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Case 234

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A 56- year-old man attends the emergency department complaining of severe, acute, breathing-related chest pain radiating to the abdomen. Long-standing history of controlled hypertension, in use of Beta-Blocker. On examination: patient in pain, pallor, sweating. No abnormalities were observed in the respiratory, cardiovascular and digestive systems. BP: 155/94 mmHg; HR; 88 bpm; RR: 22 bpm; SpO2: 96%. A computed tomographic (CT) angiography of the abdominal and thoracic aorta was requested.

Considering the images and the clinical data, which is the most likely diagnosis?

a) Acute mesenteric ischemia

25%

b) Acute coronary syndrome

25%

c) Acute aortic dissection

25%

d) Pulmonary thromboembolism

25%
   

Image analysis

Image 1: Axial image at level of pulmonary arteries shows intimal flap separating true and false lumen at descending aorta (arrows). The aortic dissection is characterized and located by the contrast-filled false lumen.

 

 

Image 2: CT angiography of the aorta, coronal reconstruction, at level of descending aorta, shows intimal dissection extending distally to the abdominal aorta, until next to the level of emergence of the renal arteries (arrows). Thrombotic component is present in the lumen at the horizontal segment of the aortic arch. 

 

Image 3: CT angiography of the aorta, sagittal reconstruction, at level of descending aorta, shows intimal dissection extending distally to the abdominal aorta, until next to the level of emergence of the renal arteries (arrows). Thrombotic component is present in the lumen at the horizontal segment of the aortic arch. 

 

Highlights

- Aortic dissection is associated with a high mortality rate (25-30%)

- The main risk factor is systemic arterial hypertension

- The ascending aortic dissection is a surgical emergency

- The most important classification of aortic dissection is anatomical, differing through the involvement of the ascending aorta (Stanford A) or not (Stanford B).

- Hemodynamically stable patients should undergo imaging tests, particularly CT angiography, that has high accuracy.

- The clinical treatment involves analgesia, the use of beta-blockers and sodium nitroprusside, if necessary.

 

References

- Manning WJ, Black III JH. Clinical features and diagnosis of acute aortic dissection. UpToDate [internet] 2016 [acesso em may 2016]. Disponível em: http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-acute-aortic-dissection.

- Lee SS, Park SH. Computed Tomography Evaluation of Gastrointestinal Bleeding and Acute Mesenteric Ischemia, Radiol Clin N Am 2013;51:29–43.

- McMahon MA, Squirrell CA. Multidetector CT of Aortic Dissection: A Pictorial Review Radi-oGraphics Mar 2010;30:445–460.

- Henzler T, Barraza Jr. M, Nance Jr. JW., Costello P, Krissak R, Fink C,

Schoepf JU, CT imaging of acute pulmonary embolism, Journal of Cardiovascular Computed Tomography, Jan/Feb 2011:5,3-11.

- Nienaber CA, Clough RE. Management of acute aortic dissection, Lancet, Feb 2015;385:800-11.

- Silva C, Müller N. Tórax. Rio de Janeiro: Elsevier, 2011 (Colégio Brasileiro de Radiologia).

 

Author

Tatiana Roberta Bogutchi Sarubi, 4th year medical student at UFMG

Email: tatianabsarubi[at]gmail.com

 

Stephanie Farias Esteves, 4th year medical student at FASEH

Email: stephaniefarias91[at]Hotmail.com

 

Maria Luisa Moreira de Moura Lima, 4th year medical student at UFMG

Email: marialuisamoreira7[at]gmail.com

 

André Ribeiro Guimarães, 6th year medical student at UFMG

E-mail: guimaraesandrer[at]hotmail.com

 

Supervisors

Gabriel Assis Lopes do Carmo, Cardiologist and Assistant Professor of the Internal Medicine Department at UFMG

Email: gabriel_carmo[at]yahoo.com.br

 

Acknowledgment

To the teacher Fabiana Paiva Martins, Radiologist specialized in Internal Medicine and Preceptor of the Medical Radiology and Diagnostic Imaging residence of the Mater Dei Hospital, Belo Horizonte, MG.

 

Reviewers

Fábio M. Satake, Laio Bastos, Mateus S. Oliveira, Cairo Mendes, Prof. Dr. Viviane Parisotto e Prof. José Nelson Vieira.

 

Translated by

Lucas Augusto Carvalho Raso, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: lucasraso[at]hotmail.com

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