Isolated, Broad-Based Apical Diverticulum: Cardiac Magnetic Resonance Is a "Terminator" of Cardiac Imaging Modality for the Evaluation of Cardiac Apex
A 30-year-old woman was referred to our center with complaints of headache and right side weakness. Her medical history was unremarkable except for intermittent migraine attacks. She had no clinical risk factors for cerebrovascular disease. Small multifocal cerebral infarctions were found in her brain through brain magnetic resonance imaging. With suspicion of a cardiac source of embolism, transthoracic echocardiography was performed, which revealed apical akinetic movement with a band-like structure (arrow in ) in the LV. LV opacification with echocardiographic contrast showed no evidence of apical thrombi (). Initial electrocardiogram did not suggest any sign of apical aneurysm, like ST elevation in anterior leads (). Computed tomographic thoracoabdominal angiography revealed normal findings, including no atherosclerosis (). In addition, she was young and had no risk factors for coronary artery disease, suggesting the impression that the chance for myocardial infarction was not high. For further evaluation of LV apex, CMR was ordered. The CMR identified a broad-based apical diverticulum (2.6×3.0 cm-sized) with mechanical activity, nearly synchronous with LV activity (), along with an LV ejection fraction of 43%. Interestingly, delayed enhancement of CMR (DECMR) conveyed high signal intensity in some parts of diverticulum (). She was finally diagnosed with a huge, isolated LV apical diverticulum with mixed muscular and fibrous type. On anticoagulation with warfarin, she was given permission to leave the hospital.