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J Thorac Cardiovasc Surg 1999;118:968-969
© 1999 Mosby, Inc.

BRIEF COMMUNICATIONS

EXTREMELY RAPID REGRESSION OF AORTIC INTRAMURAL HEMATOMA

Mikio Ohmi, MDa, Koichi Tabayashi, MDa, Yoshimasa Moizumi, MDb, Tsunehiro Komatsu, MDb, Yoshihito Sekino, MDc, Chikao Goko, MDc, Sendai, Japan

From the Departments of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine,a Sendai City Medical Center,b and Saka General Hospital,c Sendai, Japan.

Address for reprints: Mikio Ohmi, MD, Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan.

Aortic intramural hematoma (IMH) has been accurately diagnosed by modern imaging techniques and may follow various clinical courses. We report a case in which 2 episodes of aortic IMH occurred in different aortic segments within a 10-month period. In the first episode the IMH involving the descending thoracic aorta regressed in 1 month; however, the large IMH involving the ascending and transverse aorta rapidly regressed within 24 hours in the second episode. The patient has been treated medically and is doing well.

Clinical summary.
The patient was a 62-year-old woman with a complicated history: removal of a pituitary adenoma in 1987, removal of the left kidney for renal cell carcinoma in 1992, and cerebral infarction in 1996. After removal of the pituitary adenoma she had been treated with hydrocortisone (30 mg/day) and desiccated thyroid (50 mg/day) for secondary adrenal hypofunction and hypothyroidism, respectively.

The first episode of aortic IMH occurred on March 8, 1998. She came to the emergency department of Saka General Hospital with the sudden onset of severe back pain. An admission computed tomographic (CT) scan showed crescentic thickening of the posterior wall of the descending thoracic aorta and a left-sided hemothorax. An aortogram demonstrated no intimal flap and an opacified false lumen or ulcer-like projection. She was treated medically and discharged on May 4, 1998. The CT scans from the first episode are shown inFig 1.



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  		Fig. 1. Left, Admission CT scans with intravenous contrast medium in the first episode demonstrate a left-sided hemothorax adjacent to the crescent-shaped IMH (arrows) involving the descending thoracic aorta (3/8/98). Right, The crescentic thickness of the aortic wall is still present in the later CT scan (3/20/98).

 
The second episode of aortic IMH occurred on January 12, 1999, during an operation for a subcutaneous and epidural abscess in the frontal region, possibly related to the previous pituitary operation. Her blood pressure suddenly fell below 50 mm Hg in systole. The emergency CT scan showed a large ascending and transverse aortic IMH and a massive left-sided hemothorax. Her general condition was stabilized until the next day, and she was referred to Sendai City Medical Center for emergency aortic repair. When another CT scan was taken, the aortic IMH had regressed completely. Since the maximal diameter of the ascending aorta was 40 mm, surgical intervention was canceled. Fluid was drained from the left pleural cavity (1170 mL; hemoglobin, 10.4 g/dL; hematocrit value, 36%), and she recovered after receiving medical treatment. The CT scans from the second episode are shown inFig 2.



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  		Fig. 2. Left, CT scans with intravenous contrast medium in the second episode of IMH involving the ascending and transverse aorta demonstrate a large IMH (arrows) around the ascending aorta and left-sided hemothorax (1/12/99). Right, Complete regression of the IMH is observed (1/13/99).

 
Discussion.
Aortic IMH is a variant of aortic dissection recognized in 17%Go 1 to 23%Go 2 of the patients with acute aortic dissection. The natural history and prognosis of aortic IMH have not been widely studied, but it has been recommended that ascending aortic IMH should be treated surgically because of high mortality and morbidity associated with medical treatment. Although progression to a typical dissection, increased permeability of the aortic wall leading to a pleural and mediastinal hemorrhage, and an aortic rupture have been reported, the patients with descending thoracic aortic IMH could be treated with aggressive medical management. Harris and associatesGo 2 reviewed the case histories of 53 patients with descending thoracic aortic IMH, of whom 33 had received medical treatment and 20 had undergone surgery with similar survival statistics on follow-up (91% and 80%, respectively). The results of aortic IMH are variable. Vilacosta and associatesGo 1 reported on a patient with a huge ascending aortic IMH that regressed dramatically 36 hours later. In our case, the ascending and transverse aortic IMH regressed completely within 24 hours. Aortic IMH shows dynamic behavior, and thickened aortic walls tend to vary with time. The mechanism of extremely rapid regression of the IMH could not be elucidated.

Khan and SpieraGo 3 reviewed 5 cases of aortic dissection in which prolonged steroid therapy had been used for systemic lupus erythematosus, and Leonard and HasletonGo 4 reported 4 cases of hypothyroidism complicated by aortic dissection. The present patient had been treated with hydrocortisone and desiccated thyroid after pituitary surgery. This treatment might be one of the etiologic factors for aortic IMH.

References

  1. Vilacosta I, San Román JA, Ferreirós J, Aragoncillo P, Méndez R, Castillo JA, et al. Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection. Am Heart J 1997;134:495-507.[Medline]
  2. Harris KM, Braverman AC, Gutierrez FR, Barzilai B, Dávila-Román VG. Transesophageal echocardiographic and clinical features of aortic intramural hematoma. J Thorac Cardiovasc Surg 1997;114:619-26.[Abstract/Free Full Text]
  3. Khan AS, Spiera H. Association of aortic aneurysm in patients with systemic lupus erythematosus: a series of case reports and a review of literature. J Rheumatol 1998;25:2019-21.[Medline]
  4. Leonard JC, Hasleton PS. Dissecting aortic aneurysm: a clinicopathological study. I. Clinical and pathological findings. Q J Med 1979;48:55-63.[Abstract/Free Full Text]
Received for publication April 9, 1999. Accepted for publication June 16, 1999.


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