European Heart Journal - Cardiovascular Imaging Advance Access published October 29, 2012

European Heart Journal – Cardiovascular Imaging REVIEW

doi:10.1093/ehjci/jes215

The role of imaging in acute aortic syndromes

Christoph A. Nienaber*
Divisions of Cardiology, Pulmology and Intensive Care Unit, Department of Internal Medicine I, Heart Center Rostock, Rostock School of Medicine, University Hospital Rostock,
Ernst-Heydemann-Str. 6, 18057 Rostock, Germany

Received 14 August 2012; accepted after revision 24 September 2012

Downloaded from http://ehjcimaging.oxfordjournals.org/ at University of California, Davis on December 4, 2012

The classic entity of life-threatening aortic dissection represents one pathology of a spectrum of acute conditions coined the acute aortic
syndrome comprising dissection, intramural haematoma, penetrating atherosclerotic ulcer, and contained aortic rupture of any cause. The
common denominator is disruption of the aortic media layers associated with severe pain and a variety of other symptoms. Any clinical
suspicion of acute aortic syndrome should prompt immediate action and confirmatory non-invasive imaging; with respect to sensitivity and
specificity for acute aortic pathology modern contrast-enhanced CT technology, MR imaging and ultrasound techniques have similar diag-
nostic accuracy near 100%. Since the prognosis of most patients with acute aortic dissection is related to undelayed diagnosis and (often
surgical) treatment swift diagnostic imaging should be the primary goal in the work-up of any patient with suspected acute aortic syn-
drome; transfer and in-hospital logistics and local expertise for the differential use of various imaging modalities should be constantly
improved.
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Keywords Aortic dissection † CT angiography † MRI † Diagnostic algorithm

for classic dissection and in Class 2 for intramural haematoma is

Introduction
Acute aortic syndrome is a modern term and consists of inter-
related emergency conditions with similar clinical characteristics
and challenges. These conditions include aortic dissection, intra-
mural haematoma (IMH), penetrating atherosclerotic ulcer (PAU
and aortic rupture); trauma to the aorta with intimal laceration
may also be considered. The common denominator of AAS is dis-
ruption of the media layer of the aorta with bleeding within the
layers as IMH, along the wall of the aorta resulting in separation
of the layers of the aorta (dissection), or transmurally through
the wall in the case of ruptured PAU or trauma.1,2 In the majority
of patients (90%), an intimal disruption is present that results in
tracking of the blood in a dissection plane within the media poten-
tially rupturing through the adventitia or back through the intima
into the aortic lumen (Figure 1). Relatively simple classification
systems are still being used to share both descriptive and prognos-
tic information in scenarios of aortic dissection (Figure 2).3,4 The
Stanford classification divides aortic dissection in type A and
B. Type A involves the ascending aorta, and eventually progresses
distally. Type B dissection starts at the level of the descending
aorta. The DeBakey classification distinguishes types I, II, and III,
with type I involving both the ascending and descending aorta,
type II only the ascending aorta and the arch, and type III sparing
the ascending aorta and the arch. Further subdivision in Class 1
less popular.
Confirmatory imaging for acute
aortic syndrome
Diagnostic imaging studies in the setting of the clinical suspicion of
dissection have important primary goals such as confirmation of
clinical suspicion, classification of dissection, localization of tears,
and the assessment of both extent of dissection and indicators
of urgency (e.g. pericardial, mediastinal, or pleural hemorrhage);
in addition biomarkers (such as myocardial markers, D-dimer eleva-
tion .500 mg/L, and smooth muscle myosin heavy chain) may be
used strategically in concert with swift aortic imaging, although an
ideal algorithm has yet to be determined.5 – 10 A concise selection
of imaging modalities is summarized in Table 1. The suspicion of
acute aortic syndrome is high with abrupt or severe retrosternal
or interscapular chest pain often migrating down the back; asso-
ciated findings can produce signs of acute aortic insufficiency, peri-
cardial effusion, or occluded aortic sidebranches causing ischaemia
or pulse differential. With predisposing factors, such as hyperten-
sion, connective tissue disorders, bicuspid aortic valve, coarctation,
and previous cardiac surgery or recent percutaneous instrumenta-
tion, undelayed diagnostic imaging is required for any of the above

