INTRODUCTION: Aortic intramural hematoma (IMH) is described as "dissection 
without intimal tear" due to rupture of vasa vasorum, which results in bleeding 
within the tunica media in the absence of intimal disruption or blood flow 
communication. The aim of our study is to validate perioperative evidence of 
intimal entry tear in patients with IMH and to suggest that this entity may 
represent a part of a disease and not a separate disease.
PRESENTATION OF CASES: We report two patients admitted to our institution with 
sudden onset thoracic pain. A CT scan showed an aneurysm of the ascending aorta 
complicated by type A IMH. The patients underwent open operation. Surgical 
set-up has included right axillary artery as arterial inflow, no cross-clamp 
before hypothermic circulatory arrest and Kazui protocol for selective antegrade 
cerebral perfusion. We found no evidence of intimal flap, but we identified an 
intimal tear in both patients. A hemiarch procedure associated with root 
replacement, using two-grafts techniques was performed in both cases. The 
postoperative course was uneventful and the patients were discharged home.
DISCUSSION: Recent data are emerging from the radiologic literature about the 
evidence of intimal lesions in IMH, but surgical reports are scant. The evidence 
of intimal tears contributes to consider as questionable the etiological role of 
vasa vasorum and it may justify updates in the management.
CONCLUSION: We consider that IMH may represent a part of a disease (aortic 
dissection), depicted by radiological images in a specific single instant of its 
clinical evolution.