aortic dissection: radiologic findingseradiology.bidmc.harvard.edu/learninglab/cardio/lozner.pdf ·...
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Alison Lozner, HMS IIIGillian Lieberman, MD
Aortic Dissection: Radiologic Findings
Alison Lozner, Harvard Medical School Year IIIGillian Lieberman, MD
January, 2004
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Alison Lozner, HMS IIIGillian Lieberman, MD
Mr. JB’s
chest pain
•
80-year-old white male visiting his wife, who was scheduled for surgery, at BIDMC
•
Sudden onset of heavy, 8/10, substernal
chest pain•
Radiated from his mid-sternum to his jaw and to his left shoulder and arm
•
Tingling of his left arm•
Right eye blurriness
•
No radiation of pain to the back, no SOB
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Alison Lozner, HMS IIIGillian Lieberman, MD
Mr. JB’s
H and P
•
HTN•
Bradycardia
s/p
pacemaker
•
Stable abdominal aortic aneurysm•
On Norvasc
and HCTZ
•
Father died of AAA rupture. Brother treated for AAA rupture.
•
Vitals: T 96.1, P 57, BP 94/50, R 16, O2 95% RA
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Alison Lozner, HMS IIIGillian Lieberman, MD
DDx-
sudden onset chest pain
•
Cardiac (MI, angina)•
Vascular (aortic dissection, PE)
•
Pulmonary (pneumothorax)•
GI (GERD, esophageal spasm)
•
MSK (costochondritis)
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Alison Lozner, HMS IIIGillian Lieberman, MD
Mr. JB’s
DDx
•
Cardiac (MI, angina)
•
Vascular (aortic dissection, PE)•
Pulmonary (pneumothorax)
•
GI (GERD, esophageal spasm)•
MSK (costochondritis)
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Alison Lozner, HMS IIIGillian Lieberman, MD
Mr. JB’s
CXR
widened mediastinum
“apparent widening of the right superior mediastinum”
“underlying vascular injury/dissection cannot be excluded”
Image and text courtesy of BIDMC
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Alison Lozner, HMS IIIGillian Lieberman, MD
DDx-
Widened Mediastinum
•
Achalasia•
Neoplasm
•
LAD•
Hematoma or Hemorrhage
•
Vascular abnormality (e.g. dilated or tortuous aorta, aneurysm, dissection, coarctation, dilated SVC)
(Reeder, 1993)
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Alison Lozner, HMS IIIGillian Lieberman, MD
Aortic Dissection on CXR
•
Widening of the superior mediastinum•
Progressive widening of the aorta on serial films
•
Left pleural effusion (Miller, 2001)
•
According to the International Registry of Acute Aortic Dissection, 12.4% of patients have no abnormality on chest radiograph. (�Hagan, 2000)
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Alison Lozner, HMS IIIGillian Lieberman, MD
R ventricle
L atrium
Ascending Aorta& Intimal Flap
Mr. JB’s
CTA
Image courtesy of BIDMC
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Alison Lozner, HMS IIIGillian Lieberman, MD
Mr. JB’s
CTA
Aortic arch
Image courtesy of BIDMC
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Alison Lozner, HMS IIIGillian Lieberman, MD
Mr. JB’s
CTA
Descending Aorta
Image courtesy of BIDMC
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Alison Lozner, HMS IIIGillian Lieberman, MD
What Information Is Needed?
•
Presence of an aortic dissection•
Involvement of ascending aorta
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Alison Lozner, HMS IIIGillian Lieberman, MD
Classification of Aortic Dissections
Image courtesy of Cotran, 1999.
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Alison Lozner, HMS IIIGillian Lieberman, MD
What Information Is Needed?
•
Presence of an aortic dissection•
Involvement of ascending aorta
•
True vs. False lumen
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Alison Lozner, HMS IIIGillian Lieberman, MD
Identifying the True Lumen
•
Location of calcifications
True Lumen
• “Beak” or “Claw” sign
Image courtesy of BIDMC
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Alison Lozner, HMS IIIGillian Lieberman, MD
Identifying the True Lumen• Differing opacification
times
Image A Image B (seconds later)True lumen False lumen
Images courtesy of Neil Rofsky, M.D.
Patient 2
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Alison Lozner, HMS IIIGillian Lieberman, MD
Can you find the true lumen?
Image courtesy of BIDMC
Patient 3
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Alison Lozner, HMS IIIGillian Lieberman, MD
Can you find the true lumen?
