Friday, November 16, 2007

Images in Clinical Medicine - Quiz


A patient is transferred to the ICU for stabilization prior to surgery. The patient is complaining of back pain. The blood pressure is 180/110 and the heart rate is 95 per minute. The surgeon says that he wants the patient optimized and that the patient needs emergency surgery.


  • Based on the CT scan slices that are shown, what does the patient have?
  • Do you agree with the surgeon's decision, based on the limited CT views?
  • What would you do to "optimize" this patient?
  • What further information about this patient do you want?

This image and the clinical scenario were contributed by Daniel Zurcher (Washington University final year medical student).

More on this post to follow...

126 comments:

Andrew said...

1. Diagnosis: Type A Dissection

2. The limited CT slices indicate a type A dissection with organized thrombus. It is difficult, based on images alone to know the extent of the dissection and if it is acute or chronic. Based on symptoms and brief history, it would appear that an acute pathology is taking place, with possible extention and/or leaking of the aorta. The patient is hemodynamically stable, but needs optimization and surgery.

3/4. The goals of optimization are simple...BP/HR control (decrease sheering), pain control and thereby decrease hemorrhage risk. While obtaining H&P, an arterial line should be placed and BP control with short-acting agents like esmolol and Nitroprusside should be used to obtain SBP's of 90's-100's. In addition to standard labs,Type & Cross, ECG, CXR, an echo would be extremely valuable, as would a more extensive CT. Info important for the surgeon and anesthesiologist included proximal extention (does it include the Ao root, sinus of valsalva, transverse sinus or coronaries?). Is there blood in the pericardial sac?) This will help indicate just how "emergent" the OR is, and if circulatory arrest is indicated. Info on distal extention is also essential to aid with the decision on how and where to place art/venous bypass canula.

Anna said...

I'm going to show my ignorance as a 4th year medical student by stating as much as I can about this case. This is like "Who Wants to be a Millionaire" so you can see my reasoning, correct me if I'm wrong, and teach me something. :)

Based on the clinical history of back pain and hypertension, I would suspect an aortic dissection.

This CT series, beginning below the level of the carina, appears to be an enhanced scan done of the thoracic aorta. The descending thoracic aorta shows an area of enhancement surrounded by a nonenhancing area (consistent with aortic dissection?). However, there appears to be an outpouching in the ascending thoracic aorta (first image) and eventual leakage of contrast material into the mediastinum (last image) consistent with a ruptured aortic aneurysm ? (unless I'm seeing things that aren't there and this is just normal anatomy - quite possible).

While I initially thought that the area of enhancement surrounded by non-enhancement could indicate the true and false lumens of an aortic dissection in the descending thoracic aorta, this could simply be highlighting atherosclerotic disease within the aorta, which would be associated with the development of an aortic aneurysm.

However, I find it strange that the patient is hypertensive rather than hypotensive if this were a ruptured aneurysm, which is why I think maybe I'm just making up the leakage. The hypertension with back pain is more consistent with a descending dissection (In need of radiological help now!)

OK! So, do I agree with the surgeon? Well, it depends on what my radiologist says this is, but if the radiologist says:

1. Ruptured thoracic aortic aneurysm --> Yes, Dr. Surgeon! Emergent surgery!
2. Descending aortic dissection (Type B) --> No, sir. Medical therapy is okay for a dissection of the descending aorta.
3. Aortic dissection involving ascending aorta as well (Type A -which I didn't see any sign of) --> Operate now!

Right now, I am betting on #2, but that is a scary bet, considering the other 2 are surgical emergencies.

What would you do to "optimize" this patient?

Well, if we're saying the patient has an aortic dissection, I would want to decrease the blood pressure and heart rate. Beta-blockers and sodium nitroprusside would prevent worsening of the dissection.

I want to know what medications the patient is currently on. Definitely stop thrombolytics. I want to know co-morbidities, past medical history. See if the patient has had a history of hypertension. I want to know if there is any history of CAD so I can watch out for MI. If there's renal disease, I want to know because this would affect my choice of medication (I would not sodium nitroprusside, for example, in renal failure). Age and gender could help (40-60, male makes dissection more likely - yes, I'm consulting First Aid for Step 2 right now).

