1975, British Journal of Radiology, 48, 683-685

AUGUST

1975

Case reports Aortic dissection — atypical presentation By B. Ratkovits, M.D., P. R. Clapp, M.D., R. Berger, M.D., and E. J. Ferris, M.D. Departments of Diagnostic Radiology and Cardiac Surgery, University Hospital, 75 E. Newton Street, Boston, Massachusetts 02118 (Received July, 1974 and in revised form October, 1974)

Recently, we have seen a case of aortic dissection in which the unusual anatomical distribution and presentation warrant reporting. Case history

C.P., hospital No. 511504, a 37-year-old black married female entered University Hospital for evaluation of hypertension. Approximately two months prior to admission, she had had malaise and gradual onset of right leg numbness while taking a bath. This progressed to frank pain and she was admitted to a local hospital where abdominal arteriography showed occlusion of the right femoral artery. An embolectomy was performed at that hospitalization and she was discharged on Aldomet, 250 mg for her hypertension. She proved refractory to this medication and was referred to University Hospital for evaluation of her hypertension. At that time, her blood pressure was 150/90 with a pulse rate of 85 per minute. Some fluctuation in her blood pressure was noted over the hospital course with the diastolic pressure reaching as high as 130mm of mercury. Other pertinent physical findings included a Grade I holosystolic apical cardiac murmur and a midline systolic abdominal bruit heard loudest just above the umbilicus. Peripheral pulses and neurologic examination were normal. Apart from a serum creatinine of 1 -4 mg per cent laboratory values were within normal limits. Electrocardiogram showed changes compatible with left ventricular hypertrophy.

teflon graft. The anomalous right subclavian artery was divided at its origin and circumferential separation of its intima was quite apparent. The right subclavian artery measured approximately 4-5 cm in diameter. A 5 cm longitudinal internal tear was identified in the resected specimen at about 1 -5 cm distal to the left subclavian artery. The renal arteries were grossly normal. The patient tolerated the procedure well and left the operating room in good condition. She had a good right radial pulse without any claudication of the arm. Post-operatively, she complained of non-specific fatigue and malaise which prolonged her hospital stay. She was discharged three weeks after the operation in good condition.

Radiographic findings

The chest film showed a right paratracheal soft tissue density deviating the trachea slightly from the right to the left. An additional rounded soft tissue density was noted in the region of the aortic arch. This was consistent with a markedly dilated aortic knob. The heart was within normal limits and the region of the ascending aorta appeared normal as well, without any evidence of ascending aortic dilatation (Fig. 1). An oesophageal examination demonstrated focal deviation of the oesophagus anteriorly just above the level of the aortic arch (Fig. 2). On the basis of these films, a tentative diagnosis of aortic dissection starting distal to the left subclavian and extending into an anomalous right subclavian artery was made. Subsequent thoracoabdominal aortography revealed a classical DeBakey type III (Fig. 3) dissection with extension into the anomalous right subclavian artery (Fig. 4) and distally in the aorta to the common iliac vessels with extension into the right hypogastric, superior mesenteric and left renal arteries. The false channel was well opacified throughout its course. The right renal artery and coeliac artery filled from the true lumen. HOSPITAL COURSE

Pre-operatively, the patient remained hypertensive for several weeks with a variation of 210 to 115 systolic and 125 to 80 diastolic pressures. Following continued improvement on antihypertensive and diuretic therapy, her blood pressure was 130/90 mm of mercury at operation. On May 7, 1973 the dissected aorta was partially resected, leaving the intact posterior wall behind, and replaced by a woven

FIG. 1. The chest in postero-anterior projection demonstrates a mass at the thoracic inlet below the sternoclavicular junction on the right side.

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FIG. 3. Retrograde thoracic aortogram in the right posterior oblique projection shows partial filling of a normal ascending aorta. The sharply defined linear radiolucent filling defects representing the dissected intima and media are well seen.

FIG. 2. The oesophagus is displaced anteriorly by the dilated anomalous right subclavian artery.

