The International Journal of Cardiovascular Imaging

https://doi.org/10.1007/s10554-018-1398-x

ORIGINAL PAPER

Distinguishing acute from chronic aortic dissections using CT imaging

features
Norman A. Orabi1   · Leslie E. Quint2 · Kuanwong Watcharotone3   · Bin Nan4 · David M. Williams2 · Karen M. Kim5

Received: 28 February 2018 / Accepted: 13 June 2018

© Springer Nature B.V. 2018

Abstract
The aim was to compare computed tomography (CT) features in acute and chronic aortic dissections (AADs and CADs) and
determine if a certain combination of imaging features was reliably predictive of the acute versus chronic nature of disease
in individual patients. Consecutive patients with aortic dissection and a chest CT scan were identified, and 120 CT scans
corresponding to 105 patients were reviewed for a variety of imaging features. Statistical tests assessed for differences in
the frequency of these features. A predictive model was created and tested on an additional 120 CT scans from 115 patients.
Statistically significant features of AAD included periaortic confluent soft tissue opacity, curved dissection flap, and highly
mobile dissection flap, and features of CAD included thick dissection flap, false lumen (FL) outer wall calcification, FL
thrombus, dilated FL, and tear edges curling into the FL. The model predicted the chronicity of a dissection with an area
under the curve of 0.98 (CI 0.98–1.00). AADs and CADs demonstrated significantly different CT imaging features.

Keywords  Aortic dissection · Acute aortic syndromes · Computed tomography · Chronic dissection

Introduction to 2 months; and chronic phase more than 2 months after

An acute aortic dissection (AAD) is a medical emergency
with reported incidence of about 3–6/100,000/year; peak
incidence occurs in the 60–70 age group [1, 2]. Thoracic
aortic dissections are classified by anatomic extent. A Stan-
ford type A dissection signifies involvement of the ascend-
ing aorta, whereas a type B dissection does not involve the
ascending aorta. Regarding chronicity, a dissection may be
characterized as acute, subacute, or chronic. According to
one definition, the acute phase lasts from the onset of symp-
toms to 2 weeks thereafter; the subacute phase from 2 weeks
* Norman A. Orabi
orabi@med.umich.edu
1 procedure. Correctly classifying aortic dissections as acute
University of Michigan Medical School, Ann Arbor, USA
2
Department of Radiology, Michigan Medicine, Ann Arbor,
USA
3
Michigan Institute for Clinical and Health Research,
University of Michigan, Ann Arbor, USA
4
Department of Statistics, University of California at Irvine,
Irvine, USA
5
Department of Cardiac Surgery, Michigan Medicine,
Ann Arbor, USA
onset [3]. However, other definitions specify the subacute
phase as terminating at 6 weeks or 3 months [4, 5].
An AAD must be diagnosed and treated rapidly due to the
high mortality of the untreated condition. Untreated type A
AAD shows about a 1–2% mortality rate per hour within the
first 48 h [6], and most patients with a diagnosis of type A
AAD are treated emergently with surgery. Acute and chronic
type B aortic dissections may generally be managed medi-
cally unless there are indications for surgical repair such as
false lumen rupture, malperfusion, aortic diameter greater
than 5.5 cm, re-dissection, rapid initial growth, or dilation
greater than 1 cm/year [7]. The mortality rate associated
with open surgical and endovascular repair for chronic aortic
dissection (CAD) is much lower compared to AAD [7–10],
partly due to the elective rather than emergent basis for the
or chronic is critical for risk stratification, treatment, and
predicting survival. Occasionally, an aortic dissection may
be clinically missed at initial presentation, and when it is
detected later, the acute versus chronic nature of the disease
may be unclear. Clinical decision making may hinge on this
determination. For example, a chronic dissection would not
explain the etiology for acute chest pain, and further diag-
nostic workup would be indicated.

