Spontaneous Coronary Artery Dissection
Share |
Case of the Month Header 2011

Dear SCCT Member:


As you know, the SCCT is the only professional medical membership organization dedicated to ensuring patient access to the appropriate use of cardiovascular CT. The SCCT Board of Directors thought that it would be beneficial to our members to create a Case of the Month series showcasing cardiac CTA in various clinical scenarios. this series will be spearheaded by the collective members of the SCCT FiRST committee. Please provide feedback or forward any questions to info@scct.org 




Spontaneous Coronary Artery Dissection Diagnosed by Coronary CT Angiography 
Dustin M. Thomas, MD1; James A. Watts, MD1; Kevin E. Steel, DO; James L. Furgerson, MD1

1Cardiology Service, Department of Medicine, Brooke Army Medical Center, San Antonio, TXCorresponding author: Dustin M. Thomas, MD, Brooke Army Medical Center                   

A 42 year-old female who was 9 months post-partum presented with sudden onset of anginal chest pain following running on a treadmill. The patient was admitted to the hospital where she subsequently ruled in [MW1] for a non-ST elevation myocardial infarction (NSTEMI). Invasive coronary angiography (ICA) was performed with findings of minimal narrowing (Figure 1A) in the proximal left anterior descending (LAD). The patient underwent cardiac MRI (CMR) with findings of a transmural infarction of the mid-anteroseptal wall segment with associated regional wall motion abnormality (Figure 2). She was discharged, however returned to the emergency department 7 days later with recurrent anginal symptoms and troponin increase consistent with recurrent NSTEMI. The patient was referred for coronary CT angiography (coronary CTA) demonstrating intramural hematoma extending from the mid portion of the left main coronary artery (LMCA) into the distal LAD and including multiple diagonal and septal branches (Figure 3-5). She subsequently underwent repeat ICA with marked luminal loss corresponding to the area of intramural hematoma on coronary CTA. After consultation with interventional cardiology and cardiothoracic surgery, the decision was made to defer intervention and treat conservatively with aspirin, beta blocker, and nitrates. At post-discharge follow-up, the patient was experiencing less frequent, but persistent anginal symptoms.  

Figure 1


Figure 2


Figure 3
Figure 4
Figure 5

Invasive coronary angiography (ICA) from the RAO cranial projection obtained during the initial presentation (Figure 1A) and at second presentation (B) showing progressive LAD stenosis (arrow). Short axis CMR (Figure 2A) showing late gadolinium enhancement (LGE) in the mid-anteroseptal segment consistent with infarction. Rest CT perfusion (Figure 2B-C) at time of second presentation demonstrating a new anterior and anterolateral wall perfusion defect in addition to the persistence of the mid-anteroseptal defect. Axial coronary CTA projection (Figure 3) showing significant luminal narrowing and mural thickening involving the left main (LM) and left anterior descending (LAD) coronary arteries. Curved-multiplanar reformat (c-MPR) of the LAD (Figure 4) depicting the spiraling nature of the dissection with visualization of the associated intramural hematoma (arrows). Multiplanar reformat (MPR) of the LM in short axis (Figure 5) showing the extent of intramural hematoma (arrows) impinging on the coronary lumen (*).


Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of acute coronary syndrome (ACS). While the true incidence is unknown, findings consistent with SCAD were reported in 0.07-1.1% of all ICAs performed in two large registries of diagnostic catheterization (1,2). The pathologic hallmark of the disease is dissection of the intima or media layer of the coronary associated with intramural hematoma, though controversy persists as to exact pathophysiology. Variability exists in the clinical presentation including 44% with NSTEMI, 49% with ST elevation myocardial infarction (STEMI), and 14% with life-threatening ventricular arrhythmia (3). There is a strong association with fibromuscular dysplasia, which is detected in non-coronary vascular beds in up to 14% of female SCAD patients (3).
A commonly reported clinical presentation is a middle-aged, post-partum female with onset of symptoms following strenuous activity. A high clinical suspicion based on patient risk factors is required to make the diagnosis as referral for intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is typically required in the setting of a non-diagnostic ICA (4). Currently, coronary CTA plays a limited role in diagnosis as small intimal dissections may be missed, particularly early in the disease process, due to the limitations of spatial resolution. CT angiography is a useful diagnostic tool for screening non-coronary vascular beds for associated conditions, such as fibromuscular dysplasia (5). Coronary CTA is also described as a potential alternative to ICA to confirm healing and resolution in patients treated conservatively (6).

The optimal treatment strategy is currently unknown. Retrospective studies report favorable outcomes with conservative management in patients with preserved coronary flow, as attempted percutaneous coronary intervention is associated with high procedural failure rates (35-53%)(7). Outcomes for coronary artery bypass grafting (CABG) are no more favorable in that graft attrition rates are significantly higher than reported in atherosclerotic coronary artery disease. Long-term prognosis for SCAD patients appears favorable with low mortality rates. Recurrent SCAD is the most frequent outcome reported in retrospective cohorts with rates approaching 30% in female patients and manifests most commonly (80%) in previously unaffected coronary territories (3).
1.  Mortensen KH, Thuesen L, Kristensen IB, Christiansen EH. Spontaneous coronary artery dissection: a Western Denmark Heart Registry study. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2009;74:710-7.

2.Vanzetto G, Berger-Coz E, Barone-Rochette G et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2009;35:250-4.

3.Tweet MS, Hayes SN, Pitta SR et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012;126:579-88.

4. Alfonso F, Paulo M, Gonzalo N et al. Diagnosis of spontaneous coronary artery dissection by optical coherence tomography. Journal of the American College of Cardiology 2012;59:1073-9.
5.Liang JJ, Prasad M, Tweet MS et al. A novel application of CT angiography to detect extracoronary vascular abnormalities in patients with spontaneous coronary artery dissection. Journal of cardiovascular computed tomography 2014;8:189-97.
6.Russo V, Marrozzini C, Zompatori M. Spontaneous coronary artery dissection: role of coronary CT angiography. Heart 2013;99:672-3.

7.Tweet MS, Eleid MF, Best PJ et al. Spontaneous coronary artery dissection: revascularization versus conservative therapy. Circulation Cardiovascular interventions 2014;7:777-86. 


The Case of the Month may also be viewed at http://www.scct.org. 

Members of SCCT may view archived Cases by visiting:  




If you would like to submit a Case of the Month for publication, please contact Debra Fernandez at dfernandez@scct.org  for specifications and instructions.    

415 Church St. NE, Suite 204
Vienna, VA 22180-4751