B51-24 Syncope and Neck Pain: An Unusual Manifestation of Aortic Dissection

Acute aortic syndromes are time-critical and frequently present atypically. While tearing chest or back pain is classic, syncope and focal neck pain may be early clues. We report a Stanford type A dissection likely precipitated by an emetic/valsalva event, complicated by a large left hemothorax. A 46-year-old male with uncontrolled hypertension presented after syncope. He felt nauseated, induced emesis, and on standing briefly lost consciousness at the sink (∼10 seconds). On arrival, he reported non-radiating, pressure-like left-sided chest pain and denied dyspnea, fever, chills, visual changes, or head trauma. He was afebrile, initially hypertensive but otherwise stable. Blood pressure 172/90 mmHg, heart rate 63 bpm, respiratory rate 18, and SpO2 95% on room air. He was diaphoretic. Labs showed lactate of 10.5 mmol/L and leukocytosis to 16 x 109/L; other values were unremarkable. While seated in the emergency department, he developed abrupt 10/10 neck pain with recurrent diaphoresis; repeat systolic blood pressure was 110 mmHg. He was moved to the trauma bay, large-bore IVs were placed, and 2 L crystalloid were infused under pressure. ECG showed no STEMI. The differential included stroke, aortic dissection, cervical spine injury from a fall, myocardial infarction, and pulmonary embolism. Chest radiography demonstrated mediastinal widening and progressive left-sided opacification compatible with a pleural effusion; the aortic arch appeared prominent. Emergent CT angiography confirmed an acute Stanford type A dissection from the ascending aorta into the abdominal aorta and iliac arteries, with a large left hemothorax causing near-complete left-lung atelectasis. An esmolol infusion was started, and the patient was transferred to a tertiary center for definitive surgical management. This case illustrates that syncope with diaphoresis evolving into severe neck pain and hypotension—combined with mediastinal widening and a new unilateral effusion on chest radiography—should trigger urgent evaluation for acute aortic dissection. Although syncope and neck pain are not universal, they are well-described presenting features (∼19% and ∼25% of type A dissections), supporting a low threshold for advanced aortic imaging in this context [1]. Head/neck pain is reported more often in females (39.8% vs 31.3%) and in White patients (∼90.2% vs ∼84.0%), yet our male patient’s prominent neck pain shows this phenotype crosses demographic and should not lower suspicion for dissection [2].