Presentation
Chest pain, elevated troponin, status post cardiac catheterization and angioplasty.
Patient Data
There is delayed myocardial enhancement involving the anteroseptal , anterior, anterolateral and lateral walls extending from base to apex consistent with the recent extensive LAD occlusion. Additional non enhancing foci in LAD distribution, is highly suspicious for microvascular obstruction with underlying hemorrhage. Significant T2 prolongation in this region is likely due to wall edema.
The first image was taken early after giving the GAD at Ti of 600 shows intra-myocardial, non enhancing foci in LAD distribution, highly suspicious for microvascular obstruction and intra-myocardial hemorrhage. The second image shows set of 2 images the one on the right was taken 4 min after contrast injection, the left one was taken 14 min after the injection, the area of the hypo enhancement with the central dark zone marked by the green arrows, indicating myocardial infarction with central zone of MVO, the extent of the MVO is less on the left image due to contrast penetration over time.
Case Discussion
There is acute myocardial infarction the distribution of LAD, constitutes 40-50% of LV mass. It is dominant left circulation that is why the apex is involved as well. A dark zone of mesocardial non-enhancement in this distribution is suggestive for microvascular obstruction with underlying hemorrhage. Significant prolongation on native T2 mapping in this region is likely due to wall edema in keeping up with acute ischemia. Severely decreased left ventricular systolic function with LVEF = 25% (contouring not included).
Diffuse pericardial enhancement seen in the setting of Dressler's syndrome.
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