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title: "Thoracic Aortic Aneurysm"
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docid: "3c637054-d97c-4ae6-bc0c-ceac5f4a4f1f"
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authors:
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- key: "b00d2bdb-66e1-41ed-90b4-c52904f4d598"
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value: "Seth Kligerman, MD, MS"
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breadcrumbs:
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-
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name: "Cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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treeNodeId: "5c92cf4f-e9d5-4059-9c13-22255c51c121"
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name: "Aorta"
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slug: "aorta"
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treeNodeId: "4d206a6b-1a82-467c-9199-0df25ab749d7"
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-
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name: "Thoracic Aortic Aneurysm"
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slug: "thoracic-aortic-aneurysm"
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treeNodeId: null
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category: "Cardiac"
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documentVersionId: "2f92fee6-c59f-47c3-b87c-fcc3874adbf9"
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imageCount: 48
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lastUpdated: "02/10/25"
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pageDescription: "Thoracic Aortic Aneurysm"
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pageKeywords: "Cardiac, Diagnosis, Aorta, Thoracic Aortic Aneurysm"
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pageTitle: "Thoracic Aortic Aneurysm | STATdx"
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enhancedTitle: "Thoracic Aortic Aneurysm"
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type: "DX"
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references: true
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breadcrumbs:
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- "Cardiac"
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- "Diagnosis"
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||||
- "Aorta"
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- "Thoracic Aortic Aneurysm"
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---
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# KEY FACTS
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- ## Terminology
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- Aortic dilatation > 50% of normal diameter
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- Etiology
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- Heritable syndromes with multisystem features
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- Heritable but nonsyndromic
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- Congenital [more common in aortic aneurysm (AA) in younger patients]
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- Degenerative [more common in descending thoracic aorta (DTA) in older patients]
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- Inflammatory; infectious
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- ## Imaging
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- Radiography
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- Ascending AA: Curvilinear density along right aspect of mediastinum but often absent
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- Aortic arch aneurysm: Enlarged/obscured aortic arch
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- DTA aneurysm: Focal or diffuse abnormality of left paraaortic interface
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- Peripheral curvilinear calcification
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- Rupture: Wide mediastinum, left pleural effusion
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- CT
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- High spatial resolution allows for precise measurements
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- AA often has no or limited atherosclerotic disease and more common in heritable and congenital cases
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- DTA aneurysm commonly degenerative and associated with calcified and noncalcified atherosclerotic disease, often with mural thrombus
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- MR
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- Good for aortic measurements
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- Excellent for assessment of aortic wall
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- Evaluation of aortic valve and cardiac function
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- PET/CT can help diagnose and monitor vasculitis
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- ## Pathology
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- Variable depending on cause
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- ## Clinical Issues
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- Repair of AA or DTA if ≥ 5.5 cm or smaller if rapid growth or symptomatic
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- Repair criteria different based on syndromic and nonsyndromic heritable aneurysms or bicuspid aortic valve
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- ## Diagnostic Checklist
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- Consider ruptured aneurysm: Acute chest pain, wide mediastinum, and pleural effusion on radiography
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- Normal radiography does not exclude aneurysm or dissection; cross-sectional imaging for diagnosis
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# TERMINOLOGY
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- ## Abbreviations
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- Thoracic aortic aneurysm (TAA)
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- ## Definitions
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- Aortic dilatation**> 50% of normal diameter**
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- > 2 standard deviations (SDs) above mean
