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Chest pain can be a manifestation of aortic pathology and must be considered in any patient with a history of chest trauma, hypertension, atherosclerosis, connective tissue disorder and/or radiographically abnormal aortic contours. Acute intramural haematoma can resemble acute myocardial infarction and can be life-threatening if not correctly diagnosed. Electrocardiogram (ECG) must be carried out in all patients as it helps distinguish acute myocardial infarction (for which antiplatelets and anticoagulants may be life-saving) from intramural haematoma (for which these drugs may be detrimental). Other imaging modalities may be considered depending upon the clinical situation.

Sudden onset haematemesis occurred in a 52-year old male with oesophageal cancer. Computed tomography showed an aorto-oesophageal fistula with contrast extravasation from the aorta. Thoracic endovascular aortic repair with stent graft was done. The haematemesis stopped postoperatively, but follow-up images (Fig. 1) showed persistent contrast extravasation. The patient died of another episode of massive haematemesis 1 week later.

SUMMARY Spontaneous intramural haematoma of the oesophagus (SIHO) is an uncommon disorder. It presents usually with acute chest pain followed by dysphagia. This condition may mimic spontaneous rupture of the oesophagus (Boerhaave Syndrome), dissection of the thoracic aorta or acute myocardial infarction. Hence early accurate confirmation of the diagnosis by radiology is vital for the appropriate acute management. The condition is frequently mistaken for acute myocardial infarction which may prompt inappropriate thrombolytic therapy. The appearances on contrast studies of oesophagus and on CT scanning are characteristic. Despite this, the diagnosis may easily be missed, if appropriate careful radiological technique is not used. This paper reports three consecutive cases of SIHO managed in one institution. These cases illustrate that early gastrografin contrast radiology followed by barium contrast radiology and if necessary by thoracic CT is diagnostic in all cases of this condition.

Acute aortic syndrome (AAS) is a constellation of potentially life-threatening acute aortic diseases. The spectrum includes penetrating atherosclerotic ulcer, intramural haematoma, dissection, and unstable thoracic aneurysm. AAS cannot be reliably diagnosed clinically and multidetector computed tomography (MDCT) has revolutionized the diagnosis and management of this group of conditions in the acute setting due to its availability, speed, and accuracy. The purpose of this review is to illustrate key MDCT findings of AAS. Imaging techniques, radiological findings, and common pitfalls are also discussed.

Eight cases of aortic dissection with atypical CT appearances are described. Seven were clinical diagnoses, one was confirmed at operation. The findings were those of an intramural haematoma, often crescentic and not necessarily compressing the aortic lumen. Evidence is presented to show that some intramural haematomas may subsequently develop ulceration, resulting in the appearances described in penetrating atheromatous ulcer of the aorta.

Cardiac contusion is defined as the myocardial cellular damage that can result from nonpenetrating chest trauma. However the noninvasive diagnosis of this lesion is problematic. Among the criteria suggested for the diagnosis of cardiac contusion is an elevation of serum levels of the heart-specific isoform of the enzyme creatine kinase (CK-MB). We present here the case of a patient who, on the basis of an initial elevation of CK-MB, was suspected of having cardiac contusion as a result of a motor vehicle accident. The patient was clinically stable and there were no other signs to support this diagnosis. Serial analyses showed a fall in total CK to below the upper limit of the reference interval but, as a percent of total activity, CK-MB was constantly slightly elevated (values 5.1-6.5%, upper limit of normal = 4%). At the same time the patient appeared to be improving clinically. The patient's status deteriorated suddenly and he eventually went to surgery where a large intramural haematoma and a left ventricular aneurysm were discovered. The significance of the elevations of serum CK-MB is discussed and a brief review of the literature is presented.

Spontaneous intramural haematoma of the oesophagus is an uncommon condition which may follow rapid increases in intra-oesophageal pressure and is predisposed to by coagulation disorders. The characteristic clinical presentation and findings at radiology and endoscopy frequently result in misdiagnosis and confusion with more sinister pathology. Awareness of the condition and conservative treatment with correction of coagulation abnormalities, when present, are the mainstays of management. Spontaneous resolution invariably occurs, and the condition is rarely fatal unless surgical treatment is attempted.

Duodenal injury following blunt abdominal trauma is uncommon. The severity of injury can vary from an intramural haematoma to a duodenal rupture with associated transection of the pancreatic duct. A case of duodenal rupture with avulsion of the ampulla of Vater is presented and discussed.

Acute aortic syndrome encompasses classic aortic dissection, intramural haematoma, penetrating aortic ulcer, and iatrogenic or traumatic transection of the aorta. These acute aortic pathologies present with characteristic ‘aortic pain’, and are managed by several operative and endovascular techniques.

