CT Imaging for Thoracic Aortic Pathology

Ending out the session with another live lecture. This is going to be from Diana Ludmanovich. The topic is CT imaging interpretation of common thoracic aortic pathology. Good morning. And for those who are not here, East Coast. Good afternoon. It's my pleasure to be here and to talk today about a topic which is very close to my heart, thoracic aortic pathology. Now, it's a huge topic and there are meetings of several days which are just... devoted to that very one topic. So what I'm going to do today, I'm not going to try to cover everything. I'm going to talk about potential tips that you as the newcomers to the world of radiology might find beneficial. Okay, so we're going to talk about how we image the aorta. We're going to talk a little bit about the important points in thoracic aortic anatomy. And we're going to talk about specific points in interpretation and the reporting of. some of the common aortic pathologies. So let's start with imaging. So we can image aorta with four different approaches. If you think about it conceptually, it could be a regular non-contrast enhanced chest CT. Can we see the aorta? Of course we can. We can do it after we administer contrast. So we will see aorta after administration of IV contrast. We can image the aorta with gating without giving contrast. and we can image the aorta with ECG gating and afterward ministered contrast. And each one of those definitely has a role in imaging of the aorta. I think we all would agree by just looking at those four images that adding gating to the imaging of the aorta gives us a very precise and sharp assessment of the aorta, which is very important for assessing the size of the aorta, which is very important for assessing the mural pathology. Now, the ECG gating... gating without contrast has its own important role in one particular case scenario, which is assessing the intramural hematoma, and I'll talk about that later. But just conceptually, there are four ways to image aorta. Now, if we are talking about the ideal imaging, which is ECG-gated imaging of the aorta, it has to have both non-contrast and contrast-enhanced components. That gives us the maximum information from the CT standpoint, okay, not from MRI. But from the CT standpoint, those are the two that give us all the information we can extract from this type of imaging. Let's talk a little bit about anatomy. Obviously, you're all very familiar with the anatomy of the aorta. We learn it from high school or from middle school. We go through that in the medical school. There are three very important points in the anatomy of the aorta that I would like you to remember before you start analyzing the pathology or the imaging of the aorta. The first... The first point is how we divide the aorta into the ascending aorta and the descending aorta. And I find it sometimes a little bit mixed up. So the classic definition and the right definition of the ascending aorta is the aorta that starts at the level of the aortic valve and continues up to this point, right before the origin of the brachiocephalic artery. So this is our ascending aorta. Within the ascending aorta, there are two important points. important anatomical landmarks. One is the senotubular junction. This is a junction between the sinuses of Valsalva and the aorta. And this is an important point to assess to see if it's there, if it's preserved. Why? I'll tell you in a second. And the other one are the actual sinuses of Valsalva and their maximal width. Because in addition to assessing the aorta, we have to look specifically into the sinuses of Valsalva. assess their size. Now, if we are talking about the aortic arch, the aortic arch, which is part of the descending aorta, starts at the origin of the brachiocephalic artery and continues all the way down into the abdomen. Now, some teachings and some approaches designate thoracic aortic arch as an asterisk. And there was a great publication by Dr. Charlie White in college. and he's a younger colleague, I'm blanking on his name, who was talking about it. And sometimes it is important to mention that we are not talking just about descending aorta, but about aortic arch. But if we are talking about ascending versus descending, this is our landmark. So, synotribular junction, the landmark between ascending and descending, and the sinuses of Valsalva. The size of the aorta is very important. Now, as you can see... see from this diagram from this table and as you know from real practice People have different sizes of the aorta. It varies between males and females. Males tend to have a little bit higher aortic diameter. It also varies along the aorta. should only get smaller as we move from the ascending towards the descending and we also know that the maximum diameter of the aorta will also be at the level of of the sinuses of Valsalva. That changes over time. Aorta gets bigger with age, same as pulmonary arteries, for example, but the aorta does get bigger with age and the aorta does get bigger with BMI sometimes just because of the BMI. If we compare people with different BMI and sometimes as people change their BMI across the lifetime and their BMI is getting bigger and the aortic diameter is getting larger. But if we look at the diameter of the aorta, we can see that the of the aorta, it's clear to us that regardless of age and regardless of gender, the aortic diameter should not exceed four centimeters. And four centimeters is, I'm being sort of very flexible. Some people say that it's 3.5 centimeters, but if you see the aorta, which is above four centimeters in diameter, it's definitely dilated. Okay. How do we measure it? Before we talk about the diameter, we have to measure it. So if we are talking about measuring aorta, especially the ascending aorta, aorta. We have to do it with a double oblique technique. Double