Note: This copy is for your personal non-commercial use only.

To order presentation-ready
copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.

EDUCATION EXHIBIT 497

Spectrum of CT Find-
ings in Rupture and
Impending Rupture
of Abdominal Aortic
Aneurysms1
Dmitry Rakita, MD ● Amit Newatia, MD ● John J. Hines, MD ● David N.
ONLINE-ONLY
CME Siegel, MD ● Barak Friedman, MD
See www.rsna
.org/education
/rg_cme.html. Prompt diagnosis of rupture and impending rupture of abdominal aor-
tic aneurysms is imperative. The computed tomographic (CT) find-
ings of ruptured abdominal aortic aneurysms are often straightforward.
LEARNING
OBJECTIVES Most ruptures are manifested as a retroperitoneal hematoma accompa-
After reading this
nied by an abdominal aortic aneurysm. Periaortic blood may extend
article and taking into the perirenal space, the pararenal space, or both. Intraperitoneal
the test, the reader
will be able to: extravasation may be an immediate or a delayed finding. Discontinuity
䡲 Recognize the im- of the aortic wall or a focal gap in otherwise continuous circumferential
aging features of in-
stability, impending wall calcifications may point to the location of a rupture. There usually
rupture, and rupture is a delay of several hours between the initial intramural hemorrhage
of abdominal aortic
aneurysms.
and frank extravasation into the periaortic soft tissues. Contained or
䡲 Describe the utility impending ruptures are more difficult to identify. A small amount of
of gadolinium as a periaortic blood may be confused with the duodenum, perianeurysmal
contrast agent for
CT angiography. fibrosis, or adenopathy. Imaging features suggestive of instability or
䡲 Identify the etiol- impending rupture include increased aneurysm size, a low thrombus-
ogy and imaging to-lumen ratio, and hemorrhage into a mural thrombus. A peripheral
features of infected
abdominal aortic an- crescent-shaped area of hyperattenuation within an abdominal aortic
eurysms and aorto- aneurysm represents an acute intramural hemorrhage and is another
enteric fistula.
CT sign of impending rupture. Draping of the posterior aspect of an
aneurysmal aorta over the vertebrae is associated with a contained rup-
TEACHING ture.
POINTS ©
RSNA, 2007
See last page

RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 ● Content Codes:

