0:00

Okay, this next case is a young woman

0:03

who has a history of spontaneous coronary

0:06

artery dissection.

0:08

This is also a uncommon diagnosis to

0:11

see on cardiac CT.

0:13

But certainly something won't include just so you've seen

0:16

it and are familiar with it in case you are asked, you know down the line

0:19

to look for a dissection in a patient.

0:22

This particular patient story was that she actually initially went

0:25

to cardiac cath because she had a St elevation

0:28

Mi and that cast showed a

0:31

dissection and at the time of the calf.

0:35

She was having chest pain.

0:37

And St changes and so actually things didn't look very

0:40

good. And so they put in a balloon pump and then

0:43

sort of stabilized her.

0:45

Center off to the floor and then she got a

0:48

little bit better, but then got a little bit worse again, and so they wanted to look at

0:51

the dissection and see as it

0:54

progressed and is it, you know something that they

0:57

need to intervene on more aggressively.

0:59

So this patient at the time as

1:02

ET actually had a known dissection but you know, we were

1:05

evaluating to see you know, what it look like compared to

1:08

what was known from the previous cap.

1:11

Now just a note about coordinated sections. Usually

1:14

we're thinking about young women in sort of the

1:17

peripartum time period particularly women who have fmd

1:20

that predisposes patients to having

1:23

a higher risk for for a spontaneous coronary dissection.

1:27

So this patient as we start out we're looking at the

1:30

left main here. Nice big vessel.

1:33

LED coming across and then we get down in Fairly and

1:36

you can see this low attenuation.

1:39

Within the left main Lumen and so it

1:42

doesn't look.

1:43

As well defined as you'd expect for a plaque.

1:47

Instead. It's just this sort of

1:50

almost amorphous looking

1:52

Low attenuation and as we go down

1:55

more inferiorly, you can see that it extends into

1:58

the origin of the circumflex.

2:00

The circumflex origin here is really tiny. There's an

2:03

early obtuse marginal.

2:06

And then as we continue down further into the circumflex.

2:10

It's actually hard to see here. I'll show

2:13

you on some of the CPR images, but there's areas

2:16

of sort of alternating.

2:18

narrowing in normal caliber circumflex

2:22

Now there's also in the LED you can see a little bit of

2:25

low signal here and here and that may be the continuation of

2:28

a flap with an LED. Honestly, it's

2:31

really hard to say.

2:32

This patient is a little on the bigger side.

2:35

So we have you know, some noise

2:38

in our images, which makes it a little

2:41

hard to see some of these very fine details that we might like to see to pick

2:44

up at a section flap in that led the RCA

2:47

though looks fine.

2:49

As we continue around and follow the RCA down

2:52

distillate into the inferior aspect

2:55

of the heart.

2:56

So let's take a closer. Look at that circumflex on

2:59

some of these CPR images.

3:02

And so here from this angle. You

3:05

can see left Main.

3:07

And then this low attenuation here and then

3:10

from that low attenuation. You can see some extension into the

3:13

proximal left circumflex. Then you see a nice Lumen and

3:16

you see it kind of gets a little narrower here and even a

3:19

little bit of low attenuation in this mid portion

3:22

not as easy to see as plaque

3:25

like it's sort of intermediate and attenuation

3:28

compared to what we're used to for plaque and the edges here

3:31

not as sharp.

3:32

That's partly due to the fact that again. This is

3:35

a bit of a noisy study then also partly

3:38

I think due to the fact that the false Lumen that we're visualizing here

3:42

is just doesn't really show up sometimes as well as we

3:45

would expect for somebody with a plaque.

3:48

Here's the LED.

3:51

And there's that area in the LED. We were wondering if there

3:54

might be intersectional app as well and that whole deeper. We unfortunately

3:57

not able to get that confirmed. It did not take her back

4:00

to cat.

4:01

Let's take a look at the calf for this patient. And

4:04

I think you'll be able to see a nice correlation. Let

4:07

me just point out before we do that that you can see quite

4:10

nicely here in the left

4:13

Main.

4:14

The section flap. Do you see that? That's the dissection flap.

4:18

That courses through the middle of the left Main and then it's kind of heaped up

4:21

here at the origin of the circumflex coming

4:24

right over here and then heaped up the origin

4:27

of circumflex. That's the dissection flap that we're going to see on the

4:30

subsequent images. So let me show you what the cath results showed.

4:34

Here's the CT on the left for this patient and then

4:37

the cardiac calf. It's a video because honestly, I

4:40

thought that captured things the best this was done

4:43

before the CT but it looked Tori at

4:46

least when you evaluate this case that the extent of disease hadn't

4:49

changed a whole lot between the time of the cap and the CT the main

4:52

finding you can see is this filling defect

4:55

right here in the

4:58

left Main.

5:00

And that's the same thing that we see here on the CT.

5:04

And what it is is it's that false Lumen that's basically heaped up

5:07

mixed with some awesome and thrombosis extending into

5:11

the left main the LED origin as well as a

5:14

circle origin. You can see how tight.

5:16

The origin for the circumflex is here. Which matches what we see

5:19

on CT at tight origin for the circumflex. You can see that

5:22

high first up to Marginal which we

5:25

see here on the CT.

5:27

And then as you look down the distal circumflex, you can

5:30

kind of see this.

5:31

Almost as spiraling appearance where it's like narrow

5:34

and then a little wider than a little narrow and a little

5:37

wider again.

5:38

I'll let that play.

5:40

And you can see that the enhancement is

5:43

changing. So in a normal calf, you

5:46

should see the enhancement go all the way down from proximal to

5:49

distal whereas in this case, you can see that it fills

5:52

and then disappears and fills then disappears and and

5:55

that's because of compression of the Moon

5:58

by the the true lemon by the false lemon. And so

6:01

these areas of narrowing like this area here which

6:04

looks a little bit like it's poorly opacified right in

6:07

there corresponds to this area

6:10

here of the parsley thrombostom and

6:13

So it's certainly not easy to diagnose a coronary dissection

6:16

by CT that really kind of pushes CT to

6:19

its limits as far as the resolution needed to find the

6:22

section, but occasionally you may be asked

6:25

to look for this and so here's an example of

6:28

what you might see you may see that false then thrombosis and

6:31

the continuation spiraling through

6:34

the vessel.