Myocardial ischemia

Case contributed by Tim Luijkx


History of coronary artery disease and infarction of inferior wall of left ventricle. Ischemia?

Patient Data

Age: 60
Gender: Male

Normal ventricular diameters (LV 54 mm and RV 32 mm). Interventricular septum within normal range (10 mm). LV ejection fraction within normal range (53%).

Slight hypokinesia of apex and anterior apical wall.
Late enhancement of inferior apical LV wall, <50% wall thickness, in keeping with infarcted, but viable myocardium (short axis viability series).
Possible late enhancement of anterior apical LV wall, no clear infarction.

On perfusion images there is a perfusion defect at the site of inferior wall infarction. On rest images otherwise normal enhancement of myocardium. However, on stress images there is a subendocardial perfusion defect of the basal and mid-ventricular midseptal wall, suggestive of ischemia (perfusion stress video mid-ventricular).

- Ischemia midventricular and basal central interventricular septum.
- Infarcted, but viable inferior apical LV wall.
- Slightly hypokinetic anterior apical LV wall with minimal late enhancement, not convincing for true infarction.

Case Discussion

This study is a good example of the differentiating capabilities of cardiac perfusion stress MR imaging, showing both frank infarction and ischemia. The latter is only evident on stress images, whereas the former is also present on rest images and late enhancement series.

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