American Journal of Emergency Medicine 32 (2014) 291.e5–291.e6
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Headache: a rare manifestation of Debakey type I aortic dissection Abstract The most common manifestations of aortic dissection (AD) are severe chest pain and back pain. However, we experienced a rare case of type I aortic dissection with bilateral common carotid artery involvement, which presented with only a sudden thunderclap bifrontal headache. A 61-year-old man was admitted to emergency department because of intense bi-frontal headache with posterior neck pain. The episode started acutely when he was sweeping the yard in the morning. The characteristic of headache was continuous throbbing. He complained this episode was the most severe headache he had ever experienced. He didn’t complain of any other thoracic or abdominal symptoms. Neck stiffness and posterior neck pain occurred coincidentally when the headache started. He had a history of hypertension diagnosed 6 years ago, and was on anti-hypertensive medication. Other cardiovascular risk factors were not known. No intracranial hemorrhage was found on admission, his temperature was 36°C, the blood pressure was 137/70 mm Hg, and the pulse was 67. There was no cardiomegaly and mediastinal widening on chest radiograph. No focal neurologic deﬁcits were found. On the initial non-contrast brain computed tomography (CT). We could auscultate carotid bruit on left side neck on following physical exams. Ultrasonography of carotid arteries revealed intimal ﬂap in left common carotid artery (CCA). Transthoracic echocardiography showed mild aortic regurgitant ﬂow with intimal ﬂap on ascending aorta. Then we took a carotid CT angiography in order to rule out vascular accident on neck vessels. Dissections on right brachiocephalic trunk and left common carotid artery were observed and there was a ﬂap on aortic arch (Fig.). The diagnosis of Debakey type I AD was conﬁrmed by serial chest contrast CT. The common manifestations of AD are chest pain and extending back pain. Nohe et al, however, reported a case of AD involving supraaortic branch and left CCA with sudden-onset headache and loss of consciousness . Zach also reported 12 cases of AD extending to involve the branch of aortic artery . Their common presenting symptoms and signs were hemiparesis, decreased consciousness and dizziness, etc. There was no case with headache as the presenting symptom. But Singh et al found one case of AD without involvement of CCA with headache as the presenting symptom in 2007 . In the case of Singh et al, that manifested headache as the main symptom did not involve the CCA. Headache may be the presenting symptom in cases without CCA involvement but it was rare in cases with neck vessel involvement.
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It is suggested that the headache is due to either distension of the carotid artery or ischemia to the pericarotid plexus . But in our case with involvement of right brachiocephalic artery and left CCA, there was neither abdominal nor thoracic symptom compared to other AD with involvement of CCA. This case is signiﬁcant because it is a rare case that involves CCA with headache as the only presenting symptom. Subarachnoid hemorrhage (SAH) should be suspected if the patient complains of sudden headache and neck pain. As 2008, Byyny et al noted that noncontrast cranial CT had 93% sensitivity for detecting SAH, thus 7% of SAH cases could be missed by CT . So spinal tapping should be considered in clinically suspicious situations. As illustrated by this case, headache could be the presenting symptom without any thoracic or abdominal symptom of AD with involvement of CCA, so AD should always be suspected as our case. We heard carotid bruit in our case when initial precontrast brain CT revealed no SAH. So, if clinical course is not presented as we assume SAH, carotid bruit should be heard before the spinal tapping is done when initial precontrast brain CT is normal in patients with headache. We also suggest the necessity of performing Ultrasonography in neck vessels to study vascular events in the situation which clinically presenting different from what we assume.
Jung-In Ko, MD Taejin Park, MD Department of Emergency Medecine National Medical Center Seoul, South Korea E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2013.10.022 References  Nohe B, Ernemann U, Tepe G, et al. Aortic dissection mimicking subarachnoidal hemorrhage. Anesth Analg 2005;101(1):233–4 table of contents.  Zach V, Zhovtis S, Kirchoff-Torres KF, et al. Common carotid artery dissection: a case report and review of the literature. J Stroke Cerebrovasc Dis 2012;21(1):52–60.  Singh S, Huang JY, Sin K, et al. Headache: an unusual presentation of aortic dissection. Eur J Emerg Med 2007;14(1):47–9.  Biousse V, D'Anglejan-Chatillon J, Massiou H, et al. Head pain in non-traumatic carotid artery dissection: a series of 65 patients. Cephalalgia 1994;14(1):33–6.  Byyny RL, Mower WR, Shum N, et al. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med 2008;51(6):697–703.
J.-I. Ko, T. Park / American Journal of Emergency Medicine 32 (2014) 291.e5–291.e6
Fig. Contrast-enhanced computed tomographic image on neck and chest shows left common carotid artery dissection (arrow) and ﬂap in aortic arch level (arrow head) (A), right brachiocephalic trunk (arrow) and left carotid artery (arrow head) dissection (B), and dissection ﬂap on aortic arch (C).