924

Congenital Radiographic

Saccular Aneurysm Features

Robert S. Hidvegi,1 Leo LaFl#{233}che2

The esses rysms, We

American Journal of Roentgenology 1979.133:924-927.

L. Modry,2

majority

of mediastinal

or cysts, play an

but vascular masses, important role in the

have

the

Dennis

encountered

form

masses

a very

of a primary

congenital

As the preoperative only

radiographic diagnosis

two

other

proc-

rated

from

predominantly aneudifferential diagnosis.

are

cava

seemed

cases,

neoplastic

vascular

saccular

we offer

entity

aneurysm

On

in

of the

of the

(fig. vena

white for

diastinal

mass.

left arm

for 2 years

pains

for

normal,

except

with

some

the

initial

density

and

more

circumscribed

definite

and

cava.

diastinal

venous

To

revealed visualization

it

puted

the

tomography

Received

Department 133:924-927,

lesion

its benign a faint

outlined

in the

pulsation

The

relation

enlarged

of the

‘ ‘cystic’

thoracic

‘ ‘lighting infraazygos

with

(figs.

21

.

1 979;

of Radiology, of Surgery, November

observed

mass

mobility after

accepted

Montreal 1979

after

Chest Chest

revision

Hospital

Hospital

0361 -803X/79/1

to

The

postoperative

inner

pure

surface.

The

wall

a single

showed

only

and

The

indicated

amount

a vascular

of previous

of fibrous

trauma,

and

fibrous

wall.

There

superior

sacgrayish

microscopitissue.

tissue

tissue

an identical

hemorrhage,

the

a smooth

thick

dense

It was channel

reddish-brown

of connective

revealed

plane.

uneventful.

It had 2 mm

of

strands

stalk

a dark

corn-

A stalk

venous of

was

be

release.

surface

blood. was

could

on 6 mm

course

layer

a small

occasional

follicles.

anterior

cava.

blood-con-

saggital

8 x

the me-

vena

which

in the the

The from

bluish

refilled

demonstrated

containing

demonstrated

the

superior

cava

denser.

pedunculated

pliable,

it rapidly

aneurysm

examination

aneurysm

the

and

with

small

structure.

was

no

The

containing All

lymthese

pathologic

or inflammatory

evi-

change.

Discussion

a

A

anterior

was

aorta

July

the 2). well

search The

of the literature revealed two similar first was a middle-aged housewife with

pain in the mediastinal

region mass

of the thoracic spine. A round was found on chest radiography.

a thin-walled, was discovered.

reexpand

when

case

was

that

our

sepa-

the azygos

entrance.

St.

Quebec

superior

vena

cava

superior On op-

bluish, cystic, 5 cm blood-containing It emptied on compression only

pressure

early Corn-

cases some

was

the lesion and it had Surgical

released.

The

difference

was located posterior a smaller stalk (2 mm) treatment

was

simple

to

from to the above

excision

6, 1979.

Centre, Centre,

me-

performed;

with (fig.

[1 , 2].

eration mass

maneuver.

to the large

up’ ‘ simultaneously superior vena cava

Montreal

but

larger

was

soft, vena

free

dence

but appeared

on Valsalva

ascending

superior

removed

1 A and

of the

angiography

the

from

and

findings

questionable

view

midportion

‘

arising a 6 cm,

aneurysm

phoid

on inspiration,

was

lesion

aneurysm revealed

1

nature.

and

expiration

separate

the

capillaries

showed

completely

mobilized

outside

ra-

was

easily

cally

were

communication.

emptied,

gradually

diagnosis

x

wall of the superior

or other

of the

the

obtained

a 5 mm

tract

stalk,

posi(Ren-

were

through

became

radiographic

divided.

was

cavity

allowed

was

to fill

it to the anterior

fully

glistening

from another

The

shadow

on the

demonstrated

February

Department

AJR

hilar

radionuclide

immediate of the

Hidvegi. 2

type.

vessels,

indicating

right

On fluoroscopy,

establish

thymoma.

revealed

her

on chest

(fig.

material

outflow the

from

The

Pathologic

on electrocardiography

was transferred

film mass

mass

changes

vena

mass

catheter

projections

began

and

cular

chest

investigations

superior

by the

contrast

several

connecting

aneurysm

pressed

and

saccular

apart

taming

lateral tomography (fig. 1 C) revealed a large, 6 x 7 cm, dense homogenous mass well

sharply

transmitted

diastinal

the

involving

The

the

entrance,

immediately

no separate

superior

Chest

midsternal

midmediastinal

6 years

over

B). Recumbent right retrosternal, spherical,

of the

The

was

Thoracotomy

of a me-

paresthesias

laboratory

of possible

chest

1

mediastinum.

and

The patient

over

Montreal

tissue. displaced

cavography

azygos

injected,

mass channel

aneurysm,

radiographic

treatment

nonexertional

segment

diagnosis

projecting

larger

ST

to the

surgical

were

episodic

clinical

upright

admitted and

complaints

and All

change

definite

Our

only

with ischemia.

hospital

was

for an anterior

and

compatible no

Her

1 year.

diography

woman investigation

fatty and

vena

of the

was

cava.

