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Two computed tomography slices showing a mural thrombus. As a difference to aortic intramural hematoma, intimal calcium remains external to the thrombus (arrow). Borders are usually irregular (arrowhead).
Source publication
Aortic intramural hematoma (AIH) is an entity within the acute aortic syndrome. Combination of a priori probability, clinical history, laboratory blood test and imaging techniques are the basis for diagnosis of AIH. This review is focused on all aspects related to diagnosis of patients with AIH, from clinical to imaging and analytical.
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Citations
... Additionally, for people with type B AIH, the standard unidentified variables in TEVAR include the lack of a healthy aortic proximal landing zone and an evident entrance tear that needs to be closed. Patients with type B AIH are often treated medically, and the development of ulcer-like projections warrants close imaging monitoring because they are linked to an increased risk of complications, particularly if they are detected on the first CT scan [80][81][82]. ...
This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an “aorta code”. Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in “aortic centres” improves long-term outcomes and decreases mortality rates.
... Multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) are the leading techniques for the diagnosis and classi cation of intramural hematoma [4]. In addition to the use of MSCT/MRI and angiographic imaging, transesophageal echocardiography (TEE) could play a role in therapeutic decision-making and in endovascular repair procedure guidance [5]. ...
Background
Aortic intramural hematoma (IMH) accounts for approximately 10–25% of Acute Aortic Syndromes (AAS), and multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) are the leading techniques for the diagnosis and classification. In this context, endovascular strategies provide a valid alternative to traditional open surgery and transesophageal echocardiography (TEE) could play a role in therapeutic decision-making and in endovascular repair procedure guidance.
Case Presentation
A 57-year-old female patient with IMH extending from the left subclavian artery (LSA) to the upper tract of the abdominal aorta, underwent endovascular aortic repair using an unibody single-branched stent grafting in the aortic arch and descending aorta with a side branch inserted in the left common carotid artery (LCCA). To restore proper flow in the left axillary artery, a carotid-subclavian bypass graft was performed. The procedure was guided by angiography and TEE. Intraoperative TEE revealed aortic intramural hematoma with a significant fluid component in the middle tunic of the aorta with a wall thickness of over 13 mm. TEE was useful in monitoring of all steps of the procedure, showing the presence of the guidewires into the true lumen, the advancement of the prosthesis, and the phases of release and anchoring.
Conclusions
This case highlights the importance of using multimodality imaging techniques to evaluate AAS and demonstrates the growing potential of TEE in guiding endovascular repairs.
... On non-contrast CT, IMH is seen as a crescentic hyperdense (60-70 HU) thickening within the aortic wall, usually more than 7mm in diameter but generally less than 15mm (Figure 10a). 4,8,9,24,25 Intimal calcifications, if present, can be seen displaced inwards, differentiating it from a mural thrombus. 9,24,25 The majority of IMH involve the descending aorta. ...
... 4,8,9,24,25 Intimal calcifications, if present, can be seen displaced inwards, differentiating it from a mural thrombus. 9,24,25 The majority of IMH involve the descending aorta. 4 On contrast-enhanced CT, the crescentic thickening remains unenhanced (Figure 10b). ...
... On non-contrast CT, IMH is seen as a crescentic hyperdense (60-70 HU) thickening within the aortic wall, usually more than 7mm in diameter but generally less than 15mm (Figure 10a). 4,8,9,24,25 Intimal calcifications, if present, can be seen displaced inwards, differentiating it from a mural thrombus. 9,24,25 The majority of IMH involve the descending aorta. ...
... 4,8,9,24,25 Intimal calcifications, if present, can be seen displaced inwards, differentiating it from a mural thrombus. 9,24,25 The majority of IMH involve the descending aorta. 4 On contrast-enhanced CT, the crescentic thickening remains unenhanced (Figure 10b). ...
Acute aortic syndromes consist of aortic dissection, intramural hematoma, penetrating aortic ulcer, and ruptured aortic aneurysm. Acute aortic syndromes are considered a clinical emergency with patients presenting with severe chest pain. MDCT is considered as the investigation of choice to evaluate and classify acute aortic syndromes. Correct diagnosis and prompt management of acute aortic syndromes are imperative to reduce mortality and morbidity. Hence, imaging departments must have a basic understanding of their pathophysiology, imaging characteristics, and possible complications. This article reviews the updates in CT imaging of these syndromes and their pitfalls.
... According to the previous reports, the presence of ULP, pericardial effusion and >50 mm dilation of the ascending aorta are risk factors for aorta-related events in patients with IMH [16][17][18]. Particularly, ULP sometimes represents an intimal tear during dissection [18] though conventional IMH results from intramedial haemorrhage of the vasa vasorum without entrance into the intimal tear [19]. These are also important findings when deciding whether to operate. ...
Objectives:
To evaluate the surgical and conservative outcomes of acute type A aortic dissection with a thrombosed false lumen of the ascending aorta in elderly patients.
Methods:
Patients aged over 75 years with acute type A aortic dissection admitted to our hospital from October 2011 to December 2020 were retrospectively reviewed, including those with non-communicating type without malperfusion and low pre-hospitalized physical capacity.
