Right aortic arch and Kommerell's diverticulum associated with acute aortic dissection and pericardial tamponade
A 62-year-old female patient arrived at our emergency department after collapsing during her household routine. After intubation, peripheral oxygenation decreased to 59%, followed by bradycardia and low blood pressure. Fifteen minutes later, the patient developed a cardiac arrest. The patient was stabilized with 3 mg of atropine and 4 mg of adrenaline. Cranial computed tomography (CCT) with perfusion imaging at the level of the basal ganglia and carotid CT angiography (120 kVp, 95 mAs, pitch of 1.2, standard image reconstruction in 0.6 mm thickness, and multiplanar reconstructions in 5 mm thickness for the carotid artery) was performed to exclude intracranial bleeding, ischemic stroke, and carotid obstruction. CT images showed no signs of intracranial or cervical pathology. However, the upper mediastinum was seen markedly enlarged. Therefore, CT angiography with coronal and sagittal reconstructions of the thoracic aorta was appended (100 kVp, 150 mAs, pitch of 1.25, 1.5, and 5 mm reconstructions). We found a complex vascular anomaly of the aorta and the supra-aortic branches with right-sided aortic arch and aneurysmal dilatation of the vascular origin of the aberrant left subclavian artery (Figs. –). Furthermore, there was a dense pericardial effusion (45 HU), strongly indicating a dissection of the ascending aorta including a hemopericardium. Due to motion artifacts at the level of the aortic root, no intimal flap was evident (Fig. a). Further electrocardiography-triggered CT of the thorax revealed a dissection of the aorta type A following the Stanford classification (DeBakey type II) with pericardial tamponade (Fig. b). Surgery with graft replacement was performed immediately. Because of the long-lasting, cerebral perfusion deficiency, the patient developed a massive cerebral ischemia with associated edema 3 days after surgery. On a follow-up CT, there was brain swelling with loss of differentiation of the cortex. The patient died 4 days after the initial event.