Key result
Delayed enhancement cardiac magnetic resonance revealed atypical mid-wall and epicardial focal hyperenhancement matching territories of coronary thrombi in a patient with acute myocardial infarction.
Case Report (n=1)
This case demonstrates that ischaemic injury from distal coronary emboli can present with atypical mid-wall or epicardial hyperenhancement on DE-CMR, challenging the traditional concept that these patterns are exclusively of non-ischaemic aetiology.
Caution advised attributing mid-wall/epicardial DE-CMR patterns solely to non-ischaemic causes in AMI; single case leaves open broader applicability.
Background: Delayed enhancement cardiac magnetic resonance (DE-CMR) is the reference standard for the non-invasive assessment of myocardial fibrosis. DE-CMR is able to distinguish ischaemic from non-ischaemic aetiologies based on differences in hyperenhancement distribution patterns. Hyperenhancement caused by ischaemic injury typically involves the endocardium, while hyperenhancement confined to the mid- and epicardial layers of the myocardium suggests a non-ischaemic aetiology. Case summary: This is a case of a 20-year-old male with an unremarkable medical history with an acute ST-elevation myocardial infarction. DE-CMR revealed two distinct patterns of hyperenhancement: (i) a 'normal' wavefront-ischaemic pattern, and (ii) multiple atypical mid-wall and epicardial areas of focal hyperenhancement. Invasive coronary angiography (ICA) and coronary computed tomographic angiography (CCTA) showed multiple intracoronary thrombi and distal emboli in the left anterior descending, ramus circumflexus, and in smaller branches of the LCA. All hyperenhancement patterns observed on DE-CMR perfectly matched the distribution territories of the affected coronary arteries. Discussion: This case with an acute myocardial infarction showed intracoronary thrombi and emboli on ICA and CCTA. Interestingly, DE-CMR showed two different patterns of hyperenhancement in the same territories of the coronary thrombi. This observation may challenge the concept that these non-endocardial areas of hyperenhancement on DE-CMR are always of non-ischaemic aetiology. It is hypothesized that occlusion of smaller distal branches of the coronary arteries may result in mid-wall or epicardial fibrosis as opposed to subendocardial fibrosis commonly found in patients with a large epicardial coronary occlusion. Clinicians should be aware of these atypical patterns to be able to initiate adequate medical therapy.
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Nies et al. (2023) conducted a case report in Acute ST-elevation myocardial infarction (n=1). Delayed enhancement cardiac magnetic resonance (DE-CMR) was evaluated on Hyperenhancement distribution patterns. Delayed enhancement cardiac magnetic resonance revealed atypical mid-wall and epicardial focal hyperenhancement matching territories of coronary thrombi in a patient with acute myocardial infarction.
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