Download CT and MR Imaging of Cardiac Tumors

CT AND MR IMAGING OF
CARDIAC TUMORS
B.Zandi
Professor of Radiology
Objectives
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To review the Spectrum of CT and MRI findings for a
variety of cardiac neoplasms.
The role of CT and MRI in :
The Diagnosis of Cardiac Tumors
To DD Benign from Malignant Masses.
the use of
MDCT in providing Anatomical Information
MRI for Tissue Characterization of Cardiac Masses.
Cardiac tumors
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Prevalence of 0.002-0.3% at Autopsy
1. Primary Cardiac Neoplasms
(Benign and malignant)
2. Metastatic
approximately 30 times more Prevalent than
primary
Imaging Modalities
Trans-thoracic Echocardiography
 Trans-esophageal Echocardiography
 Multi-detector CT Scanning (MDCT)
 Magnetic resonance imaging (MRI)
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Imaging Modalities
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Trans-thoracic Echocardiography
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Most Widely Used imaging modality
The Best Imaging modality to depict Small Masses
(Valves )
Limitations : Visualization of Extra-Cardiac Extension
TEE : less limitation of acoustic window than thoracic
mode,
The Airways and lungs can be obstacles for imaging of
the Aortic arch, Pulmonary Arteries and Veins
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:
Imaging Modalities
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MRI :
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The Modality of Choice to evaluate Cardiac Tumors.
High Contrast Resolution and MPR allow :
a Specific Diagnosis
Optimal Evaluation of Myocardial infiltration,
Pericardial involvement
and Extra-Cardiac Extension.
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Imaging Modalities
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MDCT Scan :
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MDCT Recently, has been Increasingly Utilized for Cardiac Imaging.
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Short Image Acquisition Time compared to MRI ( an advantage in Cardiac
Imaging )
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ECG Gating MDCT either by Scanning or Reconstructing Raw Data at the
point of the Least Cardiac Motion.
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CT has better Soft Tissue Contrast Resolution than Echo
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definitively characterize Fat and Calcifications
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Wide field-of-view helps :
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to assess the Extent of a Cardiac Malignancy
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and to detect Metastatic Lesions
Table 1. Primary Benign Tumors and Cysts of Heart and
Pericardium in 533 cases
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Myxoma
Lipoma
Papillary Fibroelastoma
Rhabdomyoma
Fibroma
Hemangioma
Teratoma
Mesotheloma of AV node
Granular cell tumor
Neurofibroma
Lymphangioma
Subtotal
Pericardial Cyst
Bronchogenic Cyst
Subtotal
130 (24.2)
45 (8.4)
42 (7.9)
36 (6.8)
17 (3.2)
15 (2.8)
14 (2.6)
12 (2.3)
3
3
3
319 (59.8
82 (15.4)
7 (1.3)
89 (16.7)
Myxomas
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the Most Common Benign Tumor (4th-7th decades)
LOCATION :
Inter-atrial Septum at fossa ovalis LA (Most Common )
75% LA ( typically, in the Inter-atrial Septum )
20% in RA ,
rarely in the Ventricles.
Typical Morphologic Characteristics : Gelatinous, attached to
stalk, Calcification , Hemorrhage or Necrosis; Common
Imaging Characteristics
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Echo Features : Mobile tumor, Narrow stalk
CT Features : Well-defined Spherical or Ovoid Intra-Cavitary
Mass with Heterogeneous, low attenuation, Typically
Lobular Contours
IV-CT : Heterogeneous (Hemorrhage, Necrosis, Cyst
formation, Fibrosis or Calcification)
MR Imaging Features :
Heterogeneous (before contrast)
Heterogeneous Enhancement (after contrast)
areas of Low signal intensity within the tumor (due to Calcification
or Hemosiderin ).
T2W : Markedly High Signal
MPR MDCT 4-chamber view
LV Myxoma in 38-year-old female.
A. Mass (arrow) in LA.
B. Mass (arrow) extends into LV during diastolic phase through mitral valve.
MPR MDCT
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LA Myxoma in 65-year-old male.
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A. shows LA mass attached to inter-atrial septum by broad pedicle
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Strong Enhancement in part of mass with foci of Calcification
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B. Gross specimen : Multicolor Soft Tissue Mass ( mixture of Hemorrhage,
Necrosis, Cyst formation and Fibrosis )
MRI-DIR
MRI-TIR
MRI- Gd-DIR
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RV Myxoma in 30-year-old female.