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- Per 2022 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for Diagnosis and Management of Aortic Disease
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- "Aneurysm" should be used when ascending aorta (AA) measures ≥ 4.5 cm due to significant increased risk of dissection
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- For descending thoracic aorta (DTA), aneurysm would be classified at 1.5x mean diameter, which is ~ 4 cm
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- "Dilated" should be used when AA diameter < 4.5 cm but > 2 SDs above mean for age, sex, and body surface area (BSA)
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- Aneurysm definition is variable as "normal" size varies depending on age, sex, and associated conditions
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- Diameter of aorta increases with age
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- In one study of patients undergoing lung cancer screening, average and SDs of ascending aortic diameter was 3.21 ± 0.38, 3.35 ± 0.37, and 3.46 ± 0.35 for patients in age groups 55-59, 60-64, and 65-74 years, respectively
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- Diameter is larger in men than women
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- Men (wall-to-wall measurement)
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- In 3 large studies, AA mean ranged from 34.1-36 mm
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- In Framingham heart study, 41.9 mm was 2 SDs above mean
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- For DTA [measured at level of main pulmonary artery (PA)] mean diameter was 25.8 ± 3.0 mm
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- Women
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- In 3 large studies, AA mean ranged from 31.9-33.5 mm
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- In Framingham heart study, 38.9 mm was 2 SDs above mean
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- For DTA (measured at level of main PA) mean diameter was 23.1 ± 2.6 mm
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- Diameter will be larger if measuring entire wall-to-wall diameter vs. measuring only intraluminal area (IA)
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- Men
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- In one large study, wall-to-wall diameter > 2 SDs: 40.2, 42.9, and 45.0 mm in age groups 20-40, 41-60, > 60 years, respectively
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- IA diameter > 2 SDs: 37.8, 40.5, and 42.6 mm in age groups 20-40, 41-60, > 60 years, respectively
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- Women
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- Wall-to-wall diameter > 2 SDs: 38, 40.7, and 42.4 mm for women in age groups 20-40, 41-60, > 60 years, respectively
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- > 2 SDs for IA diameter: 35.6, 38.3, and 40 mm in age groups 20-40, 41-60, > 60 years, respectively
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- Diameter is larger if measuring on axial image vs. MPR to get true transverse diameter
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- In one study
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- Men: Mean diameter decreases from 3.48 ± 0.36 to 3.41 ± 0.37 between axial and MPR measurements, respectively
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- Women: Mean diameter decreases from 3.27 ± 0.36 to 3.22 ± 0.38 between axial and MPR measurements, respectively
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- Diameter increases with increasing BSA
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- e.g., in Framingham Heart Study for men > 65 years of age, mean AA diameter increased from 35.3 to 36.3 to 38.3 with BSA < 1.9, 1.9-2.09, and ≥ 2.1, respectively
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- Similarly, for women 45-54 years of age, mean AA diameter increased from 29.7 to 31.5 to 32.5 with BSA < 1.9, 1.9-2.09, and ≥ 2.1, respectively
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- Similar trends were seen across nearly all age groups and BSAs
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- ## Causes of Thoracic Aortic Aneurysms
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- Heritable syndromes with multisystem features
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- ~ 20% of TAAs due to genetic or heritable condition
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- Marfan syndrome
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- Aortic root dilation and type A dissection are major causes of morbidity and mortality in these patients
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- Loeys-Dietz syndrome
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- Vascular Ehlers-Danlos syndrome
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- Smooth muscle dysfunction syndrome
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- Others
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- Heritable but nonsyndromic
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- Mutations in *ACTA2*, *MYH11*, *PRKG1*, *MYLK*, and others
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- Familial TAAs without identified pathogenic genetic variant known to cause heritable syndrome
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- Congenital (more common in AA in younger patients)
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- Bicuspid aortic valve (BAV)
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- Turner syndrome
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- Coarctation of aorta
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- Complex congenital heart disease
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- Degenerative (more common in DTA in older patients)
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- Atherosclerosis
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- Hypertension
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- Inflammatory
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- Vasculitis
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- Giant cell arteritis
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- Takayasu arteritis
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- Behçet disease
