Cardiac Computed Tomography to Identify and Guide Therapy of Intramural Hemorrhage in High-Risk Coronary Anatomy.

Coronary intramural hematoma can present with acute coronary syndrome. We present a 39-year-old man with post-assault stress-induced left main intramural hematoma. We used computed tomography coronary angiogram with lesion characterization and suspected the diagnosis of intramural hematoma despite its limited spatial resolution; computed tomography was used for follow-up imaging and proper monitoring of therapeutic measures. (Level of Difficulty: Advanced.).

Thoracic Aortic Syndromes.

Aortic dissection (AD) is a lethal, treatable disruption of the aortic vessel wall. It often presents without classic features, mimicking symptoms of other conditions, and diagnosis is often delayed. Established high-risk markers of AD should be sought and indicate advanced aortic imaging with CT, MRI, or TEE. Treatment is immediate surgical evaluation, aggressive symptom relief, and reduction of the force of blood against the aortic wall by control of heart rate, followed by blood pressure.

Aortic intramural hemorrhage: A distinct disease entity with mystery.

Aortic intramural hemorrhage (IMH) is one of the disease processes that comprise the spectrum of acute aortic syndrome (AAS) with clinical manifestations and a mortality rate similar to those of classic aortic dissection (AD). However, IMH should be considered as a distinct disease entity rather than a precursor to classic dissection because of differences in their pathology, etiology, natural history, and imaging findings. Multidetector computed tomography (CT) is recommended as the first-line diagnostic imaging modality for IMH, but transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are also helpful. There is still debate over the appropriate treatment of IMH. Medical treatment of type B IMH appears effective and safe, while surgical treatment is recommended for type A IMH. Thoracic endovascular aortic repair (TEVAR) is a promising treatment for selected patients, and more clinical evidence needs to be assembled.

Submucosal esophageal hematoma precipitated by chronic idiopathic thrombocytopenic purpura.

Submucosal esophageal hematoma is an uncommon clinical entity. It can occur spontaneously or secondary to trauma, toxins, medical intervention, and in this case, coagulopathy. Management of SEH is supportive and aimed at its underlying cause. This article reports an 81-year-old male patient with chronic idiopathic thrombocytopenic purpura and hypertension that develops a submucosal esophageal hematoma.

Multi-component model of intramural hematoma.

A novel multi-component model is introduced for studying interaction between blood flow and deforming aortic wall with intramural hematoma (IMH). The aortic wall is simulated by a composite structure submodel representing material properties of the three main wall layers. The IMH is described by a poroelasticity submodel which takes into account both the pressure inside hematoma and its deformation. The submodel of the hematoma is fully coupled with the aortic submodel as well as with the submodel of the pulsatile blood flow. Model simulations are used to investigate the relation between the peak wall stress, hematoma thickness and permeability in patients of different age. The results indicate that an increase in hematoma thickness leads to larger wall stress, which is in agreement with clinical data. Further simulations demonstrate that a hematoma with smaller permeability results in larger wall stress, suggesting that blood coagulation in hematoma might increase its mechanical stability. This is in agreement with previous experimental observations of coagulation having a beneficial effect on the condition of a patient with the IMH.

Colonic Perforation Secondary to Idiopathic Intramural Hemorrhage.

Intramural colonic hemorrhage is rare and often secondary to trauma or anticoagulation therapy. Idiopathic intramural hemorrhages in the alimentary tract have rarely been reported. While several reports of spontaneous perforation of an intramural rectal hematoma have been published, no reports of spontaneous perforation in the ascending colon due to a hematoma have. We describe a patient with an ascending colonic perforation secondary to spontaneous intramural hemorrhage. The patient is a 35-year-old male, who presented with acute abdominal pain and no history of trauma. An abdominal computed tomography scan showed a high-density area around the ascending colon, and nonoperative management was instituted. On the eighth hospital day, the pain worsened, and abdominal computed tomography scan showed free air. An emergent right hemicolectomy was performed. Intramural hematoma and ischemia with perforation, with no obvious etiology, were found. The patient was discharged on the 14th postoperative day.

Colonic Perforation Secondary to Idiopathic Intramural Hemorrhage

Intramural colonic hemorrhage is rare and often secondary to trauma or anticoagulation therapy. Idiopathic intramural hemorrhages in the alimentary tract have rarely been reported. While several reports of spontaneous perforation of an intramural rectal hematoma have been published, no reports of spontaneous perforation in the ascending colon due to a hematoma have. We describe a patient with an ascending colonic perforation secondary to spontaneous intramural hemorrhage. The patient is a 35-year-old male, who presented with acute abdominal pain and no history of trauma. An abdominal computed tomography scan showed a high-density area around the ascending colon, and nonoperative management was instituted. On the eighth hospital day, the pain worsened, and abdominal computed tomography scan showed free air. An emergent right hemicolectomy was performed. Intramural hematoma and ischemia with perforation, with no obvious etiology, were found. The patient was discharged on the 14th postoperative day.

