Penetrating aortic atherosclerotic ulcer

Case contributed by Talal F M Abdullah
Diagnosis almost certain


Chest discomfort, uncontrolled hypertension, hypercholesterolemia and widened mediastinum on CXR. Echo by ER doctor showed a pericardial effusion.

Patient Data

Age: 65 years
Gender: Male

Aortic arch contour deformity with a triangular contrast dense opacity suggestive of an ulcerated plaque and impending dissection. Dense pericardial effusion, consistent with hemopericardium. No intimal flap.

3D volume-rendered image nicely demonstrates the "acquired diverticulum like" protrusion

Case Discussion

CT aortogram (abdominal aorta not shown) shows a contour deformity at the ascending aorta/arch junction that opacifies with contrast mostly likely representing a non-calcified ulcerated atherosclerotic plaque. Dense pericardial effusion extending beyond the anatomic boundaries (into around the arch) in keeping with acute leaking.  No dissection intimal flap seen in this study.

Later a  second assessment with echocardiography by the cardiologist revealed a dissection flap - Stanford A (half-hour after the CT) and clotted blood in the pericardium.

This is within the spectrum of an acute aortic syndrome.

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