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Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334-e482. doi:10.1161/CIR.0000000000001106
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/blood flow has developed. An intimal tear may or may not be present. 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 the risk of progression to aortic enlargement, dissection, or rupture.
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 such as rupture; persisting, refractory, or recurrent pain; hematoma expansion; periaortic hematoma; or disruption of the intima. Just as for type B dissections, there is a group of patients with IMH with high-risk features, which include a large maximum aortic diameter (>47-50 mm), increased IMH thickness (>13 mm), development of focal intimal disruption with ulcer-like projection into the media, progression to dissection, organ ischemia (brain, myocardium, bowels, kidneys), difficult to control blood pressure, ascending aortic involvement, or increasing or recurrent pleural effusion. Decisions about stenting in patients with type B IMH and high-risk features are made on an individualized basis.
