AJR 2004; 182:609-615
© American Roentgen Ray Society
Use of Inversion Recovery Contrast-Enhanced MRI for Cardiac Imaging: Spectrum of Applications
Jan Bogaert1,
Andrew M. Taylor1,2,3,
Filip Van Kerkhove1 and
Steven Dymarkowski1
1 Department of Radiology, Gasthuisberg University Hospital, Herestraat 49,
Leuven 3000, Belgium.
2 Cardiac Unit, Institute of Child Health and Department of Radiology, Great
Ormond Street Hospital, London, England.
3 Cardiac MR Research Group, Division of Imaging Sciences, King's College
London, Guy's Hospital, London, England.
Received May 1, 2003;
accepted after revision July 28, 2003.
Address correspondence to J. Bogaert
(jan.bogaert{at}uz.kuleuven.ac.be).
A. M. Taylor is supported by a Marie-Curie Fellowship of the European
Commission.
Introduction
The clinical value of cardiac MRI has increased with the introduction of
the single inversion recovery contrast-enhanced MRI sequence
[1]. Although use of
T1-shortening contrast media in cardiac MRI was described more than a decade
ago [2], lack of sufficient
differentiation between normal and diseased tissues hampered their routine
clinical use. Now, however, it is possible to enhance contrast between tissues
with different T1-relaxation times with the addition of a 180° inversion
prepulse [1], and tissue signal
can be specifically nulled by selecting an appropriate inversion time. This
technique was first used for detecting the presence of myocardial necrosis and
scarring in patients with myocardial infarction
[3,
4]. More recently, other
cardiac applications for the technique have been developed
[5–8].
In this pictorial essay, we present an overview of the versatility of
inversion recovery contrast-enhanced MRI for investigating a spectrum of
cardiac diseases.
Materials and Methods
All studies were performed on an Intera 1.5-T scanner (Philips Medical
Systems, Best, The Netherlands) or a Sonata 1.5-T scanner (Siemens, Erlangen,
Germany) using commercially available software, vectorcardiograms or active
triggering techniques, and cardiac surface coils. Depending on the clinical
question, a combination of different sequences was used. Black blood double
inversion recovery fast spin-echo imaging of the heart was used for
morphologic imaging. Cine MRI (breath-hold balanced fast field-echo or true
fast imaging with steady-state free precession [true FISP] sequence) was used
for functional imaging. Myocardial perfusion was assessed using turbo
field-echo or turbo fast low-angle shot (turbo FLASH) sequences with an
inversion time of 200 msec during the first pass of gadopentetate dimeglumine
(0.05 mmol/kg). Finally, inversion recovery contrast-enhanced MRI using a 3D
T1-weighted turbo field-echo or true FISP technique with a single inversion
recovery pulse was performed to study abnormal enhancement of the myocardium,
pericardium, and cardiac masses. Suppression of the subcutaneous mediastinal
and subepicardial fat was effected by the addition of a spectral fat
suppression or inversion pulse. The images were obtained at different time
periods over 5–15 min after IV injection of gadopentetate dimeglumine
(0.2 mmol/kg).
Optimizing the length of the inversion time is crucial for adequate image
formation. Too short an inversion time may lead to nulling of signal in
diseased tissue and enhancement in normal tissue. Too long an inversion time
may lead to loss of contrast between normal and diseased tissue. The main
parameters that influence the length of inversion time are dose and kinetics
of the contrast medium and the time delay after injecting it. T1-tissue
relaxation depends on the dose of contrast medium: the higher the dose, the
shorter the inversion time, and vice versa. Inversion time also varies with
the delay time to imaging after the contrast medium is injected, because of
the washin and wash-out tissue kinetics of gadopentetate dimeglumine: the
longer the delay to imaging, the longer the inversion time. MRI techniques are
now available to rapidly determine the optimal inversion time after contrast
medium injection. The approach is based on either an interactive
operator-dependent real-time variation of the inversion time or a breath-hold
true FISP sequence that obtains a set of images with a different inversion
time for each image.
Myocardial Diseases
Current literature convincingly shows the usefulness of inversion recovery
contrast-enhanced MRI for depicting, locating, and accurately sizing
myocardial necrosis in patients with recent myocardial infarction
[3] (Fig.
