British Journal of Radiology (2007) 80, e275-e277
© 2007 British Institute of Radiology
doi: 10.1259/bjr/13699159
Multiple aneurysms in the female breast: a case report
J Cox, MB, BS, FRCS, FRCR
1
B Kaye, MB, ChB, DMRD, FRCR
1
D Burn, FRCP, MD
2 and
R Bliss, MA, MB, MChir, FRCS, FRCR
1
1 Breast Screening Unit, Royal Victoria Infirmary, Queen Victoria Rd and 2 Department of Neurology, Newcastle General Hospital, Newcastle-upon-Tyne, UK
Correspondence: Dr J Cox, Department of Radiology, University Hospital North Durham, North Rd, Durham, UK.. E-mail: julie.cox{at}cddah.nhs.uk
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Abstract
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Arterial aneurysms are defined as localized abnormal dilatations in an arterial wall. We report the first case of multiple true aneurysms in the female breast in a patient with a history of chronic amphetamine abuse who presented with a probable subarachnoid haemorrhage (SAH).
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Introduction
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Arterial aneurysms are defined as localized abnormal dilatations in an arterial wall. Cases of both intercostal arteriovenous fistulae [1] and axillary artery aneurysms [1] presenting as symptomatic breast lumps have been described, along with a number of cases of pseudoaneurysm formation after core biopsy [1–5]. We report the first case of multiple true aneurysms in the female breast in a patient who presented with a probable subarachnoid haemorrhage (SAH) with a history of chronic amphetamine abuse.
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Case report
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A 50-year-old right-handed woman presented to an accident and emergency department with a 4-day history of occipital headache, increasing in intensity on the day prior to admission, and five to six episodes of vomiting over the preceding 24 h. She had no past medical history of note, and took no medication. She was unemployed, separated from her partner, and lived with her teenage son. She admitted to drinking one bottle of wine and smoking 20 cigarettes per day.
On examination, she was alert and cooperative with a Glasgow Coma Scale (GCS) of 15. Neurological examination was normal. She was noted to have an 8 cm left breast haematoma, which she described as occurring spontaneously. The patient described a sudden pain in her left breast, associated with visible swelling over several seconds until she felt a "pop-like" sensation. This was followed by extensive bruising in her left breast.
Routine blood tests revealed a raised white cell count of 17 000 mm–3 blood, and an elevated erythrocyte sedimentation rate (ESR) (66 mm h–1) and C-reactive protein (CRP) (120.7 mg l–1). Urea and electrolytes, as well as liver function tests, were normal. Lumbar puncture showed evidence of xanthochromia, compatible with SAH, with a protein of 0.78 g L–1, glucose of 2.6 mmol L–1 and polymorphonuclear cells in the sample of cerebrospinal fluid. A CT scan of the patient's head was initially reported as normal, but on review was thought to show some subarachnoid blood in the quadrigeminal cistern. She underwent cerebral angiography, which demonstrated no definitive intracerebral aneurysms but confirmed diffuse arterial spasm, in keeping with SAH, and some focal dilatation of the basilar artery (Figure 1
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Figure 1. Images(lateral and Townes' views) from cerebral angiography demonstrated focal dilatation of the mid basilar artery (white arrow) and spasm (blue arrow), providing secondary evidence of subarachnoid haemorrhage (SAH).
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She was treated with nimodipine on the basis that she had undergone a SAH. Over the next few days, she became increasingly agitated and disorientated. She subsequently admitted to a history of alcohol abuse (up to a bottle of spirits per day) and long-term amphetamine abuse. She maintained a low-grade temperature until day 6, with elevated inflammatory markers. On day 15, she underwent a cerebral MRI scan with magnetic resonance angiography. Both showed no evidence of haemorrhage or vasculitis. Her neurological status gradually improved with supportive measures.
As an inpatient, she was also referred to the breast symptomatic department owing to her rather unusual presentation with a spontaneous breast haematoma. On examination, a large left breast haematoma was noted. The right breast appeared clinically normal.
Bilateral mammography (Figure 2) demonstrated an area of asymmetrical density in the upper half of the left breast consistent with clinical haematoma, and multiple bilateral focal arterial dilatations consistent with aneurysms. Presence of flow within the aneurysms was confirmed with Doppler evaluation during breast ultrasound (Figure 3). As there was no evidence of malignancy, the patient was reassured and discharged. On follow-up at 2 months in the neurological outpatient clinic, the patient was well and asymptomatic.
