MRI Quiz 30.03.2017

Philip Haaf

Kardiologische Klinik, Universitätsspital Basel

Cardiac MRI

MRI made easy… kurze Einleitung (T1, T2)

MRI Quiz

Anatomie

Klinische Fälle

MRI made easy…

1. The patient is placed in a scanner (magnet)

2. A radio wave is sent in,

3. The radio wave is turned off,

4. The patient emits a signal, which is recieved and

used for

5. Reconstruction of the image.

6. Interpretation of the image.

Kardiologie From: Schild HH. MRI made easy (… well almost)

1. The patient is placed in a magnet…

Primary origin of the MR signal is from the H+ protons

H+ protons align themselves in the external magnetic field (B0 = MRI scanner).

Kardiologie

1. The patient is placed in a magnet…

MRI scanner (1.5 T/3 T) = Strong external magnetic field

1 Tesla = 10.000 Gauss (Earth magnetic field ≈ 0.5 Gauss)

Kardiologie

1. The patient is placed in a magnet…

MRI scanner (1.5 T/3 T) = Strong external magnetic field

1 Tesla = 10.000 Gauss (Earth magnetic field ≈ 0.5 Gauss)

Golden Rule in the MR department:

Only put the patient in the magnet, avoid ferromagnetic objects.

Kardiologie

Missile accident

1. The patient is placed in a magnet…

Protons (H+) ~ little planets

Constantly spinning around an axis [Eigendrehimpuls]

Moving electrical charge electrical current magnetic

field

Kardiologie

2. A radio wave is sent in

Kardiologie Cardiovascular MR Manual, Sven Plein

2. A radio wave is sent in

Kardiologie

Equilibrium

A radio wave

is sent in…

From: Schild HH. MRI made easy (… well almost)

3. The radio wave is turned off

Kardiologie

T1 relaxation

Longitudinal relaxation

process along z-axis

Different relaxation times

for Fat, Muscle, and Fluid.

Cardiovascular MR Manual, Sven Plein

3. The radio wave is turned off

Kardiologie

T1 relaxation

Longitudinal relaxation

process along z-axis

Different relaxation times

for Fat, Muscle, and Fluid.

T2 relaxation

Transverse relaxation

process along x/y-axis

Cardiovascular MR Manual, Sven Plein

4. Patient emits a signal, which is used for MR image

Which tissues have long T1 and T2 relaxation times?

Liquids have long T1 and T2.

Pathological/diseased tissues

often have a long T1 and/or T2

(fibrosis, higher water content).

Kardiologie

4. Patient emits a signal, which is used for MR image

Which tissues have short T1 and T2 relaxation times?

Fat has short T1 and T2.

Kardiologie

5. Reconstruction of the picture

Kardiologie Haaf P et al. JCMR 2016

6. Interpretation of the image

Native T1 ↑

Oedema

tissue water↑ in e.g. AMI, inflammation

Increase of interstitial space

(replacement) fibrosis, scar, cardiomyopathy,

amyloid deposition

T2 ↑

Oedema (more sensitive than T1)

Kardiologie

Native T1 ↓

Lipid overload

lipomatous metaplasia in chronic

MI, Anderson-Fabry, lipoma

Iron overload

T2 ↓

Fat

Iron (T2*↓)

Cardiac MRI

MRI made easy… kurze Einleitung

MRI Quiz

Anatomie

Klinische Fälle

Anatomie

„Ärzte ohne Anatomie sind wie

Maulwürfe:

sie arbeiten im Dunkeln,

und ihrer Hände Tagewerk sind

Erdhügel.“

Kardiologie

Friedrich Tiedemann, 1820

Kardiologie

1

2

3

Axial/Transversal

4

Kardiologie

1 =RCA

2 = Coronary Sinus

3 = Descending aorta

Axial/Transversal

4 = Papillary muscle

Kardiologie

Sagittal

1

2 3

Kardiologie

Sagittal

1

2 3

1= Truncus pulmonalis

2 = Aortenklappe

3 = Linker Vorhof

Kardiologie

Coronal

1

2

3

Kardiologie

Coronal

1

2

3

1= Truncus pulmonalis

2 = Truncus

brachiocephalicus

3 = Rechter Vorhof

Coronary Anatomy

Kardiologie

1 2

3

4

Problem?

