0:00

So this case we have a 63 year old woman

0:02

with recent chest pain and elevated troponin.

0:06

She didn't have any significant ECG changes

0:09

and so the thought from the clinical team was

0:12

that this was a case of myocarditis

0:14

and again, the strength of cardiac MR is that you can kind

0:17

of rule in or out several diagnosis with one test.

0:22

So she came to cardiac MR really to look for myocarditis.

0:26

So looking here at our two chamber view

0:30

looks relatively normal.

0:34

Four chamber, pretty normal.

0:37

She does have, and I think we'll see it here, a little bit

0:41

of an abnormal appearance of her mitral valve not related

0:45

to the ischemia here.

0:46

If you take a look at this, this is kind of not normal, sort

0:49

of looks like maybe a parachute mitral valve

0:52

or some papillary muscle abnormality.

0:54

But again, that's not related to the case, uh, in terms

0:57

of her ischemic evaluation.

0:59

But she, so far on these long axis hues, I,

1:02

I don't see any regional motion abnormalities

1:06

that I would be inclined to comment on working

1:09

through her short axis here.

1:14

And as I work through looking for any areas of hypokinesis,

1:20

probably nothing that I would have commented on

1:23

prospectively working our way all the way down.

1:28

So, so far not much to uh, necessarily hang our hat on

1:33

in terms of a diagnosis.

1:36

So, uh, an important part of myocarditis evaluation

1:39

and ischemic evaluation is the LGE imaging

1:44

and then obviously the T two weighted

1:46

imaging that we talked about.

1:49

And so here is our LG imaging.

1:52

We're gonna work now from base to apex.

1:55

So here we're coming down and on slice

2:00

or two down from the base we see a sub endocardial

2:04

focus of late gadolinium enhancement kind of involving up

2:08

to about 50% of the myocardium here in the

2:11

anterolateral segment.

2:13

And this, this I would pass on by the way,

2:16

I think it's partial volume.

2:18

We need to look on the two chamber to double check that,

2:22

but you know, we'll see what it looks like there.

2:25

This may or may not be real in this case.

2:28

So definitely got something that looks like a vascular

2:31

type enhancement pattern on Lake Galium enhancement here.

2:35

And then we need to look at a few other slices

2:39

to see if we can tease out any of these other areas.

2:42

So I'm gonna go to the four chamber stack here next.

2:48

And what's interesting is actually on this four chamber

2:50

stack, we kind of see another area, focal area

2:54

of sub endocardial lake gadolinium enhancement here in the

2:57

septum that we probably

2:58

Just passed over with our short axis.

3:01

Either, you know, it was not included in the slice that we

3:05

happened to obtain through there

3:07

or we just sort of didn't see it as well.

3:09

This is gonna be our area of kind of

3:12

that sub endocardial LGE that we're talking about

3:15

on the short axis.

3:17

Look at the three chamber view here.

3:19

There's that septal kind of focal, really focal transmural,

3:23

sub endocardial focus of lake Aline enhancement there.

3:28

Then let's look at the two chamber, kind

3:31

of do our due diligence on all of these.

3:35

And again, this is the one that I wanted to look at

3:38

to look at that inferior segment.

3:40

I'm happy to pass that actually on this

3:43

we see another little, looks like a little bite out

3:46

of myocardium here

3:47

and an anterior segment that maybe we didn't appreciate

3:50

on some of the other views.

3:52

So what this is starting to look like is kind

3:55

of multiple small foci

3:57

of sub endocardial lake gadolinium enhancement.

4:00

The largest here is this one here in the kind

4:03

of basal mid anterolateral segment.

4:06

But yeah, probably what happened is usually we,

4:10

we only do about 10 slices through the short axis

4:13

and so we end up skipping about one centimeter,

4:17

10 millimeters between each of these slices.

4:19

And so some of these septal findings that we see, you know,

4:23

on these long axis views we just didn't capture

4:27

in the images that we required in short axis.

4:29

So you know, the fact that we have multiple,

4:31

they're in multiple different vascular territories,

4:33

but they all look like vascular scar,

4:35

sub endocardial near transmural.

4:38

This is a really good look for an embolic infarct,

4:41

not myocarditis in this case myocarditis enhancement.

4:44

LGE would look quite a bit different.

4:46

And the one thing that we have here to sort of

4:50

also look at is the T two weighted imaging.

4:52

This is AT two, the raw T two map data.

4:57

And I'm trying to window

4:58

and level it a bit, not a ton of anything

5:02

that I would look at qualitatively.

5:04

And the numbers I can tell you on this one didn't

5:06

necessarily show anything that was elevated.

5:09

Here's sort of our dark blood T two weighted imaging

5:14

and again, kind of unrevealing a lot

5:17

of this stuff is just artifact from kind

5:19

of stagnant blood in the ventricular cavities.

5:22

And so in this case, you know, not a ton of edema.

5:25

So another thing that really rules out,

5:28

certainly acute myocarditis,

5:30

but makes it harder to determine if these kind

5:34

of embolic looking infarcts how acute they are as well.

5:38

So in this case we said this is most consistent

5:40

with an embolic infarct that's kind of age

5:43

and determinant given that she presented with chest pain.

5:46

Could one or more of these have been acute?

5:47

Certainly, but it certainly looks more like an embolic

5:51

phenomenon.