oblique technique gives us the ability to measure perpendicular to the axis of the blood flow, and it's extremely important in the ascending aorta. The ascending aorta is a little bit usually more straight going without turns, but if we're measuring the ascending aorta, we must do it with a double oblique technique. This is an example why double oblique technique is so important. This is one of the probably most pronounced cases of... aortic tortuosity. And you can appreciate that if we would just measure along the axial plane, our measurement at this level would be approximately 11 centimeters as opposite to the true measurement that would be perpendicular to the true long axis of the aorta and would be still large, but about seven centimeters. So it's very important to precisely measure the aorta because when we are talking about aortic aneurysms... and aortic aneurysms grows, we are talking about millimeters over a long period of time. So very precise measurements are extremely important. This is another important point that I was talking about earlier, the sinuses of Valsalva. We measure the maximum width of the sinuses of Valsalva, and we know that the maximum width of the sinuses of Valsalva diameter might be a few millimeters larger than the aorta. So if we are talking about... 3.5 centimeters for the ascending aorta, we can accept up to 4 centimeters at the level of the sinuses of Valsalva. And when we are looking at the sinuses of Valsalva, we should look, and it's part of the assessment of the aorta, at the aortic valve, because we can appreciate bicuspid versus tricuspid valve, which is a very important piece of information while assessing aorta, and especially aortic aneurysm and potential aortic dissection. So let's talk about the thoracic aortic aneurysm, which We talked about how we measure it. We talked about the aortic anatomy. And we have to remember that the etiology of the aneurysms differ between the ascending aorta and descending aorta. Actually, within the ascending aorta, it's very rare to find an aneurysm that would be due to atherosclerotic disease. Usually, it's either inherited connective tissue disorders or bicuspid valves like the one I just showed you, our titers, or the idiopathic non-inflammatory aneurysms very often ascend. associated with hypertension. Atherosclerosis is the one that you will see in the descending aorta with the huge plaques and calcifications and the very ugly appearance of the aneurysm. It also could be chronic dissection, type B chronic dissection in the descending aorta or aortitis that actually can affect both ascending and descending aorta. So let's take a look at a couple of examples. We're looking now at the ascending aortic aneurysm. This is Marfan disease. And here is a reminder why it's so important for... us to look at the sinus tubular junction and to appreciate if it's preserved or not. You can see here this appearance of the ascending aorta, very bulbous. Some people call it onion bulb. The other ones who are more poetic will call it a tulip bulb. Doesn't matter. Still we see that the sinus tubular junction is gone, and that's very classic for Marfan disease. As opposite, for example, for this idiopathic aneurysm of the ascending aorta, where we can appreciate this dilated aorta, ascending aorta, but we can can see that the sinutribular junction is preserved. This is a case of the bicuspid uric valve. Just to show how we can appreciate it, and we know that in this particular case, this is the association with the extending aortic aneurysm. And here you can see a case of aortitis, probably one of the most classic ones I could find. You can see... the aneurysm and you can see the thickening of the aorta at the level of the ascending aorta. And if we look closely, we can see that it also involves pulmonary artery. So this is in our titus, a case of a Takayasu that involves both. Let's look at the descent. descending aorta, we can see the classic atherosclerotic aneurysm, large plaque, calcifications, very irregular appearance of the plaque, classic descending atherosclerotic aneurysm, a case of classic dissection, and I say classic because we see two lumens, true and false, and we can see even a little bit of contrast getting into the false lumen, and again, another case of aortitis, where both ascending and descending aorta are distended. Thank you. If we are talking about artitis just for a moment, and I really try to think about artitis for this particular lecture as a case that might lead to an aneurysm, we are looking at a few points. We are looking at the aortic wall thickening, we are looking at the diameter of the aorta, and we are looking at the potential narrowing or stricture. Now, imaging is very rarely done for artitis as a primary diagnosis. It's usually just one of the diagnostic methods, and there are no specific protocols or techniques. techniques that we use specifically to image aortic arthritis. When we have a high level of suspicion, we can identify that. And then we have other clues that can help us. We can look at the delayed MRI imaging, like in this case with giant cell arteritis, or at the PET-CT. Both will show us abnormality within the wall consistent with aortic arthritis. So how do we report it? When you report the aortic aneurysm, you have to talk about the width, the length, and the relationship to the aortic arch branches. again the sino-tubular junction is very important we talk about the atherosclerotic disease aortic wall thickness and the presence of strictures and at the end we can suggest the potential etiology of this particular aneurysm let's now switch gears and talk about acute aortic syndrome again another huge topic just a couple of points i would like to make what is the acute aortic syndrome those four entities okay starting with classic dissection and going all the way