Image of the Day 34: Leaking Thoracic Aneurysm Stanford B/ De Bakey III

This Chest X ray image of a 50 Year old gentleman presented with one week history of left sided chest pain that is tearing in nature and radiating to the back. Pain score is 4-5/10 persisting more than 10 minutes, on and off and no known precipitating or relieving factor. He also develop hoarseness of voice. Vitals signs are as follow; BP 140/100, PR 60 b.p.m, RR 18/min, SPO2 100%, general examination reveal a healthy 50 years old gentleman. What would be your differential diagnosis and how would you proceed in confirming the diagnosis.

The Chest X ray image shows widening of mediastinum arising from the central of the mediastinum with well defined border. The homogenous mass seems to be in continuation fashioned, descending behind the heart border. No effusion noted and no significant perihilar lymphadenopathy.

Based on history and chest x ray image, a diagnosis of Dissecting Aortic Aneurysm was made and he was proceed for CT Thorax with contrast.

CT Thorax report shows fusiform dilatation of the aortic arch and descending thoracic aorta with features of leak of arch and thoracic aortic aneurysm..

A Diagnosis of Leaking Thoracic Aneurysm Stanford B/ De Bakey III with Recurrent Laryngeal Nerve Palsy was made.

Image of the Day 1: Wide Mediastinum 1  [link]

Image of the Day 2: Wide Mediastinum 2  [Link]

Image of the Day 1: Wide Mediastinum 1

This is a Chext X Ray finding belongs to a 72 years old male with known case of hypertension, hyperlipidaemia and Ischemic heart disease who presented with left sided chest pain radiating to the back and cough. The Chest X ray findings shows widened mediastinum  with blunting of left costophrenic angle. A Diagnosis of Leaking Dissecting Aortic Aneurysm was made.

At this point, the patient should undergo further radiological evaluation. At this point, contrasted enhanced CT scan should be performed. If patient to undergo operation, therefore, he should be referred to center with vascular surgery facility and have a CT Aortogram.

For doctors working in a district hospital. You should refer this case to a tertiary center. In a meantime, few simple measure should be taken which is 1) Aim systolic BP 90-100, 2) Adequate pain management, 3) Aim for a good urine output > 0.5 cc/kg/hr, 4) palpate for other pulses to ensure no co existing vascular problem, 5) Ensure two large bore IV branulla available, 6) At least 3 pints whole blood already being crossed matched.