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A 49 year old man collapsed and developed convulsions after complaining about breathlessness. On initial examination the patient was hypotensive, stuporous, with no reaction to painful stimulus on the left side. A cerebral computerised tomography suggested a right occipital ischaemic lesion, and the patient was transferred to our institution. Upon arrival to our hospital, the patient was intubated, non-sedated, and had no reaction to painful stimuli on the right side, as well as a lack of brain stem reflexes. He was hypotensive despite treatment with catecholamines. The ECG showed pronounced anterolateral ST segment depression and biphasic T waves, consistent with severe myocardial ischaemia; chest x ray findings were consistent with acute lung oedema. Transoesophageal echocardiography showed a type A aortic dissection with a long intimal flap (panel A, arrowheads: Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle), protruding into the left ventricle during diastole (panel B, arrowheads), and as a consequence severe aortic regurgitation (panel C). Duplex sonography could not demonstrate any flow in the right common carotid artery. Cardiac surgery was not carried out because of the poor neurological prognosis, and the patient died a few hours later.
Necropsy showed a type A aortic dissection with antegrade extension of the intimal flap in both carotid arteries and almost complete occlusion of the lumina (panel D). The left main coronary artery was found to be occluded by a flail retrograde intimal flap.