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Early aortic intimal tear without haematoma or dissection: early diagnosis by cardiac magnetic resonance imaging
  1. T F Longe,
  2. J R Lesser,
  3. R S Schwartz

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A 22 year old man was found to have a 5.4 cm aortic root aneurysm upon screening echocardiogram. He had no Marfanoid features. His 19 year old brother had died suddenly of an acute ascending aortic dissection six weeks previously. A cardiology appointment was scheduled, but in the interim he developed transient chest, neck, and jaw burning. He was transferred pain-free from his local emergency room for further evaluation.

A computed tomographic (CT) scan with contrast showed an enlarged ascending aorta. A second CT and a two dimensional echocardiogram were performed within seven hours and was unchanged. Though no dissection was seen, he was recommended to have surgery. Cardiac magnetic resonance imaging (MRI) was performed before the surgery. At surgery, a subacute, nearly circumferential intimal and medial tear of the ascending aorta was found above the aortic valve. There was no dissection in either the antegrade or retrograde direction. The pericardial space contained no free blood. The patient received a 25 mm St Jude composite graft with coronary artery reimplantation, and he recovered uneventfully.

In this case cardiac MRI enabled an early intimal tear to be visualised before the better known features of dissection became present.

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Cardiovascular magnetic resonance (CMR) left ventricular outflow tract (LVOT) view. Dilated sinuses of Valsalva (5.4 cm) with effaced sinotubular junction. A persistent 1 cm non-mobile linear protrusion into the sinuses was seen without independent motion (longer arrow), aortic wall thickening, contrast staining, or significant pericardial effusion. There was mild aortic insufficiency across a trileaflet valve (thick arrow). LA, left atrium; LV, left ventricle; SV, sinuses of Valsalva.

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Pathology showing cystic medial necrosis. Ascending aorta with cystic medial necrosis and dissection, low magnification to show entire wall. The lumen (L) is on the right of the field. An aortic dissection (*) is present within the aortic media, associated with haemorrhage involving the media (M) as well. Inset: wall of the cystic degeneration with dissection shows fibroblasts and organising blood clot (haematoxylin and eosin).

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Cystic medial necrosis. Elastin fibres at high magnification. The elastin fibres (dark strands, highlighted with dark arrows) are notably irregular and discontinuous, typical of degenerative changes seen in cystic medial necrosis. The dissection is present at the top of the field (open arrows) (elastin stain).