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A. Isointense mass occupying RVOT
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B. High Signal Intensity in most parts of mass
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C. Hyperenhancement of mass
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D. Yellow Soft Tissue Mass with narrow base of attachment to RV.
short-axis view systole
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RV myxoma in a 55-year-old man.
a mass prolapsing into the main PA .
Lipomas
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The Second Most Common Benign Cardiac Tumors in adults.
Age : Variabale
Associated Syndromes : Tuberous Sclerosis (few cases)
Location : Pericardial Space or any Cardiac Chamber
Typical Morphologic Characteristics : Very large, Broad-based; no
Calcification, Hemorrhage, or Necrosis
Echo : Usually Hypoechoic in the Pericardial Space, Echogenic in a cardiac
Chamber
Specific CT and MR imaging Characteristics.
CT : Homogeneous, low-attenuation mass
MRI : Homogeneous High Signal intensity on the T1/T2
that decreases with the use of Fat-Sat sequences.
do not show Contrast enhancement
ECG-g MDCT
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RA lipoma in 62-year-old female.
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A. Homogeneously low-attenuated mass with pedicle (arrow) attached to free wall of RA
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B. Gross specimen : shows fatty nature of mass.
apical 4ch view
T1W MR
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RA lipoma in a 72- year-old man.
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A . large mass (M) arising from the postero-lateral wall of the RA
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B . Circumscribed, broad-based mass , High Signal fills most of the RA.
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C . Smooth lipoma filling the RA.
Intra-operative photograph
4ch, T2 BB
delayed 10 min
T1 BB
fat-suppressed, T2
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Lipomatous Hypertrophy of the inter-atrial septum /35-year-old woman with AF .
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sparing the adjacent Fossa Ovalis, favouring the diagnosis of lipomatous hypertrophy
rather than lipoma.
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Fatty infiltration of the inter-atrial septum in a 69-year-old, mildly obese
woman with palpitations, dyspnea, and an atrial tachyarrhythmia.
wedge-shaped fatty thickening of the inter-atrial septum (arrows).
extension of fatty tissue into the RV (arrowhead).
Papillary Fibroelastomas
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Are Benign Endocardial Papillomas
Age : Middle-age
Typical Morphologic Characteristics : Small (<1.5 cm) frond- like,
narrow stalk mass attached to the Moving Valves ; Calcification
rare, no Hemorrhage or Necrosis
Location : Cardiac Valves
75% of all Cardiac Valvular tumors .
Echo : small masses with “Shimmering” edges
CT and MR Features : Usually not seen
MRI : Typically a mass on a Valve Leaflet or on the Endocardial
surface
Cine MR : Turbulence in the blood flow.
ECG-gated MDCT
cine MR
Oblique TIR MR
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Papillary Fibroelastoma of AO Valve in 60-year-old female.
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A : abnormal Thickening of AO Valve (arrow).
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B, C : small mass (arrows) attached to Aortic Valve ( moving according to valvular motion ).
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D : slightly high signal intensity of small mass (arrow).
Rhabdomyomas
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the Most Common Cardiac Tumors in Infancy and
Childhood,
Associated Syndromes : Tuberous Sclerosis in up to 50% of
cases
Mostly Asymptomatic and generally regress spontaneously.
Location : Typically in the Myocardium of Ventricles, and
multiple lesions up to 90% of cases.
MRI :
T1W ; Isointense to marginally Hyperintense
T2W ; Hyperintense
Gd-E T1W
Sagittal T1W SE MR
Axial Gd-E T1W SE MR
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Cardiac Rhabdomyoma in Newborn with Tuberous Sclerosis.
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A. Nodules in Caudate Nuclei and Frontal Lobes
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B. Iso-Intense mass in Septum and anterior wall of LV.
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C. Mild Enhancement
T1
T2
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SSFP (WB)
Delayed10 min
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Fibroma of the LV in a 32-year-old F, with recurrent syncope and runs of V Tach.
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(a,b,c) a well-defined, low-signal mass within the anterior wall of the LV.
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(d) uniform enhancement and a thin rim of surrounding compressed myocardium.
Table 1. Primary Malignant Tumors and Cysts of Heart
and Pericardium in533 cases
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Malignant
Angiosarcoma
Rhabdomyosarcoma
Mesothelioma
Fibrosarcoma
Malignant Lymphoma
Extraskeletal Osteosarcoma
Neurogenic Sarcoma
Malignant Teratoma
Thymoma
Leiomyosarcoma
Liposarcoma Synovial Sarcoma
Subtotal
39 (7.3)
26 (4.9)
19 (3.6)
14 (2.6)
7 (1.3)
5
4
1
1
1
1
125 (23.5)
Angiosarcomas
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The Most Common Cardiac Sarcomas (37%)
Location : RA and involves the Pericardium.
