Aortic media separated by intimomedial flap between false and true aortic lumina
Entrance and re-entrance tears (occasionally several communications)
IMH or class 2 dissection
Aortic media hemorrhage from spontaneous vasa vasorum rhexis (occasionally trauma)
Absent (or very small) entrance and re-entrance tears
ID or class 3 dissection
Also known as subtle or discrete AD, ~ 7% of all dissections
Entrance tear (intimal laceration) with no flap or IMH
If only contained by adventitia (contained aortic rupture) appears as subadventitial hematoma
Better outcome compared to classic dissection (lower operative mortality, shorter hospital stay, less frequent transfusions)
PAU or class 4 dissection
Ulcerated atherosclerotic lesion that penetrates internal elastic lamina
Associated with variable amounts of intramural hemorrhage
Rhexis: Rupture of vasa vasorum leading to IMH
Focal aortic projection (FAP): Intrinsic contrast collection within intramural or subadventitial hematoma
Intramural blood pool (IBP) (branch pseudoaneurysm); benign, can be observed
PAU
Ulcer-like projection (ULP); treated as PAU
IMAGING
General Features
Radiographic Findings
CT Findings
MR Findings
Echocardiographic Findings
Imaging Recommendations
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
General Features
Staging, Grading, & Classification
CLINICAL ISSUES
Presentation
Natural History & Prognosis
Treatment
Essential Imaging Report Content
Selected References
Bossone E et al: Imaging and biomarkers in acute aortic syndromes: diagnostic and prognostic implications. Curr Probl Cardiol. 46(3):100654, 2021
Carroll BJ et al: Imaging for acute aortic syndromes. Heart. 106(3):182-9, 2019
Sailer AM et al: Computed tomography imaging features in acute uncomplicated stanford type-B aortic dissection predict late adverse events. Circ Cardiovasc Imaging. 10(4), 2017
Gutschow SE et al: Emerging concepts in intramural hematoma imaging. Radiographics. 36(3):660-74, 2016
Hiratzka LF et al: 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 121(13):e266-369, 2010. Erratum in: Circulation. 122(4):e410, 2010
Vilacosta I et al: Acute aortic syndrome: a new look at an old conundrum. Postgrad Med J. 86(1011):52-61, 2010
Attia R et al: In patients with acute aortic intramural haematoma is open surgical repair superior to conservative management? Interact Cardiovasc Thorac Surg. 9(5):868-71, 2009
Ramanath VS et al: Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc. 84(5):465-81, 2009
Lohan DG et al: MR imaging of the thoracic aorta. Magn Reson Imaging Clin N Am. 16(2):213-34, viii, 2008
Smith AD et al: CT imaging for acute aortic syndrome. Cleve Clin J Med. 75(1):7-9, 12, 15-7 passim, 2008
Chirillo F et al: Clinical and anatomical characteristics of subtle-discrete dissection of the ascending aorta. Am J Cardiol. 100(8):1314-9, 2007
François CJ et al: MRI of the thoracic aorta. Cardiol Clin. 25(1):171-84, vii, 2007
Flachskampf FA: Assessment of aortic dissection and hematoma. Semin Cardiothorac Vasc Anesth. 10(1):83-8, 2006
Evangelista A et al: Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 111(8):1063-70, 2005
Hartnell GG et al: Aortic fenestration: a why, when, and how-to guide. Radiographics. 25(1):175-89, 2005
Ko SF et al: Effects of heart rate on motion artifacts of the aorta on non-ECG-assisted 0.5-sec thoracic MDCT. AJR Am J Roentgenol. 184(4):1225-30, 2005
Tsai TT et al: Acute aortic syndromes. Circulation. 112(24):3802-13, 2005
Macura KJ et al: Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol. 181(2):309-16, 2003
Song JK et al: Outcomes of medically treated patients with aortic intramural hematoma. Am J Med. 113(3):181-7, 2002
Erbel R et al: Diagnosis and management of aortic dissection. Eur Heart J. 22(18):1642-81, 2001
Sawhney NS et al: Aortic intramural hematoma: an increasingly recognized and potentially fatal entity. Chest. 120(4):1340-6, 2001
Batra P et al: Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography. Radiographics. 20(2):309-20, 2000
Hayashi H et al: Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Radiographics. 20(4):995-1005, 2000
Maraj R et al: Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 86(6):664-8, 2000
Pepi M et al: Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography. Eur J Echocardiogr. 1(1):72-9, 2000
Svensson LG et al: Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation. 99(10):1331-6, 1999
Arita T et al: Abdominal aortic aneurysm: rupture associated with the high-attenuating crescent sign. Radiology. 204(3):765-8, 1997
Murray JG et al: Intramural hematoma of the thoracic aorta: MR image findings and their prognostic implications. Radiology. 204(2):349-55, 1997
Williams DM et al: The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology. 203(1):37-44, 1997
Slonim SM et al: True lumen obliteration in complicated aortic dissection: endovascular treatment. Radiology. 201(1):161-6, 1996
Burns MA et al: Motion artifact simulating aortic dissection on CT. AJR Am J Roentgenol. 157(3):465-7, 1991
