Left Pleural Hemorrhagic Effusion: A Presenting Sign of Thoracic Aortic Dissecting Aneurysm

doi:10.1378/chest.106.2.636

Chest

Volume 106, Issue 2, August 1994, Pages 636-638

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Left hemorrhagic pleural effusion was the presenting sign of painless aortic dissecting aneurysm in two elderly hypertensive patients. Computed tomography (CT) of the chest revealed the aneurysmal dilatation of the thoracic aorta and an intimal flap connecting its descending part with the left pleural space. The patients were treated conservatively with blood transfusions and drugs directed to control blood pressure. The first reported 71-year-old patient remains in stable condition for 16 months without evidence of recurrent active aortic dissection. The second 85-year-old patient remained in stable condition for 28 days, but finally had a second fatal episode of dissection into the left pleural space. The differential diagnosis of nontraumatic left hemorrhagic pleural effusion in an elderly hypertensive patient should include dissecting aneurysm of the descending thoracic aorta and CT of the chest should be performed as the next preferable diagnostic procedure.

Section snippets

Case 1

A 70-year-old man with a history of hypertension treated with nifedipine, mild COPD, and chronic renal failure was admitted to the hospital in December 1991 with a 3-day duration of dyspnea. On examination, the patient was a slightly overweight, pale, elderly man in no apparent distress. The pulse rate was 88 beats per minute; respiration rate, 26 breaths per minute; and blood pressure, 160/90 mm Hg. Increased dullness to percussion and decreased breath sounds were apparent over the base of the

Discussion

Our two patients had a left pleural hemorrhagic effusion as a rare presentation of dissecting aortic aneurysm. They had no evidence of congestive heart failure or severe COPD, but suffered from dyspnea as a main complaint. Dissection of the descending thoracic aorta communicating with the left pleural space was suspected when a hemorrhagic aspirate was obtained and a CT scan of the chest confirmed that diagnosis. Our two patients were treated conservatively by blood transfusion and

References (12)

SlaterEE et al.
The clinical recognition of dissection aortic aneurysm
Am J Med
(1976)
TreasureT. et al.
Investigation of suspected dissection of the thoracic aorta
Lancet
(1991)
MillerPF et al.
Aging and pain perception in ischemic heart disease
Am Heart J
(1990)
CookeSF et al.
Progress in the diagnosis and management of aortic dissection
Mayo Clin Proc
(1986)
HirstAE et al.
Dissecting aneurysm of the aorta: a review of 505 cases
Medicine (Baltimore)
(1958)
GlowerDD et al.
Management and long-term outcome of aortic dissection
Ann Surg
(1991)

There are more references available in the full text version of this article.

Cited by (27)

