A 65-year-old woman presented with syncope after having breakfast. She reported dizziness and blackout like symptoms before the syncope episode; however, the neurologic examination showed no evidence of hemiplegia or other neurologic residue. The brain computed tomography (CT scan) revealed no evidence of intracranial hemorrhage or stroke lesion. The patient collapsed with presentation of shock and altered consciousness 2 h after arriving at the emergency department. The physical examination revealed hypotension and engorged jugular veins. Emergent whole-body CT scan was performed, and the noncontrast-enhanced CT scan showed a high attenuation crescent sign in the ascending aortic wall consistent with an intramural hematoma (IMH), and filling of the pericardium consistent with an intramural hemopericardium (Fig. 1a). Contrast-enhanced CT scan demonstrated low attenuation of the ascending aortic wall and a penetrating atherosclerotic ulcer (PAU) in the aortic root (Fig. 1b). The patient received emergent ascending aorta grafting surgery. The postoperative period was uneventful, and the patient recovered well.
IMH with PAU of aorta are included in the acute aortic syndromes as aortic dissection variants. IMH and aortic dissection share similar risk factors, and are classified the same way as Stanford type A and type B. Ascending aorta IMH may cause aortic regurgitation, hemopericardium or aortic rupture. Predictors of adverse outcomes include syncope, enlarged aorta diameter (>55 mm) and increased hematoma thickness (>16 mm) [1]. PAU often has a variable degree of IMH. Patients with type A IMH with PAU should have early surgery, if possible, since they are at high risk for dissection, rupture, aortic regurgitation, cardiac tamponade, or myocardial infarction. PAU accounts for 2–7 % of symptomatic patients with suspected acute aortic syndrome, and an IMH can be identified in approximately 6 % of aortic dissections [2, 3]. Noncontrast enhanced CT scan with a high attenuation crescent sign provides a tool for differential diagnosis of an acute aortic syndrome as well as prognostic information [1, 4].
References
Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, Song JM, Choo SJ, Kang DH, Chung CH, Lee JW, Lim TH (2009) Outcomes of patients with acute type a aortic intramural hematoma. Circulation 120(21):2046–2052. doi:10.1161/CIRCULATIONAHA.109.879783
Harris KM, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, Peterson MD, Voehringer M, Fattori R, Januzzi JL, Gilon D, Montgomery DG, Nienaber CA, Trimarchi S, Isselbacher EM, Evangelista A (2012) Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection. Circulation 126(11 Suppl 1):S91–S96. doi:10.1161/CIRCULATIONAHA.111.084541
Eggebrecht H, Plicht B, Kahlert P, Erbel R (2009) Intramural hematoma and penetrating ulcers: indications to endovascular treatment. Eur J Vasc Endovasc Surg 38(6):659–665. doi:10.1016/j.ejvs.2009.09.001
Lemos AA, Pezzullo JC, Fasani P, Gullo M, Giannitto C, Lo Gullo R, Biondetti PR (2014) Can the unenhanced phase be eliminated from dual-phase CT angiography for chest pain? Implications for diagnostic accuracy in acute aortic intramural hematoma. AJR Am J Roentgenol 203(6):1171–1180. doi:10.2214/AJR.13.11915
Conflict of interest
None.
Statement of human and animal rights
All procedures followed were in accordance with the ethical standards of the responsible committees (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Informed consent
Informed consent was obtained from the participant for being included in this study according to Ethics Committees requirements.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chuang, CY., Chang, TI., Lin, YK. et al. Type A intramural hematoma and hemopericardium secondary to penetrating atherosclerotic ulcer. Intern Emerg Med 11, 155–156 (2016). https://doi.org/10.1007/s11739-015-1273-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-015-1273-x