Aortic dissection masked by psychosis

A 43-year-old man presented from a psychiatric assisted living facility to our emergency department for erratic and aggressive behaviour. He had a history of essential primary hypertension, schizoaffective disorder, and alcohol and cannabis use disorder. Haloperdol and lorazepam for acute psychosis were given. He was noted to have a troponin T of 0.025 ng/mL (troponin T normal value <0.010 mg/ml). An electrocardiogram showed non-specific ST- and T-wave changes in anterolateral leads. Blood pressure was 124/53 mmHg with a heart rate of 83 beats per minute.

The next day, the patient was calm and in no pain or distress. He then stated that he felt a ‘heat entering [his] chest’ on the night of presentation that made him feel restless. Transthoracic echocardiogram revealed a type I aortic dissection with a dissection flap (Video 1) and acute severe aortic regurgitation (Video 2). Computer tomography angiography revealed a DeBakey Type I dissection of the aortic root, thoracic aorta (Figure 1, blue arrow), descending aorta (Figure 2, green arrows), extending to the left iliac artery (Figure 1, yellow arrow), and left common femoral artery (Video 3).

Figure 1.

Coronal computer tomography angiography with intravenous contrast of the chest, abdomen, and pelvis revealing a DeBakey type I dissection of the thoracic aorta (blue arrow), extending to the left iliac artery (yellow arrow).

Figure 2.

Sagittal computer tomography angiography with intravenous contrast of the chest, abdomen, and pelvis showing a dissection of the ascending and descending aorta down to the left common iliac artery (green arrows). The posterior compartment of the dissection depicts the false lumen.

Patient was made aware of the findings and emergent need for surgery. However, he vehemently declined becoming verbally and physically aggressive. Psychiatry evaluated him and was considered to lack capacity. The patient underwent surgery for ascending aortic graft and bioprosthetic aortic valve replacement. After surgery, he was co-operative and calm. He expressed he could not remember any occurrence since his arrival at the emergency department.

Patients afflicted by psychiatric disorders have increased cardiovascular risks.¹ Images obtained were an unanticipated finding triggered by a mild elevation of troponin ordered at admission. Acute psychosis can overshadow underlying life-threatening cardiovascular conditions. The acuity of a mental illness can prevent an adequate medical evaluation. Since evaluation and treatment inequity in this population is not uncommon,² a thorough clinical assessment is warranted in these patients to not miss a diagnosis that would have otherwise been apparent.

Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.

Conflict of interest: None declared.

Funding: None.