Aortic intramural hemorrhage secondary to ...

Author’s Accepted Manuscript Aortic intramural hemorrhage secondary to penetrating atherosclerotic ulcers Rahul Hegde, Shuo Li, Nishant Gupta, Steven Cohen www.elsevier.com

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S0002-9629(17)30535-9 http://dx.doi.org/10.1016/j.amjms.2017.10.004 AMJMS558

To appear in: The American Journal of the Medical Sciences Cite this article as: Rahul Hegde, Shuo Li, Nishant Gupta and Steven Cohen, Aortic intramural hemorrhage secondary to penetrating atherosclerotic ulcers, The American Journal of the Medical Sciences, http://dx.doi.org/10.1016/j.amjms.2017.10.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title: Aortic intramural hemorrhage secondary to penetrating atherosclerotic ulcers. Authors: Rahul Hegde* Shuo Li Nishant Gupta Steven Cohen Bridgeport Hospital, Department of Radiology, 267 Grant St, Bridgeport, CT 06460 *corresponding author. Resident Bridgeport Hospital Radiology 267 Grant St Bridgeport, CT 06460 UNITED STATES +14846868324 [email protected] Conflicts of interest: None Funding: None Submission is original and all the authors approve of the submission.


Aortic intramural hemorrhage secondary to penetrating atherosclerotic ulcers. Case: A 77 year old female came to the emergency department with acute onset pain in the left side of her chest and back. Her past medical history was remarkable for hypertension, hyperlipidemia, chronic obstructive pulmonary disease and extensive aortic atherosclerotic disease on prior Computed Tomographic (CT) imaging of her chest and abdomen from a year ago. Physical examination was remarkable for a blood pressure of 186/79 mm Hg. Pulses in both upper and lower limbs were intact. Electrocardiogram (EKG) did not show any evidence of acute myocardial ischemia and two serial serum troponin levels were normal. Given concern for acute aortic syndrome, a CT aortogram study was ordered. The CT angiogram study demonstrated subintimal hyperdensity in the distal aortic arch and descending thoracic aorta on noncontrast phase, consistent with intramural hemorrhage in the aortic wall (Figure A). On the post contrast angiographic imaging, multiple small outpouchings of contrast extravasation were seen from the aortic lumen extending into the subintimal region consistent with penetrating aortic ulcers, which were the cause of the aortic intramural hemorrhage (Figures B and C). The patient was managed conservatively with antihypertensive medication and a follow up CT angiogram performed 3 days later showed stable intramural hemorrhage and resolution of one of the larger penetrating ulcers. Aortic intramural hemorrhage is a more recently described cause of acute aortic syndrome compared to aortic dissection, however both can have fairly similar clinical presentations with tearing chest pain radiating to the back. [1] Pathophysiologically, aortic intramural hemorrhage most often is thought to occur from spontaneous rupture of the periadventitial vasa vasorum and less commonly secondary to penetrating atherosclerotic ulcers. [2] Noncontrast CT imaging can demonstrate the hyperdensity of the hemorrhage and penetrating atherosclerotic ulcers may be seen as foci of contrast outpouching from the aortic lumen on CT angiography. Conservative management with antihypertensive drugs is the first line management; however if patient is unstable and there is progression of hemorrhage, endovascular treatment with stent grafting is recommended. [3]


References:

1. Vilacosta I, Aragoncillo P, Canadas V et al. Acute aortic syndrome: a new look at an old conundrum. Heart. 2009 Jul 15;95(14):1130-9. 2. Macura KJ, Corl FM, Fishman EK et al. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. American Journal of Roentgenology. 2003 Aug;181(2):309-16. 3. Mestres G, Rodríguez R, García-Madrid C et al. Endovascular treatment of penetrating aortic ulcers: mid-term follow-up. Revista Española de Cardiología (English Edition). 2012 Jan 31;65(1):54-9.

Figure legend: Figure with panels A, B and C. Computed tomographic (CT) aortic angiogram study. Panel A (noncontrast axial CT) shows a crescentic area of hyperdensity (arrowhead) in the subintimal region on medial aspect of the descending thoracic aorta consistent with acute intramural hemorrhage in the aortic wall. Panels B (axial post contrast) and C (sagittal post contrast) demonstrate flask shaped outpouchings of contrast extravasation from the aortic lumen (white arrows) consistent with penetrating atherosclerotic ulcerations.

