Septal Enhancement Research Articles

The Value of Necrotic Area Features in Contrast-Enhanced Ultrasound for Distinguishing Between Benign and Malignant Subpleural Pulmonary Lesions

ObjectiveTo analyze Necrotic Area Features of subpleural pulmonary lesions (SPLs) demonstrated by contrast-enhanced ultrasound (CEUS) and investigate their value in differentiating between malignant and benign SPLs. MethodsPatients with SPLs who underwent CEUS at our hospital from January to May 2021. The following patient information was recorded: (i) age, (ii) sex, (iii) lesion size, (iv) lesion location, (v) size of necrotic areas and (vi) necrotic area morphology, including sieve-like necrosis, necrotic area with septal enhancement, necrotic area with annular enhancement margins, and necrotic area with burr-like enhancement margins. These parameters were analyzed using univariate and multivariate logistic regression. Subgroup analyses based on lesion size were further conducted using the collected data. ResultsA total of 212 patients with 212 SPLs were enrolled, comprising 99 benign and 113 malignant cases. Significant differences were observed between malignant and benign groups in terms of age, sex, lesion size and necrotic area morphology (all, p < 0.05). ConclusionNecrotic area's features observed on CEUS were valuable for distinguishing between benign and malignant SPLs. Age, sex, lesion size and the presence of burr-like enhancement margins are identified as independent predictors of malignant lesions.

CT and MRI features of adrenal hemangioma: A study of 21 cases from two centers

PurposeTo retrospectively analyze the CT and MR imaging presentations of adrenal hemangioma (AH) and to strengthen the recognition for such tumors. Materials and methodsThis retrospective study enrolled 21 patients with 22 lesions histologically proven AH from two centers between October 2010 and November 2023. The clinical presentation and preoperative diagnosis were recorded. Two radiologists reviewed the CT and MR imaging features in consensus, including number, size, shape, boundary, attenuation, signal intensity, and dynamic enhancement pattern. ResultsThe study included nine men and twelve women (mean age 55.6 ± 12.5 years, range, 35–77 years) without hormone production. AH was unilateral in 19 cases, bilateral in 2 cases. The maximum diameter was more than 3 cm in 19/22(86 %). AHs had oval (10/22,45 %), round (5/22, 23 %), or (7/22, 32 %) multilocular shape, and well-defined boundary (18/22,82 %). On unenhanced CT, 11/20 (55 %) displayed peripheral iso-density and central hypo-intensity, 3/20 (15 %) heterogeneously hyper-density, 6/20 (30 %) hypodensity, and 14/20 (70 %) contained speckled calcification. On T2-weighted images, 7/12 (58 %) exhibited nodular hyper-intensity peripherally, markedly hyper-intensity centrally, and hypo-intense fibrotic scar in between, 5/12 (42 %) hyperintensity. On T1-weighted images, 6/12 (50 %) displayed center hyper-intensity surrounded by peripheral hypo-intensity,5/12 hypo-intensity, 1/11 (9 %) hyperintensity. On DWI, 7/12 (58 %) demonstrated peripheral hyper-intensity and central hypo-intensity, 5/12 (42 %) hyper-intensity. CT and MR imaging findings were suggestive of cystic change and necrosis (19/22,86 %, 4 cystic tumors), hemorrhage (15/22,68 %), fat (7/22, 33 %) within the tumors. CT and MR enhanced images showed peripheral nodular enhancement with (3/22,14 %) or without (13/22, 59 %) delayed central filling, nodular peripheral and center enhancement with progressive partial fill-in (2/22,9%), capsular and/or septal mild enhancement (4/22, 18 %), and capsule (16/22,73 %). The solid part was significantly enhanced, similar to the abdominal aorta (AA) with no statistical difference between the two (P > 0.05). ConclusionsSmall AHs (<3cm) have the typical imaging features of hemangioma. The imaging findings of large AHs were various, the combination of T2-hyperintense signal with inner hypo-intense fibrotic scar, speckled calcification, central extensive necrosis and hemorrhage, and nodular peripheral enhancement with persistently slight further contrast accumulation may contribute to suggest the possibility. Cystic AH should be considered as a differential diagnosis for cystic adrenal masses.

