Intramural Hematoma of the Aorta

Abstract

Background-Aortic intramural hematoma (IMH) is a variant of overt aortic dissection. The predictors of progression of IMH to dissection and rupture are still unknown, and strategies for management are not established. Methods and Results-A multicenter study was conducted comprising 66 patients with IMH and hospital admission Յ48 hours after onset of initial symptoms. Among these, progression to aortic dissection or rupture occurred in 30 (45%) and death occurred in 13 (20%) patients within 30 days. Late progression was noted in 14 (21%) and death in 11 (17%) patients, yielding a 1-, 2-, and 5-year survival of 76%, 73%, and 43%, respectively. In a set of 9 variables, multivariate analysis identified IMH location in the ascending aorta (type A; Pϭ0.02) and moderately ectatic aortic diameters (49Ϯ13 mm with progression versus 57Ϯ16 mm without progression; Pϭ0.03) as independent predictors of early progression. In type A IMH, early mortality was 8% with swift surgery versus 55% without surgery (Pϭ0.004). The risk of late progression of IMH was independently associated with age at index diagnosis (Pϭ0.01) and absence of ␤-blocker therapy during follow-up (Pϭ0.03). Kaplan-Meier analysis confirmed improved 1-year survival of IMH with ␤-blocker therapy (95% versus 67% without ␤-blockers; Pϭ0.004). Conclusions-Regardless of aortic diameter, IMH of the ascending aorta (type A) is at high risk for early progression, and, thus, undelayed surgical repair should be performed. Moreover, oral ␤-blocker therapy may improve long-term prognosis of IMH independent of anatomical location.

Acute Intramural Hematoma of the Aorta

“…4 Regression may occur but is less common and is not predictable in proximal IMH involving the ascending aorta. 16 On the other hand, acute IMH involving the descending aorta had an in-hospital mortality risk of Ͻ10%, similar to that seen with descending or type B AD (Table 6). The initial medical treatment for this condition appears justified.…”

Aortic Dissection: New Frontiers in Diagnosis and Management

“…43-45,54 -56 The prevalence of intramural hemorrhage and hematoma in patients with suspected aortic dissection, as observed by various modern imaging techniques, seems to be in the range of 10% to 30%. 42,45,55,56 IMH can lead to acute aortic dissection in 28% to 47% of the patients and is associated with aortic rupture in 21% to 47%. Regression is seen in Ϸ10% of patients.…”

“…The cardiological and surgical communities have generally concluded that acute IMH involving the ascending aorta should be managed surgically because of an unacceptably high mortality rate with medical treatment. [41][42][43]45,46,54,56,73 Studies in Asian patients from Japan and Korea have argued that wall hematoma reflects a more benign condition, in which aggressive medical therapy and serial imaging may allow watchful waiting and avoidance of surgery in some patients. 57,59,74 The reasons for this disparity may relate either to a different gene pool of Asian and white patients or to critical semantic differences.…”

“…46,[62][63][64][65] In case of multiple lesions, each one has to be carefully checked for signs of penetration or rupture, as evidenced by fluid extravasation into the pericardium, pleural space, and/or mediastinum, which often heralds the risk of sudden death from exsanguination. 56,74 The presence of pericardial fluid around the aortic root is a sign of ongoing penetration or imminent perforation regardless of dissection or IMH. Fluid within the pleural space can be detected by echocardiography, CT, and MRI.…”

Granulocyte macrophage colony-stimulating factor is required for aortic dissection/intramural haematoma

“…The two conditions are distinguished by a tear in the aortic intima as present in the former classical form of aortic dissection, which results in blood flow into the aortic wall and is absent in the latter form of intramural haematoma with bleeding confined within the aortic wall. This aortopathy is presently understood to be a continuum, with the latter a variant and precursory condition of the former [7][8][9] . Advancements in the understanding of genetic underpinnings (for example, ACTA2) 10,11 , clinical/epidemiological aspects (for example, The International Registry of Acute Aortic Dissections (IRAD)) 4,5 as well as biochemical approaches (for example, smooth muscle biomarkers) 5,6 have been made in the last decade, but underlying mechanisms have remained obscure owing much to lack of a reliable animal model.…”