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- IgG4-related disease
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- ANCA-related disease
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- Sarcoidosis
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- Infectious (pseudoaneurysm common)
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- Bacterial
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- Fungal
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- Syphilitic
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- Posttraumatic (pseudoaneurysm common)
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# IMAGING
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- ## Radiographic Findings
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- Radiography
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- **May not be visible (frequent)**
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- Contour abnormality along aortic interface
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- Aortic ascending aneurysm
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- Abnormal convexity along superior right cardiomediastinal silhouette in frontal radiograph
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- Fullness of retrosternal space in lateral radiograph
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- Rightward tracheal &/or esophageal deviation
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- Hilum overlay sign (in distal arch and descending aortic aneurysm)
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- Lateralization of left paraaortic interface (in descending aortic aneurysm)
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- Ruptured aneurysm
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- Mediastinal widening compared with prior studies
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- Pleural effusions
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- ## CT Findings
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- Contrast-enhanced CT is excellent tool for aortic assessment
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- ECG-gated preferred for AA assessment
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- Aorta measured using multiplanar reconstructions as axial measurements overestimate size
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- Typical landmarks include sinuses of Valsalva, sinotubular junction, maximum AA (often near level of main PA), distal AA, aortic arch, proximal DTA, mid-DTA, distal DTA near diaphragmatic hiatus
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- Commonly used terms and definitions
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- Aneurysm
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- AA: ≥ 4.5 cm
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- More commonly encountered in younger patients with little degenerative changes to AA, even with sporadic cases
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- DTA: ≥ 4 cm
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- Most common encountered in older patients with prominent atherosclerotic disease
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- Dilation or ectasia
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- AA: ≥ 4cm, < 4.5cm
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- Morphology
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- Fusiform
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- Symmetric dilation of aorta
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- Most common
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- Saccular
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- Asymmetric bulging of aorta
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- Can be seen with both true aneurysm and pseudoaneurysm
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- Often encountered in arch or proximal DTA
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- Annuloaortic ectasia (AAE)
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- Conspicuous dilation of aortic root and AA leading to effacement of sinotubular junction
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- Associated with heritable syndromes
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- Specific patterns and associations
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- Marfan, vascular Ehlers-Danlos, Loeys-Dietz: AAE
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- Marked tortuosity of vertebral arteries in Loeys-Dietz
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- BAV: Variable morphology
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- Root phenotype (20%)
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- BAV with aortic regurgitation: Diffuse dilatation of aorta from root to arch
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- Ascending phenotype (70%)
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- BAV with aortic stenosis: Dilatation in tubular AA most common
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- More common in Sievert type 1 BAV (fused raphe)
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- Extended phenotype
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- Dilation from aortic root through proximal half of aortic arch
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- More common in Sievert type 0 BAV (true bicuspid without fused raphe)
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- Degenerative: Most commonly affects DTA with calcified and noncalcified atherosclerotic disease
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- Often associated with mural thrombus
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- Can be crescentic or circumferential
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- Contrast can invaginate between areas of mural thrombus and can mimic penetrating atherosclerotic ulcer
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- However, contrast does not extend beyond confined of aortic wall with irregular mural thrombus
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- Turner syndrome: Coarctation with aneurysm being less common
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- Vasculitis: Aortic wall thickening with associated areas of aneurysmal dilation and stenosis; aortic wall enhancement may be present
