Lung DOI 10.1007/s00408-013-9548-3
Rare Cause of Dyspnea: Yin–Yang Thoracic Aortic Aneurysm Princy Ghera • Don Hayes Jr.
Received: 18 September 2013 / Accepted: 14 December 2013 Ó Springer Science+Business Media New York 2014
Abstract Aortic aneurysmal diseases, mostly found incidentally, have high mortality and morbidity. Complications mostly are associated with and accelerated in the presence of systemic hypertension, aortic valve disease, or aortic atherosclerosis. Presenting signs and symptoms can be nonspecific and need immediate and accurate recognition. We present a case of incidental finding of a large descending aortic aneurysm with ‘‘yin–yang’’ sign and discuss the importance of differentiating pseudoaneurysm versus intramural thrombus. Keywords
Aorta Thoracic Yin–Yang Aneurysm
Case Report An 86-year-old female presented to the emergency department with 2-hour duration of intermittent episodes of dyspnea, diaphoresis, chest tightness, nausea, and vertigo. Her past medical history was significant for hypertension. Her initial evaluation included a computed
tomographic (CT) scan of the head and electrocardiogram as well as complete blood count, chemistry panel, and cardiac enzymes, which were all unremarkable. Chest X-ray (Fig. 1) revealed a large mass in the left upper chest. CT scan of the chest (Fig. 2) showed an aneurysm of the descending thoracic aorta with evidence of several penetrating ulcers and formation of a large intramural hematoma. Figure 3 clearly shows the shape of ‘‘yin–yang’’ of the thoracic aorta at the thoracic level with the aneurysm measuring approximately 10 9 11 cm2 without any evidence of dissection. Similar images were reproduced in sagittal plane as well (Fig. 4), further identifying the anatomy. Although cardiothoracic surgery service was consulted, the patient declined surgical intervention and accepted palliative measures with continued beta blockers for blood pressure control and instructions to avoid heavy lifting. The patient was treated with metoprolol to optimize blood pressure control, but she died 8 months later when the aneurysm ruptured.
Discussion P. Ghera D. Hayes Jr. Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA P. Ghera D. Hayes Jr. (&) The Ohio State University College of Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA e-mail: [email protected] D. Hayes Jr. Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
Incidence of dissection and death is approximately 14 % per year if the ascending aortic aneurysm reaches 6 cm and descending aortic aneurysm reaches 7 cm in diameter. Annual growth rate is 0.12 cm. A faster rate of growth or size more than 5.5 and 6.5 cm for ascending and descending aortic aneurysm respectively needs urgent evaluation and treatment per cardiothoracic surgery service [1–5]. The yin–yang sign can be seen on contrast-enhanced CT imaging with a configuration of a well-defined round or oval mass with increased attenuation in half of
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its area and decreased attenuation in the other half, resembling the ancient Chinese yin–yang symbol [1–3]. Moreover, the yin–yang sign helps to facilitate the diagnosis of partially thrombosed true arterial
aneurysms compared with false aneurysms. Increased attenuation in one portion of the thrombosed aneurysm can indicate partially contrast material-filled lumen, whereas reduced attenuation in the remaining portion of
Fig. 1 Chest radiograph demonstrating a large mass in the left upper chest
Fig. 3 CT scan of the chest demonstrating a descending aortic 10 9 11 cm2 aneurysm with ‘‘yin–yang’’ pattern without any evidence of dissection
Fig. 2 CT scan of the chest a without contrast and b with contrast demonstrating a descending aortic aneurysm with penetrating ulcers and large intramural hematoma
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without symptoms, reaching large dimensions as in this case. In contrast, another vascular abnormality commonly seen is an aortic dissection where a tear in the intima is associated with degeneration of the media [4]. Ultimately, blood enters into the media through this tear, separating the intima from the surrounding media or adventitia, thereby creating a false lumen. The propagation of the dissection can occur both distal and proximal to the initial tear, involving branch vessels and the aortic valve and entering the pericardial space [5]. Therefore, a quick and accurate diagnosis of these vascular abnormalities is fundamental to avoid rupture, which can be sudden and life-threatening. Acknowledgments The work and subsequent manuscript was completed at The Ohio State University, Columbus, Ohio. Conflict of interest The authors report no conflict of interest while not having any relevant disclosures.
References Fig. 4 CT scan with demonstration of descending aortic aneurysm in sagittal plane
the thrombosed aneurysm is indicative of a mural thrombus [1]. True aneurysms are due to acquired or congenital arterial disease where all layers of blood vessel walls are dilated but intact, whereas false aneurysms are acquired lesions that lack an arterial wall and are constrained by the surrounding hematoma and soft tissues. Both true and false aneurysms can rapidly grow
1. Lupattelli T (2006) The yin–yang sign. Radiology 238(3):1070–1071 2. Kutlu R, Baysal T, Sigirci A, Ege E, Sarac K (2003) Right subclavian artery aneurysm: yin–yang sign on CT. Cardiovasc Intervent Radiol 26(2):184–185 3. Wang CW, Liang PC, Hsieh JT (2009) The yin–yang sign. Kidney Int 75(1):128 4. Larson EW, Edwards WD (1984) Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 53(6):849–855 5. Nienaber CA, Eagle KA (2003) Aortic dissection: new frontiers in diagnosis and management. Part I: from etiology to diagnostic strategies. Circulation 108(5):628–635
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Rare Cause of Dyspnea: Yin–Yang Thoracic Aortic Aneurysm Princy Ghera • Don Hayes Jr.