Presentation : Rt-sided Heart Failure or Tamponade
Late Presentation (often Metastases at the time of
diagnosis, particularly to the Lung )
Invasive behavior ( Pericardial or Pleural Effusion ).
Angiosarcomas
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CT : a Low-Density Irregular or Nodular Mass in the RA
Specific MR feature: (on T1/T2 ) a Heterogeneous Papillary
Appearance , with and Nodular areas of High Signal
interspersed within areas of Intermediate Signal
Enhancement : Linear along the Vascular Spaces as a
“Sunray”
. ECG-gated MDCT
DIR MR
TIR MR
Gd-E DIR MR
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Angiosarcoma of RA in 48- year-old male.
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A. large mass at the free wall of RA.(irregular and nodular contour and strong contrast
enhancement).
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B. mostly Isointense mass in RA.
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C. Heterogeneously Hyperintense mass .
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D. Heterogeneous Hyper-enhancement /areas of no enhancement (Intra-tumoral Thrombosis).
T1W DIR FSE
GdE T1W DIR FSE
T2W DIR FSE
4Ch SSFP
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Primary Cardiac Angiosarcoma in a 55-year-old man with Weight loss, Dyspnea, and
Peripheral Edema.
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A. a large, Heterogeneous, Isointense mass completely obliterates the RA. (areas of low and
High signal , (due to hemorrhage , necrosis ).
The influence of different MR Sequences
Primary Cardiac Angiosarcoma
T1WSE echo-planar
T2W DIR fast SE
T2W DIR Fat-Supp
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Primary cardiac angiosarcoma in a 25-year old woman :
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with leg swelling, abdominal pain, bloating, and dyspnea.
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A. a large Heterogeneous mass at the RA free wall. predominantly isointense ,
some areas of High-Signal (localized hemorrhage)
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B,C. large, Hyperintense, Water- rich mass, left pl eff
Other Cardiac Sarcomas
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Including :
Undifferentiated Sarcomas
Malignant Fibrous Histiocytomas (MFHs)
Leiomyosarcomas
Osteosarcomas
Lymphosarcomas
Myxosarcomas
Neurogenic Sarcomas
Synovial Sarcomas
Neurofibrosarcomas
Kaposi’s Sarcomas
Although most Angiosarcomas occur in the RA, the other sarcomas
affect the LA more frequently, (an important differentiating feature)
Rhabdomyosarcoma
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is the Commonest Childhood Primary Cardiac Malignancy
two distinct Histological Types:
Embryonal types, occur in Children and Adults
Pleomorphic , Much Less Frequent and occur in Adulthood
Location : No Specific Chamber
Valves involvement , is more likely than any other Primary
Cardiac Sarcoma
Multiple sites of involvement
Rhabdomyosarcoma
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The presentation: Depends on the area of involvement,
but as the other Cardiac Sarcomas, CHF is common.
MRI :
T1W Iso-intense to myocardium
Homogeneous Gd-enhancement
Some areas of low Signal Intensity (Central Necrosis).
MDCT+IV
T1 SE
T1 SE
T1 SE
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Rhabdomyosarcoma in 22 year old
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A,D. MDCT+IV : LA mas Extending through the septum to the RA
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B,C. T1 SE 6 months after resection , Recurrence at the septum and pericardial involvement
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Fibrosarcoma
CT 4 Chamber Involvement
T1W 1 year later after therapy
Primary Cardiac Lymphomas
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Extremely Rare, ( incidence of 0.15 to 1% )
Most Common Type : Diffuse Large B cell
Mostly : Solid Infiltrative Tumors in one or multiple
chambers of the heart.
Mimicking Classic HCM (massive infiltration of the
myocardium )
Primary Cardiac Lymphomas
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CT :
as Hypo- or Iso-attenuated Infiltration
Enhancement : Heterogeneous
MRI :
T1W ; Isointense
T2W ; Heterogeneously Hyperintense
Gd-E ; Heterogeneous Enhancement
Enh-MDCT
Gd-E DIR MR
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Primary Cardiac Lymphoma (diffuse large B-cell type) in 73-year-old male.
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A. Homogeneous infiltration at RA wall and inter-atrial septum.
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Pericardial effusion; (Pericardial invasion ?)
