eMedicine Specialties > Radiology > Vascular/Interventional

Abdominal Aortic Aneurysm, Rupture: Imaging

Author: Walter A Tan, MD, MS, Assistant Professor of Medicine (Cardiology) and Radiology, Director of Vascular Medicine Program, Departments of Medicine and Radiology, Division of Cardiology, University of North Carolina at Chapel Hill
Coauthor(s): Michel S Makaroun, MD, Professor of Surgery, Chief, Division of Vascular Surgery, University of Pittsburgh School of Medicine; Program Director, Medical Director of Peripheral Vascular Laboratory, University of Pittsburgh Medical Center
Contributor Information and Disclosures

Updated: Mar 23, 2007

Radiography

Findings

A curvilinear calcified rim often to the left of the midline is apparent on some plain abdominal radiographs. Lateral radiography can depict large AAAs on the basis of calcification in the wall. This finding can be seen in more than half of patients.

Degree of Confidence

The degree if confidence is low. Suspicious findings on the abdominal radiograph should be confirmed by using another imaging modality.

False Positives/Negatives

Mural calcification can be radiographically inapparent and lead to a false-negative finding in as many as half of small AAAs. Magnification errors are also possible, leading to over- or underestimation of AAA diameter.

Computed Tomography

Findings

General findings

Unlike angiography, CT and MRI provide information about the wall of the aorta, and they delineate the presence of thrombus.46 They provide detail about surrounding abdominal structures and their relationship to the AAA (see Image 1). Perianeurysmal fibrosis, venous anomalies (eg, retroaortic left renal vein, circumaortic venous collar), and horseshoe kidney are reliably demonstrated. However, these modalities (particularly MRI) are currently time and labor intensive, and they are not suitable for use in patients in unstable condition.

Helical or spiral CT angiography (CTA) allows reasonable visualization of branches of the aorta in the context of surrounding structures. Postprocessing of images and 3-dimensional reconstruction are possible.

Magnetic resonance angiography (MRA) has the advantage of eliminating the need for potentially nephrotoxic contrast agents and ionizing radiation, but its acquisition speed, cost, and image quality still need to be improved. Ferromagnetic implants or severe claustrophobia also can preclude use of MRI and/or MRA.

Findings that indicate possible AAA rupture include soft tissue hyperintensity outside the aortic wall, an indistinct aortic wall, thinning or fracture of a calcified aortic wall segment, penetration of a hematoma into the leaves of the mesentery, or contrast extravasation into the psoas muscle or retroperitoneum.

The nonenhanced study shows a mass or collection that extends into the perirenal spaces, or, less commonly, into the pararenal spaces. The AAA is often obscured or anteriorly displaced. Other possible findings include a focally indistinct aortic margin (usually the site of rupture), enlargement or obscuration of the psoas muscle, and anterior displacement of the kidney.

CT-specific findings

Freshly extravasated blood typically has a high CT attenuation value, whereas an isoattenuating or hypoattenuating hematoma signifies that a leak that is days or weeks old.

The crescent sign is an enhancement within the AAA mural thrombus or wall that is thought to represent intramural hematoma.47 This was found to be a sign of acute or impending rupture in a retrospective series, with a sensitivity, specificity, and positive predictive value of 77%, 93%, and 53%, respectively.48

Periaortic fibrosis outside of the subintimal calcification is suggestive of inflammatory aneurysm.

Degree of Confidence

The degree of confidence is high.

False Positives/Negatives

Soft tissue attenuation outside of the abdominal aorta can be related to changes secondary to an inflammatory process. These findings may possibly be related to pathology from other abdominal viscera. The sensitivity and specificity for the detection of AAA rupture decreases if a nonenhanced study is performed.

Magnetic Resonance Imaging

Findings

MRI is a valuable alternative to CT in patients with renal insufficiency in whom contrast material–induced nephropathy is a concern.49 MRI is also helpful in further delineating the aorta in the context of a large retroperitoneal collection that obscures the borders between adjacent structures, as well as laminated clot or atherosclerotic debris on the aneurysmal wall (Lee, 1984).

