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NewYork-Presbyterian Hospital Psychiatry
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Case of the Month 08/08

This asymptomatic 72 year old hypertensive female was sent to the ED after an abnormal finding on an outpatient pre-operative echocardiogram. Question 1: What is wrong with this CXR?

(Hint – here is the chest CT done during the same visit.

Answer 1

The mediastinum is significantly widened (especially when compared to former chest x-rays.) The aortic dissection is seen on the CT scan below.

Question 2: What percentage of patients with this diagnosis have this finding on CXR?
View answer

The most extensive article on aortic dissection to date (Klompas, M. Does This Patient Have an Acute Thoracic Aortic Dissection? JAMA. 2002; 287: 2262-2272) found during a thorough literature review that previous researchers had found that anywhere from 11 to 94 percent of patients with aortic dissection were noted to have a widened mediastinum on CXR (average of all studies was 64%). Some of these percentages were found when the chest x-rays were reviewed after the diagnosis of aortic dissection was already known The International Registry of Acute Aortic Dissection also found that in reviewing 464 cases of aortic dissection, only 62% were found to have had mediastinal widening on chest x-ray. (Hagan G, Nienaber CA, Isselbacher EM, et al. IRAD New Insights Into an Old Disease. JAMA 2000; 283: 897-903).

The take home point is that it is completely possible to have a normal mediastinal width on chest x-ray with an aortic dissection. If dissection is clinically suspected, further imaging should be pursued in these cases. If an abnormality is noted on the chest x-ray, compare the image with prior images if possible.

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