Intramural Hematoma

An aortic intramural hematoma (IMH) is a hemorrhage limited to the medial layer of the aortic wall without intimal disruption (Figs. 3 and 15A,B; please see companion DVD for corresponding video for Fig. 15). Although the pathogenesis of IMH remains unclear, rupture of the vasa vasorum located within the medial layer of the aorta and rupture of an atherosclerotic plaque are considered to be the initiating events that lead to IMH.

TEE is an important imaging modality for the diagnosis of IMH. The typical TEE finding of IMH is a focal or diffuse thickening of the aortic wall in the absence of an intimal flap or any communication between the aortic lumen and the IMH. IMH should be differentiated from thrombosed aortic aneurysms, dissection with thrombosed false lumen, and complex aortic atherosclerotic plaques.

Table 7 TEE Findings in AD

1. Mobile dissection (intimal) flap within aortic root, aortic arch, ascending and descending aorta

2. True and false lumen separated by intimal flap

3. Intimal tear(s) with communication site(s): entry or exit site(s)

4. Aortic aneurysm

5. Coronary branch artery involvement

6. Aortic branch artery involvement

7. Aortic intramural hematoma

8. Flail aortic leaflet(s)

9. Acute aortic insufficiency

10. Hemopericardium and pericardial tamponade

In some patients, IMH may regress or even completely disappear, whereas it may progress to aortic

Fig. 13. Midesophageal short-axis view (omniplane 0°). Color flow Doppler examination in this 42-yr-old female patient with acute aortic dissection reveals the entry site and flow from true lumen (TL) to the false lumen (FL). (Please see companion DVD for corresponding video.)
Fig. 14. (See legend, facing page)

Fig. 14. (A) Descending aortic long axis view in a patient with Type B aortic dissection shows intimal tear (arrow) and flow acceleration at entry site. Note acoustic shadowing from calcific atheromatous changes near intimal tear. Mirror artifacts are common on transesophageal echocardiography (see Chapter 1, Fig. 8). (B) Pulse Doppler interrogation at the site of intimal tear confirms flow from true to false lumen.

Fig. 14. (A) Descending aortic long axis view in a patient with Type B aortic dissection shows intimal tear (arrow) and flow acceleration at entry site. Note acoustic shadowing from calcific atheromatous changes near intimal tear. Mirror artifacts are common on transesophageal echocardiography (see Chapter 1, Fig. 8). (B) Pulse Doppler interrogation at the site of intimal tear confirms flow from true to false lumen.

Fig. 15. (A) Midesophageal ascending aortic long axis view in 72-yr-old female showing proximal ascending aorta with large echodensisity protruding into aortic lumen, but confined by intima. It proved to be an intramural hematoma that involved the entire ascending aorta. No intimal tear was seen at surgery. (B) Color flow Doppler examination of patient (A) shows flow confined to the true aortic lumen with no communication visible between both cavities. (C) Midesophageal ascending aortic short-axis views of the aora in the same patient showing the intramural hematoma (left panel) and luminal flow confined to the aortic lumen (right panel). (Please see companion DVD for corresponding video.)

Fig. 15. (A) Midesophageal ascending aortic long axis view in 72-yr-old female showing proximal ascending aorta with large echodensisity protruding into aortic lumen, but confined by intima. It proved to be an intramural hematoma that involved the entire ascending aorta. No intimal tear was seen at surgery. (B) Color flow Doppler examination of patient (A) shows flow confined to the true aortic lumen with no communication visible between both cavities. (C) Midesophageal ascending aortic short-axis views of the aora in the same patient showing the intramural hematoma (left panel) and luminal flow confined to the aortic lumen (right panel). (Please see companion DVD for corresponding video.)

dissection and aortic rupture in other patients. These vascular complications account for the high acute mortality from IMH (up to 30%). In general, proximal IMH are treated surgically, whereas medical management with serial imaging studies is reserved for patients with distal IMH. Persistence of IMH has been associated with a poor prognosis so close follow-up is recommended.

Fig. 15. (Continued)

OTHER DISEASES OF THE AORTA: PROXIMAL AORTIC ANEURYSM WITHOUT DISSECTION AND MARFAN SYNDROME

As previously mentioned, patients with Marfan syndrome are at significantly increased risk for aortic dissection. Echocardiography evaluation of patients with Marfan syndrome should include a careful evaluation of the proximal aorta. The aortic size should be measured in three separate locations (Fig. 9; see Chapter 12, Fig. 3) at the root, just below the aortic valve, at the sinotubular junction, and approx 1 cm above the sinotubular junction. In advanced aortic disease secondary to Marfan syndrome, the normal contour of the root and sinotubular junction (which resembles an old-fashioned Coca-Cola®

glass, wider at the sinuses and tapering at the sinotubular junction), can become stretched and the sinotubular junction itself can become indistinct. Aortic diameters more than 5 cm or rapidly changing aortic diameter (even at lower absolute diameters) in patients with Marfan syndrome should prompt surgical intervention.

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