CARDIAC IMAGING 4 Flashcards

Question

What are 4 causes of Constrictive Pericarditis?

Answer 1

Constrictive Pericarditis Causes 1. TB (most common cause) 2. Other infections (viral, pyogenic) 3. Cardiac surgery 4. Radiation injury

Answer 2

* Radiographic Features * Calcifications are common. * 50% of patients with calcification have constrictive pericarditis. * 90% of patients with constrictive pericarditis have pericardial calcification. * Pericardial calcification is more common in the AV grooves. * Pericardial thickening \>4 mm * Pleural effusion, 60% * PVH, 40% * Elevated RV pressure: dilated SVC and azygos, 80% Pericardial calcification is noted inferiorly and posteriorly. Sternotomy wires noted. Case Discussion Trans-thoracic echocardiography confirmed calcification is pericardial rather than myocardial and also demonstrated constrictive pericarditis. The cause was not determined in this case. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 31830

Answer 3

Benign 1. _Myxoma_: **most common benign adult cardiac tumor,** LA \> RA, often originates from interatrial septum with stalk, may be mobile with prolapse through MV (obstruction); T1- and T2-heterogeneous signal, heterogeneous or homogeneous enhancement. May have frond-like surface projections. 2. _Rhabdomyoma_: **most common benign tumor in children,** associated with tuberous sclerosis, T1-isointense, T2-hyperintense, hypoenhancement 3. _Lipoma_: **second most common benign adult** cardiac tumor, fat signal, no enhancement 4. _Fibroma_: s**econd most common benign cardiac tumor in children,** RV free wall, T1- and T2-hypointense, may or may not enhance 5. Papillary fibroelastoma: most common tumor of valves, usually \<1.5 cm, atrial surface of AV valves and aortic surface of aortic valve 6. Hemangioma: capillary, cavernous, or AV malformation, may involve any chamber, T1-hypointense, T2-hyperintense, heterogeneous enhancement

Answer 4

* Malignant * Angiosarcoma: * most common primary malignant tumor in adults, most commonly in the RA and AV groove, T2-hyperintense with heterogeneous enhancement * Rhabdomyosarcoma: * most common primary malignant tumor in children, may be found in any chamber, associated with heart failure, may demonstrate homogeneous enhancement or necrosis * Primary cardiac lymphoma: * rare, usually immunocompromised, most commonly affects RA but may involve multiple chambers and pericardium, T2-hyperintense, heterogeneous enhancement * Osteosarcoma: * rare, dense calcifications better demonstrated on CT * Metastases: * most common malignant process involving heart, * may occur via * lymphatics * (lung), * hematogenous spread * (melanoma), * transvenous extension * (RCC, * hepatoma, * adrenocortical carcinoma) * Lung \> lymphoma, leukemia, breast, esophagus * Pericardium \> myocardium * T1-hypointense (except melanoma) and T2-hyperintense, enhancement * Enhancement distinguishes tumor from bland thrombus

Answer 5

Angiosarcoma: * most common primary malignant tumor in adults, * most commonly in the **RA and AV groove,** * T2-hyperintense with heterogeneous enhancement Radiographic features * Two main morphologic types have been described in angiosarcoma: * **well-defined mass** protruding into a cardiac chamber, usually the right atrium * CT shows a low-attenuation right atrial mass, which may be irregular or nodular (usually arises from the right atrial free wall) * contrast material enhancement is heterogeneous * **diffusely infiltrative** mass extending along the pericardium * pericardial space may be obliterated with haemorrhagic, necrotic tumour debris Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 72108 Case courtesy of Dr Danilo Ferreira Maia, Radiopaedia.org, rID: 66010 Treatment and prognosis Prognosis is poor, which may be due in part to the delay in diagnosis (patients usually have metastatic involvement at presentation).