Endomyocardial biopsy in the diagnosis of cardiac sarcoidosis

Abstract Background Definite diagnosis of cardiac sarcoidosis (CS) requires proof of sarcoid granulomas in the heart. Endomyocardial biopsy (EMB) is considered a risky procedure with poor sensitivity (&amp;lt;25%) in CS (1), although comprehensive studies on its diagnostic performance are not available. Purpose We investigated the sensitivity, complications, and prognostic significance of EMB in a large cohort of patients with CS to help to choose diagnostic strategy when the disease is suspected. Methods We analysed the data of 260 consecutive patients diagnosed with CS in 1988-2022 at our institution. All met the diagnostic criteria of the Heart Rhythm Society (1). The use, findings, and complications of EMB were retrospectively noted in addition to patients’ demographics, presenting phenotype, diagnostic examinations, and future serious cardiac events. The data were retrieved from hospital records and an ongoing CS registry (2). Advanced imaging studies (cardiac magnetic resonance, positron emission tomography) were re-analysed and the follow-up information was updated until June 2023. EMB’s performance was assessed also in 30 cardiac transplant recipients having CS at the histopathologic study of the explanted heart. Results Of the 260 patients (mean age 49, 60% females), 216 (83%) underwent diagnostic EMB, 48 with repeat procedures. The sensitivity of EMB was 38%, rising to 49% after repeats. The predictors of positive EMB (Table 1) included the presenting phenotype and characteristics of the activity, extent, and location of myocardial involvement. Presentation with ventricular tachyarrhythmia, left ventricular (LV) ejection fraction ≤45%, elevation of cardiac troponins, and presence of middle or apical LV septal late gadolinium enhancement on magnetic resonance imaging were independent predictors (p&amp;lt;0.05) of positive biopsy. The sensitivity of EMB was directly related to the count of the predictors present (Figure 1). The rate of procedural complications was 9.7% overall and 0.7% for major events. One pericardial effusion needed drainage, but no deaths or long-term sequels followed the biopsies. Minor complications included 10 paroxysms of ventricular tachycardia and 6 small pericardial effusions. The 10-year rate (95% CI) of the composite of cardiac death, end-stage heart failure, or ventricular tachyarrhythmia was 55% (44-67%) with positive EMB vs 29% (17-44%) with negative EMB (p&amp;lt;0.001). When adjusted for the presenting phenotype and LV ejection fraction, EMB did not predict outcome events. In the 30 patients with CS in explanted hearts, the sensitivity of EMB, including the repeats, was 60%. Conclusion The sensitivity of EMB is better than usually presented in CS and the higher the more extensive myocardial involvement is. Risk of serious complications is &amp;lt;1%. In patients with suspect CS, the pre-test likelihood and value of positive EMB should be weighed against the procedural risks in shared decision-making when choosing the diagnostic pathway.

Myocardial parametric mapping in patients with suspected acute myocarditis: a prognosis study

Abstract Background T1 mapping and T2 mapping have become essential components of the 2018 Lake Louise criteria and obtained excellent results in diagnosing myocarditis. However, their prognostic value in acute myocarditis has not yet been well recognized or established. Purpose Our study aims to investigate the prognostic value of T1 mapping, T2 mapping, and extracellular volume fraction (ECV) in a large cohort of patients with suspected acute myocarditis. Materials Patients meeting the recommended clinical criteria for suspected acute myocarditis were consecutively enrolled. The primary endpoint is the composite of cardiac death, heart failure hospitalization, heart transplantation, sustained ventricular arrhythmia, and recurrent myocarditis, defined as major adverse cardiovascular events (MACE). All patients underwent CMR at 3.0 T scanner using a standardized, routine imaging protocol, and the three short-axis view slices (basal, mid-ventricular, and apical) were divided into 16 segments according to the American Heart Association 17-segment model (apex excluded). We also averaged the native T1 values, ECV, and T2 values of all 16 segments to get global T1 and ECV fraction values, respectively. Statistically significant parameters from univariate Cox analyses were put into multivariate Cox analysis. Results A total of 235 patients (150 men; 32±13 years) were enrolled in this study. During a mean follow-up of 43.0±3.6 months, MACE occurred in 37 patients (15.7%) and was univariably associated with heart failure presentation, left ventricular ejection fraction, left ventricular end-systolic volume index, left ventricular end-diastolic volume index, native T1 and ECV. Patients with MACE showed higher global native T1, ECV, and T2 values (1348±59 vs 1266±51, p=&amp;lt;0.001; 40.0±8.7 vs 32.8±5.9, p&amp;lt;0.001; 63.4±12.1 vs. 55.5±9.1, p=0.011), and were more likely to have tissue changes in the interventricular septum and anterior wall (Figure 1). In a series of nesting multivariable Cox regression models, the addition of native T1 (per 10-ms increase: HR, 1.128; 95% CI: 1.043, 1.220; p = 0.003; Harrell’s C-index = 0.833) or ECV (per 5% increase: HR, 1.382; 95% CI: 1.060, 1.802; p = 0.017; Harrell’s C-index = 0.847) improved prognostication compared with the model based on clinical variables, left ventricular ejection fraction, and septal late gadolinium enhancement (Harrell’s C-index = 0.762) (Figure 2). T2 in multivariate Cox regression analysis didn’t show predictive value, but his inclusion increased the C-index of the model to 0.814. Conclusions Myocardial parametric mapping not only holds substantial diagnostic value but also plays a critical role in the prognostic assessment and risk prediction of myocarditis. Their utilization in these contexts enhances the accuracy and effectiveness of clinical evaluations and decision-making processes.

