Acute aortic dissection (AAD) is a life‑threatening cardiovascular emergency that classically presents with sudden, severe chest, back, and/or abdominal pain. Painless presentations are uncommon and frequently lead to diagnostic delay. A 68‑year‑old man presented with an hour‑long episode of altered consciousness without chest pain or other typical symptoms. Neurological examination revealed no focal deficits, and cardiovascular assessment showed mild bradycardia and low‑normal blood pressure, attributed to his antihypertensive therapy, which included a rate‑limiting agent. His computed tomography head scan was unremarkable, and abnormalities on his electrocardiogram and chest radiograph were attributed to longstanding hypertension. He was admitted for observation with a presumed acute neurological event, possibly a non-convulsive seizure with a post-ictal state. Several hours later, oxygen desaturation prompted a computed tomography pulmonary angiography, which unexpectedly revealed an extensive type A aortic dissection extending from the aortic root to the level of the renal arteries. He underwent emergency aortic root and hemiarch replacement, metallic aortic valve replacement, and reimplantation of the coronary buttons (Bentall procedure). His postoperative course was complicated by multiple bilateral embolic brain infarcts and seizures, requiring prolonged stroke rehabilitation. This case highlights the diagnostic challenge of painless AAD, in which end‑organ complications such as cerebral malperfusion may dominate the clinical picture and delay recognition. To avoid potentially catastrophic delays in diagnosis, clinicians should maintain a high index of suspicion for AAD in patients presenting with acute or sudden‑onset neurological symptoms or signs, even in the absence of pain, particularly when initial assessment does not confidently establish any of the more common neurological or cardiac diagnoses.
Osigwe et al. (2026) studied this question.