- Email: [email protected]
Hemorrhage in the Myocardium Following Infarction
JACC: CARDIOVASCULAR IMAGING
VOL. 3, NO. 6, 2010
© 2010 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00 DOI:10.1016/j.jcmg.2009.12.019
Hemorrhage in the Myocardium Following Infarction Charles Cannan, MBCHB,*† Ingo Eitel, MD,*‡ James Hare, MBBS,*§ Andreas Kumar, MD,* Matthias Friedrich, MD*
HEMORRHAGE IN THE MYOCARDIUM FOLLOWING MYOCARDIAL INFARCT I O N , especially larger amounts, leads to severe regional inflammation and affects the healing process as well as local physiology. Thus, detection of myocardial hemorrhage by noninvasive techniques such as cardiac magnetic resonance could add to risk stratification following myocardial infarction. Some studies on the importance of myocardial hemorrhage following myocardial infarction have used a T2-weighted short tau inversion time (STIR) method to document myocardial hemorrhage (1). Decreased signal intensity within the area of edema visualized by T2-weighted STIR has been considered indicative of myocardial hemorrhage (2). However, microvascular obstruction—which may not be associated with hemorrhage—may also be represented by a drop in signal intensity within the area of edema seen on T2-weighted STIR imaging (3) (Fig. 2B). Microvascular obstruction is also represented on late gadolinium enhancement images as a nonenhancing central core surrounded by late gadolinium enhancement (Fig. 2A and 2C; Fig. 3A and 3C).
T2* imaging of the myocardium (Fig. 2D and Fig. 3D) has been shown to detect the paramagnetic effects of iron or hemorrhage in the myocardium (4). In order to more accurately assess the presence or absence of hemorrhage within the zone of myocardial infarction, a T2* imaging technique should be considered in addition to T2-weighted imaging. We present clinical cases following ST-segment elevation myocardial infarction with similar findings on T2-weighted images and late gadolinium enhancement yet different post-infarct reperfusion treatment. The utility of T2* imaging is demonstrated (Figs. 1 and 4).
From the *Departments of Cardiac Sciences and Radiology, Stephenson Cardiovascular Magnetic Resonance Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; †Division of Cardiology, The Vancouver Clinic, Vancouver, Washington; ‡Department of Internal Medicine/Cardiology, University of Leipzig, Heart Center, Leipzig, Germany; and the §University of Queensland, Brisbane, Australia.
Address for correspondence: Dr. Matthias Friedrich, Stephenson Cardiovascular MR Center, Foothills Medical Center, 1403 - 29th Street NW, Suite 0700, 1403 - Special Services Building, Calgary, AB T2N 2T9 Canada. E-mail: [email protected].
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Cannan et al. Myocardial Hemorrhage Following Infarction
JACC: CARDIOVASCULAR IMAGING, VOL. 3, NO. 6, 2010 JUNE 2010:665– 8
Figure 1. A 72-Year-Old Woman Presented More Than 24 H After the Onset of Central Chest Pain, Nausea, and Vomiting At the time of evaluation, her symptoms had resolved. A 12-lead electrocardiogram (A) showed sinus tachycardia and left axis deviation with Q-waves present in leads V1 to V5 and residual STsegment elevation in these leads. An echocardiogram demonstrated a large anterior regional wall motion abnormality with an ejection fraction of 20%. Coronary angiography was performed demonstrating an occluded proximal left anterior descending coronary artery (arrows) seen in the right anterior oblique view (B) and the left anterior oblique caudal view (C). As the patient was more than 24 hours from the onset of the event and clinically stable, percutaneous coronary intervention (PCI) was not performed.
