Multislice Computed Tomography of Aortic Intramural Hematoma With Progressive Intercostal Artery Tears
The Chinese Ring-Sword Sign
A 67-year-old man was admitted to the emergency department because of acute chest pain that radiated to his back. We suspected acute aortic syndrome, and 16-slice computed tomography (CT) was performed. Noncontrast CT showed a high-density, crescent-shaped intramural hematoma (Figure 1A) from the distal aortic arch to the infrarenal aorta. Postcontrast enhancement showed a contrast pooling in the intramural hematoma (Figure 1B). Although he received intensive medical care immediately, the man’s severe back pain recurred on the third day of his hospital stay. Repeat CT showed an increase in the size and number of the contrast poolings (Figure 2), which were clearly connected to the intercostal artery and caused no overt intimal disruption to the true lumen. Since the man’s initial treatment, a large amount of left-side pleural effusion had developed. Multiplanar reconstruction further demonstrated a string of contrast poolings precisely intersecting with the intercostal arteries (Figure 3A). This finding suggests that the contrast poolings may have resulted from progressive intercostal artery tears in the aortic wall. Given the progressive hemodynamic instability, the patient received emergent aortic replacement.
We proposed the term “Chinese ring-sword sign” (Figure 3B) for an aortic intramural hematoma with a string of contrast poolings, which suggested progressive intercostal artery tears and served as an emergent surgical indication for aortic intramural hematoma.
This work was supported in part by the National Science Council, Taiwan, ROC, under grant NSC-93-2314-B-75B-007.