Aortic dissection is a dynamic and evolving pathology, as I said on the previous case. This patient presented with chest pain to a general hospital and the radiology service did MR and CT and diagnosed an ascending aortic intramural haematoma (IMH). Pretty good work. He was transferred to us for consideration of surgery, but when he arrived the next day he was pain free and stable. We did this CT, and the haematoma had become very obvious as the clot self-enhanced on the non-contrast run. At the time we were aware of the spectrum of IMH and of the importance of a non-contrast CT run to show it, but there was doubt about the role of surgery. (We now know that, although some patients seem to heal up nicely, around half of them will advance to free dissection in the following days.) As he was pain free, we decided to observe overnight.
The next morning I was asked to do an urgent carotid Doppler as he had lost sight in the left eye. The images are below. There is almost complete occlusion of the left common carotid by likely thrombus. I did an echo with the same machine, and the aorta showed a free dissection. Still no chest pain! He had a good surgical repair but his vision did not completely recover. I think the aortic haematoma was liberated as the intimal flap came free, and some of it embolised the carotid.
