Akute Aortendissektion: Ein lebensbedrohlicher Notfall auch in der neurologischen Notfallmedizin

Zusammenfassung

Eine akute Aortendissektion ist selten, aber lebensbedrohlich. Die Symptome hängen von der Lokalisation und Minderperfusion der nachgeschalteten Organe oder Extremitäten ab und sind dementsprechend variabel. Es können neurologische Symptome auftreten, die nicht unmittelbar zur Diagnosestellung führen und so die notwendige Therapie verzögern. Die Kenntnis der Frühsymptome und Warnsignale einer Aortendissektion sind deswegen auch in der neurologischen Notfallversorgung wichtig, um die Betroffenen schnell zu identifizieren und der Akuttherapie zuzuführen. Eine Fehldiagnose mit verzögerter Therapieeinleitung kann die Prognose der Patienten deutlich verschlechtern. Ziel dieser Arbeit ist es, einen standardisierten Diagnostik- und Therapiealgorithmus bei Verdacht auf eine akute Aortendissektion in der neurologischen Notfallversorgung zu etablieren. Eine enge interdisziplinärer Zusammenarbeit ist dabei essentiell.

Abstract

Acute aortic dissection is rare but life-threatening. The symptoms depend on the localization and reduced perfusion of the downstream organs or limbs and are therefore variable. Neurological symptoms may occur that do not immediately lead to a diagnosis and thus delay the necessary therapy. Knowing the early symptoms and warning signs of aortic dissection is therefore also crucial in neurological emergency care for quickly identifying the affected patients and for providing acute therapy. A misdiagnosis with delayed initiation of therapy can significantly worsen the patient's outcome. This study aims to establish a standardized diagnostic and therapeutic algorithm for suspected acute aortic dissection in neurological emergency care. Close interdisciplinary cooperation is mandatory.

Schlüsselwörter

akute Aortendissektion - Aortensyndrom - Malperfusionssyndrom - neurologische Symptome - Differentialdiagnose

Key words

acute aortic dissection - aortic syndrome - malperfusion syndrome - neurological symptoms - differential diagnosis

