Typical and atypical imaging of thoracic and abdominal aortic rupture

Transcription

1 Typical and atypical imaging of thoracic and abdominal aortic rupture Poster No.: C-0453 Congress: ECR 2014 Type: Educational Exhibit Authors: J. Isogai, T. Ichihara, T. Inoue, T. Kanamori ; Asahi/JP, Tokyo/JP Keywords: Haemorrhage, Aneurysms, Surgery, CT, Arteries / Aorta DOI: /ecr2014/C-0453 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 36

2 Learning objectives 1. To describe CT radiological features of typical and atypical aortic ruptures in the thoracic and abdominal aortic dissection or aneurysm based on 35 and 45 patients, respectively. 2. To illustrate each compartment of mediastinal and retroperitoneal interfascial spaces into which hematoma dissected. Page 2 of 36

3 Background Acute rupture of thoracic and abdominal aorta has a high mortality. Surgical evacuation of hematoma and ligation of bleeding sites are performed for common interventional procedures. Therefore an urgent CT plays a critical role in identifying bleeding sites. CT diagnosis of typical aortic rupture has simple criteria of evidence of mediastinal and retroperitoneal hematoma possibly draining into thoracic and abdominal cavity, with or without active extravasation of contrast medium. However a small proportion of aortic ruptures require great attention for its diagnosis due to atypical and unexpected disruption. Page 3 of 36

4 Findings and procedure details Patients are studied preoperatively with MDCT. MDCT is performed during the arterial and equilibrium phase. Suitable reconstructions are obtained using a dedicated workstation. From January 2006 to September 2013, 35 thoracic and 45 abdominal aortic ruptures were performed in our protocol of pre-surgical imaging. Mean age was 70.3 years (21-91 y.). 1) Features of typical aortic rupture (Tab. 1) Table 1: Features of typical aortic ruptures. Most commonly encountered in our practice. References: Radiology, Asahi General Hospital - Asahi/JP 2) To classify CT features of typical aortic rupture according to the distribution of extrapleural and extraperitoneal hematoma with or without intrathoracic and intraperitoneal hemorrhage. Page 4 of 36

5 2a) Typical ascending aortic rupture (Fig. 1) Posterior wall leakage of ascending aorta just distal to aortic valve (Most commonly encountered in our practice) Fig. 1: Ascending aortic rupture of aortic dissection in Stanford Type A with posterior wall leakage. Sagittal (a) and coronal (b) reformatted CT images show a crescentic high-attenuation clot within false lumen of the proximal ascending aorta (arrows) with hemopericardium (open arrows). Note intimal flap separating two aortic channels (yellow arrow). References: Radiology, Asahi General Hospital - Asahi/JP 2b) Typical proximal descending aortic rupture (Fig. 2) Left lateral wall leakage of upper descending aorta distal to left subclavian artery Page 5 of 36

6 Fig. 2: Upper descending aortic rupture of aortic dissection in Stanford Type B with left lateral wall leakage. Axial (a/b) and sagittal oblique reformatted (c) CT images show left hemothorax (arrows) with massive mediastinal hematoma (open arrows). Note active extravasation of contrast material (yellow arrows) into the mural thrombus, as well as extensive mediastinal hemorrhage. References: Radiology, Asahi General Hospital - Asahi/JP 2c) Typical aortic transection and traumatic aortic pseudoaneurysm (Fig. 3). The majority of aortic transection occurs at the aortic isthmus, the site of insertion of the ligamentum arteriosum, which is vulnerable to traumatic shear stress. Page 6 of 36

7 Fig. 3: Upper descending aortic rupture of aortic transection (a) and post-traumatic pseudoaneurysm (chronic aortic pseudoaneurysm) (b/c). A axial (a/b) and sagittal oblique reformatted (c) CT images show left hemothorax (arrows) with mediastinal hematoma (open arrows). Note extravasation of conrast material (yellow arrows) at the aortic isthmus which is vulnerable to traumatic shear stress. References: Radiology, Asahi General Hospital - Asahi/JP 2d) Typical distal descending aortic rupture (Fig. 4) Page 7 of 36

