Suspicion Of Acute Aortic Dissection Research Articles

Case Report of a Contained Ascending Aortic Rupture

Aortic aneurysm rupture is typically the failure of the aortic wall to withstand the tension placed upon it by a patient’s blood pressure. Along with clinical judgement and an assessment of signs and symptoms, a computed topography angiogram (CTA) is amongst the first line of diagnostic studies having 87-94% sensitivity for rupture. Therefore, while the possibility of a CTA not catching an aortic rupture is present, the chance is very low. Usually a missed or delayed diagnosis for this type of pathology is catastrophic resulting in patient death. We present the case report of a 68-year-old male with a contained aortic rupture that was initially missed on CTA. He presented to the ED with shock like symptoms after a syncopal episode at home. Initial computed topography (CT) scan revealed a pericardial effusion with concern for hemopericardium and mass effect on the right ventricle. A follow up CTA was obtained; however, it was negative for any acute process. Given patient’s continued instability, a TTE was performed which showed concern for a dissection flap. Subsequently, a TEE was performed showing an aortic dissection at the anterior aortic root as well as severe aortic insufficiency with a perforated right coronary cusp. The patient underwent emergent cardiac surgery and recovered well despite the delay in diagnosis. This case demonstrates the importance of a high index of suspicion for acute aortic dissection despite an initial negative CTA.

An Interesting Case of Right Sided Haemorrhagic Pleural Effusion

Hemorrhagic pleural effusions is common in our clinical practice and its usually due to trauma, malignancy and pulmonary embolism. Other rare causes are Bleeding diathesis, Spontaneous hemopneumothorax, Aortic dissection or rupture, Aneurysm rupture or dissection of internal mammary artery, Post-cardiac injury syndrome, Infections like dengue hemorrhagic fever, pulmonary tuberculosis, etc. Aortic dissection is uncommon, a high index of suspicion for acute aortic dissection must be kept in mind when evaluating patients with unexplained chest or back pain. Here by presenting a case of elderly male patient with acute onset right sided chest pain with right haemorrhagic effusion and whose CT thorax revealed aortic dissection. Pleural effusion in aortic dissection is mainly due to inflammation and is a rare presentation. Keywords: Hemorrhagic pleural effusion, Pancreatitis, Cause.

Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta-analysis.

Acute aortic dissection is a life-threatening condition due to a tear in the aortic wall. It is difficult to diagnose and if missed carries a significant mortality. We conducted a librarian-assisted systematic review of PubMed, MEDLINE, Embase, and the Cochrane database from 1968 to July 2016. Titles and abstracts were reviewed and data were extracted by two independent reviewers (agreement measured by kappa). Studies were combined if low clinical and statistical heterogeneity (I2 <30%). Study quality was assessed using the QUADAS-2 tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 were performed. We identified 792 records: 60 were selected for full text review, nine studies with 2,400 participants were included (QUADAS-2 low risk of bias, κ= 0.89 [for full-text review]). Prevalence of aortic dissection ranged from 21.9% to 76.1% (mean±SD= 39.1%±17.1%). The clinical findings increasing probability of aortic dissection were 1) neurologic deficit (n=3, specificity= 95%, positive likelihood ratio [LR+]= 4.4, 95% confidence interval [CI]= 3.3-5.7, I2 = 0%) and 2) hypotension (n=4, specificity= 95%, LR+= 2.9 95% CI= 1.8-4.6, I2 = 42%), and decreasing probability were the absence of a widened mediastinum (n=4, sensitivity= 76%-95%, negative likelihood ratio [LR-]= 0.14-0.60, I2 = 93%) and an American Heart Association aortic dissection detection (AHA ADD) risk score<1 (n=1, sensitivity= 91%, LR-= 0.22, 95% CI= 0.15-0.33). Suspicion for acute aortic dissection should be raised with hypotension, pulse, or neurologic deficit. Conversely, a low AHA ADD score decreases suspicion. Clinical gestalt informed by high- and low-risk features together with an absence of an alternative diagnosis should drive investigation for acute aortic dissection.