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Figure 2. Mediolateral oblique/craniocaudal (MLO/CC) views of both breasts demonstrating asymmetrical density in the upper half of the left breast at the site of the haematoma (yellow arrows) and aneurysmal dilatation of arteries (black arrows) in both breasts.
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Figure 3. Ultrasound image from the right breast demonstrating the aneurysmal vessel that had flow on Doppler evaluation.
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Discussion
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True aneurysms in the female breast have not previously been described in the literature. Dehn and Lee [1] report a case in a hypertensive 57-year-old woman who presented with sudden pain from a mass and bruising in the right breast after an episode of fulminant hypertension. The cause of this was demonstrated on angiography to be an arteriovenous fistula between the right second anterior intercostal artery and vein, and not an aneurysm. This was treated successfully by ligation of the artery and vein.
Trikha et al [2] describe a more recent case of an 84-year-old woman with a history of aortic and mitral regurgitation and atrial fibrillation who presented with painless swelling of her right axillary tail. Bilateral axillary artery aneurysms were confirmed on Doppler ultrasound, and the patient was managed conservatively.
A number of cases of pseudoaneurym formation in the female breast have been reported after core biopsy with a variety of needle sizes: two after stereotactic breast biopsy with a 14G needle [4, 5]; two after ultrasound-guided biopsy with a 14G needle [6]; and one after ultrasound-guided biopsy with an 18G needle [7]. The latter was repaired with a sonographically guided needle injection of thrombin.
Our patient, as well as being the first reported case of multiple breast aneurysms, also highlights an intriguing link between amphetamine abuse and vascular disorders. She presented with symptoms and signs of possible intracranial haemorrhage, and with imaging evidence of SAH on cerebral angiography.
Abuse of drugs such as amphetamine, cocaine and ecstasy is rapidly replacing traditional aetiological factors as the commonest cause of intracerebral haemorrhage in young adults [1]. Although these cases may represent hypertensive haemorrhages, there is some evidence that these patients also harbour underlying vascular malformations. In a series of 13 patients with a documented history of drug abuse and intracerebral haemorrhage, 10 underwent cerebral angiography. Intracranial aneurysms were demonstrated in six patients and arteriovenous malformation in three. A further patient who had not undergone angiography was documented as having a middle cerebral artery aneurysm at autopsy. Therefore, drug-related intracerebral haemorrhage may be frequently related to underlying vascular malformations
Methamphetamine has also been established as a risk factor for aortic dissection, principally through its hypertensive effect [1]. Multiple visceral aneurysms (splanchnic and renal) were demonstrated on angiography in two patients who had histories of chronic oral amphetamine abuse but no other risk factors for aneurysm formation [1]. We postulate that amphetamine abuse may have been a factor in the development of multiple breast aneurysms in our patient.
Received for publication June 27, 2006.
Revision received August 13, 2006.
Accepted for publication August 24, 2006.
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References
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- Dehn TCB, Lee ECG. Aneurysm presenting as a breast mass. BMJ (Clin Res Ed) 1986;292:1240[Free Full Text]
- Trikha SP, Rose V, Sharma AK. An unusual origin of a breast lump: a case report. The Breast Journal 2002;8:391[CrossRef][Medline]
- Dixon AM, Enion DS. Pseudoaneurysm of the breast: case study and review of the literature. Br J Radiol 2004;77:694–7.[Abstract/Free Full Text]
- Smith SM. Breast pseudoanerysm after core biopsy. AJR 1996;167:817[Medline]
- Beres RA, Harrington DG, Wenzel MS. Percutaneous repair of breast pseudoaneurysm: sonographically guided embolisation. AJR 1997;169:425–7.[Free Full Text]
- Chorny K, Raza S, Bradley FM, Baum JK. Pseudoaneurysm formation in the breast after needle core biopsy. J Ultrasound 1997;16:849–51.
- McNamara MP, Boden T. Pseudoaneurysm of the breast related to 18G core biopsy: successful repair using thrombin injection. AJR 2002;179:924–6.[Free Full Text]
- McEvoy AW, Kitchen ND, Thomas DG. Intracerebral haemorrhage and drug abuse in young adults. Br J Neurosurg 2000;14:449–54.[CrossRef][Medline]
- Swallwell CI, Davis GC. Methamphetamine as a risk factor for acute aortic dissection. J Forensic Sci 1999;44:23–6.[Medline]
- Welling TH, Williams DM, Stanley JC. Excessive oral amphetamine use as possible causes of renal and splanchnic arterial aneurysms: a report of two cases. J Vascular Surgery 1998;28:727–31.[CrossRef][Medline]
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Abstract
Introduction
