CASE

45 Aortic intramural hematoma

Matthew H. Nett

Imaging description
Aortic intramural hematoma (IMH) results from rupture
of the vasa vasorum and hemorrhage into the arterial media,
which leads to weakening of the aortic wall, but absence of the
intimal disruption that characterizes an aortic dissection [1].
Intramural hematoma of the thoracic aorta can be classified
with the Stanford system similar to aortic dissections, with a
Stanford type A involving the ascending aorta, and a Stanford
type B involving the descending aorta.
Intramural hematoma can be diagnosed with echocardiog-
raphy, CT, and MRI. Transesophageal echocardiography
has been reported to have a sensitivity of up to 100% and
specificity of 91%, and transthoracic echocardiography has a
reported sensitivity range of 77–80%, although both of these
modalities are operator dependent. CT and MR also have a
sensitivity and negative predictive value which approach 100%
[1, 2], but because it is less time-consuming and typically more
readily available than MR, CT has become the diagnostic test
of choice in suspected acute aortic syndrome (AAS).
The typical appearance of IMH on CT is a hyperdense,
typically crescentic collection located eccentrically in the wall
of the aorta (Figure 45.1A). Because intravascular contrast
may obscure an IMH and therefore prevent early detection
(Figure 45.1B), a non-contrast phase performed prior to CT
angiography (CTA) is generally considered a necessary com-
ponent of an AAS protocol [1, 3, 4]. Narrow window settings
when reviewing these images can also increase the conspicuity
of subtle areas of hyperdensity and focal aortic wall thickening.
However, a prospective study evaluating the benefit of this
additional non-contrast phase is yet to be performed. As IMH
is uncommon, performing a single phase gated post-contrast
CTA could be considered an optional screening technique in
the emergency department setting, similar to protocols used
for gated “multi-rule out” CTA. A delayed non-contrast exam-
ination 10–15 minutes after the initial examination could be
performed if there is any suspicion of aortic wall thickening to
suggest an acute IMH [5].
The differentiation of IMH from either atherosclerotic
thickening of the aorta, thrombus, or thrombosed dissection
may infrequently be difficult on CT, and in such settings, MRI
can be a valuable problem-solving tool, especially when
dynamic cine gradient-echo sequences are applied [3]. MRI
may also help to determine the age of a hematoma based on
the signal characteristics of hemoglobin degradation products.
Importance
Intramural hematoma is a potentially lethal syndrome which
can progress to aortic rupture, dissection, or aneurysm [6].
Because IMH may lie on a pathologic continuum that precedes
aortic dissection, early detection could mean earlier interven-
tion and improved clinical outcomes [4].
Typical clinical scenario
Aortic IMH is part of AAS, along with aortic dissection
and penetrating atherosclerotic ulcer. The typical presenting
clinical scenario is chest pain radiating to the back, with hyper-
tension being the most common predisposing factor. In a retro-
spective evaluation of 373 cases of suspected AAS syndrome in
patients with these symptoms, 67 (18%) of patients had an aortic
dissection on CT and a further 14 (3.8%) were positive for an
IMH [2]. Very rarely, IMH may be due to trauma [7].
Options for treatment of IMH include surgery, or medical
management. Morbidity and mortality studies have shown type
A and type B IMH led to aortic dissection in 25% and 13%, to
aortic rupture in 28% and 9%, and did not progress in 28% and
76%, respectively. There is a 30-day mortality with surgical
repair of 18% for type A IMH, and 33% for type B IMH,
compared to 60% and 8% 30-day mortality with medical treat-
ment, respectively [6]. Management of type B IMHs is therefore
typically conservative. Treatment of type A IMHs is less well
established and requires consideration of the imaging charac-
teristics, patient demographics, surgical and perioperative risks,
persistent or recurrent episodes of pain, and the risk of progres-
sion to type A dissection. All patients, regardless of the type of
IMH, require surveillance imaging [1].
Differential diagnosis
The three causes of AAS are clinically indistinguishable, but
have characteristic imaging findings. A thrombosed false lumen
of aortic dissection can mimic IMH. An intimal flap will be seen
on contrast-enhanced imaging with aortic dissection. If an IMH
is seen adjacent to a contrast-filled luminal outpouching, this is
typical of a penetrating aortic ulcer. The ulcers may vary in size
and depth, but are usually best visualized on axial images and
most commonly occur in the mid to distal descending aorta.
To evaluate for hyperdense IMH on CTA, either include
a non-contrast CT phase as a component of an AAS CT
protocol, or perform a delayed phase 10–15 minutes post-
contrast CT in all patients with mural thickening.
references
1. Chao CP, Walker TG, Kalva SP. Natural history and CT appearances
of aortic intramural hematoma. Radiographics. 2009;29(3):791–804.
2. Hayter RG, Rhea JT, Small A, Tafazoli FS, Novelline RA. Suspected
aortic dissection and other aortic disorders: multi-detector row CT in 373
cases in the emergency setting. Radiology. 2006;238(3):841–52.

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 CASE 45 Aortic intramural hematoma

3. Litmanovich D, Bankier AA, Cantin L, Raptopoulos V, Boiselle PM.
CT and MRI in diseases of the aorta. AJR Am J Roentgenol. 2009;
193(4):928–40.
4. Ledbetter S, Stuk JL, Kaufman JA. Helical (spiral) CT in the
evaluation of emergent thoracic aortic syndromes. Traumatic aortic
rupture, aortic aneurysm, aortic dissection, intramural hematoma,
and penetrating atherosclerotic ulcer. Radiol Clin North Am. 1999;
37(3):575–89.
5. Sodickson A. Strategies for reducing radiation exposure in
multi-detector row CT. Radiol Clin North Am. 2012;50(1):1–14.
6. Baikoussis NG, Apostolakis EE, Siminelakis SN, Papadopoulos GS,
Goudevenos J. Intramural haematoma of the thoracic aorta: who's to
be alerted the cardiologist or the cardiac surgeon? J Cardiothorac Surg.
2009;4:54.
7. Gunn ML. Imaging of aortic and branch vessel trauma. Radiol Clin
North Am. 2012;50(1):85–103.

A B

Figure 45.1 A. Axial low-dose non-contrast CT from a 63-year-old man with chest pain radiating to the back demonstrates crescentic
hyperdensity in the wall of the ascending aorta (arrowheads) diagnostic of an intramural hematoma, Stanford type A. B. Axial contrast-enhanced
CT at the same level again shows hyperdensity in the ascending aortic wall (arrow) although it is much less conspicuous and could be easily
overlooked. Note the intima is intact.

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