CASE 18259 Published on 18.08.2023

Case of abdominal aortic aneurysm rupture



Case Type

Clinical Cases


Bibek K. C.1, Asha Shrestha2

1. Department of Radiology, Institute of Medicine, Tribhuwan University Teaching Hospital, Kathmandu, Nepal

2. Department of Obstetrics and Gynecology, Nepal Medical College Teaching Hospital, Kathmandu, Nepal


42 years, male

Area of Interest Abdomen, Anatomy, Emergency, Vascular ; Imaging Technique CT
Clinical History

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.

Imaging Findings

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].


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.

Differential Diagnosis List
Ruptured fusiform aneurysm of the infra-renal abdominal aorta with retro-peritoneal hematoma and active retro-peritoneal extravasation
Aortic dissection: Acute aortic dissection can present with severe abdominal pain and enlarged aorta with two distinct lumen, i.e., true and false lumen
Aorto-enteric fistula: Aneurysm not only leads to rupture into the peritoneum some can form fistula with the small bowel loop, especially when associated with mycotic aneurysms
Final Diagnosis
Ruptured fusiform aneurysm of the infra-renal abdominal aorta with retro-peritoneal hematoma and active retro-peritoneal extravasation
Case information
DOI: 10.35100/eurorad/case.18259
ISSN: 1563-4086