ABSTRACT
BACKGROUND: a 76-year-old man presented with transient loss of consciousness associated with swelling of the neck, bruising in the suprasternal notch and an absent left carotid pulse. Blood pressure was equal in both arms and chest x-ray was normal, but computed tomography of the neck and thorax showed dissection and rupture of the thoracic aorta with extensive intra-mediastinal bleeding. OUTCOME: surgical intervention was inappropriate in this situation and the patient died within 4 hours of presentation. CONCLUSION: syncope is a common presentation to hospital in older people and its cause may be difficult to elucidate, particularly if the patient is unable to provide a reliable history. Syncope without pain is a rare presentation of aortic dissection and the occurrence of anterior chest wall bruising has not been described previously. Pulse deficits and abnormal chest x-ray findings are often cited as indicative of aortic dissection but are rare manifestations and their absence should not be used to exclude this diagnosis.