Coronary Anatomy

Kardiologie

RCA LAD

CX

LAD

ACAOS of LAD

with interarterial,

extramural

course

ACAOS

Anomalous origin of a Coronary Artery from the Opposite Sinus

Kardiologie Lim, JCE. 2011 Nat. Rev. Cardiol

Normal

Interarterial

(intra-/extramural)

course

Prepulmonary

course

Retroaortic

course

Subpulmonic

course

Malign

ACAOS

Present in 0.2-2.0% of the population

Majority: No haemodynamic or

prognostic implication

Minority with interarterial course:

ischaemia and SCD

Kardiologie

Cardiac MRI

MRI made easy… kurze Einleitung

MRI Quiz

Anatomie

Klinische Fälle

Pericardial fat, effusion or inflammation?

Kardiologie

1

2

3

4

6. Interpretation of the image

Native T1 ↑

Oedema

tissue water↑ in e.g. AMI, inflammation

Increase of interstitial space

(replacement) fibrosis, scar, cardiomyopathy,

amyloid deposition

T2 ↑

Oedema (more sensitive than T1)

Kardiologie

Native T1 ↓

Lipid overload

lipomatous metaplasia in chronic

MI, Anderson-Fabry, lipoma

Iron overload

T2 ↓

Fat

Iron (T2*↓)

Pericardial fat, effusion or inflammation?

Kardiologie

T1=1450 ms

T1=270 ms

T1=1631 ms T1=295 ms

1

2

3

4

Is it really fat?

Ask a T1 map.

Fall: Unklarer Thoraxschmerz

Klinik

seit 4-5 Tagen wässrig, gelbliche Diarrhoe mit Bauchschmerzen im

gesamten Abdomen, kein Fieber

vor 5 Tagen beim Fitness gewesen, 10 min anhaltende thorakale Schmerzen

Aktuell Thoraxschmerz VAS 5/10 bewegungs- und lageunabhängig

kein Schwindel, kein Dyspnoe

Labor

hs-cTnT: 146 220 ng/L

D-Dimere normal

EKG

ncSR, S-Persistenz bis V6,

unspez. Reizleitungsstörung

TTE

Normalbefund

Kardiologie

Native T1 Map T2 Map

LGE Post contrast Map

LGE

LGE T2 Mapping

LGE

LGE T2 Mapping

Acute

Perimyocarditis

ASD I, ASD II, PFO?

Kardiologie

Native T1 map

Lipomatous hypertrophy of the interatrial septum (LHIAS)

non-encapsulated

non-neoplastic fatty infiltration of

the interatrial septum

sparing the fossa ovalis

Kardiologie

Native T1 map

“barbell sign”

Fall: rezidierende AP-Symptomatik

Diagnosen:

1. Hypertrophe Kardiopathie:

11/2003: normales Ruhe-EKG, unauffällige Echokardiographie

03/2010: abnorme MPS mit fraglicher Randischämie septal und

anterior

03/2010: normale Koronarangiographie

11/2014: AP und Dyspnoe

04/2015: AP und Dyspnoe Grad CCS II

01/2016: typische und atypische Beschwerden,

unauffälliges 24h- EKG betreffend relevante Arrhythmien

2. Adipositas, BMI 39,4kg/m2

3. Depression

4. Fibromyalgie

Kardiologie

Kardiologie

Cine

LAX

Modified LVOT LVOT

4 Ch 3 Ch 2 Ch

Native T1

Kardiologie

Organ?

Kardiologie

Rest ? Stress (Adenosin) ?

Kardiologie

'Splenic switch-off' to detect adenosine understress

Kardiologie Manisty C, JCMR 2014

Stress Perfusion adequate with “splenic switch off”

Kardiologie

Stress

Stress

Stress

Rest

Rest

Rest

LGE

Kardiologie

Post-contrast T1 map

Kardiologie

Diagnosis?

