Presentation
Shortness of breath, fever, and cough. No surgical history. No trauma.
Patient Data
The mediastinum is widened with a large mainly superior mediastinal non-calcified rounded opacity deviating the trachea to the right side.
Precontrast, a large well-defined rounded mainly superior mediastinal relatively homogenous non-calcified lesion is seen in direct contact and inseparable from the right wall of the aortic arch with an apparent continuity through a narrow-necked wall defect. Eccentric mural hyperdensity is seen along the right lateral wall of the lesion. No wall calcification is noted. Aortic arch mural calcification is noted.
Post-contrast, there is contrast opacification within the described lesion similar to the adjacent aortic arch with a direct connection between them through a narrow-neck representing a large saccular aortic arch aneurysm. Mural thrombus is seen within the aneurysmal sac.
Significant mass-effect is noted on the trachea and esophagus with deviation to the right side. Significant narrowing with incomplete encasement of the trachea and proximal main bronchi.
Possible dissection flap of the most proximal left subclavian artery.
No evidence of aneurysmal dilatation of ascending aorta, aortic arch branches, and descending aorta.
Mild pericardial and bilateral pleural effusions with slightly hyperattenuating fluid representing hemopericardium and hemothorax likely from a leak.
Multiple small consolidative opacities noted in the right lower lobe suggestive of an infectious process. Multiple enlarged subcarinal lymph nodes.
Conclusion:
Appearances are in keeping with a large aortic arch aneurysm with mural thrombus associated with hemopericardium and hemothorax concerning for a leak.
Case Discussion
The patient was seeking medical advice complaining of respiratory symptoms. Chest CT without contrast was done and revealed a right lung consolidation and mediastinal mass. The initial clinical differential diagnosis list did not include an aneurysm. A contrast study was performed a few hours later, which lead to the diagnosis of an aortic arch aneurysm and a possible leak.
Unfortunately, we were informed later by the referring physician that the patient had died a few hours later.
This is likely a false rather than a true aneurysm because the aortic arch itself is not widened and the mural calcifications are not changed in location, i.e. the vessel wall is unchanged in position. Also there is a communicating defect in the right wall of the arch resulting in aneurysm formation.
This case illustrates that an aneurysm should be included in the differential diagnosis of a mediastinal lesion.
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