CTICasesAcute Aortic Syndrome (Intramural Hematoma) with Intercostal Artery Pseudoaneurysms
Imaging findings
Initial CT showed a type B acute aortic syndrome with intramural blood along the medial wall of the descending aorta (attenuation around 80 HU) without a discrete intimal flap. A follow-up CT only four days later showed a large intimal/medial breach (fenestration) at the site of the intramural blood, with contrast tracking superiorly within the aortic wall, plus multiple smaller foci more inferiorly, described as a "Chinese ring sword sign," representing rupture of the vasa vasorum at intercostal artery origins with formation of intramural blood pools and branch-vessel pseudoaneurysms.
Key takeaways
These small intercostal-artery-origin pseudoaneurysms and intramural blood pools are a recognized complication of type B intramural hematoma/acute aortic syndrome, reflecting disruption of the intramural portions of branch vessel origins. They can appear and enlarge rapidly over just a few days as faster, higher-resolution CT increasingly resolves them, but published series suggest they do not portend a worse outcome and can be managed conservatively rather than triggering intervention.
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