Correlation between C-reactive Protein and Morphology of Aortic Intramural Hematoma on CT Angiography

Objectives To investigate the morphologic characteristics of intramural hematoma(IMH)on CT angiography(CTA),and evaluate the possible correlation of serum C-reactive protein(CRP)with morphologic characteristics of IMH.Material and Methods Forty-two patients who were initially diagnosed as IMH by aortic CTA and also had serum CRP examination on the same day of CTA were enrolled in this retrospective study,including 30 males and 12 females,with the mean age of 61±14 years old.The volumetric CT data were retrospectively processed and analyzed on post-processing workstation.Based on the thickness of IMH and the length-area curve,the crosssectional area of true lumen and total vessel were measured,the hematoma-vessel ratio(HVR)was calculated.Imaging characteristics were compared between patients who had pathological elevated CRP(>0.8 mg/dl)and those did not.Spearman correlation analyses of CRP level and morphological characteristics of IMH were performed,and the receiver operating characteristic(ROC)curve was used to evaluate the diagnostic validity of CRP.Results Of all 42 IMH patients,the mean serum CRP was 3.94±4.71 mg/dl,and the mean HVR was 46.7%±14.2%.HVR in patients with elevated CRP was significantly higher than those with normal CRP(49.7%±15.0%vs.40.7%±10.5%,P=0.030).HVR was mildly correlated with CRP in all patients(r=0.48,P<0.001).CRP levels differed neither between patients with Stanford type A and B(P=0.207),nor between patients with and without intimal disruption(P=0.230).To discriminate HVR>47%(the mean value),the area under curve(AUC)were 0.700(95%CI:0.535-0.865)for CRP at a cutoff point of 3.55 mg/dl,with a sensitivity of 54.5%and a specificity of 90.0%.Conclusion CRP was mildly correlated with the severity of cross-sectional hematoma area of IMH,but not with Stanford types and the presence of intimal disruption.

Recurrent massive bleeding due to dissecting intramural hematoma of the esophagus: Treatment with therapeutic angiography

Spontaneous or traumatic intramural bleeding of the esophagus, which is often associated with overlying mucosal dissection, constitutes a rare spectrum of esophageal injury called dissecting intramural hematoma of the esophagus (DIHE). Chest pain, swallowing diffi culty, and minor hematemesis are common, which resolve spontaneously in most cases. This case report describes a patient with spontaneous DIHE with recurrent massive bleeding which required critical management and highlights a potential role for therapeutic angiography as an alternative to surgery.

Achalasia combined with esophageal intramural hematoma:Case report and literature review

A 62-year-old male patient was admitted to our hospital due to severe chest pain,odynophagia,and hematemesis.Chest computed tomography showed an esophageal submucosal tumor.Esophagogastroduodenoscopy(EGD) revealed a longitudinal purplish bulging tumor of the esophagus.Endoscopic ultrasound(EUS) showed a mixed echoic tumor with partial liquefaction from the submucosal layer.The patient was diagnosed with esophageal intramural hematoma as well as achalasia by upper gastrointestinal endoscopy,esophagography and esophageal manometry.The patient was managed conservatively with intravenous nutrition,and oral feeding was discontinued.Follow-up EGD and EUS showed complete recovery of the esophageal wall,and finally,the patient underwent endoscopic dilatation for achalasia.The patient was symptom free at the time when we wrote this manuscript.

Gastric intramural hematoma accompanied by severe epigastric pain and hematemesis after endoscopic mucosal resection

Gastric intramural hematoma is a rare injury of the stomach,and is most often seen in patients with underlying disease.Such injury following endoscopic therapy is even rarer,and there are no universally accepted guidelines for its treatment.In this case report,we describe a gastric intramural hematoma which occurred within 6 h of endoscopic mucosal resection(EMR).Past medical history of this patient was negative,and laboratory examinations revealed normal coagulation profiles and platelet count.Following EMR,the patient experienced severe epigastric pain and vomited 150 mL of gastric contents which were bright red in color.Subsequent emergency endoscopy showed a 4 cm × 5 cm diverticulum-like defect in the anterior gastric antrum wall and a 4 cm × 8 cm intramural hematoma adjacent to the endoscopic submucosal dissection lesion.Following unsatisfactory temporary conservative management,the patient was treated surgically and made a complete recovery.Retrospectively,one possible reason for the patient's condition is that the arterioles in the submucosa or muscularis may have been damaged during deep and massive submucosal injection.Thus,endoscopists should be aware of this potential complication and improve the level of surgery,especially the skills required for submucosal injection.

