# The critical role of non-contrast chest CT in avoiding thrombolysis catastrophe: A case of acute aortic dissection masquerading as ischemic stroke

## TL;DR

A case shows how non-contrast chest CT can prevent dangerous stroke treatments in patients with hidden aortic dissection.

## Contribution

The paper advocates for integrating non-contrast chest CT into stroke protocols to avoid thrombolysis in patients with undiagnosed aortic dissection.

## Key findings

- Non-contrast chest CT can reveal aortic dissection in stroke patients, preventing harmful thrombolysis.
- Current stroke guidelines should include aortic screening for high-risk elderly patients.
- Diagnostic delays occur when subtle signs of aortic dissection are missed in stroke evaluations.

## Abstract

Aortic dissection (AD) complicating acute ischemic stroke poses significant therapeutic challenges, particularly regarding thrombolytic contraindications that may substantially increase mortality risk. This underscores the critical need for expedited differential diagnosis in such clinical scenarios.

An 80-year-old male presented with acute-onset left-sided hemiplegia and unresponsiveness.

Initial cerebral neuroimaging demonstrated a substantial ischemic penumbra (136.2 ml Tmax >6 s) in the right middle cerebral artery (MCA) territory, with a core infarction volume of 13.6 ml. Emergency intravenous thrombolysis with alteplase was administered for presumed acute ischemic stroke, followed by mechanical thrombectomy via femoral artery access. Retrospective analysis of preoperative chest Computed tomography (CT) imaging revealed ascending aortic dilation. Subsequent emergency aortic CTA confirmed Stanford Type A dissection extending from the aortic root to the first lumbar vertebral level. Despite comprehensive risk counseling, the patient's family ultimately elected for discharge against medical advice. Telephone follow-up at 30 days post-discharge confirmed patient demise.

This case highlights two critical clinical considerations: Subtle radiographic manifestations of AD in stroke patients may lead to diagnostic delays; the hyper-dense crescent sign on non-contrast cranial CT warrants heightened clinical suspicion for concurrent aortic pathology.

•Chest CT Saves Lives: Routine integration of non-contrast chest CT into stroke protocols for high-risk patients (hypertension, NIHSS >10, unexplained ECG anomalies, history of aortic disease) can prevent lethal thrombolysis errors.•Time for Guideline Reform: Current stroke pathways must prioritize aortic screening in elderly populations, balancing the "time-is-brain" paradigm with vascular safety.•Our case suggests that patients considering stroke should have a simultaneous non-contrast chest CT in addition to head CT.

Chest CT Saves Lives: Routine integration of non-contrast chest CT into stroke protocols for high-risk patients (hypertension, NIHSS >10, unexplained ECG anomalies, history of aortic disease) can prevent lethal thrombolysis errors.

Time for Guideline Reform: Current stroke pathways must prioritize aortic screening in elderly populations, balancing the "time-is-brain" paradigm with vascular safety.

Our case suggests that patients considering stroke should have a simultaneous non-contrast chest CT in addition to head CT.