DOI:10.2214/AJR.04.1632
AJR 2006; 186:841-843
© American Roentgen Ray Society
Acute Aortic Dissection with Intimal Intussusception: MRI Appearances
Zhan Ming Fan1,
Zhao Qi Zhang1,
Xiao Hai Ma1 and
Xi Guo1
1 All authors: Department of Radiology, Anzhen Hospital, Capital University of
Medical Sciences, Anzhenli, Chaoyang District, Beijing 100029, P. R.
China.
Received October 19, 2004;
accepted after revision January 24, 2005.
Address correspondence to Z. M. Fan
(maxiaohai{at}263.net).
Keywords: aortic dissection • intussusception • MRI
Introduction
Intimointimal intussusception is an unusual type of acute aortic
dissection, with fewer than 15 cases reported in the English-language
literature
[1-9].
Several reports have described the findings of aortography
[1-3,
6,
8], transesophageal
echocardiography (TEE) [4,
5,
8,
9], and CT
[6-9],
but the MRI findings, to our knowledge, have not been reported. We describe
here the MRI findings in a patient with acute aortic dissection with
intimointimal intussusception.
Case Report
A 49-year-old man was admitted to our hospital with sudden chest and back
pain and hemiparesis in the right extremities. The patient had chronic
hypertension. On physical examination, blood pressure was 180 over 110 mm Hg
and pulses were absent in the right upper extremity. The chest was clear to
auscultation and there were no heart murmurs.
Transthoracic echocardiography showed an enlargement of the ascending
aorta, slight aortic regurgitation, and several intimal flaps freely floating
in the ascending aorta and aortic arch, but intimal entries were not clear.
Fast breath-hold MRI, true fast imaging with steady-state free precession
(FISP), and 3D contrast-enhanced MR angiography were performed with a 1.5-T
scanner (Sonata, Siemens Medical Solutions). MR images showed a relatively
short flap in the aortic root (Fig.
1A), a dilated ascending aorta, and no evidence of intimal flap in
the mid ascending aorta (Fig.
1B). A true lumen collapse, an unusual toe-like flap that was
thicker (
2 mm) than the usual intimal flap, and irregular folds showed in
the distal ascending aorta and aortic arch (Figs.
1C and
1D). The dissection intimae
extended into each of the brachiocephalic arteries and caused partial
obstruction of them (Figs. 1D
and 1E). The intimal flap was
also found in the descending aorta.
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Fig. 1B —49-year-old man with acute aortic dissection with intimal
intussusception. Axial true fast imaging with steady-state free precession
(FISP) shows dilated ascending aorta and no evidence of intimal flap in
ascending aorta.
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Fig. 1D —49-year-old man with acute aortic dissection with intimal
intussusception. Oblique sagittal MPRs show thickening of intimal flap with
irregular folds in distal ascending aorta and aortic arch
(arrowheads). Intimal flaps extend into each of arch vessels
(arrows).
|
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Fig. 1E —49-year-old man with acute aortic dissection with intimal
intussusception. Oblique sagittal MPRs show thickening of intimal flap with
irregular folds in distal ascending aorta and aortic arch
(arrowheads). Intimal flaps extend into each of arch vessels
(arrows).
|
|
Emergency surgery was done with the patient under profound systemic
hypothermia. The ascending aorta was replaced with a graft. When the ascending
aorta was open, the circumferential tear of the intima was noted above the
aortic valve with no intimal flap in the ascending aorta. The fold intimae
were located in the aorta arch and extended into each of the arch vessels. The
diagnosis of a type A aortic dissection was confirmed with an uneventful
postoperative course.
Discussion
Intimointimal intussusception is an unusual type of acute aortic dissection
in which the intimal tear occurs circumferentially with intussusception of the
intima downstream. Since Hufnagel and Conrad
[1] described the first case in
1962, fewer than 15 cases have been reported in the literature
[1-9].
The preoperative diagnosis is important to allow for appropriate surgical
planning [3], but there may
sometimes be difficulties in reaching the appropriate diagnosis due to lack of
the classic echocardiographic and CT signs of a type A aortic dissection
[9].
Because the intussuscepted flap can partly occlude the aortic arch and the
brachiocephalic arteries, neurologic manifestation may be more frequent. Of
the 12 cases reported with intimointimal intussusceptions, eight (67%) had
neurologic signs and symptoms on presentation
[1-9].
The same neurologic symptoms appeared in the patient presented here. In
addition, it was very difficult for the catheter to pass beyond the aortic
arch during aortography [1,
2,
6-8].
An aortogram showed a dilated ascending aorta, a curvilinear or a windsock
linear filling defect in the aortic arch, and partially occluded arch vessels
[2,
3,
6].
Noninvasive imaging examinations—including TEE, CT, and MRI—are
the most important and accurate diagnostic tools for the aortic dissection. On
TEE and CT, the characteristic appearance of intimointimal intussusception was
a relatively short flap in the aortic root, absence of an intimal flap in the
mid ascending aorta, windsock linear or curvilinear filling defects in the
aortic arch with involvement of the arch vessels, and circumferential tears of
the intima just above the aortic valve
[4-9].
Currently MRI is considered to be one of the best imaging techniques for
evaluating aortic dissection. In this case study, we report the characteristic
MRI findings in a patient with intimointimal intussusception in acute aortic
dissection, including an absence of an intimal flap in the mid ascending
aorta, a relatively short flap in the aortic root, and a true lumen collapse
and toe-like flap in the aortic arch that was thicker than the usual intimal
flap and irregular folds, which were revealed by surgery and are consistent
with those of TEE and CT described in several previous reports
[4-9].
In summary, intimointimal intussusception is a rare type of aortic
dissection and, because of possible rupture of the aortic wall or a neurologic
event, is fatal more often than classic aortic dissection. Therefore, prompt
and accurate diagnosis is essential to the prognosis of the patient. However,
reaching an accurate diagnosis may be difficult because of lack of typical
imaging findings of type A aortic dissection. As mentioned previously, MRI can
show the characteristic imaging appearances of this condition. If
intimointimal intussusception is suspected in a patient, MRI should be
considered as one of the most reliable diagnostic tools for arriving at the
correct diagnosis for this rare type of aortic dissection.
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Introduction
Case Report