1A,
1B,
1C,
1D). It has proved superior to
SPECT in detecting subendocardial infarctions
[3] and provides valuable
prognostic information about the presence of microvascular obstruction in the
infarct area, the so-called "no-reflow phenomenon." In patients
with chronic myocardial ischemia presenting with left ventricular dysfunction,
this technique enables the detection of infarct-related scar tissue and is
helpful in choosing the most appropriate treatment
[4].
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Fig. 1A. —36-year-old man with acute transmural myocardial infarction
in midventricular part of anterior left ventricular wall caused by occlusion
of first diagonal branch of left anterior descending coronary artery. Patient
had clinical findings suggestive of perimyocarditis. Echocardiograms (not
shown) did not reveal abnormalities. MRI was performed to exclude myocardial
damage. T2-weighted fast spin-echo STIR image (TR/TE, 2 heart beats/100) with
double inversion recovery black blood prepulse in midventricular cardiac short
axis (triple inversion recovery sequence) shows high signal intensity in
anterior left ventricular wall (arrows) corresponding to myocardial
edema.
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Fig. 1B. —36-year-old man with acute transmural myocardial infarction
in midventricular part of anterior left ventricular wall caused by occlusion
of first diagonal branch of left anterior descending coronary artery. Patient
had clinical findings suggestive of perimyocarditis. Echocardiograms (not
shown) did not reveal abnormalities. MRI was performed to exclude myocardial
damage. Cine MR image obtained at end systole using balanced fast field-echo
technique in midventricular cardiac short axis (3.4/1.7) shows akinesia and
absent systolic wall thickening in anterior left ventricular wall
(arrow).
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Fig. 1C. —36-year-old man with acute transmural myocardial infarction
in midventricular part of anterior left ventricular wall caused by occlusion
of first diagonal branch of left anterior descending coronary artery. Patient
had clinical findings suggestive of perimyocarditis. Echocardiograms (not
shown) did not reveal abnormalities. MRI was performed to exclude myocardial
damage. Contrast-enhanced T1-weighted 3D fast field-echo image (4.3/1.3;
inversion time, 250 msec) obtained 11 min after injection of 0.2 mmol/kg of
gadopentetate dimeglumine in midventricular cardiac short axis shows
transmural myocardial infarction (small arrows) with subendocardial
no-reflow zone in anterior left ventricular wall (large arrow).
Infarct was caused by occlusion of first diagonal of left anterior descending
coronary artery, which was diagnosed at coronary catheterization (not
shown).
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Fig. 1D. —36-year-old man with acute transmural myocardial infarction
in midventricular part of anterior left ventricular wall caused by occlusion
of first diagonal branch of left anterior descending coronary artery. Patient
had clinical findings suggestive of perimyocarditis. Echocardiograms (not
shown) did not reveal abnormalities. MRI was performed to exclude myocardial
damage. Contrast-enhanced T1-weighted 3D fast field-echo image (4.3/1.3;
inversion time, 250 msec) obtained 13 min after injection of 0.2 mmol/kg of
gadopentetate dimeglumine in cardiac vertical long axis shows subendocardial
no-reflow zone (large arrow). Atypical infarct location (small
arrows) in anterior wall was caused by occlusion of first diagonal
branch.
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Other applications include detection of myocardial damage in patients with
clinical findings suggestive of myocarditis (Fig.
2A,
2B) and visualization of
abnormal myocardial tissue, which typically is fibrous tissue in patients with
hypertrophic and dilated cardiomyopathy
[6,
7] (Figs.
3A,
3B and
4A,
4B,
4C). Areas of abnormal
myocardial enhancement have also been reported in patients with infiltrative
and storage diseases [8] (Figs.
5A,
5B,
5C,
5D and
6A,
6B,
6C). This technique can also
be applied to evaluate the consequences of diagnostic or therapeutic
procedures such as endomyocardial biopsy (Fig.
7A,
7B) or septal artery
alcoholization in patients with obstructive hypertrophic cardiomyopathy (Fig.
4A,
4B,
4C).
