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New Development of an Ulcerlike Projection in Aortic Intramural Hematoma: CT Evaluation¹

¹ From the Departments of Radiology (E.S.) and Cardiovascular Surgery (T.I.), Omura Municipal Hospital, Japan; Department of Radiology, National Nagasaki-chuo Hospital, Omura, Japan (Y.M.); and Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8502 Japan (E.S., T.O., I.S., K.H.). Received June 6, 2001; revision requested June 27; final revision received February 4, 2002; accepted February 26. Address correspondence to E.S. (e-mail: eijunsueyoshi@aol.com).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To investigate the natural history and predictors of progression of a newly developed ulcerlike projection in patients with an aortic intramural hematoma.

MATERIALS AND METHODS: Serial computed tomographic (CT) findings in 52 patients with intramural hematoma were reviewed. Sixteen patients had Stanford type A intramural hematoma, and 36 had Stanford type B. Diagnosis of intramural hematoma was established with CT. Regular follow-up studies were performed every week during the 1st month and two or three times a year after the 2nd month. The presence or absence of an ulcerlike projection, diameter and progression of the projection, and aortic diameter were evaluated. Relationships among ulcerlike projections, clinical data, and CT findings were analyzed.

RESULTS: In 17 (33%) of the 52 patients, 17 ulcerlike projections were newly identified during the follow-up period. Patients with type A intramural hematoma had a significantly higher frequency of new development of ulcerlike projection than that of patients with type B intramural hematoma (P = .002). In 17 patients with new development of ulcerlike projection, 12 (70%) of 17 projections progressed to complications such as enlargement (n = 10) or progression to overt aortic dissection (n = 2). One of 10 enlarged projections progressed to rupture. A significant predictor of progression of ulcerlike projection was based on location from the ascending aorta to the aortic arch with the use of univariate (P = .009) and multivariate Cox (P = .018) regression analyses.

CONCLUSION: The location of ulcerlike projections is the principal predictor of progression, and careful follow-up study is needed for patients with an ulcerlike projection located from the ascending aorta to the aortic arch.

© RSNA, 2002

Index terms: Aorta, CT, 94.12912, 94.12915 • Aorta, diseases, 941.72, 941.74, 942.72, 942.74, 943.72, 943.74 • Aorta, dissection. 941.74, 942.74, 943.74

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
In aortic dissections, the radiologic finding of an ulcerlike projection (ulcerlike lesion) is defined as a localized blood-filled pouch protruding from the true lumen into the thrombosed false lumen of the aorta. Ulcerlike projections have usually been considered to represent the site of an intimal disruption, such as an intimal tear and penetrating atherosclerotic ulcer (PAU) (1–5).

With use of recent noninvasive imaging techniques, aortic intramural hematoma has been recognized as and characterized primarily by an aortic wall hematoma without intimal tear or penetrating ulceration (6–12). In intramural hematoma, ulcerlike projections can also be identified during the follow-up period and may be considered as a new intimal disruption. The authors of recent reports on intramural hematoma (4,9,10,13) suggest that some ulcerlike projections can progress to aneurysm and overt aortic dissection, but some disappear or remain unchanged during the follow-up period. Therefore, controversy surrounds the treatment of ulcerlike projections in intramural hematomas. The purpose of this study was to investigate the natural history and predictors of progression of newly developed ulcerlike projections in patients with intramural hematomas.

	MATERIALS AND METHODS

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The study group consisted of 52 patients from two hospitals (Omura Municipal Hospital and National Nagasaki-chuo Hospital) who had intramural hematoma diagnosed between 1986 and 2000. The ethics committees at both hospitals approved this study. Informed consent was not required, as patient privacy was maintained.