Answer 6

* Tumor-like * Thrombus: * typically LA or LV, * T1- and T2-hyperintense when acute, * hypointense when chronic, * no enhancement * Valvular vegetations (clinical endocarditis, valvular destruction) * Normal anatomic structures * Eustachian valves (RA) * Crista terminalis (RA) * Moderator band (RV) (1st pic) * Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rID: 31559

Answer 7

Fig. 12.25 Upper row. The crista terminalis varies in size and extent in different individuals. Axial CT scans show how the crista terminalis (arrows) varies in length and thickness. Lower row. Axial CT scans show differing amounts of fat infiltration of the crista terminalis (blue arrows) and varying degrees (from mild to severe) of lipomatous hypertrophy of the septum (yellow arrow). A large crista terminalis can mimic a mass at echo studies. https://radiologykey.com/12-general-anatomy-of-the-heart/

Answer 8

Figure 2: Cardiac computed tomography axial view demonstrating prominent eustachian valve in the right atrium. RV: right ventricle, RA: right artium. A 51-year-old man presented with paroxsysmal atrial fibrillation (AF). Transthoracic echocardiography revealed mass of 2.3x0.6 cm adjacent to the superior part of the right atrium (RA) compatible with thrombus. Although thrombus formation in the setting of AF is more common in left atrial appendage and left atrium it can also be seen in right atrial appendage and RA. We performed cardiac computerized tomography (CCT) in order to clarify the nature of mass in RA and exclude coronary stenosis. CCT showed prominent eustachian valve measuring 3.2 cm which was not clear on echocardiography. This case underscores the importance of complementary cardiovascular imaging to facilitate the correct diagnosis. https://www.sciencerepository.org/prominent-eustachian-valve-mimicking-thrombus-in-right-atrium-diagnosed-with\_RDI-2020-2-102#\_

Answer 9

Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 31210 Left atrial appendage thrombus Filling defect in the left atrial appendage. This is not the typical site of myxoma (the major differential diagnosis). The patient is chronically fibrillating (atrial) thus thrombus is most likely. Case Discussion Clot in the left atrial appendage is a potential source of embolism producing ischaemic stroke and infarction of other organs including the spleen, bowel and kidneys.

Answer 10

Cardiac myxomas, although uncommon are one of the commonest primary cardiac tumours and account for ~50% primary benign cardiac tumours. Clinical presentation Approximately 20% of patients are asymptomatic, with myxomas being found incidentally on imaging of the heart 7. Presumably, as the amount of imaging increases, so will this figure. Clinical features are variable and depend on the location and other associated pathology, e.g. valve destruction. However, a triad of symptoms is recognised 7-8: * **valvular obstruction** * left sided: dyspnoea, orthopnoea, pulmonary oedema * right sided: symptoms of right heart failure * **embolic event** * distribution will depend on the location of the tumour * most are left sided, and, therefore, most are systemic (brain or extremities) * **constitutional symptoms** * weight loss, fatigue, weakness * may resemble infective endocarditis (fever, arthralgia, lethargy) **Associations** An uncommon but well-described association with multiple endocrine neoplasia syndromes has been described, and is known as **Carney complex** 7-8. * Case courtesy of Dr Annette Johnstone, Radiopaedia.org, rID: 81633

Answer 11

Rhabdomyosarcoma (cardiac) Cardiac rhabdomyosarcoma is a muscular tumour that arises in the heart. Epidemiology They account for only 4-7% of cardiac sarcomas overall but are the most common cardiac malignancy in infants and children. There is a slight male predilection. Pathology Location Cardiac rhabdomyosarcoma has no predilection for any one chamber and may arise anywhere in the myocardium. More likely than other sarcomas to involve or arise from cardiac valves and they are often multiple. May invade the pericardium. Unlike cardiac angiosarcoma, a portion of the tumour should always involve the myocardium. Radiographic features CT may show a smooth or irregular low-attenuation mass in a cardiac chamber. Signal intensity characteristics at MR imaging are variable. https://radiopaedia.org/cases/cardiac-rhabdomyosarcoma

