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Original Report
Mark A. LePage 1
Leslie E. Quint 1
Aortic Dissection: CT Features that
Seema S. Sonnad 2 Distinguish True Lumen from False Lumen
G. Michael Deeb 3
David M. Williams 1 OBJECTIVE. The purpose of this study was to determine which CT findings are reliable
indicators of the true or false lumen in an aortic dissection.
CONCLUSION. The beak sign and a larger cross-sectional area were the most useful in-
dicators of the false lumen for both acute and chronic dissections. Features generally indica-
tive of the true lumen included outer wall calcification and eccentric flap calcification. In
cases showing one lumen wrapping around the other lumen in the aortic arch, the inner lumen
was invariably the true lumen.

A
cute aortic dissection is readily diag- January 1993 and May 2000. Patients who under-
nosed using CT scanning, with the went contrast-enhanced CT and had involvement
reported diagnostic accuracy rang- of the descending thoracic aorta were included in
ing from 88% to 100% [1–3]. After making a di- this study. Patients were excluded if they had un-
dergone previous surgery or endograft placement
agnosis of aortic dissection, it is important for
for the dissection or if complete (or near complete)
the radiologist to determine the luminal origins thrombosis of the false lumen was seen at CT.
of branch vessels in patients who may undergo Fifty-one patients were identified in this manner.
surgical repair or percutaneous treatment with
endografts [4–8]. Although some authors have Imaging
written about compression of the true lumen by All but six patients underwent helical CT imag-
the false lumen [6], few authors have directly ing at our institution using a dedicated aortic proto-
addressed differentiation of the true and false col with a 2.5- to 5-mm-section collimation and a
lumens using imaging [9, 10]. In most CT ex- 1.3- to 5-mm-section spacing (the technique varied
aminations, the identity of the true lumen may according to type of helical scanner used). Between
be determined by its continuity with an undis- 120 and 200 mL of iodinated contrast material was
sected portion of aorta. However, in some pa- IV administered at a rate of 3–4 mL/sec. Patients
were scanned from the aortic arch to the aortic bifur-
tients, this continuity is difficult to appreciate. In
cation (superior to inferior). Three patients had con-
other patients, it may be impossible to establish trast-enhanced CT examinations at our institution
continuity because only a portion of the aorta using a conventional (nonhelical) scanner, and three
Received November 15, 2000; accepted after revision has been scanned or because the entire aorta is
January 16, 2001. others had contrast-enhanced CT performed at out-
1 Department of Radiology, University of Michigan Health
dissected. In these circumstances, it may be use- side institutions using various techniques.
Center, Box 0030, 1500 E. Medical Center Dr., Ann Arbor, MI
ful to base the distinction between true and false Chronic dissections were defined as those persist-
48109-0030. Address correspondence to L. E. Quint. lumens on other imaging findings. The purpose ing more than 2 weeks after the acute event. If more
2 of this study was to determine whether certain than one CT examination was available for a particu-
Zuedema Program for Surgical Core Outcomes Research
and Evaluation, University of Michigan Health Center, CT findings are reliable indicators of the true or lar patient, the earliest acute scan and the latest
Ann Arbor, MI 48109. false lumen in aortic dissections. chronic scan were used for the purposes of this study.
3
Department of Surgery, Section of Cardiothoracic Surgery, Hard copies of the axial images were retrospec-
University of Michigan Health Center, Ann Arbor, MI 48109. tively reviewed independently by two experienced ra-
Materials and Methods diologists who were unaware of the acute versus
AJR 2001;177:207–211
Thoracic surgery records were reviewed to chronic nature of each patient’s disease. When there
0361–803X/01/1771–207 identify all patients who were seen at our institu- was disagreement between the two CT reviewers’ in-
© American Roentgen Ray Society tion for acute or chronic aortic dissection between terpretations of an individual feature, a consensus was

AJR:177, July 2001 207

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LePage et al.

