Intramural Hematoma of the Ascending Aorta; Diagnosis, Management and Outcome

  • Martin Czerny
  • Jürg Schmidli


The first description of IMH was given by Krukenberg in 1920 being defined at that time as aortic dissection without an intimal flap or tear that would lead to direct flow communication between the true and the false lumen. IMH was determined as to arise from hemorrhage of the vasa vasorum located within the medial layer of the aorta. The reason for the hemorrhage was thought to be the consequence of spontaneous rupture of the vasa vasorum. However, later on it was noted that hematoma formation within the aortic wall could also be the consequence of PAU.

Symptoms of IMH are very similar to those of acute aortic dissection and they may well be indistinguishable. Patients present with a history of chest and/or back pain and with a history of hypertension. Chest pain is associated with type A IMH and back pain is associated with type B IMH. Interestingly, patients with IMH report more intensive pain than patients with aortic dissection. In addition, patients with IMH are less likely to suffer from malperfusion syndrome. Finally, patients with IMH are in general one decade older than patients with classical acute aortic dissection.

The natural progression of IMH is unpredictable. While some cases of IMH progress to dissection, aneurysm or rupture, others remain stable, regress or completely resolve. Recent literature has identified several potential risk factors for progression including the presence of PAU, older age, an aortic diameter larger than 5 cm and wall thickness of the hematoma greater than 1 cm.

The main objective of treatment of IMH is the prevention of aortic rupture as well to prevent the progression to classic aortic dissection. As type A IMH has a high and early risk of complication and death with medical treatment alone, surgery is usually indicated. Treatment of type B IMH is less straightforward as the prognosis is less uniform and predictable. A more conservative approach for uncomplicated type B IMH such as antihypertensive treatment and watchful monitoring is currently preferred as it appears to be a safer strategy. However, in some cases the disease might still progress despite optimal medical treatment.


Intramural hematoma Type A aortic dissection Entry tear TEVAR 


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Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Department of Cardiovascular SurgeryInselspital BernBernSwitzerland
  2. 2.Department of Cardiovascular SurgeryInselspital, University Hospital BernBernSwitzerland

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