60-year-old female:
* Known with hypertension
* Acute pain on the chest
* X-ray
* Abnormal?
* Differential Diagnosis: No.
What should we think of and do next?
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Clinically suspect for aortic dissection
What protocol?
Non-enhanced chest CT, followed by CT angiography chest-abdomen
No NECT was made:
Imaging findings and key messages
* Soft tissue surrounding ascending aorta from the root, continuing around the aortic arch and descending aorta
* Between the soft-tissue band and the intraluminal contrast, we see intimal calcifications, these are NOT displaced outwards
* At some spots, there is contrast extravasation in the soft tissue
* No intimal tear or dissection flap is seen
* Slight pericardial effusion
What is the diagnosis?
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Aortic intramural hematoma.
Treatment is like an aortic dissection with anti-hypertensive medication. In this case, it is a type A since the mural hematoma is seen proximal to the left subclavian artery, involving the ascending aorta.
Differential Diagnosis
* Thrombosed false lumen in classic aortic dissection: Typically spirals longitudinally around the aorta, whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall
* Aortitis: Typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration
Treatment/Prognosis
* If an intramural haematoma involves the ascending aorta (Stanford A), treatment is surgical to prevent rupture and progression to a classic aortic dissection
* Conservative management is indicated for an intramural haematoma of the descending aorta (Stanford B)
* 77% of intramural haematomas regress at 3 years
* Survival of >90% at 5 years
* Untreated, an intramural haematoma can be life-threatening as it can lead to: aortic rupture, aortic dissection, aortic aneurysm.