Aortic intramural haematoma

Case contributed by Dr David Preston

Presentation

A 78 year old female was brought into ED by ambulance with a fluctuating GCS from 8 - 14. The story from the ambulance officers was that her husband called after she vomited at home. No other history was available.

Patient Data

Age: 78
Gender: Female
X-ray

A mobile chest x-ray was obtained as part of the initial resuscitation.

A widened mediastinum was noted, although an AP projection it was wide enough to evoke suspicion of an aortic dissection.

Using the ED ultrasound there was a small amount of pericardial fluid seen. Neither of the operators was experienced or confident enough to make a diagnosis. The patient became coherent enough to say that she was sitting on the couch and developed "overpowering chest pain".

The Radiology reg was called to request a CT Aortogram. The patient became unresponsive again and was intubated in the resus bay.

X-ray

PA film from 9 months earlier

Comparing the AP film to a PA film 9 months earlier showed an increase in the thickness of the aortic wall at the aortic knuckle from 2 to 8mm.

CT

The CT confirms haematoma around the ascending aorta and aortic root, associated with intimal irregularity and outpouching in the left aspect of the ascending aorta, but without an enhancing false lumen or intimal flap. There is a small haemopericardium.  The descending, thoracic and abdominal aorta demonstrate atheromatous calcification but otherwise demonstrates contrast enhancement and normal calibre.
In the chest, there is bibasal atelectasis and prominent upper lobe pulmonary vasculature. No pleural effusion identified. The tip of the endotracheal tube lies 3 cm from the carina. No mediastinal free gas identified.

Comment
The haematoma around the ascending aorta and aortic root, with associated intimal irregularity at the ascending aorta and small haemopericardium, is compatible with a Stanford type A aortic dissection with thrombosed false lumen. The differential is an intramural aortic haematoma. No distal propagation into the descending thoracic aorta noted.

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Case information

rID: 27746
Case created: 18th Feb 2014
Last edited: 19th Nov 2015
Systems: Vascular, Chest
Inclusion in quiz mode: Included

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