1From the Department of Radiology, Division of Body Imaging and Division of Interventional Radiology, Long Island Jewish Medical Center, 270-05
76th Ave, New Hyde Park, NY 11040. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received March 16, 2006; revision re-
quested June 14 and received August 4; accepted August 10. All authors have no financial relationships to disclose. Address correspondence to D.R.
(e-mail: rakitamd@gmail.com).
©
RSNA, 2007
498 March-April 2007
Introduction
Most abdominal aortic aneurysms are true aneu-
rysms. A true aortic aneurysm is a localized dila-
tation of the aorta caused by weakening of its
wall; it involves all three layers (intima, media,
and adventitia) of the arterial wall. A pseudoan-
eurysm (false aneurysm) is a collection of flowing
blood that communicates with the arterial lumen
but is not enclosed by the normal vessel wall; it is
contained only by the adventitia or surrounding
soft tissue (Fig 1). Aneurysms may develop in any
segment of the aorta, but most involve the aortic
segment below the renal arteries. An aortic diam-
eter of 3 cm or more is used to define an abdomi-
nal aortic aneurysm (1). Aneurysmal dilatation of
the abdominal aorta is a disease of aging and is
rare before age 50 but is found in 2%– 4% of the
population older than 50 years (2). The average
age at the time of diagnosis is 65–70 years, and
more men than women are affected. Concurrent
coronary artery disease and peripheral vascular
disease, as well as a family history of abdominal
aortic aneurysm, are strong risk factors for the
development of this condition.
A retroperitoneal hematoma adjacent to an
abdominal aortic aneurysm is the most common
imaging finding of rupture (3). Extension of hem-
orrhage into the retroperitoneum, including the
perirenal and pararenal spaces, psoas muscles,
and peritoneum, is a common occurrence. Intra-
peritoneal extravasation may be an immediate or
a delayed finding.
Patients who present with abdominal pain, a
large abdominal aortic aneurysm, and no frank
rupture pose a diagnostic dilemma. The symp-
toms may be attributable to aneurysmal instabil-
ity, impending rupture, or a contained leak.
Imaging Techniques
Computed tomography (CT) is the modality of
choice for evaluation of acute aortic syndrome,
because of the speed of the examination and the
widespread availability of CT. With a multidetec-
tor CT scanner in the emergency department, an
examination can be performed and the images
interpreted within minutes. Magnetic resonance
(MR) imaging requires a much longer acquisition
time, and MR imaging may be less available and
RG f Volume 27 ● Number 2
Figure 1. Types of aortic aneurysms. Schematic de-
picts the normal arterial wall structure and the wall
structures of true and false aneurysms.
less convenient. Ultrasonography (US) plays a
limited role in the assessment of acute aortic ab-
normalities. Frequently, the entire aorta cannot
be evaluated because of overlying bowel gas and
body habitus. In addition, US is operator depen-
dent, and the necessary expertise may not be
readily available. A bedside examination with US
may be helpful for patients whose condition is too
unstable to allow their transfer to the CT scanner.
US may help determine the size of the aneurysm
and help identify hemoperitoneum. However, the
utility of US for identifying an impending rupture
or a contained rupture of an aneurysm is limited.
The use of CT angiography has become rou-
tine for imaging of a suspected abdominal aortic
aneurysm rupture. Because the clinical signs and
symptoms frequently are confused with those of
appendicitis, pancreatitis, or bowel obstruction,
abdominal aortic aneurysm rupture sometimes is
detected at a nonemergent CT evaluation for
nonspecific abdominal pain or renal colic.
Unenhanced CT may help detect an aneurysm
rupture by depicting an abdominal aortic aneu-
rysm with surrounding retroperitoneal hemor-
rhage. Contrast-enhanced CT provides additional
information about the size of the aneurysmal lu-
men, presence of active extravasation, and rela-
tionship of the aneurysm to the celiac, superior
mesenteric, renal, and inferior mesenteric arter-
ies. Our abdominal aortic aneurysm CT protocol,
performed on a four– or 16 – detector row scan-
ner, consists of unenhanced scanning through the
abdomen and pelvis at 5-mm collimation, fol-
lowed by bolus-tracked CT angiography of the
abdomen and pelvis at 1-mm collimation and
then by delayed imaging of the abdomen and pel-
vis in the portal venous phase (80 seconds) at
5-mm collimation. The acquisition of thin sec-
tions is essential for multiplanar reformatting,
 RG f Volume 27 ● Number 2 Rakita et al 499

Figure 2. Aortic aneurysm rupture in an 80-year-old woman with abdominal pain and hypotension.
Axial (a) and sagittal (b) CT angiographic images demonstrate active extravasation of contrast material
(arrow) into the thrombosed portion of an abdominal aortic aneurysm, as well as extensive retroperito-
neal hemorrhage (arrowhead).

Figure 3. Aortic aneurysm rupture in a 67-year-old man with abdominal pain and hypotension. Axial
CT angiographic images depict a large ruptured abdominal aortic aneurysm with active retroperitoneal
extravasation (arrow in a) and intraperitoneal hemorrhage (arrow in b).

