Aortic dissection with pulmonary artery intramural hematoma

Case contributed by Dr Joachim Feger

Presentation

Acute chest pain radiating to the left arm and neck, dilated aortic root on echocardiography.

Patient Data

Age: 45 years
Gender: Male

Findings

Aorta

Pulmonary arteries, mediastinum, and lungs

  • high-density fluid along and around the pulmonary trunk and both pulmonary arteries with a relatively narrow lumen of the right pulmonary arteries
  • probably extravasation of blood into the pulmonary recesses and transverse pericardial sinus
  • fat stranding and non-enlarged lymph nodes in the mediastinum
  • no alveolar hemorrhage

Heart and coronary arteries

Impression

Key images

  • large false lumen (yellow overlay) left to the dissecting intimal flap
  • intimal entry tear in the posterior aortic root (red arrow) and re-enty tears in the aortic arch (blue arrows)
  • aortic intramural hematoma visible at the posterior border of the ascending aorta (red overlay)
  • pulmonary artery intramural hematoma predominantly around the pulmonary trunk and the right pulmonary artery (blue overlay)

Case Discussion

Acute aortic dissection of the ascending aortaStanford type A, is a form an acute aortic syndrome that requires immediate surgical management.

Pulmonary artery intramural hematoma is a rare complication of aortic dissection with unknown clinical significance 1. It has been described in cases where the posterior wall of the aortic root is affected as a result of the extravasation of blood into the common aortopulmonary adventitia 1-3. It can appear as crescentic or circumferential hyperdense thickening of the pulmonary artery wall and can aid in the diagnosis of aortic dissection in cases where the intimal flap is not readily visible or in cases where pulsation artifacts are present 1. In this case, the hyperdensities spreading along the course of pulmonary arteries with an obtuse angle toward the pulmonary artery wall indicate the diagnosis. Differential diagnoses include frank mediastinal hemorrhage and extravasation of blood into the pericardial recesses 1.

An additional incidental finding is a hypoplastic right coronary artery in the setting of left coronary arterial dominance.

The patient was immediately transferred to a cardiothoracic surgery unit and received an aortic prosthesis of the aortic arch and an aortic valve and root replacement.

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