T2-STIR Images Research Articles

Abstract 17755: Post-Cardiac Injury Syndrome From Robotic Atrial Septal Defect Closure: A Case of Recurrent Pericarditis

Case Presentation: A 23-year-old female rugby player presented for recurrent chest pain. She has a history of atrial septal defect (ASD) repaired with robotic ASD closure. She developed acute pericarditis postoperatively and was treated with naproxen and colchicine inpatient. Her subsequent recurrences occurred with playing rugby and were treated with ibuprofen, colchicine, and prednisone. Electrocardiogram showed sinus bradycardia at 59 beats per minute but without ST segment changes. Cardiac magnetic resonance (CMR) imaging showed mild-to-moderate circumferential pericardial late gadolinium enhancement (LGE) without signal hyperintensity on T2 STIR imaging. She was diagnosed with chronic recurrent pericarditis secondary to post-cardiac injury syndrome (PCIS) and was started on rilonacept. On follow-up after 1 year, the patient remained symptom-free. She gradually increased her activity level to walking 3 miles per day and weaned down to rilonacept monotherapy. Repeat CMR showed mild pericardial LGE that was improved from before. Discussion: PCIS is a known cause of pericarditis due to local and systemic inflammatory responses to cardiothoracic surgery. Robotic ASD closure is a minimally invasive endoscopic procedure that has a favorable safety profile; PCIS is not a previously documented complication. Treatment of pericarditis secondary to PCIS includes NSAIDs plus 3 months of colchicine for acute pericarditis, NSAIDs plus 6 months of colchicine for a first recurrence, with corticosteroids or interleukin-1 inhibitors added for further recurrences. Incomplete treatment of acute pericarditis, as in this patient's case, is a risk factor for recurrent pericarditis. The risk of recurrences with physical activity is debated and current guidelines recommend restriction from physical activity until there is no evidence of active disease, though the data is not robust. In clinical practice, a gradual return-to-play program is frequently utilized.

Abstract 19163: A Rare Case of Pericarditis as an Initial Manifestation of Rheumatoid Arthritis

Case Presentation: A 69-year-old male with a history of chronic recurrent pericarditis presented with a 3-week episode of chest pain. Despite treatment with ibuprofen, colchicine, prednisone, and anakinra, he experienced multiple flares upon attempting to wean off anakinra. His current workup revealed an elevated C-reactive protein and an echocardiogram showing a small pericardial effusion. Cardiac magnetic resonance imaging showed mild pericardial late gadolinium enhancement and increased pericardial signal on T2 STIR imaging, confirming a flare of recurrent pericarditis. The patient was started on rilonacept while being weaned off anakinra. During a follow-up after 3 months, the patient reported new onset polyarthralgia, prompting a referral to rheumatology. Rheumatoid factor was negative, but anti-citrullinated protein antibodies were positive, leading to a diagnosis of rheumatoid arthritis (RA). Azathioprine was added to the treatment regimen alongside rilonacept. Discussion: The patient's recurrent pericarditis was initially considered idiopathic but, with the subsequent RA diagnosis, it was suspected that RA may have been the underlying cause. While pericarditis is a known cardiac complication of RA, it is uncommon for pericarditis to be the initial manifestation of RA. Anakinra and rilonacept are both interleukin-1 (IL-1) inhibitors, with anakinra being FDA-approved for RA treatment. However, rilonacept has not been extensively studied in patients with RA. The case suggests that the use of certain medications may have masked RA symptoms, and as those medications were tapered, the RA symptoms became more evident. This case highlights the possibility of idiopathic pericarditis evolving into an autoimmune etiology, such as RA, over time. The combination of rilonacept and azathioprine for treating RA has limited evidence, emphasizing the need for further research in this area.

Abstract 17846: Successful Treatment of Recurrent Pericarditis With Rilonacept in the Setting Of ATRA/ATO Use in Acute Promyelocytic Leukemia

Case Presentation: A 40-year-old female was admitted for a 4-day history of recurrent left-sided pleuritic chest pain. Physical examination was pertinent for tachycardia and presence of a pericardial friction rub. Past medical history included recently diagnosed Acute Promyelocytic Leukemia undergoing active chemotherapy. Complete blood count showed leukopenia. Brain natriuretic peptide was slightly elevated at 241 pg/mL. Electrocardiogram demonstrated sinus tachycardia with diffuse ST-segment elevation and PR-segment depression (Figure 1. A). Echocardiogram showed normal biventricular function with a small posterior and lateral pericardial effusion and small pericardial effusion adjacent to the right ventricle (Figure 1. B). Cardiac magnetic resonance (CMR) imaging showed a moderate circumferential pericardial effusion and increased pericardial signal on T2 STIR imaging and late gadolinium enhancement (LGE) (Figure 1. C, D). Given the constellation of symptoms and findings, the patient was diagnosed with acute pericarditis secondary to differentiation syndrome (DS) suspected to be due to her underlying malignancy and anti-cancer treatments. She was started on aspirin and colchicine. Steroids and rilonacept were later added for incomplete treatment response. On follow-up, she was doing well. Repeat CMR demonstrated mild to moderate pericardial delayed enhancement with no edema and no pericardial effusion (Figure 1. E,F). Discussion: The presentation of DS can vary, and consensus diagnostic criteria are lacking. Cases of myopericarditis with concurrent pericardial effusions have been reported in the setting of patients undergoing chemotherapeutic treatment with differentiating agents. Management is complicated and requires multi-disciplinary care. Our case illustrates that rilonacept may be considered as an alternative to corticosteroids in the treatment of recurrent pericarditis in a patient with a hematologic malignancy.