evaluating the relationship of the aneurysm to
other abdominal vascular structures, and plan-
ning endovascular stent-graft placement. Con-
trast injection rates of 3– 4 mL/sec are optimal;
however, slower rates of 1.5–2 mL/sec yield im-
ages with diagnostic quality. A total of 90 mL of
nonionic intravenous contrast material is suffi-
cient to reliably produce diagnostic-quality im-
ages. Oral contrast material is not administered.
Findings of Aneurysm Rupture
A retroperitoneal hematoma adjacent to an ab-
Teaching dominal aortic aneurysm is the most common
Point imaging finding of abdominal aortic aneurysm
rupture (3).
Periaortic blood may extend into the
perirenal space, pararenal space, or the psoas
muscles. Intraperitoneal extension may be an im-
mediate or a delayed finding. These findings are
readily visible on unenhanced CT images, which
may have been obtained for another indication or
as part of an aneurysm evaluation protocol. On
contrast-enhanced CT images, active extravasa-
tion of contrast material is frequently demon-
strated (Figs 2, 3). Although open surgical tech-
niques have traditionally been used to repair
500 March-April 2007 RG f Volume 27 ● Number 2

Figure 4. Aortic aneurysm rupture in a 68-year-old man with

abdominal and right hip pain. (a, b) Axial contrast-enhanced CT
images (a at a level higher than b) show a retroperitoneal hemor-
rhage (arrowhead) and a right psoas hematoma (arrow). (c) Post-
treatment angiogram shows successful repair of the ruptured aneu-
rysm with endovascular stent placement.

ruptured aneurysms, endovascular repair (Fig 4)

has gained increasing acceptance for elective use
in patients who are at high risk for complications
from open surgery and for relatively stable pa-
tients (4,5).
Some patients who are believed to have a rup-
tured abdominal aortic aneurysm may have a con-
traindication (eg, allergy) to the use of iodinated
intravenous contrast media. CT angiography with
the use of gadolinium as a contrast agent may be
an effective alternative option (Fig 5). Gadolin-
ium-enhanced CT angiography requires a high
dose of the contrast agent (0.3– 0.5 mmol/kg), of high-dose gadolinium as a substitute for iodin-
and imaging is best performed with a multidetec- ated contrast material is controversial in patients
tor CT scanner with 16 channels or more to allow at risk for nephrotoxic effects or with preexisting
rapid acquisition, as the volume of gadolinium is renal insufficiency (8).
smaller than that of an iodinated contrast agent An important imaging feature that may be seen
and because there is a smaller temporal window in a contained rupture of an abdominal aortic an- Teaching
of adequate opacification (6,7). However, the use eurysm is the draped aorta sign (9). This sign is Point
considered present when the posterior wall of the
aorta either is not identifiable as distinct from ad-
jacent structures or when it closely follows the
contour of adjacent vertebral bodies (Fig 6).
RG f Volume 27 ● Number 2 Rakita et al 501

Figure 6. Draped aorta sign in a 55-year-old man with a known abdominal aortic aneurysm and recent
vague back pain. Axial CT angiographic images (a at a level higher than b) depict an 8-cm abdominal
aortic aneurysm with a posterior aortic wall that follows the contour of the vertebral bodies with a drap-
ing effect (arrow in b). The latter finding is indicative of a contained rupture.

Figure 5. Aortic aneurysm rupture superior to an aorto-

biiliac stent-graft in a 75-year-old man with chronic renal
insufficiency and abdominal pain after endovascular re-
pair. Axial (a at a level higher than b) and sagittal (c) gad-
olinium-enhanced CT angiographic images demonstrate
active extravasation of contrast material superior to the
graft (arrowhead in b and c) and retroperitoneal hemor-
rhage around the aorta (arrow).
502 March-April 2007 RG f Volume 27 ● Number 2

Figure 7. Large ruptured aneurysm in a 68-year-old man with an acute onset of right flank pain radiat-
ing to the back. Axial unenhanced CT images (a at a level higher than b) depict a ruptured 10.7-cm ab-
dominal aortic aneurysm and a retroperitoneal hemorrhage (arrow).

Figure 8. Discontinuity of aortic wall calcifications in an abdominal aortic aneurysm in a 60-year-

old woman. Axial unenhanced CT images from two examinations of the same patient in 2003 (a) and
2005 (b) demonstrate the development of discontinuity in calcifications and of draping of the posterior
aortic wall (arrow in b).

