Traumatic
Pseudoaneurysms
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JACK
of the Thoracic
H. HIRSCH,’
STEPHEN
J. CARTER,
The mechanical considerations resulting in traumatic rupture of the thoracic aorta from sudden deceleration have been well described [1-5]. We present two patients surviving aortic injury with unusual pseudoaneunysm formation. Case Case
L. 0.
Reports
,
a 56-year-old mass
white
male, was admitted
discovered
on a routine
no other
significant
negative. Chest radiographs
trauma.
radiograph.
to the chest, but had a patient had also fallen in 1946 which resulted and ankle fracture. He
Serology
taken oven a 14 year period
for
syphilis
was
were reviewed
1). A 3 cm soft tissue density seen adjacent to the aortic in February 1977 had increased in size since 1975. The
mass was not present in 1963, but was detectable as a second contour adjacent to the aortic knob in 1971 . Tomography revealed no calcification. An aortognam demonstrated the aneunysm, and at surgery a 3 x 5 cm pseudoaneurysm was removed from the aortic arch just proximal to the ligamentum arteniosum.
Case
2
P. 5. , a 59-year-old white male, was hospitalized in January 1977 after sustaining multiple bilateral anterior and lateral rib fractures in an automobile accident resulting in a flail chest. The hospital course was complicated by left lower lobe pneumonia which was treated. The patient was discharged after 12 days. He was neadmitted 17 days later with a 3 cm convex soft tissue
density
adjacent
to the distal
descending
thoracic
aorta
(fig. 2). This finding was definitely not present on a pretrauma chest radiograph in December 1976. The region was obscured by atelectasis and infiltrate on the posttraumatic examinations during
hospitalization,
so
its
presence
cannot
be
excluded
during this interval. Aortography revealed the aneurysm, and at surgery a pseudoaneurysm of the distal thoracic aorta with an intimal tear originating in an atherosclerotic plaque was resected
of a number
and
replaced
with
a Gooley
interposition
distal
Discussion
only
descending
Received July 7, 1977; accepted after revision October 4, 1977. I All authors: Department of Radiology, University of Washington and Veterans Administration Washington 98108. Address reprint requests to J. H. Hirsch at the Veterans Administration Hospital. Am J Roentgenol
130:157-160,
Roentgen
January Ray Society
1978
M. CHIKOS
of years of
Cases
an
before
aneurysm
to die
delayed development occurs [7, 9-11]. The Eiseman and Rainem [9] injury 43 years before isthmus region which 4 years. Rice and Wittsurvived 27 years with
of a sudden
rupture
after
8 days
thomacic
aorta,
while
94
had
teams
through the isthmus region. There were no fractures of the thoracic spine or posterior nibs in our case 2, although these injuries were frequently associated with rupture of the descending thomacic aorta in two other series [3, 6]. The unusual site of pseudoaneumysm formation in case 2 may be explained by two contributing mechanisms. Rice and Wittstruck [4] and Zehnder [5] described some anterior motion during deceleration of the central portion of the descending thomacic aorta between its stabilizing points at the diaphragm and arch. The intimal team in our patient occurred through the site of an atherosclerotic plaque
graft.
