Article, Cardiology

Aortic intramural hematoma with pulmonary artery extension mimics pulmonary embolism

Unlabelled imageintramural hematoma with pulmonar”>Case Report

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American Journal of Emergency Medicine

journal homepage: locate/ ajem

aortic intramural hematoma with pulmonary artery extension mimics pulmonary embolism

Abstract

A 59-year-old woman presented to emergency department with sudden onset of Chest tightness and shortness of breath. Laboratory test revealed elevated D-dimer (1558 ng/mL). The electrocardiogram revealed Right axis deviation, S1Q3T3 pattern, and T-wave inversion in leads V1 to V6. computed tomographic angiography was per- formed with 64-slice computed tomography for suspicious of pulmonary embolism. contrast-enhanced CTA showed no filling defect in the pulmonary arteries; however, luminal narrowing of the right pulmonary artery was noted. Nonenhanced computed tomographic scan showed smooth eccentric high attenuation change along the wall of main pulmonary artery and right pulmonary artery and also along the ascending and descending aorta. The high attenuation lesions in both of the aorta and pulmonary artery showed no Contrast enhancement indicating presence of intramural hemato- ma (IMH). Based on the image findings, a diagnosis of type A aortic IMH with pulmonary artery extension, instead of chronic pulmonary embolism, was made. Follow-up CTA 3 months later showed much improved of the right pulmonary artery narrowing and nearly complete resolution of the IMH.

A 59-year-old woman presented to emergency department with sudden onset of chest tightness and shortness of breath. She had a history of hypertension without medical control. Initial blood pres- sure was 196/113 mm Hg. Laboratory test revealed elevated D-dimer (1558 ng/mL). The electrocardiogram revealed right axis deviation, S1Q3T3 pattern, and T-wave inversion in leads V1 to V6. The chest x-ray revealed cardiac enlargement and prominent bronchovascular markings. Computed tomographic angiography (CTA) was performed with 64-slice computed tomography (CT) for suspicious of pulmonary embolism. Contrast-enhanced CTA showed no filling defect in the pulmonary arteries; however, luminal narrowing of the right pulmonary artery (RPA) was noted (Fig. A). Nonenhanced CT scan showed smooth eccentric high attenuation change along the wall of main pulmonary artery and RPA and also along the ascending and descending aorta (Fig. B). The maximal external diameter of the Ascending aorta was 44 mm. The maximal thickness of high attenuation change along the wall of RPA and ascending aorta were 6 and 6.5 mm, respectively. The high attenuation lesions in both of the aorta and pulmonary artery showed no contrast enhancement indicating presence of intramural hematoma (IMH). Based on the image findings, a diagnosis of type A aortic IMH with pulmonary artery extension, instead of chronic pulmonary embolism, was made. The patient was admitted to intensive care unit. Follow-up CTA at 1 week later showed mild regression of the IMH (Fig. C and D). The patient was clinically stable and was discharged 1 month later and

regularly followed up at cardiovascular clinics. Follow-up CTA 3 months later showed much improved of the RPA narrowing (Fig. E) and nearly complete resolution of the IMH (Fig. F).

Pulmonary artery extension of IMH in type A aortic IMH is rare. The aortic IMH is usually severe and extensive. It is postulated to be caused by the rupture of vasa vasorum from the posterior aspect of the aortic root penetrating the shared adventitia of the aorta and pulmonary artery [1]. In our patient, the aortic IMH was thin (6.5 mm), whereas IMH of RPA was of similar thickness (6.0 mm). If diagnosis was made only on contrast-enhanced CTA, the eccentric wall thickening and luminal narrowing of RPA caused by IMH did mimic CT feature of chronic pulmonary embolism [2] and might lead to a misdiagnosis of chronic pulmonary embolism. This misdiagnosis was particularly likely for our patient because she had clinical fea- tures of sudden onset of chest tightness, elevated D-dimer, and ab- normal electrocardiographic findings, which all suggested the possibility of pulmonary embolism.

Although the Optimal treatment for patients with type A aortic IMH remains controversial, Song et al [3] suggest timely surgery by cutoff values of 16 mm for IMH thickness and 55 mm for external diameter of ascending aorta. Our patient did not meet the criteria and, therefore, received medical treatment uneventfully.

Our case illustrated that pulmonary artery IMH extended from aortic IMH, although rare, should be included in the differential diagnosis of pulmonary embolism. In addition, it may not alter the clinical management of aortic IMH.

En-Li Shiau MD

Department of Radiology, Kaohsiung Veterans General Hospital

Kaohsiung 813, Taiwan

Fu-Zong Wu MD Yi-Luan Huang MD Ming-Ting Wu MD

Departments of Radiology, Kaohsiung Veterans General Hospital

Kaohsiung 813, Taiwan School of Medicine, National Yang-Ming University

Taipei, Taiwan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.05.036

References

  1. Sueyoshi E, Matsuoka Y, Sakamoto I, Uetani M. CT and clinical features of hemorrhage extending along the pulmonary artery due to ruptured aortic dissection. Eur Radiol 2009;19:1166-74.

    0735-6757/$ – see front matter (C) 2013

    image of Fig

    Fig. A, Computed tomographic angiography showed no filling defect in pulmonary arteries (PA); however, there was luminal narrowing of the RPA (asterisk). B, Nonenhanced CT scan showed smooth eccentric high attenuation change (black arrowheads) along the wall of main PA and RPA and also along the ascending and descending aorta (white arrowheads). C, Follow-up CTA at 1 week later showed improvement of luminal narrowing of the RPA (C) and mild regression of the IMH (D). Follow-up CTA 3 months later showed much improved of the RPA narrowing (E) and nearly complete resolution of the IMH (F).

    Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard JO, McLoud TC. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. Radiographics 2004;24:1219-38.

  2. Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, et al. Outcomes of patients with acute type A aortic intramural hematoma. Circulation 2009;120: 2046-52.

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