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DOI: 10.1148/rg.272065026
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Spectrum of CT Findings in Rupture and Impending Rupture of Abdominal Aortic Aneurysms1

Dmitry Rakita, MD, Amit Newatia, MD, John J. Hines, MD, David N. Siegel, MD and Barak Friedman, MD

1 From the Department of Radiology, Division of Body Imaging and Division of Interventional Radiology, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received March 16, 2006; revision requested June 14 and received August 4; accepted August 10. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Types of aortic aneurysms. Schematic depicts the normal arterial wall structure and the wall structures of true and false aneurysms.

 

Figure 2A
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  		Figure 2a.  Aortic aneurysm rupture in an 80-year-old woman with abdominal pain and hypotension. Axial (a) and sagittal (b) CT angiographic images demonstrate active extravasation of contrast material (arrow) into the thrombosed portion of an abdominal aortic aneurysm, as well as extensive retroperitoneal hemorrhage (arrowhead).

 

Figure 2B
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  		Figure 2b.  Aortic aneurysm rupture in an 80-year-old woman with abdominal pain and hypotension. Axial (a) and sagittal (b) CT angiographic images demonstrate active extravasation of contrast material (arrow) into the thrombosed portion of an abdominal aortic aneurysm, as well as extensive retroperitoneal hemorrhage (arrowhead).

 

Figure 3A
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  		Figure 3a.  Aortic aneurysm rupture in a 67-year-old man with abdominal pain and hypotension. Axial CT angiographic images depict a large ruptured abdominal aortic aneurysm with active retroperitoneal extravasation (arrow in a) and intraperitoneal hemorrhage (arrow in b).

 

Figure 3B
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  		Figure 3b.  Aortic aneurysm rupture in a 67-year-old man with abdominal pain and hypotension. Axial CT angiographic images depict a large ruptured abdominal aortic aneurysm with active retroperitoneal extravasation (arrow in a) and intraperitoneal hemorrhage (arrow in b).

 

Figure 4A
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  		Figure 4a.  Aortic aneurysm rupture in a 68-year-old man with abdominal and right hip pain. (a, b) Axial contrast-enhanced CT images (a at a level higher than b) show a retroperitoneal hemorrhage (arrowhead) and a right psoas hematoma (arrow). (c) Post-treatment angiogram shows successful repair of the ruptured aneurysm with endovascular stent placement.

 

Figure 4B
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  		Figure 4b.  Aortic aneurysm rupture in a 68-year-old man with abdominal and right hip pain. (a, b) Axial contrast-enhanced CT images (a at a level higher than b) show a retroperitoneal hemorrhage (arrowhead) and a right psoas hematoma (arrow). (c) Post-treatment angiogram shows successful repair of the ruptured aneurysm with endovascular stent placement.

 

Figure 4C
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  		Figure 4c.  Aortic aneurysm rupture in a 68-year-old man with abdominal and right hip pain. (a, b) Axial contrast-enhanced CT images (a at a level higher than b) show a retroperitoneal hemorrhage (arrowhead) and a right psoas hematoma (arrow). (c) Post-treatment angiogram shows successful repair of the ruptured aneurysm with endovascular stent placement.

 

Figure 5A
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  		Figure 5a.  Aortic aneurysm rupture superior to an aortobiiliac stent-graft in a 75-year-old man with chronic renal insufficiency and abdominal pain after endovascular repair. Axial (a at a level higher than b) and sagittal (c) gadolinium-enhanced CT angiographic images demonstrate active extravasation of contrast material superior to the graft (arrowhead in b and c) and retroperitoneal hemorrhage around the aorta (arrow).

 

Figure 5B
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  		Figure 5b.  Aortic aneurysm rupture superior to an aortobiiliac stent-graft in a 75-year-old man with chronic renal insufficiency and abdominal pain after endovascular repair. Axial (a at a level higher than b) and sagittal (c) gadolinium-enhanced CT angiographic images demonstrate active extravasation of contrast material superior to the graft (arrowhead in b and c) and retroperitoneal hemorrhage around the aorta (arrow).

 

Figure 5C
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  		Figure 5c.  Aortic aneurysm rupture superior to an aortobiiliac stent-graft in a 75-year-old man with chronic renal insufficiency and abdominal pain after endovascular repair. Axial (a at a level higher than b) and sagittal (c) gadolinium-enhanced CT angiographic images demonstrate active extravasation of contrast material superior to the graft (arrowhead in b and c) and retroperitoneal hemorrhage around the aorta (arrow).

 

Figure 6A
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  		Figure 6a.  Draped aorta sign in a 55-year-old man with a known abdominal aortic aneurysm and recent vague back pain. Axial CT angiographic images (a at a level higher than b) depict an 8-cm abdominal aortic aneurysm with a posterior aortic wall that follows the contour of the vertebral bodies with a draping effect (arrow in b). The latter finding is indicative of a contained rupture.