There were 29 men and 23 women, who were 43–90 years of age and had a mean age of 69.8 years ± 11.0 (SD). All patients had sudden back or chest pain. Patients with Marfan syndrome or traumatic intramural hematoma were excluded from this study. Forty-four of the 52 patients had a history of hypertension. At admission, hypertension was present in all patients, and no patients died during surveillance imaging. Although there is controversy surrounding the treatment of Stanford type A intramural hematoma (surgical or medical therapy) (8,12), medical therapy is initially selected for all patients in our hospitals. Hypertension was well controlled in all patients (systolic blood pressure < 140 mm Hg) during the follow-up period.

The term aortic intramural hematoma tends to be used for aortic wall hematoma without intimal disruption. In this study, we defined aortic intramural hematoma as primary aortic wall hematoma without an ulcerlike projection at imaging (6–10).

The diagnosis of intramural hematoma was established with computed tomography (CT) within 24 hours of the onset of pain. This diagnosis was made with the initial CT scan by using the following criteria: (a) a crescent-shaped area along the wall of the aorta that showed higher attenuation than that of blood on the CT scan obtained before contrast material enhancement, (b) no contrast enhancement effect within the area seen on the CT scan obtained after contrast enhancement, (c) no intimal flap in the aorta, and (d) no intimal tear or PAU (no detectable ulcerlike projection).

The initial diagnosis of intramural hematoma was reconfirmed in all cases with use of transesophageal echocardiography, magnetic resonance (MR) imaging, and/or angiography. Sixteen patients had Stanford type A intramural hematomas (involving the ascending aorta), and 36 patients had Stanford type B (all other intramural hematomas) (14). Twelve of the 16 patients with type A intramural hematoma had arch involvement, and 22 of the 36 patients with type B also had arch involvement.

Follow-up
The mean CT follow-up period was 10.7 months ± 11.1 (range, 0.67–48.0 months). Regular follow-up studies were performed every week during the 1st month and two or three times a year after the 2nd month. In patients with a new episode that suggested complications during follow-up periods, additional examinations were performed. The patients who did not have intramural hematoma or its complications at 2 years after onset were excluded from further follow-up CT. The CT follow-up period after surgery was not included in this study. Seven patients died of other causes during the follow-up period.

Imaging
In all patients, a total of 322 examinations were performed with conventional (n = 210) or spiral CT (n = 112). Follow-up CT examinations were performed with and without contrast material enhancement in all patients. Contrast-enhanced CT was performed with a bolus injection of 100 mL of ionic or nonionic contrast material. Venous access was achieved with a 19–21-gauge needle inserted in the antecubital fossa or forearm. All CT was performed with a model 9800, High Speed Advantage, or Light Speed Qx/i scanner (GE Medical Systems, Milwaukee, Wis), generating transverse scans with contiguous 5-mm-thick sections from the top of the aortic arch to the abdominal aorta. At spiral CT, a power injector was used, and imaging began 20–30 and 120–130 seconds (two phases) after the start of contrast material injection.

Image Evaluation
CT scans were evaluated by two experienced cardiovascular radiologists (E.S., Y.M.; >10 years of experience). The presence or absence of an ulcerlike projection, the diameter and progression of the projection, if one was present, and the aortic diameter were evaluated. The time of development of a new ulcerlike projection and the time of progression from the onset were also evaluated. Final decisions regarding the findings were reached by means of consensus.

An ulcerlike projection (ulcerlike lesion) was defined as a localized blood-filled pouch protruding into the thrombosed lumen of the aorta. It showed the same degree of contrast enhancement as the aortic lumen on postcontrast CT scans. Progression of an ulcerlike projection was defined as an increase in size of the projection, progression to overt aortic dissection, and/or rupture. The aortic diameter was defined as the maximum diameter of the outer contour of the aorta. The diameter of the ulcerlike projection was defined as the maximum diameter of the localized blood-filled pouch on transverse CT scans. (However, a potential limitation of this study was the difficulty in obtaining accurate measurements of ulcerlike projections on transverse CT scans alone.) In the aortic arch, the diameter of the aorta perpendicular to the curvature was measured.

