0:00

For moving right along here.

0:03

And we'll go from easier cases to harder cases. So here's a

0:06

sort of Mystery Case for you. Let me

0:09

start at the top and I'll scroll through this case.

0:17

And I'll open the poll questions now. So

0:20

what do you think the most significant abnormality

0:23

is here almost to the side and I'll keep scrolling.

0:31

If you just a few more seconds just finish answering.

0:35

All right, let's close the poll and see what people thought.

0:41

All right, and I'm curious. So some people

0:44

said the septum and other people

0:47

said The myocardium, so let's take a look and see I am

0:50

try to guess what people are going to say on

0:53

these cases so I can understand people said septum

0:56

because I I believe that they perceive that the septum here

1:00

is is thin or perhaps you can't see a septum

1:03

but I can tell you if this were a

1:06

big ASD one thing that usually see with that big of

1:09

an AST is Right hard and enlargement which we don't see right there.

1:12

So the symptom is really there. There's no ASD the persons

1:15

who said Mike hurting them are correct. So, let's see

1:18

what the findings. Are. You see low attenuation Foci

1:21

in The myocardium of the left ventricle,

1:24

especially at the left ventricular Apex.

1:27

And you can see that this is so low attenuation. It looks a

1:30

lot like fat. In fact, it is fat.

1:32

However, the mycardium is not really very

1:35

thin. It's sort of normal thickness my cardium.

1:38

I can show you that here. So the question is are these

1:42

old infirks like we see almost every

1:45

day where we see fat fatty metaplasia

1:48

of the left ventricle from inferks. Well, no,

1:51

these are multiple territories. It

1:54

doesn't really confine itself too. I've asked

1:57

for territory also, it's very globular. So

2:00

when is the last time you've seen an inference look like that look like

2:03

a blob of fat and furthermore,

2:06

although some of these areas are some endocardial

2:09

which in Forks old and

2:12

forks. Love to give you others are actually some epicardial

2:15

and midwal like this.

2:18

So that's not typical for old inference.

2:21

Now, what could this be? This could

2:24

be a couple different things if I told you this patient had tubers for

2:27

Roses. Well two sclerosis is famous

2:30

for producing the so-called inter.

2:32

Cardial fatty Foci, which can look

2:35

like this you can just get fatty deposition within the

2:38

heart also, you can get fatty deposition within

2:41

the heart with just aging but that tends to

2:44

involve the heart diffusely. It tends to be patchy tends to

2:48

involve the right ventricle a lot as well as the left ventricle intense not

2:51

to be as focal as this

2:54

So let me show you and Mr. Of this patient

2:57

and let's go to the next series here. So the

3:01

Mr. Here if you're not a cardiac imager, you're

3:04

not you may not be used to looking at this but this is a

3:07

short axis view. We're looking at a slice right through the

3:10

heart here and you can see that the

3:13

normal myocardium is going to be dark and

3:16

this is so called an old myocardium and the the

3:19

hyperintense area here. This is

3:22

after we've injected Galilean and waited about

3:25

10 minutes. So this is late abnormal Catalina

3:28

in enhancement. You can see that their focal globular areas

3:31

of enhancement here in the left ventricle and

3:34

scanning on down you see it particularly at the Apex a lot

3:37

of enhancement of the left ventricle. I can

3:40

go to the next series here and show you even more of

3:43

this enhancement. So you can see now we're

3:46

looking at the left ventricle along the long

3:49

access here. You can see a lot of enhancement globular enhancement

3:52

and this is not a Vas.

3:54

Territory, this is actually patient with myocarditis and myocarditis.

3:57

Although we don't see it every day on

4:00

non-gated CT do this. It's one

4:03

of the things that when it is is burned

4:06

out so to speak it can leave areas of

4:09

fatty amount of plasia within the heart within

4:12

especially the left ventricle. So when you

4:15

see nonvascular territory fat like this one of the

4:18

things that you may want to think about is another insult

4:21

that the patient may have had like a myocarditis or

4:24

even a burnout sarcoidosis could also

4:27

have this appearance. Although have to say I've never seen a sarcoidosis

4:31

do this. I have seen my cardio. Myocarditis do

4:34

this several times. So so a nice case of

4:37

fatty replacement of areas of the left ventricle due

4:40

to a prior my carditis.