88 The Permanente Journal/ Spring 2011/ Volume 15 No. 2

CLINICAL MEDICINE

ImageDiagnosis:ThoracicAorticDissectionandThoracicAorticAneurysmSundeep R Bhat, MD Gus M Garmel, MD, FACEP, FAAEM

Sundeep R Bhat, MD, is an Emergency Medicine Resident in the Stanford/Kaiser Emergency Medicine Residency Program in CA. E-mail: sbhat@stanford.edu.Gus M Garmel, MD, FACEP, FAAEM, is a Senior Emergency Medicine Physician at the Kaiser Santa Clara Medical Center, Co-Program Director of the Stanford/Kaiser Emergency Medicine Residency Program, and Clinical Professor (Affiliated) of Surgery (Emergency Medicine) at Stanford University School of Medicine in CA. He is also a Senior Editor for The Permanente Journal. E-mail: gus.garmel@kp.org.

Figure1.ThoracicAorticDissectionAlthoughplainfilmchestradiographmaybeusedtoscreenforawidenedmediastinum(ImageA)whichsuggeststhoracicaortic

dissection,computedtomography(CT)angiographyortraditionalangiographyaregold-standardtestsandshouldbeobtainedinanystablepatientforwhomdissectionissuspected.1,2ThoracicaorticdissectionisgenerallyclassifiedusingtheStanfordscheme,althoughsometextsandcardiothoracicsurgeonsstillusetheDeBakeyclassification(typesI-III).ImageBdemonstratesdissectionflapsseeninboththeascendinganddescendingaorta(StanfordTypeA—anyinvolvementoftheascendingaortairrespectiveofsiteofintimaltearordistalextension).2ComplicationsofTypeAdissectionsincludeaorticvalveinsufficiency,dissectionintocoronaryvesselscausingacutemyocardialinfarction,anddissectionintothepericardialsac(ImageC)causinghemopericardiumandpossibletamponadephysiology.1TypeAdissectionrequiresimmediatesurgicalintervention.ImageDshowsanintimalflapinthedescendingaortaonly(StanfordTypeB).PatientswithuncomplicatedTypeBdissectionsaretypicallymanagedmedically,withbloodpressurecontrolbypharmacologicintervention.1,2

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89The Permanente Journal/ Spring 2011/ Volume 15 No. 2

CLINICAL MEDICINEImageDiagnosis:ThoracicAorticDissectionandThoracicAorticAneurysm

Figure 2.ThoracicAorticAneurysmwithRupture

Aneurysmal dilatation of the de-scendingthoracicaortacanbeseeninpatients with atherosclerotic disease,as well as in patients with collagenvascular disorders like Marfan’s syn-drome.1Theseimages(ImageAandB)demonstratethoracicaorticaneurysmrupture with extravasation of bloodinto the adjacent pleural space. Riskofruptureincreaseswithsize;growthmaybe0.1-0.4centimeters(cm)peryear;riskofrupturebecomeshighafterreaching6cmindiameter.Forstablepatientswithoutsymptoms,computedtomography or magnetic resonanceimagingat regular intervals is recom-mended,asisbeta-blockertherapyforbloodpressurecontrol.1v

References 1. Creager MA, Loscalzo J. Diseases of

the Aorta. In: Fauci AS, Braunwald E, Kasper DL, et al. Harrison’s Principles of Internal Medicine (17th edition). New York, NY: McGraw-Hill Compa-nies Inc; 2008. p 1563-7.

2. Manthey DE . Aortic Dissection and Aneurysms. In: Ma OJ, Cline DM, Tintinalli JE, et al. Emergency Medicine Just the Facts (2nd edition). New York, NY: McGraw-Hill Companies Inc; 2004. p 118-20.

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