Diagnostic Role of Native T1 Mapping Compared to Conventional Magnetic Resonance Techniques in Cardiac Disease in a Real-Life Cohort.

We sought to compare native T1 mapping to conventional late gadolinium enhancement (LGE) and T2-STIR techniques in a cohort of consecutive patients undergoing cardiac MRI (CMR). CMR was performed in 323 patients, 206 males (64%), mean age 54 ± 8 years, and in 27 age- and sex- matched healthy controls. In T2-STIR images, myocardial hyperintensity suggesting edema was found in 41 patients (27%). LGE images were positive in 206 patients (64%). T1 mapping was abnormal in 171 (49%). In 206 patients (64%), a matching between LGE and native T1 was found. T1 was abnormal in 32 out of 41 (78%) with edema in T2-STIR images. Overall, LGE and/or T2-STIR were abnormal in 209 patients, whereas native T1 was abnormal in 154 (52%). Conventional techniques and T1 mapping were concordant in 208 patients (64%). In 39 patients, T1 mapping was positive despite negative conventional techniques (12%). T1 mapping was able in conditions with diffuse myocardial damage such as cardiac amyloidosis, scleroderma, and Fabry disease (additive role in 42%). In contrast, T1 mapping was less effective in cardiac disease with regional distribution of myocardial damage such as myocardial infarction, HCM, and myocarditis. In conclusion, conventional LGE/T2-STIR and T1 mapping are complementary techniques and should be used together in every CMR examination.

Mucoid degeneration of the anterior cruciate ligament: A case study

Mucoid degeneration of anterior cruciate ligament (ACL) is a rare pathological condition characterized by knee pain and restriction of movements. In this condition, ACL is infiltrated by mucoid (glycosaminoglycans) like material within its substance. We discuss the case and present a review of literature including clinical and radiological features and management options. We encountered a 33-year-old female complaining of increasing pain in right knee since last 6 years with difficulty in squatting and sitting cross-legged. There was no history of significant trauma or instability of the knee. Clinical examination demonstrated pain on deep knee flexion, negative Lachman, and anterior drawer test. Plain radiograph of knee suggested early onset degenerative changes of knee in the form of medial joint space reduction. Magnetic resonance imaging (MRI) showed hyperintense signal in ACL substance in T1W and T2W images which is classically described as Celery Stalk appearance on T2 STIR images. This was often mistaken as partial tear of ACL. Patient was planned for diagnostic arthroscopy. During arthroscopy, ACL was occupying the whole intercondylar notch. It was hypertrophied, homogenous, and firm. Arthroscopic debulking of ACL was done cautiously and mucoid tissue was removed. The specimen was sent for histopathological examination which confirmed the diagnosis of mucoid degeneration. Post-operatively patient was relieved of symptoms and was doing well without any specific complaints like instability till last follow up at 18 months. Repeat MRI was not done as patient was not symptomatic. Mucoid ACL degeneration affects active persons in third to fourth decade of life without significant trauma. MRI is the most useful tool for diagnosis with specific findings. If this disease is considered preoperatively, it can be diagnosed early. Treatment with debulking or partial resection shows good functional results.

395 Diagnostic role of native T1 mapping compared to conventional magnetic resonance techniques in cardiac diseases: a real-life study