Torsional and shearing stresses produced by sudden deceleration may result in teams in the aortic wall extending from the intima toward the adventitia [1]. If the tear is incomplete or successful tamponade is produced by the adjacent mediastinal tissues, a pseudoaneurysm can develop [3, 5, 6]. Less than 5% of all victims survive long enough to form a chronic pseudoaneurysm [7, 8]. Much less frequently the patient will survive a latent
© 1978 American
Unusual
of chest pain. Steinberg [11], in a series of five chronic aneurysms, had an asymptomatic survivor of 25 years. The first documented appearance of an aneurysm in our case 1 was 25 years after injury, with gradual enlargement without symptoms over the subsequent 6 years (fig. 1). Although such long survival periods are rare, it is not exceptional for those surviving the first 3 weeks to develop delayed aneurysm enlargement with or without the most common symptoms of pain, dyspnea, or cough. In a series of 105 chronic traumatic aneurysms [7], 17% of the patients developed enlargement or symptoms more than 10 years after injury. Even though posttraumatic pseudoaneumysms may be an incidental finding and appear stable over many years on chest radiography, theme is evidence that the majority are progressive and will eventually develop complications [7] . Consequently elective resection is generally recommended. As seen from lange postmortem series [3, 6, 12] the sites of aortic rupture in closed chest injury are generally predictable (table 1). In those surviving long enough to have artemiographic evaluation, results are even more striking: approximately 95% of the ruptures occurred in the region of the aortic isthmus at or just distal to the site of the ligamentum arteniosum [7, 8, 13-15]. Disruption of the ascending aorta in particular results in a higher mortality often involving intrapemicardial bleeding and acute tamponade. Symbas et al. [15] reviewed 105 patients treated surgically in the first 3 weeks after injury, and only three patients had sites of rupture in the
for evaluation
chest
PAUL
enlargement
an aneurysm
The patient had no symptoms referable past history of treated tuberculosis. The two stories down an open elevator shaft in multiple rib fractures, a head injury, related
AND
Two
longest interval was reported by in a patient who sustained a chest discovery of an aneurysm of the then enlarged oven the ensuing struck [4] described a patient who
1
of a mediastinal
(fig. arch
period or
Aorta:
157
Hospital,
4435
Beacon
0361 -803X/78/01
Avenue
00-01
South,
Seattle,
57 $02.00
158
CASE
REPORTS
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1
C
I
-
.
.‘
,:.E:;
.
I
: F
1 -Case
1 . A, Posteroantenior
I
demonstrating normal mediastinal contours. B, Film in 1971 showing earliest detectable pseudoaneurysm as subtle second profile just inferior to aortic knob (arrow). C, Film in 1975 showing interval enlargement of pseudoaneurysm (arrow). D, Continued enlargement (arrows). E, Aortogram in anteroposterion projection (5 days after 0) demonstrating wide-based pseudoaneurysm. Fig.
chest
film
in 1963
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Til
‘C Fig. 2.-Case 2. A, Pretrauma chest radiograph showing normal distal aortic contour. B, Posttrauma chest film prior to hospital discharge. Note how resolving left lower lobe pneumonia obscures distal thoracic aorta. C, Film 17 days later showing resolution of pneumonia and revealing convex bulge on lateral descending thoracic aorta representing pseudoaneurysm (arrows). 0, Aortogram 1 day after C demonstrating pseudoaneurysm (arrows) and arteriosclerotic irregularity of lumen. Apparent change in position of aneurysm from posteroanterior chest radiographs is related to anteroposterior supine filming.
160
CASE TABLE Sites of Traumatic
Aortic
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Total -
converted
. . . .
Strassmsn
64
(61
traumatic
Series Greendyke
8
22 124 35 . . . .
4. Rice WG, Wittstnuck
1
Tear in Autopsy
Parmley et 51. (3)
Ascending aorta Arch Isthmus Thoracicaorta Abdominal aorta Multiple sites
‘‘‘
(12J
1 ...
38 12
22 7
13
3
4
17
11
8
275
72
42
from percentsg e to number
REPORTS
of cases.
REFERENCES Cammack K, Rapport AL, Paul J, Baird WG: Deceleration injuries of the thonacic aorta. Arch Surg 79 : 244-251 , 1959 2. Hass GM: Types of internal injuries of personnel involved in aircraft accidents. J Aviation Med 15 : 77-84, 1944 3. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ: Nonpenetrating traumatic injury of the aorta. Circulation 17: 1086-1101, 1958
KP: Acute of the aorta.
hypertension JAMA
and delayed
147:915-918,
1951
5. Zehnder MA: Delayed post-traumatic rupture of the aorta in a young healthy individual after closed injury. Angio!ogy 7:252-267, 1956 6. Strassman G: Traumatic rupture of the aorta. Am Heart J 33:508-514, 1947 7. Bennett DE, Cherry JK: The natural history of traumatic aneurysms of the aorta. Surgery 61 : 516-523, 1967 8. Sanborn JC, Heitzman RE, Markanian B: Traumatic rupture of the thonacic aorta. Radiology 95 : 293-298, 1970 9. Eiseman B, Aainer WG: Clinical management of posttrau-
10.