Focal intramural hematoma as a potential pitfall for iatrogenic aortic dissection during subclavian artery stenting: A case report

BACKGROUND Iatrogenic aortic dissection(IAD)is a rare but fatal complication of interventional treatment for the proximal supra-aortic large vessels.Several cases of IAD after endovascular treatment of subclavian artery have been reported.Nevertheless,the pathogenesis of IAD is still unclear.Here we report a patient with IAD following a balloon expandable stent implanted into the left subclavian artery(LSA).CASE SUMMARY An 84-year-old man with a history of hypertension was admitted to the Neurology Department of our hospital complaining of dizziness and gait disturbance for more than 1 mo.Computed tomography angiography of the head and neck showed severe stenosis at the proximal LSA and the origin of the left vertebral artery.Magnetic resonance diffusion-weighted imaging of the brain revealed subacute infarctions in cerebellum,occipital lobe and medulla oblongata.He suffered a Stanford type B aortic dissection after the proximal LSA angioplasty with a balloon expandable stent.Thoracic endovascular aortic repair was performed immediately with the chimney technique and he was discharged 20 d later.After exploring the pathogenesis with multimodal imaging analysis,an easily neglected focal intramural hematoma(IMH)in the aorta near the junction of the LSA was found to be the main cause of the IAD.The risk of IAD should be sufficiently evaluated according to the characteristics of aortic arch lesions before the proximal LSA angioplasty.CONCLUSION Focal aortic IMH is a potential risk factor for IAD during a seemingly simple stenting of the proximal LSA.

Clinical medical decision-making of acute aortic intramural hematoma: A non-randomized retrospective case study

Objective:This study explored the timing of interventional treatment for acute intramural aortic hematoma(IMH)and the corresponding high-risk factors for its development into local aortic dissection(AD).Method:This retrospective case study method examined clinical follow-up data of 42 patients with acute IMH between April 2013 and October 2016 from the First Affiliated Hospital of Xi?an Jiaotong University.SPSS 17.0 and PPMS1.5 were used to analyze follow-up data spanning 3–12 months(mean,7.5?3.7 months).Results:Patients were divided into the conversion group and the hematoma group according to whether they developed AD.Among them,16 patients(38.1%)developed AD and were treated with thoracic endovascular aortic repair(TEVAR).The remaining patients(61.89%)were treated conservatively.After 1 week,the mean aortic diameter of the conversion versus hematoma group was significantly widened.Hemodynamically unstable patients and those with hematoma to the abdominal aorta extension were more likely to develop AD.Patient outcomes after TEVAR were similar between groups.Conclusion:Our findings suggest that aortic isthmus diameter!3.0 cm,hematoma extending to the abdominal aorta,and hemodynamic instability are associated with AD development in acute IMH patents.TEVAR should be considered if hematoma thickening,calcification ingression,ulcer progression,or contrast enhancement within the intramural hematoma is noted beyond 2 weeks after IMH onset.

A comprehensive review and outlook on risk factors of type A aortic intramural hematoma

Background:Type A aortic intramural hematoma(IMH)is characterized by aortic lesions involving the ascending aorta and aortic arch,with no detectable intimal tear on imaging,no true or false lumen,and no direct communication between the hematoma and the vascular lumen.The typical pathological changes present as annular or crescent-shaped thickening of the ascending aortic wall.Due to the substantially higher risk associated with Type A IMH compared to Type B IMH,treatment approaches vary across countries and medical centers,with the primary treatment strategies being closely related to surgical interventions.Previous risk factors for Type A IMH mainly focused on aortic diameter and hematoma thickness;however,our research group is the first to consider hematoma volume as a risk factor.This article provides a comprehensive review of Type A IMH and an outlook on its risk factors.

Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China

Background::Acute type A aortic dissection(ATAAD)and acute type A intramural hematoma(ATAIMH)are life-threatening diseases with high mortality.To better understand their clinical features in the Chinese population,we analyzed the data from the first Registry of Aortic Dissection in China(Sino-RAD)to promote the understanding and management of the diseases.Methods::All patients with ATAAD and ATAIMH enrolled in Sino-RAD from January 1,2012 to December 31,2016 were involved.The data of patients’selection,history,symptoms,management,outcomes,and postoperation complications were analyzed in the study.The continuous variables were compared using the Student’s t test for normal distributions and the Mann-Whitney U test for non-normal distributions.Categorical variables were compared using the Chi-square test or Fisher exact test.Results::A total of 1582 patients with ATAAD and 130 patients with ATAIMH were included.The mean age of all patients was 48.4 years.Patients with ATAAD were significantly younger than patients with ATAIMH(48.9 years vs.55.6 years,P<0.001).For the total cohort,males were dominant,but the male ratio of patients with ATAAD was significantly higher compared to those with ATAIMH(P=0.01).The time range from the onset of symptom to hospitalization was 2.0 days.More patients of ATAIMH had hypertension than that of ATAAD(82.3%vs.67.6%,P<0.05).Chest and back pain were the most common clinical symptoms.Computerized tomography(CT)was the most common initial diagnostic imaging modality.84.7%received surgical treatment and in-hospital mortality was 5.3%.Patients with ATAAD mainly received surgical treatment(89.6%),while most patients with ATAIMH received medical treatment(39.2%)or endovascular repair(35.4%).Conclusions::Our study suggests that doctors should comprehensively use clinical examination and genetic background screening for patients with ATAAD and ATAIMH and further shorten the time range from symptoms onset to intervention,achieving early diagnosis and treatment,thereby reducing the mortality rate of patients with aortic dissection in China.We should standardize the procedures of aortic dissection treatment and improve people’s understanding.Meanwhile,the curing and transferring efficiency should also be improved.

Spontaneous gastric hematoma as a rare cause of acute abdomen:A case report

BACKGROUND Spontaneous gastric hematoma is an exceedingly rare condition characterized by the accumulation of blood within the gastric wall without any apparent iatrogenic or traumatic cause.Coagulopathies are the most frequent cause of gastric he-matomas.However,other causes include amyloidosis,pancreatitis,visceral vas-cular aneurysms,endoscopy complications and others.The pathophysiology of spontaneous gastric hematoma is not completely understood.However,it is postulated that it is caused by disruption of submucosal vessels that leads to dissection of the muscularis layer and formation of false lumen.The rarity of this condition increases the challenge of diagnosis,and there is no standard treatment protocol.CASE SUMMARY We present the case of a spontaneous gastric hematoma in a 22-year-old male.He presented to our emergency department complaining of pain in the left flank area lasting for 2 wk.There was no history of trauma,antico-agulant medications or endoscopy procedures.His hemoglobin and hematocrit levels were slightly lower than normal.Multi-slice computed tomography,ultrasound and endoscopy confirmed a gastric intramural hematoma.We recommended conservative treatment because there was no hemodynamic instability nor significant bleeding.The patient responded well,and there were no unexpected events.At the 3-mo follow-up,the ultrasound exa-mination revealed complete regression of the hematoma.CONCLUSION After reviewing the literature and our experience,we recommend that more of these cases should be treated conservatively.The tendency to treat these cases with potentially burdensome procedures such as total or subtotal gastrectomy should be significantly reduced.

Intramural Hematoma versus Thrombus： Radiation-induced Heart Disease Results in Mass Formation after Radiofrequency Ablation

Radiofrequency catheter ablation （RFCA）,albeit an effective therapy for drug-refractory atrial fibrillation （AF）,can be associated with complications in 3.9-22.0% of cases, of which cerebrovascular embolization,cardiac tamponade,and pulmonary vein stenosis are more common,and atrial hematoma is more rare.Here,we presented a case describing an elderly woman diagnosed with an intramural left atrial hematoma after AF ablation.

Endovascular treatment of traumatic renal artery pseudoaneurysm with a Stanford type A intramural haematoma:A case report

BACKGROUND Aortic intramural hematoma(IMH) associated with aortic branch tear and intramurally located pseudoaneurysm after blunt trauma has not been reported.Here,we report a case of progressive type A aortic IMH associated with a pseudoaneurysm arising from the injured proximal renal artery after blunt trauma.CASE SUMMARY During logging operations,a 66-year-old man experienced blunt force trauma after being injured by a fallen tree.He arrived at our trauma center with a left flank pain complaint.Computed tomography(CT) revealed a pseudoaneurysm arising from the proximal renal artery(localized within the aortic media) and Stanford type A IMH.A covered stent was deployed along the left main renal artery,bridging the pseudoaneurysm and covering the parent artery,successfully excluding the pseudoaneurysm as confirmed using aortography.However,although the degree of the pseudoaneurysm decreased,follow-up CT revealed remnant pseudoaneurysm,likely caused by an endoleak.Subsequently,a covered stent was additionally installed through the previously deployed covered stent.Successful exclusion of the pseudoaneurysm was confirmed using final aortography.In the 7-mo follow-up CT scan,the IMH and pseudoaneurysm completely disappeared with no evidence of stent-related complications.CONCLUSION Endovascular treatment such as stent-graft placement can be an effective and safe treatment for traumatic renal artery injury.