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EMGuideWire's Radiology Reading Room: Aortic Dissection

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EMGuideWire's Radiology Reading Room: Aortic Dissection

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Aortic Dissection and is brought to you by Matthew Cravens, MD, Tyler Siekmann, MD, and Shelby Hixson, PA. It is has special guest editor: Bryant Allen, MD

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Aortic Dissection and is brought to you by Matthew Cravens, MD, Tyler Siekmann, MD, and Shelby Hixson, PA. It is has special guest editor: Bryant Allen, MD

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EMGuideWire's Radiology Reading Room: Aortic Dissection

  1. 1. Aortic Dissection Case Studies Matthew Cravens, MD Shelby Hixson, PA Tyler Siekmann, MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Faculty Editors: Bryant Allen, MD & Michael Gibbs, MD The Chest X-Ray Mastery Project™
  2. 2. Disclosures This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center. The goal is to promote widespread mastery of CXR interpretation. There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process Many are providing clinical cases, and presentations are shared with all contributors on our departmental educational website. Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: ACUTE AORTIC DISSECTION.
  4. 4. Visit our website www.EMGuidewire.com For a complete archive of chest x-ray presentations and much more!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. CXR evaluation for aortic dissection centers on the mediastinum – focus on the mediastinal width at the level of the aortic knob, and on the aortic contour. Normal PA CXR
  8. 8. Aortic Dissection“A man was seized with pain of the right arm and soon after the left. He was ordered to think seriously and piously of his departure from this mortal life, which was very near at hand and inevitable.” J.B. Morgagni, 1761. “There is no diagnosis more conducive to clinical humility than dissection of the aorta.” Sir William Osler, 1900.
  9. 9. Image credit 1: http://www.iradonline.org/about.html Image credit 2: https://torontonotes.ca/cardiology-cvs-new/coloured-atlas-cardiology-cvs-new/gross-pathology/aortic-dissection/ What is aortic dissection? Intima of the aorta tears & blood flows into media Blood tracks proximally/distally, creating a false lumen A false lumen in the thoracic aorta can widen the mediastinum The intimal flap can occlude branches off the true lumen -> end organ ischemia
  10. 10. Chest x-ray is often the first imaging study performed in patients with clinical suspicion for non-traumatic aortic dissection. While certainly not the gold standard imaging modality, several chest x-ray findings can be helpful in raising suspicion for aortic dissection. Our best data on aortic dissection imaging findings comes from a prospective case series of 400+ patients enrolled in the late 1990’s. This case series became the foundation for the International Registry of Acute Aortic Dissections, a multinational research consortium also known as IRAD. IRAD data was first published in 2000 and updated in 2018.
  11. 11. IRAD 2000: Chest X-ray Findings 427 patients presenting with confirmed acute aortic dissection CXR Findings: Widened mediastinum 66.1% Abnormal aortic contour 49.6% Pleural effusion 19.2% Wall Ca++ displacement 14.1% Normal CXR 12.4% Hagan PG. JAMA 2000.
  12. 12. Widened mediastinum was the most frequent IRAD finding for acute aortic dissection Classically defined as >6-8 cm at level of aortic knob on PA film BUT many critically ill ED patients get portable CXRs, which are AP. AP films artifactually widen the mediastinum! Widened mediastinum 66.1% Abnormal aortic contour 49.6% Pleural effusion 19.2% Wall Ca++ displacement 14.1% Normal CXR 12.4% Hagan PG. JAMA 2000. So what width should we use? PA film (formal CXR): 6-8cm? AP film (portable CXR): ??
  13. 13. AP film of a healthy patient: mediastinum appears wide… Same patient’s PA/formal film. Image credit: Case courtesy of Dr Yi-Jin Kuok, Radiopaedia.org, rID: 17910
  14. 14. PA (formal) : 7.5 cm Sens 90%, Spec 88% AP (portable): 8.7 cm Sens 72%, Spec 80% Emerg Radiol 2012 • 2012 case series of 100 CXRs of patients with acute aortic dissection and 120 controls • PA films were more sensitive and specific, and had lower cutoff for mediastinal width
  15. 15. Tips for evaluating the mediastinum on CXR PA films should be preferred but are not always feasible. Measure mediastinal width horizontally at the aortic knob. The classic cutoff of 6-8 cm may require adjustments, especially for AP/portable films. Consider a cutoff of 7-8cm for PA and 8-9cm for AP films. Always compare to prior, even if under cutoff!