Der 73-jahrige Patient wurde wegen akut aufgetretener, starker Bauchschmerzen und Desorientiertheit in die Notaufnahme eingeliefert. Als Vorerkrankung war ein anbehandelter, arterieller Hypertonus bekannt. Bei Aufnahme waren die Blutdruckwerte hypoton (85/60 mmHg, HF 67/min) und das EKG unauffallig. Die Blutgasanalyse zeigte bis auf die Werte fur Laktat (4,4 mmol/l) und D-Dimere (9,6 mg/l) keine Auffalligkeiten; Troponin T war normwertig bei echokardiographisch normaler rechts- und linksventrikularer Funktion. In der Thorax-CT mit Kontrastmittel wurden eine akute Aortendissektion und eine Lungenarterienembolie zunachst ausgeschlossen. Bei klinischem Verdacht auf ein akutes Aortensyndrom wurden die CT-Aufnahmen nochmals genau gepruft. Dabei fielen 3 pathologische Veranderungen im Verlauf der Aorta thoracalis descendens auf.

Intramural haematoma of the esophagus (IHE) is an uncommon clinical condition, which can mimic other cardiothoracic emergencies in both clinical and imaging perspectives. We presented the case of a 54-year-old female who presented to the emergency department with a clinical triad of retrosternal chest pain, odynophagia, and haematemesis for 3 days. Multi-detector computed tomography (MDCT) revealed long-segmental, well-defined, isodense mass in postero-lateral wall of esophagus with smooth arc-shaped indentation into the lumen and no obvious enhancement after IV contrast administration. The preserved fat plane between the thickened esophagus and the aorta allows exclusion of aortic dissection. Subsequent esophagogram and endoscopy confirmed the finding of IHE and thus, patient was successfully treated with conservative treatment and discharged uneventfully. Owing to the presence of clinical and image mimickers of IHE, the recognition of clinical triad of retrosternal pain, odynophagia, and haematemesis, and the typical MDCT and esophagographic presentation of submucosal haematoma are important in avoiding misdiagnosis with inappropriate treatment.

Figure 1: This patient, who had undergone thoracic endovascular aortic repair (TEVAR) on the descending thoracic aorta for suspected intramural haematoma 4 weeks before in a community hospital, was admitted for mild fever (37.5°C) and persistent back pain (A). Two weeks after TEVAR, follow-up computed tomography (CT) from the previous hospital showed crescentic low attenuation in the descending aortic wall, which represented thrombotic organization (B). On this admission, CT revealed fluid collection and a slight increase in the size of attenuation around the endovascular stent graft, compared with the previous CT (C). The standardized uptake value (SUV) at the enhancement site was high (10.4), approaching that of the myocardium (13.3). However, no micro-organisms or leucocytosis was found in blood cultures and samples despite a slight elevation in the C-reactive protein level. Even after empirical antibiotic treatment for suspected endovascular stent graft infection for 1 week, the back pain did not show any decrease in intensity. For further diagnostic clarification, fluoro-2-deoxy-D-glucose positron emission tomography was performed showing focal tracer enhancement at the site of the zone between the aortic wall and the endovascular stent graft (D).

To describe the technique of laparoscopic reconstruction of the uterine wall defect after laparoscopic enucleation of intramural fibroid, using a modified type of reusable laparoscopic knot pusher which enhances precise positioning and adequate tightening of the Roeder knot. A stand-alone one-day surgery unit. Six patients having laparoscopic enucleation of an intramural fibroid. The defect in the uterine wall was reconstructed with open surgery sutures tied extracorporeally using a Roeder knot which was slid and tightened with the knot pusher. Since the Roeder knots were slid and tightened without blockage and the uterine wall was reconstructed without postoperative intramural haematoma in all patients, the impression is that the modified type of Roeder knot pusher used on standard sutures could be a low-price alternative to endoscopic sutures.

Summary points Aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. It is part of the “acute aortic syndrome”—an umbrella term for aortic dissection, intramural haematoma, and symptomatic aortic ulcer (table⇓).1 Acute dissection is the most common aortic emergency, with an annual incidence of 3-4 per 100 000 in the United Kingdom and United States, which exceeds that of ruptured aneurysm.2 w1 w2 The prognosis is grave, with 20% preadmission mortality and 30% in-hospital mortality.2 View this table: European Society of Cardiologists’ classification of acute aortic syndrome The best treatment depends on the anatomical and temporal classification of the disease. Aortic dissection is therefore categorised according to the site of the entry tear and the time between the onset of symptoms and diagnosis. A dissection is considered “acute” when the diagnosis is made within 14 days of onset, and thereafter it is termed “chronic.” The location of the entry tear plays a key role in treatment and outcome, and it is classified by being in the ascending aorta (Stanford type A dissection) or distal to …

We report the case of an ascending aorta aneurysm with intramural haematoma (IMH) in a patient with severe hypotension without history of thoracic pain or hypertension. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) demonstrated the presence of subacute IMH and also revealed sacciform aneurysm of the aortic arch. The patient refused hospitalization and one week later he underwent emergency aortic replacement for dissection. CTA is the technique of choice in acute aortic syndrome and magnetic resonance is helpful in IMH detection and age determination.

