The diaphoretic patient with tearing chest or back pain is a dreaded clinical scenario which demands the very best of our diagnostic acumen and tools. Acute aortic syndromes1 comprise a spectrum of abnormalities, all of which have the potential for acute mortality and rapid progression. This group of disorders includes:

• aortic dissection

• aortic intramural haematoma

• penetrating aortic ulcer

• leaking aneurysm

• aortic rupture.

These may all present with severe pain and be clinically indistinguishable, one from the other, before imaging. Any of them can be mistaken for acute coronary syndrome, an error which can lead to inappropriate anticoagulation and disastrous complications.2

With the advent of more detailed and frequent imaging of the aorta in the evaluation of patients presenting with chest pain, understanding the variable pathology, prognosis and treatment of aortic syndromes has become critical. The extent to which these diseases share aetiology, prognosis and response to surgical, medical or endovascular therapy is still being defined, just as the options for treatment continue to improve.

Of the acute aortic syndromes, intramural haematoma (IMH) stands out as a lesion that can be very challenging to clearly separate from the other acute aortic syndromes, particularly aortic dissection or penetrating ulcer. The presence of an intramural collection of blood without identifiable intimal flap, tear or ulceration is the pathognomonic finding of this condition.3 Over the first 30 days after diagnosis, IMH can evolve into classic dissection, contained rupture or aneurysm, or reabsorb without further sequelae.4 Indeed, IMH may represent a phase in the evolution of these other highly morbid conditions; IMH is found in 10–15% of patients with suspected dissection.5 Reliable methods for defining the individual’s risk for complications and best therapy is a critical need, and continues to be the subject of intensive investigation.