A pictorial review of acute aortic syndrome: discriminating and overlapping features as revealed by ECG-gated multidetector-row CT angiography
The term "acute aortic syndrome" (AAS) encompasses a spectrum of life-threatening conditions characterized by acute aortic pain. AAS traditionally embraces three abnormalities including classic aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. Although the underlying etiologies and conditions predisposing to AAS are diverse, the clinical features are indistinguishable.
Multidetector-row computed tomography (CT) with electrocardiographic gating (ECG-gated MDCT) has greatly improved imaging of acute thoracic aortic diseases by virtually eliminating pulsation artifacts transmitted from cardiac motion and reveals subtle aortic abnormalities, which have been difficult to recognize by conventional non-gated CT.
While these advances in imaging technology provide additional discriminating features of acute aortic diseases, they also reveal a range of overlapping features of these life-threatening conditions that not uncommonly are dynamic and evolving. These overlapping and transitional features may be a major source of misunderstanding, confusion, and controversy for diseases that cause AAS.
In this pictorial review, we describe the discriminating and typical imaging features as revealed by modern ECG-gated MDCT angiography. In addition to the discriminating features, recognition of the overlapping and transitional features in AAS will allow a more comprehensive understanding of their underlying pathophysiologic conditions and their natural history, and may improve therapeutic management.
• The superior visualization of ECG-gated CTA improves the diagnostic accuracy of acute aortic syndrome.
• ECG-gated CTA provides discriminating features of underlying pathophysiologic conditions of AAS.
• Also, recognition of the overlapping features in AAS will allow a more comprehensive understanding.
- Vilacosta, I, Roman, JA (2001) Acute aortic syndrome. Heart 85: pp. 365-368 CrossRef
- Hiratzka, LF, Bakris, GL, Beckman, JA (2010) ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/ SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology. Circulation 121: pp. e266-369 CrossRef
- Vilacosta, I, Aragoncillo, P, Canadas, V, San Roman, JA, Ferreiros, J, Rodriguez, E (2009) Acute aortic syndrome: a new look at an old conundrum. Heart 95: pp. 1130-1139
- Hayter, RG, Rhea, JT, Small, A, Tafazoli, FS, Novelline, RA (2006) Suspected aortic dissection and other aortic disorders: multi-detector row CT in 373 cases in the emergency setting. Radiology 238: pp. 841-852 CrossRef
- Shiga, T, Wajima, Z, Apfel, CC, Inoue, T, Ohe, Y (2006) Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med 166: pp. 1350-1356 CrossRef
- Fleischmann, D, Mitchell, RS, Miller, DC (2008) Acute aortic syndromes: new insights from electrocardiographically gated computed tomography. Semin Thorac Cardiovasc Surg 20: pp. 340-347 CrossRef
- Roberts, WC (1981) Aortic dissection: anatomy, consequences, and causes. Am Heart J 101: pp. 195-214 CrossRef
- Lesauskaite, V, Tanganelli, P, Sassi, C (2001) Smooth muscle cells of the media in the dilatative pathology of ascending thoracic aorta: morphology, immunoreactivity for osteopontin, matrix metalloproteinases, and their inhibitors. Hum Pathol 32: pp. 1003-1011 CrossRef
- Erdheim, J (1930) Medionecrosis aortae idiopathica cystica. Arch Pathol Anat 276: pp. 187-229 CrossRef
- Hagan, PG, Nienaber, CA, Isselbacher, EM (2000) The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 283: pp. 897-903 CrossRef
- Morisaki, H, Akutsu, K, Ogino, H (2009) Mutation of ACTA2 gene as an important cause of familial and nonfamilial nonsyndromatic thoracic aortic aneurysm and/or dissection (TAAD). Hum Mutat 30: pp. 1406-1411 CrossRef
- Stanson, AW, Kazmier, FJ, Hollier, LH (1986) Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1: pp. 15-23
- Svensson, LG, Labib, SB, Eisenhauer, AC, Butterly, JR (1999) Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation 99: pp. 1331-1336 CrossRef
- Chirillo, F, Salvador, L, Bacchion, F, Grisolia, EF, Valfre, C, Olivari, Z (2007) Clinical and anatomical characteristics of subtle-discrete dissection of the ascending aorta. Am J Cardiol 100: pp. 1314-1319 CrossRef
