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For personal use only; all rights reserved

Original Report
Mark A. LePage 1
Leslie E. Quint 1
Aortic Dissection: CT Features that
Seema S. Sonnad 2 Distinguish True Lumen from False Lumen
G. Michael Deeb 3
David M. Williams 1 OBJECTIVE. The purpose of this study was to determine which CT findings are reliable
indicators of the true or false lumen in an aortic dissection.
CONCLUSION. The beak sign and a larger cross-sectional area were the most useful in-
dicators of the false lumen for both acute and chronic dissections. Features generally indica-
tive of the true lumen included outer wall calcification and eccentric flap calcification. In
cases showing one lumen wrapping around the other lumen in the aortic arch, the inner lumen
was invariably the true lumen.

Received November 15, 2000; accepted after revision
January 16, 2001.
1 Department of Radiology, University of Michigan Health
Center, Box 0030, 1500 E. Medical Center Dr., Ann Arbor, MI
48109-0030. Address correspondence to L. E. Quint.
2 of this study was to determine whether certain
Zuedema Program for Surgical Core Outcomes Research
and Evaluation, University of Michigan Health Center,
Ann Arbor, MI 48109.
3
Department of Surgery, Section of Cardiothoracic Surgery,
University of Michigan Health Center, Ann Arbor, MI 48109.
AJR 2001;177:207–211
0361–803X/01/1771–207
© American Roentgen Ray Society
A
cute aortic dissection is readily diag-
nosed using CT scanning, with the
reported diagnostic accuracy rang-
ing from 88% to 100% [1–3]. After making a di-
agnosis of aortic dissection, it is important for
the radiologist to determine the luminal origins
of branch vessels in patients who may undergo
surgical repair or percutaneous treatment with
endografts [4–8]. Although some authors have
written about compression of the true lumen by
the false lumen [6], few authors have directly
addressed differentiation of the true and false
lumens using imaging [9, 10]. In most CT ex-
aminations, the identity of the true lumen may
be determined by its continuity with an undis-
sected portion of aorta. However, in some pa-
tients, this continuity is difficult to appreciate. In
other patients, it may be impossible to establish
continuity because only a portion of the aorta
has been scanned or because the entire aorta is
dissected. In these circumstances, it may be use-
ful to base the distinction between true and false
lumens on other imaging findings. The purpose
CT findings are reliable indicators of the true or
false lumen in aortic dissections.
Materials and Methods
Thoracic surgery records were reviewed to
identify all patients who were seen at our institu-
tion for acute or chronic aortic dissection between
January 1993 and May 2000. Patients who under-
went contrast-enhanced CT and had involvement
of the descending thoracic aorta were included in
this study. Patients were excluded if they had un-
dergone previous surgery or endograft placement
for the dissection or if complete (or near complete)
thrombosis of the false lumen was seen at CT.
Fifty-one patients were identified in this manner.
Imaging
All but six patients underwent helical CT imag-
ing at our institution using a dedicated aortic proto-
col with a 2.5- to 5-mm-section collimation and a
1.3- to 5-mm-section spacing (the technique varied
according to type of helical scanner used). Between
120 and 200 mL of iodinated contrast material was
IV administered at a rate of 3–4 mL/sec. Patients
were scanned from the aortic arch to the aortic bifur-
cation (superior to inferior). Three patients had con-
trast-enhanced CT examinations at our institution
using a conventional (nonhelical) scanner, and three
others had contrast-enhanced CT performed at out-
side institutions using various techniques.
Chronic dissections were defined as those persist-
ing more than 2 weeks after the acute event. If more
than one CT examination was available for a particu-
lar patient, the earliest acute scan and the latest
chronic scan were used for the purposes of this study.
Hard copies of the axial images were retrospec-
tively reviewed independently by two experienced ra-
diologists who were unaware of the acute versus
chronic nature of each patient’s disease. When there
was disagreement between the two CT reviewers’ in-
terpretations of an individual feature, a consensus was

AJR:177, July 2001 207

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LePage et al.