Clinical Comparison of Aortic Intramural Hemorrhage with Aortic Dissection Involving the Ascending Aorta

BACKGROUND AND OBJECTIVES: Although aortic intramural hemorrhage (AIH) is different from classic aortic dissection (AD) in terms of absence of continuous direct flow communication through intimal tear, the same treatment strategy, emergent surgical repair, has been applied for patients with AIH involving the ascending aorta. The impact of different false lumen hemodynamic has not been seriously investigated and clinical features of AIH and AD have not been directly compared. METHODS: From 1990 to December 1998, clinical evaluation with various imaging modalities confirmed the diagnosis of proximal AD and AIH in 73 and 18 patients, respectively. Direct comparison of clinical data including clinical features, hospital course, and follow-up data was performed retrospectively. RESULTS: Patients with AIH were older (69+/-10 years-old 49+/-14, p0.05). CONCLUSIONS: Patients with proximal AIH shows different clinical features and much better prognosis with medical treatment compared to those with AD. These results support our initial hypothesis that AIH is not just a precursor of overt AD but a distinct disease entity and absence of continuous flow communication in AIH can have different clinical impact. This should encourage systematic investigations to find out the predictors of development of complications and to assess the role of elective surgery with frequent imaging follow-up in proximal AIH.

Aortic Dissection Without Intimal Tear (Aortic Intramural Hemorrhage): Its Incidence & Prognosis Associated with Medical Treatment / 대한내과학회지

OBJECTIVES: This study was performed to verify the incidence and prognosis of aortic dissection without intimal tear(aortic intramural hemorrhage, IMH) who took only medical treatment in special reference to Stanford type A. METHODS: We analysed the patients of IMH confirmed by TEE, CT, MRI, angiography or CT-angiography in Seoul National University Hospital between 1987 and 1995, retrospectively. RESULTS: The diagnosis of IMH was established in 20 of 143 patients(14%). Nine patients were Stanford type A, 11 patients were type B. The longitudinal extent varied between 8 and 30cm, and IMH size varied between 10 and 30mm. Surgery was performed in two of type A patients because of persistent chest pain and one of type B patients because of progressive aortic dilatation despite of medical treatment. Follow-up imaging studies (mean follow-up period of 20.0+/-2.0 months) were done in 10/17 patients who were treated medically. Complete resolution of IMH was observed in seven cases, four of them were Stanford type A, and the mean size of IMH was 12mm(10-l7mm). Partial resolution was observed in one case, Stanford type A, with the IMH size of 15mm. There was no significant change in the size of IMH in two cases. Initial mean size of IMH was 25mm. In no case, aortic rupture or death was observed during the follow up period. CONCLUSION: In the management of the patient with IMH, same surgical indications as classic aortic dissection have been advocated based on similar prognosis. However our study showed better prognosis in IMH patients treated medically compared to the previous publications. Therefore, even in cases of proximal IMH, medical treatment should be seriously considered.

Clinical and Echocardiographic Outcome of Aortic Intramural Hemorrhage Compared with Acute Aortic Dissection

BACKGROUND: Aortic intramural hemorrhage (IMH), which presents clinical manifestations identical to acute aortic dissection, is suggested to have different pathology and pathophysiology. The purposes of this study were to diagnose IMH by transesophageal echocardiography (TEE) prospectively and to compare clinical and echocardiographic outcome of IMH with those of aortic dissection. METHODS: Between August 1991 and November 1996, 27 IMH and 73 acute aortic dissection were diagnosed using TEE in 202 consecutive patients with suspected aortic dissection. TEE diagnoses of IMH and aortic dissection were initially compared with computed tomography and magnetic resonance imaging and later confirmed by operative findings (n=39) or follow-up changes (n=12). RESULTS: In the 49 patients whose diagnosis was confirmed by operation or follow-up changes, the sensitivity and specificity for the diagnosis of IMH were 27 of 27 (100%) and 20 of 22 (91%), respectively. There were 11 deaths (15%) in acute aortic dissection and 1 death (4%) in IMH during follow-up of 1.7+/-1.5 years (p=NS). Stanford classification and types of treatment were not related to death in both groups. Complications were less frequently noted in IMH (3/27) than in acute aortic dissection (24/73) (p<0.001) and no death occurred in uncomplicated IMH who were medically treated. Follow-up study of 12 IMH patients showed 8 complete resolution, 3 regression, 1 progression. CONCLUSION: TEE is very useful in diagnosis of IMH and IMH has better outcome than the aortic dissection due to absence of communication and intimal tear.

Clinical and Echocardiographic Outcome of Aortic Intramural Hemorrhage Compared with Acute Aortic Dissection

BACKGROUND: Aortic intramural hemorrhage (IMH), which presents clinical manifestations identical to acute aortic dissection, is suggested to have different pathology and pathophysiology. The purposes of this study were to diagnose IMH by transesophageal echocardiography (TEE) prospectively and to compare clinical and echocardiographic outcome of IMH with those of aortic dissection. METHODS: Between August 1991 and November 1996, 27 IMH and 73 acute aortic dissection were diagnosed using TEE in 202 consecutive patients with suspected aortic dissection. TEE diagnoses of IMH and aortic dissection were initially compared with computed tomography and magnetic resonance imaging and later confirmed by operative findings (n=39) or follow-up changes (n=12). RESULTS: In the 49 patients whose diagnosis was confirmed by operation or follow-up changes, the sensitivity and specificity for the diagnosis of IMH were 27 of 27 (100%) and 20 of 22 (91%), respectively. There were 11 deaths (15%) in acute aortic dissection and 1 death (4%) in IMH during follow-up of 1.7+/-1.5 years (p=NS). Stanford classification and types of treatment were not related to death in both groups. Complications were less frequently noted in IMH (3/27) than in acute aortic dissection (24/73) (p<0.001) and no death occurred in uncomplicated IMH who were medically treated. Follow-up study of 12 IMH patients showed 8 complete resolution, 3 regression, 1 progression. CONCLUSION: TEE is very useful in diagnosis of IMH and IMH has better outcome than the aortic dissection due to absence of communication and intimal tear.