Non cardiovascular findings on cmr
Download
1 / 86

Non-Cardiovascular Findings on CMR - PowerPoint PPT Presentation


  • 113 Views
  • Uploaded on

A major teaching hospital of Harvard Medical School. Non-Cardiovascular Findings on CMR. Marty Smith M.D. Instructor in Radiology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA. Objectives.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Non-Cardiovascular Findings on CMR' - jadon


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Non cardiovascular findings on cmr

A major teaching hospital of Harvard Medical School

Non-Cardiovascular Findings on CMR

Marty Smith M.D.

Instructor in Radiology

Beth Israel Deaconess Medical Center

Harvard Medical School

Boston, MA


Objectives
Objectives

  • Review data for incidental non-cardiovascular findings (NCF) in cross-sectional cardiac imaging

  • Approach to non-cardiovascular structures on CMR imaging

  • Overview of common lesions and their expected appearance on CMR


What is covered
What is covered?

Imaged volume – Base of Neck → Kidneys

Base of Neck - Thyroid, parathyroid, trachea, esophagus, muscles, vertebral bodies, lymph nodes, nerves, fat

Thorax

  • Thyroid

  • Mediastinum – thymus, trachea & bronchi, esophagus, vertebral bodies, spinal canal, lymph nodes, nerves, fat

  • Lungs and pleura

  • Chest wall – bones, muscles, lymph nodes, nerves, fat

  • Breasts

  • Diaphragm


What is covered1
What is covered?

Abdomen

  • Liver

  • Gall bladder and bile ducts

  • Pancreas

  • Kidneys

  • Adrenal Glands

  • Spleen

  • Stomach

  • Bowel and Mesentery

  • Vertebral column, nerves, spinal canal, paravertebral musculature, fat, fascia, & lymph nodes


Background non cardiac findings
Background: Non-Cardiac Findings

Dewey M, et al. Non-cardiac findings on coronary computed tomography and magnetic resonance imaging.Eur Radiol 2007 Feb 1; [Epub ahead of print].

  • 108 consecutive patients suspected of having CAD who had CTA & MRA

  • Significant NCF → clinical or radiology F/U

  • CT – 5 (5%) significant non-cardiac findings

    • PE, pleural effusion, sarcoid, HH, & pulmonary nodule

  • MRI – 2 (2%) significant non-cardiac findings

    • Pleural effusion & sarcoid – both seen on CT


Non cardiac findings
Non-Cardiac Findings

Of 108 pts.

Dewey at al. Eur Radiol 2007

Conclusion: Incidental NCF are common; images should be analyzed by radiologists to ensure findings not missed & unnecessary follow-up avoided.


Non cardiac findings on cardiac ct
Non-Cardiac Findings on Cardiac CT

  • Cardiac MDCT in 503 pts1

    • 346 new NCF in 292 pts (58.1%)

    • 114 pts (22.7%) had clinically significant findings

      • 4 cases of malignancy (0.8%).

      • 49 lung nodules <1cm (12 > 1cm), 8 aortic,17 pleural effs

  • Cardiac MDCT in 166 pts, suspected CAD2

    • NCF in 41 pts (24.7%), major (4.8%)

  • EBCT in 1326 pts for coronary Ca2+ scoring3

    • NCF requiring f/u in 103 pts (7.8%)

  • EBCT in 1812 consecutive pts4

    • NCF in 630 (35%); 50 (2.8%) f/u imaging

  • Summary for CT:

  • NCF in 24-58%

  • NCF needing f/u in 2-23%

  • Classification criteria variable

1 Onuma Y, et al. J Am Coll Cardiol 2006 2 Haller S, et al. AJR Am J Roentgenol; 2006

3 Horton KM, et al. Circulation 2002 4 Hunold P, et al. Eur Heart J 2001


Bidmc cmr experience part i
BIDMC CMR Experience – Part I

  • 1534 clinical CMR reports reviewed 2002-061

  • 129 NCF in 116 (8.2%) studies

    • 55 “major” findings in 50 (3.3%) studies

      • lymphadenopathy - 22 (1.4%)

      • lung abnormalities - 19 (1.2%)

      • mediastinal masses - 6 (0.4%)

      • breast lesions - 4 (0.3%), ascites - 3 (0.2%), soft tissue masses - 1 (0.1%)