Long-term prognostic performance of cardiac magnetic resonance imaging markers versus complicated clinical presentation after an acute myocarditis

BackgroundIdentifying markers associated with adverse events after acute myocarditis (AM) is relevant to plan follow-up. We assessed the prognostic performance of previously described cardiac magnetic resonance imaging (CMRI) markers and their combination: septal late gadolinium enhancement (LGE) localization and left ventricular ejection fraction (LVEF) < 50 % on baseline CMRI versus complicated clinical presentation (CCP: the presence of sustained ventricular tachycardia, or LVEF<50 % on the first echocardiogram or fulminant presentation). MethodsWe retrospectively assessed 248 AM patients (median age of 34 years, 87.1 % male) from 6 hospitals with onset of cardiac symptoms<30 days, increased troponin, and CMRI/histology consistent with myocarditis to identify those at risk of major cardiac events (cardiac death, heart transplantation, aborted sudden cardiac death, sustained ventricular tachycardia, or heart failure hospitalization). ResultsThirteen patients (5.2 %) experienced at least one major cardiac event after a median follow-up of 4.7 years with a significant hazard ratio of 35.8 for CCP vs. 9.2 for septal LGE vs. 12.4 for LVEF<50 % on baseline CMRI (p = 0.001). CCP had the best c-index to identify patients with events: 0.836 vs. 0.786 for septal LGE and 0.762 for LVEF<50 %, while the combination of CCP plus LVEF<50 % or septal LGE has the highest c-index of 0.866. All 3 markers had high negative predictive value (NPV) of ≥0.98. ConclusionsMajor cardiac events after an AM are relatively low, and CCP, septal LGE, and LVEF<50 % are significantly associated with events. These markers have especially high NPV to identify patients without events after an AM. These observations can help clinicians to monitor the patients after an AM.

Assessment of Tubo-Ovarian Abscess Using Diffusion-Weighted Magnetic Resonance Imaging

Aim: To evaluate systematically the magnetic resonance imaging (MRI) features of tubo-ovarian abscess (TOA), the efficacy of diffusion-weighted imaging (DWI) in the assessment of TOA, and the differentiation of TOA from ovarian masses. Material and methods: PubMed/MEDLINE, Web of Science, and ResearchGate were searched with keywords: Tubo-ovarian abscess and Diffusion-weighted magnetic resonance imaging. No restrictions regarding the language or publication year were applied. Inclusion criteria regarded research papers evaluating the role of MRI and DWI in the assessment of TOA, and the differentiation of TOA from ovarian tumours. Studies appearing to meet inclusion criteria were reviewed in full. Results: A total of 14 studies were included. TOA is usually presented as a multilocular, cystic, pelvic mass with a heterogeneously high signal on T2-weighted (T2W) and low signal on T1-weighted (T1W) images with the “penumbra sign” on T1W images. Following contrast administration, septal and thick wall rim enhancement could be visualized. TOA usually demonstrated hyperintensity on DWI and hypointensity on ADC maps with lower ADC values of cystic, and higher ADC values of solid components compared to ovarian malignancy. TOA was smaller in size, and invasion into adjacent organs and tubal dilatation were more frequent in TOA than in ovarian neoplasms. In comparison to other methods, DWI possessed the highest sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in differentiating TOA from adnexal tumours. Conclusions: The addition of DWI with ADC values improves the detection, characterization, and overall diagnostic accuracy of TOA and its distinction from ovarian malignancy. The combination of DWI with MRI in the assessment of TOA is obligatory.

Characteristics of imaging in hepatic inflammatory pseudotumors: a comparison between IgG4-related and IgG4-unrelated cases

ObjectivesThe objective of this study was to examine the imaging features of hepatic inflammatory pseudotumors (IPTs) associated with IgG4-related and IgG4-unrelated conditions and to enhance the approach toward distinguishing between these two types of IPTs.MethodsA retrospective study was conducted, involving 20 patients diagnosed with hepatic IPTs. Imaging procedures were conducted within a timeframe of 4 weeks prior to hepatectomy or biopsy. The imaging features were then analyzed and compared using chi-squared analysis.ResultsSeventeen (81.0%) IPTs were located in the hepatic subcapsular area; six (66.7%) IgG4-related IPTs were distributed around the hepatic hilum; and eleven (91.7%) IgG4-unrelated and three (33.3%) IgG4-related IPTs had unclear boundaries. All lesions exhibited similar characteristics in CT scans, T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and diffusion-weighted imaging (DWI), with the apparent diffusion coefficient (ADC) values slightly higher than the surrounding liver tissue. Delayed hypoenhancement, observed in five cases (55.6%), was exclusively present in IgG4-related IPTs. The remaining IPT lesions displayed progressive enhancement, septal and marginal enhancement, and persistent enhancement. Central enhancement was absent in three IgG4-related IPTs (33.3%) and ten IgG4-unrelated IPTs (83.3%). The duct-penetrating sign was identified in two IgG4-unrelated IPTs (16.7%) and seven IgG4-related IPTs (77.8%). Furthermore, seven patients with IgG4-related IPTs had additional lesions outside the liver.ConclusionsIgG4-related lesions are frequently found in the vicinity of the hepatic hilum; they display the duct-penetrating sign and affect other organs as well. Both groups exhibited progressive or persistent contrast enhancement in typical IPT lesions, but delayed hypoenhancement was only observed in the IgG4-related IPT group. IgG4-unrelated IPT lesions often exhibited indistinct boundaries lacking central enhancement.Critical relevance statementDifferences in imaging features differentiate IgG4-related and -unrelated inflammatory pseudotumors (IPT). IgG4-related lesions are frequently near the hepatic hilum, display duct-penetrating sign, and affect other organs. Only the IgG4-related group demonstrated delayed hypoenhancement. IgG4-unrelated IPT lesions often exhibited indistinct boundaries lacking central enhancement.Key PointsCompared with IgG 4-unrelated IPTs, IgG4-related IPTs show delayed hypoenhancement and affect other organs.IgG4-unrelated IPTs have unclear boundaries and lack central enhancement.Improved IPT diagnostic capabilities can help minimize additional, potentially unnecessary, interventions.Graphical

