as a Pulmonary Mass. Received May 21 , 1985; accepted after revision September 11, 1985. .... The hematoma also extended through the right hemidiaphragm.
155
Abdominal Aneurysm: Myung
S. Shin,1
Atherosclerotic
Pseudoaneurysm Arising from a True Presentation as a Pulmonary Mass Kang-Jey
Ho,2 John
W. Kirklin,3
John
M. Forman,3
of the abdominal aorta often it ruptures into the pleural, peritoneal, or retroperitoneal space or compresses adjacent structures [1 -4]. The most common symptom is pain, but an asymptomatic, nontender, pulsatile mass is often palpable above the umbilicus. We describe a case of a ruptured atherosclerotic aneurysm of the abdominal aorta with minimal symptomatology that simulated a lower lung mass on conventional chest radiography. The correct diagnosis was made by CT and was confirmed at surgery.
produces
aneurysm
no symptoms
unless
Case Report A 61 -year-old
man was admitted
with a 3-month
history
of cough,
hemoptysis, and weight loss. He was hypertensive and had a history of seizure disorder probably associated with alcohol abuse and withdrawal. He also had smoked two packs of cigarettes per day for more than 30 years and had only recently reduced to one-half pack per day. His cough
was productive
of white
sputum
The patient refused surgical intervention and was discharged; 1 month later he developed massive hemoptysis. When brought to the emergency room, he was in shock followed by apnea and cardiac arrest requiring cardiopulmonary resuscitation. Chest radiography revealed irregular opacification of the right lower lung base with pleural effusion. CT showed marked enlargement of the original false aneurysm,
2
3
AJR
Department Department
146:155-156,
Address
reprint
requests
to M.
irregular
border
and right posterior surgery. At surgery,
of the mass of diaphragmatic
pleural effusion.
the giant retroperitoneal
1986 0361-803X/86/1461-0155
false aneurysm
was confirmed.
Discussion Most patients than
60; more
who develop than
aortic aneurysms
half have
long survival
aneurysm
are men older
hypertension
and
with
minimal
symptoms
[5]. The suspicion
after
the rupture
of the
of lung cancer was unavoidable
in a patient with a newly developed chest mass associated with cough, hemoptysis, weight loss, and a long history of heavy cigarette smoking. After a futile clinical search for lung cancer, CT proved extremely useful, as has been the experi-
ence ofothers in identifying aortic aneurysms [6, 7]. CT clearly delineated the extent of the false aneurysm and its relation to the aorta (figs. 1C and 1 D). The CT findings of a smoothly outlined, irregularly shaped mass with a density identical to that of blood, lying in direct continuity with a dilated segment of aorta, are quite diagnostic of a false aneurysm secondary to rupture of a true aneurysm. It has been shown that when the diameter of an aneurysm is greater than 6 cm, the possibility of rupture in a 1 0-year
S. Shin.
0 American Roentgen
associated
many are cigarette smokers [1 , 4]. Our patient fits such a profile. However, there are several unique aspects of this case, such as the unusual location of the aneurysm and the
Hospital, and Wiversity
of Pathology, University of Alabama School of Medicine and Veterans Administration Hospital, Birmingham, of Cardiovascular Surgery, University of Alabama School of Medicine and Veterans Administration Hospital, January
eventration,
At this time the patient agreed to
After a huge amount of blood clot was evacuated, a large opening measuring 4 x 6 cm became evident on the right side ofthe abdominal aorta just superior to the origin of the celiac artery. The hematoma also extended through the right hemidiaphragm to the chest cavity, eroding into the lung parenchyma. Although the aortic aneurysm was successfully repaired by patch graft, the patient developed wound dehiscence and aspiration and died 10 days after surgery. No autopsy was performed.
Received May 21 , 1985; accepted after revision September 1 1 , 1985. 1 Department of Radiology, University of Alabama School of Medicine, Veterans Administration AL 35233.
L. Berland
and occasionally
fresh blood and was associated with low back pain and a 17-kg weight loss. The pertinent findings on admission included a blood pressure of 140/1 00 mm Hg, pulse of 96/mm, greatly diminished dorsalis pedis and posterior tibial pulses bilaterally, epigastric tenderness without palpable mass, a packed cell volume of 32%, and hemoglobin of 1 1 g/dl. A chest radiograph showed a fairly smooth, well demarcated mass at the right lung base (fig. 1A) that had not been present 6 months earlier. The initial clinical impression was bronchogenic carcinoma. Bronchoscopy revealed a small amount of blood in the anterior basal segment of the right lower lobe but no visible endobronchial lesion. The cytologic studies of the bronchial washing and brushing specimens and the sputums were all negative for malignancy. A CT scan then showed that the mass at the right lung base was the upper part of a 9 x 13.5 cm mass located in the retropentoneal space between the diaphragm and the renal hila (figs. 1B-i D). The mass had a smooth outline, irregular shape, and homogeneous density with an attenuation value of 40-45 H, similar to that of the blood. The lumen of the abdominal aorta was irregularly dilated with a less dense area between the lumen and calcified wall suggestive of mural thrombus (fig. 1 D). These CT findings were compatible with a giant pseudoaneurysm arising from a ruptured atherosclerotic aneurysm of the abdominal aorta and associated with a diaphragmatic eventration.
Birmingham,
and Lincoln
Ray Society
of Alabama AL 35233. Birmingham,
Hospitals, 619 5.
AL 35233.
19th St.,
156
SHIN
ET
AL.
AJR:146,
Fig. 1 -A,
January
1986
film on admission. mass lesion at right lung base. Contrast-enhanced CT scans at levels above (B) and below (C)diaphragm and at renal hila (0). Note lobulated demarcated mass adjacent to aorta with diaphragmatic eventration. Posteroanterior
Well demarcated
period is 45%-50%, diameter
is less
whereas than
6 cm
it is only 15%-20% [3, 8]. The
aneurysm before rupture in this case was theless, it did rupture into the retroperitoneal likely that the unusually high position ofthe in a massive but contained retroperitoneal of intraperitoneal rupture and rapid demise. of the aneurysm
the diaphragm
also allowed
and present
the false
actual
when the size
of the
unknown. Neverspace. It is most aneurysm resulted hematoma instead The high position
aneurysm
to eventrate
as an intrathoracic
mass.
555
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Gore
Hirst AE Jr. Arteriosclerotic aneurysms of the abdominal Cardiovasc Dis 1973;16: 1 13-1 50 Bergan JJ, Yao JST. Modern management of abdominal aortic aneurysms. Surg Clin North Am 1974;54: 175-193 aorta.
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AF,
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DeAusso aortic
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