Abstract Aims T1 mapping is a validated technique in cardiac magnetic resonance (CMR), however in real-life clinical practice its effectiveness to diagnose myocardial disease is still unclear. To compare native T1 mapping to conventional late gadolinium enhancement (LGE) and T2-STIR techniques for the evaluation of a cohort of consecutive patients undergoing CMR for the suspicion of myocardial disease. Methods and results CMR was performed in 323 patients, 206 males (64%), mean age 54 ± 8 years, and in 27 age- and sex-matched healthy controls. LGE, T2-STIR, and pre- and post-contrast T1 mapping were acquired as suggested by the SCMR position paper. The CMR findings of global and regional T1 mapping were compared to the respective results of LGE and T2-STIR techniques. The main baseline indications for CMR were: suspicion of ARVC in 20%; non-ischaemic DCM in 19%; HCM in 16%; chest pain without obstructive coronary artery in 14% of patients (suspicion of MINOCA, Tako-tsubo or myocarditis); other indications (amyloidosis, scleroderma, previous myocardial infarction, pericarditis, LV non-compaction) in the remaining of cases. At T2-STIR images myocardial hyperintensity suggesting oedema was found in 41 patients (27%). LGE images were positive in 206 patients (64%). Native T1 mapping was abnormal in 171 (49%). In 206 patients (64%) a matching between LGE and native T1 was found (both positive in 132 and negative in 74). T1 was also abnormal in 32 out of 41 (78%) with oedema at T2-STIR. Overall, LGE and/or T2-STIR were abnormal in 209 patients, whereas native T1 in 154(52%). Conventional techniques and T1 mapping were concordant in 208 patients (64%). Conventional techniques were abnormal in 76 (24%) of patients with negative T1 mapping. Finally, in 39 patients T1 mapping was positive despite negative conventional techniques (12%). Among these latter 39 patients, only in 18 T2-STIR were acquired based on clinical decision. Then, the percentage of cases where T1 mapping could have an additive role would range between 6% and 12%. T1 mapping was particularly able in conditions with diffuse myocardial damage as cardiac amyloidosis, scleroderma and fabry disease (additive role in 42%). On contrast, T1 mapping was less effective in cardiac disease with regional distribution of myocardial damage as myocardial infarction, HCM, myocarditis (additive role in 1%). Conclusions T1 mapping may give additive information in 6–12% of patient but is less effective cardiac disease presenting with regional or segmental distribution of myocardial damage. Results of the present study suggest that conventional LGE/T2-STIR and T1 mapping are complementary techniques and should be used together in every CMR examination.

Implementation of Rapid CMR Protocol in the COVID-19 era: improving scanning efficiency and increasing scanning capacity

Funding AcknowledgementsType of funding sources: None.BackgroundDuring the COVID-19 pandemic, many non-urgent elective cardiac MRI (CMR) appointments were cancelled to minimise the risk of infection to patients coming to hospital. At the time of the first lockdown, our scanning schedule allowed on average 228 scans/month. Non-urgent elective studies were cancelled from April-June 2020, resulting in 684 scans added to the waiting list.Upon reactivation of our clinical CMR service, we developed a service quality improvement initiative consisting of using a ‘Rapid CMR’ protocol to reduce scanning time without compromising the test’s diagnostic accuracy, increase our scanning capacity and improve efficiency in reducing the backlog of requests.PurposeTo demonstrate the increased scanning capacity generated by the adoption of the "Rapid CMR" protocol.MethodsThe Rapid CMR protocol was implemented in November 2020 to all scans requiring cines, late gadolinium enhancement ± adenosine stress (non-stress and stress studies). The protocol was modelled on prior published experiences[1,2]. Patients who underwent these scans with additional imaging (e.g. T2-STIR imaging) were excluded. Data was collected from Nov 2020 to Jan 2021 and compared with the same time period the previous year when the standard protocol was used (cf. Image 1). Data collected included scan duration (time from first to last image), whether the Rapid CMR studies maintained diagnostic quality (yes/no), and the did-not-attend (DNA) rate.ResultsWith the Rapid CMR protocol 254 patients were scanned (114 non-stress, 140 stress), compared with 286 patients scanned with standard protocol in November 2019 to January 2020 (155 non-stress, 131 stress).Median scanning time in minutes for non-stress was 29 (IQR 25-34; Rapid) vs 37 (IQR 33-41; standard); (p < 0.001). For stress studies the median scanning time in minutes was 32 (IQR 28-36; Rapid) vs 41 (IQR 29-45; standard; (p < 0.001). The rate of suboptimal imaging due to patient factors (such as breathing or arrhythmia) was similar for each protocol (14.4% Rapid, 20.2% standard; p = 0.04). All Rapid studies were of diagnostic quality (Table 1). Saving c.8 minutes per scan led to an improved scanning time and schedule capacity of 21%. Fewer patients were scanned with the Rapid protocol due to pandemic related issues: patient reluctance to accept appointments (unfilled slots), cleaning measures between patients (on average ∼5 mins per slot reducing overall capacity), and a higher DNA rate: 15.3% (Rapid) vs 6.5% (standard); p < 0.001.ConclusionThe Rapid CMR protocol resulted in a statistically significant reduction in scanning time (-8 min for both stress and non-stress CMRs) increasing our schedule capacity and improving efficiency by 21%, whilst maintaining diagnostic quality. The implementation of the Rapid CMR protocol is a feasible and effective strategy to tackle the backlog of CMR clinical request accumulated during the pandemic. Figure. Image 1. Scanning Protocols Table 1. Rapid CMR study

