The potential value of intravascular ultrasound imaging in diagnosis of aortic intramural hematoma

Abstract

To evaluate the potential value of intravascular ultrasound (IVUS) imaging in the diagnosis of aortic intramural hematoma (AIH).
From September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection (AD) underwent both IVUS imaging and spiral computed tomography (CT). Six patients diagnosed as acute type B AIH by CT or IVUS composed the present study group.
The study group consisted of five males and one female with mean age of 66 years old. All of them had chest or back pain. In one patient, CT omitted a localized AIH and an associated penetrating atherosclerotic ulcer (PAU), which were detected by IVUS. In another patient, CT mistaken a partly thrombosed false lumen as an AIH, whereas IVUS detected a subtle intimal tear and slow moving blood in the false lumen. In the four rest patients, both CT and IVUS made the diagnosis of AIH, however, IVUS detected three PAUs in three of them, only one of them was also detected by CT, and two of them escaped initial CT and were confirmed by follow up CT or magnetic resonance imaging.
IVUS imaging is a safe examination and has high accuracy in the diagnosis of AIH, particularly for diagnosing localized AIH, distinguishing AIH with thrombosed classic AD and detecting accompanied small PAUs.

Full text

Journal of Geriatric Cardiology (2011) 8: 224−229
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Research Articles • Open Access •
The potential value of intravascular ultrasound imaging in diagnosis of aortic
intramural hematoma
Wei Hu 1, Francois Schiele2, Nicolas Meneveau2, Marie-France Seronde2, Pierre Legalery2,
Jean-Francois Bonneville3, Sidney Chocron4, Jean-Pierre Bassand2
1Department of Cardiology, Min Hang District Central Hospital, Shanghai 201100, China
2Department of Cardiology, University Hospital Jean Minjoz, Besançon 25000, France
3Department of Radiology, University Hospital Jean Minjoz, Besançon 25000, France
4Department of Cardiac Surgery, University Hospital Jean Minjoz, Besançon 25000, France
Abstract
Objective To evaluate the potential value of intravascular ultrasound (IVUS) imaging in the diagnosis of aortic intramural hematoma
(AIH). Methods From September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection (AD) underwent
both IVUS imaging and spiral computed tomography (CT). Six patients diagnosed as acute type B AIH by CT or IVUS composed the
present study group. Results The study group consisted of five males and one female with mean age of 66 years old. All of them had chest
or back pain. In one patient, CT omitted a localized AIH and an associated penetrating atherosclerotic ulcer (PAU), which were detected by
IVUS. In another patient, CT mistaken a partly thrombosed false lumen as an AIH, whereas IVUS detected a subtle intimal tear and slow
moving blood in the false lumen. In the four rest patients, both CT and IVUS made the diagnosis of AIH, however, IVUS detected three
PAUs in three of them, only one of them was also detected by CT, and two of them escaped initial CT and were confirmed by follow up CT
or magnetic resonance imaging. Conclusions IVUS imaging is a safe examination and has high accuracy in the diagnosis of AIH,
particularly for diagnosing localized AIH, distinguishing AIH with thrombosed classic AD and detecting accompanied small PAUs.
J Geriatr Cardiol 2011; 8: 224−229. doi: 10.3724/SP.J.1263.2011.00224
Keywords: intravascular ultrasound; diagnosis; aortic intramural hematom
1 Introduction
Aortic intramural hematoma (AIH), first described in 1920
by Krukenberg,[1] belongs to “acute aortic syndrome (AAS)”
followed by penetrating atherosclerotic ulcer (PAU) and
the classic acute aortic dissection. It occurs as a bleeding
into the aortic wall (media) without initial rupture of the
intima, the classic flap formation and direct flow
communicating between the true and the false lumen. With
advent of non-invasive imaging techniques such as
computed tomography (CT), magnetic resonance imaging
(MRI) and transesophageous echography (TEE), AIH has
been frequently recognized. Although these non-invasive
modalities have been reported to have accuracy in
diagnosis of AIH,[2–5] they also have some limitations.[3,6–8]
Correspondence to: Wei Hu, MD, PhD, Department of Cardiology, Min
Hang District Central Hospital, No 170, Xin Song Road, 201100, Shanghai,
China. E-mail: huwei0516@hotmail.com
Telephone: +86-21-64925557 Fax: +21-64923400-5158
Received: May 1, 2011 Revised: September 8, 2011
Accepted: September 15, 2011 Published online: December 28, 2011
Only a few studies have evaluated the value of
intravascular ultrasound (IVUS) imaging in patients with
AAS, moreover, most of them used a 20-MHz IVUS probe
that has limitations in a dilated aorta.[6,9–12] Recently, a 9
MHz IVUS probe is commercially available; however, the
experiences about it are very scant.
