Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept1
Hideyuki Hayashi, MD,
Yohjiro Matsuoka, MD,
Ichiro Sakamoto, MD,
Eijun Sueyoshi, MD,
Tomoaki Okimoto, MD,
Kuniaki Hayashi, MD and
Naofumi Matsunaga, MD
1 From the Department of Radiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan (H.H., Y.M., I.S., E.S., T.O., K.H.); and the Department of Radiology, Yamaguchi University School of Medicine, Yamaguchi, Japan (N.M.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received March 25, 1999; revision requested May 19 and received June 29; accepted June 29. Address correspondence to H.H.
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Figure 1. Course of atheromatous ulcer. Although these ulcers occur in patients with advanced atherosclerosis, they are usually asymptomatic and confined to the intimal layer (a). Penetrating atherosclerotic ulcer is defined as a deep atheromatous ulcer that penetrates through the elastic lamina and into the media (b). Penetrating atherosclerotic ulcer can lead to aortic dissection (c, d), aortic aneurysm (e), or rupture (f). Yellow arrows indicate course of penetrating atherosclerotic ulcer that is stabilized with appropriate treatment, white arrows indicate course of rupture of aortic dissection and aortic aneurysm, and the red arrow indicates course of spontaneous aortic rupture.
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Figure 2a. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 2b. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 2c. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 2d. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 2e. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 2f. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 2g. Case 7. Ruptured penetrating atherosclerotic ulcer in a 73-year-old man with terminal laryngeal cancer and sudden onset of chest pain. (a) Contrast material-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta with surrounding intramural hematoma (arrow). The patient was treated conservatively. (b, c) Follow-up CT scans obtained 14 (b) and 35 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and hematoma. (d) Multiplanar reconstructed image clearly demonstrates the extent of the penetrating atherosclerotic ulcer and intramural hematoma. Surgical treatment was not attempted, and the patient died 36 days after onset with severe hematemesis due to an aortoesophageal fistula. (e) Photograph of the autopsy specimen clearly depicts ulceration (arrow) and intramural hematoma extending to the esophageal wall. Scale is in centimeters. (f) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates atheromatous ulcer penetrating the media and intramural hematoma extending under the thickened intima. (g) High-power photomicrograph of the unruptured portion of the ulcer (original magnification, x175; hematoxylineosin stain) demonstrates an intracellular lipid in the thickened intima. Extracellular lipid deposition is seen in the underlying intima (arrow).
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Figure 3a. Case 12. Penetrating atherosclerotic ulcer in a 74-year-old man with sudden onset of chest pain. (a) Contrast-enhanced CT scan shows a small penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b, c) Follow-up CT scans obtained 7 (b) and 21 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and gradual reduction of the hematoma. (d) Thoracic aortogram clearly delineates the extent of the ulcer. The patient underwent surgery, the results of which confirmed penetrating atherosclerotic ulcer.
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Figure 3b. Case 12. Penetrating atherosclerotic ulcer in a 74-year-old man with sudden onset of chest pain. (a) Contrast-enhanced CT scan shows a small penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b, c) Follow-up CT scans obtained 7 (b) and 21 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and gradual reduction of the hematoma. (d) Thoracic aortogram clearly delineates the extent of the ulcer. The patient underwent surgery, the results of which confirmed penetrating atherosclerotic ulcer.
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Figure 3c. Case 12. Penetrating atherosclerotic ulcer in a 74-year-old man with sudden onset of chest pain. (a) Contrast-enhanced CT scan shows a small penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b, c) Follow-up CT scans obtained 7 (b) and 21 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and gradual reduction of the hematoma. (d) Thoracic aortogram clearly delineates the extent of the ulcer. The patient underwent surgery, the results of which confirmed penetrating atherosclerotic ulcer.
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Figure 3d. Case 12. Penetrating atherosclerotic ulcer in a 74-year-old man with sudden onset of chest pain. (a) Contrast-enhanced CT scan shows a small penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b, c) Follow-up CT scans obtained 7 (b) and 21 (c) days after onset show gradual enlargement of the penetrating atherosclerotic ulcer and gradual reduction of the hematoma. (d) Thoracic aortogram clearly delineates the extent of the ulcer. The patient underwent surgery, the results of which confirmed penetrating atherosclerotic ulcer.
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Figure 4a. Case 5. Penetrating atherosclerotic ulcer in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b) Follow-up CT scan obtained 48 days after onset shows enlargement of the penetrating atherosclerotic ulcer and reduction of the intramural hematoma. (c) Oblique sagittal cine MR image obtained 3 months after onset clearly demonstrates the extent of the penetrating atherosclerotic ulcer. The ulcer has a smooth edge and has not changed in size (cf b). Over 5 years later, the patient remains asymptomatic and the penetrating atherosclerotic ulcer remains unchanged in size.