reached via joint reevaluation of the images. Each tion between the true and false lumens was readily CT findings for the true and false lumens in
scan was evaluated for the presence of the following made at open aortotomy because of the distinctive ap- acute and chronic cases are delineated in Table
imaging features on one or more images in each lu- pearance of the intima in the true lumen. 1. The beak sign and cobwebs were seen only in
men of the descending aorta: the beak sign, outer wall Approval of the institutional review board was ob- the false lumen (p < 0.05 for the beak sign, p >
calcification, intraluminal thrombus, eccentric flap tained; informed consent from patients was waived.
0.05 for cobwebs) (Figs. 1 and 2). However,
calcification, and cobwebs. The beak sign was defined
as the presence of an acute angle between the dissec- Statistics
whereas the beak sign was present on all scans,
tion flap and the outer wall; the space formed by the cobwebs were present in only 9% of the scans
Frequencies of CT findings were compared be-
acute angle could be filled with high-attenuation ma- tween true and false lumens using the McNemar
of acute dissections and 17% of those of chronic
terial (contrast-enhanced blood) or low-attenuation test. This test was used because of the paired na- dissections. Outer wall calcification (Figs. 3 and
material (hematoma). The lumen in which this feature ture of the data and the correlation between the re- 4) was never present in the false lumen on scans
was predominant was identified, after taking into ac- sult from the true lumen and the false lumen for a of acute dissections (p < 0.05), although it was
count all the images in the examination. Eccentric flap given subject. Frequencies of CT findings were occasionally present on scans of chronic dissec-
calcification in one lumen was called when the side of compared between acute and chronic dissections tions (17% of the cases) (p < 0.05). Intraluminal
the dissection flap facing that lumen contained calcifi- using Fisher’s exact test. Eight patients had scans thrombus was more common in the false lumen
cation, whereas the side of the flap facing the other lu- of both acute and chronic dissections; for statisti- (46% of the acute cases, 83% of the chronic
men was of soft-tissue attenuation without apparent cal analysis, these patients were excluded from the
calcification. Cobwebs were defined as thin, linear ra-
cases) compared with the true lumen (6% of the
acute group, because it was the larger of the two
diolucent filling defects in the lumen that were at- acute cases, 4% of the chronic cases) (p < 0.05)
groups. The level of significance for each test was
tached to the wall at one end; the other end could be a p value of less than 0.05.
(Fig. 3). Except for one case, eccentric flap cal-
attached to the flap or the wall or have no attachment. cification was only seen on the true lumen side
In addition, the following features of each lumen of the flap (p < 0.05) (Fig. 5).
were subjectively evaluated at one quarter, one half, Results At one quarter of the distance along the dis-
and three quarters of the distance along the dissected Fifty-one patients were included in the study. sected length of the aorta, for both acute and
length of the descending thoracic aorta and abdomi- There were 21 type A dissections and 30 type B chronic cases, the larger lumen was usually the
nal aorta: relative cross-sectional area and the pres- dissections. Eight patients had CT examinations false lumen (85% of the acute cases, 83% of
ence and direction of flap curvature. If the central
during both the acute and chronic phases of dis- the chronic cases) ( p < 0.05) (Figs. 1 and 5).
portion of the flap was curved toward one lumen, at
a particular level, then the flap curvature was coded
ease (one type A and seven type B), leading to a For acute dissections, the flap was most com-
as present for that lumen. If the flap was flat, then no total of 59 CT examinations (35 of acute dissec- monly curved toward the false lumen at this
curvature was coded. These features were evaluated tions and 24 of chronic dissections). For patients level (56% of the cases) ( p < 0.05), although it
at three different points along the length of the dis- with chronic dissection, the mean age of the dis- was often flat (38% of the cases), and occa-
sected portion of the aorta because of the possibility section was 23 months (range, 2–84 months). sionally curved toward the true lumen (6% of
that results might differ depending on location.
For patients with involvement of the transverse por-
tion of the aortic arch and proximal descending aorta TABLE 1 CT Findings in Acute and Chronic Aortic Dissections
(depicted as a long-axis view on a transverse CT im- Acute (n = 35 scans) Chronic (n = 24 scans)
age), one lumen sometimes appeared to wrap partially CT Finding
or completely around the other lumen, occasionally True Lumen False Lumen True Lumen False Lumen
even giving the appearance of three separate lumens. In Beak sign 0 (0)a 35 (100)a 0 (0)a 24 (100)a
these cases, the identity of the inner lumen was noted.