Septal late enhancement by cardiac CT is associated with repeat ablation in nonischemic cardiomyopathy patients.

Scar substrate in nonischemic cardiomyopathy (NICM) patients is often difficult to identify. Advances in cardiac imaging, especially using late iodine-enhanced computed tomography (LIE-CT), allow better characterization of scars giving rise to ventricular tachycardia (VT). Currently, there are limited data on clinical correlates of CT-derived scar substrates in NICM. We sought assess the relationship between scar location on LIE-CT and outcomes after radiofrequency catheter ablation (RFCA) in NICM patients with VT. From 2020 to 2022, consecutive patients with NICM undergoing VT RFCA with integration of cardiac CT scar modeling (inHeart, Pessac, France) were included at two US tertiary care centers. The CT protocol included both arterial-enhanced imaging for anatomical modeling and LIE-CT for scar assessment. The distribution of substrate on CT was analyzed in relation to patient outcomes, with primary endpoints being VT recurrence and the need for repeat ablation procedure. Sixty patients were included (age 64 ± 12 years, 90% men). Over a median follow-up of 120 days (interquartile range [IQR]: 41-365), repeat ablation procedures were required in 32 (53%). VT recurrence occurred in 46 (77%), with a median time to recurrence of 40 days (IQR: 8-65). CT-derived total scar volume positively correlated with intrinsic QRS duration (r = .34, p = 0.008). Septal scar was found on CT in 34 (57%), and lateral scar in 40 (7%). On univariate logistic regression, septal scar was associated with increased odds of repeat ablation (odds ratio [OR]: 2.9 [1.0-8.4]; p = 0.046), while lateral scar was not (OR: 0.9 [0.3-2.7]; p = 0.855). Septal scar better predicted VT recurrence when compared to lateral scar, but neither were statistically significant (septal scar OR: 3.0 [0.9-10.7]; p = 0.078; lateral scar OR: 1.7 [0.5-5.9]; p = 0.391). In this tertiary care referral population, patients with NICM undergoing VT catheter ablation with septal LIE-CT have nearly threefold increased risk of need for repeat ablation.

The Role of Cardiac MRI and Late Gadolinium Enhancement Grading Protocol in Evaluation of the Right Ventricle in Patients with Repaired Fallot Tetralogy

Abstract Background Tetralogy of Fallot represents 7–10% of congenital heart diseases occurring in 0.5/1000 live births and is the second most common form of complex congenital heart diseases. The four elements of Tetralogy of Fallot: (a) sub-pulmonary obstruction resulting in (b) right ventricle hypertrophy, and (c) malalignment ventricular septal defect resulting in (d) apparent overriding of the aorta over both ventricles. Primary cardiac repair for Fallot Tetralogy patients includes right ventricular out flow tract widening interventions and ventricular septal defect closure. For such patients right ventricular assessment in the postoperative period is essential in aiding further management planning. The purpose of this study is to emphasize the role of cardiac MRI in functional and structural assessment of the right ventricle in Fallot tetralogy patients after surgical management. Results The current study included 30 Fallot Tetralogy patients underwent cardiac MRI after surgical management. The majority of patients 26 out of 30 (86.6%) showed right ventricular dilatation. Four patients had right atrial dilatation. Less than one-third of patients 8 out of 30 (26.6%) had right ventricular systolic dysfunction. The majority of patients 29 out of 30 (96.6%) had main pulmonary artery regurgitation. More than half of the patients 18 out of 30 (60%) had main pulmonary artery stenosis. The majority of patients 25 out of 30 (83.3%) had right ventricular outflow tract late gadolinium enhancement and 18 patients (60%) had base of interventricular septal enhancement. Conclusions MRI is an extremely useful imaging method for functional and structural assessment of the right ventricle after surgical repair of Fallot tetralogy patients with absence of ionizing radiation.

