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Findings: CT scan 2/26/97 reveals an irregular penetrating atherosclerotic ulcer of the descending thoracic aorta. Inferior to the ulcer there is a crescent shaped collection of contrast which extends inferiorly for 1.6 cm (2 scans). The thoracic aorta measures approximately 3 cm and contains mural thrombus, bilateral effusions and minimal compressive atelectasis.
CT scan 3/30/97 demonstrates a discrete intimal flap and double lumen sign within the descending thoracic aorta. Previously identified pleural effusions have cleared. No evidence of acute leak.
Diagnosis: Penetrating atheromatous ulcer PAU.
Discussion: Kazerooni et al provide the best review of this seemingly uncommon and poorly understood entity. The discussion that follows is a summary of their paper. Clinically penetrating atheromatous ulcers mimic aortic dissection in both presentation and treatment. This patient’s presentation is typical of both entities. Distinction at time of CT examination is important because surgical repair of penetrating ulcer requires placement of a longer interposition graft and resection than a descending dissection (Type III). In both cases, surgical repair is associated with paraparesis and death. Conservative management, control of hypertension is favored, unless patients are or become hemodynamically unstable, or unless they experience persistent or recurrent chest or back pain.
Stanson(3) described penetrating ulcers as an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the media of the aortic wall. The angiographic appearance would be analogous to that of a peptic ulcer seen during an UGI series.
The ulcers are most frequently identified in the mid to distal descending aorta. CT findings in 16 patients reported include intramural hematoma (16), focal ulcer (15), calcified displaced intima (13), thickened, enhancing aortic wall (6), pleural fluid (7), mediastinal fluid (4) and contained perforation or pseudoaneursym. Associated dissections may be focal since progression is limited by medial fibrosis and atherosclerotic disease.
The authors recommend performance of contiguous, dynamic, contrast-enhanced CT scanning beginning at the aortic arch and extending to the diaphragmatic hiatus for optimal diagnosis.
This case demonstrates most of the elements needed for diagnosis, including the ulceration with associated intramural hematoma on the initial scan 2/26/97, with progression to a classic limited dissection on 3/30/97 demonstrating an intimal flap and double lumen associated with dissection.
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