Statistical Analysis
All values are expressed as means ± SDs. Statistical analysis was performed on clinical and morphologic variables, with the ² or Fisher exact test used for categoric variables (including age 70 years, sex, history of hypertension, diabetes mellitus, atherosclerotic diseases, hemodialysis, pleural effusion, Stanford type, and location), and the Mann-Whitney U test was used for continuous variables (diameters of the aorta and ulcerlike projection). If the expected number of cells was less than five, the Fisher exact test was used for categoric variables. The Cox proportional hazards model was used to identify predominant predictors for progression of the ulcerlike projection throughout the follow-up period with the use of stepwise multivariate analyses (entry and removal thresholds, .05 and .1, respectively). In all tests, a P value less than .05 was considered to indicate a significant difference. Data analysis was performed with the use of a computer program (Stat-View J-4.5 for Macintosh; Abacus Concepts, Berkeley, Calif).

	RESULTS

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In 17 (33%) of the 52 patients, 17 ulcerlike projections were newly identified during the follow-up period from 1 day to 3 months (mean time from onset, 17.8 days ± 21.4). Three projections were located in the ascending aorta; six, in the aortic arch; five; in the descending aorta; and three; in the abdominal aorta. In 10 (62%) of the 16 patients with type A intramural hematoma, 10 ulcerlike projections were newly identified during the follow-up period. In seven (19%) of the 36 patients with type B intramural hematoma, seven ulcerlike projections were newly identified during the follow-up period. Table 1 shows that the following characteristics were not significantly different between the group with and that without ulcerlike projections: age 70 years or older, sex, history of hypertension, diabetes mellitus, atherosclerotic diseases (including atherosclerotic aneurysm, ischemic heart disease, and cerebrovascular disease), hemodialysis, pleural effusion, and maximum aortic diameter of the affected aorta. There was a significant difference in Stanford type between the two groups, and patients with type A had a significantly higher frequency of new development of ulcerlike projections (P = .002).

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Type A aortic intramural hematoma in an 81-year-old woman. (a) Initial transverse CT scan shows intramural hematoma formation (arrowheads) from the ascending to the descending aorta. There is no ulcerlike projection. (b) Follow-up transverse CT scan obtained 2 days after a shows a new ulcerlike projection (arrowhead) in the ascending aorta. The ascending aortic intramural hematoma has increased in size. (c) Follow-up transverse CT scan obtained 3 months after b shows enlargement of the ulcerlike projection. After 3 more months, surgery was performed.

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Type A aortic intramural hematoma in an 81-year-old woman. (a) Initial transverse CT scan shows intramural hematoma formation (arrowheads) from the ascending to the descending aorta. There is no ulcerlike projection. (b) Follow-up transverse CT scan obtained 2 days after a shows a new ulcerlike projection (arrowhead) in the ascending aorta. The ascending aortic intramural hematoma has increased in size. (c) Follow-up transverse CT scan obtained 3 months after b shows enlargement of the ulcerlike projection. After 3 more months, surgery was performed.

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 1c. Type A aortic intramural hematoma in an 81-year-old woman. (a) Initial transverse CT scan shows intramural hematoma formation (arrowheads) from the ascending to the descending aorta. There is no ulcerlike projection. (b) Follow-up transverse CT scan obtained 2 days after a shows a new ulcerlike projection (arrowhead) in the ascending aorta. The ascending aortic intramural hematoma has increased in size. (c) Follow-up transverse CT scan obtained 3 months after b shows enlargement of the ulcerlike projection. After 3 more months, surgery was performed.

