The natural history and preferred approach to patients with intramural hematoma of the aorta remains controversial. We describe herein the management of the case of a 45-year-old woman with acute onset of chest pain, intramural hematoma of the arch and proximal descending aorta, and left pleural effusion. In this particular case, a nonsurgical approach led to complete recovery of the patient and documented resolution of the hematoma. © 2002 by The Society of Thoracic Surgeons.