Findings Predictive mural pressure, and R is the vessel radius. A pa-

of Impending Rupture
Increased Aneurysm Size
The most common finding predictive of rupture
and, thus, the most common indicator for elective
surgical management, is the maximum diameter
of the aneurysm (10). Wall tension in aortic aneu-
rysms is proportional to the mean vessel radius,
according to the Laplace law T ⫽ PR, in which T
is the circumferential wall tension, P is the trans-
tient with a very large abdominal aortic aneurysm
(diameter of ⬎7 cm) who presents with symp-
toms of acute aortic syndrome has a high likeli-
hood of aneurysm rupture (Fig 7). Furthermore,
an enlargement rate of 10 mm or more per year is
also used as an indication for surgical repair (10).
Thrombus and Calcifications
Nonruptured aneurysms generally contain more
thrombus than do ruptured aneurysms, and the
thrombus-to-lumen ratio decreases with increas-
RG f Volume 27 ● Number 2 Rakita et al 503

Figure 9. Impending aneurysm rupture in a 66-year-old man with back pain, who underwent imaging
for suspicion of renal colic. Axial unenhanced CT images (a and b are the same section with different
window settings) demonstrate an abdominal aortic aneurysm with a hyperattenuating crescent sign (ar-
row) that represents an acute hematoma within the aneurysm wall.

Figure 10. Impending aneurysm rupture in a 57-year-old man with a known abdominal aortic aneu-
rysm and increasing abdominal pain. Axial unenhanced (a) and axial contrast-enhanced (b) CT images
depict an abdominal aortic aneurysm with a hyperattenuating crescent sign (arrow in a), which repre-
sents an acute hematoma within the aneurysm wall.

ing aneurysm size (11). These observations sug-
gest that a thick circumferential thrombus is pro-
tective against rupture. In addition, enlargement
of the patent lumen is indicative of partial lysis of
the thrombus, which predisposes an aneurysm to
rupture (11,12).
A focal discontinuity in circumferential wall
calcifications is more commonly observed in un-
stable or ruptured aneurysms (3). This finding is
most helpful when a previous CT study is avail-
able and its comparison with the current CT
study shows that an area of discontinuity in mural
calcifications is new (Fig 8).
Hyperattenuating Crescent Sign
A well-defined peripheral crescent of increased
Teaching
attenuation within the thrombus of a large ab-
Point
dominal aortic aneurysm is a CT sign of acute or
impending rupture (13,14). This finding is best
appreciated on unenhanced CT images (Figs 9,
10). It represents an internal dissection of blood
into either the peripheral thrombus or the aneu-
rysm wall, a process that either causes or results
from a loss in the ability of the thrombus to pro-
tect the aneurysm from rupture (15). It is one of
the earliest and most specific imaging manifesta-
tions of the rupture process (3,13–15).
504 March-April 2007 RG f Volume 27 ● Number 2

Figure 11. Mycotic pseudoaneurysm with associated vertebral

osteomyelitis in a 45-year-old man with back and abdominal
pain, fever, and an elevated white blood cell count. Sagittal (a)
and axial (b, c) contrast-enhanced CT images (b at a level
higher than c) show a large pseudoaneurysm (arrowhead) with
communication to the aorta (white arrow). Note the destructive
changes in adjacent vertebral bodies (black arrow.)