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness withtroublemoving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of Confidence

The degree of confidence is high.

False Positives/Negatives

Soft tissue intensity changes outside of the abdominal aorta can be related to changes secondary to an inflammatory process. These findings might actually be related to pathology from other abdominal viscera.

Ultrasonography

Findings

Unlike most other modalities (eg, aortography, CT, MRI), abdominal US can be performed expeditiously and at the bedside.24

For partially encapsulated hematomas, a hypoechoic or anechoic para-aortic space-occupying lesion may be detected.

Color-flow Doppler can aid in detecting the site of leak or extravasation, although adjustment to low-velocity scales may be necessary to register leaks with low flow rates.

Degree of Confidence

The degree of confidence is high for the detection of AAA and low for the detection of AAA rupture.

Although duplex US is competitive with CT or MRI for the detection of an AAA (>95% sensitivity), the visualization of surrounding structures is poor, and the sensitivity and specificity for rupture are low.

False Positives/Negatives

Conditions that limit the detection and measurement of AAAs or its branches include excessive bowel gas, obesity, and recent abdominal surgery.

If a ruptured AAA is clinically suspected, other diagnostic modalities should be pursued even if the sonographic results are negative.

Angiography

Findings

Digital subtraction angiography (DSA) provides high-spatial-resolution images of the lumen of the vascular tree and permits the quantification of significant stenoses in renal, mesenteric, and iliofemoral arteries.38 CT also depicts aberrant vessels well.

Angiographic findings of AAA rupture include the following:

  • Contained rupture: Circumscribed extraluminal contrast enhancement is present. Additional views (oblique or lateral) may be required to detect this finding.
  • Leaking aneurysm: Frank extravasation of contrast material with poor washout is observed. This is rarely demonstrated because the patients are typically in unstable condition and are transported directly to the operating room.
  • Displacement of the visceral arteries or kidneys and ureters: Sometimes, this finding can be evident in larger collections of blood.
  • Contrast enhancement: Contrast material may flow into these structures from the AAA in the rare circumstance of rupture into the GI tract or IVC.

Degree of Confidence

The degree of confidence is low.

Angiography is rarely used in the setting of suspected rupture and is relatively contraindicated except when endovascular stent grafting is planned because this is an experimental procedure. However, unusual manifestations of AAA rupture, such as into the IVC or GI tract (aortoenteric fistula) is demonstrated well with angiography.

False Positives/Negatives

The absence of extraluminal contrast cannot be used to totally rule out a small leak or stabilized rupture. If the degree of suspicion is high, a tomographic imaging modality should be performed.

Laminated or mural thrombus may give the false arteriographic impression that no AAA is present. A calcified aortic shell and the absence of lumbar arteries are clues to the presence of an aneurysm.

More on Abdominal Aortic Aneurysm, Rupture

Overview: Abdominal Aortic Aneurysm, Rupture
Imaging: Abdominal Aortic Aneurysm, Rupture
Follow-up: Abdominal Aortic Aneurysm, Rupture
Multimedia: Abdominal Aortic Aneurysm, Rupture
References
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Further Reading

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Keywords

AAA, perforated aneurysm, leaking aneurysm, pararenal aneurysm, aortic aneurysm, thoracoabdominal aneurysm, anastomotic aneurysm

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Contributor Information and Disclosures

Author

Walter A Tan, MD, MS, Assistant Professor of Medicine (Cardiology) and Radiology, Director of Vascular Medicine Program, Departments of Medicine and Radiology, Division of Cardiology, University of North Carolina at Chapel Hill
Walter A Tan, MD, MS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michel S Makaroun, MD, Professor of Surgery, Chief, Division of Vascular Surgery, University of Pittsburgh School of Medicine; Program Director, Medical Director of Peripheral Vascular Laboratory, University of Pittsburgh Medical Center
Michel S Makaroun, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Association of VA Surgeons, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Eric P Weinberg, MD, Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital
Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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