AbstractAcute aortic dissection is an uncommon but life-threatening emergency, which is often missed in up to 38% of patients on initial evaluation, and in up to 28% of patients the diagnosis is made at autopsy. Painless aortic dissection has been reported, but is relatively uncommon. The mortality rates are estimated at 50% by 48 hours and increase by 1% per hour if undiagnosed. We report a case of atypical aortic dissection who presented to ER with subtle unspecific renal colicky like pain as a primary symptom, which had made the prompt diagnosis very challenging and difficult

Chen, Wei-Lung

Tai, Henry Chih-Hung

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Journal of Acute Medicine 6 (2016) 61e63
www.e-jacme.comCase Report
Acute aortic dissection mimicking as ureteral calculus
Henry Chih-Hung Tai a,b, Wei-Lung Chen a,b,*
a Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
b School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
Received 15 July 2015; revised 15 June 2016; accepted 26 July 2016
Available online 15 September 2016AbstractAcute aortic dissection is an uncommon but life-threatening emergency, which is often missed in up to 38% of patients on initial evaluation,
and in up to 28% of patients the diagnosis is made at autopsy. Painless aortic dissection has been reported, but is relatively uncommon. The
mortality rates are estimated at 50% by 48 hours and increase by 1% per hour if undiagnosed. We report a case of atypical aortic dissection who
presented to ER with subtle unspecific renal colicky like pain as a primary symptom, which had made the prompt diagnosis very challenging and
difficult.
Copyright © 2016, Taiwan Society of Emergency Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: aortic dissection; atypical; ureteral calculus1. Introduction
Flank pain is a common complaint in the emergency
department with a variety of causes. The causes could be as
trifling as myofascial pain to more severe such as renal cal-
culus and extend to critical such as abdominal aortic aneurysm
or aortic dissection. Overall, acute ureteral obstructions are the
most common and disturbing cause. Due to the complex
innervation pattern of the flank, pain can arise from a number
of different organ systems.1 Multiple studies have shown that
after using noncontrast computed tomography (CT) scans in
patients who were thought to have renal colic, ~10% are ul-
timately given an alternate diagnosis.2
Acute aortic dissection is a relatively rare but life-
threatening medical emergency, and can be extremely diffi-
cult to diagnose, especially when it presents atypically. The
mortality rates are estimated at 50% by 48 hours and increase
by 1% per hour if undiagnosed.3 The outcome is usually fatal* Corresponding author. Department of Emergency Medicine,
Cathay General Hospital, Number 280, Section 4, Jen-Ai Road, Taipei 106,
Taiwan.
E-mail address: weilung.chen@msa.hinet.net (W.-L. Chen).
http://dx.doi.org/10.1016/j.jacme.2016.07.002
2211-5587/Copyright © 2016, Taiwan Society of Emergency Medicine. Published b
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).with rapid development of serious complications. Clinical
manifestations of acute aortic dissection are diverse in the
general population. According to the previous report by Hagan
et al only ~ 72.7% of patients present with typical textbook
presentations such as severe tearing chest pain.4 There is still a
significant percentage of patients presenting with diverse
atypical signs and symptoms which might mislead the first line
physician to misdiagnose such a lethal condition.2. Case Report
A 58-year-old male presented to our Emergency Depart-
ment (ED) at Taipei Cathay General Hospital complaining of
sudden onset and persisting left flank soreness for the past 30
minutes. He also complained of mild left lower limb numbness
without weakness. He had a medical history of chronic
obstructive pulmonary disease but denied having hypertension
or diabetes. He was also treated for a left ureteral stone a few
months ago with extracorporeal shock wave lithotripsy in
another medical facility. The patient described the left flank
soreness with radiation to the groin, which was exactly the
same feeling he had experienced with his previous left ureteral
stone. Upon arrival to the ED, the patient's vital signs were asy Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND
Figure 2. A segment of mural thrombosis of nearly 3.5 cm in length at left
common iliac artery (arrow).
62 H.C.-H. Tai, W.-L. Chen / Journal of Acute Medicine 6 (2016) 61e63follows: blood pressure, 129/44 mmHg; pulse, 46 beats/min
with regular sinus bradycardia (for which the patient was not
taking any medication that could affect the heart rate at the
moment); respirations, 17 breaths/min; and body temperature,
36.7C.
On physical examination, a significant left costovertebral
knocking pain was demonstrated on percussion. Besides the
numbness of his left lower limb, the muscle power was
normal. The patient's four extremities' peripheral pulse and
blood pressure revealed no significant difference. Under the
clinical signs and symptoms described by the patient; the pain
was similar to what he had experienced a few months previous
when he was diagnosed and treated with left ureteral calculus.
