Aortic intramural hematoma: Review of high-risk imaging features

A single-center experience of type B aortic intramural hematoma

OBJECTIVE

The outcomes of the best medical treatment (BMT) and intervention treatment (INT) in a single-center experience were reported in type B intramural hematoma (IMH).

METHODS

From February 2015 to February 2021, a total of 195 consecutive patients with type B IMH were enrolled in the study. The primary end point was mortality, and the secondary end points included clinical and imaging outcomes. The clinical outcomes were aortic-related death, retrograde type A aortic dissection, stent graft-induced new entry tear, endoleak, and reintervention. The imaging outcome was evaluated through the latest follow-up computed tomography angiography, which included aortic rupture, aortic dissection, aortic aneurysm, rapid growth of aortic diameter, newly developed or enlarged penetrating aortic ulcer or ulcer-like projection (ULP) and increased aortic wall thickness. Kaplan-Meier curves were used to assess the association between different treatments.

RESULTS

Among the enrolled patients, 115 received BMT, and 80 received INT. There was no significant difference in early (1.7% vs 2.5%; P = 1.00) and midterm all-cause death (8.3% vs 5.2%; P = .42) between the BMT and INT groups. However, patients who underwent INT were at risk of procedure-related complications such as stent graft-induced new entry tear and endoleaks. The INT group was associated with a profound decrease in the risk of ULP, including newly developed ULP (4.3% vs 26.9%; P < .05), ULP enlargement (6.4% vs 31.3%; P < .05), and a lower proportion of high-risk ULP (10.9% vs 45.6%; P < .05). Although there was no significant difference in the incidence of IMH regression between the two groups, the maximum diameter of the descending aorta in patients receiving INT was larger compared with those treated with BMT.

CONCLUSIONS

Based on our limited experience, patients with type B IMH treated with BMT or INT shared similar midterm clinical outcome. Patients who underwent INT may have a decreased risk of ULPs, but a higher risk of procedure-related events and patients on BMT should be closely monitored for ULP progression.

Clinical characteristics and outcomes of Stanford type B aortic intramural hematoma: A single centre experience

Objective

To compare the clinical characteristics of Stanford type B aortic intramural hematoma (IMH) and Stanford type B aortic dissection (AD), and to identify the differences between thoracic endovascular aortic repair (TEVAR) and medical management (MM) in the Stanford type B IMH patients.

Methods

A retrospective observational study was conducted in patients treated between January 2015 and December 2016. The clinical characteristics and CT images of patients with type B IMH and type B AD were compared, and the clinical characteristics and CT images of patients in the type B IMH group who were treated with TEVAR and MM were compared.

Results

A total of 176 patients were included in this study, including 62 patients of type B IMH and 114 patients of type B AD. Five patients died in the IMH group and three in the AD group. The proximal hematoma or entry tear in both groups was mainly located in the descending aorta, and the proportion of the iliac artery involved in the AD group was significantly higher than that in the IMH group (31.6% vs. 8.1% P < 0.05). There were 50 MM patients and 12 TEVAR patients in the IMH group. No death occurred in the TEVAR group, while five patients in the MM group died. Seven patients in the MM group had disease progression vs. 12 in the TEVAR group (P < 0.05). The patients in the TEVAR group had more intima lesions than those in the MM group (83.3% vs. 30.0%, P < 0.05). TEVAR group involved more iliac artery hematoma than MM group (33.3% vs. 2.0%, P < 0.05). The maximum thickness of hematoma in TEVAR group was 14.9 ± 3.4 mm, which was significantly larger than that of MM group (10.2 ± 2.8 mm) (P < 0.05).

Conclusion

In the diagnosis of IMH, patients' symptoms and high-risk signs of CTA should be paid attention to. TEVAR therapy should be actively considered on the basis of effective medical management when there are intima lesions (ULP/PAU), increased aortic diameter and hematoma thickness, extensive hematoma involvement, and pleural effusion.