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B. Diffuse Infiltrative Mass in RA
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Homogeneous Enhancement (distinguishes it from pericardial eff)
Primary cardiac lymphoma : different patterns of cardiac involvement.
SSFP (WB)
T1 BB
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(a) A 35-year-old man with AIDS presented with dyspnoea.
a large, solid mass filling the LA isointense with myocardium.
(b) A 42-year-old F, no history of immunosuppression /with cardiac failure.
Diffuse soft-tissue mass filling the pericardial space and the free wall of the RA
and LV
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Secondary Cardiac Lymphoma , bilateral Adrenal, renal and
intera and retroperitoneal involvement.
Metastatic Involvement
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Much More Common than Primary Tumors, Ratio of 30:1
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Cardiac mets occur in 11% of cases of malignancies
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Most Frequent Malignancies to the heart :
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Lung , Breast, Melanomas and Lymphomas
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The Most Common site : Epicardium
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Spreading means :
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1. mainly the Mediastinal Lymphatics to the Epicardial Surface
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2. Hematogenously through the :
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Coronary arteries, or less commonly IVC
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3. Direct Extension ( Thymic , Bronchial, Breast and Esophagus )
Metastatic Involvement
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Commonly Coincidence Hematogenous Mets in other
organs (Lungs).
Trans-Venous tumor spread :
into the RA through the SVC (lung ) or IVC (kidney or liver)
into the LA via the Pulmonary Veins.
DD of Metastases from Thrombus :
Enhancement Patterns after IV Gd-E: (Hetergenous Enh)
IR Time 400-500msec
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Intracardiac Metastases ( 20-year-old, Seminoma ; with dyspnoea and chest pain.
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MDCT : Several large low attenuation masses within the RV.
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the changes in both lungs, caused by multiple tumour emboli.
MDCT
Gd-e DIR MR
Arterial (C) and delayed (D) CT
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Hematogenous Cardiac Metastases from HCC
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A ,B . Marked Diffuse Thickening of RV free wall (arrows).
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C, D. HCC Characteristic pattern of early enhancement and wash out
Nonenhanced T1W SE echo-planar
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Direct Venous Extension of a left-sided RCC
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LRV and IVC are filled by a isointense mass extending into the RA
Tumorlike Lesions
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Thrombus is The commonest Mimic of a cardiac
Neoplasms
Most likely to be located posteriorly in the LA,( AF ,
or severe LV Dysfunction)
It can also be found in the right side of the heart
Tumor-like Lesions (Thrombus)
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MR Characteristics : Variable depending on the age of the
thrombus.
Acute thrombus : Bright on both T1 and T2
Subacute thrombus : Bright on T1, and Low-Signal areas on T2
(the Paramagnetic effects of Methemoglobin )
Chronic organized thrombus : T1/T2; Low Signal (Water depletion ,
with or without calcification )
Gd-E ; Useful for DD thrombus from tumors ( Thrombus doesn't
enhance)
Long Inversion time (400 msec)
Note : Organized Thrombus may show some surface Enhancement)
DD : Slow or Static Flow / Flows through the imaging plane
Vertical, long axis (2-ch) delayed
10 min ,long IR time(500 ms)
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Intracardiac Thrombus.
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(a) A 64-year-old man with a past history
of anterior wall myocardial infarction.
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non-enhanced mass (arrows) and an
overlying (high signal) full thickness MI.
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(b) A 55-year-old man with a prior history
of anterior myocardial infarction.
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a low-attenuation mass within the LV
delayed- 10 min +
500mSec IR
SSFP
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Flow artefact within the RV as a low attenuation filling defect
‘‘pseudotumour’’ IVC inflow
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Thrombus different locations
T
Axial SSFP
Coronal Gd-E First pass
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RCA Aneurysm.
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a smoothly marginated mass indenting the RV free wall.
CONCLUSION
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CT and MRI may be useful in the DD of Benign/Malignant cardiac masses.
CT is useful for the evaluation of Ca and Fat content within a mass
The High Spatial Resolution of MDCT is beneficial to define Small Lesions
MDCT is useful in the Staging of Malignant Tumors.
The Excellent Contrast Resolution of MRI allows Characterization of
Fibromas and Hemangiomas.
Homogeneity of a mass due to compact cellularity may be characteristic
of a Lymphoma.
Acquisition of Post-Contrast Sequences enables better depiction of tumor
Vascularity and can be used to define Tumor Borders.
MRI has an important role in DD Thrombi from Cardiac Tumors.
MDCT and MRI might help determine Resectability of a Tumor and allow
planning for reconstruction of the cardiac chambers.