Endgames Spot Diagnosis

Well patient, worrying thoracic magnetic resonance aortogram

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1367 (Published 29 March 2017) Cite this as: BMJ 2017;356:j1367
  1. Jack Andrews, cardiology registrar and clinical research fellow,
  2. Marc Dweck, British Heart Foundation intermediate clinical research fellow, senior lecturer and consultant cardiologist
  1. University of Edinburgh Medical School, Edinburgh, UK
  1. Correspondence to Jack.Andrews{at}ed.ac.uk

An asymptomatic 82 year old man attending an outpatient clinic underwent thoracic magnetic resonance (MR) aortography, which showed a striking abnormality (fig 1). What is the potentially life threatening diagnosis on this image, and how should it be managed?

Fig 1 Sagittal oblique view of thoracic magnetic resonance aortogram

Short answer

The aortogram shows previously repaired, chronic aortic dissection. Strict blood pressure control and imaging surveillance are indicated, but not emergency surgery to repair the dissection.

Discussion

At first glance, the findings of a large dissection in the dilated descending aorta with thrombus in the false lumen would suggest that this patient requires emergency surgery. However, on closer inspection there are several findings that would argue against this management pathway. Firstly, the patient was asymptomatic, which would be highly unusual in acute aortic dissection. Secondly, he had undergone MR imaging, which is …

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