DR RAKESH ROSHAN

AORTIC DISSECTION

Review ofAorticAnatomy

Layers of Aortahellip

What is dissection of aorta

Tear in the aortic intima that directly exposes an underlying diseased medial layer to the driving force (or pulse pressure) of intraluminal blood

This blood penetrates the diseased medial layer and cleaves the media longitudinally thereby dissecting the aortic wall

Driven by persistent intraluminal pressure the dissection process extends a variable length along the aortic wall typically antegrade but sometimes retrograde from the site of the intimal tear

The blood-filled space between thedissected layers of the aortic wallbecomes the false lumen

Shear forces may lead to further tears inthe intimal flap (the inner portion of thedissected aortic wall) and produce exitsites or additional entry sites for bloodflow into the false lumen

Distention of the false lumen with bloodmay cause the intimal flap to bow intothe true lumen and thereby narrow itscaliber and distort its shape

EPIDEMIOLOGY

Uncommon but potentially catastrophic illness

Occurs with an incidence of at least 2000 cases per year

Early mortality is as high as 1 per hour if untreated

The peak incidence ndash fifth and sixth decades of life

Male to female--- 31

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Review ofAorticAnatomy

Layers of Aortahellip

What is dissection of aorta

Tear in the aortic intima that directly exposes an underlying diseased medial layer to the driving force (or pulse pressure) of intraluminal blood

This blood penetrates the diseased medial layer and cleaves the media longitudinally thereby dissecting the aortic wall

Driven by persistent intraluminal pressure the dissection process extends a variable length along the aortic wall typically antegrade but sometimes retrograde from the site of the intimal tear

The blood-filled space between thedissected layers of the aortic wallbecomes the false lumen

Shear forces may lead to further tears inthe intimal flap (the inner portion of thedissected aortic wall) and produce exitsites or additional entry sites for bloodflow into the false lumen

Distention of the false lumen with bloodmay cause the intimal flap to bow intothe true lumen and thereby narrow itscaliber and distort its shape

EPIDEMIOLOGY

Uncommon but potentially catastrophic illness

Occurs with an incidence of at least 2000 cases per year

Early mortality is as high as 1 per hour if untreated

The peak incidence ndash fifth and sixth decades of life

Male to female--- 31

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Layers of Aortahellip

What is dissection of aorta

Tear in the aortic intima that directly exposes an underlying diseased medial layer to the driving force (or pulse pressure) of intraluminal blood

This blood penetrates the diseased medial layer and cleaves the media longitudinally thereby dissecting the aortic wall

Driven by persistent intraluminal pressure the dissection process extends a variable length along the aortic wall typically antegrade but sometimes retrograde from the site of the intimal tear

The blood-filled space between thedissected layers of the aortic wallbecomes the false lumen

Shear forces may lead to further tears inthe intimal flap (the inner portion of thedissected aortic wall) and produce exitsites or additional entry sites for bloodflow into the false lumen

Distention of the false lumen with bloodmay cause the intimal flap to bow intothe true lumen and thereby narrow itscaliber and distort its shape

EPIDEMIOLOGY

Uncommon but potentially catastrophic illness

Occurs with an incidence of at least 2000 cases per year

Early mortality is as high as 1 per hour if untreated

The peak incidence ndash fifth and sixth decades of life

Male to female--- 31

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

What is dissection of aorta

Tear in the aortic intima that directly exposes an underlying diseased medial layer to the driving force (or pulse pressure) of intraluminal blood

This blood penetrates the diseased medial layer and cleaves the media longitudinally thereby dissecting the aortic wall

Driven by persistent intraluminal pressure the dissection process extends a variable length along the aortic wall typically antegrade but sometimes retrograde from the site of the intimal tear

The blood-filled space between thedissected layers of the aortic wallbecomes the false lumen

Shear forces may lead to further tears inthe intimal flap (the inner portion of thedissected aortic wall) and produce exitsites or additional entry sites for bloodflow into the false lumen

Distention of the false lumen with bloodmay cause the intimal flap to bow intothe true lumen and thereby narrow itscaliber and distort its shape

EPIDEMIOLOGY

Uncommon but potentially catastrophic illness

Occurs with an incidence of at least 2000 cases per year

Early mortality is as high as 1 per hour if untreated

The peak incidence ndash fifth and sixth decades of life

Male to female--- 31

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

The blood-filled space between thedissected layers of the aortic wallbecomes the false lumen

Shear forces may lead to further tears inthe intimal flap (the inner portion of thedissected aortic wall) and produce exitsites or additional entry sites for bloodflow into the false lumen

