Aneurysm

Recognition

Abdominal aortic aneurysm (AAA): Most common clinically significant type. Occurs below the renal arteries in 90% of cases. Men over 65, smokers, and hypertensive clients are at highest risk (4–6x more common in men). Most AAAs are asymptomatic until rupture. A deep, constant abdominal or back pain that is new and unexplained may indicate an expanding aneurysm. A pulsatile, expansile mass in the epigastric region is the hallmark physical finding.
Cerebral (berry) aneurysm: Thin-walled outpouchings at arterial bifurcations in the circle of Willis. Asymptomatic until rupture, which causes subarachnoid hemorrhage — "worst headache of my life" with sudden thunderclap onset, neck stiffness, photophobia, and altered consciousness.
Thoracic aortic aneurysm: Associated with Marfan syndrome, Ehlers-Danlos syndrome, and chronic hypertension. May cause chest or back pain, hoarseness (recurrent laryngeal nerve compression), or difficulty swallowing.
Pathophysiology: Atherosclerotic degeneration weakens the tunica media, destroying elastic fibers and smooth muscle. Chronic hypertension increases wall stress, accelerating dilation. Connective tissue disorders (Marfan, EDS) cause congenital weakness of the vessel wall. Mural thrombus frequently lines the aneurysm interior and can embolize distally.

Deep abdominal massage is absolutely contraindicated when AAA is known or suspected. This includes psoas work, deep visceral techniques, and any sustained pressure on the abdomen.
If a pulsatile, expansile mass is felt during abdominal or psoas palpation — stop immediately, reposition the client, and refer urgently. An expansile mass pushes the palpating fingers apart with each heartbeat. This distinguishes a true aneurysm from transmitted aortic pulsation.
For clients with known small, monitored aneurysms (< 5 cm) and physician clearance, general relaxation massage avoiding the abdomen is appropriate. Keep techniques gentle and stress-reducing — avoid techniques that significantly raise blood pressure.
Clients are commonly on antihypertensives and statins. Beta-blockers reduce heart rate and cause orthostatic hypotension — allow slow position transitions.

Pulsatile abdominal mass during bodywork: Stop abdominal work immediately. Refer urgently for vascular imaging
"Worst headache of my life" (thunderclap onset): Call 911 — possible ruptured cerebral aneurysm
Sudden severe abdominal or back pain with hypotension: Call 911 — possible ruptured AAA

Aneurysms are often silent until rupture, which carries extremely high mortality (> 80% for ruptured AAA)
A pulsatile abdominal mass felt during bodywork is a critical red flag requiring immediate referral — never continue abdominal work
Deep abdominal and psoas work is absolutely contraindicated when AAA is known or suspected
"Worst headache of my life" with thunderclap onset may indicate ruptured cerebral aneurysm — call 911
Connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome) significantly increase aneurysm risk at younger ages