55-year-old man presented to the emergency department via EMS transport after he was found seizing. He was last seen in his prior state of health approximately 45 minutes prior to presentation. Primary evaluation revealed an unresponsive patient with a GCS of 3 who was undergoing full body shaking punctuated with short periods of extensor positioning. Initial vital signs were within normal limits, auscultatory findings of the heart and lungs revealed no abnormalities, the abdomen was soft, pulses in all 4 extremities were easily palpable and symmetric. The patient was intubated and treated for status epilepticus to no effect. An intracranial bleed was ruled out by CT head. A portable chest x-ray revealed a mildly widened mediastinum. Transabdominal ultrasound was performed (Figures 1 and 2).

Diagnosis…

 Aortic Dissection, DeBakey Type I.

An aortic dissection occurs when the inner lining of the aorta, the intima, becomes damaged enough for blood flow to penetrate the middle layer of the aorta, the media. When this occurs, the high pressure arterial blood flow can dissect through the media, separating the intima from the adventitia, creating a true lumen and a false lumen to the vessel. When the layers are dissecting in the same direction as blood flow, this is called anterograde dissection, and the reverse is called retrograde dissection. Retrograde dissection is dangerous, as a defect that starts distal to the aortic root can dissect backwards into the pericardium to create an acute pericardial effusion that leads to cardiac tamponade. A dissection that involves aortic branches, such as the coronary, carotid, subclavian, celiac, mesenteric, renal, and iliac arteries can lead to presentations of dissection commensurate with ischemia to the corresponding organ or region supplied by each vessel.

CT aortogram showed a Type 1 dissection starting at the aortic root and extending into the carotids bilaterally, the right subclavian artery, celiac trunk, SMA, and left iliac.