(fig. 2). The combination of anterior motion in a region of plaque formation with its resultant increased rigidity may explain the susceptibility to injury in that area.
rupture
matic rupture of the thoracic aorta. J Thorac Surg 35:347358, 1958 Pastershank SP, Chow KG: Blunt trauma to the aorta and its major branches. J Can Assoc Radio! 25 :202-210, 1974
11. Steinberg I: Chronic traumatic aneurysm aorta. N EngI J Med 257 : 913-91 8, 1957
of the thoracic
12.
JAMA
Greendyke
530, 13.
AM: Traumatic
Fishbone
G, Robbins
the thoracic
1.
rupture
of aorta.
195 : 527-
1966
2:543-554,
Dl, Osbomn
DJ, Grnja Radio!
aorta and great vessels.
V: Trauma to Clin North Am
1973
14. Freed TA, Neal MP, Vinik M: Roentgenographic extra cardiac injury secondary to blunt chest trauma. Am J Roentgeno! 104 :424-432, 1968
findings in automobile
15.
Rupture
Symbas
PN, Tyras DH, Ware ER, Hatcher CR: Thorac Surg 15:405-410, 1973
the aorta.Ann
of
Pseudoaneurysms
Downloaded from www.ajronline.org by 116.207.152.127 on 11/05/15 from IP address 116.207.152.127. Copyright ARRS. For personal use only; all rights reserved
JACK
of the Thoracic
H. HIRSCH,’
STEPHEN
J. CARTER,
The mechanical considerations resulting in traumatic rupture of the thoracic aorta from sudden deceleration have been well described [1-5]. We present two patients surviving aortic injury with unusual pseudoaneunysm formation. Case Case
L. 0.
Reports
,
a 56-year-old mass
white
male, was admitted
discovered
on a routine
no other
significant
negative. Chest radiographs
trauma.
radiograph.
to the chest, but had a patient had also fallen in 1946 which resulted and ankle fracture. He
Serology
taken oven a 14 year period
for
syphilis
was
were reviewed
1). A 3 cm soft tissue density seen adjacent to the aortic in February 1977 had increased in size since 1975. The
mass was not present in 1963, but was detectable as a second contour adjacent to the aortic knob in 1971 . Tomography revealed no calcification. An aortognam demonstrated the aneunysm, and at surgery a 3 x 5 cm pseudoaneurysm was removed from the aortic arch just proximal to the ligamentum arteniosum.
Case
2
P. 5. , a 59-year-old white male, was hospitalized in January 1977 after sustaining multiple bilateral anterior and lateral rib fractures in an automobile accident resulting in a flail chest. The hospital course was complicated by left lower lobe pneumonia which was treated. The patient was discharged after 12 days. He was neadmitted 17 days later with a 3 cm convex soft tissue
density
adjacent
to the distal
descending
thoracic
aorta
(fig. 2). This finding was definitely not present on a pretrauma chest radiograph in December 1976. The region was obscured by atelectasis and infiltrate on the posttraumatic examinations during
hospitalization,
so
its
presence
cannot
be
excluded
during this interval. Aortography revealed the aneurysm, and at surgery a pseudoaneurysm of the distal thoracic aorta with an intimal tear originating in an atherosclerotic plaque was resected
of a number
and
replaced
with
a Gooley
interposition
distal
Discussion
only
descending
Received July 7, 1977; accepted after revision October 4, 1977. I All authors: Department of Radiology, University of Washington and Veterans Administration Washington 98108. Address reprint requests to J. H. Hirsch at the Veterans Administration Hospital. Am J Roentgenol
130:157-160,
Roentgen
January Ray Society
1978
M. CHIKOS
of years of
Cases
an
before
aneurysm
to die
delayed development occurs [7, 9-11]. The Eiseman and Rainem [9] injury 43 years before isthmus region which 4 years. Rice and Wittsurvived 27 years with
of a sudden
rupture
after
8 days
thomacic
aorta,
while
94
had
teams
through the isthmus region. There were no fractures of the thoracic spine or posterior nibs in our case 2, although these injuries were frequently associated with rupture of the descending thomacic aorta in two other series [3, 6]. The unusual site of pseudoaneumysm formation in case 2 may be explained by two contributing mechanisms. Rice and Wittstruck [4] and Zehnder [5] described some anterior motion during deceleration of the central portion of the descending thomacic aorta between its stabilizing points at the diaphragm and arch. The intimal team in our patient occurred through the site of an atherosclerotic plaque
graft.