Elevated myocardial extracellular volume fraction is associated with the development of conduction pathway defects following transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has become an established method of aortic stenosis treatment but suffers from the risk of heart block and pacemaker requirement. Risk stratification for patients who may develop heart block remains imperfect. Simultaneously, myocardial fibrosis as measured by cardiac magnetic resonance imaging (CMR) has been demonstrated as a prognostic indicator of ventricular recovery and mortality following TAVR. However, the association of CMR-based measures of myocardial fibrosis with post-TAVR conduction disturbances has not yet been explored. We evaluated whether myocardial fibrosis, as measured by late gadolinium enhancement and extracellular volume (ECV) from CMR would be associated with new conduction abnormalities following TAVR. One hundred seventy patients who underwent CMR within 2 months before TAVR were retrospectively reviewed. Septal late gadolinium enhancement (LGE) and ECV measurements were made as surrogates for replacement and interstitial fibrosis respectively. New conduction abnormalities were defined by the presence of transient or permanent atrioventricular block, new bundle branch blocks, and need for permanent pacemaker. Association of myocardial fibrosis and new conduction derangements were tested using receiver operator curve (ROC) and regression analysis in patients with and without pre-existing conduction issues. Forty-six (27.1%) patients developed post-TAVR conduction deficits. ECV was significantly higher among patients who experienced new conduction defects (26.2 ± 3.45% vs. 24.7% ± 4.15%, p value: 0.020). A greater fraction of patients that had new conduction defects had an elevated ECV of ≥26% (54.3% vs. 36.3%, p value: 0.026). ECV ≥ 26% was independently associated with the development of new conduction defects (odds ratio [OR]: 2.364, p value: 0.030). ROC analysis revealed a significant association of ECV with new conduction defects with an area under the receiver operating characteristic curve (AUC) of 0.632 (95% confidence interval: 0.555-0.705, p value: 0.005). The combination of prior right bundle branch block (RBBB) and ECV revealed a greater AUC of 0.779 (0.709-0.839, p value: <0.001) than RBBB alone (Delong p value: 0.049). No association of LGE/ECV with new conduction defects was observed among patients with pre-existing conduction disease. Among patients without baseline conduction disease, ECV was independently associated with the development of new conduction deficits (OR: 3.685, p value: 0.008). The present study explored the association of myocardial fibrosis, as measured by LGE and ECV with conduction deficits post-TAVR. Our results demonstrate an association of ECV, and thereby interstitial myocardial fibrosis, with new conduction derangement post-TAVR and introduce ECV as a potentially new risk stratification tool to identify patients at higher risk for needing post-TAVR surveillance and/or permanent pacemaker.

Contrast-enhanced ultrasound features of hepatic sarcomatoid carcinoma different from hepatocellular carcinoma.

Hepatic sarcomatoid carcinoma (HSC) is a rare malignancy of the liver. The ultrasound and clinical features of HSC have not been determined. To investigate and compare the ultrasound and clinical features of HSC and hepatocellular carcinoma (HCC), and to reveal the valuable features of HSC. The ultrasound features and clinical data of pathologically proven HSC (n = 37) were compared with HCC (n = 92) in a matching ratio of 1:4 using the propensity score (age, gender and tumor size). The HSC patients were more likely to accompany with clinical symptoms and vascular invasion than HCC patients (40.5% vs 17.4%, 24.3% vs 6.5%, P < 0.05). The size of HSCs was significantly larger than that of HCCs (P < 0.05). The proportion of patients with elevated alpha-fetoprotein was significantly lower in HSC (35.1% vs 54.3%, P < 0.05). On gray-scale ultrasound images, the HSCs were more likely to demonstrate as indistinct margin and irregular shape lesions compared to HCCs (78.4% vs 48.8%; 70.3% vs 23.9%, P < 0.05). Under color Doppler flow imaging (CDFI), the blood flow signals were more frequently detected in HSC lesions (75.7% vs 56.5%, P < 0.05). Resistance index (RI) was higher in HSCs than in HCCs [0.78 (0.70,0.82) vs 0.70 (0.62,0.76), P < 0.05]. On contrast-enhanced ultrasound (CEUS), HSCs mainly showed entirety heterogeneous hyper-enhancement (48.6%), entirety homogeneous enhancement (18.9%), peripheral and internal septal enhancement (18.9%). The incidence of non-enhanced areas inside HSC lesions was higher than that inside HCC lesions (56.8% vs 31.5%, P < 0.05). During the portal venous and late phases, most of the lesions revealed hypo-enhancement in both groups, whereas earlier washout was observed in HSCs [43.0 s (30.5,58.0) vs 60.0 s (46.3,100.0), P < 0.05]. CEUS features are useful in preoperative and non-invasive differentiation of hepatic sarcomatoid carcinoma and hepatocellular carcinoma.

The CT and MRI features of benign calvarium and skull base osteoblastoma.

