Aortic intramural hematoma

Case contributed by Dr David Preston


Fluctuating GCS 8 - 14. Ambulance officers say that her husband called after she vomited at home. No other history was available.

Patient Data

Age: 80 years
Gender: Female

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.

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.


The CT confirms hematoma 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 hemopericardium.  The descending, thoracic and abdominal aorta demonstrate atheromatous calcification but otherwise demonstrates contrast enhancement and normal caliber.

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.


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

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