Intramural haematoma of the thoracic aorta: who's to be alerted the cardiologist or the cardiac surgeon?

Abstract

This review article is written so as to present the pathophysiology, the symptomatology and the ways of diagnosis and treatment of a rather rare aortic disease called Intra-Mural Haematoma (IMH). Intramural haematoma is a quite uncommon but potentially lethal aortic disease that can strike as a primary occurrence in hypertensive and atherosclerotic patients to whom there is spontaneous bleeding from vasa vasorum into the aortic wall (media) or less frequently, as the evolution of a penetrating atherosclerotic ulcer (PAU). IMH displays a typical of dissection progress, and could be considered as a precursor of classic aortic dissection. IMH enfeebles the aortic wall and may progress to either outward rupture of the aorta or inward disruption of the intima layer, which ultimately results in aortic dissection. Chest and back acute penetrating pain is the most commonly noticed symptom at patients with IMH. Apart from a transesophageal echocardiography (TEE), a tomographic imaging such as a chest computed tomography (CT), a magnetic resonance (MRI) and most lately a multy detector computed tomography (MDCT) can ensure a quick and accurate diagnosis of IMH. Similar to type A and B aortic dissection, surgery is indicated at patients with type-A IMH, as well as at patients with a persistent and/or recurrent pain. For any other patient (with type-B IMH without an incessant pain and/or without complications), medical treatment is suggested, as applied in the case of aortic dissection. The outcome of IMH in ascending aorta (type A) appears favourable after immediate (emergent or urgent) surgical intervention, but according to international bibliography patients with IMH of the descending aorta (type B) show similar mortality rates to those being subjected to conservative medical or surgical treatment. Endovascular surgery and stent-graft placement is currently indicated in type B IMH.

Figure 1

Contrast-enhanced CT reveals an intramural haematoma (IMH) of the ascending aorta located mainly in the anterolateral wall (arrow). The haematoma is appeared as a thickening of the aortic wall.

Figure 2

Oblique reformation image of a contrast-enhanced CT scan of the same patient. The IMH is appeared as a thickening of the aortic wall extended in the aortic arch compressing the origin of the brachiocephalic artery (arrow).

Figure 3

The possible ways of treatment of the intramural haematoma of the thoracic aorta taking in consideration its location, the clinical presentation and the aortic diameter.