Newly developed ulcer-like projection (ULP) in aortic intramural haematoma on follow-up CT: is it different from the ULP seen on the initial CT?

doi:10.1016/j.crad.2007.07.020

Clinical Radiology

Volume 63, Issue 2, February 2008, Pages 201-206

https://doi.org/10.1016/j.crad.2007.07.020 Get rights and content

Aim

To show whether the clinical and radiological features of newly developed ulcer-like projections (nULPs) in an aortic intramural haematoma (IMH) on follow-up computed tomography (CT) images, are different from those of the initial ULPs (iULPs) on the initial CT images.

Materials and methods

A review of the radiological database revealed 98 patients with IMH with at least two follow-up CT examinations with a follow-up period of more than 1 month. The patients were divided into four groups: patients without iULPs or nULPs throughout the follow-up periods (group A); patients with iULPs on the initial CT images (group B); patients with nULPs on follow-up CT images but without iULPs on the initial CT images (group C); and patients with both iULPs and nULPs (group D). The type of IMH, aortic diameter, thickness of the haematoma, and complications were analysed. The clinical and CT findings and complications in the four groups were compared.

Results

Forty-two patients had no iULPs nor nULPs (group A); 27 patients had 45 iULPs on the initial CT images (group B); 16 patients had 17 nULPs on follow-up CT images without any ULP on the initial CT images (group C); and 21 nULPs developed in 13 patients with iULPs (group D). There was no significant difference in the demographic or initial CT findings in the four groups. There was no statistical difference in the incidence of complications between groups B (59.3%), group C (62.5%), and group D (69.2%; p = 0.830), but there was a significant difference in the incidence of complications between the patients without any ULPs (21.5% in group A) and those with ULPs (62.5% in groups B, C, and D).

Conclusion

There were no significant differences in the CT findings or complications between the patients with iULPs and nULPs. Regardless of the developing time of the ULPs, the incidence of complications of IMH in patients with ULPs was higher than that in those without ULPs. Careful and regular follow-up CT examinations are needed for patients with ULPs.

Introduction

Ulcer-like projections (ULPs) were, not was first described in 1965 as a “defect in the intima leading to a clotted second channel” in aortic dissection (thrombosed type).¹ ULP has been considered to represent the site of an intimal tear or the site of occlusion or detachment of the orifice of aortic branches or penetrating atherosclerotic ulcers (PAUs),1, 2, 3 but the definition still remains unclear.

The role of ULPs is still unclear as a prognostic factor in IMH. The presence of ULP was considered as the important factor for predicting the prognosis of intramural haematoma (IMH). In previous studies, authors have suggested that IMH with ULPs or PAUs was significantly associated with a progressive disease course.4, 5 Conversely, other authors have suggested that most ULPs are asymptomatic and do not expand.⁶ New ULPs (nULPs) can arise during the follow-up period in patients with IMH without an ULP seen on the initial computed tomography (CT) examination. It is suggested that many nULPs on follow-up CT examinations progress to complications, such as aneurysm, aortic dissection, or aortic rupture.5, 7 However, to the authors' knowledge, no studies have been performed to compare ULPs on initial CT (iULPs) and nULPs, in terms of incidence, complications, and prognosis.

The purpose of this study was to ascertain whether the clinical and CT features of nULPs on follow-up CT in patients with aortic IMH are different from those of the iULPs, and to ascertain whether the complication rate differs between IMH without ULPs and IMH with ULPs.

Section snippets

Materials and methods

Between January 1998 and January 2005, 2755 consecutive patients clinically suspected of having acute aortic dissection underwent contrast-enhanced CT in a tertiary referral hospital with 2200 beds. A retrospective analysis of the imaging reports was performed to detect the presence of IMH or “thrombosed aortic dissection” by searching the radiology information systems database for patients with clinically suspected acute aortic dissection and in whom contrast-enhanced CT examinations had been

Results

There were 42 patients without iULPs or nULPs throughout follow-up periods (group A); 27 patients with 45 iULPs at the initial CT examination (group B), 16 patients with 17 nULPs on follow-up CT without iULPs on the initial CT images (group C); and 21 nULPs developed in 13 patients with iULPs (group D). Fifty-eight iULPs were identified in 40 patients and 38 nULPs developed in 29 patients. Seventy-nine percent of the nULPs (30 of 38) developed within 1 month of the initial CT examination. The

Discussion

The main finding of this study was that the CT features and complication rates of patients with nULP on follow-up CT in patients with aortic IMH do not differ from those with ULP found on the initial CT images. However, patients with ULPs had more complications than patients without ULPs.

