Clinical Case
Edie Waskel, D.O.
Sarah Bunch, M.D.
HPI
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
Labs
CBC
Magnesium: 1.8
Lipase: 30
SARS-COV-2 PCR: not detected
Lactic Acid: 1.8
CMP
Urinalysis
Imaging
CT Head or Brain w/o Contrast
IMPRESSION:
No hemorrhage. No acute intracranial process by noncontrast CT.
Mild chronic microvascular ischemic disease
Old lacunar infarct right basal ganglia
Mild symmetric cerebral cortical and moderate central volume loss and mild prominence of the temporal horns and moderate cerebellar volume loss, unchanged.
Mild calcification atherosclerotic calcification carotid siphons.
XR Chest
IMPRESSION:
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
IMPRESSION:
No acute intra-abdominal/pelvic abnormality by noncontrast technique. Etiology of the patient's symptoms is unclear from this exam and remains to be determined and must be managed clinically.
Moderate chronic hiatal hernia
Nonobstructive 2.3 cm left renal calculus, lower pole, increased from 2 cm. Couple new tiny nonobstructive right renal calculi. No ureteral or bladder calculi. No hydroureteronephrosis. No perinephric stranding. Urinary bladder unremarkable.
Long chronic infrarenal dissection with associated infrarenal abdominal aortic aneurysm 2.3 x 2.6 cm, slightly increased from prior exam, similar morphology (previously 2.2 x 2.4 cm). No perienteric inflammatory changes/fluid collections. Suggest 5 years surveillance.
Tiny hypodense liver nodule, indeterminate but benign. If patient has risk factors for primary metastatic liver disease, follow-up MRI 6 months time may be pursued.
Additional stable findings, as above.
TIME OF SIGNOUT: Ordered one more image, pending results. Oncoming resident and attending aware...
CTA Impression:
Stanford type B dissection extending from beyond patent left subclavian artery to distal abdominal aortic bifurcation terminating in med left common iliac artery. True and false lumens patent. Patent IMA supplied by false lumen. Remaining great abdominal vessels supplied by true lumen, widely patent. No perienteric inflammatory changes or fluid collections. No pleural effusion.
Fusiform aneurysm descending aorta up to 5.0 x 5.5 cm orthogonal diameter. No periaortic inflammatory changes or fluid collections. No pericardial effusion or pleural effusion.
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%)
Mortality
Acute cardiac tamponade (18.7%)
Acute aortic insufficiency (32%)
Aortic free rupture (18%)
End-organ ischemia (33%)
Fed by true lumen vs false lumen
Dynamic vs static obstruction
Risk Factors
Personal Hx of bicuspid valve
Connective tissue disease
Uncontrolled HTN
Cocaine
Pregnancy
Thoracic Trauma
Aortic coarctation
Iatrogenic
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:
Pulse deficit
Murmur (aortic regurgitation)
BP changes (syncope, hypotension, and/or shock)
Focal neurologic deficits
Work Up
EKG
CXR
Troponin, CBC, CMP, BNP, Type & Screen
D dimer*
Bedside US
CTA
ADD-RS + D dimer:
Needs to be externally validated
Unclear for patients who have multiple indicators in one category
Acute aortic syndrome includes aortic intramural hematoma, penetrating aortic ulcer, ruptured aorta, and aortic dissection
Management
Urgent surgical consultation
Adequate analgesia
HR at 60 bpm, then SBP <120
Beta blockage - Esmolol IV preferred due to short ½ life
Nicardipine IV or Clevidipine IV or Sodium nitroprusside IV
Diltiazem may be used if contraindication to BB
Disposition: OR or ICU
References
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 https://www-uptodate-com.proxy.cc.uic.edu/contents/overview-of-acute-aortic-dissection-and-other-acute-aortic-syndromes?search=aortic+dissection+treatmetn§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. http://emcrit.org/wp-content/uploads/2014/07/bolus-dose-nicardipine.pdf
EMA December 2016: Acute Aortic Dissection And Intramural Hematoma: A Systematic Review. EM:RAP. https://www.emrap.org/episode/ema-2016-12/abstract6. 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. https://www.emrap.org/corependium/chapter/recN9AXGWMstEm8CO/Aortic-Dissection#h.v3yqk4t2n4n. 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