Frequency of Aortic Dissection Presenting with Stroke Symptoms
Approximately 17% of all aortic dissections present with neurologic symptoms, and among Type A dissections specifically, 29% present with neurologic complications at initial presentation, with ischemic stroke accounting for about 53% of these neurologic manifestations. 1
Overall Neurologic Presentation Rates
Pooled data from over 1,300 patients across 13 studies (including both Type A and B dissections) found neurologic symptoms in 17% of cases 1
In Type A dissections specifically, 29% of patients had neurologic symptoms on initial presentation 1
Among patients with neurologic symptoms, 53% had ischemic stroke (predominantly right hemispheric), while 37% had ischemic neuropathy 1
Stroke in Acute Stroke Presentations
When examining patients presenting to emergency departments with suspected acute stroke:
AAD accounts for 0.31% (95% CI 0.04-0.57) of all suspected acute stroke patients 2
Among confirmed acute ischemic stroke patients, AAD was the underlying cause in 1.09% (95% CI 0.14-2.05) of cases 2
For acute ischemic stroke patients presenting within 4 hours of onset, AAD accounted for 1.70% (95% CI 0.05-3.36) of cases 2
In surgical series, 10.6-15.7% of Type A dissection patients presented with preoperative stroke 3, 4
Critical Clinical Implications
Up to one-third of patients with neurologic symptoms from dissection present without chest pain complaints, creating a diagnostic trap 1
Up to 50% of dissection-related neurologic symptoms may be transient, further complicating diagnosis 1
Patients presenting with syncope (13% of dissections) more frequently have associated stroke, cardiac tamponade, and decreased consciousness 1
Neurologic deficits occur in up to 40% of patients with proximal (Type A) dissection 5
Mechanisms of Stroke in Dissection
Neurologic complications result from multiple mechanisms 1:
- Hypotension
- Malperfusion of cerebral vessels
- Distal thromboembolism
- Nerve compression
Among patients presenting with cerebral malperfusion signs, 38.4% developed permanent stroke 4
Predictive Factors for Dissection in Stroke Patients
When evaluating acute stroke patients for possible underlying dissection 2:
- Low systolic blood pressure in the right arm (≤110 mmHg) had 100% sensitivity and 94.4% specificity
- Elevated D-dimer (≥5.0 μg/ml) had 100% sensitivity and 91.7% specificity
- Most AAD patients presenting as stroke had disturbed consciousness and did NOT complain of chest pain
Critical Pitfall
Administering thrombolytic therapy (r-TPA) to patients with aortic dissection misdiagnosed as stroke is catastrophic, with reported mortality rates of 71% 6, 7