0:00

Okay, next case.

0:01

This is a 30 year old man with a history

0:03

of vasos spastic angina,

0:06

and we did this stress profusion, Mr.

0:08

To look for evidence of inducible ischemia, uh,

0:12

showing you the profusion images here, top row again,

0:16

stress, bottom, row rest, and then again base mid

0:21

and apex from left to right.

0:23

And what I hope you can appreciate is that at stress

0:28

we have a pretty much circumferential area

0:31

of sub endocardial hypoperfusion that we see at the base,

0:37

at the mid region and at the apex.

0:41

And if we look here on rest, kind of done at the same point

0:45

of enhancement, there is no perfusion defect.

0:48

So this again, is consistent with a reversible uh,

0:53

perfusion defect.

0:54

You know, we only see it at stress. We don't see it at rest.

0:56

But what's unique about this is now it's,

0:59

it's a circumferential defect.

1:01

So this differential diagnosis here,

1:03

first you think is this dark REM artifact

1:05

and it, it is not dark REM artifact

1:07

'cause we don't see it at rest artifact.

1:09

We should see it both. So the next thought is,

1:12

is this three vessel disease or microvascular disease?

1:16

And it's hard for us to say one

1:17

or the other on cardiac m mr,

1:20

but certainly it looks like there's something involving all

1:23

coronary artery territories.

1:24

Now of course we have to look

1:25

and see is, is any of this somehow related

1:27

to myocardial infarction or is there some other disease?

1:30

Maybe amyloidosis would be very rare in a 30 year old

1:33

that maybe amyloid causing microvascular disease could

1:36

result in something that looks like this.

1:38

So we have to look at our LG images for completeness.

1:42

Then going from base to apex.

1:45

There's really no leak GA

1:47

enhancement on any of these images.

1:50

And so no evidence of infarct

1:52

or any other kind of cardiomyopathy

1:56

that we would suggest here.

1:58

So, you know, with the history of vaso spastic angina,

2:02

seems like all coronary artery

2:04

territories seem to be involved.

2:06

And that's probably the underlying diagnosis here is

2:08

ischemia related to his vasso spastic angina.