Post-mortem computed tomography and post-mortem magnetic resonance imaging as triage tools for autopsy – A case report
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Citation Excerpt :
Rupture of the aorta due to dissection is a rare event that mostly results in death. The literature regarding this event is sparse (few case reports), but mainly refers to type B dissection and consequent involvement of the left hemithorax [9,10]. Most patients suffering aortic dissection die due to multi-organ failure, resulting from insufficient perfusion.
Pericardial tear as a consequence of cardiopulmonary resuscitation (CPR) involving chest compression: A report of two postmortem cases of acute type A aortic dissection with hemopericardium
2014, Legal Medicine
Citation Excerpt :
A hemothorax also occurs in some AoD cases, and most cases are considered to be the result of a rupture in the descending aorta [7–9]. Other cases have had an unusual presentation of a left pleural effusion complicated by AoD [10,11] or a congenital pericardial defect with ruptured type A AoD [12–15]. Complications of cardiopulmonary resuscitation (CPR) are frequently encountered in the field of forensics [16,17].
We present two cases of a pericardial tear as a consequence of cardiopulmonary resuscitation involving chest compressions in fatal acute type A aortic dissection (AoD) with hemopericardium. For each case, postmortem computed tomography revealed a hematoma in the false lumen of the ascending aorta with a slight hemopericardium and a large left hemothorax, as well as focal pericardial dimpling and discontinuity around the left ventricle. At autopsy, we confirmed a convex lens-shape gaping pericardial tear at the left posterolateral site of the pericardium and a massive volume of bloody fluid in the left thoracic cavity. It has been hypothesized that the pericardium ruptured due to chest compressions during resuscitation in these cases of acute type A AoD with hemopericardium and that intrapericardial blood leakage through the pericardial tear resulted in a hemothorax.
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease
2010, Journal of the American College of Cardiology
Citation Excerpt :
Of clinical note, up to 50% of dissection-related neurologic symptoms may be transient and as many as one-third of patients with neurologic symptoms present without complaints of chest pain, complicating appropriate diagnosis and treatment (253,255,256,262,269–271). Pleural effusion, the most common pulmonary complication of acute AoD, is noted in 16% of cases at presentation (37); whereas large effusions may result from leaking of blood from the aorta into the pleural space, small effusions are typically a nonhemorrhagic exudate believed to be inflammatory in origin (37,272–275). Other pulmonary complications of acute AoD include dissection-related compression of the pulmonary artery and development of an aortopulmonary fistula, either of which may present with dyspnea as a prominent symptom (276–278).
The Use of Echocardiographic Contrast-Enhanced Rapid Diagnosis of Ruptured Aortic Dissection with Transthoracic Echocardiography
2007, Journal of the American Society of Echocardiography
Citation Excerpt :
Furthermore, our case report shows how intravenous ultrasound contrast can be useful in the diagnosis of aortic rupture. Pleural effusion is a common finding in aortic dissection, especially Stanford type B, and may be the dissection’s only presenting feature.9,10 Typically, pleural effusion becomes evident 4.5 ± 3.9 with a range of 1 to 15 days after presentation.11
Aortic dissection is an uncommon but often fatal condition if not promptly managed. Although the diagnosis is generally established by transesophageal echocardiography, contrast computed tomography, or magnetic resonance imaging, clinical and radiologic assessment and transthoracic echocardiography represent the first-line approach to patients with sudden onset of severe tearing thoracic pain. Although surface image quality and spatial resolution may prevent detection of an intimal flap, the presence of aortic dilatation, aortic regurgitation, segmental ventricular dysfunction, and effusions indicate a greater likelihood of a lethal outcome and hasten urgent management. Because an aortic rupture may be the cause of an effusion, rapid diagnosis is crucial. We report an unusual case of Stanford type B aortic dissection with rupture that was diagnosed by transthoracic echocardiography and confirmed with an ultrasound contrast injection.
Left hemothorax caused by aortic dissection
2007, Revue de Pneumologie Clinique
Les hémothorax sont, dans la majorité des cas, secondaires à un traumatisme, à une technique invasive thoracique ou à certaines pathologies pulmonaires ou pleurales. Un hémothorax secondaire à une dissection aortique est rare.
Nous rapportons l’observation d’un patient âgé de 69 ans, tabagique, hypertendu, ayant été hospitalisé pour l’exploration d’une opacité pleurale gauche avec élargissement médiastinal. La ponction pleurale a ramené un liquide hémorragique. La tomodensitométrie thoracique a conclu à une dissection aortique type B de Stanford. Le patient a été mis sous antihypertenseurs, avec un recul actuel de 16 mois.
Une dissection aortique doit être envisagée devant un hémothorax, surtout s’il survient chez un sujet hypertendu présentant une anomalie de l’arc aortique ou un élargissement du médiastin à la radiographie thoracique. La tomodensitométrie permet généralement de poser le diagnostic et le traitement, médical ou chirurgical, dépendra du siège de la lésion et de la gravité du tableau clinique.
La dissection de l’aorte est une étiologie d’hémothorax qu’il ne faut pas méconnaître, surtout lorsque le patient présente un terrain favorable ou une anomalie radiologique suggestive.
Hemothorax is generally secondary to trauma, invasive thoracic surgery or specific lung of pleural disease. Hemothorax secondary to aortic dissection is rare.
We report a case in a 69-year-old man with a history of smo-king and hypertension. The patient was referred for exploration of a left pleural opacity with mediastinal widening. Pleural puncture produced a hemorrhagic fluid. The thoracic scan led to the diagnosis of Stanford type B aortic dissection. The patient was given antihypertensive treatment and now has a sixteen month follow-up.
Aortic dissection can give rise to hemothorax, especially in a hypertensive subject with an anomalous aortic arch or mediastinal widening on the chest X-ray. Computed tomography generally gives the diagnosis. Treatment may be medical or surgical, depending on the site of the lesion and the severity of the clinical presentation.
Aortic dissection is a cause of hemothorax, particularly in patients with favorable conditions or a suggestive radiological anomaly.
Painless right hemorrhagic pleural effusions as presentation sign of aortic dissecting aneurysm [1]
2005, American Journal of Medicine

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Chest

Selected ReportsLeft Pleural Hemorrhagic Effusion: A Presenting Sign of Thoracic Aortic Dissecting Aneurysm

Section snippets

Case 1

Discussion

Am J Med

Lancet

Am Heart J

Progress in the diagnosis and management of aortic dissection

Mayo Clin Proc

Dissecting aneurysm of the aorta: a review of 505 cases

Medicine (Baltimore)

Management and long-term outcome of aortic dissection

Ann Surg

Selected Reports
Left Pleural Hemorrhagic Effusion: A Presenting Sign of Thoracic Aortic Dissecting Aneurysm