0:01

This next case is an 80 some year old male who has a history of remote sarcoidosis

0:06

but then would start experience palpitations.

0:08

The question for cardiac MRI was whether

0:10

there was any evidence of acute cardiac sarcoidosis.

0:14

So we're starting here with the cine four

0:16

chamber images, looking at cardiac function.

0:20

And what stands out to me when I look

0:22

at this image is this area of the septum right here.

0:25

You can see that when you're looking

0:28

at the degree of wall motion, that there's good thickening of the mid

0:32

wall of the septum, the apex and the lateral wall.

0:35

But that this basal part of the septum right here is just not really thickening

0:41

to the same degree as the rest of the septum.

0:43

So you have reduced function in the basal septum.

0:46

And as we know, cardiac sarcoidosis really

0:49

likes to involve the septum and the conduction tissue.

0:52

And that all lives right here in this basal septum.

0:55

So this is in a patient, with a history of sarcoidosis,

0:59

this is really suspicious that they've got

1:01

some scarring in this region from cardiac sarcoidosis involvement.

1:05

As we move ahead, the key question here is, do they have acute sarcoidosis?

1:09

And so how do we figure that out?

1:10

We want to look at the edema imaging.

1:12

So these are T2-weighted dark blood images.

1:15

And remember that we really need to window

1:18

these severely to look for any areas of bright signal that might suggest edema.

1:22

Now, these are limited a little bit because of motion artifact.

1:25

You can see the ghosting here,

1:28

but you don't really see anything that stands out from the background.

1:33

Here, maybe a little bit of brightness right

1:35

here, but there's some artifact there, so I'm going to ignore that.

1:38

The rest of it looks okay.

1:40

They actually repeated one of the slices to reduce some of the artifacts.

1:44

And that actually looks nice in uniform

1:46

and signal with no areas that stand out as bright.

1:49

So best we can tell here, no edema.

1:53

If we skip ahead to the short access images and we go to the base of the heart,

1:58

what we're going to see is there is this basal thinning and reduced function.

2:04

So as I move forward,

2:05

you can see here is this basal septum. There's thinning as you go into systole,

2:11

the lateral wall, inferior wall, anterior walls, they're all thickening.

2:15

Whereas this basal septum doesn't really thicken at all.

2:19

It just stays pretty much the same,

2:21

just kind of rocking back and forth with the rest of the cardiac motion.

2:24

So that's an area of akinesia in the basal septum.

2:29

As we move to the mid cavity,

2:30

you can see there is septal thickening right here, right?

2:32

You can see that area.

2:33

The septum is functioning normally as well as the remainder of the wall.

2:38

So it's just really isolated to that basal septum.

2:41

Now, when we go ahead and skip forward

2:43

to the delayed enhancement images, what we're going to find is that there is

2:47

some late enhancement in that basal septum.

2:51

So here's that basal septum. Here, you can see mid-wall, bright signal.

2:56

Relatively normal signal, maybe a bit of noise,

2:59

but otherwise normal, uniform, low signal in the remainder of the left ventricle.

3:03

And then a little more that bright signal

3:05

here as we move towards the apex, and then normal.

3:09

And if we go to a long axis view, you're going to see the same finding.

3:15

You see that the basal septum here has that bright mid-wall signal.

3:20

So this is enhancement in a non ischemic

3:22

pattern, associated with thinning and no edema in a patient with known sarcoidosis.

3:28

So, in summary, the key findings here to report are that you have a patient

3:34

with what looks like chronic myocardial scar in the basal septum in sarcoidosis,

3:39

with no findings suggestive of acute sarcoidosis.

3:42

This patient actually ended up, they didn't, you know,

3:45

believe the MRI or they were still concerned based on his history.

3:49

So he ended up actually getting a PET CT,

3:51

and that PET CT confirmed that there was

3:53

no active cardiac sarcoidosis in the heart.

3:56

So two modalities confirming

3:59

that there was no active disease, only this chronic scarring.