[DrSeddik]

A 68 year old male patient presents to the ER with tearing abdominal pain radiating to the the back at the interscapular region. He is not a smoker but he has a long history of hypertension, and he is not compliant with his medications. Heart examination is not remarkable except for an abnormal heart sound just before S1. CT scan of the chest shows biluminal aorta that starts at the beginning of the descending aorta. What can be possibly seen on clinical examination:

a- Blood pressure measured at the right arm is higher that of the left arm
b- Blood pressure measured at the left arm higher that of the right arm
c- Bilateral lower limb weakness with palpable femoral pulses
d- Blood pressure measured at the lower limbs are higher than that of the upper limbs.

 

[khanar]

Dissecting aortic aneurysm because of hypertension
I will go with option A
But am not sure

 

[khanar]

Answer is B, I think

 

[tima]

I am between A and B =]

 

[lemontea88]

I think the answer is A because since it starts at the beginning of the descending aorta, probably the left subclavian is affected?

 

[zain4ev2k]

Answer is A guys.

 

[DrSeddik]

Adamkiewicz artery

Coarctation of the aorta has a variable clinical presentation and consequences according to the aortic branches closed by the dissecting intramural part of the aorta. Patients may have strokes, renal failure, MI, mesenteric ischemia, peripheral limb ischemia or paraparesis. Paraparesis/paraplegia is not uncommon, presenting in 10% of cases, usually not due to involvement of the arch branches rather than the artery of Adamkiewicz (arteria radicularis magna). The later has a highly variable origin but it usually originates from the lower intercostal arteries or from upper lumbar artery, a posterior aortic branch, to join the anterior spinal artery at T8, making this area a watershed area and vulnerable to ischemia.

a- For management purpuses, aortic dissection has been categorised type A or B, type A involves the arch of the aorta and it's usually managed surgically for fear of invovement of arch branches, type B spares the arch and is usually managed medically, unless complications arise. Clinically, it's ominous to find that BP reading on the right arm is higher than the left arm because it means invovement of the arch, specifically left subclavian artery, which is not a branch from the descending aorta. Some authors classify type A or B according to the involvement of left subclavian artery or sparing it respectively. Type A acconts for two thirds of cases.
c- Correct answer
d- Blood pressure readings in the lower limbs should be lower than upper limbs.

The dissection takes place at the media, pain is tearing in quality and mybe felt in the chest (ascending aorta) or interscapular (dessecding aorta involvement).

 

[khanar]

Interesting
Nobody answered it right

 

[DrSeddik]

I certainly wouldn't answer it right, though it does happen clinically, and it's referred to in FA.. But anyway, it gives a deeper understanding to the subject.

 

[lemontea88]

Wow, great info!

Between DrSeddik, i still don't get why would the femoral pulses be palpable? Shouldn't it be weaker?

 

[DrSeddik]

They should be weaker that's correct... by palpable pulses I meant not absent, to avoid the possibility of bilateral lower limb ischemia as a cause for the lower limb weakness, in the case the artery affected is above the common iliacs, so femoral pulses should not be absent, they should be weak..

 

[lemontea88]

Ahh I see. Thanks.