Ulcerlike Lesions of the Aorta: Imaging Features and Natural History

Quint, Leslie E.; Williams, David M.; Francis, Isaac R.; Monaghan, Hilary; Sonnad, Seema S.; Patel, Shushma; Deeb, G. Michael

doi:10.1148/radiology.218.3.r01mr24719

Cited by 159 publications

(105 citation statements)

References 6 publications

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“…Stanson et al 2 and Coady et al 7 found PAUs to be malignant, but most of these patients had acute symptoms. In contrast, Harris et al 16 and Quint et al 17 reported a lower incidence of life-threatening complications in a patient sample where asymptomatic patients were enrolled. The considerable difference in prognosis probably can be explained by the differences in patient substrate (symptomatic versus asymptomatic).…”

Section: Natural History Of Paumentioning

confidence: 89%

Prognosis of Aortic Intramural Hematoma With and Without Penetrating Atherosclerotic Ulcer

et al. 2002

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Background-Advances in imaging techniques have increased the recognition of aortic intramural hematomas (IMHs) and penetrating atherosclerotic ulcers (PAUs); however, distinction between IMH and PAU remains unclear. We intended to clarify differences between IMH coexisting with PAU and IMH not associated with PAU by comparisons of clinical features, imaging findings, and patient outcome to derive the optimal therapeutic approach. Methods and Results-We performed a retrospective analysis of 65 symptomatic patients with aortic IMH. There were 34 patients with IMH associated with PAU (group 1) and 31 patients with IMH unaccompanied by PAU (group 2). Involvement of the ascending aorta (type A) was more frequent in group 2 (8 of 31, 26%), whereas most of the patients in group 1 had exclusive involvement of the descending aorta (type B) (31of 34, 91%). Patients were subdivided into 2 categories, those with clinical progression and those with stable disease. Forty-eight percent of patients in group 1 and 8% in group 2 were in the progressive category (Pϭ0.002). Clinical and radiological findings were compared between those group 1 patients who had a progressive disease course (nϭ12) and those who were stable (nϭ13). Sustained or recurrent pain (PϽ0.0001), increasing pleural effusion (Pϭ0.0003), and both the maximum diameter (Pϭ0.004) and maximum depth (Pϭ0.003) of the PAU were reliable predictors of disease progression. Considered by many to be a variant of aortic dissection, the pathogenesis of IMH still remains unclear. Two different pathophysiological processes can lead to intramural hematoma formation. One is IMH without intimal disruption; in this entity, it is believed that spontaneous rupture of aortic vasa vasorum is responsible for hematoma formation within the aortic wall. 1 The other type of IMH is associated with an atherosclerotic ulcer that penetrates into the internal elastic lamina and allows hematoma formation within the media of the aortic wall. [2][3][4] Conclusions-This See p 284In previous reports, these 2 types of IMH are rarely distinguished in discussing prognoses and optimal treatment methods. 3,5,6 The concept of the Stanford classification scheme for aortic dissection has been applied to IMH because the prognostic impact of the location of IMH and its standard treatment have been considered similar to those for classic aortic dissection. 5 It is generally accepted that patients with type B (exclusive involvement of the descending aorta) IMH can be managed conservatively in the absence of disease progression, whereas early surgical interventions are recommended for type A (involvement of the ascending aorta) IMH. 5,6 On the other hand, Coady et al 7 recently reported that the prognoses of acutely symptomatic hospitalized patients with penetrating atherosclerotic ulcers (PAUs) was worse than those with classic aortic dissection due to a higher incidence of aortic rupture.We reviewed 65 symptomatic patients with aortic IMH. Thirty-four patients had a PAU that was considered to be the cause of I...

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Section: Natural History Of Paumentioning

confidence: 89%

Prognosis of Aortic Intramural Hematoma With and Without Penetrating Atherosclerotic Ulcer

et al. 2002

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“…In contrast to penetrating atherosclerotic ulcer, these ulcer-like images are not a cause of IMH but an early complication. On the other hand, the prognosis of these ulcer-like lesions is better than that of penetrating atherosclerotic ulcer, 26,27 because some may show complete regression. 17,23 Variables predicting progression to aortic dissection were echolucency and IMH extension.…”