- Yamada, T, Tada, S, Harada, J (1988) Aortic dissection without intimal rupture: diagnosis with MR imaging and CT. Radiology 168: pp. 347-352
- Ganaha, F, Miller, DC, Sugimoto, K (2002) Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation 106: pp. 342-348 CrossRef
- Evangelista, A, Mukherjee, D, Mehta, RH (2005) Acute intramural hematoma of the aorta: a mystery in evolution. Circulation 111: pp. 1063-1070 CrossRef
- O’Gara, PT, DeSanctis, RW (1995) Acute aortic dissection and its variants. Toward a common diagnostic and therapeutic approach. Circulation 92: pp. 1376-1378 CrossRef
- Neri, E, Capannini, G, Carone, E, Diciolla, F, Sassi, C (1999) Evolution toward dissection of an intramural hematoma of the ascending aorta. Ann Thorac Surg 68: pp. 1855-1856 CrossRef
- Nienaber, CA, Sievers, HH (2002) Intramural hematoma in acute aortic syndrome: more than one variant of dissection?. Circulation 106: pp. 284-285 CrossRef
- Erbel, R, Alfonso, F, Boileau, C (2001) Diagnosis and management of aortic dissection: Recommendations of the Task Force on Aortic Dissection, European Society of Cardiology. Eur Heart J 22: pp. 1642-1681 CrossRef
- Sueyoshi, E, Matsuoka, Y, Imada, T, Okimoto, T, Sakamoto, I, Hayashi, K (2002) New development of an ulcerlike projection in aortic intramural hematoma: CT evaluation. Radiology 224: pp. 536-541 CrossRef
- Vilacosta, I, San Roman, JA, Ferreiros, J (1997) Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection. Am Heart J 134: pp. 495-507 CrossRef
- Ide, K, Uchida, H, Otsuji, H (1996) Acute aortic dissection with intramural hematoma: possibility of transition to classic dissection or aneurysm. J Thorac Imaging 11: pp. 46-52 CrossRef
- Winnerkvist, A, Lockowandt, U, Rasmussen, E, Radegran, K (2006) A prospective study of medically treated acute type B aortic dissection. Eur J Vasc Endovasc Surg 32: pp. 349-355 CrossRef
- Murray, CA, Edwards, JE (1973) Spontaneous laceration of ascending aorta. Circulation 47: pp. 848-858 CrossRef
- Kaplan, M, Yapici, F, Erkan, M, Sargin, M, Demirtas, MM (2002) Ascending aortic dissection without intimal tear: a case report. Heart Surg Forum 5: pp. E39-E41
- Kouchoukos, NT, Murphy, MC (2009) Intramural hematoma associated with an intimal tear. J Am Coll Surg 209: pp. 284 CrossRef
- Timperley, J, Banning, AP (2003) Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation 107: pp. e63 CrossRef
- Cho, KR, Stanson, AW, Potter, DD, Cherry, KJ, Schaff, HV, Sundt, TM (2004) Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. J Thorac Cardiovasc Surg 127: pp. 1393-1399 CrossRef
- Davies, RR, Goldstein, LJ, Coady, MA (2002) Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg 73: pp. 17-27 CrossRef
- Booher, AM, Eagle, KA (2011) Diagnosis and management issues in thoracic aortic aneurysm. Am Heart J 162: pp. 38-46.e1 CrossRef
- Debakey, ME, Henly, WS, Cooley, DA, Morris, GC, Crawford, ES, Beall, AC (1965) Surgical management of dissecting aneurysm of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 49: pp. 130-149
- Agmon, Y, Khandheria, BK, Meissner, I (2003) Is aortic dilatation an atherosclerosis-related process? Clinical, laboratory, and transesophageal echocardiographic correlates of thoracic aortic dimensions in the population with implications for thoracic aortic aneurysm formation. J Am Coll Cardiol 42: pp. 1076-1083 CrossRef
- Reed, D, Reed, C, Stemmermann, G, Hayashi, T (1992) Are aortic aneurysms caused by atherosclerosis?. Circulation 85: pp. 205-211 CrossRef
- A pictorial review of acute aortic syndrome: discriminating and overlapping features as revealed by ECG-gated multidetector-row CT angiography
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Insights into Imaging
Volume 3, Issue 6 , pp 561-571
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- Aortic diseases
- X-ray computed
- Aortic dissection
- Aortic aneurysm
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- Author Affiliations
- 1. Department of Radiology, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
- 2. Department of Radiology, Centre Hospitalier de L’Univeristé de Montréal, 3480 rue St. Urbain, Montreal, Quebec, Canada
- 3. Northern Virginia Radiology Consultants, PLLC, 1701 N. George Mason Drive, Arlington, VA, 22205, USA
- 4. Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA