Medical Image of the Week: Type A Aortic Dissection Extending Into Main Coronary Artery

Figure 1. Electrocardiogram at presentation showing ST segment elevation in anterior leads (arrows).

Figure 2. Coronary angiogram showing RAO caudal view of left main coronary artery after contrast injection with the smooth proximal linear irregularity suspicious for dissection flap into the left anterior descending artery (arrow).

Figure 3. Panel A: Computed tomography angiogram transverse view showing true lumen and false lumen of both ascending and descending aorta (arrow). Panel B: Computed tomography angiogram sagittal view showing dissection from root into abdominal aorta. 

A 58-year-old woman with no significant past medical history, presented to the emergency department with complains of sudden onset, severe , non-radiating epigastric pain associated with nausea and vomiting. An electrocardiogram (EKG) done in emergency department showed ST segment elevation in the anterior leads (Figure 1). Blood pressure at presentation was 141/79, and she had symmetrical bilateral pulses of the upper extremities, no diastolic murmur, and no neurologic deficit. The patient was taken to catherization laboratory, for ST segment elevated myocardial infarction (STEMI). She was found have aortic dissection extending to the left main coronary artery (Figure 2). Cardiothoracic surgery was called immediately. Computed tomography angiogram (CTA) of the thoracic and abdominal aorta revealed Debakey type 1 aortic dissection. (Figure 3). The patient was taken to the operating room. Unfortunately, the patient suffered pulseless electrical activity (PEA) arrest during anesthesia induction from which she could not be revived.

Aortic dissection is a critical compromise in the lining of the main arterial outflow from the heart (1).  Two theories have been proposed to explain the pathogenesis. A tear in the tunica intima, of the aorta, leads to blood from the aortic lumen surging into the tunica media (2). In contrast, the second theory holds that the vasa vasorum in the more outer portions of the tunica media hemorrhage first and then cause the rupture of the tunica intima (2). The pressure of the pulsatile blood flow extends the dissection, typically in an anterograde fashion (2). Anatomically aortic dissection is classified as Debakey 1,2, and 3 and Stanford A and B (1). Rarely aortic dissections can also extend in a retrograde fashion to reach the coronary ostia (3). Signs of myocardial ischemia including ST segment changes, adversely affect survival outcomes in patients with type A aortic dissection extending to the coronary arteries (4).

Ali Osama Malik MD¹, Oliver Abela MD², Chowdhury Ahsan MD², and Jimmy Diep MD²

¹Department of Internal Medicine

²Department of Cardiovascular Medicine

University of Nevada School of Medicine

Las Vegas, NV USA

References

1. Golledge J, Eagle KA. Acute aortic dissection. Lancet. 2008 Jul 5;372(9632):55-66. [CrossRef] [PubMed]
2. Patel AY, Eagle KA, Vaishnava P. Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection. Ann Cardiothorac Surg. 2014 Jul;3(4):368-74. [CrossRef] [PubMed]
3. Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg. 2001 Mar;121(3):552-60. [CrossRef] [PubMed]
4. Imoto K, Uchida K, Karube N, Yasutsune T, Cho T, Kimura K, et al. Risk analysis and improvement of strategies in patients who have acute type A aortic dissection with coronary artery dissection. Eur J Cardiothorac Surg. Sep;44(3):419-24; discussion 24-5. [CrossRef] [PubMed]

Cite as: Malik AO, Abela O, Ahsan C, Diep J. Medical image of the week: type A aortic dissection extending into main coronary artery. Southwest J Pulm Crit Care. 2017;14(5):238-9. doi: https://doi.org/10.13175/swjpcc044-17 PDF 

Medical Image of the Week: Hydropneumothorax

Figure 1. Gastrograffin Esophagram revealing the presence of contrast in the right pleural space (arrow).

Figure 2. Chest CT revealing right hydropneumothorax containing Gastrograffin. Note the presence of Gastrograffin in the esophagus as well as pleural space (arrow).

Figure 3. Chest CT showing a communicating channel between the esophagus and right pleural space (arrow).

A 67-year-old woman who underwent a robotic laparoscopic surgical repair secondary to a large paraesophageal hernia with gastric volvulus. Post-operatively, she developed respiratory distress and a chest CT revealed a large right hydropneumothorax. A Gastrograffin esophagram was done showing Gastrograffin in the esophagus, stomach as well as in the right pleural space suggesting an esophageal-pleural fistula (Figure 1). A chest tube was placed and contrast was present revealing a esophageal-pleural fistula (Figures 2 and 3).

Esophageal perforation should be considered in all patients with unexplained chest pain. Rapid recognition and diagnosis is key as delay in treatment is associated with increased mortality and morbidity (1). Causes of esophageal perforations include upper endoscopy, Boerhaave’s syndrome, foreign body ingestion, trauma, malignancy and intra-operative injury (2). Treatment depends on the location and the extent of the perforation as surgical intervention is the gold standard.

Bassel Saksouk MD¹, Choua Thao MD¹ and Carmen Luraschi MD²

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Division of Pulmonary and Critical Care

Las Vegas, NV

References

1. Iannettoni MD, Vlessis AA, Whyte RI, Orringer MB. Functional outcome after surgical treatment of esophageal perforation. Ann Thorac Surg. 1997;64(6):1606-9. discussion 1609-10. [PubMed]
2. Bayram AS, Erol MM, Melek H, Colak MA, Kermenli T, Gebitekin C. The success of surgery in the first 24 hours in patients with esophageal perforation. Eurasian J Med. 2015;47(1):41-7. [CrossRef] [PubMed] 

Cite as: Saksouk B, Thao C, Luraschi C. Medical image of the week: hydropneumothorax. Southwest J Pulm Crit Care. 2015;11(3):124-5. doi: http://dx.doi.org/10.13175/swjpcc095-15 PDF

Medical Image of the Week: Focal Myopericarditis

Figure 1. Transverse view (panel A) and longitudinal view (panel B) of MRI with gadolinium enhanced contrast of chest showing abnormal enhancement at the level of the cardiac apex and also at the mid aspect of the infero-lateral wall and near the cardiac base within the lateral wall, consistent with the clinically suspected diagnosis of focal myopericarditis.

A 44-year-old man with no significant past medical history was admitted with a history of two episodes of substernal chest pain unrelated to exertion which had resolved spontaneously. Admission vital signs were within normal limits and physical examination was unremarkable. Basic lab tests were normal and urine toxicology was negative. Electrocardiogram was unremarkable with no ST/T changes. Troponin I was elevated at 4.19 which trended up to 6.57. An urgent cardiac angiogram was done which revealed normal patent coronaries. His transthoracic echocardiogram was also reported to be normal. He continued to have intermittent episodes of chest pain that was partially relieved by morphine. Erythrocyte sedimentation rate and C-reactive protein were elevated. Work up for autoimmune diseases, vasculitis, myocarditis panel were insignificant. Later, magnetic resonance imaging (MRI) with gadolinium enhanced contrast (Figure 1) was obtained which showed abnormal epicardial/subepicardial myocardial enhancement within the inferolateral wall and cardiac apex consistent with focal myopericarditis. He was started on Ibuprofen and colchicine. His chest pain significantly improved and he is currently following up as an outpatient.

Acute myo-pericarditis is primarily a pericarditic syndrome with variable myocardial involvement which is usually seen in male adolescents (1,2). There are 3 main etiologic categories: idiopathic, infectious or immune mediated. Patients present with chest pain that is sharp in nature with gradual onset radiating to the interscapular region, increasing with inspiration and easing with leaning forward. Pericardial friction rub on physical exam is considered pathognomonic. A typical pattern of ECG evolution includes diffuse ST segment elevation and PR depression, followed by normalization of ST and PR segments and then diffuse T wave inversion. Troponin I levels may be elevated, provides a rough estimate of the extent of myocardial inflammation. Cardiac MRI with gadolinium contrast is the best imaging modality to define the extent of myocardial involvement and patency of coronary system which is not always readily available. Therapy of choice is aspirin (1-1.5 g/day as mean dose) or nonsteroidal anti-inflammatory drugs such as ibuprofen for 7-10 days until symptom resolution. Colchicine should be the initial therapy in all refractory cases and in recurrent pericarditis. Physical exercise is contraindicated for at least 6 months from the onset of illness.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD, and Venu Ganipisetti MD

