Chest Pain and Intimal Flap Detected by Chest Computed Tomography Scans
A 47-year-old man was referred to us for an evaluation of chest pain. Upon arrival, he had a blood pressure of 156/80 mm Hg and a heart rate of 87 bpm. The physical examination was unremarkable. An ECG was normal, and a cardiac echocardiogram showed normal left ventricular wall motion, no valvular lesions, and a normal ascending aorta. A contrast-enhanced chest computed tomography scan without ECG-gating was performed, and a flap-like liner construction was observed in the ascending aorta just above the aortic valve (Figure 1A and 1B). Repeated echocardiography from the parasternal and suprasternal views did not show an intimal flap in the aorta. Nonsteroidal analgesics promptly relieved chest pain. The patient’s vital signs were stable, and we decided to observe the patient closely in the ward. The next day, we performed an ECG-gated, contrast-enhanced chest computed tomograph to minimize possible motion artifacts and found that his aorta was completely normal, without evidence of dissection or mural hematoma (Figure 1C and 1D).
Intimal flap-like constructions in the ascending aorta are occasionally seen in normal subjects and are attributed to cardiac movements. Such images could be misleading in clinical judgments, especially in emergency rooms. ECG-gated scans are highly valuable for accurate diagnosis (or rule-out) of aortic dissection in cases of intimal flap localized only in the ascending aorta.