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- Infectious
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- Bacterial and fungal: Saccular aneurysm with paraortic soft tissue stranding, fluid, or mass
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- Often with rapid progression and pseudoaneurysm formation
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- Signs of infection in adjacent structure
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- Enhancement in aortic wall
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- Syphilitic: Calcified ascending aortic aneurysm with circumferential wall thickening; wall can enhance on delayed imaging
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- Rupture: Ill-defined aortic wall with surrounding mediastinal hematoma &/or hemothorax
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- ## MR Findings
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- Similar findings as CT
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- Obtained without use of radiation
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- Similar specific patterns as described above
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- Gated MRA should be performed if possible for root assessment
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- Can measure aorta during different phases of cardiac cycle
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- Aortic measurements will be larger during systole
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- Additional value
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- T2W imaging to assess for wall edema and plaque characterization
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- T1W/T1W+ imaging to assess for wall enhancement and plaque characterization
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- Delayed enhancement: Assess wall fibrosis (not commonly used)
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- 4D flow: Assess aortic flow patterns
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- ## Nuclear Medicine Findings
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- PET/CT
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- Excellent tool for differentiating aortic inflammation or infection from other causes of TAA
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- Helpful in monitoring for active disease
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- ## Imaging Recommendations
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- Best imaging tool
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- CT or MR for evaluation of aneurysm location and size, relationship to major branch vessels, and complications [e.g., dissection, mural thrombus, intramural hematoma (IMH), free rupture]
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- Protocol advice
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- ECG gating for anatomic and functional aortic valve assessment
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- MR angiography can be performed with contrast and noncontrast techniques
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# DIFFERENTIAL DIAGNOSIS
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- ## Tortuosity (Aging) of Aorta
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- Diffuse aortic redundancy
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- May require cross-sectional imaging for assessment
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- ## Mediastinal Mass
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- Radiographic differentiation from neoplasm may be challenging and at times not possible
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- Hilum overlay classic in anterior mediastinal masses
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- Curvilinear calcification typical of vascular lesions
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- ## Pseudoaneurysm
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- Contained rupture of aorta contained by piece of adventitia
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- Extends beyond normal aortic wall
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- Can mimic saccular aneurysm
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- Common after previous aortic surgery, trauma, or infection
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- Can have narrow or wide neck but extends beyond regular confines of aortic wall
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- Often has surrounding inflammatory changes
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- Disruption of intimal calcification with pseudoaneurysm
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- ## Acute Aortic Syndrome
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- Aortic dissection (AD), IMH, and penetrating aortic ulcer (PAU) often occur in setting of TAA
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- Acute aortic syndrome (AAS) is often symptomatic, whereas TAA is often asymptomatic unless ruptured or causing compression
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- During acute stage, imaging findings of AAS can mimic certain findings seen with TAA
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- Mural thrombus in TAA can mimic IMH in some instances
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- In IMH, blood in wall of aorta will often have smooth crescentic shape but can be circumferential
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- Contour is more irregular with mural thrombus
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- Intramural blood in IMH is often more dense that layering mural thrombus in TAA
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- Best seen on noncontrast imaging
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- PAU can be difficult to differentiate from aneurysm with mural thrombus
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- PAU extends beyond confines of aortic wall
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- Discontinuity of atherosclerotic calcification often seen
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- Surrounding hematoma may be present
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- Additionally, imaging findings with healed AAS can also mimic findings seen with TAA
