CTICasesAcute Aortic Intramural Hematoma Extending into the Pulmonary Artery Wall
Imaging findings
Initial contrast-enhanced CT pulmonary angiogram (CTPA) shows contrast opacification restricted almost entirely to the right-sided cardiac chambers and pulmonary arteries, with virtually no contrast in the left heart or aorta, indicating severely compromised cardiac output. Subsequent non-contrast CT reveals a crescent of high-attenuation acute intramural hematoma (IMH) in the ascending aorta and tracking directly into the wall of the main pulmonary artery. Contrast-enhanced CTA confirms the aortic wall thickening, a focal intimal tear, hemopericardium, and an embolic infarct of the inferior pole of the left kidney.
Key takeaways
Aortic dissection or intramural hematoma can track along the shared adventitial sheath of the aorta and pulmonary artery, resulting in hematoma within the pulmonary artery wall that can mimic a pulmonary embolus on contrast-enhanced CT. Non-contrast chest CT is essential for identifying the high-attenuation crescent of acute IMH and avoiding misdiagnosis. Furthermore, extremely sluggish or absent left-sided contrast opacification on CTPA should raise immediate suspicion for severe cardiac tamponade and cardiogenic shock.
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