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Imaging modalities for the early diagnosis of acute aortic syndrome

Nature Reviews Cardiology volume 10, pages 477–486 (2013)Cite this article

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Abstract

The term acute aortic syndrome (AAS) incorporates aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. The common feature of these entities is disruption of the medial layer of the aortic wall. Owing to the life-threatening nature of these conditions, prompt and accurate diagnosis is of paramount importance—misdiagnosis can be fatal. The noninvasive imaging techniques that have a fundamental role in the diagnosis and management of patients with AAS include CT, MRI, transoesophageal echocardiography (TEE), and transthoracic echocardiography (TTE). CT is the most-commonly used imaging modality owing to its wide availability, accuracy, and large field of view. CT plus TTE is the best combination for diagnosing AAS and its complications, and allows important morphological and dynamic aspects of AAS to be assessed and appropriately managed. Ideally, TEE should be performed immediately before surgery or endovascular treatment, in the operating theatre and under general anaesthesia. In stable patients with an uncertain diagnosis of intramural haematoma despite high clinical suspicion, MRI is the technique of choice to make a definitive diagnosis. Imaging techniques have an important role in the primary diagnosis, treatment strategy, and risk stratification of patients with AAS.

Key Points

  • CT is the best imaging modality to diagnose acute aortic syndrome, owing to its accuracy, widespread availability, and because it allows the rapid evaluation of the entire aorta and branches

  • Transthoracic echocardiography (TTE) is useful as the initial imaging modality in the emergency setting when aortic dissection is suspected, particularly involving the proximal ascending aorta; contrast agents can improve accuracy

  • Acute aortic syndrome is best diagnosed using a combination of CT and TTE; TTE complements CT by adding information on diagnosis and quantification of aortic regurgitation, pericardial tamponade, and left ventricular function

  • The main applications of transoesophageal echocardiography are to define the entry tear location and size, the mechanisms and severity of aortic regurgitation, and flow dynamics of the two lumina

  • Hyperintense T1-weighted MRI is the technique of choice to visualize small intramural haematoma; this technique can be indicated in stable patients in whom the diagnosis is uncertain

  • The diagnostic imaging strategy should be individualized according to a patient's condition, the relevant diagnostic questions to be answered, and local institutional factors, such as expertise and technological availability

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Figure 1: 2D transthoracic echocardiographic images of type A aortic dissection.
Figure 2: Contrast-enhanced transthoracic echocardiographic images.
Figure 3: Transoesophageal echocardiographic evaluation of type B aortic dissection.
Figure 4: CT scan images.
Figure 5: Sagittal oblique view of a 3D MRI angiogram in a patient with a surgically repaired type A aortic dissection and a residual type B dissection.
Figure 6: 3D transoesophageal echocardiographic images of a large entry tear in a type B aortic dissection located in the proximal descending aorta.
Figure 7: Aortic intramural haematoma evaluated by various imaging techniques.
Figure 8: Penetrating aortic ulcers.
Figure 9: Diagnostic algorithm in patients with acute aortic dissection.

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  1. Department of Cardiology, Hospital Vall d'Hebron, P° Vall d'Hebron 119, Barcelona, 08035, Spain

    Artur Evangelista, Amelia Carro, Sergio Moral, Gisela Teixido-Tura, José F. Rodríguez-Palomares, Hug Cuéllar & David García-Dorado

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A. Evangelista researched data for the article. A. Evangelista, A. Carro, and H. Cuéllar contributed substantially to discussion of the content of the article. A. Evangelista and A. Carro wrote the manuscript. A. Carro, S. Moral, G. Teixido-Tura, J. F. Rodríguez-Palomares, H. Cuéllar, and D. García-Dorado reviewed/edited the manuscript before submission.

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Evangelista, A., Carro, A., Moral, S. et al. Imaging modalities for the early diagnosis of acute aortic syndrome. Nat Rev Cardiol 10, 477–486 (2013). https://doi.org/10.1038/nrcardio.2013.92

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