0:00

This is a case of a 76 year old woman

0:03

with adrenal insufficiency who was found to have chest pain,

0:08

troponin elevation and global s st segment elevations on an

0:12

ACG in the emergency department.

0:14

So given sort of that presentation, she was taken to cath

0:18

and found to have a clean cast,

0:21

so no obstructive coronary artery disease in this woman.

0:24

And so came to cardiac Mr really to look for other causes,

0:28

potential causes of troponin elevation.

0:31

So again, we're kind of now in the Manoa pathway.

0:34

Is this gonna be something where it's manoa

0:36

and we have to invoke one of those diagnoses,

0:39

or is this gonna be another cause

0:41

myocarditis some of the other things.

0:43

So this is what cardiac Mr.

0:44

Again is, is really useful for helping tease out.

0:47

So starting with our two chamber view,

0:50

if anybody's seen this

0:51

before, they probably already know the diagnosis.

0:54

So we see a very, uh, vigorous contraction here

0:57

of the basal segments

0:59

and almost Kinesis, some may even use the word ballooning

1:04

of the apical segments here

1:07

that we see nicely on the two chamber.

1:10

We're gonna see similar findings here on this four chamber.

1:13

Not the best, uh, arranged four chamber here,

1:15

but we also see that kind of similar appearance here.

1:19

Keep an eye, uh, as we go

1:21

through on this location right here.

1:24

Something that we've already seen today.

1:27

We'll talk about that in a little bit.

1:28

Here's three chambers showing the same kind

1:32

of apical ballooning with really, you know,

1:34

good contraction, good function at the base.

1:38

Now looking at short axis images,

1:42

vigorous basal contraction here,

1:44

function looks excellent on these slices.

1:47

No regional wall motion abnormality here.

1:49

And then as we start to get into the mid

1:52

and even more so as we move down into the apical segments,

1:55

you really see hypokinesis and,

1:58

and what looks like thinning of all these segments.

2:02

That just gets more

2:03

and more pronounced as we move down towards the apex here.

2:08

Okay, so looking at our LGE.

2:11

So, so the question now has to become

2:13

what, what has caused this?

2:14

And we, we've gotta understand if this is gonna be a,

2:17

you know, something like a large infarct, we wouldn't expect

2:20

that based off the clean coronaries

2:22

or what else might be going on here.

2:24

So LG e can help us tease out other patterns of diseases as,

2:27

as we've seen in several cases.

2:29

So working our way from base to apex.

2:31

There's pretty much no LGE in this case.

2:35

So no Lake Catalan enhancement.

2:38

Keep going here on, just so that I can convince you of that.

2:41

We'll keep going on several of these, uh, long axis views,

2:46

no LGE, however, there is this thing that I pointed out

2:50

to you, uh, on the CA four chamber.

2:53

So that's gonna be what looks like a

2:55

thrombus again in this case.

2:57

So something definitely

2:58

That we need to report.

3:00

There's a, you know, we have this sort of poor wall motion

3:04

and it seems like a thrombus has now formed in that

3:07

location again, in this patient as well, but no LGE.

3:11

And so we're kind of moved out

3:13

of the myocarditis spectrum already seemed to have moved out

3:17

of the infarct spectrum here.

3:20

We don't have LGE,

3:22

but this was an acute injury protocol luckily.

3:24

So we do have T two weighted imaging,

3:26

and this is our T two maps.

3:28

And you can see here in the,

3:29

certainly in the apical segments, there's a lot of this kind

3:32

of purplish look, which is associated

3:34

with this color lookup table.

3:36

That's a high T twos.

3:38

And if I show you the quantification of that, sure enough,

3:41

there's really elevated T twos at the apex

3:44

and quite elevated T twos in the mid

3:46

circumferentially as well.

3:48

So given the apical ballooning appearance

3:52

that we see here, and then elevated T twos

3:57

throughout the mid

3:58

and amical regions with no LGE,

4:01

we were comfortable calling this stress-induced

4:03

cardiomyopathy or SBO cardiomyopathy, which is one

4:07

of our differentials for acute chest pain,

4:09

especially in patients with

4:10

nonobstructive coronary artery disease.

4:12

And in this particular case, it was complicated

4:14

by thrombus forming at the apex.