Diagnosis
Aortic dissection
Tear of the arterial intima causing blood entering the intima-media space and resulting in separation of the layers within the aortic wall:
Stanford type A: ascending aortic dissection
Stanford type B: descending aortic dissections
Etiology
Cause [3kd]
Congenital causes: Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, Annuloaortic ectasia, Familial aortic aneurysm/dissections, Polycystic kidney disease, Turner syndrome, Noonan syndrome, Osteogenesis imperfecta, Bicuspid aortic valve, Coarctation of the aorta, Connective tissue disorders, homocystinuria, familial hypercholesterolemia, familial aneurysm-osteoarthritis syndrome (SMAD 3 mutations)
Degenerative aortic disease including preexisting thoracic aortic aneurysm and abdominal aortic aneurysm
Inflammatory conditions: Takayasu arteritis, giant cell arteritis, syphilitic aortitis
Acquired causes: Hypertention, deceleration injury (chest trauma), cocaine, pregnancy, aortic instrumentation, iatrogenic (surgery).
Pathophysiology
Mechanical trauma: The aortic wall is exposed to high pressure and shear stress
Wall tension = pressure x radius --> risk of:
Dilatation
Rupture
Dissection
Intimal tear -> separation of the intima and media layers -> double-barreled aorta with a true lumen (lined by intima) and a false lumen (lined by media).
False lumen have slower flow and high risk of:
Aneurysm
Organ ischemia
Most aortic dissections in the ascending aorta (90%)
Risk factors
Hypertension
Connective tissue disorders
Congenital aortic stenosis
Bicuspid aortic valve
Genetics
Epidemiology
Incidence per 100.000 [9p8]
Symptoms & findings
Symptoms
Anhidrosis, Anxiety, Aphasia, Arrhythmia, Ataxia, Claudication, Coma, Crepitations, Decreased consciousness, Diastolic murmur, Distant heart sounds, Dysphagia, Dyspnea, Fever, Hemoptysis, Hypertension, Hypotension, Jugular vein distention, Kussmaul's sign, Miosis, Orthopnea, Paralysis, Paresis, Paresthesia, Ptosis, Syncope, Tachycardia, Wide pulse pressure
Clinical findings
Anemia, Decreased hematocrit, Elevated Blood Urea Nitrogen, Elevated Creatinine, Elevated CRP, Elevated D-dimer, Elevated Jugular Venous Pressure, Elevated Lactic Dehydrogenase, Elevated Troponin, Friction rub, Hemopericardium, Hemothorax, Leukocytosis, Mediastinal widening, Pericardial effusion, Pulsus paradoxus, ST depression, ST elevation
Anamneses
None listed.
Localized findings
Approach
Blood test
Blood gas
ECG
Echocardiography
Transesophageal echocardiography
Chest x-ray
CT thorax
CT abdomen
MRI
Aortography
Smooth muscle myosin heavy-chain assay
Treatment
Resuscitation for hypotensive patients [3kd]
Control heart rate (<60 beats/minute) and blood pressure (<120/80)
Intravenous beta-blockers or calcium channel blockers.
Pain control
Identification of malperfusion syndromes
Aortic repair
Differential diagnoses
Aortic regurgitation, Cardiac tamponade, Horner syndrome, Myocardial infarction, Myocarditis, Pericarditis, Pleural effusion, Pneumothorax, Pulmonary edema, Pulmonary embolism, Ruptured aortic aneurysm, Shock, Stroke, Superior vena cava syndrome, Thoracic outlet syndrome
References
[1] https://www.uptodate.com/contents/management-of-acute-type-a-aortic-dissection
[2] Yeh et al. Epidemiology and Medication Utilization Pattern of Aortic Dissection in Taiwan: A Population-Based Study. Medicine (Baltimore). 2015 Sep;94(36):e1522.
[3] http://emedicine.medscape.com/article/157325 (2014-01-21); [Medscape]
[4] http://emedicine.medscape.com/article/2062452 (2014-01-23); [Medscape]
[5] Levy D, Sharma S, Farci F, et al. Aortic Dissection. [Updated 2024 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441963/