The 3 diagnoses are considered as part of the same spectrum of disease and are investigated and treated similarly. Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. (2004) The Annals of thoracic surgery. In most cases, this is associated with a sudden onset of severe chest or back pain, often described as "tearing" in character. Approximately 80% of patients with thoracic aorticinjury die at the scene of the trauma. Srichai MB, Lieber ML, Lytle BW, Kasper JM, White RD. Weissleder R, Wittenberg J, M.D. Distinguishing between the two is often straightforward, but in some instances, no clear continuation of one lumen with normal artery can be identified. Sudden tearing or ripping chest pain 2. {"url":"/signup-modal-props.json?lang=us\u0026email="}, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":918,"mcqUrl":"https://radiopaedia.org/articles/aortic-dissection/questions/198?lang=us"}. McMahon MA, Squirrell CA. Intraoperative transesophageal echocardiography provides incremental information to the original imaging examination in the management of type-A acute aortic dissection in nearly two-thirds of patients, leading to a change in the planned surgery in 39% of patients, thus supporting its role as sugges … Pulsation artefact can mimic dissection, is very common and seen in up to 92% of non-gated CTA studies 8. The aortic knob was very enlarged and had displaced the trachea to the right. 2005;184 (4): 1225-30. Clinical presentation may include chest or mid-scapular back pain, signs of external chest trauma or hemodynamic instability. Computed tomography of thoracic aortic dissection: accuracy and pitfalls. CTA has now replaced it as the first-line investigation, not only due to it being non-invasive but also on account of better delineation of the poorly opacifying false lumen, intramural hematoma and end-organ ischemia. Mosby Inc. (2007) ISBN:0323040683. Sebastià C, Pallisa E, Quiroga S et-al. If the blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal.Aortic dissection is relatively uncommon. Emerg Radiol. Primer of Diagnostic Imaging, Expert Consult- Online and Print. Aortic dissection: CT features that distinguish true lumen from false lumen. MG et-al. 2003;181 (2): 309-16. Gleeson CE, Spedding RL, Harding LA, et al The mediastinum—Is it wide? A typical helical scanning protocol for aortic dissection includes the following parameters: 5-mm collimation, 1.5 pitch, and 7.5-mm imaging spacing. Multidetector CT may be performed with 1-2.5 mm collimation. thoracic aortic dilatation (differential), D-loop transposition of the great arteries, L-loop transposition of the great arteries, rupture into the pericardial sac with resulting, medical management with blood pressure control, type A: dissections with a tear in the ascending aorta including a segment with the branching of the brachiocephalic trunk, type B: all dissections with proximal tear distal to the branching of the brachiocephalic trunk, type A: proximal extent in ascending aorta, non-A-non-B dissection: retrograde extent or proximal tear in the arch between the brachiocephalic trunk and left subclavian artery, type B: proximal extent in descending aorta distal to left subclavian artery. Multidetector CT of Aortic Dissection: A Pictorial Review. Along with the DeBakey classification, the Stanford classification 7 is used to separate aortic dissections into those that need surgical repair, and those that usually require only medical management. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Conventional digital subtraction angiography has historically been the gold standard investigation. (2018). Continued. Risks of angiography include general risks of angiography plus the risk of catheterizing the false lumen and causing aortic rupture. Findings: There was a left, apical, pleural cap. 218492318810087. 12. A variety of imaging modalities are available in the emergency department, though CT angiography is the most widely used definitive study for this condition. In a very small minority, an underlying connective tissue disorder may be present. DISSECT: a new mnemonic-based approach to the categorization of aortic dissection. There have been efforts to construct a clinical decision rule stratify risk of acute aortic dissection and avoid over-investigation. Findings include 1-3,5: An essential part of the assessment of aortic dissection is identifying the true lumen, as the placement of an endoluminal stent-graft in the false lumen can have dire consequences. 19 (1): 45-60. True versus false channel o False channel usually arises anterior in the ascending aorta and spirals to posterior and left lateral in descending aorta o True channel is usually larger 10 (3): 237-47. Petasnick JP, Radiologic evaluation of aortic dissection. Abstract The classic entity of life-threatening aortic dissection represents one pathology of a spectrum of acute conditions coined the acute aortic syndrome comprising dissection, intramural haematoma, penetrating atherosclerotic ulcer, and contained aortic rupture of any cause. A total of 29 women (mean [standard deviation (SD)] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Check for errors and try again. Emergency Medicine Journal 2001;18:183-185. Diagnostic Imaging in the Evaluation of Suspected Aortic Dissection -- Old Standards and New Directions New England Journal of Medicine, Vol. CT is the principal modality used to diagnose acute aortic dissection (AAD). Radiology. 