Aortic IMH has been recognized as a variant of aortic dissection.2, 8, 10, 11, 12, 13 IMH was first described in 1920 as dissection without intimal tear. With the development of non-invasive imaging techniques,

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Cited by (30)

Prognostic Implications of Initial Focal Contrast Enhancement in Acute Type B Intramural Hematoma
2024, Journal of the American College of Cardiology
The prognostic implication of initial focal contrast enhancement (FCE), including focal intimal disruption (FID) and intramural blood pool (IBP), in acute type B intramural hematoma (IMH) remain unclear.
The purpose of this study was to compare the prognostic implications in IMH with or without FCE.
A total of 574 patients were enrolled. FID was defined as an intimal disruption with contrast-filled out-pouching from the aorta lumen with a communicating orifice of >3 mm, and IBP was defined as a localized contrast medium-filled pool inside the IMH.
A total of 207 (36.1%) patients with initial FCE, including 132 (63.8%) FIDs and 75 (36.2%) IBPs, were identified. Patients with FCE accompanying IMH were more likely to have hypertension (P = 0.001), pleural effusion (P = 0.006), fewer aortic segments involved (P < 0.001), more adverse aortic events (AAEs) (P < 0.001), and fewer freedom from intervention (P = 0.002). Pleural effusion (HR: 1.79; 95% CI: 1.25-2.55; P = 0.001) and FCE (HR: 1.51; 95% CI: 1.12-2.02; P = 0.006) were identified to be the independent risk factors of AAEs. In the subgroup analysis, IMH with initial FID were more likely to progress than those with initial IBP (P < 0.001). FIDs located at the proximal descending aorta (HR: 2.95; 95% CI: 1.65-5.29; P < 0.001) were associated with AAEs.
Patients with FCE accompanying IMH were more likely to progress, especially in those initial FID localized at the proximal descending aorta. (Nature course and predictors of progression of intramural hematoma: A retrospective, multicenter study; ChiCTR2300073829).
Prediction of adverse events in patients with initially medically treated type A intramural hematoma
2020, International Journal of Cardiology
Citation Excerpt :
IMH was initially described as aortic dissection without an intimal tear [23,24], however, intimal defects were detected in 70% with CT and 70–80% of the surgically treated IMH [13,24,25], and some tiny intimal defects might not be well identified by CT. ULP, also described as localized intimal defect, was detected by imaging techniques in 20% to 50% of IMH in previous studies [12,26,27], and was detected in 46.5% patients by CT in our initially medically treated type A IMH cohort. This raised a question to the traditional theory with vasa vasorum bleeding, conventional definition of IMH might be changed [24].
Prior studies provided limited data regarding natural history of initially medically treated type A intramural hematoma (IMH).
To develop predictive models for adverse aorta-related events in patients with type A IMH.
We performed a retrospective pooled analysis of individual patient data, including baseline clinical and CT characteristics. All patients enrolled were followed up for adverse aorta-related events, defined as a composite of aortic disease-related death and the presence of aortic complications that required aortic invasive treatment.
A total of 172 patients (52.9% men) were included, with a mean age of 61.1 ± 11.2 years. During a median follow-up time of 770.5 (45.3–1695.8) days, 60 patients (34.9%) experienced adverse aorta-related events. In Cox regression model for predicting adverse aorta-related events, hypertension (HR = 3.78, p = .067), MAD (HR = 1.05, p = .018), presence of ULP (HR = 2.43, p = .002) and pericardial effusion (HR = 1.65, p = .061) were independently associated with adverse aorta-related events. A majority of the adverse aorta-related events (n = 46, 76.7%) occurred within acute and subacute phase (90 days) of IMH. In predictive model for 90 days aortic events, MAD≥50.7 mm (OR = 2.79, p = .006) and presence of ULP (OR = 3.20, p = .002) were independent predictors. C statistic of the predictive model were 0.71 (p < .001).
Predictive models including baseline clinical and CT characteristics as predictors allow for accurate estimation of risk of adverse aorta-related events in patients with type A IMH. The proposed predictive models are helpful for risk estimates and decision making.
