IMH is quite easily differentiated from classical aortic dissection; intimal tear or flap is absent, and there is no evidence of direct flow communication. However, the diagnosis can be very difficult when the false lumen of dissection is totally thrombosed. In this case, only identification of an entry tear, during surgery or necropsy, permits correct differentiation. On the other hand, only complete chronologic imaging technique findings can permit a correct differential diagnosis between aortic dissection with total thrombus of the proximal
or distal part versus an intramural hematoma that evolves to classical dissection in one of the segments.
One of the challenging differential diagnoses of intramural hematoma is with aortic wall thickening caused by atherosclerotic changes or with aneurys-mal dilatation with mural thrombi25. In distinguishing IMH from other aortic conditions, identification of the intima and careful observation of the inner surface of the thickened aortic wall are helpful. Usually, the inner margin of IMH is smooth, and aortic thickening occurs beneath the bright echo-dense intima, whereas an irregular margin caused by thickening above the intima with dilated aorta is commonly observed in patients with aneurysmal dilatation and mural thrombi. In this respect, the presence of intimal calcium can often be used to distinguish intramural hematoma from intraluminal thrombus26.
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