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Fig. 2A. —33-year-old man with acute myocarditis presented with
non–exercise-related retrosternal chest pain and slightly raised
troponin levels. Coronary arteries were normal at coronary catheterization
(not shown). Contrast-enhanced T1-weighted 3D fast field-echo image (TR/TE,
4.3/1.3; inversion time, 230 msec) obtained 8 min after injection of 0.2
mmol/kg of gadopentetate dimeglumine in basal cardiac short axis shows
well-defined area of enhancement in mid portion of left ventricular septum
(arrows).
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Fig. 2B. —33-year-old man with acute myocarditis presented with
non–exercise-related retrosternal chest pain and slightly raised
troponin levels. Coronary arteries were normal at coronary catheterization
(not shown). Contrast-enhanced T1-weighted 3D fast field-echo image (4.3/1.3;
inversion time, 230 msec) obtained 9 min after injection of 0.2 mmol/kg body
weight of gadopentetate dimeglumine in horizontal cardiac long axis shows
well-defined enhancement of basal ventricular septum (arrow).
Findings are concordant with focal myocarditis with myocardial necrosis.
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Fig. 3A. —50-year-old man with asymmetric septal hypertrophic
cardiomyopathy. MRI was performed to evaluate disease severity.
Contrast-enhanced T1-weighted 3D fast field-echo image (TR/TE, 4.3/1.3;
inversion time, 250 msec) obtained 10 min after injection of 0.2 mmol/kg of
gadopentetate dimeglumine in basal cardiac short axis shows extensive wall
thickening of anteroseptal wall with focal patchy enhancement in thickened
area (arrow). Enhancement probably corresponds to extensive fibrosis
in hypertrophic myocardium.
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Fig. 3B. —50-year-old man with asymmetric septal hypertrophic
cardiomyopathy. MRI was performed to evaluate disease severity. Cine MR image
using spatial modulation of magnetization technique (30/4) in basal short axis
at end systole shows decreased myocardial deformation of abnormally thickened
wall (arrow). Note normal deformation in other wall segments.
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Fig. 4A. —54-year-old woman with hypertrophic obstructive
cardiomyopathy treated with alcoholization of first septal perforator coronary
artery to reduce outflow tract obstruction. T1-weighted fast spin-echo image
(TR/TE, 2 heart beats/8.6) with double inversion recovery black blood prepulse
in basal cardiac short axis shows thickening of ventricular septum with
diameter of 23 mm.
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Fig. 4B. —54-year-old woman with hypertrophic obstructive
cardiomyopathy treated with alcoholization of first septal perforator coronary
artery to reduce outflow tract obstruction. Contrast-enhanced T1-weighted 3D
fast field-echo image (4.3/1.3; inversion time, 220 msec) obtained 6 min after
injection of 0.2 mmol/kg of gadopentetate dimeglumine in basal cardiac short
axis shows large hypointense zone (arrows) surrounded by thin
hyperintense rim in thickened septum, corresponding to occlusive infarct
caused by alcoholization.
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Fig. 4C. —54-year-old woman with hypertrophic obstructive
cardiomyopathy treated with alcoholization of first septal perforator coronary
artery to reduce outflow tract obstruction. Contrast-enhanced T1-weighted 3D
fast field-echo image (4.3/1.3; inversion time, 230 msec) obtained 8 min after
injection of 0.2 mmol/kg of gadopentetate dimeglumine in horizontal cardiac
long axis shows occlusive infarct in basal part of ventricular septum
(arrows).
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Fig. 5A. —72-year-old woman with idiopathic hypereosinophilia involving
lateral wall of left ventricle. Echocardiograms (not shown) revealed lateral
wall thickening. MRI was performed for further evaluation. T1-weighted fast
spin-echo image (TR/TE, 2 heart beats/8.6) with double inversion recovery
black blood prepulse in horizontal cardiac long axis shows apparent extensive
lateral wall thickening (arrow) with otherwise homogeneous signal
intensity.
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Fig. 5B. —72-year-old woman with idiopathic hypereosinophilia involving
lateral wall of left ventricle. Echocardiograms (not shown) revealed lateral
wall thickening. MRI was performed for further evaluation. T1-weighted fast
spin-echo image (2 heart beats/8.6) with double inversion recovery black blood
prepulse in midventricular cardiac short axis shows apparent extensive
thickening of lateral wall (arrow).
