What pattern is seen in late gadolinium enhancement?
Intense pericardial enhancement as well as a focal patchy subepicardial pattern of late gadolinium enhancement.
What helps in the evaluation of myocardial oedema in this case?
Detection of signal differences of the inflammatory and remote myocardium in the STIR and T2 mapping sequences as well as increased signal intensity (T2 signal-intensity ratio >2) compared to the skeletal muscle in the same image.
Which pathologies can cause myocardial oedema?
Any acute myocardial injury causes myocardial oedema including myocardial inflammation, Tako-tsubo cardiomyopathy or transplant rejection, but also in acute myocardial infarction or reperfusion injury.
According to the updated Lake Louise criteria (2018), what criteria should be present for the diagnosis of myocardial inflammation?
At least one T2-based criterion for myocardial oedema and one T1-based criterion for associated non-ischaemic myocardial injury should be positive to have strong evidence for myocardial inflammation.
Findings:
Heart rate: ~65 bpm, haematocrit: 0.4
Image quality: good, occasional artifact, some movement artifacts on T1 & T2 mapping
Morphology and functional analysis (endo-volume):
LV-EDVI: 88 mL/m²
LV-ESVI: 40 mL/m²
LV-SVI: 48 mL/m²
LV-EF: 55%
cardiac output: 7.0 L/min
cardiac index: 2.8 L/min/m²
LV-ED wall mass index (without papillary muscle): 62 g/m²
Septum thickness: max. 12 mm
Findings:
mild global hypokinesia.
no regional left ventricular wall motion abnormalities.
visually normal atrial size
no significant cardiac valve pathology
no intracavitary thrombi
intense pericardial enhancement, mild pericardial effusion on the left free lateral wall
minimal bilateral pleural effusions
Myocardial tissue properties
Mildly high signal in the inferoseptal, inferior and inferolateral basal and midventricular segments on the STIR sequence indicating myocardial oedema (T2SI ratio >2)
Relatively intense pericardial enhancement as well as subepicardial and patchy intramyocardial late gadolinium enhancement (LGE) visible in the inferolateral and inferior basal segments.
T1 mapping native: mildly increased ~1060-1080 in basal inferoseptal and inferolateral segments
extracellular volume (ECV): mildly increased 32-35% inferolaterlly
T2 mapping: more inhomogeneity and throughout higher values in inferior than anterior segments
*Normal reference ranges based on local data:
-
native T1: 940-1060 ms; ECV: >32%; T2: 44-56 ms
Impression:
Inflammatory changes of the pericardium and basal inferior and inferolateral myocardium indicate perimyocarditis.
Exam courtesy: Kirsten Fleckstein (radiographer)