Intramural Hematoma of the Ascending Aorta; Diagnosis, Management and Outcome
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.
KeywordsIntramural hematoma Type A aortic dissection Entry tear TEVAR
- 3.Evangelista A, Mukherjee D, Mehta R, O'Gara PT, Fattori R, Cooper JV, Smith DE, Oh JK, Hutchison S, Sechtem U, Isselbacher EM, Nienaber CA, Pape LA, Eagle KA, International Registry of Aortic Dissection (IRAD) Investigators. Acute intramural hematoma of the aorta: a mystery in evolution. Circulation. 2005;111:1063–70.PubMedCrossRefGoogle Scholar
- 4.Krukenberg E. Beitrage zur Frage des Aneurysma dissecans. Beitr Pathol Anat Allg Pathol. 1920;67:329–51.Google Scholar
- 5.Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM, 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; Society for Vascular Medicine. 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. 2010;55:e27–129.PubMedCrossRefGoogle Scholar
- 7.Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, Radegran K, Sechtem U, Taylor J, Zollikofer C, Klein WW, Mulder B, Providencia LA, Task Force on Aortic Dissection, European Society of Cardiology. Diagnosis and management of aortic dissection. Eur Heart J. 2001;18:1642–81.CrossRefGoogle Scholar
- 18.Kitai T, Kaji S, Yamamuro A, Tani T, Tamita K, Kinoshita M, Ehara N, Kobori A, Nasu M, Okada Y, Furukawa Y. Clinical outcomes of medical therapy and timely operation in initially diagnosed type a aortic intramural hematoma: a 20-year experience. Circulation. 2009;120(11 Suppl):S292–8.PubMedCrossRefGoogle Scholar
- 20.Czerny M, Krähenbühl E, Reineke D, Sodeck G, Englberger L, Weber A, Schmidli J, Kadner A, Erdoes G, Schoenhoff F, Jenni H, Stalder M, Carrel T. Mortality and neurologic injury after surgical repair with hypothermic circulatory arrest in acute and chronic proximal thoracic aortic pathology: effect of age on outcome. Circulation. 2011;124:1407–13.PubMedCrossRefGoogle Scholar