Aortic intramural hematoma
Sudden onset severe back pain.
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Pre-contrast and aortic phase intravenous contrast enhanced examination throughout the thoracoabdominal aorta.
The distal arch, descending thoracic and proximal abdominal aorta contain eccentric not quite circumferential mural thickening which is subtly hyperdense on precontrast images, with no opacification on arterial phase images.
This extends from the origin of the left subclavian artery throughout the remainder of the thoracic aorta to the level of the renal arteries.
Proximally in the descending thoracic aorta the mural thickening is maximal posteriorly and to the right, while in the lower thoracic region it is maximal anteriorly and to the right.
Total aortic dimensions are enlarged, dilated up to maximal diameter of 4.2 x 4.3 cm in the proximal descending thoracic aorta.At the level of the diaphragmatic hiatus, a smooth contrast filled protrusion into the eccentric mural thickening (projecting anteriorly and to the left) has dimensions of 7.5 x 6 x 6 mm.
No intimal flap is identified. No mediastinal hematoma. No hemothorax.
Nonenhancing aortic intramural hematoma, extending from aortic arch to the level of the renal arteries.
The etiology of this is usually from spontaneous rupture of a vasa vasorum, or less commonly due to penetrating ulcer.
The small contrast opacified anteromedial projection at the level of the diaphragmatic hiatus may represent the latter. No intimal flap or enhancing false lumen to suggest a patent aortic dissection.
Key learning points:
- aortic intramural hematoma presents as a high-density "cuff" around the aorta without an intimal flap
- thought to be from (most commonly) a spontaneous rupture of the vasa vasorum