Figure 2. Cardiac Magnetic Resonance Was Performed 72 H After the Nonreperfused Myocardial Infarction A steady-state free precession cine of the left ventricular short-axis view is shown in Online Video 1. A representative slice obtained in the shortaxis view 10 min after gadolinium administration (late enhancement) is shown (A). A large anterior and septal area of late enhancement is seen (white arrows). A central core of unenhanced myocardium representing microvascular obstruction is seen within the area of late enhancement. This is shown in the 2-chamber long-axis view as well (C). A dense, dark area of no enhancement is seen from the proximal to mid-anterior wall going around the apex and involving the apical inferior wall. A thin layer of white late enhancement is seen around this. T2-weighted short tau inversion recovery image in a short-axis view is seen (B). A central ring of low signal intensity is seen within the edema of the myocardial infarction (red arrows). T2* imaging is shown in Panel D. There is no focal evidence of decreased signal intensity in the area of myocardial infarction to demonstrate hemorrhage and the T2* in the area of infarct was found to be generally higher than 15 ms (mean 20.1 ⫾ 1.3 ms). Hemorrhage into the myocardium following myocardial infarction requires reperfusion (spontaneous, pharmacological or mechanical). A nonreperfused myocardial infarction will therefore not have myocardial hemorrhage present and thus the area of low signal intensity in T2weighted image is unlikely due to hemorrhage. It is, however, consistent with a large area of microvascular obstruction giving the same decrease in signal intensity as seen with hemorrhage on T2-weighted imaging. This is further confirmed by the use of T2* imaging as shown above. The use of the T2-weighted images alone to assess for the presence of myocardial hemorrhage may give a false-positive result.
JACC: CARDIOVASCULAR IMAGING, VOL. 3, NO. 6, 2010 JUNE 2010:665– 8
Cannan et al. Myocardial Hemorrhage Following Infarction
667
Figure 3. A Second Clinical Case Is Presented for Comparison to Demonstrate the Findings of Cardiac Magnetic Resonance Suggesting Myocardial Hemorrhage Following Myocardial Reperfusion A 42-year-old man presented with sudden onset of severe, burning chest pain. The patient presented within an hour of symptoms to the emergency department. Twelve-lead electrocardiogram showed STsegment elevation in the inferolateral leads (A). Aspirin, clopidrogrel, and heparin were administered in the emergency department. Immediate coronary angiography demonstrated an occluded left circumflex artery seen in the right anterior oblique view (B). Primary PCI was performed with placement of a bare-metal stent in the left circumflex coronary artery (C). Abciximab was used at the time of PCI. Abbreviation as in Figure 1.
Figure 4. Cardiac Magnetic Resonance Was Performed on the Same Admission Following PCI Steady-state free precession cine of the left ventricle in the short-axis view is shown in Online Video 2. Late enhancement in the short-axis view is shown in (A) and in the 3-chamber long-axis view in (C). In the short-axis view there is enhancement seen in the lateral wall due to persistence of gadolinium in the infarcted myocardium (white arrows). A dark area within the infarct zone has no gadolinium present, consistent with microvascular obstruction. The same can be seen in the long-axis view. A T2-weighted image in the short axis at the same slice location is shown in (B). Increased signal intensity due to myocardial edema is seen in the lateral wall. A hypointense area (red arrows) corresponding to the area of microvascular obstruction seen in (A) is present. A T2* image in the short axis at the same slice location is shown in (D). The dark area on the endocardial side of the lateral wall (red arrows) shows decreased signal intensity suggesting myocardial hemorrhage. An epicardial artifact in a typical location is also noted (*). The T2* time in this area was 7.9 ⫾ 0.4 ms. In this case the area of decreased signal intensity on the T2-weighted image most likely represents both microvascular obstruction and hemorrhage. Abbreviation as in Figure 1.
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Cannan et al. Myocardial Hemorrhage Following Infarction
REFERENCES
1. Ganame J, Messalli G, Dymarkowski S, et al. Impact of myocardial haemorrhage on left ventricular function and remodelling in patients with reperfused acute myocardial infarction. Eur Heart J 2009;30:1440 –9. 2. Beek AM, Nijveldt R, van Rossum AC. Intramyocardial hemorrhage and
JACC: CARDIOVASCULAR IMAGING, VOL. 3, NO. 6, 2010 JUNE 2010:665– 8
microvascular obstruction after primary percutaneous coronary intervention. Int J Cardiovasc Imaging 2010; 26:49–55. 3. Mikami Y, Sakuma H, Nagata M, et al. Relation between signal intensity on T2-weighted MR images and presence of microvascular obstruction in patients with acute myocardial in-
farction. AJR Am J Roentgenol 2009; 193:W321– 6. 4. O’Regan DP, Ahmed R, Karunanithy N, et al. Reperfusion hemorrhage following acute myocardial infarction: assessment with T2* mapping and effect on measuring the area at risk. Radiology 2009;250:916 –22.
