0:00

So the next case is a 53 year old woman who came

0:03

in with multiple myeloma. So we have two steady

0:06

state free procession images. The one on the

0:09

left is going to be a four chamber sequence. So again, we have the left

0:12

ventricle right ventricle right atrium and

0:15

left atrium. And the one on the right is going to be a short axis stack

0:18

again kind of looking through the heart.

0:21

And so a few things looking at morphology first, we can

0:24

see that both Atria seem dilated.

0:27

The contraction of the left ventricle also doesn't seem

0:30

to be contracting quite as much so this looks like Global left

0:33

ventricular hypokinesis. It's definitely not as

0:36

bad as the last case but the contraction seems

0:39

down a little bit when we're looking at the short axis

0:42

images again kind of align yourself to the

0:45

diaphragm here. And so this is going to

0:48

be the answer wall up here. We're starting at the base of the left

0:51

ventricle. This is gonna be the lateral wall the inferior wall.

0:54

And then the septal wall. You can see that Global. There's

0:57

just a little bit of global hyperkinesis, but there

1:00

doesn't appear to be any Regional wall motion abnormalities.

1:04

The other thing to note is when you're looking at myocardial thickness

1:07

The myocardium actually looks thick in

1:10

this case. And so I would describe this as concentric left

1:13

ventricular hypertrophy in terms of ancillary findings.

1:16

I'm just seeing a small left plural effusion.

1:20

And so this is just that same cine image here. Again,

1:23

the steady state free procession. This is

1:26

really helpful looking for wall thickness as well

1:29

as contraction any sort of valve abnormalities.

1:32

This is just a single image at in diastole

1:35

again showing that circumferential

1:39

Left ventricular hypertrophy and so you

1:42

always want to comment on left ventricular wall thickness. Is

1:45

it the few Suite thickened? Is it focally thickened

1:48

is it diffusely thin or is it focally thin?

1:51

And it's helpful to look at this at in diastole.

1:54

And so we always comment on left ventricular wall thickness

1:57

at in diastole. In this case. You could if you

2:00

were to measure this you would see that there's diffuse left ventricular wall

2:03

thickness and you want to exclude the trabeculations when

2:06

you're actually doing that measurement in this case. It measures greater

2:09

than 10 millimeters. And so it's circumferentially thickened.

2:15

This is a short axis image. This is going to be a triple

2:18

inversion recovery sequence. And again the goal

2:21

of this sequence is to look for any sort of myocardial edema.

2:25

And so you're essentially just looking at The myocardium. Do

2:28

you see any areas that kind of stand out in terms

2:31

of Edema?

2:32

You often will get this slow flow artifact within their

2:35

trabeculations. That's normal. As long

2:38

as it is in occurring in The myocardium. There's you

2:41

know, no a demon in this case. And so in this

2:44

case, I don't see any evidence of myocardial edema. I don't

2:47

see any left ventricular Mass. I just

2:50

again see this kind of circumferential left ventricular hypertrophy.

2:56

And then after those triple inversion recovery sequences, we've

2:59

again injected gadolinium contrast and

3:02

then we're generally waiting 10 to

3:05

15 minutes after injecting catalanium contrast and

3:08

then we're performing the lake catalanium enhanced images. And so

3:12

these are four different images. These are all these these

3:15

three images are gonna be short axis images. So this

3:18

is the left ventricle. This is the right ventricle left ventricle

3:21

left ventricle. And then this is

3:24

a four chamber image here again Lake idling

3:27

and images and as we discussed on the

3:30

last case you want to pick an inversion time where the

3:33

normal myocardium is old or essentially turns

3:36

black.

3:37

And so in this case, it's really hard

3:40

to pick out any black myocardium. So

3:43

you're kind of like did we do these images incorrectly? What

3:46

exactly is going on?

3:49

And so the next question is what is the most likely diagnosis

3:52

kind of given this diffuse enhancement pattern

3:55

of the left ventricular? Myocardium. You think

3:58

this is myocardial infarct sarcoidosis myocarditis

4:01

or amyloidosis?

4:06

And the correct answer here is amyloidosis.

4:11

And so this is a characteristic appearance for amyloidosis.

4:15

And so the lake adelantium enhanced images with amyloidosis are

4:18

often difficult to interpret. So we

4:21

generally have to image these patients a little sooner. So

4:24

rather than waiting the typical 10 to

4:27

15 minutes. We often want to image them right around five

4:30

minutes after gadolinian contrast.

