Severe chest pain radiating to the back
A 55 year old man presented to the emergency department with a two hour history of sudden onset chest pain radiating to his back. His past medical problems included hypertension, and he was a smoker.
Although initial observations were normal, within a few minutes he became drowsy, agitated, and started developing weakness of his left arm. The pulses in his left arm were absent.
All initial blood investigations, including cardiac enzymes, were within normal limits, with a haemoglobin concentration of 139 g/l. Twelve lead electrocardiography and chest radiography performed on admission were normal. Tests for cardiac enzymes were subsequently repeated, and results remained within normal limits.
An urgent computed tomogram of the chest and abdomen was performed (figs 1 and 2).
The Stanford system classifies dissections into 2 types—A and B.1 Type A involves the ascending aorta and type B does not. Modified Stanford classification further denotes whether the tear