Intramural hematoma imh of the thoracic aorta only recently has been described in the literature as a distinct entity. Dec 12, 2008 spontaneous intramural intestinal haematoma is a rare complication of anticoagulation therapy. A bruise is a discoloration of the skin caused by a blow. Aortic intramural hematoma imh is one of several conditions included in the acute aortic syndrome aas. We present the case of a 57yearold woman who had an intramural hematoma of the ascending aorta and aortic arch. Sixteen patients had stanford type a intramural hematoma, and 36 had stanford type b. However, in rare cases, imh may also be caused by a penetrating ulcer or an intimal tear. Get a printable copy pdf file of the complete article 1. Thoracic aortic dissection ad is one of the most common aortic emergencies. Assessment of clinical and radiological features in comparison to acute aortic dissection1 kwonha yoon, m. Aortic intramural hematoma imh is an important acute aortic syndrome that presents symptoms similar to those of classic aortic dissection. Evaluation by ct can identify imaging features associated with higher risk of complications.
Within the features of this syndrome can be found, the penetrating ulcer, intramural hematoma, and with aortic dissection being one of the most common features. On most cases, a predisposing or precipitating factor may be seen, with the most common ones being the history of esophagic instrumentation, food impactations and thrombocytopenia. It can be fatal if not promptly diagnosed and treated. An 85 year old lady presented to us with acute abdomen. A crescentshaped area along the aorta wall with higher attenuation than that of blood on the noncontrast ct scan no contrast enhancement effect within the area on the postcontrast ct scan smooth lumenwall interface 2. An intramural hematoma results from rupture of the vasa vasorum and hemorrhage into the arterial media, which leads to weakening of the aortic wall. Spontaneous intramural intestinal haematoma is a rare complication of anticoagulation therapy. Intramural aortic hematoma and anticoagulation intramural aortic hematoma is one of a group of conditions covered by the term acute aortic syndrome. Findings in spontaneous intramural intestinal hematoma imaging. Intramural esophagic hematoma secondary to coumarinic. Management of intramural hematoma of the ascending aorta and. As the report suggests, an intramural hematoma is similar to an aortic dissection, essentially a tear within the wall of the aorta. Intramural hematoma of the aorta imh, a variant of classic aortic dissection, shows very dynamic process in the early phase. Recent advances in imaging techniques have significantly improved the diagnosis and heightened the clinical understanding of imh, which accounts for a frequency of 10% to 30% of all acute aortic syndromes.
Since then others have described additional typical findings and have suggested pathophysiological processes to account for them. There was eccentric thickening of one wall of the aorta arrowhead that was consistent with thrombus or intramural hematoma. Bruisehematoma the student health provider has treated you today for a bruise or hematoma. Aortic intramural hematoma is among the spectrum of pathologies that comprises acute aortic syndrome and carries a risk of progression to aortic dissection, aneurysm, rupture, and other complications. Aortic intramural hematoma imh is an entity included in the acute aortic syndrome aas together with aortic dissection and penetrating aortic ulcer 3. Many aspects of its natural history remain poorly understood, and the best treatment is not known. Aortic intramural haematoma imh is an atypical form of aortic dissection due to haemorrhage into the wall from the vasa vasorum without an intimal tear. However, the appropriate management of intramural hematoma is neither as well defined nor as widely understood as that of classic dissection. Hematoma intramural aortico y anticoagulacion revista espanola. It is not a common diagnosis but is a potentially lethal disorder and imh is sometimes considered as a lead up to classic aortic dissection, rupture or aneurysm. Aortic intramural haematoma radiology reference article.
She was on warfarin and was found to have grossly deranged clotting parameters. Aortic remodeling after thoracic endovascular aortic repair. Computed tomography scan revealed a long loop of markedly thickwalled proximal. Natural history and ct appearances of aortic intramural.
We read with interest the article on the successful diagnostic and treatment of this difficult and rare pathology. The common d enominator for this pathology is the disruption of the middle layer with bleeding along the wall of the aorta resulting in separation of the layers or in some cases break trauma. The aim of this study is to evaluate clinical outcomes of patients with acute aortic imh from real world registry data. Conservative treatment of a left atrial intramural hematoma after left atrial thrombus resection and concomitant mitral valve replacement case report.