Answer 12

Case courtesy of Dr Nolan Walker, Radiopaedia.org, rID: 38690 Cardiac lymphoma Cardiac lymphoma is a rare tumour of the myocardium and/or pericardium. It may be considered as primary or secondary. Epidemiology Primary cardiac lymphoma is a rare occurrence, representing only 10% of primary malignant cardiac tumours (1% of all primary cardiac tumours). Secondary involvement of the heart by disseminated lymphoma (diffuse large B-cell) is more common than primary cardiac lymphoma, but is still a rare occurrence. Both forms are much more common in patients with HIV/AIDS.

Answer 13

**Cardiac rhabdomyoma.** **Case Discussion** Approximately 6 mm, rising from left ventricle apex, grown into the ventricle, well marginated, hyperechoic solid mass. This case is an example of the most common intrauterine fetal cardiac tumour - cardiac rhabdomyoma. **INTRO** Cardiac rhabdomyomas are a type of benign myocardial tumour and are considered the most common fetal cardiac tumour. They have a strong association with tuberous sclerosis. **Epidemiology** Cardiac rhabdomyomas are often multiple and can represent up to 90% of cardiac tumours in the paediatric population 1. The majority are diagnosed before the age of 1 year. The estimated incidence is at ~1 in 20,000 births 8. **Clinical presentation** The majority of cardiac rhabdomyomas are asymptomatic although there can be a broad clinical spectrum. Occasionally, they may present with left ventricular outflow tract obstruction or refractory arrhythmias. Pathology It is a hamartomatous lesion consisting of cardiac muscle tissue (derived from embryonal myoblasts). Macroscopically, they appear as yellow-tan solid, circumscribed, unencapsulated lesions. Microscopically, a characteristic spider cell is seen which is a large clear cell with cytoplasmic strands composed of glycogen extending to the plasma membrane. **Location** They may arise anywhere in the myocardium but are more common in the ventricles (may involve the left ventricle the most) 6. **Associations** there is a well-known association with tuberous sclerosis, with \>50% of all cardiac rhabdomyomas found in patients with later confirmed **tuberous sclerosis 1,2** congenital renal anomalies 8 Case courtesy of Dr Ersen Alp Özbalcı, Radiopaedia.org, rID: 37043

Answer 14

Papillary fibroelastoma most common tumor of valves, usually \<1.5 cm, atrial surface of AV valves and aortic surface of aortic valve

Answer 15

Cardiac fibroma **second most common benign cardiac tumor in children, RV free wall, T1- and T2-hypointense, may or may not enhance** Cardiac fibromas, also known as cardiac fibromatosis, are benign congenital cardiac tumours that usually manifest in children. Epidemiology Cardiac fibromas are tumours that primarily affect children (most cases are detected in infants or in utero) with a ratio of 4:1 compared with adults 5. They are the second most common benign primary cardiac tumour in children after cardiac rhabdomyoma and second most frequent fetal cardiac tumour 2. Clinical presentation Cardiac fibromas are often associated with arrhythmias which can be a presenting feature. They can also cause haemodynamic compromise and congestive heart failure. These tumours also may be found incidentally in asymptomatic patients. Pathology Microscopic appearance Cardiac fibromas represent a collection of fibroblasts interspersed among large amounts of collagen (some authors believe that this tumour is a hamartoma rather than a neoplasm). Macroscopic appearance These tumours are well-defined, solitary, intramyocardial lesions with smooth margins and usually large, with a mean diameter of ~5 cm and may obliterate the ventricular cavity. They almost always arise in the left ventricular free wall, interventricular septum or right ventricular free wall (in descending order) 5. Unlike many primary cardiac tumours, fibromas usually have no foci of cystic change, haemorrhage, or necrosis. Calcification is a common finding. **Associations** **There is an increased prevalence of cardiac fibromas in Gorlin syndrome** Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 39267

Answer 16

Cardiac Lipoma Lipoma: second most common benign adult cardiac tumor, fat signal, no enhancement Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 15292

Answer 17

**Cardiac Hemangioma: capillary, cavernous, or AV malformation, may involve any chamber, T1-hypointense, T2-hyperintense, heterogeneous enhancement** Findings: Her cardiac CT showed one space-taking lesion of soft tissue density confined in right atrium, without extension into adjacent organ. Cardiac MRI showed one well-defined intra-cardiac mass in right atrium attaching to myocardium. The tumor showed intermediate to bright on T1- and T2-weighted images and enhancement after Gd-DTPA administration. Diagnosis: Cardiac hemangioma Discussion: The most frequent mass within a cardiac chamber is thrombus. The overall frequency of cardiac tumor is 0.15 percent in echocardiographic series. Of all cardiac tumors, primary tumors are rare, while secondary tumors are about 40 times more frequent than primary cardiac tumors. Cardiac hemangiomas are composed of endothelial cells that line interconnecting vascular channels. They are usually asymptomatic when diagnosed after infancy, and the commonest presentation is dyspnea on exertion if symptomatic. Imaging findings: Cardiac hemangiomas may involve the endocardium, myocardium, or epicardium. They can arise from all chambers and also pericardium. On T1-weighted images, hemangiomas are intermediate to hyperintense. On T2-weighted images, they are hyperintense to myocardium. After Gd-DTPA administration, they usually have rapid enhancement during first-pass Gd contrast infusion because of their high vascularity, and usually show intense but inhomogeneous enhancement Differential diagnosis: There are some methods to differentiate between thrombus and tumor on medical images. A thrombus shows low signal intensity on gradient-echo images, while tumors are hyperintense to myocardium. However, exceptions to this generalization are fresh blood clot can have high signal intensity, and some myxomas containing iron produce low signal and mimic thrombus. Besides, thrombus does not enhance after the administration of Gd-DTPA, whereas tumors show enhancement. About 80 percent of primary cardiac tumors are benign, including myxoma, lipoma, papillary fibroelastoma, rhabdomyoma, and hemangioma. Cardiac pheochromocytoma is also reported and is very rare. Myxoma is the most common benign cardiac tumor. Myxoma is dumbbell shape, and is usually mobile with its shape varied during cardiac cycle. One-fourth of primary cardiac tumors are malignant, with sarcomas being the most common, followed by primary cardiac lymphomas. There are features indicating malignancy of a primary cardiac tumor on medical images, including involvement of more than 1 cardiac chamber, wide point of attachment to the wall, necrosis within the tumor, extension outside the heart, and hemorrhagic pericardial effusion. Other signs of malignancy include intramural and intracavitary location, extension into the mediastinum, and rapid growth. Conclusion: Cardiac hemangioma is a rare benign tumor of the heart. The differentiation of this benign tumor from the malignant types is essential in planning subsequent management. Cardiac MRI is a valuable tool to differentiate this tumor from other benign and malignant tumors. https://www.diagnosticimaging.com/view/cardiac-hemangioma

Answer 18

Primary Cardiac Osteosarcoma: • Osteosarcoma: rare, dense calcifications better demonstrated on CT * Figure 2 Four-chamber reconstruction from retrospectively gated cardiac CT angiography demonstrates a 6 × 5.6-cm mass with internal calcifications that fills a large portion of the left atrium and extends to the mitral valve (black arrow). * The mass has invaded the left inferior pulmonary vein (black arrowheads) and left superior pulmonary vein (not shown). * The mass also obstructs the ostium of the right inferior pulmonary vein (white arrowheads). * A linear area of calcification in the left ventricular wall (white arrow) was suggestive of a metastatic lesion. https://pubs.rsna.org/doi/full/10.1148/rg.2015140265

CARDIAC IMAGING 4 Flashcards

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