Pediatric Radiology
Pediatr. Radiol. 8, 263-265 (1979)
9 bySpringer-Verlag1979
Traumatic Aneurysm of the Ascending Aorta in a Child G. A. Grajo, K o o k Sang Oh, and L. W. Y o u n g Department of Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, USA
Abstract. A case of traumatic aneurysm of the ascending aorta in a child is reported. This complication must be suspected in a child who sustains severe injury from closed thoracic trauma and develops an abnormally wide anterior mediastinum. A mechanism for ascending aortic rupture and aneurysm is proposed. A o r t o g r a p h y is essential when aortic injury and its complications are suspected.
Key words: Aneurysm, ascending aorta - Aorta, rupture - Trauma, chest wall
in Marfan's syndrome. Closed thoracic trauma in adults, as occurs in automobile accidents, may cause aortic injury and aneurysm. A search of the literature for this complication in children yielded only one reference [2]. W e report this case not only because of its apparent rarity, but also because in this age of steadily increasing trauma, the incidence of traumatic injury to the ascending aorta may also increase.
Case Report Aortic aneurysms in children are usually secondary to complications of coarctation of the aorta or aortic stenosis, or to "mycotic" infection from sub-acute bacterial endocarditis or to cystic medial necrosis, as
J.R., (CHP #24-45-34), a boy 3V2 years of age, was admitted to Children's Hospital of Pittsburgh (CHP) because of fever, anorexia, and abdominal pain. On physical examination, the only abnormal findings were a Grade 2/6 nonradiating harsh systolicmurmur high along the left sternal border and a systolic click at the cardiac apex.
Fig. 1. a Posteroanterior radiograph 3 weeks previouslyshows normal heart and mediastinum, b Admissionchest radiograph showsa large mediastinal mass adjacent to the right heart obscuring the clear space between the right atrium and the pulmonary artery
0301-0449/79/0008/0263/$01.00
264 Pertinent laboratory findings were hemoglobin 9.3 grams and hematocrit 29%. Peripheral blood smear showed normochromic, normocytic cells. Bone marrow showed normal cellularity. His chest radiograph (Fig. 1 b) upon admission showed an anterior mediastinal mass which was non-pulsatile at fluoroscopy. (Later, during the course of an extensive workup, the mother remembered that one month prior to admission J. R. fell while playing, developed a bruise over his midsternal region, and three days later he had vomiting and fever. A chest radiograph done at that time at another hospital was normal (Fig. 1 a). He seemed to be well after a couple of days until the present illness.)
G.A. Grajo et al.: Traumatic Aneurysm of the Ascending Aorta Thoracic ultrasonography (Fig. 2) showed a cystic right anterior mediastinal mass, about 7.6 cm in length and 6.8 cm in width. The initial clinical impression was that the mass was of neoplastic origin. At thoracotomy a vascular lesion in the anterior mediastinum was found. Needle aspiration of the mass yielded fresh blood which clotted on standing. No attempt was made to resect the vascular mass. Cardiac angiography showed a large saccular aneurysm in the ascending aorta with the site of rupture about 3 cm above the aortic valve (Fig. 3 a, b). At surgical re-exploration, a large false aneurysm in the ascending aorta was found with an oblong, vertical tear about 17 mm in length and 9 mm in width. The aneurysmal sac was resected and a Dacron graft was used to patch the defect. The aortic valve was normal. The patient did very well postoperatively and was discharged home in a good condition on the eighth postoperative day. Microscopy of the wall of the aneurysm showed fibrous granulation tissue and laminated fibrin clots. A special stain for elastic tissue did not demonstrate elastic tissue in the wall of the aneurysm. No microorganisms grew on bacteriological cultures. It was concluded that this was a post traumatic false aneurysm of the ascending aorta.
Discussion
Fig. 2. Longitudinal ultrasonogram, 2 cm to the right of the midline, shows a large echo-free cystic mass (An), adjacent to the right atrium (RA), and liver (L)
Post traumatic aneurysms of the thoracic aorta may b e e n c o u n t e r e d in a d u l t s a f t e r s u d d e n d e c e l e r a t i o n i n j u r y in h i g h s p e e d a u t o m o b i l e a c c i d e n t s . S t r a s s m a n reported that 80% of such patients die instantly bec a u s e of f r e e a o r t i c r u p t u r e a n d 2 0 % s u r v i v e l o n g enough to reach the hospital with contained aortic a n e u r y s m s [4]. T h e a o r t i c i s t h m u s is i n v o l v e d in 9 5 % o f c a s e s a n d t h e a s c e n d i n g a o r t a in 5 % [2, 4]. A m e c h a n i s m o f r u p t u r e at t h e a o r t i c i s t h m u s h a s b e e n p r e v i o u s l y p r o p o s e d a n d is w i d e l y a c c e p t e d [5].
