Conservative management of Type B aortic intramural hematoma guided by imaging surveillance

Aortic intramural hematoma is a life-threatening condition within the spectrum of acute aortic syndromes and is often misdiagnosed. We present the case of a 76-year-old man who attended the Emergency Department with mild, atypical chest pain. Initial assessment and laboratory tests were reassuring, and a musculoskeletal cause was considered; however, high blood pressure and diagnostic uncertainty prompted computed tomography angiography. Imaging revealed type B aortic intramural hematoma. The patient was managed conservatively with strict control of blood pressure and heart rate and close imaging surveillance. Short-interval repeat computed tomography angiography demonstrated stability, supporting continued medical therapy. Over 3 years, the outcome was favorable with progressive resolution of the hematoma. This case highlights the importance of considering acute aortic pathology in older hypertensive patients with atypical pain, and it illustrates how imaging surveillance can guide safe conservative management.