动脉-急性主动脉综合症

nullnullthe Acute Aortic Syndrome邹瑞琪急性主动脉综合症（AAS）急性主动脉综合症（AAS） 主动脉夹层：Aortic Dissection (AD) 壁间血肿：Intramural Hematoma (IMH) 穿透性粥样硬化性溃疡：Penetrating Atherosclerotic Ulcer (PAU). Imaging protocolImaging protocolNE-CT CE-CT 20s 60s 3ml/sec，100ml 伪影伪影AASAASStanford 分型Stanford 分型DebakeyDebakeyAortic Dissection (AD)Aortic Dissection (AD)Incidence: 1-10 : 100.000 mostly men rarely < 60 year (etiology = media degeneration) hypertension > 70% Type A mortality 1-2% per hour after onset of symptoms, total up to 90% non-treated, 40% when treated. 1 year survival Type B up to 85% if medically treated (5 year > 70%) ADADManagement decisionsManagement decisionsType A or Type B Place of entry & re-entry Side branches involved, originating form true / false lumen Organs at risk (1/3 of mortality is caused by organ failure) Complications (rupture, coronary occlusion, aortic insufficiency, neurological ) Diameters of true and false lumina at: proximal and distal landing zones, at entry and at minimum Iliac vessel tortuosity Imaging featuresImaging featuresnullTrue lumenTrue lumenSurrounded by calcifications (if present) Smaller than false lumen Usually origin of celiac trunk, SMA and right renal artery False lumenFalse lumenFlow or occluded by thrombus (chronic). Delayed enhancement Wedges around true lumen (beak-sign) Larger than true lumen Circular configuration (persistent systolic pressure) Outer curve of the arch Usually origin of left renal artery Surrounds true lumennullnullnullnullnull20 months follow upnullpericardial fluid / hematoma no pericaldial hematomanullAneurysm with thrombus versus thrombosed dissectionAneurysm with thrombus versus thrombosed dissectionIntramural Hematoma Intramural Hematoma Intramural HematomaIntramural HematomaSpontaneous hemorrhage caused by rupture of vasa vasorum in media 10% of dissections, resorpted Difficult to distinguish from thrombosed AD Can proceed to classic dissection (16-47%) Long time to diagnosis: usually overlooked due to lack of non-enhanced scan Mortality at 1 year after dismission ~ 25% Intramural HematomaIntramural HematomaIMHIMHIMHIMHtype A or Type B Predictors of mortality: - Ascending Aorta > 5 cm Ø - IMH thickness > 2 cm - Pericardial effusion (to less extend pleural effusion) IMH may persist or evolve into aneurysm or PAU Associated PAU - worse prognostic outcome IMH thickness stays below 2 cm, making regression of this Type B IMH likely (up to 80%).Penetrating Atherosclerotic UlcerPenetrating Atherosclerotic UlcerPAUPAUPatients with severe systemic atherosclerosis Rarely rupture, yet worse prognosis due to extensive atherosclerosis which causes organfailure (e.g. acute myocardial infarction) Cause of most saccular aneurysms Located in arch and descending aorta Often multiple (therefore surgical treatment difficult, mostly treated medically) PAUPAUPAUPAUType A or Type B Single or multiple Associated IMH (if not present, be cautious to mention PAU, clinical symptoms might not be caused by PAU, which is probably stable) Possibility of endovascular treatment ComplicationsComplicationsSaccular aneurysm formation Compression of nearby structures Rupture However most patients have a poor prognosisTHANKSTHANKSAortic aneurysm ruptureAortic aneurysm rupturePrimary signs of Aortic Aneurysm rupture Second signs of AAA rupturenullnullretroperitoneal hematoma retroperitoneal hematoma Signs of Pending Aneurysm RuptureSigns of Pending Aneurysm RuptureHigh-attenuating crescentHigh-attenuating crescenta frank AAA rupturea frank AAA ruptureFocal discontinuity of intimal calcificationFocal discontinuity of intimal calcificationTangential calcium signTangential calcium signDraped AortaDraped Aortatwo weeks later there is a rupture Draped AortaDraped Aorta