Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Clinical Medicine Journal

  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Clinical Medicine Journal

clinmedicine Logo
  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

Image of the month: An unusual cause of cough, stridor and dyspnoea: A giant aortic arch aneurysm

Bhupinder Singh, Abhishek Goyal, Shibba T Chhabra, Naved Aslam, Bishav Mohan and Gurpreet S Wander
Download PDF
DOI: https://doi.org/10.7861/clinmed.2021-0095
Clin Med May 2021
Bhupinder Singh
ADayanand Medical College and Hospital, Ludhiana, India
Roles: associate professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: dr_bhupinders@yahoo.in
Abhishek Goyal
ADayanand Medical College and Hospital, Ludhiana, India
Roles: associate professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Shibba T Chhabra
BDayanand Medical College and Hospital, Ludhiana, India.
Roles: professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Naved Aslam
BDayanand Medical College and Hospital, Ludhiana, India.
Roles: professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bishav Mohan
BDayanand Medical College and Hospital, Ludhiana, India.
Roles: professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gurpreet S Wander
BDayanand Medical College and Hospital, Ludhiana, India.
Roles: professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
Loading

ABSTRACT

A 78-year-old man with hypertension presented with dry cough and gradually progressive dyspnoea for 3 months. The patient had an audible stridor. Cardiovascular examination was unremarkable. Respiratory system examination revealed both inspiratory and expiratory grunting sound. Laboratory investigations were normal. Electrocardiography showed sinus rhythm with left ventricular hypertrophy (LVH). Chest X-ray showed superior mediastinal widening. Transthoracic echocardiography showed preserved LV functions and dilated aortic arch. Contrast-enhanced computed tomography of the thorax showed a huge aortic arch aneurysm compressing the adjacent trachea. The patient was planned for hybrid aortic arch repair but the patient refused and was discharged on antihypertensive, antiplatelet and statin therapy. The patient continued to have limiting cough, dyspnoea and stridor for 4 months of follow-up until he suddenly died while at home. This case highlights an unusual presentation of a potentially lethal disease. Evaluation of patients presenting with cough and dyspnoea should not be restricted to respiratory diseases. The critical observations made from history

KEYWORDS:
  • dyspnoea
  • stridor
  • aortic aneurysm

Case presentation

A 78-year-old man with hypertension presented to the cardiology clinic with dry cough and gradually progressive dyspnoea for the previous 3 months. The patient also gave a history of grunting sound with respiration. He had no fever, chest pain, orthopnoea or pedal oedema. On examination, he had a pulse rate of 78 beats per minute, blood pressure of 168/82 mmHg and normal peripheral arterial oxygen saturation. The patient had an audible stridor. Cardiovascular examination was unremarkable. Respiratory system examination revealed both inspiratory and expiratory grunting sound.

Routine laboratory investigations (including brain natriuretic peptide and cardiac enzymes) were normal. Electrocardiography was sinus rhythm with left ventricular hypertrophy (LVH). Chest X-ray (Fig 1) showed superior mediastinal widening. Transthoracic echocardiography showed moderate concentric LVH, preserved LV functions and dilated aortic arch. Contrast-enhanced computed tomography (Fig 2a) of the thorax showed a huge aortic aneurysm (10.9 × 9.2 cm) arising from the floor of the aortic arch, which was compressing the adjacent trachea (Fig 2b). The aneurysm was having thrombus at the periphery (Fig 2b). Coronary artery disease was ruled out on conventional coronary angiography. The patient was planned for hybrid aortic arch repair but he refused to give consent for it, therefore, he was discharged on antihypertensive, antiplatelet and statin therapy. The patient continued to have limiting cough, dyspnoea and stridor for 4 months of follow-up until he suddenly died while at home.

Fig 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 1.

Chest X-ray showing superior mediastinal widening.

Fig 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 2.

Contrast-enhanced computed tomography of the thorax. a) Computed tomography showing 3-dimensional reconstruction of an aortic arch aneurysm (measuring 10.9 × 9.2 cm). b) Computed tomography showing tracheal compression (white arrow) on its anterior aspect by the aortic arch aneurysm. Thrombus visible in the periphery of the aneurysm (black asterisk).

Discussion

With increasing life expectancy and better screening protocols, the incidence of thoracic aortic aneurysms (TAAs) is increasing. TAAs commonly involve ascending aorta (60%) followed by descending thoracic aorta (40%), aortic arch (10%) and thoracoabdominal aorta (10%). Clinically most of the aortic aneurysms remain asymptomatic for a long time and are incidentally detected for imaging for other medical reasons. Sometimes giant thoracic aneurysms can have local mass effect; patients become symptomatic due to compression of adjacent structures such as vertebral bone erosion (back pain), oesophageal (causing dysphagia), recurrent laryngeal nerve (Ortner's syndrome), trachea or main bronchus (cough, dyspnea and stridor). Tracheo-bronchial compression by huge aortic arch aneurysm is mentioned in literature.1,2 Management of aortic arch aneurysms is challenging.3 Its repair is associated with higher morbidity and mortality rates compared with the treatment of ascending aortic aneurysms, owing to a high risk of cerebral complications. Nowadays hybrid aortic arch repair is preferred over only surgical repair.

  • © Royal College of Physicians 2021. All rights reserved.

References

  1. ↵
    1. MacGillivray RG
    . Tracheal compression caused by aneurysms of the aortic arch. Implications for the anaesthetist. Anaesthesia 1985;40:270–7.
    OpenUrlPubMed
  2. ↵
    1. Lin F
    , Chen CC, Su YJ, Lai YC, Chang WH. Ruptured aortic aneurysm presenting as a stridor. Int J Gerontol 2010;4:96–8.
    OpenUrl
  3. ↵
    1. Crawford ES
    , Saleh SA, Schuessler JS. Treatment of aneurysm of transverse aortic arch. J Thorac Cardiovasc Surg 1979;78:383–93.
    OpenUrlPubMed
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Image of the month: An unusual cause of cough, stridor and dyspnoea: A giant aortic arch aneurysm
Bhupinder Singh, Abhishek Goyal, Shibba T Chhabra, Naved Aslam, Bishav Mohan, Gurpreet S Wander
Clinical Medicine May 2021, 21 (3) e313-e314; DOI: 10.7861/clinmed.2021-0095

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Image of the month: An unusual cause of cough, stridor and dyspnoea: A giant aortic arch aneurysm
Bhupinder Singh, Abhishek Goyal, Shibba T Chhabra, Naved Aslam, Bishav Mohan, Gurpreet S Wander
Clinical Medicine May 2021, 21 (3) e313-e314; DOI: 10.7861/clinmed.2021-0095
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • ABSTRACT
    • Case presentation
    • Discussion
    • References
  • Figures & Data
  • Info & Metrics

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Segmental microbleeds: a radiological sign for cranial dural arteriovenous fistula
  • Unilateral upper cervical cord infarction in Opalski's syndrome caused by spontaneous vertebral artery dissection
  • Purple urine bag syndrome
Show more Image of the month

Similar Articles

FAQs

  • Difficulty logging in.

There is currently no login required to access the journals. Please go to the home page and simply click on the edition that you wish to read. If you are still unable to access the content you require, please let us know through the 'Contact us' page.

  • Can't find the CME questionnaire.

The read-only self-assessment questionnaire (SAQ) can be found after the CME section in each edition of Clinical Medicine. RCP members and fellows (using their login details for the main RCP website) are able to access the full SAQ with answers and are awarded 2 CPD points upon successful (8/10) completion from:  https://cme.rcplondon.ac.uk

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home
clinmedicine Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2023 by the Royal College of Physicians