[Aortic dissection. A diagnostic hypothesis that is frequently discussed]

Aortic dissection is a dramatic event which too often carries an ominous prognosis. The characteristic clinical presentation has been well described in medical texts and cannot be misdiagnosed. However, in some not infrequent cases, symptoms and signs may be so misleading and subtle that a subsequent catastrophic evolution then seems unexpected. The diagnosis may be easily confirmed or excluded by modern diagnostic tools such as transesophageal echocardiography, magnetic resonance imaging or spiral computed tomography, which all offer such accurate anatomic images of the aortic wall that nowadays it is possible to diagnose even those minimal lesions that can precede dissection, such as intramural hemorrhages or penetrating ulcers. However, these techniques are complex, costly and require experienced operators for optimum sensitivity and accuracy. Their use in patients with suspected acute aortic syndromes is of proven necessity. However, how often is all this feasible in a crowded Emergency Department where hundreds of patients with aspecific and overlapping symptoms and signs all require immediate attention? Furthermore, how often is a subtle intriguing initial presentation then followed by fatality, which might also come about some days later? Can failing to make an early diagnosis be cause for prosecution for having given a faulty diagnosis or might it be accepted as a risk related to the imprecise, probabilistic nature of the medical approach to the diagnosis? How can an Emergency Department doctor produce a reliable document of his way of proceeding in order to offer verifiable legal proof of his methodological integrity and thus be able to avoid misinterpretation of guilt? It is all too easy to judge overlooked clinical recognition when the clear and "simple" pathological diagnosis is available, if one does not consider the complexity of the disease and its possible manifestations in the single patient. In order to answer these questions it is necessary to collect the experience of doctors and others involved in this field. It is the aim of this paper and the clinical case presented to stimulate discussion and initiate the task in hand.