Acute aortic syndrome (AAS) encompasses a spectrum of pathological processes, including aortic dissection, intramural hematoma (IMH), and penetrating aortic ulcer (PAU) [1,2]. Patients with uncomplicated type B intramural hematoma (TBIMH) are initially treated with best medical therapy (BMT) and undergo serial imaging surveillance. However, the natural course of TBIMH is unpredictable, and several studies have reported a high failure rate for BMT. With improved imaging technology and resolution, more focal intimal disruptions have been detected, which significantly increase the risk of disease progression into dissection, aneurysmal dilatation, and aortic rupture. Therefore, there is increasing consideration of thoracic endovascular aortic repair (TEVAR) for TBIMH [[3], [4], [5]]. Based on these observations, early TEVAR may be beneficial for selected patients with TBIMH who are at risk of disease progression; however, the indications for this intervention remain controversial. In clinical practice, computed tomography (CT) is the most commonly used imaging modality for the initial evaluation of aortic pathologies. The aim of this study was to analyze CT morphological predictors and risk score stratification to predict patients who are more likely to fail initial BMT, where more frequent surveillance and endovascular intervention may be warranted.