2111

Cerebral Infarction Due to Painless Thoracic
Aortic and Common Carotid Artery Dissections
Catherine Veyssier-Belot, MD; Ariel Cohen, MD; Didier Rougemont, MD; Claude Levy, MD;
Pierre Amarenco, MD; Marie-Germaine Bousser, MD
Background: Aortic arch dissection is usually lethal unless emergency surgery is performed. The
dissection rarely may have a benign outcome or may occur without pain and be revealed by cerebral
infarction. It is then likely to be seen primarily by a neurologist. In such cases, the value of new
noninvasive diagnostic testing has not been reported.
Case Description: A 51-year-old man had a sudden left-sided hemiplegia due to hemorrhagic capsular
and caudate infarcts on the right side. Cervical ultrasound examination with color flow imaging showed
a bilateral common carotid artery dissection extending up to the bifurcation. Transesophageal echocardiography showed an aortic arch dissection, involving the inominate and left common carotid artery
origins, which was confirmed by magnetic resonance imaging and aortography. The patient spontaneously
fully recovered and is still alive 24 months after the stroke onset.
Conclusions: This case emphasizes the usefulness of new noninvasive techniques such as transesophageal echocardiography and color-coded Doppler echocardiography in the diagnosis and follow-up of
painless dissection of aortic and common carotid arteries. This cause of stroke may be underestimated.
(Stroke. 1993;24:2111-2113.)
ultrasonics
KEY WoRDs * aortic arch * cerebral infarction * dissection * echocardiography
*

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N eurological symptoms related to acute aortic
dissection have been reported",2 and have
been found to clearly worsen the prognosis.3
However, their mechanism is generally unclear because
such patients usually rapidly died. New screening tools
such as transesophageal echocardiography, color-coded
Doppler echocardiography, and magnetic resonance
imaging are now available for the diagnosis of aortic
arch and common carotid artery dissections4 and should
allow a better understanding of the mechanism of
cerebral infarction in such cases. We had the unique
opportunity to compare the usefulness of these new
noninvasive techniques with angiography in a patient
presenting with an ischemic stroke as the first symptom
of aortic and common carotid artery dissections.

Case Report
A 51-year-old right-handed man with a past history of
heavy smoking suddenly had a left-sided hemiplegia
with facial palsy and dizziness. Computed tomographic
(CT) scan without contrast showed a right capsular and
caudate hemorrhagic infarct. Blood pressure was initially normal, and the patient did not report any thoracic
pain. Electrocardiogram was normal. The next day the
Received May 20, 1993; final revision received July 6, 1993;
accepted July 6, 1993.
From the Departments of Neurology (C.V.-B., D.R., P.A.,
M.-G.B.), Cardiology (A.C.), and Neuroradiology (C.L.), H6pital
Saint-Antoine, Universite Pierre et Marie Curie, Paris, France.
Review of this manuscript was directed by Editor-in-Chief Mark
L. Dyken.
Correspondence to P. Amarenco, MD, Service de Neurologie,
H6pital Saint-Antoine, 184 rue du Fg St-Antoine, 75571 Paris
Cddex 12, France.

patient developed signs of cardiovascular collapse with
convulsions and coma. He was transferred to the intensive care unit, where the shock resolved rapidly and the
state of consciousness improved. Over the next few
days, blood pressure remained high (190/100 mm Hg),
and fever (39°C), inflammatory state, and anemia appeared (erythrocyte sedimentation rate, 130 mm/h;
platelet count, 900 000/mm3; fibrin, 12 g/L; white blood
cell count, 25 000/mm3). The patient was treated for a
presumed aspiration pneumonia.
Two weeks later, the patient was fully conscious but
still had a left-sided hemiplegia and facial weakness,
with no sensory or visual field disturbance. Blood pressure was 180/100 mm Hg. Femoral pulses were weak,
and left posterior tibial and dorsalis pedis pulses were
not found. Bruits were present in carotid and femoral
arteries bilaterally. No diastolic murmur was heard at
cardiac examination. Serum creatinine was 120 ,umol/L.
Cervical ultrasound examination with color-coded
Doppler showed a subintimal dissection with a false
lumen of the right inominate artery and of the right and
left common carotid arteries extending up to their
bifurcation (Fig 1 left). Transcranial Doppler was normal. Transthoracic echocardiography was normal, but
thoracic aorta was poorly visualized. Transesophageal
echocardiography was performed under local anesthesia, mild sedation (midazolam 5 mg IV), and continuous
blood pressure monitoring. It showed a dissection involving the ascending aorta, the arch, and the thoracic
aorta (Fig 1 right). The mobile intimal flap separating
the true and false lumen was visualized 2 cm above the
aortic leaflets. There was no evidence of entry tear using
Doppler color flow imaging and no sign of aortic valve

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Stroke Vol 24, No 12 December 1993

FIG 1. Left, Echography of the common carotid artery with color flow imaging. Dissection of the artery is shown; the
residual lumen is coded in red and the false channel in blue. Right, Transesophageal echocardiography of the aortic arch
with color flow imaging. The residual lumen is coded in red and false channel of the dissection in black (white arrows).