Section: Prognostic Factorsmentioning

confidence: 98%

Long-Term Follow-Up of Aortic Intramural Hematoma

Evangelista¹,

Domínguez²,

Sebastiá³

et al. 2003

Circulation

184

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Background-Aortic intramural hematoma (IMH) evolves very dynamically in the short-term to regression, dissection, or aortic rupture. The aim of the present study was to assess the long-term clinical and morphological evolution of medically treated IMH. Methods and Results-Fifty of 68 consecutive patients with aortic IMH monitored clinically and by imaging techniques at 3, 6, and 12 months and annually thereafter were prospectively studied. Mean follow-up was 45Ϯ31 months. In the first 6 months, total IMH regression was observed in 14 and progression to aortic dissection in 18 patients; in 14 of these, the dissection was localized, and 12 later developed pseudoaneurysm. At the end of follow-up, the IMH had regressed completely without dilatation in 17 patients (34%), progressed to classical dissection in 6 (12%), evolved to fusiform aneurysm in 11 (22%), evolved to saccular aneurysm in 4 (8%), and evolved to pseudoaneurysm in 12 (24%). Evolution to dissection was related to echolucency (PϽ0.02) and to longitudinal extension of IMH (PϽ0.01). Multivariate analysis showed an independent association between regression and smaller maximum aortic diameter and between aneurysm formation and atherosclerotic ulcerated plaque and absence of echolucent areas in IMH. Conclusions-The most frequent long-term evolution of IMH is to aortic aneurysm or pseudoaneurysm. Complete regression without changes in aorta size is observed in one third of cases, and progression to classical dissection is less common. A normal aortic diameter in the acute phase is the best predictor of IMH regression without complications, and absence of echolucent areas and atherosclerotic ulcerated plaque are associated with evolution to aortic aneurysm.

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“…The intramural hematoma weakens the aortic wall and may progress either to outward rupture of the aortic wall in 35% of cases or to inward disruption of the intima, leading to communicating dissection in 3% to 5% of cases [38]. In penetrating aortic ulcer, an atheromatous plaque burrowing deeply through the intima into the media [39], the media is exposed to pulsatile arterial flow, which causes hemorrhage into the walls that then leads to intramural hematoma [40] and adventitial erosion may cause rupture in 42% of cases [41]. These nonflap lesions are more common in the descending aorta especially in elderly hypertensive individuals [42].…”

Section: Pathophysiologymentioning

confidence: 99%

Proximal Aortic Dissection with Rupture into the Main Pulmonary Artery—A Case Report

Muthiah¹

2017

CRCM

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Aim: To present a rare occurrence of aortopulmonary fistula due to rupture of proximal aortic dissection in a 48-year-old woman. Introduction: Aortic dissection is defined as disruption of the medial layer provoked by intramural bleeding, resulting in separation of aortic wall layers and subsequent formation of a true lumen and a false lumen with or without communication. Case Report: A 48-year-old female presented with vague anterior chest discomfort, high blood pressure, systolic-diastolic murmur in the left sternal border with ECG changes of myocardial ischemia. Echocardiography revealed a dilated aortic root with intimal flaps, a leak into the pulmonary artery and regional hypokinesis with contractile dysfunction suggesting a proximal aortic dissection with rupture into the main pulmonary artery. Discussion: The etiology of aortic dissection was mostly hypertension in 80% of cases and aortopathies such as connective tissue disorders, inflammatory and idiopathic. Aortic wall stress is a major trigger of intimal tear and two-dimensional transthoracic echocardiography is an excellent, initial diagnostic gold standard to detect the dissecting flaps, especially in proximal aortic dissection. Conclusion: Blood pressure control is the mainstay of treatment and urgent surgery is indicated in proximal aortic dissection since there is higher chance of rupture with an increase in mortality.

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Ulcerlike Lesions of the Aorta: Imaging Features and Natural History

Abstract: Most ulcerlike aortic lesions are asymptomatic and do not enlarge. About one-third of lesions progress, generally resulting in mild interval aortic enlargement.

Cited by 159 publications

References 6 publications

Prognosis of Aortic Intramural Hematoma With and Without Penetrating Atherosclerotic Ulcer

Prognosis of Aortic Intramural Hematoma With and Without Penetrating Atherosclerotic Ulcer

Long-Term Follow-Up of Aortic Intramural Hematoma

Proximal Aortic Dissection with Rupture into the Main Pulmonary Artery—A Case Report

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