Impact of various types of microvascular injury on area at risk in patients with primary myocardial infarction with ST segment elevation (STEMI)

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grants Council of the Russian President for state support of young Russian scientists and state support of leading scientific schools of the Russian Federation CMR can quantify the area at risk (AAR). It includes both salvaged and infarcted myocardium. Furthermore, CMR permits to determine with high sensitivity the presence of microvascular injury phenomena: intramyocardial haemorrhage (IMH) and microvascular obstruction (MVO) in patients with STEMI. There is not enough known about the relation of AAR and different types of microvascular injury. Aim. To analyze the correlation between the risk zone and the phenomena of microvascular injury in patients with primary STEMI . Materials and methods. The study included 60 patients with primary STEMI, admitted within the first 12 hours after the onset of disease, who underwent stenting of the infarct-associated coronary artery. Exclusion criteria: pulmonary edema, cardiogenic shock, estimated glomerular filtration rate &amp;lt;30 mL/min/1,73 m2 or dialysis, severe comorbidity, acute psychotic disorders and inability to undergo or contra-indications for CMR. Each patient included in the study underwent CMR imaging at day 2 post-STEMI. The AAR extent was quantified on short-axis T2-STIR images. MVO and IMH were assessed using late gadolinium enhancement and T2-weighted CMR imaging. Results. It was demonstrated that the AAR occupies 12% (7,8-17,7%) of the total myocardium. Evidence of microvascular injury phenomena was present in 41 patients (68.3%), the combination of MVO and IMH - in 22 patients (36.6%). The isolated IMH phenomenon was visualized in 9 patients (15%). The isolated MVO phenomenon was visualized in 10 patients (16,7%). Relation between of size of ARR, MVO and IMH areas is demonstrated in Table 1. A comparison study showed that the ARR was larger in patients a combination of IMH and MVO. Patients with isolated IMH and isolated MVO had an ARR similar with to a group without microvascular injury. Correlation analysis showed a moderate direct correlation between the IMH and MVO sizes, and ARR (R = 0,42; p = 0,0007 and R = 0,55, p = 0,000004). Conclusions. The analysis of the influence of different microvascular injury phenotypes on the ARR of the myocardium as assessed by CMR in the early postinfarction period in patients with primary STEMI has shown that the combination of IMH with MVO associate with a large ARR. Correlations between the IMH and MVO sizes and increased ARR have been demonstrated. Table 1. CMR parametersArea at risk, %No phenomena MVO and IMH, n = 198,1 (5-17)Isolated MVO, n = 1010,1 (9-13)Isolated IMH, n = 911 (8-12)Combination of IMH and MVO, n = 2217,3 (10-27)

Insight form cardiovascular magnetic resonance on cardiac sarcoidosis: a single centre experience

Abstract Background Clinically manifest cardiac sarcoidosis (CS) has a prevalence of 5%, but is more frequent in autoptic series (25%). Diagnosis is multiparametric and relies on clinical criteria and imaging findings, although a certain diagnosis, especially in the case of isolated CS (ICS), can only be based on endomyocardial biopsy. Cardiovascular magnetic resonance (CMR) has a comprehensive role in the assessment of CS: left ventricular (LV) dysfunction and extent of late gadolinium enhancement (LGE)are important predictors of prognosis, T2 mapping provides information on disease activity and global longitudinal strain (GLS) analysis can uncover subclinical LV impairment. Purpose To assess the prevalence of CS by CMR in patients with biopsy-proven extracardiacsarcoidosis (ECS); to describe the imaging characteristics of patients with ECS and those with high clinical suspicionof ICS; to investigate the contribution of more recent techniques to the diagnosis of CS alongside traditional LGE assessment. Methods We retrospectively enrolled 84 patients (66% males, mean age 59±13 years) referred to our centreforsuspected CS (biopsy-proven ECS, n=61; clinical presentation suggestive of CS,, n=23). CMR was performed on a 1.5T scanner, with a protocol comprehensive of biventricular functional assessment and post-contrast images; T2-STIR images (n=30), native myocardial T1 mapping (n=24) and T2 mapping (n=19) were also performed in selected patients. Tissue tracking analysis was perfomed in all patients using a dedicated software. Results Based on CMR findings, 35 patients (42%) with ECS did not show cardiac involvement (SS), 26 (31%) showed both cardiac and systemic involvement (CS-SS) and 23 (27%) had evidence of ICS (ICS). 43% of patients had history of arrhythmias, but life-threatening tachyarrhythmiaswere more frequent in patients with CS (p=0.02).Patients with CS had significantly lower LVEF (p&amp;lt;0,01), larger LV volumes (p&amp;lt;0,01) and greater LV mass (p&amp;lt;0,01). GLS values were impaired in all the groups but significantly more in patients with CS (p&amp;lt;0,01). With regards to LGE distribution, ICS patients showed a higher number of segments involved (p=0,011) as compared to CS patients. T2-STIRimages were positive in 3 out of 30 patients; T2 mapping detected myocardial oedema in 1 patient with negative T2- STIR and was positive in 7 who did not undergo traditional oedema evaluation. T1 mapping mainly confirmed the results provided by LGE, but was altered in 1 patient who could not receive gadolinium. Conclusions CMR findings consistent with CS were found in 49 patients referred for suspected CS. Patients with cardiac involvement, particularly if isolated, had significantly lower LVEF, greater LV volumes and more impaired GLS. Patients with SS, despite a normal LV function, showed mildly impaired GLS, subtending subclinical cardiac involvement. Funding Acknowledgement Type of funding source: None

