CTICasesAortic Intramural Hematoma Evolving into an Ulcer-Like Projection
Imaging findings
A 56-year-old with back pain had a non-contrast CT showing a type B intramural hematoma at the aortic arch as a crescentic high-attenuation wall thickening extending down to the diaphragmatic hiatus, with a tiny focus of contrast blush on the arterial phase of the same study. On a follow-up study obtained about 18 days later, that focus had evolved into a large, broad-based, mushroom-cloud-shaped outpouching communicating with the aortic lumen, consistent with an ulcer-like projection.
Key takeaways
A tiny focus of contrast blush within an acute intramural hematoma can evolve over roughly two weeks into a large ulcer-like projection, illustrating the pathophysiologic overlap and nomenclature confusion between intramural hematoma, ulcer-like projection, penetrating atherosclerotic ulcer, and classic aortic dissection; unlike penetrating ulcer, which classically occurs in atherosclerotic aortas (atherosclerosis actually protects against dissection by scarring the wall), this patient had relatively little atherosclerosis, and the extensive elongated hematoma favors a dissection-type process with a contained, non-communicating false lumen rather than a primary penetrating ulcer.
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