Acute hypertension as a diagnostic clue in traumatic rupture of the thoracic aorta

Acute Hypertension Traumatic

as a Diagnostic

Rupture

of the Thoracic

EUGENE G. LAFORET, M.D., Boston,

From the Departmentsof Thoracic Surgery, Boston University School of Medicine, Massachusetts Memorial Hospitals, Boston City Hospital, and Newton- Wellesley Hospital, Boston, Massachusetts.

method

to determine

patient

who

has

matic rupture When

A

should

mentally even

be

fatal study

which

there rupture

tinctly

of

of the thoracic

the diagnosis

is no effective

long

technics.

enough Since

ment demands diagnosis is the clinical

to

paper

of persistent

may

constitute

ble

10 will

dence.

manage-

often

to describe

Accidents

resulting

diag-

OF TRAUMATIC

rupture injuries

of the thoracic of the chest”

which

rupture

origin

of the

from a height, involve

from abrupt associated

occurs left

aorta.

are the classic variety usually

just

falls may

root.

When

artery.

in the

In

the aortic

subclavian

beyond

on the other hand, rupture the aortic

and immediate

tion

a subadventitial

is prevented, develops.

cause fatal rupture chronic

traumatic

“Steering-wheel

ture is incomplete hematoma

deceleration

with

“traumatic

(Fig.

rup-

exsanguinaperiaortic

1.) This may either

secondarily aneurysm.”

or progress There

traumatic

frequency

has

are compati-

rupture

of

enlargement

increases been

the

in a patient the

of the

diagnostic

aortography,

and

upon

of a shadow

confi-

of course, employed

is

with

in recent years. CASE REPORT

RUPTURE OF THE THORACIC AORTA

are most commonly

becomes

year old man was admitted to Newton-Wellesley Hospital one hour after the car he had been driving ran into a ditch. He had been hurled violently against the steering wheel, receiving injury to the anterior part of the chest. Although there was clinical evidence of shock, the patient was coherent and oriented. Injuries included facial lacerations, left anterior rib fractures, and fractures of the left clavicle, left forearm, and left femur. Blood pressure, which had been unobtainable, rose to 80/40 mm. Hg with blood transfusion and other resuscitative measures. When the clinical status stabilized, a portable anteroposterior chest roentgenogram was obtained. This showed widening of the superior mediastinum to the left and displacement of the trachea to the right (Fig. 2) in addition to rib fractures on the left. As often happens, the mediastinal changes were ascribed to technical factors involved in obtaining a chest roentgenogram in a severely injured patient. Proteinuria and microscopic hematuria were present. Blood pressure the day after A

nostic clue. PATHOGENESIS

of

Progressive

shadow

the

hyperten-

an important

depends

and clinical findings

Emergency decisive

greater

it

diagnosis

demonstration

those aorta.

mediastinal

and since such

acute

will follow. to be estab-

intervention

with hemomediastinum

with

thoracic

modern

a high index of suspicion,

of this

finding

by

the

whose history

Spencer

surgical

precise diagnosis,

purpose

sion, which

salvable

consistent

dis-

that

essence

roentgenographic

Trau-

with this injury

be

In

for

quite

category.

appropriate

requires

not,

have estimated

to 20 per cent of patients live

aorta

aorta

a

trau-

DIAGNOSIS

sophis-

treatment.

of the thoracic

for example,

or

survived

is considered

surgical

lesions,

in the

lethal

of these courses

funda-

curable

than

diseases,

in

which

momentarily

mandatory.

physician

interested

falls into the former [I],

the

potentially

uncommon,

matic et al.

more but

though

ticated

pragmatist

Aorta

Massachusetts

lished, therefore,

s a benevolent

Clue in

to a is no 948

forty-two

American

Journal

of Surgery

Rupture

of Thoracic

FIG. 1. A, diagrammatic representation of traumatic rupture of the aorta distal to the origin of the left subclavian artery, with compression of the aorta by periaortic hematoma and partial obstruction of lumen by the clot. Kate shift of the trachea to the right by the mediastinal hematoma. B, complete transection of aorta, with the exception of adventitia. There is distraction of the ends and total obstruction of the lumen by clot. (Both illustrations modified from Zehnder [IZ] .)

