Painless Stanford type A aortic dissection presenting with isolated bilateral lower-limb neurological deficits: a case report

Introduction Stanford type A aortic dissection (AAD) constitutes a life-threatening cardiovascular emergency. Painless AAD manifesting exclusively as isolated bilateral lower-limb neurological deficits represents an uncommon but recognised presentation of aortic dissection that is prone to misdiagnosis. This case report adds real-world clinical data regarding atypical AAD and delivers practical diagnostic and surgical insights for front-line clinicians. Main symptoms and important clinical findings A 58-year-old Han Chinese female presented with acute-onset bilateral lower-limb numbness and weakness lasting one hour, in the absence of chest, back or abdominal pain. Physical examination uncovered an inter-arm systolic blood-pressure discrepancy together with bilateral lower-limb motor weakness (3/5). Emergency non-contrast chest-abdominal CT identified the aortic double-lumen sign and inward-displaced aortic wall calcified plaques, whereas bilateral distal peripheral pulses remained preserved. Main diagnoses, therapeutic interventions, and outcomes Painless Stanford type A aortic dissection complicated by suspected transient spinal cord malperfusion was diagnosed. Following urgent inter-hospital transfer, the patient underwent emergency Bentall procedure combined with aortic arch reconstruction and frozen elephant-trunk graft implantation, with a distal landing zone in the proximal descending thoracic aorta. Her bilateral lower-limb neurological deficits had fully resolved by postoperative day 2. A residual chronic dissection with a thrombosed false lumen persisted distally below the stent-graft and remained stable without interval enlargement. Six-month follow-up confirmed complete functional recovery without residual neurological sequelae or proximal dissection recurrence. Conclusion Undiagnosed painless Stanford type A aortic dissection presenting with isolated bilateral lower-limb neurological deficits is associated with substantial mortality. Routine bilateral upper-arm blood-pressure measurement and recognition of calcification displacement signs on non-contrast CT facilitate early clinical suspicion. Timely confirmation by CTA and urgent comprehensive surgical reconstruction are essential to reverse end-organ malperfusion and optimize neurological as well as survival outcomes.