ACUTE AORTIC SYNDROMES
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1 ACUTE AORTIC SYNDROMES AGNETA FLINCK MD, PhD Dept. of Thoracic Radiology Sahlgrenska University Hospital ACUTE AORTIC SYNDROMES Aortic dissection Intramural hematoma (IMH) 5-20% Penetrating atherosclerotic ulcer (PAU) 10%? Aortic aneurysm leak and rupture
2 Incidence of Thoracic Aortic Disease in Sweden / men, 7.1/ women / men, 9.1/ women 52% increase in men and 28% in women 22% died outside hospital 30 day mortality for all who reached hospital alive was 34% Surgical 30 day mortality decreased from 25% to 13% during the study period Circulation 2006;114:2611 Risk of Death in Untreated Aortic Dissection 25% during the first 24 hours 50% during the first week 75% during the first month 90% during the first year
3 DIAGNOSIS CT MRI TEE How to Perform the CT 1. Unenhanced CT of the thorax (diagnosis of IMH) 2. Contrast-enhanced CT From a few centimeters above the aortic arch to the common femoral arteries.
4 Diagnostic Goals Delineate the extent of AD, IMH or PAU Assess involvement of branches Detect thoracic complications: pericardial and pleural effusion Detect aneurysm rupture or impending rupture Differentiate true and false lumen Localise intimal tears
5 Aortic Wall a = intima (endothelial lining plus thin layer of underlying c.t.). b = media (alternating layers of elastic membranes and smooth muscle, bound together by areolar c.t.) This is by far the thickest layer. c = adventitia (fairly dense c.t. carrying small blood vessels, the vasa vasorum). Typical Aortic Dissection With a Tear of the Intimal Layer
6 Dissection Type A Aortic Dissection Type A
7 Pitfalls Pulsation artefacts Normal periaortic anatomy can mimic dissection (great vessels, veins, atrial appendages) Thymus, pericardial recesses, lymphadenopathy, atelectasis can mimic periaortic hematoma Pericardial Effusion
8
9 True and False Lumen The beak-sign"
10 Intramural Hematoma (IMH) Without Intimal Tear Intramural Hematoma High attenuation crescent on unenhanced CT scan
11 ww 100 wl 40 ww 700 wl 100 Thrombus in the Aortic Wall Low attenuation on unenhanced scan
12 Evolution of IMH
13 Evolution of IMH ACUTE FOLLOW UP 54% Evangelista A et al. Circulation 2003; 108:583-9
14 Final Morphological Outcomes Baseline Findings Regression, n=17 Classical Dissection, n=6 Pseudoaneurysm, n=12 Aneurysm, Saccular, n=4 Aneurysm, Fusiform, n=11 Type A (%) 2 (40) 2 (40) (20) Type B (%) 15 (33) 4 (9) 12 (27) 4 (9) 10 (22) Maximum 38.9±4.5 * 45.0± ± ± ±6.1 diameter, mm Maximum 11.8± ± ± ± ±4.7 thickness, mm Echolucent areas (%) 7 (28) 5 (20) 10 (40) 1 (4) 3 (12) Extensive (%) 9 (24) 6 (16) 11 (30) 3 (8) 8 (22) Circular shape 5 (31) 1 (6) 6 (38) 1 (6) 3 (19) (%) Ulcerated plaque (%) 2 (20) 1 (10) 0 4 (40) * 3 (30) *P<0.001, P<0.05 for comparisons with the remaining values in each row. Evangelista A et al. Circulation 2003; 108: patients with acute aortic syndrome. 58 (5,7%) had IMH. IMH in the ascending aorta had a mortality of 39.1%. In-hospital mortality for IMH according to site of origin Evangelista et al.circulation 2005;111:1063
15 Meta-analysis of the out-come of 143 cases of IMH confirms the appropriateness of operative therapy for those involving the ascending aorta, and nonoperative management of those sparing the ascending aorta. The Annals of Thoracic Surgery 2007;83:S835 The Four Stages in the Formation of a Penetrating Atherosclerotic Ulcer (PAU) Castañer Incidence of aortic rupture 10-40%. PAU has a risk equal to or higher than that of acute aortic dissection or intramural hematoma Castaner et al.radiographics 2003; 23:
16
17 Group 1 IMH caused by PAU Group 2 IMH without PAU 91% in group 1 had IMH type B IMH type A more common without PAU IMH type B with PAU had more progressive disease Ganaha et al Circulation 2002;106:
18 IMH with PAU Indicators and Predictors of Disease Progression Uncontrollable pain Increasing pleural effusion Diameter of PAU >20mm or depth >10mm; early surgical or endovascular treatement recommended PAU in ascending aorta, aortic arch or proximal descending aorta Ganaha et al Circulation 2002;106:
19 Aneurysm Aortic aneurysm is defined as irreversible dilation of the aorta to twice its normal diameter. Aortic diameter varies with age and gender. Thoracic aortic diameter >5 cm = aneurysm.
20 Pseudoaneurysm Complications Rupture Dissection Aortic regurgitation Compression of adjacent structures
21 Acute or Impending Rupture Hemorrhage (mediastinal or retroperitoneal) High attenuation crescent of blood within a mural thrombus The draped aorta sign
22 The draped aorta sign AJR 2007;188:W57
23 Acute Chest- Triple Rule Out Acute pulmonary embolism Aortic dissection Coronary arteries
24 54-year-old man with dyspnea and pleuritic chest pain since 12 hours. Appears weak and pale. Systolic murmur I 4 sin. Pulmonary embolism? We performed an ECG-triggered MDCT of the aorta and pulmonary arteries.
25
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