Paraparesis: A rare presentation of thrombosis of the abdominal aorta

Abstract

Acute aortic occlusion is an uncommon entity requiring prompt recognition and intervention to limit morbidity and mortality. Thrombosis of the abdominal aorta usually presents with vascular compromise of the lower limbs and presentation, as paraparesis, is very rare. We report the clinical case of a 69-year-old woman, with a known history of diabetes mellitus, hypertension, dyslipidemia, who was referred to our emergency department presenting with acute paraparesis and low back pain. On admission, she had normal mental status and hemodynamic stability. Her physical examination revealed paraparesis grade 1/2 (Medical Research Council (MRC) Scale for Muscle Strength), with palpable pulses in lower extremities. Full blood count test showed an elevated hematocrit (60.4%), elevated white blood cell count (15.1 K/μL), and a normal platelet count. Baseline biochemical profile showed signs of renal failure with hyperkalemia and liver cell injury. Arterial blood gas demonstrated metabolic acidosis with acidemia. Abdominal CT scan and echocardiography were normal. Because these findings did not confirm a specific diagnosis, the patient was reassessed and the clinical examination was repeated and showed metabolic acidosis progression and hyperkalemia. The patient became anuric and required hemodialysis. At this point we performed a contrast-enhanced CT scan that showed a thrombus between the superior mesenteric artery and the level of origin of the renal arteries, with complete occlusion of blood flow. CT findings included evidence of renal, hepatic and splenic infarction. The patient was referred to the surgery department for an iliofemoral thromboembolectomy with removal of some thromboembolic material but without complete restoration of the blood flow. After, the patient developed complete ischemia of the lower limbs and died of multiple organ failure. Acute aortic occlusion is a catastrophic event and may present with paraparesis, because of acute spinal cord ischemia. This can mislead the clinician to a wrong diagnosis and delay initiation of definite treatment.