A 42-year-old male patient presented to the emergency department with complaint of severe abdominal pain. On examination, he had distended abdomen and unstable vitals. His pulse was weak and feeble, along with heart rate of 121 bpm. He had blood pressure reading of 70/41 mm of Hg. Previously he had ultrasound of abdomen which revealed infra-renal abdominal aortic aneurysm with diameter of 4.5cm.
On contrast-enhanced CT of abdomen and pelvis, there was fusiform dilation of the infrarenal abdominal aorta spanning a length of 11.3cm extending from just distal to the origin of the renal arteries involving up to the abdominal aortic bifurcation. However, no involvement of the bilateral common iliac arteries was seen. Maximum dilated segment measured 5.7cm in diameter. There was focal defect of 11mm seen in the right lateral wall of the aorta at the level of lower border of L1 vertebra. Active extravasation of the contrast media was seen into the surrounding retro-peritoneal high-density hematoma. Active spillage of contrast into the retro-peritoneal space was seen. This extravasated contrast was outlining the reto-peritoneal space around the posterior wall of the bowels. The hematoma around the aneurysm was seen compressing the IVC causing its luminal narrowing. Both of the renal arteries were seen originating from the normal segment of the aorta proximal to the aneurysm.
Abdominal aortic aneurysm is more common in males compared to females with incidence of 8% in men over the age of 65 years. These are asymptomatic until they rupture with fatal complications. Fatality of the rupture abdominal aortic aneurysm is about 80% [1, 2]. Atherosclerotic changes is strong predisposing factor for the development of the abdominal aortic aneurysm. Positive association with number of years of smoking and negative association with cessation was seen. Hypertension, higher body mass index, hypercholestrolemia, diabetes and pulmonary disease are other associated conditions [3, 4].
On imaging, there are signs of impending aortic aneurysm rupture and signs of aortic rupture.
Signs of impending rupture include high attenuating crescent sign, draped aorta sign, focal discontinuity in calcification and tangential calcification signs.
Signs of the rupture include focal discontinuity in the aortic wall, presence of aorto-enteric fistula, aorto-calval fistula, retroperitoneal hematoma, intraperitoneal hematoma and active contrast extravasation [5, 6].
Outcome
The patient was unresponsive by the time he was taken to the operation theatre. He was on multiple ionotropes and fluids. However, the patient could not be revived.
Take home message
Abdominal aortic aneurysm rupture must be suspected and searched for in a hemodynamically unstable patient presenting with acute severe abdominal pain. High index of suspicion is needed if there is preexisting abdominal aneurysm.
All patient data are completely anonymised throughout the entire manuscript and related files.
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[2] Marcaccio CL, Schermerhorn ML (2021) Epidemiology of abdominal aortic aneurysms. Seminars in Vascular Surgery 34(1):29–37
[3] Moneta GL (2011) Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. Yearbook of Vascular Surgery 2011:103–5
[4] Kim H, Cho S, Sakalihasan N, Hultgren R, Joh JH (2023) Prevalence and risk factors of abdominal aortic aneurysms detected with ultrasound in Korea and Belgium. Journal of Clinical Medicine 12(2):484
[5] Vu K-N, Kaitoukov Y, Morin-Roy F, Kauffmann C, Giroux M-F, Thérasse É, et al (2014) Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms. Insights into Imaging 5(3):281–93
[6] Heiken JP (2006) Aortic aneurysm rupture [Internet]. The Radiology Assistant: Aortic Aneurysm Rupture 2006 [cited 2023Mar22]. Available from: https://radiologyassistant.nl/abdomen/aorta/aneurysm-rupture
| URL: | https://eurorad.org/case/18259 |
| DOI: | 10.35100/eurorad/case.18259 |
| ISSN: | 1563-4086 |
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