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- False lumen of AD can thrombose and mimic aneurysm with mural thrombus
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- Thrombosed false lumen usually has crescentic shape
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- False lumen may be patent elsewhere along aorta
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# PATHOLOGY
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- ## General Features
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- **True aneurysm**: Contains all 3 aortic wall layers
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- **Atherosclerotic aortic aneurysm**
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- Degenerative process, most common (75%)
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- Old age, smoking, hypertension
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- Shape: Fusiform > saccular
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- Location: Most common in DTA
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- **Infectious (mycotic) aneurysm**: Saccular; any location
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- Predisposing causes: IV drug abuse, valvular disease, congenital aortic/cardiac disease, prior aortic/cardiac surgery, adjacent pyogenic infection, immunocompromise
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- Most common pathogens: *Salmonella* spp. and *S.**aureus*
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- Shape: Saccular
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- Often pseudoaneurysms
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- **Cystic medial necrosis**
|
||||
- Degeneration of aortic media with medial necrosis
|
||||
- Degeneration and fragmentation of elastic fibers, loss of smooth muscle cells, and interstitial collections of basophilic-staining ground substance
|
||||
- Most commonly associated with syndromic and nonsyndromic heritable aneurysms
|
||||
- However, also occurs in normal aging and accelerated by hypertension
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- Shape: Fusiform
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||||
- Location: AA most common
|
||||
- ## Gross Pathologic & Surgical Features
|
||||
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||||
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||||
- **Saccular**: Focal, mass-like aortic dilatation
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||||
- May result from remodeling of penetrating aortic ulcer
|
||||
- **Fusiform**: Diffuse, elongated aortic dilatation
|
||||
|
||||
# CLINICAL ISSUES
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||||
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||||
- ## Presentation
|
||||
|
||||
|
||||
- Most common signs/symptoms
|
||||
- Atherosclerotic aortic aneurysm: Asymptomatic (most common), chest pain, compression (hoarseness, dysphagia, atelectasis, superior vena cava syndrome)
|
||||
- Infectious (mycotic) aneurysm: Fever, leukocytosis
|
||||
- Acute chest pain: Rupture, dissection
|
||||
- ## Demographics
|
||||
|
||||
|
||||
- Age
|
||||
- Atherosclerotic aortic aneurysms often free from significant atherosclerotic disease and more common in heritable and congenital cases
|
||||
- Descending TAA more commonly degenerative and associated with calcified and noncalcified atherosclerotic disease
|
||||
- Sex
|
||||
- M > F
|
||||
- Prevalence
|
||||
- Increased from 3.5-7.6 per 100,000 persons between 2002-2014, primarily due to increased imaging
|
||||
- ## Treatment
|
||||
|
||||
|
||||
- Risk reduction: Hypertension control, smoking cessation
|
||||
- Indications for surgical or interventional aortic repair
|
||||
- Sporadic or degenerative aneurysms
|
||||
- **AA**≥ **5.5 cm**
|
||||
- ≥ 5.0 cm reasonable if patient scheduled to undergo repair of trileaflet aortic valve
|
||||
- **Descending aorta**≥ **5.5 cm**; smaller diameter threshold for repair include
|
||||
- Symptomatic aneurysms
|
||||
- Saccular aneurysm morphology
|
||||
- Female
|
||||
- Thoracic endovascular aortic repair (TEVAR) reasonable for patients who do not have syndromic aneurysm
|
||||
- **Rapid growth**
|
||||
- ≥ 0.5 cm in 1 year
|
||||
- ≥ 0 .3 cm a year for 2 consecutive years
|
||||
- Marfan syndrome
|
||||
- Repair of any part of aorta if diameter > 5cm
|
||||
- Repair of aortic root if diameter ≥ 4.5 cm is reasonable if there are high-risk features
|
||||
- Family history of dissection
|
||||
- Rapid growth
|
||||
- Diffuse aortic root and AA dilation
|
||||
- Marked vertebral artery tortuosity
|
||||
- Cross-sectional aortic root area:patient height ratio ≥ 10 cm²/m
|
||||
- Loeys-Dietz syndrome
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||||
- Prophylactic repair of aortic root and AA
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||||
- Size threshold, which ranges ≥ 4 cm to ≥ 5 cm based specific genetic variant, phenotypic features, patient age, aortic growth rates, and family history
|
||||
- Vascular Ehlers-Danlos
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||||
- No specific guidelines due to increased surgical risk from vascular fragility and increased bleeding
|
||||
- Decision should involve multidisciplinary team
|
||||
- Heritable but nonsyndromic
|
||||
- Diameter ≥ 5.0 cm in absence of high-risk features
|
||||
- ≥ 4.5 cm in presence of high-risk features
|
||||
- Family history of dissection at aortic diameter < 5.0 cm
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||||
- Unexplained sudden death at age < 50 years
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||||
- Rapid aortic growth defined as ≥ 0.5 cm in 1 year or ≥ 0.3 cm per year in 2 consecutive years
|
||||
- BAV
|
||||
- Aortic diameter ≥ 5.5 cm
|
||||
- Repair of aortic root if diameter 5-5.4 cm is reasonable if there are high-risk features
|
||||
- Family history of dissection
|
||||
- Growth rate > 0.3 cm per year
|
||||
- Aortic coarctation
|
||||
- Root phenotype with isolated root dilation
|
||||
- Aortic diameter ≥ 4.5 cm at time of aortic valve replacement or repair
|
||||
- Recommend screening of all 1st-degree relatives via echocardiogram
|
||||
- Surgical repair
|
||||
- Open repair: Artificial or biologic grafts
|
||||
- Closed repair: Endovascular stent graft
|
||||
- ## Imaging Follow-Up
|
||||
|
||||
|
||||
- Nonsyndromic: Annual CTA or MRA
|
||||
- Marfan syndrome: Yearly CT/MR if stable; more frequently if > 4.5 cm/growth
