European Radiology

, Volume 29, Issue 12, pp 6571–6580 | Cite as

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

  • Zhennan Li
  • Bin LuEmail author
  • Yuan Chen
  • Zhihui Hou
  • Baojin Chen
  • Yan Zhang
  • Yunqiang An
  • Yingjie Wei
Computed Tomography



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


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.


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).


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.


Aortic diseases Hematoma Prognosis Computed tomography angiography 



Acute aortic syndrome


Body mass index


Confidence interval


Computed tomography


Hazard ratio


Intramural blood pool


Intramural hematoma


Maximal aortic diameter


Maximal hematoma thickness


Odds ratio


Receiver operating characteristic


Ulcer-like projection



We thank the technician Lei Han for proofreading and we are grateful to Dr. Chuangshi Wang for statistical support.


The present study was supported by the Ministry of Science and Technology of China, National Key Research and Development Project (2016YFC1300400), and CAMS Innovation Fund for Medical Sciences (No. 2016-I2M-1-011).

Compliance with ethical standards


The scientific guarantor of this publication is Bin Lu.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Dr. Chuangshi Wang kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic or prognostic study

• performed at one institution


  1. 1.
    Bossone E, LaBounty TM, Eagle KA (2018) Acute aortic syndromes: diagnosis and management, an update. Eur Heart J 39:739–749dCrossRefGoogle Scholar
  2. 2.
    Hiratzka LF, Bakris GL, Beckman JA et al (2010) 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol 55:e27–e129CrossRefGoogle Scholar
  3. 3.
    Erbel R, Aboyans V, Boileau C et al (2014) 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 35:2873–2926CrossRefGoogle Scholar
  4. 4.
    Moral S, Cuéllar H, Avegliano G et al (2017) Clinical implications of focal intimal disruption in patients with type B intramural hematoma. J Am Coll Cardiol 69:28–39CrossRefGoogle Scholar
  5. 5.
    Kaji S, Akasaka T, Katayama M et al (2003) Long-term prognosis of patients with type B aortic intramural hematoma. Circulation 108:II307–II311PubMedGoogle Scholar
  6. 6.
    Timperley J, Ferguson JD, Niccoli G, Prothero AD, Banning AP (2003) Natural history of intramural hematoma of the descending thoracic aorta. Am J Cardiol 91:777–780Google Scholar
  7. 7.
    Kruse MJ, Johnson PT, Fishman EK, Zimmerman SL (2013) Aortic intramural hematoma: review of high-risk imaging features. J Cardiovasc Comput Tomogr 7:267–272CrossRefGoogle Scholar
  8. 8.
    Kitai T, Kaji S, Yamamuro A et al (2011) Detection of intimal defect by 64-row multidetector computed tomography in patients with acute aortic intramural hematoma. Circulation 124:S174–S178CrossRefGoogle Scholar
  9. 9.
    Sawaki S, Hirate Y, Ashida S, Takanohashi A, Yagami K, Usui M (2010) Clinical outcomes of medical treatment of acute type A intramural hematoma. Asian Cardiovasc Thorac Ann 18:354–359Google Scholar
  10. 10.
    Evangelista A, Dominguez R, Sebastia C et al (2003) Long-term follow-up of aortic intramural hematoma: predictors of outcome. Circulation 108:583–589CrossRefGoogle Scholar
  11. 11.
    Song JM, Kim HS, Song JK et al (2003) Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma. Circulation 108:II324–II328CrossRefGoogle Scholar
  12. 12.
    Schlatter T, Auriol J, Marcheix B et al (2011) Type B intramural hematoma of the aorta: evolution and prognostic value of intimal erosion. J Vasc Interv Radiol 22:533–541CrossRefGoogle Scholar
  13. 13.
    Evangelista A, Dominguez R, Sebastia C et al (2004) Prognostic value of clinical and morphologic findings in short-term evolution of aortic intramural haematoma. Therapeutic implications. Eur Heart J 25:81–87CrossRefGoogle Scholar
  14. 14.
    Sebastià C, Evangelista A, Quiroga S, Cuellar H, Aguilar R, Muntanyà X (2012) Predictive value of small ulcers in the evolution of acute type B intramural hematoma. Eur J Radiol 81:1569–1574Google Scholar
  15. 15.
    von Kodolitsch Y, Csösz SK, Koschyk DH et al (2003) Intramural hematoma of the aorta predictors of progression to dissection and rupture. Circulation 107:1158–1163CrossRefGoogle Scholar
  16. 16.
    Quint LE, Williams DM, Francis IR et al (2001) Ulcerlike lesions of the aorta: imaging features and natural history. Radiology 218:719–723CrossRefGoogle Scholar
  17. 17.
    Kitai T, Kaji S, Kim K et al (2014) Prognostic value of sustained elevated C-reactive protein levels in patients with acute aortic intramural hematoma. J Thorac Cardiovasc Surg 147:326–331CrossRefGoogle Scholar
  18. 18.
    Wu MT, Wang YC, Huang YL et al (2011) Intramural blood pools accompanying aortic intramural hematoma: CT appearance and natural course. Radiology 258:705–713CrossRefGoogle Scholar
  19. 19.
    Bonaca MP, O’Gara PT (2014) Diagnosis and management of acute aortic syndromes: dissection, intramural hematoma, and penetrating aortic ulcer. Curr Cardiol Rep 16:536CrossRefGoogle Scholar
  20. 20.
    Tanaka A, Leake S, Estrera AL (2017) Management strategies in acute type B aortic intramural hematoma. Curr Opin Cardiol 32:687–691CrossRefGoogle Scholar
  21. 21.
    Park KH, Lim C, Choi JH et al (2008) Prevalence of aortic intimal defect in surgically treated acute type A intramural hematoma. Ann Thorac Surg 86:1494–1500CrossRefGoogle Scholar
  22. 22.
    Park GM, Ahn JM, Kim DH et al (2011) Distal aortic intramural hematoma: clinical importance of focal contrast enhancement on CT images. Radiology 259:100–108CrossRefGoogle Scholar
  23. 23.
    Wu MT, Wu TH, Lee D (2005) Multislice computed tomography of the aortic intramural hematoma with progressive intercostal artery tears: the Chinese ring-sword sign. Circulation 111:e92–e93CrossRefGoogle Scholar
  24. 24.
    Kitai T, Kaji S, Yamamuro A et al (2009) Clinical outcomes of medical therapy and timely operation in initially diagnosed type A aortic intramural hematoma: a 20-year experience. Circulation 120:S292–S298CrossRefGoogle Scholar
  25. 25.
    Song JK, Yim JH, Ahn JM et al (2009) Outcomes of patients with acute type a aortic intramural hematoma. Circulation 120:2046–2052CrossRefGoogle Scholar
  26. 26.
    Maslow A, Atalay MK, Sodha N (2018) Intramural hematoma. J Cardiothorac Vasc Anesth 32:1341–1362Google Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Zhennan Li
    • 1
  • Bin Lu
    • 1
    Email author
  • Yuan Chen
    • 1
  • Zhihui Hou
    • 1
  • Baojin Chen
    • 2
  • Yan Zhang
    • 3
  • Yunqiang An
    • 1
  • Yingjie Wei
    • 4
  1. 1.Department of Radiology, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China
  2. 2.Department of Radiology, Shandong Provincial HospitalShandong UniversityJinanPeople’s Republic of China
  3. 3.Department of RadiologyAffiliated Hospital of Guizhou Medical UniversityGuiyangPeople’s Republic of China
  4. 4.State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China

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