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Aortic intramural haematoma: natural history and predictive factors for complications
  1. C A Nienaber,
  2. B M Richartz,
  3. T Rehders,
  4. H Ince,
  5. M Petzsch
  1. Division of Cardiology at the University Hospital Rostock, Department of Internal Medicine, Rostock, Germany
  1. Correspondence to:
    Christoph A Nienaber, MD
    Division of Cardiology, University Hospital of Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany;

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Intramural haematoma (IMH) of the aorta is attracting growing interest as a variant of aortic dissection and is more frequently diagnosed by modern tomographic imaging modalities in the evaluation of acute aortic syndromes.1,2 The evolution from IMH to overt dissection or even rupture may occur suddenly or is heralded by ongoing acute aortic (pain) syndrome. Unlike classic aortic dissection, IMH has no mechanisms of decompression by a re-entry tear but rather reveals intramural (intramedial) thickening or echolucent pockets of non-communicating blood with potential for rupture or, at times, regression and resorption of haematoma with time.3–,6 As in overt dissection, widening of the mediastinum or the aortic shadow, pleural effusion and pain, aortic regurgitation, and pericardial effusion may emerge after initial IMH, whereas focal neurological signs or malperfusion syndrome are incidental.7 Hence, the subtle initial pathology of IMH is more likely to be missed than overt dissection, especially in the absence of recurrent pain (“aortic syndrome”). While diagnostic and therapeutic implications of IMH continue to impact on vascular medicine, description of natural course and prediction of individual risk is far from settled.6,8–,10


Observational data from independent groups revealed evidence that the IMH evolves to resorption or progression to either classic dissection, contained rupture or formation of an aneurysm within 30 days of hospital admission.

Proximal location of IMH is clearly considered an independent predictor of progression to dissection, contained rupture, or aneurysm formation. In our series of 66 cases of IMH (38 type A and 28 type B), 73% of progressive IMH were type A as compared to 44% in stable IMH (odds ratio (OR) 4.3, 95% confidence interval (CI) 1.5 to 12.3; p  =  0.02); early progression was unrelated to age, sex, chronic arterial hypertension, Marfan syndrome, bicuspid aortic valve, …

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