The typical features of intramural hematoma (IMH) are a crescentic or circular local aortic wall thickening without a visible intimal tear or flap (Fig-
ures 6.4 and 6.5)19. Murray et al. performed serial examinations in 22 patients with intramural hematoma (IMH) to analyze the time course of different findings20. The MRI examination consisted of Tl-weighted "dark-blood" spin-echo sequences and cine "bright-blood" gradient-echo sequences. The presence of blood flow within the thickened portion of the aortic wall was examined with the use of a dynamic phase-contrast sequence. There were moderately strong correlations between days after symptom onset and signal intensity of hematoma on spin-echo sequences. The signal intensity of the hematoma changed from intermediate to high after about seven days on spinecho sequences and on gradient-echo sequences. MRI was useful in monitoring the course of the illness, which resulted in some patients in resolution of the IMH, whereas others experienced recurrent bleeding and dissection. Hematoma site was the only finding on MRI that correlated with the course of the illness, with patients with a hematoma in the ascending aorta having a worse prognosis than patients with hematoma of the descending aorta.
Atheromatose mural plaques can lead to penetrating atherosclerotic ulcers (PAU). These ulcers may finally penetrate the elastic lamina and result in an adjacent IMH21. The combination of PAU with IMH is observed preferentially in the descending aorta.
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