Ruptured thoracic aortic dissection

Case contributed by Dr Chris O'Donnell

Presentation

Sudden onset of severe chest pain and shortness of breath

Patient Data

Age: 75 years
Gender: Female

Marked enlargement of the mediastinum at the level of the aortic knuckle with tracheal deviation and left pleural effusion.

One month earlier

X-ray

The findings of aortic knuckle widening and left pleural effusion were not present 1 month earlier.

Large left hemothorax and mediastinal hematoma with dilated ascending aorta and false aortic lumen starting at the apex of the arch extending into the left common carotid and base of the left subclavian arteries, and then into the descending thoracic aorta albeit the false lumen is thrombosed distally.  Contrast in the false lumen at the arch is irregular in contour and although there is no contrast leak into the left pleural space, this is likely to be the point of rupture.

Case Discussion

Thoracic aortic dissection is rare but based on my forensic experience, a common cause of sudden unexpected death in adults usually involving the ascending aorta and rupturing into the pericardial cavity (hemopericardium) or involving the coronary arteries leading to myocardial ischemia.  This is an unusual case as the dissection arises at the apex of the arch beyond the pericardial reflection thus leak is into the mediastinum and left pleural space.  The other important issue, in this case, is the availability of a previous chest radiograph.  I was rung by the ED physician to comment on the CXR.  It was easy to make a rapid diagnosis of ruptured aortic dissection as I saw that the CXR was essentially normal the month previously.  We were then able to able to arrange rapid CT angiography for a definitive diagnosis.

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