    • 74 “minor” findings in 70 (4.6%) studies

      • pleural effusions, liver lesions, renal cysts, HH, diaphragmatic abnormalities, splenic abnormalities, paraspinal lipomas, & anomalous vasculature

  • NCF mean age 54 vs 49 w/o (p <0.001)

1 Chan PG, etal. JACC 2009


Bidmc cmr experience part ii
BIDMC CMR Experience – Part II

  • 495 clinical CMR exams in 2006 reviewed for NCF by radiologist w/o prior readings

  • NCF classification

    • Benign (gynecomastia, simple cyst)

    • Indeterminate (pleural effusion, liver & renal lesions)

    • Worrisome (lung nodules)

  • Follow-up of indeterminate & worrisome NCF using Careweb

    • New vs known abnormality

    • What follow-up performed


Results ncf prevalence
Results: NCF Prevalence

  • 295 NCF in 212 / 495 (43%) studies

    • 144 Benign: 123 / 495 (25%) studies

    • 137 Indeterminate: 105 / 495 (21%) studies

    • 14 Worrisome: 14 / 495 ( 3%) studies

      Benign: Gynecomastia (41), HH (22), Renal Cyst (17), Liver cyst/hemangioma (16), Scoliosis (11), Mediastinal LAN <1.5 cm (10), Other (27)

      Indeterminate:Pleural effusion (29), Renal lesion (27), Atelectasis (11), Mediastinal LAN >1.5 cm (11), Lung consolidation (7), Big HH (6), Liver lesion (6), Other (40)

      Worrisome:Lung nodules (11), Aortic dissection (1), Aortic ulcer (1), Mediastinal mass (1)


Results ncf detection f u
Results: NCF Detection & F/U

  • 105 / 295 (36%) NCF listed in clinical report

    • Benign (21%), Indeterminate (50%), Worrisome (50%)

  • 11 NCF in reports missed by reviewer

  • 65 NCF in 52 pts needed f/u → performed on 25 (38%)*

  • Of NCF reported, 22 needed f/u → performed on 12 (55%)**

* No online medical record information currently available for pts with 16 findings

** No online medical record information currently available for pts with 7 findings


Known follow up
Known Follow-up

Management changing findings in 11 pts:

  • Lung cancer (2)

  • Pulmonary nodule requiring further follow-up (2)

  • Typical pulmonary carcinoid

  • Cryptogenic organizing pneumonitis (COP)

  • Multifocal pneumonia secondary to newly diagnosed AML

  • Mediastinal lymphadenopathy requiring further follow-up

  • Breast implant rupture

  • Obstructed atrophic kidney

  • New AAA (previously repaired but with recurrence)


Results radiologist s presence
Results: Radiologist’s Presence

  • Radiologist at joint read-out – 384/495 (78%) scans

  • 42% (95/228) of NCF reported when radiologist at joint readout

  • 15% (10/67) of NCF reported when radiologist read remotely (p<0.01)


Results sequences
Results: Sequences

  • Scouts showed NCF 186/295 (63%)

  • T1W FSE showed NCF 176/295 (60%)

  • Only 12 (4%) NCF not visualized on one of these sequences

    • 10 benign, 2 indeterminate)