reached via joint reevaluation of the images. Each tion between the true and false lumens was readily CT findings for the true and false lumens in
scan was evaluated for the presence of the following made at open aortotomy because of the distinctive ap- acute and chronic cases are delineated in Table
imaging features on one or more images in each lu- pearance of the intima in the true lumen. 1. The beak sign and cobwebs were seen only in
men of the descending aorta: the beak sign, outer wall Approval of the institutional review board was ob- the false lumen (p < 0.05 for the beak sign, p >
calcification, intraluminal thrombus, eccentric flap tained; informed consent from patients was waived.
0.05 for cobwebs) (Figs. 1 and 2). However,
calcification, and cobwebs. The beak sign was defined
as the presence of an acute angle between the dissec- Statistics
whereas the beak sign was present on all scans,
tion flap and the outer wall; the space formed by the cobwebs were present in only 9% of the scans
Frequencies of CT findings were compared be-
acute angle could be filled with high-attenuation ma- tween true and false lumens using the McNemar
of acute dissections and 17% of those of chronic
terial (contrast-enhanced blood) or low-attenuation test. This test was used because of the paired na- dissections. Outer wall calcification (Figs. 3 and
material (hematoma). The lumen in which this feature ture of the data and the correlation between the re- 4) was never present in the false lumen on scans
was predominant was identified, after taking into ac- sult from the true lumen and the false lumen for a of acute dissections (p < 0.05), although it was
count all the images in the examination. Eccentric flap given subject. Frequencies of CT findings were occasionally present on scans of chronic dissec-
calcification in one lumen was called when the side of compared between acute and chronic dissections tions (17% of the cases) (p < 0.05). Intraluminal
the dissection flap facing that lumen contained calcifi- using Fisher’s exact test. Eight patients had scans thrombus was more common in the false lumen
cation, whereas the side of the flap facing the other lu- of both acute and chronic dissections; for statisti- (46% of the acute cases, 83% of the chronic
men was of soft-tissue attenuation without apparent cal analysis, these patients were excluded from the
calcification. Cobwebs were defined as thin, linear ra-
cases) compared with the true lumen (6% of the
acute group, because it was the larger of the two
diolucent filling defects in the lumen that were at- acute cases, 4% of the chronic cases) (p < 0.05)
groups. The level of significance for each test was
tached to the wall at one end; the other end could be a p value of less than 0.05.
(Fig. 3). Except for one case, eccentric flap cal-
attached to the flap or the wall or have no attachment. cification was only seen on the true lumen side
In addition, the following features of each lumen of the flap (p < 0.05) (Fig. 5).
were subjectively evaluated at one quarter, one half, Results At one quarter of the distance along the dis-
and three quarters of the distance along the dissected Fifty-one patients were included in the study. sected length of the aorta, for both acute and
length of the descending thoracic aorta and abdomi- There were 21 type A dissections and 30 type B chronic cases, the larger lumen was usually the
nal aorta: relative cross-sectional area and the pres- dissections. Eight patients had CT examinations false lumen (85% of the acute cases, 83% of
ence and direction of flap curvature. If the central
during both the acute and chronic phases of dis- the chronic cases) ( p < 0.05) (Figs. 1 and 5).
portion of the flap was curved toward one lumen, at
