It is a medical emergency! Act fast: a case report of painless aortic dissection

BACKGROUND: A painless presentation of aortic dissection is rare in about 5% of cases. A few case reports discussed about involvement of coronary arteries causing bradycardia. In our case, we are presenting a rare presentation of aortic dissection with initial presentation as bradycardia without involvement of coronary arteries and without cardiac symptoms. CASE SUMMARY: A 56-year-old man with history of hypertension presented with acute onset of altered mental status and right hand numbness. Initial vital signs were remarkable for bradycardia with heart rate 36/min. Physical exam was only significant for decreased sensation for light touch on right hand. Electrocardiogram showing marked sinus bradycardia. Initial computed tomography (CT) head did not show any acute abnormalities. On Day 2, patient complained of new weakness in left upper extremity. On exam, he had dysmetria, left upper extremity drift and cold to touch. Blood pressure was significantly different in both arms with 141/83 mmHg on right and 44/23 mmHg on left. He underwent immediate CT angiography chest showing Type 1 aortic dissection with extension into the brachiocephalic artery and right common carotid artery (RCCA) with thrombosis in RCCA. Patient was emergently taken for surgical repair of aortic dissection and resuspension of aortic valve. DISCUSSION: In our case, the initial presentation of aortic dissection included isolated sinus bradycardia without cardiac symptoms and no evidence for atrioventricular block. The mechanism may have been involvement in the arterial supply of the carotid body receptors. Patients with coexisting symptoms such as bradycardia and neurological deficits should be evaluated for aortic dissection.