Cmr sequence overview
CMR Sequence Overview

  • Abdomen & base of neck

    • FFE scouts

    • Limited coverage by other sequences

  • Thorax – Potentially all sequences

    • Most →T1-w TSE, FFE scouts, B-FFE cines

    • Other T1-w imaging

      • T1-w TSE FS

      • Post gado T1-w TSE, T1-w IR GRE, T1-w SPGR

    • T2-w imaging

      • T2-w TSE dark blood

      • Fat suppressed T2-w → SPIR, STIR


Ffe scouts
FFE Scouts

  • Limited soft tissue lesion detection & characterization

  • Large inter-slice gap, low resolution

  • Contrast based on T2/T1 ratio

    • Bright = Fluid or fat

    • Not bright = Soft tissue, some complex fluid

  • Motion insensitive

    • Shape & margin with well defined lesions

    • Internal structures of cysts

  • B-FFE and TFE similar for NC lesions


Tse t1
TSE T1

  • True T1-weighted sequence with IR blood suppression

    • Bright – fat, hemorrhage, protein, some flow, some Ca2+

    • Dark – Simple fluid, most Ca2+, air

    • In-between – most masses

  • Cover from top of liver to above arch

    • Excellent for anatomy

    • Best look at mediastinum, breasts, chest wall, lungs

  • Navigator problematic around diaphragm

  • More helpful when combined with T1 FS


Ffe tse t1
FFE & TSE T1

  • Most commonly see lesions on T1 & FFE

Fat, Hemorrhage

Hemorrhage, Protein

Soft Tissue

Cyst


Other t1 weighted sequences
Other T1 Weighted Sequences

  • T1-w TSE with fat saturation

    • Identify fatty lesions definitively

    • Increased conspicuity of T1 bright lesions

  • Post gadolinium – Tissues vs fluids (inflammation, atelectasis, infarcts)

    • T1-w TSE → less conspicuity of enhancement

    • T1-w FS SPGR → usu. early; best for enhancement

    • T1-w IR GRE → Delayed; caveat of IR

    • Subtractions helpful for intrinsic T1 bright lesions


T2 weighted imaging
T2 Weighted Imaging

  • T2-w TSE – True T2-w sequence

  • STIR –T1-w & T2-w; good fat suppression

  • SPIR – True T2-w; less homogeneous fat suppression

  • Bright on FFE & T2-w TSE

    • Cysts, hemangiomas, fat, some hemorrhage

  • Mildly bright on T2-w TSE → Usu. concerning

  • Increased brightness with SPIR, STIR

    • Fibrous tumors (eg, breast ca) still dark


T2-w TSE

SPIR


Big picture
Big Picture

  • Brighter lesion on FFE, T1-w TSE, or T2-w TSE → More likely it’s benign

    • Look for subtle nodularity, esp. with hemorrhage

  • No gadolinium → f/u imaging or not?

    • Well seen, sharp margin, homogeneously bright on FFE or T2-w TSE, not bright on T1-w TSE → Benign → Stop

      • Except breast

    • Not well seen, irregular margin, heterogeneous, bright on T1(& not fat), not bright on T2-w TSE → f/u imaging

  • Enhancement→ Usu. f/u imaging for further characterization or diagnostic procedure


Big picture1
Big Picture

  • Need to look separately for NCF

  • Develop a system

  • If you aren’t looking for it, you won’t see it

  • Symmetry is your friend

  • Use cross referencing tools

  • The only thing better than your MR . . . is an old MR (or CT)



Mediastinum diversion
Mediastinum Diversion

Old Radiology

  • Anterior Mediastinum – posterior to sternum, anterior to trachea & posterior aspect of heart

    • thymus, lymph nodes, nerves, fat

  • Middle Mediastinum – b/w anterior & posterior mediastinum

    • trachea & bronchi, esophagus, lymph nodes, nerves, fat

  • Posterior Mediastinum – b/w posterior chest wall & 1 cm behind anterior margin of vertebral column

    • vertebral bodies, spinal canal, lymph nodes, nerves, fat


Cross sectional mediastinum
Cross Sectional Mediastinum

  • Differential based on tissue where mass arises

  • If not possible, then localize by region

    • Supraaortic mediastinum (superior mediastinum)