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incompetence, pericardial effusion, or left ventricular
dysfunction. The false channel was well defined and
extended into the ostia of the inominate and left
common carotid arteries. Magnetic resonance imaging
showed the false channel in common carotid arteries
and along the thoracic and abdominal aorta (Fig 2).
Aortography confirmed the lesions and showed an
involvement of the abdominal aorta, left renal artery,
and both common femoral arteries (Fig 3). There were
no signs of fibromuscular dysplasia and no clinical and
familial evidence of Marfan or Ehlers-Danlos syndrome. The patient did not undergo surgery.
Within 8 weeks, the patient fully recovered. Two
years later, he is still alive and has had no recurrent
neurological or cardiovascular symptoms. Follow-up
cervical ultrasound examination with color-coded
Doppler and transesophageal echocardiography showed

FIG 2. Magnetic resonance imaging of the aortic arch
and cervical arteries showing a dissection with false
channel (arrows).

spontaneous echo contrast in the false lumen with no
thrombosis in both the cervical arteries and aorta.

Discussion
The clinical presentation of this patient was most
unusual. First the typical "tearing pain" of aortic arch
dissection was lacking, a feature observed in less than
10% of cases.1,5 Second, short- and long-term outcomes
were favorable. Painless aortic dissections with neurological symptoms are more likely to be seen by neurologists and might have been underdiagnosed in the past
in the absence of angiography with aortography. Neurological ischemic complications are found in less than
20% of patients with aortic dissection and involve the
brain, spinal cord, and peripheral nerves.3,6
Cerebral infarcts are due to common carotid occlusion or artery-to-artery embolism from a thrombus

FIG 3. Angiography of the aortic arch showing a narrowing of the lumen of the thoracic aorta and left carotid.

Veyssier-Belot et al Painless Aortic Arch Dissection

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developed on the intimal surface of the dissected artery.
However, in such a severe condition the exact mechanism is usually determined at autopsy.27 The common
carotid artery can be occluded at its origin by progression of the false lumen with subsequent thrombosis or
by intimal detachment at the branch orifice. It can also
be involved by the upward progression of the dissection
without lumen occlusion. In our patient, it was demonstrated using color flow duplex scanning of extracranial
arteries and transesophageal echocardiography (Fig 1).
This is, to our knowledge, the first case report of a living
individual with combined common carotid and aortic
arch dissections demonstrated by these noninvasive
techniques.
The common carotid artery is often poorly visualized
at aortic arch angiography, and this might explain why
the association of aortic and common carotid artery
dissection, although common at autopsy,7 was never
reported intravitam.8 9 Doppler color flow imaging with
B-mode duplex scanning is now recommended for the
diagnosis of common carotid artery dissection.8
Aortography is still considered the gold standard to
demonstrate the dissection of the aorta and its branches
and recognize aortic valve incompetence; furthermore,
it allows coronary angiography. However, it is an invasive and potentially dangerous procedure that requires
several injections of contrast media and can be falsely
negative. Both CT and ultrafast CT are accurate in
detecting aortic dissection, its extent, and pericardial
effusion in critically ill patients, but they give no information about the aortic valve and require several bolus
injections of contrast material. Magnetic resonance
imaging is useful to evaluate thoracic aortic dissection,
flow void, and false lumen10 with a sensitivity of 90%
and a specificity of 100%, but it cannot be performed in
patients with assisted ventilation, metallic prosthetic
heart valve, or pacemaker. Transesophageal echocardiography allows noninvasive bedside diagnosis of aortic
dissection'1 with a 99% sensitivity and 98% specificity.12
It also assesses the ascending aorta, pericardium, and
aortic valve and in most cases allows a decision regarding surgery to be made without other investigations.4"11'13"4 However, transesophageal echocardiography can be falsely negative in localized aortic arch
dissections and falsely positive in the presence of echo
reverberations. Transesophageal echocardiography is
also acknowledged to be more sensitive than transthoracic echocardiography in searching for a source of
emboli in patients with cerebral infarction.16 The present case shows that it is probably the best way to
diagnose aortic arch dissection in that situation and to
follow up this lesion.
Aortic arch dissection is rarely seen at a chronic stage
(with onset of dissection more than 15 days previously)
because of the high mortality rate in the first 15 days.
Rapid surgery is usually required' and significantly
improves survival,3 even in patients with neurological
symptoms.3 However, in the present case, the extension

2113

of the dissection from the aortic arch up to the bifurcation of common carotid arteries contraindicated surgery. Nevertheless, at 24-month follow-up the patient
had no residual symptoms or signs, and duplex scanning
and transesophageal echocardiography found a spontaneous echo contrast within the false lumen without any
vessel dilatation or thrombus formation.
Painless aortic arch dissection can rarely occur with
cerebral infarction and in that case is likely to be seen by
neurologists. In that situation, Doppler color flow imaging and transesophageal echocardiography are accurate and complementary noninvasive techniques to detect aortic arch and common carotid artery dissections.

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