True Lumen
Image courtesy of BIDMC
Patient 3
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Alison Lozner, HMS IIIGillian Lieberman, MD
What Information Is Needed?
•
Presence of an aortic dissection•
Involvement of ascending aorta
•
True vs. False lumen•
Extent of dissection
•
Sites of entry and re-entry•
Involvement of branch vessels
•
Aortic insufficiency•
Pericardial effusion (Cigarroa, 1993)
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Alison Lozner, HMS IIIGillian Lieberman, MD
Comparison of Modalities for AD Diagnosis
•
CT•
MRI
•
TEE
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Alison Lozner, HMS IIIGillian Lieberman, MD
Pros and Cons of CTPros:•
Noninvasive
•
Equipment generally available on an emergent basis
•
Operator IN-dependent•
Helpful for identifying other causes of mediastinal
wideningCons:•
Requires IV contrast
•
Sensitivity: 94%, Specificity: 87% (Nienaber, 1993)
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Alison Lozner, HMS IIIGillian Lieberman, MD
MRI
Image courtesy of Neil Rofsky, M.D.
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Alison Lozner, HMS IIIGillian Lieberman, MD
Pros and Cons of MRIPros:•
Sensitivity: 98%, Specificity: 98% (Nienaber, 1993)
•
Noninvasive and no IV contrast required•
Multiple planes of view help with dx
•
Cine-MRI can identify aortic insufficiencyCons:•
Contraindicated for some patients
•
Patients are relatively inaccessible during the MRI•
MRI may not be available emergently
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Alison Lozner, HMS IIIGillian Lieberman, MD
Image courtesy of Cigarroa, 1993.
Transesophageal
Echo
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Alison Lozner, HMS IIIGillian Lieberman, MD
Pros and Cons of TEEPros:•
Sensitivity: 98%, Specificity: 77% (Nienaber, 1993)
•
Widely available at the bedside•
Doppler can identify aortic insufficiency
Cons:•
Semi-invasive
•
Operator dependent•
Image quality comparatively poor for surgical planning
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Alison Lozner, HMS IIIGillian Lieberman, MD
Summary: Dx
Aortic Dissection
•
Choose modality (TEE, CT, or MRI) based on availability and expertise
•
Identify an intimal
flap•
Type A or Type B dissection?
•
Which is the true lumen?–
intimal
calcifications
–
“beak” or “claw” sign–
differing times to opacification
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Alison Lozner, HMS IIIGillian Lieberman, MD
References
•
Cigarroa
et al. 1993. “Medical Progress: Diagnostic Imaging in the Evaluation of Suspected Aortic Dissection--Old Standards and New Directions.”
N Engl J Med. 328 (1):35-43.•
Cotran, et al. 1999. Robbins Pathologic Basis of Disease. 6th ed. NY: WB Saunders Company.•
Hagan et al. 2000. “The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease.”
JAMA. 283(7): 897-903.•
Ledbetter et al. 1999. “Helical (Spiral) CT in the Evaluation of Emergent Thoracic Aortic Syndromes: Traumatic Aortic Rupture, Aortic Aneurysm, Aortic Dissection, Intramural Hematoma, and Apenetrating
Atherosclerotic Ulcer.”
The Radiologic Clinics of North America: Advances in Emergency Radiology I. 37(3): 575-590.
•
Miller, W. ed. 2001. Seminars in Roentgenology: Thoracic Aortic Aneurysms. 36(4).•
Nienaber
et al. 1993. “The Diagnosis of Thoracic Aortic Dissection By Noninvasive Imaging Procedures.”
N Engl J Med. 328 (1):1-9.•
Nienaber, C. and Kim Eagle. 2003. “Aortic Dissection: New Frontiers in Diagnosis and Management Part 1: From Etiology
to Diagnostic Strategies.”
Circulation. 108: 628-635.•
Reeder, M. 1993. Reeder and Felson’s Gamut’s In Radiology Comprehensive Lists of Roentgen Differential Diagnoses. 3d ed. NY: Springer-Verlag.
•
Sarasin et al. 1996. “Detecting Acute thoracic Aortic Dissection in the Emergency Department: Time Constraints and Choice of the Optimal Diagnostic Test.”
Annals of Emergency Medicine. 28(3): 278-288.
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Alison Lozner, HMS IIIGillian Lieberman, MD
Acknowledgements
•
Daniel Cornfeld, MD•
Neil Rofsky, MD
•
Larry Barbaras, Webmaster•
Gillian Lieberman, MD
•
Pamela Lepkowski, Clerkship Coordinator