Interact CardioVasc Thorac Surg 2009;8:275-276. doi:10.1510/icvts.2008.188979
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Vascular thoracic |
Mediastinal hematoma: another lethal sign of aortic dissection
Yoshito Inoue*,
Ryuichi Takahashi,
Ichiro Kashima and
Koji Tsutsumi
Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi 321-0974, Japan
Received 22 July 2008;
received in revised form 14 October 2008;
accepted 16 October 2008
*Corresponding author. Tel.: +81-28-626-5500; fax: +81-26-626-5594.
E-mail address: yosito_inoue{at}saimiya.com (Y. Inoue).
 |
Abstract
|
|---|
Acute compressive hemomediastinum due to type A acute aortic dissection in a 70-year-old man caused acute simultaneous obstruction of pulmonary artery and superior vena cava, leading to sudden death, presenting acute progressive bruising of the upper half of the body and subsequent massive hemoptysis. Computed tomography scanning revealed acute severe stenosis of the superior vena cava and right pulmonary artery by mediastinal hematoma. Mediastinal hematoma combined with simultaneous obstruction of pulmonary artery and superior vena cava is a rare entity and should be recognized as one of the acutely fatal signs of type A dissection.
Key Words: Acute aortic dissection; CT findings; Mediastinal hematoma
|
1. Introduction
|
|---|
In type A acute aortic dissection, the leakage of blood from the aorta into the periaortic space is frequently observed, and mediastinal hematoma due to aortic dissection may not always have been reported as one of the lethal signs. However, superior mediastinal obstruction caused by acute aortic dissection concomitant with pulmonary artery compression is a very rare entity carrying a high mortality [1, 2]. We would like to report an uncommon case with simultaneous pulmonary artery and superior vena cava obstruction relevant to mediastinal hematoma in patients with acute type A aortic dissection, presenting hemoptysis and sudden death.
|
2. Case report
|
|---|
A 70-year-old man with a history of systemic hypertension was emergently admitted due to transient chest pain. At the emergency room, the patient was in hemodynamically stable condition; blood pressure was 124/76 mmHg, pulse rate was 64 beats/min and regular sinus rhythm. He was free from any symptoms indicating organ ischemia. A chest X-ray revealed widening of the mediastinum, a cardiothoracic ratio of 58%, and normal lung fields. His abdomen was unremarkable. Laboratory examinations revealed a white blood cell count of 14,000/µl, red blood cell count of 436x104/µl, hemoglobin of 14.4 g/dl, and platelet count of 19.6x104/µl. Arterial gas analysis on 10 l/min oxygen inspiration was pH 7.38, PaCO2 26.6 mmHg, PaO2 288.1 mmHg, SaO2 98.8% and HCO3– 15.6 mmol/l. Ultrasonographic examination revealed no aortic regurgitation and slight pericardial effusion. Computed tomographic scanning revealed type A acute aortic dissection and mediastinal hematoma with severe compression of the right pulmonary artery (Fig. 1) and superior vena cava (Fig. 2) between the aorta and the vertebral body. Emergency operation was readied for the type A acute aortic dissection, but as soon as the patient was intubted in the operating room, acute progressive bruising of the upper half of the body appeared and subsequently massive hemoptysis occurred, followed by hemodynamic collapse and he died within 3 h of presentation.
View larger version (83K):
[in this window]
[in a new window]
|
Fig. 1. Computed tomographic scanning revealed type A acute aortic dissection with perfused false lumen and severe compression of the right pulmonary artery between the dissected aorta and the vertebral body by mediastinal hematoma (asterisk).
|
|
View larger version (100K):
[in this window]
[in a new window]
|
Fig. 2. Computed tomographic scanning demonstrates type A acute aortic dissection and severe compression of the superior vena cava between the expanding ascending dissected aorta and the mediastinal hematoma (asterisk).
|
|
|
3. Comment
|
|---|
Lethal signs of type A acute aortic dissections are mostly related to left heart arterial system, which we routinely check at the emergency room, such as the symptoms or signs of aortic valve insufficiency, occlusion of major arterial vessels and cardiac tamponade and aortic rupture. The presented case lacked critical signs in left heart and arterial system, however, stenosis of pulmonary artery and superior vena cava due to mediastinal hematoma, which might not appear in the check list of the important signs of type A acute dissection, was only observed in venous system. This case indicates that, despite lethal signs of left heart and arterial system, mediastinal hematoma by itself could be an acutely fatal sign of type A acute aortic dissection, potentially causing acute simultaneous compression of the right pulmonary artery and of superior vena cava [3].
