Chronic rupture of abdominal aortic aneurysm manifesting as crural neuropathy

Chronic rupture of abdominal aortic aneurysm (AAA) resulting in unusual cli nical manifestations can occur if the resistance of structures surrounding the aorta is sufficient to contain hemorrhage. In this report, we describe five cases of chronic ruptured AAA in which the presenting feature was crur al neuropathy. All patients were male with a mean age of 74 +/- 1.8 years. At the time of presentation, crural neuropathy had been ongoing for 3 to 9 weeks. In three cases, AAA was not initially suspected because an inadequat e clinical examination was performed (not in the vascular surgery departmen t) and because of the small diameter of the aorta in relation to the patien t's morphology. Two patients had one episode of hypotension that was wrongl y attributed to vagal attack. Abdominal CT scanning was always diagnostic o f chronic rupture. In two cases, rupture was associated with erosion of the body of one or more vertebrae and laboratory evidence of inflammation, i.e ., increase in sedimentation rate and fibrinogen level. The mean diameter o f the AAA was 7.1 +/- 0.9 cm (range 5-10 cm). All patients underwent midlin e laparotomy, which was performed under emergency conditions in two cases, under semi-emergency conditions in one case, and electively in two cases. P erforation was consistently located on the posterolateral wall of the aorta and varied from 1 to 3 cm in length. Repair was performed using an aortobi femoral prosthesis in four cases, and a straight tube in one case. The pati ent who underwent emergency surgery died 4 days after the procedure. The re maining four patients recovered uneventfully and were discharged after 10 d ays. In the elderly, ruptured AAA should be included in the differential di agnosis of crural neuropathy. An episode of hypotension, regardless of its duration, in an elderly patient should be given serious consideration as a possible sign of ruptured AAA with ongoing retroperitoneal hemorrhage.