Neck ecchymosis: a rare symptom in a ruptured thoracic aorta dissection | |
DOI: 10.5606/e-cvsi.2015.331 | |
Abdülkadir Ercan1, Orçun Gürbüz1, Gencehan Kumtepe1, İlker Hasan Karal2, Yusuf Velioğlu3, Hakan Özkan4, Serdar Ener5 | |
1Department of Cardiovascular Surgery, Medical Faculty of Balıkesir University, Balıkesir, Turkey 2Department of Cardiovascular Surgery, Samsun Training and Research Hospital, Samsun, Turkey 3Department of Cardiovascular Surgery, Medical Park Uşak Hospital, Uşak, Turkey 4Department of Cardiology, Medical Faculty of Bahçeşehir University, İstanbul, Turkey 5Department of Cardiovascular Surgery, Acıbadem Bursa Hospital, İstanbul, Turkey |
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Keywords: Neck ecchymosis; ruptured thoracic aortic dissection; thoracic endovascular aortic aneurysm repair | |
A 73-year-old woman was admitted to the emergency room with sudden onset of neck swelling, ecchymosis, and chest pain. Computed
tomography revealed a ruptured type B dissection and mediastinal hematoma extending towards the neck. The patient underwent
emergent endovascular repair and the procedure was accomplished without any signs of endoleak. She was discharged on the fourth
postoperative day and has been followed for 50 months without any complaints. |
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Acute type B aortic dissection is a life-threatening
condition associated with high morbidity and mortality
in the current era.[1] Medical therapy is the first
treatment of choice for uncomplicated type B acute
aortic dissection, while complicated acute type B
dissections require an urgent approach by an open
surgical or endovascular intervention. Sudden-onset
chest or back pain without any evidence of myocardial
ischemia is the most common symptom.[1,2] Other
signs and symptoms such as syncope, cerebrovascular
accidents, altered mental status, numbness and tingling,
pain or weakness in the extremities, the pressure
difference between the extremities or pulseless, Horner
syndrome, dyspnea, hemoptysis, dysphagia, flank pain
abdominal pain, anxiety and premonitions of death are
also well-described.[1,2] In very rare cases, ecchymosis
on the skin of the neck and upper chest wall caused
by a rupture into the mediastinum has been also
reported.[3-5] Herein, we report an unusual case of a patient who presented to the emergency department with complaints of sudden neck swelling and ecchymosis. The patient was diagnosed with a ruptured type B dissection and treated by endovascular technique. This case is presented due to its rarity and discussed in the light of treatment options based on the literature data. |
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CASE PRESANTATION
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A 73-year-old woman presented to the emergency
department with sudden onset of chest pain, neck
swelling and ecchymoses (Figure 1). Her medical history revealed no head or neck trauma. She was on
treatment for ischemic heart disease, hypertension,
chronic obstructive pulmonary disease, and type 2
diabetes mellitus. She also had a previous history of
thyroid surgery. Figure 1: Large neck ecchymosis extending onto the upper chest wall. Physical examination revealed a large neck ecchymosis extending onto the upper chest wall. All peripheral pulses were symmetrically palpable and there was no pressure difference between the upper extremities. Neurological examination was unremarkable. Her blood pressure was 160/90 mmHg, heart rate was 112 bpm, respiratory rate was 25 bpm, temperature was 36.5 °C, and oxygen saturation by pulse oximetry was 90% on room air. The hemoglobin level was 9.8 g/dL. A complete blood count demonstrated white blood cell count of 14,300/mm3, hemoglobin level of 9.8 g/dL, and platelet count of 231,000/mm3. Coagulation studies revealed an international normalized ratio (INR) of 1.2. Computed tomography (CT) examination demonstrated a ruptured type B dissection causing mediastinal and neck hematomas without hemothorax (Figure 2). She was immediately brought to the angiography suite for endovascular treatment. Through left femoral artery, two thoracic endografts (Medtronic Valiant, Medtronic AVE, Santa Rosa, CA) were deployed from just beyond the origin of the left subclavian artery to the mid-descending thoracic aorta. Repeated angiogram did not show any evidence of endoleak at the end of the procedure. She was discharged on the fourth postoperative day. The follow-up CT at one month showed total exclusion of dissection without endoleak and size reduction of the mediastinal hematoma (Figure 3). |
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Ruptured aorta dissection is a fatal disorder, if left
undiagnosed and untreated timely. It presentation
may be nonspecific. Sudden-onset chest or back
pain without any evidence of myocardial ischemia
is the most common symptom, which accounts for
approximately 90% of cases.[3,4] Paraplegia, hemiplegia,
peripheral ischemia, and syncope are among the other
well-described symptoms.[1,2] Our case presented with
sudden onset neck ecchymosis, which is uncommon
and unexpected.[3-5] The mechanism of the neck
ecchymosis can be explained as follows: the posterior
mediastinum extends into the retropharyngeal space,
providing a communication between the chest and
neck. Therefore, bleeding into the mediastinum may
be seen subcutaneously in the anterior neck due to
connections between retropharynx and parapharyngeal
spaces. Hypertension is the most important risk factor
presenting in up to 75% of patients with Stanford
type B aortic dissection.[1,2] Computed tomography
aortography is the gold standard for the diagnosis
of aortic dissections due to its high sensitivity
(98-100%) and specificity (95-98%).[2] Although
magnetic resonance angiography, transesophageal
echocardiography, and aortography are alternative
diagnostic imaging modalities, all require institutional
availability and patient stability. Acute type B aortic dissection is treated medically, unless complicated by malperfusion, rupture, intractable pain, early false lumen expansion or uncontrolled hypertension. All complicated acute type B dissections require an urgent approach by an open surgical or endovascular intervention. The aim of endovascular repair of complicated aortic dissections is to prevent death from rupture, correction of malperfusion syndromes, and cease diameter expansion of the aneurysm. In a metaanalysis, Parker and Golledge[6] reported an in-hospital mortality incidence of 9%, an emergency surgical conversion rate of 0.6%, a periprocedural stroke rate of 3.1%, a mean 20-month survival of 88%, an endovascular re-intervention rate of 7.6% and a surgical re-intervention rate of 2.8% following endovascular repair of type B aortic dissections. On the other hand, open surgery for acute type B aortic dissection carries a 18 to 22% risk of in-hospital mortality even at experienced centers.[7] Therefore, surgery has been replaced by endovascular repair with a grade 1A recommendation.[7,8] In conclusion, a ruptured acute type B aortic dissection may present with neck ecchymosis. This unusual presentation should always be kept in mind when managing patients with acute chest pain without any evidence of myocardial ischemia. Endovascular treatment, if applicable, should be considered the first-line treatment in complicated acute type B dissection with favorable initial and long-term outcomes.
Declaration of conflicting interests
Funding |
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