Abdominal aortic aneurysms are common and affect ~7.5% of patients aged over 65 years 6.
The classical triad of pain, hypotension, and pulsatile abdominal mass due to rupture into the retroperitoneum is only seen in 25-50% of patients.
Unusual presentations of ruptured abdominal aortic aneurysm are
- transient lower-limb paralysis
- right upper quadrant pain
- groin pain
- testicular pain
- testicular ecchymosis (blue scrotum sign of Bryant)
- iliofemoral venous thrombosis
The aneurysmal rupture is thought to occur when the mechanical stress is in excess of the wall strength. Thus, the aortic aneurysmal wall tension and the aneurysmal diameter are a significant predictor of impending rupture.
The commonest sites of rupture and their relative incidences are
- intraperitoneal rupture: 20%
- retroperitoneal rupture: 80%
- aortocaval fistula: 3-4%
- primary aorto-enteric fistula: < 1%
- aorto-left renal vein fistula: very rare; < 30 cases reported
Abdominal radiographs are not a sensitive mode of detection. A calcified aortic aneurysm may be seen with a secondary blurring of the psoas outline in case of retroperitoneal hemorrhage.
Not used for routine diagnosis but reported features include.
- focal dilatation of the aorta (aneurysm)
- focal defect at the interface between the vessel lumen and intraluminal thrombus
- sharply demarcated aortic mural defect
- partially detached, mobile layer of intraluminal thrombus 7
- hypoechoic para-aortic fluid collection 8
- free intraperitoneal fluid
- heterogenous collection within a retroperitoneal space
- represents retroperitoneal hemorrhage
CT / CT angiography
Retroperitoneal hemorrhage adjacent the aneurysm is the most common finding. The peri-aortic blood may be seen to extend into perirenal or pararenal spaces or the psoas muscles. Intraperitoneal extension of the hemorrhage may be seen as an immediate or a delayed finding.
An important feature seen in contained rupture of an aortic aneurysm is the draped aorta sign - in which the posterior wall of the aorta is not seen distinctly from adjacent structures, and the contour of the aorta follows that of adjacent vertebrae.
A hyperattenuating crescent sign, which is an area of increased attenuation within the aortic aneurysmal mural thrombus, can be demonstrated on plain CT images. This is caused by the insinuation of fresh blood into the mural thrombus and aortic wall.
On post-contrast studies or CT angiography, active extravasation of contrast material can be seen.
Findings predictive of impending rupture
- increased aneurysm size on serial imaging (rate of 10 mm or more per year)
- very large abdominal aortic aneurysm > 7 cm
- reduced thrombus size
- thrombus fissuration
- discontinuity in calcification
- hyperattenuating crescent sign
- well defined peripheral crescent of increased attenuation within the thrombus of a large abdominal aortic aneurysm
Treatment and prognosis
Treatment of an acute rupture should be prompt and can be with endovascular aneurysm repair (EVAR) or open surgery. The mortality rate is very high being > 90% 6.
- 1. Rakita D, Newatia A, Hines JJ et-al. Spectrum of CT findings in rupture and impending rupture of abdominal aortic aneurysms. Radiographics. 2007;27 (2): 497-507. doi:10.1148/rg.272065026 - Pubmed citation
- 2. Catalano O, Siani A. Ruptured abdominal aortic aneurysm: categorization of sonographic findings and report of 3 new signs. J Ultrasound Med. 2005;24 (8): 1077-83. Pubmed citation
- 3. Kurosawa K, Matsumura JS, Yamanouchi D. Current Status of Medical Treatment for Abdominal Aortic Aneurysm. Circ. J. . Pubmed citation
- 4. Schermerhorn ML, Bensley RP, Giles KA et-al. Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study. Ann. Surg. 2012;256 (4): 651-8. doi:10.1097/SLA.0b013e31826b4f91 - Free text at pubmed - Pubmed citation
- 5. Schwartz SA, Taljanovic MS, Smyth S et-al. CT findings of rupture, impending rupture, and contained rupture of abdominal aortic aneurysms. AJR Am J Roentgenol. 2007;188 (1): W57-62. doi:10.2214/AJR.05.1554 - Pubmed citation
- 6. Assar AN, Zarins CK. Ruptured abdominal aortic aneurysm: a surgical emergency with many clinical presentations. Postgrad Med J. 2009;85 (1003): 268-73. doi:10.1136/pgmj.2008.074666 - Pubmed citation
- 7. Catalano O, Catalano SA, Catalano. Ruptured abdominal aortic aneurysm: categorization of sonographic findings and report of 3 new signs. (2005) Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. doi:10.7863/jum.2005.24.8.1077 - Pubmed
- 8. Diaz O, Eilbert W. Ruptured abdominal aortic aneurysm identified on point-of-care ultrasound in the emergency department. (2020) International journal of emergency medicine. 13 (1): 25. doi:10.1186/s12245-020-00279-9 - Pubmed
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