Distention of the false lumen with bloodmay cause the intimal flap to bow intothe true lumen and thereby narrow itscaliber and distort its shape

EPIDEMIOLOGY

Uncommon but potentially catastrophic illness

Occurs with an incidence of at least 2000 cases per year

Early mortality is as high as 1 per hour if untreated

The peak incidence ndash fifth and sixth decades of life

Male to female--- 31

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

EPIDEMIOLOGY

Uncommon but potentially catastrophic illness

Occurs with an incidence of at least 2000 cases per year

Early mortality is as high as 1 per hour if untreated

The peak incidence ndash fifth and sixth decades of life

Male to female--- 31

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Clinical Presentation

Sudden onset of sharp tearing intractable chest pain may radiate to the back esp interscapular region

Asymmetrical peripheral pulse

Diastolic murmur or bruit

Pulmonary edema

Previously hypertensive now in shock

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

LOCATION

Ascending aorta 65

Descending aorta 20

just distal to the origin of the left subclavianartery at the site of the ligamentumarteriosum

Aortic arch 10 and

Abdominal aorta 5

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Commonly used classifications

Stanford types A and B and

DeBakey types I II and III

Anatomical categories proximal and distalrdquo

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Stanford Type A All dissections involving the ascending aorta regardless of the site of origin

Type B All dissections

not involving the ascending aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

DeBakeyrsquos

DeBakeyrsquos Type I Originates in the

ascending aorta propagates at least to the aortic arch and often beyond it distally

Type II Originates in and is confined to the ascending aorta

Type III Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Proximal IncludesDeBakeytypes I and II or Stanford type A

Distal Includes DeBakeytype III or Stanford type B

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

ETIOLOGY Hypertension 72 ndash 80 ( most common) cystic Medial degeneration as evidenced by

deterioration of medial collagen and elastin is most common predisposing factor

Atherosclerosis Connective tissue disorder (Marfan Ehlers-Danlos) Takayasu (giant cell) arteritis Pregnancy (normal women during 3rdtrimester) Congenital bicuspicaortic valve Aortic coarctation Skeletal abnormalities (scoliosis pectus) Mycotic aneurysm Aortic laceration

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Rare causes

Trauma

Iatrogenic

1 Intraarterial catheterization and

2 the insertion of intraaortic balloon pumps

3 Cardiac surgery Aortic valve replacement

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Predisposing conditions

Bicuspid aortic valve 7 -14

Coarctation of the aorta

Noonan and Turner syndromes

Cocaine abuse

Pregnancy third trimester amp postpartum period

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

ACR Appropriateness Criteria for Aortic Dissection

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Laboratory data

1 Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured

2 BUN and creatinine are elevated if the dissection involves the renal arteries

3 Hematuria oliguria and even anuria(lt50 mLd) may occur if the dissection involves the renal arteries

4 CKMB and TroponinT may be elevated in acute thoracic aorta dissection

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

In acute thoracic dissection ECG can mimic the changes seen in acute cardiac ischemia In the presence of chest pain these signs can make distinguishing dissection from AMI very difficult

STT depression and T wave inversion

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

IMAGING FINDINGS

o Chest X ndash Ray

Mediastinal widening Left paraspinal stripe ldquo Calcium sign ldquois a

finding that suggests aortic dissection It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Double aortic knob sign (present in 40 of patients)

Diffuse enlargement of the aorta with poor definition or irregularity of the aortic contour

Inward displacement of aortic wall calcification by more than 10 mm

Tracheal displacement to the right

Pleural effusion (more common on the left side suggests leakage)

Pericardial effusion

Cardiac enlargement

Displacement of a nasogastric tube

Other radiographic findings include the following

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

CT and CTA

CT especially with arterial contrast enhancement (CTA) is the investigation of choice able not only to diagnose and classify the dissection but also evaluate for distal complications

Post contrast CT (CTA preferably) gives excellent detail Findings include

intimal flap

double lumen

dilatation of aorta

Identification of true lumen is important Helpful featurees

True lumen

Surrounded by calcifications (if present)

Smaller than false lumen

Usually origin of celiac trunk SMA and right renal artery

False Lumen

Flow or occluded by thrombus (chronic)

Delayed enhancement

Wedges around true lumen (beak-sign)

Collageneous media-remnants (cobwebs)

Larger than true lumen

Circular configuration (persistent systolic pressure)

Outer curve of the arch

Usually origin of left renal artery

Surrounds true lumen in Type A dissection

Chronic dissection flaps are often thicker and straighter than those seen in acute dissections