* Corresponding author. Tel: +49 0381 494 77 00; fax: +49 0381 494 77 02, Email: christoph.nienaber@med.uni-rostock.de
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email: journals.permissions@oup.com
Page 2 of 9
Figure 1 Schematic of aortic dissection (left), penetrating ulcer (middle), and intramural haematoma (IMH) (right) all causing acute aortic
syndrome.
Figure 2 Aortic dissection classification: DeBakey and Stanford classification as the currently most frequently used classification systems for
aortic dissection.
symptoms. While transthoracic ultrasound provides vital informa-
tion (new-onset aortic insufficiency, pericardial effusion, or even
visualization of proximal dissection), additional transoesophageal
(TOE) interrogation of the thoracic aorta is the logical next step,
or MD-CT scanning of the entire aorta if considered safe.11 – 15
Both imaging modalities provide further detail beyond classification
as type A and B (or distal) dissection and allow for strategic plan-
ning; ultrasound technology is portable, avoids transport of a crit-
ically ill patient and may even be hold in the operating theatre15.
MRI has no place in urgent diagnostic work-up of acutely symp-
tomatic patients. Additional information not essential for immedi-
ate management decisions such as coronary, arch vessel, and
side-branch involvement is usually depicted on CT angiograms
C.A. Nienaber
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without the need for invasive angiography even in the presence
of ST changes.
Choice of imaging modality
Considering the excellent accuracy of all modalities, imaging proto-
cols for both chronic and suspected acute aortic diseases should
adapt to local expertise and to specific questions about the
target of interest.11,12,16 For unstable patients with suspected
aortic syndromes in the emergency room often unfit for transpor-
tation, bedside echocardiographic techniques combined with
transoesophageal echogram and colour-Doppler interrogation
have first priority, even though abdominal segments of the aorta
Role of imaging in acute aortic syndromes Page 3 of 9

Table 1 Diagnostic Algorithm (Aortic Dissection).

Clinical suspicion of AAS

...............................................................................................................................................................................
Non-imaging exams Unstable/critical conditions Follow-up evaluation
...............................................................................................................................................................................
Compulsory: TEE with the colour-Doppler MRI with Gd enhancement
ECG, chest radiography, biomarkers MD-CT with CT angiography MR angiography (with or without Gd)
(TNT, TNI, D-dimer .500 mg/L) 3D reconstruction
Virtual angioscopy
Stable clinical condition
Optional: TEE with the colour-Doppler flow MRI with Gd enhancement
ECG, chest radiography, biomarkers MD-CT with CT angiography or MRI with MR angiography (with or without Gd)
(TNT, TNI, and D-dimer) MR angiography 3D reconstruction
Angiography rarely required Virtual angioscopy

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AAS, acute aortic syndrome; TNT, troponin t; TNI, troponin I; MD-CT, multidetector computer tomography; Gd, gadolinium; TEE, transoesophageal echocardiography.

Figure 3 Stanford type B aortic dissection on volume-rendered 64-slice CT angiography with severly compressed true lumen (TL) and
expanded false lumen (FL). Axial slices are displayed in the centre. The proximal entry to the dissection (black arrow) is adjacent to the offspring
of a Lusorian artery (white arrow).

