Aortic intramural hemorrhage: A distinct disease entity with mystery

Yu, Yun; Fei, Aihua; Wu, Zengbin; Wang, Hairong; Pan, Shuming

doi:10.5582/irdr.2017.01011

Cited by 8 publications

(12 citation statements)

References 76 publications

(77 reference statements)

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“…Although MRI is advantageous in providing high contrast-resolution images and signal characterization of the age of the hematoma without radiation exposure; limited availability and long examination impede its role as a first-line modality for acutely sick patients with IMH [2,3,18]. Besides 96-100% sensitivity and 100% negative predictive value, widespread availability, high spatial resolution, and full anatomic assessment of the whole aorta within a short duration make CT the preferred tool for diagnosing IMH [3,5,[17][18][19]. Unenhanced CT is crucial for delineating the hyper-attenuating crescentic aortic wall thickening with longitudinal or circumferential propagation in a nonspiral fashion.…”

Section: Discussionmentioning

confidence: 99%

Broken-crescent sign at CT indicates impending aortic rupture in patients with acute aortic intramural hematoma

Sheu

et al. 2020

Insights Imaging

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Background: This retrospective study evaluated the computed tomography (CT) features and clinical implications of a novel broken-crescent sign in patients with acute aortic intramural hematoma (IMH). Methods: Out of 104 patients with aortic IMH encountered in our institution between 2003 and 2018, nine patients exhibited a positive broken-crescent sign, which was defined as a focal defect within the hyper-attenuating crescentic IMH on unenhanced CT, corresponding to a smooth out-bulging of the aortic lumen on enhanced study. The clinical findings, CT features, and outcomes of these nine patients were analyzed. Results: Of five males and four females (age range 48-84 years, mean 69.7 years), six had type A and three had type B IMH. Five patients who had medical treatment and stable status for 1 to 3 days suffered sudden death, two of whom showed ascending aortic rupture with hemopericardium in one and adventitial tear with outward spillage of IMH in another at follow-up CT. The other four patients had early surgical or endovascular management survived; two demonstrated ascending aorta ecchymosis with adventitial tear and intact intima at surgery. Our results support the supposition that aortic IMH complicated with adventitial tear and partial outward seepage of IMH may generate a broken-crescent sign in CT. Despite initially stable clinical status, the residual intact inner aortic wall carries a high risk of sudden aortic rupture. Conclusions: In patients with acute aortic IMH, identification of a broken-crescent sign in CT is highly suggestive of impending aortic rupture, and early aggressive treatment is mandatory.

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Section: Discussionmentioning

confidence: 99%

Broken-crescent sign at CT indicates impending aortic rupture in patients with acute aortic intramural hematoma

Sheu

et al. 2020

Insights Imaging

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“…This was shown in our study's MPS group, where 17% in-hospital mortality occurred. Although MPS is less frequently s e e n i n ATA A I M H c o m p a r e d t o c l a s s i c ATA A D (1)(2)(3)7,8,16), it still occurs and yields a worse prognosis, so it is important for clinicians to recognize. In ATAAIMH without MPS, emergent open aortic repair should be performed since the operative mortality is very low in both our study (0% in-hospital mortality) and other studies (3,32,35) compared to 40% mortality in ATAAIMH patients managed only medically (8).…”

Section: Discussionmentioning

confidence: 99%

“…In conclusion, ATAAIMH patients with visceral/ extremity MPS could be managed with initial endovascular reperfusion of the vascular territories affected by malperfusion and delayed open aortic repair as our experience shows it achieves favorable short-and mid-term outcomes in this complex disease. RCP only 20 [25] 3 [33] 17 [24] Both ACP and RCP 14 [18] 3 [33] 11 [16] Neither ACP nor RCP 4 [ 1-2 13 [16] 2 [22] 11 [16] 3-4 15 [19] 2 [22] 13 [19] ≥5 24 [30] 2 [22] 22 [31] Data presented as median (interquartile range) for continuous variables and number (percentage) for categorical variables. MPS, malperfusion syndrome; TEVAR, thoracic endovascular aortic repair; AVR, aortic valve replacement; CABG, coronary artery bypass graft; MV, mitral valve procedure; TV, tricuspid valve procedure; CPB, cardiopulmonary bypass; HCA, hypothermic circulatory arrest; ACP, antegrade cerebral perfusion; RCP, retrograde cerebral perfusion; PRBC, packed red blood cell.…”

Section: Discussionmentioning

confidence: 99%

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Management of malperfusion syndrome in acute type A aortic intramural hematoma

Norton

Williams

Kim

et al. 2019

Ann. Cardiothorac. Surg.