Characteristic findings of an aortic intramural hematoma include a crescentic hyperattenuating fluid collection at unenhanced computed tomography ct and a smooth, nonenhancing, thickened aortic wall at contrast materialenhanced ct. What other tests will i need to confirm the diagnosis. Much uncertainty is caused by the variable natural history of intramural hematoma, which may include the confound. The major complications of acute aortic syndrome, periaortic hematoma and hemorrhagic pericardial effusion, occur more frequently in imh. An aortic intra mural hematoma in ventilationperfusion. Computed tomography scan revealed a long loop of markedly thick. Emerging concepts in intramural hematoma imaging radiographics. To compare the cl inical and radiological features of aortic intramural. Atypical presentation of intramural hematoma of the ascending aorta using a conservative approach aortic intramural hematoma is a severe disease, secondary to vasa vasorum bleeding andor aortic microulcers without connection with the true lumen of the vessel. Intramural hematoma imh, penetrating atherosclerotic ulcer pau, and aortic dissection comprise a spectrum of acute aortic pathologies.
Department of cardiology, john radcliffe hospital, oxford, uk background. While, in classical aortic dissection, flow communication occurs though a primary intimal tear and blood propagation creates a false lumen, in intramural hematoma hemorrhage occurs within the. Imh also frequently leads to aortic emergency, which can be fatal unless rapidly diagnosed and treated. Aortic intramural hematoma imh is an atypical form of aortic dissection due to hemorrhage into the wall from the vasa vasorum without an intimal tear. Acute aortic syndromes represent a spectrum of disease ranging from acute intramural hematoma imh, to penetrating atherosclerotic ulcer, to the more familiar aortic dissection. Acute aortic dissection and intramural hematoma american. Request pdf intramural aortic hematoma and anticoagulation intramural aortic hematoma is one of a group of conditions covered by the term acute aortic syndrome. None of the patients had recurrence of intestinal tract hematoma, abdominal. In the following manuscript, the authors present the case of a 54yearsold male. Some authors have suggested that imh is the result of spontaneous rupture. Here we presented a case of an aortic intramural hematoma imh diagnosed on the ldct portion of vq spect combined with ct. To the best of our knowledge, there is no report of endoluminal thrombus combined with intramural hematoma associated with cpr in the literature. It is associated with high blood pressure, smoking, and atherosclerosis the same process that causes coronary artery disease and heart attacks. Atypical presentation of intramural hematoma of the.
A crescentshaped area along the aorta wall with higher attenuation than that of blood on the noncontrast ct scan no contrast enhancement effect within the area on the postcontrast ct scan. B,typebaortic dissection,axialcontrastenhanced ctatthelevelofthecarina starfalselumen. Diagnosis and treatment of thoracic aortic intramural hematoma. Intramural hematoma of the small bowel should be suspected in any patient with signs or symptoms of small bowel obstruction who is having anticoagulant drug therapy, especially if it is longterm therapy and if the prothrombin time is excessively prolonged. Its occasional finding in the absence of symptoms or aortic trauma is quite rare. Intramural hematoma and penetrating atherosclerotic ulcer of. Intramural hematoma is generally held to account for between 5% and 20% of patients admitted to hospital with the diagnosis of acute aortic syndrome or acute dissection 1518. Treatment patterns and their outcomes of acute aortic intramural hematoma in real world. Although thoracic endovascular aortic repair tevar has increasingly been applied to aortic dissection, there is a paucity of data on the anatomic effect of tevar for imh. Rupture of the vasa vasorum into the media of the aortic wall results in an aortic intramural hematoma. The most commonly cited explanation for imh is rupture of vasa vasora with intramural hemorrhage, although data to support this contention are thin.
