Acute Coronary Syndrome due to Intramural Hematoma
A 43-year-old female who had 3 healthy children (12, 10, and 6 years old) was admitted to the emergency room with chest oppression. An ECG revealed elevated ST-segments in leads V2 to V6. Emergency coronary angiography was performed, and a severe stenosis was observed in the left anterior descending artery. Intravascular ultrasound was performed after the angiography. Interestingly, intravascular ultrasound findings demonstrated that the angiographic stenosis was attributable to an intramural hematoma of the proximal left anterior descending artery, extending to left main coronary artery (Figure 1). Furthermore, the vessel wall around the hematoma segments seemed to be less atherosclerotic and nearly healthy in structure. Because both ischemic symptoms and signs completely disappeared during catheterization, we decided not to perform any additional interventional treatments for this patient.
Thirty-five days after admission, coronary angiogram and intravascular ultrasound were reperformed to assess serial changes of this coronary lesion. Surprisingly, the intramural hematoma had completely healed, and it presented normally on both angiogram and intravascular ultrasound (Figure 2). The huge coronary hematoma seen on admission (Figure 1) had healed entirely and naturally within 5 weeks.
A spontaneous intramural hematoma/dissection is one of the possible causes of acute coronary syndrome. Several factors such as the pre- and postpartum periods, trauma, hypertension, vasculitis, and the use of contraceptives or illicit medications may potentially relate to this phenomenon, yet this patient did not possess any of them. Importantly, a hematoma’s healing process is absorption of the hemorrhage, which is quite different from those of plaque rupture or erosion.