a particular level, then the flap curvature was coded
ease (one type A and seven type B), leading to a For acute dissections, the flap was most com-
as present for that lumen. If the flap was flat, then no total of 59 CT examinations (35 of acute dissec- monly curved toward the false lumen at this
curvature was coded. These features were evaluated tions and 24 of chronic dissections). For patients level (56% of the cases) ( p < 0.05), although it
at three different points along the length of the dis- with chronic dissection, the mean age of the dis- was often flat (38% of the cases), and occa-
sected portion of the aorta because of the possibility section was 23 months (range, 2–84 months). sionally curved toward the true lumen (6% of
that results might differ depending on location.
For patients with involvement of the transverse por-
tion of the aortic arch and proximal descending aorta TABLE 1 CT Findings in Acute and Chronic Aortic Dissections
(depicted as a long-axis view on a transverse CT im- Acute (n = 35 scans) Chronic (n = 24 scans)
age), one lumen sometimes appeared to wrap partially CT Finding
or completely around the other lumen, occasionally True Lumen False Lumen True Lumen False Lumen
even giving the appearance of three separate lumens. In Beak sign 0 (0)a 35 (100)a 0 (0)a 24 (100)a
these cases, the identity of the inner lumen was noted.
Outer wall calcification 21 (60)a 0 (0)a 17 (71)a 4 (17)a
To determine which lumen was true and which was
false, we followed the two lumens in the descending Intraluminal thrombus 2 (6)a 16 (46)a 1 (4)a 20 (83)a
aorta proximally and distally on the CT scans. The lu- Eccentric flap calcification 9 (26)a 1 (3)a 14 (58)a 0 (0)a
men in the dissected portion of aorta that was continu- Cobwebs 0 (0) 3 (9) 0 (0)a 4 (17)a
ous with the lumen of an undissected portion of aorta Larger area at one-quarter 3 (9)a–c 29 (85)a–c 3 (13)a,e 20 (83)a,e
was deemed to be the true lumen. If a lumen ended in a distance
blind sac, it was deemed to be the false lumen. These
Flap curvature at one-quarter 2 (6)a,c 19 (56)a,c 0 (0)a 6 (25)a
standards were used to define the lumens in all patients
distance
except four, in whom continuity could not be deter-
mined at CT. In these four patients (all with an acute Larger area at one-half distance 2 (6)a,d 31 (94)a,d 1 (4)a 23 (96)a
type A dissection), the boundary between the lumens Flap curvature at one-half 10 (30)d 11 (33)d 1 (4)a 7 (29)a
was blurred in the aortic root. In two of the four pa- distance
tients, the determination was made via comparison Larger area at three-quarters 2 (6)a,d,e 30 (91)a,d,e 0 (0)a 24 (100)a
with a later postoperative scan. On the postoperative distance
study, the lumen within the remaining native dissected Flap curvature at three-quarters 9 (27)d 13 (39)d 0 (0) 0 (0)
portion of aorta that was continuous with the aortic in- distance
terposition graft was deemed to represent the true lu-
men. In one of the four patients, one lumen completely Note.—Numbers in parentheses are percentages.
a Statistically significant frequency difference between true and false lumens within acute group or chronic group ( p < 0.05).
surrounded the other lumen; the inner lumen was
b In two cases, the true lumen area was equal to the false lumen area.
deemed to represent the true lumen, and this was con-
c In one case, no images were obtained at this level (noncontiguous sections).
firmed via comparison with surgical notes. Luminal
d In two cases, enhancement was poor at this level;
identification in the fourth patient was also made via images were not coded.
e In one case, the true lumen area was equal to the false lumen area.
comparison with detailed surgical notes. Differentia-