Intimomedialflap inascendingaorta

Contrastextravasation intoanteriormediastinum

intimomedialflap in aorticarchMediastinal

hematoma

False lumen hypodensecompared to true lumen

True lumen hyperdensecompared to false lumen

Type A dissection with clear intimaflap seen within the aortic arch RIGHT Type B dissection Entry point distal to left subclavianartery

Type B dissection Green arrow indicates entry False lumen is indicated by yellow arrows and is seen spiraling around the true lumen

Cobweb seen within the false lumen

Dissection into abdominal arteries

The celiac trunc SMA and right renal artery flow usually originates from the true lumenLeft renal artery flow mostly originates from the false lumenImpaired perfusion of end-organs can be due to 2 mechanisms1) static = continuing dissection in the feeding artery (usually treated by stenting)2) dynamic = dissection flap hanging in front of ostium like a curtain (usually treated with fenestration

Left Continued dissection into the celictrunk showing bigger false lumen significantly contributing to organ perfusionRight SMA and renal artery involvement illustrating possible cause of organ malperfusion

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Intimomedialflap inascendingaorta

Contrastextravasation intoanteriormediastinum

intimomedialflap in aorticarchMediastinal

hematoma

False lumen hypodensecompared to true lumen

True lumen hyperdensecompared to false lumen

Type A dissection with clear intimaflap seen within the aortic arch RIGHT Type B dissection Entry point distal to left subclavianartery

Type B dissection Green arrow indicates entry False lumen is indicated by yellow arrows and is seen spiraling around the true lumen

Cobweb seen within the false lumen

Dissection into abdominal arteries

The celiac trunc SMA and right renal artery flow usually originates from the true lumenLeft renal artery flow mostly originates from the false lumenImpaired perfusion of end-organs can be due to 2 mechanisms1) static = continuing dissection in the feeding artery (usually treated by stenting)2) dynamic = dissection flap hanging in front of ostium like a curtain (usually treated with fenestration

Left Continued dissection into the celictrunk showing bigger false lumen significantly contributing to organ perfusionRight SMA and renal artery involvement illustrating possible cause of organ malperfusion

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Type A dissection with clear intimaflap seen within the aortic arch RIGHT Type B dissection Entry point distal to left subclavianartery

Type B dissection Green arrow indicates entry False lumen is indicated by yellow arrows and is seen spiraling around the true lumen

Cobweb seen within the false lumen

Dissection into abdominal arteries

The celiac trunc SMA and right renal artery flow usually originates from the true lumenLeft renal artery flow mostly originates from the false lumenImpaired perfusion of end-organs can be due to 2 mechanisms1) static = continuing dissection in the feeding artery (usually treated by stenting)2) dynamic = dissection flap hanging in front of ostium like a curtain (usually treated with fenestration

Left Continued dissection into the celictrunk showing bigger false lumen significantly contributing to organ perfusionRight SMA and renal artery involvement illustrating possible cause of organ malperfusion

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Type B dissection Green arrow indicates entry False lumen is indicated by yellow arrows and is seen spiraling around the true lumen

Cobweb seen within the false lumen

Dissection into abdominal arteries

The celiac trunc SMA and right renal artery flow usually originates from the true lumenLeft renal artery flow mostly originates from the false lumenImpaired perfusion of end-organs can be due to 2 mechanisms1) static = continuing dissection in the feeding artery (usually treated by stenting)2) dynamic = dissection flap hanging in front of ostium like a curtain (usually treated with fenestration

Left Continued dissection into the celictrunk showing bigger false lumen significantly contributing to organ perfusionRight SMA and renal artery involvement illustrating possible cause of organ malperfusion

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Cobweb seen within the false lumen

Dissection into abdominal arteries

The celiac trunc SMA and right renal artery flow usually originates from the true lumenLeft renal artery flow mostly originates from the false lumenImpaired perfusion of end-organs can be due to 2 mechanisms1) static = continuing dissection in the feeding artery (usually treated by stenting)2) dynamic = dissection flap hanging in front of ostium like a curtain (usually treated with fenestration

Left Continued dissection into the celictrunk showing bigger false lumen significantly contributing to organ perfusionRight SMA and renal artery involvement illustrating possible cause of organ malperfusion

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Dissection into abdominal arteries

The celiac trunc SMA and right renal artery flow usually originates from the true lumenLeft renal artery flow mostly originates from the false lumenImpaired perfusion of end-organs can be due to 2 mechanisms1) static = continuing dissection in the feeding artery (usually treated by stenting)2) dynamic = dissection flap hanging in front of ostium like a curtain (usually treated with fenestration

Left Continued dissection into the celictrunk showing bigger false lumen significantly contributing to organ perfusionRight SMA and renal artery involvement illustrating possible cause of organ malperfusion

