Aortic aneurysm rupture is typically the failure of the aortic wall to withstand the tension placed upon it by a patient’s blood pressure. Along with clinical judgement and an assessment of signs and symptoms, a computed topography angiogram (CTA) is amongst the first line of diagnostic studies having 87-94% sensitivity for rupture. Therefore, while the possibility of a CTA not catching an aortic rupture is present, the chance is very low. Usually a missed or delayed diagnosis for this type of pathology is catastrophic resulting in patient death. We present the case report of a 68-year-old male with a contained aortic rupture that was initially missed on CTA. He presented to the ED with shock like symptoms after a syncopal episode at home. Initial computed topography (CT) scan revealed a pericardial effusion with concern for hemopericardium and mass effect on the right ventricle. A follow up CTA was obtained; however, it was negative for any acute process. Given patient’s continued instability, a TTE was performed which showed concern for a dissection flap. Subsequently, a TEE was performed showing an aortic dissection at the anterior aortic root as well as severe aortic insufficiency with a perforated right coronary cusp. The patient underwent emergent cardiac surgery and recovered well despite the delay in diagnosis. This case demonstrates the importance of a high index of suspicion for acute aortic dissection despite an initial negative CTA.

Aortic rupture, Ascending aortic aneurysm, Contained aortic rupture