Therefore, renal calculus was highly suspected initially.
However, his urinalysis results were within the normal
range, with no significant finding on kidney, ureter, and
bladder (KUB) X-ray, nor was hydronephrosis found on renal
ultrasound. Due to the unusual neurological presentation
accompanied with the ureteral colic pain, vascular pathology
was also suspected. Contrast enhanced thoracal and abdominal
aorta CT was performed and revealed an extensive Stanford
type A aortic dissection (Figure 1) involving whole aorta and
bilateral common iliac arteries, with orifice of superior
mesenteric artery (SMA) false lumen and a nearly 3.5 cm (in
length) mural thrombosis in the left common iliac artery
(Figure 2). The dissection was also extended to the left renal
artery with regional cortical infarction at the inferior aspect of
the left kidney (Figure 3). The patient was operated upon byFigure 1. Presence of intimal flap with double lumens throughout ascending
aorta (arrow) from the aortic root to descending and abdominal aorta and stop
at bilateral common iliac arteries.
Figure 3. Regional less contrast enhancement at inferior aspect of left kidney
(arrow).the cardiovascular surgeons and had an uneventful post-
operative course.
3. Discussion
Acute aortic dissection is missed in up to 38% of patients
on initial evaluation, and in up to 28% of patients the diagnosis
is made at autopsy.5 A 2011 report estimates an incidence of
acute aortic dissection is three or four cases per 100,000
people per year.6 According to the International Registry of
Acute Aortic Dissection (IRAD), the typical patient with acute
aortic dissection is a male in his 70s with a history of hyper-
tension, who presents with an abrupt onset of tearing, cutting,
or shearing chest pain. Several case series found that only ~
60e70% of patients present with typical manifestations.7
Absence of typical pain in patients with acute aortic dissec-
tion was noticed with a prevalence of 5e15% in Western
populations.8
The clinical manifestations of acute aortic dissection are
diverse in the general population. Different symptoms occur
because of perfusion defect of the brain, limbs, and visceral
63H.C.-H. Tai, W.-L. Chen / Journal of Acute Medicine 6 (2016) 61e63organs. Thus, there appeared to be a wide range of clinical
presentations, which prolongs investigation in the ED and
increases the risk of in-hospital death. In fact, it suggests the
need for first emergency physicians to be highly attentive
when making diagnosis of this life-threatening disease.
In our case, the patient presented with some subtle unspe-
cific symptoms such as left flank pain and left lower numb-
ness, which had made the diagnosis very difficult and
challenging for the emergency physician. The left flank pain
that mimic ureteral colic pain is due to ischemia infarction of
the left kidney, which is caused by the perfusion defect from
left renal artery dissection. The ischemic pain of the kidney
caused by vascular angina was devastating and often mistaken
as renal colic by the patient. Along the ischemic change of the
kidney which caused visceral pain that may elevate the vagal
tone9 and cause the patient's bradycardia. The patient also
complained of left lower limb numbness which was due to
occlusion of the left common iliac artery by mural thrombosis
from the extensive aortic dissection.
Classic presentations should not always be expected at the
emergency room. Atypical presentation is not uncommon, but
may cause a delay or misdiagnosis due to diverse subtle pre-
sentations. Ischemic necrosis due to ceased visceral circulation
is one of the most severe complications of acute aortic
dissection. A malperfusion syndrome occurs in 25e30% cases
of acute aortic dissection and can dramatically reduce the
chance of a successful outcome.10 Neurologic deficits have
been associated with 18e30% of cases of acute aortic
dissection.11 However, acute aortic dissection presenting with
isolated ischemia of the leg is rare, occurring in ~ 10% of
patients, but it has been well described.12 Therefore, knowing
the subtle and atypical presentations well and thinking beyond
classic textbook descriptions are essential for emergency
physicians in diagnosis of atypical acute aortic dissection.
Proper diagnosis of acute aortic dissection can be difficult
when patients present atypically, especially with subtle un-
specific symptoms. In the case we reported, the patient pre-
sented with the signs and symptoms of isolated limb ischemic
injury without obvious cause; aortic dissection should be
considered, even without the presence of characteristic pain. A
heightened level of attention with correct usage of diagnostic
tools such as echocardiogram and CT, are needed for better
diagnosis and management of aortic dissection. For emergencyphysicians, integration and addressing all of the patient's
seemingly unspecific complaints may very well be one of the
most important factors in diagnosis of the atypical aortic
dissection.
Conflicts of interest
None of the authors have any conflicts to disclose.
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Acute aortic dissection mimicking as ureteral calculus 

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