A transient spinal cord ischemia reveals a silent type A aortic dissection

Aortic dissection is a life-threatening vascular emergency that requires a prompt diagnosis and management. Isolated spinal transient ischemic accident is an extremely rare manifestation of Aortic Dissection (AD) type A. Thus, AD should be on the top of the aetiology list, despite the isolated character of the neurological presentation. A 53-year-old man, previously healthy, presented to the emergency department for a right sided renal colic documented by a uroscan showing a right ureterovesical junction stone (Figure 1). Initial blood tests were normal. While symptomatic treatment was being administered, he presented an acute paraplegia with anaesthesia of both lower limbs in all modalities below T4. Deep tendon reflexes were absent and plantar reflex was indifferent bilaterally. His blood pressure was 200/140 mmHg. His symptoms self-resolved after 20 minutes. He denied any significant thoracic or back pain, and had no signs of limb ischemia. Cardiac auscultation was normal and pulses were palpable and symmetric in all extremities. Electrocardiogram, transthoracic echocardiography and enhanced total spine MRI (Figure 2) were all normal. CT angiography of the aorta (Figure 3) identified a Stanford type A AD extending from the supravalvular segment until the right iliac artery. All branches of the aorta arose from the true lumen. The patient's blood pressure was controlled with intravenous labetalol and he received urgent surgical repair of the dissection with a 36 mm Hemashield graft and an aortic valve replacement with a 25 St. Jude Trifecta valve. His evolution was uneventful and was discharged home soon after.