Department of Internal Medicine,

Presence Saint Francis Hospital

Evanston, IL USA

References

1. Imazio M, Cooper LT. Management of myopericarditis. Expert Rev Cardiovasc Ther. 2013;11(2):193-201. [CrossRef] [PubMed]
2. Sharma J, Fernandes N, Alvarez D, Khanna S.Acute myopericarditis in an adolescent mimicking acute myocardial infarction. Pediatr Emerg Care. 2015;31(6):427-30. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: focal myopericaditis. Southwest J Pulm Crit Care. 2015;11(1):47-8. doi: http://dx.doi.org/10.13175/swjpcc064-15 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1: Panel A: Axial view of the thoracic CT angiography showing aortic dissection in descending aorta where the true lumen (yellow arrow) with outer-wall calcification (red arrow) as well as false lumen with contrast (orange arrow) is seen.  Panel B: Coronal view showing the true (T) and false (F) lumen.

An 85-year-old gentleman with the past medical history significant for hypertension, smoking, and coronary artery disease presented to the emergency department (ED) with complains of sudden onset of chest pain.  His pain was described as squeezing and radiating to the back, associated with nausea and vomiting. His chest pain improved with nitroglycerin in ED.  Chest x-ray showed a tortuous aortic knob and widened mediastinum.

He underwent a CT angiogram, which showed, Stanford Type B aortic dissection, from distal aortic arch to renal arteries (Figure 1).  He was managed in the hospital conservatively with tight blood pressure control given the type of dissection and no surgical intervention was done. He was uneventfully discharged with follow up arranged with vascular surgery.

Aortic dissection is classified by Stanford Criteria as Type A which involves the ascending aorta and arch and Type B when it involves the descending aorta. Type A dissection is a surgical emergency and guidelines suggest medical / non-surgical management for Type B dissection except in cases where the pain is not controlled despite BP control, acute expansion of the false lumen, peri-aortic hematoma or distal mal-perfusion.

Hem Desai MD¹, Aung Bajaj MD¹, Kamalani Hanamaikai MD¹ & Bhupinder Natt MD²

¹Department of Internal Medicine and the ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine  

University of Arizona

Tucson, AZ USA

References

1. LePage MA, Quint LE, Sonnad SS, Deeb GM, Williams DM. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol. 2001;177(1):207-11. [CrossRef] [PubMed]
2. von Kodolitsch Y, Nienaber CA, Dieckmann C, Schwartz AG, Hofmann T, Brekenfeld C, Nicolas V, Berger J, Meinertz T. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116(2):73-7. [CrossRef] [PubMed]

Reference as: Desai H, Bajaj A, Hanamaikai K, Natt B. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2015;10(6):348-9. doi: http://dx.doi.org/10.13175/swjpcc063-15 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1. Acute aortic dissection presenting with the following radiographic signs: rightward deviation of the trachea (red arrow); left apical pleural capping (blue arrow); aortic “double-calcium” sign (between white arrows); depression of the left bronchus (purple arrow); pleural effusion (green arrow); widened mediastinum and loss of the aorto-pulmonary window (not labeled).

The patient was a 75 year old woman with a past medical history of uncontrolled hypertension and recent type-A aortic dissection post graft repair. She presented with a sudden onset of sharp mid-back pain which awoke her from sleep. In the emergency room a chest x-ray revealed numerous features consistent with a de novo type B aortic dissection which was ultimately confirmed by magnetic resonance angiography of the chest and abdomen. This dissection extended from the left subclavian artery to the right renal artery. There was no evidence of end-organ mal-perfusion and the patient was medically managed by way of blood pressure control.

Seth Assar, MD; Thien Vo, MD; Jarrod Mosier, MD

The University of Arizona College of Medicine, Tucson, Arizona

Reference

Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007;6(1):64-7. [CrossRef]

Reference as: Assar S, Vo T, Mosier J. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2014;8(4):234. doi: http://dx.doi.org/10.13175/swjpcc039-14 PDF