View larger version (169K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Type B aortic intramural hematoma in a 75-year-old man. (a) Initial transverse CT scan shows hematoma formation (arrowheads) in the abdominal aorta. There is no ulcerlike projection. (b) Follow-up transverse CT scan obtained 1 day after a shows a new ulcerlike projection (arrowhead) in the abdominal aorta. (c) Follow-up transverse CT scan obtained 6 days after b shows that the ulcerlike projection has disappeared.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Type B aortic intramural hematoma in a 75-year-old man. (a) Initial transverse CT scan shows hematoma formation (arrowheads) in the abdominal aorta. There is no ulcerlike projection. (b) Follow-up transverse CT scan obtained 1 day after a shows a new ulcerlike projection (arrowhead) in the abdominal aorta. (c) Follow-up transverse CT scan obtained 6 days after b shows that the ulcerlike projection has disappeared.

View larger version (170K): [in this window] [in a new window] [Download PPT slide]   Figure 2c. Type B aortic intramural hematoma in a 75-year-old man. (a) Initial transverse CT scan shows hematoma formation (arrowheads) in the abdominal aorta. There is no ulcerlike projection. (b) Follow-up transverse CT scan obtained 1 day after a shows a new ulcerlike projection (arrowhead) in the abdominal aorta. (c) Follow-up transverse CT scan obtained 6 days after b shows that the ulcerlike projection has disappeared.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

Intramural hematoma was first described in 1920 as dissection without intimal tear. With the development of noninvasive imaging techniques, many intramural hematomas have been reported (6–11,19). Although the exact mechanism for formation of this hematoma remains to be clarified, the cause is believed to be rupture of the vasa vasorum in the aorta, resulting in hematoma formation (7,11,15,16).

Ulcerlike projection was first described in 1965 as a defect in the intima leading to a clotted second channel, and it has been recognized as one of the radiologic findings in aortic dissection (1–5). At CT and angiography, the ulcerlike projection appears as a localized blood-filled pouch protruding into the thrombosed lumen of the aorta, showing the same degree of contrast enhancement as the aortic lumen. On MR images, it appears as an area of signal void owing to blood flow (1–5,13). Investigators in recent studies (4,5,9,13) have suggested that the ulcerlike projection can be seen in the three aortic diseases previously mentioned. The ulcerlike projection has usually been considered a PAU or intimal tear. In intramural hematoma, ulcerlike projection is not identified at initial imaging; however, the projection can be newly identified during the follow-up period and may be considered a new intimal disruption. Although some ulcerlike projections of intramural hematoma can progress to aneurysm and overt aortic dissection, there are relatively few reports about ulcerlike projections of intramural hematoma (4,5,9,10,13).

In the current study, 17 ulcerlike projections were newly identified in intramural hematomas during the follow-up period. New ulcerlike projections were located predominantly in the region from the ascending aorta to the aortic arch, and patients with type A intramural hematoma had a significantly higher occurrence of new development of ulcerlike projection than patients with type B. These results suggest that new intimal disruption of intramural hematoma may be related to hydraulic stress because the portion of aorta from the ascending aorta to the aortic arch is under greater hydraulic stress than is the distal part of the aorta (4,7,20).

In contrast, the PAU typically involves the descending and abdominal aorta, which are severely atherosclerotic (16,21–23). In classic aortic dissection, most intimal disruptions are also related to mechanical stress (20). In both classic aortic dissection and intramural hematoma, intimal disruptions usually occur at points of great mechanical stress. Therefore, a new ulcerlike projection of intramural hematoma may be similar or equal to intimal tear in classic aortic dissection with an early thrombosed false lumen. We hypothesize that intimal disruptions may have similar natural histories in both diseases, because the flow dynamics are similar.

Some authors have recommended that type A intramural hematoma requires early surgery because it tends to develop classic overt dissection and/or rupture (7,24). Although further studies are needed to establish the therapeutic strategy for type A intramural hematoma, careful follow-up is certainly needed for this type.