Publikationsverlauf

Eingereicht: 13. Oktober 2021

Angenommen nach Revision: 03. März 2022

Artikel online veröffentlicht:
04. Mai 2022

• Literatur

• 1 Howard DP, Banerjee A, Fairhead JF. et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013; 127: 2031-2037
• 2 Pape LA, Awais M, Woznicki EM. et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol 2015; 66: 350-358
• 3 Hagan PG, Nienaber CA, Isselbacher EM. et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283: 897-903
• 4 Klompas M. Does this patient have an acute thoracic aortic dissection?. JAMA. 2002; 287: 2262-2272
• 5 Evangelista A, Isselbacher EM, Bossone E. et al. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation 2018; 137: 1846-1860
• 6 Harris KM, Strauss CE, Eagle KA. et al. Correlates of delayed recognition and treatment of acute type A aortic dissection: The International Registry of Acute Aortic Dissection (IRAD). Circulation 2011; 124: 1911-1918
• 7 Nienaber CA, von Kodolitsch Y. Meta-analysis of changing mortality pattern in thoracic aortic dissection. Herz 1992; 17: 398-416
• 8 Masuda Y, Yamada Z, Morooka N. et al. Prognosis of patients with medically treated aortic dissections. Circulation 1991; 84: III7-III13
• 9 Tsai TT, Fattori R, Trimarchi S. et al. International Registry of Acute Aortic Dissection. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation 2006; 114: 2226-2231
• 10 Erbel R, Aboyans V, Boileau C. et al. ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873-2926
• 11 Hiratzka LF, Bakris GL, Beckman JA. et al. Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease, A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. 2010
• 12 Fattori R, Cao P, De Rango P. et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013; 61: 1661-1678
• 13 Landenhed M, Engström G, Gottsäter A. et al. Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study. J Am Heart Assoc 2015; 4: e001513
• 14 Januzzi JL, Sabatine MS, Eagle KA. et al. Iatrogenic aortic dissection. Am J Cardiol 2002; 89: 623-626
• 15 Januzzi JL, Marayati F, Mehta RH. et al. Comparison of aortic dissection in patients with and without Marfan’s syndrome (results from the International Registry of Aortic Dissection). Am J Cardiol 2004; 94: 400-402
• 16 Rosman HS, Patel S, Borzak S. et al. Quality of history taking in patients with aortic dissection. Chest 1998; 114: 793-795
• 17 Upchurch GR, Nienaber C, Fattori R. et al. Acute aortic dissection presenting with primarily abdominal pain: a rare manifestation of a deadly disease. Ann Vasc Surg 2005; 19: 367-373
• 18 Yuan X, Mitsis A, Tang Y. et al. The IRAD and beyond: what have we unravelled so far?. Gen Thorac Cardiovasc Surg 2019; 67: 146-153
• 19 Kohn MA, Kwan E, Gupta M, Tabas JA. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med 2005; 29: 383-390
• 20 Gaul C, Dietrich W, Friedrich I. et al. Neurological symptoms in type A aortic dissections. Stroke 2007; 38: 292-297
• 21 Mészáros I, Mórocz J, Szlávi J. et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000; 117: 1271-1278
• 22 von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med 2000; 160: 2977-2982
• 23 Beggs AD, Al-Rawi H, Parfitt A. Chest pain fleeting neurological signs. Lancet 2005; 365: 1514
• 24 Mathys J, Lachat M, Herren T. Headache as a manifestation of a life-threatening vascular disorder. Headache 2004; 44: 706-709
• 25 Nohe B, Ernemann U, Tepe G. et al. Aortic dissection mimicking subarachnoidal hemorrhage. Anesth Analg 2005; 101: 233-234
• 26 Singh S, Huang JY, Sin K. et al. Headache: an unusual presentation of aortic dissection. Eur J Emerg Med 2007; 14: 47-49
• 27 Blanco M, Díez-Tejedor E, Larrea JL. et al. Neurologic complications of type I aortic dissection. Acta Neurol Scand 1999; 99: 232-235
• 28 Gaul C, Dietrich W, Erbguth FJ. Neurological symptoms in aortic dissection: a challenge for neurologists. Cerebrovasc Dis 2008; 26: 1-8
• 29 Koga M, Iguchi Y, Ohara T. et al. Acute ischemic stroke as a complication of Stanford type A acute aortic dissection: a review and proposed clinical recommendations for urgent diagnosis. Gen Thorac Cardiovasc Surg 2018; 66(8): 439-445
• 30 Fessler AJ, Alberts MJ. Stroke treatment with tissue plasminogen activator in the setting of aortic dissection. Neurology 2000; 54: 1010
• 31 Ibaraki T, Fukumoto H, Nishimoto Y. et al. Surgical management of acute type A aortic dissection with a complaint of disturbance of consciousness; report of a case. Kyobu Geka 2002; 55: 1053-1056
• 32 Chua CH, Lien LM, Lin CH. et al. Emergency surgical intervention in a patient with delayed diagnosis of aortic dissection presenting with acute ischemic stroke and undergoing thrombolytic therapy. J Thorac Cardiovasc Surg 2005; 130: 1222-1224
• 33 Hong KS, Park SY, Whang SI. et al. Intravenous recombinant tissue plasminogen activator thrombolysis in a patient with acute ischemic stroke secondary to aortic dissection. J Clin Neurol 2009; 5: 49-52
• 34 Shivkumar V, Nemade D. Intravenous tPA in the treatment of acute stroke related to aortic dissection. BMJ Case Rep 2019; 12: e229982
• 35 Noel M, Short J, Farooq MU. Thrombolytic therapy in a patient with acute ischemic stroke caused by aortic dissection. Clin Neurol Neurosurg 2010; 112: 695-696
• 36 Kamp TJ, Goldschmidt-Clermont PJ, Brinker JA. et al. Myocardial infarction, aortic dissection, and thrombolytic therapy. Am Heart J. 1994; 128: 1234-1237
• 37 Reznik ME, Espinosa-Morales AD. et al. Endovascular thrombectomy in the setting of aortic dissection. J Neurointerv Surg 2017; 9: 17-20
• 38 Pawlukiewicz AJ, Long D, Mehta S. Large Vessel Occlusion Stroke Secondary to Acute Aortic Dissection. Cureus. 2020; 12: e9278
• 39 Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002; 122: 311-328
• 40 Lefebvre V, Leduc JJ, Choteau PH. Painless ischemic lumbosacral plexopathy and aortic dissection (letter). J Neurol Neurosurg Psychiatry 1995; 58: 641
• 41 Khan IA, Wattanasauwan N, Ansari AW. Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome; Ortner‘s syndrome. Am J Emerg Med 1999; 17: 361-363
• 42 Elefteriades JA, Feldman M. Acute type A aortic dissection: surgical intervention for all: CON. Cardiol Clin 2010; 28: 325-331
• 43 Park SW, Hutchison S, Mehta RH. et al. Association of painless acute aortic dissection with increased mortality. Mayo Clin Proc 2004; 79: 1252-1257
• 44 Nallamothu BK, Mehta RH, Saint S. et al. Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications. Am J Med 2002; 113: 468-471
• 45 Tsai TT, Bossone E, Isselbacher EM. et al. Clinical characteristics of hypotension in patients with acute aortic dissection. Am J Cardiol 2005; 95: 48-52
• 46 Chua M, Ibrahim I, Neo X. et al. Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis. Am J Emerg Med 2012; 30: 1622-1626
• 47 Crawford TC, Beaulieu RJ, Ehlert BA. et al. Malperfusion syndromes in aortic dissections. Vasc Med 2016; 21: 264-273
• 48 Rogers AM, Hermann LK, Booher AM. et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation 2011; 123: 2213-2218
• 49 Ohle R, Anjum O, Bleeker H. et al. What is the specificity of the aortic dissection detection risk score in a low prevalence population?. Acad Emerg Med 2019; 26: 632-638
• 50 Moore AG, Eagle KA, Bruckman D. et al. Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD). Am J Cardiol 2002; 89: 1235-1238
• 51 Cecconi M, Chirillo F, Costantini C. et al. The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome. Am Heart J 2012; 163: 112-118
• 52 Shiga T, Wajima Z, Apfel CC. et al Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med 2006; 166: 1350-1256
• 53 Marill KA. Serum D-dimer is a sensitive test for the detection of acute aortic dissection: a pooled meta-analysis. J Emerg Med 2008; 34: 367-376
• 54 Watanabe H, Horita N, Shibata Y. et al. Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects. Sci Rep 2016; 6: 26893
• 55 Sodeck G, Domanovits H, Schillinger M. et al. D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study. Eur Heart J 2007; 28: 3067-3075
• 56 Suzuki T, Distante A, Zizza A. et al. Diagnosis of acute aortic dissection by D-dimer: the International Registry of Acute Aortic Dissection Substudy on Biomarkers (IRAD-Bio) experience. Circulation 2009; 119: 2702-2707
• 57 Suzuki T. et al. Type-selective benefits of medications in treatment of acute aortic dissection (from the International Registry of Acute Aortic Dissection [IRAD]). Am J Cardiol 2012; 109: 122-127
• 58 Grabenwöger M, Alfonso F, Bachet J. et al. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2012; 42: 17-24