Intramural hematoma and penetrating ulcer in the descending aorta: differences and similarities

Abstract

Acute aortic syndromes include a variety of overlapping clinical and anatomic diseases. Intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection can occur as isolated processes or can be found in association. All these entities are potentially life threatening, so prompt diagnosis and treatment is of paramount importance. IMH and PAU affect patients with atherosclerotic risk factors and are located in the descending aorta in 60-70% of cases. IMH diagnosis can be correctly made in most cases. Aortic ulcer is a morphologic entity which comprises several entities-the differential diagnosis includes PAU, focal intimal disruptions (FID) in the context of IMH evolution and ulcerated atherosclerotic plaque. The pathophysiologic mechanism, evolution and prognosis differ somewhat between these entities. However, most PAU are diagnosed incidentally outside the acute phase. Persistent pain despite medical treatment, hemodynamic instability, maximum aortic diameter (MAD) >55 mm, significant periaortic hemorrhage and FID in acute phase of IMH are predictors of acute-phase mortality. In these cases, TEVAR or open surgery should be considered. In non-complicated IMH or PAU, without significant aortic enlargement, strict control of cardiovascular risk factors and frequent follow-up imaging appears to be a safe management strategy.

Multidetector Computed Tomography in Traumatic and Nontraumatic Aortic Emergencies: Emphasis on Acute Aortic Syndromes

“…4,15,16 Patients with IMH and PAU are older than those with classical AD, with higher incidence of other risk factors such as hypertension, hypercholesterolemia, and smoking. 14…”

“…The sequence of events leading to rupture includes the occurrence of an IMH, which advances to leak into the mediastinum or retroperitoneum and followed by progressive leak into the pleural cavity, pericardium, or retroperitoneum. 14…”

“…The Svensson classification describes the 3 main entities as variants of the same process (Table 1) and can occur as isolated phenomena or in tandem. 14 Although AD can occur as a distinct entity, it may also arise from progression of IMH, PAU, or limited dissection 15 as illustrated in Figure 2.…”

“…4,15,16 Patients with IMH and PAU are older than those with classical AD, with higher incidence of other risk factors such as hypertension, hypercholesterolemia, and smoking. 14 Given the high mortality, rapid and accurate diagnosis becomes a necessity, which can be achieved with MDCT. Imaging also aids in classification of AD and IMH into their respective Stanford types which has an implication in treatment and prognosis.…”

“…The sequence of events leading to rupture includes the occurrence of an IMH, which advances to leak into the mediastinum or retroperitoneum and followed by progressive leak into the pleural cavity, pericardium, or retroperitoneum. 14 Imaging findings reflect these stages as hyperattenuating wall thickening representing an IMH followed by a periaortic mediastinal or retroperitoneal hematoma (Figure 11). Pleural and pericardial effusion are also detected by MDCT along with signs suggestive of hypovolemic shock.…”