Dual Threat: Hemodynamic Challenges in Stroke With Acute Type A Aortic Dissection

Introduction: Management of acute ischemic stroke in the setting of concurrent aortic dissection presents a clinical dilemma due to conflicting hemodynamic goals. Stroke management typically avoids significant blood pressure reduction to preserve cerebral perfusion, whereas acute aortic dissection requires anti-impulse therapy to minimize aortic wall stress.


Description: A 72-year-old male with hypertension and BPH presented as a stroke alert with right facial droop and left-sided weakness (NIHSS 28). Initial imaging revealed an intimal flap in the aorta, prompting CT angiography, which showed a Stanford type A dissection extending from the aortic root to the right femoral and left common iliac arteries. Visceral branches involved included the IMA, SMA, celiac, and right carotid arteries, with associated right cerebral infarction. tPA was not contraindicated. Esmolol and nicardipine infusions were started with goals of systolic BP < 120 mmHg and HR < 60 bpm. Given the early stage of potential stroke evolution, neurointerventional radiology supported emergent surgical repair. Cardiothoracic surgery performed emergent repair with hemiarch graft replacement, moderate hypothermic circulatory arrest, and antegrade cerebral perfusion. Postoperatively, BP was maintained around 140 mmHg with HR < 100 bpm using norepinephrine, nitroglycerin, and nicardipine infusions. CT brain revealed right frontoparietal and occipital infarcts in a watershed pattern. The patient eventually woke up and able to follow commands except persistent left upper extremity weakness.


Discussion: Concurrent ischemic stroke and aortic dissection demand careful, individualized hemodynamic management. Prioritizing aortic protection may risk cerebral hypoperfusion, while maintaining cerebral perfusion may exacerbate aortic wall injury. This case emphasizes the importance of tailored decision-making to navigate conflicting therapeutic goals and reduce morbidity in critically ill patients.