 

Figure 6B
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  		Figure 6b.  Draped aorta sign in a 55-year-old man with a known abdominal aortic aneurysm and recent vague back pain. Axial CT angiographic images (a at a level higher than b) depict an 8-cm abdominal aortic aneurysm with a posterior aortic wall that follows the contour of the vertebral bodies with a draping effect (arrow in b). The latter finding is indicative of a contained rupture.

 

Figure 7A
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  		Figure 7a.  Large ruptured aneurysm in a 68-year-old man with an acute onset of right flank pain radiating to the back. Axial unenhanced CT images (a at a level higher than b) depict a ruptured 10.7-cm abdominal aortic aneurysm and a retroperitoneal hemorrhage (arrow).

 

Figure 7B
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  		Figure 7b.  Large ruptured aneurysm in a 68-year-old man with an acute onset of right flank pain radiating to the back. Axial unenhanced CT images (a at a level higher than b) depict a ruptured 10.7-cm abdominal aortic aneurysm and a retroperitoneal hemorrhage (arrow).

 

Figure 8A
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  		Figure 8a.  Discontinuity of aortic wall calcifications in an abdominal aortic aneurysm in a 60-year-old woman. Axial unenhanced CT images from two examinations of the same patient in 2003 (a) and 2005 (b) demonstrate the development of discontinuity in calcifications and of draping of the posterior aortic wall (arrow in b).

 

Figure 8B
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  		Figure 8b.  Discontinuity of aortic wall calcifications in an abdominal aortic aneurysm in a 60-year-old woman. Axial unenhanced CT images from two examinations of the same patient in 2003 (a) and 2005 (b) demonstrate the development of discontinuity in calcifications and of draping of the posterior aortic wall (arrow in b).

 

Figure 9A
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  		Figure 9a.  Impending aneurysm rupture in a 66-year-old man with back pain, who underwent imaging for suspicion of renal colic. Axial unenhanced CT images (a and b are the same section with different window settings) demonstrate an abdominal aortic aneurysm with a hyperattenuating crescent sign (arrow) that represents an acute hematoma within the aneurysm wall.

 

Figure 9B
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  		Figure 9b.  Impending aneurysm rupture in a 66-year-old man with back pain, who underwent imaging for suspicion of renal colic. Axial unenhanced CT images (a and b are the same section with different window settings) demonstrate an abdominal aortic aneurysm with a hyperattenuating crescent sign (arrow) that represents an acute hematoma within the aneurysm wall.

 

Figure 10A
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  		Figure 10a.  Impending aneurysm rupture in a 57-year-old man with a known abdominal aortic aneurysm and increasing abdominal pain. Axial unenhanced (a) and axial contrast-enhanced (b) CT images depict an abdominal aortic aneurysm with a hyperattenuating crescent sign (arrow in a), which represents an acute hematoma within the aneurysm wall.

 

Figure 10B
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  		Figure 10b.  Impending aneurysm rupture in a 57-year-old man with a known abdominal aortic aneurysm and increasing abdominal pain. Axial unenhanced (a) and axial contrast-enhanced (b) CT images depict an abdominal aortic aneurysm with a hyperattenuating crescent sign (arrow in a), which represents an acute hematoma within the aneurysm wall.

 

Figure 11A
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  		Figure 11a.  Mycotic pseudoaneurysm with associated vertebral osteomyelitis in a 45-year-old man with back and abdominal pain, fever, and an elevated white blood cell count. Sagittal (a) and axial (b, c) contrast-enhanced CT images (b at a level higher than c) show a large pseudoaneurysm (arrowhead) with communication to the aorta (white arrow). Note the destructive changes in adjacent vertebral bodies (black arrow.)

 

Figure 11B
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  		Figure 11b.  Mycotic pseudoaneurysm with associated vertebral osteomyelitis in a 45-year-old man with back and abdominal pain, fever, and an elevated white blood cell count. Sagittal (a) and axial (b, c) contrast-enhanced CT images (b at a level higher than c) show a large pseudoaneurysm (arrowhead) with communication to the aorta (white arrow). Note the destructive changes in adjacent vertebral bodies (black arrow.)

 

Figure 11C
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  		Figure 11c.  Mycotic pseudoaneurysm with associated vertebral osteomyelitis in a 45-year-old man with back and abdominal pain, fever, and an elevated white blood cell count. Sagittal (a) and axial (b, c) contrast-enhanced CT images (b at a level higher than c) show a large pseudoaneurysm (arrowhead) with communication to the aorta (white arrow). Note the destructive changes in adjacent vertebral bodies (black arrow.)

 

Figure 12A
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  		Figure 12a.  Mycotic aneurysm rupture in a 74-year-old man with abdominal pain and an elevated white blood cell count. Axial (a), sagittal (b), and coronal (c) contrast-enhanced CT images demonstrate a retroperitoneal hematoma (arrowhead) and small bubbles of gas (curved arrow) within the aneurysm lumen and surrounding soft tissue. An adjacent pseudoaneurysm (straight arrow in a and b) also is seen. The differential diagnosis included mycotic aneurysm and aortoduodenal fistula. A mycotic aneurysm was found at surgery.