may not be seen from standard subcostal views.1,3,8 Conversely,
rapid acquisition CT technology using 16-, 64-, and even
256-slice CT scanners has essentially replaced invasive diagnostic
angiography for large- and medium-sized vessels of both the
chest and the abdomen (Figure 3). The technology is robust and
rapidly performed with high spatial resolution to differentiate intra-
mural haematoma from ulcers and dissection of the aorta, but
requires transportation and stable haemodynamic conditions.13,14
MR angiography (MRA) is also capable of high-resolution aortic
imaging with three–dimensional post-processing; delayed imaging
allows the evaluation of venous structures without additional con-
trast. The ability to image thin intimal flaps, intramural processes,
and the morphology of aortic wall inflammation may offer new
insight into vascular disease detection and classification. Indeed,
intramural haematoma and asymptomatic aortic flaps, aortic
ulcers, and aneurysms are reported at increasing frequency with
access to tomographic imaging.8,17
In contrast to both CT and MR technology, modern ultrasound
equipment is mobile and especially attractive at the bedside for un-
stable cases. TEE interrogation added to transthoracic suprasternal
screening ultrasound is superb for acute aortic dissection (type A)
even intraoperatively with near perfect sensitivity and specifi-
city,12,15 even considering a blind spot at the proximal arch from
bronchial air. Colour Doppler is instrumental to assess entry
sites and false lumen flow in real time in order to confirm proximal
dissection (Figure 5). In addition, important prognostic information,
such as pericardial effusion, acute aortic regurgitation, and prox-
imal coronary obstruction, can be visualized. For patients in
Page 4 of 9
Figure 4 (A) Coronal MIP 3D MR-angiogram shows significant stenosis of the right common carotid artery (small arrow). The left subclavian
artery reveals two stenotic segments (large arrows) with some post-stenotic irregularities of the left common carotid artery. Axial unenhanced
(C) and gadolinium-enhanced (B) T1-weighted MR-images show wall thickening of the ascending aorta (arrows).
shock and very high clinical suspicion of ascending aortic
dissection, transthoracic echocardiography (TTE) alone seems rea-
sonable prior to surgery, with TEE performed prior to sternotomy
even in the operating room. Although both ultrasound techniques
are important bedside tools for acute dissection, both fail to
provide sufficient anatomic detail to plan endovascular
interventions.13
Catheter-based and digital subtraction angiography as well as
ultrasound-based techniques have recently been replaced by
contrast-enhanced CT and MRA; MRA requires no iodinated con-
trast or ionizing radiation, allows three-dimensional multiplanar ac-
quisition, and is particularly useful for patients unable to tolerate
contrast due to allergy or renal failure. With acute aortic dissection
linked to young patients with fibrillinopathies, diagnostic evaluation
during pregnancy and lactation becomes an issue. Whereas foetal
radiation exposure needs to be avoided (in the initial 20 weeks
of pregnancy) for teratogenic and carcinogenic reason,18 any
iodine component of contrast media given during pregnancy has
potential to initiate neonatal hypothyroidism. Even with MR con-
trast agents a minimal teratogenic risk cannot be excluded since
paramagnetic agents like gadolinium cross the placenta with
unknown long-term effects. Although exposure during the first tri-
mester has not been associated with an adverse impact on the
foetus, controversy is ongoing. While European guidelines consider
gadolinium ‘probably safe during pregnancy’ since distributed
extracellularly and eliminated into urine, most centres in the
USA discourage gadolinium during pregnancy in fear of retention
in amniotic fluid and toxicity.19 For suspected aortic disease in
pregnancy, non-contrast MRI using steady-state free precession
(SSFP) techniques ensures both maximum safety and high diagnos-
tic precision.20
C.A. Nienaber
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Specific considerations in the
choice of a modality
MRA is not as severely affected by calcification as is CT. Heavily
calcified arteries may still induce an artefact on MR angiograms,
but luminal narrowings and intramural haematoma are depicted
even in the presence of atherosclerotic calcification. Thus, MRA
is better suited for evaluating occlusive disease of medium-sized ar-
teries and, therefore, modality of choice for patients with lower or
upper extremity vascular disease (Figure 4). Despite easier post-
processing MRA has lower spatial resolution than CT and images
are sensitive to metal (implanted clips or stents) causing distortion
and artefact. Patients with pacemakers, defibrillators, or older
mechanical valves are confined to CT angiography (contraindica-
tions for MRI). CT is less sensitive to small implants, but large me-
tallic objects, such as hip prostheses degrade image quality. With
recent scanners complex vessel morphology as seen in dissections,
irregular aneurysms, and vascular tortuosity is better delineated
ECG gated by CT, whereas MR imaging may produce an artefact
