Aortic CT: Intramural Hematoma. Leslie E. Quint, M.D.
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1 Aortic CT: Intramural Hematoma Leslie E. Quint, M.D.
2 43 M Mid back pain X several months
3
4
5 What type of aortic disease? A. Aneurysm with intraluminal thrombus B. Chronic dissection with thrombosed false lumen C. Acute intramural hematoma D. Penetrating atheromatous ulcer
6 Aneurysm Treated with open repair
7 INTRAMURAL HEMATOMA Long segment ATS & INTRALUMINAL THROMBUS Shorter segment Normal diameter ao Smooth interface Displaced intimal calcification Aneurysmal aorta Irregular/lobulated interface No displaced intimal calcification
8 Intramural hematoma
9 Atherosclerotic aneurysm with intraluminal thrombus
10 78 F Chest pain X 2 weeks
11
12
13 What type of aortic disease? A. Aneurysm with intraluminal thrombus B. Acute intramural hematoma C. Penetrating atheromatous ulcer D. A and C
14 Acute, type B intramural hematoma Long, longitudinal intimal tear Dilated aorta Treated with endograft
15 Intramural Hematoma Pre-contrast: Crescentic / circumferential hi attenuation in aortic wall Up to 2 wks s/p acute event Post-contrast: smooth, nonenhancing, thick aortic wall Displaced intimal Ca++ Chao CP. Radiographics 2009;29:791
16 Intramural Hematoma Pathology Bleeding into the medial layer of the aortic wall
17 Etiologies Intramural Hematoma Rupture of vasa vasorum due to degenerative changes in the media Intact intima Courtesy of Jay Faust, M.D.
18 Etiologies Intramural Hematoma Intimal tear with hematoma in the aortic wall (false lumen) Tear nonvisualized Tear appears as ulcer-like projection
19 Etiologies Intramural Hematoma Intimal tear with hematoma in the aortic wall (false lumen) Tear nonvisualized Tear appears as ulcer-like projection Lee CW. Int J Cardiovasc Imaging 2010;26:295
20 Large intimal tear with outpouching of contrast
21 Intramural Hematoma Etiologies Bleeding associated with penetrating atheromatous ulcer Rarely trauma Baikoussis NG. J Cardiothor Surg 2009;4:54 Lee CW. Int J Cardiovasc Imaging 2010;26:295 Yoo SM. RCNA 2010;48:67
22 86 M Cough and 10 lb wt loss X 2 months CXR CT No acute distress
23
24 What type of aortic disease? A. Ruptured aneurysm B. Ruptured intramural hematoma from penetrating atheromatous ulcer C. Ruptured double barreled dissection D. Ruptured intramural hematoma from an intimal tear
25 Penetrating atheromatous ulcer Intramural hematoma and rupture Endograft placed
26 Penetrating Atheromatous Ulcer Extensive atheromatous disease Irregular outpouching, adjacent plaque Usually in descending thoracic aorta
27 Intramural Hematoma Demographics Usually in older patients (except genetic syndromes) Majority of patients have hypertension Many patients have atherosclerosis with or without aneurysm Presentation: acute chest and/or back pain ~ 6-20% of acute aortic syndromes Baikoussis NG. J Cardiothor Surg 2009;4:54 Chao CP. Radiographics 2009;29:791 Evangelista A. Circulation 2005;111:1063 Litmanovich D. AJR 2009;193:928 Svensson LG Ann Thor Surg 2008;85:S1
28 Intramural Hematoma More common in descending aorta vs ascending aorta Similar mortality to classical AD 8% descending 39% ascending Rupture or end organ ischemia Less likely to have malperfusion, pulse deficits, or aortic valve insufficiency than classical AD Evangelista A. Circulation 2005;111:1063 Svensson LG Ann Thor Surg 2008;85:S1
29 Intramural Hematoma Treatment Beta blockers to reduce aortic wall stress and control hypertension Baikoussis NG. J Cardiothor Surg 2009;4:54
30 Intramural Hematoma Treatment Beta blockers to reduce aortic wall stress and control hypertension Type A: controversial; usually surgery Type B: Observation Surgery (open or endovascular) persistent or recurrent pain aneurysm formation, hematoma, leaking, long longitudinal tear Re-dissection, long longitudinal tear Baikoussis NG. J Cardiothor Surg 2009;4:54
31 Intramural Hematoma Treatment Endograft for: intimal defect leakage Friable wall due to hematoma may lead to new tears at endograft landing zones Baikoussis NG. J Cardiothor Surg 2009;4:54 Patel H. J Vasc Surg 2010;51:829
32 Intramural Hematoma High risk features Type A Aortic diameter > 4.5 cm Thickness > 10 mm Ulcer like projections Age > 70 Buckley O. Int J Cardiovasc Imaging 2010;26:65
33 68 M Follow-up known aortic aneurysm New severe back pain X 1 day
34
35
36 What type of aortic disease? A. Aneurysm with intraluminal thrombus B. Chronic dissection with thrombosed false lumen C. Acute intramural hematoma D. Combination of A and C
37 New intramural hematoma in pre-existing aneurysm
38 Treated with endograft
39 Aortic Aneurysms and IMH Two major complications of aneurysms:
40 Aortic Aneurysms and IMH Two major complications of aneurysms: Dissection (including IMH) Rupture Aneurysm and IMH may be seen together
41 Intramural hematoma and aneurysm with intraluminal thrombus
42 73 M Sudden onset of pleuritic chest pain, back pain, and shortness of breath while at the chiropractor Hypotensive in emergency department
43 Intramural hematoma or double barreled dissection?
44 Intramural hematoma or double barreled dissection?
45 Some aortic segments may show IMH and others may show double barreled dissection IMH and double barreled dissection may co-exist in same segment of aorta
46 59 F Severe chest pain radiating to back while shoveling snow
47 1/18/11
48 1/20/11
49 1/20/11
50 Some aortic segments may show IMH and others may show double barreled dissection IMH and double barreled dissection may co-exist in same segment of aorta IMH may evolve into double barreled dissection
51 53 M Pronounced non productive cough with pleuritic chest pain Transferred from OSH
52
53
54 Type A intramural hematoma Large intimal tear
55 Intramural blood pools in false lumen Due to tiny intimal tears Or branch artery pseudoaneurysms at origins of branch vessels Williams, DM. JVIR 2006;17:765 Williams, DM. JVIR 2006;17:773 Wu M. Radiology 2011;258:705
56 69 F History of previous Type B intramural hematoma Now left sided chest pain s/p MVA
57 Branch artery pseudoaneurysm
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