Download Aortic Dissection: Radiologic Findings

Alison Lozner, HMS III
Gillian Lieberman, MD
January, 2004
Aortic Dissection: Radiologic Findings
Alison Lozner, Harvard Medical School Year III
Gillian Lieberman, MD
Alison Lozner, HMS III
Gillian 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 III
Gillian Lieberman, MD
Mr. JB’s H and P
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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 III
Gillian Lieberman, MD
DDx- sudden onset chest pain
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Cardiac (MI, angina)
Vascular (aortic dissection, PE)
Pulmonary (pneumothorax)
GI (GERD, esophageal spasm)
MSK (costochondritis)
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Alison Lozner, HMS III
Gillian Lieberman, MD
Mr. JB’s DDx
• Cardiac (MI,
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angina)
Vascular (aortic dissection, PE)
• Pulmonary (pneumothorax)
• GI (GERD, esophageal spasm)
• MSK (costochondritis)
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Alison Lozner, HMS III
Gillian Lieberman, MD
Mr. JB’s CXR
“apparent
widening of the
right superior
mediastinum”
widened mediastinum
“underlying
vascular
injury/dissection
cannot be
excluded”
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Image and text courtesy of BIDMC
Alison Lozner, HMS III
Gillian Lieberman, MD
DDx- Widened Mediastinum
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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 III
Gillian Lieberman, MD
Aortic Dissection on CXR
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Widening of the superior mediastinum
Progressive widening of the aorta on serial films
Left pleural effusion
According to the International Registry of Acute
Aortic Dissection, 12.4% of patients have no
abnormality on chest radiograph.
(Miller, 2001)
( Hagan, 2000)
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Alison Lozner, HMS III
Gillian Lieberman, MD
Mr. JB’s CTA
R ventricle
Ascending Aorta
& Intimal Flap
L atrium
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Image courtesy of BIDMC
Alison Lozner, HMS III
Gillian Lieberman, MD
Mr. JB’s CTA
Aortic arch
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Image courtesy of BIDMC
Alison Lozner, HMS III
Gillian Lieberman, MD
Mr. JB’s CTA
Descending Aorta
Image courtesy of BIDMC
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Alison Lozner, HMS III
Gillian Lieberman, MD
What Information Is Needed?
• Presence of an aortic dissection
• Involvement of ascending aorta
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Alison Lozner, HMS III
Gillian Lieberman, MD
Classification of Aortic Dissections
Image courtesy of Cotran, 1999.
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Alison Lozner, HMS III
Gillian 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 III
Gillian Lieberman, MD
Identifying the True Lumen
True Lumen
• Location of calcifications
• “Beak” or “Claw” sign
Image courtesy of BIDMC
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Alison Lozner, HMS III
Gillian Lieberman, MD
Identifying the True Lumen
Patient 2
• Differing opacification times
Image A
True lumen
Image B (seconds later)
False lumen
Images courtesy of Neil Rofsky, M.D.
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Alison Lozner, HMS III
Gillian Lieberman, MD
Can you find the true lumen?
Patient 3
Image courtesy of BIDMC
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Alison Lozner, HMS III
Gillian Lieberman, MD
Can you find the true lumen?
Patient 3
True Lumen
Image courtesy of BIDMC
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Alison Lozner, HMS III
Gillian Lieberman, MD
What Information Is Needed?
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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 III
Gillian Lieberman, MD
Comparison of Modalities for AD
Diagnosis
• CT
• MRI
• TEE
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Alison Lozner, HMS III
Gillian Lieberman, MD
Pros and Cons of CT
Pros:
• Noninvasive
• Equipment generally available on an emergent
basis
• Operator IN-dependent
• Helpful for identifying other causes of mediastinal
widening
Cons:
• Requires IV contrast
• Sensitivity: 94%, Specificity: 87%
(Nienaber, 1993)
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Alison Lozner, HMS III
Gillian Lieberman, MD
MRI
Image courtesy of Neil Rofsky, M.D.
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Alison Lozner, HMS III
Gillian Lieberman, MD
Pros and Cons of MRI
Pros:
• Sensitivity: 98%, Specificity: 98%
• Noninvasive and no IV contrast required
• Multiple planes of view help with dx
• Cine-MRI can identify aortic insufficiency
Cons:
• Contraindicated for some patients
• Patients are relatively inaccessible during the MRI
• MRI may not be available emergently
(Nienaber, 1993)
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Alison Lozner, HMS III
Gillian Lieberman, MD
Transesophageal Echo
Image courtesy of Cigarroa, 1993.
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Alison Lozner, HMS III
Gillian Lieberman, MD
Pros and Cons of TEE
Pros:
• Sensitivity: 98%, Specificity: 77%
• Widely available at the bedside
• Doppler can identify aortic insufficiency
Cons:
• Semi-invasive
• Operator dependent
• Image quality comparatively poor for surgical
planning
(Nienaber, 1993)
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Alison Lozner, HMS III
Gillian 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 III
Gillian 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 III
Gillian Lieberman, MD
Acknowledgements
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Daniel Cornfeld, MD
Neil Rofsky, MD
Larry Barbaras, Webmaster
Gillian Lieberman, MD
Pamela Lepkowski, Clerkship Coordinator
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