in areas of the turbulent blood flow. 21,22 In cases of iodinated con-
trast allergy, CT angiography can also be performed after i.v. injec-
tion of gadolinium (60–80 mL); although gadolinium provides less
intense enhancement, diagnostic images are feasible. The status of
branch arteries and quantitative morphology of both aneurysm or
dissection on CT or MRI is essential for strategic planning and thus
either modality is recommended prior to endovascular repair of
aneurysm and dissection.13,22
Both MR and CT angiography are useful for extra-aortic path-
ologies, often vascular in nature such as mycotic aneurysms or
traumatic pseudoaneurysm, and even for inflammatory vascular
disease. Moreover, the loss of elastic properties, aortic shear
Role of imaging in acute aortic syndromes
Figure 5 Diagnosis of type A aortic dissection by TEE with arrows pointing to the intimal flap (left) and surgical treatment options (right). FL,
false lumen; TL, true lumen.
stress, and increased wall tension can be quantified with flow-
sensitive MR sequences. For serial follow-up after surgical or endo-
vascular repair, three-dimensional MRI sequences are preferred
particularly when stent-graft components consist of nitinol; in
the presence of stainless steel MD-CT is better to identify endo-
leak or confirm complete isolation of an aneurysm since steel
causes MRI artefact from magnetic disturbances.
CT angiography of the aorta
Whereas invasive angiography visualizes two-dimensional lumino-
grams, non–invasive multi-detector CT is the result of rapid
image acquisition and three-dimensional reconstruction in high
resolution during brief contrast opacification. The technical evolu-
tion with MD-CT was the cone-shaped X-ray beam generating
image data over a volume, rather than from an axial section per ro-
tation, being displayed as three –dimensional image along the cen-
treline of the flow (useful for evaluating vascular disease
morphology and planning endovascular procedures). The ability
to view vessels in multiple projections and orientations helps
evaluating three –dimensional anatomy of the aorta accentuated
by tortuosity, dilation, or spiralling dissection (Figure 3). The
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advantages of modern CT include rapid image acquisition,
post-processing flexibility, and less image noise resulting in high-
definition CTA from the neck to the abdomen in ,20 s. A signifi-
cant drawback of MD-CT is a radiation dose of 10 –25 mSv,
especially of concern in young patients often subject to serial car-
diovascular imaging.12,14,23
In suspected acute aortic syndrome, a non-contrast scan
through the chest is useful to screen for acute haemorrhage or
intimal vascular calcifications, particularly in the aortic wall (intra-
mural haematoma or separation of wall layers). Subsequently, to
facilitate three-dimensional reformatting a thin (1 mm) scan is
acquired during rapid bolus administration of contrast at
4 –5 mL/s. Since vascular imaging is dependent on the iodine flux
(iodine concentration multiplied by the flow rate) excellent vascu-
lar images require injections via venous catheters or implanted
ports.24 Arterial phase imaging has to coincide with arterial con-
trast opacification; delayed venous phase imaging is also useful to
evaluate solid organs for mass lesions or for endoleaks in patients
with stent-grafts (by the use of three-dimensional multi-planar re-
construction). In aortic sidebranches such as coronaries or renal
arteries, CT angiography tends to overestimate calcified stenoses
and underestimate luminal narrowing by a non-calcific plaque,
Page 6 of 9
potentially relevant when correlating clinical signs with imaging
findings. Occasionally, CT artefacts occur in obese or uncoopera-
tive patients with noise and motion causing image distortion. ECG-
gated CT acquisition can improve image quality especially in the
aortic root, where pulsation artefacts are common and likely to
mimic dissection. Meanwhile, first reports emphasize the potential
of virtual vascular endoscopy based on gated acquisition for both
detailed anatomic evaluation and therapeutic guidance. 25,26
Ultrasound/transoesophageal
echocardiography
TTE has limited value for the evaluation of the entire aorta, but
is highly useful in identifying aortic valve dysfunction, pericardial
tamponade or wall motion abnormalities, and may screen for
proximal and descending aortic dissection in patients with
shock in the emergency room. It is limited, however, in visualiz-
ing the distal ascending and transverse aorta. Advantages of TEE
for the detection of acute aortic syndromes result from close
proximity of the oesophagus to the thoracic aorta and its
ability to visualize both the ascending and the descending aorta
and parts of the arch with high spatial resolution in real time.
Although TEE requires oesophageal intubation, it is portable
and images are acquired at bedside and immediately interpreted
(Figure 5). Aortic dissection is confirmed when two lumens are
separated by an intimal flap visualized within the aorta. Tears
can be identified and differentiation between true and false
lumen is often easy and diagnostic with optional colour-Doppler
flow mapping or contrast ultrasound27; intimal tear(s) can be
