Elsevier

World Neurosurgery

Volume 110, February 2018, Pages 232-239
World Neurosurgery

Case Report
Delayed Traumatic Aortic Pseudoaneurysm Formation Causing Vertebral Body Erosion and Back Pain: Case Report and Literature Review

https://doi.org/10.1016/j.wneu.2017.11.035Get rights and content

Background

Aortic pseudoaneurysms are a rare cause of chronic back pain, usually resulting from compression of the adjacent neurovasculature. It is uncommon for patients with pseudoaneurysms of the abdominal aorta to present in a delayed fashion after initial traumatic injury.

Case Description

We describe an unusual case of delayed pseudoaneurysm formation with subsequent erosion into the adjacent L1 vertebral body. This pseudoaneurysm was secondary to a gunshot wound with retained ballistic fragment that had occurred 27 years previously. Herein, we discuss the patient's presenting symptoms, imaging, and overall treatment. In this particular case, we used a combined surgical and endovascular (hybrid) approach after the patient experienced recurrent low back pain, weeks after a primary endovascular treatment was performed. We additionally review the current literature on the management of aortic pseudoaneurysms causing vertebral body erosion and back pain.

Conclusions

In our patient, a combined surgical and endovascular (hybrid) approach led to the complete resolution of his back pain symptoms and to complete exclusion of the pseudoaneurysm on follow-up imaging. Endovascular management of aortic pseudoaneurysms may be a reasonable alternative to open surgery in high-risk patients; however, this approach may result in a higher recurrence of pseudoaneurysm and initial presenting symptoms. Further investigation is needed to elucidate the efficacy of endovascular treatment of these lesions.

Introduction

An aneurysm is defined as a dilatation of an artery contained by all 3 layers of the arterial wall: intima, media, and adventitia. A pseudoaneurysm, by contrast, may be confined by only 2 layers, only 1 layer, or only the surrounding connective tissue with persistent flow outside the vessel.1, 2, 3 Multiple causes of pseudoaneurysm formation have been reported in the literature, including iatrogenic, traumatic, anastomotic, or secondary to infection.1 Other pathologic features associated with generalized vascular inflammation such as atherosclerotic ulceration, in which an atherosclerotic plaque penetrates the media, have been reported in pseudoaneurysm formation.3 These pseudoaneurysms may undergo spontaneous thrombosis, may progress to compression of local neurovascular structures, or may even rupture.2

Traumatic pseudoaneurysms generally present acutely, although the literature describes rare cases of delayed presentation.4, 5 Back pain is the most common manifestation of traumatic pseudoaneurysm formation of the aorta and is frequently the only symptom.5, 6, 7, 8 Other signs and symptoms include a pulsatile mass with or without a bruit; thromboembolism causing distal ischemia and necrosis; and compression of adjacent structures such as the biliary tree causing jaundice, chest pain, abdominal pain, gastrointestinal bleeding, and rupture with subsequent hemorrhage and shock.4, 5, 9, 10, 11, 12 Typically, back pain is due to local neurovascular compression by the pseudoaneurysm. However, there are some rare cases of pseudoaneurysm erosion into the adjacent vertebral body (VB) and subsequent development of chronic back pain.6, 13, 14 Here we describe an interesting case of a 66-year-old man who presented with persistent back pain caused by VB erosion from a pseudoaneurysm arising from the abdominal aorta secondary to a gunshot wound that had occurred 27 years previously.

Section snippets

History

A 66-year-old man presented to his primary care physician because of new-onset lumbar back pain. The patient described the pain as sharp and constant, and he noted that the pain was worse with walking and was relieved by lying down. The patient stated that the pain had initially started as intermittent and variable in intensity but was typically worse in the morning and lessened in severity as the day progressed. The pain occasionally radiated from his back to his flank, but he did not describe

Discussion

Pseudoaneurysm formation is typically due to an iatrogenic, an traumatic, or an anastomotic event or can be secondary to infection or inflammation.1, 15 After trauma, a hematoma can form within the surrounding tissue and become encapsulated by fibrous tissue.9 A continued communication between the vessel and the hematoma results in a pseudoaneurysm.9 Specifically, the retroperitoneal location of the abdominal aorta may tamponade hemorrhage from aortic rupture, predisposing to pseudoaneurysm

Conclusions

Pseudoaneurysm of the abdominal aorta is associated with high morbidity and mortality. In patients with a history of penetrating trauma involving the abdomen and a delayed presentation of back pain, a traumatic pseudoaneurysm must be ruled out. Treatment for aortic pseudoaneurysms ranges from surgical to endovascular, depending on the morphology of the pseudoaneurysm and its location. In our patient, a combined surgical and endovascular approach led to the complete resolution of his back pain

Acknowledgments

Richard Neville, M.D., at George Washington University Hospital contributed to this report by providing the imaging and was actively involved in the clinical care of our patient.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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