Hypertrophic CMP (1:500-5.000)

CMR features

• LVED wall thickness ≥15 mm (Caucasian)

≥20 mm (Black)

• septal to lateral wall thickness ratio >1.3-1.5

• localized hypertrophy with RWMA of hypertrophied segments

• Patchy mid-wall LGE of hinge points (non-specific)

• LGE localised to region of hypertrophy

• LGE (7x risk↑ for NSVT absence of LGE: reassurance)

• Native T1↑, post-contrast T1↓ (may detect subclinical/early stages)

• Myocardial crypts may help to define HCM mutation carriers without LV

hypertrophy

SCD risk

• Extent of LGE correlates with risk of SCD

• ICD ? ESC risk calculator: doc2do.com/hcm/webHCM.html

RV insertion points

Myocardial crypts

Fall: Koronare Herzkrankheit

76 Jahre alter Mann

Koronare 2-Gefäss-Erkrankung

RIVA Mitte 100%

D1 50-75%

ACD Mitte 100% (antegrade Autokollateralisation)

Viabilitäts-MRI vor geplantem AKBP

Gibt es eine (absolute oder relative) Kontraindikation für die Bypass-Operation?

Herz-MRI zur Bestimmung der präoperativen Viabilität

Apikale Akinesie ohne Hinweis auf einen apikalen Thrombus

Native T1 Mapping (without contrast agent)

55

Normal native T1

very short native T1 of 150 ms

????

Native T1 Mapping (without contrast agent)

56

Lipomatous Metaplasia? Fat?

Iron?

Haaf P et al. JCMR 2016

Native T1 Mapping (without contrast agent)

57

Methemoglobin, hemosiderin in the

thrombus ↓

paramagnetic Fe3

destroys T1 signal ↓

Very low native T1 values in apical

thrombus

EGE with long TI=600 ms

Large apical mural thrombus

EGE with long TI=600 ms

Mehrere MRI-Verlaufskontrollen unter

adäquater OAK mit stationärem apikalem

Thrombus.

„Bei nicht mobilem, organisiertem

Thrombus OP unter vertretbarem Risiko

möglich“

OP-Bericht

„Ventrikelspitze komplett rigide und verkalkt

und am ehesten einhergehend mit apikalem

Aneurysma und sukzessiver

Thrombusbildung mit Möglichkeit zur

Organisation im Laufe der Zeit.“

Fall: Flow Measurement

Frau, 53 y

Anstrengungsabhängige Dyspnoe

Palpitationen (supraventrikulär)

Grenzwertig erhöhter Pulmonaldruck

Fixe Spaltung des 2. Herztons

kvRF: nicht-kontrollierte arterielle Hypertonie

62

Flow measurement

1 ?

2 ?

3 ?

Flow measurement

1

SVC 2

Asc. Aorta 3

Desc. aorta

What is wrong?

What is wrong?

1/3

2/3

3/3

What is wrong?

Forward Backward Net forward

Ascending aorta 97 ml 1 ml 96 ml

Descending aorta 63 ml 0 ml 63 ml

SVC 114 ml 1 ml 113 ml

Pulmonary artery 160 ml 4 ml 154 ml

Qp: Qs = 154 ml / 96 ml = 1.60

L/R Shunt

3/3

2/3

1/3?

Sinus venosus defect Cavopulmonary window

SVC Cavopulmonary

window

Cavopulmonary window

Pulmonary artery dilatation

Vielen Dank.

Kardiologie

Where is the ball gone…?

Heterogeneous round

structure attached to

coumadin ridge

TOE 11.01.2017 11:00

TOE 10.02.2017

After 4 weeks

Marcoumar

CMR 11.01.2017 17:00

Where is the ball gone…?

Heterogeneous round

structure attached to

coumadin ridge

TOE 11.01.2017 11:00

TOE 10.02.2017

After 4 weeks

Marcoumar

CMR 11.01.2017 17:00

Temporal resolution

TOE > MRI (80 ms)