We retrospectively reviewed the CT and MRI features of patients with benign osteoblastoma in the calvarium and skull base (CSBOB). Nine cases of pathologically confirmed benign CSBOB were analysed retrospectively. The patients had undergone CT and/or MRI. Tumour location, size, and imaging features were reviewed and recorded. The patients included four males and five females with a mean age of 27.0 years (age 14-40 years). The tumours were located in the frontal bone in 3 patients, the occipital bone in 3 patients, and in the parietal bone, sphenoid bone, and skull base in 1 patient each. On CT, the tumours measured 5.1 ± 3.3 (1.8-8.4) cm. Seven tumours were shown to have caused expansile bony destruction with an eggshell appearance and varying degrees of calcification or matrix mineralization. Multiple septa were observed in 5 tumours. Intracranial growth was observed in 5 tumours. On MRI, 7 tumours showed heterogeneous hypo- to isointensity on T1WI. Heterogeneous high signal patterns with low signal rims and septa were observed in 6 tumours on T2WI, and 4 showed a fluid-fluid level. On contrast-enhanced imaging, 6 tumours showed peripheral and septal enhancement, and 2 showed the dural tail sign. Benign CSBOB is a rare tumour characterized by expansile bony destruction, septa, a sclerotic rim and calcification or matrix mineralization on CT and MRI. The findings from this study contribute to a better understanding of benign CSBOB and provide valuable imaging features that can aid in its diagnosis and differentiation from other tumours in the calvarium and skull base.

Septal scar as a barrier to left bundle branch area pacing.

The use of left bundle branch area pacing (LBBAP) for bradycardia pacing and cardiac resynchronization is increasing, but implants are not always successful. We prospectively studied consecutive patients to determine whether septal scar contributes to implant failure. Patients scheduled for bradycardia pacing or cardiac resynchronization therapy were prospectively enrolled. Recruited patients underwent preprocedural scar assessment by cardiac MRI with late gadolinium enhancement imaging. LBBAP was attempted using a lumenless lead (Medtronic 3830) via a transeptal approach. Thirty-five patients were recruited: 29 male, mean age 68years, 10 ischemic, and 16 non-ischemic cardiomyopathy. Pacing indication was bradycardia in 26% and cardiac resynchronization in 74%. The lead was successfully deployed to the left ventricular septum in 30/35 (86%) and unsuccessful in the remaining 5/35 (14%). Septal late gadolinium enhancement was significantly less extensive in patients where left septal lead deployment was successful, compared those where it was unsuccessful (median 8%, IQR 2%-18% vs. median 54%, IQR 53%-57%, p<.001). The presence of septal scar appears to make it more challenging to deploy a lead to the left ventricular septum via the transeptal route. Additional implant tools or alternative approaches may be required in patients with extensive septal scar.

CT and MRI Features of Chondrosarcoma in the Mastoid Involving the Facial Nerve in Comparison to Facial Nerve Schwannoma.

Chondrosarcoma in the mastoid is extremely rare, and it is easily misdiagnosed as a facial nerve schwannoma. To identify and compare computed tomography (CT) and magnetic resonance imaging (MRI) features of chondrosarcoma in the mastoid involving the facial nerve, including diffusion-weighted MRI characteristics, with those of facial nerve schwannoma. CT and MRI features of 11 chondrosarcomas in the mastoid involving the facial nerve and 15 facial nerve schwannomas, confirmed by histopathology, were retrospectively reviewed. The tumor location, size, morphological features, bone change, calcification, signal intensity, texture, enhancement characteristics, the extent of lesions, and apparent diffusion coefficients (ADCs) were evaluated. On CT imaging, calcification could be found in 81.8% of chondrosarcomas (9/11) and 33.3% of facial nerve schwannomas (5/15). Chondrosarcoma in the mastoid appeared significantly hyperintense on T2-weighted images (T2WI) with low signal intensity septa in eight patients (72.7%, 8/11). After contrast, all chondrosarcomas showed inhomogeneous enhancement, and septal and peripheral enhancement could be found in six cases (54.5%, 6/11). Facial nerve schwannoma demonstrated inhomogeneous hyperintensity on T2WI in 12 cases (80%, 12/15), with obvious hyperintense cystic changes in seven cases. There were significant differences in calcification (P=0.014), T2 signal intensity (P=0.006), and septal and peripheral enhancement (P=0.001) between chondrosarcomas and facial nerve schwannomas. The ADCs of chondrosarcoma were significantly higher than those of facial nerve schwannomas (P<0.001). CT and MRI with ADCs had the potential to improve the diagnostic accuracy of chondrosarcoma in the mastoid involving the facial nerve.