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Rupture into pericardium and thoracic cavity

Even the slightest amount of fluid in pericardium mediastinum or pleural cavity is suggestive of rupture of the dissectionThe cases on the left show evident rupture with presence of extensive hematomaNote extreme hematothorax and hematomediastinum causing shift of the mediastinum and compression on the pulmonary veins and even aortaNo pericardial effusion visible

Left pericardial fluid hematoma indicatesrupture of the dissected aortaRightMassive hematoma caused by rupture ofthe dissected aorta into the mediastinumand pleural cavity no pericaldial hematoma

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Aneurysm with thrombus versus thrombosed dissection

It can be difficult to differentiate an aneurysm with thrombus from a dissection with a thrombosed false lumenIf there are intima calcifications this will be very helpfullA false lumen displaces the intimalcalcifications

LEFT Dissection with a thrombosed false lumenRIGHT Aneurysm with thrombus on the inner side of the intimal calcifications

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

INTRAMURAL HEMATOMA

Intramural Hematoma is a result of ruptured vasa vasorum

Brief facts

bullSpontaneous hemorrhage caused by rupture of vasa vasorum in media13 of dissections usually no pulse deficitbullDifficult to distinguish from thrombosed ADbullCan proceed to classic dissection (16-47)bullLong time to diagnosis usually overlooked due to lack of non-enhanced scanbullMortality at 1 year after adismission~ 25

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Classic example of IMH Hyperdensehematoma on NECT Intima calcifications surround the true lumen

Same case CECT of Intramural hematoma

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Contrast‐filldaortaNo contrast in

intramural hematoma

CT

Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT Intimal calcification may be displaced inwardsUnlike aortic dissection no intimal flap is present

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Penetrating Atherosclerotic Ulcer

PAU is defined as an ulceration of an atheromatous plaque that has eroded the inner elastic layer of the aortic wallIt has reached the media and produced a hematoma within the media

Brief facts

Patients with severe systemic atherosclerosisRarely rupture yet worse prognosis due to extensive atherosclerosis which causes organ failure (eg acute myocardial infarction)Cause of most saccular aneurysmsLocated in arch and descending aortaOften multiple (therefore surgical treatment difficult mostly treated medically)

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Imaging features

Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaquesFocally displaced and separated intima calcificationsCrater andor contrast extravasation-Focal IMH longitudinal spread limited by mediafibrosisPossibly enhancing aortic wall

Typical illustration of PAU focal outpouchings of contrast separating extensive intimal calcifications

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

Complications

Complications of all types of aortic dissection include

dissection and occlusion of branch vesselsabdominal organ ischaemialimb ischaemiaischaemic strokeparaplegia involvement of artery of Adamkiewicz

distal thromboembolismaneurysmal dilatation this is an indication for endovascular or surgical interventionaortic ruptureA type A dissection may also result incoronary artery occlusionaortic incompetencerupture into pericardial sac with resulting cardiac tamponade

MRI

1 Intimal flap2 Slow flow and clot in false lumen

Lumen Partition of a three-dimensional contrast-enhanced MRA shows intimal flap (arrows ) in the distal aortic arch and descending aorta

1 Freely movable flap within the lumen of the vessel2 Differential Doppler detection of true vs false lumen

Freely movable flap within the aorta

Transesophgeal echocardiogram

Angiography

1 Intimalflap2 True and false lumen (may be failure if the falsechannel is thrombosed)3 Aortic regurgitation4 Coronary artery

Oblique arteriogram of the thoracic aorta demonstrates the double-barrel aorta sign of aortic dissection Both the true and false lumina are opacified

MANAGMENT

Type A aortic dissection

Treatment for type A aortic dissection may includeSurgery Surgeons remove as much of the dissected aorta as possible block the entry of blood into the aortic wall and reconstruct the aorta with a synthetic tube called a graft If the aortic valve leaks as a result of the damaged aorta it may be replaced at the same time The new valve is placed within the graft used to reconstruct the aorta

Medications Some medications such as beta blockers and nitroprusside (Nitropress) reduce heart rate and lower blood pressure which can prevent the aortic dissection from worsening They may be given to people with type A aortic dissection to stabilize blood pressure before surgery

Type B aortic dissection

Treatment of type B aortic dissection may include

Surgery The procedure is similar to that used to correct a type A aortic dissection Sometimes stents mdash small wire mesh tubes that act as a sort of scaffolding mdash may be placed in the aorta to repair complicated type B aortic dissections

Medications The same medications that are used to treat type A aortic dissection may be used without surgery to treat type B aortic dissectionsAfter treatment you may need to take blood pressure lowering medication for life In addition you may need follow-up CTs or MRIs periodically to monitor your condition

