Aortic intramural hematoma

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Aortic intramural haematoma (IMH) is an atypical form of aortic dissection due to haemorrhage into the wall from the vasa vasorum without an intimal tear.

Epidemiology

Typically aortic intramural haematomas are seen in older hypertensive patients. The same condition may also develop as a result of blunt chest trauma with aortic wall injury or penetrating atherosclerotic ulcer ^1-2.

Pathology

This condition is thought to begin with spontaneous rupture of the vasa vasorum, the blood vessels that penetrate the outer half of the aortic media from the adventitia and arborize within the media to supply the aortic wall ².

The haematoma propagates along the media layer of the aorta.

Consequently, intramural hematoma weakens the aorta and may progress either to outward rupture of the aortic wall or to inward disruption of the intima, the latter leading to communicating aortic dissection ².

~~Radiographic features~~
CT

~~Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT. Intimal calcification may be displaced inwards.~~

~~Unlike aortic dissection, no intimal flap is present.~~

~~Echocardiography and MRI may also detect the abnormality but conventional angiography will not.~~
~~Treatment and prognosis~~

~~If intramural haematoma involves the ascending aorta, treatment is surgical to prevent rupture or progression to a classic~~ ~~aortic dissection~~.

~~Conservative management is indicated for aortic intramural hematomas of the descending aorta.~~
~~Differential diagnosis~~

~~The main differential diagnoses are:~~

~~thrombosed false lumen in classic~~ ~~aortic dissection: typically spirals longitudinally around the aorta whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall~~

~~aortitis: typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration~~

Classification

Similar to aortic dissections, intramural hematomas are classified according to the Stanford classification system ⁴:

type A: involves the ascending aorta, with or without descending aortic involvement
type B: confined to the descending aorta, distal to the origin of the left subclavian artery

Radiographic features

CT

Acute intramural haematomas appear as crescentic, high-attenuating (60-70 HU) regions of thickening of the aortic wall on non-contrast CT. The lesions apparently exhibit low attenuation in relation to the aortic lumen on post-contrast CT. Intimal calcification may be displaced inwards.

Unlike aortic dissection, no intimal flap is present.

Echocardiography and MRI may also detect the abnormality but conventional angiography will not.

Treatment and prognosis

If intramural haematoma involves the ascending aorta, treatment is surgical to prevent rupture or progression to a classic aortic dissection.

Conservative management is indicated for aortic intramural hematomas of the descending aorta.

Differential diagnosis

The main differential diagnoses are:

thrombosed false lumen in classic aortic dissection: typically spirals longitudinally around the aorta whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall
aortitis: typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration

-<p><strong>Aortic intramural haematoma (IMH)</strong> is an atypical form of <a href="/articles/aortic-dissection">aortic dissection</a> due to haemorrhage into the wall from the <a href="/articles/vasa-vasorum">vasa vasorum</a> without an intimal tear.</p><h4>Epidemiology</h4><p>Typically aortic intramural haematomas are seen in older hypertensive patients. The same condition may also develop as a result of blunt chest trauma with aortic wall injury or <a href="/articles/penetrating-atherosclerotic-ulcer">penetrating atherosclerotic ulcer</a> <sup>1-2</sup>.</p><h4>Pathology</h4><p>This condition is thought to begin with spontaneous rupture of the vasa vasorum, the blood vessels that penetrate the outer half of the aortic media from the adventitia and arborize within the media to supply the aortic wall <sup>2</sup>.</p><p>The haematoma propagates along the media layer of the aorta.</p><p>Consequently, intramural hematoma weakens the aorta and may progress either to outward rupture of the aortic wall or to inward disruption of the intima, the latter leading to communicating <a href="/articles/aortic-dissection">aortic dissection</a> <sup>2</sup>.</p><h4>Radiographic features</h4><h5>CT</h5><p>Non-contrast CT shows a cuff of high attenuation around the aortic lumen in the acute phase that is low attenuation on post-contrast CT. Intimal calcification may be displaced inwards.</p><p>Unlike aortic dissection, no intimal flap is present.</p><p>Echocardiography and MRI may also detect the abnormality but conventional angiography will not.</p><h4>Treatment and prognosis</h4><p>If intramural haematoma involves the ascending aorta, treatment is surgical to prevent rupture or progression to a classic <a href="/articles/aortic-dissection">aortic dissection</a>.</p><p>Conservative management is indicated for aortic intramural hematomas of the descending aorta.</p><h4>Differential diagnosis</h4><p>The main differential diagnoses are:</p><ul>
+<p><strong>Aortic intramural haematoma (IMH)</strong> is an atypical form of <a href="/articles/aortic-dissection">aortic dissection</a> due to haemorrhage into the wall from the <a href="/articles/vasa-vasorum">vasa vasorum</a> without an intimal tear.</p><h4>Epidemiology</h4><p>Typically aortic intramural haematomas are seen in older hypertensive patients. The same condition may also develop as a result of blunt chest trauma with aortic wall injury or <a href="/articles/penetrating-atherosclerotic-ulcer">penetrating atherosclerotic ulcer</a> <sup>1-2</sup>.</p><h4>Pathology</h4><p>This condition is thought to begin with spontaneous rupture of the vasa vasorum, the blood vessels that penetrate the outer half of the aortic media from the adventitia and arborize within the media to supply the aortic wall <sup>2</sup>.</p><p>The haematoma propagates along the media layer of the aorta.</p><p>Consequently, intramural hematoma weakens the aorta and may progress either to outward rupture of the aortic wall or to inward disruption of the intima, the latter leading to communicating <a href="/articles/aortic-dissection">aortic dissection</a> <sup>2</sup>. <!--[if gte mso 9]><xml>
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+<![endif]--> </p><h5>Classification</h5><p>Similar to aortic dissections, intramural hematomas are classified according to the <a title="Stanford classification" href="/articles/stanford-classification">Stanford classification</a> system <sup>4</sup>:</p><ul>
+<li>
+<strong>type A</strong>: involves the ascending aorta, with or without descending aortic involvement</li>
+<li>
+<strong>type B</strong>: confined to the descending aorta, distal to the origin of the left subclavian artery</li>
+</ul><p></p><h4>Radiographic features</h4><h5>CT</h5><p>Acute intramural haematomas appear as crescentic, high-attenuating (60-70 HU) regions of thickening of the aortic wall on non-contrast CT. The lesions apparently exhibit low attenuation in relation to the aortic lumen on post-contrast CT. Intimal calcification may be displaced inwards.</p><p>Unlike aortic dissection, no intimal flap is present.</p><p>Echocardiography and MRI may also detect the abnormality but conventional angiography will not.</p><h4>Treatment and prognosis</h4><p>If intramural haematoma involves the ascending aorta, treatment is surgical to prevent rupture or progression to a classic <a href="/articles/aortic-dissection">aortic dissection</a>.</p><p>Conservative management is indicated for aortic intramural hematomas of the descending aorta.</p><h4>Differential diagnosis</h4><p>The main differential diagnoses are:</p><ul>

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