SICU MeetingIntramural Hematoma

日期： 2003.06.30

報告者： Ri 詹宗諭

Intramural Hematoma

Aortic intramural hematoma was first described in 1920 as a "dissection without intimal tear "

Incidence: 12-23% of all aortic dissections

Risk Factors:Old age

Hypertension

Atherosclerosis

smoking

Aortic dissection

Aortic Dissection

Pathogenesis:Classic Aortic Dissection – intimal tear allows blood to

course freely along a false lumen in the outer third of the media

Intramural Hematoma (IMH)-rupture of the vasa vasorum of the aortic wall resulting in a

cirmuferentially oriented blood-containing space; no intimal break seen

Penetrating Atherosclerotic Ulcer (PAU) – atheromatous plaque disrupts the internal elastic lamina

burrowing into the aortic media; may cause localized dissection and hematoma formation

IMH

Classic Aortic Dissection

Classic Aortic Dissection

Vasa vasorum

Intramural Hematoma

Penetrating Atherosclerotic Ulcer

Penetrating Atherosclerotic Ulcer

Penetrating Atherosclerotic Ulcer

Intramural Hematoma

Presentation: Similar to classic aortic dissection Excruciating chest or back pain that is of sudden

onset Hypertensive IMH – may have signs and symptoms associated

with false lumen compromising branches of the aorta:

Unequal pulses, Aortic regurgitation, Pericardial rub

Horner’s syndrome, Syncope, Signs of Acute Renal

Failure, Intestinal infarction

Intramural Hematoma

Presentation: PAU – no false lumen is present, so features of

vascular compromise are usually absent

Diagnosis:

CT, MRI, or TEE( transesophageal echocardiography)

• (angiography will not diagnose IMH because of the lack of contrast filling of the hematoma

D/D of IMH And PAU

Diagnosis cont:

• Diagnosis of a penetrating atherosclerotic ulcer is made by demonstration of a contrast –filled outpouching in the aorta in the absence of a dissection flap or a false lumen, and often in the presence of extensive aortic calcifications

• Diagnosis of an intramural hematoma is made by demonstration of a circumferentially oriented blood-containing space with no evidence of an intiaml tear of atherosclerotic ulcer. May also see intimal calcium displaced medially.

IMH VS PAU

Pathology:– IMH – Hematoma is located just cells away from a thin

layer of adventitia which may explain high propensity for rupture

– PAU – intimal degeneration and replacement with cholesterol clefts burrowing through the media to the adventitia

– Both IMH and PAU are strongly associated with AAA (seen concomitantly in 42% of PAU patients and 29.4% of IMH patients)

– Both IMH and PAU are largely diseases of the descending aorta (90% PAU, 71% IMH)

Intramural Hematoma

Management:

Ascending Aorta – early operative intervention

Descending Aorta -Treat aggressively with B-blockers and afterload reduction to control blood pressure; provide pain relief

• Observe closely – these lesions are more serious than classic descending aortic dissection and a low threshold for surgical intervention must be maintained.

Principle of Treatment

Management cont:

• Repeat imaging in 3 to 5 days in the absence of ominous radiographic findings. Surgery if any progression has occurred. Surgery if symptoms are not controlled or recur on medical treatment.

• If radiographic findings are ominous (severely bulging hematoma, extensive subadventitial spread, extra-adventitial blood, bloddy pleural effusion, deeply penetrating ulcer) surgery should be performed preemptively

Management

Management cont:

• If the patient tolerates early medical management without clinical deterioration she may continue to be followed conservatively

Circulation 1995;92:1465-1472

References

Nienaber CA, von Kodolitsch Y, Petersen B, et al. Intramural hemorrhage of the thoracic aorta: diagnostic and

therapeutic implications. Circulation 1995;92:1465-1472 Coady, Michael A. et al. Pathologic Variants of Thoracic

Aortic Dissections. Cardiology Clinics of North America. Nov 1999; 17 (4): 635-657.

Harris, Kevin M. et al. Transesophageal Echocardiographic and Clinical Features of Aortic Intramural Hematoma. The Journal of Thoracic and Cardiovascular Surgery 1997; 114 (4): 619-626.

References

Vilacosta, Isidre et al. Natural History and Serial Morphology of Aortic Intramural Hematoma: A Novel Variant of Aortic Dissection. American Heart Journal. Sep 1997; 134(3): 495-507.

Harris KM, Rosenbloom M. Aortic intramural hematoma. N Engl J Med 1997;336:1875-1875

The END………….