208 AJR:177, July 2001

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CT Features of Aortic Dissection

the cases) (Figs. 1 and 6). For chronic dissec- dissections, the flap was almost equally likely At three quarters of the distance along the
tions, the flap was usually flat (75% of the to be flat (36% of the cases), curved toward the dissected length of the aorta, the larger lu-
cases) and occasionally curved toward the false lumen (33% of the cases), or curved to- men was always the false lumen in chronic
false lumen (25% of the cases) ( p < 0.05). ward the true lumen (30% of the cases) ( p > cases and almost always the false lumen in
At one half of the distance along the dis- 0.05) (Fig. 6). For chronic dissections, the flap acute cases (91% of the cases) ( p < 0.05).
sected length of the aorta, for both acute and was usually flat (67% of the cases) (Fig. 2) and For acute dissections, the flap was nearly
chronic cases, the larger lumen was almost al- occasionally curved toward the false lumen equally likely to be flat (33% of the cases),
ways the false lumen (94% of the acute cases, (29% of the cases) ( p < 0.05); in only one case curved toward the false lumen (39% of the
96% of the chronic cases) ( p < 0.05). For acute was it curved toward the true lumen. cases), or curved toward the true lumen (27%
of the cases) ( p > 0.05). For chronic dissec-
tions, the flap was always flat at this level.
Statistically significant differences ( p <
0.05) between acute and chronic dissections
were as follows. Chronic dissections were
more likely to show eccentric flap calcification
of the true lumen, outer wall calcification of
the false lumen, and intraluminal thrombus of
the false lumen compared with acute dissec-
tions. Acute dissections were more likely to
show a curved flap (as opposed to a flat flap) at
one-quarter and three-quarters distance com-
pared with chronic dissections.
Forty-five of 51 patients had involvement
of the transverse portion of the aortic arch
and proximal descending aorta. In 24 of the
45 patients, one lumen appeared to wrap
around the other lumen. In all 24 patients
showing this finding, the inner lumen was
the true lumen (Fig. 7).
Fig. 1.—41-year-old man with acute aortic dissection. CT Fig. 2.—51-year-old woman with chronic aortic dis-
scan obtained at one-quarter distance along length of dis- section. CT scan obtained at one-half distance along
sected portion of aorta shows descending aortic dissection length of dissected portion of aorta shows flat dis- Discussion
flap (arrows) that is curved toward false lumen (F). Beak sign section flap. False lumen beaks are filled with low- It is important to determine the luminal ori-
(arrowheads) is present in false lumen. Note that false lu- attenuation thrombus (arrowheads). Faintly visual-
men area is larger than true lumen area. ized cobweb (arrows) is present in false lumen (F). gins of branch vessels before endograft or bare
stent placement within the aorta or within the
branch vessels, to plan optimal deployment and
avoid end-organ ischemia. In most cases, the
true lumen may be identified on CT by its conti-
nuity with an undissected portion of aorta.
Sometimes, however, this rule is difficult to ap-
ply, particularly in cases with involvement of
the aortic root and especially in those with cir-
cumferential dissection of the root. In addition,
patients occasionally undergo only abdominal
CT (e.g., in the setting of abdominal pain), and
therefore the true lumen cannot be traced back
to the aortic root. Our study showed several ad-
ditional CT imaging features that were helpful
in differentiating the true and false lumens. The
best feature was the beak sign; it was only seen
in the false lumen, and it was present in all
cases, both acute and chronic. Moreover, it was
generally easily identified on CT. The beak sign
Fig. 3.—65-year-old woman with chronic aortic Fig. 4.—76-year-old man with chronic aortic dissection. CT is the cross-sectional imaging manifestation of
dissection. CT scan obtained at one-quarter dis- scan obtained at three-quarters distance along length of dis- the wedge of hematoma that cleaves a space for
tance along length of dissected portion of aorta sected portion of aorta shows flat dissection flap. Outer wall the propagating false lumen and that is present
shows flat dissection flap. Outer wall calcification calcification (arrows) and thrombus (asterisk) are present in
microscopically in all dissections [10]. Cob-
(straight arrow) is present in true lumen (T). Throm- false lumen (F). T = true lumen.
bus (arrowheads) is present in false lumen. Curved webs (ribbons of media that are incompletely
arrow indicates thrombus within false lumen beak. sheared off by the dissection) were also present

AJR:177, July 2001 209

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LePage et al.

