coronary artery spontaneous dissection is a rare and uncommon cause of sudden cardiac death and acute coronary syndrome .
we report a case of a 31-year - old male admitted to our hospital with an acute coronary syndrome .
a dissection of the left main coronary artery was diagnosed with a multidetector computed tomography ( ct ) scan and it was decided to perform an emergency coronary artery bypass grafting .
a 31-year - old male , airline pilot , with no clinical history or cardiovascular risk factors , was admitted to the emergency room with 12 h history of retrosternal chest pain radiating to the jaw and upper extremities , during a trans - atlantic flight , which did not improve with analgesia .
because of persistent pain , he came to our hospital . upon arrival to the emergency room , his vital signs were stable and he had a normal physical examination but complained of precordial pain .
the cardiac enzymes were elevated and the ekg detected s - t changes consistent with mi ( fig .  1 ) .
a multidetector ct coronary angiography was performed showing left main trunk dissection with 50% stenosis ( fig . 
figure  2:multidetector coronary angio - tomography reveals dissection at the ostium of the left main coronary artery .
multidetector coronary angio - tomography reveals dissection at the ostium of the left main coronary artery .
the patient underwent emergent coronary revascularization with saphenous vein grafts to the first obtuse marginal and the left anterior descending artery ( lad ) .
control ct coronary angiography was performed 2 months later revealing patent aorto - coronary grafts ( fig . 
figure  3:ct coronary angiography reconstruction showing patent grafts to the lad and obtuse marginal arteries .
in 1931 harold pretty described the first case of spontaneous dissection of a right coronary artery during the autopsy of a woman who presented with precordial chest pain .
this condition is a rare cause of ischemic heart disease and affects mainly young healthy women . in 1987 , 85 cases were reported in the literature , currently more than 300 cases have been published [ 2 , 3 ] . before the coronariography era , these cases were reported during autopsies of patients having sudden cardiac deaths and its incidence may have been under - estimated . with the advent of these studies , the incidence has been reported to range between 0.07 and 1.1% .
dissection of the lad artery is most common in women , whereas in men it is the right coronary artery [ 2 , 4 ] .
the left main coronary artery involvement , like in our case , is rare , occurring in up to 12% of the cases , but is the most severe injury and presents as mi .
hemodynamic and hormonal factors determine morphological changes in the arterial wall , and these may contribute to spontaneous dissection of the coronary arteries , with a peak incidence during the second week after birth [ 3 , 4 ] . to date , the pathophysiology is unclear [ 24 ] . in a subgroup of patients
it is not possible to identify a specific condition causing spontaneous coronary dissection and is therefore classified as idiopathic . in patients with connective tissue disorders such as marfan s and ehlers 
danlos syndromes , predisposing to the dissection arises from medial degeneration of the coronary arteries .
certain vasculitis , including systemic lupus erythematosus and polyarteritis nodosa , has been associated with the occurrence of coronary artery dissection .
other factors that can cause vascular spasm and coronary dissection include intense exercise , sneezing and prolonged cocaine abuse [ 2 , 3 ] .
it should show the presence of a double radiopaque lumen separated by a radiolucent intimal flap or a slow clearance of contrast from the false lumen .
an intimal tear is present in only a minority of cases and a medial hematoma may not be recognized on coronary angiography as the medial hemorrhage may cause luminal narrowing or occlusion by pushing the inner media against the opposing wall .
several cases in the literature have shown that ct coronary angiography provides additional information over invasive coronary angiography , with an accurate demonstration of the intimal flap and extent of the intramural hematoma .
this study constitutes an emerging noninvasive alternative for diagnosis and also the follow - up of coronary artery spontaneous dissection .
there are no specific guidelines for the management of spontaneous dissections of the coronary arteries [ 3 , 5 ] .
coronary artery bypass surgery is indicated in patients with multivessel dissection , failed angioplasty and dissection of the trunk of the left main coronary artery [ 35 ] .
although spontaneous dissection of a coronary artery is an uncommon condition , treatment should be based on the clinical status and imaging studies , including conservative and surgical means depending on the clinical presentation , location and characteristics of the dissection , we elected to proceed with surgery based on the ct findings .
 spontaneous dissection of the coronary arteries is a rare disease with a wide range of clinical presentations ranging from angina to myocardial infarction ( mi ) ; its pathophysiology has not yet been fully established . in this paper , we present the case of a 31-year - old male with an acute coronary syndrome . 
 the initial results of the electrocardiogram and cardiac enzymes were consistent with mi . 
 however , a coronary angio - tomography revealed a dissection of the left main coronary artery and the patient underwent emergent surgery with coronary artery bypass grafting . 
 the treatment of spontaneous dissection of the coronary arteries depends on the anatomical location and the patient 's clinical presentation . 
 coronary revascularization is associated with good results . 
INTRODUCTION
CASE REPORT
DISCUSSION