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Aortic Dissection

7/28/2014

This Image of the Week comes from Drs McNally, Lefkove, Dudley and Iledare who diagnosed an acute aortic dissection in a young female patient presenting with severe chest and back pain with bedside US and confirmed it with CT angiography (which showed an extensive Type A dissection). Patient was transferred for emergent cardiothoracic surgery.

Acute aortic dissection is a life threatening, time-dependent emergency whose diagnose can be screened for and expedited by point-of-care (POC) ultrasound, as evidenced by numerous case reports in the literature. There are 3 locations where aortic dissection can be screened for on ultrasound – cardiac echo, suprasternal notch view, and abdominal aorta.

In this case, they used a curvilinear probe with the probe marker pointing to the patient’s head and placed it in midline epigastric region of abdomen to get a sagittal view of the aorta. In this view, the aorta will appear as a tubular structure above the spine shadow produced by vertebral bodies– note that no dilatation (aneurysm) can be appreciated here. A linear mobile structure is noted within the lumen of the aorta – this is the dissection flap.

Image 1

aortic dissection

Video 1

The dissection flap can also be seen in the transverse (cross-sectional) view of the aorta, obtained by rotating the transducer to the patient’s right.  In this view, the aorta and IVC lay adjacent to each other above the spine.

Video 2

POC Ultrasound does have some limitations. You cannot rule out a dissection if you don’t see a flap (i.e. it is not a good rule-out test) so if clinical suspicion is high, you should get further imaging – CT, MRI, TEE. Also ultrasound cannot help with determining if dissection is acute or chronic, or if there is a “leaking” aorta – as the retro-peritoneum is not well imaged on ultrasound.


Happy scanning!

Additional references:

1. Kaban, J. and Raio, C. (2009), Emergency Department Diagnosis of Aortic Dissection by Bedside Transabdominal Ultrasound. Academic Emergency Medicine, 16: 809–810. doi: 10.1111/j.1553-2712.2009.00448.x
2. Budhram, G. and Reardon, R. (2008), Diagnosis of Ascending Aortic Dissection Using Emergency Department Bedside Echocardiogram. Academic Emergency Medicine, 15: 584. doi: 10.1111/j.1553-2712.2008.00106.x

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Jehangir Meer, MD RDMS
Director of Emergency Ultrasound
Assistant Professor, Emory University SOM
jehangir.meer@emory.edu