Point-of-care ultrasound diagnosis of thoracic aortic aneurysm in a patient presenting with hemoptysis

Abstract

IntroductionHemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions.Case ReportA 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day.DiscussionThe vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Hemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions. A 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day. The vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Figure 1. POC-US of suprasternal notch view showed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma (arrow). Figure 2. CTA of the aorta revealed proximal ruptured thoracic aortic aneurysm with adjacent hematoma.•Sun D, Mehta S. Hemoptysis caused by erosion of thoracic aortic aneurysm. CMAJ. 2010; 182:186.•Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg 1985; 89:50.•Nair G, Jindal S, Chandra A, Swami S, Garg P. Haemoptysis - a rare presentation of aortic aneurysm. Lung India. 2008;25:20.