Acute Aortic Syndromes: A Second Look at Dual-Phase CT

OBJECTIVE. The purpose of this article is to assess the diagnostic performance of the unenhanced and contrast-enhanced phases separately in patients imaged with CT for suspected acute aortic syndromes. MATERIALS AND METHODS. All adults (n = 2868) presenting to our emergency department from January 1, 2006, through August 1, 2010, who underwent unenhanced and contrast-enhanced CT of the chest and abdomen for suspected acute aortic syndrome were retrospectively identified. Forty-five patients with acute aortic syndrome and 45 healthy control subjects comprised the study population (55 women; mean age, 61 +/- 16 years). Unenhanced followed by contrast-enhanced CT angiography (CTA) images were reviewed. Contrast-enhanced CTA examinations of case patients and control subjects with isolated intramural hematoma were reviewed. Radiation exposure was estimated by CT dose-length product. RESULTS. Forty-five patients had one or more CT findings of acute aortic syndrome: aortic dissection (n = 32), intramural hematoma (n = 27), aortic rupture (n = 10), impending rupture (n = 4), and penetrating atherosclerotic ulcer (n = 2). Unenhanced CT was 89% (40/45) sensitive and 100% (45/45) specific for acute aortic syndrome. Unenhanced CT was 94% (17/18) and 71% (10/14) sensitive for type A and type B dissection, respectively (p = 0.142). Contrast-enhanced CTA was 100% (8/8) sensitive for isolated intramural hematoma. Mean radiation effective dose was 43 +/- 20 mSv. CONCLUSION. Unenhanced CT performed well in detection of acute aortic syndrome treated surgically, although its performance does not support its use in place of contrast-enhanced CTA. Unenhanced CT may be a reasonable first examination for rapid triage when IV contrast is contraindicated. Contrast-enhanced CTA was highly sensitive for intramural hematoma, suggesting that unenhanced imaging may not always be needed. Acute aortic syndrome imaging protocols should be optimized to reduce radiation dose.