Multimodal imaging in the diagnosis of intramyocardial dissecting hematoma

To describe the diagnostic and therapeutic approach to a case of intramyocardial dissecting hematoma (IDH), a rare complication of acute myocardial infarction, highlighting the value of multimodal imaging in its identification and management.

We present the case of a 50-year-old man who presented to the emergency department with chest pain and dyspnea of 12 hours duration. The electrocardiogram revealed an anterior myocardial infarction, and coronary angiography showed occlusion of the left anterior descending artery, which was treated with angioplasty. During hospitalization, transthoracic echocardiography revealed a hypoechoic mass at the apex, raising the differential diagnosis of intramyocardial hematoma, pseudoaneurysm, or mural thrombus. A cardiac computed tomography scan was performed, which ruled out complete rupture or pseudoaneurysm but did not allow for a definitive distinction. Subsequently, cardiac magnetic resonance imaging confirmed the presence of a hematoma contained within the myocardium, without epicardial rupture, and with surrounding areas of transmural fibrosis. Given the patient’s clinical stability and absence of signs of progression, an initial conservative treatment approach was chosen, with close clinical and imaging follow-up.

IDH is a rare and potentially serious complication of acute myocardial infarction. Its diagnosis can be challenging and requires a multimodal approach. Cardiac magnetic resonance provides accurate tissue characterization that allows differentiation of intramyocardial dissecting hematoma from other similar entities and plays a key role in clinical decision-making. In stable patients, conservative management may be safe and effective.