2 Methods
2.1 Patients
This was a single centre, prospective and observational
study. We included patients with suspected aortic dissection
(AD) after obtaining an informed content and excluded
patients who need an urgent intervention. All patients
underwent both IVUS imaging and spiral CT. CT was
performed within 24 hours from onset of symptom, and
the interval time between CT and IVUS imaging was less
than one week. In the present study, we will focus on the
patients who were diagnosed as AIH by CT or IVUS.
2.2 IVUS imaging
A 9F 9-MHz mechanic IVUS probe (Ultra ICETM
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Hu W et al. Diagnostic value of IVUS in AIH 225
intracardiac echo catheter, Boston Scientific) was introduced
to aortic root with the help of a 0.035-inch guide wire and
a 110-cm long sheath under fluoroscopy via right femoral
artery. After obtaining an optimal cross-sectional aortic
image, it was manually pulled back and IVUS images
were simultaneously recorded on the videotape for
subsequent analysis.
2.3 IVUS imaging analysis
Two cardiologists (Hu W & Schiele F) who were
blinded to the results of other imaging techniques
performed IVUS imaging analysis. We adopted Alfonso’s
definition for AIH by IVUS and made some modifications.
AIH was defined as a crescentic, focal or diffuse
thickening aortic wall with layered structures separated by
echolucent spaces. PAU was defined as a crescentic,
localized and outpouching thickening aortic wall with
heterogenerous echoic density that communicated with the
lumen via an uncontinuous intimal. The circumferential
and longitudinal extent of an AIH, as well as its
relationship with aortic side branches and peri-aortic
effusion were also recorded.
2.4 Spiral CT
We performed spiral CT (Simens, 4 multibarret, with
and without injection of contrast media) by standard
methods. Radiologists interpreted CT by adopting standard
definitions. Briefly, without contrast, an AIH is defined as
crescentic or circular, focal or diffuse thickening aortic
wall with a higher density than blood, and with contrast, it
has the same features, but with a lower density than blood.
PAU is defined as a narrow neck, outpouching, contrast
filled ulceration.[2,4,5]
3 Results
3.1 Patient demographics (Table 1)
From September 2002 to May 2005, a consecutive series
of 15 patients underwent both IVUS imaging and spiral CT.
Six of them diagnosed as acute type B AIH by these two
modalities composed the current study, which included five
males and one female with mean age of 66 years old. All of
them had symptom and had CT and IVUS. Four of them
were also performed TEE or MRI or aortography.
3.2 IVUS and CT findings (Table 2)
There were no complications related to IVUS imaging
in all the patients and the mean procedure time was 15
minutes. Even in a very dilated aorta, IVUS could provide
a good cross-sectional aortic image of entire aorta and
most of the side branches. The largest aortic diameter was
89 mm. The detecting rate of three arch branches, celiac
trunk artery, superior and inferior mesenteric arteries, and
renal arteries were 100%.
In case 1, CT omitted a localized AIH and an associated
PAU, which were detected by IVUS (Figure 1). In case 2,
CT mistaken a partly thrombosed false lumen as an AIH,
while IVUS detected a subtle intimal tear and slow
moving blood in the false lumen (Figure 2). In case 3, 4, 5
and 6, both CT and IVUS made the diagnosis of type B
AIH. However, IVUS detected three accompanied PAUs,
only one of them was also detected by CT (Figure 5), two
others were overlooked by CT and confirmed by follow up
CT or MRI (Figure 3 and 4).
3.3 Treatment and follow up
All patients received medical therapy except case 1,
who was treated surgically because of aneurismal dilatation
of the false lumen. All of them were followed by clinic
visits or telephone interviews and received regular
Figure 1. CT and IVUS imaging of case 1. There was no
evidence of AIH or PAU in image A and B (CT with contrast,
2002/10/18), but a localized AIH was found by IVUS as shown in
image C and E (indicated by a black arrow, IVUS, 2002/10/23).
