Bedside echocardiography evaluation of a male with transient global amnesia

A 50-year-old male with a history of hypertension, migraines, chronic back pain, and tobacco use presented to the emergency department (ED) for evaluation of altered mentation. His wife reported that he suddenly became confused with short-term memory loss and was repeating questions after his morning cigarette. He denied head trauma, headache, vision changes, speech changes, weakness, or sensation loss to the extremities, chest pain, palpitations, shortness of breath, syncope, abdominal pain, or atypical back pain. Vital signs were within normal limits, except for initial blood pressure of 93/51 mm Hg. On physical examination, the patient was awake, alert, disoriented to time and place, and notable for global amnesia, however, there were no focal neurological deficits otherwise. The patient underwent emergent computed tomography (CT) brain imaging and neurology evaluation. Underlying intracranial bleed or acute ischemic stroke was ruled out. Neurology deemed the clinical presentation most consistent with transient global amnesia (TGA). Electrocardiogram revealed normal sinus rhythm without acute ischemic changes. All laboratory studies, which included cardiac biomarkers and urine drug screen, were within normal limits or negative. Bedside focused cardiac ultrasound (FOCUS) was performed to evaluate for a potential cardiovascular etiology due to hypotension; FOCUS demonstrated a dilated proximal thoracic aorta diameter of 4.6 cm in the parasternal long-axis window and an aortic dissection flap visualized in the suprasternal notch window (Figure 1). CT angiography of the chest subsequently confirmed the diagnosis of type A aortic dissection (AoD) (Figure 2) for which cardiothoracic surgery emergently performed a successful operative repair of the aortic root. Timely ED detection of the seldom encountered, but highly lethal, condition of thoracic AoD is critical yet challenging given the considerable range of symptomatology.1-5 Our case provides a very rare description of painless AoD presenting as pure TGA, which has only been communicated in a few previous reports.6-12 Emergency physicians should specifically recognize thoracic AoD as a potential underlying etiology of TGA-like syndromes. The use of FOCUS in evaluating undifferentiated hypotension and a multitude of cardiovascular emergencies including AoD has been well-described.13, 14 Importantly, our case also illustrates an invaluable role for sonographic assessment of the thoracic aorta arch from the suprasternal notch window if AoD is suspected.15, 16 This report highlights a unique application of emergency physician-performed FOCUS to expedite the prompt bedside diagnosis of AoD in ED patients presenting with TGA. This research was supported in part by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

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