Presentation
Acute chest pain radiating to the left arm and neck, dilated aortic root on echocardiography.
Patient Data
Findings
Aorta
dissecting intimal flap extending from the aortic root to the aortic arch with a typical double-lumen appearance
large false lumen on the right compressing the smaller true lumen on the left
intimal entry tear in the aortic root in the transition area of the left sinus of Valsalva and the noncoronary sinus
two re-entry tears in the aortic arch: the first, between the origins of the brachiocephalic trunk and the left common carotid, and the second, distal to the origin of the left subclavian artery
the coronary arteries, the left common carotid and the left subclavian artery originate from the true lumen; the brachiocephalic trunk originates from the false lumen
intramural hematoma along the posterior aspect of the ascending aorta
Pulmonary arteries, mediastinum, and lungs
high-density fluid along and around the pulmonary trunk and both pulmonary arteries with a relatively narrow lumen of the right pulmonary arteries
probably extravasation of blood into the pulmonary recesses and transverse pericardial sinus
fat stranding and non-enlarged lymph nodes in the mediastinum
mild alveolar ground glass opacities around the superior segmental artery of the right lower lobe indicating alveolar hemorrhage
Heart and coronary arteries
left coronary dominance
hypoplastic right coronary artery
both the left main coronary artery and right coronary artery originate from the true lumen
no evidence of coronary artery dissection
no coronary occlusion or stenosis
cardiac chambers not dilated
no relevant pericardial effusion
Impression
aortic dissection from the aortic root to the aortic arch, Stanford type A
intimal tear in the posterior aortic root, two re-entry tears in the aortic arch
posterolateral aortic intramural hematoma
associated pulmonary artery intramural hematoma
Key images
large false lumen (yellow overlay) left to the dissecting intimal flap
intimal entry tear in the posterior aortic root (red arrow) and re-entry tears in the aortic arch (blue arrows)
aortic intramural hematoma visible at the posterior border of the ascending aorta (red overlay)
pulmonary artery intramural hematoma predominantly around the pulmonary trunk and the right pulmonary artery (blue overlay)
Case Discussion
Acute aortic dissection of the ascending aorta, Stanford type A, is a form of an acute aortic syndrome that requires immediate surgical management.
Pulmonary artery intramural hematoma is a rare complication of aortic dissection with unknown clinical significance 1. It has been described in cases where the posterior wall of the aortic root is affected as a result of the extravasation of blood into the common aortopulmonary adventitia 1-3. It can appear as crescentic or circumferential hyperdense thickening of the pulmonary artery wall and can aid in the diagnosis of aortic dissection in cases where the intimal flap is not readily visible or in cases where pulsation artifacts are present 1. In this case, the hyperdensities spreading along the course of pulmonary arteries with an obtuse angle toward the pulmonary artery wall indicate the diagnosis. Differential diagnoses include frank mediastinal hemorrhage and extravasation of blood into the pericardial recesses 1.
An additional incidental finding is a hypoplastic right coronary artery in the setting of left coronary arterial dominance.
The patient was immediately transferred to a cardiothoracic surgery unit and received an aortic prosthesis of the aortic arch and an aortic valve and root replacement.