  16. 16. CASES Let’s move on to examples of real patients presenting to the emergency department with non-traumatic acute aortic dissection. Note whether the film is labeled AP (“Port”) or PA Measurements are not included here
  17. 17. 71-year-old from Ghana with chest pain.
  18. 18. Wide Mediastinum 71-year-old from Ghana with chest pain. Note that the normal smooth aortic knob contour is lost.
  19. 19. This same patient’s CT showing thoracic aortic aneurysm with Type A dissection 71-year-old from Ghana with chest pain.
  20. 20. 41-year-old with Marfan syndrome.
  21. 21. Thoracic aortic aneurysm and chronic Type B dissection Wide Mediastinum 41-year-old with Marfan syndrome.
  22. 22. CT Scan demonstrating thoracic aortic aneurysm and chronic Type B dissection 41-year-old with Marfan syndrome.
  23. 23. 69-year-old with acute neck and chest pain.
  24. 24. Wide Mediastinum 69-year-old with acute neck and chest pain.
  25. 25. Dilated Aortic Root This patient’s ED bedside ultrasound Aortic Free Wall 69-year-old with acute neck and chest pain.
  26. 26. This patient’s CT demonstrating Type A aortic dissection 69-year-old with acute neck and chest pain.
  27. 27. Now for some more subtle examples…
  28. 28. During his ED stay, the pain migrates to his abdomen… 51-year-old with burning chest pain for one hour after a verbal argument.
  29. 29. 51-year-old with burning chest pain for one hour after a verbal argument.
  30. 30. Type A aortic dissection 51-year-old with burning chest pain for 1 hour after getting into an argument.
  31. 31. 73-year-old with HTN develops acute chest pain radiating to the back.
  32. 32. Wide Mediastinum 73-year-old with HTN develops acute chest pain radiating to the back.
  33. 33. This patient’s CT demonstrating Type A Dissection 73-year-old with HTN develops acute chest pain radiating to the back.
  34. 34. This patient’s ED bedside ultrasound Dissection Flap Thoracic Aorta 73-year-old with HTN develops acute chest pain radiating to the back.
  35. 35. 65-year-old man with history of HTN presents to the ED with chest pain.
  36. 36. Type A aortic dissection 65-year-old man with history of HTN presents to the ED with chest pain.
  37. 37. Type A aortic dissection 65-year-old man with history of HTN presents to the ED with chest pain.
  38. 38. Let’s introduce another CXR sign of dissection: the Eggshell Sign Many older patients have calcifications in the vessel intima Blood in the media pushes the calcified intima inward Eggshell sign: 5mm between wall Ca2+ & lateral border of aorta Widened mediastinum 66.1% Abnormal aortic contour 49.6% Pleural effusion 19.2% Wall Ca ++ displacement 14.1% Normal CXR 12.4% Hagan PG. JAMA 2000.
  39. 39. Can you see the abnormality?
  40. 40. Eggshell Sign Eggshell Sign: Dissection pushes the calcified aortic wall inward
  41. 41. Can you see the abnormality?
  42. 42. Eggshell Sign Egg Shell Sign: The Dissection Pushes The Calcified Aortic Wall Inward.Eggshell Sign: Dissection pushes the calcified aortic wall inward
  43. 43. CASES Just a few more cases! Look at the mediastinum, aortic contour, and check for eggshell sign.
  44. 44. 36-year-old with acute chest and back pain with leg numbness. Scout film of CT. CXR abnormalities?
  45. 45. Wide mediastinum on CT scout film 36-year-old with acute chest and back pain with leg numbness.
  46. 46. Type A dissection, from aortic root to bilateral iliac arteries 36-year-old with acute chest and back pain with leg numbness.
  47. 47. Today 1 Year Ago 36-year-old with poorly controlled HTN presents with 2 days of chest pain. Note: both are PA films.
  48. 48. Today Subtly widened mediastinum on formal measurement Type A aortic dissection 36-year-old with poorly controlled HTN presents with 2 days of chest pain. Note: both are PA films. 1 Year Ago
  49. 49. False Lumen True Lumen Type A aortic dissection 36-year-old with poorly controlled HTN presents with 2 days of chest pain.
  50. 50. 55-year-old woman with HTN and chest and abdominal pain.
  51. 51. Type A aortic dissection 55-year-old woman with HTN and chest and abdominal pain.