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Fig. 5C. —72-year-old woman with idiopathic hypereosinophilia involving
lateral wall of left ventricle. Echocardiograms (not shown) revealed lateral
wall thickening. MRI was performed for further evaluation. Contrast-enhanced
T1-weighted 3D fast field-echo image (4.3/1.3; inversion time, 210 msec)
obtained 5 min after injection of 0.2 mmol/kg of gadopentetate dimeglumine in
horizontal cardiac long axis shows combination of wall thickening and adjacent
mural thrombus, visible as dark structure (arrows) adjacent to
thickened myocardium.
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Fig. 5D. —72-year-old woman with idiopathic hypereosinophilia involving
lateral wall of left ventricle. Echocardiograms (not shown) revealed lateral
wall thickening. MRI was performed for further evaluation. Contrast-enhanced
T1-weighted 3D fast field-echo image (4.3/1.3; inversion time, 220 msec)
obtained 8 min after injection of 0.2 mmol/kg of gadopentetate dimeglumine in
midventricular cardiac short axis again shows combination of wall thickening
and adjacent mural thrombus (arrow).
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Fig. 6A. —41-year-old woman with sarcoidosis presenting with
asymptomatic atrioventricular block. MRI was requested to exclude structural
abnormalities. T1-weighted fast spin-echo image (TR/TE, 2 heart beats/8.6)
with double inversion recovery black blood prepulse in cardiac short axis
shows area of moderate wall thickening inferolaterally (arrow).
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Fig. 6B. —41-year-old woman with sarcoidosis presenting with
asymptomatic atrioventricular block. MRI was requested to exclude structural
abnormalities. Contrast-enhanced T1-weighted 3D fast field-echo image
(4.3/1.3; inversion time, 260 msec) obtained 10 min after injection of 0.2
mmol/kg of gadopentetate dimeglumine in midventricular cardiac short axis
shows strong enhancement of thickened area inferolaterally (arrow)
with thin nonenhancing subendocardial and subepicardial rim.
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Fig. 6C. —41-year-old woman with sarcoidosis presenting with
asymptomatic atrioventricular block. MRI was requested to exclude structural
abnormalities. Contrast-enhanced T1-weighted 3D fast field-echo image
(4.3/1.3; inversion time, 260 msec) obtained 12 min after injection of 0.2
mmol/kg of gadopentetate dimeglumine in horizontal cardiac long axis shows
several areas of strong enhancement throughout left ventricular wall
(arrows). Splenic biopsy revealed noncaseating granulomas. Diagnosis
of cardiac sarcoidosis was made.
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Fig. 7A. —48-year-old man with myocardial postbiopsy injury. Patient
with restrictive cardiomyopathy underwent right-sided endomyocardial biopsy to
test for infiltrative cardiac disease. MRI was requested to exclude structural
and functional abnormalities. MRI was performed shortly after endomyocardial
biopsy. T1-weighted spin-echo images (not shown) did not reveal abnormalities.
Contrast-enhanced T1-weighted 3D fast field-echo image (TR/TE, 4.3/1.3;
inversion time, 250 msec) obtained 12 min after injection of 0.2 mmol/kg of
gadopentetate dimeglumine in cardiac short axis shows single area of strong
enhancement (arrow) in inferoseptal subepicardial region at insertion
of right ventricle.
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Fig. 7B. —48-year-old man with myocardial postbiopsy injury. Patient
with restrictive cardiomyopathy underwent right-sided endomyocardial biopsy to
test for infiltrative cardiac disease. MRI was requested to exclude structural
and functional abnormalities. MRI was performed shortly after endomyocardial
biopsy. T1-weighted spin-echo images (not shown) did not reveal abnormalities.
Contrast-enhanced T1-weighted 3D fast field-echo image (4.3/1.3; inversion
time, 250 msec) obtained 10 min after injection of 0.2 mmol/kg of
gadopentetate dimeglumine in vertical cardiac long axis confirms findings
shown in A. Area of enhancement (arrow) corresponds to small
injury as result of right heart endomyocardial biopsy. Histology of biopsied
specimen revealed no abnormalities.
