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Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014 Nov 1;35(41):2873-926. doi: 10.1093/eurheartj/ehu281. Epub 2014 Aug 29. Erratum in: Eur Heart J. 2015 Nov 1;36(41):2779. PubMed PMID: 25173340.
Definition, Etiology, PathogenesisTop
Aortic intramural hematoma (IMH) is a type of acute aortic syndrome in which blood accumulates in the media of the aortic wall but no false lumen has developed and intimal tear is absent. Just like acute aortic dissection, IMH may be divided into type A or type B and generally presents as chest or back pain without evidence of rupture or malperfusion.
The greatest concern with intramural hematomas is that most clinicians believe they are part of the same spectrum of disease as dissections and as such carry similar risks in case of progression.
Natural HistoryTop
In 30% to 40% of patients with IMH type A, aortic dissection occurs (the risk is highest within 8 days of symptom onset).
DiagnosisTop
Computed tomography (CT) and magnetic resonance imaging (MRI) are the key diagnostic studies used to diagnose and classify IMH.
TreatmentTop
1. Medical treatment: Control of pain and blood pressure. Repeat imaging studies.
2. Invasive treatment:
1) In IMH type A coexisting with a pericardial effusion, periaortic hematoma, or large aneurysm, start emergency surgical treatment.
2) In other cases of IMH type A, urgent surgical treatment is necessary (within <24 hours of diagnosis), although in many elderly patients and those with significant comorbidities initial medical treatment may be justified (provided the aortic diameter is ≤50 mm and thickness of the intramural hematoma is <11 mm).
3) In IMH type B, medical management is the primary treatment but invasive treatment (usually endovascular stenting) is indicated in case of complications.
ComplicationsTop
Recurrent pain, hematoma expansion, periaortic hematoma, or disruption of the intima.
Risk factors for complications of IMH: Persistent or recurrent pain despite aggressive medical treatment, difficult blood pressure control, ascending aortic involvement, maximum aortic diameter ≥50 mm, progressive maximum aortic wall thickness (>11 mm), enlarging aortic diameter, recurrent pleural effusion, unstable atherosclerotic plaque (penetrating ulcer or ulcer-like projection) secondary to localized dissections in the involved segment, organ ischemia (brain, myocardium, bowels, kidneys).