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Because patients with AAD may present in a nonspe-
cific fashion, diagnostic imaging is generally necessary to
confirm the diagnosis. Computed tomography (CT) is the
preferred and most frequently used imaging modality due
to its widespread availability, non-invasive quality, ability to
assess the distal extent of the dissection, and similar sensi-
tivity and specificity as compared to aortography, magnetic
resonance imaging, and transesophageal echocardiography
[3, 11]. The purpose of our study was to assess and compare
a variety of CT imaging features in AAD and CAD and
to determine if some combination of imaging features was
reliably predictive of the acute versus chronic nature of the
disease in individual patients.
Methods
Institutional review board approval, with waiver of informed
consent, was obtained for this HIPAA-compliant, retrospec-
tive study.
Study population
All patients seen in adult Cardiology and Cardiac Surgery
clinics between 1/1/2010 and 1/1/2015 with a clinical diag-
nosis of aortic dissection and a chest CT with intravenous
(IV) contrast were identified via data abstraction from hos-
pital information systems.
Patients were sorted in reverse chronological order
based on the date of the initial CT scan (newest to oldest).
Patients were excluded from further analysis if they had
already undergone open aortic surgery or endograft place-
ment prior to the initial CT scan or if any of the following
findings were present at CT: focal dissection flap (arbitrar-
ily defined as less than 10 cm in length), acute dissection
superimposed on known chronic dissection, and/or very poor
vascular opacification with contrast material. In addition, for
the test population only (see below), we excluded patients
if the scans could not be evaluated for flap mobility due to
lack of either retrospectively ECG gated or non-gated images
because measurement of flap mobility was required to test
our predictive model.
After these exclusions, the first 60 patients with scans
during the acute phase of the dissection and the first 60
patients with scans during the chronic phase of the dissec-
tion were selected for further evaluation. Because 15 patients
had scans in both the acute and the chronic phases of the dis-
ease, a total of 120 scans from 105 patients were evaluated.
The acute phase of the dissection was defined as within
2  weeks of the start of symptoms, and the scan closest
to the onset of symptoms was evaluated. Conversely, the
chronic phase of the dissection was defined as greater than
2 months from the onset of symptoms, and the most recent
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The International Journal of Cardiovascular Imaging
scan (farthest from the onset of symptoms) without opera-
tive intervention was evaluated. Patients who presented with
an incidental, asymptomatic dissection that was deemed
chronic by the treating cardiothoracic surgeon, cardiologist,
or interventional radiologist were included in the chronic
group.
Following the assessment of these 120 CT scans, a pre-
dictive model was created from this initial set of patient
data using five predictors (see “Statistical analysis” section,
below). Subsequently, 60 acute and 60 chronic scans from
additional patients in our database (the test population) were
evaluated in a similar fashion in order to test the model. This
resulted in a test data set of 120 CT scans corresponding to
115 patients.
A flow diagram of the patient selection process is pre-
sented in Fig. 1.
Imaging features evaluated
Each CT scan was evaluated for a variety of imaging features
by a medical student who was trained to evaluate each fea-
ture by a faculty cardiothoracic radiologist. The first 10 CT
scans were evaluated simultaneously by the medical student
and cardiothoracic radiologist to ensure competency. The
cardiothoracic radiologist remained available throughout
the subsequent data collection to assist with any difficult
features. Regarding intra-observer variability, a random set
of 10 CT scans was re-evaluated for the categorical variables