Results:
Sixty-six patients were consecutively enrolled in the medical (M, n = 30) and surgical (S, n = 36) groups. Ascending aorta was the most replaced section in the S group (78%). Groups did not differ significantly in hospital deaths, and intensive care unit and hospital stays. Two patients (7%) underwent surgery and three (10%) underwent re-dissection in the M group. No significant difference existed in physical performance decline during hospitalization between the groups. Seven patients in the M group (24%) experienced aorta-related events in the late period, as opposed to none in the S group (P = 0.003). Survival rates after 4 years were 78.3% and 71.4% in the S and M groups, respectively (P = 0.154). Cumulative incidence of overall reintervention due to aorta-event was significantly higher in the M group; however, the two groups did not differ significantly in overall aorta-related death.
Conclusions:
Surgical outcomes of non-communicating acute type A aortic dissection in elderly patients were favorable. There was no significant difference of maintaining physical function at discharge, and the medical group had a significantly higher overall aorta-event rate than the surgical group.
... However, there is increasing recognition based on surgery and autopsy findings (and recently also on imaging due to improved technology and resolution) that IMH may result from microscopic intimal tears, often not detectable by imaging studies. Currently, there is a belief that IMH is a variant or precursor of AD [74][75][76][77][78]. IMH is more frequently observed in the DTA (Type B IMH, 60-70%) and less commonly in the ascending aorta and arch (Type A IMH; 30% and 10%, respectively) [79]. Essentially, the aortic wall layers are separated and filled with thrombus (maybe because IMH has an entry tear only without a re-entry site) rather than free-flowing blood of a classic dissection, and those cases labeled as IMH are actually cases of acute AD or AD with an acutely occluded and thrombosed FL (a non-communicating type of aortic dissection) [78]. ...
Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient's management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replica-ble, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.
... Aortic intramural haematomas (AIH) typically occur in older females with cardiovascular risk factors and usually involve the descending aorta. 1 Although traditionally considered the result of a haemorrhage of the vasa vasorum, AIH is now defined as a thrombosed aortic dissection. 2 Presenting symptoms such as chest or back pain are non-specific; so is elevated plasma D-dimer which, however, may also imply extension of a pre-existing AIH or dissection. Computed tomography (CT) remains the goldstandard technique for diagnosis, follow-up and detection of complications. ...
... Finally, an incomplete dissection does not cause separation of the medial layers. 1 Although most of AIH (70%) resolve spontaneously, a 4-10% mortality and a 57% complication rate are reported. 8,9 To date, there are no univocal guidelines about the treatment of AIH type B. Patients with stable haemodynamics and no complications should be managed with beta-blockers and nitroprusside, keeping systolic pressure under 120 mm Hg. 6,7 On the contrary, acute ULPs, intimal erosions over 20 mm in width or 10 mm in depth, refractory hypertension, uncontrolled pain, progressive pleural effusion, MAD over 45 mm all represent indications for a surgical/endovascular treatment. ...
... 1 TEVAR prevents aortic rupture and visceral malperfusion and decreases significantly aorta-specific mortality at 5 years 7 ; the aim is to occlude the entry tear (favouring thrombosis within the false lumen) and to re-expand the true aortic lumen. 1 After CT-angiographic evaluation of femoral-iliac systems and intercostal arteries (whose extensive coverage may lead to spinal cord ischaemia and postoperative paraplegia, both related to the artery of Adamkiewicz), an appropriate stent-graft is chosen. A 20-mm-long proximal and distal seal zone are mandatory to avoid endoleak or device migration and a variable oversize must be applied according to each manufacturer's recommendations; potential coverage of one or more of the arch/abdominal aorta branches may be avoided using the newest fenestrated grafts. ...
Management of acute type B aortic intramural haematoma (AIH) still represents a challenging issue. Although most resolve spontaneously or with conservative therapy, several cases of AIH may complicate into classic aortic dissection with subsequent risk of aortic rupture and visceral malperfusion, thus needing urgent or preemptive thoracic endovascular aneurysm repair (TEVAR). Despite the long-term aorta-related survival, TEVAR might lead to graft obstruction, migration, infection, stroke/paraplegia, visceral ischemia, endoleak and, last but not least, retrograde aortic dissection (AD), frequent in the acute phase and associated with a high mortality risk. In order to highlight such a close relationship between AIH and AD and the possibility to perform endovascular treatment, we report the experience of an adult female patient with an aortic intramural haematoma evolving into a classic aortic dissection. Despite successful thoracic endovascular aneurysm repair (TEVAR), our patient developed an aortic dissection type A at one month with subsequent indication for cardiac surgery still representing the elective approach in case of pathologies including the ascending aorta. Thus, the aim of our discussion is to create a debate on the most appropriate management for the treatment of descending AIH.
... In traditional examination methods, using electrocardiogram or myocardial enzyme screening to judge them is unsatisfactory. Studies have shown that MRI, transesophageal echocardiography (TEE) and computed tomography angiography (CTA) are often uesd in the diagnosis of IMH [6][7] . However, the MRI examination takes a long time, and patients with metal materials in their bodies are not intolerant. ...
IMH is a common manifestation of aortic disease, which is also a common lesion in acute aortic syndromes. It is often considered as a precursor of AD. Paying close attention to the development of IMH is important for the prognosis of patients. CTA can effectively determine the location and range of IMH and whether it is associated with AD. At present, post-processing techniques of computed tomography angiography include MPR, CPR, VR. These methods are commonly used to evaluate IMH.
