A 70-year-old hypertensive man undergoes CT angiography for back pain. The aorta shows concentric wall thickening with intimal calcification that remains attached to the outer aortic wall, and a crescent of high-density material within the aortic wall on non-contrast CT without an intimal flap. This is most consistent with:

• A Intramural hematoma of the aorta ✓
• B Aortic dissection
• C Aortic aneurysm with mural thrombus
• D Penetrating aortic ulcer

Explanation

Intramural hematoma (IMH) is a variant of acute aortic syndrome resulting from rupture of vasa vasorum within the aortic media, producing a crescent or circular high-attenuation thickening of the aortic wall on non-contrast CT without an intimal flap or false lumen. The displaced intimal calcifications (calcium sign) remain attached and are bowed inward by the hematoma. Unlike classic aortic dissection, there is no visible intimal flap or dual-lumen enhancement. IMH carries significant risk of progression to dissection or rupture.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.