8 Fig. 4: Upper descending aortic rupture of aortic transection (a) and post-traumatic pseudoaneurysm (chronic aortic pseudoaneurysm) (b/c). A axial (a/b) and sagittal oblique reformatted (c) CT images show left hemothorax (arrows) with mediastinal hematoma (open arrows). Note extravasation of conrast material (yellow arrows) at the aortic isthmus. References: Radiology, Asahi General Hospital - Asahi/JP 2e) Typical abdominal aortic rupture with posterolateral leakage (Fig. 5) Unilateral retroperitoneal hematoma within posterior pararenal spaces occasionally extending perirenal spcaes. Draped aorta sign Page 8 of 36

9 Fig. 5: Infrarenal aortic rupture of abdominal aneurysm with right posterolateral wall leakage (arrows). Sagittal reformatted (a) and axial (b/c) CT images show retroperitoneal hematoma within posterior pararenal spaces which displaces the kidney ventrally and demonstrate posterior aortic walls which follow the contour of vertebral bodies with a draping effect (open arrows). Note that a fat plane between hematoma and psoas muscle is absent (yellow arrows). References: Radiology, Asahi General Hospital - Asahi/JP 2f) Typical abdominal aortic rupture with anterolateral leakage (Fig. 6) Bilateral retroperitoneal hematoma within retromesenteric plane extending up-, downand backward into interfascial planes Page 9 of 36

10 Fig. 6: Infrarenal aortic rupture of abdominal aneurysm with anterolateral wall leakage. Axial (a/b) and coronal reformatted (c) CT images show bilateral large retroperitoneal hematoma within retromesenteric plane extending up-, down- and backward which deviates the duodenum ventrally (open arrow) without displacement of the kidney. Note that active extravasation of conrast material (arrows) extends widely out of the thrombosed portion of aneurysms and a fat plane between hematoma and the psoas muscle (yellow arrow) is spared. References: Radiology, Asahi General Hospital - Asahi/JP 2g) Typical mycotic aneurysm rupture (Fig. 7) The development rate of mycotic aneurysms is faster than that of atherosclerotic aneurysms. Page 10 of 36

11 Fig. 7: Proximal (a/b) and distal (c/d) descending mycotic aneurysm rupture due to Mycobacterium and S. aureus in ten days and a month later of previous exam respectively. Axial CT images show rapid change in the size or shape of saccular aneurysms with periaortic soft-tissue density, mediastinal hematoma and left hemothorax (b/d). References: Radiology, Asahi General Hospital - Asahi/JP 3) To demonstrate atypical aortic rupture and unusual complications such as penetrating intestinal or respiratory tract. 3a) Atypical ascending aortic rupture (Fig. 8) Medial or upper wall leakage of ascending aorta Page 11 of 36

12 Fig. 8: Unusual ascending aortic rupture of aortic dissection in Stanford Type A with medial (a) and upper (b/c) wall leakage. An axial CT image (a) shows an unusual medial false lumen in contiguity with the pulmonary artery and coronal reformatted CT images (b) show more anterior mediastinal hematoma (arrow) than a typical posterior wall leakage. References: Radiology, Asahi General Hospital - Asahi/JP 3b) Atypical transverse aortic rupture (Fig. 9) Inferior or superior wall leakage of transverse aorta tracheal compression hoarse voice due to aortopulmonary window hematoma Page 12 of 36

13 Fig. 9: Transverse aortic rupture of thoracic aortic aneurysm (a) and aortic dissection in Stanford Type B (b/c) with superior (a) and inferior (b/c) wall leakage. Sagittal oblique reformatted CT images (a/b) show massive mediastinal hematoma (arrows) along upper and inner side of the aortic arch without hemothorax. Note posterior tracheal compression with massive hematoma (open arrow). A coronal reformatted CT image (c) shows aortopulmonary window hematoma (yellow arrow) as the cause of hoarse voice. References: Radiology, Asahi General Hospital - Asahi/JP 3c) Atypical descending aortic rupture into the contralateral thoracic cavity (Fig. 10) Medial wall leakage of upper and lower descending aorta occasionally due to the penetrating aortic ulcer (PAU). A PAU of the aorta appears as an irregular, focal out-pouching of the aortic wall, associated with atherosclerosis and aneurysm formation. Page 13 of 36

