“How we do”

CMR in acute myocardial infarction

Derek J Hausenloy, Anna S Herrey, James C Moon
UCLH Heart Hospital and
The Hatter Institute, University College London, UK.

This presentation posted for members of SCMR

as an educational guide – it represents the views and
practicesof the author, and not necessarily those of SCMR.
CMR in acute myocardial infarction

Established indications in AMI STEMI:

• Assess global and regional LV function.
• Detect LV thrombus.
• Detect and quantify microvascular obstruction.
• Detect and quantify acute myocardial infarct size
• Detect and quantify preserved myocardium.

Potential future indications in STEMI:

• Detect and quantify the area at risk of infarction- myocardial oedema.
• Determine the myocardial salvage index
(infarct size-area at risk/area at risk)
• Detect and quantify myocardial haemorrhage. Coronal
• Detect and quantify the peri-infarct ‘grey’ zone.

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 CMR and other Imaging Modalities in AMI

Function Infarct Thrombus MVO Radiation Haem Area Myocardial

Dose at risk salvage
Cardiac MRI +++ +++ +++ +++ 0 ++ ++ +++

Nuclear + ++ 0 0 ++ 0 ++ ++

Echo ++ + ++ + 0 0 Coronal
+ 0

Cardiac CT + + ++ + ++ 0 + 0

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Facilitating CMR in AMI

• Fine balance between time available and completeness of protocol.

• Need to optimize protocol to <45 min.
• Non breath-hold approaches to CMR:
3D whole heart navigated sequences
Single-shot LGE
Motion corrected averaging Coronal

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CMR in AMI – general considerations

1. Aim to image on day 2-3 i.e. on day of discharge, although safe within 24 hours
Phrommintikul et al Eur J Radiol. 2009 Apr 16. [Epub]

2. Coronary stents are not a problem

Patel et al Radiology. 2006;240(3):674-80.

3. Patient may still be unwell

4. Difficulty breath holding and tachycardia in patient

5. Ensure resuscitation facilities nearby

Coronal
6. Check renal function. If eGFR<30, only rarely does the benefits of CMR outweigh risk of contrast (NSF)
7. Aim to complete scan within 45 minutes

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Summary of CMR protocol for AMI

1. Axial scouts. Time

2. Multi-slice SSFP cine MRI in long and short axes

for volumes and function.
(see ‘How I do a volume study’) 10 min

3. Early post-contrast T1-weighted 2D inversion-

recovery GRE (or SSFP) with long TI. Multi-slice:
a. MVO (presence and size)
b. Acute thrombus 20 min

5. 5-15 min post-contrast T1-weighted 2D inversion-recovery GRE (or SSFP). Multislice for:
a. Infarct (presence and size)
Coronal
b. MVO (presence and size) 30 min

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Optional imaging for AMI

Time
2a Optional – before giving contrast: Multi-slice T2
weighted TIRM or STIR for:
a. Area at risk (size)
b. Myocardial haemorrhage (presence and size). +15 min

2b Optional resting perfusion – minimum 3 SA slices

– basal, mid, apical for: Coronal
a. no-reflow (microvascular obstruction) +5 min

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Early gadolinium enhancement

- 1-3 min post-gadolinium, IR GRE or SSFP sequence, 2D or 3D

set inversion time to ~440ms-480ms (higher if ↓HR or trigger 1)

- ToRCA
detect intra-cardiac thrombus (see arrow).
clip artefact
Late Gadolinium Enhancement (LGE) - 1

- Quantification of myocardial infarct size

- T1 inversion recovery sequence (GRE or SSFP)
- Usually image in diastole to reduce motion artefacts
- Manually adjust TI (start depends on time, dose and trigger/HR)
Late gadolinium enhancement (2)

- Can also detect and quantify MVO (dark core –see arrow).
- presence of MVO linked to worse clinical outcomes
- preventing MVO is a viable target/mechanism for cardioprotection
Late gadolinium enhancement (3)

• Further LGE information: see

• AMI ‘Resources’ section of SCMR website
• (includes protocols, cases, standardized datasets, talks)
• 2D Inversion recovery sequence (GRE)
- Alternatives: IR–SSFP, 3D sequences, PS-IR
• Image in diastole to reduce motion artefacts.
• Endocardial structures: systole (reduce segments) and later (blood pool down)
• Image technique
• Go and learn it. artefact recognition and reduction
• Manually adjust TI (260ms-480ms)
• Compulsory –even PS-IR sequences work better
• Gd dose: if not already given, use 0.1-0.2mmol/kg
• Image positions: Copy from cines, phase swaps, cross cuts
Optional imaging -T2 oedema imaging (1)

- Myocardial oedema/inflammation appear as increased signal intensity on T2-weighted

sequences (see AMI ‘Resources’ talks on T2W imaging)
- This can be used to detect an AMI, myocarditis, or delineate the ‘area at risk of infarction’.
- Several T2 weighted sequence e.g. TSE (black blood), STIR, TIRM, T2P-SSFP, ACUT2E.

T2 TSE TIRM

Area at Area at
Risk Risk
Optional imaging -T2 oedema imaging (2)

Problems with T2 oedema imaging

1. Low SNR
-therefore difficult to delineate and quantify.

2. Surface coil sensitivity

-T2 sequences are very prone to variations

3. Bright subendocardial rims

-due to stagnant blood.

4. Posterior wall signal loss

-due to cardiac movement,
Optional imaging –Myocardial hemorrhage

• The presence of myocardial hemorrhage within the infarct is

associated with worse LV remodelling and clinical outcomes. Early Gd
• It can be detected using either STIR or dual-inversion black-blood gradient multi-echo T2* imaging
sequences.
• Hypointense region on T2 weighted imaging.
• Appears to correspond to area of MVO.

STIR imaging LGE

T2* imaging Perfusion LGE

Ganame et al Eur Heart J 2009 Apr Epub

O’Regan et al Radiology 2009;250:916-22.

Optional imaging – Rest perfusion

- Myocardial perfusion imaging (<1 min post-gadolinium).

- To detect/quantify microvascular obstruction (see arrow).
- See “How we do perfusion”
Optional imaging – Peri-infarct ‘grey’ zone

• Detecting and quantification of the peri-infarct ‘grey’ zone (intermediate contrast), which is associated with post-infarct
sudden cardiac death, may be used for risk-stratification post-MI. Yan et al Circ 2006;114;32-39
Schmidt et al Circ 2007;115;2006-2014

• Detect using LGE and quantify using thresholds (SD±2-3) or full-width half max.

• See ‘On-Line talks:

(copy and paste these into your browser)
http://www.scmr.org/Members/CMR-online-video-on-demand-lectures/scmr-2009/Sunday_Plenary/Sun_Plenary-2-Kwong.html
http://www.scmr.org/Members/CMR-online-video-on-demand-lectures/scmr-2009/Sunday_Plenary/SunPlen-3-Lee.html

From Schmidt et al, above

Example- LAD infarct

Cine TIRM Perfusion LGE

LGE

Acknowledgement:: Derek Hausenloy