Aortic tears

Traumatic disruption of the aorta usually occurs as a result of an automobile accident, with the drivers
chest striking the steering wheel. Rupture of the aorta causes 15% to 40% of the fatalities in motor vehicle
accidents. Rapid deceleration can cause the aorta to tear, usually in the proximal portion of the
descending aorta at the level of the attachment of the ligamentum arteriosum. Ninety-five percent occur at
this level, and approximately 5% occur at the level of the aortic root. Signs of a tear on a frontal chest xray include a mediastinal width of more than 8 to 10 cm at or above the level of the aortic arch, apical
pleural density (capping) due to blood above the apical portion of the lung, and deviation of the trachea or
nasogastric tube to the right. Usually poor definition of the aortic arch and opacification of the
aortopulmonary window also are seen ( Fig. 530 ). Tears should be suspected if a mediastinal
hematoma is found on a CT scan done on a traumatized patient ( Fig. 531 ).

Figure 5-30 Aortic tear. A chest x-ray (A) obtained in an individual who was in a
motor vehicle accident shows multiple rib fractures (black arrows), filling in of the
normal concavity of the anteroposterior window (long white arrow), and fluid over
the apex of the left lung. These latter two findings are suggestive of mediastinal
hemorrhage. A digital subtraction contrast aortogram (B) shows a bulge of contrast
(arrow) due to a tear in a very typical location.

Figure 5-31 Mediastinal hematoma. The chest x-ray (A) in a traumatized patient
shows a widened upper mediastinum. A contrast-enhanced computed tomography
(CT) scan at the level of the thoracic inlet (B) and at the level of the aortic arch (C)
shows gray soft tissue density surrounding the vessels, indicating hemorrhage
(arrows) and vascular damage.

CA SE 48 PERICARDIAL CYST

The CXR shows a homogeneous opacity in the right cardio-phrenic angle. This opacity has a rounded
border and sharp margins. The right heart border and the diaphragm are obliterated. CT (Fig. 48.2)
shows the mass to be cystic with lowdensity material. All these are features of a pericardial cyst (also
called spring water cyst).

CA SE 49 PERICARDIAL FAT PAD

The CXR shows opacity in the right cardio-phrenic angle (Fig. 49.2). Again, the opacity has obliterated
the right heart margin and the diaphragm. CT (Fig. 49.3) shows the density to be fat making this a
pericardial fat pad.