VOL. 3, NO. 6, 2010
© 2010 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00 DOI:10.1016/j.jcmg.2009.12.019
Hemorrhage in the Myocardium Following Infarction Charles Cannan, MBCHB,*† Ingo Eitel, MD,*‡ James Hare, MBBS,*§ Andreas Kumar, MD,* Matthias Friedrich, MD*
HEMORRHAGE IN THE MYOCARDIUM FOLLOWING MYOCARDIAL INFARCT I O N , especially larger amounts, leads to severe regional inflammation and affects the healing process as well as local physiology. Thus, detection of myocardial hemorrhage by noninvasive techniques such as cardiac magnetic resonance could add to risk stratification following myocardial infarction. Some studies on the importance of myocardial hemorrhage following myocardial infarction have used a T2-weighted short tau inversion time (STIR) method to document myocardial hemorrhage (1). Decreased signal intensity within the area of edema visualized by T2-weighted STIR has been considered indicative of myocardial hemorrhage (2). However, microvascular obstruction—which may not be associated with hemorrhage—may also be represented by a drop in signal intensity within the area of edema seen on T2-weighted STIR imaging (3) (Fig. 2B). Microvascular obstruction is also represented on late gadolinium enhancement images as a nonenhancing central core surrounded by late gadolinium enhancement (Fig. 2A and 2C; Fig. 3A and 3C).
T2* imaging of the myocardium (Fig. 2D and Fig. 3D) has been shown to detect the paramagnetic effects of iron or hemorrhage in the myocardium (4). In order to more accurately assess the presence or absence of hemorrhage within the zone of myocardial infarction, a T2* imaging technique should be considered in addition to T2-weighted imaging. We present clinical cases following ST-segment elevation myocardial infarction with similar findings on T2-weighted images and late gadolinium enhancement yet different post-infarct reperfusion treatment. The utility of T2* imaging is demonstrated (Figs. 1 and 4).
From the *Departments of Cardiac Sciences and Radiology, Stephenson Cardiovascular Magnetic Resonance Centre at the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; †Division of Cardiology, The Vancouver Clinic, Vancouver, Washington; ‡Department of Internal Medicine/Cardiology, University of Leipzig, Heart Center, Leipzig, Germany; and the §University of Queensland, Brisbane, Australia.
Address for correspondence: Dr. Matthias Friedrich, Stephenson Cardiovascular MR Center, Foothills Medical Center, 1403 - 29th Street NW, Suite 0700, 1403 - Special Services Building, Calgary, AB T2N 2T9 Canada. E-mail: [email protected].
666
Cannan et al. Myocardial Hemorrhage Following Infarction
JACC: CARDIOVASCULAR IMAGING, VOL. 3, NO. 6, 2010 JUNE 2010:665– 8
Figure 1. A 72-Year-Old Woman Presented More Than 24 H After the Onset of Central Chest Pain, Nausea, and Vomiting At the time of evaluation, her symptoms had resolved. A 12-lead electrocardiogram (A) showed sinus tachycardia and left axis deviation with Q-waves present in leads V1 to V5 and residual STsegment elevation in these leads. An echocardiogram demonstrated a large anterior regional wall motion abnormality with an ejection fraction of 20%. Coronary angiography was performed demonstrating an occluded proximal left anterior descending coronary artery (arrows) seen in the right anterior oblique view (B) and the left anterior oblique caudal view (C). As the patient was more than 24 hours from the onset of the event and clinically stable, percutaneous coronary intervention (PCI) was not performed.
