Keywords
aortic dissection - embolism - foreign body - pulmonary embolism
Hemopericard in combination with acute back pain typically raises the concern for
acute type A aortic dissection. It is important to recognize that according to the
recent case reports, a wide variety of rare conditions can mimic aortic dissections.
Our case illustrates that prompt assessment and appropriate surgical care are fundamental
in the management of these patients.
Case Presentation
A 62-year-old woman admitted to the hospital complaining of acute chest pain. She
described sudden onset of stabbing pain between her shoulder blades. Her medical history
was unremarkable, except for spine surgery in 2008. The clinical symptoms appeared
to be consistent with the diagnosis of acute aortic dissection. Transthoracic echocardiography
and a CT scan of the chest revealed a 7 to 16 mm pericardial effusion without the
evidence of a dissection flap in the ascending aorta, dilation of the aortic root,
or aortic valve insufficiency. Coronary angiography did not show any signs of coronary
artery disease. Three irregular shaped, 8 to 15 cm long and thin pieces of foreign
body material appeared to be located in the IVC ([Figs. 1], [2]), the right atrium, and the right ventricular wall. Another piece was found in a
branch of the right pulmonary artery. These structures could clearly be identified
on CT images. The patient was taken to the operating room. Intraoperative findings
included a small amount of hemorrhagic pericardial effusion as well as foreign body
material perforating the inferior wall of the right ventricle close to the posterior
descending coronary artery. The 2 to 3 mm thick foreign body could be extracted completely
from the right ventricle. The two pieces in the IVC could not be entirely removed
from the inferior vena cava because they appeared adherent to the vessel wall distally.
The extracted material was sent to the pathology for further examination. During her
postoperative course, no relevant complications occurred. The patient was discharged
within 3 weeks.
Figure 1 2D reconstruction: palacosstick inside the IVC, illustration of both augmented vertebral
bodies.
Figure 2 3D reconstruction: palacosstick compared with aorta.
Discussion
Although acute type A aortic dissection should lead to rapid surgical treatment, a
thorough history, clinical exam, and work-up are of major importance to identify the
correct diagnosis and provide appropriate care. Eagle et al analyzed 55 patients who
admitted to the emergency department complaining of symptoms initially suggesting
acute aortic dissection.[1] Negative aortograms prompted further testing and revealed a wide variety of entities
including myocardial infarction, aneurysms, mediastinal tumors, as well as rare findings
such as cholecystitis. Several case reports describe rare conditions like ingested
fish bones, and dislodged transcatheter closure devices causing symptoms masquerading
acute dissections.[2]
[3]
More than 8 cm long, thin and almost entirely straight cement sticks in the IVC and
right ventricular wall is a very seldom finding. Our question was: how did it get
there? The patient had undergone kyphoplasty 2 years prior to the presentation, the
only possible reason for the cement finding in her body. The procedure is used for
pain relief of osteoporotic vertebral body compression fractures. After percutaneous
injections of palacos the material solidifies. This process generates temperatures
as high as 70°C with the potential of causing tissue damage allowing leakage of bone
cement into surrounding structures. In her case, we must assume that the cement application
was difficult. Besides the palacos pieces in the IVC and right heart, a relatively
large pulmonary embolus can be identified on CT images, suggesting palacos embolization
into a branch of the right pulmonary artery ([Fig. 3]). Similar observations have been reported in the recent publications.[4]
[5]
[6]
[7]
[8]
[9] We assume that over time one of the spiky cement sticks has worked itself through
the right ventricular wall eventually causing a perforation with hemopericard and
acute onset of symptoms resembling an aortic dissection.
Figure 3 Palacos embolus into a branch of right pulmonary artery.
Our case report illustrates a rare condition initially suggesting a wrong diagnosis.
The described scenario emphasizes the importance of a thorough history and unbiased
review of imaging tests. Missing out on the correct diagnosis in our patient could
have resulted in a life-threatening condition or death.
