主动脉壁内血肿-影像学检查可以预测夹层的发生吗

主动脉壁内血肿：

影像学检查可以预测夹层的发生吗？Aorticintramuralhematoma:Caninagingpredictthefalselumen?AnatomecaClassificationMechanismclassificationClassdescription1Separationofintima/media;duallumens(classic)2Intramuralhematomaseparationofintima/media;nointraluminaltearorflapimaged3Intimaltearwithouthematome(limiteddissection)andeccentricbulge4Atheroscleroticpenetratingulcer;ulcerusuallypenetratingtoadventitiawithlocalizedhematoma5Latrogenic/traumaticdissectionTABLE1.classificationofVariantsofAorticDissection内外膜分离，双腔壁间血肿穿透性溃疡，动脉粥样硬化医源性、外伤性3importanttypesFalselumenIntramuralhematomaAtheroscleroticpenetratingulcer3importanttypesFalselumenIntramuralhematomaAtheroscleroticpenetratingulcerTable1.DiagnosticfrequencyandclinicaloutcomesofpatientswithtypeAIMHevaluatedinwesternandeasterncountriesandintheInternationalRegistryofAcuteAorticdissection(IRAD)EesternbWesternaIRADCPvalueDiagnosticfrequencyrelativetoclassicAD,n(%)167/655(25.5)236/2168(10.9)64/1808(3.5)0.0001Earlymedicaltreatment,n(%)135/167(80.8)78/160(48.8)10/64(15.5)＜0.0001Overallhospitalmortality,n(%)11/167（6.6）36/160(20.6)17/64(26.6)＜0.0001Earlymedicalhospitalmortality,n(%)8/135(5.9)26/78(33.3)4/10(40)＜0.0001Earlysurgicalhospitalmortality,n(%)3/32(9.4)7/82(8.5)13/64(24.1)＜0.0001AD,aorticdissection:IMH,intramuralhematoma.Pooleddatafrom10dinicalreportsfromNorthAmericaandEurope[1]Pooleddatafromtwoinstitutions(AsanMedicalcenter.KoreaandKobeCitymedicalcenterGeneralHospital.Japan)[2,3]InternationalRegistryofAcuteDissectionregistrydataof30aorticreferralcentersin10countries[25][1]EvangelistaAetalCirculaion2005;111:1063-70.[2]PelzelJMetalJAmSocEchocardiogr2007;20:1260-8.[3]KitaiTatalCirculation2009;120(Suppl.1)；A292-8.[25]SongJK,LimJH,AhnJM,KimDH,KangJW,LeeTY,SongJM,ChooSJ,KangDH,ChungCH,LeeJW,LimTH.OutcomesofpatientswithacutetypeAaorticintramuralhematoma.Circulation2009;120:2046-52.SongJK.JournalofCardiology(2014)64153-161AorticIntramuralHematoma(AIMH)AorticDissectionWithoutIntimalRuptureHypothesisofpathogenesis:RuptureofvasavasarumFateofAorticIMHstable持续的胸痛难以控制的高血压主动脉介入治疗主动脉最大径线≥50mm主动脉壁变厚大于1cm主动脉进一步的扩大复发的积液穿透性溃疡或类溃疡的病灶器官缺血（脑部，心肌，肠道，肾脏）60yead-oldManWhichisRisky?ABBothNoneinitialAfter5days60yead-oldManinitialAfter5daysAfter11monthsDetectionofIntimalDefectby64-RowMultidetectorComputedTomographyinPatientsWithAcuteAorticIntramuralHematomaTkeshiKitai,ShuichiroKaji,AtsushiYamamuro,TomokoTani,MakotoKinoshita,NatsuhikoEhara,AtushiKobori,KitaeKim,ToruKitaandYutakaFurukawacirculation.2011;124:S174-S178FalsenegativeTruepositiveFalsenegativeTruepositiveThepotentialofintravascularultrasoundimagingindiagnosisofaorticintramuralhematomaULPnotedbyIVUSonlyABCDEFGULPnotedonlaterCTNo,ruptureofvasavasorumTinyulcerpreceded,notimagedNewulcerdevelopedafterIMHIntimalDefectinIMH?NewIntimalDefectatlateCT2005/3/182005/5/1105/3/18chestpain,AIMHtypeB05/5/11chestpainre-attackNewlydevelopmentofulcer-likeprojection→falselumenHypothesisofformationofUlcer-likeProjection

对溃疡状突起形成的假说(ReentryTear)D.M.Williamsetal,JVascIntervRadiol17,773(May,2006)aorticintramuralhematoma:reviewofhigh-riskimagingfeatures

主动脉壁间血肿高风险影像学特征的回顾分析ULP：＞10-20mmwide,＞5-10mmdeeplocationoverascending/archMaxdiameter:type-A,＞45-55mm,type-B,＞41mmIMHthickness:＞11-16mmStanfordtype-APleural/pericardialeffusion:notindependentfactor;hemorrhagic?Intramuralbloodpool:recentlydescribed,prognosisuncertainKruseMjetal.,JCCT2013；7:267AnInspiratoryCase60Y/OMale,AcuteChestPain+1week,ProgressionofIMHMultiple“ulcer-likeprojection”=?aorticintramuralhematoma:reviewofhigh-riskimagingfeatures

主动脉壁间血肿高风险影像学特征的回顾分析ULP：＞10-20mmwide,＞5-10mmdeeplocationoverascending/archMaxdiameter:type-A,＞45-55mm,type-B,＞41mmIMHthickness:＞11-16mmStanfordt