8. 1 Aortic dissection and aortic aneurysm surgery: Clinical observations, experimental investigations, and statistical analyses part III On finding extensive descending aortic dissection extending into the abdominal aorta and left common carotid artery, further CTA was performed of the neck, abdomen and pelvis as well as a ECG-gated CTA of the aortic root. Saunders Ltd. ISBN:0702030465. An aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears. Editor's Choice - Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Aortic dissection can be rapidly fatal, with many patients dying before presentation to the emergency department (ED) or before diagnosis is made in the ED.No one sign or symptom can positively identify Multidetector CT of Aortic Dissection: A Pictorial Review. AJR Am J Roentgenol. The CTPA is of good quality and no pulmonary embolus is identified. The Stanford classification divides dissections by the most proximal involvement: A special case that is neither reflected in the original Stanford nor the DeBakey classification are dissections that involve the aortic arch but not the ascending aorta (between 8 and 15% of all aortic dissections 4). Dake MD, Thompson M, van Sambeek M, Vermassen F, Morales JP. Imaging Assessment Chest x-ray. In those who make it to hospital, clinical diagnosis is difficult. The radiologic assessment of patients suspected of having an aortic dissection must be based on an understanding of the treatment options and how these are to be employed in any clinical setting. Hurwitz LM, Goodman PC. Lai V, Tsang WK, Chan WC et-al. 2019]. (2019) European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. In most cases the vessel wall is abnormal. J Comput Assist Tomogr. 77 (6): 2012-20; discussion 2020. Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection. A new classification system was proposed which is referred with the acronym DISSECT (duration, intimal tear, size of the dissected aorta, the segmental extent of involvement, clinical complications, and thrombosis of the false lumen) 18. Effects of heart rate on motion artifacts of the aorta on non-ECG-assisted 0.5-sec thoracic MDCT. 19 (1): 45-60. 1986; 10: 211 – 215. The majority of aortic dissections are seen in elderly hypertensive patients. Thoracic endovascular aortic repair for retrograde type A aortic dissection with an entry … 46 (2): 175-90. Lempel JK, Frazier AA, Jeudy J, Kligerman SJ, Schultz R, Ninalowo HA, Gozansky EK, Griffith B, White CS. Pereles FS, Mccarthy RM, Baskaran V et-al. Acute thoracic dissection is life-threatening and requires immediate diagnosis and treatment (Castaner et al. This review focuses on the role of CT and MRI in the diagnosis, follow-up, and surgical planning of aortic aneurysms and acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer. Age-related presentation of acute type A aortic dissection. (2018) BMJ (Clinical research ed.). Vasile N, Mathieu D, Keita K, Lellouche D, Bloch G, Cachera JP. 2018 Oct 31. Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients. Shu C, Wang T, Li QM, Li M, Jiang XH, Luo MY, et al. 2. Unable to process the form. Management of acute aortic dissections. 3. Aortitis is a pathologic term for the presence of inflammatory changes of the aortic wall, regardless of the underlying cause. Radiology. Lepage MA, Quint LE, Sonnad SS et-al. 20. [Medline] . Fourteen patients with aortic dissection without intimal rupture were examined by means of magnetic resonance (MR) imaging, computed tomography (CT), or both. 6. 6. 2012;19 (4): 309-15. AJR Am J Roentgenol. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect). 11. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Ko SF, Hsieh MJ, Chen MC et-al. Penetrating atherosclerotic ulcers of the descending thoracic aorta: evaluation with CT and distinction from aortic dissection. true FISP) may see MRI having a larger role to play in the acute diagnosis, particularly in patients with impaired renal function 4. 360: k678. Infectious aortitis may be secondary to tuberculosis, syphilis, or infection with Salmonellaor … 15. AJR Am J Roentgenol. Aortic dissection: diagnosis and follow-up with helical CT. Radiographics. Aortic Dissection . (2020) The Annals of thoracic surgery. Definitive imaging [5] Definitive imaging is used to determine the type of lumen, location, and extent of the dissecting membrane. The term Acute Aortic Syndrome (AAS) is used to describe three closely related emergency entities of the thoracic aorta: classic Aortic Dissection (AD), Intramural Hematoma (IMH) and Penetrating Atherosclerotic Ulcer (PAU). The differential on chest x-ray is that of a dilated thoracic aorta. Aortic wall inflammation may be infectious or more commonly noninfectious. 