PATHOLOGY

Microscopic examination of the resected aorta showed moderate arteriosclerotic changes, mural thrombus and cystic medial necrosis out of proportion to her age. DISCUSSION

It is generally accepted that medial degeneration is a prerequisite for dissection of a haematoma within the media (Hirst, Johns and Kime, 1958). Dissection ordinarily occurs distally from the point of communication between true and false lumina, extending for variable distances but commonly stopping at the aortic or iliac bifurcations (De Bakey et al., 1966). Usually, the dissection will spiral around the aorta, generally following the convex curve of the aorta. Retrograde or proximal

dissection in the aorta is fairly common but commonly does not extend for more than 1 or 2 cm. While our case initially may appear atypical, its atypicality is a result not of the dissection, but of the pre-existing vascular anomaly, namely anomalous origin of the right subclavian artery, distal to the left subclavian. The dissection itself is actually a straight-forward type III DeBakey dissection (DeBakey et al., 1966). Since the anomalous right subclavian arises from the convexity of the descending aortic curve, it is logical that it should become involved in the dissection. While severe tearing chest pain is a common presenting symptom, our patient and indeed many patients will not present with pain (O'Donovan, Osmundson and Payne, 1964). Our patient presented as a hypertension problem

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1975, British Journal of Radiology, 48, 685-686

AUGUST 1975

Case reports FIG. 4. Same retrograde thoracic aortogram in a later phase demonstrates the dilated anomalous right subclavian artery.

with no history of pain, possibly due to slow progression of the aortic dissection. The underlying pathology in our patient was arteriosclerosis and cystic medial necrosis of the aorta. Her race and hypertension were predisposing factors, although dissection may well have antedated hypertension. With the exception of sudden right femoral artery occlusion, there were no symptoms suggesting aortic dissection. The radiographic presentation seen on admission chest film is most unusual for aortic dissection and we cannot find an example of an identical plain radiographic appearance in the literature. REFERENCES DEBAKEY, M. E., BEALL, A. C , Jun., COOLEY D. A., CRAWFORD, E. S., MORRIS, G. C , 1966. Dissecting

anuerysms of the aorta; Surgical Clinics of North America, 4,1045-1055. HIRST, A. E., Jun., JOHNS, V. J., Jun., KIME, S. W. Jun.,

1958. Dissecting aneurysm of the aorta; A review of 505 cases. Medicine 37; 217-279. O'DONOVON, T. P. B., OSMUNDSON, P. J., and PAYNE, W.

S., 1964. Painless dissecting aneurysm of the aorta. Circulation, 29, 782-786.

Urinothorax—an unusual pleural effusion By L B. Barek, M.D., and O. S. Cigtay, M.D. Department of Radiology, Georgetown University Hospital, Washington, D.C. {Received September, 1974) Post-operative pleural effusions are not uncommon. The aetiologies of these effusions are often apparent to the clinician. This case presents an unusual cause for the pleural effusion, that is, extravasation of urine from the peritoneum and retroperitoneal space into the thoracic cavity. Case history A 47-year-old white female presented with a sub-mucous aborting fibroid with severe menorrhagia. Pre-operative urography showed a congenital absence of the right kidney and collecting system. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The right ovary was noted to be a streak ovary. In the recovery room the patient's urinary output was noted to be unsatisfactory in spite of adequate hydration. An intravenous urogram showed non-visualization on the left side. A retrograde pyelogram was performed and showed extravasation of opaque material along the drain on the left side of the bladder and distal ureter (Fig. 1). At this time a chest film revealed a left pleural effusion. At re-exploration an obstructed left ureter and a laceration of the

bladder were found. Urine was noted in the peritoneal cavity and retroperitoneal spaces. Drains were placed in the retroperitoneal space and peritoneal cavity. In addition, a drain was inserted in the left ureter and a supra-pubic drain was placed in the bladder. The post-operative chest films again revealed the presence of a large left pleural effusion (Fig. 2). Thoracentesis revealed the pleural fluid to be urine. With continued satisfactory drainage to the left kidney and bladder, the pleural effusion cleared. Renal function remained normal throughout the hospital course. The patient was discharged in satisfactory condition with a suprapubic drain in place eleven days after the corrective surgery. DISCUSSION

Urinothorax is an uncommon aetiology for pleural effusion. Friedland, Axman, and Love (1971) reported urinothorax in a neonate as a complication of posterior urethral valves. In addition, Corriere, Miller and Murphy (1968) described two cases of right-sided pleural effusions in patients with

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Aortic dissection--atypical presentation.

1975, British Journal of Radiology, 48, 683-685 AUGUST 1975 Case reports Aortic dissection — atypical presentation By B. Ratkovits, M.D., P. R. Cla...
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