0:00

So case four is a 53 year old

0:03

woman who presents with arrhythmias.

0:07

And so we have two cine steady-stage

0:10

3 procession images here.

0:13

So we have a four chamber view on the left a two

0:16

chamber or a parasept a long axis you on

0:19

the right and so looking at these different views again. We're

0:22

looking for Global contraction. And so

0:25

I would say that Global contraction actually looks pretty good.

0:29

I don't see any abnormalities Global contraction.

0:32

I would say maybe The ventricle wall

0:35

looks a little bit thickened in a few areas. But all

0:38

in all the contraction looks normal looking at the

0:41

valves and so I'm not seeing much of a spendy phasing

0:44

Jet and neither the mitral or the tricuspid valve to

0:47

indicate any significant stenosis or regurgitation.

0:52

We have short access images going from the

0:55

base to the apex of the left ventricle and looking

0:58

at this again looking for

1:01

any sort of global contraction abnormalities as

1:04

well as Regional contraction abnormalities.

1:07

And again looking at this the global contraction looks

1:10

normal. The regional contraction looks normal.

1:15

The next sequence here is going to be a triple inversion recovery

1:18

sequence. And so these are black blood

1:21

plus fatsat. And these are most helpful for Mass

1:24

characterization as well as to look for any sort of

1:27

a demo.

1:28

I find these the most difficult images to interpret the

1:31

way that it often works for me is I'll see

1:34

an abnormality on a different sequence and then I come back to

1:37

this and I'm like, okay, they're actually see an informality

1:40

in this case when you're kind of scrolling through

1:43

from the Apex to the base want to

1:46

kind of draw your attention to this area here in the intro

1:49

lateral wall. And so you can see that maybe there's

1:52

a touch increase intensity in

1:55

this intro lateral wall on the left ventricle. So again, this is

1:58

the inferior wall answer your wall the lateral wall

2:01

and the set the wall, maybe compared to kind of the anterior wall.

2:04

There's a little bit increase signal intensity. So there may

2:07

be some myocardial.

2:10

This is a four chamber triple inversion

2:13

recovery sequence again, just showing that lateral wall

2:16

has a little bit increased signal intensity, but also

2:19

to the other areas suggesting that there may be some edema

2:22

in that lateral wall.

2:25

Now after the triple inversion recovery sequences, we've now

2:28

injected catalanium contrast. We wait

2:31

10 to 15 minutes. We'd run that

2:34

Sydney inversion recovery sequence to try

2:37

to pick an inversion time to know the normal myocardium.

2:40

So the normal myocardium shows up as black and

2:43

the abnormal myocardium will show up as bright.

2:46

And so here we have the short axis kind of image starting

2:49

at the Apex going to the base.

2:54

In what we can notice here is in that

2:57

same area of this intra lateral lateral law.

3:00

You can see that there's quite a bit of Lake edelenium enhancement.

3:04

So these areas showing up as bright here.

3:07

The other thing to notice is that you look at the adjacent pericardium.

3:10

It's actually enhancing quite a bit too. And

3:13

so we have quite a bit of pericardial enhancement here.

3:17

And so when you're dealing with Lake edelenium enhancement you want to try to ask yourself

3:20

one is a present and then

3:23

two do I think it's ischemic enhancement or

3:26

non-essemic enhancement? And in

3:29

this case, it's actually a little tricky because remember

3:32

Ischemic enhancement will follow a vascular territory start

3:35

in the sub-indocardium go transmiral in this

3:38

case. This looks like transmural enhancement technically could

3:41

follow vascular territory. And so

3:44

that's when you really want to look at the additional history that kind of

3:47

clue us into you know, should I go the ischemic route

3:50

routes or should I go the non-ischemic route?

3:54

And so this person had a myocardial pet study

3:57

and you can see this intense fdg uptake corresponding

4:00

to this area of Lake Adeline enhancement.

4:03

S you can also see this abnormal pericardial enhancement compared

4:06

to the more anterior pericardium, that's

4:09

kind of anterior to the right ventricle here. You can

4:12

see this is what a normal pericardium should look like so this is abnormal pericardial

4:15

enhancements.

4:17

The station actually had a CT scan as well.

4:20

This is the CT scan from that patient just a few

4:23

selected slices. We have an axial and

4:26

a coronal CT slice.

4:28

So the question here is this patient

4:31

has a bunch of nodules what best characterizes the

4:34

nodule distribution you think these are random nodules

4:37

periolymphatic nodules Central lobular nodules

4:40

or tree and Bud nodules.

4:44

Okay.

4:45

So these are best characterized as perilymphatic nodules.

4:48

And so the

4:51

This can be fairly tricky. But one of the things that

4:54

I look for is to try to differentiate Central

4:57

lobular from random Imperial lymphatic nodules.

5:00

I like to ask myself. Do I see nodules along the

5:03

fissures. Do I see nodules in the sub plural lung

5:06

and if the answer is no then you're likely dealing with

5:09

Central ogular nodules.

5:11

When I asked myself this question on this case, this is going

5:14

to be the right major fissure here. I'll just kind of go back

5:17

to this.

5:19

Slice here, so you can see the fissures here and the subplural

5:22

long so you can see all these nodules kind of beating along

5:25

the subplural lung as well as the fissures. So here's

5:28

another Visual and so these can't be

5:31

Central Avenue or nodules and so once you've

5:34

decided that you see nodules long fissures and

5:37

along the subplural lung.

5:39

The next question is do I think these are randomly distributed

5:42

throughout the secondary lobule or do I

5:45

think that they seem to be grouped where lymphatic's lie.

5:48

So do they see more situated along the

5:51

lymphatics or are they randomly distributed? If you

5:54

look here you can see that there's tons of nodular beating of

5:57

these vessels. There's a lot of nodules clustered along the fissures as

6:00

well as the subfloor along. So these are perilymphatic nodules.

6:05

And so now we have perilymphatic nodules plus this

6:08

pattern of Lake edelenium enhancements.

6:11

And so given this picture we didn't think this was achemic

6:14

enhancement. We thought this was more likely not ischemic enhance.

6:18

Ment. So what is the most likely diagnosis in this case?

6:22

And so the correct answer here is sarcoidosis.

6:27

And so in order to make this diagnosis most patients

6:30

with cardiac sarcoid will have a diagnosis of

6:33

sarcoidosis already by the time they come to Mr. So

6:36

they're essentially looking for cardiac involvement by

6:39

sarcoidosis. And so it makes it a little bit easier.

6:43

And so this is an example of sarcoidosis with both myocardial as

6:46

well as pericardial involvement. And so

6:49

this is an idiopathic disease characterized by nonkeys eating

6:52

granulomas. You often get patchy or

6:55

nodular T2 hypertens full size, which is what we saw in

6:58

the triple inversion recovery sequence, and then you often

7:01

have wall thickening as well as Lake Animal enhancement and

7:04

allow cardium.

7:06

Mr. Of chronic disease can look a little bit different you

7:09

can actually result in a restrictive cardiomyopathy where

7:12

you have poor diastolic filling due to

7:15

increased ventricular stiffness.