Management of spontaneous coronary dissection and intramural haematoma is controversial. Percutaneous intervention carries a risk of propagation of haematoma either proximally or distally during ba...

The clinical presentation of aortic intramural haematoma resembles aortic dissection in many aspects, but the underlying pathophysiology is quite different. Chronic aortic dissection may present as a febrile disease, but is seldom in aortic intramural haematoma. Here we report a case with aortic intramural haematoma with an initial presentation of febrile disease. The patient underwent surgical repair of the diseased aorta successfully and the fever resolved shortly after the operation.

Acute abdominal pain in haemophiliacs should be approached as haemorrhage until proven otherwise. With advancements in factor repletion and coagulopathic management a conservative approach should be considered. We describe a case of double colo-colonic intussusception lead by an intramural haematoma occurring spontaneously and resolving with conservative management in a young haemophiliac. This demonstrates that intussusception in these cases may be transient, and does not require surgical intervention.

Isolated basilar artery dissection is a rare vascular pathology with varied clinical presentations and prognoses. We report a case of a 54-year-old woman, presented with subarachnoid hemorrhages (Hunt-Hess grade II). Brain computed tomography demonstrated a perimesencephalic pattern of haemorrhage. Magnetic resonance angiography revealed an isolated basilar artery dissection. Conservative treatment was performed. A complete resolution of the clinical symptoms occurs over a period of 30 days. There was no recurrent haemorrhage. On a follow-up magnetic resonance angiography three months later, a complete resolution of the intramural haematoma in the basilar artery was demonstrated. Some of the cases of basilar artery dissection with perimesencephalic pattern of subarachnoid haemorrhages could have a good prognosis, and could be treated conservatively.

We read with interest the recent article by Evangelista et al. ,1 regarding the 3-month history of patients with aortic intramural haematoma (IMH). The authors state that they made the diagnosis when haematoma thickness was ≥7 mm; however, smaller IMHs can be encountered in clinical practice. The population described (68 patients) included 12 type A (18%) and 56 type B (82%) IMHs with an A/B ratio of 1:4.7. This may imply a different natural history before arrival at the hospital, that is, in untreated patients (more favourable to type B IMH as for classic dissection). …

Dissecting intramural haematoma of the oesophagus (DIHO) is a rare condition, which has an excellent prognosis when managed conservatively. Awareness of this condition is vital to guide subsequent investigations and avoid inappropriate treatment or unnecessary surgical intervention. We describe an unusual case of massive DIHO causing left atrial compression presenting with pericarditic electrocardiographic changes and document the utility of endoscopic ultrasound/computed tomography to make the diagnosis.

A patient on oral anticoagulation with dabigatran presented with chest pain and dyspnoea. A CT scan of the chest revealed an intramural haematoma of the ascending aorta with a large pericardial effusion. The patient underwent a modified Bentall procedure. In the absence of a specific antidote for this novel oral anticoagulant medication, even in an emergency situation, successful surgical treatment was possible with an aggressive use of available prohaemostatic agents.

Bright rectal bleeding in a neonate is most commonly due to necrotising enterocolitis, gastrointestinal infection or cows milk protein intolerance. We present here an infant who developed PR bleeding after cardiac surgery. Bleeding persisted despite presumptive treatment for the most common causes. A colonic intramural haematoma was identified on colonoscopy most likely related to anticoagulation in the setting of cardiac surgery.

An acute aortic syndrome with simultaneous presence of a penetrating aortic ulcer, an intramural haematoma, a thoracic aortic dissection and an abdominal aortic aneurysm rupture has not previously been reported. Herein, we describe our experience with a patient treated by endovascular means with an 8-year follow-up.

Figure 1: 320-slice computed tomographic angiography shows a giant floating ascending aortic mass (66 × 18 × 16 mm), with distal edge progressing deeply into the left carotid artery. (A) Axial, (B) sagittal and (C) three-dimensional reconstruction. Figure 2: Intraoperative picture. We chose right axillary artery cannulation to prevent further cerebral embolism. The mass was 7 cm long, the distal edge stuck into the left carotid artery (white asterisk). The mass was attached loosely to the ascending aorta, and it was pulled out easily with forceps. Ascending aorta had no macroscopic signs of atherosclerosis or intramural haematoma. Pathological examination confirmed that the mass was fresh thrombus. Black arrow: head.