Septal Midwall Late Gadolinium Enhancement in Ischemic Cardiomyopathy and Nonischemic Dilated Cardiomyopathy—Characteristics and Prognosis

Septal midwall late gadolinium enhancement (LGE) is a characteristic finding on cardiac magnetic resonance imaging (CMR) in nonischemic dilated cardiomyopathy (DCM) and is associated with adverse events. Its significance in ischemic cardiomyopathy (ICM) is unknown. With this multicenter observational study, we aimed to study the characteristics of septal midwall LGE and evaluate its prognostic value in ICM. A total of 1,084 patients with an impaired left ventricular (LV) ejection fraction (<50%) on LGE-CMR, either because of ICM (53%) or DCM, were included retrospectively. Septal midwall LGE was defined as midmyocardial stripe-like or patchy LGE in septal segments and was present in 10% of patients with ICM compared with 34% of patients with DCM (p<0.001). It was significantly associated with larger LV volumes and lower LV ejection fraction, irrespective of etiology. The primary endpoint was all-cause mortality and secondary endpoint was ventricular arrhythmias (VAs), including resuscitated cardiac arrest, sustained VA, and appropriate implantable cardioverter-defibrillator (ICD) therapy. During a median follow-up of 2.7years, we found a significant association between septal midwall LGE and mortality in patients with DCM (hazard ratio [HR] 1.92, p=0.03), but not in patients with ICM (HR 1.35, p=0.39). Risk of VAs was significantly higher in patients with septal midwall LGE on CMR, both in DCM (HR 2.80, p<0.01) and in ICM (HR 2.70, p<0.01). In conclusion, septal midwall LGE, typically seen in DCM, was also present in 10% of patients with ICM and was associated with increased LV dilation and worse function, irrespective of etiology. When present, septal midwall LGE was associated with adverse outcome.

1070 PROGNOSTIC PERFORMANCE OF CARDIAC MAGNETIC RESONANCE IMAGING MARKERS VERSUS COMPLICATED CLINICAL PRESENTATION AFTER AN ACUTE MYOCARDITIS

Abstract Background Identifying markers associated with adverse events after acute myocarditis (AM) is clinically relevant to plan follow-up. We aimed to compare the prognostic performance of previously described cardiac magnetic resonance imaging (CMRI) markers: septal late gadolinium enhancement (LGE) localization and left ventricular ejection fraction (LVEF)&amp;lt;50% on baseline CMRI, versus complicated clinical presentation (CCP) of AM (defined as the presence of sustained ventricular arrhythmias or LVEF &amp;lt;50% on the first echocardiogram or fulminant presentation). Methods We retrospectively assessed 248 AM patients from 6 hospitals with onset of cardiac symptoms &amp;lt;30 days, increased troponin, and CMRI consistent with myocarditis. Results Patients had a median age of 34 years (male prevalence of 87.1%) and a median LVEF of 61% on baseline CMRI. Thirteen patients (5.2%) experienced at least one major cardiac event after a median follow-up of 1708 days. Among these 13 patients, 10 (76.9%) had septal LGE, 8 (61.5%) had LVEF&amp;lt;50%, and 12 (92.3%) had a CCP. The best performance was observed for CCP in terms of sensitivity (0.99), and for LVEF&amp;lt;50% in terms of specificity (0.90). The negative predictive value was at least 0.98 for all markers. Conclusions Major cardiac events after an AM are relatively low, and septal LGE, LVEF&amp;lt;50% on CMRI, and CCP are significantly associated with events. The most relevant finding is the high NPV of these markers to identify patients without events after an AM. This observation can help clinicians to monitor the patients after an AM, in fact, patients without these markers had an uneventful follow-up. Figure A] Acute Myocarditis with complicated clinical presentation (CCP AM) vs non-complicated clinical presentation (NO CCP AM); B] FE &amp;gt; 50% vs FE &amp;lt; 50% at basal cardiac MRI; C] Presence of septal late gadolinium enhancemnet (LGE) vs no septal LGE on basal cardiac MRI.

Radiological evaluation of ovarian mass by contrast-enhanced computed tomography abdomen with clinicopathological correlation in Eastern Indian population

Background: Adenexal masses present diagnostic challenges. After identification of the ovarian mass, the most critical step is to determine the degree of suspicion for malignancy. It is mainly based on imaging modalities and clinicopathological correlation. Aims and Objectives: This radiological study was designed to differentiate benign and malignant ovarian masses by contrast enhanced-computed tomography (CECT) of abdomen and correlation of the radiological findings with histopathological report. Materials and Methods: This was a hospital-based prospective study conducted in Department of Radiodiagnosis, Nilratan Sircar Medical College and Hospital, Kolkata during January 2019–June 2020. The study was done on clinically suspected 50 patients of 15–50 years with ovarian mass having CECT diagnosed solid/complex solid cystic mass. Results: Among 50 cases under study, 37(74.0%) were benign which was significantly higher than that of malignant cases (26.0%). Malignancy was significantly associated with wall irregularity, solid-cystic composition, presence of thick septations, septal enhancement, presence of both septal, and solid enhancement pattern in CECT. Conclusion: Based on the results of the present study, multi-detector contrast-enhanced CT could be a rapid non-invasive and cost-effective step in the evaluation of ovarian masses.

Patterns of cardiovascular magnetic resonance inflammation in acute myocarditis from South Asia and Middle East.

