PMC9744601_01
Chest radiograph in posteroanterior (a) and lateral (b) view: nothing abnormal detected.
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fig1
A 77-year-old woman with a past medical history of uncontrolled hypertension, presented to the emergency room with 24 hours of unrelenting sudden-onset chest and back pain (Figure 1).
Unenhanced axial CT images of proximal thoracic aorta, showing a very thin aortic intramural hematoma below intimal calcifications (yellow arrowheads in (a-c)).
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fig2
Unenhanced CT phase showed a thin, but extensive IMH propagating along the proximal thoracic aorta (Figure 2).
Unenhanced CT images showing the obliterated anterior descending aortic and paraesophageal fat due to hyperattenuating fluid collection (red arrowhead in (a)). The fluid flowed anteriorly through the extrapericardial inlet, under the left branch of the pulmonary artery, and above the left pericardial pulmonic recess of transverse sinus (green arrowhead in (a)). The fluid reached the anterior surface of the pericardial sac, between the prevascular and visceral mediastinal compartments (yellow arrowheads in (a-c) and (g-i)), and then flowed out caudally, covering the anterior wall of the right ventricle (yellow arrowheads in (f)), as a sort of "bib" on the heart (j). No associated pericardial effusion (red arrowheads in (d)). High-attenuation extrapericardial fluid (average 31 HU) consistent with hemomediastinum (e).
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fig3
The fluid collection reached the anterior surface of the pericardial sac, between the prevascular and visceral mediastinal compartments, and then flowed out caudally, covering the anterior wall of the right ventricle as a sort of "bib" on the heart (Figure 3 and Figure 4).
3D volume-rendering of the heart evaluated through various angles, demonstrating how the bib-like mediastinal hematoma is arranged and the path that it travels from the rupture site of the proximal descending thoracic aorta, up to the anterior surface of the heart (a-c). Corresponding CT images (d, e).
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fig4
The fluid collection reached the anterior surface of the pericardial sac, between the prevascular and visceral mediastinal compartments, and then flowed out caudally, covering the anterior wall of the right ventricle as a sort of "bib" on the heart (Figure 3 and Figure 4).
CTA showed a focal contrast-filled outpouching (PAU) of the proximal descending thoracic aorta (green arrowhead in (e, f, and h)), associated with a ULP originating from the entrance port of the PAU (yellow arrowheads in (b-d) and red arrowhead in g, h)). Obliterated paraesophageal fat (* in (a-d)) and aortic intramural hematoma are clearly visible (yellow arrowheads in (a)). Aortic 3D volume-rendering (i) and focal detail show a bifurcated aspect of PAU (green arrowhead) and ULP (red arrowhead) union.
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fig5
CTA showed a focal contrast-filled outpouching of the proximal descending thoracic aorta, representing the PAU, associated with a ULP originating from the entrance port of the PAU, inside the IMH (Figure 5).
After 1 month, CTA reported a complete reabsorption of the IMH and a complete exclusion of the PAU and ULP (a-c).
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fig6
After 1 month, CTA evaluation reported a complete reabsorption of the IMH and a complete exclusion of the PAU and ULP (Figure 6).