Cáceres Corner Case – Vignette 238

Dear Friends,

Today I am showing a preoperative PA radiograph in a 72-year-old woman.

Diagnosis:

1. Aortic elongation
2. Aortic dissection
3. Aortic aneurysm
4. Any of the above

What do you see?

Click here to see the answer

Findings: the obvious finding is elongation of the descending aorta. Usually, the diameter of the aorta cannot be determined in the plain film because only the outer wall is outlined by lung air, whereas the medial wall is obscured by the mediastinal structures.

In this case, the tortuous lower aorta projects the medial wall against the lung, allowing to measure the aortic diameter, which is increased (A, red line).
In the other hand, the ascending aorta is not prominent. This a negative finding against aortic elongation, which should involve the whole thoracic aorta.
Therefore, answers 1 and 4 can be excluded. To differentiate between answer 2 and 3 an enhanced CT is needed.

Click here to see more images

Enhanced CT was done. Axial and sagittal images are shown.
What would be your diagnosis?

1. Type B aortic dissection
2. Aneurysm with thrombus
3. Any of the above

Click here to see the answer

Findings: enhanced axial and coronal CT show a normal ascending aorta and a partially thrombosed dilated descending aorta. The fact that the outer wall is calcified (B-C, arrows) indicates that the intima is not displaced and rules out an aortic dissection. The correct diagnosis is aneurysm with partial thrombosis.

Final diagnosis: unsuspected aneurysm of descending aorta

I saw this case three days ago and thought it was a nice demonstration of a negative finding (lack of dilatation of ascending aorta) as mentioned in my last webinar.
As a result of the findings in the plain film, an enhanced CT demonstrated a partially thrombosed aneurysm and the patient was referred for vascular surgery.

This is the last vignette of the season. Since the pandemic is abating, I will resume next week the usual Caceres’ corner cases and Diploma presentations.

3 thoughts on “Cáceres Corner Case – Vignette 238

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