4:33

In amyloid will typically give you a few

4:36

different enhancement patterns. So one of the more common

4:39

ones is diffuse sub-indocardial enhancement. And the

4:42

other more common one is we see in this case is diffuse

4:45

enhancement. The image quality is often poor because

4:48

amyloid will actually disrupt the gadolinium kinetics

4:51

and it's very hard to actually pick a normal TI

4:54

time. And so you look at the images and you really can't

4:57

pick a normal TI time. That's because all The myocardium

5:00

is essentially abnormal.

5:03

And so this is a an example of non-ischemic Lake

5:06

edelinium enhancement. So it doesn't follow a vascular

5:09

territory. So it's involving all vascular territories and

5:12

it's diffuse. And so the three most

5:15

common diagonalsies that will cause a non-ischemic pattern

5:18

of Lake catalanium enhancement are going to be sarcoidosis. So

5:21

they're on the short axis image. You can see the subup epicardial

5:24

enhancement notice how it spares the

5:27

sub-inocardium. So ischemic enhancement should start in

5:30

the southern or party and go transmiral.

5:32

Amyloidosis where the images are often very poor quality.

5:35

This is one of my better examples of amyloidosis

5:38

where you have this diffuse enhancement of The myocardium

5:41

as well as the right ventricle here and then

5:44

myocarditis we can which can have one of a few different flavors.

5:47

It's often patchy. It's in this

5:50

case. You can see kind of just his patchy enhancement again, it

5:53

doesn't follow vascular territory some of

5:56

its southernocardial but a lot of it is sub epicardial.

6:00

So with cardiac amyloidosis, we see a non-ischemic pattern

6:03

of Lake edelenium enhancement. The two most common patterns

6:06

are going to be diffuse enhancement or diffuse Southern

6:09

accardio enhancement, and they're often very bad. Looking Lake

6:12

adalene enhanced images.

6:14

One additional thing that she can look for. This is a

6:17

different patient with amyloidosis is remember initially

6:20

after we inject with contrast. And before

6:23

we do the lake edelenium enhanced images you do

6:26

that sinian version recovery sequence or the lookwalker

6:29

sequence, which the whole aim of

6:32

that sequence is to try to pick the inversion time. We're normal

6:35

myocardium this but no so you

6:38

pick that TI time so that you can do the lake Edelman

6:41

enhance images.

6:42

So with amyloid what happens is you'll actually have

6:45

an inversion. So normally what happens is the

6:48

blood pool will now prior to The myocardium, but

6:51

with amyloid that actually gets flipped in most cases. So

6:54

in this case, you can see that The myocardium here

6:57

is nulling or turning black prior to

7:00

the blood pool, which is the opposite of normal. So The myocardium

7:03

terms black.

7:05

Shortly, thereafter the blood pool turns back. And again

7:08

that's opposite of the normal and that's very typical of amyloidosis. And

7:11

so we can use that sinian version recovery. It'll

7:14

look like our sequence to actually help make this diagnosis in

7:17

patients with amyloidosis.

7:21

This is just another patient with this city inversion

7:24

recovery sequence showing kind of the opposite of

7:27

what normally happens. So The myocardium actually turns

7:30

black.

7:32

Prior to the blood pool, which is very typical of this diagnosis.

7:36

So this is a patient with amyloid on the top you can

7:39

see that The myocardium terms black and then the blood pool

7:42

turns black. This is the opposite. This is a patient

7:45

with a myocardial infarct on the bottom. You can see that the blood

7:48

pool turns black prior to The myocardium and so

7:51

using that sinian version recovery sequence can really help

7:54

us making the dark and making the diagnosis of amyloidosis.

7:59

So again, The myocardium knowledge

8:02

prior to the blood pool that's opposite of normal. So if

8:05

you see that think of amyloidosis in this

8:08

case, you can see diffuse enhancement typical of

8:11

amyloidosis.

8:13

And so amyloid deposits in the heart disrupts

8:16

this gaddling in kinetics causing this loss of

8:19

contrast between Normal and abnormal. Myocardium. We talked

8:22

that in amyloid patients you often want to do the Imaging

8:26

the lake edelenium enhance the Imaging a little bit

8:29

earlier than the typical patient. So often starting five eight

8:32

minutes rather than waiting the 10 to 15 minutes in the

8:35

most common enhancement pattern that we're going to see is

8:38

diffuse enhancement or diffuse Southern endocardial enhancement.