case_images: PMC8088475_01
case_images: 71-year-old male with a history of Q wave myocardial infarction and episodes of chest discomfort. Transthoracic echocardiography in four-chamber view with asymmetrical apical bulging (white arrow), midventricular hypertrophy (asterisk), and apical remodeling (red arrow).
case_images: JCIS-11-20-g001.jpg
case_images: PMC8088475_01_JCIS-11-20-g001.jpg
case_images: F1
case_images: The LV apical remodeling was visualized with an asymmetrical thin-walled bulging of the LV apex, which showed a paradoxical motion [Figure 1]. The bulge's neck was moderately narrowed, which can be a morphological hallmark favoring pseudoaneurysm [Figure 2 and Video 1].
case_images: 71-year-old male with a history of Q wave myocardial infarction who presented with episodes of chest discomfort with suspicion for an apical LV pseudoaneurysm on echocardiography. Cardiac CT angiography - volume rendering technique reconstruction in systole showing asymmetrical apical bulging with neck narrowing (white arrow). Note almost complete LV lumen obliteration due to mid-ventricular hypertrophy (yellow arrow).
case_images: JCIS-11-20-g002.jpg
case_images: PMC8088475_01_JCIS-11-20-g002.jpg
case_images: F2
case_images: The bulge's neck was moderately narrowed, which can be a morphological hallmark favoring pseudoaneurysm [Figure 2 and Video 1].
case_images: 71-year-old male with a history of Q wave myocardial infarction and episodes of chest discomfort with suspicion for an apical LV pseudoaneurysm on echocardiography. Dual-energy CT (delayed enhancement) iodinated map in two-chamber view with increased iodine concentration (yellow arrow) in the wall of the asymmetrical bulging extending to the endocardial area (white arrow) representing myocardial wall fibrosis. These findings confirm true apical LV aneurysm.
case_images: JCIS-11-20-g003.jpg
case_images: PMC8088475_01_JCIS-11-20-g003.jpg
case_images: F3
case_images: The late enhancement DECT iodine map and virtual monoenergetic imaging (VMI) reconstructions performed at 70 kV showed transmural iodine accumulation in the wall of asymmetric apical bulge extending to the apex and adjacent subendocardial portion of the interventricular septum, representing a myocardial scar [Figure 3].
case_images: Dual-energy CT delayed enhancement virtual monochromatic image reconstruction at 70 kV in short axis view midventricular (a) showing an inhomogeneous interventricular septum and anterior LV wall with patchy areas of delayed enhancement (arrow) representing fibrotic changes in hypertrophic cardiomyopathy. Dual-energy CT virtual monochromatic image reconstruction at 70 kV -graph of dependence of attenuation (HU) on energy (kV) (b) in normal myocardium (yellow line) and in fibrotic foci in interventricular septum (orange curve). There is an increased difference in attenuation with decreasing energy proving the iodine content and the delayed enhancement of the myocardium's patchy areas.
case_images: JCIS-11-20-g004.jpg
case_images: PMC8088475_01_JCIS-11-20-g004.jpg
case_images: F4
case_images: Patchy enhancement was visualized in the hypertrophic myocardium [Figure 4], which is associated with arrhythmias and requires additional antiarrhythmic therapy.
case_images: 71-year-old male with a history of Q wave myocardial infarction and chest discomfort episodes evaluated for suspect apical LV pseudoaneurysm. Delayed enhancement MRI in the two-chamber view shows increased enhancement in the asymmetrical bulging wall extending to the endocardial area (white arrow). The findings represent a true apical LV aneurysm. Please note an excellent correlation with dualenergy CT image [Figure 3].
case_images: JCIS-11-20-g005.jpg
case_images: PMC8088475_01_JCIS-11-20-g005.jpg
case_images: F5
case_images: Follow-up cardiac MRI performed a few weeks later showed an apical scar, confirming the DECT diagnosis of a true aneurysm as well as fibrotic changes in the area of midventricular hypertrophy [Figures 5 and 6].
case_images: 71-year-old male with a history of Q wave myocardial infarction and chest discomfort episodes evaluated for suspect apical LV pseudoaneurysm. Cardiac MRI delayed enhancement image in short axis view midventricular shows patchy areas of enhancement within interventricular septum and anterior LV wall representing fibrotic changes in hypertrophic cardiomyopathy (yellow arrow). Notice the correlation with DECT late enhancement [Figure 4a].
case_images: JCIS-11-20-g006.jpg
case_images: PMC8088475_01_JCIS-11-20-g006.jpg
case_images: F6
case_images: Follow-up cardiac MRI performed a few weeks later showed an apical scar, confirming the DECT diagnosis of a true aneurysm as well as fibrotic changes in the area of midventricular hypertrophy [Figures 5 and 6].