Case Presentation An 80-year-old woman presents to the emergency room complaining about a high-intensity chest pain. She was admitted 12 hours after the pain onset, maintaining the same characteristics, excruciating and continuous. The pain arose after physical activity (dance), radiating to the shoulders. The patient denied sweating and dyspnea. She referred that the pain worsened with inspiration and had no improvement factor. On physical examination, the patient was admitted normocardial and normotensive, with no signs that attracted attention except for the facies of pain. Peripheral pulses present and symmetrical. A 12-lead ECG and blood test for troponin are negative for acute myocardial infarction. Past Medical History The patient’s past medical history included hypertension and rheumatoid arthritis. Differential Diagnosis Differential diagnoses of acute chest pain are broad and include acute coronary syndrome, pulmonary embolism, acute aortic syndrome, spontaneous pneumotorax esophageal, rupture as the main malignant causes. Investigations The X-ray showed enlarged mediastinum on admission. The transthoracic echocardiogram performed showed a significant increase in the ascending aorta (52 mm). Aortic root measured 35 mm, aortic arch 28 mm and proximal abdominal aorta 20 mm. An echogenic image was observed in the ascending aorta with 9 mm and in less curvature of the aortic arch, corresponding to an intramural hematoma.

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