Infected Aneurysms aortic aneurysms occur in the infrarenal abdomi-

Infected (mycotic) aneurysms are uncommon and
account for only 0.7%–2.6% of aortic aneurysms;
they are most often pseudoaneurysms. Infected
aneurysms are prone to rupture, with a rupture
rate of 53%–75% at surgical repair. Hematoge-
nous seeding of the aorta usually occurs in the
setting of septicemia, which is most commonly
caused by endocarditis (16). The direct spread of
infection from adjacent vertebral osteomyelitis
and from renal and psoas abscesses also has been
documented (16). Whereas most atherosclerotic
nal aorta, the majority of infected aneurysms oc-
cur in the thoracic or suprarenal abdominal aorta
(16).
CT findings of infected aneurysms include a
saccular shape; lobular contours; and periaortic Teaching
inflammation, abscess, and mass. Other findings Point
include periaortic gas and adjacent vertebral body
abnormalities due to the spread of infection (Figs
11, 12). Rapid change in the size or shape of a
saccular aneurysm on serial CT studies over a
short time period should arouse suspicion about
the possible presence of infection, since the ex-
pansion rate of mycotic aneurysms is faster than
that of atherosclerotic aneurysms (16).
 RG f Volume 27 ● Number 2 Rakita et al 505

Figure 12. Mycotic aneurysm rupture in a 74-

year-old man with abdominal pain and an elevated
white blood cell count. Axial (a), sagittal (b), and
coronal (c) contrast-enhanced CT images demon-
strate a retroperitoneal hematoma (arrowhead) and
small bubbles of gas (curved arrow) within the aneu-
rysm lumen and surrounding soft tissue. An adja-
cent pseudoaneurysm (straight arrow in a and b)
also is seen. The differential diagnosis included my-
cotic aneurysm and aortoduodenal fistula. A my-
cotic aneurysm was found at surgery.

Aortoenteric Fistulas
Primary aortoenteric fistulas are a complication of
Teaching
atherosclerotic aortic aneurysms, whereas second-
Point
ary aortoenteric fistulas are a complication of aor-
tic reconstructive surgery (17). Most fistulas in- Surgical exploration is usually necessary
volve the duodenum, most commonly its third to confirm the diagnosis and for treatment.
and fourth portions. Symptoms include abdomi- Secondary aortoenteric fistulas are much more
nal pain, hematemesis, and melena. common and must be distinguished from graft
Primary aortoenteric fistulas may pose a diag- infection, since perigraft gas may be seen in both
nostic dilemma for the clinician, especially in the conditions and since both entities may occur as
absence of gastrointestinal tract bleeding. Upper- delayed complications of aortic aneurysm repair.
gastrointestinal-tract endoscopy may help rule Aortoenteric fistulas have been reported to oc-
out other causes of bleeding but rarely helps diag- cur between 2 weeks and 8 years after surgery
nose a fistula. CT imaging features include an (17,18).
abdominal aortic aneurysm, often with signs of
rupture, and intraluminal and periaortic extralu-
minal gas (Fig 13). CT with the use of intrave-
nous contrast material may show contrast mate-
rial extravasation from the aorta into the involved
portion of the bowel, if a patent fistula is present
(17,18).
506 March-April 2007 RG f Volume 27 ● Number 2

Figure 13. Aortoduodenal fistula in a 71-year-old woman with a known abdominal aortic aneu-
rysm, abdominal pain, and a guaiac-positive stool test. Axial (a, b), close-up axial (c), and coronal (d)
CT angiographic images depict small gas bubbles within a ruptured aneurysm sac (arrows in a, b,
and d), as well as disruption of the anterior aortic wall, with a faint fistulous tract between the
thrombosed portion of the aortic aneurysm and the third portion of the duodenum (arrowhead in b
and c). The differential diagnosis included aortoduodenal fistula and mycotic aneurysm. The pa-
tient died of a massive gastrointestinal hemorrhage the next day.