to generate a correct classification rate.
The categorical variables included the following (present
on at least one cross sectional image): regions of high attenu-
ation (60–70 HU) in the false lumen (FL) on pre-contrast
images; calcification on the FL side of the flap; calcification
in the outer wall of the FL; non-occlusive FL thrombus;
periaortic fat infiltration; pericardial effusion; and pleu-
ral effusion. FL thrombus was coded as present, absent or
indeterminate (the latter due to the difficulty in distinguish-
ing thrombus from poor/incomplete opacification on some
scans). Fat infiltration was defined as the presence of soft
tissue density opacities in the periaortic fat; this was further
codified as (1) confluent soft tissue opacity (coalescent soft
tissue density), (2) soft tissue stranding (irregular linear soft
tissue streaks), or (3) absent. Flap shape was assessed at the
axial cross section where the aortic diameter was largest
and classified as either predominantly straight or curved.
Intimal tear edges were classified as visible or non-visible;
if visible, the tear edges were assessed to determine if they
curled towards the FL like a blunted funnel.
The continuous variables included the size or amplitude
of the following features on one or more axial CT images:
maximum flap thickness, FL maximum diameter, size ratio
of the FL to true lumen (TL), and flap mobility. The follow-
ing definitions were used.
The International Journal of Cardiovascular Imaging
Fig. 1  Patient selection criteria.
Consort diagram showing
inclusion criteria for this study.
Asterisk includes acute on
chronic aortic dissections and
subacute aortic dissections.
AAD acute aortic dissection,
CAD chronic aortic dissection
• Maximum flap thickness: the largest edge-to-edge
measurement perpendicular to the plane of the flap.
• FL maximum diameter: the largest luminal measure-
ment perpendicular to the plane of the flap from the
flap edge bordering the FL to the inner edge of the FL
outer wall.
• Size ratio of the FL to the TL: the ratio of the axial cross-
sectional area of the FL to the TL. The size ratios were
recorded at four separate anatomical positions, if the dis-
section involved these aortic regions: middle ascending
aorta, immediately distal to the left subclavian artery
(LSA), midway between the LSA and celiac trunk, and
immediately proximal to the celiac trunk.
• Flap mobility: the maximum amplitude of flap move-
ment, measured perpendicular to the plane of the flap. On
scans performed using retrospective electrocardiographic
(ECG) gating, this measurement was made by comparing
images at the same anatomic level obtained during dif-
ferent phases of the cardiac cycle. On scans performed
without ECG gating, the amplitude of flap movement
was measured as the maximum perpendicular distance
between corresponding flap edges on consecutive axial
sections.
Diameters, distances and flap thickness were measured
using electronic calipers. Luminal areas were measured
using a freehand, electronic region of interest.
CT imaging techniques
CT examinations were obtained on a variety of CT scan-
ners using a variety of techniques, although all utilized IV
contrast material. In addition, 45/120 scans from the first set
of data also included pre-contrast images through the aorta.
126/240 CT scans were performed at outside institutions
and 114/240 CT scans were performed at our institution.
157/240 CT scans were non-ECG gated. 83/240 CT scans
were ECG gated, with 18 using prospective cardiac gating
and 65 using retrospective cardiac gating. All of the scans
that utilized retrospective cardiac gating were performed at
our institution. 203/240 CT scans included the chest and
abdomen and 37/240 included the chest only. Chest slice
thickness ranged from 0.5 to 5 mm (except for two out-
side scans with 7–7.5 mm thick sections) (mean 1.94 mm,
median 1.25 mm). Abdomen slice thickness ranged from 0.5
to 5 mm (except for two outside scans with 7–7.5 mm thick
sections) (mean 2.03 mm, median 1.25 mm).
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 The International Journal of Cardiovascular Imaging

