0:01

Our next case is a 49 year old man with a history of uh,

0:04

coronary artery disease who presented

0:06

to the emergency department with an upper GI bleed

0:09

and then was found during his workup

0:11

to have evidence of a stemi.

0:13

So he went to the cath lab

0:16

and then we get an MRA few days later to assess

0:20

for complications or viability.

0:23

So starting in our usual fashion two chamber

0:29

would be a little bit of apical

0:31

and inferior wall motion abnormality here.

0:34

But overall, not too bad here though, I think you can start

0:38

to appreciate on this four chamber view,

0:41

the septum is actually moving and contract

0:44

and thickening pretty normally.

0:46

But the lateral wall out here,

0:50

while not really thin, is not really thickening,

0:54

at least not to the same extent that the septum is.

0:59

And here's our three chamber view showing some similar

1:03

findings, particularly down towards the mid

1:06

and apical region here.

1:09

So then moving into our short axis stack,

1:14

moving from base to apex.

1:17

So we can already start to see that here.

1:21

Even at the base, there's sort of

1:25

what I would term global hypokinesis.

1:28

It's not like these segments and the anterior septal

1:32

and inferior segments are contracting great,

1:36

but compared to they are moving better compared to sort

1:41

of these antola inferolateral segments in this case,

1:47

you can see here and it'll be even more apparent

1:50

as we move down

1:56

and even more so here as we get more apical really Now

2:02

inferior segments involved

2:03

and the anterolateral infra lateral segments are

2:06

basically a kinetic.

2:07

And the only thing that's thickening is the septal

2:10

and anterior segments.

2:15

So next in our algorithm is the LGE images

2:20

get a good window and level for you here.

2:23

And as I start back towards the base,

2:27

it's gonna be pretty apparent very

2:30

quickly that there's a problem.

2:31

So normal myocardium here

2:34

and in the areas where we saw hypokinesis,

2:38

it's actually kind of difficult to tell.

2:41

If we look at this slice,

2:42

we definitely see late GTA limb enhancement.

2:44

It's transmural, but there is so much of that, those islands

2:49

of hypo intensity here.

2:51

So the areas of microvascular obstruction here

2:54

that sometimes it totally almost takes up the whole

2:57

thickness of the myocardium.

2:59

The other thing that's interesting about this case,

3:02

as I scroll back and forth here to to notice

3:04

is the papillary muscles themselves

3:07

actually don't show any enhancements.

3:09

So this is, you know, suggested that, you know,

3:12

this infarct is involving vasculature

3:14

that actually supplies these papillary muscles,

3:16

which can be a risky risks, you know, potential fla,

3:20

mitral valve leaflets and those sorts of things.

3:22

So it's relevant to mention that.

3:25

But the descriptor here would be basically transmural,

3:29

late Gaden Liam enhancement,

3:31

which involves the basal two apical,

3:35

anterior lateral, and infra lateral segments with

3:39

extensive microvascular obstruction

3:43

and non enhancement of papillary muscles is kind of the way

3:46

that you would wanna describe this finding.

3:49

Let me go to, I think a four chamber view.

3:52

We'll show it nicely as well. I get a good window and level.

3:57

Again, there's so much MVO here, microvascular disease

4:01

that it's really, so this is, you know,

4:03

transmural enhancement, but all of this hypo intensity

4:06

is microvascular obstruction.

4:09

And then, you know, this is an acute case.

4:10

So we've, we've got the T two maps to look at as well.

4:14

Here are these sort of like more purpley regions are areas

4:19

of elevated T twos here qualitatively.

4:21

And then if we look at the T two map, you can see that in

4:26

that territory where there's LGE

4:28

and WAMO abnormality, there's certainly areas

4:29

of elevated T two involving those regions.

4:32

A couple of remote regions are actually involved as well,

4:35

which is kind of relevant to mention, um,

4:37

because that may imply some area at risk,

4:41

even though it's in a different vascular territory.

4:43

But all this together is consistent

4:45

with an acute myocardial infarction

4:47

and the circ territory with microvascular obstruction.