Four patients with acute aortic intramural haematoma are presented. In all patients the typical crescentic hyperdense rim within the aortic wall was not obvious on unenhanced CT when reviewed on standard mediastinal windows, but the hyperdense crescentic rim was well seen on narrow window settings. The findings suggest that all patients with a typical clinical presentation of acute thoracic aortic dissection who do not have a classical dissection on contrast-enhanced CT or a hyperdense intramural haematoma on standard mediastinal settings, should have the non-contrast scans reviewed on narrow window settings.

Although segmental bowel necrosis is a recognized complication of pancreatitis, the duodenum is rarely involved. We report a unique case of acute duodenal obstruction characterized by transmural necrosis and intramural duodenal haematoma in a young man with acute alcohol-induced pancreatitis. The patient recovered following pancreaticoduodenectorny

Sir, Further to the series published by McIntyre et al .1 we would like to report a case of dissecting intramural haematoma of the oesophagus originally treated as cardiac chest pain and complicated by treatment with heparin. A 74-year-old woman was admitted with a 30-min history of a sudden onset of central chest pain radiating to her jaw and neck, associated with sweating. She had a past medical history of hypertension and angina and was taking aspirin and lisinopril. She had not had symptoms of angina for 10 years. The pain had occurred when she had got out of bed to go to the toilet. An ambulance was called, and she was given GTN spray, following which she had …

A 64-year-old man with history of ischaemic heart disease and coronary artery bypass graft surgery, but no history of peptic ulcer or liver disease, presented with retrosternal pain and coffee-ground vomitus. Endoscopy revealed a long column of bluish discolouration with normal mucosa interpreted as a grade IV oesophageal varix. Computed tomography showed a non-enhancing low-density submucosal columnar lesion in the mid- and lower oesophagus consistent with a submucosal haematoma. This resolved on follow-up at 10 days. The magnetic resonance features of intermediate signal intensity on T1-weighted images and hyperintense signal on T2-weighted images of this lesion are also highlighted.

The letter of Pocar et al. 1 underlines important queries regarding the management of aortic intramural haematoma, which have not yet been definitively answered. Mortality in our series of 68 intramural haematoma was high (19%) in the first 3 months of evolution.2 On multivariate analysis, mortality-related variables were diameter >50 mm and ascending aorta involvement. We agree that in this series ascending aorta involvement was low (18%), and similar to that described in other series.3,4 The majority of published studies report type A mortality similar to type A dissection, except in the Asian groups. …

Magnetic resonance imaging (MRI) features of 12 cases with vertebrobasilar dissecting aneurysms (VBDA) were compared with those of 80 cases with nondissecting aneurysms (NDA). Seven patients with VBDA showed an eccentrically narrowed true lumen adjacent to the semilunar clot in the false lumen. Such findings were also found in patients with thrombosed NDA. However, the segment of the mural haematoma was longer in those with VBDA. An intimal flap was detected in only 3 cases of VBDA. Two patients with VBDA showed only iso- or high signal intensity of the vertebral artery; therefore, differentiation from obstruction of the vertebral artery was difficult. Flow-dependent spatial misregistration, seen adjacent to the normal vessels, sometimes mimics intramural haematoma.

A 73-year-old lady presented with clinical features of gastric outlet obstruction. It was found to be secondary to a spontaneous haematoma in duodenal wall as a complication of warfarin therapy given for atrial fibrillation. The diagnosis was confirmed by abdominal CT scan and upper G I endoscopy. Warfarin was stopped and blood transfusions given. She recovered completely after three weeks of conservative treatment. Repeat CT scan and upper G I endoscopy done after two months showed complete resolution.

Left atrial wall haematoma is a very uncommon entity, associated mainly to cardiac surgery, interventional procedures, or trauma. Spontaneous cases are supposed to be associated with left atrial wall pathology. We present a case of a 53-year-old male who was admitted for prolonged chest pain, with transthoracic and transesophagic echocardiography documentation of a left atrial mass in close proximity to a mitral annular calcification. Tissue characterization with cardiac magnetic resonance suggested the aetiology of the mass, which was confirmed histologically.

A 63-year-old man underwent an aortic valve replacement (Carbomedics Top Hat No 23) for a severe aortic stenosis. A tricuspid annuloplasty and closure of an ostium secundum atrial septal defect were also performed. The preoperative electrocardiogram showed a left bundle branch block. There were no significant …

Two cases of spontaneous intramural oesophageal haematoma are described with particular reference to the appearances seen on comuted tomography.