Learning Radiology xray montage

Penetrating Aortic Ulcer
Submitted by Anthony Chang, MD


  • Ulceration of an atherosclerotic plaque which penetrates into the internal elastic lamina
  • Hematoma then forms within the media of the aortic wall
  • Occurs in the elderly who usually have a history of severe atherosclerosis, hypertension, and hyperlipidemia
  • Similar presentation to those with a descending thoracic aortic dissection i.e. acute chest or back pain
  • Plaque ulceration usually in the middle to distal third of the descending aorta
  • Intramural hematoma accompanies the penetrating ulcer 80% of the time
  • Associated with abdominal aortic aneurysm
  • Disease progresses from intimal plaque ulceration to media hematoma formation to adventitial saccular pseudoaneurysm formation and finally rupture if there is transmural penetration
  • Speculated as the cause of descending or thrombosed type dissections with all three 

Radiographic findings

  • Focal contrast collection projecting beyond the aortic lumen on CT
    • Intramural hematoma is indistinguishable from intraluminal thrombus
  • Intimal flap is uncommon
  • Intramural wall thickening or thrombus is frequently found
  • On angiography, there is aortic wall thickening and the ulcerated plaque seen
  • On MRI
    • High signal intensity on both T1 and T2 with subacute hematoma
  • Can be demonstrated by computed tomography, magnetic resonance, angiography and trans-esophageal echocardiography
  • Differential diagnosis:
    • Aortic dissection (has an intimal flap)
    • Atheroma – has a low signal on both T1 and T2  


  • Surgical cases are those demonstrating hematoma expansion, impending rupture, inability to control blood pressure
  • Patients routinely have co-morbid conditions that make them poor surgical candidates and are treated with transluminal placement of endovascular stent grafts


Penetrating Aortic Ulcer

Penetrating Aortic Ulcer. Enhanced CT scan through the lower thoracic aorta demonstrates a focal outpouching of contrast posteriorly representing a penetrating aortic ulcer