Presentation
Worsening chest pain.
Patient Data
Tortuous thoracic aorta. Contained, oval outpouching of contrast along the right lateral aspect of the proximal ascending aorta communicating with the true lumen through a large opening, which extends inferiorly to the level of the sinus of Valsalva. Relatively subtle, higher-attenuation of the fluid rim surrounding and slightly above this aneursym sac.
Additional, similarly configured contained outpouching along the inferior left lateral aspect of the aortic arch, communicating with the true lumen through a large opening. Atherosclerosis of the right and left main coronary arteries which arise from the true lumen.
Large pericardial effusion with fluid tracking cranially into the pericardial recesses. Small left pleural effusion and trace right pleural effusion.
Ascending aorta has been replaced by a tube graft. High density material about the proximal and distal aspects of the graft represent postoperative material rather than extravasation/leak from the graft. No findings of complication. Resolved pericardial effusion. Increasing medium to large sized left pleural effusion.
Case Discussion
An unusual case of two large pseudoaneurysms of the ascending aorta. A large pleural effusion is highly concerning for rupture of the pseudoaneurysm, likely from the caudal one given the thin rim of higher attenuation fluid surrounding the aneurysm sac and lack of significant fluid/stranding about the upper aneurysm within the superior mediastinum. The presence of pleural effusion is often a reactive finding and does not necessarily indicate blood products within the pleural space, as differing densities of the fluid can be appreciated on the original examination. This patient was successfully managed with urgent graft replacement of the ascending aorta.
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