Outer wall calcification 21 (60)a 0 (0)a 17 (71)a 4 (17)a
To determine which lumen was true and which was
false, we followed the two lumens in the descending Intraluminal thrombus 2 (6)a 16 (46)a 1 (4)a 20 (83)a
aorta proximally and distally on the CT scans. The lu- Eccentric flap calcification 9 (26)a 1 (3)a 14 (58)a 0 (0)a
men in the dissected portion of aorta that was continu- Cobwebs 0 (0) 3 (9) 0 (0)a 4 (17)a
ous with the lumen of an undissected portion of aorta Larger area at one-quarter 3 (9)a–c 29 (85)a–c 3 (13)a,e 20 (83)a,e
was deemed to be the true lumen. If a lumen ended in a distance
blind sac, it was deemed to be the false lumen. These
Flap curvature at one-quarter 2 (6)a,c 19 (56)a,c 0 (0)a 6 (25)a
standards were used to define the lumens in all patients
distance
except four, in whom continuity could not be deter-
mined at CT. In these four patients (all with an acute Larger area at one-half distance 2 (6)a,d 31 (94)a,d 1 (4)a 23 (96)a
type A dissection), the boundary between the lumens Flap curvature at one-half 10 (30)d 11 (33)d 1 (4)a 7 (29)a
was blurred in the aortic root. In two of the four pa- distance
tients, the determination was made via comparison Larger area at three-quarters 2 (6)a,d,e 30 (91)a,d,e 0 (0)a 24 (100)a
with a later postoperative scan. On the postoperative distance
study, the lumen within the remaining native dissected Flap curvature at three-quarters 9 (27)d 13 (39)d 0 (0) 0 (0)
portion of aorta that was continuous with the aortic in- distance
terposition graft was deemed to represent the true lu-
men. In one of the four patients, one lumen completely Note.—Numbers in parentheses are percentages.
a Statistically significant frequency difference between true and false lumens within acute group or chronic group ( p < 0.05).
surrounded the other lumen; the inner lumen was
b In two cases, the true lumen area was equal to the false lumen area.
deemed to represent the true lumen, and this was con-
c In one case, no images were obtained at this level (noncontiguous sections).
firmed via comparison with surgical notes. Luminal
d In two cases, enhancement was poor at this level;
identification in the fourth patient was also made via images were not coded.
e In one case, the true lumen area was equal to the false lumen area.
comparison with detailed surgical notes. Differentia-

208 AJR:177, July 2001

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the cases) (Figs. 1 and 6). For chronic dissec-
tions, the flap was usually flat (75% of the
cases) and occasionally curved toward the
false lumen (25% of the cases) ( p < 0.05).
At one half of the distance along the dis-
sected length of the aorta, for both acute and
chronic cases, the larger lumen was almost al-
ways the false lumen (94% of the acute cases,
96% of the chronic cases) ( p < 0.05). For acute
Fig. 1.—41-year-old man with acute aortic dissection. CT
scan obtained at one-quarter distance along length of dis-
sected portion of aorta shows descending aortic dissection
flap (arrows) that is curved toward false lumen (F). Beak sign
(arrowheads) is present in false lumen. Note that false lu-
men area is larger than true lumen area.
Fig. 3.—65-year-old woman with chronic aortic
dissection. CT scan obtained at one-quarter dis-
tance along length of dissected portion of aorta
shows flat dissection flap. Outer wall calcification
(straight arrow) is present in true lumen (T). Throm-
bus (arrowheads) is present in false lumen. Curved
arrow indicates thrombus within false lumen beak.
AJR:177, July 2001
CT Features of Aortic Dissection
dissections, the flap was almost equally likely
to be flat (36% of the cases), curved toward the
false lumen (33% of the cases), or curved to-
ward the true lumen (30% of the cases) ( p >
0.05) (Fig. 6). For chronic dissections, the flap
was usually flat (67% of the cases) (Fig. 2) and
occasionally curved toward the false lumen
(29% of the cases) ( p < 0.05); in only one case
was it curved toward the true lumen.