localized in the majority of patients.7,8 Furthermore, variants of
acute aortic syndromes such as IMH, atherosclerotic penetrating
ulcers, and side-branch obstruction can also be identified.17
Overall, the European Cooperative Study Group and others
showed that TEE can reach a sensitivity of 99% with a specificity
of 89%, positive-predictive accuracy of 89%, and negative predict-
ive accuracy of 99% findings later confirmed in IRAD.1,2,11 Al-
though TEE is swiftly performed in unstable patients at
bedside, an experienced operator is needed for image acquisition
Figure 6 Magnetic resonance spin-echo images in a patient with intramural haematoma identified by arrows of the ascending and descending
thoracic aorta: Acute phase T1-weighted SE images show circular wall thickening of the ascending and descending aorta (A); T2-weighted images
show high signal intensity indicative of fresh intramural blood (B). In the subacute phase, the formation of methaemoglobin within the aortic wall
is identified by high signal intensity in T1-weighted SE sequences (C).
C.A. Nienaber
and interpretation. Yet, the adjunctive use of colour-Doppler in-
terrogation is instrumental to confirm the blood flow in both
true and false lumen, to identify communication sites, to visualize
dynamic side-branch obstruction and other aortic emergencies15;
in selected cases contrast-enhanced echocardiography (including
TEE) may facilitate the differentiation of true and false lumen27,28
and three-dimensional echograms may soon further improve
image interpretation. TEE is limited in assessing abdominal side
branches and unpleasant for patients who cannot tolerate
topical anaesthesia or conscious sedation. Given these issues,
and considering availability, excellent quality, and scanning
speed of multi-detector CT angiography, TEE may be advanta-
geous for urgent cases of suspected type A dissection. Never-
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theless, TEE is an important imaging adjunct to perform
endovascular stent-grafting in complicated type B dissection
and to document immediate procedural success.27
Magnetic resonance imaging of the
thoracic aorta
MRA is a complementary, rather than competing imaging modality
for the thoracic aorta. With neither ionizing radiation, nor iodi-
nated contrast required, MRA is ideal for patients with multiple
follow-up scans and/or contrast allergies.
Spin echo T1-weighted imaging provides best patho-anatomical
detail of intramural haematoma, intimal flaps, or atheromas,
whereas T2-weighted images allow tissue characterization of
aortic wall or blood compounds (Figure 6). ECG triggering is essen-
tial to minimize pulsatility artefact. With additional preparatory
radiofrequency pulses superior black blood fast T1- and
T2-weighted sequences are generated and improve image quality
in any plane.26 Dynamic and functional information is derived
from gradient-echo MRI based on flow-related signal enhancement.
Although MR angiographic methods without contrast enhance-
ment have been available for a long time, gadolinium-enhanced
MRA has dramatically shortened examination time and emerged
as preferred MR modality for aortic disease; adequate images
result from only 15 mL of gadolinium.29 Although MRA was
Role of imaging in acute aortic syndromes
considered ideal in renal failure, discovery of nephrogenic systemic
fibrosis in patients with renal dysfunction receiving gadolinium has
tempered enthusiasm and contributed to a renaissance of
non-enhanced MRA.30 Among established non-enhanced
sequences beyond ECG-gated partial Fourier fast spin echo,
balanced SSFP has emerged as a central technique to provide
vivid imaging of flowing blood.30 Non-contrast SSFP imaging
enables rapid exclusion of dissection in the ‘single shot’ mode
and a more detailed evaluation (for entry location and flow
pattern) in the cine mode both visualizing dissection in any
plane. The high signal-to-noise and contrast-to-noise ratio (due
to cardiac and respiratory gating) renders SSFP particularly useful
for patients incapable of breath holding, or in suspected aortic syn-
drome with better detection of aortic wall pathologies such as
intramural haematoma than by MRA alone. True MRA without
gadolinium is also feasible, but inferior to gadolinium-enhanced
MRA and three –dimensional volume-rendering or maximum in-
tensity reconstruction (Figure 7).
The ability of MRI acquisition in any plane and three dimensions
enables swift and high-resolution imaging for both chronic patholo-
gies or even acute aortic dissection. Because of the closed bore
design of the magnet and the need for monitoring and resuscitative
equipment close to magnetic field, MRI is less suitable for unstable
patients than CT. Both for CT and MRI, real-time video sequences
and serial examinations allow assessing instantaneous haemo-
dynamics and longitudinal evolution in transition from acute to
chronic aortic dissection; four-dimensional imaging including time
domain is eventually becoming standard. Post-processing involves
multi-planar, volume-rendered, and MIP reconstructions, as well
as virtual endoscopy for complex evaluation of aortic dimensions,
coarctation, parietal thrombus and ulcers, dissection, intramural