 

Figure 12B
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  		Figure 12b.  Mycotic aneurysm rupture in a 74-year-old man with abdominal pain and an elevated white blood cell count. Axial (a), sagittal (b), and coronal (c) contrast-enhanced CT images demonstrate a retroperitoneal hematoma (arrowhead) and small bubbles of gas (curved arrow) within the aneurysm lumen and surrounding soft tissue. An adjacent pseudoaneurysm (straight arrow in a and b) also is seen. The differential diagnosis included mycotic aneurysm and aortoduodenal fistula. A mycotic aneurysm was found at surgery.

 

Figure 12C
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  		Figure 12c.  Mycotic aneurysm rupture in a 74-year-old man with abdominal pain and an elevated white blood cell count. Axial (a), sagittal (b), and coronal (c) contrast-enhanced CT images demonstrate a retroperitoneal hematoma (arrowhead) and small bubbles of gas (curved arrow) within the aneurysm lumen and surrounding soft tissue. An adjacent pseudoaneurysm (straight arrow in a and b) also is seen. The differential diagnosis included mycotic aneurysm and aortoduodenal fistula. A mycotic aneurysm was found at surgery.

 

Figure 13A
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  		Figure 13a.  Aortoduodenal fistula in a 71-year-old woman with a known abdominal aortic aneurysm, abdominal pain, and a guaiac-positive stool test. Axial (a, b), close-up axial (c), and coronal (d) CT angiographic images depict small gas bubbles within a ruptured aneurysm sac (arrows in a, b, and d), as well as disruption of the anterior aortic wall, with a faint fistulous tract between the thrombosed portion of the aortic aneurysm and the third portion of the duodenum (arrowhead in b and c). The differential diagnosis included aortoduodenal fistula and mycotic aneurysm. The patient died of a massive gastrointestinal hemorrhage the next day.

 

Figure 13B
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  		Figure 13b.  Aortoduodenal fistula in a 71-year-old woman with a known abdominal aortic aneurysm, abdominal pain, and a guaiac-positive stool test. Axial (a, b), close-up axial (c), and coronal (d) CT angiographic images depict small gas bubbles within a ruptured aneurysm sac (arrows in a, b, and d), as well as disruption of the anterior aortic wall, with a faint fistulous tract between the thrombosed portion of the aortic aneurysm and the third portion of the duodenum (arrowhead in b and c). The differential diagnosis included aortoduodenal fistula and mycotic aneurysm. The patient died of a massive gastrointestinal hemorrhage the next day.

 

Figure 13C
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  		Figure 13c.  Aortoduodenal fistula in a 71-year-old woman with a known abdominal aortic aneurysm, abdominal pain, and a guaiac-positive stool test. Axial (a, b), close-up axial (c), and coronal (d) CT angiographic images depict small gas bubbles within a ruptured aneurysm sac (arrows in a, b, and d), as well as disruption of the anterior aortic wall, with a faint fistulous tract between the thrombosed portion of the aortic aneurysm and the third portion of the duodenum (arrowhead in b and c). The differential diagnosis included aortoduodenal fistula and mycotic aneurysm. The patient died of a massive gastrointestinal hemorrhage the next day.

 

Figure 13D
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  		Figure 13d.  Aortoduodenal fistula in a 71-year-old woman with a known abdominal aortic aneurysm, abdominal pain, and a guaiac-positive stool test. Axial (a, b), close-up axial (c), and coronal (d) CT angiographic images depict small gas bubbles within a ruptured aneurysm sac (arrows in a, b, and d), as well as disruption of the anterior aortic wall, with a faint fistulous tract between the thrombosed portion of the aortic aneurysm and the third portion of the duodenum (arrowhead in b and c). The differential diagnosis included aortoduodenal fistula and mycotic aneurysm. The patient died of a massive gastrointestinal hemorrhage the next day.

 

Figure 14A
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  		Figure 14a.  Inflammatory aneurysm in a 50-year-old man with a known abdominal aortic aneurysm, abdominal pain, and an elevated erythrocyte sedimentation rate. Axial contrast-enhanced CT images (a at a level higher than b) demonstrate a large abdominal aortic aneurysm with circumferential perianeurysmal fibrosis and inflammation (arrow).

 

Figure 14B
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  		Figure 14b.  Inflammatory aneurysm in a 50-year-old man with a known abdominal aortic aneurysm, abdominal pain, and an elevated erythrocyte sedimentation rate. Axial contrast-enhanced CT images (a at a level higher than b) demonstrate a large abdominal aortic aneurysm with circumferential perianeurysmal fibrosis and inflammation (arrow).

 




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