PEARLS AND PITFALLS IN CARDIOVASCULAR IMAGING Pseudolesions, Artifacts and Other Difficult Diagnoses PEARLS AND PITFALLS IN CARDIOVASCULAR IMAGING Pseudolesions, Artifacts and Other Difficult Diagnoses Edited by Stefan L. Zimmerman Assistant Professor of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA Elliot K. Fishman Professor of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA University Printing House, Cambridge CB2 8BS, United Kingdom Cambridge University Press is part of the University of Cambridge. It furthers the University's mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/9781107023727 © Cambridge University Press 2015 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licencing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2015 Printed in the United Kingdom by TJ International Ltd, Padstow, Cornwall A catalog record for this publication is available from the British Library Library of Congress Cataloging in Publication data Pearls and pitfalls in cardiovascular imaging : variants and other difficult diagnoses / [edited by] Stefan L. Zimmerman, Elliot K. Fishman. p. ; cm. Includes bibliographical references and index. ISBN 978-1-10702372-7 (Hardback) I. Zimmerman, Stefan L., editor. II. Fishman, Elliot K., editor. [DNLM: 1. Cardiovascular Diseases–diagnosis. 2. Diagnostic Imaging. 3. Diagnostic Techniques, Cardiovascular. WG 141] RC683.5.I42 616.1′0754–dc23 2014039489 ISBN 978-1-10702372-7 Hardback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. Contents List of contributors Preface Section Cardiac pseudotumors and other challenging diagnoses 1. Case Right atrial pseudotumor due to crista terminalis 1. Stefan L. Zimmerman Case Cardiac pseudotumor due to lipomatous hypertrophy of the interatrial 2. septum Pejman Motarjem and Stefan L. Zimmerman Case Cardiac pseudotumor due to caseous mitral annular calcification 3. Stefan L. Zimmerman Case Cardiac pseudotumor due to focal hypertrophic cardiomyopathy 4. Celia P. Corona-Villalobos and Stefan L. Zimmerman Case Pseudothrombus in the left ventricle due to microvascular obstruction 5. Stefan L. Zimmerman Case Pseudothrombus in the left atrial appendage 6. Stefan L. Zimmerman Case Pseudolymphadenopathy due to fluid in the pericardial recess 7. Satomi Kawamoto Case Valvular masses 8. Stefan L. Zimmerman Case Cardiac angiosarcoma 9. Stefan L. Zimmerman Case Ventricular non-compaction 10. Nathan Johnson and Stefan L. Zimmerman Case Hypertrophic cardiomyopathy mimics 11. Stefan L. Zimmerman Case Stress cardiomyopathy Case Stress cardiomyopathy 12. Stefan L. Zimmerman Case Epipericardial fat necrosis 13. Atif Zaheer Section Cardiac aneurysms and diverticula 2. Case True and false left ventricular aneurysms 14. Stefan L. Zimmerman Case Ventricular diverticula, clefts, and crypts 15. Stefan L. Zimmerman Case Left atrial diverticula 16. Stefan L. Zimmerman Case Aneurysm of the membranous ventricular septum 17. Stefan L. Zimmerman Case Aneurysm of the interatrial septum 18. Stefan L. Zimmerman Case Sinus of Valsalva aneurysm 19. Vivek Halappa and Atif Zaheer Section Anatomic variants and congenital lesions 3. Case Patent foramen ovale and left atrial septal pouch 20. Stefan L. Zimmerman Case Partial cor triatriatum 21. Stefan L. Zimmerman Case Congenital absence of the pericardium 22. Tessa S. Cook Case Partial anomalous pulmonary venous return 23. Tessa S. Cook Case Unroofed coronary sinus 24. Mark Stellingworth and Stefan L. Zimmerman Case Patent ductus arteriosus 25. 