• Images in cardiology

Aortic intramural haematoma (AIH), a variant form of aortic dissection, is characterised by absence of intimal tear and direct flow communication between the true and false lumen. Diagnostic criteria for AIH by transoesophageal echocardiography (TOE) include: (1) absence of dissection membrane; (2) no communication between the false and true lumen upon Doppler examination; (3) regional circular or crescentic thickening of the aortic wall > 0.7 cm.

In AIH, wall morphology may change very rapidly. Bleeding into the aortic media may be self limiting, but may lead to classic dissection, as well as to rapid aortic dilatation or circumferential and longitudinal extension of the haematoma.

A 64 year old hypertensive patient was admitted because of chest pain with radiation to the back. The ECG was normal, as were myocardial enzymes and ventricular wall motion assessed by transthoracic echocardiography. An aortic dissection was then suspected; the TOE (below left) revealed an AIH, characterised by thickening (> 7 mm) of the descending aorta. The haematoma extended for about 8 cm.

The patient was monitored, and blood pressure was maintained as low as possible; symptoms disappeared in six hours. Four days later, the chest pain re-occurred with the same characteristics. A new TOE (below centre) showed an aortic dissection, with a large tear, at the level of the previously observed AIH. A computed tomographic scan confirmed the dissection. An endoluminal aortic prosthesis was then applied, followed by complete resolution of the dissection (below right).