71 year-old female presented with acute chest pain. MR angiography of the thoracic aorta was requested to exclude aortic dissection.

Figure 1: Gadolinium-enhanced 3D MR angiography of the thoracic aorta is remarkably normal. Except for a small contour abnormality in the descending aorta that may represent a small penetrating ulcer, no significant abnormalities are seen.

Figure 2: Black blood spin echo imaging of the thoracic aorta demonstrates a small left pleural effusion and a rim of high signal intensity in the wall of the descending and ascending aorta.

Figure 3: Fat-suppressed spin echo imaging (STIR) through the same level as Figure 2 confirms high signal intensity in the ascending aortic wall, consistent with hemorrhage.

Intramural hematoma with involvement of ascending aorta.

Intramural hematoma is part of the spectrum of aortic dissection in which an intimal tear is not apparent. The management of these patients is similar to dissections; involvement of the ascending aorta is considered a surgical emergency because of the risks of involvement of the coronary arteries and pericardial effusion and tamponade.