Severe chest pain radiating to the back
BMJ 2008; 336 doi: https://doi.org/10.1136/sbmj.0804161 (Published 01 April 2008) Cite this as: BMJ 2008;336:0804161
- Balakrishnan Saravanan, senior house officer1,
- D T Williams, senior lecturer and consultant vascular surgeon1
- 1Department of Vascular Surgery, Ysbyty Gwynedd, Bangor LL57 2PW
A 55 year old man presented to the emergency department with a two hour history of sudden onset chest pain radiating to his back. His past medical problems included hypertension, and he was a smoker.
Although initial observations were normal, within a few minutes he became drowsy, agitated, and started developing weakness of his left arm. The pulses in his left arm were absent.
All initial blood investigations, including cardiac enzymes, were within normal limits, with a haemoglobin concentration of 139 g/l. Twelve lead electrocardiography and chest radiography performed on admission were normal. Tests for cardiac enzymes were subsequently repeated, and results remained within normal limits.
An urgent computed tomogram of the chest and abdomen was performed (figs 1 and 2).
Coronal reformat of computed tomogram of the chest at the level of aortic arch
Transverse computed tomogram of the abdomen at the level of L1 vertebrae
Questions
(1) What diagnosis do figures 1 and 2 indicate?
(2) At what does the unlabelled arrow in figure 1 point?
(3) Can you identify the arterial branch, from figure 2, affected by the condition?
Answers
(1) Figures 1 and 2 show aortic dissection involving the aortic arch and abdominal aorta.
(2) The arrow points to the dissection flap in the aortic arch.
(3) Figure 2 shows the dissection flap involving the superior mesenteric branch of the abdominal aorta. The superior mesenteric artery can be identified because it usually arises at the level of the L1 vertebral body and just superior to the origin of the renal arteries.
Discussion
Aortic dissection is a condition that needs the clinician's urgent attention and prompt treatment. The condition is twice as common in men as in women, with incidence greatest at ages 55-65. …
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