|
||||
- Loeys-Dietz: Yearly MRA
|
||||
- Turner syndrome: Every 5-10 years if no risk factors; yearly if abnormalities
|
||||
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||||
# DIAGNOSTIC CHECKLIST
|
||||
|
||||
- ## Consider
|
||||
|
||||
|
||||
- Ruptured aneurysm in patients with acute chest pain, wide mediastinum, and pleural effusion on radiography
|
||||
- Normal radiography does not exclude aneurysm or dissection
|
||||
- Cross-sectional imaging is used for diagnosis
|
||||
- ## Reporting Tips
|
||||
|
||||
|
||||
- AAE (blunt sinotubular junction) suggests Marfan syndrome; affects surgical procedure
|
||||
- Assess coronary arteries and great vessels in cases with associated dissection
|
||||
|
||||
baa5b128-9459-450c-a064-f49badc6d92f
|
||||
|
||||
## References
|
||||
|
||||
# Selected References
|
||||
|
||||
1. [Rodríguez-Palomares JF et al: Mechanisms of aortic dilation in patients with bicuspid aortic valve: JACC state-of-the-art review. J Am Coll Cardiol. 82(5):448-64, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37495282%5Bpmid%5D)
|
||||
1. [Isselbacher EM et al: 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 146(24):e334-482, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36322642%5Bpmid%5D)
|
||||
1. [Wang J et al: Aortic dilatation in patients with bicuspid aortic valve. Front Physiol. 12:615175, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34295254%5Bpmid%5D)
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||||
1. [Kallianos KG et al: Imaging thoracic aortic aneurysm. Radiol Clin North Am. 58(4):721-31, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32471540%5Bpmid%5D)
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||||
1. [Rooprai J et al: Thoracic aortic aneurysm growth in bicuspid aortic valve patients: role of aortic stiffness and pulsatile hemodynamics. J Am Heart Assoc. 8(8):e010885, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30966855%5Bpmid%5D)
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||||
1. [McComb BL et al: Normative reference values of thoracic aortic diameter in American College of Radiology Imaging Network (ACRIN 6654) arm of National Lung Screening Trial. Clin Imaging. 40(5):936-43, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27203287%5Bpmid%5D)
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||||
1. [Erbel R et al: 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 35(41):2873-926, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25173340%5Bpmid%5D)
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||||
1. [Goldfinger JZ et al: Thoracic aortic aneurysm and dissection. J Am Coll Cardiol. 64(16):1725-39, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25323262%5Bpmid%5D)
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||||
1. [Rogers IS et al: Distribution, determinants, and normal reference values of thoracic and abdominal aortic diameters by computed tomography (from the Framingham Heart Study). Am J Cardiol. 111(10):1510-6, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23497775%5Bpmid%5D)
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||||
1. [Mao SS et al: Normal thoracic aorta diameter on cardiac computed tomography in healthy asymptomatic adults: impact of age and gender. Acad Radiol. 15(7):827-34, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18572117%5Bpmid%5D)
|
||||
1. [Atar E et al: MR angiography for abdominal and thoracic aortic aneurysms: assessment before endovascular repair in patients with impaired renal function. AJR Am J Roentgenol. 186(2):386-93, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16423943%5Bpmid%5D)
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||||
1. [Isselbacher EM et al: Thoracic and abdominal aortic aneurysms. Circulation. 111(6):816-28, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15710776%5Bpmid%5D)
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||||
1. [Hager A et al: Diameters of the thoracic aorta throughout life as measured with helical computed tomography. J Thorac Cardiovasc Surg. 123(6):1060-6, 2002](http://www.ncbi.nlm.nih.gov/pubmed/?term=12063451%5Bpmid%5D)
|
||||
1. [Guo D et al: Familial thoracic aortic aneurysms and dissections: genetic heterogeneity with a major locus mapping to 5q13-14. Circulation. 103(20):2461-8, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11369686%5Bpmid%5D)
|
||||
1. [LePage MA et al: Aortic dissection: CT features that distinguish true lumen from false lumen. AJR 177:207-11, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11418429%5Bpmid%5D)
|
||||
1. [Posniak HV et al: CT of thoracic aortic aneurysms. Radiographics 10:839-55, 1990](http://www.ncbi.nlm.nih.gov/pubmed/?term=2217974%5Bpmid%5D)
|
||||
1. [Feigl D et al: Mycotic aneurysms of the aortic root. A pathologic study of 20 cases. Chest. 90(4):553-7, 1986](http://www.ncbi.nlm.nih.gov/pubmed/?term=3757565%5Bpmid%5D)
|
||||
|
||||
|
||||
## Images
|
||||
|
||||
|
||||
### Selected Images
|
||||
|
||||
|
||||
*PA radiograph in a 73-year-old man with a history of bicuspid valve status post repair <img src='img/arrows/CC.png'/> shows abnormal right-sided convexity along the superior cardiomediastinal silhouette <img src='img/arrows/CO.png'/>, suggestive of an ascending aortic (AA) aneurysm. In this case, atherosclerotic calcifications allow for partial visualization of the AA.*
|
||||
|
||||
|
||||
*PA radiograph in a 73-year-old man with a history of bicuspid valve status post repair <img src='img/arrows/CC.png'/> shows abnormal right-sided convexity along the superior cardiomediastinal silhouette <img src='img/arrows/CO.png'/>, suggestive of an ascending aortic (AA) aneurysm. In this case, atherosclerotic calcifications allow for partial visualization of the AA.*
|
||||
|
||||
|
||||
*Coronal CECT MIP in the same patient shows the AA atherosclerosis <img src='img/arrows/CO.png'/>. The AA is aneurysmal with a maximum diameter of 5 cm.*
|
||||
|
||||
|
||||
*Lateral radiograph shows a prosthetic aortic valve <img src='img/arrows/CC.png'/> with surrounding calcification of the aortic root and AA <img src='img/arrows/CO.png'/>. A portion of the more superior AA can be partially visualized due to atherosclerosis and adjacent surgical clips from prior aortotomy <img src='img/arrows/CS.png'/>.*
|
||||
|
||||
|
||||