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Figure 4b. Case 5. Penetrating atherosclerotic ulcer in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b) Follow-up CT scan obtained 48 days after onset shows enlargement of the penetrating atherosclerotic ulcer and reduction of the intramural hematoma. (c) Oblique sagittal cine MR image obtained 3 months after onset clearly demonstrates the extent of the penetrating atherosclerotic ulcer. The ulcer has a smooth edge and has not changed in size (cf b). Over 5 years later, the patient remains asymptomatic and the penetrating atherosclerotic ulcer remains unchanged in size.
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Figure 4c. Case 5. Penetrating atherosclerotic ulcer in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the descending thoracic aorta (arrow) with intramural hematoma. The patient was treated conservatively. (b) Follow-up CT scan obtained 48 days after onset shows enlargement of the penetrating atherosclerotic ulcer and reduction of the intramural hematoma. (c) Oblique sagittal cine MR image obtained 3 months after onset clearly demonstrates the extent of the penetrating atherosclerotic ulcer. The ulcer has a smooth edge and has not changed in size (cf b). Over 5 years later, the patient remains asymptomatic and the penetrating atherosclerotic ulcer remains unchanged in size.
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Figure 5a. Case 1. Penetrating atherosclerotic ulcer in the abdominal aorta in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the abdominal aorta (arrow). The patient was treated conservatively. (b, c) On follow-up contrast-enhanced CT scans obtained 2 weeks (b) and 2 years (c) after onset, the size of the penetrating atherosclerotic ulcer is virtually unchanged (cf a). The celiac trunk is seen originating from the false channel. (d) Maximum-intensity-projection image obtained 2 months after onset clearly demonstrates the penetrating atherosclerotic ulcer and severe calcification of the aorta.
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Figure 5b. Case 1. Penetrating atherosclerotic ulcer in the abdominal aorta in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the abdominal aorta (arrow). The patient was treated conservatively. (b, c) On follow-up contrast-enhanced CT scans obtained 2 weeks (b) and 2 years (c) after onset, the size of the penetrating atherosclerotic ulcer is virtually unchanged (cf a). The celiac trunk is seen originating from the false channel. (d) Maximum-intensity-projection image obtained 2 months after onset clearly demonstrates the penetrating atherosclerotic ulcer and severe calcification of the aorta.
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Figure 5c. Case 1. Penetrating atherosclerotic ulcer in the abdominal aorta in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the abdominal aorta (arrow). The patient was treated conservatively. (b, c) On follow-up contrast-enhanced CT scans obtained 2 weeks (b) and 2 years (c) after onset, the size of the penetrating atherosclerotic ulcer is virtually unchanged (cf a). The celiac trunk is seen originating from the false channel. (d) Maximum-intensity-projection image obtained 2 months after onset clearly demonstrates the penetrating atherosclerotic ulcer and severe calcification of the aorta.
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Figure 5d. Case 1. Penetrating atherosclerotic ulcer in the abdominal aorta in a 73-year-old man with back pain. (a) Contrast-enhanced CT scan shows a penetrating ulcer in the abdominal aorta (arrow). The patient was treated conservatively. (b, c) On follow-up contrast-enhanced CT scans obtained 2 weeks (b) and 2 years (c) after onset, the size of the penetrating atherosclerotic ulcer is virtually unchanged (cf a). The celiac trunk is seen originating from the false channel. (d) Maximum-intensity-projection image obtained 2 months after onset clearly demonstrates the penetrating atherosclerotic ulcer and severe calcification of the aorta.
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Figure 6a. Multiple penetrating atherosclerotic ulcers in a 73-year-old man with back pain. (a) Unenhanced CT scan shows high-attenuation intramural hematoma in the descending aorta. (b) Follow-up contrast-enhanced CT scan shows a penetrating aortic ulcer with intramural hematoma. (c) Follow-up contrast-enhanced CT scan obtained 2 weeks after onset demonstrates multiple penetrating atherosclerotic ulcers in the descending thoracic aorta (arrows). (d) Maximum-intensity-projection image clearly demonstrates multiple ulcers (arrows). (This case was not included in the Table because the follow-up period was not long enough to allow prediction of the prognosis.)
