Çıkan aorta diseksiyonu BT bulguları

Özet

Ani göğüs ağrısı, senkop veya nabız farkı olan hastada çıkan aorta duvarının ayrışması hızla tanınması gereken akut aortik sendromdur. EKG eşzamanlı BTA, kökten arkusa kadar flebi ve koroner ostiumlarla ilişkisini gösterirken tüm aorta incelemesi distal uzanımı belirler. Tanı gecikirse tamponad, akut aort yetersizliği, koroner malperfüzyon veya rüptür gelişebilir. Görüntüde çıkan aortanın tutulması, diseksiyonun Stanford A kapsamına girdiğini belirler.

Faz ve pencere

Kontrastsız: Aort duvarında akut kanama varsa duvar içi hiperdens hilal, intimal kalsifikasyonun lümene doğru yer değiştirmesi veya mediastinal/perikardiyal kan görülebilir; kontrastsız seri tek başına intimal flebi dışlamaz.
BTA tanısal: Aort kökü ve çıkan aortada kontrastlı lümeni ayıran intimal flep, gerçek ve yalancı lümen, giriş yırtığı ve koroner ostiumlara uzanım değerlendirilir; EKG eşzamanlaması kök hareket artefaktını azaltır.

Önerilen pencereler: Anjiyo (G 600 / M 150), Mediasten (G 350 / M 50).

BT bulguları

İntimal flep — kontrastlı lümeni iki kanala ayıran ince membran; kökten arkusa kesintisiz izlenebilir.
Gerçek lümen — intimal fleple ayrılan kanallardan olup, aort duvarı kalsifikasyonunun konumu ve proksimal normal aortla devamlılığı tanıya yardımcı olur.
Yalancı lümen — intimal fleple sınırlandırılan, bazen tromboz içerebilen ve akış dinamiği gerçek lümenle farklılık gösterebilen kanaldır.
Yalancı lümenin sınırları, intimal flep ile dış duvar arasındaki anatomik ilişkiler ve flebin devamlılığı değerlendirilerek belirlenir.
Koroner ostium tutulumu — diseksiyonun koroner sinüsleri veya ostiumları düzeyine uzayıp uzamadığının ve bunların hangi kanaldan dolduğunun incelenmesi gerekir.
Aort kökü ve kapak bileşkesi — sinüsler, sinotübüler bileşke ve çıkan aorta duvarı boyunca flep yayılımı.
Hemoperikardiyum — kontrastsız BT’de yüksek atenüasyonlu perikard sıvısı kanamayı destekler; yalnız efüzyon hemoperikardiyum veya tamponad tanısı koydurmaz. Kök tutulumu ve klinik bulgularla birlikte raporlayın.
Akut aort yetersizliği ipuçları — kök genişlemesi, kapak düzeyinde flep ve eşlik eden sol ventrikül/perikard bulguları.

Ölçütler ve sınıflamalar

Stanford sınıflaması: Tip A: çıkan aortayı içeren diseksiyon; arkus ve inen aortaya uzanabilir. Tip B: çıkan aortayı içermez.
DeBakey sınıflaması: Tip I çıkan aortada başlar ve distal aortaya yayılır; Tip II çıkan aortada sınırlıdır. Tip III inen aortada başlar.
2024 ESC Type–Entry–Malperfusion (TEM) çerçevesi: Akut aortik sendromu hastalık tipi (Tip A, Tip B veya non-A/non-B), primer intimal giriş yeri (Entry) ve malperfüzyon durumunu (Malperfusion) birlikte tanımlar. Kök/çıkan aorta tutulumu ile proksimal ve distal yayılım ayrıca anatomik olarak gösterilmelidir.

Normalde

Normal aort kökünde sinüsler ve sinotübüler bileşke tek, düzgün kontrastlı lümen oluşturur; çıkan aorta duvarında lümeni bölen çizgisel membran bulunmaz. Normal aort köküyle karşılaştırma yapılırken, aort duvarı kalsifikasyonunun yerleşimi, aort çapı ve perikard boşluğundaki sıvı miktarı değerlendirilmelidir.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0115; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Aortik intramural hematom: aort medyasında intim yırtığı olmadan gerçekleşen kanama ile karakterizedir ve intim tabaka rüptürü durumunda akut aort diseksiyonuna dönüşebilir.
Aort kökü hareket artefaktı: yalnızca kök hareketinin en belirgin olduğu kesitlerde görünür ve EKG eşzamanlı görüntülerde düzgün duvar boyunca sürekli bir membran oluşturarak devam etmez.
Aortit: aort duvarı inflamasyonu ile duvar kalınlaşması ve çevresel yumuşak doku değişikliklerine yol açar; ancak intimal yırtık ile ayrılan gerçek ve yalancı lümen oluşturmaz.
Mural trombüs: aort duvarına bitişik eksantrik dolum kusuru olarak izlenir; diseksiyona özgü intimal flep ve çift kanal yapısı göstermez.

Tuzaklar

Aort kökündeki pulsasyon çizgisini flep sanmayın; multiplanar görüntüde çizginin devamlılığını ve EKG eşzamanlı kesitleri kontrol edin.
Yalancı lümenin tamamen tromboze olduğu segmentte ikinci kanal seçilmeyebilir; kontrastsız duvar hiperdensitesini ve distal/proksimal devamlılığı inceleyin.
Kısa bir koroner ostium uzanımı bile klinik açıdan önemlidir; yalnız en belirgin flep seviyesini değil her iki koroner çıkışı da izleyin.

Kendini dene

Aort kökünde kontrastlı lümeni ikiye ayıran flep ve küçük bir perikard efüzyonu görülüyor. En olası tanı nedir?
Cevabı göster
Çıkan aorta diseksiyonu. Lümeni ayıran intimal flep diseksiyonu gösterir ve çıkan aorta tutulumu Stanford A kapsamındadır. İntramural hematom duvar içinde kalınlaşmadır; aortit duvar inflamasyonu yapar, mural trombüs ise duvar içi çift kanal oluşturmaz.
Aort kökünde şüpheli ince çizgi yalnız hareket bulanıklığında seçiliyor; tekrar rekonstrüksiyonda kayboluyor. En uygun açıklama hangisidir?
Cevabı göster
Pulsasyon artefaktı. Kök hareketine bağlı yalancı çizgi, EKG eşzamanlı veya farklı faz rekonstrüksiyonunda devamlılığını kaybedebilir. Tromboze yalancı lümen duvar boyunca kalıcı yapısal bulgu oluşturur; ostium diseksiyonu ve ülser de anatomik olarak tekrarlanabilir lezyonlardır.

Bu konunun yer aldığı turlar

İlgili konular

Aortik intramural hematom

Kaynaklar

Bu sayfadaki 46 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez. İçerik yapay zekâ destekli bir süreçle güncel literatüre göre cümle cümle kaynaklarla karşılaştırıldı, ancak uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.