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Type A aortic dissections: challenges of atypical presentation in remote New Zealand.

Clinical vignette SM, a 62 year-old male of Māori descent, was seen by ambulance for right hemiparesis with no signifi cant medical history. At the scene, he deteriorated into ventricular fi brillation, requiring cardiopulmonary resuscitation and cardioversion, eventually reverting back into sinus rhythm. He was transferred to the Gisborne Hospital with bag-and-mask ventilation and Glasgow Coma Scale of 3. He was intubated on arrival, maintaining a systolic blood pressure of 80. Investigations showed evidence of coronary (Troponin 45, ST elevation in leads III, aVF with reciprocal changes) and end-organ (eGFR 60, Lactate 2.4, pH 7.24) malperfusion. A widened mediastinum on chest x-ray instigated computed tomography (CT) scans, demonstrating type A aortic dissection (TAAD) extending from the aortic root, across the aortic arch and down the aorta into external iliac arteries. Poor fl ow was noted in right subclavian, vertebral and common carotid with a right renal artery occlusion. The CT brain was normal. He was accepted and transferred to Waikato District Health Board (WDHB). On arrival to WDHB, his cardiac (Troponin 7,982, dynamic ST changes), renal (eGFR 37) and neurologic (non-responsive pupils) status deteriorated. The aortic team was convened; at our centre, this is a multidisciplinary meeting of the cardiothoracic and vascular surgical teams, interventional radiology, intensive care unit and anaesthetic department. A decision for repeat CT imaging for neurological prognostication and assessment of coronary ostia was made, demonstrating a large acute right parietal lobe infarct. Given poor neurological prognosis and gross end-organ malperfusion, there was a consensus for palliation after discussion with the family.