Introduction:
Aortic aneurysms result from the progressive degradation of elastin, collagen, and fibrolamellar structures, leading to medial thinning and reduced tensile strength. Sudden, unpredictable expansion can occur, with larger aneurysms carrying a higher rupture risk, often with catastrophic consequences². Patients typically present with sudden, severe chest pain, back pain, or syncope. Physical clues include asymmetric blood pressure (>20 mmHg difference between arms), Pulse deficits in major arteries (carotid, brachial, or femoral), New diastolic murmur suggestive of aortic regurgitation, Signs of end-organ ischemia (stroke, limb ischemia, acute renal failure)^3,4. Imaging such CT angiography is the gold standard for confirming aortic dissection. Conservative management of acute aortic dissection is a viable option for Type B dissections in hemodynamically stable patients without life-threatening complications. The mainstay of treatment is blood pressure control with beta-blockers and nitrates, along with close monitoring for signs of deterioration. Surgery may become necessary if the dissection progresses or complications arise⁵.

Clinical History and Presentation:
An 84-year-old female presented in the emergency department, experienced a sudden loss of consciousness (LOC). Patient was a known case of heart failure secondary to hypertension atherosclerosis cardiovascular disease. Patient was maintained on Losartan 50 mg/tab, trimetazidine 35 mg/tab, simvastatin 25 mg/tab. One hour prior to admission, the patient was ambulatory when suddenly had syncope and was found cold, clammy and with no breathing, which prompted the relative to initiate CPR for approximately 2–3 minutes until spontaneous breathing had returned. Then, the patient was subsequently transported to our institution for further evaluation and management via a transport vehicle. On initial assessment the patient was palpatory 60 mmhg, tachycardic (108 bpm), tachypneic (26 cpm), 36.5 temperature, with oxygen saturation at 98%, conscious, coherent, weak looking, no neck vein engorgement, symmetrical chest expansion, clear breath sound, adynamic precordium, normal rate, no murmur, abdomen is flabby with normal active bowel sound, soft and nontender, GCS 13-14, no facial asymmetry, reactive pupils with rightward gaze, but with noticeable left arm and lower leg motor deficit,.

Case Management:
Patient was hooked to O2 support via face mask, cardiac monitor and pulse oximetry. Initial ECG showed sinus tachycardia with lateral wall ischemia. Ultrasound guided fluid resuscitation for hypotension was immediately addressed. Due to intractable hypotension and a new onset of epigastric pain radiating at the back, difference in the BP of both arms (right unappreciated, left 80/50 mmhg) aortic dissection was immediately considered. Extended FAST ultrasound was done which did not exhibit fluid collection in the independent portions of the abdomen, no abdominal aortic dilatation. However suspicious minimal pericardial effusion was noted. Patient was started with norepinephrine. Paracetamol 1 gram was given for pain. Patient sensorium improved and vitals signs were stabilized. Close monitoring of patients was done. Hence plain whole abdominal CT and plain cranial CT was performed in investigating for the probable cause of hypotension. Prompt referral to thoracic cardiovascular surgery and vascular internal medicine were done. Further work up was done which revealed mild anemia, with mild leukocytosis, and adequate platelet count. Coagulation studies were within the normal range. The Blood Chem panel was done with no noted electrolyte imbalance and a Trop I of 18.6ng/L. Chest x ray revealed basal crowding of the lungs with a magnified heart. Initial cranial CT findings revealed no acute bleed or infarct. Work up done was not congruent to the patient's clinical presentation.

Hence, Chest CT with IV contrast was done which revealed A long segment aortic dissection involving the ascending aorta, with an intimal flap from the aortic root extending to the brachiocephalic artery. The true and false lumen exhibit equal opacification at the level of T7 vertebra up to the level of T3 vertebra without contrast extravasation (see figure 1).

Patient was advised for the definitive surgical repair of the dissected vessel to a more capable hospital, however refused and opted to maximize supportive and medical management. Patient was admitted in SICU despite the risk, complications and untoward events. Later on, the patient succumbed to her death.