By Kane McKenzie, DO
HPI: A 55 year old woman presents to the emergency department for back pain. She reports that while walking she suddenly felt a sharp pain in the center of her back. It feels like stabbing, and is worse with a deep breath or movement. She denies recent trauma. She has a history of hypertension for which she does not take medications. ECG shows NSR with new T wave inversions in lateral leads.
Vitals: BP 230/114 HR 80 RR 20 SaO2 97%
PE: Appears uncomfortable. No murmurs, lungs clear but breath sounds diminished. 3+ Radial and Dorsalis Pedis pulses. Mild tenderness to upper thoracic spine. Neurologic exam is nonfocal.
Labs: High sensitivity troponins 24>24, CBC and BMP unremarkable
Imaging: CTA chest shows intramural hemorrhage of the aortic arch and descending thoracic aorta
Diagnosis: Aortic Intramural hemorrhage – Considered an acute aortic disorder but often differentiated from dissection
Management:
Similar to aortic dissection. Anti-impulse therapy: HR preferred with Esmolol or Labetolol (HR < 80) , BP (systolic < 120) with Nicardipine or nitroprusside + Emergent surgical consultation
Pathophysiology:
-Hematoma within the medial layer of the aorta without a detectable intimal tear
-Can develop into aortic dissection
-Classified using Stanford or Debakey, same as dissections
-Estimated to account for 5-20% of patients with symptoms consistent with an aortic dissection
-Theorized to occur by either rupture of a penetrating atherosclerotic ulcer or spontaneous rupture of the vasa vasorum
-There is debate whether intramural hematoma should be classified as dissection with thrombosis of the false lumen
-Intimal defects are present in 70% of cases initially diagnosed as intramural hematoma
-Often not able to be identified until surgical repair
References:
Black, James H III. Overview of acute aortic dissection and other acute aortic syndromes. In: UptoDate, Connor RF (Ed), Wolters Kluwer. (Accessed August 16, 2024.)
Tintinalli’s Emergency Medicine
Gaillard F, Hacking C, Jones J, et al. Aortic intramural hematoma. Reference article, Radiopaedia.org (Accessed on 16 Aug 2024) https://doi.org/10.53347/rID-919
