CASE 4203 Published on 13.12.2005

Aortic rupture in acute type a dissection evaluated with multislice CT

Section

Cardiovascular

Case Type

Clinical Cases

Authors

Di Girolamo M, Sessa B, Pochesci I, Grauso G

Patient

76 years, female

Clinical History
Thoracic pain, dyspnoea and hemorrhagic shock.
Imaging Findings
A 76 years old white women was admitted in E.R. with progressive dyspnoea, thoracic pain irradiating to the back, hypotension (blood pressure: 80/40 mmHg) and tachycardia (105 bpm). She had a long story of hypertension in treatment with nifedipina . The patient underwent ECG which confirmed tachycardia with sinus rhythm together with ventricular ripolarization non specific anomalies. Ten minutes after ECG the patient underwent contrast-enhanced multislice CT which demonstrated a mild ectasia of the thoracic ascending aorta with the presence of an intimal flap originating at the level of the proximal tract (Fig. 1 a-b), where the CT exam detected a little fissure of the posterior wall with hemomediastinum and hemopericardium (Fig. 1 c). She had also bilateral pleural effusion and the presence of a little amount of perithoneal fluid. The patient had very dramatic clinical complications such as cardiac arrest due to cardiac tamponade and hypovolemic shock and died 10 minutes after CT exam immediately before the access to the cardio-surgical department. The anatomo-patological procedure confirmed all the diagnostic features detected by CT.
Discussion
Aortic dissection is the most common catastrophic disorder affecting the thoracic aorta. It has divided by Stanfort classification system into two types on the basis of the location. The acute aortic dissection which involved the ascending aorta is defined as type A and all which do not involve the ascending tract are defined as type B. The type A aortic dissection has a large spectrum of clinical features but the most common symptom at the beginning is chest pain radiating to the back. The acute aortic dissection could be followed by some lethal complications such as aortic rupture, cardiac tamponade, aortic regurgitation and myocardial infarction. About 33% of patients die within the first 24 h and about 50% die within 48 h by the onset of symptoms [1]. Therefore, it’s very important a rapid right diagnosis for an adequate surgical treatment consisting of replacing the ascending aorta and a variable portion of the aortic arch. MSCT is nowadays the most sensitive, specific and fast imaging technique for the prompt diagnosis of acute aortic dissection and for the evaluation of its extension and complications. All the possible aortic dissection complications that we can find in litterature are pleural rupture, pericardial rupture, aortic insufficiency, cardiac tamponade, loss of peripheral pulses, compromised renal perfusion, stroke, shock , acute oliguria/anuria, paraplegia and compromised visceral perfusion; in our case the patient died for the outburst of an important concealed hemorrhage caused by a little fissure in the posterior wall of thoracic ascending aorta that produced hemopericardium and cardiac tamponade . In conclusion multislice CT could be nowadays considered the gold standard exam in suspected acute aortic dissection allowing a promp diagnosis and the detection of its complications.
Differential Diagnosis List
Aortic rupture in acute type A dissection.
Final Diagnosis
Aortic rupture in acute type A dissection.
Case information
URL: https://www.eurorad.org/case/4203
DOI: 10.1594/EURORAD/CASE.4203
ISSN: 1563-4086