Intramural hematoma (IMH) is one of the acute aortic syndromes (AAS) along with acute aortic dissection (AAD) and penetrating aortic ulcer (PAU). The three conditions can occur alone or in combination with overlapping presentation. Medical, open surgical and endovascular treatment is tailored depending on clinical presentation, timing and location within the aorta. Among patients who present with acute IMH affecting the ascending aorta (Type A), urgent open surgical repair is considered the primary line of treatment in patients who are suitable candidates and unstable. The management of IMH in the descending aorta and aortic arch (Type B) is similar to that applied to treat acute dissections in the same segment. Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia or rapid aortic enlargement. This review discusses the ideal timing for treatment of IMH.
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