Dr Shyam Prasad Shetty

Case Report : 

Case Report Dr. Shyam Prasad Shetty FRCS (CT) , FRCS(ENG), FRCS(EDIN) Cardiothoracic Surgeon Apollo BGS Hospital, Mysore Dr. Sunil Kumar MD, DM Cardiologist Apollo BGS Hospital, Mysore

Case History : 

Case History Mrs. X aged 70 years DOA: 26th Dec 2007, 5.00 am C/o : Sudden onset intermittent Retrosternal chest pain since 8 pm of 25th Dec , each episode lasting for 30- 40 mins ( 3 episodes) radiating to the back and left shoulder and associated with sweating. H/o vomiting 3-4 times No h/o Breathlessness / Palpitations

History…. : 

History…. Past History : Not a Known DM / HTN / IHD Operated 3 years back for # left femur

Examination : 

Examination Elderly female, Conscious, oriented, Afebrile No Pallor / Icterus / Cyanosis/ Clubbing / Edema / LN JVP : not raised PR – 84 / min Regular, all peripheral pulsations + BP – 110/ 70 mm of Hg RS – B/l air entry equal CVS – S1 S2 + P/A, CNS - NAD

Investigation reports : 

Investigation reports Trop T : < 0.010 ng / ml Hb - 10.9 gm % WBC : 16000 / cmm N - 88 %L - 10 %E - 02 %M - 00B - 00 RBS - 174 mg / dl Creatinine - 0.9 mg / dl Total Chol- 131 mg / dl Trigly - 80 mg / dl HDL - 44 mg / dl LDL - 71 mg / dl VLDL - 16 mg / dl

Day 1 : 

Day 1 10.30 AM Patient was asymptomatic Pulse- 100/ min, BP- 90/60 mmHg, RR - 20 /min CVS : NAD RS : Absent breath sounds in Lt basal region P/A and CNS : NAD Repeat ECG : No fresh changes Adv : CXR

Slide 7: 

Chest X ray 26th Dec 07- 11 AM

ECG : 

ECG Shallow T inversion in leads III, aVF, V3 - V6

Slide 9: 

Antiplatelet agents and Heparin were withheld IV NTG was stopped CT thorax was asked Pleurocentesis was done Fluid was Hemorrhagic Sugar - 78 mg/dl WBC - 2400 /cmm Protein - 4.3 g/dl RBC - 28000/cmm N – 80 L – 19 Mesothelial – 1, no malignant cells

CT Thorax Report : 

CT Thorax Report B/L Moderate Pleural effusion Lt > Rt Passive atelectasis in both lower lobes Circumferential wall thickening of descending aorta with layering on left lateral wall Impression : ? Dissection with Thrombus MRI was done subsequently

MRI Thorax Report : 

MRI Thorax Report Evidence of crescentric thickening of proximal descending aorta in the anterior and lateral aspect. Thickening is isointense on T1W and hyperintense on T2W sequences Impression : - Intramural haematoma of Proximal descending aorta - B/ L pleural collection ? Haemothorax

TEE : 

TEE

64 slice CT -Normal coronaries : 

64 slice CT -Normal coronaries Subsequently she underwent 64 slice CT Coronary angiogram, which showed Normal Coronaries

Slide 21: 

Diagnosis : Acute Coronary Syndrome – USA /NSTEMI Was Started on Antiplatelet agents – Aspirin / Clopidogrel, IV NTG, and LMWH- Enox in ER 2D Echo- No RWMA/ LVEF – 58% Trop-T, Hb, TC, DC, Creatinine, FBS, Lipid Profile, Chest X ray were asked

Slide 22: 

She improved symptomatically Patient was conservatively managed In v/o advanced age/ IMH confined to proximal descending thoracic aorta and no haemodynamic comprise Repeat chest X ray ( after 4 days) showed resolved effusion Was discharged in stable condition on B blocker Diagnosis : INTRAMURAL HAEMATOMA OF PROXIMAL DES THORACIC AORTA

INTRAMURAL HAEMATOMA : 

INTRAMURAL HAEMATOMA

Aortic IMH : 

Aortic IMH Is a potentially lethal entity , there is haemorrhage into the aortic media in the absence of an intimal tear, Although intimal tear is not present prognosis is similar to that of classic aortic dissection therefore early diagnosis is critical .

Etiology of IMH : 

Etiology of IMH 1 Hypertension 2 Iatrogenic ( coronary angioplasty) 3 Road Traffic accidents

Pathogenesis : 

Pathogenesis 1 Ruptured Vasovasorum 2 Underlying medial degeneration predisposes to rupture of vasovasorum 3 IMH can rupture through the intima to evolve as an aortic dissection

INVESTIGATING Aortic IMH : 

INVESTIGATING Aortic IMH MRI SPIRAL CT TEE

Literature Review : 

Literature Review Aortic Intramural haematoma ( AIH ) is a part of Acute aortic syndrome together with Aortic dissection and Penetrating Aortic Ulcer AIH represents 12 % AAS Indistinguishable from Aortic Dissection in Clinical presentation but pathologically distinct Although haemorrhage into aortic media occurs in both disorders, an intimal tear with resultant false lumen is not present in IMH.

Slide 29: 

IMH is a life threatening because it may Rupture , Extend causing Cardiac Tamponade, Haemothorax, Mesenteric Ischaemia, Stroke, Renal Insufficiency etc. IMH has a variable clinical course May progress to classical dissection – 33 % Mortality – up to 30 % ( High in proximal aortic IMH )

Treatment of IMH : 

Treatment of IMH Aggressive control of BP with ICU monitoring Involvement of descending thoracic aorta alone can be managed without surgery in the absence of coexisting aneurysmal dilatation or disease progression Early surgery in pts who have ascending aortic involvement or those who have existing aneurysm and IMH

ACUTE AORTIC SYNDROME : 

ACUTE AORTIC SYNDROME 1 Aortic Dissection 2 Penetrating atherosclerotic ulcers 3 Intra mural haematoma

NORMAL : 

NORMAL

IMH : 

IMH

PENETRATING ATHEROMATOUS ULCER : 

PENETRATING ATHEROMATOUS ULCER

DISSECTION : 

DISSECTION

IMH, ULCER : 

IMH, ULCER

IMH, DISSECTION : 

IMH, DISSECTION

STENTING : 

STENTING

STENTING : 

STENTING

SURGICAL TREATMENT : 

SURGICAL TREATMENT

REPLACEMENT : 

REPLACEMENT

Take Home message : 

Take Home message Characteristic images of IMH To keep Acute aortic syndrome as DD in our mind

Thank You : 

Thank You