  52. 52. 55-year-old woman with HTN and chest and abdominal pain. Type A aortic dissection
  53. 53. 69-year-old male with 5 days of vague chest and abdominal pain.
  54. 54. Eggshell Sign Type B aortic dissection 69-year-old male with 5 days of vague chest and abdominal pain. Wide Mediastinum
  55. 55. Type B aortic dissection 69-year-old male with 5 days of vague chest and abdominal pain.
  56. 56. Today One Year Ago 44-year-old woman with HTN presents with chest/back/abd pain.
  57. 57. Today One Year Ago Type A Dissection Wide Mediastinum 44-year-old woman with HTN presents with chest/back/abd pain.
  58. 58. Type A dissection 44-year-old woman with HTN presents with chest/back/abd pain.
  59. 59. * * * * * Type A dissection: hemopericardium 44-year-old woman with HTN presents with chest/back/abd pain.
  60. 60. Aortic Dissection That completes our cases! Now a brief review of the literature. • Classification: Stanford Type A and B • Risk Factors • Clinical presentation • Organ ischemic complications • Aortic valve/Pericardial complications • Risk stratification tools
  61. 61. Stanford Type A involves aortic arch
  62. 62. Stanford Type B originates distal to left subclavian artery
  63. 63. Risk Factors • Hypertension is #1 • Cocaine • Trauma • Pregnancy Iatrogenic • Heart surgery • Aortic valve repair • Arterial catheterization Congenital • Aortic coarctation • Bicuspid valve • Marfan syndrome • Ehlers-Danlos syndrome • Turner syndrome
  64. 64. IRAD update, 2018: Demographics, Risk Factors Type A 67% Type B 33% Risk Factors Hypertension 77% Atherosclerosis 27% Known aneurysm 16% Cardiac surgery 16% Marfan syndrome 5% Iatrogenic 4% Cocaine use1 2% 1Cocaine use 12% in black patients 66% of patients were male The mean age was 63 years
  65. 65. IRAD 2000: Clinical Manifestations Pain reported in 95.5%: Chest pain 72.7% Anterior chest pain 60.9% Back pain 53.2% Abdominal pain 29.6% Hagan PG. JAMA 2000.
  66. 66. IRAD 2000: Clinical Manifestations Quality of pain: Abrupt onset 84.4% ‘Worst pain ever’ 90.6% Sharp 64.4% Tearing or ripping 50.6% Radiating 28.3% Migratory 16.6% Hagan PG. JAMA 2000.
  67. 67. IRAD 2000: Syncope Syncope in 9.4% More common with Type A dissection Higher risk of tamponade & stroke Mortality History of Syncope 34% Overall 28% Hagan PG. JAMA 2000.
  68. 68. IRAD update, 2018: Clinical Manifestations Pain1 reported in 93.7%: A B Chest pain 79% 63% Back pain 43% 64% HPTN on presentation 36% 70% Pulse deficit 30% 20% Syncope2 19% 1,2Painless AAD and patients presenting with syncope had a higher risk of heart failure, tamponade and death. A = Type A Dissection B = Type B Dissection
  69. 69. Chien N. Annals of EM 2018. Chien 2018: Clinical Manifestations Neuro deficit, pulse deficit, and hypotension were the most helpful positive physical exam findings.
  70. 70. Branch Vessel Compromise Organ Ischemia/Infarction
  71. 71. Artery Complication Coronary Myocardial Infarction Carotid Stroke Radiculomedullary Spinal cord ischemia Renal Renal failure Subclavian/femoral Limb ischemia Mesenteric Bowel ischemia
  72. 72. Chest Pain Back Pain Stroke symptoms Paraplegia Acute abdomen Renal failure Aortic Dissection? Paretic extremity
  73. 73. Aortic Valve Dysfunction, Hemopericardium Aortic insufficiency Acute pulmonary edema Pericardial tamponade
  74. 74. Chest Pain Back Pain Acute CHF New AI murmur Syncope Aortic Dissection?
  75. 75. Loss of aortic contour + STEMI = Aortic Dissection?
  76. 76. Here’s the problem… We are NOT very good at making the diagnosis. When we miss the diagnosis, patients die We shouldn’t CTA every patient with chest/back/abdominal pain. Initial diagnosis correct 15-50% Diagnosis >24 hours in 40% Klompas M. JAMA 2002.