Fig. 2.—51-year-old woman with chronic aortic dis-
section. CT scan obtained at one-half distance along
length of dissected portion of aorta shows flat dis-
section flap. False lumen beaks are filled with low-
attenuation thrombus (arrowheads). Faintly visual-
ized cobweb (arrows) is present in false lumen (F).
Fig. 4.—76-year-old man with chronic aortic dissection. CT
scan obtained at three-quarters distance along length of dis-
sected portion of aorta shows flat dissection flap. Outer wall
calcification (arrows) and thrombus (asterisk) are present in
false lumen (F). T = true lumen.
At three quarters of the distance along the
dissected length of the aorta, the larger lu-
men was always the false lumen in chronic
cases and almost always the false lumen in
acute cases (91% of the cases) ( p < 0.05).
For acute dissections, the flap was nearly
equally likely to be flat (33% of the cases),
curved toward the false lumen (39% of the
cases), or curved toward the true lumen (27%
of the cases) ( p > 0.05). For chronic dissec-
tions, the flap was always flat at this level.
Statistically significant differences ( p <
0.05) between acute and chronic dissections
were as follows. Chronic dissections were
more likely to show eccentric flap calcification
of the true lumen, outer wall calcification of
the false lumen, and intraluminal thrombus of
the false lumen compared with acute dissec-
tions. Acute dissections were more likely to
show a curved flap (as opposed to a flat flap) at
one-quarter and three-quarters distance com-
pared with chronic dissections.
Forty-five of 51 patients had involvement
of the transverse portion of the aortic arch
and proximal descending aorta. In 24 of the
45 patients, one lumen appeared to wrap
around the other lumen. In all 24 patients
showing this finding, the inner lumen was
the true lumen (Fig. 7).
Discussion
It is important to determine the luminal ori-
gins of branch vessels before endograft or bare
stent placement within the aorta or within the
branch vessels, to plan optimal deployment and
avoid end-organ ischemia. In most cases, the
true lumen may be identified on CT by its conti-
nuity with an undissected portion of aorta.
Sometimes, however, this rule is difficult to ap-
ply, particularly in cases with involvement of
the aortic root and especially in those with cir-
cumferential dissection of the root. In addition,
patients occasionally undergo only abdominal
CT (e.g., in the setting of abdominal pain), and
therefore the true lumen cannot be traced back
to the aortic root. Our study showed several ad-
ditional CT imaging features that were helpful
in differentiating the true and false lumens. The
best feature was the beak sign; it was only seen
in the false lumen, and it was present in all
cases, both acute and chronic. Moreover, it was
generally easily identified on CT. The beak sign
is the cross-sectional imaging manifestation of
the wedge of hematoma that cleaves a space for
the propagating false lumen and that is present
microscopically in all dissections [10]. Cob-
webs (ribbons of media that are incompletely
sheared off by the dissection) were also present
209
Downloaded from www.ajronline.org by 2400:1a00:b011:304:94ef:ba4e:8ede:d244 on 11/04/22 from IP address 2400:1a00:b011:304:94ef:ba4e:8ede:d244. Copyright ARRS. For personal use only; all rights reserved
Fig. 5.—59-year-old man with chronic aortic dissec-
tion. CT scan obtained at one-quarter distance along
length of dissected portion of aorta shows flat dissec-
tion flap. Eccentric flap calcification (arrow) is present
along true lumen side of flap. Notice that false lumen
(F) contains thrombus (arrowheads) and is larger than
true lumen at this level.
only in the false lumen; however, this feature
was of limited usefulness because of its rarity.
This finding is in agreement with previous stud-
ies that have reported cobwebs as a specific, but
relatively insensitive, indicator of the false lu-
men [9, 10]. The lower prevalence of cobwebs
in our study compared with that reported in a
previous intravascular sonographic study [10]
may reflect, in part, the greater spatial resolution
of intravascular sonography relative to CT.
Outer wall calcification always indicated
the true lumen on scans of acute dissections. In
chronic dissections, however, this finding was
somewhat unreliable because the false lumen
lining may endothelialize and subsequently
210
LePage et al.
