What are the clinical features of a ruptured aneurysm?

Clinical Features of Ruptured Aneurysm

Acute onset of severe pain—in the chest/back for thoracic aneurysms or abdomen/back/flank for abdominal aneurysms—is the cardinal presenting symptom of aneurysm rupture and should trigger immediate evaluation for life-threatening hemorrhage. 1, 2

Symptom Profile

Pain Characteristics

• Abdominal aortic aneurysm (AAA) rupture presents with acute abdominal, back, or flank pain in 65-90% of cases 2, 3
• Thoracic aortic aneurysm rupture manifests as acute chest and/or back pain, with concurrent abdominal pain possible in thoracoabdominal aneurysms 1
• Pain may radiate to the groin in AAA rupture 1
• Recurrent or refractory pain identifies patients at highest risk of progression from contained to complete rupture 1, 2

Associated Symptoms

• Syncope occurs in 27.8% of ruptured AAA cases 3
• Nausea and vomiting are common 1
• Fever is present in ≥70% of ruptured AAA cases 2

Important caveat: Classic symptoms have poor sensitivity—abdominal pain (61.7%), back pain (53.6%), and syncope (27.8%)—meaning their absence does not rule out rupture 3

Physical Examination Findings

Hemodynamic Instability

• Hypotension is present in only 30.9% of cases, making it an unreliable sign 3
• Hemorrhagic shock with tachycardia and decreased capillary refill indicates free rupture 4
• Contained ruptures remain hemodynamically stable because periaortic structures (pleura, pericardium, retroperitoneum) seal the hemorrhage 1, 2

Abdominal Examination

• Pulsatile abdominal mass is detected in only 47.1% of cases 3
• Abdominal distension may be present 1

Neurological Signs

• Altered level of consciousness 1
• Focal weakness or cranial nerve deficits (more common with intracranial aneurysm rupture) 1
• Lower limb motor or sensory deficits (with thoracoabdominal aneurysms causing vertebral erosion) 1

Specific Presentations by Aneurysm Type

Intracranial Aneurysm Rupture (Subarachnoid Hemorrhage)

• Severe "thunderclap" headache is the hallmark symptom 1
• Photophobia and nuchal rigidity from meningeal irritation 1
• Clinical grading uses Hunt and Hess or World Federation of Neurological Surgeons scales 1
• Grade 1: Mild headache with Glasgow Coma Scale (GCS) 15 1
• Grade 2: Moderate to severe headache with nuchal rigidity, GCS 13-14 without motor deficit 1
• Grade 3: Lethargy, confusion, mild focal deficit, GCS 13-14 with motor deficit 1

Thoracic Aortic Aneurysm Rupture

• Acute respiratory failure from free rupture into the left hemithorax 1
• Hemoptysis from aortobronchial fistula 1
• Hematemesis from aorto-esophageal fistula 1
• Mortality is 54% at 6 hours and 76% at 24 hours after rupture 1

Visceral Artery Aneurysm Rupture

• Acute abdominal pain with hemorrhagic shock 4, 5, 6
• Splenic artery aneurysm rupture presents with sudden onset abdominal pain and hypovolemic shock 5
• Hepatic and ileocolic artery aneurysm ruptures present similarly with acute pain, tachycardia, and hypotension 4, 6

Imaging Findings

CT Angiography (Preferred Modality)

• Sensitivity 91.4%, specificity 93.6% for diagnosing AAA rupture, though some cases are missed 2, 3
• Periaortic stranding or soft tissue changes indicate rupture 2
• Contrast extravasation confirms active bleeding and complete rupture 2
• Intramural hematoma on non-contrast phase signals impending rupture 1, 2, 7
• Pleural or peritoneal effusions, especially if increasing, indicate contained or complete rupture 1, 2
• Perivascular hematoma sealed by retroperitoneal structures defines contained rupture 1, 2

Point-of-Care Ultrasound

• Sensitivity 97.8%, specificity 97.0% for detecting AAA (though cannot confirm rupture) 3
• Positive RUSH (Rapid Ultrasound for Shock and Hypotension) exam aids rapid diagnosis 4

Critical Clinical Distinctions

Contained vs. Free Rupture

• Contained rupture: Hemodynamically stable, preserved aortic wall integrity on imaging, sealed hemorrhage 1, 2
• Free rupture: Hemorrhagic shock, massive hematoma, rapid progression to death 1
• Impending rupture: Acute pain with preserved wall integrity but intramural changes on imaging 1, 2

Risk Factors Present in History

• Hypertension (present in nearly all cases) 1
• Tobacco use 1
• Female sex (rupture occurs at smaller diameters) 1
• Familial predisposition 1
• Connective tissue disorders 1

Clinical pearl: Any patient with known aneurysm presenting with acute pain should be presumed to have impending rupture requiring ICU admission and urgent repair within 24-48 hours, regardless of aneurysm size 1, 2