16. Other conditions or predisposing factors may also be encountered, in which case they will be reflected in the demographics. The authors describe dissections that originate from the arch or extend proximally into the arch without the involvement of the ascending aorta which are not adequately accounted for in the Stanford nor the DeBakey classification systems. You’ll need imaging tests to make sure you have an aortic dissection. (2010) Radiographics : a review publication of the Radiological Society of North America, Inc. 30 (2): 445-60. doi:10.1148/rg.302095104 - Pubmed. 18. In 2014, a special report was published in Radiology 4 that recognized an uncommon form of aortic dissection. 328, No. Some cases of aortic dissection may result in rupture, causing collapse and often death. The Chest X-Ray: A Survival Guide. The aim was to compare computed tomography (CT) features in acute and chronic aortic dissections (AADs and CADs) and determine if a certain combination of imaging features was reliably predictive of the acute versus chronic nature of disease in individual patients. Detecting an aortic dissection can be tricky because the symptoms are similar to those of a variety of health problems. Thoracic aortic dissection and aneurysm: evaluation with nonenhanced true FISP MR angiography in less than 4 minutes. CCT has emerged as the initial diagnostic modality to identify or exclude AAD by virtue of: Imaging both the thoracic and abdominal aorta (vs. echocardiography), which … Type A dissection typically requires urgent surgical intervention, whereas type B dissection can often be treated medically. No signs of right ventricular strain. Stanford classification of aortic dissection, Stanford classification of aortic dissections. Aortic dissection is the most common form of the acute aortic syndromes and a type of arterial dissection. Blount KJ, Hagspiel KD. Type A aortic dissection involves the ascending thoracic aorta and may extend into the descending aorta, whereas in a type B dissection the intimal tear is located distal to the left subclavian artery. Mosby. 17. Clinically these conditions are indistinguishable. 2007;24 (4): 310. The diagnosis of aortic aneurysms and aortic dissection has been revolutionized by developments in cross-sectional imaging. Complications of all types of aortic dissection include: A Stanford type A dissection may also result in: Although the combination of blood pressure control and surgical intervention has significantly lowered in-hospital mortality, it remains significant, at 10-35%. There may be a difference in blood pressure between the two arms depending on where the dissection occurs. Widening of the aorta on chest X-ray 3. Diagnostic imaging plays a substantial role in meeting this objective in the case of thoracic aortic dissection. Transesophageal echocardiography (TOE) has very high sensitivity and specificity for assessment of acute aortic dissection, but due to limited access and its invasive nature, it has largely been replaced by CTA (or MRA in some instances) 5. If clinical suspicion for acute aortic dissection persists, perform a second imaging study! One option to repair an aortic dissection is for an Interventional Radiologist to perform an aortic fenestration procedure. 4. Akutsu K, Yoshino H, Tobaru T, Hagiya K, Watanabe Y, Tanaka K, Koyama N, Yamamoto T, Nagao K, Takayama M. Acute type B aortic dissection with communicating vs. non-communicating false lumen. Acute Aortic Syndromes. The signs and symptoms are non-specific and distracting injuries are often present. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Chest radiography may be normal or demonstrate a number of suggestive findings, including: Depending on etiology, there may be signs of periaortic or mediastinal hematoma which include: CT, especially with arterial contrast enhancement (CTA) is the investigation of choice, able not only to diagnose and classify the dissection but also to evaluate for distal complications. (1970) The Annals of thoracic surgery. Th… 2. Non-contrast CT may demonstrate only subtle findings; however, a high-density mural hematoma is often visible. 2009;192 (5): W222-9. Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, Chiesa R, Clough RE, Eberle B, Etz C, Grabenwöger M, Haulon S, Jakob H, Kari FA, Mestres CA, Pacini D, Resch T, Rylski B, Schoenhoff F, Shrestha M, von Tengg-Kobligk H, Tsagakis K, Wyss TR, Document Reviewers, Chakfe N, Debus S, de Borst GJ, Di Bartolomeo R, Lindholt JS, Ma WG, Suwalski P, Vermassen F, Wahba A, Wyler von Ballmoos MC. 79 (3): 567-73. 2005;184 (4): 1245-6. [online] Available at: https://www.gov.uk/drug-safety-update/systemic-and-inhaled-fluoroquinolones-small-increased-risk-of-aortic-aneurysm-and-dissection-advice-for-prescribing-in-high-risk-patients [Accessed 22 Jun. 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