Intramural hematoma type b lesions e f a,typeaaorticdissection,axial contrastenhancedcomputed tomographyctatthelevelofthe pulmonaryarterybifurcation starfalselumen. Intramural hematoma and penetrating atherosclerotic ulcers. Intramural hematoma of the small bowel has been recognized for many years as a complication of blunt trauma, especially in children. The blow breaks small blood vessels, releasing blood in the skin and fatty tissue under the skin. It is thought to be a direct consequence of vasa vasorum. Hematoma intramural aortico y anticoagulacion revista. Intramural hematoma treatment beta blockers to reduce aortic wall stress and control hypertension type a. Intramural hematoma journal of cardiothoracic and vascular. Intramural hematoma imh of the aorta is recognized as distinct from classic doublebarreled ad. Pdf natural history and ct appearances of aortic intramural. Intramural aortic hematoma and anticoagulation sciencedirect. Esophagic intramural hematoma is an uncommon clinical condition, with a prognosis which is essentially benign.
Intramural coronary haematoma following percutaneous coronary intervention in the absence of coronary dissection is a rare phenomenon. Small bowel obstruction due to intramural hematoma during. Imh consists of a blood collection within the aortic wall, presumably due to rupture of the vaso vasorum. Abstractwe describe the case of a patient with an intramural hematoma and floating. Endovascular repair of aortic dissection and intramural. Intramural aortic hematoma and anticoagulation rev esp cardiol.
Acute aortic syndrome is an acute, potentially fatal pathology within the wall of the aorta, including aortic dissection, intramural hematoma imh, and penetrating atherosclerotic ulcer. The hematoma around the ascending aorta and aortic root, with associated intimal irregularity at the ascending aorta and small hemopericardium, is compatible with a stanford type a aortic dissection with thrombosed false lumen. The official publication for icd9cm and icd10cmpcs coding. A computed tomographic ct scan confirmed these findings. Aortic luminal thrombus and intramural hematoma after. Intramural hematoma imh represents an emergency condition accounting for approximately 10% to 25% of acute aortic syndromes, most commonly occurring in the descending thoracic aorta 60% to 70% of cases and in older patients 1. To investigate the natural history and predictors of progression of a newly developed ulcerlike projection in patients with an aortic intramural hematoma. Intramural hemorrhage of the small intestine morgan eiland, md. New development of an ulcerlike projection in aortic. Intramural hematoma calgary thoracic aorta program. Intramural hematoma and penetrating atherosclerotic ulcers of the aorta. Aortic intramural hematoma radiology reference article.
Aortic intramural hematoma type b, images of an entity with different evolution. Aortic intramural hematoma imh is an important component of acute aortic syndrome. Intramural hematoma and penetrating atherosclerotic ulcers of the. Aug 19, 2014 aortic intramural hematoma imh is an important acute aortic syndrome that presents symptoms similar to those of classic aortic dissection. Hematoma intramural e ulcera penetrante da aorta scielo. Aortic intramural hematoma and its complications circulation. Thoracic endovascular aortic repair for type b intramural. A ct scan revealed extensive descending aortic intramural hematoma imh with posterior hemomediastinum and bilateral hemathoraces. Radiological evolution of type b aortic intramural hematoma imh in patient 1. Recently, thoracic endovascular aortic repair tevar has. Pdf we report a case of type a intramural aortic hematoma imh occurred in a 78 years old female. This leakage does not occur due to a tear in the aortic wall and, because of this, the condition has been difficult to diagnose until recently. Acute aortic syndrome is made up of three entities. From observation to therapeutic strategies susanne mohrkahaly, md mainz, germany noninvasive diagnostic imaging procedures, such as magnetic resonance imaging mri, computed tomography ct and transesophageal echocardiography tee 15, have allowed the detection of aortic abnormalities with an.
Aortic intramural hematoma aha coding clinic icd9cm article. Thomas tilbury, maurice enriquezsarano, artur evangelista, soon j. The natural histories of intramural hematoma imh and penetrating atherosclerotic ulcer pau are highly variable as they may progress to aneurysm formation. Atypical presentation of intramural hematoma of the ascending. After initial blood pressure control and imaging studies, the patient underwent limited surgical repair that consisted of ascending aortic. Intramural hematoma imh is included in the spectrum of acute aortic syndrome and appears as an area of hyperattenuating crescentic thickening in the aortic wall that is best seen at nonenhanced computed tomography. Intramural aortic hematoma and anticoagulation revista.
