Images in Differential intraluminal ow turbulence: a ...Ravindran Rajendran, Bhupinder Singh,...
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Images in… Differential intraluminal flow turbulence: a marker of aortic dissection Ravindran Rajendran, Bhupinder Singh, Shivakumar Bhairappa, C N Manjunath Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India Correspondence to Dr Ravindran R, [email protected] DESCRIPTION A 54-year-old hypertensive patient presented with chest and back pain for the last 4 h. Physical examination was normal except for a blood pressure of 180/100 mm Hg in both upper limbs. ECG and a chest x-ray were normal, cardiac biomarkers were negative. A bedside transthoracic echocardiogram (TTE) showed concentric left ventricular hypertrophy with normal left ventricular function, normal valves and no evidence of pericardial effusion. The aortic arch as visualised from suprasternal view was also unremarkable except for a differential intraluminal turbu- lence on colour Doppler, just distal to the origin of the left subclavian artery (video 1). Pulse Doppler interroga- tion showed dual flow velocities within the aortic lumen, a normal forward flow pattern in the outer part and a sluggish flow pattern in the inner part ( figure 1). Based on this, a descending aortic dissection was suspected, that was confirmed by a CT aortogram. The volume rendered imaging showed Stanford type B acute aortic dissection extending upto bilateral common iliac arteries ( figure 2). The patient was managed conservatively as symptoms subsided with control of blood pressure and there was no major organ compromise. TTE is considered inferior to transoesophageal echocar- diography for aortic dissection. 1 But, TTE being available at the bedside in most of the emergency departments could give a valuable clue pointing to the cause of chest pain, even in patients with symptoms not typical for aortic dissection as many such patients are seen in the chest pain clinic. Routine Doppler interrogation of aorta during TTE should be a part of the screening echo as it may be rewarding as in our case. Doppler interrogation showing differential intraluminal turbulence with dual flow velocities despite non-visualisation of flap would still suggest a dissection and the need for a more specific investigation. Video 1 Colour comparison of aortic arch from suprasternal view showing no evidence of flap (left) on two-dimensional echo and differential intraluminal flow turbulence on colour doppler (right). BMJ Case Reports 2012; doi:10.1136/bcr-2012-007429 1 of 3 on 14 October 2020 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Reports: first published as 10.1136/bcr-2012-007429 on 29 November 2012. Downloaded from
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Differential intraluminal flow turbulence a marker of aorticdissection
Ravindran Rajendran Bhupinder Singh Shivakumar Bhairappa C N Manjunath
Department of Cardiology Sri Jayadeva Institute of Cardiovascular Sciences and Research Bangalore Karnataka India
Correspondence to Dr Ravindran R rravi_drrediffmailcom
DESCRIPTIONA 54-year-old hypertensive patient presented with chestand back pain for the last 4 h Physical examination wasnormal except for a blood pressure of 180100 mm Hg inboth upper limbs ECG and a chest x-ray were normalcardiac biomarkers were negative A bedside transthoracicechocardiogram (TTE) showed concentric left ventricularhypertrophy with normal left ventricular functionnormal valves and no evidence of pericardial effusion Theaortic arch as visualised from suprasternal view was alsounremarkable except for a differential intraluminal turbu-lence on colour Doppler just distal to the origin of theleft subclavian artery (video 1) Pulse Doppler interroga-tion showed dual flow velocities within the aortic lumena normal forward flow pattern in the outer part and asluggish flow pattern in the inner part (figure 1) Basedon this a descending aortic dissection was suspected thatwas confirmed by a CT aortogram The volume rendered
imaging showed Stanford type B acute aortic dissectionextending upto bilateral common iliac arteries (figure 2)The patient was managed conservatively as symptomssubsided with control of blood pressure and there was nomajor organ compromise