Predictors of Intervention in Acute Type B Aortic Penetrating Ulcer and Intramural Hematoma

We aimed to investigate predictors of intervention of acute type B aortic penetrating ulcer (PAU) and intramural hematoma (IMH). We conducted a retrospective chart review of all patients admitted for acute type B PAU or IMH in a tertiary referral hospital. Indications to intervention were "complicated" (rupture, impending rupture, malperfusion) or "high risk for unfavorable outcome" (refractory hypertension and/or pain despite best medical treatment, morphologic aortic evolution, transition to a new aortic syndrome, or increase in IMH/PAU depth >5 mm) during the acute/subacute phase. The primary outcomes were overall mortality, aortic-related mortality, and freedom from intervention. Time-dependent outcomes were estimated with Kaplan-Meier curves. Cox proportional hazards models were used to identify predictors of intervention and mortality. There were 54 acute aortic syndromes, 37 PAUs and 17 IMHs. Mean age was 69 ± 14 years and 33 patients (62.2%) were male. Six (11.5%) patients had complicated aortic syndromes and underwent urgent repair. Two (3.7%) additional patients developed an impending rupture during the acute phase. Eleven (21.1%) patients were classified as at "high risk" during the initial hospitalization. Overall, 22 (40.7%) patients required an aortic intervention during the initial admission (n = 16, 72.7% during the acute phase; n = 6, 27.3% during the subacute phase). In-hospital mortality was 5.5% (1 PAU and 2 IMH), and was aorta-related in all cases. For IMH, disease extension in >3 aortic zones (HR 1.94, 95%CI 1.17-32.6; p = 0.038) and presence of ulcer-like projections (ULPs) (HR 1.23, 95%CI 1.02-9.41; p = 0.042) were associated with the need for intervention. There were no aortic-related deaths or intervention during the chronic phase. PAU width >20 mm (HR 1.68, 95%CI 1.07-16.08; p = 0.014), PAU depth >15 mm (HR 6.74, 95%CI 1.31-34.18; p = 021), PAU depth/total aortic diameter >0.3 (HR 4.31, 95%CI 1.17-20.32; p = 0.043), and location at the level of the paravisceral aorta (HR 2.24, 95%CI 1.23-4.70; p = 0.035) were significantly associated with need for intervention. Six additional (16.2%) PAUs required intervention during the chronic phase owing to PAU growth. Maximum aortic diameter >35 mm was significantly associated with intervention (HR 1.45, 95%CI 1.00-2.32; p = 0.037). Acute symptomatic type B IMHs and PAUs are characterized by a high risk of complications during the first month from presentation. Morphologic features associated with intervention were IMH with ULPs or extension in more than 3 aortic zones, as well as PAUs with depth>15 mm, width >20 mm, or depth/aortic diameter ratio>0.3. A strict follow-up protocol or consideration for early intervention within 30 days from presentation should be taken into account for these high-risk patients. During the chronic phase imaging follow-up is particularly important for PAUs in order to identify progression to saccular aneurysms.

Aortic Intramural Hematoma due to Intercostal Artery Aneurysms

BackgroundIntercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.

Prediction of adverse events in patients with initially medically treated type A intramural hematoma

BACKGROUND

Prior studies provided limited data regarding natural history of initially medically treated type A intramural hematoma (IMH).

OBJECTIVES

To develop predictive models for adverse aorta-related events in patients with type A IMH.

METHODS

We performed a retrospective pooled analysis of individual patient data, including baseline clinical and CT characteristics. All patients enrolled were followed up for adverse aorta-related events, defined as a composite of aortic disease-related death and the presence of aortic complications that required aortic invasive treatment.

RESULTS

A total of 172 patients (52.9% men) were included, with a mean age of 61.1 ± 11.2 years. During a median follow-up time of 770.5 (45.3-1695.8) days, 60 patients (34.9%) experienced adverse aorta-related events. In Cox regression model for predicting adverse aorta-related events, hypertension (HR = 3.78, p = .067), MAD (HR = 1.05, p = .018), presence of ULP (HR = 2.43, p = .002) and pericardial effusion (HR = 1.65, p = .061) were independently associated with adverse aorta-related events. A majority of the adverse aorta-related events (n = 46, 76.7%) occurred within acute and subacute phase (90 days) of IMH. In predictive model for 90 days aortic events, MAD≥50.7 mm (OR = 2.79, p = .006) and presence of ULP (OR = 3.20, p = .002) were independent predictors. C statistic of the predictive model were 0.71 (p < .001).

