0:00

Next case is a young man, 29 year old man

0:04

with a recent St STEMI in the LAD territory.

0:08

And I'm showing you this case to show you that

0:12

not all cardiac ischemia

0:14

and cardiac myocardial infarction, it's not all related

0:16

to coronary artery disease, uh, that we think of in terms

0:20

of, you know, atherosclerotic plaque and narrowing.

0:24

So here's his two chamber view.

0:27

We can already see on this that there's thinning

0:29

and almost aneurysmal appearance of his apex here.

0:35

Four chamber is gonna, you know, show us something similar

0:40

and same with the three chamber.

0:44

And let's go to the cenes next.

0:52

We're working our way down.

0:53

Things are looking okay,

0:55

and then we kind of get into this mid

0:59

to apical segment starting here

1:01

and we start to see some marked thinning

1:05

and, uh, hypo to kinesis

1:08

of the anter inferral septal segments here.

1:11

So this is sort of a pretty good look for LAD territory.

1:16

Lemme go back to one slice to show you a little bit more.

1:18

So here's a good slice where you see kind of normal,

1:21

relatively normal function

1:24

of certainly the infra lateral segment and,

1:27

and probably ant lateral segment as well with some

1:30

of these other segments looking a kinetic at, uh,

1:34

hypokinetic and then really thinned out and apex here.

1:38

Then I'm gonna show you the LGE images next.

1:41

So this is our short axis, LGE

1:44

and coming down from base to apex.

1:48

So as we get into those areas

1:49

that we thought were a little thin

1:51

and hypokinetic, you can see sub endocardial,

1:54

late gadolinium enhancement here involving the anter septal

1:58

segment, interseptal segment.

2:00

Probably some areas of no reflow notice here

2:04

that there's a little tiny rim of hypo intensity in

2:08

that endocardial region.

2:10

Now, you know, if this was a person who we didn't know

2:14

the etiology of his infarct in this case, you might have

2:19

to wonder I is that preserved sub endocardium?

2:23

And if it is, does that make this more of like a myocarditis

2:26

or, you know, kind of mid myocardial scar?

2:29

In this case, we know he is had an infarct in this region.

2:31

So one of the things you have

2:32

to be at least a little bit thinking about in this is this

2:37

actually kind of laminated thrombus, you know,

2:40

thrombus right along the mural surface there.

2:43

That's kind of, you see a lot in chronic mis

2:46

where people's wall motion is severely down.

2:49

So something that would need to be thought about

2:51

and commented on in this case.

2:53

And as we work our way on down, you know, through the mid

2:57

and apical segments,

2:58

We basically see the, the finding kind

3:01

of persisting all the way down

3:02

and getting to be, you know, nearly transmural in most

3:05

of these mid to apical segments.

3:08

So, you know, this is consistent

3:10

with an LAD myocardial infarction.

3:11

We kind of knew that. But

3:13

what I think is really interesting about this case is

3:16

if I show you the, this is a now

3:22

three D balanced steady state free procession acquisition

3:27

to really sort

3:28

of like a bright blood vascular imaging technique.

3:31

And if I scroll through,

3:33

I'm gonna direct your attention here to the coronary artery.

3:36

So here's, this is left main and then LAD coming off here.

3:42

And what you'll notice is

3:43

that there's a big aneurysmal segment

3:47

of the LAD here that kind of then all

3:49

of a sudden gets back to normal.

3:51

This is a 29 year old man.

3:54

Similarly, if we look on the RCA side,

3:57

so here's RCA coming out right here,

4:00

and if we follow that down, you see another area

4:04

of aneurysm in the RCA right here

4:07

and this person that then rapidly kind

4:09

of goes back to normal caliber.

4:10

So this is a person with multiple coronary artery aneurysms,

4:15

probably most likely in someone like this.

4:17

This is related to Kawasaki's disease when he was a child.

4:22

And unfortunately he probably has developed an infarct

4:27

related to some kind of thrombotic event in these aneurysms

4:31

that then embolize distally.

4:34

But the point is this is not gonna be related to, you know,

4:37

the traditional kind of coronary artery disease

4:39

that we often think of.

4:41

Another thing that I want to point out

4:44

that we noticed on this, so this is also an LGE image,

4:49

but kind of captured one shot here

4:52

of the aneurysmal LAD.

4:55

But what you might notice is that in this case we can kind

4:59

of see the lumen of the LAD here

5:02

and then we have this area of enhancement of

5:04

that vessel wall on this lake gal lumen enhanced image.

5:08

And then it turns out also if you look

5:11

on these T two weighted images, this is RCA, that area,

5:15

this is AT two weighted image

5:16

and we see a little bit of LAD.

5:18

There's actually edema.

5:19

So this was a case not only of myocardial infarction,

5:21

but coronary artery vasculitis, which may be contributing

5:24

to his symptoms and or infarction in this case.

5:28

So not everything that presents as an infarct is related to

5:33

obstructive coronary artery disease from plaque.