Statistical analysis was used for continuous variables, depending on whether or

not the normality assumption was met. A χ2 test or Fisher’s
Descriptive statistics of the first data set are summarized exact test was used for categorical variables, depending on
in Table 1. A two-sample t test or Wilcoxon rank sums test if the observations were sparse in each category. Multiple

Table 1  Imaging features in acute and chronic aortic dissections

Variable Acute (N = 60 ­patientsa) Chronic (N = 60 ­patientsa) P-value*

Flap thickness (mm) 2.90 ± 0.87 4.01 ± 1.15 < 0.0001**S

FL maximum diameter (mm) 26.05 ± 9.89 32.07 ± 10.2 0.0005**S
FL/TL area ratio
 Mid ascending aorta 3.57 ± 3.93 (N = 26b) 2.05 ± 1.31 (N = 5) 0.28**
 Distal LSA 2.09 ± 1.25 (N = 55) 3.45 ± 2.44 (N = 45) 0.01**S
 At celiac trunk 3.21 ± 3.78 (N = 51) 3.48 ± 4.87 (N = 50) 0.051**
 Halfway between LSA and celiac trunk 2.61 ± 1.88 (N = 56) 3.93 ± 2.12 (N = 50) 0.0003**S
Pre-contrast scan available 0.09
 Yes 18 (30%) 27 (45%)
If yes, high attenuation in FL 3 (16.7%) 0 0.06**
 No 42 (70%) 33 (55%)
Pericardial effusion 0.51
 Yes 6 (10%) 4 (6.7%)
 No 54 (90%) 56 (93.3%)
Pleural effusion 0.75
 Yes 5 (8.3%) 6 (10%)
 No 55 (91.7%) 54 (90%)
FL-side flap calcification 0.36**
 Yes 1 (1.7%) 4 (6.7%)
 No 59 (98.3%) 56 (93.3%)
FL outer wall calcification < 0.0001**S
 Yes 0 17 (28.3%)
 No 60 (100%) 43 (71.7%)
FL thrombus < 0.0001S
 Yes 6 (10%) 41 (68.3%)
 Indeterminate 21 (35%) 1 (1.7%)
 No 33 (55%) 18 (30%)
Fat infiltration 0.0046**S
 Soft tissue stranding 13 (21.7%) 5 (8.3%)
 Confluent soft tissue opacity 5 (8.3%) 0
 No 42 (70%) 55 (91.7%)
Visible tear edges < 0.0001S
 Yes 29 (48.3%) 53 (88.3%)
If yes, tear edges curled into FL 6 (20.7%) 24 (45.3%) 0.03S
 No 31 (51.7%) 7 (11.7%)
Flap shape < 0.0001*S
 Straight 4 (6.7%) 49 (81.7%)
 Curved 56 (93.3%) 11 (18.3%)
Flap motion (mm) 6.62 ± 4.94 (n = 53) 1.69 ± 1.84 (n = 52) < 0.0001**S
a
 N = 60 patients for all values unless otherwise indicated in the associated box
b
 One of the 27 acute type A dissections did not extend to the mid ascending aorta
*Two-sample t test for continuous variables and χ2 test for categorical variables
**Wilcoxon rank sums test for continuous variables and Fisher’s exact test for categorical variables
S
 Significant at 5% level of significance

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The International Journal of Cardiovascular Imaging
Table 2  Odds ratios using multiple logistic regression analysis on the
presence of a CAD adjusted for imaging features
Effect Odds ratio (95%CI)
FL maximum diameter 1.140 (1.032, 1.301)
Visible tear edges 6.847 (1.345, 55.602)
Straight flap shape 22.501 (4.589, 200.968)
Flap motion 0.774 (0.602, 0.936)
FL thrombus: present versus 7.967 (1.479, 58.544)
indeterminate/absent
logistic regression with Firth’s penalized maximum likeli-
hood estimation was fitted on acute/CAD using the first data
set, and the fitted model is provided in Table 2. Five predic-
tors were selected for the model: FL maximum diameter, FL
thrombus, visible tear edges, flap shape, and flap motion.
Two potential predictors, FL outer wall calcification and
confluent soft tissue opacity were excluded due to the exist-
ence of zero observations in a certain category. The back-
ward elimination was used for the model selection. Then,
the fitted model was applied to the second (test) data set to
compute the predicted probability and calculate sensitivity,