CONCLUSIONS

Predictive models including baseline clinical and CT characteristics as predictors allow for accurate estimation of risk of adverse aorta-related events in patients with type A IMH. The proposed predictive models are helpful for risk estimates and decision making.

A Review on the Surgical Management of Intramural Haematoma of the Aorta

Intramural haematoma (IMH) of the aorta is one of the causes of acute aortic syndrome which often requires emergency or urgent life-saving surgery. In this review, we discuss the pathophysiology, epidemiology, clinical presentation, diagnostic imaging, surgery and clinical outcomes associated with IMH.

Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma

PURPOSE

To evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH).

MATERIALS AND METHODS

From April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases.

RESULTS

Successful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57.

CONCLUSIONS

TEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.

Acute type B aortic intramural hematoma: the added prognostic value of a follow-up CT

OBJECTIVES

To investigate prognostic significance of follow-up CT findings for initially medically treated type B aortic intramural hematoma (IMH).

METHODS

We performed a retrospective pooled analysis of individual patient data, including baseline and follow-up CT characteristics. All enrolled patients were followed up for adverse aorta-related events, defined as a composite of aortic disease-related death and surgical or endovascular aortic repair.

RESULTS

A total of 238 patients (73.9% men) were included, with a mean age of 58.1 ± 9.8 years. During follow-up, 83 patients (34.9%) experienced adverse aorta-related events, most of the events (83.1%) occurred within 1 month after follow-up CT imaging (n = 69). In the Cox regression model for predicting adverse aorta-related events, baseline maximal aortic diameter (MAD) (HR = 1.05, p = 0.008), ulcer-like projection (ULP) (HR = 2.47, p < 0.001), changes of maximal hematoma thickness (MHT) (HR = 1.22, p < 0.001), newly developed ULP (HR = 4.44, p < 0.001), and newly developed pleural effusion (HR = 2.46, p = 0.002) were powerful independent predictors. In combined predictive model for 1-month aortic events, baseline MHT ≥ 11.8 mm (OR = 4.39, p = 0.001), ULP (OR = 3.98, p < 0.001), changes of MHT (OR = 1.46, p < 0.001), newly developed ULP (OR = 9.27, p = 0.002), and newly developed pleural effusion (OR = 3.45, p = 0.015) were independent predictors. Besides, in patients with pleural effusion at baseline, resorption of pleural effusion was associated with adverse aorta-related events (HR = 0.36, p = 0.027) and 1-month aortic events (OR = 0.23, p = 0.026).

CONCLUSIONS

Follow-up CT findings provide strong and incremental prognostic information for initially medically treated type B IMH, which are helpful for risk estimates and decisions-making.

KEY POINTS

• Follow-up CT provides strong and incremental prognostic information for initially medically treated type B aortic intramural hematoma. • Follow-up CT is highly recommended for type B intramural hematoma in patients who did not receive urgent invasive therapy. • Follow-up CT is helpful for risk estimates and decisions-making.

CT imaging of complications of aortic intramural hematoma: a pictorial essay

Aortic intramural hematoma (IMH) is a pathologic process with a clinical presentation identical to aortic dissection and associated with significant morbidity and mortality. Radiologists must be familiar with the imaging appearances of IMH as computed tomography (CT) plays a critical role in both diagnosis and patient management. The course of IMH is variable and the process may regress, remain stable, or progress in extent and therefore imaging findings associated with a negative prognosis must be recognized and included in the formal radiology report. Potentially life-threatening complications and findings associated with IMH include hemopericardium and cardiac tamponade, coexisting aortic dissection, ulcer-like projection, intramural blood pool, and extension of hematoma along the pulmonary or coronary arteries, which are identifiable with aortic protocol CT. The purpose of this pictorial review is to provide the reader with an image-based review of the diagnostic criteria, related complications, and associated critical prognostic features in patients presenting with aortic IMH.

