Stroke and ruptured infrarenal aortic aneurysm

An 86-year old lady with aphasia, left sided hemiparesis, a heart rate, of 110 bpm and a blood pressure of 110/60 mmHg was intubated by the emergency physician. She was given 1000 crystalloid fluid IV and brought to our department with suspected stroke. Clinical examination revealed a pulsatile abdominal mass, while immediate CT-scan excluded an intracranial hemorrhage. The patient developed, shock and lactic acidosis, and ultrasound examination confirmed the diagnosis of a ruptured abdominal aortic aneurysm. The patient underwent emergency laparotomy, and after cross clamping of the aorta a tube prosthesis was inserted. The following day a CT-scan revealed an ischemic brain infarction in the territory of the right middle cerebral artery. On duplex examination, no relevant stenoses of the extracranial arteries could be found. Postoperatively, the patient suffered from bilateral pleural effusions and pneumonia. Finally, she was weaned successfully from the respirator and transferred to a neurologic rehabilitation, clinic on day 52 after admission. Even focal neurological deficits, especially when combined with hypotension, may have systemic causes such as anemia and volume depletion, as in this patient with at first hand unnoticed bleeding.