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Enhancement in a wide spectrum of myocardial diseases depends partly on the
characteristics of the contrast medium being used. The gadolinium-based
paramagnetic contrast agents are small extracellular molecules that rapidly
diffuse through the vessel wall into the interstitium. Local T1 shortening,
and thus enhancement, is related to the wash-in and washout properties and to
the distribution volume and can be found in areas of necrosis, inflammation,
and fibrosis. Although current contrast agents lack specificity, inversion
recovery contrast-enhanced MRI provides valuable information about the
presence and extent of myocardial damage when it is combined with the other
information obtained on MRI: myocardial morphology, function, and perfusion.
However, because image contrast is created by suppressing normal myocardium,
diseases with diffuse myocardial involvement can potentially be missed.
Moreover, correct choice of inversion time is crucial to avoid nulling the
signal in the area of interest.
Pericardial Diseases
Spin-echo imaging is excellent for depicting the pericardium, but inversion
recovery contrast-enhanced MRI may prove complementary, especially for
depicting pericardial inflammation. The spectral inversion pulse selectively
suppresses adjacent fat, and the nonselective inversion pulse enables contrast
between tissues with differing T1 relaxations to be enhanced. As a result,
high contrast is created between inflamed pericardium (high signal intensity)
and the surrounding fat and adjacent myocardium (intermediate signal
intensity). Pericardial fluid is visible as areas of low signal intensity
because of its long T1 relaxation time. Applications include depiction of
inflammation of the pericardial layers, as seen in patients with acute and
chronic inflammatory pericarditis (Fig.
8A,
8B) and detection of
associated postinfarct pericarditis in patients with recent myocardial
infarction. The mechanism of enhancement in pericardial inflammation is
probably related to the presence of interstitial edema in acute pericarditis
and fibrous tissue in chronic inflammatory pericarditis.
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Fig. 8A. —47-year-old woman with history of relapsing inflammatory
pericarditis. MRI was performed to evaluate pericardium. Axial T1-weighted
fast spin-echo image (TR/TE, 2 heart beats/8.6) with double inversion recovery
black blood prepulse shows diffuse pericardial thickening
(arrows).
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Fig. 8B. —47-year-old woman with history of relapsing inflammatory
pericarditis. MRI was performed to evaluate pericardium. Contrast-enhanced
T1-weighted 3D fast field-echo image (TR/TE, 4.3/1.3; inversion time, 240
msec) obtained 9 min after injection of 0.2 mmol/kg of gadopentetate
dimeglumine in cardiac short axis shows strong enhancement (arrows)
of diffusely thickened pericardium surrounding the heart. No pericardial
effusion is shown. Diagnosis of acute inflammatory pericarditis was made.
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Imaging of the Cardiac Chambers
An indirect application of the IV injection of paramagnetic contrast
material used to study the myocardium is the creation of positive blood pool
contrast in the enhancing of vessels and cardiac chambers. Inversion recovery
contrast-enhanced MRI reveals abnormal intracavitary structures such as
thrombi (Fig. 9A,
9B,
9C,
9D), as dark structures
surrounded by bright contrast-enhanced blood. It is significantly better than
cine MRI or echocardiography in revealing ventricular thrombi in patients with
ischemic heart disease and differentiating slow or stagnant flow and thrombus
in the atrial appendages
[5].
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Fig. 9A. —70-year-old man with thrombus in left atrial appendage
presented with history of transient ischemic attacks and history of chronic
atrial fibrillation. Echocardiograms (not shown) did not reveal abnormalities.
MRI was requested for further evaluation. Axial T1-weighted fast spin-echo
image (TR/TE, 2 heart beats/8.6) with double inversion recovery black blood
prepulse shows absence of dark signal intensity or flow void in moderately
dilated left atrial appendage (arrows) that may represent slow flow
or thrombus.
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Fig. 9B. —70-year-old man with thrombus in left atrial appendage
presented with history of transient ischemic attacks and history of chronic
atrial fibrillation. Echocardiograms (not shown) did not reveal abnormalities.
MRI was requested for further evaluation. Axial cine MR image at end diastole
using balanced fast field-echo technique (3.4/1.7) shows gray zone in left
atrial appendage (arrows).
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Fig. 9C. —70-year-old man with thrombus in left atrial appendage
presented with history of transient ischemic attacks and history of chronic
atrial fibrillation. Echocardiograms (not shown) did not reveal abnormalities.
