DOI: 10.36347/sjmcr.2017.v05i05.009

Pages: 324-326

An 87-year-old female became comatose after complaining of severe headache. Upon arrival, her Glasgow Coma Scale was a sum score of 6, with a systolic blood pressure of 60 mmHg and heart rate of 120 beats per minute. She had isocoric non-reactive pupils 3 mm in diameter. Other her results of a physical examination were negative. Although plain head CT showed no intracranial hemorrhage, enhanced trunk CT disclosed Stanford A type aortic dissection (AD) with cardiac tamponade without expansion of dissection to either or both the carotid or vertebral artery. After immediate pericardiocentesis, she achieved stable circulation and was thereafter transferred to another hospital for emergency operation. Headache without chest or back pain as the initial manifestation of acute AD is extremely rare, and examination of the literature revealed three previous cases with the following patterns of presentation: 1) the headache is referred pain from the AD, 2) the expansion of dissection to either or both the carotid or vertebral artery from the AD causes a headache, and 3) the headache is a complication of hemorrhagic stroke and the AD due to hypertension. Atypical cases often lead to misdiagnosis and poor outcome. One point to note in detecting AD with atypical presentation is that patients presenting with headache due to AD may have hypotension, which is unusual in standard stoke cases. Given the high morbidity and mortality after misdiagnosis of the AD, patients with headache and shock should be evaluated by enhanced truncal computed tomography.