to penetrating atherosclerosis ulcer. The heterogenic and traumatic dissection, it's part of the syndrome, but different entity in terms of pathophysiology. Again, anatomy is very important. When we are looking at the classic dissection, we have to be familiar with the classification, type A versus type B, involvement versus no involvement of the ascending aorta. And when you're looking at the flap extension, it's very important to see where the flap goes, not where it starts, because the flap can go, can start in the... the descending aorta, but go in retrograde fashion into the ascending aorta, that would make it a type A dissection. You can suspect dissection, even on a non-contrast imaging. You can see those classifications in the middle of the lumen of the aorta. So that should ring a bell in your head and kind of create a suspicion of what's going on here. And after you give contrast, you see that this is the intimal flap and this is a dissection. Type A dissection involving ascending aorta, this is a case of Marfan, by the way, if you look again at the appearance of the ascending aorta, and type B dissection involving the descending aorta. Complications. This is the next thing you're in your head mentally doing a checklist of. So we're looking, first of all, of a rupture, like you can see here, active extravasation. We're looking for hemopericardium or hemothorax, the three major complications that we are so afraid of. We are also looking into the pulmonary artery dissection, because if there is a type A section of the aorta through the adventitiate can go and involve pulmonary artery, like in this case. And the dissection, if involves pulmonary artery, usually will go all the way into the lung parenchyma because pulmonary artery does not have that much resistance to sort of fight back the dissection. It will go all the way into the parenchyma. Involvement of the aortic branches, another important topic to look at, and also compression of the true lumen. Sometimes full lumen will continue to expand until it compresses substantially the true lumen. that impairs the perfusion of the organs. This is just one of the suggested templates for reporting. You can find it, this lecture is recorded, you can find it online. I'm not going to go into details. But it doesn't matter what structure you adopt. As long as you have a systematic assessment of everything we just talked about, then the report will be fulfilling in what your clinician will be expecting from you to give you. Intramural hematoma. A very interesting animal. We know now, because we see the intramural hematomas more often associated with small intramural flaps, that actually the intramural hematoma might originate from a small intramural tear. Like in this case, you can see the intramural hematoma that's crescenting hyperdensity. After you give contrast, you can appreciate those small focal areas of contrast within the intramural hematoma. So there is a communication, there is a tear. that leads actually to intramural hematoma. And although there is no flow and there is no really a defined lumen, the complications of intramural hematoma might be devastating. And one of the more frequent ones is actually the haemopericardium. Sometimes in some studies considered to be more often associated with intramural hematoma than with actually type A dissection. So be aware of intramural hematoma. Suspect it. It's better over-diagnose it than under-diagnose it. and think about the potential complications. The last but not least is the penetrating atherosclerotic ulcer. This is part of acute aortic syndrome, and very often the clinical presentation is identical to dissection patients present with sharp chest pain that started. And on imaging, what we are looking for is the atherosclerotic disease with a lesion, with a penetration. of the internal elastic lamina and very often the acute cases are associated almost invariably they are associated with intramural hematoma. The difficulty when diagnosing those comes from the two entities. One of them is the complex atherosclerotic plaque. So complex atherosclerotic plaque has a lot of similarity in appearance on the first glance but when we look really closely we see a major difference. With penetrating atherosclerotic ulcer the ulcer is going outwards. The ulcer is going outside of the vessel, into the wall and out, disturbing the contours and essentially being within the wall. With the atherosclerotic plaque, the pathology is within the lumen. The pathology is within the lumen and there is no distortion of the contours of the aorta. Another important distinction to make, which is not always possible, is between the PAU, penetrating ulcer, and false aneurysm. This is a PAU, we all agree. This is a false aneurysm, we all agree. Now let's look at those three cases. You know, this is, I think everybody will agree, is a penetrating ulcer. Now this is definitely an aneurysm, but what is this? We don't know exactly what is that, so this is probably in between. Now is that important? Yes and no. It's important to think about it, but if you think about our recommendations, Both of those have to be very closely followed with imaging. So we can suggest both and recommend a close imaging follow-up. Okay? In summary, high-quality CT imaging, especially with ECG gating, is what we currently need to really precisely assess all the pathologists within the aorta. We have to be familiar with the anatomy of the aorta. It helps us to suggest the appropriate pathology and etiology of what we see, especially for the aneurysms. We have to be familiar with the spectrum with atherosclerotic diseases in the aorta, and we have to remember that the structured reporting has to go along all those findings that we detected in the way that it describes the entire picture for the referring physician. Thank you very much.