MRI was requested for further evaluation. Axial contrast-enhanced T1-weighted
3D fast field-echo image (4.3/1.3; inversion time, 250 msec) obtained 10 min
after injection of 0.2 mmol/kg of gadopentetate dimeglumine shows dark
nonenhancing structure in appendage corresponding to thrombus
(arrows), which is surrounded by enhancing blood.
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Fig. 9D. —70-year-old man with thrombus in left atrial appendage
presented with history of transient ischemic attacks and history of chronic
atrial fibrillation. Echocardiograms (not shown) did not reveal abnormalities.
MRI was requested for further evaluation. Contrast-enhanced T1-weighted 3D
fast field-echo image (4.3/1.3; inversion time, 240 msec) obtained 8 min after
injection of 0.2 mmol/kg of gadopentetate dimeglumine in vertical cardiac long
axis shows thrombus in left atrial appendage (arrows).
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Cardiac Masses
Inversion recovery contrast-enhanced MRI can also be used to heighten
contrast within cardiac masses and between cardiac masses and the surrounding
structures after the administration of contrast media (Figs.
10A,
10B and
11A,
11B). Although the morphology
of cardiac masses is normally evaluated using a combination of T1- and
T2-weighted MRI after contrast media injection, inversion recovery
contrast-enhanced MRI may provide additional information about the composition
of the mass and thus may help refine the differential diagnosis.
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Fig. 10A. —70-year-old woman with cardiac paraganglioma. Patient was
known to have cardiac tumor for more than 10 years, history of arterial
hypertension, and episodes of vomiting and flushing. MRI was performed to
evaluate tumor growth. Axial T1-weighted fast spin-echo image (TR/TE, 2 heart
beats/8.6) with double inversion recovery black blood prepulse shows large
mass (arrows) above left atrium, which compresses adjacent
structures. T2-weighted spin-echo images (not shown) revealed homogeneous high
signal intensity.
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Fig. 10B. —70-year-old woman with cardiac paraganglioma. Patient was
known to have cardiac tumor for more than 10 years, history of arterial
hypertension, and episodes of vomiting and flushing. MRI was performed to
evaluate tumor growth. Axial contrast-enhanced T1-weighted 3D fast field-echo
image (4.3/1.3; inversion time, 210 msec) obtained 6 min after injection of
0.2 mmol/kg of gadopentetate dimeglumine at same level as A shows
strong peripheral enhancement with central dark area (arrows)
corresponding to prominent central liquefaction.
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Fig. 11A. —72-year-old man with benign calcium-containing cyst arising
in the mitral–aorta intervalvular fibrosa. Patient had history of
chronic inferolateral myocardial infarction and abnormal structure in left
atrium on echocardiography suggestive of malignancy. MRI was requested for
further evaluation. Axial T1-weighted fast spin-echo image (TR/TE, 2 heart
beats/8.6) with double inversion recovery black blood prepulse shows
well-defined hypointense structure (arrows) between mitral and aortic
valves (i.e., mitral–aorta intervalvular fibrosa). T2-weighted spin-echo
images (not shown) revealed hypointense signal.
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Fig. 11B. —72-year-old man with benign calcium-containing cyst arising
in the mitral–aorta intervalvular fibrosa. Patient had history of
chronic inferolateral myocardial infarction and abnormal structure in left
atrium on echocardiography suggestive of malignancy. MRI was requested for
further evaluation. Axial contrast-enhanced T1-weighted 3D fast field-echo
image (4.3/1.3; inversion time, 210 msec) obtained 5 min after injection of
0.2 mmol/kg of gadopentetate dimeglumine at same level as A shows
well-defined nonenhancing structure (arrows). Findings are not
suggestive of cardiac malignancy on MRI but are compatible with benign
nontumoral condition containing calcium (low signal intensity on spin-echo
MRI). Surgery revealed benign cystic structure filled with calcified
debris.
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Conclusion
This pictorial essay presents a wide spectrum of applications for inversion
recovery contrast-enhanced MRI for assessing patients with cardiac disease.
The technique is simple and robust and can be performed on routine MRI
scanners, providing novel information that may not be gleaned from routine MRI
sequences. Therefore, these sequences should be included in MRI protocols that
are used to assess patients with myocardial disease, in patients with
pericardial disease, and in patients with findings suggestive of cardiac
thrombi and cardiac masses.
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Introduction
Materials and Methods
