Atypical dissection of the thoracic aorta

Case contributed by Dr Erik Ranschaert


An elderly lady who became a victim of high impact trauma, unexplained hemoglobin loss on third-day of admission.

Patient Data

Gender: Female

Initial CT Scan on Day 1

CT Angiography made on the day of admission. The wall of the aortic arch and descending aorta is somewhat thickened. No clear leakage of contrast is demonstrated, no obvious intima dissection can be noted. A small ulcer can be seen in the arch (arrow). Also, note the fracture in the left shoulder and 2 vertebrae in the thoracic spine (both at the level of the aortic arch).


Follow-up CT Scan Day 3

Another CT scan performed on the third day of admission for unexplained loss of hemoglobin. The ulcer in the arch is now clearly demonstrated (arrow) and perforating the media. The aortic wall is thickened compared with the previous scan, and a mild enhancement of the media is seen throughout the descending aorta. Additional findings are partial atelectasis in the left lower lung base and pleural fluid.

Also, note the left shoulder fracture and vertebral fractures in the upper thoracic spine.

Case Discussion

The intimal defect is located just distal of the left subclavian artery, which is typical for a traumatic rupture. On this level the patient also has vertebral fractures and a shoulder fracture.

The wall of the descending aorta is thickened and shows  mild concentric enhancement, the intima is displaced medially (calcifications). This means that there is a tear or hematoma in the media. Since there is no typical "flap" as seen with most type B dissections, it is considered as an "atypical aortic dissection" with intramural hematoma.


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