MRI Quiz 30.03 - Unispital Basel · MRI Quiz Anatomie Klinische Fälle . ... Cardiovascular MR...
Transcript of MRI Quiz 30.03 - Unispital Basel · MRI Quiz Anatomie Klinische Fälle . ... Cardiovascular MR...
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MRI Quiz 30.03.2017
Philip Haaf
Kardiologische Klinik, Universitätsspital Basel
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Cardiac MRI
MRI made easy… kurze Einleitung (T1, T2)
MRI Quiz
Anatomie
Klinische Fälle
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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)
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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
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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
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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
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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
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2. A radio wave is sent in
Kardiologie Cardiovascular MR Manual, Sven Plein
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2. A radio wave is sent in
Kardiologie
Equilibrium
A radio wave
is sent in…
From: Schild HH. MRI made easy (… well almost)
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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
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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
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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
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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
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5. Reconstruction of the picture
Kardiologie Haaf P et al. JCMR 2016
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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*↓)
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Cardiac MRI
MRI made easy… kurze Einleitung
MRI Quiz
Anatomie
Klinische Fälle
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Anatomie
„Ärzte ohne Anatomie sind wie
Maulwürfe:
sie arbeiten im Dunkeln,
und ihrer Hände Tagewerk sind
Erdhügel.“
Kardiologie
Friedrich Tiedemann, 1820
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Kardiologie
1
2
3
Axial/Transversal
4
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Kardiologie
1 =RCA
2 = Coronary Sinus
3 = Descending aorta
Axial/Transversal
4 = Papillary muscle
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Kardiologie
Sagittal
1
2 3
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Kardiologie
Sagittal
1
2 3
1= Truncus pulmonalis
2 = Aortenklappe
3 = Linker Vorhof
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Kardiologie
Coronal
1
2
3
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Kardiologie
Coronal
1
2
3
1= Truncus pulmonalis
2 = Truncus
brachiocephalicus
3 = Rechter Vorhof
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Coronary Anatomy
Kardiologie
1 2
3
4
Problem?
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Coronary Anatomy
Kardiologie
RCA LAD
CX
LAD
ACAOS of LAD
with interarterial,
extramural
course
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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
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ACAOS
Present in 0.2-2.0% of the population
Majority: No haemodynamic or
prognostic implication
Minority with interarterial course:
ischaemia and SCD
Kardiologie
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Cardiac MRI
MRI made easy… kurze Einleitung
MRI Quiz
Anatomie
Klinische Fälle
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Pericardial fat, effusion or inflammation?
Kardiologie
1
2
3
4
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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*↓)
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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.
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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
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Native T1 Map T2 Map
LGE Post contrast Map
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LGE
LGE T2 Mapping
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LGE
LGE T2 Mapping
Acute
Perimyocarditis
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ASD I, ASD II, PFO?
Kardiologie
Native T1 map
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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”
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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
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Kardiologie
Cine
LAX
Modified LVOT LVOT
4 Ch 3 Ch 2 Ch
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Native T1
Kardiologie
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Organ?
Kardiologie
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Rest ? Stress (Adenosin) ?
Kardiologie
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'Splenic switch-off' to detect adenosine understress
Kardiologie Manisty C, JCMR 2014
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Stress Perfusion adequate with “splenic switch off”
Kardiologie
Stress
Stress
Stress
Rest
Rest
Rest
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LGE
Kardiologie
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Post-contrast T1 map
Kardiologie
Diagnosis?
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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
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Myocardial crypts
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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
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Gibt es eine (absolute oder relative) Kontraindikation für die Bypass-Operation?
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Herz-MRI zur Bestimmung der präoperativen Viabilität
Apikale Akinesie ohne Hinweis auf einen apikalen Thrombus
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Native T1 Mapping (without contrast agent)
55
Normal native T1
very short native T1 of 150 ms
????
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Native T1 Mapping (without contrast agent)
56
Lipomatous Metaplasia? Fat?
Iron?
Haaf P et al. JCMR 2016
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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
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EGE with long TI=600 ms
Large apical mural thrombus
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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“
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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.“
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Fall: Flow Measurement
Frau, 53 y
Anstrengungsabhängige Dyspnoe
Palpitationen (supraventrikulär)
Grenzwertig erhöhter Pulmonaldruck
Fixe Spaltung des 2. Herztons
kvRF: nicht-kontrollierte arterielle Hypertonie
62
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Flow measurement
1 ?
2 ?
3 ?
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Flow measurement
1
SVC 2
Asc. Aorta 3
Desc. aorta
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What is wrong?
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What is wrong?
1/3
2/3
3/3
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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?
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Sinus venosus defect Cavopulmonary window
SVC Cavopulmonary
window
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Cavopulmonary window
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Pulmonary artery dilatation
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Vielen Dank.
Kardiologie
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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
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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)