14 Fig. 10: Distal (a) and proximal (b/c) descending aortic rupture of thoracic aortic aneurysm with contralateral hemothorax. A penetrating aortic ulcer (yellow arrow) of the descending aorta may cause aortic dissection. Axial (a/b) and coronal reformatted (c) CT images show posterior mediastinal hematoma with contralateral hilar extension (open arrow) and pleural effusion (arrows). Note that an uncommon medial leakage of descending aorta allows mediastinal hematoma to extend along bronchial branches (yellow open arrow). References: Radiology, Asahi General Hospital - Asahi/JP 3d) Atypical configuration of aortic rupture (Fig. 11) three-channeled aorta right aortic arch Page 14 of 36

15 Fig. 11: Proximal descending (a) and ascending (b/c) aortic rupture of aortic dissection in Stanford Type B (a), A (b) and traumatic transection (c). Axial CT (a/b) images show three-channeled aorta (Mercedes.Benz sign) due to two false channels with intimomedial tear (arrows) entering false lumen (F) from false lumen. (T = true lumen). Axial CT (c) demonstrates ascending intramural hematoma and hemopericardium in the right aortic arch (open arrow) with aberrant left subclavian artery as an unusual pattern of the aortic transecion. Note right-sided subcutaneous emphysema (yellow arrow). References: Radiology, Asahi General Hospital - Asahi/JP 3e) Unusual complication of aortic rupture: Interstitial pulmonary hemorrhage (Fig. 12) Pleural adhesion was found at surgery in all cases. Page 15 of 36

16 Fig. 12: Proximal (a/b) and distal (c) descending aortic rupture of mycotic aneurysm (a), aortic dissection in Stanford Type B (b) and thoracic aneurysm (c) with pulmonary hemorrhage. Axial CT images show ruptured aneurysm surrounded by ground-glass opacity (arrows) with left hemothorax. References: Radiology, Asahi General Hospital - Asahi/JP 3f) Unusual complication of aortic rupture: Aortoenteric and aortocaval fistula (Fig. 13) The aortoenteric fistula is rare and most commonly seen as a delayed complication of aortic reconstruction. Page 16 of 36

17 Fig. 13: Primary aortoesophageal (a), secondary aortoduodenal (b) and aortocaval fistula of aortic dissection in Stanford Type B (a) and postoperative pseudoaneurysm (b/c) with intestinal hemorrhage (a/b). Axial CT images show a focal out-pouching of the anterior and posterior aortic wall (arrows) forming a fistulous tract into the midthoracic esophagus, the third portion of duodenum and IVC. Note a loss of the fat plane between the duodenum or IVC (open arrows) and the aorta. References: Radiology, Asahi General Hospital - Asahi/JP 3g) Atypical of aortic rupture: Active extravasation on the delayed image (Fig. 14) The classic pattern of active extravasation at dual phase CT is a focal area of hyper attenuation within a hematoma on initial images, that fades into an enlarged, enhanced hematoma on delayed images. Radiologists must be aware of an unusual pattern of active extravasation. Page 17 of 36

18 Fig. 14: Abdominal aortic aneurysm rupture in unenhanced (a), arterial (b) and delayed (c) phase of contrast-enhanced CT. Axial CT images show retoperitoneal hematoma as high attenuation area and depict inhomogeneous extravasation (arrows) of contrast material not in arterial but delayed phase without enlarged or enhanced hematoma. Note delayed contrast material excretion in bilateral ureters (yellow arrows). References: Radiology, Asahi General Hospital - Asahi/JP Page 18 of 36

19 Images for this section: Table 1: Features of typical aortic ruptures. Most commonly encountered in our practice. Radiology, Asahi General Hospital - Asahi/JP Page 19 of 36

20 Fig. 1: Ascending aortic rupture of aortic dissection in Stanford Type A with posterior wall leakage. Sagittal (a) and coronal (b) reformatted CT images show a crescentic high-attenuation clot within false lumen of the proximal ascending aorta (arrows) with hemopericardium (open arrows). Note intimal flap separating two aortic channels (yellow arrow). Radiology, Asahi General Hospital - Asahi/JP Page 20 of 36

