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Sat May 3 06:51:16 BST 2008

Ian, I agree that in trauma survivors a lesion at the level of the takeoff of the left subclavian artery is much more common then an ascending aortic injury:

At the point of the greatest shearing force, the isthmus of the aorta, 95% of injuries are found; only 5% are detected in the ascending aorta. At the point of the greatest shearing force, the isthmus of the aorta, 95% of injuries are found; only 5% are detected in the ascending aorta. http://www.mdconsult.com/das/article/body/93775974-2/jorg=journal&source=&sp=984672&sid=0/N/47574/1.html?issn=0749-0704#H073308

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http://radiology.rsnajnls.org/cgi/reprint/209/2/335
In patients who survive long enough toreach the hospital, the most commonlocations of ATAIs are the aortic isthmus(in 80%-90% of patients), the ascending
aorta (in 5-9%), and the diaphragmatic
aorta (in 1%-3%) (4-6,19,26,49,63-71).Multiple aortic lacerations or concomi
aontic branch vessel injuries occur in
6%-20% 
(2-4,7,8,56,64,72-82).In autopsy
series (2,3,6-8,17,19,63,64,66,80,83,84),
up to 22% of ATAIs are in the ascending
aorta, death having been immediate and
commonly associated with severe cardiactantand 4%-10% of cases, respectivelyinjuries (in 80% of cases), including pericardialtamponade, aortic valve tear, myocardialcontusion, and coronary artery injury.

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However, the difference between the two entities has to do more with the etiology of the injury and the actual lesion can be similar: in both situations there is initially a tear/laceration of the aortic wall. This can then lead to a dissection(=longitudinal tear), transection(=circular tear), aortic intramural hematoma, pseudoaneurysm, periaortic hematoma, contained rupture etc. During the development of these steps the pathology on TEE can be similar - existence of true and false lumens, pulsations towards the false lumen, a jet at the point of entry of the blood, communicating or noncommunicating additional lumen etc.etc:

 Transection of proximal distal thoracicaorta adjacent to the isthmus.

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Left, aortic dissection with intimal flapand entry site of distal thoracic aorta; 
Right, aortic dissectionrenal flow via color flow Doppler through intimal tear. 
TL,true lumen; FL, false lumen.

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 Ivan Hronek MD
Los Angeles, CA
http://health.groups.yahoo.com/group/Anesthideas/

"We are what we repeatedly do.  Excellence, then, is not an act, but a habit."  Aristotle
PPlease don't print this e-mail unless you really need to.

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Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 
________________________________

----- Original Message ----
From: Ian Seppelt <seppeli at wahs.nsw.gov.au>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>; ivanhronek at yahoo.com
Sent: Thursday, May 1, 2008 5:04:18 PM
Subject: Re: unusual case

Ascending aorta DISSECTION is not a traumatic injury, and is totally
unrelated pathologically to traumatic aortic RUPTURE which is most
commonly seen at the level of the ligamentum arteroisum / left
subclavian artery.

Ian

correspondence to: seppelt at med.usyd.edu.au

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Director of Clinical Research, Sydney West AHS
Clinical Lecturer, University of Sydney

>>> ivanhronek at yahoo.com 05/02/08 4:47 am >>>
We recently had a small plane pilot crash victim allergic to iodine and
so assessed the aorta with TEE.
Typical ascending aorta dissections are relatively easy to diagnose
with a visible flap and a second lumen with flow.
Commonly there is also AI and pericardial effusion accompanying. Arch
is not visible on TEE due to the left mainstem bronchus interposition.
Descending aorta is nicely visible on long and short axis ("tube" and
"salami" cuts), typical site transsections are accessible. One can also
see AIH - aortic intramural hematomas - no flow in the accessory lumen.
There are VOMITs possible - the arch cen have a reverberation artifact
which looks like a second lumen. Also, which happened in our case, there
is the left innominate vein which normally adheres to the arch and has
flow in the opposite direction, which can be pulsatile so close to the
right heart, especially with e.g. TR. It too can mimic a dissection.
Ivan Hronek MD
Los Angeles, CA
http://health.groups.yahoo.com/group/Anesthideas/ 

"We are what we repeatedly do.  Excellence, then, is not an act, but a
habit."  Aristotle
PPlease don't print this e-mail unless you really need to.

________________________________

Confidentiality Notice: This transmission and any attached documents
may be confidential and contain information protected by State and
Federal Medical Privacy statutes and is legally privileged. They are
intended for use only by the addressee. If you are not the intended
recipient of this transmission, or an agent of the intended recipient,
you are prohibited from reading, disclosing, printing, saving, copying,
using, or otherwise disseminating any information contained in this
transmission. If you received this transmission in error, please accept
our apologies and notify me at  ivanhronek at yahoo.comand delete the
entire message and its attachments. Thank you. Disclaimer: this message
contains the personal views of the author. The author will not be
responsible in any way for procedures or approaches perfomed in the way
suggested in this note. 
________________________________

----- Original Message ----
From: jduchesne1 <jduchesn at tulane.edu>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Thursday, May 1, 2008 10:38:35 AM
Subject: Re: unusual case

It is really hard to see the ct Ao injury which I think that is what
you r trying to point out. In the event of a true (not a VOMIT) Ao
injury with combine TBI, non operative management with control of
patient delta P/delta T with breviblock is indicated. On the other hand
special attention needs to be taken for good ICP/CPP readings in order
to prevent secondary brain injury. Good judgment and close ICU care is a
most.
Please send more cuts of the CT.
Always remember communication is of the essence among physicians in
polytrauma patients.
Good case.
Juan
CharityOne
Sent via BlackBerry by AT&T

-----Original Message-----
From: Tchaka Shepherd <tshepherdmd at hotmail.com>

Date: Thu, 1 May 2008 10:09:29 
To:"Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Subject: RE: unusual case

Can you send more images of the CTA?

----------------------------------------
> To: trauma-list at trauma.org 
> From: nappio at aol.com 
> Date: Thu, 1 May 2008 16:50:34 +0000
> Subject: Re: unusual case
> 
> CHI and c spine injury. What is unusual?
> Sent from my Verizon Wireless BlackBerry
> 
> -----Original Message-----
> From: "Michael Stein M.D." 
> 
> Date: Thu, 1 May 2008 19:37:42 
> To:"'Trauma & Critical Care mailing list'" 
> Subject: RE: unusual case
> 
> 
> Not enough cuts from the CTA but...
> If Neuro don't want him STAT in the OR, perform FORMAL Arch + 4
vessel
> Angiography and go on from there.
> Mickey
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
> On Behalf Of daniel simon
> Sent: Thursday, May 01, 2008 6:29 PM
> To: trauma-list at trauma.org 
> Subject: unusual case
> 
> 43 year old motorcycle crash victim , on scene intubation for GCS of
5. On
> admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7
(T) .
> PE: skin lacerations and  central hematoma anterior neck - zone 1.
> Head CT - SAH, Frontal contusions,small Frontal SDH, many skull
fractures.
> C-spine:  fracture of C1
> Chest XR and relevant cuts from the chest  CTA included.
> Abdominal CT normal
> What would you do now?
> 
> --
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Aorta: dissection vs. transection