low-flow segments of the false lumen. In cases

of chronic dissection, the false lumen remains
prone to thrombus formation because of stasis
related to aneurysmal enlargement and be-
cause of atheromatous changes in the neoint-
ima, which can outstrip atheromatous
degeneration in the native intima.
In an in vitro model of dissection with two
patent lumens, one published study showed
that the true lumen collapses and the false lu-
men distends even when the pressure gradi-
ent across the dissection flap is zero [13].
Moreover, for in vivo aortic dissections in
humans, pressure in the false lumen fre-
quently exceeds that in the true lumen [8]
and superimposes an element of compres-
Fig. 5.—59-year-old man with chronic aortic dissec- Fig. 6.—65-year-old man with acute aortic dissec-
tion. CT scan obtained at one-quarter distance along tion. CT scan obtained at one-quarter distance along
sion onto the underlying true lumen collapse.
length of dissected portion of aorta shows flat dissec- length of dissected portion of aorta shows dissection Thus, it is not surprising that in our study,
tion flap. Eccentric flap calcification (arrow) is present flap that is curved toward true lumen. Anterior false larger lumen size was a good marker for the
along true lumen side of flap. Notice that false lumen lumen beak (arrowheads) is partially opacified and false lumen in both acute and chronic dissec-
(F) contains thrombus (arrowheads) and is larger than partially filled with thrombus. F = false lumen.
true lumen at this level. tions. This finding was commonly present,
and usually obvious, particularly at one half
Fig. 7.—69-year-old woman with or three quarters along the distance of the
acute aortic dissection. CT scan ob- dissected aorta.
tained at level of transverse aortic The direction of flap curvature was gener-
arch shows that outer false lumen
(F) wraps around inner true lumen
ally not useful in distinguishing the true from
(T). Dissection flap extends into in- false lumen. However, acute dissections usu-
nominate artery. Note cobweb in ally had some curvature to the flap, whereas
false lumen (arrow) and bilateral chronic dissections usually had a flat flap over
pleural effusions (P).
much of its length. This appearance of the flap
is probably caused by cellular and mechanical
changes in the aorta wall. As the flap heals, fi-
brosis and neointima formation [14] lead to
thickening and rigidity of the flap. In addition,
we hypothesize that as the false lumen dilates,
the lines along which the dissection flap joins
the outer wall of the aorta are drawn apart,
stretching the flap taut. Our impression is that
this flattening of the dissection flap is particu-
larly notable in larger false lumens.
In patients with involvement of the aortic
arch, it is common for one lumen to appear to
wrap partially or completely around the other
only in the false lumen; however, this feature calcify in long-standing dissections [11, 12], lumen, sometimes even giving the appearance
was of limited usefulness because of its rarity. leading to calcification in the outer wall of the of three lumens. The different appearance in
This finding is in agreement with previous stud- false lumen. Although, theoretically, this phe- the transverse arch, compared with the appear-
ies that have reported cobwebs as a specific, but nomenon could also lead to calcification on the ance in the descending aorta, is because of the
relatively insensitive, indicator of the false lu- false luminal surface of the flap in chronic dis- different angle of sectioning, relative to the
men [9, 10]. The lower prevalence of cobwebs sections, no such cases were identified in our long axis of the aorta. In such cases, the inner
in our study compared with that reported in a study. Intraluminal thrombus was a fairly good lumen is invariably the true lumen.
previous intravascular sonographic study [10] marker for the false lumen, although in pa- Accurate CT differentiation between the true
may reflect, in part, the greater spatial resolution tients with an underlying aneurysm, thrombus and the false lumen has previously been rela-
of intravascular sonography relative to CT. may be present in the true lumen as well. False tively unimportant, because surgery has been
Outer wall calcification always indicated lumen thrombus was significantly more fre- the mainstay for therapy, and therapeutic deci-
the true lumen on scans of acute dissections. In quent in chronic dissections than acute dissec- sions have relied predominantly on the presence
chronic dissections, however, this finding was tions. Thrombus formation in acute dissection or absence of involvement of the ascending
somewhat unreliable because the false lumen is due partly to the thrombogenic exposed me- aorta [15, 16]. However, at the current time, per-
lining may endothelialize and subsequently dia, which lines the false lumen, and stasis in cutaneous treatment methods are maturing and

210 AJR:177, July 2001

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CT Features of Aortic Dissection

have become more prevalent, partly fueled by 2. Sebastia C, Pallisa E, Quiroga S, Alvarez-Castells aorta. III. Anatomy and radiologic diagnosis of branch-
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AJR:177, July 2001 211

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