P1308 A peculiar case of an acute pulmonary embolism

Abstract INTRODUCTION Cardiac tumors represent a challenging diagnosis, since the heart is an unusual site of metastasis from any malignancy.Metastatic tumors usually arise from lung, breast, renal cancer, melanomas, and lymphomas but cardiac metastization from bladder urothelial carcinoma is an extremely rare event. Here, we report the case of an 82-year-old man in whom right ventricular extension of cardiac metastization was diagnosed after a pulmonary thromboembolism. CASE REPORT DESCRIPTION An 82-year-old male was admitted to our hospital with a history of cough with streaky hemoptysis, fever and anorexia for 2 weeks, and breathlessness on exertion for 2 day. He had a history of bladder urothelial carcinoma 3 months ago, with extensive areas of epidermoid differentiation, treated only surgically with cystectomy. On physical examination, he was afebrile with a blood pressure of 135/70, tachycardic at 115beats/min, and his respiratory rate was 26breaths/min. The room air oxygen saturation was 90%, and arterial blood gas analysis revealed hypoxemia with an elevated alveolo-arterial oxygen gradient. The blood test revealed a normocytic normochromic anemia and an elevated levels of D-dimer. The echocardiogram revealed a pediculated and mobile mass attached to the apex of the right ventricle. A CT pulmonary angiography was performed and found an acute and bilateral pulmonary thromboembolism, being the patient immediately hypocoagulated. It was also performed a cardiac MRI (with and without contrast) that showed a large mass in the RV. It was arising from the RV free wall and was occupying almost half of the RV (mid and apical cavity). It had irregular edges with intermediate enhancement on T1 images and is hyperintense on T2 stir images. There was some evidence of contrast uptake on T1 weighted contrast images. It did not seem to have a significant fatty component on T1 weighted images with fat saturation. The cardiac MRI features were consistent with tumorous involvement of the RV. As part of the work for primary cancer, a colonoscopy was performed which also showed the presence of metastases in the proximal sigmoid colon from the bladder urothelial carcinoma. During hospitalization, the echocardiogram was repeated, showing an increase in the mass previously described, extending to the trunk of the pulmonary artery. Soon after, our patient died suddenly after an episode of sudden dyspnea and hemodynamic instability. CONCLUSION We experienced a very uncommon case of a metastatic cardiac tumor from urothelial carcinoma. To the best of our knowledge, only a small number of cases were reported and the reason for the rarity of cardiac metastasis from urothelial carcinoma is unclear. Although the echocardiography has become the gold standard for the diagnosis of intracardiac masses, cardiac MRI plays an important role in the evaluation of cardiac masses of non-neoplastic and neoplastic origin, allowing a comprehensive characterization of such lesions. Abstract P1308 Figure. pediculated and mobile mass (20x56mm) at

P1813Impact of cardiac MRI imaging on detection rates of myocarditis

Abstract Background The Lake Louise Criteria for the diagnosis of myocarditis by cardiac MRI (CMR) was published in 2009 (JACC April 2009; 53(17): 1475–1487) utilizing T2 STIR, “early” gadolinium enhancement (EGE) and late gadolinium enhancement (LGE). In 2012, our CMR unit adopted a chest pain protocol to enhance detection of inflammatory heart disease, using all 3 pulse sequences. In 2017, T1 relaxing mapping and T2 relaxation mapping were added to the chest pain protocol. Purpose This study was designed to assess the impact of pulse sequence changes in the CMR chest pain protocol on the detection rate of myocarditis. Methods An institutional cardiac imaging database was queried for all patients with chest pain who underwent a CMR study from 2009 thru 2018. The number of newly diagnosed cases of myocarditis per year was computed, based on the prevailing CMR diagnostic criteria at that time. The detection rate of new myocarditis cases per year, was calculated by dividing the number of new cases by the total of CMR studies performed for evaluation of chest pain, during each calendar year. Results Of the 4,946 patients in the cardiac imaging database, 2,126 patients underwent CMR imaging for complaints of chest pain. Detection rates of myocarditis by year are shown in Figure 1. Prior to inclusion of T1 STIR pulse sequences, CMR detection of myocarditis was nearly nil. Use of T2 STIR imaging allowed for an increased rate of myocarditis detection. However, addition of T1 mapping and T2 mapping in 2017 resulted in another increase in myocarditis detection rates from baseline. Figure 1. Detection rate of myocarditis. Conclusions Detection rates of myocarditis using CMR were improved by using T2 STIR pulse sequences, per the initial Lake Louise Criteria. Further enhancement of myocarditis detection rates is achieved by addition of T1 and T2 mapping. These CMR impact data provide additional support for the adoption of the recently modified Lake Louise Criteria (JACC Dec 2018; 72(24): 3158–3176).

