MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

Abstract

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.

Right Heart Failure as an Atypical Presentation of Chronic Type A Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A case report and mini-review of literature

“…The first-line imaging modality in the setting of aortic diseases (acute or chronic) is computed tomography [35]. The excellent diagnostic performance of CCTA (98-100% specificity/sensibility) is well-established in the evaluation of complete aortic anatomy, including the aorta's branches and periaortic structures [36]. The ECG-gated CCTA findings in this case (i.e., the presence of chronic haematoma with signs of right atrial and bicaval compression and limited antegrade dissection with respect to the origin of the brahiocephalic trunk) confirmed and fulfilled the initial TTE data and helped the cardiac surgeon to determine the best approach.…”

Bib Sign in Proximal Descending Thoracic Aorta Rupture on CT Angiography: Presentation of a Paradigmatic Case

“…Acute aortic syndromes are the major nontraumatic component of aortic emergencies; they include penetrating atherosclerotic ulcer (PAU), intramural haematoma (IMH), and acute aortic dissection. All of those pathological entities share common clinical signs and symptoms, characterized by abrupt onset and severe back, chest, or abdominal pain [ 2 , 3 ]. Diagnosis of thoracic acute aortic syndromes is mainly based on imaging; in particular, state of the art multidetector computed tomography angiography (CTA) is the gold standard for conclusive diagnosis and is fundamental for treatment planning [ 3 , 4 ].…”

“…All of those pathological entities share common clinical signs and symptoms, characterized by abrupt onset and severe back, chest, or abdominal pain [ 2 , 3 ]. Diagnosis of thoracic acute aortic syndromes is mainly based on imaging; in particular, state of the art multidetector computed tomography angiography (CTA) is the gold standard for conclusive diagnosis and is fundamental for treatment planning [ 3 , 4 ]. An optimized chest CTA scan protocol is mandatory to reduce pitfalls, to get to the right diagnosis, and effectively start the treatment of acute aortic disease [ 5 ].…”

“…A common differential diagnosis for PAU is the ulcer-like projection (ULP), which represents a newly formed local disruption of the intima layer, with a wide connection to the aortic lumen, seen in IMH undergoing unstable evolution: the blood fills the IMH and enlarges it, increasing the risk of aortic dissection and rupture [ 3 ]; moreover, ULP can be also found in patients with no evidence of atherosclerosis [ 9 ]. At CTA, ULP pouch enhances to the same degree of the aortic lumen after contrast medium injection [ 14 ].…”

Role of Triple Rule-Out Computed Tomography Angiography in the Management of Covid-19 Patients Presenting with Acute Chest Pain in Emergency Department

“…The term "acute aorta syndrome" (AAS) refers to a group of life-threatening conditions that include penetrating aortic ulcer (PAU), intramural hematoma (IMH), and thoracic aortic dissection (TAD) [17] .…”