Clinical Case 

Edie Waskel, D.O.

Sarah Bunch, M.D.


A 65 year-old female with history of hypertension, diabetes and asthma presents complaining of subjective fevers, nausea, and vomiting for the past two days. Today her symptoms worsened, and she developed a persistent headache and neck pain. She also reports weakness which is worse in her left upper and lower extremities. Over the past several weeks, she has also noted constant, central chest pain which she attributed to reflux. She presently denies abdominal pain, diarrhea, sore throat, nuchal rigidity, numbness or tingling, vision changes, shortness of breath, or rash.

Review of Systems

Physical Exam

Vitals: BP 149/115, Pulse 74, Temp 98 °F (oral), Resp 16, SpO2 98% on Room Air 

General: alert, oriented to person, place and time 

Eyes: no scleral icterus, EOMI, no nystagmus 

Neck: mild paraspinal tenderness, no c-spine tenderness, full ROM of neck without rigidity 

CV: regular rate and rhythm, 2+ radial pulses bilaterally

Lungs: clear to auscultation bilaterally

Abdominal: soft, nontender throughout, no CVA tenderness bilaterally

MSK: no lower extremity edema, full ROM 

Skin: no rash 

Neuro: ⅘ muscle strength to the left upper and lower extremities compared to right, sensation grossly intact, no facial droop, normal finger to nose and normal heel to shin bilaterally



Magnesium: 1.8

Lipase: 30

SARS-COV-2 PCR: not detected

Lactic Acid: 1.8




CT Head or Brain w/o Contrast


XR Chest 


Heart is mildly enlarged. Aortic is ectatic and tortuous but unchanged. There is elevation left hemidiaphragm with blunting left lateral costophrenic angle, consider scarring, pleural thickening or small pleural effusion. Left-sided Port-A-Cath in place its tip at level of the caval atrial junction. Detail is limited and followup PA and lateral views chest are recommended.

CT Abd/Pelvis w/o Contrast


TIME OF SIGNOUT: Ordered one more image, pending results. Oncoming resident and attending aware...

CTA Impression:

Click for diagnosis and more!

Aortic Dissection

The aorta is histologically composed of 3 predominant layers: the tunica intima, media, and adventitia. 

Disruption of tunica intima → false lumen propagated by pulsatile aortic flow

Increased risk: areas of repeated mechanical stress or subject to higher hydrodynamic forces (ascending aorta and first portion of descending thoracic aorta)

Classification: Stanford Type A (67%) and Type B (33%)


Acute cardiac tamponade (18.7%)

Acute aortic insufficiency (32%)

Aortic free rupture (18%)

End-organ ischemia (33%)

Risk Factors

Personal Hx of bicuspid valve

Connective tissue disease

Uncontrolled HTN



Thoracic Trauma

Aortic coarctation


Family Hx of aortic aneurysm, AD, bicuspid valve, sudden cardiac death

Clinical Presentation*

Missed as initial presentation in as many as ⅓ of patients (often mistaken for ACS, PE, CVA, shock, HTN emergency, intra-abdominal emergency, acute limb ischemia)

Classic presentation: sudden severe “tearing” pain, often preceded by acute physical exertion or acute emotional event

Type A: thought to originate and be maximal at anterior chest just under sternum

Descending: back between shoulder blades, may migrate distally to abdomen and legs

Other signs & symptoms:

Work Up

ADD-RS + D dimer:

Acute aortic syndrome includes aortic intramural hematoma, penetrating aortic ulcer, ruptured aorta, and aortic dissection


Disposition: OR or ICU


American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thoracic Aortic Dissection, Diercks DB, Promes SB, et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2015;65(1):32-42.e12. doi:10.1016/j.annemergmed.2014.11.002

Black III, J. H., & Manning, W. J. (2022, June 9). Overview of acute aortic dissection and other acute aortic syndromes. Shibboleth authentication request. Retrieved August 10, 2022, from§ionRank=2&usage_type=default&anchor=H1628662340&source=machineLearning&selectedTitle=3~150&display_rank=3#H1628662340

Circulation. 2018 Jan 16;137(3):250-258. doi: 10.1161/CIRCULATIONAHA.117.029457. Epub 2017 Oct 13. Nazerian, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.

Curran MP et al. Intravenous Nicardipine. Drugs 2006; 66(13): 1755-1782.

EMA December 2016: Acute Aortic Dissection And Intramural Hematoma: A Systematic Review. EM:RAP. Updated September 20, 2017. Accessed July 8, 2022.

Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine [published correction appears in J Am Coll Cardiol. 2013 Sep 10;62(11):1039-40]. J Am Coll Cardiol. 2010;55(14):e27-e129. doi:10.1016/j.jacc.2010.02.015

Jr. James Friere Skiba, Norvell Cara. Aortic Dissection. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. Updated July 8, 2022. Accessed August 10, 2022.

Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026