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Emergency chest radiology: thoracic aortic disease and pulmonary embolism

¹ Royal Infirmary, Edinburgh EH16 4SA, ² Borders General Hospital, Melrose TD6 9BS, UK

Correspondence: John H Reid, Borders General Hospital, Melrose TD6 9BS, UK

• Both acute thoracic aortic disease and pulmonary embolism carry high mortality rates and imaging is central to the diagnosis of both.
  
• Acute dissection, intramural haematoma (IMH) and penetrating artheromatous ulcers (PAU) comprise the "acute aortic syndrome".
  
• Aortic dissections of Stanford type A disease are generally treated surgically.
  
• Stanford type B disease is initially treated with aggressive medical therapy.
  
• The diagnosis of pulmonary embolism (PE) comprises a significant proportion of work in a radiology department. The chest radiograph remains the first line investigation, with CT pulmonary angiography (CTPA) now the "gold standard" of investigation.
  
• Correct utilization of the D-dimer assay is essential in thromboembolic disease.
  

Both acute thoracic aortic disease and pulmonary embolism carry high mortality rates. Imaging is central to the diagnosis of both. Acute dissection, intramural haematoma (IMH) and penetrating artheromatous ulcers (PAU) comprise the "acute aortic syndrome", where each can arise de novo or by a process of evolution. The common denominators between them are aortic pain and hypertension. The most common sequelae of these conditions is aneurysmal dilatation or aortic rupture. Pre- and post-contrast enhanced multidetector CT (MDCT) is the first line investigation. Stanford type A disease is generally treated surgically; type B disease is initially treated with aggressive medical therapy. Follow-up imaging is recommended to exclude long-term problems. Aneurysms of the thoracic aorta have a wide aetiology including artheroma, connective tissue disease, infection and following trauma. Presentation typically occurs when they expand rapidly, or following a leak. Acute traumatic aortic injury carries a high initial mortality. Acutely, MDCT is modality of choice, and a search for pseudoaneurysm formation, direct and indirect signs of injury should be made by the examining radiologist. The diagnosis of pulmonary embolism (PE) comprises a significant proportion of work in a radiology department. Plain chest radiography remains the first line investigation, with CTPA now the gold standard investigation. It is both highly sensitive and specific for PE, and may diagnose alternative or coexisting thoracic disease. Other modalities such as lung perfusion scintiography and pulmonary artery angiography are now second line investigations. Correct utilization of the D-dimer assay is essential in thromboembolic disease.