21 Fig. 2: Upper descending aortic rupture of aortic dissection in Stanford Type B with left lateral wall leakage. Axial (a/b) and sagittal oblique reformatted (c) CT images show left hemothorax (arrows) with massive mediastinal hematoma (open arrows). Note active extravasation of contrast material (yellow arrows) into the mural thrombus, as well as extensive mediastinal hemorrhage. Radiology, Asahi General Hospital - Asahi/JP Page 21 of 36

22 Fig. 3: Upper descending aortic rupture of aortic transection (a) and post-traumatic pseudoaneurysm (chronic aortic pseudoaneurysm) (b/c). A axial (a/b) and sagittal oblique reformatted (c) CT images show left hemothorax (arrows) with mediastinal hematoma (open arrows). Note extravasation of conrast material (yellow arrows) at the aortic isthmus which is vulnerable to traumatic shear stress. Radiology, Asahi General Hospital - Asahi/JP Page 22 of 36

23 Fig. 4: Upper descending aortic rupture of aortic transection (a) and post-traumatic pseudoaneurysm (chronic aortic pseudoaneurysm) (b/c). A axial (a/b) and sagittal oblique reformatted (c) CT images show left hemothorax (arrows) with mediastinal hematoma (open arrows). Note extravasation of conrast material (yellow arrows) at the aortic isthmus. Radiology, Asahi General Hospital - Asahi/JP Page 23 of 36

24 Fig. 5: Infrarenal aortic rupture of abdominal aneurysm with right posterolateral wall leakage (arrows). Sagittal reformatted (a) and axial (b/c) CT images show retroperitoneal hematoma within posterior pararenal spaces which displaces the kidney ventrally and demonstrate posterior aortic walls which follow the contour of vertebral bodies with a draping effect (open arrows). Note that a fat plane between hematoma and psoas muscle is absent (yellow arrows). Radiology, Asahi General Hospital - Asahi/JP Page 24 of 36

25 Fig. 6: Infrarenal aortic rupture of abdominal aneurysm with anterolateral wall leakage. Axial (a/b) and coronal reformatted (c) CT images show bilateral large retroperitoneal hematoma within retromesenteric plane extending up-, down- and backward which deviates the duodenum ventrally (open arrow) without displacement of the kidney. Note that active extravasation of conrast material (arrows) extends widely out of the thrombosed portion of aneurysms and a fat plane between hematoma and the psoas muscle (yellow arrow) is spared. Radiology, Asahi General Hospital - Asahi/JP Page 25 of 36

26 Fig. 7: Proximal (a/b) and distal (c/d) descending mycotic aneurysm rupture due to Mycobacterium and S. aureus in ten days and a month later of previous exam respectively. Axial CT images show rapid change in the size or shape of saccular aneurysms with periaortic soft-tissue density, mediastinal hematoma and left hemothorax (b/d). Radiology, Asahi General Hospital - Asahi/JP Page 26 of 36

27 Fig. 8: Unusual ascending aortic rupture of aortic dissection in Stanford Type A with medial (a) and upper (b/c) wall leakage. An axial CT image (a) shows an unusual medial false lumen in contiguity with the pulmonary artery and coronal reformatted CT images (b) show more anterior mediastinal hematoma (arrow) than a typical posterior wall leakage. Radiology, Asahi General Hospital - Asahi/JP Page 27 of 36

28 Fig. 9: Transverse aortic rupture of thoracic aortic aneurysm (a) and aortic dissection in Stanford Type B (b/c) with superior (a) and inferior (b/c) wall leakage. Sagittal oblique reformatted CT images (a/b) show massive mediastinal hematoma (arrows) along upper and inner side of the aortic arch without hemothorax. Note posterior tracheal compression with massive hematoma (open arrow). A coronal reformatted CT image (c) shows aortopulmonary window hematoma (yellow arrow) as the cause of hoarse voice. Radiology, Asahi General Hospital - Asahi/JP Page 28 of 36