  77. 77. IRAD 2018 abstract: Acute Aortic Dissections are challenging to diagnose and treat (even 20 years later)
  78. 78. To Summarize: • Aortic dissection is a challenging diagnosis and is associated with high morbidity and mortality • Hypertension is by far the leading risk factor • Most reliable historical features include sudden onset, severe pain to the chest or back (although presentation symptoms vary widely) • Most reliable PE findings include neurologic deficits, pulse deficits and abnormal blood pressure at presentation. Other potential findings include end-organ ischemia, aortic insufficiency, and tamponade. Chest x-ray, while not perfect, can help us in evaluating for this diagnosis.
  79. 79. Comprehensive English language MEDLINE literature review from 1966 to 2000. Thirteen studies permitted the analysis of 1337 chest X-rays.  90% of patient with aortic dissection had at least one CXR abnormal finding  The absence of a wide mediastinum had a [-] LR of 0.3 (95% CI: 0.2 – 0.4)
  80. 80. The absence of a wide mediastinum on CXR had a negative likelihood ratio ranging from 0.14 to 0.60, making this a finding that decreases the risk of aortic dissection Evidence-based review of nine studies between 1986 and 2013, [n=2,400] 2018 Chien N. Annals of EM 2018.
  81. 81. How can we continue to improve our diagnostic accuracy for acute aortic dissection? In addition to mastering the interpretation of imaging studies, new tools are currently being created such as: • Clinical Decision Calculators • Laboratory test adjuncts (i.e. D-dimer)
  82. 82. ADD-RS (Aortic dissection detection-risk score) Rogers AM. Circulation 2011. Score of 0 or 1 = low risk. 2 or 3 = high risk. Only 1 point per category (e.g. new AI murmur + pulse deficit = 1 point only) Image from https://www.mdcalc.com/aortic-dissection-detection-risk-score-add-rs
  83. 83. Nazerian 2018, ADvISED Study • Prospective multicenter trial, n=1850 • Investigated targeted use of D-dimer as a rule-out test in patients deemed low risk by ADD-RS • Negative D-dimer (<500) and ADD-RS of 0 or 1 (low-risk) ruled out Acute Aortic Syndrome with a 0.3% failure rate • Has not yet been externally validated – not currently recommended for use • Of the 8 patients with Acute Aortic Syndrome with negative D-dimer, 2 had widened mediastinum, 2 had no CXR (table on next slide) Nazerian P. Circulation 2018.
  84. 84. Nazerian P. Circulation 2018.
  85. 85. Aortic Dissection • A challenging diagnosis currently lacking validated rules for imaging • HTN is the #1 risk factor • Ischemia can involve every organ system • Always look at the mediastinum and aortic silhouette on your CXR!
  86. 86. THE PRESENT A ND FUTURE J A CC REV IEW TOPIC O F THE W EEK Optimal Treatment of Uncomplicated Type B Aortic Dissection JACC Review Topic of the W eek Rami O. Tadros, MD,a Gilbert H.L. Tang, MD, MSC, MBA,b Hanna J. Barnes, BA,a Idine Mousavi, BA,a Jason C. Kovacic, MD, PHD,c Peter Faries, MD,a Jeffrey W. Olin, DO,c Michael L. Marin, MD,a David H. Adams, MDb JACC JOURNAL CME/ MOC/ ECME This article has been selected as the month’s JACC CME/MOC/ECME activity, available online at http://www.acc.org/jacc-journals-cme by selecting the JACC Journals CME/MOC/ECME tab. Accreditation and Designation Statement The American College of Cardiology Foundation (ACCF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ACCF designates this Journal-based CME activity for a maximum of 1AMA PRA Category 1Credit(s)Ô. Physicians should claim only the credit 2. Carefully read the CME/MOC/ECME-designat ed article available on- line and in this issue of the Journal. 3. Answer the post-test questions. A passing score of at least 70% must be achieved to obtain credit. 4. Complete a brief evaluation. 5. Claim your CME/MOC/ECME credit and receive your certificate electronically by following the instructions given at the conclusion of the activity. J OU RN A L OF THE A MERI CA N CO L L EGE OF CA RDI OL OGY V OL . 7 4 , N O. 11, 2 0 19 ª 20 19 B Y THE A MERI CA N CO L L EGE OF CA RD I OL OGY FOUN D A TI O N PUB L I SH ED B Y EL SEV I ER
  87. 87. If You Have Interesting Cases Of Acute Aortic Dissection, We Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To: michael.gibbs@atriumhealth.org Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

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