LO075: Clinical exam for acute aortic dissection: a systematic review and meta-analysis

Introduction: Acute aortic dissection (AAD) is difficult to diagnose and if missed carries a significant mortality rate. Our aim was to assess the accuracy of history, physical exam and plain radiographs compared to advanced imaging in the diagnosis of AAD in adults presenting to the ED with a clinical suspicion of AAD. Methods: We conducted a librarian assisted systematic review. Databases searched: Pubmed, Medline, Embase and the Cochrane database from 1968 to January 2016. No restrictions for language were imposed. Studies were reviewed and data extracted by two independent reviewers. AAD was defined by CTA, MRI or TEE Prospective and retrospective studies of patients presenting with a clinical suspicion of AAD were included. Case series were excluded. Studies were combined if low clinical and statistical heterogeonity (I2&lt;30%). Study quality was assessed using the QUADAS tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 was performed. Results: We identified 792 records: 61 selected for full text review, 13 included and a further 7 from reference searches. 20 studies with 4721 participants were included (mean QUADAS score 12/14 SD 1.2, Kappa 0.8). Prevalence of AAD ranged from 9.6-76.1% (mean 39.1% SD 17.1%). Mean diagnosis in those without AAD varied between studies with ACS (30.3% SD 30.1%), Anuerysm(12.4% SD 9.8%), Chest wall pain(18.1% SD 13.3%) and PE(7.9% SD 7.85%) being the most common. The clinical findings most suggestive of AAD were, neurological deficit (specificity 94% LR 4.1 [95% CI, 3.1-5.2], I2 0%, n=9), hypotension(specificity 94% LR 2.6 [95% CI 1.6-4.2], I2 0%, n=8), pulse deficit (specificity 92% LR 3.4 [95% CI 1.8-6.4], I2 0%, n=9) and syncope (specificity 92% LR 1.4 [95% CI 1.1-1.8], I2 10%, n=6). The most useful for identifying patients less likely to have AAD were an absence of a widened mediastinum (sensitivity 80% LR 0.3 [95% CI 0.2-0.5], I2 20%, n=13) and an AHA Aortic dissection risk score &lt;1 (n=2 sensitivity 91%,99% LR 0.02,0.22, [95% CI 0.003-0.128, 95%CI 0.2-0.3]). Conclusion: Suspicion for AAD should be raised with syncope, hypotension and pulse or neurological deficit in the appropriate clinical setting. Conversely the absence of a widened mediastinum and a low ADD score decreases likelihood. Clinical exam alone cannot rule out acute aortic dissection but it can help risk stratify for further testing.

Classic Dissection of Thoracic Aorta Complicated by Ascending Aortic Intramural Hematoma: Promt Diagnosis and Successful Endovascular Repair

We reported a case of 68-year-old man, with a previous history of hypertension. Patient was admitted to our institution for evaluation of a severe, constant, tearing anterior chest pain radiated to the neck with suspicion of acute aortic dissection. A multidetector computed tomography scan of thorax and abdomen demonstrated a dissection starting from the middle part of aortic arch and extending downward to the descending aorta till the middle part of the thoracic aorta. The dissection was classified as Stanford A, De Bakey I. Surgical treatment of patient was started with bypass graft from the right common carotid artery to the left common carotid with subsequent revascularization of left subclavian artery. Lower parts of above-mentioned arteries were ligated. At the second stage an emergent prosthetic stent-graft was placed distally from the truncus brachiocephalicus up to the proximal part of the descending aorta. We reported a case report to present diagnostic and possible interventional treatment for patient with acute aortic type A dissection.

Can D-dimer testing help emergency department physicians to detect acute aortic dissections?

To determine the diagnostic accuracy of D-dimer testing for detection of acute aortic dissection. This study is a retrospective chart review of patients who had been evaluated with suspicion of acute aortic dissection. All patients' D-dimer levels were determined prior to their further work up in the emergency department. The study was conducted in a tertiary care center between February 2006-August 2008. The D-dimer assay used was the immunoturbidimetric assay, with a normal range up to 0.246 µg/ml. Statistical analysis was accomplished using Chi-square test, Student's t-test and a receiver-operating characteristics (ROC) curve analysis. Ninety-nine patients were included in the study, 30 patients were diagnosed as having acute aortic dissection and 69 patients were evaluated in non-acute aortic dissection group. In comparison of the two groups, positive D-dimer results were found to be significantly higher in acute aortic dissection group than in non-acute aortic dissection group (p=0.001). Sensitivity of the D-dimer test in detection of acute aortic dissection was found as 96.6% and the negative predictive value of the test was 97.3%. Specificity and positive predictive value of the D-dimer test were 52.2% and 46.8%, respectively. The area under the ROC curve yielded an acceptable certainty for excluding acute aortic dissection on base of negative results (AUC: 0.764; CI 95%: 0.674-0.855; p=0.001). D-dimer testing is helpful for emergency physicians in detection of patients with suspected acute aortic dissection in the emergency department.

