Diagnostic Characteristics

The presentation of aortic dissection is quite variable; hence understanding of pathological presentation is essential for prompt diagnosis. Commonly observed morphologies from autopsy, surgical, and imaging studies have demonstrated the following spectrum of findings:

• Intimal avulsion, tear alone without hematoma

• Intimal tear with a localized false aneurysm with thrombus

• Highly mobile intimal flap with a true lumen and a false lumen with blood flow within them

• Immobile intimal flap separating the true lumen from the false lumen each with varying degrees of thrombosis of the false lumen

• True lumen, intimal flap, and aneurysmal enlargement of the false lumen with no or minimal thrombus.

In addition to the above spectrum of pathology seen in classic dissection, recent developments in the imaging modalities have identified two pathologic variants of aortic dissection, intramural hematoma (Figure 4.2B) and penetrating aortic ulcer (Figures 4.5A, 4.5B). Hence, the morphology of these two entities should be kept in mind.

Figure 4.5A. Gross aortic specimen demonstrating significant atherosclerosis of the intimal surface with ulcers.

Figure 4.5B. Transesophageal echo (TEE) cross sectional image of descending thoracic aorta demonstrating a penetrating aortic ulcer (arrow) and the asterisks point to the overlying mobile debris.

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