Aortic intramural hematoma: Current diagnostic and therapeutic recommendations

Abstract

Aortic intramural hematoma (IMH) is an acute, potentially lethal disorder that is similar to but pathologically distinct from acute aortic dissection. Although hemorrhage into the aortic media occurs in both disorders, an intimal tear with resultant false lumen is not present in IMH. Instead, hemorrhage occurs within the aortic wall either due to rupture of the vasa vasorum or, less commonly, because of an atherosclerotic penetrating aortic ulcer. The most common risk factors associated with IMH are hypertension, atherosclerosis, and advanced age. IMH is life-threatening because the hematoma may extend along or rupture through the aorta, leading to hemothorax, cardiac tamponade, stroke, mesenteric ischemia, or renal insufficiency. Optimal treatment is still somewhat controversial; however, there is no question that hypertension must be treated effectively and immediately. This is usually best accomplished by intravenous infusion of beta-blocking agents, with or without the addition of sodium nitroprusside. Recent studies support surgical treatment (ie, aortic root replacement) for IMH involving the ascending aorta, although some subsets of this population may be at lower risk and may benefit from medical therapy alone. In patients with IMH involving only the descending aorta, medical therapy alone is recommended (unless impending rupture, aortic aneurysm, or end-organ ischemia occurs). Patients who survive the acute event require intensive treatment of hypertension and frequent follow-up examinations. Because this population (especially the subset with penetrating aortic ulceration) is at high risk for aortic aneurysm and rupture, serial imaging studies of the aorta are essential.

Detection of inflammation in patients with acute aortic syndrome: comparison of FDG-PET/CT imaging and serological markers of inflammation

“…Focal lesions in the ascending aorta require immediate surgical therapy, but a focal wall lesion in the aortic arch or descending aorta can initially be handled conservatively with an intensive medical treatment of hypertension. In these cases a thorough follow-up imaging is essential 23. The poor prognosis of these vessel pathologies makes the correct and timely decision for a case and stage-adapted therapy mandatory.…”

CT and MRI in the Evaluation of Thoracic Aortic Diseases

“…Similar to aortic dissection, type A IMH usually requires open surgical repair, while type B IMH can often be managed medically except in the presence of aneurysm, progression, dissection, impending rupture, or end-organ ischemia, with any of which open or endovascular repair is performed. Serial follow-up CT or MRI examinations are indicated for patients who are followed conservatively [21]. …”

Intramural Hematoma of the Aorta: Delayed Pericardial Tamponade

“…Intramural aortic hematoma (IAH) is an uncommon entity that accounts for 10 -30% of all cases of acute aortic syndrome; it originates from spontaneous rupture of the aortic vasa vasorum into the media or from a penetrating atherosclerotic ulcer. It differs from an aortic dissection in that anatomically there is absence of an intimal tear with a resultant false lumen [1]. The hematoma can extend along or rupture through the aorta.…”