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Radiologic-Pathologic Conferences of the University of Alabama at Birmingham

Infective Pseudoaneurysm in a Neonate

¹ Department of Diagnostic Radiology, University of Alabama at Birmingham, 619 S. 19th St., Birmingham, AL 35233.
² Present address: Radiology Associates, One Independence Plaza, Ste. 110, Birmingham, AL 35209.
³ Department of Pediatric Imaging, The Children's Hospital of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Birmingham, AL 35233.
⁴ Present address: Pediatric Medical Imaging Department, Primary Children's Medical Center, 100 N. Medical Dr., Salt Lake City, UT 84113.
⁵ Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL 35233.
⁶ Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233.

Received August 18, 1999; accepted after revision May 12, 2000.

 
Address correspondence to O. Faye-Petersen.

Introduction

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A neurysms in children are rare. Causes include congenital anomalies (coarctation of the aorta or aneurysm of the sinus of Valsalva), infection, vasculitis (Takayasu's arteritis or Kawasaki syndrome), connective tissue disease (Marfan syndrome or Ehlers-Danlos syndrome), neurofibromatosis, tuberous sclerosis, inborn errors of metabolism (cystinosis), and trauma. Since the early 1980s, iatrogenic trauma, induced by umbilical artery catheterization, and complicating sepsis have become the major causes of infective pseudoaneurysms in infants, and Staphylococcus aureus is the most commonly isolated organism from these lesions [1]. Nonresected pseudoaneurysms have high mortality rates [2, 3]. Our case illustrates radiologic follow-up for a neonate with an indwelling umbilical artery catheter and a hospital stay complicated by sepsis.

A 31-week gestational age male neonate weighing 1730 g underwent placement (tip at T7) of an umbilical artery catheter. At age 12 days, the neonate was diagnosed with S. aureus infection, sepsis, and meningitis, and the catheter was removed. Abdominal sonography revealed aortic thrombi near the origin of the superior mesenteric artery and at the iliac bifurcation. Despite antibiotic therapy, complications developed, including cutaneous abscess formation, osteomyelitis, and necrotizing enterocolitis. Approximately 2 months later, a routine chest radiograph revealed a left paraspinal opacity (Fig. 1A). CT showed a 2-cm enhancing paraaortic mass (Fig. 1B); transthoracic sonography showed a 1.8 x 1.2 cm hypoechoic mass abutting the mid thoracic aorta; and catheter angiography showed a large thoracic aneurysm and two smaller abdominal aneurysms (Fig. 1C). A thoracic aneurysmectomy produced an intact specimen: a spheric fluctuant focally translucent pseudoaneurysm 1.8 cm in diameter, with a 0.3-cm luminal ostium. The bisected specimen (Fig. 1D) showed the ostium flanked by organizing intramural thrombus and hemorrhage that undermined the wall and resulted in an hour-glass-shaped portal. The gross features of periosteal intramural dissection and thrombus corresponded with the crescent-shaped dark outlines on both sides of the pseudoaneurysm's connection to the aorta on contrast-enhanced CT (Fig. 1B). Bisection also revealed severe mural thinning opposite the ostium; the area of translucency of the specimen was essentially composed of compressed adventitia. We also noted chronic luminal thrombosis that probably contributed to the irregularities in the pseudoaneurysm seen on CT. Microscopically, inflammatory destruction of the pseudoaneurysm wall was evidenced by thickened neointima overlying the chronic mural thrombus, disruption of the internal elastic lamina and medial elastin, severe medial attenuation and hemosiderosis, and nonspecific chronic aortitis and microcalcification. Cultures for fungal, aerobic and anaerobic bacterial, and acid-fast pathogens were negative, as were special stains for microorganisms. The final diagnosis was infective aortic pseudoaneurysm.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —86-day-old male neonate with infective pseudoaneurysm. Anteroposterior chest radiograph shows left paraspinal mass (arrow).

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —86-day-old male neonate with infective pseudoaneurysm. Contrast-enhanced CT scan shows 2-cm enhancing mass contiguous with descending thoracic aorta (arrow).

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —86-day-old male neonate with infective pseudoaneurysm. Aortogram reveals large aneurysm of descending thoracic aorta (straight arrow) and two smaller abdominal aortic lesions (curved arrows).

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —86-day-old male neonate with infective pseudoaneurysm. Bisected gross pseudoaneurysm specimen used to correlate findings in B.

The early diagnosis of pseudoaneurysms is important for timely surgical intervention, and imaging plays a critical role in early detection [2, 3]. A paraspinal mass on chest or abdominal radiography in a neonate with a history of umbilical artery catheterization and sepsis should alert radiologists to the possibility of an infective aortic pseudoaneurysm. The descending thoracic aorta is the most common site for these lesions, followed by the abdominal aorta and the iliac arteries [4]. Sonography is considered by some to be the imaging technique of choice. However, contrast-enhanced CT is the superior technique for detection; it is more sensitive in the early stages than other techniques and depicts the entire anatomic abnormality [2]. Angiography is used for preoperative planning, and MR imaging and MR angiography hold promise for the evaluation of infective pseudoaneurysms in the future [5].

References

Top Introduction References

 

1. Millar AJ, Gilbert RD, Brown RA, Immelman EJ, Burkimsher DA, Cywes S. Abdominal aortic aneurysms in children. J Pediatr Surg 1996;31:1624 -1628[Medline]
2. Lobe TE, Richardson CJ, Boulden TF, Swischuk LE, Hayden CK, Oldham KT. Mycotic thromboaneurysmal disease of the abdominal aorta in preterm infants: its natural history and its management. J Pediatr Surg 1992;27:1054 -1060[Medline]
3. Gomes MN, Choyke PL. Infected aortic aneurysms: CT diagnosis. J Cardiovasc Surg 1992;33:684 -689[Medline]
4. Drucker DE, Freenfield LJ, Ehrlich F, Salzberg AM. Aorto-iliac aneurysms following umbilical artery catheterization. J Pediatr Surg 1986;21:725 -730[Medline]
5. Walsh DW, Ho VB, Hagerty MF. Mycotic aneurysms of the aorta: MRI and MRA features. J Magn Reson Imaging 1997;7:312 -315[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cartner, A. Articles by Faye-Petersen, O. Search for Related Content PubMed PubMed Citation Articles by Cartner, A. Articles by Faye-Petersen, O. Social Bookmarking                      What's this?