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Figure 6b. Multiple penetrating atherosclerotic ulcers in a 73-year-old man with back pain. (a) Unenhanced CT scan shows high-attenuation intramural hematoma in the descending aorta. (b) Follow-up contrast-enhanced CT scan shows a penetrating aortic ulcer with intramural hematoma. (c) Follow-up contrast-enhanced CT scan obtained 2 weeks after onset demonstrates multiple penetrating atherosclerotic ulcers in the descending thoracic aorta (arrows). (d) Maximum-intensity-projection image clearly demonstrates multiple ulcers (arrows). (This case was not included in the Table because the follow-up period was not long enough to allow prediction of the prognosis.)
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Figure 6c. Multiple penetrating atherosclerotic ulcers in a 73-year-old man with back pain. (a) Unenhanced CT scan shows high-attenuation intramural hematoma in the descending aorta. (b) Follow-up contrast-enhanced CT scan shows a penetrating aortic ulcer with intramural hematoma. (c) Follow-up contrast-enhanced CT scan obtained 2 weeks after onset demonstrates multiple penetrating atherosclerotic ulcers in the descending thoracic aorta (arrows). (d) Maximum-intensity-projection image clearly demonstrates multiple ulcers (arrows). (This case was not included in the Table because the follow-up period was not long enough to allow prediction of the prognosis.)
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Figure 6d. Multiple penetrating atherosclerotic ulcers in a 73-year-old man with back pain. (a) Unenhanced CT scan shows high-attenuation intramural hematoma in the descending aorta. (b) Follow-up contrast-enhanced CT scan shows a penetrating aortic ulcer with intramural hematoma. (c) Follow-up contrast-enhanced CT scan obtained 2 weeks after onset demonstrates multiple penetrating atherosclerotic ulcers in the descending thoracic aorta (arrows). (d) Maximum-intensity-projection image clearly demonstrates multiple ulcers (arrows). (This case was not included in the Table because the follow-up period was not long enough to allow prediction of the prognosis.)
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Figure 7a. Saccular aneurysm caused by penetrating atherosclerotic ulcer in an asymptomatic 65-year-old man. (a) CT scan shows a contrast material-filled ulcer and mural thrombus. (b) Shaded-surface-display image clearly demonstrates the aneurysm. (c) Photograph of the surgical specimen shows ulceration penetrating the intima and forming a saccular aneurysm. Scale is in millimeters. (d) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates the false aneurysm with complete disruption of the media (arrow). Hematoma can be seen under the atherosclerotic intima and the media. (This case was not included in the Table because the lesion was discovered incidentally, making follow-up from onset impossible.)
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Figure 7b. Saccular aneurysm caused by penetrating atherosclerotic ulcer in an asymptomatic 65-year-old man. (a) CT scan shows a contrast material-filled ulcer and mural thrombus. (b) Shaded-surface-display image clearly demonstrates the aneurysm. (c) Photograph of the surgical specimen shows ulceration penetrating the intima and forming a saccular aneurysm. Scale is in millimeters. (d) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates the false aneurysm with complete disruption of the media (arrow). Hematoma can be seen under the atherosclerotic intima and the media. (This case was not included in the Table because the lesion was discovered incidentally, making follow-up from onset impossible.)
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Figure 7c. Saccular aneurysm caused by penetrating atherosclerotic ulcer in an asymptomatic 65-year-old man. (a) CT scan shows a contrast material-filled ulcer and mural thrombus. (b) Shaded-surface-display image clearly demonstrates the aneurysm. (c) Photograph of the surgical specimen shows ulceration penetrating the intima and forming a saccular aneurysm. Scale is in millimeters. (d) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates the false aneurysm with complete disruption of the media (arrow). Hematoma can be seen under the atherosclerotic intima and the media. (This case was not included in the Table because the lesion was discovered incidentally, making follow-up from onset impossible.)
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Figure 7d. Saccular aneurysm caused by penetrating atherosclerotic ulcer in an asymptomatic 65-year-old man. (a) CT scan shows a contrast material-filled ulcer and mural thrombus. (b) Shaded-surface-display image clearly demonstrates the aneurysm. (c) Photograph of the surgical specimen shows ulceration penetrating the intima and forming a saccular aneurysm. Scale is in millimeters. (d) Low-power photomicrograph (original magnification, x35; elastica van Gieson stain) demonstrates the false aneurysm with complete disruption of the media (arrow). Hematoma can be seen under the atherosclerotic intima and the media. (This case was not included in the Table because the lesion was discovered incidentally, making follow-up from onset impossible.)
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Figure 8. Diagram illustrates the relationship between penetrating atherosclerotic ulcer and aortic dissection. Considerable overlap is seen.
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Copyright © 2000 by the Radiological Society of North America.