25. Tessa S. Cook Case Bicuspid aortic valve with raphe mimicking tricuspid valve 26. Stefan L. Zimmerman Case Pseudocoarctation due to aortic tortuosity 27. Vivek Halappa and Atif Zaheer Section Coronary arteries 4. Case Respiratory and cardiac gating artifacts in cardiac CT 28. Tessa S. Cook Case Overestimation of coronary artery stenosis due to calcified plaque 29. Stefan L. Zimmerman Case Right coronary artery pseudostenosis due to streak artifact 30. Stefan L. Zimmerman Case Pseudostenosis from stair-step reconstruction artifact 31. Stefan L. Zimmerman Case Pseudostenosis in the coronary arteries due to motion artifact 32. Stefan L. Zimmerman Case Pseudostenosis on curved planar reformatted images 33. Stefan L. Zimmerman Case Coronary stent visualization 34. Stefan L. Zimmerman Case Myocardial bridging 35. Stefan L. Zimmerman Case Intramural versus septal course for anomalous interarterial coronary 36. arteries Stefan L. Zimmerman Case Coronary artery fistulas and anomalous coronary artery origin 37. Stefan L. Zimmerman Case Giant coronary artery aneurysms 38. Mark Stellingworth, Saurabh Jha, Koteswara Pothineni, and Stefan L. Zimmerman Case Caseous calcification of the mitral annulus mimicking circumflex Case Caseous calcification of the mitral annulus mimicking circumflex 39. coronary artery aneurysm Stefan L. Zimmerman Case Vein graft aneurysms after CABG 40. Tessa S. Cook Case Hypoattenuating myocardium 41. Vivek Halappa and Atif Zaheer Section Pulmonary arteries 5. Case Pitfalls in obtaining optimal vascular contrast for pulmonary embolism 42. examinations Pamela T. Johnson Case Artifacts mimicking pulmonary embolism 43. Pamela T. Johnson Case Pulmonary artery imaging for pulmonary embolism in patients with 44. Fontan shunt for congenital heart disease Pamela T. Johnson Case Pulmonary arteriovenous malformations 45. Maera Haider and Atif Zaheer Case Pulmonary artery sarcoma 46. Stefan L. Zimmerman Section Cardiovascular MRI artifacts 6. Case Inappropriate inversion time selection for late gadolinium enhancement 47. imaging David Bonekamp and Stefan L. Zimmerman Case Pseudothrombus on dark blood images 48. Stefan L. Zimmerman Case Gibbs ringing artifact 49. David Bonekamp and Stefan L. Zimmerman Case Aliasing artifact in phase-contrast cardiac MRI 50. Stefan L. Zimmerman Case Pseudostenoses on MR angiography from susceptibility artifact 51. Stefan L. Zimmerman Case Pseudostenosis on time-of-flight magnetic resonance angiography 52. David Bonekamp and Stefan L. Zimmerman Case Maki effect 53. David Bonekamp and Stefan L. Zimmerman Section Acute aorta and aortic aneurysms 7. Case Pitfalls in arterial enhancement timing 54. Pamela T. Johnson and Spencer T. Lake Case Misdiagnosis of acute aortic syndrome in the ascending aorta due to 55. cardiac motion Nathan Johnson and Stefan L. Zimmerman Case Aortic pseudodissection from penetrating atherosclerotic ulcer 56. Tessa S. Cook Case Ductus diverticulum mimicking ductus arteriosus aneurysm 57. Pejman Motarjem and Stefan L. Zimmerman Case Pericardial recess mimicking traumatic aortic injury 58. Stefan L. Zimmerman Case Neointimal calcifications mimicking displaced intimal calcifications on 59. unenhanced CT Saurabh Jha Case The value of non-contrast CT in vascular imaging 60. Saurabh Jha and Benoit Desjardins Case Shearing of branch arteries in intramural hematoma: a mimic of active 61. extravasation Saurabh Jha Case Imaging features of aortic aneurysm instability 62. Pamela T. Johnson Case Aortoenteric fistula 63. Siva P. Raman Case Infammatory aortic aneurysm