Intimal disruption in type B aortic intramural hematoma. Does size matter? A systematic review and meta-analysis
2018, International Journal of Cardiology
Type B intramural hematoma (IMH) is considered a low-risk entity for aortic complications if aortic dilation, containing rupture or clinical instability are absent. However, the development of intimal disruptions (ID), present in >40% of cases, poses an unknown risk.
To establish which ID characteristics imply a higher risk of aortic complications and, therefore, merit invasive treatment.
A systematic review and a meta-analysis were made following a search in EMBASE, MEDLINE and PsycINFO for articles published between January 1995 and December 2017. The combined endpoint was defined as aortic mortality, invasive treatment for aortic disease and/or increase in maximum aortic diameter ≥55 mm. Lesions with communicating orifice ≤3 mm were defined as tiny ID (TID) and those with >3 mm as focal ID (FID).
Six studies with 564 participants diagnosed of type B IMH were included. Incidence of ID was 54.3% (306 individuals): 27.7% (156 individuals) initially met TID criteria; however, 13.9% of these (21 of 151 with morphologic evolution) evolved to FID within the first 6 months. Ninety-two cases suffered clinical aorta-related events (16.3%; mean follow-up range: 15–85 months; median: 52 months). Patients with TID had a similar risk of aorta-related events to those without ID (RR = 0.904; 95% CI, 0.335–2.440; P = 0.842; I² = 42.5%), but lower than those with FID (RR = 0.299; 95% CI, 0.094–0.952; P = 0.041; I² = 26.9%).
Tiny intimal disruption in type B IMH evolution is not related to an increased risk of complications and should not be considered an indication for invasive treatment. However, since 14% of TID evolve to FID within the first 6 months, close follow-up with imaging techniques is advisable.
Clinical Implications of Focal Intimal Disruption in Patients With Type B Intramural Hematoma
2017, Journal of the American College of Cardiology
Citation Excerpt :
Remarkably, our pathology studies showed the presence of FID (>3 mm) with preservation of the adventitia in 3 patients in chronic phase on necropsy studies, and confirmed complete aortic rupture in 4 patients during hospitalization: 3 in necropsy studies and 1 who underwent open surgery. Management recommendations for intimal disruption in type B IMH have been highly controversial given the different mechanisms and clinical outcome of these lesions (3,9–14,25). Jang et al. (11) reported that 40% of patients presented intimal disruptions on the initial imaging study.
Focal intimal disruption (FID) has been described in >20% of type B intramural hematomas (IMH), with unclear prognosis and management.
This study aimed to evaluate the short- and long-term evolution of medically treated patients with type B IMH with and without FID.
There were 107 consecutive patients with acute type B IMH were included prospectively in a multicenter protocol of clinical and imaging follow-up. FID was defined as an intimal disruption with contrast material-filled outpouching from the aorta lumen with a communicating orifice of >3 mm.
There were 43 patients (40%) who developed an FID with larger basal maximum aortic diameter and hematoma thickness. Patients with acute FID had a higher risk of aorta-related events than those without FID (hazard ratio: 24.43; 95% confidence interval: 7.65 to 78.04; p < 0.001). Of the 94 discharged patients, 33 (35%) developed an FID within the first 6 months of follow-up: 19 evolved with mild (<1 mm/year), 8 with moderate (1 to 2 mm/year), and 6 with severe (>2 mm/year) aortic enlargement. Chronic FID was not associated with aorta-related events (hazard ratio: 0.98; 95% confidence interval: 0.22 to 4.34; p = 0.987).
The development of FID in the acute phase of type B IMH has a poor prognosis owing to the high risk of aortic rupture. In the chronic phase, most FIDs evolve with slow aortic dilation and without complications. Although acute FIDs should be treated early and invasively, lesions developing in the subacute-chronic phase can be managed with medical treatment and close imaging surveillance.