*Sagittal CECT MIP shows the contours of the AA in related to the sternum and other mediastinal structures. While the AA is aneurysmal with a maximum transverse diameter of 5 cm, the aortic arch and descending thoracic aorta (DTA) are normal in size.*
|
||||
|
||||
|
||||
*Coronal oblique arterial-phase CECT in a 38-year-old with annuloaortic ectasia shows balloon-like AA dilation and effacement of the sinotubular junction. There is rapid tapering of the AA in its midportion. Subsequent work-up diagnosed Marfan syndrome.*
|
||||
|
||||
|
||||
*Coned down 3-chamber echocardiogram in a 36-year-old with Marfan syndrome shows balloon-like dilation of the AA <img src='img/arrows/CO.png'/> above the aortic valve <img src='img/arrows/CC.png'/>. During diastole, there is severe aortic regurgitation <img src='img/arrows/WO.png'/> with flow paralleling adjacent mitral inflow <img src='img/arrows/WC.png'/>.*
|
||||
|
||||
|
||||
*Axial CECT images from the years 2004, 2009, 2015, and 2022 are shown. The AA grew from 4.1 cm to 4.3 cm to 4.5 cm to 5.4 cm, respectively. Similarly, the DTA grew from 2.7 cm to 3 cm to 3.4 cm to 4.2 cm.*
|
||||
|
||||
|
||||
*Parasagittal (left) and coronal oblique (right) images through the aorta in a 79-year-old show diffuse fusiform atherosclerotic aneurysm of the DTA with extensive layering mural thrombus with areas of calcification due to degenerative changes. The maximum aortic diameter was 6.8 x 6.3 cm. The AA is normal.*
|
||||
|
||||
|
||||
*Oblique sagittal chest CECT in the same patient shows 2 saccular aneurysms <img src='img/arrows/CS.png'/> with rather extensive atherosclerotic changes of the thoracic aorta.*
|
||||
|
||||
|
||||
*4D flow MR in a patient with a Sievert type 1 bicuspid aortic valve and aortic regurgitation shows vortical flow in the aneurysmal AA <img src='img/arrows/WO.png'/>. The entire AA is enlarged.*
|
||||
|
||||
|
||||
*Coronal 5-mm MIP (left) shows circumferential thickening of the AA, which is irregularly dilated to 4.8 cm, not including the wall thickening <img src='img/arrows/CS.png'/>. Sagittal image (right) shows the AA wall thickening <img src='img/arrows/CO.png'/> as well as areas of wall thickening and mild stenosis in the abdominal aorta <img src='img/arrows/CC.png'/>.*
|
||||
|
||||
|
||||
*Axial images from a CTA (left) and PET/CT (right) show intense FDG uptake in the wall of the AA <img src='img/arrows/CS.png'/>. The patient was diagnosed with large vessel vasculitis.*
|
||||
|
||||
|
||||
*AP chest x-ray in a 58-year-old man admitted for deteriorating mental status over 2 months shows prominence of aortic contour <img src='img/arrows/CO.png'/>. It was unclear if this was related to tortuosity or aneurysm.*
|
||||
|
||||
|
||||
*Subsequent CTA shows circumferential wall thickening and aneurysmal dilation of the AA <img src='img/arrows/CO.png'/> measuring 5 cm. Wall thickening extends into the DTA <img src='img/arrows/CC.png'/> but is more mild without dilation. Thickening extends around the ostia of the arch vessels with severe stenosis or the left common carotid artery <img src='img/arrows/CS.png'/>.*
|
||||
|
||||
|
||||
*Sagittal T1W (L), T1W+ (R), and axial T1W+ (inset) spine MR images show diffuse aortic wall enhancement <img src='img/arrows/CC.png'/>. CFS-VDRL was 1:1024, diagnosing neurosyphilis. Aorta has a typical appearance for syphilitic aortitis.*
|
||||
|
||||
|
||||
*Coronal (L) and sagittal oblique (center) images show a penetrating atherosclerotic ulcer (PAU) with hematoma <img src='img/arrows/CC.png'/> extending beyond the aorta wall <img src='img/arrows/BC.png'/>. Adjacent intimal calcification <img src='img/arrows/CO.png'/> is absent in PAU region. Six years later (R), PAU <img src='img/arrows/WC.png'/> has increased in size, representing a pseudoaneurysm.*
|
||||
|
||||
|
||||
*Axial CT in a 74-year-old man with chest pain shows a large volume of mediastinal hematoma <img src='img/arrows/CC.png'/> compressing the left atrium. Hemothorax <img src='img/arrows/CO.png'/> is also present. The DTA is aneurysmal with calcified and noncalcified atherosclerotic disease.*
|
||||
|
||||
|
||||
*Image more inferiorly in the same patient shows mediastinal hematoma <img src='img/arrows/CC.png'/> and large right hemothorax <img src='img/arrows/CO.png'/>. The DTA is aneurysmal with atherosclerotic disease and mural thrombus <img src='img/arrows/CS.png'/>. Focal rupture of the DTA in this region was confirmed on catheterization.*
|
||||
|
||||
|
||||
*Aortic root images in a patient with Marfan syndrome and AA graft repair show aneurysmal dilation of the coronary artery button grafts (BGs) <img src='img/arrows/CC.png'/>, which have increased in size between the years 2004 and 2020. The BGs are from the native aorta and thus susceptible to aneurysm formation.*
|
||||
|
||||
|
||||
*Axial (left) and sagittal oblique (right) CECT images of the thoracic aorta in a 73-year-old show extensive fusiform aneurysmal dilation of the DTA measuring up to 5.3 cm with diffuse layering mural thrombus <img src='img/arrows/CC.png'/>.*
|
||||
|
||||
|
||||
*PA radiograph in a patient with severe emphysema and small left effusion shows a large mass in the superior mediastinum <img src='img/arrows/CO.png'/> displacing the trachea <img src='img/arrows/CS.png'/> and esophagus <img src='img/arrows/CC.png'/> rightward. The location and rounded appearance could be due to an aneurysm.*
|
||||
|
||||
|
||||
*Coronal CTA in the same patient shows a large fusiform aneurysm of the proximal DTA <img src='img/arrows/CO.png'/> displacing the esophagus <img src='img/arrows/CC.png'/> rightward.*
|
||||
|
||||
|
||||
### Additional Images
|
||||
|
||||
|
||||
*Sagittal CTA shows a fusiform aneurysm of the descending aorta with a large amount of eccentric anterior endoluminal thrombus <img src='img/arrows/BS.png'/> and posterior partially calcified atherosclerotic plaque <img src='img/arrows/WC.png'/>.*
|
||||
|
||||
|
||||
*PA chest radiograph shows a focal left superior mediastinal mass that obscures the superior aspect of the left paraaortic interface <img src='img/arrows/CO.png'/>. AAs may mimic nonvascular mediastinal masses.*
|
||||
|
||||
|
||||
*Frontal aortogram in the same patient shows that the mass represents a polylobular saccular aneurysm <img src='img/arrows/CO.png'/> of the descending aorta. Posttraumatic, infectious, and atherosclerotic aneurysms would be considered in the differential diagnosis.*
|
||||
|
||||
|
||||
