Coarctation of the abdominal aorta: an uncommon cause of arterial hypertension and stroke.

A 14-year old male with no previous medical history presented with headache, left third cranial nerve palsy, and generalized tonic-clonic seizures. Magnetic resonance imaging of the brain revealed subarachnoid hemorrhage secondary to an aneurysm of the left posterior communicating artery. The patient underwent successful transcatheter coil occlusion of the aneurysm, and his neurological symptoms improved (Figure 1). During admission, he remained hypertensive, with an arterial blood pressure of 170/96 mm Hg in the upper limbs despite medical treatment with atenolol, amlodipine, and enalapril. On physical examination, an abdominal systolic bruit was heard, and weak femoral pulses were noted. Blood pressure in the right and left arms was similar, but there was a significant differential pressure (50 mm Hg) compared with the lower limbs. Aortic coarctation and renal artery stenosis were considered to be the causes of arterial hypertension. An echocardiogram showed moderate left ventricular hypertrophy and preserved systolic function. No abnormality in the aortic arch or proximal descending aorta was noted on echocardiography. An abdominal ultrasound showed a small abdominal aorta with diffuse narrowing and increased peak systolic velocity (509 cm/s). Presence of runoff flow throughout the entire diastole was also noted (Figure 2). Magnetic resonance angiography of the aorta confirmed the diagnosis of coarctation of the abdominal aorta and showed a narrowing of considerable length starting 5 cm below the diaphragm. This narrowing tapered to become a critical stenosis at the level of origin of the renal arteries (Figure 3). The abdominal aorta measured 2.8 mm at its smallest point and was consistently poorly opacified. Prominent collateral circulation from the mammary artery and the intercostal arteries to the abdomen was present. At cardiac catheterization, there was a pullback gradient of 56 mm Hg from the ascending aorta to the descending