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How to assess myocardial inflammation using cardiac magnetic resonance imaging Cover

How to assess myocardial inflammation using cardiac magnetic resonance imaging

Romanian Journal of Cardiology
Volume 35 (2025): Issue 1 (March 2025)
By: Robert Adam,  Sebastian Onciul,  Ruxandra Jurcuţ and  James Moon  
Open Access
|Mar 2025

Figures & Tables

Figure 1

Contrast-enhanced cardiac magnetic resonance imaging of a patient with acute myocarditis at baseline and 6-month follow-up. High signal intensity in the basal and mid-to-apical lateral wall on cine and T2-STIR sequences (yellow arrows) corresponding to focally elevated myocardial T2 and native T1, indicating myocardial edema. The same myocardial segments also showed patchy, subepicardial high signal intensity on both EGE and LGE sequences (yellow arrows), revealing myocardial hyperemia, and myocyte necrosis and fibrosis, respectively. At the 6-month follow-up scan, a complete resolution of myocardial edema was observed on both T2-STIR and T2 mapping, though only a partial resolution of myocyte injury was seen on native T1 mapping and LGE (yellow arrows). All images were acquired using a 1.5 T scanner, with normal T1 ranging between 970 and 1050 ms and normal T2 between 40 and 51 ms. b-SSFP, balanced steady-state free precession, EGE (early gadolinium enhancement), LGE (late gadolinium enhancement), STIR (Short Tau Inversion Recovery).
Contrast-enhanced cardiac magnetic resonance imaging of a patient with acute myocarditis at baseline and 6-month follow-up. High signal intensity in the basal and mid-to-apical lateral wall on cine and T2-STIR sequences (yellow arrows) corresponding to focally elevated myocardial T2 and native T1, indicating myocardial edema. The same myocardial segments also showed patchy, subepicardial high signal intensity on both EGE and LGE sequences (yellow arrows), revealing myocardial hyperemia, and myocyte necrosis and fibrosis, respectively. At the 6-month follow-up scan, a complete resolution of myocardial edema was observed on both T2-STIR and T2 mapping, though only a partial resolution of myocyte injury was seen on native T1 mapping and LGE (yellow arrows). All images were acquired using a 1.5 T scanner, with normal T1 ranging between 970 and 1050 ms and normal T2 between 40 and 51 ms. b-SSFP, balanced steady-state free precession, EGE (early gadolinium enhancement), LGE (late gadolinium enhancement), STIR (Short Tau Inversion Recovery).

Figure 2

Contrast-enhanced cardiac magnetic resonance imaging of a patient with dilated cardiomyopathy and heart failure revealing trace circumferential pericardial effusion and a small area of epicardial fat adjacent to the basal inferior and inferolateral walls, with high signal intensity on the LGE-PSIR sequences. b-SSFP (balanced steady-state free precession), LGE (late gadolinium enhancement).
Contrast-enhanced cardiac magnetic resonance imaging of a patient with dilated cardiomyopathy and heart failure revealing trace circumferential pericardial effusion and a small area of epicardial fat adjacent to the basal inferior and inferolateral walls, with high signal intensity on the LGE-PSIR sequences. b-SSFP (balanced steady-state free precession), LGE (late gadolinium enhancement).

Figure 3

Contrast-enhanced cardiac magnetic resonance imaging of a patient with acute pericarditis showing significant thickening of the pericardial leaflets on Cine sequences (yellow arrows), high signal intensity on T2-weighted sequences (yellow arrows), and pericardial hyperenhancement on the LGE sequences (yellow arrows). This is associated with a trace pericardial effusion, which appears as low signal intensity between the two pericardial leaflets (blue arrows). b-SSFP (balanced steady-state free precession), LGE (late gadolinium enhancement).
Contrast-enhanced cardiac magnetic resonance imaging of a patient with acute pericarditis showing significant thickening of the pericardial leaflets on Cine sequences (yellow arrows), high signal intensity on T2-weighted sequences (yellow arrows), and pericardial hyperenhancement on the LGE sequences (yellow arrows). This is associated with a trace pericardial effusion, which appears as low signal intensity between the two pericardial leaflets (blue arrows). b-SSFP (balanced steady-state free precession), LGE (late gadolinium enhancement).