Ending out the session with another live lecture. This is going to be from Diana Ludmanovich. The topic is CT imaging interpretation of common thoracic aortic pathology. Good morning.

And for those who are not here, East Coast. Good afternoon. It's my pleasure to be here and to talk today about a topic which is very close to my heart, thoracic aortic pathology. Now, it's a huge topic and there are meetings of several days which are just... devoted to that very one topic.

So what I'm going to do today, I'm not going to try to cover everything. I'm going to talk about potential tips that you as the newcomers to the world of radiology might find beneficial. Okay, so we're going to talk about how we image the aorta.

We're going to talk a little bit about the important points in thoracic aortic anatomy. And we're going to talk about specific points in interpretation and the reporting of. some of the common aortic pathologies. So let's start with imaging. So we can image aorta with four different approaches.

If you think about it conceptually, it could be a regular non-contrast enhanced chest CT. Can we see the aorta? Of course we can.

We can do it after we administer contrast. So we will see aorta after administration of IV contrast. We can image the aorta with gating without giving contrast. and we can image the aorta with ECG gating and afterward ministered contrast. And each one of those definitely has a role in imaging of the aorta.

I think we all would agree by just looking at those four images that adding gating to the imaging of the aorta gives us a very precise and sharp assessment of the aorta, which is very important for assessing the size of the aorta, which is very important for assessing the mural pathology. Now, the ECG gating... gating without contrast has its own important role in one particular case scenario, which is assessing the intramural hematoma, and I'll talk about that later. But just conceptually, there are four ways to image aorta.

Now, if we are talking about the ideal imaging, which is ECG-gated imaging of the aorta, it has to have both non-contrast and contrast-enhanced components. That gives us the maximum information from the CT standpoint, okay, not from MRI. But from the CT standpoint, those are the two that give us all the information we can extract from this type of imaging.

Let's talk a little bit about anatomy. Obviously, you're all very familiar with the anatomy of the aorta. We learn it from high school or from middle school.

We go through that in the medical school. There are three very important points in the anatomy of the aorta that I would like you to remember before you start analyzing the pathology or the imaging of the aorta. The first...