29 Fig. 10: Distal (a) and proximal (b/c) descending aortic rupture of thoracic aortic aneurysm with contralateral hemothorax. A penetrating aortic ulcer (yellow arrow) of the descending aorta may cause aortic dissection. Axial (a/b) and coronal reformatted (c) CT images show posterior mediastinal hematoma with contralateral hilar extension (open arrow) and pleural effusion (arrows). Note that an uncommon medial leakage of descending aorta allows mediastinal hematoma to extend along bronchial branches (yellow open arrow). Radiology, Asahi General Hospital - Asahi/JP Page 29 of 36

30 Fig. 11: Proximal descending (a) and ascending (b/c) aortic rupture of aortic dissection in Stanford Type B (a), A (b) and traumatic transection (c). Axial CT (a/b) images show three-channeled aorta (Mercedes.Benz sign) due to two false channels with intimomedial tear (arrows) entering false lumen (F) from false lumen. (T = true lumen). Axial CT (c) demonstrates ascending intramural hematoma and hemopericardium in the right aortic arch (open arrow) with aberrant left subclavian artery as an unusual pattern of the aortic transecion. Note right-sided subcutaneous emphysema (yellow arrow). Radiology, Asahi General Hospital - Asahi/JP Page 30 of 36

31 Fig. 12: Proximal (a/b) and distal (c) descending aortic rupture of mycotic aneurysm (a), aortic dissection in Stanford Type B (b) and thoracic aneurysm (c) with pulmonary hemorrhage. Axial CT images show ruptured aneurysm surrounded by ground-glass opacity (arrows) with left hemothorax. Radiology, Asahi General Hospital - Asahi/JP Page 31 of 36

32 Fig. 13: Primary aortoesophageal (a), secondary aortoduodenal (b) and aortocaval fistula of aortic dissection in Stanford Type B (a) and postoperative pseudoaneurysm (b/c) with intestinal hemorrhage (a/b). Axial CT images show a focal out-pouching of the anterior and posterior aortic wall (arrows) forming a fistulous tract into the mid-thoracic esophagus, the third portion of duodenum and IVC. Note a loss of the fat plane between the duodenum or IVC (open arrows) and the aorta. Radiology, Asahi General Hospital - Asahi/JP Page 32 of 36

33 Fig. 14: Abdominal aortic aneurysm rupture in unenhanced (a), arterial (b) and delayed (c) phase of contrast-enhanced CT. Axial CT images show retoperitoneal hematoma as high attenuation area and depict inhomogeneous extravasation (arrows) of contrast material not in arterial but delayed phase without enlarged or enhanced hematoma. Note delayed contrast material excretion in bilateral ureters (yellow arrows). Radiology, Asahi General Hospital - Asahi/JP Page 33 of 36

34 Conclusion The aortic rupture has a high mortality rate, which requires fast and accurate diagnosis of hemodynamic states of aortic pathology. Radiologists must be aware of various types of aortic rupture, contained an atypical rupture. Page 34 of 36

35 Personal information J. Isogai,T. Ichihara, T.Inoue, T. Kanamori 2 1 Radiology, Asahi General Hospital, Asahi, Chiba, Japan 2 Cardiovascular surgery, IMS Katsushika Heart Center, Katsushika, Tokyo Page 35 of 36

36 References 1. Vilacosta I, Aragoncillo P (2009) Acute aortic syndrome: a new look at an old conundrum. Heart; 95: Troxler M, Mavor A (2001) Penetrating atherosclerotic ulcers of the aorta. British Journal of Surgery; 88: Salvolini L, Renda P (2008) Acute aortic syndromes: role of multi-detector CT. Euro J Radiol; 65: Dmitry Rakita, Amit Newaita (2007) Spectrum of CT Findings in Rupture and Impending Rupture of Abdominal Aortic Aneurysms. RadioGraphics; 27: Stephanie A. Schwartz (2007) CT Findings of Rupture, Impending Rupture, and Contained Rupture of Abdominal Aortic Aneurysms. AJR; 188: W57-W62 6. KJ. Macura (2003) Pathogenesis in Acute Aortic Syndromes: Aortic Aneurysm Leak and Rupture and Traumatic Aortic Transection. AJR; 181: JD, Hamilton, Manickam Kumaravel (2008) Multidetector CT Evaluation of Active Extravasation in Blunt Abdominal and Pelvic Trauma Patients. RadioGraphics; 28: Page 36 of 36