TTE is considered inferior to transoesophageal echocar-diography for aortic dissection1 But TTE being availableat the bedside in most of the emergency departmentscould give a valuable clue pointing to the cause of chestpain even in patients with symptoms not typical foraortic dissection as many such patients are seen in thechest pain clinic Routine Doppler interrogation of aortaduring TTE should be a part of the screening echo as itmay be rewarding as in our case Doppler interrogationshowing differential intraluminal turbulence with dualflow velocities despite non-visualisation of flap wouldstill suggest a dissection and the need for a more specificinvestigation
Video 1 Colour comparison of aortic arch from suprasternal view showing no evidence of flap (left) on two-dimensional echo anddifferential intraluminal flow turbulence on colour doppler (right)
BMJ Case Reports 2012 doi101136bcr-2012-007429 1 of 3
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Figure 1 (A) Colour comparison of aortic arch from suprasternal view showing no evidence of flap (left) on two-dimensional echo anddifferential intraluminal flow turbulence on colour Doppler (right) (B) Pulse Doppler with sample in the centre of the lumen showingsluggish flow (C) Turbulent forward flow with sample volume over the outer half
Figure 2 Volume rendered reconstructed CT image showing Stanford type B aortic dissection
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Learning points
High degree of suspicion is needed for diagnosing anaortic dissection
Turbulence in the absence of a dissection flap is stillsuggestive of dissection
Transthoracic echocardiogram (TTE) though inferior toTEE could still give some clues of an underlyingdissection
Competing interests None
Patient consent Obtained
REFERENCES1 Ince H Nienaber CA Diagnosis and management of patients with aortic
dissection Heart 200793266ndash70
Copyright 2012 BMJ Publishing Group All rights reserved For permission to reuse any of this content visithttpgroupbmjcomgrouprights-licensingpermissionsBMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission
Please cite this article as follows (you will need to access the article online to obtain the date of publication)
Rajendran R Singh B Bhairappa S Manjunath CN Differential intraluminal flow turbulence a marker of aortic dissectionBMJ Case Reports 2012101136bcr-2012-007429 Published XXX
Become a Fellow of BMJ Case Reports today and you can Submit as many cases as you like Enjoy fast sympathetic peer review and rapid publication of accepted articles Access all the published articles Re-use any of the published material for personal use and teaching without further permission
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BMJ Case Reports 2012 doi101136bcr-2012-007429 3 of 3
on 14 October 2020 by guest P
rotected by copyrighthttpcasereportsbm
jcom
BM
J Case R
eports first published as 101136bcr-2012-007429 on 29 Novem
ber 2012 Dow
nloaded from
Learning points
High degree of suspicion is needed for diagnosing anaortic dissection
Turbulence in the absence of a dissection flap is stillsuggestive of dissection
Transthoracic echocardiogram (TTE) though inferior toTEE could still give some clues of an underlyingdissection
Competing interests None
Patient consent Obtained
REFERENCES1 Ince H Nienaber CA Diagnosis and management of patients with aortic
dissection Heart 200793266ndash70
Copyright 2012 BMJ Publishing Group All rights reserved For permission to reuse any of this content visithttpgroupbmjcomgrouprights-licensingpermissionsBMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission
Please cite this article as follows (you will need to access the article online to obtain the date of publication)
Rajendran R Singh B Bhairappa S Manjunath CN Differential intraluminal flow turbulence a marker of aortic dissectionBMJ Case Reports 2012101136bcr-2012-007429 Published XXX
Become a Fellow of BMJ Case Reports today and you can Submit as many cases as you like Enjoy fast sympathetic peer review and rapid publication of accepted articles Access all the published articles Re-use any of the published material for personal use and teaching without further permission
For information on Institutional Fellowships contact consortiasalesbmjgroupcom
Visit casereportsbmjcom for more articles like this and to become a Fellow
BMJ Case Reports 2012 doi101136bcr-2012-007429 3 of 3
on 14 October 2020 by guest P
rotected by copyrighthttpcasereportsbm
jcom
BM
J Case R
eports first published as 101136bcr-2012-007429 on 29 Novem
ber 2012 Dow
nloaded from
