What is the predictive value of a widened mediastinum in diagnosing an aortic dissection?

Does this patient have an acute thoracic aortic dissection?  Database of Abstracts of Reviews of Effects. Issue 2, 2015. This is a review of this rational clinical exam in JAMA.2002;287(17):2262-2272

Short answer: The presence of a normal aorta and mediastinum in the chest x-ray decreased the probability of dissection, but no particular radiographic abnormality was present consistently.

Objective: To review the accuracy of clinical history taking, physical examination, and plain chest radiograph in the diagnosis of acute thoracic aortic dissection.

Particulars: Systematic review of 21 case series (n=1,848)  that included at least 18 patients & were either retrospective (after confirmation by gold standard study) or prospective (based on clinical presentation).   Diagnostic reference standard for the various studies included surgical exploration, autopsy, aortogram, magnetic resonance imaging, computed tomography, or transesophageal echocardiography.    All but one study was graded as level 4 quality.

Data of interest

For 3 studies (n=180), pooled likelihood ratios for enlarged aorta or widened mediastinum on chest x-ray in patients with high clinical suspicion:   Negative LR = 0.3, 95% CI: 0.2-0.4 and Positive LR = 2.0, 95% CI: 1.4-3.1

For 8 studies (n=1,184), the pooled sensitivity of wide mediastinum in the diagnosis of acute aortic dissection is 64%, 95% CI: 44%-80%

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Clinical Informationist at EUH Branch Library
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