statdx/docs_md/articles/aortic-intramural-abnormality_75d7b37f-bc37-493b-8961-8b2a9001fb94.md

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Aortic Intramural Abnormality	75d7b37f-bc37-493b-8961-8b2a9001fb94	key value df804626-c042-4296-96e3-836a6da50fd6 Gregory Kicska, MD, PhD	name slug treeNodeId Cardiac cardiac fa90100b-619c-430e-8074-b5b9789bab39 name slug treeNodeId Differential Diagnosis differential-diagnosis 952326a0-b3ea-4a21-aa7a-d796cc9325ed name slug treeNodeId Aortic Intramural Abnormality aortic-intramural-abnormality null	Cardiac	8ad4b88e-7101-4be0-a839-eb819f6dfe08	9	03/17/22	Aortic Intramural Abnormality	Cardiac, Differential Diagnosis, Aortic Intramural Abnormality	Aortic Intramural Abnormality | STATdx	Aortic Intramural Abnormality	DDX	true	Cardiac Differential Diagnosis Aortic Intramural Abnormality

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title: "Aortic Intramural Abnormality" docid: "75d7b37f-bc37-493b-8961-8b2a9001fb94" authors:

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ESSENTIAL INFORMATION

• Key Differential Diagnosis Issues

  • Aortic wall should measure < 4 mm
  • Aortic wall should be isointense to lumen

• Helpful Clues for Common Diagnoses

  • Atherosclerosis/Adherent Thrombus - Concentric diffuse involvement vs. spiral involvement of intramural hematoma - Aorta often tortuous with atherosclerotic disease in branch vessels
  • Aortic Dissection - Intimal flap readily seen on CECT as unenhanced line through lumen - Intraluminal calcifications on NECT suggest diagnosis and represent displaced intimal calcifications - "Beak" sign: False lumen side of dissection flap meets outer wall with acute angle - "Cobweb" sign: False lumen traversed by media fibers - Confusion with pulsation artifact at aortic root avoided by inspecting coronal images

• Helpful Clues for Less Common Diagnoses

  • Aortic Intramural Hematoma - Hyperdense aortic wall compared to lumen when acute, isodense when old - Check LV chamber for hypodense blood to avoid pitfall of confusion anemia - Patient more likely to progress to dissection with coexistence of ulcer-like projections - Most commonly in descending aorta
  • Penetrating Atherosclerotic Ulcer - Luminal irregularity - Must extend beyond expected contour of intima - Outer aortic wall thickening indicates acuity

• Helpful Clues for Rare Diagnoses

  • Takayasu/Giant Cell Arteritis - Radiographically indistinguishable, differentiated based on age (Takayasu < 50 years, giant cell > 50 years) - FDG PET can determine active disease - Aortic caliber will be reduced - Subclavian stenosis is hallmark finding - Pulmonary artery strictures and mesenteric vessel stenosis are common
  • Radiation - Vascular calcifications confined to radiation field - Radiation history will be present

References

Selected References

1. Ko JP et al: Chest CT Angiography for acute aortic pathologic conditions: pearls and pitfalls. Radiographics. 41(2):399-424, 2021
2. 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
3. Carroll BJ et al: Imaging for acute aortic syndromes. Heart. 106(3):182-9, 2019
4. Abbara S et al: Thoracic aortic disease: spectrum of multidetector computed tomography imaging findings. J Cardiovasc Comput Tomogr. 1(1):40-54, 2007

Images

Selected Images

Atherosclerosis/Adherent Thrombus Axial CECT shows a mural thrombus in an otherwise dilated aorta. Note that intimal calcifications are on the outer edge of the thrombus .

Atherosclerosis/Adherent Thrombus Axial CECT shows a mural thrombus in an otherwise dilated aorta. Note that intimal calcifications are on the outer edge of the thrombus .

Aortic Dissection Axial CECT shows a severely displaced dissection flap, compressing the true lumen and occluding the SMA . Note true lumen and false lumen . This was treated with fenestration.

Aortic Dissection Axial CECT shows a dissection flap in the descending aorta with a displaced intimal calcification . The dissection did not involve the arch and was managed medically.

Aortic Intramural Hematoma Coronal NECT shows asymmetric thickening and hyperdense aortic wall, representing the hematoma. Note the displaced intimal calcification .

Aortic Intramural Hematoma Axial CECT shows hyperdense, thickened aortic wall in a hypertensive patient who presented to the ER with back pain. This finding can be missed on an enhanced exam.

Penetrating Atherosclerotic Ulcer Axial CECT shows a small focus of contrast extending beyond the expected aortic wall . Adjacent wall thickening suggested it is likely acute and explains the patient's back pain.

Takayasu/Giant Cell Arteritis Axial CECT shows thickened aortic wall with inner intimal calcifications. Although causing aortic narrowing, this may progress to aneurysmal dilation.

Radiation Double oblique CECT shows dense aortic and pulmonary artery 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.

Additional Images

Aortic Dissection Axial NECT shows displaced intimal calcifications representing aortic dissection .