Role of right ventricular involvement in acute myocarditis, assessed by cardiac magnetic resonance

ObjectivesRight ventricular (RV) myocarditis (MY) is unrecognized, and its prevalence is unknown. We evaluated the prevalence of RV involvement in acute MY and its association with cardiac events (cardiac death, cardiac arrest, ventricular assist device, transplantation, and appropriate ICD intervention). MethodsWe enrolled 151 patients who underwent cardiac magnetic resonance for clinical suspicion of acute MY. The CMR protocol included T2-STIR images for edema detection, post-contrast cine-SSFP for hyperemia detection and late gadolinium enhancement (LGE) images. ResultsSigns of RV MY were found in 27 patients (17.8%): RV edema at T2-STIR in all of these 27 patients; RV LGE was detected in 11 patients (7.3%). The median RV myocardial segment involved was 2 (1–3). In 13 patients, RV edema was in direct continuity with LV edema of septum and inferior wall or with anterior septum and anterior wall. In 2 patients RV myocarditis was found without any signs of LV involvement. Patients with RV MY had higher RV end-diastolic volume index (p = 0.04) and RV mass index (p = 0.03), and lower RV ejection fraction (p < 0.001) than others. At Kaplan-Meier survival curve patients with RV MY had more cardiac events than those without RV involvement (p = 0.015). RV involvement, anteroseptal LGE and RV LGE were associated with cardiac events. ConclusionRV involvement in acute MY is more frequent than previously hypothesized. RV MY was associated with cardiac events.

The role of magnetic resonance imaging (MRI) in assessment of ACL graft failure

ObjectiveThe aim of this work is to assess the role of MRI in the diagnosis of ACL graft failure and detection of complications that may follow ACL reconstruction. Patients and methodsThis study included 55 patients (50 male & 5 female) with age ranged from 18 to 60 years with a mean age of 32y. All patients underwent MRI using sagittal T1WI, T2WI, proton density WI, and axial T2 and coronal STIR images. MRI images were assessed by two radiologists who were blinded to each other. Arthroscopic knee examination was considered as a gold standard of reference. ResultsObserver one found that the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of MRI in the detection of ACL graft failure were 97.8%, 80%, 95.6%, 88.9 and 94.5% respectively. Observer two found that MRI has a sensitivity of 95.6%, specificity of 70%, PPV of 93.5%, NPV of 77.8% and accuracy of 90.9%. ConclusionMRI is considered as a reliable method for assessment of ACL graft failure and detection of complications following ACL reconstruction.

High-field MR spectroscopy in the multiparametric MRI evaluation of breast lesions

IntroductionThe aim of this work was to assess the role of 3T-MR spectroscopy (MRS) in the multi-parametric MRI evaluation of breast lesions, using a pattern-recognition based classification method. Methods291 patients (301 lesions, median 2.3cm3) were enrolled in the study (age 18–85y, mean 54.2y). T1-TSE (TR/TE=400/10ms) and T2-STIR imaging (TR/TE=5000/60ms), dynamic-contrast-enhanced MRI (DCE-MRI), apparent diffusion coefficient (ADC) (b=0–800s/mm2), and single-voxel MRS (10×10×10mm3, PRESS, TR/TE=3000ms/135ms) were performed by means of a 3T scanner. MRS results were accepted if the FWHM of the water peak was ⩽45Hz. Total choline (tCho) was considered detected if the signal-to-noise ratio (SNR) of the 3.2ppmpeak was ⩾2. A classifier-based analysis (support-vector-machines, SVM) was performed with 4-dimensional vectors including type of margin, DCE-MRI kinetic curve type, ADC mean value, and tCho SNR. A comparison with 3-dimensional vectors (without tCho SNR) was used to assess MRS impact on sensitivity, specificity, and positive-negative predictive values (PPV-NPV) for malignancy. Results228 lesions (180 malignant/48 benign) showed acceptable spectral quality. Comparison of classification results with histopathological examination of surgical specimens showed sensitivity=93.7%, specificity=84.9%, PPV=95.2%, NPV=81.5% without the inclusion of MRS in the SVM analysis. When MRS was included, the figures increased to 95.1%, 90.7%, 97.2%, and 85.0%, respectively. ConclusionsInclusion of 3T-MRS in the multi-parametric MRI evaluation of breast lesions improved the performance of the SVM-based classifier, showing a possible role of high-field MR spectroscopy in the differential diagnosis between benign and malignant breast lesions. Further research is however needed to confirm this initial evidence.

