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Pathogenesis in Acute Aortic Syndromes: Aortic Aneurysm Leak and Rupture and Traumatic Aortic Transection

¹ All authors: The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21287-0750.

View larger version (170K): [in a new window]   Fig. 1. —Drawing shows enlarging aortic aneurysm. First, wall tension is proportional to vessel radius, according to Laplace's law: T = P x r, where T is circumferential wall tension, P is transmural pressure, and r is mean vessel radius. Second, increased tension stress from blood pressure results in progressive vessel dilatation and weakening of aortic media, which lead to enlargement of aortic aneurysm. Third, when mechanical stress on wall exceeds strength of wall tissue, aortic aneurysm ruptures.

View larger version (131K): [in a new window]   Fig. 2A. —79-year-old man with acute rupture of abdominal aortic aneurysm that occurred during CT. Contrast-enhanced CT scan obtained at level of extravasation (open arrow) shows large left retroperitoneal hematoma and enhanced blood in left paracolic gutter (solid straight arrow). Note eccentric intramural hematoma (curved arrow) within aortic lumen on side of extravasation.

View larger version (165K): [in a new window]   Fig. 2B. —79-year-old man with acute rupture of abdominal aortic aneurysm that occurred during CT. Coronal multiplanar reformatted CT image shows aortic rupture with active extravasation from irregular ulcerlike lesion in distal abdominal aorta (open arrow). Note enhanced blood (solid arrow) around spleen (S) and that spleen is displaced medially.

View larger version (168K): [in a new window]   Fig. 3A. —76-year-old woman with disseminated tuberculosis and saccular pseudoaneurysm arising from distal descending thoracic aorta. Volume-rendered CT scan of axial view of descending thoracic aorta shows large pseudoaneurysm (straight arrow) that arises posteriorly and causes flattening of aortic lumen (curved arrow).

View larger version (150K): [in a new window]   Fig. 3B. —76-year-old woman with disseminated tuberculosis and saccular pseudoaneurysm arising from distal descending thoracic aorta. Volume-rendered CT scan of left anterior oblique view of aorta shows calcified atherosclerotic plaque (arrowheads), limiting superior and inferior extent of pseudoaneurysm.

View larger version (141K): [in a new window]   Fig. 4A. —71-year-old woman with thoracic aortic pseudoaneurysm due to penetrating atherosclerotic ulcer. Volume-rendered CT scan of axial view shows contrast material leaking from aortic lumen (solid arrow) into posterior pseudoaneurysm (open arrow) of proximal descending thoracic aorta.

View larger version (155K): [in a new window]   Fig. 4B. —71-year-old woman with thoracic aortic pseudoaneurysm due to penetrating atherosclerotic ulcer. Volume-rendered CT scan of oblique view of pseudoaneurysm shows site of contrast leak (arrow).

View larger version (115K): [in a new window]   Fig. 5. —Diagram shows aortic wall transection with injury to intima and media but with intact adventitia and formation of pseudoaneurysm.

View larger version (174K): [in a new window]   Fig. 6. —33-year-old man involved in deceleration injury that caused traumatic transection of aorta. Left anterior oblique thoracic aortogram shows pseudoaneurysm (arrow) in classic location, approximately 2 cm distal to origin of left subclavian artery.

View larger version (114K): [in a new window]   Fig. 7A. —13-year-old boy who was struck by car while riding his bicycle. Patient sustained subarachnoid hemorrhage; traumatic aortic transection; contusions of liver, spleen, and kidneys; and pelvic and lower extremity fractures. Contrast-enhanced CT scan shows periaortic hematoma. Note difference in attenuation between thymus (curved arrow) and hematoma (straight arrow). Nasogastric tube is not deviated.

View larger version (118K): [in a new window]   Fig. 7B. —13-year-old boy who was struck by car while riding his bicycle. Patient sustained subarachnoid hemorrhage; traumatic aortic transection; contusions of liver, spleen, and kidneys; and pelvic and lower extremity fractures. Axial CT scan shows intimal disruption with pseudoaneurysm (arrow) filled with contrast material.

View larger version (105K): [in a new window]   Fig. 7C. —13-year-old boy who was struck by car while riding his bicycle. Patient sustained subarachnoid hemorrhage; traumatic aortic transection; contusions of liver, spleen, and kidneys; and pelvic and lower extremity fractures. Volume-rendered CT scan shows small pseudoaneurysm (arrow) in classic location distal to left subclavian artery.

View larger version (125K): [in a new window]   Fig. 7D. —13-year-old boy who was struck by car while riding his bicycle. Patient sustained subarachnoid hemorrhage; traumatic aortic transection; contusions of liver, spleen, and kidneys; and pelvic and lower extremity fractures. Left anterior oblique and anteroposterior angiograms of thoracic aorta show contained transection of proximal descending aorta (arrows), just below level of ligamentum arteriosum.

View larger version (165K): [in a new window]   Fig. 8A. —69-year-old man involved in severe motor vehicle collision 34 years earlier. Volume-rendered CT scan obtained in left anterior oblique projection shows classic location for traumatic aortic transection (arrowheads), just beyond origin of left subclavian artery. Pseudoaneurysm is partially thrombosed with peripheral calcifications that indicate its chronic nature.

View larger version (172K): [in a new window]   Fig. 8B. —69-year-old man involved in severe motor vehicle collision 34 years earlier. Volume-rendered CT scan of anteroposterior view of thoracic aorta shows extent of pseudoaneurysm (arrowheads).

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