Endgames Picture Quiz

A case of “tearing” back pain and acute limb ischaemia

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a3114 (Published 05 February 2009) Cite this as: BMJ 2009;338:a3114
  1. R Allison, specialist registrar in radiology1,
  2. M G Wyatt, consultant vascular surgeon2,
  3. R Williams, consultant interventional radiologist1
  1. 1Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN
  2. 2Department of Vascular Surgery, Freeman Hospital
  1. Correspondence to: M G Wyatt mike.wyatt{at}nuth.nhs.uk

    A 50 year old man presented to his local accident and emergency department with sudden onset of severe “tearing” interscapular back pain and a cold white insensate left leg. At initial assessment he had pronounced hypertension, an ischaemic left leg, and an impalpable left femoral pulse. His medical history was unremarkable. An urgent computed tomography angiogram was obtained (fig 1).

    Fig 1 Three dimensional reconstruction from the computed tomography angiogram showing the aortic arch and the iliac bifurcation


    • 1 What is the diagnosis?

    • 2 What is the most common classification system, and how would you classify this case?

    • 3 What complication does the patient have?

    • 4 What are the treatment options?


    Short answers

    • 1 The angiogram shows a thoracic aortic dissection (fig 2).

    Fig 2 Three dimensional reconstruction from the computed tomography angiogram showing the aortic arch and the iliac bifurcation. The left arrow shows the intimal flap and the right arrow indicates the occluded left commom iliac artery

    • 2 The most common classification system is the Stanford classification. This is a Stanford type B dissection. It starts distal to the left subclavian artery.

    • 3 The intimal flap has occluded the left common iliac artery causing acute ischaemia of the left leg.

    • 4 Complicated type B dissections should be treated by endovascular insertion of an aortic stent graft or open surgery to replace the affected aortic segment. Uncomplicated dissections should be treated by aggressive blood pressure management.

    1 Diagnosis

    The angiogram shows …

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