There

cava Centre

compressed

The

connecting

A 54-year-old

by mediastinal

level

76) 3B).

cm stalklike

Report

Hospital

mass slightly

superior

at the

ografin

resulted in a correct of literature revealed

a review

the

selective

tioned

approach to this unusual entity. This may enable the radiologist to distinguish it from the fusiform type of aneurysmal dilatation of the superior vena cava and other vascular and nonvascular masses of the mediastinum.

Case

Cava:

3A).

has a characteristic behavexaminations, but angioga definitive diagnosis.

investigation and the review

Vena

and

infrequent

superior vena cava. The lesion iour on conventional radiographic raphy is necessary to establish

of the Superior

3650 Montreal,

335-0924

St. Urbain Quebec

$00.00

.

Montreal,

H2X 2P4,

© American

H2X

Canada.

Roentgen

Ray Society

2P4,

Canada.

Address

reprint

requests

to R. S.

November

CASE

1979

American Journal of Roentgenology 1979.133:924-927.

AJR:133,

925

REPORTS

Fig. visible

1 -A, mass

Posteroanterior projects over

right

inspiration upright chest radiograph. hilar shadow. B, Posteroanterior

Faintly expiration

upright chest radiograph. Mass is more prominent than on inspiration and extends almost to right hemidiaphragm (arrowhead). C, Recumbent lateral tomogram. Large, homogeneous, spherical, well defined cystlike in anterior

mediastinum

projects

above

right

primary reported

fusiform dilatation of the superior [3-1 2]. Seven reports described

rysms [3-1 0], one discussed reported it as idiopathic dilatation

view right mass

atrium.

vena cava were fusiform aneu[1 1 ], and one

phlebectasia [1 2]. The

reports

indicated

that the fusiform aneurysm, phlebectasia, or idiopathic dilatation refers to greater or lesser dilatation of the lumen with increased width of the superior vena cava. These primary lesions

must

venous

aneurysms

be

ondary

to other

differentiated that venous

from

a group

develop

in conjunction

anomalies.

A well

of secondary with

known

or sec-

example

is

total anomalous pulmonary venous return diverting an enormously increased blood flow into the superior vena cava. Another group is represented by acquired lesions causing compression or obstruction of venous structures leading to dilatation.

Leigh

On

the

basis

[1 3] proposed

of the superior remarked on

ligation and interruption the superior cava.

The

second,

more

of the

dimensions

recent

and

excised.

represent superior

Review superior

the vena

given)

report

vena

to the

Our

report

three cava

congenital to date.

of the

literature

cava

also

correct diagnosis. Analysis of the

communication

rysms was

with an anterior mediastinal mass. veal the diagnosis. On exploratory representing a saccular aneurysm (no

narrow

of a 27-year-old

Venography did not resurgery a 6 cm mass attached by a short stalk

superior

and

man

vena

these

two

saccular

cava

was

published aneurysms

found cases of the

of the

revealed

nine

dilatation instances

of the

(figs.

where

in

and azygos venography

cystic indicates

cava

investigating

Abbott

in our

case

others of the

in radiographic demonstrated the

and

fusiform

aneu-

an important

role

a venous nature of a mediastinal enlargement on expiration, on Val-

appeared

1 B). Computed aneurysms.

and

disease

angiography in identifying the vasmass, even to the point of suggestThe conventional radiographic find-

maneuver, or in recumbent of the superior vena cava 1 A and

systems usually

vena

ings may also suggest mass. Reports indicated

aneurysm of aneurysmal

etiology,

of aneurysmal

1 2 congenital

superior

for thoracic radionuclide cularity of a mediastinal ing the involved vessel.

salva rysms

varied

vena cava in 1 964. These authors and the similarity between the dilatation

superior vena caval appearance. Thoracic after with

of this

a classification

position in fusiform aneu[2, 3, 9, 1 1 ]. The saccular

to enlarge

tomography

Its clear

can

definition

on expiration also

be useful

of the large

926

CASE

thoracic

vessels

and

anatomy

is well

known

their

cross-sectional

from

other

and

publications

REPORTS

AJR:133,

topographic

planned

as well.

cation,

the

for

most

cava,

result

in disastrous

and

not

contrast

material

must

be

carefully

be

mediastinoscopy

compli-

contraindicated

accurate

surgical

as

Exploratory

may

should

diagnosis

preoperative

correction

it

surgery

of congenital

is

fusiform

superior vena cava may be hazardous and the simple excision of saccular aneurysm entailed no risk to the patients in the three reported cases. None of the saccular aneurysms contained thrombi, which

‘.

[2],

had been reported surgery with one

‘‘“1

.

to avoid

of the

unwarranted

..

-

when

While

aneurysm ..-

‘.

is

hemorrhage.

required

possible.

The

.

.

and

as perforation of a fusiform aneurysm [13]. In the surgical management of aneurysm of the superior

vena

of the

results

1979

such

Demonstration of the vascular anatomic detail requires angiography. Selective thoracic venography is the method of choice in this condition. The placement of the catheter tip deposition

accurate

November

difference

to have caused serious complications fatality in two of the fusiform aneurysms. in prognosis

and

treatment

further

at

empha-

‘.,‘

sizes

the need

for accurate

recognition

of aneurysmal

dilatation

of the fusiform

and

.‘

saccular

forms

of the

superior

vena

cava.

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American Journal of Roentgenology 1979.133:924-927.

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;\‘L i:,

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:. .q

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aorta

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American Journal of Roentgenology 1979.133:924-927.

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