CTICasesType A Aortic Dissection with Contrast Extravasation and Apical Cap
Imaging findings
A patient with extensive aortic wall calcification arrested and was intubated. The initial chest radiograph showed an obscured aortic arch and a prominent apical cap from hematoma tracking along the left subclavian artery and lung apex, with loss of the left pulmonary artery silhouette. CT, initially performed as a PE-protocol study, showed a type A aortic dissection with a large ascending aneurysm, a fenestration with contrast filling the false lumen, and mediastinal hematoma. A rapid follow-up non-contrast dissection-protocol scan performed only about fifteen minutes later, with residual contrast still on board from the PE study, showed contrast that had spilled into the left pleural space, mediastinum, and pericardium, with a different distribution than on the initial acquisition.
Key takeaways
An apical cap on a chest radiograph, especially with an obscured aortic arch, should raise concern for an underlying aortic process such as dissection or rupture. Sequential imaging performed only minutes apart with residual intravascular contrast can capture dynamic extravasation into the pleural, mediastinal, and pericardial spaces, illustrating the trajectory and severity of aortic rupture even when a true non-contrast study was not obtained.
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