Differentiation of myocardial scar from potential pitfalls and artefacts in delayed enhancement MRI

Abstract

ABSTRACT. Delayed enhancement cardiac magnetic resonance (DE-CMR) imaging is used increasingly to identify and quantify focal myocardial scar. Our objective is to describe factors used in the interpretation of DE-CMR images and to highlight potential pitfalls and artefacts that mimic myocardial scar. Inversion recovery gradient recalled echo sequence is commonly accepted as the standard of reference for DE-CMR. There are also alternative sequences that can be performed in a single breath-hold or with free breathing. Radiologists need to be aware of factors affecting image quality, and potential pitfalls and artefacts that may generate focal hyperintense areas that mimic myocardial scar. Delayed enhancement cardiac magnetic resonance (DE-CMR) imaging can identify the presence, location and extent of myocardial scar (dense myocardial fibrosis) due to ischaemic and non-ischaemic heart diseases. This technique is also called late gadolinium-enhanced MRI (LGE-MRI), myocardial delayed enhanced (MDE) MRI and delayed hyperenhanced MRI (DHE-MRI) in the literature. DE-CMR has been shown to be more sensitive than other imaging methods in detecting small subendocardial infarctions [1] and has recently been used in population-based studies to assess the presence of myocardial scar [2,3]. The technique is relatively straightforward to implement, and images can be interpreted visually for the presence of myocardial scar (hyperenhanced region) without the need for post-processing.This article is intended to describe quality control procedures, factors affecting image quality, assessment of myocardial scar, and potential pitfalls and artefacts causing focal hyperintensities that mimic myocardial scar in delayed enhancement imaging.

Cardiovascular Magnetic Resonance Imaging in the Evaluation of the Right Ventricle and its Pathologies

“…36 A avaliação de áreas infartadas em VD pela RMC é realizada mediante realce tardio, método já estabelecido para diagnóstico de infarto. 37 A sua importância estabelecese por permitir o achado de miocárdio infartado no VE e sua extensão para a parede de VD. 11 Devem ser realizadas também avaliações morfológicas e funcionais para quantificação de função ventricular direita.…”

“…Pacientes que apresentam comunicações interatriais (CIA) moderadas ou importantes podem ter aumento de fluxo pulmonar com elevação da pressão da artéria pulmonar e consequente inversão do shunt pela CIA (síndrome de Eisenmenger). 37 Ecodopplercardiografia transesofágica é o método de imagem mais utilizado para o diagnóstico e quantificação de defeitos do septo atrial. A RMC, no entanto, por meio da avaliação morfológica em sequência SSFP, e avaliação de fluxo (phase contrast), já foi demonstrada ser um complemento ao exame ecocardiográfico em situações em que seja necessário evitar o método mais invasivo.…”

Ischemic Late Gadolinium Enhancement

“…

Appearance: The classic appearance of ischemic myocardial late gadolinium enhancement (LGE) is subendocardial hyperenhancement in the distribution of a major coronary artery (Fig. 6 Reference to myocardial thickness on SSFP images also helps differentiate microvascular obstruction located within the myocardium from thrombus that resides in the adjacent ventricular cavity.

The thickness or transmurality of the LGE is variable and may extend across the entire myocardial wall.…”

“…6 Reference to myocardial thickness on SSFP images also helps differentiate microvascular obstruction located within the myocardium from thrombus that resides in the adjacent ventricular cavity. myocardium, which helps distinguish true LGE from normal blood pool in myocardium containing large trabeculations.…”

Utility of cadiovascular magnetic resonance imaging with contrast enhancement : beyond the scope of viability

“…84 Observers should be aware of potential pitfalls and artifacts that may generate hyperintense areas that mimic myocardial scar such as partial volume effects, epicardial and pericardial fat, and hyperintense blood between myocardium and papillary muscles. 85 In this respect, it is important to confirm the presence of a hyperintense area in more than one contiguous slice, in more than one projection, and by assessing the corresponding cine images. Moreover, hyperintese areas should be confirmed by at least two independent observers.…”