This AIH was accompanied by a small PAU (indicated by a black
arrow in image D and F, redo IVUS imaging after adjusting zoom,
2002/10/23). CT: computed tomography; IVUS: intravascular
ultrasound; AIH: aortic intramural hematoma; PAU: penetrating
atherosclerotic ulcer.
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226 Hu W et al. Diagnostic value of IVUS in AIH
CT examinations. The mean follow up time was 17.7 ±
12.2 months (Ranged from 4 months to 33 months). No
deaths occurred. In case 3, 4 and 5, the AIH developed
into aneurysm at site of the PAU. The AIH almost
resolved completely in case 6. The subtle intimal tear kept
unchanged in case 2.
Figure 2. CT and IVUS imaging of case 2. Descending AIH and abdominal CAD were documented in image A-D (CT with contrast,
2005/02/25). Image E-G were correspondent IVUS images (2002/02/25). The black arrow in image E indicated slow moving blood. The
black arrow in image F indicated a subtle intimal tear. After carefully reviewing CT images, we found this intimal tear (indicated by a black
arrow in image D). CT: computed tomography; IVUS: intravascular ultrasound; CAD: classic aortic dissection.
Figure 3. CT and IVUS imaging of case 3. A descending AIH was showed in image A and B, but with no evidences of PAU (CT with
contrast, 2002/09/18. Image B was a zoomed copy of image A). Image C was a correspondent IVUS image (2002/09/18). The white arrow
indicated AIH and the black arrow indicated a PAU. This PAU was confirmed by MRI (2002/09/25, indicated by a black arrow in image D
and E, Image E was a zoomed copy of image D). CT: computed tomography; IVUS: intravascular ultrasound; PAU: penetrating
atherosclerotic ulcer; MRI: magnetic resonance imaging.
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Hu W et al. Diagnostic value of IVUS in AIH 227
Figure 4. CT and IVUS imaging case 4. AIH was showed in image A and B (CT with contrast, 2004/03/17), there were no evidence of a
PAU. A small PAU was detected by IVUS imaging (2004/03/19), which was indicated by a black arrow in image C. The disappearance of
AIH and the appearance of a small PAU were showed in image D and E (indicated by a white arrow in image D. CT with contrast,
2004/04/14). The enlargement of the PAU was showed in image F and G (indicated by a white arrow in image F. CT with contrast,
2004/08/03). CT: computed tomography; IVUS: intravascular ultrasound; AIH: aortic intramural hematoma; PAU: penetrating
atherosclerotic ulcer.
Figure 5. CT and IVUS imaging of case 5. There was no ulcer-like projection in imaging A and B (CT with contrast, 2004/04/17). A new
onset of ulcer-like projection suspected as a PAU in image C and D (indicated by a black arrow in image D, CT with contrast, 2004/06/08).
This new onset of ulcer-like projection was demonstrated as a PAU by IVUS in image F (indicated by a black arrow in image F,
2004/06/15).This PAU was also confirmed by follow up CT in image E and G (indicated by a double–head arrow in image G, CT with
contrast, 2004/08/03). CT: computed tomography; IVUS: intravascular ultrasound; AIH: aortic intramural hematoma; PAU: penetrating
atherosclerotic ulcer.
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228 Hu W et al. Diagnostic value of IVUS in AIH
Table 1. Patient demographics.
Case Gender Age HTA HCT DM Smoke FH Symptom
1 M 53 + - - - - +
2 F 64 - - - - - +
3 M 74 + - - + - +
4 M 54 + - - + - +
5 M 73 - - - + - +
6 M 75 + - - - - +
M: male; F: female; HTA: hypertension; HCT: hypercholesterolemia; DM: diabetes mellitus; FH: family history; +: Yes; -: No. Symptom represented acute
chest or back pain.
Table 2. Comparison between IVUS and CT imaging.
Case CT IVUS Interval time (days) Confirmations Treatment Outcome
1 CAD CAD+AIH+PAU 5 No Surgical Stable
2 CAD+AIH CAD 0 Reviewing Medical Stable
3 AIH AIH+PAU 0 Follow up MRI Medical Aneurysm
4 AIH AIH+PAU 2 Follow up CT Medical Aneurysm
5 AIH+PAU AIH+PAU 7 No Medical Aneurysm
6 AIH AIH 2 No Medical Regressed
IVUS: intravascular ultrasound; CT: computed tomography; CAD: classic aortic dissection; AIH: aortic intramural hematoma; PAU: penetrating
atherosclerotic ulcer; MRI: magnetic resonance imaging.