1 Freely movable flap within the lumen of the vessel2 Differential Doppler detection of true vs false lumen

Freely movable flap within the aorta

Transesophgeal echocardiogram

Angiography

1 Intimalflap2 True and false lumen (may be failure if the falsechannel is thrombosed)3 Aortic regurgitation4 Coronary artery

Oblique arteriogram of the thoracic aorta demonstrates the double-barrel aorta sign of aortic dissection Both the true and false lumina are opacified

MANAGMENT

Type A aortic dissection

Treatment for type A aortic dissection may includeSurgery Surgeons remove as much of the dissected aorta as possible block the entry of blood into the aortic wall and reconstruct the aorta with a synthetic tube called a graft If the aortic valve leaks as a result of the damaged aorta it may be replaced at the same time The new valve is placed within the graft used to reconstruct the aorta

Medications Some medications such as beta blockers and nitroprusside (Nitropress) reduce heart rate and lower blood pressure which can prevent the aortic dissection from worsening They may be given to people with type A aortic dissection to stabilize blood pressure before surgery

Type B aortic dissection

Treatment of type B aortic dissection may include

Surgery The procedure is similar to that used to correct a type A aortic dissection Sometimes stents mdash small wire mesh tubes that act as a sort of scaffolding mdash may be placed in the aorta to repair complicated type B aortic dissections

Medications The same medications that are used to treat type A aortic dissection may be used without surgery to treat type B aortic dissectionsAfter treatment you may need to take blood pressure lowering medication for life In addition you may need follow-up CTs or MRIs periodically to monitor your condition

Angiography

1 Intimalflap2 True and false lumen (may be failure if the falsechannel is thrombosed)3 Aortic regurgitation4 Coronary artery

Oblique arteriogram of the thoracic aorta demonstrates the double-barrel aorta sign of aortic dissection Both the true and false lumina are opacified

MANAGMENT

Type A aortic dissection

Treatment for type A aortic dissection may includeSurgery Surgeons remove as much of the dissected aorta as possible block the entry of blood into the aortic wall and reconstruct the aorta with a synthetic tube called a graft If the aortic valve leaks as a result of the damaged aorta it may be replaced at the same time The new valve is placed within the graft used to reconstruct the aorta

Medications Some medications such as beta blockers and nitroprusside (Nitropress) reduce heart rate and lower blood pressure which can prevent the aortic dissection from worsening They may be given to people with type A aortic dissection to stabilize blood pressure before surgery

Type B aortic dissection

Treatment of type B aortic dissection may include

Surgery The procedure is similar to that used to correct a type A aortic dissection Sometimes stents mdash small wire mesh tubes that act as a sort of scaffolding mdash may be placed in the aorta to repair complicated type B aortic dissections

Medications The same medications that are used to treat type A aortic dissection may be used without surgery to treat type B aortic dissectionsAfter treatment you may need to take blood pressure lowering medication for life In addition you may need follow-up CTs or MRIs periodically to monitor your condition

MANAGMENT

Type A aortic dissection

Treatment for type A aortic dissection may includeSurgery Surgeons remove as much of the dissected aorta as possible block the entry of blood into the aortic wall and reconstruct the aorta with a synthetic tube called a graft If the aortic valve leaks as a result of the damaged aorta it may be replaced at the same time The new valve is placed within the graft used to reconstruct the aorta

Medications Some medications such as beta blockers and nitroprusside (Nitropress) reduce heart rate and lower blood pressure which can prevent the aortic dissection from worsening They may be given to people with type A aortic dissection to stabilize blood pressure before surgery

Type B aortic dissection

Treatment of type B aortic dissection may include

Surgery The procedure is similar to that used to correct a type A aortic dissection Sometimes stents mdash small wire mesh tubes that act as a sort of scaffolding mdash may be placed in the aorta to repair complicated type B aortic dissections

Medications The same medications that are used to treat type A aortic dissection may be used without surgery to treat type B aortic dissectionsAfter treatment you may need to take blood pressure lowering medication for life In addition you may need follow-up CTs or MRIs periodically to monitor your condition

Type B aortic dissection

Treatment of type B aortic dissection may include

Surgery The procedure is similar to that used to correct a type A aortic dissection Sometimes stents mdash small wire mesh tubes that act as a sort of scaffolding mdash may be placed in the aorta to repair complicated type B aortic dissections

Medications The same medications that are used to treat type A aortic dissection may be used without surgery to treat type B aortic dissectionsAfter treatment you may need to take blood pressure lowering medication for life In addition you may need follow-up CTs or MRIs periodically to monitor your condition