Prognostic factors in patients with uncomplicated acute type B aortic dissection
2014, Annals of Thoracic Surgery
Citation Excerpt :
In our study, any blood-filled pouch projecting into the thrombosed false lumen was defined as a ULP, which were detected by CT in 62.3% of patients with a completely thrombosed false lumen. The ULP is considered to represent the site of an entry tear [23]. Based on their experience with surgical treatment for type A intramural hematoma, Park and colleagues [24] reported that a large proportion of type A intramural hematomas had entry tears.
The benefit of thoracic endovascular aortic repair (TEVAR) for uncomplicated acute type B aortic dissection is unclear. Reliable prognostic factors are needed to identify candidates for prophylactic TEVAR. The aim of this study was to detect prognostic factors in patients with uncomplicated acute type B aortic dissection.
From January 2003 to April 2012, a total of 228 patients with uncomplicated acute type B aortic dissection were admitted to our institute. Cox proportional hazards analysis was performed to identify risk factors for death, dissection-related death, and aortic events.
Independent predictors of mortality were age (hazard ratio [HR], 1.08; p < 0.001) and false lumen thickness (mm) (HR, 1.10; p = 0.013), and the risk factor for dissection-related death was false lumen thickness (mm) (HR, 1.14; p < 0.001). Independent risk factors for aortic events were diameter of the descending aorta (mm) (HR, 1.14; p < 0.001) and entry in a proximal site (HR, 2.90; p = 0.02). The actuarial freedom from aortic events in patients with a descending aortic diameter of less than 40 mm and no entry in a proximal site at 1, 3, and 5 years was 96.6%, 90.8%, and 82.5%, respectively, whereas in patients with 1 of these 2 factors, it was 80.1%, 66.8%, and 53.5%, respectively.
In uncomplicated acute type B aortic dissection, the diameter of the descending aorta and entry in a proximal site were independent prognostic factors for aortic events. Prophylactic TEVAR should be considered for patients with these risk factors.
Predictive value of small ulcers in the evolution of acute type B intramural hematoma
2012, European Journal of Radiology
To assess the long-term evolution and predictive factors of type B intramural hematoma (IMH).
34 patients (33 men), mean age: 67 years (47–87) diagnosed with type B IMH by computed tomography (CT) and followed up clinically and by CT yearly. Mean follow-up was 5.9 years (2–13 years). Two evolution patterns were considered: (a) regression and (b) progression. Clinical and imaging variables were analyzed for assessing their predictor values.
Evolution at one year was to regression in 56% and to progression in 44% of cases. There were no association among age, sex, other aortic abnormalities, presence of atherosclerotic disease or blood pressure, initial maximum aortic diameter, indexed maximum aortic diameter, IMH thickness or length, presence or absence of mediastinal hematoma and the evolution of type B IMH. Ten patients had small aortic ulcers in the acute phase. The presence of ulcers was related with progression of IMH. No differences were observed in evolution between the control at first year and the last control.
The presence of small ulcers is a strong predictor of evolution in acute type B IMH. In addition, the regression group remains completely stable after the first year of evolution.

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Newly developed ulcer-like projection (ULP) in aortic intramural haematoma on follow-up CT: is it different from the ULP seen on the initial CT?

Aim

Materials and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Ann Thorac Surg

Am J Cardiol

Am Heart J

Clin Radiol

Radiol Clin North Am

Cardiol Clin North Am

Dissecting aneurysms of the aorta: roentgen manifestations including a comparison with other types of aneurysm

Radiology

Intramural hemorrhage of the thoracic aorta: diagnostic and therapeutic implications

Circulation

Thoracic aorta: comparison of gadolinium-enhanced three-dimensional MR angiography with conventional MR imaging

Radiology

Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis

Circulation

Fate of intramural hematoma of the aorta: CT evaluation

J Comput Assist Tomogr