Disruptive Knee Pain in a Cross Country Runner

HISTORY: An 18 year old male cross country runner presented to the office for non-radiating sharp lateral right knee pain. He was running approximately 20 miles per week. His pain progressively worsened over the past 10 months and he could no longer run. He had no pain at rest or while walking, and no locking, clicking, snapping, or buckling. His knee did swell mildly the last time he ran. There was no trauma and he never experienced any back or hip pain. He was initially seen by his PMD who diagnosed him with a knee sprain and prescribed physical therapy (PT), rest, ice, naproxen, and ordered an MRI. The MRI showed a trace knee effusion, but was otherwise negative. After completing PT with no relief, he was referred to a sports medicine orthopedist who diagnosed him with IT band friction syndrome and continued PT with rest. He did not improve and had a landmark based cortisone injection into the distal IT band with no relief. PHYSICAL EXAMINATION: Right knee exam: normal alignment and gait, no effusion, and tender lateral joint line. Quadriceps and hamstring strength was 4/5 with 100 loss of flexion. Positive Noble’s and McMurray test. All other provocative tests were negative, including Ober. Hip exam normal DIFFERENTIAL DIAGNOSIS: IT band syndrome Occult lateral meniscus tear Patellofemoral pain syndrome Loose body TEST AND RESULTS: MRI T2 STIR images showed a subtle signal abnormality between the IT band and the lateral femoral condyle consistent with IT band friction syndrome and a minimal linear signal abnormality posterior of the lateral meniscus junction within the distal strut in the popliteus hiatus of indeterminate significance. The posterolateral corner structures were normal. A dynamic study of an ultrasound guided cortisone injection into the distal IT band insertion and then running directly afterward and at one week produced no relief. An intra-articular lidocaine injection and running directly afterward produced complete resolution of symptoms. FINAL WORKING DIAGNOSIS: Meniscal capsular disruption TREATMENT AND OUTCOMES: He had a knee arthroscopy that repaired the meniscal capsular junction tear and a hypermobile lateral meniscus. After repair, bone marrow aspirate concentrate was injected into the posterior lateral capsule. He completed post-operative PT and is now long distance running pain-free.

Diffuse, Subendocardial Vasculitis Identified by Cardiovascular Magnetic Resonance. Use of Images to Learn Pathophysiology

Diffuse Subendocardial Vasculitis (DSV), either primary or secondary, may occur during autoimmune diseases and lead to high mortality and morbidity. Recently, Cardiovascular Magnetic Resonance (CMR), a non-invasive, nonradiating technique, capable to perform tissue characterization has been used in the evaluation of cardiac vasculitis in the autoimmune diseases. CMR by performing tissue characterisation can detect diffuse, subendocardial oedema during the acute phase of DSV. To assess oedema, T2STIR images, T2 mapping and native T1 mapping can be used. Furthermore, diffuse subendocardial fibrosis can be also detected in both acute and chronic DSV. For this purpose, Late Enhanced Images (LGE) should be taken 15 minutes after the intravenous injection of the paramagnetic contrast agent gadolinium. Diffuse, subendocardial scar can be quantified and expressed as percentage of LV mass and this index have an important clinical value together with the LV ejection fraction in both ischemic and nonischemic cardiomyopathy. DSV can be identified by CMR in both acute and chronic autoimmune diseases. Acute DSV has the potential to be reversed completely by autoimmune and cardiac treatment modification. CMR is a powerful tool to early diagnose DSV and guide therapeutic decisions. However, further studies are needed to establish its impact in the patients’ risk stratification and treatment follow up.

A longitudinally extensive myelopathy in a patient with AIDS

A 42-year-old right-handed African–American woman had been diagnosed with AIDS 11 years before the abrupt onset of numbness and heaviness in her left lower limb. On presentation, her absolute CD4...

Abnormal T2-STIR magnetic resonance in hypertrophic cardiomyopathy: a marker of advanced disease and electrical myocardial instability.