Fig. 3. a Pulmonary angiogram shows displacement of the heart to the left and compression of the right main pulmonary artery. Note the restriction of flow into the right pulmonary arterial branches, b Delayed phase angiocardiogram shows extravasation of contrast medium outside the lumen of the ascending aorta (solid arrow) and opacification of the false aneurysm (open arrow)
265
G. A. Grajo et al.: Traumatic Aneurysm of the AscendingAorta A mechanism of ascending aortic rupture due to closed thoracic trauma to our knowledge has not been previously speculated in the literature. Anatomically, the heart is covered by fibroserous pericardial tissue which is attached distally at the diaphragm. Proximally, the pericardium is attached firmly and blends with the outer coats of the great vessels. The ascending aorta coursing from anterior to posterior is tethered by its major branches. The posterior displacement and rotation of the heart and its pericardium from a severe blow to the sternum probably causes a major stress at the junction of the aortic arch and the fixed peficardial attachment along the ascending aorta. C o m p o u n d e d by an increased intraluminal pressure within the aorta, the stretching force may cause the anterior aortic wall to tear. The diagnosis of thoracic aortic rupture and false aneurysm may be elusive. The clinical findings are meager and plain radiographic findings are nonspecitic. This may be c o m p o u n d e d by concurrent problems of abdominal visceral injury, shock, unconsciousness, and skeletal fractures. The clinician may overlook the possibility of injury to the thoracic aorta. The single most important factor, therefore, in early diagnosis is to suspect the injury even in the presence of mild mid-thoracic trauma. The radiologist plays a major role in the diagnostic w o r k u p and plan of management of a seriously injured patient. Radiographic findings of ruptured thoracic aorta and aneurysm are widening of the mediastinum, obliteration of the clear space between the heart borders and main pulmonary arterial branches, abnormal aortic contour, inferior displacement of the left mainstem bronchus, deviation of the trachea, and hem0pneumothorax [1, 3]. These findings when correlated with clinical findings; sudden onset of elevated blood pressure in the upper limbs, a harsh precordial systolic murmur, absence of a pulsation of any major branch of the aortic arch, and persistence of a low systemic blood pressure after transfusions for blood loss [1], should lead to aortography for defin-
itive diagnosis. Ultrasonography and computed tomography are other radiological methods which may help in determining the nature of the mediastinal mass. Traumatic aneurysm was not initially suspected in our case. This complication was entertained only after thoracotomy, cardiac angiography, and failure to prove another etiology. A history of previous trauma to the mid-sternal area was subsequently obtained.
Acknowledgements. We thank Ms. Susan Arlen and Miss Rochelle Minter for their kind assistance in the preparation of this manuscript, Mr. Norman Rabinovitz for the prints from selected radiographs, and Dr. James R. Zuberbuhler for his critical and helpful review of the manuscript. References 1. Kirsh, M.M., Crane, J.D., Kahn, D.R., Gago, O., Moores, W. Y., Redman, H., Bookstein, J. J., Sloan, H.: Roentgenographic evaluation of traumatic rupture of the aorta. Surg. Gynecol. 200, 904 (1970) 2. Mustard, W.T., Trusler, G.A., Williams, W. G.: Care for the injured child. Chap. 17, 143-149. Baltimore: Williams & Wilkins 1975 3. Parmley, L. F., Martingly, T. W., Manion, W. C., Jahnke, B. J.: Non-penetrating traumatic injury of the aorta. Circulation 17, 1086 (1958) 4. Sanborn, J. C., Heitzman, R. E., Markarian, B.: Traumatic rupture of the thoracic aorta, roentgen-pathological correlations. Radiology 95, 293 (1970) 5. Strassman, G.: Traumatic rupture of the aorta. Am. Heart J. 33, 508-515 (1947)
Date of final acceptance: January 8, 1979
Lionel W. Young, M. D. Department of Radiology Children's Hospital of Pittsburgh 125 DeSoto Street Pittsburgh, PA 15213 USA
Pediatr. Radiol. 8, 263-265 (1979)
9 bySpringer-Verlag1979
Traumatic Aneurysm of the Ascending Aorta in a Child G. A. Grajo, K o o k Sang Oh, and L. W. Y o u n g Department of Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, USA
Abstract. A case of traumatic aneurysm of the ascending aorta in a child is reported. This complication must be suspected in a child who sustains severe injury from closed thoracic trauma and develops an abnormally wide anterior mediastinum. A mechanism for ascending aortic rupture and aneurysm is proposed. A o r t o g r a p h y is essential when aortic injury and its complications are suspected.