    • Prevascular space, Anterior cardiophrenic angles

    • Pretracheal & subcarinal spaces, AP window

    • Paraesophageal or azygoesophageal recess

    • Paravertebral

  • Caveat: Be sure it is from the mediastinum

    • Deep to vessels → Definitely

    • Broad Base, smooth margin; not spiculated or irregular


Lymph nodes
Lymph Nodes

  • Every site in mediastinum

  • Lymphoma, Mets, Sarcoid, Granulomatous Infxn

  • Pattern can be important

    • Symmetric bilateral hilar & paratracheal – likely sarcoid

    • Prevascular nodal mass – Hodgkin’s Lymphoma > NHL

    • Unilateral hilar +/- paratracheal – Lung > other mets

    • Posterior mediastinum – Lymphoma (NHL) vs mets

    • Cardiophrenic angle – Mets vs lymphoma

  • Intermediate T1, bright T2, enhancement

    • Necrosis – Mets, lymphoma (NHL) ,Tb, fungus

    • Ca2+ – Granulomatous infxn, sarcoid; treated lymphoma






Thyroid lesions
Thyroid Lesions

  • Supraaortic Mediastinum

    • Can extend into prevascular space, around trachea

  • Goiter

    • Bland Goiter – Low SI T1-wi & intermediate SI T2-wi

    • Multinodular Goiter – Heterogeneous on T1-wi & T2-wi

  • Thyroid Cancer

    • Can be invasive, but usually not

    • Carcinoma in multinodular goiter – 7.5 %

    • MRI can not definitively differentiate benign & malignant


Thymus thymic masses
Thymus & Thymic Masses

  • Prevascular Space

  • Normal thymus

    • Fat proportion increases with age → harder to see

    • Intermediate on T1-w, bright on T2-w; margins important; interdigitating fat

  • Thymic rebound– stress (chemo, burns)

  • Thymoma – # 1 adult 1° mediastinal tumor

    • Variable; homogeneous, cystic, nodules; invasion

  • Thymolipoma; thymic cyst, carcinoma, carcinoid; lymphoma, mets



T1-w TSE

SPIR


Foregut cysts
Foregut Cysts

  • Bronchogenic – Most common

    • Any location – 50% subcarinal, 20% paratracheal

    • Rounded, smooth, sharply defined (imperctible wall)

    • Fluid contents variable

  • Pericardial

    • 90% touch diaphragm, 65%R 35%L cardiophrenic angle

    • Usually simple fluid, sometimes hemorrhage

  • Esophageal duplication

  • Neurenteric

    • Associated vertebral anomaly


Germ cell tumors
Germ Cell Tumors

  • Anterior Mediastinal Mass (prevascular)

  • More in young adults; 80% benign

  • Teratomas

    • All germinal layers

    • Cysts, fat (Fat-fluid levels), Ca2+, soft tissue

  • Seminomas

    • Men; most common malignant GCT; homogeneous

  • Nonseminomatous GCT

    • Rare, heterogeneous


Hernias
Hernias

  • Hiatal

    • Sliding (most common), Paraesophageal, Mixed

  • Bochdalek

    • Posterolateral and left more common

    • Retroperitoneal fat, rarely kidney or liver

  • Morgagni

    • Anteromedial

    • Omental fat (Pseudomass), Transverse Colon

  • Traumatic Diaphragmatic

    • Small at inception → grow latently


Esophagus
Esophagus

  • Thickening

    • Esophagitis, Barrett’s, cancer

  • Mass

    • Leiomyoma, lipoma, cancer


Paravertebral region
Paravertebral Region

  • Neurogenic Tumors

    • Nerve Sheath (Schwannomas), sypmathetic ganglia tumors, paragangliomas

    • Commonly bright on T2, avidly enhancing

  • Thoracic Spine abnormalities

    • Fractures, Malalignment, DDD, Hemangiomas, Tumors

  • Meningoceles and nerve sleeve cysts

  • Extramedullary hematopoesis

    • Multiple bilateral paravertebral tumors, hyperenhance

  • Nodes are still most common


Vertebral

Hemangioma


Lungs
Lungs

  • All new nodules & masses* need Chest CT

    • Lung cancer can be round, spiculated, infiltrative

    • Multiple – Mets, granulomatous dz, sarcoid, septic emboli

  • Atelectasis

    • common dependently; should enhance

    • Non-dependent consolidation → obstruction, other cause

  • Pneumonia

    • Non-dependent or patchy, filled airways, Hypoenhancement

  • Pulmonary Edema

    • Usu. symmetric; Sometimes difficult to diff from pneumonia

  • Pulmonary Infarcts

    • Peripheral wedge shaped, hypoenhancement & necrosis

  • Fibrosis (sarcoid, XRT, CTD, Amiodarone)





Pleura
Pleura

  • Pleural effusions

    • Simple vs exudative vs hemorrhagic

    • Associated pleural thickening and enhancement

    • Loculation, empyema

  • Plaques - Asbestos

  • Masses

    • Metastases – Lung, Breast

      • Usually associated with effusion

    • Fibrous Tumors of the Pleura

    • Malignant Mesothelioma


Chest wall
Chest Wall

  • Bones

    • Metastases

    • Primary Benign > Primary Malignant

  • Fat

    • Lipoma, Low Grade Liposarcoma

  • Muscle

    • Atrophy, Edema

    • Intramuscular Lipomas

    • Mets > Sarcomas

  • Subcutaneous and Dermis

    • Sebaceous cysts most common



Breasts
Breasts

  • Simple Cysts

    • Must be FFE +/- T2 Bright and T1 dark, no enhancement → still confirm with Ultrasound

  • Proteinaceous / Hemorrhagic Cysts→ US

  • Fibroadenoma

    • Well circumscribed, T1 dark, usu. T2 bright, progressive enhancement → mammogram & US

  • Breast Cancer

    • Not always spiculated; also can be in cysts

    • T1 dark and usu. TSE T2 dark, mildly bright STIR/SPIR

    • Variable enhancement, but usu peak 90-180 sec.

