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Number 10-04: Hemorrhagic Myocardial Infarction
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Number 10-04: Hemorrhagic Myocardial Infarction

Case from: Lorenzo Monti, Barbara Nardi, Elena Corrada, Patrizia Presbitero, Antonio Spinillo, Luca Balzarini 
Cardiology and Radiology Department, Istituto Clinico Humanitas, Rozzano (MI), ITALY

Clinical history: 47 year old male with persistent of ST-elevation three days after a successful primary PTCA of an anterior myocardial infarction (ischemia time 3.5 hours) was referred for CMR for myocardial tissue characterization.

 

 

 

 Figure 1 ECG (click to enlarge)

Figure 2 (click to enlarge)

 

Pre-contrast T2-weighted STIR images show a dark mid-wall rim in the central part (Figure 2A, 2B) of the increased signal intensity (edematous area1), suggesting intramyocardial hemorrhage.  A subsequent T2-weighted echo-planar image (Figure 2C), which is more sensitive than T2-weighted imaging to susceptibility artifacts, and T2 star (Figure 2D - TE 4.6 msec, TR 12 msec) both confirmed the presence of hemoglobin degradation products (dark signal).  Resting perfusion shows the persistence of anterior and septal perfusion defects (Movie 1).  LGE images imply a large myocardial infarction in the mid and apical anterior wall and septum (LAD territory) with a large dark core representing microvascular obstruction (Figure 3).

 

 

Movie 1

 

 

Figure 3

 

    

Movie 2                                                      Movie 3

 

Cine CMR: Akinesia of the anterior wall, anterior septum and apex with a LVEF of 39% (Movie 2 and Movie 3). Please note that the SSPF cine images were acquired after contrast administration therefore the large area of microvascular obstruction (large hypointese area in the septum and anterior wall) is evident also in these images (see also Figure 3).  The 1 year follow-up scan showed that persistent LV dysfunction and regional wall motion abnormalities were unchanged with a LVEF of 42%.

Perspective: CMR has the unique capability to visualize in vivo the occurrence of intramyocardial hemorrhage after an acute myocardial infarction through the combination of T2, T2 star, and LGE imaging.  The differentiation between hemorrhagic and non-hemorrhagic myocardial infarction has clinical and prognostic implications.  Independent of initial infarct size (which LGE may overestimate soon after acute injury due to the persistence of tissue edema and recent cell death), there is suggestion that regions of hemorrhagic infarct and overall left ventricular ejection fraction are less likely to recover in those with intramyocardial hemorrhage2

References:
1. Garcia-Dorado D, Theroux P,  Solares J, et al.. Determinants of Hemorrhagic Infarcts. Am J Pathol 1990; 13 7:301-311.
2. 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: 1440–1449.

 


COTW handling editor: Kevin Steel

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