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title: "Aortic Intramural Abnormality"
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docid: "75d7b37f-bc37-493b-8961-8b2a9001fb94"
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authors:
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- key: "df804626-c042-4296-96e3-836a6da50fd6"
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value: "Gregory Kicska, MD, PhD"
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breadcrumbs:
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-
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name: "Cardiac"
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slug: "cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "952326a0-b3ea-4a21-aa7a-d796cc9325ed"
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-
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name: "Aortic Intramural Abnormality"
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slug: "aortic-intramural-abnormality"
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treeNodeId: null
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category: "Cardiac"
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documentVersionId: "8ad4b88e-7101-4be0-a839-eb819f6dfe08"
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imageCount: 9
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lastUpdated: "03/17/22"
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pageDescription: "Aortic Intramural Abnormality"
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pageKeywords: "Cardiac, Differential Diagnosis, Aortic Intramural Abnormality"
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pageTitle: "Aortic Intramural Abnormality | STATdx"
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enhancedTitle: "Aortic Intramural Abnormality"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Cardiac"
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- "Differential Diagnosis"
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- "Aortic Intramural Abnormality"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Aortic wall should measure < 4 mm
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- Aortic wall should be isointense to lumen
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- ## Helpful Clues for Common Diagnoses
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- **Atherosclerosis/Adherent Thrombus**
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- Concentric diffuse involvement vs. spiral involvement of intramural hematoma
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- Aorta often tortuous with atherosclerotic disease in branch vessels
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- **Aortic Dissection**
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- Intimal flap readily seen on CECT as unenhanced line through lumen
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- Intraluminal calcifications on NECT suggest diagnosis and represent displaced intimal calcifications
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- "Beak" sign: False lumen side of dissection flap meets outer wall with acute angle
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- "Cobweb" sign: False lumen traversed by media fibers
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- Confusion with pulsation artifact at aortic root avoided by inspecting coronal images
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- ## Helpful Clues for Less Common Diagnoses
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- **Aortic Intramural Hematoma**
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- Hyperdense aortic wall compared to lumen when acute, isodense when old
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- Check LV chamber for hypodense blood to avoid pitfall of confusion anemia
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- Patient more likely to progress to dissection with coexistence of ulcer-like projections
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- Most commonly in descending aorta
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- **Penetrating Atherosclerotic Ulcer**
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- Luminal irregularity
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- Must extend beyond expected contour of intima
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- Outer aortic wall thickening indicates acuity
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- ## Helpful Clues for Rare Diagnoses
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- **Takayasu/Giant Cell Arteritis**
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- Radiographically indistinguishable, differentiated based on age (Takayasu < 50 years, giant cell > 50 years)
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- FDG PET can determine active disease
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- Aortic caliber will be reduced
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- Subclavian stenosis is hallmark finding
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- Pulmonary artery strictures and mesenteric vessel stenosis are common
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- **Radiation**
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- Vascular calcifications confined to radiation field
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- Radiation history will be present
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## References
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# Selected References
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1. [Ko JP et al: Chest CT Angiography for acute aortic pathologic conditions: pearls and pitfalls. Radiographics. 41(2):399-424, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33646903%5Bpmid%5D)
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1. [Murillo H et al: Aortic dissection and other acute aortic syndromes: diagnostic imaging findings from acute to chronic longitudinal progression. Radiographics. 41(2):425-46, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33646901%5Bpmid%5D)
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1. [Carroll BJ et al: Imaging for acute aortic syndromes. Heart. 106(3):182-9, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31822571%5Bpmid%5D)
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1. [Abbara S et al: Thoracic aortic disease: spectrum of multidetector computed tomography imaging findings. J Cardiovasc Comput Tomogr. 1(1):40-54, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=19083876%5Bpmid%5D)
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## Images
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### Selected Images
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**Atherosclerosis/Adherent Thrombus**
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*Axial CECT shows a mural thrombus in an otherwise dilated aorta. Note that intimal calcifications are on the outer edge of the thrombus <img src='img/arrows/WS.png'/>.*
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**Atherosclerosis/Adherent Thrombus**
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*Axial CECT shows a mural thrombus in an otherwise dilated aorta. Note that intimal calcifications are on the outer edge of the thrombus <img src='img/arrows/WS.png'/>.*
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**Aortic Dissection**
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*Axial CECT shows a severely displaced dissection flap, compressing the true lumen and occluding the SMA <img src='img/arrows/WO.png'/>. Note true lumen <img src='img/arrows/WS.png'/> and false lumen <img src='img/arrows/WC.png'/>. This was treated with fenestration.*
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**Aortic Dissection**
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*Axial CECT shows a dissection flap <img src='img/arrows/WC.png'/> in the descending aorta with a displaced intimal calcification <img src='img/arrows/WS.png'/>. The dissection did not involve the arch and was managed medically.*
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**Aortic Intramural Hematoma**
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*Coronal NECT shows asymmetric thickening and hyperdense <img src='img/arrows/BS.png'/> aortic wall, representing the hematoma. Note the displaced intimal calcification <img src='img/arrows/WS.png'/>.*
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**Aortic Intramural Hematoma**
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*Axial CECT shows hyperdense, thickened aortic wall <img src='img/arrows/WS.png'/> in a hypertensive patient who presented to the ER with back pain. This finding can be missed on an enhanced exam.*
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**Penetrating Atherosclerotic Ulcer**
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*Axial CECT shows a small focus of contrast <img src='img/arrows/WC.png'/> extending beyond the expected aortic wall <img src='img/arrows/WS.png'/>. Adjacent wall thickening suggested it is likely acute and explains the patient's back pain.*
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**Takayasu/Giant Cell Arteritis**
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*Axial CECT shows thickened aortic wall <img src='img/arrows/WS.png'/> with inner intimal calcifications. Although causing aortic narrowing, this may progress to aneurysmal dilation.*
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**Radiation**
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*Double oblique CECT shows dense aortic <img src='img/arrows/BS.png'/> and pulmonary artery <img src='img/arrows/WS.png'/> calcifications in a patient who received prior mediastinal radiation. Vascular calcifications were not present elsewhere. Note that calcifications are spatially confined to the radiation field.*
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### Additional Images
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**Aortic Dissection**
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*Axial NECT shows displaced intimal calcifications representing aortic dissection <img src='img/arrows/WS.png'/>.*
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