Acute Aortic Intramural Hematoma: An Analysis From the International Registry of Acute Aortic Dissection

Study Questions:

How do the presentation, management, and outcome of patients with intramural hematoma (IMH) compare with those with classic aortic dissection (AD)?


The authors reported an analysis of data from the International Registry of Acute Aortic Dissection (IRAD), an international investigational collaboration at 30 aortic referral centers in 10 countries, between 1996-2011, examining differences between patients with IMH and AD, diagnosed on an initial imaging test. Groups were compared on the basis of presentation and demographics, imaging, management, and outcomes.


Of 2,830 patients with acute aortic syndrome reported, 178 had IMH (64 type A [42%], 90 type B [58%], and 24 arch). Patients with IMH were older at presentation, and patients with type A IMH were less likely to present with aortic regurgitation or pulse deficits, and were more likely to have periaortic hematoma and pericardial effusion than aortic dissection patients. Type B IMH patients were more frequently treated medically than type B aortic dissection patients. In-hospital mortality was not significantly different for type A IMH compared to type A AD (26.6% vs. 26.5%; p = 0.998). The mortality for both type A IMH and type A AD patients managed medically was very high (40% vs. 61.8%; p = 0.195). There was a trend toward lower in-hospital mortality for type B IMH than for type B AD (4.4% vs. 11.1%; p = 0.062). Mortality at 1 year was not significantly different between AD and IMH.


The authors concluded that acute IMH has similar presentation to classic aortic dissection, but is more frequently complicated with pericardial effusions and periaortic hematoma. They further opined that patients with IMH have a mortality that does not differ statistically from those with classic AD. The authors further observed that the small group of type A IMH patients managed medically has significant in-hospital mortality.


This important study from the IRAD investigators provides a large number of patients with IMH for observation. These data strongly support the current approach to patients with IMH: They should be managed in the same manner as patients with frank, classic dissection. The high mortality facing patients with aortic IMH should remind us that diagnosis of this entity is of equal importance with diagnosis of classic aortic dissection. In addition to diagnostic vigilance for this highly lethal condition, the high observed mortality suggests that further study of new approaches to treatment is warranted.

Clinical Topics: Cardiac Surgery, Pericardial Disease, Vascular Medicine, Aortic Surgery

Keywords: Cooperative Behavior, Hospital Mortality, Aortic Aneurysm, Thoracic, Cardiology, Cardiovascular Diseases, Hematoma, Pericardial Effusion

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