INCIC cases ·
Late enhancement in the inferior wall?
30-year-old patient with hypertrophic cardiomyopathy and an abnormal ECG. Late gadolinium enhancement and cine in short-axis and two-chamber views; the arrows point to a finding in the basal inferior wall.
Case by Julián Vega Adauy · jvega@incic.org
Late enhancementInferior wallLV hypertrophy
What is your diagnosis?
Answer
Deep myocardial crypt mimicking late enhancement
Myocardial cryptHCM
The inferior finding is not fibrosis: it is a deep crypt, a narrow cleft in the wall that fills with blood. On late enhancement images, blood in the crypt is as bright as the cavity and can be mistaken for enhancement.
Teaching points
- What a crypt is. A narrow, deep invagination perpendicular to the wall, most often in the basal inferior and inferoseptal wall. It is associated with hypertrophic cardiomyopathy, even in genotype-positive carriers without hypertrophy, although it is also seen in healthy people.
- Why it mimics enhancement. It holds gadolinium-filled blood, which has the same bright signal as the cavity on late enhancement images.
- How to tell. On cine, the crypt fills in diastole and narrows or disappears in systole. Its signal is continuous with and equal to the blood pool, and it can be seen in two planes.
- Differentials. A diverticulum is wider and contracts. HCM fibrosis is usually patchy and intramyocardial, at the RV insertion points or in the most hypertrophied segments, with no connection to the cavity.