• aortic intramural haematoma
• penetrating atherosclerotic ulcers

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