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Background: We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair. Methods: Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database. Results: Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% vs. 1%, P<0.0001) and acute paralysis (17% vs. 0%, P=0.02). Patients with MPS amenable to endovascular reperfusion (n=10) underwent endovascular fenestration/ stenting and delayed aortic repair. Those with cerebral or coronary MPS (n=2) and those without MPS (n=70) underwent emergent open aortic repair. Of the ten patients undergoing fenestration/stenting, seven went on to aortic repair, one survived to discharge without aortic repair, one died from aortic rupture on hospital day 34, and one died from organ failure prior to aortic repair. Following endovascular fenestration/stenting or aortic repair, all patients with MPS had higher in-hospital mortality (17% vs. 0%), P=0.02. Following aortic repair, patients with MPS had more postoperative sepsis and longer postoperative length of stay (all P<0.05). However, both groups had a 0% operative mortality (including in-hospital and 30-day mortality following aortic repair). The 5-year survival of all ATAAIMH patients was 79%. The 2-year survival was significantly better in the No MPS group (94% vs. 62%, P=0.006). Conclusions: ATAAIMH with MPS can be effectively managed with upfront endovascular fenestration/ stenting followed by delayed aortic repair.

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“…Aortic dissection comprises around 85-95% of AAS, with IMH making up 5-15% and penetrating atheromatous ulcer (PAU) around 5%. Traditionally, IMH has been attributed to rupture of the vasa vasorum, however, improvements in imaging and reporting have led to conclusions that true lumen communication via micro-intimal tears may also be causative (3,4). Complicated cases of type B intramural hematoma (IMH-B) are defined by ongoing pain, increasing diameter of the lesion or presence of ulcer-like projections (ULP) (5).…”

Section: Introductionmentioning

confidence: 99%

Endovascular versus medical management of type B intramural hematoma: a meta-analysis

Chakos

Twindyawardhani

Evangelista

et al. 2019

Ann. Cardiothorac. Surg.

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Background: Aortic intramural hematoma constitutes one of the three classifications of acute aortic syndrome (AAS). Type B intramural hematoma (IMH-B) is localized to the descending thoracic aorta and can be managed through medical, endovascular or surgical means. Data comparing contemporary management with thoracic endovascular aortic repair (TEVAR) versus traditional medical management (MM) is sparse and only moderate strength recommendations for TEVAR are provided in guidelines. This meta-analysis aimed to pool available data from comparative studies between TEVAR and MM and examine differences in outcomes. Methods: Literature search of electronic medical databases was conducted to identify studies comparing TEVAR and MM for management of IMH-B. Data extraction from studies fulfilling the inclusion criteria was performed by two authors and meta-analysis using a random-effects model applied to pool baseline data and examine risk ratios (RR) for management outcomes. Results: Of the initial 2,349 studies, nine studies were identified for analysis. There were 161 TEVAR patients and 166 who were medically managed. The mean age of the cohort was 62.2 years [95% confidence interval (CI): 55.8-68.7 years]. Patients with complicating features of IMH-B at presentation were more likely to appear in the TEVAR group, with more penetrating atheromatous ulcer (PAU) [risk difference (RD)

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Aortic intramural hemorrhage: A distinct disease entity with mystery

Cited by 8 publications

References 76 publications

Broken-crescent sign at CT indicates impending aortic rupture in patients with acute aortic intramural hematoma

Broken-crescent sign at CT indicates impending aortic rupture in patients with acute aortic intramural hematoma

Management of malperfusion syndrome in acute type A aortic intramural hematoma

Endovascular versus medical management of type B intramural hematoma: a meta-analysis

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