Ischemic stroke, aortic dissection, and thrombolytic therapy--the importance of basic clinical skills

Aortic dissection masquerading as ischemic stroke is particularly challenging in the era of thrombolysis as a result of narrow diagnostic time window and severe hemorrhagic potential. We describe a case of a 77-year-old patient with a presumed ischemic cerebral infarct, in whom planned treatment with tissue plasminogen activator therapy (TPA) was withheld because of partial spontaneous improvement in his condition. Shortly afterwards, newly elicited clues in the medical history and physical examination led to timely diagnosis and treatment of ascending thoracic aorta dissection, which was the underlying disorder. Analysis of the features of this case and similar previously published cases illustrates the importance of using and mastering basic diagnostic skills.