CT - CT aortic angiography after onset of chest pain
Axial C+ arterial MIP
Coronal C+ arterial MIP
Sagittal C+ arterial MIP
New onset large mediastinal hematoma with compression of the left atrium and inferior pulmonary veins, right hemothorax and mild hemopericardium. Because of the known severe descending aortic atherosclerosis, an aortic false aneurysm (penetrating atherosclerotic ulcer) with intra-mural hematoma and aortic rupture was initially considered, despite the appearance of the irregular atheromatous plaque itself being unchanged.
Further questioning of the clinical team revealed that the patient had endobronchial ultrasound-guided (EBUS) biopsy of mediastinal lymph nodes 4 days prior. She had slight central chest pain since then, but following an intense cough, her pain intensified to 10/10.
Upon revising the images, an arterial pooling of contrast is seen in the immediate subcarinal area, with bronchial arteries coursing nearby. Delayed images were not available to confirm if there was blushing which would help differentiate between active extravasation and a pseudoaneurysm, although the morphology of the contrast pooling suggests the former hypothesis.