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A 51-year-old man presented with persistent headaches of 2 months' duration. An ultrasonogram of the carotid arteries revealed subclavian steal on the right. The patient had a substantial surgical history that involved reconstructive skin grafting and local flaps to the head and neck secondary to burn injuries when he was a child. Accordingly, to better evaluate the aortic arch and its brachiocephalic branches, computed tomographic angiography of the neck was performed. The examination revealed an ascending aortic dissection (Fig. 1). The intimal flap extended to the level of the distal aortic arch (Fig. 2) and into the right brachiocephalic and right subclavian arteries (Fig. 3). Antegrade flow was identified in both internal carotid arteries. Computed tomography of the thorax confirmed the diagnosis of a type 1 aortic dissection and a small pericardial effusion. A predisposing factor was not identified. An electrocardiogram revealed sinus rhythm without ischemic changes. A perioperative transesophageal echocardiogram revealed no abnormal morphology or function of the aortic valve and confirmed a type 1 aortic dissection with flow in the true and false lumina. The patient underwent successful surgical repair of the ascending aorta with graft placement.
Acute aortic dissection is an emergency that may cause substantial morbidity and often results in death.1 A timely diagnosis can prove difficult, in the event of an atypical presentation.
Classically, a patient with acute aortic dissection presents with a history of sudden-onset, excruciating, ripping, or tearing anterior chest pain with or without radiation to the back.2 Although studies have shown that a considerable number of patients present with atypical or nonclassical signs or symptoms, headache has not yet been documented among them.3 The cause of this patient's headaches is still unclear. The mechanism of action may be related to decreased cerebral perfusion secondary to antegrade flow and subclavian steal. This novel case exemplifies the importance of pursuing persistent symptoms in order to establish a timely diagnosis and initiate appropriate care.
The authors thank Bruce Kole, MD (Department of Neurology, Providence Hospital & Medical Center) for his evaluation of and care for the patient.
Address for reprints: Danielle Runyan, DO, 350 N. Main St., Unit 812, Royal Oak, MI 48067