Figure 4

Contrast-enhanced cardiac magnetic resonance imaging (CMR) of four patients with myocardial inflammation. First row: A 15-year-old patient presenting with chest pain and elevated serum troponin levels. Cine (b-SSFP) sequences in 4-chamber (native, A) and short axis at the papillary muscle level (post-contrast, B) views during diastole revealed a nondilated LV with normal systolic function. T2w-STIR sequences (4-chamber, C; short axis, D) show patchy, near-circumferential high signal intensity (yellow arrows) corresponding to elevated T2 on T2 mapping (E, F) and elevated T1 on T1 mapping (G, H). Post-contrast imaging reveals extensive circumferential epicardial LGE, especially in the basal and mid-segments (I, J). A follow-up scan at 6 months showed complete resolution of myocardial edema but persistent LGE. Genetic testing identified a pathogenic variant in the desmoplakin (DSP) gene. Second row: A 46-year-old patient presenting with acute decompensated heart failure. Cine (b-SSFP) sequences (4-chamber native, A; short axis post-contrast, B) during systole and diastole, respectively, revealed biventricular hypertrophy, moderate systolic dysfunction, and some pericardial fluid. T2w-STIR sequences (C, D) showed no areas of high signal intensity, but parametric mapping revealed globally elevated native T2 (E, F) and T1 (G, H), particularly in the septum. Diffuse transmural LGE with abnormal gadolinium kinetics were noted (I, J), suggestive of cardiac amyloidosis. Third row: A 52-year-old patient with risk factors presenting with chest pain, ST-segment elevation, and elevated serum troponin. Emergency coronary angiography revealed normal coronary arteries. CMR cine (b-SSFP) sequences in 2-chamber (A, B) and shortaxis views (C, D) during diastole and systole show akinesia in the mid-anterior wall (yellow arrows). T2 mapping reveals elevated T2 in the mid-anterior and anterolateral walls on short axis (F) and 4-chamber views (E), corresponding to elevated T1 in the same regions (G, H, blue arrows). Transmural ischemic LGE is seen in the mid-anterior and anterolateral walls (I, J, yellow arrows), with dense microvascular obstruction in the subendocardial area (blue arrows), characteristic of acute myocardial infarction. After a closer review of the coronary angiography, a proximal occlusion of the first diagonal branch was identified. Fourth row: A 27-year-old patient presenting with an electrical storm. After stabilization, CMR was performed. Cine (b-SSFP) sequences in the 4-chamber (A) and short-axis views (B) during diastole revealed normal biventricular size and function but focal LV hypertrophy in the basal anterolateral wall (yellow arrow). High signal intensity is noted on T2w-STIR sequences (C, D, yellow arrows), corresponding to elevated T2 (E, F) and T1 (G, H) on parametric mapping. Extensive patchy LGE is present in multiple LV segments (I, J), predominantly in the basal-to-mid anterior wall (yellow arrows) and extending to the RV free wall (blue arrows), creating a characteristic “shepherd’s crook” appearance at the RV insertion point. These findings strongly suggest cardiac sarcoidosis, confirmed by 18-F FDG PET scan and endomyocardial biopsy. b-SSFP (balanced steady-state free precession), CMR (cardiac magnetic resonance), EGE (early gadolinium enhancement), LGE (late gadolinium enhancement), LV (left ventricle), STIR (Short Tau Inversion Recovery), RV (right ventricle).
Contrast-enhanced cardiac magnetic resonance imaging (CMR) of four patients with myocardial inflammation. First row: A 15-year-old patient presenting with chest pain and elevated serum troponin levels. Cine (b-SSFP) sequences in 4-chamber (native, A) and short axis at the papillary muscle level (post-contrast, B) views during diastole revealed a nondilated LV with normal systolic function. T2w-STIR sequences (4-chamber, C; short axis, D) show patchy, near-circumferential high signal intensity (yellow arrows) corresponding to elevated T2 on T2 mapping (E, F) and elevated T1 on T1 mapping (G, H). Post-contrast imaging reveals extensive circumferential epicardial LGE, especially in the basal and mid-segments (I, J). A follow-up scan at 6 months showed complete resolution of myocardial edema but persistent LGE. Genetic testing identified a pathogenic variant in the desmoplakin (DSP) gene. Second row: A 46-year-old patient presenting with acute decompensated heart failure. Cine (b-SSFP) sequences (4-chamber native, A; short axis post-contrast, B) during systole and diastole, respectively, revealed biventricular hypertrophy, moderate systolic dysfunction, and some pericardial fluid. T2w-STIR sequences (C, D) showed no areas of high signal intensity, but parametric mapping revealed globally elevated native T2 (E, F) and T1 (G, H), particularly in the septum. Diffuse transmural LGE with abnormal gadolinium kinetics were noted (I, J), suggestive of cardiac amyloidosis. Third row: A 52-year-old patient with risk factors presenting with chest pain, ST-segment elevation, and elevated serum troponin. Emergency coronary angiography revealed normal coronary arteries. CMR cine (b-SSFP) sequences in 2-chamber (A, B) and shortaxis views (C, D) during diastole and systole show akinesia in the mid-anterior wall (yellow arrows). T2 mapping reveals elevated T2 in the mid-anterior and anterolateral walls on short axis (F) and 4-chamber views (E), corresponding to elevated T1 in the same regions (G, H, blue arrows). Transmural ischemic LGE is seen in the mid-anterior and anterolateral walls (I, J, yellow arrows), with dense microvascular obstruction in the subendocardial area (blue arrows), characteristic of acute myocardial infarction. After a closer review of the coronary angiography, a proximal occlusion of the first diagonal branch was identified. Fourth row: A 27-year-old patient presenting with an electrical storm. After stabilization, CMR was performed. Cine (b-SSFP) sequences in the 4-chamber (A) and short-axis views (B) during diastole revealed normal biventricular size and function but focal LV hypertrophy in the basal anterolateral wall (yellow arrow). High signal intensity is noted on T2w-STIR sequences (C, D, yellow arrows), corresponding to elevated T2 (E, F) and T1 (G, H) on parametric mapping. Extensive patchy LGE is present in multiple LV segments (I, J), predominantly in the basal-to-mid anterior wall (yellow arrows) and extending to the RV free wall (blue arrows), creating a characteristic “shepherd’s crook” appearance at the RV insertion point. These findings strongly suggest cardiac sarcoidosis, confirmed by 18-F FDG PET scan and endomyocardial biopsy. b-SSFP (balanced steady-state free precession), CMR (cardiac magnetic resonance), EGE (early gadolinium enhancement), LGE (late gadolinium enhancement), LV (left ventricle), STIR (Short Tau Inversion Recovery), RV (right ventricle).

