Aortic Intramural Hematoma and Its Complications

> It has long been an axiom of mine that the little things are infinitely the most important.1 > > Sherlock Holmes to Dr Watson> > —Arthur Conan Doyle,> > The Adventures of Sherlock Holmes: A Case of Identity. Case Presentation: A 70-year-old woman with hypertension presents for evaluation of a single episode of nonexertional chest pain of moderate intensity, atypical for myocardial infarction. Clinical signs of acute aortic dissection and cardiac tamponade are absent. A 12-lead ECG and blood test for troponin are negative for acute myocardial infarction. M-mode transthoracic echocardiogram of the aortic root shows dense echoes anteriorly and posteriorly at the level of the aortic valve and a large pericardial effusion (Figure 1A). After discussing a diagnosis of acute aortic syndrome, she asks, “What other tests will I need to confirm the diagnosis? Will I undergo surgery?”Figure 1. A and B , M-mode echocardiogram at the level of the aortic valve. Dense echoes along right and noncoronary sinuses caused by periaortic hematoma from a perforated aortic ulcer (white arrows, A ) compared with a normal echo ( B ). C , Cardiac computed tomography angiography orthogonal view equivalent to transthoracic echocardiographic parasternal long-axis view. This view is optimized to visualize (white arrow) perforated ulcer in the ascending aorta, hemorrhagic pericardial effusion with blood collection along right and noncoronary aortic sinuses correlating with M mode echo at the level of the aortic valve. AV indicates aortic valve; LA, left atrium; LV, left ventricle; PA, pulmonary artery; and RV, right ventricle.Intramural hematoma (IMH) is a life-threatening aortic disease included within acute aortic syndrome, together with aortic dissection and penetrating aortic ulcer (PAU).2,3 IMH is a contained aortic wall hematoma with bleeding within the media but without initial intimal flap formation (Figure 2).3 Its natural history is variable; it may be reabsorbed …