Aortic media separated by intimomedial flap between false and true aortic lumina
Entrance and re-entrance tears (occasionally several communications)
IMH or class 2 dissection
Aortic media hemorrhage from spontaneous vasa vasorum rhexis (occasionally trauma)
Absent (or very small) entrance and re-entrance tears
ID or class 3 dissection
Also known as subtle or discrete AD, ~ 7% of all dissections
Entrance tear (intimal laceration) with no flap or IMH
If only contained by adventitia (contained aortic rupture) appears as subadventitial hematoma
Better outcome compared to classic dissection (lower operative mortality, shorter hospital stay, less frequent transfusions)
PAU or class 4 dissection
Ulcerated atherosclerotic lesion that penetrates internal elastic lamina
Associated with variable amounts of intramural hemorrhage
Rhexis: Rupture of vasa vasorum leading to IMH
Focal aortic projection (FAP): Intrinsic contrast collection within intramural or subadventitial hematoma
Intramural blood pool (IBP) (branch pseudoaneurysm); benign, can be observed
PAU
Ulcer-like projection (ULP); treated as PAU
IMAGING
General Features
Radiographic Findings
CT Findings
MR Findings
Echocardiographic Findings
Imaging Recommendations
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
General Features
Staging, Grading, & Classification
CLINICAL ISSUES
Presentation
Natural History & Prognosis
Treatment
Essential Imaging Report Content
Selected References
Bossone E et al: Imaging and biomarkers in acute aortic syndromes: diagnostic and prognostic implications. Curr Probl Cardiol. 46(3):100654, 2021
Carroll BJ et al: Imaging for acute aortic syndromes. Heart. 106(3):182-9, 2019
Sailer AM et al: Computed tomography imaging features in acute uncomplicated stanford type-B aortic dissection predict late adverse events. Circ Cardiovasc Imaging. 10(4), 2017
Gutschow SE et al: Emerging concepts in intramural hematoma imaging. Radiographics. 36(3):660-74, 2016
Hiratzka LF et al: 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. Circulation. 121(13):e266-369, 2010. Erratum in: Circulation. 122(4):e410, 2010
Vilacosta I et al: Acute aortic syndrome: a new look at an old conundrum. Postgrad Med J. 86(1011):52-61, 2010
Attia R et al: In patients with acute aortic intramural haematoma is open surgical repair superior to conservative management? Interact Cardiovasc Thorac Surg. 9(5):868-71, 2009
Ramanath VS et al: Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc. 84(5):465-81, 2009
Lohan DG et al: MR imaging of the thoracic aorta. Magn Reson Imaging Clin N Am. 16(2):213-34, viii, 2008
Smith AD et al: CT imaging for acute aortic syndrome. Cleve Clin J Med. 75(1):7-9, 12, 15-7 passim, 2008
Chirillo F et al: Clinical and anatomical characteristics of subtle-discrete dissection of the ascending aorta. Am J Cardiol. 100(8):1314-9, 2007
François CJ et al: MRI of the thoracic aorta. Cardiol Clin. 25(1):171-84, vii, 2007
Flachskampf FA: Assessment of aortic dissection and hematoma. Semin Cardiothorac Vasc Anesth. 10(1):83-8, 2006
Evangelista A et al: Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 111(8):1063-70, 2005
Hartnell GG et al: Aortic fenestration: a why, when, and how-to guide. Radiographics. 25(1):175-89, 2005
Ko SF et al: Effects of heart rate on motion artifacts of the aorta on non-ECG-assisted 0.5-sec thoracic MDCT. AJR Am J Roentgenol. 184(4):1225-30, 2005
Tsai TT et al: Acute aortic syndromes. Circulation. 112(24):3802-13, 2005
Macura KJ et al: Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol. 181(2):309-16, 2003
Song JK et al: Outcomes of medically treated patients with aortic intramural hematoma. Am J Med. 113(3):181-7, 2002
Erbel R et al: Diagnosis and management of aortic dissection. Eur Heart J. 22(18):1642-81, 2001
Sawhney NS et al: Aortic intramural hematoma: an increasingly recognized and potentially fatal entity. Chest. 120(4):1340-6, 2001
Batra P et al: Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography. Radiographics. 20(2):309-20, 2000
Hayashi H et al: Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept. Radiographics. 20(4):995-1005, 2000
Maraj R et al: Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 86(6):664-8, 2000
Pepi M et al: Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography. Eur J Echocardiogr. 1(1):72-9, 2000
Svensson LG et al: Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Circulation. 99(10):1331-6, 1999
Arita T et al: Abdominal aortic aneurysm: rupture associated with the high-attenuating crescent sign. Radiology. 204(3):765-8, 1997
Murray JG et al: Intramural hematoma of the thoracic aorta: MR image findings and their prognostic implications. Radiology. 204(2):349-55, 1997
Williams DM et al: The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology. 203(1):37-44, 1997
Slonim SM et al: True lumen obliteration in complicated aortic dissection: endovascular treatment. Radiology. 201(1):161-6, 1996
Burns MA et al: Motion artifact simulating aortic dissection on CT. AJR Am J Roentgenol. 157(3):465-7, 1991
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