AORTIC

DISSECTION!
Dr. Nikrish S Hegde
LEARNING OBJECTIVES!
 Identify the two types of aortic dissection and
list the indications for treatment.

 Describe the imaging parameters and the
typical and atypical imaging findings in aortic
dissections.

 Discuss the imaging features of complications
that can arise from aortic dissections.
IMPORTANCE!
 Most common

 Fatal outcome

 Prompt diagnosis and treatment.

AORTA
 made of three layers, called from the
luminal side outward, the tunica intima,
the tunica media and the tunica
adventitia
What is aortic dissection?
 Dissection is the result of a spontaneous
longitudinal separation of the aortic
intima and adventitia caused by
circulating blood gaining access to and
splitting the media of the aortic wall
TYPES:-
DeBakey

Standford
 Type A dissections account for 60%–70%
of cases and typically require urgent
surgical intervention.

 Stanfordtype B dissection involves the

descending thoracic aorta distal to the left
subclavian artery and accounts for 30%–
40% of cases. Management takes the
form of medical treatment of hypertension.
Indications for immediate
surgery
 Hemodynamic instabilty.
 Uncontrolled HTN.
 Diameter > 6cm.
 Ischaemic Complications.
PRESENTATION.
 CHEST PAIN
 SYNCOPE
 RIGHT HYPOCHONDRIAL PAIN
..ABNORMAL LFT
 OLIGURIA ..ANURIA ..ABNORMAL RFT
 NAUSEA ..VOMITING..PAIN
ABDOMEN..BLOODY DIARRHOEA..
 LOWER LIMB ISCHAEMIA
ACUTE VS CHRONIC
 The dissection is termed acute when it is
diagnosed within 14 days after the first
symptoms appear.

 Itis termed chronic when it is diagnosed

later .
HELICAL CT AND AORTIC
DISSECTION.
 Aortography.
 Shorter acquisition time, wide availability, and
high diagnostic accuracy and has, therefore,
classically been the modality of choice for the
evaluation of aortic dissection.
 The intimal flap, type and extent of dissection
,presence of thrombus and the presence of
associated complications and follow up
changes.
TECHNIQUE
 Theexamination begins with conventional
unenhanced CT.

 Coverage begins 2 cm above the aortic

arch and continues to the superior aspect
of the femoral head.

 We then inject 100 mL of nonionic at a

rate of 2 mL/sec through a 20-gauge
catheter positioned in the right arm.
Helical CT is performed 30 seconds after
administration of contrast
TYPICAL AORTIC DISSECTION
 The classic feature of aortic dissection is a
partition between the true and false
channels.
 Secondary findings include internal
displacement of intimal calcifications or a
hyperattenuating intima; delayed
enhancement of the false lumen;
widening of the aorta; and
mediastinal, pleural, or pericardial
hematoma .
STANDFORD TYPE A
STANFORD B
How do we distinguish false
lumen from the true lumen??
 SIZE
 POSITION-False channel usually arises
anterior in the ascending aorta and spirals
to posterior and left lateral in descending
aorta.
 FLOW
 SECONDARY CHANGES – THROMBOSIS
 BEAK’S SIGN
BEAK’S SIGN
THROMBOSED FALSE LUMEN
ATYPICAL AORTIC DISSECTION

 INTRAMURAL HEMATOMA:
Unenhanced CT shows a cuff or crescent
of high attenuation and displacement of
intimal calcifications. On enhanced CT
scans, a smooth region of low attenuation
can be seen
 Penetrating atherosclerotic ulcer is
defined as an atherosclerotic lesion with
ulceration that penetrates the internal
elastic lamina; such penetration facilitates
hematoma formation within the media of
the aortic wall
Ruptured Type B Dissection
Atypical Configuration of the
Intimal Flap

circumferential
intimal flap
filiform
Mercedes-
Benz sign
CHANGES DURING FOLLOW-UP
PITFALLS
 TheCT appearances of several entities
can cause them to be mistaken for
atypical AAD.
 CTscan shows an atheromatous thrombus
with an irregular internal border in the
thoracic descending. A thrombosed
aortic dissection usually demonstrates a
smooth internal border.
N
Perivenous streaks
 combination of beam hardening and
motion
 orientation of such streaks typically varies
from section to section and extends
beyond the confines of the aortic wall
 minimize perivenous streaks by performing
bolus injection into the right arm at a rate
of 2 mL/sec
Aortic motion artifact
 ascending aorta and is related to
movement of the aortic wall
 artifact is seen at the left anterior and
right posterior margins of the aortic
circumference
 a serrated appearance of the left anterior
ascending aorta on two- or three-
dimensional reconstruction images
BRANCH VESSEL OCCLUSION
 Thereare two types of branch-vessel
occlusion.

1)STATIC
2)DYNAMIC
STATIC
 theintimal flap intersects or enters the
branch-vessel origin. Static obstruction is
treated locally with an intravascular stent
DYNAMIC
 theintimal flap spares the branch-vessel
wall but prolapses across the branch-
vessel origin and covers it like a curtain .
Dynamic obstruction is treated with a
fenestration procedure
ADVANCES
TEE
MRI
TRIPLE-RULE-OUT -CT
Transesophageal
echocardiography
 secondary signs of an aortic dissection
such as aortic root dilatation, aortic
regurgitation, coronary ostial
patency, pericardial effusions, or regional
abnormal wall motion can be diagnosed.
 TEE can be performed in the emergency
department at the bedside of unstable
patients.
 MR angiography
 suitable for the investigation of aortic
dissection in medically stable patients or
those with chronic dissections
 including lack of nonionizing
radiation, multiplanar evaluation, and
greater vessel coverage at high resolution
with fewer sections.
 It cannot be performed in unstable
patients due to longer acquisition time
and difficulty in monitoring, and it is not
appropriate for patients with implanted
electronic devices
TRIPLE-RULE-OUT -CT
 Assessthe aorta, coronary arteries, and
pulmonary arteries and the middle and
lower portions of the lungs during a single
scan with use of several optimally timed
boluses of contrast material and ECG
gating.
 Biphasic injection of iodinated contrast
material (≤100 mL)