Fact-sheet: Intramural hematoma of the aorta
Updated on 08/29/2017 at 3:38 PM
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Definition
Noncirculating hematoma splitting the aortic wall.
Two mechanisms have been described:
- Rupture of the vasa vasorum,
- Atherosclerotic ulcer, with plaque rupture.
This corresponds to an intimomedial rupture giving rise to the dissecting hematoma.
Variant of classic aortic dissection.
Male predominance.
Mean age 65 years. Main risk factor: hypertension.
Clinical features
- History of angina
- History of hypertension or hypertensive crisis
- Asymmetry of peripheral pulses
- Neurological deficit signs
- Syncope
- Psychiatric disturbances
- Claude Bernard-Horner syndrome
- Respiratory signs (dyspnea, cyanosis, polypnea, etc.)
Ultrasound
Transesophageal echocardiography:
- Crescentic or circumferential thickening of the aortic wall, thickness >7mm
- The hematoma has a granular, heterogeneous appearance (alternating granular pattern and echo-free areas)
- Central luminal displacement of intimal calcifications lining the inner aspect of the hemorrhagic parietal crescent.
- Generally increased aortic caliber.
- Assessment for signs of complications: hemopericardium, hemothorax, hemomediastinum.
CT
Non-contrast CT with systematic gating:
- Crescentic, spontaneously hyperdense thickening of the aortic wall due to intramural hematic infiltration, thickness > 7mm.
- Absence of enhancement after contrast administration.
Assessment for a possible entry point (inconstant):
- Penetrating atherosclerotic ulcer: Rounded outpouching with a wide neck located within the aortic wall.
- Intimomedial tear: Flat, ear lobe-shaped outpouching.
- Ostial avulsion: Small round outpouching located between the circulating aortic lumen and a stretched collateral vessel (most often intercostal).
Systematic assessment for associated hemopericardium, hemomediastinum, or hemothorax.
Management
Emergency therapeutic indication for complicated forms: rupture, ischemia.
Often regresses with medical treatment.
Prolonged CT follow-up is required to assess lesion evolution over time.
Classification
The Stanford classification, used for aortic dissections, is applicable to intramural hematomas:
- Type A: Involvement of the ascending aorta
- Type B: Involvement of the descending aorta
Differential diagnosis
Penetrating atherosclerotic ulcers complicated by a localized wall hematoma.
Mural thrombus on an aneurysmal aorta.
Aortic dissection with a thrombosed narrow false lumen.