The first point is how we divide the aorta into the ascending aorta and the descending aorta. And I find it sometimes a little bit mixed up. So the classic definition and the right definition of the ascending aorta is the aorta that starts at the level of the aortic valve and continues up to this point, right before the origin of the brachiocephalic artery.

So this is our ascending aorta. Within the ascending aorta, there are two important points. important anatomical landmarks. One is the senotubular junction. This is a junction between the sinuses of Valsalva and the aorta.

And this is an important point to assess to see if it's there, if it's preserved. Why? I'll tell you in a second.

And the other one are the actual sinuses of Valsalva and their maximal width. Because in addition to assessing the aorta, we have to look specifically into the sinuses of Valsalva. assess their size. Now, if we are talking about the aortic arch, the aortic arch, which is part of the descending aorta, starts at the origin of the brachiocephalic artery and continues all the way down into the abdomen.

Now, some teachings and some approaches designate thoracic aortic arch as an asterisk. And there was a great publication by Dr. Charlie White in college. and he's a younger colleague, I'm blanking on his name, who was talking about it.

And sometimes it is important to mention that we are not talking just about descending aorta, but about aortic arch. But if we are talking about ascending versus descending, this is our landmark. So, synotribular junction, the landmark between ascending and descending, and the sinuses of Valsalva.

The size of the aorta is very important. Now, as you can see... see from this diagram from this table and as you know from real practice People have different sizes of the aorta. It varies between males and females.

Males tend to have a little bit higher aortic diameter. It also varies along the aorta. should only get smaller as we move from the ascending towards the descending and we also know that the maximum diameter of the aorta will also be at the level of of the sinuses of Valsalva. That changes over time. Aorta gets bigger with age, same as pulmonary arteries, for example, but the aorta does get bigger with age and the aorta does get bigger with BMI sometimes just because of the BMI.

If we compare people with different BMI and sometimes as people change their BMI across the lifetime and their BMI is getting bigger and the aortic diameter is getting larger. But if we look at the diameter of the aorta, we can see that the of the aorta, it's clear to us that regardless of age and regardless of gender, the aortic diameter should not exceed four centimeters. And four centimeters is, I'm being sort of very flexible.

Some people say that it's 3.5 centimeters, but if you see the aorta, which is above four centimeters in diameter, it's definitely dilated. Okay. How do we measure it?

Before we talk about the diameter, we have to measure it. So if we are talking about measuring aorta, especially the ascending aorta, aorta. We have to do it with a double oblique technique. Double oblique technique gives us the ability to measure perpendicular to the axis of the blood flow, and it's extremely important in the ascending aorta. The ascending aorta is a little bit usually more straight going without turns, but if we're measuring the ascending aorta, we must do it with a double oblique technique.

This is an example why double oblique technique is so important. This is one of the probably most pronounced cases of... aortic tortuosity.

And you can appreciate that if we would just measure along the axial plane, our measurement at this level would be approximately 11 centimeters as opposite to the true measurement that would be perpendicular to the true long axis of the aorta and would be still large, but about seven centimeters. So it's very important to precisely measure the aorta because when we are talking about aortic aneurysms... and aortic aneurysms grows, we are talking about millimeters over a long period of time. So very precise measurements are extremely important. This is another important point that I was talking about earlier, the sinuses of Valsalva.

We measure the maximum width of the sinuses of Valsalva, and we know that the maximum width of the sinuses of Valsalva diameter might be a few millimeters larger than the aorta. So if we are talking about... 3.5 centimeters for the ascending aorta, we can accept up to 4 centimeters at the level of the sinuses of Valsalva. And when we are looking at the sinuses of Valsalva, we should look, and it's part of the assessment of the aorta, at the aortic valve, because we can appreciate bicuspid versus tricuspid valve, which is a very important piece of information while assessing aorta, and especially aortic aneurysm and potential aortic dissection. So let's talk about the thoracic aortic aneurysm, which We talked about how we measure it.