*PA radiograph of the chest in a patient with distal DTA aneurysm shows lateral displacement of the left paraaortic interface <img src='img/arrows/CS.png'/>.*
|
||||
|
||||
|
||||
*Lateral chest radiograph in the same patient optimally demonstrates the extensive calcification and dilatation of the ascending aorta <img src='img/arrows/WS.png'/> and a normal descending aorta. The differential diagnosis should also include syphilis (luetic aortitis) and type II hyperlipidemia.*
|
||||
|
||||
|
||||
*PA chest radiograph in a patient with prior trauma shows dilatation of the ascending aorta with a thick rim of curvilinear calcification <img src='img/arrows/CS.png'/>.*
|
||||
|
||||
|
||||
*Lateral radiograph of the chest in the same patient shows dilatation of the distal thoracic aorta <img src='img/arrows/WS.png'/>. While intervention of an ascending AA is often recommended at 5.5 cm (5.0 cm for Marfan syndrome and bicuspid aortic valve), a DTA aneurysm is generally repaired if > 6.5 cm.*
|
||||
|
||||
|
||||
*PA radiograph of the chest in a patient with proximal DTA aneurysm shows an abnormal contour overlying the left hilum <img src='img/arrows/WC.png'/>, the so-called hilum overlay sign.*
|
||||
|
||||
|
||||
*Lateral chest radiograph in the same patient shows marked tortuosity and dilatation of the proximal descending aorta <img src='img/arrows/WS.png'/>. Given the high risk of rupture, all aneurysm exceeding 6.5 cm along the descending thoracic aorta require intervention.*
|
||||
|
||||
|
||||
*Lateral chest radiograph in the same patient shows fullness of the retrosternal clear space. While this findings is nonspecific, it is frequently seen in anterior mediastinal masses, including ascending AAs.*
|
||||
|
||||
|
||||
*Oblique sagittal SSFP MR of the chest in a patient with bicuspid aortic valve and ascending AA shows ascending aortic dilatation <img src='img/arrows/WC.png'/> with preservation of the sinotubular junction <img src='img/arrows/BS.png'/>, a feature that helps differentiate from dilatation due to Marfan syndrome.*
|
||||
|
||||
|
||||
*Oblique contrast-enhanced 3D MRA of the chest was performed in the same patient. Of all sequences, MRA provides the best overview of aneurysm extent, although motion artefact may cause some blurring of the aortic root.*
|
||||
|
||||
|
||||
*PA chest radiograph in a patient with atherosclerotic aneurysm of the ascending aorta shows mediastinal widening. Note that the ascending aorta <img src='img/arrows/WS.png'/> overlies the right hilum, a sign concerning for mediastinal mass. Often, chest radiography is not sensitive enough to detect this abnormality.*
|
||||
|
||||
|
||||
*Axial CTA of the chest in the same patient demonstrates marked dilatation of the ascending aorta <img src='img/arrows/WC.png'/>. Note an atherosclerotic plaque <img src='img/arrows/BS.png'/> along the descending aorta.*
|
||||
|
||||
|
||||
*Axial chest CECT in the same patient shows dilated distal ascending thoracic aorta <img src='img/arrows/WS.png'/>. Note that there is thin intraluminal thrombus <img src='img/arrows/WC.png'/> within the aneurysm. Also note that the pulmonary trunk exhibits a discordant diameter <img src='img/arrows/WO.png'/>.*
|
||||
|
||||
|
||||
*PA chest radiograph in a patient with a saccular aneurysm involving the distal aortic arch shows abnormal convexity with linear calcification <img src='img/arrows/WC.png'/> occupying the AP window. An abnormal mediastinal contour abnormality with peripheral curvilinear calcification is a common radiographic appearance in AA.*
|
||||
|
||||
|
||||
*Axial chest CECT in the same patient shows saccular aneurysm <img src='img/arrows/WC.png'/> involving the aortic arch. Note that the curvilinear calcification surrounding the aneurysm.*
|
||||
|
||||
|
||||
*Coronal chest CECT in the same patient shows fusiform dilatation of the ascending aorta <img src='img/arrows/CS.png'/> with preservation of the sinotubular junction <img src='img/arrows/CC.png'/>. Effacement of the sinotubular junction is frequently seen in the setting of Marfan syndrome.*
|
||||
|
||||
|
||||
*PA chest radiograph in a patient with saccular aneurysm involving the distal ascending aorta and proximal aspect of the aortic arch shows abnormal convexity along the superior cardiomediastinal silhouette <img src='img/arrows/WS.png'/>. Abnormal cardiomediastinal contour abnormalities are always concerning of mediastinal mass, among which aneurysm is a common etiology.*
|
||||
|
||||
|
||||
*Oblique coronal chest CECT in the same patient shows a saccular aneurysm <img src='img/arrows/WS.png'/> involving the distal ascending thoracic aorta and proximal aortic arch. Saccular aneurysms are thought to be related to remodeling of penetrating aortic ulcers undiagnosed during the acute setting.*
|
||||
|
||||
|
||||
*Axial NECT in the same patient reveals a mediastinal hematoma <img src='img/arrows/WC.png'/> with the crescent sign along the DTA <img src='img/arrows/WS.png'/> and left pleural effusion <img src='img/arrows/CO.png'/>. These 3 CT signs are all associated with aortic rupture, which (when present) constitutes an indication of emergent repair.*
|
||||
|
||||
|
||||
*Axial CTA in the same patient shows a DTA aneurysm with an intraluminal thrombus <img src='img/arrows/BS.png'/>, periaortic hematoma <img src='img/arrows/WS.png'/>, mediastinal hematoma <img src='img/arrows/WC.png'/>, and hemothorax <img src='img/arrows/CO.png'/>.*
|
||||
|
||||
|
||||
*AP radiograph of the chest in a patient with a ruptured aneurysm of the aorta shows marked mediastinal widening <img src='img/arrows/BS.png'/> and a moderate-sized left pleural effusion <img src='img/arrows/CO.png'/>.*
|
||||
|
||||
|
||||
*Axial NECT of the chest in the same patient also shows an aneurysm of the proximal DTA associated with high-attenuation pleural fluid as well as a hematocrit-fluid level, indicating rupture and hemothorax <img src='img/arrows/WC.png'/>.*
|
||||
|
||||
|
||||
*Axial CTA of the chest in the same patient additionally shows an aneurysm of the proximal DTA associated with extensive intraluminal thrombus <img src='img/arrows/BS.png'/>.*
|
||||
|
||||
|
||||
*Graphic shows the Crawford classification of aortic aneurysms. Type I affects the descending thoracic and proximal abdominal aorta, type II the entire descending thoracic and abdominal aorta, type III the distal descending and abdominal aorta, and type IV the abdominal aorta.*
|
||||
|
||||
Reference in New Issue
Block a user