specificity, positive predicted values (PPV), and negative
predicted values (NPV), where the observations with posi-
tive linear predictors were classified as chronic cases. A 5%
level of significance was used to evaluate statistical signifi-
cance in all analyses. Statistical analyses were performed
using SAS software, Version 9.4 (SAS Institute Inc., Cary,
NC, USA).
Results
For the initial data set, the average patient ages
were 57.38 ± 14.33  years for acute dissections and
58.32 ± 12.27 years for chronic dissections. 41/60 (68.3%)
patients with an acute dissection and 44/60 (73.3%) patients
with a chronic dissection were male. 27/60 (45%) acute dis-
sections were type A and 5/60 (8.3%) chronic dissections
were type A. With day 0 defined by symptom onset, the
age of acute dissections ranged from 0 to 6 days (mean 0.5,
median 0), whereas the age of a chronic dissection ranged
from 64 to 5326 days (mean 818, median 615).
For the test data set, the average patient ages
were 58.13 ± 12.53  years for acute dissections and
62.82 ± 11.68 years for chronic dissections. 47/60 (76.7%)
patients with an acute dissection and 37/60 (61.7%) patients
with a chronic dissection were male. 34/60 (56.7%) acute
dissections were type A and 8/60 (13.3%) chronic dissec-
tions were type A. The age of acute dissections ranged from
0 to 7 days (mean 0.83, median 0), whereas the age of a
chronic dissection ranged from 81 to 4632 days (mean 1775,
median 1800).
P-value Using bivariate statistical analysis in the initial data set,
there were significant differences in CT imaging charac-
0.0140
teristics between acute and chronic dissections, as shown
0.0312
in Table 1. All variables were assessed for all 60 scans in
0.0004
each category unless indicated otherwise in the table by
0.0162
an N < 60. The intra-observer correct classification rate
0.0199
for the categorical variables was 95.5%. FL outer wall cal-
cification was only present in chronic dissections (17/60,
28.3%) (P < 0.05) (Fig. 2); 2 were less than one-year-old,
10 had an average age of 1803 days, and the remaining 5
were incidentally found (exact age unknown). FL throm-
bus was more frequently present in chronic dissections
(41/60, 68.3%) as opposed to acute dissections (6/60, 10%)
(P < 0.05) (Fig. 2). However, substantially more acute dis-
sections (21/60, 35%) showed indeterminate FL thrombus
due to poor contrast enhancement compared to chronic
dissections (1/60, 1.7%) (P < 0.05). Periaortic soft tissue
stranding was more frequently present in acute dissections
(13/60, 21.7%) compared to chronic dissections (5/60,
8.3%), and confluent soft tissue opacity was only seen in
acute dissections (P < 0.05) (Figs. 3, 4). Tear edges were
visible in 53/60 (88.3%) chronic dissections and 29/60
(48.3%) acute dissections (P < 0.05). Of those scans that
showed visible tear edges, curling of tear edges into the
FL was seen more frequently in chronic dissections (24/53,
45.3%) compared to acute dissections (6/29, 20.7%)
(P < 0.05) (Fig.  5). Almost all of the acute dissections
(56/60, 93.3%) had a predominantly curved flap shape
whereas the majority of chronic dissections (49/60, 81.7%)
Fig. 2  61 year-old male with an approximately 11 year-old chronic
type B aortic dissection. CT scan at the level of the proximal
descending thoracic aorta shows a straight flap (arrowhead), FL
thrombus (star), and FL outer wall calcification (arrows)
13