Torsional and shearing stresses produced by sudden deceleration may result in teams in the aortic wall extending from the intima toward the adventitia [1]. If the tear is incomplete or successful tamponade is produced by the adjacent mediastinal tissues, a pseudoaneurysm can develop [3, 5, 6]. Less than 5% of all victims survive long enough to form a chronic pseudoaneurysm [7, 8]. Much less frequently the patient will survive a latent
© 1978 American
Unusual
of chest pain. Steinberg [11], in a series of five chronic aneurysms, had an asymptomatic survivor of 25 years. The first documented appearance of an aneurysm in our case 1 was 25 years after injury, with gradual enlargement without symptoms over the subsequent 6 years (fig. 1). Although such long survival periods are rare, it is not exceptional for those surviving the first 3 weeks to develop delayed aneurysm enlargement with or without the most common symptoms of pain, dyspnea, or cough. In a series of 105 chronic traumatic aneurysms [7], 17% of the patients developed enlargement or symptoms more than 10 years after injury. Even though posttraumatic pseudoaneumysms may be an incidental finding and appear stable over many years on chest radiography, theme is evidence that the majority are progressive and will eventually develop complications [7] . Consequently elective resection is generally recommended. As seen from lange postmortem series [3, 6, 12] the sites of aortic rupture in closed chest injury are generally predictable (table 1). In those surviving long enough to have artemiographic evaluation, results are even more striking: approximately 95% of the ruptures occurred in the region of the aortic isthmus at or just distal to the site of the ligamentum arteniosum [7, 8, 13-15]. Disruption of the ascending aorta in particular results in a higher mortality often involving intrapemicardial bleeding and acute tamponade. Symbas et al. [15] reviewed 105 patients treated surgically in the first 3 weeks after injury, and only three patients had sites of rupture in the
for evaluation
chest
PAUL
enlargement
an aneurysm
The patient had no symptoms referable past history of treated tuberculosis. The two stories down an open elevator shaft in multiple rib fractures, a head injury, related
AND
Two
longest interval was reported by in a patient who sustained a chest discovery of an aneurysm of the then enlarged oven the ensuing struck [4] described a patient who
1
of a mediastinal
(fig. arch
period or
Aorta:
157
Hospital,
4435
Beacon
0361 -803X/78/01
Avenue
00-01
South,
Seattle,
57 $02.00
158
CASE
REPORTS
Downloaded from www.ajronline.org by 116.207.152.127 on 11/05/15 from IP address 116.207.152.127. Copyright ARRS. For personal use only; all rights reserved
1
C
I
-
.
.‘
,:.E:;
.
