Clinical Radiology 69 (2014) e60ee60
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: Acute aortic syndrome: CT findings In their recent article, Chiu et al.1 described the use of multidetector computed tomography (MDCT) for the diagnosis of acute aortic syndrome (AAS). We agree that the MDCT has superseded other imaging methods [such as plain film, catheter angiography, and transoesophageal echocardiography (TOE)] in the early diagnosis of the AAS. Current MDCT equipped with state-of-the art tube and detector technology, and optimal temporal and spatial resolution has become widely available globally. With appropriately obtained MDCT data in patients who have findings suspicious for AAS, the diagnostic accuracy of MDCT is nearly 100%. However, we have a question about intramural haematoma (IMH). The pathogenesis of IMH is not fully understood. Two major pathophysiological mechanisms of IMH are bleeding of the vasa vasorum and intimal tear with complete thrombosis of false lumen. Several recent reports suggest that most IMH results from an entry tear similar to classic aortic dissection.2e4 Park and colleagues,5 reported that intimal defects were identified during surgery in 27 patients (73%) among 37 patients with type A IMH, whereas preoperative CT detected intimal defects in only 13 patients (35.1%). In a previous article6, we described the case of a patient with type B IMH that at 36 months of TOE follow-up showed an increase in the thickness of the IMH (11 mm) associated with a crescent-like echo-free space (EFS) and a single “intimal micro-tear” (2 mm in diameter). At the 1 month follow-up, the EFS was completely absorbed and the thickness of the IMH had reduced (7 mm diameter). The CT
DOI of original article: http://dx.doi.org/10.1016/j.crad.2013.03.001.
examination performed did not show these aspects shown by TOE. Today we know that the prevalence of EFSs at TOE has been high and that the presence of EFS and “intimal microtear” did not appear to be a predictor either of the development of aortic dissection or of poor clinical outcome in patients with type B IMH. Is that case that Chiu et al. believe that contemporary MDCT units are able to demonstrate these entities and to evaluate the progression during follow-up?
References 1. Chiu KW, Lakshminarayan R, Ettles DF. Acute aortic syndrome: CT findings. Clin Radiol 2013;68:741e8. 2. Beauchesne LM, Veinot JP, Brais MP, et al. Acute aortic intimal tear without a mobile flap mimicking an intramural hematoma. J Am Soc Echocardiogr 2003;16:285e8. 3. Berdat PA, Carrel T. Aortic dissection limited to the ascending aorta mimicking intramural hematoma. Eur J Cardiothorac Surg 1999;15:108e9. 4. Bozzani A, Arici V, Bellinzona G, et al. Iatrogenic pulmonary artery rupture due to chest-tube insertion. Tex Heart Inst J 2010;37:732e3. 5. Park KH, Lim C, Choi JH, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma. Ann Thorac Surg 2008;86:1494e500. 6. Bozzani A, Palmieri P, Arici V, et al. Echo-free space and intimal microtear: initiating event or decompression rent of intramural haematoma? EJVES Extra 2009;17:17e9.
A. Bozzani*, P. Palmieri, V. Arici, M. Lovotti, F. Ragni Foundation I.R.C.C.S., Policlinico San Matteo, Pavia, Italy E-mail address: [email protected] (A. Bozzani)
* Guarantor and correspondent: A. Bozzani, Foundation I.R.C.C.S. Policlinico San Matteo, Vascular Surgery, P.le Golgi 19, 27100 Pavia, Italy. Tel.: þ39 0 382 502940; fax: þ39 0 382 502007.
0009-9260/$ e see front matter Ó 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2013.08.014
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: Acute aortic syndrome: CT findings In their recent article, Chiu et al.1 described the use of multidetector computed tomography (MDCT) for the diagnosis of acute aortic syndrome (AAS). We agree that the MDCT has superseded other imaging methods [such as plain film, catheter angiography, and transoesophageal echocardiography (TOE)] in the early diagnosis of the AAS. Current MDCT equipped with state-of-the art tube and detector technology, and optimal temporal and spatial resolution has become widely available globally. With appropriately obtained MDCT data in patients who have findings suspicious for AAS, the diagnostic accuracy of MDCT is nearly 100%. However, we have a question about intramural haematoma (IMH). The pathogenesis of IMH is not fully understood. Two major pathophysiological mechanisms of IMH are bleeding of the vasa vasorum and intimal tear with complete thrombosis of false lumen. Several recent reports suggest that most IMH results from an entry tear similar to classic aortic dissection.2e4 Park and colleagues,5 reported that intimal defects were identified during surgery in 27 patients (73%) among 37 patients with type A IMH, whereas preoperative CT detected intimal defects in only 13 patients (35.1%). In a previous article6, we described the case of a patient with type B IMH that at 36 months of TOE follow-up showed an increase in the thickness of the IMH (11 mm) associated with a crescent-like echo-free space (EFS) and a single “intimal micro-tear” (2 mm in diameter). At the 1 month follow-up, the EFS was completely absorbed and the thickness of the IMH had reduced (7 mm diameter). The CT
DOI of original article: http://dx.doi.org/10.1016/j.crad.2013.03.001.
examination performed did not show these aspects shown by TOE. Today we know that the prevalence of EFSs at TOE has been high and that the presence of EFS and “intimal microtear” did not appear to be a predictor either of the development of aortic dissection or of poor clinical outcome in patients with type B IMH. Is that case that Chiu et al. believe that contemporary MDCT units are able to demonstrate these entities and to evaluate the progression during follow-up?
References 1. Chiu KW, Lakshminarayan R, Ettles DF. Acute aortic syndrome: CT findings. Clin Radiol 2013;68:741e8. 2. Beauchesne LM, Veinot JP, Brais MP, et al. Acute aortic intimal tear without a mobile flap mimicking an intramural hematoma. J Am Soc Echocardiogr 2003;16:285e8. 3. Berdat PA, Carrel T. Aortic dissection limited to the ascending aorta mimicking intramural hematoma. Eur J Cardiothorac Surg 1999;15:108e9. 4. Bozzani A, Arici V, Bellinzona G, et al. Iatrogenic pulmonary artery rupture due to chest-tube insertion. Tex Heart Inst J 2010;37:732e3. 5. Park KH, Lim C, Choi JH, et al. Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma. Ann Thorac Surg 2008;86:1494e500. 6. Bozzani A, Palmieri P, Arici V, et al. Echo-free space and intimal microtear: initiating event or decompression rent of intramural haematoma? EJVES Extra 2009;17:17e9.
A. Bozzani*, P. Palmieri, V. Arici, M. Lovotti, F. Ragni Foundation I.R.C.C.S., Policlinico San Matteo, Pavia, Italy E-mail address: [email protected] (A. Bozzani)
* Guarantor and correspondent: A. Bozzani, Foundation I.R.C.C.S. Policlinico San Matteo, Vascular Surgery, P.le Golgi 19, 27100 Pavia, Italy. Tel.: þ39 0 382 502940; fax: þ39 0 382 502007.
0009-9260/$ e see front matter Ó 2013 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2013.08.014
