We report the case of a 74 year old female who presented with imaging concerning for an intramural hematoma of the ascending aorta. Despite multiple imaging modalities consistent with intramural hematoma, operative findings confirmed a peri-aortic lymphoma or what was once lymphoma.
Intramural hematomas (IMH) are a potentially ominous finding due to the concern for progression to frank aortic dissection. Thought to be a variant of aortic dissection without the typical entry/exit site or false lumen flow, IMHs are unpredictable in their behavior and thus challenging to manage. Particularly with ascending IMHs, the high morbidity and mortality associated with a delay in surgical intervention makes timely diagnosis a priority. Most patients present with a sudden onset of chest pain or a mechanism sufficient to cause the suspected injury, such as trauma. Ultrasound and computed tomography (CT) imaging in patients with IMH demonstrate a peri-aortic asymmetric density, either within a focal segment of the aortic wall or completely surrounding the aortic lumen. Intravenous contrast may be used to differentiate intraluminal thrombus and peri-aortic thoracic soft tissue tumors or lymphomas, which will often contrast-enhance. The differential diagnosis in patients with suspected IMH includes: aortic dissection, thrombus, intra-thoracic soft tissue tumors, and lymphoma. Echocardiography, CT, and magnetic resonance imaging (MRI) are useful in better characterizing a suspicious lesion, its location, and guiding management (surgical versus medical). However, despite the advances in imaging technology, limitations remain in diagnosing a suspected aortic IMH or dissection. Complex medical and surgical histories and non-specific symptoms can present further challenges.
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