BackgroundMyocardial hyperintensity on T2-weighted short-tau inversion recovery (STIR) (HyT2) cardiac magnetic resonance (CMR) images has been demonstrated in patients with hypertrophic cardiomyopathy (HCM) and is considered a sign of acute damage. The aim of the current study was to evaluate the relationship between HyT2 and both a) markers of ventricular electrical instability and b) clinical and CMR parameters.MethodsSixty-five patients underwent a thorough clinical examination, consisting of 24-h ECG recording and CMR examination including functional evaluation, T2-STIR images and late gadolinium enhancement (LGE).ResultsHyT2 was detected in 27 patients (42%), and subjects with HyT2 showed a greater left ventricle (LV) mass index (p<0.001), lower LV ejection fraction (p = 0.05) and greater extent of LGE (p<0.001) compared to those without HyT2. Twenty-two subjects (34%) presented non-sustained ventricular tachycardia (NSVT) on the 24-h ECG recording, 21 (95%) of whom exhibited HyT2. Based on the logistic regression analysis, HyT2 (odds ratio [OR]: 165, 95% CI 11–2455, p<0.001) and LGE extent (1.1, 1.0–1.3, p<0.001) served as independent predictors of NSVT, while the presence of LGE was not associated with NSVT occurrence (p = 0.49). The presence of HyT2 was associated with lower heart rate variability (p = 0.006) and a higher number of arrhythmic risk factors (p<0.001).ConclusionsIn HCM patients, HyT2 upon CMR examination is associated with more advanced disease and increased arrhythmic burden.

A fast and effective method to assess myocardial hyperemia in acute myocarditis by magnetic resonance

Current cardiac magnetic resonance (CMR) quantitative signs for the diagnosis of myocarditis include myocardial edema, fibrosis and myocardial hyperemia (Hyp). Methods for the assessment of Hyp are actually complex and time-consuming. To test a simple and fast method to assess Hyp, using contrast enhancement steady state free precession (ceSSFP) technique. CMR imaging at 1.5T was performed on 39 patients with diagnosis of acute myocarditis and in 20 healthy controls. Hyp was evaluated in systolic and diastolic frames (Hyp-SYS and Hyp-DIA) as areas of myocardial hyperintensity in ceSSFP images early after gadolinium injection. Myocardial edema was evaluated using T2-STIR images. Myocardial fibrosis was assessed in conventional late gadolinium enhancement (LGE) images. A value of ≤12.1 g of Hyp-DIA was obtained as cut-off of normality in healthy controls. Using this threshold, Hyp was detected in 30 patients (77 %) with myocarditis. LGE was detected in 36 patients (92 %), and myocardial edema in 38 (97 %) patients with myocarditis A linear relation was found between Hyp-DIA and the extent of myocardial edema (R(2) 0.48, 95 % CI 0.47-0.85, p < 0.001) and the extent of LGE (R(2) 0.41, 95 % CI 0.31-0.61, p < 0.001). Patients with hyperemia had higher levels of C-reactive protein (p < 0.001), a higher extent of LGE (p < 0.05) and a larger left atrial area (p < 0.05). ceSSFP sequence at CMR is a novel and fast method to assess myocardial hyperemia in patient with acute myocarditis. Compared with non-Hyp subjects, patients with Hyp had more signs of inflammation and myocardial damage.

Relation between myocardial oedema and cocaine assumption in heavy-user asymptomatic cocaine addicts

Purpose: A great prevalence of myocardial damage was previously reported in asymptomatic cocaine addicts by cardiovascular magnetic resonance (CMR): either myocardial fibrosis (73%) was detected by late gadolinium enhancement (LGE) technique or oedema (47%) on T2-STIR images, the latter likely secondary to a recent damage (within 1 month). To evaluate the effect of drug withdrawal on myocardial oedema, we studied by CMR subjects with chronic (>1-year) cocaine addiction, before and after 1-month rehabilitation program. Methods: Twenty-five consecutive subjects were enrolled, with psychiatric diagnosis of cocaine addiction (21 men, 37±8 years) entering the rehabilitation therapy and with no history of cardiac symptoms/disease. A first CMR examination (T2-weighted STIR images and LGE technique for evaluation of myocardial oedema and fibrosis, respectively) was performed 48h after drug withdrawal (CMR-I) and a second one (CMR-II) after 1-month rehabilitation. Abstinence was monitored by urine assay for cocaine metabolites performed within two weeks before CMR-I and every 3 days. Results: Mean reported baseline dose of cocaine as 2.9 g/assumption; abstinence was confirmed in 12 subjects (48%) by urine assay. Myocardial oedema was present in 19/25 (76%) subjects at CMR-I, while it was observed at CMR-II in 13/25 (52%). At CMR-II in 11 subjects with positive urine test (44%) myocardial oedema was detected. De-novo oedema was detected in 2 other subjects (8%). Conversely, oedema disappeared at CMR-II in 8 subjects (32%), who had signs of myocardial oedema at CMR-I and respecting abstinence at urine test. Finally in 4 (16%) oedema was absent in both CMR. A good agreement was found between the results of urinary analysis and the detection of myocardial oedema in both examinations (agreement in 91% of cases, p<0.0001). Conclusions: In heavy users, cocaine assumption was tightly associated with myocardial oedema, while 1-month ascertained drug withdrawal was frequently associated with its reversal at CMR examination.