Diagnosis

Aortic dissection is usually diagnosed by using imaging techniques before

the result of blood work is interpreted. The choice of imaging techniques depends
in part on whether or not the patient is hemodynamically stable.1

Chest radiography is the initial imaging technique and may or may not
reveal any abnormality. Computed tomography (CT) is useful in hemodynamically
stable patients; emergency CT angiography (CTA) with three-dimensional (3D)
reconstruction is rapidly becoming the diagnostic test of choice. Magnetic
resonance imaging (MRI) is as accurate as CT and may benefit patients who have
adverse reactions to the use of intravenous (IV) contrast agents. For
hemodynamically unstable patients, echocardiography is ideal.2

Aortography is still considered by some as the diagnostic criterion standard

test for aortic dissection. However, it is being replaced by newer imaging
modalities. All patients with suspected thoracic aortic dissection should undergo
12-lead electrocardiography (ECG). However, ECG often demonstrates a
nonspecific abnormality or normal results.3

A complete blood count (CBC), serum chemistry studies, and cardiac

marker assays should be performed. On the CBC, leukocytosis may be present,
which usually represents a stress state. Decreases in hemoglobin and hematocrit
values are ominous findings suggesting that the dissection is leaking or has
ruptured.

Elevation of the blood urea nitrogen (BUN) and creatinine levels may
indicate involvement of the renal arteries or prerenal azotemia resulting from blood
loss or associated dehydration (mainly when the BUN-to-creatinine ratio exceeds
20). Patients with dissection involving the renal arteries may also exhibit hematuria,
oliguria, or even anuria (< 50 mL/day)

Myocardial muscle creatine kinase isoenzyme, myoglobin, and troponin I

and T levels are elevated if the dissection has involved the coronary arteries and
caused myocardial ischemia. The lactate dehydrogenase level may be elevated
because of hemolysis in the false lumen. Measurement of the degradation products
of plasma fibrin and fibrinogen can facilitate the diagnosis of acute aortic
dissection. In symptomatic patients, aortic dissection with a patent false lumen
should be considered if the plasma fibrin degradation product (FDP) level is 12.6
μg/mL or higher; the possibility of dissection with complete thrombosis of the false
lumen should be considered if the FDP level is 5.6 μg/mL or higher.4

1. Spittell PC, Spittell JA Jr, Joyce JW, Tajik AJ, Edwards WD, Schaff HV, et
al. Clinical features and differential diagnosis of aortic dissection:
experience with 236 cases (1980 through 1990). Mayo Clin Proc. 1993 Jul.
68 (7):642-51
2. Jacobs JE, Latson LA Jr, Abbara S, et al, Expert Panel on Cardiac Imaging.
ACR Appropriateness Criteria® acute chest pain -- suspected aortic
dissection. American College of Radiology. 2014
3. Braverman AC, Schermerhorn M. Diseases of the aorta. Zipes DP, Libby
P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's
Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed.
Philadelphia: Elsevier; 2019. Vol 2: Chap 63.
4. Hagiwara A, Shimbo T, Kimira A, Sasaki R, Kobayashi K, Sato T. Using
fibrin degradation products level to facilitate diagnostic evaluation of
potetntial acute aortic dissection. J Thromb Thrombolysis.2013. Jan.
35(1):15-22