The ECG may be normal or may show ischemia or infarction in any territory owing to involvement of the coronary ostia. The chest radiograph shows mediastinal widening and enlargement of the aortic contour in up to 70 per cent of cases ( Fig, 1); however, this may be difficult to appreciate on a portable film. Tracheal and esophageal displacement are common, and inward displacement of a calcified aortic rim more than 6 mm from the aortic border is a valuable feature which is found in 17 per cent of cases. Fluid in the pleural space, usually the left, may be apical or basal or may contribute to mediastinal widening. Although chest radiographs are now performed with decreasing frequency before thrombolysis, a film should be taken if there is any diagnostic doubt or if there are any features suggestive of dissection. However, dissection can occur when the chest radiograph is entirely normal.

Fig. 1 Characteristic chest radiograph appearance of aortic dissection demonstrating mediastinal widening, aortic unfolding, and tracheal displacement.

CT, aortography, transesophageal echocardiography, and magnetic resonance imaging (MRI) have now evolved with complementary roles ( Goldman et al. 1986; Erbel. .et a/ 1990).

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