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Acute Aortic Syndromes (AAS) comprise a spectrum of life-threatening aortic pathologies involving the aortic wall, often presenting with acute chest or back pain. These conditions share similar clinical presentations and often require emergent imaging and management.

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![Acute aortic syndromes:

a | Normal aorta b | Classic aortic dissection: Disruption of the medial layer results in separation of the aortic wall layers and subsequent formation of true and false lumens divided by an intimal flap. c | Intramural haematoma can develop in the media of the aortic wall in the absence of a false lumen and intimal tear. d | Penetrating aortic ulcer: Ulceration of an aortic atherosclerotic plaque, penetrating through the internal elastic lamina into the media. e | Pseudoaneurysm: Dilatation of the aorta owing to disruption of all the aortic wall layers, contained only by the periaortic connective tissue. f | Traumatic aortic injury: Rupture of all aortic wall layers caused by a trauma.

Bossone, E., Eagle, K.A. Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes. Nat Rev Cardiol 18, 331–348 (2021). https://doi.org/10.1038/s41569-020-00472-6](attachment:98df4a05-1d52-4728-ad4d-8b2e5d9d1899:image.png)

Acute aortic syndromes:

a | Normal aorta b | Classic aortic dissection: Disruption of the medial layer results in separation of the aortic wall layers and subsequent formation of true and false lumens divided by an intimal flap. c | Intramural haematoma can develop in the media of the aortic wall in the absence of a false lumen and intimal tear. d | Penetrating aortic ulcer: Ulceration of an aortic atherosclerotic plaque, penetrating through the internal elastic lamina into the media. e | Pseudoaneurysm: Dilatation of the aorta owing to disruption of all the aortic wall layers, contained only by the periaortic connective tissue. f | Traumatic aortic injury: Rupture of all aortic wall layers caused by a trauma.

Bossone, E., Eagle, K.A. Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes. Nat Rev Cardiol 18, 331–348 (2021). https://doi.org/10.1038/s41569-020-00472-6

Main Entities in AAS

Clinical Presentation

• Sudden severe chest, back, or abdominal pain (tearing or ripping)
• Pulse deficits, blood pressure differential
• Neurologic symptoms (e.g., stroke, syncope)
• Signs of shock (especially with rupture or pericardial tamponade)

Radiology

CT Angiography (CTA) of the entire aorta is the gold standard due to speed and accuracy.

Key imaging features:

![Imaging of acute aortic syndromes: a | Aortic dissection. Axial CECT image showing an ascending thoracic aortic aneurysm (TAA; arrowhead) complicated by a type A dissection (arrows) caused by elastic tissue dystrophy in a patient with Marfan syndrome.  b | Coronal CECT reconstruction showing an ascending TAA (arrowhead) with an intimal dissection (arrow) that extends into the anonymous trunk lumen in a patient with Marfan syndrome.  c | Coronal CECT reconstruction showing an intimal flap inside the aortic lumen that extends into the common right iliac artery lumen (arrow).  d | Intramural haematoma. Axial CECT image showing a thoracic aortic arch haematoma with intramural blood collection (arrow).  e | Axial CECT image showing a descending thoracic aortic haematoma with intramural semilunar blood collection (arrow).  f | Sagittal CECT reconstruction showing a descending thoracic aortic haematoma with intramural blood collection (arrows) with a decreased diameter of the aortic lumen.  g | Penetrating aortic ulcer. Oblique sagittal contrast-enhanced CT reconstruction showing an aortic arch ulcer (arrow) with out-pouching of contrast medium extending from the aortic lumen into an intramural haematoma.  h | Volume-rendered, CECT reconstruction showing an aortic arch ulcer (arrowhead) extending from the aortic lumen into the aortic–pulmonary window (arrows).

Images courtesy of L. Romano (A. Cardarelli Hospital, Naples, Italy). Bossone, E., Eagle, K.A. Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes. Nat Rev Cardiol 18, 331–348 (2021). https://doi.org/10.1038/s41569-020-00472-6](attachment:507e287b-e21e-49a0-a06f-3dfb11cf5931:41569_2020_472_Fig5_HTML.webp)

Imaging of acute aortic syndromes: a | Aortic dissection. Axial CECT image showing an ascending thoracic aortic aneurysm (TAA; arrowhead) complicated by a type A dissection (arrows) caused by elastic tissue dystrophy in a patient with Marfan syndrome.  b | Coronal CECT reconstruction showing an ascending TAA (arrowhead) with an intimal dissection (arrow) that extends into the anonymous trunk lumen in a patient with Marfan syndrome.  c | Coronal CECT reconstruction showing an intimal flap inside the aortic lumen that extends into the common right iliac artery lumen (arrow).  d | Intramural haematoma. Axial CECT image showing a thoracic aortic arch haematoma with intramural blood collection (arrow).  e | Axial CECT image showing a descending thoracic aortic haematoma with intramural semilunar blood collection (arrow).  f | Sagittal CECT reconstruction showing a descending thoracic aortic haematoma with intramural blood collection (arrows) with a decreased diameter of the aortic lumen.  g | Penetrating aortic ulcer. Oblique sagittal contrast-enhanced CT reconstruction showing an aortic arch ulcer (arrow) with out-pouching of contrast medium extending from the aortic lumen into an intramural haematoma.  h | Volume-rendered, CECT reconstruction showing an aortic arch ulcer (arrowhead) extending from the aortic lumen into the aortic–pulmonary window (arrows).

Images courtesy of L. Romano (A. Cardarelli Hospital, Naples, Italy). Bossone, E., Eagle, K.A. Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes. Nat Rev Cardiol 18, 331–348 (2021). https://doi.org/10.1038/s41569-020-00472-6

Radiologic Signs

Management