What are the symptoms of an aortic aneurysm in an 18-year-old?

Symptoms of Aortic Aneurysm in an 18-Year-Old

Most aortic aneurysms in young patients are asymptomatic until they rupture or are at imminent risk of rupture, making them particularly dangerous in adolescents who may not be routinely screened due to their age.

Clinical Presentation

Common Symptoms

• Chest and/or back pain - Acute onset, severe, and tearing in quality is the most common presenting symptom of thoracic aortic aneurysm 1
• Abdominal pain - May be present with thoracoabdominal or abdominal aortic aneurysms 1
• Pulsatile abdominal mass - May be palpable in thin individuals with abdominal aortic aneurysms

Emergency Symptoms (Indicating Potential Rupture)

• Severe, sudden-onset pain - Described as tearing or ripping in quality
• Recurrent or refractory pain - Particularly concerning for contained rupture 1
• Syncope or near-syncope - Due to hypotension from blood loss
• Hypotension - Sign of hemodynamic compromise
• Pleural or peritoneal effusions - Especially if increasing, identifies patients at highest risk 1

Rare but Serious Symptoms

• Hemoptysis - May indicate aortobronchial fistula 1
• Hematemesis - May indicate aorto-esophageal fistula 1
• Hoarseness - Due to compression of recurrent laryngeal nerve
• Dysphagia - Due to compression of esophagus
• Dyspnea - Due to compression of trachea or bronchi

Risk Factors in Young Patients

Aortic aneurysms in 18-year-olds are rare but typically associated with:

• Genetic/connective tissue disorders:

  • Marfan syndrome
  • Loeys-Dietz syndrome
  • Vascular Ehlers-Danlos syndrome 1
  • Turner syndrome
  • Bicuspid aortic valve 2

• Family history of aortic aneurysm or sudden death 1, 2

• Trauma - Blunt thoracic trauma from motor vehicle accidents, falls, or sports injuries can lead to pseudoaneurysms 1

• Iatrogenic causes - Previous aortic surgery or catheter-based interventions 1

• Infection - Mycotic aneurysms (rare) 1

Diagnostic Approach

When an aortic aneurysm is suspected in an 18-year-old:

1. Transthoracic Echocardiography (TTE) - First-line imaging for thoracic aortic dilatation 2

2. CT or MRI - Required to:

   • Confirm TTE measurements
   • Rule out aortic asymmetry
   • Establish baseline diameters
   • Provide complete visualization of the entire aorta 2

3. CT with contrast - Specifically indicated when rupture is suspected, using a protocol including:

   • Non-contrast phase to detect intramural hematoma
   • Contrast injection to delineate presence of contrast leaks indicating rupture 1

Important Considerations

• High mortality risk - Mortality may be as high as 54% at 6 hours and 76% at 24 hours after rupture 1

• Rapid intervention needed - Contained rupture requires urgent treatment as overt free rupture leads rapidly to internal bleeding and death 1

• Diagnostic challenges - At the time of imaging, aortic rupture may be difficult to differentiate from contained rupture 1

• Location significance - The closer the aneurysm location is to the aortic valve, the greater the risk of death 1

Management Principles

• Symptomatic aneurysms require prompt surgical evaluation regardless of size 2

• Rapid growth (>0.5 cm/year) indicates high risk and should prompt surgical consideration 2

• Genetic testing should be considered in young patients with aortic aneurysms

• Blood pressure control is critical, with beta-blockers as preferred first-line medication 2

Young patients with aortic aneurysms require specialized care at centers experienced in managing aortic disease in adolescents and young adults, as management approaches differ significantly from those used for older adults.