Difficulties in the diagnosis of acute aortic dissection

Abstract

A69-year-old woman with known hypertension presented to hospital with sudden onset severe central chest pain radiating between her shoulder blades and into her abdomen. This was associated with loss of power and sensation in her left leg lasting for 30 minutes. She complained of residual discomfort between her scapulae. Examination revealed a well-looking woman with unequal blood pressures in both arms: right 140/70 mmHg, left 100/80 mmHg, a pulse rate of 84/min and no audible murmurs. There was no vascular or neurological deficit in either leg. 12-lead electrocardiogram showed left ventricular hypertrophy by voltage criteria and chest radiograph was normal. Urgent spiral computed tomography of the chest and abdomen showed an extensive type A dissection of her aorta from her aortic valve to the abdominal aortic bifurcation (Figure 1). Despite attempts at haemodynamic resuscitation, she died in the ambulance en route to the regional cardiothoracic centre. Post mortem revealed a tense haemopericardium.

Suspected Aortic Dissection and Other Aortic Disorders: Multi–Detector Row CT in 373 Cases in the Emergency Setting

“…The current role of aortography is that of a potential adjunctive examination for use in the event that the primary imaging examination yields inconclusive results and more detailed information is necessary (42). However, other noninvasive imaging modalities also may serve in this role (31,43).…”

“…In this scenario, the time spent performing imaging is minimized because the patient is imaged in a portable manner in as little as 5 minutes while in a state of general anesthesia in the emergency department or operating room. However, TEE requires a skilled operator to achieve proper safety levels and high diagnostic value (43).…”

“…Transthoracic echocardiography, an alternative choice for bedside imaging, has too low a sensitivity for detection of aortic dissection and other aortic disorders and thus has poor prognostic value and is more suitable for the diagnosis of potential cardiac complications (43). However, MR angiography offers an alternative approach for patients in emergency settings who are unable to tolerate intravenous contrast material owing to impaired renal function or iodinated contrast material allergy (42).…”