We talked about the aortic anatomy. And we have to remember that the etiology of the aneurysms differ between the ascending aorta and descending aorta. Actually, within the ascending aorta, it's very rare to find an aneurysm that would be due to atherosclerotic disease.

Usually, it's either inherited connective tissue disorders or bicuspid valves like the one I just showed you, our titers, or the idiopathic non-inflammatory aneurysms very often ascend. associated with hypertension. Atherosclerosis is the one that you will see in the descending aorta with the huge plaques and calcifications and the very ugly appearance of the aneurysm.

It also could be chronic dissection, type B chronic dissection in the descending aorta or aortitis that actually can affect both ascending and descending aorta. So let's take a look at a couple of examples. We're looking now at the ascending aortic aneurysm. This is Marfan disease. And here is a reminder why it's so important for...

us to look at the sinus tubular junction and to appreciate if it's preserved or not. You can see here this appearance of the ascending aorta, very bulbous. Some people call it onion bulb.

The other ones who are more poetic will call it a tulip bulb. Doesn't matter. Still we see that the sinus tubular junction is gone, and that's very classic for Marfan disease.

As opposite, for example, for this idiopathic aneurysm of the ascending aorta, where we can appreciate this dilated aorta, ascending aorta, but we can can see that the sinutribular junction is preserved. This is a case of the bicuspid uric valve. Just to show how we can appreciate it, and we know that in this particular case, this is the association with the extending aortic aneurysm. And here you can see a case of aortitis, probably one of the most classic ones I could find. You can see...

the aneurysm and you can see the thickening of the aorta at the level of the ascending aorta. And if we look closely, we can see that it also involves pulmonary artery. So this is in our titus, a case of a Takayasu that involves both. Let's look at the descent. descending aorta, we can see the classic atherosclerotic aneurysm, large plaque, calcifications, very irregular appearance of the plaque, classic descending atherosclerotic aneurysm, a case of classic dissection, and I say classic because we see two lumens, true and false, and we can see even a little bit of contrast getting into the false lumen, and again, another case of aortitis, where both ascending and descending aorta are distended.

Thank you. If we are talking about artitis just for a moment, and I really try to think about artitis for this particular lecture as a case that might lead to an aneurysm, we are looking at a few points. We are looking at the aortic wall thickening, we are looking at the diameter of the aorta, and we are looking at the potential narrowing or stricture. Now, imaging is very rarely done for artitis as a primary diagnosis. It's usually just one of the diagnostic methods, and there are no specific protocols or techniques.

techniques that we use specifically to image aortic arthritis. When we have a high level of suspicion, we can identify that. And then we have other clues that can help us.

We can look at the delayed MRI imaging, like in this case with giant cell arteritis, or at the PET-CT. Both will show us abnormality within the wall consistent with aortic arthritis. So how do we report it?

When you report the aortic aneurysm, you have to talk about the width, the length, and the relationship to the aortic arch branches. again the sino-tubular junction is very important we talk about the atherosclerotic disease aortic wall thickness and the presence of strictures and at the end we can suggest the potential etiology of this particular aneurysm let's now switch gears and talk about acute aortic syndrome again another huge topic just a couple of points i would like to make what is the acute aortic syndrome those four entities okay starting with classic dissection and going all the way to penetrating atherosclerosis ulcer. The heterogenic and traumatic dissection, it's part of the syndrome, but different entity in terms of pathophysiology. Again, anatomy is very important. When we are looking at the classic dissection, we have to be familiar with the classification, type A versus type B, involvement versus no involvement of the ascending aorta.

And when you're looking at the flap extension, it's very important to see where the flap goes, not where it starts, because the flap can go, can start in the... the descending aorta, but go in retrograde fashion into the ascending aorta, that would make it a type A dissection. You can suspect dissection, even on a non-contrast imaging. You can see those classifications in the middle of the lumen of the aorta. So that should ring a bell in your head and kind of create a suspicion of what's going on here.

