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Aortic Intramural Haematoma Classification — EECC MCQ

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ModerateAortic DiseaseAortic Intramural Haematoma ClassificationEECC

A 50-year-old man presents with acute chest pain. CT aortography shows an intramural haematoma (IMH) of the ascending aorta without an intimal flap. How is this classified and managed?

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Correct answer: E — IMH of the ascending aorta is classified as type A acute aortic syndrome (equivalent to type A dissection) — emergency surgical management is recommended, as IMH can progress to dissection or rupture

Intramural haematoma (IMH) is part of the acute aortic syndrome (AAS) spectrum alongside classical dissection and penetrating aortic ulcer. IMH is characterised by haemorrhage within the aortic media WITHOUT an intimal tear/flap — likely from rupture of the vasa vasorum. The ESC 2024 Aortic Disease Guidelines classify IMH by location: Type A IMH (ascending aorta): treated as type A dissection — emergency surgical repair (Class I), as Type A IMH progresses to overt dissection in 16-47% and has significant rupture risk. Type B IMH (descending aorta): managed medically (IV antihypertensives, pain control, serial imaging) with intervention reserved for complications (progression, expansion, rupture) — similar to uncomplicated type B dissection. Serial CT imaging at 1 week, 1 month, then 3-6 monthly monitors for progression or resolution.

Reference: ESC (2024): Aortic Disease Guidelines