Edward T.D. Hoey

Magnetic Resonance Imaging of Cardiac Tumors: Part 2, Malignant Tumors and Tumor-Like Conditions

Cardiovascular magnetic resonance imaging (CMRI) is the reference noninvasive imaging technique for assessment and characterization of a suspected cardiac or juxta-cardiac mass. The multiplanar assessment of anatomy, tissue composition, and functional impact afforded by CMRI allows for early differentiation between a nonneoplastic mass and a tumor mass, be it benign or malignant. Malignant cardiac tumors have a poor prognosis; however, early detection and characterization confer some survival advantage, enabling early instigation of chemotherapy and/or consideration of a surgical debulking procedure. Cardiac metastases are far more common than primary tumors and are an important consideration in patients with disseminated disease. Angiosarcoma accounts for the majority of primary malignant lesions. Less common primary malignant cardiac tumors include sarcomas with myofibroblastic differentiation, lymphoma, rhabdomyosarcoma, pericardial mesothelioma, and pericardial synovial sarcoma. A number of benign masses and normal anatomical variants can cause confusion to the inexperienced observer and must be recognized to avoid unnecessary intervention. These include intracardiac thrombus, bronchogenic and pericardial cysts, and anatomical structures, such as the Crista terminalis and moderator band.

Magnetic Resonance Imaging of Cardiac Tumors: Part 1, Sequences, Protocols, and Benign Tumors

Cardiovascular magnetic resonance imaging (CMRI) is the reference noninvasive technique for assessment and characterization of a suspected cardiac or juxta-cardiac mass. The multiplanar assessment of anatomy, tissue composition, and functional impact afforded by CMRI allows for early differentiation between a nonneoplastic mass and a tumor mass, be it benign or malignant. CMRI has superior tissue contrast resolution compared with competing noninvasive imaging modalities (echocardiography and multidetector computed tomography). A number of different imaging sequences are employed for a comprehensive CMRI assessment. Black-blood prepared sequences are mainly used for tissue characterization and assessment of lesion enhancement characteristics. Bright blood prepared sequences provide functional information, such as lesion mobility and impact on adjacent valves and chambers. Atrial myxoma is the most common primary benign cardiac tumor and can present with obstructive or embolic phenomena. Fibroelastomas are smaller lesions that do not alter hemodynamic function but can cause symptoms secondary to systemic embolization. Less common benign cardiac tumors include lipoma, fibroma, hemangioma, paraganglioma, and cystic tumor of the atrioventricular nodal region.

Endovascular Embolization: Review of Currently Available Embolization Agents

Percutaneous vascular embolization is one of the major applications of interventional radiology. A wide variety of embolization agents are currently available for clinical use. The interventional radiologist needs to be up to date with the newer and different types of embolic agents available along with their biopharmaceutical characteristics, strengths, and weaknesses that have been reviewed. For the purpose of this review, we have classified embolization agents into mechanical occlusion devices, particulate agents, and liquid agents, with some degree of overlap between some of the agents.

Transcatheter coil embolisation: a novel definitive treatment option for intralobar pulmonary sequestration.

Pulmonary sequestrations have been conventionally treated surgically with removal of the tissue mass and ligation of its feeding vessels. There is established evidence to support the use of transcatheter arterial coil embolisation as an effective definitive treatment option for extralobar sequestration especially in the paediatric literature describing good long-term clinical outcomes. We present a case of an adult with intralobar sequestration in whom the diagnosis was established with multi-detector computed tomography (MDCT) and in whom transcatheter arterial coil embolisation was successfully performed as a definitive treatment option to support the growing body of evidence of transcatheter arterial coil embolisation as a safe and effective treatment option for both form of pulmonary sequestrations.

The emerging role of cardiovascular MRI for risk stratification in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common inheritable cardiovascular disorder. Although many HCM patients remain asymptomatic, sudden death (SD) can occur as the initial manifestation of the disease. It has been hypothesized that myocardial architectural disorganization and scarring represent an unstable electrophysiological substrate that creates susceptibility to malignant ventricular arrhythmias. Cardiovascular magnetic resonance imaging (CMR) is widely used for the diagnosis of HCM, especially in patients with an incomplete or inconclusive echocardiography study. CMR can provide precise non-invasive assessment of biventricular function, wall thickness, and assessment of myocardial fibrosis, using inversion recovery gadolinium-enhanced sequences. CMR is also one of the most promising avenues of research in HCM, and in recent years, has provided many new insights and identified a number of potential adverse prognostic indicators for SD. Future work is still needed to integrate CMR findings into traditional risk assessment algorithms. This paper reviews the evolving role of CMR for risk stratification in HCM including assessment of myocardial hypertrophy, fibrosis and ischaemia.

Trauma musculoskeletal ultrasound

Musculoskeletal ultrasound has benefited from the recent exponential improvement in probe technology to the extent that it is now the imaging modality of choice for many peripheral soft tissue injuries. This article aims to highlight these areas and encourage the use of this modalilty in these scenarios rather than the currently more favoured magnetic resonance imaging scan.

Cardiac Aneurysms and Diverticula: Magnetic Resonance and Computed Tomography Appearances

Echocardiography is the first-line imaging modality for assessment of structural heart disease but magnetic resonance imaging and multi-detector computed tomography are being increasingly used for cardiac morphologic assessment. Aneurysms and diverticulae of the cardiac chambers and related structures represent a diverse group of conditions with varying etiologies and clinical manifestations. This article reviews the magnetic resonance imaging and multi-detector computed tomography features of these lesions with consideration of the emerging role that cross-sectional imaging has to play in their evaluation. Radiologists should be familiar with the salient imaging appearances of these conditions to facilitate optimal patient management.

Computed tomography–guided pericardiocentesis: utility in the management of malignant pericardial effusion

Transthoracic echocardiography is an established means of diagnosing a pericardial effusion and has become the reference guidance modality for drainage of symptomatic collections. However, echocardiographic drainage is not feasible in all patients for a variety of technical and patient-related factors. Computed tomography (CT)-directed pericardiocentesis using a standard Seldinger technique is an alternative means of draining pericardial effusions and overcomes many of the limitations associated with echocardiography. We present a case in which a CT-guided approach was used to successfully drain a malignant pericardial effusion in the emergent setting. Clinicians should be aware of the potential role of CT in this setting.

Complete left pericardial defect: Evaluation with supine and decubitus dual source CT

We present a case of complete left pericardial defect which was evaluated with retrospectively gated dual source CT. Imaging findings included right heart chamber dilatation, extreme levoposition and excessive cardiac mobility which was demonstrated by repeat imaging in the left lateral decubitus position. Cardiac CT is an excellent means of evaluating pericardial disease owing to its high spatial resolution. Decubitus imaging helps confidently distinguish partial from complete forms of pericardial defect.

Imaging Appearances of Congenital Thoracic Lesions Presenting in Adulthood

Many congenital lesions of the thorax are detected for the first time in adulthood when they can simulate a wide range of pathologies, including infection and neoplasia. They can be broadly classified into tracheobronchial, parenchymal, vascular, and combined parenchymal/vascular abnormalities. An awareness of their typical imaging features enables a confident diagnosis and helps direct appropriate patient management.