Aortic Dissection

Kevin Zahraee, MS4

August 2013

Aditi Gulabani, MD

• CC: abdominal pain • HPI: 34 year old F with SLE, hemophilia, and HTN presented to

ED in AM. Had been having abdominal pain overnight. Described the pain as stabbing and diffuse radiating to mid-back and worse with sitting. Also having nausea and 3 episodes of emesis. Tried hydrocodone, gas meds, and Tylenol without relief. No urinary complaints. Normal BMs. No fever, cough, sob. Recent hx of peritoneal dialysis.

• VS: BP: 240/122 P: 101 T: 98.5 RR: 20 O2 sat: 100%• PE: Abdomen: diffuse tenderness and bilateral CVA tenderness w/o

spinal tenderness

Cardiac: S1 and S2 present, no murmurs

Extremities: bilateral pitting edema

Pulses: 2+ equal in all four extremities

Patient Presentation

• Differential includes gastroenteritis, appendicitis, gynecologic pathology, aortic dissection (high BP)

• Imaging Options– KUB– CT abdomen and pelvis – Chest x-ray (high BP, pain radiating to back)– CT chest (high BP, pain radiating to back)– CT chest angiogram (BP, pain radiating to back) – Ultrasound abdomen and pelvis

Differential Dx and Imaging Options

Appropriateness Criteria

CT Abdomen & Pelvis w Contrast (axial)

MRN: 6006275

Comparison from 6/22/13 CT

Appears fairly normal, BUT… this was done without contrast

Dedicated CT Angiogram Chest (sagittal)

Chest X-ray of Patient (portable upright AP)

• Diagnostic Criteria on CT– Demonstration of intimal flap separating true from false lumen– Internal displacement of intimal calcifications – Delayed enhancement of false lumen – Aortic widening

• Limitations of CT– Aortic motion artifacts – Mural thrombi in a fusiform aneurysm – Structures or masses around aorta can distort interpretation

• Accuracy (dependent of many factors used to generate image and location of dissection)– Sensitivity >90%– Specificity >85%

Radiologic Diagnosis

• Tear in aortic intima leads to…– Blood passes into aortic media – Separates intima from media and/or adventitia – Creates false lumen

• Risk factors– Hypertension – Previous aortic aneurysm – Inflammatory diseases that cause vasculitis – Collagen disorders (Marfan’s, Ehler’s Danlos, etc.)

• Classifications (2 types)– DeBakey (Type I, II, or III) – Stanford (Type A and type B)

Aortic Dissection Pathology

• DeBakey– Type I: originates in ascending aorta and goes to at least

aortic arch – Type II: originating and limited to ascending aorta – Type III: originating in descending and moving either

proximally or distally

• Stanford (more commonly used) – Type A: any ascending aorta involvement – Type B: all others without ascending aorta involvement – Further subtyped into a and b

Classifications of Aortic Dissection

Classifications of Aortic Dissection

Placement of Thoracic Endograft (US fluoroscopy)

Placement of Thoracic Endograft

Placement of Thoracic Endograft

Placement of Thoracic Endograft

• On POD #1, the patient became aphasic and had CT and MRI brain. CT brain and CTA head and neck were unremarkable.

• MRI brain showed some restricted diffusion in left superior frontal gyrus, anterior frontal lobe, and right inferior cerebellum. Had EEG, which showed diffuse non-specific encephalopathy.

• Neuro concluded it was a reaction to prochlorperazine. • Medication was stopped and patient returned to baseline neuro

status. • Patient also had swelling in LUE. US LUE revealed an

enlarging brachial artery pseudoaneurysm. IR performed a thrombin injection.

Clinical Outcome Post-Endograft

• Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, Radegran K, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA; Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001 Sep;22(18):1642-81.

• http://www.uptodate.com.ezproxy.rush.edu/contents/clinical-manifestations-and-diagnosis-of-aortic-dissection?detectedLanguage=en&source=search_result&search=aortic+dissection&selectedTitle=1%7E150&provider=noProvider#H7

• http://www.acr.org/Quality-Safety/Appropriateness-Criteria/Diagnostic

Resources