4 Discussion
AIH was first described in 1920 by Krukenberg,[1] and
characterized by the absence of intimal tear and direct
flow communicating between true and false lumen.
Because aortography had been long time as a standard
imaging technique in patients with aortic disease, but it is
insensitive in the diagnosis of AIH, and AIH was less
recognized before. With advent of non-invasive imaging
techniques such as CT, TEE and MRI, AIH has been
frequently reported. By using these non-invasive modalities,
the prevalence of AIH among patients with suspected AAS
is ranged from 5% to 20%, correlated well with autopsy
studies that ranged from 4% to 13%.[4,13–15] Although these
non-invasive modalities have been demonstrated to have
high accuracy in diagnosis of AIH, they also have some
limitations.[2–8]
In 1990, Weintraub et al.[9] first performed IVUS
imaging in a patient with acute classic aortic dissection
(CAD). After that, several studies have evaluated the value
of IVUS imaging in patients with CAD, but up to now,
only one study performed IVUS imaging in a series of
eight patients with AIH.[6,9–12] Therefore, the role of IVUS
imaging is far from established in patients with AIH.
Moreover, most of these studies used a 20-MHz IVUS
probe, which had limitations in a very dilated aorta.
Recently, a 9-MHz IVUS probe is commercially available,
which can theoretically overcome this kind of limitation.
However, the experiences about it are very scant. To our
knowledge, our study is the first one that used this new
system in a series of patients with suspected AD. Not
surprisingly, our study showed that it could supply us a
good cross-sectional aortic image of entire aorta even in a
very dilated aorta and most of its side branches.
According to international registration of aortic dissection
study, CT is presently the most often used imaging technique,
and it often needs two or more imaging techniques to
establish the diagnosis of AIH.[4,5] In our study, all six
patients underwent spiral CT and four of them were also
performed TEE, MRI or aortography, which may reflect
the actual clinical practice. It is generally accepted that
spiral CT has a similar accuracy as TEE and MRI in
diagnosis of AIH. Therefore, IVUS findings were mainly
compared with those of spiral CT in our study.
We adopted Alfonso’s definition for AIH by IVUS and
made some modifications.[6] By using this definition,
IVUS imaging made the diagnosis of AIH in five patients,
four were confirmed by CT, but one localized AIH was
overlooked by CT. In addition, CT made a false diagnosis
of AIH in one case, because it overlooked a subtle intimal
tear and slow moving blood in the false lumen, which
were detected by IVUS. Thus, we believe that IVUS has a
high accuracy in diagnosis of AIH. However, we can not
draw any definite conclusions on the sensitivity and
specificity of IVUS in diagnosis of AIH because of our
small sample size and non-randomised characteristics.
In 1995, Alfonso et al.[6] reported that two localized
AIHs detected by IVUS were overlooked by TEE. In our
study, as stated above, one localized AIH detected by
IVUS was overlooked by CT. Therefore, we think that
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Hu W et al. Diagnostic value of IVUS in AIH 229
IVUS may be more sensitive than non-invasive imaging
techniques to detect a localized AIH.
Although current imaging techniques have high sensitivity
and specificity in the diagnosis of CAD, it is still a big
problem for them to differentiate an AIH from a CAD with
a subtle intimal tear and a fully or partly thrombosed false
lumen.[2] One case example in our study showed that
IVUS could be helpful in this aspect.
Despite the remaining controversy,[16–19] more and more
authors agree that the prognosis of AIH with a PAU is
worse than that without a PAU. Recently, Ganaha et al.[17]
reported the occurrence of 52% PAU in their patients with
AIH by using CT, and they demonstrated that AIH with
PAU had poorer outcome than AIH without PAU.
However, small PAU will escape current used imaging
techniques.[18,19] In our study, four of five AIH were found
by IVUS to be accompanied by a PAU, one of them was
also detected by CT, and two of rest three were confirmed
by follow up CT or MRI. So we believe that IVUS is more
sensitive than CT to detect a small PAU. The frequency of
PAU in patients with AIH reported by us was strikingly
higher than that reported by others, which should be
interpreted cautiously because we included exclusively
type B AIH and used a different modality.