Inflammatory Aneurysms and an elevated erythrocyte sedimentation rate

A description of inflammatory aneurysms is in-
cluded in this article for historical reasons, as slow
aneurysmal leakage was initially thought to be its
cause (19). The term inflammatory aneurysm was
initially used in 1972 (19) to describe aortic aneu-
rysm disease with significant perianeurysmal in-
flammation and adhesions to surrounding struc-
tures. This subtype of aneurysm has been re-
ported to account for 3%–10% of aortic
aneurysms and is predominantly found in men
(20). In contrast to atherosclerotic aneurysms,
most inflammatory aneurysms are symptomatic,
and they are associated with an increased risk of
rupture irrespective of their size (19 –21). In ap-
proximately 20%–30% of patients, hydronephro-
sis or renal failure is present at the time of diagno-
sis because the inflammatory process involves one
or both ureters. In addition, fever, weight loss,
may be present (21).
CT imaging features include inflammatory or
fibrotic changes in the periaortic regions of the
retroperitoneum (Fig 14) (20). The etiology of
inflammatory aneurysms is poorly understood but
is thought to be related to periaortic retroperito-
neal fibrosis and various autoimmune diseases,
including rheumatoid arthritis, systemic lupus
erythematosus, and giant cell arteritis (22).
Summary
Imaging findings of aortic aneurysm rupture vary
along a spectrum from impending rupture to con-
tained rupture and from small aortic leaks with
subtle infiltration of retroperitoneal fat to frank
retroperitoneal or intraperitoneal extravasation.
Aortic aneurysms most commonly occur as a con-
sequence of atherosclerotic disease of the aorta.
Alternatively, they may be associated with infec-
tious seeding of the native or surgically repaired
vessel.
RG f Volume 27 ● Number 2
Figure 14. Inflammatory aneurysm in a 50-year-old man with a known abdominal aortic aneurysm,
abdominal pain, and an elevated erythrocyte sedimentation rate. Axial contrast-enhanced CT images (a
at a level higher than b) demonstrate a large abdominal aortic aneurysm with circumferential perianeu-
rysmal fibrosis and inflammation (arrow).
References
1. Scott RA, Ashton HA, Kay DN. Abdominal aortic
aneurysm in 4,237 screened patients: prevalence,
development and management over 6 years. Br J
Surg 1991;78:1122–1125.
2. Bengtsson H, Bergqvist D, Sternby NH. Increas-
ing prevalence of abdominal aortic aneurysms: a
necropsy study. Eur J Surg 1992;158:19 –23.
3. Siegel CL, Cohan RH, Korobkin M, Alpern MB,
Courneya DL, Leder RA. Abdominal aortic aneu-
rysm morphology: CT features in patients with
ruptured and non-ruptured aneurysms. AJR Am J
Roentgenol 1994;163:1123–1129.
4. Maher MM, McNamara AM, MacEneaney PM,
Sheehan SJ, Malone DE. Abdominal aortic an-
eurysms: elective endovascular repair versus
conventional surgery— evaluation with evidence-
based medicine techniques. Radiology 2003;228:
647– 658.
5. Parodi JC, Palmaz JC, Barone HD. Transfemoral
intraluminal graft implantation for abdominal aor-
tic aneurysms. Ann Vasc Surg 1991;5:491– 499.
6. Remy-Jardin M, Dequiedt P, Ertzbischoff O, et al.
Safety and effectiveness of gadolinium-enhanced
multi-detector row spiral CT angiography of the
chest: preliminary results in 37 patients with con-
traindications to iodinated contrast agents. Radiol-
ogy 2005;235:819 – 826.
7. Wicky S, Greenfield A, Fan CM, et al. Aortoiliac
gadolinium-enhanced CT angiography: improved
results with a 16-detector row scanner compared
with a four-detector row scanner. J Vasc Interv
Radiol 2004;15(9):947–954.
8. Thomsen HS. Guidelines for contrast media from
the European Society of Urogenital Radiology.
AJR Am J Roentgenol 2003;181:1463–1471.
9. Halliday KE, Al-Kutoubi A. Draped aorta: CT
sign of contained leak of aortic aneurysms. Radiol-
ogy 1996;199:41– 43.
10. Lederle FA, Johnson GR, Wilson SE, et al. Rup-
ture rate of large abdominal aortic aneurysms in
patients refusing or unfit for elective repair. JAMA
2002;287:2968 –2972.
This article meets the criteria for 1.0 AMA PRA Category 1 Credit . To obtain credit, see www.rsna.org/education
/rg_cme.html.
Rakita et al 507
11. Pillari G, Chang JB, Zito J, et al. Computed to-
mography of abdominal aortic aneurysm: an in
vivo pathological report with a note on dynamic
predictors. Arch Surg 1988;123:727–732.
12. Mower WR, Quinones WJ, Gambhir SS. Effect of
intraluminal thrombus on abdominal aortic aneu-
rysm wall stress. J Vasc Surg 1997;26:602– 608.
13. Gonsalves CF. The hyperattenuating crescent
sign. Radiology 1999;211:37–38.
14. Mehard WB, Heiken JP, Sicard GA. High-attenu-
ating crescent in abdominal aortic aneurysm wall
at CT: a sign of acute or impending rupture. Radi-
ology 1994;192:359 –362.
15. Arita T, Matsunaga N, Takano K, et al. Abdomi-
nal aortic aneurysm: rupture associated with the
high-attenuating crescent sign. Radiology 1997;
204:765–768.
16. Macedo TA, Stanson AW, Oderich GS, Johnson CM,
Panneton JM, Tie ML. Infected aortic aneurysms: im-
aging findings. Radiology 2004;231:250 –257.
17. Orton DF, LeVeen RF, Saigh JA, et al. Aortic
prosthetic graft infections: radiologic manifesta-
tions and implications for management. Radio-
Graphics 2000;20:977–993.
18. Yoshikawa K, Yamaguti T, Nakamura M, et al.
The role of dual-phase enhanced helical computed
tomography in difficult intestinal bleeding. J Clin
Gastroenterol 2000;31:83– 84.
19. Walker DI, Bloor K, Williams G, et al. Inflamma-
tory aneurysms of the abdominal aorta. Br J Surg
1972;59:609 – 614.
20. Arrive L, Correas JM, Leseche G, Ghebontni L,
Tubiana JM. Inflammatory aneurysms of the ab-
dominal aorta: CT findings. AJR Am J Roentgenol
1995;165:1481–1484.
21. Pennell RC, Hollier LH, Lie JT, et al. Inflamma-
tory abdominal aortic aneurysms: a thirty-year re-
view. J Vasc Surg 1985;2:859 – 869.
22. Haug ES, Skomsvoll JF, Jacobsen G, et al. Inflam-
matory aortic aneurysm is associated with in-
creased incidence of autoimmune disease. J Vasc
Surg 2003;38:492– 497.
TM
RG Volume 27 • Volume 2 • March-April 2007 Rakita et al

