Aortic arch dissection

Aortic arch dissection can cause profound hypotension, with global, and sometimes boundary zone, cerebral ischemia or focal cerebral ischemia if the dissection spreads up one of the neck arteries. Clues to this diagnosis are anterior chest or interscapular pain, along with diminished, unequal or absent arterial pulses in the arms or neck and a normal electrocardiogram, unlike acute myocardial infarction, acute aortic regurgitation and pericardial effusion. 

Possible cardiac source of embolism, or clinical, ECG, transesophageal evidence of embologenic heart ultrasound or radiographic disease, aortic arch dissection... 

Tenderness of the branches of the external carotid artery (occipital, facial, superficial temporal) points towards giant cell arteritis. Tenderness of the common carotid artery in the neck can occur in acute carotid occlusion but is more Ukely to be a sign of dissection, or arteritis. Absence of several neck and arm pulses in a young person occurs in Takayasu s arteritis (Ch. 6). Delayed or absent leg pulses suggest coarctation of the aorta or, much more commonly, peripheral vascular disease. Other causes of widespread disease of the aortic arch are atheroma, giant cell arteritis, syphihs, subintimal fibrosis, arterial dissection and trauma. 

Mitral and aortic valve vegetations Prosthetic heart valve malfunction Aortic arch atherothrombosis/dissection Mitral valve prolapse... 

The challenge for spinal artery CTA is to provide sufficient arterial enhancement but to scan before arrival of contrast medium in the venous system. An ROI of the bolus tracking system placed in the ascending aorta might be affected by inflow artifacts of the SVC and may result in a mistimed early scan. Therefore, placement of the ROI in the aortic arch or descending aorta is recommended. In the presence of aortic dissection, caution should be taken that the ROI is not too big or positioned in the false lumen or across the dissection membrane, respectively. In these cases, manual start of the scan should be considered. The Hounsfield unit threshold should be around 100 HU above baseline. Scan start is usually delayed by time for table movement (<3 s), which is usually right above the origin of the vertebral arteries. An additional scan delay of 3 s is recommended for scanners with equal to or more than 16 rows and rotation time equal or less than 0.4 s. Hounsfield unit values of attenuated blood in the thoracic aorta should never be lower than within the pulmonary trunk. 

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