BackgroundCardiovascular magnetic resonance (CMR) is the test of choice for diagnosis and risk stratification of myocardial inflammation in acute viral myocarditis. The objective of this study was to assess patterns of CMR inflammation in a cohort of acute myocarditis patients from Northern Africa, Asia, and the Middle East using unsupervised machine learning.MethodsA total of 169 racially and ethnically diverse adults (18 years of age) with CMR confirmed acute myocarditis were studied. The primary outcome was a combined clinical endpoint of cardiac death, arrhythmia, and dilated cardiomyopathy. Machine learning was used for exploratory analysis to identify patterns of CMR inflammation.ResultsOur cohort was diverse with 25% from Northern Africa, 33% from Southern Asia, and 28% from Western Asia/the Middle East. Twelve patients met the combined clinical endpoint – 3 had arrythmia, 8 had dilated cardiomyopathy, and 1 died. Patients who met the combined endpoint had increased anterior (p = 0.034) and septal (p = 0.042) late gadolinium enhancement (LGE). Multivariable logistic regression, adjusted for age, gender, and BMI, found that patients from Southern Asia (p = 0.041) and the Middle East (p = 0.043) were independently associated with lateral LGE. Unsupervised machine learning and factor analysis identified two distinct CMR patterns of inflammation, one with increased LGE and the other with increased myocardial T1/T2.ConclusionsWe found that anteroseptal inflammation is associated with worsened outcomes. Using machine learning, we identified two patterns of myocardial inflammation in acute myocarditis from CMR in a racially and ethnically diverse group of patients from Southern Asia, Northern Africa, and the Middle East.

Cardiac MRI Features and Prognostic Value in Immune Checkpoint Inhibitor-induced Myocarditis.

Background Cardiac MRI features are not well-defined in immune checkpoint inhibitor (ICI)-induced myocarditis (ICI-M), a severe complication of ICI therapy in patients with cancer. Purpose To analyze the cardiac MRI features of ICI-M and to explore their prognostic value in major adverse cardiovascular events (MACE). Materials and Methods In this retrospective study from May 2017 to January 2020, cardiac MRI findings (including late gadolinium enhancement [LGE], T1 and T2 mapping, and extracellular volume fraction [ECV] z scores) of patients with ICI-M were compared with those of patients with cancer scheduled to receive ICI therapy (pre-ICI group) and patients with viral myocarditis. As a secondary objective, the potential value of cardiac MRI for predicting MACE in patients with ICI-M by using Cox proportional hazards models was explored. Results Thirty-three patients with ICI-M (mean age ± standard deviation, 68 years ± 14; 23 men) were compared with 21 patients scheduled to receive to ICI therapy (mean age, 65 years ± 14; 14 men) and 85 patients with viral myocarditis (mean age, 32 years ± 13; 67 men). Compared with the pre-ICI group, patients with ICI-M showed higher global native T1, ECV, and T2 z scores (0.03 ± 0.85 vs 1.79 ± 1.93 [P < .001]; 1.34 ± 0.57 vs 2.59 ± 1.97 [P = .03]; and -0.76 ± 1.41 vs 0.88 ± 1.96 [P = .002], respectively), and LGE was more frequently observed (27 of 33 patients [82%] vs two of 21 [10%]; P < .001). LGE was less frequent in patients with ICI-M than those with viral myocarditis (27 of 33 patients [82%] vs 85 of 85 [100%]; P < .001) but was more likely to involve the septal segments (16 of 33 patients [48%] vs 25 of 85 [29%]; P < .001) and midwall layer (11 of 33 patients [33%] vs two of 85 [2%]; P < .001). Septal LGE was the only cardiac MRI predictor of MACE at 1 year even after adjustment for peak troponin (adjusted hazard ratio, 2.7 [95% CI: 1.1, 6.7]; P = .03). Conclusion Cardiac MRI features of immune checkpoint inhibitor (ICI)-induced myocarditis (ICI-M) seem to differ from those in patients scheduled to receive ICIs and patients with viral myocarditis. Septal late gadolinium enhancement might be a predictor of major cardiovascular events in patients with ICI-M. Clinical trial registration no. NCT03313544 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Edelman and Pursnani in this issue.

Coronary artery branch misinterpreted as pathological septal late gadolinium enhancement: a common pitfall during evaluation of athletes with ventricular arrhythmias.

Cardiac magnetic resonance (CMR) is increasingly prescribed in sport cardiology during pre-participation screening. Common indications are electrocardiography abnormalities, rhythm disturbances, cardiovascular symptoms like syncope, family history for hereditary cardiomyopathy or sudden death, which are all conditions that increase the likelihood of underlying cardiac disease at risk of arrhythmic events with exercise. However, despite its unique capability of tissue characterization and accurate thickness, volume, and function estimation, CMR can be prone to false-positive findings, especially during late gadolinium enhancement (LGE) assessment, leading to cardiac disease overdiagnosis and inappropriate disqualification from competitive sports activity. Herein, we report the case of a 45-year-old male middle distance runner, who came to our attention for frequent premature ventricular beats. Arrhythmias had a prevalent right bundle branch morphology and showed a mild worsening in amount and complexity during effort. Echocardiogram was unremarkable. Conversely, the CMR post-contrast images detected a mid-wall hyperintense signal on basal interventricular septum,...