1. Aortic Dissection Kevin Zahraee, MS4 August 2013 Aditi Gulabani, MD

2. CC: abdominal pain HPI: 34 year old F with SLE, hemophilia, and HTN presented to ED in AM. Had been having abdominal pain overnight. Described the pain as stabbing and diffuse radiating to mid-back and worse with sitting. Also having nausea and 3 episodes of emesis. Tried hydrocodone, gas meds, and Tylenol without relief. No urinary complaints. Normal BMs. No fever, cough, sob. Recent hx of peritoneal dialysis. VS: BP: 240/122 P: 101 T: 98.5 RR: 20 O2 sat: 100% PE: Abdomen: diffuse tenderness and bilateral CVA tenderness w/o spinal tenderness Cardiac: S1 and S2 present, no murmurs Extremities: bilateral pitting edema Pulses: 2+ equal in all four extremities Patient Presentation

3. Differential includes gastroenteritis, appendicitis, gynecologic pathology, aortic dissection (high BP) Imaging Options – KUB – CT abdomen and pelvis – Chest x-ray (high BP, pain radiating to back) – CT chest (high BP, pain radiating to back) – CT chest angiogram (BP, pain radiating to back) – Ultrasound abdomen and pelvis Differential Dx and Imaging Options

4. Appropriateness Criteria

5. CT Abdomen & Pelvis w Contrast (axial) MRN: 6006275

6. Comparison from 6/22/13 CT Appears fairly normal, BUT… this was done without contrast

7. Dedicated CT Angiogram Chest (sagittal)

8. Chest X-ray of Patient (portable upright AP)

9. Diagnostic Criteria on CT – Demonstration of intimal flap separating true from false lumen – Internal displacement of intimal calcifications – Delayed enhancement of false lumen – Aortic widening Limitations of CT – Aortic motion artifacts – Mural thrombi in a fusiform aneurysm – Structures or masses around aorta can distort interpretation Accuracy (dependent of many factors used to generate image and location of dissection) – Sensitivity >90% – Specificity >85% Radiologic Diagnosis

10. Tear in aortic intima leads to… – Blood passes into aortic media – Separates intima from media and/or adventitia – Creates false lumen Risk factors – Hypertension – Previous aortic aneurysm – Inflammatory diseases that cause vasculitis – Collagen disorders (Marfan’s, Ehler’s Danlos, etc.) Classifications (2 types) – DeBakey (Type I, II, or III) – Stanford (Type A and type B) Aortic Dissection Pathology

11. DeBakey – Type I: originates in ascending aorta and goes to at least aortic arch – Type II: originating and limited to ascending aorta – Type III: originating in descending and moving either proximally or distally Stanford (more commonly used) – Type A: any ascending aorta involvement – Type B: all others without ascending aorta involvement – Further subtyped into a and b Classifications of Aortic Dissection

13. Placement of Thoracic Endograft (US fluoroscopy)

14. Placement of Thoracic Endograft

17. On POD #1, the patient became aphasic and had CT and MRI brain. CT brain and CTA head and neck were unremarkable. MRI brain showed some restricted diffusion in left superior frontal gyrus, anterior frontal lobe, and right inferior cerebellum. Had EEG, which showed diffuse non-specific encephalopathy. Neuro concluded it was a reaction to prochlorperazine. Medication was stopped and patient returned to baseline neuro status. Patient also had swelling in LUE. US LUE revealed an enlarging brachial artery pseudoaneurysm. IR performed a thrombin injection. Clinical Outcome Post-Endograft

18. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, Radegran K, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA; Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001 Sep;22(18):1642-81. http://www.uptodate.com.ezproxy.rush.edu/contents/clinical-manifestations-and- diagnosis-of-aortic- dissection?detectedLanguage=en&source=search_result&search=aortic+dissection &selectedTitle=1%7E150&provider=noProvider#H7 http://www.acr.org/Quality-Safety/Appropriateness-Criteria/Diagnostic Resources