Intramural Hematoma With Complex Atherosclerosis of the Descending Aorta
A 75-year-old man with a history of hypertension presented with acute abdominal pain radiating to the back. Initial physical examination revealed symmetric high blood pressure (170/100 mm Hg) without pulse deficit. The thoracic aorta was enlarged on chest x-ray. Computed tomography (Figure, A) showed a dilatation of the thoracic aorta, with complex atherosclerosis of the descending segment; central displacement of intimal calcifications (arrows) raised the suspicion of aortic intramural hematoma of the descending aorta. Transesophageal echocardiography confirmed complex aortic plaques of the descending aorta with mobile elements and a crescent-like echo-free space under the atherosclerotic plaques (Figure, B, arrows). Blood pressure and symptoms were stabilized with aggressive antihypertensive medications. Magnetic resonance imaging confirmed severe atherosclerosis of the descending aorta, with a deeper crescent-like thickening of the aortic wall (Figure, C, arrows) containing high-signal areas (true fast imaging with steady state precision sequence with T2 weighting) due to methemoglobin formation, demonstrating intramural hemorrhage.