Urolithiasis mimic: isolated spontaneous renal artery dissection in the emergency department

Abstract

A 40-year-old man, with no relevant medical or family history, presented with acute onset left flank pain radiating to his lower back. He was hypertensive (168/75 mmHg); however, his other vital signs were normal. No costovertebral angle knocking pain or abdominal tenderness was elicited. At onset, he complained of left flank pain and subsequently at presentation, he complained of moderate abdominal pain in the lower left quadrant. Laboratory results were normal. Abdominal ultrasound and non-contrast computed tomography (CT) ruled out renal abnormalities, including hydronephrosis or hydroureters (Fig. 1A). However, we undertook contrast-enhanced CT based on a high index of clinical suspicion for vascular lesions because of his persistent abdominal pain. This revealed left-sided noncommunicating isolated renal artery dissection (Fig. 1B,C). Spontaneous renal artery dissection (SRAD) is rare. Ultrasonography and urinalysis are useful in distinguishing between urolithiasis and SRAD. 1 SRAD can cause renal infarction or renovascular hypertension. 2 Treatment options consist of blood pressure control, anticoagulant drugs, endovascular therapy, and open surgery. 3 The absence of urolithiasis and hydronephrosis on noncontrast CT and of hematuria on urinalysis in patients with severe flank pain normally necessitates contrast-enhanced CT to investigate the vascular system for diseases, such as SRAD or acute renal infarction. DISCLOSURE Approval of the research protocol: N/A. Informed consent: Written informed consent was obtained from the patient. Registry and registration no. of the study/trial: N/A.

Isolated Renal Artery Dissection: A Systematic Review of Case Reports

“…The reason for the disparity of the prevalence in males remains unknown. In this cohort, abdominal pain was the most common presenting symptom making the diagnosis challenging and separating this etiology from a gastrointestinal (GI) or genitourinary (GU) source difficult [7].…”

“…Conservative management refers to the use of antihypertensives, systemic anticoagulation, and pain control. Calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers are the more frequently used anti-hypertensives [6][7][8][9][10][11][12]. The rationale of using anticoagulation is to prevent the development of thrombosis at the site of endothelial injury, which can result in intramural thrombus formation that can propagate the dissection.…”