As the right pulmonary artery and the ascending aorta share a common adventitia, the perfused false lumen of type A acute aortic dissection with high blood pressure directly compress pulmonary arterial system with lower pressure [4]. And the common adventitia also restricts decompression of mediastinal hematoma around the pulmonary artery, and hematoma spreads along the adventitial planes of the pulmonary arteries out into the lungs [5, 6]. Concomitant hemoptysis without aorto-bronchial fistula indicated acute extension of the mediastinal hematoma along the pulmonary artery. Acute pulmonary arterial compression caused right ventricular failure, and combined with acute superior vena cava obstruction, massive hemoptysis occurred and the patient was strangulated by acute massive airway hyperemia and subsequent hemoptysis [7].
In conclusion, mediastinal hematoma should not be underestimated, especially presenting obstruction of pulmonary artery and superior vena cava caused by thoracic aortic dissection, and should be recognized as one of the acutely fatal signs of type A dissection, and emergency surgical repair should be performed to avoid subsequent catastrophic events.
|
References
|
|---|
- Buja LM, Ali N, Fletcher RD, Roberts W. Stenosis of the right pulmonary artery: a complication of acute dissecting aneurysm of the ascending aorta. Am Heart J 1972;83:89–92.[CrossRef][Medline]
- Erbel R, Oelert H, Meyer J, Puth M, Mohr-Katoly S, Hausmann D, Daniel W, Maffei S, Caruso A, Covino FE, Daletto G, Iacono C, Cotrufo M, Baroni M, Terrazzi M, Fraser A, Taams M, Slavich G, Sutherland G, Roelandt J, Marcaggi X. Effect of medical and surgical therapy on aortic dissection evaluated by transesohpageal echocardiography. Implications for prognosis and therapy. Circulation 1993;87:1604–1615.[Abstract/Free Full Text]
- Masuo M, Takano H, Takamoto S, Tanaka J, Kitamura S, Saito T. Pulmonary artery obstruction caused by thoracic aortic dissection. A case with unique pathological findings. Circ J 2004;68:392–395.[CrossRef][Medline]
- Downey RJ, Austin JH, Pepino P, Dickstein ML, Homma S, Rose EA. Right ventricular obstruction in aortic dissection: a mechanism of hemodynamic collapse. Ann Thorac Surg 1996;61:988–990.[Abstract/Free Full Text]
- Sueyoshi E, Sakamoto I, Uetani M, Matsuoka Y, Suenaga E. CT findings of ruptured intramural hematoma of the aorta extending along the pulmonary artery. Cardiovasc Intervent Radiol 2007;30:321–323.[CrossRef][Medline]
- Castaner E, Andreu M, Gallardo X, Mata FP, Cabezuelo MA, Pallardo Y. CT in nontraumatic acute thoracic aortic diseases: typical and atypical features and complications. Radiographics 2003;23:S93–S110.[Abstract/Free Full Text]
- Schepers-Bok R, Mallens WM. Obstruction of the superior vena cava due to aortic dissection: CT findings of collateral venous flow via the bronchia veins. Eur Radiol 1996;6:753–755.[Medline]
Related Article
-
eComment: Aortic dissection and confusing nomenclature
- Stephen R. Large
Interactive CardioVascular and Thoracic Surgery 2009 8: 276.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
S. R. Large
eComment: Aortic dissection and confusing nomenclature
Interactive CardioVascular and Thoracic Surgery,
February 1, 2009;
8(2):
276 - 276.
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Introduction