Cardiac Masses - Cases

1354474 - A comprehensive approach to recognise cardiac thrombus with early gadolinium high inversion time sequence

Thursday, January 26, 2023

7:00 AM – 7:50 AM

Location: Pacific Jewel

Presenting Author(s)

MA

Mansoor Ahmad, MD

Fellow
University of Illinois-Chicago
Peoria, Illinois, United States

Primary Author(s)

MA

Mansoor Ahmad, MD

Fellow
University of Illinois-Chicago
Peoria, Illinois, United States

Co-Author(s)

VP

Vijayasree Paleru, MD

Clinical Assistance Professor
University of Illinois-Chicago, United States

Description of Clinical Presentation: 62-year-old female with a history of atrial fibrillation, and subarachnoid hemorrhage presents with dyspnea on exertion with an abnormal stress test. Transthoracic echocardiogram (TTE) showed aneurysmal apex, with severely hypokinetic mid to distal septum, with no overt evidence of LV thrombus. Cardiac MRI (CMR) was done for further evaluation and to rule out LV apical thrombus.

Diagnostic Techniques and Their Most Important Findings: Single shot 2,3, and 4 chamber early gadolinium enhancement with high inversion time (IT time of 600 ms) was added in addition to the routine axial imaging.
Fiesta imaging had shown normal LV size and moderately reduced LV ejection fraction of 40%, with akinetic mid to distal infero-septum, antero-septum, apex, with apical aneurysm. A small low signal intensity mass attached to mid to distal infero-septum was noted, suspicious for thrombus. (Image 1, Left)
Axial imaging using high IT time was suspicious for mural thrombus. (Image 2)
Four-chamber early gadolinium imaging using high IT time confirmed the low signal intensity mass as a thrombus. (Image 3)
Delayed gadolinium enhancement imaging showed transmural enhancement involving mid and distal septum, and apical aneurysm suggestive of prior transmural infarct. Mural thrombus was again visualised. (Image 1, Right)

Learning Points from this Case: Performing single-shot 2, 3 and 4 early gadolinium imaging, in addition to the routine imaging, will enhance sensitivity for the detection of small mural thrombus. We have adopted multi view imaging protocol in our practice to detect subclinical thrombi on MRI. However further studies will be needed to validate the added significance of this protocol in the future.