Hématome intramural de l’aorte thoracique : traitement médical ou chirurgie ?

Intramural hematoma (IMH) of the aorta is an uncommon entity. This disease shares many characteristics with acute aortic dissection. Treatment of IMH remains controversial. We report the case of a 58 years old man with hypertension disease who was admitted in emergency department with suspicion of acute aortic dissection. Transoesophageal echocardiography showed IMH involving the descending aorta which spred afterwards to the ascending aorta. Patient was treated medically and echocardiographic follow-up showed that aortic hematoma remains stable. Two years later, patient is alive and the last TEE reveals disappearance of hematoma in ascending aorta and decrease of it in descending aorta.

Is d-Dimer Testing Useful for Ruling Out Acute Aortic Dissection?

Acute aortic dissection (AAD) is a devastating vascular emergency that must be diagnosed early and differentiated from other causes of chest or back pain. The routine evaluation for excluding AAD often is both time- and resource-consuming. A reliable biomarker would be very useful, especially in cases with low-to-intermediate suspicion for AAD. Researchers performed a systematic literature review and meta-analysis to …

A Thymic Carcinoid Mimicking Acute Aortic Dissection

Thymic carcinoids are extremely rare. We present an 80 year old hypertensive patient who presented as an emergency with sudden onset of severe chest and upper back pain raising the suspicion of acute aortic dissection or acute coronary syndrome. Further investigations revealed a carcinoid tumour of thymic origin.

A thymic carcinoid mimicking acute aortic dissection

Thymic carcinoids are extremely rare. We present an 80 year old hypertensive patient who presented as an emergency with sudden onset of severe chest and upper back pain raising the suspicion of acute aortic dissection or acute coronary syndrome. Further investigations revealed a carcinoid tumour of thymic origin.

Clinical diagnosis of acute aortic dissection

Despite the availability of modern imaging technology, 35% of aortic dissections remain undiagnosed in vivo because clinical criteria for aortic dissection are not available to date. The present study analyzed 250 patients with acute chest and/or back pain, absence of an established differential diagnosis of the pain syndrome and clinical suspicion of acute aortic dissection for presence of 26 clinical variables. Multivariate analysis identified an aortic pain syndrome with immediate onset and/or tearing or ripping character (P < 0.0001), mediastinal and/or aortic widening on chest radiography (P < 0.0002) and pulse- and/or blood pressure differentials (P < 0.0001) as predictors of acute aortic dissection. Probability of dissection was low (7%) with absence of all three variables, intermediate (31 and 39%, respectively) with isolated findings of "aortic pain" or "mediastinal widening", and high (> 83%) with either isolated "pulse- and/or blood pressure differentials" or any combination of the three variables. This model appears useful to improve selection of patients for emergency imaging of the thoracic aorta.

Clinical prediction of acute aortic dissection.

Clinical criteria for aortic dissection are poorly defined. Thus, 35% of aortic dissections remain unsuspected in vivo, and 99% of suspected cases can be refuted. To identify independent predictors of acute aortic dissection and create a prediction model for facilitated estimation of the individual risk of dissection. Two hundred fifty patients with acute chest pain, back pain, or both; absence of an established differential diagnosis of the pain syndrome; and clinical suspicion of acute aortic dissection were evaluated for the presence of 26 clinical variables in a prospective, observational study. Multivariate analysis was performed to create a prediction model of aortic dissection. Aortic pain with immediate onset, a tearing or ripping character, or both; mediastinal widening, aortic widening, or both on chest radiography; and pulse differentials, blood pressure differentials, or both (P<.001 for all) were identified as independent predictors of acute aortic dissection. Probability of dissection was low with absence of all 3 variables (7%), intermediate with isolated findings of aortic pain or mediastinal widening (31% and 39%, respectively), and high with isolated pulse or blood pressure differentials or any combination of the 3 variables (> or = 83%). Accordingly, 4% of all dissections were assigned to the low-probability group, 19% to the intermediate-probability group, and 77% to the high-probability group of aortic dissection. Assessment of 3 clinical variables permitted identification of 96% of the acute aortic dissections and stratification into high-, intermediate-, and low-probability groupings of disease. With better selection for prompt diagnostic imaging, this prediction model can be used as an aid to improve patient care in aortic dissection. Arch Intern Med. 2000;160:2977-2982