A blind spot in the eye of imaging technology: penetrating atheromatous ulcer.

Acute aortic syndrome (AAS) is a term that is used to describe a similar clinical profile that may have different underlying pathophysiological mechanisms. It includes classic aortic dissection, intramural aortic hematoma, 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 penetrating 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.