Letter to the Editor Heartbreak ridge: Multimodality imaging of an apical intramural hematoma Seleena K. Bajwa a , Ronak Rajani a , Nicholas Child b , Michael S. Marber b , Amedeo Chiribiri b , Matthew J. Wright b, ⁎ a Department of Cardiology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom b Divisions of Imaging Sciences & Wellcome Trust/EPSRC Department of Biomedical Engineering & Cardiology, The Rayne Institute, St. Thomas' Hospital, London SE1 7EH, United Kingdom article info Article history: Received 29 May 2012 Accepted 24 June 2012 Available online 15 July 2012 Keywords: Myocardial infarction Intramyocardial hematoma Mural thrombus Cardiac magnetic resonance Cardiac computed tomography A 43-year-old man was admitted to hospital with a 4-week history of progressive dyspnea and lethargy following an episode of vomiting and chest discomfort. A 12-lead electrocardiogram demonstrated the presence of Q waves in leads V1–5 and the patient was referred urgent- ly for a transthoracic echocardiogram. This confirmed the presence of an extensive anterior myocardial infarction with a left ventricular true aneurysm and an associated apical filling defect (Fig. 1A). On ultra- sound contrast administration this apical filling defect failed to opacify (Fig. 1B) and a differential diagnosis of either a mural thrombus or a dissecting intramyocardial hematoma was made. The patient was promptly commenced on a beta-blocker and angio- tensin converting enzyme inhibitor and was referred for urgent cardiac magnetic resonance imaging (CMR). This showed that the filling defect at the apex of the heart was comprised of two distinct physical states of blood constrained by two layers of necrotic myocardium (an endocar- dial and epicardial layer) (Fig. 1C). Consequently, the underlying diagnosis was revised to an intramyocardial hematoma and an urgent cardiothoracic opinion was requested and further diagnostic refine- ment sought through computed tomographic angiography (CTA). Coronary CTA showed a 100% occlusion of the proximal left anterior descending artery but unobstructed left circumflex and right coronary arteries. Consistent with the echocardiogram, on first pass contrast im- aging, there was a large left ventricular true aneurysm with an apical filling defect (Fig. 2A). This had a variable Hounsfield unit density con- sistent with partially liquefied thrombus (23–40 HU). Upon delayed imaging, hyper-enhancement was seen extending from the mid inferoseptal, apical inferoseptal, apical and apical lateral segments in keeping with a large anterior myocardial infarction (Fig. 2B). No clear hyper-enhancement was seen on the endocardial surface lining the thrombus. It was felt that given the findings of the coronary CTA, the contrast echocardiogram and the likelihood of the apical mass being thrombus that the patient should be anticoagulated and a repeat cardi- ac MRI performed after a 4-week interval. At 4 weeks the patient's symptoms had improved (NYHA II). The repeat CMR scan showed a resolution of the apical mass and a clear demarcation of the left ventricular true aneurysm (Fig. 3A). On late gadolinium imaging, two discrete layers of hyper-enhancement were seen at the anteroseptal and apical segments in close apposition to one another (Figs.3B–D). In between these two layers, a thin rim of residual organized intramyocardial hematoma was identified that confirmed the initial CMR diagnosis (Fig. 3D). Intramyocardial hemorrhage and subsequent hematoma formation is a rare complication of myocardial infarction with an estimated mor- tality of between 47 and 78% [1]. The reduced tensile strength of the in- farcted region leads to dissection along the planes between ventricular spiral muscle fibers and results in hemorrhage into the myocardium between the endocardial and epicardial layers. Although most fre- quently occurring in the interventricular septum and left ventricular free wall [1], there are case reports of this phenomenon also occurring within the right ventricular free wall [2]. Intramyocardial hemorrhage was historically an autopsy diagnosis, however echocardiography, with and without ultrasound contrast, now remains the mainstay of di- agnostic evaluation [3]. More recently, CMR is proving to be a valuable diagnostic investigation by virtue of its ability to accurately delineate infarcted territories, identify thrombus and characterize tissue [4]. There is no current general consensus as to the optimal management of intramyocardial hematoma with conservative management, anti- coagulation and surgical intervention all having been reported with varying success. The current case firstly demonstrates the rare occurrence of a left ventricular apical intramyocardial hematoma that was detected 4 weeks following a “silent” anterior myocardial infarction. Secondly it demonstrates the use of CMR to not only resolve discrepant imaging findings, but also to accurately detect and characterize intramyocardial hematoma. Acknowledgements Drs. Bajwa and Rajani contributed equally to this manuscript. The authors of this manuscript have certified that they comply with the International Journal of Cardiology 163 (2013) e4–e6 ⁎ Corresponding author. Tel.: +44 207 188 2335; fax: +44 207 188 0970. E-mail address: matthew.wright@kcl.ac.uk (M.J. Wright). 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. 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