    • Any concern → Mammogram & US +/- MRI

  • Only Fat containing lesions do not need workup


Liver
Liver

  • Cysts– most common

    • Smooth margin, round or oval, bright FFE +/- T2, dark T1, no enhancement → Benign

    • Other than thin septation, any complexity → F/U MRI

  • Hemangiomas – second most

    • Similar to cyst in shape & on FFE, T1, T2, but enhance

      • Flash fill or peripheral discontinuous → filling centripetally

  • Any non cyst-like lesion → f/u MRI

    • Focal Nodular Hyperplasia(FNH) – Most common mass

    • Primary Malignancies – HCC and Cholangio Ca

    • Metastases – Colon, Gastric, Pancreaticobiliary, Lung, Breast, Melanoma

  • Diffuse Dz – Cirrhosis, Fatty, Hemachromatosis



Cirrhosis

Hemosiderosis

Hemochromatosis


Gall bladder
Gall Bladder

  • Gall Stones – very common

    • Round or faceted filling defects in GB

    • Usu. dark on all sequences; can be bright on T1-w

  • Polyps – common

    • Hard to diff. from adherent gall stones w/o contrast

  • Adenomyomatosis – common

    • Usu. Fundal, wall thickening, can have T2-bright foci

  • GB wall edema – uncommon

    • Usu. liver dysfxn; if not T2-bright ? Chronic cholecystitis

  • GB Cancer – rare

    • Any GB mass requires work-up


Kidney
Kidney

  • Cysts – most common

    • Smooth margin, round or oval, bright FFE +/- T2, dark T1, no enhancement → Benign

    • Other than thin septation, any complexity → F/U

      • If hemorrhagic or clearly nodules → MRI

  • Masses

    • All potential masses (heterogeneous, not bright FFE or T2, not dark T1) need F/U

    • Renal Cell > Transitional Cell

  • Hydronephrosis – Partial or Complete

  • Renal Atrophy, Agenesis



Sag Left

Sag Right


Spleen
Spleen

  • Splenomegaly, Splenules, No spleen - Common

  • Hemangiomas

    • Just like liver for the most part

  • False Cysts

    • Post traumatic or infarct

    • Can be hemorrhagic and calcify

  • Epithelial Cysts, Lymphangioma -rare

  • Metastases – uncommon




Final thoughts
Final Thoughts

  • Surprising

    • No Adrenal Lesions

    • No Pancreatic cysts or lesions

    • No upper abdominal nodes

    • No real bone lesions

  • Not surprising

    • No bowel or stomach lesions (motion)

    • No mesenteric masses

    • Minimal unknown cancers


References
References

Chan PG, Rofsky NM, Yeon SB, Hauser TH, Appelbaum E, Smith MP, Manning WJ. Non-cardiac pathology on clinical cardiac magnetic resonance imaging. Accepted for publication in JACC Cardiovascular Imaging 2009.

Dewey M, Schnapauff D, Teige F, Hamm B. Non-cardiac findings on coronary computed tomography and magnetic resonance imaging. Eur Radiol 2007 Feb 1; [Epub ahead of print].

Onuma Y, Tanabe K, Nakazawa G et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 2006; 48:402–406.

Haller S, Kaiser C, Buser P, Bongartz G, Bremerich J. Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings. AJR Am J Roentgenol; 2006; 187:105–110

Horton KM, Post WS, Blumenthal RS, Fishman EK. Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations. Circulation 2002; 106:532–534

Hunold P, Schmermund A, Seibel RM, Gronemeyer DH, Erbel R. Prevalence and clinical significance of accidental findings in electron-beam tomographic scans for coronary artery calcification. Eur Heart J 2001; 22:1748–1758


ad