0:00

And so this is the first case and so

0:03

this is a 65 year old man who came in with dyspnea on

0:06

exertion.

0:08

And so we have two thinny steady-state free procession sequences.

0:12

The image on the right here is going to be our four chamber sequence.

0:15

And so again, we have the left ventricle the right ventricle the

0:18

right atrium and the left atrium.

0:22

And so the first thing I want everyone to notice is how

0:25

would you characterize this contraction? And

0:28

so to me this looks like there is global left

0:31

ventricular hypokinesis. The left

0:34

ventricle also looks very dilated.

0:37

This on the left hand side of the screen is going to be a left

0:40

ventricular also attract you where we have the left atrium the

0:43

left ventricle and then the aorta here and again,

0:46

you can see global left ventricular hypokinesis.

0:50

If you look at this anterior wall, however, it

0:53

doesn't look like it's contracted quite as much

0:56

as the remainder of the wall. So it's more focally a kinetic

0:59

in that region.

1:00

The other thing to notice is that we have this

1:03

black jet that's originating from this mitral

1:06

valve in is directed posteriorly into the left

1:09

atrium.

1:10

And so that represents a spendy phasing artifact of

1:13

mitral regurgitation or insufficiency.

1:17

And then finally we have this kind of thickened appearance here

1:20

along this anterior wall the

1:23

left ventricle extending to the Apex. You can kind of

1:26

see a similar type thing here and we'll have

1:29

to look at that at other sequences to try to determine what exactly is

1:32

going on.

1:33

If we look outside of the heart, we see some ancillary findings.

1:36

And so this person has bilateral plural effusion

1:39

as well as a small pericardial effusion

1:42

kind of surrounding the the left ventricle free wall

1:45

here.

1:48

And so the next sequence is another steady state free procession

1:51

sequence this now in the short axis plane so

1:54

are essentially cross sectioning the

1:57

heart in the short axis going from the base, which is near the

2:00

mitral valve going all the way to the apex of the

2:03

heart.

2:05

And so when we're looking at this we're looking at a few

2:08

different things on these short axis images. So we

2:11

want to see how is the left ventricle Contracting here? And

2:14

so again when you're looking at a short axis image,

2:17

this is going to be the answer while the left ventricle the septal

2:20

wall the free or the lateral wall and

2:23

then the inferior wall and so it's helpful to describe contraction.

2:26

Not only globally but also regionally

2:29

and in this case, there's definitely Global

2:32

left ventricular hypokinesis, but we're

2:35

also seeing kind of more Regional akinesia and

2:38

those areas that we talked about on the other planes. And so

2:41

if you look at this anterior wall as it's Contracting down you

2:44

can see it's not Contracting quite as much as this inferior wall.

2:47

And we also see this area of thickening again here kind

2:50

of extending to the Apex along the

2:53

anterior and the septal portion.

2:56

Looking at the right ventricle here, so you

2:59

can see the right ventricular contraction. You can see that the right

3:02

ventricles Contracting better than the left ventricle, but

3:05

it still has a little hypokinesis. We can also appreciate this

3:08

plural effusion here next to

3:11

the heart.

3:13

And so now we've looked at kind of global left

3:16

ventricular while motion addermalities. We describe

3:19

the regional wall motion abnormalities in

3:22

the next part of the cardiac Mr. Sequences

3:25

essentially going to be injecting get alinium contrast. So

3:28

again, we inject that contrast. We usually like

3:31

to wait 10 to 15 minutes after contrast injection. And

3:34

then we're gonna pick a inversion time.

3:37

We're essentially The myocardium is null.

3:40

So the normal myocardium is null terms black.

3:43

And so anything that shows up as bright here

3:46

should be abnormal. Myocardium.

3:49

And so this is a short axis image again. We've

3:52

injected contrast. We've picked normal myocardium so

3:55

that it shows up as black and any sort of bright. Myocardium

3:58

is going to show up is

4:01

abnormal and bright and so here's a short axis image.

4:04

We can see the left ventricle the right ventricle again,

4:07

just kind of scrolling through these short axis

4:10

image. We're starting out at the base, which is going to be near the

4:13

mitral valve and then extending to the mid level

4:16

which is usually where you see the papillary muscles and then

4:19

the eight packs towards the apex of the left ventricle and

4:22

so we can see quite a bit of abnormal Lake

4:25

catalanium enhancement here at the Apex.

4:29

And as we scroll to the middle level you can see more abnormal Lake

4:32

idling enhancements.

4:36

And then as we get more towards the base of The

4:39

myocardium seems more normal in appearance. And so

4:43

when you're describing late catalanium enhancement, it's helpful to

4:46

describe its distribution in terms of anterior

4:49

in this case septal and lateral wall extending from

4:52

the base to the Apex.

4:55

And then we also have some kind of

4:58

more unusual black filling defects associated

5:01

with it, which kind of corresponds to those areas

5:04

of what we weren't quite

5:07

sure what they represented on the steady state free procession images whether

5:10

or not this was wall thickness or an underlying math.

5:19

And so the first polling question that we're going to ask is what

5:22

sequence is used to perform Lake edelenium

5:25

enhanced Imaging.

5:27

single inversion recovery GRE steady state

5:30

free procession double inversion recovery

5:33

GRE or triple inversion recovery

5:36

GRE

5:38

I'll give you guys a couple seconds just to kind of

5:41

think about that.

