REFERENCE

a single-institutional experience. BJU Int 2007;99:1123–6. Penetrating atherosclerotic ulcer: another case of the ‘great pretender’ A 57-year-old woman presented with acute retrosternal discom-fort. An ECG demonstrated diffuse Twave inversion and she was treated for an acute coronary syndrome. Upon further review, CT aortography was arranged. This was reported as showing aortic wall thickening consistent with aortitis (figure 1). Subsequently the patient deteriorated. Echocardiography revealed a prominent aorta with cardiac tamponade. Suspecting an acute aortic syndrome (AAS), she was transferred to a cardio-thoracic unit. A penetrating atherosclerotic ulcer (PAU) with peri-aortic haematoma was confirmed perioperatively (figure 2). She has since made a full recovery. Thirty per cent of patients with AAS are initially misdiag-nosed.1 PAU is rare but increasingly recognised, comprising 7.6 % of AAS cases.2 It arises from erosion of atherosclerotic plaque through the internal elastic lamina with medial haema-toma formation.3 CT typically shows an aortic wall protrusion and thickening, without a dissection flap.4 Involvement of the ascending aorta is frequently fatal and surgical intervention is recommended.