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SICU MeetingIntramural Hematoma
日期: 2003.06.30
報告者: Ri 詹宗諭
Intramural Hematoma
Aortic intramural hematoma was first described in 1920 as a "dissection without intimal tear "
Incidence: 12-23% of all aortic dissections
Risk Factors:Old age
Hypertension
Atherosclerosis
smoking
Aortic dissection
Aortic Dissection
Pathogenesis:Classic Aortic Dissection – intimal tear allows blood to
course freely along a false lumen in the outer third of the media
Intramural Hematoma (IMH)-rupture of the vasa vasorum of the aortic wall resulting in a
cirmuferentially oriented blood-containing space; no intimal break seen
Penetrating Atherosclerotic Ulcer (PAU) – atheromatous plaque disrupts the internal elastic lamina
burrowing into the aortic media; may cause localized dissection and hematoma formation
IMH
Classic Aortic Dissection
Classic Aortic Dissection
Vasa vasorum
Intramural Hematoma
Penetrating Atherosclerotic Ulcer
Penetrating Atherosclerotic Ulcer
Penetrating Atherosclerotic Ulcer
Intramural Hematoma
Presentation: Similar to classic aortic dissection Excruciating chest or back pain that is of sudden
onset Hypertensive IMH – may have signs and symptoms associated
with false lumen compromising branches of the aorta:
Unequal pulses, Aortic regurgitation, Pericardial rub
Horner’s syndrome, Syncope, Signs of Acute Renal
Failure, Intestinal infarction
Intramural Hematoma
Presentation: PAU – no false lumen is present, so features of
vascular compromise are usually absent
Diagnosis:
CT, MRI, or TEE( transesophageal echocardiography)
• (angiography will not diagnose IMH because of the lack of contrast filling of the hematoma
D/D of IMH And PAU
Diagnosis cont:
• Diagnosis of a penetrating atherosclerotic ulcer is made by demonstration of a contrast –filled outpouching in the aorta in the absence of a dissection flap or a false lumen, and often in the presence of extensive aortic calcifications
• Diagnosis of an intramural hematoma is made by demonstration of a circumferentially oriented blood-containing space with no evidence of an intiaml tear of atherosclerotic ulcer. May also see intimal calcium displaced medially.
IMH VS PAU
Pathology:– IMH – Hematoma is located just cells away from a thin
layer of adventitia which may explain high propensity for rupture
– PAU – intimal degeneration and replacement with cholesterol clefts burrowing through the media to the adventitia
– Both IMH and PAU are strongly associated with AAA (seen concomitantly in 42% of PAU patients and 29.4% of IMH patients)
– Both IMH and PAU are largely diseases of the descending aorta (90% PAU, 71% IMH)
Intramural Hematoma
Management:
Ascending Aorta – early operative intervention
Descending Aorta -Treat aggressively with B-blockers and afterload reduction to control blood pressure; provide pain relief
• Observe closely – these lesions are more serious than classic descending aortic dissection and a low threshold for surgical intervention must be maintained.
Principle of Treatment
Management cont:
• Repeat imaging in 3 to 5 days in the absence of ominous radiographic findings. Surgery if any progression has occurred. Surgery if symptoms are not controlled or recur on medical treatment.
• If radiographic findings are ominous (severely bulging hematoma, extensive subadventitial spread, extra-adventitial blood, bloddy pleural effusion, deeply penetrating ulcer) surgery should be performed preemptively
Management
Management cont:
• If the patient tolerates early medical management without clinical deterioration she may continue to be followed conservatively
Circulation 1995;92:1465-1472
References
Nienaber CA, von Kodolitsch Y, Petersen B, et al. Intramural hemorrhage of the thoracic aorta: diagnostic and
therapeutic implications. Circulation 1995;92:1465-1472 Coady, Michael A. et al. Pathologic Variants of Thoracic
Aortic Dissections. Cardiology Clinics of North America. Nov 1999; 17 (4): 635-657.
Harris, Kevin M. et al. Transesophageal Echocardiographic and Clinical Features of Aortic Intramural Hematoma. The Journal of Thoracic and Cardiovascular Surgery 1997; 114 (4): 619-626.
References
Vilacosta, Isidre et al. Natural History and Serial Morphology of Aortic Intramural Hematoma: A Novel Variant of Aortic Dissection. American Heart Journal. Sep 1997; 134(3): 495-507.
Harris KM, Rosenbloom M. Aortic intramural hematoma. N Engl J Med 1997;336:1875-1875
The END………….