CASE 16387 Published on 03.06.2019

Aortic intramural haematoma blood pools: the Chinese ring-sword sign



Case Type

Clinical Cases


Jessie Zulay Ramírez Calderón, Ángel Sanchez, Jaime Alonso;

Hospital Universitario 12 de Octubre,



71 years, male

Area of Interest Arteries / Aorta, Vascular ; Imaging Technique CT-Angiography
Clinical History

A 71-year-old diabetic male patient presented to the emergency department with chest pain radiating to the interscapular region and hypertensive crisis (systolic arterial tensions up to 230 mmHg).

Imaging Findings

A clinical diagnosis of an acute aortic syndrome was made. CT scan was performed and at the noncontrast phase there was a high-density, crescent-shaped image within the postero-lateral aortic wall, diagnostic of intramural aortic haematoma. It extends caudal to the origin of the left subclavian artery to the origin of the right renal artery. No signs of dissection or penetrating ulcers were observed. Eighteen days later, control CT was obtained, showing growth of the aortic intramural haematoma and at least 7 small pools of contrast extravasation inside the intramural haematoma, all of them associated with the site of origin of intercostal branches, suggestive of pseudoaneurysms. Due to these findings, a thoracic aortic endoprothesis was implanted with good results.


Intramural haematoma (IMH) can present as an acute aortic syndrome. Actually it has been defined as a variant or a precursor of aortic dissection with a small intimal defect and thrombosed false lumen without re-entry tear [1].

At CT scan, a subintimal crescent-shaped hyperdensity is the most classic and important finding in noncontrast images. The aortic lumen is patent: no intimal flap or aortic wall enhancement can be seen. Subintimal semi-circular or curvilinear calcifications can be present. IMHs are classified according to the Stanford classification, same as aortic dissection [1].

Pools of contrast material extravasations have been described inside an intramural haematoma. This contrast pooling has been classified as two types:

  1. Ulcer-like projection (ULP): is a localised blood-filled pouch protruding from the true lumen into the thrombosed false lumen of the aorta. This is an indicator of the formation of a flow channel between the two lumens, which can become an aortic dissection or can heal and resolve [1]. The key feature of a ULP that distinguishes it from the intramural blood pool is that the opening is usually wide (> 3 mm) [2].
  2. Intramural blood pool (IBP): are localised contrast-filled pools inside the IMH on post-contrast MDCT images secondary to the damage caused by IMH propagation across the origin of an aortic branch artery (bronchial, intercostal, intercostobronchial, pericardial, lumbar) that is partially or completely torn [1]. The communication between the contrast medium–filled pool and true lumen can be absent or be a tiny orifice less than 2 mm in diameter [3].

Pools may be visible as a string of contrast agent poolings on coronal or sagittal reconstructed

images [2]. Wu et al has proposed the term “Chinese ring-sword sign” to describe this finding [4]. IBP mainly occur in the descending thoracic abdominal aorta [3].

In the current available literature, intramural blood pool does not appear to carry increased risk for IMH progression, need for surgery, or mortality, but does have a higher risk for incomplete haematoma resorption. Larger intramural blood pools and those with a visible connection to a branch artery are at higher risk for incomplete resorption and may grow over time, necessitating endovascular embolisation [2].

If luminal dilatation, penetrating ulcer, enlargement of the IMH or dissection occur, surgical or endovascular treatment should be considered [1].

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Aortic intramural haematoma with intramural blood pools - “Chinese ring-sword sign”
Penetrating atherosclerotic ulcer
Ulcer-like projection in intramural haematomas
Final Diagnosis
Aortic intramural haematoma with intramural blood pools - “Chinese ring-sword sign”
Case information
ISSN: 1563-4086