And after you give contrast, you see that this is the intimal flap and this is a dissection. Type A dissection involving ascending aorta, this is a case of Marfan, by the way, if you look again at the appearance of the ascending aorta, and type B dissection involving the descending aorta. Complications. This is the next thing you're in your head mentally doing a checklist of. So we're looking, first of all, of a rupture, like you can see here, active extravasation.

We're looking for hemopericardium or hemothorax, the three major complications that we are so afraid of. We are also looking into the pulmonary artery dissection, because if there is a type A section of the aorta through the adventitiate can go and involve pulmonary artery, like in this case. And the dissection, if involves pulmonary artery, usually will go all the way into the lung parenchyma because pulmonary artery does not have that much resistance to sort of fight back the dissection. It will go all the way into the parenchyma.

Involvement of the aortic branches, another important topic to look at, and also compression of the true lumen. Sometimes full lumen will continue to expand until it compresses substantially the true lumen. that impairs the perfusion of the organs.

This is just one of the suggested templates for reporting. You can find it, this lecture is recorded, you can find it online. I'm not going to go into details.

But it doesn't matter what structure you adopt. As long as you have a systematic assessment of everything we just talked about, then the report will be fulfilling in what your clinician will be expecting from you to give you. Intramural hematoma.

A very interesting animal. We know now, because we see the intramural hematomas more often associated with small intramural flaps, that actually the intramural hematoma might originate from a small intramural tear. Like in this case, you can see the intramural hematoma that's crescenting hyperdensity.

After you give contrast, you can appreciate those small focal areas of contrast within the intramural hematoma. So there is a communication, there is a tear. that leads actually to intramural hematoma.

And although there is no flow and there is no really a defined lumen, the complications of intramural hematoma might be devastating. And one of the more frequent ones is actually the haemopericardium. Sometimes in some studies considered to be more often associated with intramural hematoma than with actually type A dissection. So be aware of intramural hematoma.

Suspect it. It's better over-diagnose it than under-diagnose it. and think about the potential complications. The last but not least is the penetrating atherosclerotic ulcer.

This is part of acute aortic syndrome, and very often the clinical presentation is identical to dissection patients present with sharp chest pain that started. And on imaging, what we are looking for is the atherosclerotic disease with a lesion, with a penetration. of the internal elastic lamina and very often the acute cases are associated almost invariably they are associated with intramural hematoma. The difficulty when diagnosing those comes from the two entities.

One of them is the complex atherosclerotic plaque. So complex atherosclerotic plaque has a lot of similarity in appearance on the first glance but when we look really closely we see a major difference. With penetrating atherosclerotic ulcer the ulcer is going outwards. The ulcer is going outside of the vessel, into the wall and out, disturbing the contours and essentially being within the wall. With the atherosclerotic plaque, the pathology is within the lumen.

The pathology is within the lumen and there is no distortion of the contours of the aorta. Another important distinction to make, which is not always possible, is between the PAU, penetrating ulcer, and false aneurysm. This is a PAU, we all agree. This is a false aneurysm, we all agree. Now let's look at those three cases.

You know, this is, I think everybody will agree, is a penetrating ulcer. Now this is definitely an aneurysm, but what is this? We don't know exactly what is that, so this is probably in between. Now is that important? Yes and no.

It's important to think about it, but if you think about our recommendations, Both of those have to be very closely followed with imaging. So we can suggest both and recommend a close imaging follow-up. Okay?

In summary, high-quality CT imaging, especially with ECG gating, is what we currently need to really precisely assess all the pathologists within the aorta. We have to be familiar with the anatomy of the aorta. It helps us to suggest the appropriate pathology and etiology of what we see, especially for the aneurysms.

We have to be familiar with the spectrum with atherosclerotic diseases in the aorta, and we have to remember that the structured reporting has to go along all those findings that we detected in the way that it describes the entire picture for the referring physician. Thank you very much.

Transcript for:CT Imaging for Thoracic Aortic Pathology

Transcript for:
CT Imaging for Thoracic Aortic Pathology