Received: 18 September 2013 / Accepted: 14 December 2013 Ó Springer Science+Business Media New York 2014
Abstract Aortic aneurysmal diseases, mostly found incidentally, have high mortality and morbidity. Complications mostly are associated with and accelerated in the presence of systemic hypertension, aortic valve disease, or aortic atherosclerosis. Presenting signs and symptoms can be nonspecific and need immediate and accurate recognition. We present a case of incidental finding of a large descending aortic aneurysm with ‘‘yin–yang’’ sign and discuss the importance of differentiating pseudoaneurysm versus intramural thrombus. Keywords
Aorta Thoracic Yin–Yang Aneurysm
Case Report An 86-year-old female presented to the emergency department with 2-hour duration of intermittent episodes of dyspnea, diaphoresis, chest tightness, nausea, and vertigo. Her past medical history was significant for hypertension. Her initial evaluation included a computed
tomographic (CT) scan of the head and electrocardiogram as well as complete blood count, chemistry panel, and cardiac enzymes, which were all unremarkable. Chest X-ray (Fig. 1) revealed a large mass in the left upper chest. CT scan of the chest (Fig. 2) showed an aneurysm of the descending thoracic aorta with evidence of several penetrating ulcers and formation of a large intramural hematoma. Figure 3 clearly shows the shape of ‘‘yin–yang’’ of the thoracic aorta at the thoracic level with the aneurysm measuring approximately 10 9 11 cm2 without any evidence of dissection. Similar images were reproduced in sagittal plane as well (Fig. 4), further identifying the anatomy. Although cardiothoracic surgery service was consulted, the patient declined surgical intervention and accepted palliative measures with continued beta blockers for blood pressure control and instructions to avoid heavy lifting. The patient was treated with metoprolol to optimize blood pressure control, but she died 8 months later when the aneurysm ruptured.
Discussion P. Ghera D. Hayes Jr. Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA P. Ghera D. Hayes Jr. (&) The Ohio State University College of Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA e-mail: [email protected] D. Hayes Jr. Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
Incidence of dissection and death is approximately 14 % per year if the ascending aortic aneurysm reaches 6 cm and descending aortic aneurysm reaches 7 cm in diameter. Annual growth rate is 0.12 cm. A faster rate of growth or size more than 5.5 and 6.5 cm for ascending and descending aortic aneurysm respectively needs urgent evaluation and treatment per cardiothoracic surgery service [1–5]. The yin–yang sign can be seen on contrast-enhanced CT imaging with a configuration of a well-defined round or oval mass with increased attenuation in half of
123
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its area and decreased attenuation in the other half, resembling the ancient Chinese yin–yang symbol [1–3]. Moreover, the yin–yang sign helps to facilitate the diagnosis of partially thrombosed true arterial
aneurysms compared with false aneurysms. Increased attenuation in one portion of the thrombosed aneurysm can indicate partially contrast material-filled lumen, whereas reduced attenuation in the remaining portion of
Fig. 1 Chest radiograph demonstrating a large mass in the left upper chest
Fig. 3 CT scan of the chest demonstrating a descending aortic 10 9 11 cm2 aneurysm with ‘‘yin–yang’’ pattern without any evidence of dissection
Fig. 2 CT scan of the chest a without contrast and b with contrast demonstrating a descending aortic aneurysm with penetrating ulcers and large intramural hematoma
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without symptoms, reaching large dimensions as in this case. In contrast, another vascular abnormality commonly seen is an aortic dissection where a tear in the intima is associated with degeneration of the media [4]. Ultimately, blood enters into the media through this tear, separating the intima from the surrounding media or adventitia, thereby creating a false lumen. The propagation of the dissection can occur both distal and proximal to the initial tear, involving branch vessels and the aortic valve and entering the pericardial space [5]. Therefore, a quick and accurate diagnosis of these vascular abnormalities is fundamental to avoid rupture, which can be sudden and life-threatening. Acknowledgments The work and subsequent manuscript was completed at The Ohio State University, Columbus, Ohio. Conflict of interest The authors report no conflict of interest while not having any relevant disclosures.
References Fig. 4 CT scan with demonstration of descending aortic aneurysm in sagittal plane
the thrombosed aneurysm is indicative of a mural thrombus [1]. True aneurysms are due to acquired or congenital arterial disease where all layers of blood vessel walls are dilated but intact, whereas false aneurysms are acquired lesions that lack an arterial wall and are constrained by the surrounding hematoma and soft tissues. Both true and false aneurysms can rapidly grow
1. Lupattelli T (2006) The yin–yang sign. Radiology 238(3):1070–1071 2. Kutlu R, Baysal T, Sigirci A, Ege E, Sarac K (2003) Right subclavian artery aneurysm: yin–yang sign on CT. Cardiovasc Intervent Radiol 26(2):184–185 3. Wang CW, Liang PC, Hsieh JT (2009) The yin–yang sign. Kidney Int 75(1):128 4. Larson EW, Edwards WD (1984) Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 53(6):849–855 5. Nienaber CA, Eagle KA (2003) Aortic dissection: new frontiers in diagnosis and management. Part I: from etiology to diagnostic strategies. Circulation 108(5):628–635
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