haematoma, and perivascular fat.
Figure 7 Contrast-enhanced MR angiogram of type B dissection originating from the aortic arch in maximum intensity projection (MIP) (A)
and as volume-rendered 3D reconstruction (B). Arrow identified the entry location. Follow-up MR angiogram at 7 days reveals no communi-
cation after stent-graft, a sealed proximal entry, and a thrombosed false lumen. The TL diameter is normalized and the descending aorta is
reconstructed (C).
Page 7 of 9
Catheter angiography and
intravascular ultrasound
Although no longer used for an initial diagnosis of aortic dissection,
catheter angiography and IVUS may be useful during endovascular
procedures or when non-invasive modalities were inconclu-
sive.31,32 The sensitivity and specificity of angiography for diagnos-
ing aortic dissection are 88 and 95%, respectively,33 with a
relatively high rate of false-negative studies because of occasionally
inadequate opacification of the false lumen or in the stage of IMH.
Incomplete visualization of the false lumen can also occur when the
catheter tip is placed distal to the primary tear. Other important
features of aortic dissection that cannot be visualized by a lumino-
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graphical modality include aortic wall thickness in patients with
aortitis or the aortic diameter in the presence of mural thrombus
and of course extraluminal findings. Moreover, cost and time
required for angiography is considerably greater than for cross-
sectional imaging. With almost no role in the diagnostic work-up
in the setting of suspected dissection angiography is being used
during endovascular management of these conditions, primarily
to seal communications between the true and false lumen, and
for the placement of endovascular stent-grafts.34,35
Integration of imaging and
intervention
In contrast to both CT and MR technology, modern ultrasound
equipment is mobile and especially attractive at the bedside for un-
stable emergency cases. TEE interrogation added to transthoracic
suprasternal screening ultrasound is superb for acute aortic dissec-
tion (type A) even intraoperatively with near perfect sensitivity and
Page 8 of 9
specificity,36 but has a blind spot confined to the proximal arch due
to bronchial air. Colour Doppler is instrumental to assess entry
sites and the false lumen flow in real time in order to confirm
proximal dissection (Figure 5). In addition, prognostic information
such as pericardial effusion, acute aortic regurgitation, and prox-
imal coronary obstruction can be visualized. For patients in
shock and with a very high clinical suspicion of ascending aortic dis-
section, TTE alone is reasonable prior to immediate transfer to
surgery, with TEE performed prior to sternotomy. Although TTE
and TEE are important bedside tools in dissection, both fail to
provide sufficient anatomic detail to plan endovascular interven-
tions. Intravascular ultrasound may emerge as a useful adjunct to
endovascular procedures, but is of little value for primary
diagnosis.
Future trends in aortic imaging
Although molecular imaging is largely confined to neoplasia and
degenerative diseases, vascular applications of molecular imaging
are emerging with the goal of identifying early stages of athero-
sclerosis by an endothelial expression of vascular adhesion mole-
cules.36,37 Additionally, biochemical markers of acute dissection,
such as elevated myosin heavy chain concentration, D –dimer
levels, and soluble elastin fragments, may assist in preselecting
patients for imaging. The rapid evolution of CT and MR technology
supports the investigational, but emerging ‘triple rule-out’ concept
by simultaneously evaluating coronary arteries (acute coronary
syndrome), thoracic aorta (dissection, ulcer), and pulmonary arter-
ies (pulmonary embolism).38
Further technological advances are on the horizon with multiple
X –ray sources around the patient to minimize CT scan time to
seconds; 3 T MR units are already clinical reality and provide an
improved signal/noise ratio with better MRA image contrast than
1.5 T magnets. ECG-gated CTA can accurately determine aortic
distensibility in both phantom models and real patients, and 3 T
MRA with three-dimensional velocity mapping offers haemo-
dynamic evaluation of normal and diseased thoracic aorta.39
Both techniques attempt to visualize stress and strain impacting
early on aortic wall. Intravascular ultrasound imaging or optical co-
herence tomography may be particularly useful in conjunction with
endovascular procedures and visualize wall architecture, associated
plaques, haematoma, and microdissections. Moreover, real-time
MR-guided vascular interventions have been demonstrated in
animals and in patients.40,41
Conclusion
Acute aortic syndrome is not an uncommon condition. Currently,
TEE and non-invasive tomographic imaging play a leading role in
both primary diagnosis and treatment planning. In the near
future, new approaches based on refined multi-detector MD-CT
and MR imaging protocols, will not only further improve diagnostic
precision, but allow risk stratification as part of diagnostic imaging.
Conflict of interest: none declared.
C.A. Nienaber
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