Multimodal Treatment in Large Vessel Occlusion Stroke Due To Aortic Dissection

Background: Neurological symptoms such as ischemic stroke are present in 18-30% of patients with aortic dissection. These symptoms are due to systemic hypotension or dissection/ occlusion of one or more aortic side branches supplying the brain. There are still controversies whether the neurological deficit in aortic dissection leads to a poor outcome or hospital death. Meanwhile, one of the absolute contraindications of intravenous fibrinolytic in acute ischemic stroke management is aortic dissection.

Case report: A 40-year-old male had onset of chest pain due to aortic dissection, followed by severe motor aphasia, right hemiparesis, and became unconscious one month prior to admission. He had history of hypertension and dyslipidemia. After undergoing immediate Bentall procedure and being treated in intensive care unit for a month, he slowly regained consciousness, but neurological deficits persisted. Brain magnetic resonance imaging and angiography test showed subacute infarct at left frontal-parietal-temporal-insula and
basal ganglia with severe stenosis at left middle cerebral artery. Whole abdominal CT Scan showed dissected thoracic, abdominal aorta, and left common iliac artery. Multimodal treatment with antithrombotics, neuroprotective agents, and neuromodulation therapies including transcranial magnetic stimulation, transcranial direct current stimulation, and rehabilitation were given to him. After one month, his neurological status greatly improved with the modified Rankin Scale of 2.

Conclusion: Emergency aortic surgery provides the uttermost chance for survival in this case. Clinical considerations before, during, and after surgery are essential to achieve the best outcome. Multimodal treatment with medication and neuromodulation therapy potentially aids in improving functional outcome of the patient