Fig. 6.—65-year-old man with acute aortic dissec-
tion. CT scan obtained at one-quarter distance along
length of dissected portion of aorta shows dissection
flap that is curved toward true lumen. Anterior false
lumen beak (arrowheads) is partially opacified and
partially filled with thrombus. F = false lumen.
Fig. 7.—69-year-old woman with
acute aortic dissection. CT scan ob-
tained at level of transverse aortic
arch shows that outer false lumen
(F) wraps around inner true lumen
(T). Dissection flap extends into in-
nominate artery. Note cobweb in
false lumen (arrow) and bilateral
pleural effusions (P).
calcify in long-standing dissections [11, 12],
leading to calcification in the outer wall of the
false lumen. Although, theoretically, this phe-
nomenon could also lead to calcification on the
false luminal surface of the flap in chronic dis-
sections, no such cases were identified in our
study. Intraluminal thrombus was a fairly good
marker for the false lumen, although in pa-
tients with an underlying aneurysm, thrombus
may be present in the true lumen as well. False
lumen thrombus was significantly more fre-
quent in chronic dissections than acute dissec-
tions. Thrombus formation in acute dissection
is due partly to the thrombogenic exposed me-
dia, which lines the false lumen, and stasis in
low-flow segments of the false lumen. In cases
of chronic dissection, the false lumen remains
prone to thrombus formation because of stasis
related to aneurysmal enlargement and be-
cause of atheromatous changes in the neoint-
ima, which can outstrip atheromatous
degeneration in the native intima.
In an in vitro model of dissection with two
patent lumens, one published study showed
that the true lumen collapses and the false lu-
men distends even when the pressure gradi-
ent across the dissection flap is zero [13].
Moreover, for in vivo aortic dissections in
humans, pressure in the false lumen fre-
quently exceeds that in the true lumen [8]
and superimposes an element of compres-
sion onto the underlying true lumen collapse.
Thus, it is not surprising that in our study,
larger lumen size was a good marker for the
false lumen in both acute and chronic dissec-
tions. This finding was commonly present,
and usually obvious, particularly at one half
or three quarters along the distance of the
dissected aorta.
The direction of flap curvature was gener-
ally not useful in distinguishing the true from
false lumen. However, acute dissections usu-
ally had some curvature to the flap, whereas
chronic dissections usually had a flat flap over
much of its length. This appearance of the flap
is probably caused by cellular and mechanical
changes in the aorta wall. As the flap heals, fi-
brosis and neointima formation [14] lead to
thickening and rigidity of the flap. In addition,
we hypothesize that as the false lumen dilates,
the lines along which the dissection flap joins
the outer wall of the aorta are drawn apart,
stretching the flap taut. Our impression is that
this flattening of the dissection flap is particu-
larly notable in larger false lumens.
In patients with involvement of the aortic
arch, it is common for one lumen to appear to
wrap partially or completely around the other
lumen, sometimes even giving the appearance
of three lumens. The different appearance in
the transverse arch, compared with the appear-
ance in the descending aorta, is because of the
different angle of sectioning, relative to the
long axis of the aorta. In such cases, the inner
lumen is invariably the true lumen.
Accurate CT differentiation between the true
and the false lumen has previously been rela-
tively unimportant, because surgery has been
the mainstay for therapy, and therapeutic deci-
sions have relied predominantly on the presence
or absence of involvement of the ascending
aorta [15, 16]. However, at the current time, per-
cutaneous treatment methods are maturing and
AJR:177, July 2001
Downloaded from www.ajronline.org by 2400:1a00:b011:304:94ef:ba4e:8ede:d244 on 11/04/22 from IP address 2400:1a00:b011:304:94ef:ba4e:8ede:d244. Copyright ARRS. For personal use only; all rights reserved
have become more prevalent, partly fueled by
advances in CT angiography. Reliable CT find-
ings that differentiate the true and false lumen
may become particularly important in assisting
the cardiovascular surgeon and radiologist in
planning endovascular treatment of dissection.
We conclude that the beak sign and large cross-
sectional area on contrast-enhanced CT exami-
nations are the most useful indicators of the
false lumen in classical acute and chronic aortic
dissection. The pattern of mural calcification,
presence of intraluminal thrombus or cobwebs,
and wraparound feature in the transverse arch
are less common and less reliable identifiers of
the true and false lumens.
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