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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015
AFRICA
e17
the cerebral vascular bed was affected, adverse neurological
events were reported in 5–10% of cases.
4
As in our case, when
the subclavian artery was affected, asymmetric upper extremity
blood pressures occurred.
5
When the spinal canal and peripheral
nerves are affected, symptoms such as paresis and plegia occur.
6
One of the most important factors in making a diagnosis of
aortic dissection is a high index of suspicion. Usually physical
examination leads to a diagnosis of suspicion. Hypertension is
either the main reason for dissection or it develops secondary to
severe pain. Hypotension is an important finding of tamponade
or coronary flow impairment.
Since chest pain was followed by unconsciousness in the
history of our patient with hypertension, our pre-diagnosis
was aortic dissection. Absence of a left radial pulse on physical
examination strengthened the diagnosis of aortic dissection.
Absence of flow in the left common carotid and subclavian
artery was confirmed with CT angiography. TEE revealed that
the absence of flow was due to intimo–intimal intussusception.
During surgery, it was observed that the cause of occlusion was
a dissection flap prolapsing into the aortic arch.
Suspicion of a diagnosis of intimo-intimal intussusception is
life saving. On CT angiography, the intimal flap, false lumen and
crescent sign in the ascending aorta observed in DeBakey type
I and type II aortic dissections are absent in these patients. As
in our case, a filling defect may be determined in the aortic arch
by prolapsing of the intima (Fig. 1). ‘False occlusions’ may be
observed in the vascular structures of the brain and extremities.
Delay in treatment causes transformation of the occlusion to
a ‘real occlusion’.
7
There was no evidence of dissection of the
ascending aorta in our case. TEE confirmed the haematoma in
the distal part of the ascending aorta and motion of the intimal
flap towards the ascending aorta during diastole.
Lajevardi
et al
. and Nohara
et al
. reported that the proximal
part of the circumferential dissection in the ascending aorta
occluded the coronary ostia and caused severe aortic valve
insufficiency by entering the aortic valve.
3,8
Aortic valve
insufficiency due to a dissection flap is present in 60–70% of
type I dissections.
9
This condition occurs with three mechanisms
of action: (1) central regurgitation due to annular dilation,
(2) distortion of aortic root geometry due to prolapse of the
dissection across a leaflet, (3) annulus rupture or tearing of one
of the leaflets.
10
Sometimes aortic valve insufficiency can be the only finding
suggestive of dissection of the ascending aorta in patients
without symptoms of dissection.
10
In our case, aortic valve
insufficiency was considered to be due to annular dilation. Cases
resulting in a fatal outcome due to occlusion in the coronary
ostia during diastole, caused by the proximal part of the
dissection flap, have also been reported.
3
Myocardial infarction
is seen at a rate of 1–2% in aortic dissections.
11
The dissection flap in the coronary ostia can be seen during
angiography, with a diagnosis of coronary syndrome, as in our
case.
11
A diagnosis of aortic dissection must be excluded in acute
coronary syndrome, otherwise antiplatelet and anticoagulant
therapy may have fatal outcomes. Angiography was also
performed in our case, with a diagnosis of acute coronary
syndrome. Not being able to advance the angiography catheter
into the aortic arch and determination of the false lumen caused
a misdiagnosis of type III aortic dissection. Since angiography
could not be completed, the coronary ostia could not be seen.
During surgery, we determined that the coronary ostia were
occluded by the distal part of the dissection flap during diastole.
In the literature, cases have frequently been reported of patients
misdiagnosed with type III aortic dissection when the dissection
flap was not observed in the ascending aorta.
12
Where other diagnostic methods are insufficient in the
diagnosis, TEE may be helpful, as the motion of the dissection
flap invaginated in the aortic arch can be observed. Due tomotion
of the proximal part of the dissection flap toward the ventricle,
it may be observed that it causes aortic valve insufficiency.
TEE is considered to be the reference investigation with 98%
sensitivity.
8,12
TEE was also the most powerful diagnostic method
in our case.
Conclusion
Intimo–intimal intussusception is a rare complication of aortic
dissection. However, it may be severe or fatal due to its effect
on the cerebral and peripheral vascular structures in the distal
part of the ascending aorta, and its effect on the coronary
arteries and aortic valve in the proximal part of the ascending
aorta.
It should definitely be considered in elderly patients with
hypertension in the presence of chest pain and unconsciousness.
TEE is the chosen investigative method with high sensitivity
and specificity in the diagnosis.
It is important for a differential
diagnosis during the pre-operative period and for determination
of intra-operative treatment strategy.
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