In our study, 12 (70%) of the 17 ulcerlike projections progressed to complications during the follow-up period. All nine projections located from the ascending aorta to the aortic arch progressed to complications, and a significantly higher risk of progression was associated with location of the ulcerlike projection from the ascending aorta to the aortic arch. Stanford type was not a significant predictor of progression of the projection. These results suggest that the location of the projection is the principal risk factor. In intramural hematoma, both structural weaknesses of the media and mechanical stress may cause progression of projections, and careful follow-up study is especially needed in patients with new development of ulcerlike projections from the ascending aorta to the aortic arch. In addition, three of the 12 projections that progressed were located from the descending aorta to the abdominal aorta. Therefore, all ulcerlike projections should probably be followed up.

In this study, the frequency of progression of the ulcerlike projection was high (70%) in patients with intramural hematoma. However, authors of previous reports suggest that the frequency of progression of PAU was not as high (5,18,22). In comparing our results with those of previous reports about PAU, some differences were noted in the natural history between intimal disruption of intramural hematoma and PAU. Recently, Quint et al (5) reported the natural history of ulcerlike lesions of the aorta. They noted that about one-third of ulcerlike lesions progressed, generally resulting in mild interval aortic enlargement. They evaluated ulcerlike lesions without histopathologic proof, but they presumed that many of the lesions in their series represented PAUs on the basis of clinical and imaging findings. Hayashi et al (18) reported that six of 12 patients with PAU had a poor prognosis because of the progression of PAU. In the remaining six patients, the size of the ulcer stayed the same or increased very slowly. Harris et al (22) reported that few patients with PAU developed overt aortic dissection or aortic rupture.

The aortic wall around the PAU usually has more severe atherosclerosis than that of intimal disruption caused by mechanical stress. Roberts (20) reported that extensive atherosclerotic plaque can cause underlying medical scarring or atrophy or both, which in turn interrupt the longitudinal dissection. Atherosclerotic changes of the aortic wall may thus limit progression of PAU.

As a limitation of this study, diagnoses of intramural hematoma and ulcerlike projection were established only with imaging methods. In the three aortic diseases (PAU, classic aortic dissection, and intramural hematoma), the radiologic findings are sometimes very similar. At imaging, intramural hematoma must be diagnosed by means of the findings of aortic intramural hematoma formation and no ulcerlike projection. However, the authors of some reports (15,25) have suggested that small intimal disruption may be overlooked even at surgery and autopsy. Therefore, it is impossible to completely differentiate these three aortic diseases by means of imaging alone. Another limitation of this study was the small sample size. Further studies involving larger numbers of patients are needed. Another potential limitation was the difficulty in obtaining accurate measurements of ulcerlike projections on transverse CT scans. Multiplanar reconstructed images or other modalities such as MR imaging and transesophageal echocardiography may be needed to obtain more accurate sizes of ulcerlike projections.

In conclusion, patients with type A intramural hematoma have a significantly higher frequency of new development of ulcerlike projections than patients with type B intramural hematoma. The location of the ulcerlike projection is the principal risk factor for progression, and careful follow-up study is needed for patients with new development of an ulcerlike projection from the ascending aorta to the aortic arch. The results of this study also suggest that the frequency of progression of intimal disruption of intramural hematoma may be higher than that of PAU.

	FOOTNOTES

 
Abbreviation: PAU = penetrating atherosclerotic ulcer

Author contributions: Guarantors of integrity of entire study, E.S., Y.M.; study concepts, E.S., Y.M., T.I.; study design, E.S., Y.M.; literature research, E.S., I.S.; clinical studies, E.S., Y.M., I.S.; data acquisition, E.S., T.O.; data analysis/interpretation, E.S., I.S.; statistical analysis, E.S.; manuscript preparation, E.S., Y.M., K.H.; manuscript definition of intellectual content, E.S.; manuscript editing, E.S., K.H.; manuscript revision/review and final version approval, all authors.

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This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2242011009v1 224/2/536    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sueyoshi, E. Articles by Hayashi, K. Search for Related Content PubMed PubMed Citation Articles by Sueyoshi, E. Articles by Hayashi, K.