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Sarcoid: Chronic

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

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but then would start experience palpitations.

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The question for cardiac MRI was whether

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there was any evidence of acute cardiac sarcoidosis.

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So we're starting here with the cine four

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chamber images, looking at cardiac function.

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And what stands out to me when I look

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

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You can see that when you're looking

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

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

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

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to the same degree as the rest of the septum.

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So you have reduced function in the basal septum.

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And as we know, cardiac sarcoidosis really

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likes to involve the septum and the conduction tissue.

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And that all lives right here in this basal septum.

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

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this is really suspicious that they've got

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some scarring in this region from cardiac sarcoidosis involvement.

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

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And so how do we figure that out?

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We want to look at the edema imaging.

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So these are T2-weighted dark blood images.

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And remember that we really need to window

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

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

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You can see the ghosting here,

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

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Here, maybe a little bit of brightness right

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

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The rest of it looks okay.

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

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And that actually looks nice in uniform

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and signal with no areas that stand out as bright.

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So best we can tell here, no edema.

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

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

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So as I move forward,

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

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

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

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It just stays pretty much the same,

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

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

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As we move to the mid cavity,

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

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You can see that area.

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

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

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Now, when we go ahead and skip forward

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

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some late enhancement in that basal septum.

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

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Relatively normal signal, maybe a bit of noise,

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

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And then a little more that bright signal

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

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

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

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So this is enhancement in a non ischemic

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

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

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

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with no findings suggestive of acute sarcoidosis.

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

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

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So he ended up actually getting a PET CT,

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and that PET CT confirmed that there was

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no active cardiac sarcoidosis in the heart.

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So two modalities confirming

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

Report

Faculty

Stefan Loy Zimmerman, MD

Associate Professor of Radiology and Radiological Science

Johns Hopkins Medicine Department of Radiology and Radiological Science

Tags

PET

Myocardium

MRI

Cardiac

Acquired/Developmental

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