Updated recommendations of CMR criteria of myocardial inflammation_ ECV (extracellular volume), EGE (early gadolinium enhancement), LGE (late gadolinium enhancement), LV (left ventricle), SI (signal intensity)

Original Lake Louise Criteria (Any 2 out of 3)Updated Lake Louise Criteria (2 out of 2)Diagnostic Targets
Main criteriaT2-weighted imagingRegional/Global high T2 SIT2-based imagingRegional high T2 SI orRegional or global increase of myocardialMyocardial edema
EGEAreas with high SI in a nonischemic patternLGEAreas with high SI in a nonischemic patternT2 relaxation timeT1-based imagingRegional or global increase of native myocardialT1 relaxation time or ECVorAreas with high SI in a nonischemic pattern in LGE images↑T1 – edema, hyperemia/capillary leak, necrosis, fibrosisEGE - hyperemia, capillary leakLGE - necrosis, fibrosis↑ECV – edema, hyperemia, capillary leak, necrosis, fibrosis
Supportive criteriaPericardial effusion in cine imagesRegional or global LV systolic dysfunction in cine imagesPericardial effusion in cine images orHigh SI of the pericardium in LGE images, T1- mapping or T2-mappingRegional or global LV systolic dysfunction in cine imagesPericardial inflammationLV systolic dysfunction
DOI: https://doi.org/10.2478/rjc-2025-0002 | Journal eISSN: 2734-6382 | Journal ISSN: 1220-658X
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Language: English
Page range: 1 - 6
Published on: Mar 31, 2025
Published by: Romanian Society of Cardiology
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Related subjects:
Medicine,
Clinical medicine,
Internal medicine,
Cardiology,
Surgery,
Cardiac surgery,
Pediatrics and juvenile medicine,
Paediatric cardiology

© 2025 Robert Adam, Sebastian Onciul, Ruxandra Jurcuţ, James Moon, published by Romanian Society of Cardiology
This work is licensed under the Creative Commons Attribution 4.0 License.

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