Acute aortic syndrome? (CTA)

CTACC/AHA 2022

Tearing chest or back pain; type A goes to cardiac surgery within the hour, so the report leads with the Stanford type.

Answer the surgeon

Stanford A goes to cardiac surgery now; B is managed medically unless complicated (malperfusion, rupture) — then TEVAR.

Your answer must state:

Type: A if ANY ascending involvement, B if distal to the left subclavian
Entity: classic dissection (intimomedial flap) vs intramural hematoma vs penetrating atherosclerotic ulcer
Extent from–to, arch vessel and iliac involvement
Malperfusion: which branch — coronary, carotid, visceral, renal, iliac — and off which lumen
Rupture signs: periaortic/mediastinal hematoma; hemopericardium raises concern for leakage and possible tamponade — communicate urgently and assess hemodynamic impact
True vs false lumen: false is usually larger, with the beak sign and cobwebs

Key and direct findings

1.Intimomedial flap with two lumina
The classic dissection; trace it from root to iliacs and name every branch it involves.
2.Intramural hematoma
Crescentic high-attenuation aortic wall on the UNENHANCED series without an intimal flap — same triage as classic dissection by location.
Pitfall: Skipping the unenhanced series hides an IMH — it fades into the enhanced wall after contrast.
3.Penetrating atherosclerotic ulcer
A contrast-filled outpouching through the intima into the wall, usually in a heavily atherosclerotic descending aorta.
4.Hemopericardium in type A
High-attenuation pericardial fluid raises concern for aortic leakage and possible tamponade — communicate immediately and obtain urgent clinical and echocardiographic assessment of hemodynamic impact.
Pitfall: Pericardial effusion and tamponade are not synonymous. Report the effusion and CT signs of hemodynamic compromise without diagnosing tamponade from fluid alone.

Supportive signs & checks

1.Periaortic and mediastinal hematoma
Contained rupture; with active extravasation, say so in the first line.
2.Aortic-root motion artifact
Pulsation at the root mimics a type-A flap — the artifact is fuzzy, symmetric, and extends outside the lumen; ECG-gating resolves it.
Pitfall: Calling a motion artifact a type A sends a patient toward a sternotomy — when in doubt, gate and rescan.
3.True vs false lumen
The false lumen is usually larger, shows the acute beak angle and cobweb strands, and matters when branches perfuse off it.

Wet-read snippets

Fill the blanks, then copy into your preliminary report.

Positive

Acute ___ (Stanford A/B): ___ (dissection flap / IMH / PAU) from ___ to ___. Branch involvement: ___. Malperfusion: ___. Hemopericardium/periaortic hematoma: ___. Communicated at ___.

Negative

No dissection flap, intramural hematoma, or penetrating ulcer on unenhanced and CTA series — no acute aortic syndrome.

Sources

2022 ACC/AHA guideline for the diagnosis and management of aortic disease — Isselbacher EM et al. Circulation (2022)
Multidetector CT of aortic dissection — McMahon MA, Squirrell CA. RadioGraphics (2010)

Content review: Content pending clinical review · 2026-07-15

Educational reference for trained clinicians. Verify every result against the cited original guideline before use. Not a substitute for clinical judgment or medical advice.