The clinical diagnosis of dissecting aneurysm of the aorta depends on awareness of the entity, keen clinical suspicion, and an understanding of the varied manifestations. Clinical suspicion is sharpened by association of certain preexisting conditions found to be related to an increased incidence of aortic dissection. Recognition of the Marfan's syndrome, pregnancy, or preexisting hypertension in a patient presenting as an acute catastrophe may lead to the diagnosis. A family history of aortic dissection is similarly helpful. The variable manifestations call for careful reasoning. Multiple system involvement in many cases is the initial lead in establishing the diagnosis. The many systems frequently involved in the symptomatology of aortic dissection have in common the origin of the blood supply. When the aorta is damaged, branches to various organs may be affected so that the symptoms depend on the branches involved. Because any portion of the aorta may be involved in the dissecting process, no single clinical picture suffices for its recognition. Aortic valvular findings often are seen with involvement of the ascending aorta, central neurologic findings may result from occlusion of the carotid arteries, spinal cord manifestations may result from occlusion of the intercostal arteries, renal manifestations may be seen with renal artery involvement, and so on down the aorta. However, the pattern of a catastrophic episode—whether cardiovascular, neurologic, or abdominal—calls for consideration of aortic dissection. All of the finesse of the most careful physical examination may be required to make the diagnosis but the coexistence of chest pain, aortic murmurs, and peripheral artery occlusion is practically diagnostic. Laboratory adjuncts including roentgenographic evidence of mediastinal widening, evidence of hematuria, and the absence of electrocardiographic evidence of myocardial infarction may be helpful. Electrocardiographic evidence suggestive of myocardial infarction does not, however, exclude aortic dissection. Dissecting aneurysm of the aorta now is a surgical emergency that requires early accurate diagnosis and early surgical treatment, if the natural survival rate of 10 per cent is to be improved.

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