Figure 2. Cardiac Magnetic Resonance Was Performed 72 H After the Nonreperfused Myocardial Infarction A steady-state free precession cine of the left ventricular short-axis view is shown in Online Video 1. A representative slice obtained in the shortaxis view 10 min after gadolinium administration (late enhancement) is shown (A). A large anterior and septal area of late enhancement is seen (white arrows). A central core of unenhanced myocardium representing microvascular obstruction is seen within the area of late enhancement. This is shown in the 2-chamber long-axis view as well (C). A dense, dark area of no enhancement is seen from the proximal to mid-anterior wall going around the apex and involving the apical inferior wall. A thin layer of white late enhancement is seen around this. T2-weighted short tau inversion recovery image in a short-axis view is seen (B). A central ring of low signal intensity is seen within the edema of the myocardial infarction (red arrows). T2* imaging is shown in Panel D. There is no focal evidence of decreased signal intensity in the area of myocardial infarction to demonstrate hemorrhage and the T2* in the area of infarct was found to be generally higher than 15 ms (mean 20.1 ⫾ 1.3 ms). Hemorrhage into the myocardium following myocardial infarction requires reperfusion (spontaneous, pharmacological or mechanical). A nonreperfused myocardial infarction will therefore not have myocardial hemorrhage present and thus the area of low signal intensity in T2weighted image is unlikely due to hemorrhage. It is, however, consistent with a large area of microvascular obstruction giving the same decrease in signal intensity as seen with hemorrhage on T2-weighted imaging. This is further confirmed by the use of T2* imaging as shown above. The use of the T2-weighted images alone to assess for the presence of myocardial hemorrhage may give a false-positive result.
JACC: CARDIOVASCULAR IMAGING, VOL. 3, NO. 6, 2010 JUNE 2010:665– 8
Cannan et al. Myocardial Hemorrhage Following Infarction
667
Figure 3. A Second Clinical Case Is Presented for Comparison to Demonstrate the Findings of Cardiac Magnetic Resonance Suggesting Myocardial Hemorrhage Following Myocardial Reperfusion A 42-year-old man presented with sudden onset of severe, burning chest pain. The patient presented within an hour of symptoms to the emergency department. Twelve-lead electrocardiogram showed STsegment elevation in the inferolateral leads (A). Aspirin, clopidrogrel, and heparin were administered in the emergency department. Immediate coronary angiography demonstrated an occluded left circumflex artery seen in the right anterior oblique view (B). Primary PCI was performed with placement of a bare-metal stent in the left circumflex coronary artery (C). Abciximab was used at the time of PCI. Abbreviation as in Figure 1.
Figure 4. Cardiac Magnetic Resonance Was Performed on the Same Admission Following PCI Steady-state free precession cine of the left ventricle in the short-axis view is shown in Online Video 2. Late enhancement in the short-axis view is shown in (A) and in the 3-chamber long-axis view in (C). In the short-axis view there is enhancement seen in the lateral wall due to persistence of gadolinium in the infarcted myocardium (white arrows). A dark area within the infarct zone has no gadolinium present, consistent with microvascular obstruction. The same can be seen in the long-axis view. A T2-weighted image in the short axis at the same slice location is shown in (B). Increased signal intensity due to myocardial edema is seen in the lateral wall. A hypointense area (red arrows) corresponding to the area of microvascular obstruction seen in (A) is present. A T2* image in the short axis at the same slice location is shown in (D). The dark area on the endocardial side of the lateral wall (red arrows) shows decreased signal intensity suggesting myocardial hemorrhage. An epicardial artifact in a typical location is also noted (*). The T2* time in this area was 7.9 ⫾ 0.4 ms. In this case the area of decreased signal intensity on the T2-weighted image most likely represents both microvascular obstruction and hemorrhage. Abbreviation as in Figure 1.
668
Cannan et al. Myocardial Hemorrhage Following Infarction
REFERENCES
1. Ganame J, Messalli G, Dymarkowski S, et al. Impact of myocardial haemorrhage on left ventricular function and remodelling in patients with reperfused acute myocardial infarction. Eur Heart J 2009;30:1440 –9. 2. Beek AM, Nijveldt R, van Rossum AC. Intramyocardial hemorrhage and
JACC: CARDIOVASCULAR IMAGING, VOL. 3, NO. 6, 2010 JUNE 2010:665– 8
microvascular obstruction after primary percutaneous coronary intervention. Int J Cardiovasc Imaging 2010; 26:49–55. 3. Mikami Y, Sakuma H, Nagata M, et al. Relation between signal intensity on T2-weighted MR images and presence of microvascular obstruction in patients with acute myocardial in-
farction. AJR Am J Roentgenol 2009; 193:W321– 6. 4. O’Regan DP, Ahmed R, Karunanithy N, et al. Reperfusion hemorrhage following acute myocardial infarction: assessment with T2* mapping and effect on measuring the area at risk. Radiology 2009;250:916 –22.