Fig. 3  57 year-old male with a chronic, 105 day-old type B aortic dis-
section. CT scan at level of aortic arch shows peri-aortic soft tissue
stranding (arrows)
Fig. 4  68 year-old male with an acute type B aortic dissection. CT
scan at the level of the aortic arch exhibits confluent soft tissue opac-
ity (arrows)
had a predominantly straight flap (P < 0.05) (Fig. 2). Of
those CT scans with pre-contrast images, high attenuation
in the FL was only seen in acute dissections (3/18, 16.7%),
although the difference was not statistically significant.
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The International Journal of Cardiovascular Imaging
Fig. 5  57 year-old male with a chronic, 100 day-old type B aortic dis-
section. CT scan near the level of the diaphragm shows a dissection
flap tear edge (arrow) that is thickened and curled into the FL
The frequencies of FL-side flap calcification, pericardial
effusions, and pleural effusions did not show significant
differences between acute and chronic dissections.
With regard to the continuous variables, chronic
dissections tended to have thicker dissection f laps
(mean 4.01 ± 1.15  mm) compared to acute dissec-
tions (2.90 ± 0.87  mm) (P < 0.05). Likewise, the FL
maximum diameter was larger for chronic dissections
(mean 32.07 ± 10.2 mm) compared to acute dissections
(26.05 ± 9.89  mm) (P < 0.05). The FL/TL area ratios
showed significant differences at only two anatomic
locations: at the LSA and midway between the LSA and
celiac trunk, the FL/TL ratios were significantly larger for
chronic dissections (3.45 ± 2.44 and 3.93 ± 2.12, respec-
tively) compared to acute dissections (2.09 ± 1.25 and
2.61 ± 1.88, respectively) (P < 0.05). The dissection flap
was more mobile in the acute dissections (6.62 ± 4.94 mm)
compared to chronic dissections (1.69 ± 1.84  mm)
(P < 0.05) (Fig. 6).
Multiple logistic regression showed a positive associa-
tion between increasing flap thickness, visible tear edges,
and a straight flap shape with chronic aortic dissections
(P < 0.05). Conversely, there was a positive association
between the presence of indeterminate FL thrombus and
increasing flap mobility with AADs (P < 0.05) (Table 2).
The predictive model fit the test data set well show-
ing high sensitivity (0.95), specificity (0.97), PPV (0.97),
and NPV (0.95) with an area under the receiver operating
characteristic (ROC) curve of 0.98 (Fig. 7).
The International Journal of Cardiovascular Imaging
Fig. 6  A 45 year-old male with an acute type A dissection. Retro-
spectively-gated CT scan at the level of the proximal descending
aorta demonstrates flap movement (arrows) of 5.5  mm in amplitude
during different phases of the cardiac cycle
Discussion
An aortic dissection is a life-threatening condition with
significant morbidity and mortality. The appropriate treat-
ment must be selected to provide a desirable outcome while
minimizing mortality and morbidity, and treatment differs
based on the chronicity of the dissection. For example, emer-
gent surgical intervention is the standard of care for acute
Type A dissections whereas for uncomplicated acute type B
Fig. 7  ROC curve for predicting the chronicity of an aortic dissec-
tion generated from the application of our predictive model to our test
data set with 95% CI. The ROC curve yielded an area under the curve
(AUC) of 0.98 (CI 0.98–1.00) with an associated sensitivity of 0.95
(58/61, CI 0.90–1.00), specificity of 0.97 (57/59, CI 0.92–1.00), PPV
of 0.97 (58/60, CI 0.92–1.00), and NPV of 0.95 (57/60, CI 0.89–1.00)
dissections, medical management is preferred over endovas-
cular intervention [12, 13]. Most often, the age of the dis-
section is known due to the classic presentation of an acute
dissection consisting of intense, tearing pain that radiates to
the back. However, atypical presentations occur and it can
be confounding for the physician to determine if an atypical
presentation represents an acute dissection or an incidental
finding of a chronic dissection that went previously undi-
agnosed. Although CT commonly used to evaluate aortic
dissections, the literature is lacking in a comprehensive
study that assesses for any significant differences in imag-
ing features between acute and chronic dissections. A better
understanding of CT imaging characteristics associated with
acute versus chronic aortic dissections would complement
the clinical history of a patient with an aortic dissection and
aid management decisions.
Our study demonstrated that there were several CT
imaging features helpful in differentiating between acute
and chronic aortic dissections. FL outer wall calcification
was only seen in chronic dissections, especially those that
were particularly longstanding. This observation has been
reported in other studies, and is likely due to the long time
needed for the FL to endothelialize and subsequently calcify
[14, 15].
Several features were related to the thickening and
shortening of the dissection flap as it matures secondary
to elastic recoil, fibrosis, and neointima formation [14,
13