was lW/lOO mm. Hg and three days after injury was 200/120 mm. Hg. As far as could be determined there had been no prior hypertension. The patient showed persistent tachycardia, oliguria, falling hemoglobin and hematocrit values despite transfusions, and increas ng azotemia. Serial chest roentgenograms suggested regression of the mediastinal enlargement. It was postulated that a retroperitoneal hematoma had compromised the renal arterial inflow. resulting in acute renal ischemia (“Goldblatt phenomenon”) with mounting hypertension, oliguria, and nitrogen retention PI. Elevated blood pressure persisted between 150/100 and 190/l 10 mm. Hg. Femoral pulses unfortunately were not examined. Although the patient’s condition seemed stable, it was never entirely satisfactory, and tachycardia, apprehension, and evidence of continuing blood loss were present. His major problem, however, was thought to be a renal one. On the morning of the seventh hospital day he suddenly died. Autopsy disclosed traumatic rupture of the aorta immediately beyond the origin of the left subclavian artery, with massive left extrapleural hemorrhage and left hemothorax. Both kidneys showed hypoxic nephrosis. The apparent regression of the mediastinal hematoma as demonstrated roentgenographically was probably due to extrapleural sequestering of the blood which could not be delineated on portable chest roentgenogram. With intrapleural

injury

Vol. 110. DPcembc+r 1965

.iorta

! l-i! I

of thi5 collection the tamponin:: cfl‘cct L\;IS lost and tht’ patient cssanguinated.

rupture

COMMENTS

The insistent emphasis on travel at high speeds makes it likely that traumatic rupture of the thoracic aorta will increase in frequency. Simultaneously the outlook for the patient who survives the initial injury has brightened [S]. This is the result not only of improved surgical technics for managing the lesion but also, and perhaps particularly, of greater reliance on angiographic methods of establishing a definitive diagnosis. The decision to employ aortography in a severely injured patient, however, may be a difficult one. Consequently, any clinical clue that may help to reinforce this decision might be welcome. In the case previously detailed herein, persistent hypertension was incorrectly assigned a renal cause. If its true significance had been understood, death may possibly have been averted. Rice and m’ittstruck [4] were probably first in calling attention to the association of acute hypertension with traumatic rupture of the thoracic aorta. The diagnostic value of this finding has nevertheless been generally unrecognized, although Jahnke, Fisher, and Jones [3] have recently stated that, “Significant hypertension developing shortly after trauma in a previously normotensive individual is believed to be an important confirmatory finding.” It may, of course, be difficult to ascertain from a

Laforet TABLE I OCCURRENCEOF HYPERTENSIONIN FIFTEEN PATIENTS WITH PROVEDTRAUMATICRUPTUREOF THE THORACIC AORTA

Reference

Rice and Wittstruck [4] Wyman [j] Jay and French [6] Passaro and Pace [7] Spencer et al. [I] Malm [8] Dobell, MacNaughton, and Crutchlow [9] Fleischaker, Mazur, and Baisch [IO] Jahnke, Fisher, and Jones

[31

Age hr. 1 and Sex

20, 49, 20, 30, 24, *,

F F M M M M

[ill

180/120 170/90 160/90 150/70 140/100 210/110

39, M

160/90

17, M 20, M 25, M 23,M 33, M 36, M

180/80 142/84 180/90 200/90 180/72 210/110

19, M 42, M

200/120

Stoney, Roe, and Redington Present case

Blood Pressure (mm. Hg)

*

* Not recorded.

