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SICU Meeting Intramural Hematoma

Intramural Hematoma. Aortic intramural hematoma was first described in 1920 as a "dissection without intimal tear "Incidence: 12-23% of all aortic dissectionsRisk Factors:Old ageHypertensionAtherosclerosis smoking. Aortic dissection. Aortic Dissection. Pathogenesis:Classic Aortic Dissection

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SICU Meeting Intramural Hematoma

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    1. SICU Meeting Intramural Hematoma ??:2003.06.30 ???:Ri???

    2. 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

    3. Aortic dissection

    4. 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

    5. Classic Aortic Dissection

    6. Classic Aortic Dissection

    7. Vasa vasorum

    8. Intramural Hematoma

    9. Penetrating Atherosclerotic Ulcer

    10. Penetrating Atherosclerotic Ulcer

    11. Penetrating Atherosclerotic Ulcer

    12. 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

    13. 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

    14. 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.

    15. 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)

    16. 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.

    17. 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

    18. Management Management cont: If the patient tolerates early medical management without clinical deterioration she may continue to be followed conservatively

    19. Circulation 1995;92:1465-1472

    20. 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.

    21. 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

    22. The END………….

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