I
: F
1 -Case
1 . A, Posteroantenior
I
demonstrating normal mediastinal contours. B, Film in 1971 showing earliest detectable pseudoaneurysm as subtle second profile just inferior to aortic knob (arrow). C, Film in 1975 showing interval enlargement of pseudoaneurysm (arrow). D, Continued enlargement (arrows). E, Aortogram in anteroposterion projection (5 days after 0) demonstrating wide-based pseudoaneurysm. Fig.
chest
film
in 1963
Downloaded from www.ajronline.org by 116.207.152.127 on 11/05/15 from IP address 116.207.152.127. Copyright ARRS. For personal use only; all rights reserved
Til
‘C Fig. 2.-Case 2. A, Pretrauma chest radiograph showing normal distal aortic contour. B, Posttrauma chest film prior to hospital discharge. Note how resolving left lower lobe pneumonia obscures distal thoracic aorta. C, Film 17 days later showing resolution of pneumonia and revealing convex bulge on lateral descending thoracic aorta representing pseudoaneurysm (arrows). 0, Aortogram 1 day after C demonstrating pseudoaneurysm (arrows) and arteriosclerotic irregularity of lumen. Apparent change in position of aneurysm from posteroanterior chest radiographs is related to anteroposterior supine filming.
160
CASE TABLE Sites of Traumatic
Aortic
Downloaded from www.ajronline.org by 116.207.152.127 on 11/05/15 from IP address 116.207.152.127. Copyright ARRS. For personal use only; all rights reserved
Total -
converted
. . . .
Strassmsn
64
(61
traumatic
Series Greendyke
8
22 124 35 . . . .
4. Rice WG, Wittstnuck
1
Tear in Autopsy
Parmley et 51. (3)
Ascending aorta Arch Isthmus Thoracicaorta Abdominal aorta Multiple sites
‘‘‘
(12J
1 ...
38 12
22 7
13
3
4
17
11
8
275
72
42
from percentsg e to number
REPORTS
of cases.
REFERENCES Cammack K, Rapport AL, Paul J, Baird WG: Deceleration injuries of the thonacic aorta. Arch Surg 79 : 244-251 , 1959 2. Hass GM: Types of internal injuries of personnel involved in aircraft accidents. J Aviation Med 15 : 77-84, 1944 3. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ: Nonpenetrating traumatic injury of the aorta. Circulation 17: 1086-1101, 1958
KP: Acute of the aorta.
hypertension JAMA
and delayed
147:915-918,
1951
5. Zehnder MA: Delayed post-traumatic rupture of the aorta in a young healthy individual after closed injury. Angio!ogy 7:252-267, 1956 6. Strassman G: Traumatic rupture of the aorta. Am Heart J 33:508-514, 1947 7. Bennett DE, Cherry JK: The natural history of traumatic aneurysms of the aorta. Surgery 61 : 516-523, 1967 8. Sanborn JC, Heitzman RE, Markanian B: Traumatic rupture of the thonacic aorta. Radiology 95 : 293-298, 1970 9. Eiseman B, Aainer WG: Clinical management of posttrau-
10.
(fig. 2). The combination of anterior motion in a region of plaque formation with its resultant increased rigidity may explain the susceptibility to injury in that area.
rupture
matic rupture of the thoracic aorta. J Thorac Surg 35:347358, 1958 Pastershank SP, Chow KG: Blunt trauma to the aorta and its major branches. J Can Assoc Radio! 25 :202-210, 1974
11. Steinberg I: Chronic traumatic aneurysm aorta. N EngI J Med 257 : 913-91 8, 1957
of the thoracic
12.
JAMA
Greendyke
530, 13.
AM: Traumatic
Fishbone
G, Robbins
the thoracic
1.
rupture
of aorta.
195 : 527-
1966
2:543-554,
Dl, Osbomn
DJ, Grnja Radio!
aorta and great vessels.
V: Trauma to Clin North Am
1973
14. Freed TA, Neal MP, Vinik M: Roentgenographic extra cardiac injury secondary to blunt chest trauma. Am J Roentgeno! 104 :424-432, 1968
findings in automobile
15.
Rupture
Symbas
PN, Tyras DH, Ware ER, Hatcher CR: Thorac Surg 15:405-410, 1973
the aorta.Ann
of
