score of 16, received IV-tPA 150 minutes after onset. As the standard protocol of neurosonological examination, duplex ultrasonography showed the proximal common carotid arterial occlusion
which was unusual finding of atherosclerosis and cardioembolism. Immediately after stopping IV-tPA, urgent CT revealed type A aortic dissection. Emergency operation was
performed, but her stroke symptoms did not improve much
3 months after onset. Overall, the inhospital mortality of 19
cases was 33% of patients treated by IV-tPA and 63% without IV-tPA.

Discussion
In our series, 1% of hyper-acute ischemic stroke patients

suffered aortic dissection on admission. Considering the present cases together with the previous reports, 4 major findings for stroke with aortic dissection are apparent: 1) presentation without pain; 2) left hemiparesis; 3) negative findings
on chest roentgenography; and 4) utility of carotid duplex
ultrasonography.
Chest or back pain is one of the most common and important complaints for aortic dissection. Around 80% of patients with aortic dissection present with initial chest
pain (16, 17). However, when patients have some neurological manifestation at onset, only two-thirds complain to physicians about chest or back problems (17). Painless dissection should be associated with increased mortality, and is accompanied by syncope and neurological manifestations due
to cerebral ischemia (18). The present results are partially in
line with the report by Gaul et al (17). The reason for this
may be that stroke patients with neurological deficit already
experience a loss of consciousness or syncope at onset.
When a patient is already unconscious on admission, recognition of precise complaints will obviously be difficult.
Neurological deficit on aortic dissection is mainly attributable to ischemia of the nervous system, such as the brain,
spine and peripheral nerves. Neurological involvement was
found in 30% of patients with aortic dissection (17). When
we referred to post-marketing reports of stroke cases with
aortic dissection treated by IV-tPA, all 9 cases showed left
hemiparesis (19). The mechanism of cerebral ischemia fol-

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DOI: 10.2169/internalmedicine.49.3026

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lowing aortic dissection may be considered as follows. In
most Stanford type A dissections, the aortic wall seems to
be laid open from the end of the aortic valve (2). First,
when the pseudo-lumen of the aorta does not involve the innominate artery, major neurological deficits due to cerebral
ischemia are rare. The arterial walls of the innominate and
right common carotid arteries are separate, and neurological
manifestations of the right hemisphere are found, such as
left hemiparesis and spatial neglect. Finally, when aortic dissection spreads to other arteries that have branched from the
aorta, right hemiparesis may be observed (2). With regard to
this hypothesis, laterality of pulsation is an important component for initial diagnosis, as the innominate and right carotid arteries should be completely or partially occluded. Indeed, in previous reports including the present 2 cases, 6 of
7 patients with asymmetrical pulsation displayed left hemiparesis. We thus consider both asymmetric radial pulsation
and left hemiparesis as warning signs for acute stroke with
aortic dissection.
Concerning vascular ultrasound, duplex ultrasonography
offers a sensitive and non-invasive tool for diagnosis of ca-

rotid arterial dissection when specific findings are identified (14). Established findings of arterial dissection on duplex ultrasonography are intramural hematoma, intimal flap,
false lumen, and intra-arterial floating sign in the common
carotid artery (4, 6, 14). Indeed, all 6 cases who underwent
duplex ultrasonography had positive findings in common carotid artery. Where applicable, we recommend duplex ultrasonography for acute stroke patients with eligibility for IVtPA immediately after admission.
In conclusion, 1% of hyper-acute ischemic stroke patients
admitted to our facility seem to have aortic dissection. We
urge caution for the possible presence of aortic dissection if
asymmetrical pulses, hypotension and/or left hemiparesis are
evident. Urgent estimation by duplex ultrasonography may
play an important role in diagnosing cerebral malperfusion
due to aortic dissection.
Acknowledgement
We have no conflict on interest disclosure. This manuscript has
not been supported by any grant and we do not have a financial
disclosure.

References
1. Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 122: 311-328, 2002.
2. Morita S, Shibata M, Nakagawa Y, Yamamoto I, Inokuchi S.
Painless acute aortic dissection with a left hemiparesis [online].
Available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=PubMed&dopt=Citation&list_uids=16757829
Accessed 3.
3. Yamaguchi T, Mori E, Minematsu K, et al. Alteplase at 0.6 mg/kg
for acute ischemic stroke within 3 hours of onset: Japan Alteplase

546

Clinical Trial (J-ACT). Stroke 37: 1810-1815, 2006.
4. Kawarabuki K, Sakakibara T, Hirai M, et al. Acute aortic dissection presenting as a neurologic disorder. J Stroke Cerebrovasc Dis
15: 26-29, 2006.
5. Stanley I, Sharma VK, Tsivgoulis G, Lao AY, Alexandrov AV.
Painless aortic dissection with unusual extension into intracranial
internal carotid arteries. Cerebrovasc Dis 24: 314-315, 2007.
6. Yeh JF, Po H, Chien CY. Ischaemic infarction masking aortic dissection: a pitfall to be avoided before thrombolysis. Emerg Med J

Inter Med 49: 543-547, 2010

DOI: 10.2169/internalmedicine.49.3026

24: 594-595, 2007.
7. Baydin A, Nargis C, Nural MS, Aygun D, Karatas AD, Bahcivan
M. Painless, acute aortic dissection presenting as an acute stroke.
Mt Sinai J Med 73: 1129-1131, 2006.
8. Chua CH, Lien LM, Lin CH, Hung CR. Emergency surgical intervention in a patient with delayed diagnosis of aortic dissection
presenting with acute ischemic stroke and undergoing thrombolytic therapy. J Thorac Cardiovasc Surg 130: 1222-1224, 2005.
9. Uchino K, Estrera A, Calleja S, Alexandrov AV, Garami Z. Aortic
dissection presenting as an acute ischemic stroke for thrombolysis.
J Neuroimaging 15: 281-283, 2005.
10. Wright V, Horvath R, Baird AE. Aortic dissection presenting as
acute ischemic stroke. Neurology 61: 581-582, 2003.
11. Villa A, Molgora M, Licari S, Omboni E. Acute ischemic stroke,
aortic dissection, and thrombolytic therapy. Am J Emerg Med 21:
159-160, 2003.
12. Flemming KD, Brown RD Jr. Acute cerebral infarction caused by
aortic dissection: caution in the thrombolytic era. Stroke 30: 477478, 1999.
13. Kubota T, Niwa J, Chiba M, Mikami T, Oka S. Common carotid
artery dissection propagated from acute aortic dissection: a case

successfully treated by PTA. No Shinkei Geka 28: 1015-1021,
2000.
14. Kimura K, Hashimoto Y, Dosaka A, Terasaki T, Uchino M. A case
report of thoracic aortic and common carotid artery dissecting
aneurysm diagnosed by duplex ultrasound examination. Rinsho
Shinkeigaku 36: 348-351, 1996.
15. Fessler AJ, Alberts MJ. Stroke treatment with tissue plasminogen
activator in the setting of aortic dissection. Neurology 54: 1010,
2000.
16. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International
Registry of Acute Aortic Dissection (IRAD): new insights into an
old disease. Jama 283: 897-903, 2000.
17. Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological
symptoms in type A aortic dissections. Stroke 38: 292-297, 2007.
18. Park SW, Hutchison S, Mehta RH, et al. Association of painless
acute aortic dissection with increased mortality. Mayo Clin Proc
79: 1252-1257, 2004.
19. Nakagawara J. A discussion on reported 10 cases given alteplase
and author’s seires of acute ischemic stroke with acute aortic dissection. Jpn J Stroke 30: 452-454, 2008.

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