severely injured patient whether blood pressure was normal prior to trauma, but factors such as youth or active military status may be helpful in this regard. In Table I the basic data are recorded in fifteen instances of significant hypertension associated with proved traumatic rupture of the thoracic aorta. The finding of hypertension in a severely injured patient, particularly if coupled with evidence of continuing blood loss, is somewhat of a paradox. The patient reported on by Rice and Wittstruck [4] was a twenty year old woman who, in the last month of pregnancy, was involved in an accident as a passenger in a taxicab. These writers state, “The occurrence of a severe intractable hypertension is explained on the possible basis of (a) local segmental spasm of the aorta as the result of trauma, or (b) reflex irritation of cardiac accelerator nerves aggregated in the superficial cardiac plexus at the site of the laceration. The presence of previous mild hypertension and pressor instability is believed to have formed the etiological background.” On the basis of the findings in later cases, without the complicating factors of mild antecedent hypertension and of pregnancy, it may be possible to invoke a more mechanistic cause. Figure 1 suggests that some degree of

aortic obstruction occurs in these cases. This may result from extrinsic compression by the periaortic hematoma, intraluminal blockage by clot, or from both. Operative confirmation of this thesis has been obtained by other writers [8,11]. The situation, then, is essentially one of acute coarctation of the aorta, and hypertension in the upper extremities is thus inevitable. Aortic obstruction is further suggested if there is concomitant diminution in the volume of the femoral pulses, quantitated by sphygmomanometer if possible. SUMMARY

Traumatic rupture of the thoracic aorta is a fundamentally lethal but potentially curable lesion. It is due to accidents involving abrupt deceleration. Acute hypertension in the upper extremities may constitute an important clue in the diagnosis, and results from what is basically an acute aortic coarctation. REFERENCES 1. SPENCER, F. C., GUERIN, P. F., BLAKE, H. A., and BAHNSON, H. T. A report of fifteen patients with traumatic rupture of the thoracic aorta. J. Thoracic & Cardiooasc. Sarg., 41: 1, 1961. 2. LAFORET, E. G. Malignant hypertension associated with unilateral renal artery occlusion: three cases. Ann. Int. Med., 38: 667, 1953. 3. JAHNKE, E. J., JR., FISHER, G. W., and JONES, R. C. Acute traumatic rupture of the thoracic aorta: report of six consecutive cases of successful early repair. J. Thoracic b Cardiovasc. Surg., 48: 63, 1964. 4. RICE, W. G. and WITTSTRUCK, K. P. Acute hypertension and delayed traumatic rupture of the aorta. J.A.M.A., 147: 915, 1951. 5. WYMAN, A. C. Roentgenologic diagnosis of traumatic rupture of the thoracic aorta. Arch. Swg., 66: 656, 1953. 6. JAY, J. B. and FRENCH, S. W., III. Traumatic rupture of the thoracic aorta: review of literature and case report. Arch. Surg., 68: 657, 1954. 7. PASSARO. E.. TR. and PACE, W. G. Traumatic rupture of the aorta. Surgerj, 46: 787, 1959. 8. MALM, J. R. In discussion of reference [I]. 9. DOBELL, A. R. C., MACNAUGHTON, E. A., and CRUTCHLOW, E. F. Successful early treatment of subadventitial rupture of the thoracic aorta. New England J. Med., 270: 410, 1964. 10. FLEISCHAKER, R. J.. MAZUR, J. H., and BAISCH, B. F. Surgical treatment of acute traumatic rupture of the thoracic aorta. J. Thoracic & Cardiovast. Surg., 47: 289, 1964. 11. STONEY, R. J., ROE, B. B., and REDINGTON, J. V. Rupture of thoracic aorta due to closed-chest trauma. Arch. Surg., 89: 840, 1964. 12. ZEHNDER, M. A. Aortenruptur bei stumpfem Thoraxtrauma: retrospektive Auswertung der Kasuistik und zukiinftige chirurgische Mijglichkeiten. Helvet. chir. acta, 26: 442, 1959. American Journal of Surgery