16]. Our results indicated that a straight, thicker, and less
mobile flap is highly suggestive of a chronic dissection
and this observation agrees with multiple reported studies
[14, 17–19].
Tear edges of the dissection flap were significantly more
frequently seen with chronic dissection. Although, to our
knowledge, this observation has not been previously reported
in the literature, it is likely that the thickening, shortening,
and decreased mobility of the dissection flap mentioned
above underlies this finding. For acute dissection, the curl-
ing of the tear edges into the FL was occasionally present,
as reported in the literature [20]. Chronic dissections had a
much higher frequency of tear edge curling, which could be
the result of the elastic recoil of the elastin rich media layer
and the subsequent fibrosis as the flap matures.
The size ratio of the FL to TL was significantly higher in
chronic dissections due to a relatively stable TL size in con-
junction with the FL aneurysmal degeneration that occurs
following a dissection [21, 22]. The difference was signifi-
cant just distal to the LSA and at the midway point between
the LSA and celiac trunk, which is consistent with existing
literature that suggests FL dilation is greatest in the proxi-
mal descending aorta [21, 23]. Likewise, the FL maximum
diameter was shown to be significantly greater in chronic
dissections.
Fig. 8  Algorithm to determine
the chronicity of a dissection.
Key for variables in equation:
D = FL maximum diameter
(mm); V = 1 if tear edges vis-
ible, 0 if not visible; S = 1 if
flap is straight, 0 if curved;
M = flap motion (mm); T = 1 if
FL thrombus present, 0 if absent
or indeterminate. Asterisk does
not exclude the possibility of a
co-existing dissection
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The International Journal of Cardiovascular Imaging
Several studies have reported that FL thrombus occurs
significantly more frequently in chronic dissections due
to the increased stasis in the FL secondary to aneurysmal
degeneration and atheromatous changes of neointima [14,
24]; our results agreed with this finding.
The rapid early growth rate of the aorta following a dis-
section likely contributes to the early mortality of the dis-
ease [18, 22]. Rupture of the aorta may occur during the
acute phase due to unstable growth of the aneurysm and
may be predicted by the presence of periaortic fat infiltra-
tion [25–27]. Some degree of fat infiltration may be physi-
ologic, so we distinguished between soft tissue stranding and
confluent soft tissue opacity in the hope of distinguishing
between a physiologic and a pathologic process. Our results
showed that confluent soft tissue opacity, presumably due
to mediastinal hematoma from a leaking false lumen, was
only seen in acute dissections, and all such cases proceeded
to emergent surgical repair in our study. On the other hand,
soft tissue stranding was present in both acute and chronic
dissections.
The predictive model created from our initial set of
patients include five statistically significant predictors
(Table 2), which could be used to determine the likelihood
that a dissection was acute or chronic using the equation in
Fig. 8. Moreover, the test population demonstrated that our
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model has a high specificity, sensitivity, PPV, and NPV, all
with a value of 0.95 or greater with relatively narrow 95%
confidence intervals (CI). The AUC of 0.98 indicates that
this prediction can be made with a high level of accuracy
(Fig. 7). Also, we attempted to use two additional predic-
tors, FL outer wall calcification and fat infiltration, for the
model but they were incompatible due to their separation
(see “Statistical analysis section”); FL outer wall calcifica-
tion was only seen in chronic dissections, and confluent soft
tissue opacity was only seen in acute dissections for both the
initial and test populations. However, these two predictors
could be used alongside the model because they each have
a PPV value of 1 for their associated groups.
Study limitations
One of the limitations of our study was the heterogeneity of
our population. We included both type A and B dissections
in our analysis despite their tendency to undergo slightly
different histopathological changes over time [18]. The
small number chronic type A dissections prevented a sepa-
rate analysis of type A disease; this is unavoidable because
acute type A dissections are generally surgical emergencies
and only very rarely allowed to proceed to the chronic phase.
Nonetheless, the majority of our imaging features have been
previously reported in the literature for both type A and B
dissections, therefore supporting a combined analysis [14,
15, 17–20, 23–27]. Our study’s inclusion of type A dissec-
tions may be particularly useful when deciding whether to
pursue emergent or elective repair for patients with a type
A dissection on imaging and atypical or inconclusive clini-
cal findings. Another limitation was the heterogeneity of
CT protocols from outside institutions. Homogeneity was
sacrificed in order to achieve an adequate population size
for comparison. Alternatively, this heterogeneity could be
viewed as an advantage, mirroring real-life situations.
The test population for our predictive model had a greater
average age of chronic dissections compared to the initial set
of data, which was due to our patient selection process. How-
ever, it is unlikely that this discrepancy significantly affected
our results because the majority of changes of chronic dis-
sections occur in the first 3 months [18]. Lastly, our model
is not necessarily applicable to all aortic dissection imaging
studies because it required either retrospective ECG gated or
non-gated images to assess for flap motion. Also, it does not
apply to acute on chronic dissections because these patients
may have features of both acute and chronic dissections.
An additional limitation of our study is that we did not
evaluate subacute dissections. The subacute phase is the
transition between the acute and chronic phases and, thus,
may show features of both groups. However, this limitation
does not have much clinical impact because it is unlikely
that a patient would be asymptomatic during the acute phase
but then present during the narrow interval of 14 days to
2 months from the acute event. Moreover, the management
and risks of a subacute dissection are less defined so the
comparison would have had less utility compared to acute
and chronic dissections.
In conclusion, acute and chronic aortic dissections
showed significantly different CT imaging features that
accurately distinguished between these two states in a test
population. Acute dissections were more likely to show peri-
aortic confluent soft tissue opacity, a curved dissection flap,
and a highly mobile dissection flap, whereas chronic dis-
sections were more likely to demonstrate a thick dissection
flap, FL outer wall calcification, FL thrombus, a dilated FL,
and visible tear edges curling into the FL. This information
may supplement the treating clinician’s judgment when con-
fronted with an atypical clinical presentation.
Funding  Norman Orabi received funding from the Summer Biomedi-
cal Research Program at the University of Michigan Medical School.
All other authors indicate that they have no other relevant sources of
funding.
Compliance with ethical standards 
Conflict of interest  Dr. David Williams serves on the medical advisor
board at Boston Scientific and is a consultant for W. L. Gore & As-
sociates. All other authors indicate that they have no relevant conflicts
of interest.
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