Aortic dissection

Dr Prakash Sapkale
• Aortic dissection is a
longitudinal split or partition
in the media of the aorta.
• Life threatening medical
emergency
• Common in 50-70 age group

• Pathophysiology:
– Classic aortic dissection: the
initial event was log thought to
be an intimal tear-
>extravasation of blood into the
media->extension of dissection
from point of dissection.
• Demonstration of intimal flap
was considered necessary for
diagnosis
– Aortic intramural
hematoma:degeneration of
media->rupture of vasa
vasorum->bleeding into media-
>linear extension of the
hematoma within the aortic
wall->may heal or there may be
rupture into the aortic lumen.
• Mortality/Morbidity:

– Mortality in untreated aortic dissection is 1% per hour for first

48 hrs rising to 80% in 2 weeks
– Operative mortality is considerable
– Occlusion of aortic branch vessels from aortic dissection may
result in stroke, renal failure, mesenteric ischemia, lower
extremity ischemia, and paraplegia (caused by obstruction of
the spinal artery).
– Occlusion of aortic branch vessels from aortic dissection may
result in stroke, renal failure, mesenteric ischemia, lower
extremity ischemia, and paraplegia (caused by obstruction of
the spinal artery).
– aortic intramural hematoma is rarely associated with
significant narrowing of aortic branch vessels.

• Type A mortality 1-2% per hour after onset of symptoms,

total up to 90% non-treated, 40% when treated.
• 1 year survival Type B up to 85% if medically treated (5
year > 70%)
• Risk factors:
– Chronic hypertension ,Connective tissue disorders (Marfan
syndrome, rare in Ehlers-Danlos syndrome) ,Bicuspid aortic
valve ,Coarctation of the aorta ,Turner syndrome ,Takayasu
arteritis ,Giant cell arteritis ,Pregnancy, Trauma ,Crack cocaine
use ,Cardiac catheterization ,Metabolic disorders
– Sex: Aortic dissections are more common in men than in
women (ratio, 3:1)

• Clinical features:
– Ripping or tearing pain in the interscapular area ,Abrupt onset
of the pain ,Acute, severe chest pain (Anterior chest pain can
mimic acute myocardial infarction) ,Pain extending to the neck
or jaw ,Altered mental status ,Cerebrovascular accident
symptoms ,Syncope ,Limb paresthesias ,Horner syndrome
,Dyspnea ,Dysphagia ,Flank pain if the renal arteries are
involved ,Hypertension ,Hypotension if associated with cardiac
tamponade, hypovolemia, excessive vagal tone
 classification
• Stanford classification:(
important for treatment)

– Type A: The ascending aorta is

involved.
– Type B: The descending aorta is
involved.

• DeBakey classification (now

replaced by stanford classification)

– Type I: The entire aorta is

involved.
– Type II: Only the ascending
aorta is involved.
– Type III: Only the descending
aorta is involved.
• Type IIIA involves the
descending aorta as far as the
diaphragm.
• Type IIIB involves the
descending aorta below the
diaphragm.
 Imaging modalities
• MRI has high sensitivity and
specificity but not useful in unstable
patients
• CT scan
• Transoesophageal echocardiography
 radiograph
• All findings on plain images are nonspecific but may help in
determining the need for further workup.

• Mediastinal widening (most common plain radiographic finding in

aortic dissection, noted in 80% of patients) (see Image 2)
• Double aortic knob sign (in 40% of patients)
• Diffuse enlargement of the aorta with poor definition or
irregularity of the aortic contour
• Inward displacement of aortic wall calcification of more than 10
mm
• Tracheal displacement to the right
• Pleural effusion (more common on the left side, suggests leakage)
• Pericardial effusion
• Cardiac enlargement
• Displacement of a nasogastric tube
• Left apical opacity
Aortic dissection
 CT Scan
• The sensitivity of CT is 87-94%, and the specificity is 92-100%.
• scanning is performed from the thoracic inlet to the common femoral arteries

• nonenhanced CT -diagnosis of acute hemorrhage and aortic rupture

• 25-30 seconds after the injection of contrast material. Nonionic contrast
material (120-135 mL) at a rate of 3-4 mL/s
– test injection of contrast -to determine circulation time or an automated bolus detection
scheme. one may visually differentiate the true and false lumen based on contrast
arrival time.
• delayed images of the false lumen and aortic branches.

• CT findings =
• Aortic intramural hematoma: Crescentic high-attenuating clot within the media,
with internally displaced calcification
• Intimal flap separating the two aortic channels
• Hemorrhagic pleural and pericardial effusions and mediastinal hemorrhage may
be seen.
• postoperative follow-up to depict associated complications:
– Thrombosis ,Hemorrhage ,Infection ,Pseudoaneurysms ,Aortoenteric fistula ,Ureteral
obstruction
• Aortic intramural hematoma can be misinterpreted as an aneurysm with
thrombus or arteritis.
• True lumen:
• Surrounded by calcifications (if present)
• Smaller than false lumen
• Usually origin of celiac trunk, SMA and right renal artery

• False lumen:
• Flow or occluded by thrombus (chronic).
• Delayed enhancement
• Wedges around true lumen (beak-sign)
• Collageneous media-remnants (cobwebs)
• Larger than true lumen
• Circular configuration (persistent systolic pressure)
• Outer curve of the arch
• Usually origin of left renal artery
• Surrounds true lumen in Type A dissection
 MRI
• The sensitivity and specificity are both more than 90%.unstable patients should
not be studied with MR.

• MRI findings:

• aortic dissection :
• an intimal flap of medium–signal intensity surrounded by a signal void of fast-
flowing blood on (ECG)-gated spin-echo or double inversion recovery single shot
fast spin-echo
• With cine gradient echo imaging, the intimal flap is a dark line against the high
-signal intensity of the flowing blood and may change configuration during the
cardiac cycle. Careful examination of the aortic flap during the cardiac cycle on
cine MR imaging is important to detect the presence of "true lumen collapse,"
which may be associated with end-organ ischemia. When the intima is stripped
360° from the media and is essentially "free floating," this may result in
catastrophic intimo-intimo intussusception.
• MRI findings of AIH include a crescent of blood surrounding but not compressing
the aorta. The signal intensity of the crescent varies with age on T1-weighted
imaging: it is isointense to muscle in the acute setting and markedly
hyperintense after 3-7 days
• MRI is also helpful in postoperative follow-up for associated complications-
Thrombosis, Hemorrhage , Infection, Pseudoaneurysms, Aortoenteric fistula,
Ureteral obstruction
 ULTRASOUND
• TEE:
• sensitivity of up to 98% and a
specificity of up to 97%.
• ascending thoracic dissections,
• cardiac tamponade, and aortic
regurgitation , coronary arterial
occlusion,

• Aortography:
• Not useful in emergency setting
END