Key words: Aneurysm, ascending aorta - Aorta, rupture - Trauma, chest wall
in Marfan's syndrome. Closed thoracic trauma in adults, as occurs in automobile accidents, may cause aortic injury and aneurysm. A search of the literature for this complication in children yielded only one reference [2]. W e report this case not only because of its apparent rarity, but also because in this age of steadily increasing trauma, the incidence of traumatic injury to the ascending aorta may also increase.
Case Report Aortic aneurysms in children are usually secondary to complications of coarctation of the aorta or aortic stenosis, or to "mycotic" infection from sub-acute bacterial endocarditis or to cystic medial necrosis, as
J.R., (CHP #24-45-34), a boy 3V2 years of age, was admitted to Children's Hospital of Pittsburgh (CHP) because of fever, anorexia, and abdominal pain. On physical examination, the only abnormal findings were a Grade 2/6 nonradiating harsh systolicmurmur high along the left sternal border and a systolic click at the cardiac apex.
Fig. 1. a Posteroanterior radiograph 3 weeks previouslyshows normal heart and mediastinum, b Admissionchest radiograph showsa large mediastinal mass adjacent to the right heart obscuring the clear space between the right atrium and the pulmonary artery
0301-0449/79/0008/0263/$01.00
264 Pertinent laboratory findings were hemoglobin 9.3 grams and hematocrit 29%. Peripheral blood smear showed normochromic, normocytic cells. Bone marrow showed normal cellularity. His chest radiograph (Fig. 1 b) upon admission showed an anterior mediastinal mass which was non-pulsatile at fluoroscopy. (Later, during the course of an extensive workup, the mother remembered that one month prior to admission J. R. fell while playing, developed a bruise over his midsternal region, and three days later he had vomiting and fever. A chest radiograph done at that time at another hospital was normal (Fig. 1 a). He seemed to be well after a couple of days until the present illness.)
G.A. Grajo et al.: Traumatic Aneurysm of the Ascending Aorta Thoracic ultrasonography (Fig. 2) showed a cystic right anterior mediastinal mass, about 7.6 cm in length and 6.8 cm in width. The initial clinical impression was that the mass was of neoplastic origin. At thoracotomy a vascular lesion in the anterior mediastinum was found. Needle aspiration of the mass yielded fresh blood which clotted on standing. No attempt was made to resect the vascular mass. Cardiac angiography showed a large saccular aneurysm in the ascending aorta with the site of rupture about 3 cm above the aortic valve (Fig. 3 a, b). At surgical re-exploration, a large false aneurysm in the ascending aorta was found with an oblong, vertical tear about 17 mm in length and 9 mm in width. The aneurysmal sac was resected and a Dacron graft was used to patch the defect. The aortic valve was normal. The patient did very well postoperatively and was discharged home in a good condition on the eighth postoperative day. Microscopy of the wall of the aneurysm showed fibrous granulation tissue and laminated fibrin clots. A special stain for elastic tissue did not demonstrate elastic tissue in the wall of the aneurysm. No microorganisms grew on bacteriological cultures. It was concluded that this was a post traumatic false aneurysm of the ascending aorta.
Discussion
Fig. 2. Longitudinal ultrasonogram, 2 cm to the right of the midline, shows a large echo-free cystic mass (An), adjacent to the right atrium (RA), and liver (L)
Post traumatic aneurysms of the thoracic aorta may b e e n c o u n t e r e d in a d u l t s a f t e r s u d d e n d e c e l e r a t i o n i n j u r y in h i g h s p e e d a u t o m o b i l e a c c i d e n t s . S t r a s s m a n reported that 80% of such patients die instantly bec a u s e of f r e e a o r t i c r u p t u r e a n d 2 0 % s u r v i v e l o n g enough to reach the hospital with contained aortic a n e u r y s m s [4]. T h e a o r t i c i s t h m u s is i n v o l v e d in 9 5 % o f c a s e s a n d t h e a s c e n d i n g a o r t a in 5 % [2, 4]. A m e c h a n i s m o f r u p t u r e at t h e a o r t i c i s t h m u s h a s b e e n p r e v i o u s l y p r o p o s e d a n d is w i d e l y a c c e p t e d [5].
