Acute chest pain: the role of MR imaging and MR angiography

Thoracic aortic aneurysms in patients with heritable connective tissue disease

BACKGROUND

Patients with connective tissue diseases are at high lifetime risk of developing thoracic aortic aneurysms (TAAs) due to defects in extracellular matrix composition which compromise the structural integrity of the aortic wall. It is vital to identify and manage aneurysms early to prevent fatal complications such as dissection or rupture.

METHOD

This review synthesises information obtained from a thorough literature search regarding the pathophysiology of TAAs in those with heritable connective tissue diseases (HCTDs), the investigations for timely diagnosis and current operative strategies.

RESULTS

Major complications of open repair (OR) include pneumonia (32%), haemorrhage (31%) and tracheostomy (18%), with a minor risk of vocal cord paresis (9%). For thoracic endovascular aortic repair (TEVAR), high rates of endoleak were documented (38-66.6%). Reintervention rates for TEVAR are also high at 38-44%. Mortality rates were documented as 25% for open repair and vary from 14% to 44% for TEVAR.

CONCLUSION

OR remains the mainstay of surgical management. While TEVAR use is expanding, it remains the alternative choice due to concerns over endograft durability, limited long-term outcome data and the lack of high-quality evidence regarding its use in HCTD patients.

Cardiac MR Imaging in Acute Coronary Syndrome: Application and Image Interpretation

Acute coronary syndrome (ACS) is a frequent cause of hospitalization and coronary interventions. Cardiac magnetic resonance (MR) imaging is an increasingly used technique for initial work-up of chest pain and early post-reperfusion and follow-up evaluation of ACS to identify patients at high risk of further cardiac events. Cardiac MR imaging can evaluate with accuracy a variety of prognostic indicators of myocardial damage, including regional myocardial dysfunction, infarct distribution, infarct size, myocardium at risk, microvascular obstruction, and intramyocardial hemorrhage in both acute setting and later follow-up examinations. In addition, MR imaging is useful to rule out other causes of acute chest pain in patients admitted to the emergency department. In this article, a brief explanation of the pathophysiology, classification, and treatment options for patients with ACS will be introduced. Indications of cardiac MR imaging in ACS patients will be reviewed and specific cardiac MR protocol, image interpretation, and potential diagnostic pitfalls will be discussed. ^© RSNA, 2017 Online supplemental material is available for this article.

Role of cardiovascular magnetic resonance in acute and chronic ischemic heart disease

Cardiovascular magnetic resonance (CMR) is a multi-parametric, multi-planar, non-invasive imaging technique, which allows accurate determination of biventricular function and precise myocardial tissue characterization in a one-stop-shop technique, free from the use of ionizing radiations. Though CMR has been increasingly applied over the last two decades in every-day clinical practice, its widest application has been in the assessment of ischemic cardiomyopathy.

Acute One-Stop Cardiovascular Magnetic Resonance Imaging for Differential Diagnosis in Patients with Acute Coronary Syndrome and Unobstructed Coronary Arteries

OBJECTIVE

We aimed to evaluate the contributions of acute one-stop cardiovascular magnetic resonance (CMR) imaging to the differential diagnosis of acute coronary syndrome (ACS) and unobstructed coronary arteries.

SUBJECTS AND METHODS

In this study, 32 consecutive patients who presented with ACS and unobstructed coronary arteries on angiography were enrolled between January 2010 and December 2012. Acute one-stop CMR, including cine, angiography, black-blood, first-pass perfusion and late gadolinium enhancement (LGE) imaging, was performed with a pre-specified algorithm which was decided on by the doctors for all patients. The intimal flap in the aorta and the filling defect in the pulmonary artery were detected on MR angiography imaging. Left ventricular wall motion and ventricular thickness were analyzed in cine-mode sequences. The LGE images were reviewed for the presence, anatomical distribution and extent of contrast enhancement.

RESULTS

The acute one-stop CMR study was completed in all the 32 patients without adverse events. The overall time duration was between 15 and 60 min. Of the 32 patients, a CMR diagnosis was made in 30 (93.8%). Aortic dissection was detected in 3 patients, pulmonary embolism in 2, hypertrophic cardiomyopathy in 2, acute myocardial infarction in 5, acute myocarditis in 16 and stress cardiomyopathy in 2. No confirmed diagnosis was established in the remaining 2 patients with normal CMR.

CONCLUSION

Acute one-stop CMR allowed for the identification of an aetiology in most of the patients in this study. It may prove to be of immense help in establishing a differential diagnosis in patients presenting with acute chest pain, elevated troponin I and normal coronary arteries.

Imaging acute complications in cancer patients: what should be evaluated in the emergency setting?

Increased incidence world-wide of cancer and increased survival has also resulted in physicians seeing more complications in patients with cancer. In many cases, complications are the first manifestations of the disease. They may be insidious and develop over a period of months, or acute and manifest within minutes to days. Imaging examinations play an essential role in evaluating cancer and its complications. Plain radiography and ultrasonography (US) are generally performed initially in an urgent situation due to their wide availability, low cost, and minimal or no radiation exposure. However, depending on a patient's symptoms, evaluation with cross-sectional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) is often necessary. In this review article, we discuss some of the most important acute noninfectious oncological complications for which imaging methods play an essential role in diagnosis.

Is it prime time for "rapid comprehensive cardiopulmonary imaging" in the emergency department?

Reducing hospital admissions through improved risk stratification of patients with potential acute coronary syndrome represents a critical focus for reducing health care expenditure. Coronary computed tomographic angiography (CTA) has been used with increasing frequency as part of the evaluation of chest pain in the Emergency Department. In the appropriate group of patients at low to intermediate risk CTA appears to be an excellent evaluation strategy, safely and efficiently allowing for the rapid discharge of patients home.