Spectrum of CT Findings in Rupture and Impending Rupture of

Abdominal Aortic Aneurysms
Dmitry Rakita, MD et al
RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 ● Content Codes:

Page 499
A retroperitoneal hematoma adjacent to an abdominal aortic aneurysm is the most common imaging
finding of rupture.

Page 500
An important imaging feature that may be seen in a contained rupture of an abdominal aortic
aneurysm is the draped aorta sign. This sign is considered present when the posterior wall of the aorta
either is not identifiable as distinct from adjacent structures or when it closely follows the contour of
adjacent vertebral bodies (Fig 6).

Page 503
A well-defined peripheral crescent of increased attenuation within the thrombus of a large abdominal
aortic aneurysm is a CT sign of acute or impending rupture.

Page 504
CT findings of infected aneurysms include a saccular shape; lobular contours; and periaortic
inflammation, abscess, and mass. Other findings include periaortic gas and adjacent vertebral body
abnormalities due to the spread of infection (Figs 11, 12).

Page 505
Primary aortoenteric fistulas are a complication of atherosclerotic aortic aneurysms. CT imaging
features include an abdominal aortic aneurysm, often with signs of rupture, and intraluminal and
periaortic extraluminal gas (Fig 13). CT with the use of intravenous contrast material may show
contrast material extravasation from the aorta into the involved portion of the bowel, if a patent fistula
is present.