PMC8305674_01
Initial Presentation. Intramural hemorrhage (IMH) delineated by computed tomography (CT) coronary angiogram (CTCA) and corresponding invasive coronary angiogram with intravascular ultrasound (IVUS) and coronary artery lesion characterization. Curved multiplanar reformat views of left main (LM) and left anterior descending (A), LM and left circumflex artery (B), and right coronary artery (C) show significant high-risk anatomy lesion as single-vessel LM disease (arrow). Invasive coronary angiogram (D and E) proves the CTCA findings and delineates the significant corresponding LM lesion (arrow). IVUS shows the complex lesion around LM with color-coding extravascular component (F) and monochrome delineation (G) with intact intimal border. Multiplanar reformat CTCA images showing low-attenuation core and the lesion within the vessel wall (arrows) (H). CTCA 10 mm from the LM ostium shows the corresponding LM vessel lumen with complex, heterogenous component within the lesion (I). The low-attenuation area (arrow) was covered and sealed by the intimal compartment. Color-coded tissue characterization (J) revealed a low-attenuation component suggestive of IMH coded using red color; vessel wall including endothelium is coded using light and dark green color. Heterogenous compartments are depicted on a tissue characterization graph showing the dominance of red color-coded, hemorrhagic component (K) detecting an attenuation threshold of -100 to 30 HU representing 22% of the entire lesion volume with an absolute volume of 28 mm3.
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CT image reconstruction was used with 0.6-mm slice thickness and 0.3-mm increment for further lesion characterization (QAngioCT, Medis, Leiden, Netherlands). CTCA confirmed a 0 calcium score and an inhomogeneous, obstructive lesion in the left main coronary artery (LM) (Figures 1A to 1C). Due to the nature of high-risk anatomic lesion, the patient was urgently transferred for invasive coronary angiography (Figures 1D and 1E) with the aim of intravascular ultrasound (IVUS)-guided coronary intervention. The IVUS confirmed the presence of significant lesion and supported the presence of suspected IMH with intact vessel intima and no sign of plaque rupture (Figures 1F and 1G). CTCA image set (Figures 1H and 1I) was used for further color-coded lesion characterization to delineate the different compartments in the vessel wall (Figures 1J and 1K).
Follow-Up Presentation. Resolution of IMH delineated using CTCA and corresponding coronary artery lesion characterization. Repeated CTCA in 3 months (A and B) shows significant resolution of LM lesion and disappearance of low-attenuation, hemorrhagic component. Only mild residual intimal thickening confirmed in the exact same area (10 mm distal to LM ostium) (C and D) depicted by the corresponding tissue characterization graph (E) showing a prominent reduction in the volume of hematoma to 0.25 mm3 (which represents 1% relative to the entire lesion volume). Abbreviations as in Figure 1.
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The follow up CTCA (Figures 2A and 2B) confirmed close to complete resolution of IMH with minimal residual intimal thickening in the previously affected LM vessel (Figures 2C to 2E).