Differential diagnosis, investigations and treatment
Based on the blood pressure on arrival, it was considered a shock state and a cerebrovascular disorder was not strongly suspected. Echocardiography was performed to search the cause of shock state and pericardial effusion was found. The complaint of back pain was not strong but persistent, and transient neurological symptoms were documented, so we suspected a possibility of an aortic dissection. We hesitated to use contrast medium due to renal function and then planned non-contrast CT to evaluate aortic form. CT showed a false cavity filled with hematoma along the aortic wall; therefore, it was diagnosed as AAD combined with cardiac tamponade. Since the hemodynamics were unstable, surgical treatment had to be considered. However, due to various patient backgrounds, such as advanced old age, dementia, and chronic kidney disease, perioperative risks were to be very high. We discussed the treatment policy with the patient and family members. We thought it may be fatal since the aortic replacement requires extracorporeal circulation that will be overly invasive for the patient herself. Besides, even after surviving the surgery, it will be difficult to manage during the perioperative period, including rehabilitation. Ultimately, with the consent of the patient and her family, we decided to urgently perform PD, monitor, and treat circulatory state strictly without aortic replacement. Immediately, emergent PD was performed, blood pressure was monitored, and 30ml blood was drained twice. Heart rate decreased to 90 bpm and systolic blood pressure rose to 110 mmHg. After admitted to the intensive care unit, her blood pressure was controlled with a continuous antihypertensive drug under arterial pressure monitoring. PD was drained without raising blood pressure excessively and drainage of 250 ml/8h was observed on the first day. After that, the volume of drainage decreased, and from the 2nd day, only about 30 ml/day of drainage of pale serum was observed. Pericardial effusion was evaluated by ultrasonic examination everyday, confirming that there was no sudden increase.