Study limitations: (1) there were no complications in
our study, IVUS imaging is an invasive examination that
has potential damages; (2) the time interval between IVUS
imaging and CT was short and there was no evidence of
clinic progression. Thus, we could not exclude possible
changes during that period of time. And (3) not all PAUs
had confirmations, so we can not exclude the false positive
one.
In one words, IVUS imaging is a safe examination and
has high accuracy in the diagnosis of AIH, particularly for
diagnosing localized AIH, distinguishing AIH with thrombosed
classic AD and detecting accompanied small PAUs.
References
1 Krukenberg E. Beitrage zur Frage des Aneurysma dissecans.
Beitr Pathol Anat Allg Pathol 1920; 67: 329–351.
2 Erbel R, Alfonso F, Boileau C, et al. Diagnosis and
management of aortic dissection. Eur Heart J 2001; 22:
1642–1681.
3 Harris JA, Braverman AC, Guierrez FR, et al. Transeso-
phageal echographic and clinical features of aortic intramural
hematoma. J Thorac Cardiovasc Surg 1997; 114: 619–626.
4 Evangelista A, Mukherjee D, Mehta RH, et al. Acute
intramural hematoma of aorta: a mystery in evolution.
Circulation 2005; 111: 1063–1070.
5 Hagan PG, Nienaber CA, Isselbacher EM, et al. The
international registry of acute aortic dissection (IRAD): New
insights into an old disease. JAMA 2000; 283: 897–903.
6 Alfonso F, Goicolea J, Aragoncillo P, et al. Diagnosis of
aortic intramural hematoma by intravascular ultrasound
imaging. Am J Cardiol 1995; 76: 735–738.
7 Berdat PA, Carrel. Aortic dissection limited to the ascending
aorta mimicking intramural hematoma. Eur J Cardiothorac
Surg 1999; 15: 108–109.
8 Svensson LG, Labib SB, Eisenhauer AC, et al. Intimal tear
without hematoma: an important variant of aortic dissection
that can elude current imaging techniques. Circulation 1999;
99: 1331–1336.
9 Weintraub AR, Schwartz SL, Pandian NG, et al. Evaluation of
acute aortic dissection by intravascular ultrasonography
(letter). N Engl J Med 1990; 323: 1566–1567.
10 Weintraub AR, Erbel R, Gorge G, et al. Intravascular
ultrasound imaging in acute aortic dissection. J Am Coll
Cardiol 1994; 24: 495–503.
11 Yamada E, Matsumura M, Kyo S, et al. Usefulness of a
prototype intravascular ultrasound imaging in evaluation of
aortic dissection and comparison with angiographic study,
transesophageal echocardiography, computed tomography,
and magnetic resonance imaging. Am J Cardiol 1995; 75:
161–165.
12 Chavan A, Hausmann D, Dresler C, et al. Intravascular
ultrasound-guided percutaneous fenestration of the intimal
flap in the dissected aorta. Circulation 1997; 96: 2124–2127.
13 Maraj R, Rerkpattanapipat P, Jocobs LE, et al. Meta-analysis
of 143 reported cases of aortic intramural hematoma. Am J
Cardiol 2000; 86: 664–668.
14 Hirst A, Johns VJ, Kime SW, et al. Dissecting aneurysm of
the aorta: a review of 505 subjects. Medicines 1958; 37:
217–279.
15 Wilson S, Hutchins GM. Aortic dissecting aneurysms:
causative factors in 204 subjects. Arch Pathol Lab Med 1982.
106: 175–180.
16 Stanson AW, Kazmier AC, Hollier LH, et al. Penetrating
atherosclerotic ulcers of the thoracic aorta : natural history and
clinicopathologic correlations. Ann Vasc Surg 1986; 1: 15–23.
17 Ganaha F, Miller C, Sugimoto K, et al. Prognosis of aortic
intramural hematoma with and without penetrating ather-
osclerotic ulcer. Circulation 2002; 106: 342–348.
18 Harris JA, Bis KG, Glover JL, et al. Penetrating
atherosclerotic ulcers of the aorta. J Vasc Surg 1994; 19:
90–99.
19 Quint LE, Williams DM, Francis IR, et al. Ulcerlike lesions of
the aorta: imaging features and natural history. Radiology
2001; 218: 719–723.
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