Chronic Phase Treatment

The long-term management of patients with successful initial treatment of IMH begins with aggressive antihypertensive therapy. Treatment with effective beta adrenergic blocking agents protects the aorta by reducing both systolic pressure and dP/dt. Progressive uptitration of dosage is advisable to achieve a blood pressure <135/80 mmHg. IMH should be treated with beta blockers32'39 and closely followed up with imaging techniques, until complication-free absorption of the hematoma is observed and individualized thereafter. Serial imaging of the aorta is an essential component of long-term

Figure 14.13. IMH secondary to penetrating atherosclerotic ulcer. The upper images show the hyperintensity signal of the subacute IMH. At five years of follow-up, a saccular aneurysm was observed with an increasing diameter from 38 mm to 105 mm.

treatment. Choice of imaging modality is dependent on institutional availability and expertise, as well as the extent of aortic involvement and complications. Recommendations suggest follow-up imaging and examination at 1, 3, 6, and 12 months after discharge and annually thereafter.

The subgroup of patients with aortic dilatation or with localized dissection (ulcerlike images) should be followed up and treated more aggressively if progressive aortic dilatation is observed27. Indications for surgical intervention could be (1) maximum diameter of the affected aorta >60 mm, (2) rapid enlargement of the affected aorta, (3) rapid enlargement of an ulcerlike lesion, and (4) rupture of the affected aorta. Although surgical intervention is recommended in this setting, conventional open repair requiring graft interposition is associated with high morbidity and mortality rates, especially in patients of advanced age or with comorbidity. Endovascular placement of the stent grafts

Figure 14.14. Type B IMH evolving with two pseudoaneurysm formations from two localized dissections (asteriscs).
Figure 14.15. Type B IMH with progressive dilatation in descending aorta (A-B). Endovascular treatment was performed at one year (C-D).

to cover the ulcer and part of the IMH has been recently investigated with promising initial results, including a lack of early pseudoaneurysms formation in the treated aortic segment27; however, this remains to be confirmed by results from large clinical series.

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Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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