Jessie Zulay Ramírez Calderón, Ángel Sanchez, Jaime Alonso;
Hospital Universitario 12 de Octubre,
71 years, male
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).
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 .
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 .
Pools of contrast material extravasations have been described inside an intramural haematoma. This contrast pooling has been classified as two types:
Pools may be visible as a string of contrast agent poolings on coronal or sagittal reconstructed
images . Wu et al has proposed the term “Chinese ring-sword sign” to describe this finding . IBP mainly occur in the descending thoracic abdominal aorta .
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 .
If luminal dilatation, penetrating ulcer, enlargement of the IMH or dissection occur, surgical or endovascular treatment should be considered .
Written informed patient consent for publication has been obtained.
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 Gutschow S, Walker C, Martínez-Jiménez S, Rosado-de-Christenson M, Stowell J, Kunin J (2016) Emerging Concepts in Intramural Hematoma Imaging. RadioGraphics 36(3):660-674 (PMID: 27163587)
 Wu M, Wang Y, Huang Y, Chang R, Li S, Yang P et al (2011) Intramural Blood Pools Accompanying Aortic Intramural Hematoma: CT Appearance and Natural Course. Radiology 258(3):705-713 (PMID: 21212368)
 Wu M (2005) Multislice Computed Tomography of Aortic Intramural Hematoma With Progressive Intercostal Artery Tears: The Chinese Ring-Sword Sign. Circulation 111(5):e92-e93 (PMID: 15699269)