Fig. 3. a Pulmonary angiogram shows displacement of the heart to the left and compression of the right main pulmonary artery. Note the restriction of flow into the right pulmonary arterial branches, b Delayed phase angiocardiogram shows extravasation of contrast medium outside the lumen of the ascending aorta (solid arrow) and opacification of the false aneurysm (open arrow)
265
G. A. Grajo et al.: Traumatic Aneurysm of the AscendingAorta A mechanism of ascending aortic rupture due to closed thoracic trauma to our knowledge has not been previously speculated in the literature. Anatomically, the heart is covered by fibroserous pericardial tissue which is attached distally at the diaphragm. Proximally, the pericardium is attached firmly and blends with the outer coats of the great vessels. The ascending aorta coursing from anterior to posterior is tethered by its major branches. The posterior displacement and rotation of the heart and its pericardium from a severe blow to the sternum probably causes a major stress at the junction of the aortic arch and the fixed peficardial attachment along the ascending aorta. C o m p o u n d e d by an increased intraluminal pressure within the aorta, the stretching force may cause the anterior aortic wall to tear. The diagnosis of thoracic aortic rupture and false aneurysm may be elusive. The clinical findings are meager and plain radiographic findings are nonspecitic. This may be c o m p o u n d e d by concurrent problems of abdominal visceral injury, shock, unconsciousness, and skeletal fractures. The clinician may overlook the possibility of injury to the thoracic aorta. The single most important factor, therefore, in early diagnosis is to suspect the injury even in the presence of mild mid-thoracic trauma. The radiologist plays a major role in the diagnostic w o r k u p and plan of management of a seriously injured patient. Radiographic findings of ruptured thoracic aorta and aneurysm are widening of the mediastinum, obliteration of the clear space between the heart borders and main pulmonary arterial branches, abnormal aortic contour, inferior displacement of the left mainstem bronchus, deviation of the trachea, and hem0pneumothorax [1, 3]. These findings when correlated with clinical findings; sudden onset of elevated blood pressure in the upper limbs, a harsh precordial systolic murmur, absence of a pulsation of any major branch of the aortic arch, and persistence of a low systemic blood pressure after transfusions for blood loss [1], should lead to aortography for defin-
itive diagnosis. Ultrasonography and computed tomography are other radiological methods which may help in determining the nature of the mediastinal mass. Traumatic aneurysm was not initially suspected in our case. This complication was entertained only after thoracotomy, cardiac angiography, and failure to prove another etiology. A history of previous trauma to the mid-sternal area was subsequently obtained.
Acknowledgements. We thank Ms. Susan Arlen and Miss Rochelle Minter for their kind assistance in the preparation of this manuscript, Mr. Norman Rabinovitz for the prints from selected radiographs, and Dr. James R. Zuberbuhler for his critical and helpful review of the manuscript. References 1. Kirsh, M.M., Crane, J.D., Kahn, D.R., Gago, O., Moores, W. Y., Redman, H., Bookstein, J. J., Sloan, H.: Roentgenographic evaluation of traumatic rupture of the aorta. Surg. Gynecol. 200, 904 (1970) 2. Mustard, W.T., Trusler, G.A., Williams, W. G.: Care for the injured child. Chap. 17, 143-149. Baltimore: Williams & Wilkins 1975 3. Parmley, L. F., Martingly, T. W., Manion, W. C., Jahnke, B. J.: Non-penetrating traumatic injury of the aorta. Circulation 17, 1086 (1958) 4. Sanborn, J. C., Heitzman, R. E., Markarian, B.: Traumatic rupture of the thoracic aorta, roentgen-pathological correlations. Radiology 95, 293 (1970) 5. Strassman, G.: Traumatic rupture of the aorta. Am. Heart J. 33, 508-515 (1947)
Date of final acceptance: January 8, 1979
Lionel W. Young, M. D. Department of Radiology Children's Hospital of Pittsburgh 125 DeSoto Street Pittsburgh, PA 15213 USA