Aortic intramural hematoma is a severe disease, secondary to vasa vasorum bleeding andor aortic microulcers without connection with the true lumen of the vessel. Imh develops in the external layer of the media, due to a spontaneous rupture of the vasa vasorum. She was hypotensive upon arrival with a hemoglobin of 8. Atypical presentation of intramural hematoma of the ascending aorta using a conservative approach claudia maria rodrigues alves1,2, manuel pereira marques gomes jr. These are aortic dissection ad, intramural hematoma ih, and penetrating atherosclerotic ulcer pau. In conclusion, intramural colonic hematoma should be. Aortic intramural hematoma imh is an acute aortic syndrome with symptoms similar to those of aortic dissection. C,typeaaortic dissection,sagittalcontrastenhanced ctarrowheaddissectionplane. Aortic intramural hematoma and its complications aha journals.
The challenge of associated intramural hematoma with endovascular repair for penetrating ulcers of the descending thoracic aorta. Aortic intramural haematoma imh has been accepted as an increasingly recognised and potentially fatal entity of acute aortic syndrome with acute mortality and rapid progression. Aortic intramural hematoma discussion pertinent snippets consequently, intramural hematoma weakens the aorta and may progress either to outward rupture of the aortic wall or to inward disruption of the intima, the latter leading to communicating aortic dissection. Aortic intramural haematoma imh, a variant form of classic aortic dissection, has been accepted as an increasingly recognised and potentially fatal entity of acute aortic syndrome aas. The small intestine is the common site affected by spontaneous intramural hematoma, and intramural hematoma of the colon and rectum are rare 9. Observation surgery open or endovascular persistent or recurrent pain aneurysm formation, hematoma, leaking, long longitudinal tear redissection, long longitudinal tear. Intramural hematoma of the ascending colon leading to. Intramural aortic hematoma is one of a group of conditions covered by the term acute aortic syndrome. Editorials published in the journal of the american college of cardiology reflect the views of the authors and do not necessarily represent the views of jacc or the american college of cardiology. In our case, proper clip placement could be the reason for blocking blood drainage into the bowel lumen, which, in combination with a bleeding diathesis, led to the formation of the intramural hematoma and finally to colon perforation and fatal intraperitoneal hemorrhage fig. Ri slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Aortic intramural hematoma imh is a condition characterized by blood leaking through the innermost layer of the aortic wall and flowing between the inner and outer walls. Aortic intramural haematoma imh, a variant form of classic aortic dissection, has been accepted as an increasingly recognised and potentially fatal entity of.
The occurrence of intestinal intramural hematoma secondary to anticoagulant therapy is an uncommon condition, which affects 12500 patients receiving warfarin 8. Jul 22, 2010 sicu meeting intramural hematoma 2003. She reported no shortness of breath, gastrointestinal or neurologic symptoms, or trauma. Intramural hematoma imh of the aorta is a pathological pattern whose description has become more and more frequent due to the improvement of diagnostic techniques and in which the most appropriate treatment is still debated 1,2. Intramural haematoma is a quite uncommon but potentially lethal aortic disease that can strike as a primary occurrence in hypertensive and atherosclerotic patients to whom there is spontaneous.
Intramural hematoma imh is a relatively rare but potentially fatal pathology, and one of the entities included into a group of acute aortic syndromes aas. No distal propagation into the descending thoracic aorta noted. A 74yearold man suffering from suddenonset chest pain was referred to our nuclear medicine department for pe suspicion. Treatment patterns and their outcomes of acute aortic. Intramural aortic hematoma and anticoagulation request pdf. Intramural hematoma imh is a lifethreatening aortic disease included within acute aortic syndrome, together with aortic dissection and penetrating aortic ulcer pau. A misdiagnosis may lead to an unnecessary and even hazardous surgical intervention. Improved imaging techniques have led to better definition of the range of diseases that can affect the thoracic aorta.
Natural history and ct appearances of aortic intramural hematoma. Hicks, jr, md in 1954, felson and levin1 described certain roentgenographic findings that were considered characteristicofintra mural hemorrhage in the gastrointes tinal tract. Intramural blood pools accompanying aortic intramural. Pdf rupture of the vasa vasorum into the media of the aortic wall results in an aortic intramural hematoma.
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