What concerns would you have for a patient with a history of multiple brain aneurysms and a stent in the neck presenting with left flank pain?

Immediate Concerns for Left Flank Pain in a Patient with Multiple Aneurysms

Yes, you should have significant concerns—this patient requires urgent vascular imaging with CT angiography of the abdomen and pelvis to rule out a renal artery aneurysm, visceral artery aneurysm, or aortic pathology, as flank pain in a patient with multiple aneurysms is a red flag symptom that demands immediate investigation. 1

Why This Patient Is High-Risk

Systemic Arteriopathy Pattern

• The presence of multiple cerebral aneurysms plus a cervical stent (likely carotid or vertebral artery aneurysm) strongly suggests an underlying systemic arteriopathy or genetic predisposition, dramatically elevating the risk of additional aneurysms in other vascular beds including renal, visceral, and aortic territories. 1
• Patients with one peripheral aneurysm have a high likelihood of harboring additional aneurysms elsewhere, with 13-19% of thoracic aortic aneurysm patients having first-degree relatives with similar disease even without identified genetic syndromes. 1

Critical Differential Diagnoses for Flank Pain

Renal Artery Aneurysm:

• The most concerning diagnosis given the aneurysm history and flank pain location. 2, 1
• Patients undergoing catheter-based intervention for visceral artery aneurysms should be watched closely for development of flank pain, which may indicate end-organ complications or aneurysm expansion. 2
• Flank pain specifically indicates potential renal artery involvement requiring immediate assessment. 1

Visceral Artery Aneurysm (Splenic, Mesenteric, or Renal):

• These can present with flank or abdominal pain and carry rupture risk. 2
• One concern with catheter-based management is the limited ability to assess end organs after treatment, making post-procedure flank pain particularly worrisome for bowel or renal ischemia. 2

Aortic Pathology:

• Abdominal aortic aneurysm expansion or dissection can present with flank pain. 3
• Hypertension is present in 85% of patients with ruptured aneurysms, making this a critical consideration. 3

Immediate Diagnostic Algorithm

First-Line Imaging

Order CT angiography (CTA) of the abdomen and pelvis immediately: 1

• Provides rapid examination with precise aneurysm localization
• Detects impending rupture or dissection
• Evaluates renal perfusion and end-organ viability
• Assesses for concurrent aortic pathology

What to Look For on Imaging

• Renal artery aneurysm size and morphology (saccular morphology is particularly high-risk regardless of size) 1
• Visceral artery aneurysms (splenic, hepatic, mesenteric) 2
• Abdominal aortic aneurysm diameter and any signs of expansion 3
• Evidence of dissection (intimal flap, false lumen) 1
• Perianeurysmal stranding or fluid suggesting impending or contained rupture 1

Risk Stratification Based on Findings

Immediate Surgical Consultation Required For:

• Aortic dissection (any size) 1
• Saccular aneurysm morphology (high-risk feature independent of size) 1
• Aneurysm growth ≥0.5 cm/year if prior imaging available 1
• Any symptomatic aneurysm (the flank pain itself is the symptom) 1
• Signs of rupture or impending rupture on imaging 2

Elective Management Considerations:

• Endovascular approaches are preferred when technically feasible, with technical success rates of 67-100% for visceral artery aneurysms. 2, 1
• Post-intervention monitoring is essential to detect end-organ complications. 2, 1

Critical Pitfalls to Avoid

Do not dismiss this as musculoskeletal pain: 1

• Flank pain in a patient with known aneurysmal disease requires vascular imaging before attributing symptoms to musculoskeletal causes
• While thoracolumbar junction syndrome can cause flank pain, this diagnosis should only be considered after excluding vascular pathology in this high-risk patient 4

Do not apply standard size thresholds to saccular aneurysms: 1

• Morphology itself is a high-risk feature
• Saccular aneurysms warrant intervention regardless of size when symptomatic

Do not delay imaging for "observation": 1

• The combination of multiple aneurysms and new flank pain represents a potential vascular emergency
• Rupture of visceral or renal artery aneurysms carries 38% operative mortality 2

Additional Considerations

Genetic Evaluation

• If not already performed, consider genetic testing for connective tissue disorders (Marfan syndrome, Loeys-Dietz syndrome) or familial aneurysm syndromes, particularly if the patient is younger or has family history. 3

Blood Pressure Management

• Ensure strict blood pressure control, as hypertension is present in 85% of ruptured aneurysms and dramatically increases wall stress. 3, 5