5:44

So for everyone's have a had a chance to think about that kind

5:47

of think about what the answer would be for you.

5:51

And so the correct answer here is actually single

5:54

inversion recovery GRE.

5:58

And so remember in this this is a single inversion

6:01

recovery sequence. And so essentially we will

6:07

take an inversion time where we want to know the

6:10

normal mile cardium.

6:12

And so here's a few more images from the lake atalene

6:15

enhanced sequence. So we have the short axis images

6:18

which we've already seen. We also have some four

6:21

chamber images here on the top.

6:24

And then two chamber or vertical long axis images

6:27

here on the bottom. And so this is going to be the inferior

6:30

wall the left ventricle the anterior wall. This

6:33

is gonna be the lateral wall in the septal wall.

6:36

And again, you can see this abnormal Lake edelenium enhancement

6:39

extending along the septal wall

6:42

all the way to the Apex as well as to the lateral wall. And

6:45

then you can see these black filling defects associated

6:48

with this Lake Adeline even enhancement.

6:51

And so when you're describing late gettelinium enhancement, it's it's

6:54

helpful to try to differentiate ischemic enhancement

6:57

from non-ischemic enhancements. And

7:00

we'll see cases of both of those to the in

7:03

today's talk. So with estimic enhancement it typically

7:06

is going to follow a vascular territory. So the

7:09

LED circumflex RCA territory

7:13

It usually starts in the sub-inocardium and it progresses transmiral

7:16

whereas non-ischemic enhancement will not

7:19

be a vascular territory. It may

7:22

actually spare the southernocardium and so in this case this

7:25

looks like it actually, you know involves a

7:28

sub inocardium ghost transmural near the

7:31

Apex and it really seems to follow a vascular territory.

7:35

And so this looks like ischemic like edelenium enhancement. So

7:38

our next question is which coronary artery is likely occluded. You

7:41

think it's the led the RCA or

7:44

the acute marginal?

7:46

I'll give you guys a couple seconds to think about this question.

7:51

Okay.

7:53

And so here if you think about which coronary arteries likely

7:56

included this really follows the LED territory. Uh,

7:59

also the the circumflex is

8:02

likely involved as well. So the correct answer here is

8:05

going to be the LED coronary artery.

8:09

And then finally, what is the other Salient abnormality? What

8:12

is this Mass actually represent? You

8:15

think it's a mixoma and angiosarcoma a metastasis

8:18

or thrombus? So it would be

8:21

most likely associated with a LED and circumplex

8:24

infarct. So, what do you think this Mass represents?

8:30

All right, excellent. And so this represents a thrombus and

8:33

so important Heat point

8:36

here is that thrown by can have a variety of Imaging appearances in

8:39

this case. It manifested is this kind of suitable wall

8:42

thickening but really looking at these Lake edelenium

8:45

enhanced images, you can see that this mass does not enhance

8:48

and it's associated with this area of

8:51

akinesia. So this is thrombus associated with

8:54

an old LED in left circumflex in part.

8:57

And so the important points of this case is that biability

9:00

Imaging is going to be performed 10 to 15 minutes

9:03

after the injection of contrast. We do a

9:06

single inversion recovery sequence with the aim to

9:09

really null or make black normal. Myocardium.

9:12

Non-vile-momyocardium is in an enhanced due to

9:15

the expanded interstitial space.

9:17

And then one of the kind of salient points

9:20

is that if you have enhancement greater than 50% of

9:23

the wall thickness. This is considered non viable myocardium,

9:26

and it will not benefit from revascularization.

9:30

And this is really based off of this 2010 study by

9:33

Raymond Kim that was in the New England Journal medicine

9:36

where they found that those that had greater than

9:39

50% wall thickness enhancement.

9:42

Tended to not recover function after

9:45

read vascularization be it a cabbage or

9:48

stenting and so therefore you can really use these

9:51

Lake adelantium enhanced images to help dictate management of

9:54

patients after myocardial infarction. So if

9:57

they have a long motion enormity, and there isn't any

10:00

way catalinium enhancements and you know, they have coronary artery

10:03

disease.

10:04

Those segments would likely recover function after revascularization.

10:07

Whereas in this case, you have

10:10

a wall motion abnormality. You have this large infarct that's

10:13

very, you know transmiral in

10:16

nature. So it has transmural enhancement. This patient would

10:19

likely not benefit from revascularization.

10:22

And so just to review the different vascular territories,

10:25

remember the septal and the answer wall.

10:28

This is based off of the short axis images that's going to be the led. The

10:31

lateral wall is going to be the circumflex and the

10:34

inferior walls can primarily easy RCA assuming that

10:37

the patient has a right dominant circulation.

10:41

In terms of enhancement try to differentiate ischemic enhancement

10:44

from non-ischemic enhancement, ischemic enhancement

10:47

is going to follow vascular territory start in

10:50

the southernocardium and go transmiral. Whereas not ischemic

10:53

enhancement will generally have one of these other different forms

10:56

be it diffuse enhancement sub-epocardial mid

10:59

myocardial or measocardial or

11:02

potentially patchy.

11:03

In the different patterns of non-ischemic enhancement

11:06

will really help tailor your differential diagnosis.