kl323

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Aug 29, 2009
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Well, there's actually quite a few questions but this one was bugging me the most.

Anyway, there was a quick blurb about this person who has the classical presentation of aortic dissection. Then it asks, what is the most accurate test to do?

- MRA
- TEE
- TTE
- CT angio
- Angio

It gives an answer and then in the side box, it says MRA = CTA = Angio in terms of accuracy. What gives? I get it's trying to force us to tackle the most appropriate, next best step type of questions, but maybe I'm just overthinking it.

What is really the best answer though? I checked my red book... best initial test for aortic diss is CXR followed by CT angio.
 

Fuzuli

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Aug 16, 2004
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From UpToDate:

"The initial imaging study of choice depends upon the hemodynamic status of the patient and institutional resources. It is important to rapidly distinguish acute ascending thoracic aortic dissection, which is a cardiac surgical emergency, from descending thoracic aortic dissection, which is managed medically in hemodynamically stable patients without end-organ complications. For patients with chest pain suspected of having acute aortic dissection who are clinically unstable, we prefer to perform a multiplane transesophageal echocardiography (TEE) at the bedside or in the emergency department (or operating room) to establish the diagnosis and evaluate the location of the dissection. Magnetic resonance (MR) imaging is usually preferred for those who are hemodynamically stable or have chronic aortic dissection, but is time consuming, often not available, and places the patient away from ready care. Because of its widespread availability and speed of image acquisition, computed tomography (CT) is frequently used as the initial screening study in patients with suspected aortic dissection, particularly those presenting to the emergency department setting when TEE and MR may be unavailable, especially after hours. If CT is equivocal, or further delineation of the dissection is needed, TEE or MRI is indicated. Digital subtraction aortography is indicated when noninvasive tests are unavailable or inconclusive when there is a strong suspicion for ascending aortic dissection."

In summary, use the one that is available. Other than that:

- TEE: Hemodynamically unstable
- CT: Hemodynamically unstable, TEE/MRI is not available. If CT is equivocal, use TEE or MRI.
- MRI: Hemodynamically stable, chronic AD
- DSA: If (1) TEE/CT/MRI is inconclusive, or (2) strong suspicion of ascending AD
 

NRAI2001

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Nov 6, 2001
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From UpToDate:

"The initial imaging study of choice depends upon the hemodynamic status of the patient and institutional resources. It is important to rapidly distinguish acute ascending thoracic aortic dissection, which is a cardiac surgical emergency, from descending thoracic aortic dissection, which is managed medically in hemodynamically stable patients without end-organ complications. For patients with chest pain suspected of having acute aortic dissection who are clinically unstable, we prefer to perform a multiplane transesophageal echocardiography (TEE) at the bedside or in the emergency department (or operating room) to establish the diagnosis and evaluate the location of the dissection. Magnetic resonance (MR) imaging is usually preferred for those who are hemodynamically stable or have chronic aortic dissection, but is time consuming, often not available, and places the patient away from ready care. Because of its widespread availability and speed of image acquisition, computed tomography (CT) is frequently used as the initial screening study in patients with suspected aortic dissection, particularly those presenting to the emergency department setting when TEE and MR may be unavailable, especially after hours. If CT is equivocal, or further delineation of the dissection is needed, TEE or MRI is indicated. Digital subtraction aortography is indicated when noninvasive tests are unavailable or inconclusive when there is a strong suspicion for ascending aortic dissection."

In summary, use the one that is available. Other than that:

- TEE: Hemodynamically unstable
- CT: Hemodynamically unstable, TEE/MRI is not available. If CT is equivocal, use TEE or MRI.
- MRI: Hemodynamically stable, chronic AD
- DSA: If (1) TEE/CT/MRI is inconclusive, or (2) strong suspicion of ascending AD

Thanks for the great reply!! I ve been getting a lot of UW questions on dissection and I m always second guessing myself (i guess I read too much into the question). Good summary; where did you get your information from?
 
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