ASER core curriculum illustration project: aortic intramural hematoma (IMH)

This is the 23rd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Advances in the diagnosis of acute aortic syndromes: Role of imaging techniques

Aortic diseases include a wide range of pathological conditions: aortic aneurysms, pseudoaneurysms, acute aortic syndromes, atherosclerotic and inflammatory conditions, genetic diseases and congenital anomalies. Acute aortic syndromes have acute onset and may be life-threatening. They include aortic dissection, intramural haematoma, penetrating aortic ulcer and traumatic aortic injury. Pain is the common denominator to all acute aortic syndromes. Pain occurs regardless of age, gender and other associated clinical conditions. In this review, we deal with the main findings in the clinical setting and the most recent indications for diagnostic imaging, which are aimed to start an appropriate treatment and improve the short- and long-term prognosis of these patients.

MDCT distinguishing features of focal aortic projections (FAP) in acute clinical settings

Focal aortic projections (FAP) are protrusion images of the contrast medium (focal contour irregularity, breaks in the intimal contour, outward lumen bulging or localized blood-filled outpouching) projecting beyond the aortic lumen in the aortic wall and are commonly seen on multidetector computed tomography (MDCT) scans of the chest and abdomen. FAP include several common and uncommon etiologies, which can be demonstrated both in the native aorta, mainly in acute aortic syndromes, and in the post-surgical aorta or after endovascular therapy. They are also found in some types of post-traumatic injuries and in impending rupture of the aneurysms. The expanding, routine use of millimetric or submillimetric collimation of current state-of-the-art MDCT scanners (16 rows and higher) all the time allows the identification and characterization of these small ulcer-like lesions or irregularities in the entire aorta, as either an incidental or expected finding, and provides detailed three-dimensional pictures of these pathologic findings. In this pictorial review, we illustrate the possible significance of FAP and the discriminating MDCT features that help to distinguish among different types of aortic protrusions and their possible evolution. Awareness of some related and distinctive radiologic features in FAP may improve our understanding of aortic diseases, provide further insight into the pathophysiology and natural history, and guide the appropriate management of these lesions.

The role of multidetector-row CT in the diagnosis, classification and management of acute aortic syndrome

The term "acute aortic syndrome" (AAS) encompasses several non-traumatic life-threatening pathologies of the thoracic aorta presenting in patients with a similar clinical profile. These include aortic dissection, intramural haematoma and penetrating atherosclerotic ulcers. These different pathological entities can be indistinguishable on clinical grounds alone and may be confused with other causes of chest pain, including myocardial infarction. Multidetector-row CT (MDCT) is the current modality of choice for imaging AAS with a sensitivity and specificity approaching 100%. Early diagnosis and accurate radiological classification is associated with improved clinical outcomes in AAS. We review the characteristic radiological features of the different pathologies that encompass AAS and highlight the vital role of MDCT in determining the management of these life-threatening conditions.

Update in acute aortic syndrome: intramural hematoma and incomplete dissection as new disease entities

Acute aortic syndrome is a relatively recent clinical entity. Non-invasive imaging methods, such as computed tomography and transesophageal echocardiography, have contributed significantly to the diagnosis of variant forms of classic aortic dissection, which have become important disease entities in acute aortic syndrome. Imaging findings may result in risk stratification and application of different treatment options, providing a rational approach to achieve a better outcome of this syndrome. This review will focus on the imaging characteristics of two important variant forms of classic aortic dissection, intramural hematoma and incomplete dissection, and the role of imaging methods in the evaluation of differences in the hemodynamic status of false lumens that contributes to patient prognosis.

Cervical Necrotizing Fasciitis Caused by Dental Infection

Necrotizing fasciitis (NF) is defined as rapidly progressive necrosis of subcutaneous fat and fascia. Although NF of the face is rare, its mortality rate is nearly 30%. It usually originates from dental infection and can lead to involvement of the neck, mediastinum, and chest wall. Complications resulting from pre-existing systemic diseases can increase the mortality rate. Known complication factors for NF include diabetes, malnutrition, advanced age, peripheral vascular disease, renal failure, and obesity. Here, we report a case of NF originating from dental infection in an 88-year-old woman already diagnosed with hypertension, thoracic aortic aneurysm, and renal diseases. Such conditions limited adequate surgical and antibiotic treatment. However, interdisciplinary treatment involving multiple departments was implemented with good results.