Skip to main content

Granulomatous inflammation mimicking a hematoma around the replaced ascending aorta in magnetic resonance imaging: a case report



Granulomatous inflammation results from various causes including infections and allergic reactions. It can appear as high signal intensity in T2-weighted or contrast-enhanced T1-weighted magnetic resonance imaging (MRI). Here, we describe a case of granulomatous inflammation looking like a hematoma on an ascending aortic graft in MRI.

Case presentation

A 75-year-old female was undergoing assessment for chest pain. She had a history of hemi-arch replacement for aortic dissection 10 years earlier. The initial chest computed tomography and subsequent chest MRI were suggestive of a hematoma, implying a pseudoaneurysm of the thoracic aorta, which is associated with high mortality in reoperation. Through redo median sternotomy, severe adhesion was found in the retrosternal space. A sac in the pericardial space contained yellowish and pus-like material, confirming that there was no hematoma around the ascending aortic graft. The pathologic finding was chronic necrotizing granulomatous inflammation. Microbiological tests including polymerase chain reaction analysis were negative.


Our experience indicates that an MRI finding of a hematoma at the site long after cardiovascular surgery suggests that there may be granulomatous inflammation.

Peer Review reports


As a specific form of chronic inflammation, granulomatous inflammation can be caused by infections, allergic reactions, and neoplastic conditions. It presents with mononuclear leukocytes, specifically macrophages, responding to cell injury [1]. This histologic response especially affects the lungs, skin, kidneys, liver, and lymph nodes, although it can occur in all tissues [2].

On magnetic resonance imaging (MRI), T2-weighted or contrast-enhanced T1-weighted high signal intensity can be found in granulomatous inflammation [3]. T1 or T2 mapping may be useful for recognizing granulomatous tissue infiltration of cardiac tissue, like sarcoidosis [4].

Herein, we illustrate a rare case of granulomatous inflammation on a replaced ascending aorta, which showed as a perigraft hematoma in MRI.

Case presentation

Ten years postoperatively, a 75-year-old female presented to the emergency department with a history of seven days of chest pain without fever. She had a background of hemi-arch replacement with a Hemashield platinum woven double velour vascular graft (collagen-impregnated polyester graft, Getinge AB, Lindholmspiren 7 A, Göteborg, Sweden) for ascending aortic dissection 10 years earlier. There was no history of prior trauma.

The chest x-ray showed evidence of cardiomegaly (Fig. 1A), and the initial chest computed tomography (CT) was suggestive of hematoma or abscess (Fig. 1B). The size of the mediastinal mass was about 4.5 × 3.3 cm. In patients with previous aortic surgery, the existence of a radiological perigraft hematoma means clinically that there can be an ascending aortic pseudoaneurysm, which is an uncommon complication of cardiac surgery but could be catastrophic in 0.5% of the patients [5]. And it can occur in a variety of locations including previous anastomotic sites, and cannulation and venting sites [6].

Fig. 1
figure 1

The initial findings on imaging studies. (a) Cardiomegaly was detected on the chest x-ray. (b) Initial chest computed tomography showing a mediastinal mass, possibly a hematoma (white arrow)

Despite the necessity of promptly diagnosing a pseudoaneurysm of the thoracic aorta and carrying out surgical intervention, we proceeded with caution during our preoperative assessment. Chest MRI was deemed essential to facilitate the diagnosis. The MRI scan with enhancement revealed a hematoma on the ascending aortic graft consistent with the CT findings (Fig. 2A and B). An infection could not be excluded because there was rim enhancement suspicious of an abscess on the contrast image (Fig. 2C). The blood culture of the patient was negative and other diseases causing chest pain were also ruled out.

Fig. 2
figure 2

Preoperative chest MRI. (a) T1-weighted image suggestive of hematoma (white arrow). (b) HASTE T2-weighted sequence images suggesting the possibility of a pseudoaneurysm (white arrow). (c) T1 contrast image with rim enhancement (white arrow)

MRI, magnetic resonance imaging; HASTE, half-Fourier single-shot turbo spin-echo

A well-prepared surgery was planned in case of a need for redo aortic surgery. After endotracheal general anesthesia, a repeat median sternotomy was performed, revealing severe adhesion in the retrosternal space. Inspection of the pericardial space showed a sac containing yellowish and pus-like material (Fig. 3). We confirmed that there was no hematoma around the ascending aortic graft. After collecting the material for culture and biopsy, the sac was removed and massive irrigation was performed. The chest wall was closed after chest tube insertion.

Fig. 3
figure 3

Intraoperative findings revealing yellowish material in the pericardium (white arrow)

The pathologic findings showed chronic granulomatous inflammation with necrosis (Fig. 4). The microbiologic tests of the tissue specimen including cultures and polymerase chain reaction analysis for Mycobacteria tuberculosis complex and non-tuberculosis Mycobacteria were negative.

Fig. 4
figure 4

The pathologic findings (H&E stain) demonstrated granulomatous inflammation with a rim of histiocytes (black arrow) and central necrosis (black arrowhead)

H&E, hematoxylin and eosin

The patient’s postoperative course was uneventful, and he was discharged on postoperative day 7 after confirmation by the infection specialist. No symptom was noted at the outpatient department follow-up.


We encountered a case where the preoperative differential diagnosis was very important for surgical planning. In the imaging findings of patients who underwent previous cardiovascular surgery, a radiological hematoma on the anastomosis sites may mean a pseudoaneurysm clinically. Pseudoaneurysm, with the disruption of at least one layer of the wall of the vessel around the thoracic aorta [7], has a variety of causes, including trauma, infection, and suture dehiscence [8], and that would lead to a risky reoperation frequently [9]. Multiple studies have reported that redo procedures involving the aortic root and proximal aorta were associated with high mortality rates [10,11,12].

