Painless Aortic Dissection With Bradycardia, Hypotension, and Lower Limb Weakness: A Case Report.

Aortic dissection typically presents with chest or back pain, but it can be painless. In the absence of typical pain, diagnosis may be delayed or missed. We present a case of an 84-year-old woman in which the initial manifestations were transient bilateral lower-limb weakness accompanied by bradycardia and hypotension. Electrocardiography demonstrated marked sinus bradycardia without ischemic changes, and laboratory tests were unremarkable except for an elevated D-dimer. Bedside carotid duplex ultrasonography incidentally identified an intimal flap in the common carotid artery, and contrast-enhanced computed tomography (CECT) confirmed Stanford type A aortic dissection involving the aortic arch with extension into both common carotid arteries. The patient underwent emergent valve-sparing supracoronary ascending aortic replacement. This case underscores the importance of recognizing unexplained bradycardia, hypotension, and transient muscle weakness as early clues to painless aortic dissection. Carotid duplex ultrasonography may aid diagnosis in such atypical presentations and should be considered when standard evaluations are inconclusive, potentially reducing missed or delayed diagnoses.