Ok. Teach me something! Correct my reasoning!

Anna said...

Andy - that explains the leakage I was seeing - a pericardial effusion from an ascending dissection.

http://content.nejm.org/content/vol345/issue5/images/medium/08f2.gif

My poor patient.

Thanks!

Clare said...

1. Diagnosis based on CT:
The patient has a descending aortic aneurysm, seen in all 4 images. Thrombus is evident in the non-enhancing false lumen of the descending aorta. The ascending aorta appears tortuous but no dissection flap is clearly seen in these images. This of course does not rule out the presence of an intimal dissection (a flap was seen in <75% of cases in Vasile et al, below) without hematoma formation. The patient therefore has a Type B dissection and the presence of a concurrent Type A dissection cannot be assessed with these images, since aortic arch dissection is seen in only 30% of ascending cases.

2. Do I agree with the surgeon?
No, we need to obtain the images of the aortic valve, sinus of valsalva (to evaluate the origins of the coronary arteries for coronary dissection), and intervening proximal aorta up to the images shown. The patient could have a chronic type B dissection that would be medically managed. Ascending dissections are twice as common as descending and are an indication for emergency surgery, so I would rush to obtain the additional CT images before I rushed to the OR. Of note, I would also want to obtain the abdominal CT images to evaluate the extent of the type B dissection and the possible presence of an AAA or other cause of back pain. In addition, the patient does not appear to have the aortic insufficiency, heart failure, chest pain, evidence of tamponade (hypotension, JVD, distant heart sounds, evidence of hemothorax on CT, stroke or syncope. This aneurysm could theoretically be longstanding and there could be another cause of back pain, which is seem in almost all adults at some point.

3. Optimizing the patient:
The key parameter to optimize is the dP/dt, or the change in intraluminal blood pressure over the change in time. IV beta blocker to reduce the HR to below 60 bpm to minimize wall stress (decrease dP/dt). The systolic BP should be decreased to 100-120 mmHg or the lowest level tolerated. The diastolic BP should be sufficient to fill the coronaries during diastole. Propranolol can be used for beta blockade, or labetalol for combined alpha-1 and nonselective beta blockade. If the patient has a history of cocaine use, labetalol is preferred to prevent unopposed alpha constriction. If the patient cannot tolerate beta blockade, verapamil or diltiazem can be used. Sodium nitroprusside can be used to further reduce systolic BP if needed.
Analgesia: pain increases sympathetic tone, which could be responsible for the elevated BP. Morphine is commonly used.
TEE not indicated at this time since patient is clinically stable, unless the proximal CT images reveal involvement of the aortic valve or proximal ascending aorta.

4. Further information desired:
1. Has there been any abrupt onset of thoracic/abdominal pain with a sharp/tearing/ripping character; mediastinal or aortic widening compared to past CT; absence of upper extremity or carotid pulse, or >20 mm Hg difference in BP between the right and left upper extremities?
2. The history of the back pain the patient is having and the efficacy of any treatments if any (increase suspicion of descending dissection cause if onet is abrupt, there is migratory pain, a pulse deficit in the lower extremities, or new onset of peripheral weakness or numbness). Of note, back pain is typically seen in aortic dissection distal to the subclavian as opposed to the ascending aorta.
3. ECG to evaluate for acute coronary syndrome or heart block from RCA involvement (though bradycardia is not an issue here).
4. Evaluate renal function (renal insufficiency as a manifestation of descending dissection)
5. Pertinent social history: Does the patient take crack? (Labetalol, not metoprolol)
6. Pertinent PMH: Comorbidities such as preexisting aortic aneurysm, inflammatory diseases like vasculitis, collagen vascular diseases. Known bicuspid aortic valve?
7. Other pertinent history: Recent cardiac catheterization, CABG, h/o aortic valve replacement, trauma, strenuous physical activity such as weight lifting.

Reference:
Computed tomography of thoracic aortic dissection: accuracy and pitfalls. Vasile N; Mathieu D; Keita K; Lellouche D; Bloch G; Cachera JP. J Comput Assist Tomogr 1986 Mar-Apr;10(2):211-5.

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