322 • HJC (Hellenic Journal of Cardiology) Hellenic J Cardiol 2013; 54: 322-325 Manuscript received: July 12, 2011; Accepted: October 31, 2011. Address: Jorge Romero Department of Internal Medicine St Luke’s-Roosevelt Hospital Center 1000 10th Avenue New York, NY, 10019, USA e-mail: jr2902@columbia.edu Key words: Syncope, acute aortic syndrome, chest pain, pericardial effusion, aortic dissection. Case Report Case Report A Blind Spot in the Eye of Imaging Technology: Penetrating Atheromatous Ulcer Jorge romero, Arpit ShAh, AlekSAndr korniyenko Department of Internal Medicine, St Luke’s-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, USA Acute aortic syndrome (AAS) is a term that is used to describe a similar clinical profile that may have dif- ferent underlying pathophysiological mechanisms. It includes classic aortic dissection, intramural aortic he- matoma, and penetrating atherosclerotic ulcer. We describe the case of a 77-year-old female who presented with syncope of unknown duration. The chest X-ray was suggestive of a widened mediastinum. The initial work-up with a computed tomography scan and transesophageal echocardiogram failed to diagnose a pen- etrating atherosclerotic ulcer. We discuss the importance of a high degree of clinical suspicion for AAS and the utility of different imaging technologies in making the diagnosis. A cute aortic syndrome (AAS), is a term that is used to describe a similar clinical profile that may have different underlying pathophysiolog- ical mechanisms. 1 It includes classic aor- tic dissection, intramural aortic hemato- ma, and penetrating atherosclerotic ulcer; and, more recently, incomplete dissection. There is a possibility of an underlying link, considering that these conditions coex- ist and frequently precede each other. 2 Moreover, the likelihood of a downward clinical course is high, making early diag- nosis and management of paramount im- portance. Case presentation We present the case of a 77-year-old fe- male of Japanese origin, with a past medi- cal history significant only for essential hypertension, who presented with synco- pe of unknown duration in the field. Her presenting vitals in the emergency depart- ment were: blood pressure 100/80 mmHg, heart rate 120 beats per minute, respirato- ry rate 32 per minute, temperature 38°C. At presentation she was alert, awake and oriented, but appeared tachypneic. The physical examination was unremarkable. Her initial chest X-ray (CXR) showed left upper lobe infiltrate, and evidence of left ventricular hypertrophy was present on the electrocardiogram (Figures 1-2). She was treated empirically with vancomycin and cefepime, along with 2.5 L normal sa- line. During her stay in the emergency de- partment, her blood pressure rose to 218/117 mmHg and she received intrave- nous labetalol 55 mg total (15 mg + 20 mg + 20 mg). On hospital day 2, the previous CXR, although rotated, was suggestive of a widened mediastinum. A computed to- mography (CT) scan of the chest with con- trast was performed. This study revealed an intramural hematoma within the as- cending aorta, extending to the proximal anterior arch, with hemopericardium an- teriorly and inferiorly, without any evi- dence of intimal flap, dissection, or ulcer- ated plaque (Figure 3). Transesophageal echocardiography (TEE) was also per- formed, and failed to show evidence of