Even though CT angiography is most commonly used to assess the aorta as the modality of first choice [13], cardiovascular magnetic resonance imaging (CMR) was specifically recommended in American Heart Association/American College of Cardiology guidelines and can play a vital role in many clinical scenarios [14]. It is also recommended for the identification of acute aortic disease conditions, as well as the monitoring of stable and moderate states [15]. CMR can help to estimate the age of a vessel wall hematoma and review signal intensities, which vary over time [16].

In our case, the granulomatous inflammatory subtype pattern was necrotizing granuloma. On MRI, chronic granulomatous inflammation can be found as ring-enhancing lesions [3], as in our case (Fig. 2C). Foreign body-like synthetic fibers can also cause granulomatous inflammation [2].


Our experience showed that an MRI finding of a hematoma at the site long after cardiovascular surgery suggests that there may be granulomatous inflammation. It is hoped that this case will help surgical planning in similar cases.

Data Availability

As this paper is a case report, all generated or analyzed data are included in this article.



Magnetic resonance imaging


Computed tomography


Cardiovascular magnetic resonance imaging.


  1. Shah KK, Pritt BS, Alexander MP. Histopathologic review of granulomatous inflammation. J Clin Tuberc Other Mycobact Dis 201710;7:1–12.

  2. Woodard BH, Rosenberg SI, Farnham R, Adams DO. Incidence and nature of primary granulomatous inflammation in surgically removed material. Am J Surg Pathol. 1982;6(2):119–29.

    Article  CAS  PubMed  Google Scholar 

  3. Lee M, Lee MS, Lee JS, Ko SY, Jeong SY. Spectrum of imaging findings of chronic granulomatous disease: a single center experience. Diagn Interv Radiol. 2017;23(6):472–7.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Puntmann VO, Isted A, Hinojar R, Foote L, Carr-White G, Nagel E. T1 and T2 mapping in Recognition of early cardiac involvement in systemic sarcoidosis. Radiology. 2017;285(1):63–72.

    Article  PubMed  Google Scholar 

  5. Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thorac Surg. 2000;70(2):547–52.

    Article  CAS  PubMed  Google Scholar 

  6. Stassano P, De Amicis V, Gagliardi C, Di Lello F, Spampinato N. False aneurysm from the aortic vent site. J Cardiovasc Surg (Torino). 1982;23(5):401–2.

    CAS  PubMed  Google Scholar 

  7. Marx M, Gardiner GA Jr, Miller RH 3. The truth about false aneurysms. AJR Am J Roentgenol. 1985;145(1):193–4.

    Article  CAS  PubMed  Google Scholar 

  8. Atik FA, Navia JL, Svensson LG, Vega PR, Feng J, Brizzio ME, et al. Surgical treatment of pseudoaneurysm of the thoracic aorta. J Thorac Cardiovasc Surg. 2006;132(2):379–85.

    Article  PubMed  Google Scholar 

  9. Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the european society for vascular surgery (ESVS). Eur J Cardiothorac Surg. 2019;55(1):133–62.

    Article  PubMed  Google Scholar 

  10. Crawford ES, Crawford JL, Safi HJ, Coselli JS. Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch. Ann Thorac Surg. 1985;40(5):439–55.

    Article  CAS  PubMed  Google Scholar 

  11. Estrera AL, Miller CC 3rd, Porat E, Mohamed S, Kincade R, Huynh TT, et al. Determinants of early and late outcome for reoperations of the proximal aorta. Ann Thorac Surg. 2004;78(3):837–45.

    Article  PubMed  Google Scholar 

  12. David TE, Feindel CM, Ivanov J, Armstrong S. Aortic root replacement in patients with previous heart surgery. J Card Surg. 2004;19(4):325–8.

    Article  PubMed  Google Scholar 

  13. Expert Panels on Vascular Imaging and Interventional Radiology:, Bonci G, Steigner ML, Hanley M, Braun AR, Desjardins B, Gaba RC, et al. ACR appropriateness Criteria® thoracic aorta Interventional Planning and Follow-Up. J Am Coll Radiol. 2017;14(11S):570–83.

    Google Scholar 

  14. von Knobelsdorff-Brenkenhoff F, Pilz G, Schulz-Menger J. Representation of cardiovascular magnetic resonance in the AHA / ACC guidelines. J Cardiovasc Magn Reson. 2017;19(1):70.

    Article  Google Scholar 

  15. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, American Association for thoracic surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55:e27–e129.

    Article  PubMed  Google Scholar 

  16. Habs M, Pfefferkorn T, Cyran CC, Grimm J, Rominger A, Hacker M, et al. Age determination of vessel wall hematoma in spontaneous cervical artery dissection: a multi-sequence 3T cardiovascular magnetic resonance study. J Cardiovasc Magn Reson. 2011;13(1):76.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


Not applicable.


There was no funding for this work.

Author information

Authors and Affiliations



JL participated in study design, research and manuscript writing. HAL, SBH, DYK and YHK were involved in editing this manuscript and research. HWK performed the surgery. All authors read and approved the final manuscript.

Corresponding author

Correspondence to June Lee.

Ethics declarations

Ethics approval and consent to participate

Consent was obtained from the patient for participation in the study.

Consent for publication

Consent was obtained from the patient for the publication of this report and any accompanying images.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lee, J., Lim, H.A., Hong, S.B. et al. Granulomatous inflammation mimicking a hematoma around the replaced ascending aorta in magnetic resonance imaging: a case report. J Cardiothorac Surg 18, 191 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Granulomatous inflammation
  • Magnetic resonance imaging
  • Thoracic aortic surgery