Technologist Track

Technologist Track Session 6: Oral Case Presentations and a Guide to Write a Case

Double trouble: Prenatal CMR for fetal cardiac mass in a twin gestation

Saturday, February 1, 2025

9:40 AM – 9:50 AM East Coast USA Time

Location: Hampton Ballroom

Presenting Author(s)

JB

Joni Blood, RT

Cardiac MRI Technologist
Rady Children's Hospital

Primary Author(s)

JB

Joni Blood, RT

Cardiac MRI Technologist
Rady Children's Hospital

Co-Author(s)

AR

Ana E. Rodriguez Soto, PhD

Staff Scientist, Dept of Bioengineering
University of California San Diego
Francisco J. Contijoch, PhD, FSCMR

Associate Professor
University of California San Diego
RA

Robyn Augustyn, BSc, RT

Advanced Imaging Technologist
Rady Children's Hospital
DV

Daniel Vinocur, MD

Neuroradiologist
Rady Children's Hospital
BP

Beth Feller Printz, MD

Pediatric Cardiologist
Rady Children's Hospital
Eleanor Lehnert Schuchardt, MD

Assistant Professor Health Sciences, Pediatric & Fetal Cardiology
University of California San Diego / Rady Children's Hospital
San Diego

Description of Clinical Presentation: The patient was a 32-year-old female pregnant with dichorionic-diamniotic twins with a cardiac mass on Baby A. There was no family history of tuberous sclerosis (TS). Baby A (male) was noted to have multiple cardiac masses (presumed to be rhabdomyomas) by fetal echocardiogram, but ultrasound imaging was otherwise normal. The largest cardiac mass was 2.3 cm x 1.5 cm but nonobstructive. Imaging on Baby B (female) was normal. A fetal MRI was performed to assess the brains for findings consistent with TS and characterize the cardiac mass.

Diagnostic Techniques and Their Most Important Findings:

MRI was performed at 36 weeks gestation with patient supine on a 1.5-T (Sola, Siemens Healthineers, Erlangen, Germany) with the 18-channel body array and the inherent body/spine coils. Haste localizers in true planes were used to identify each fetus and define position. (Figure 1) Then the external cardiac Doppler gating device (NorthH Medical, Hamburg, Germany) was positioned on Baby A, on maternal right and breech.

Brain imaging included T2-Haste in all three planes and DWI with ADC maps. Baby A had subtle T2 hypointense foci in the bifrontal white matter, hyperintense foci in the right ventricle and left foramen of Monro. Baby B had no intracranial abnormalities.

Cardiac imaging was directed only at Baby A and showed a large mass in the interventricular septum, which was isointense on T1 and hyperintense on T2. (Figure 2) Left ventricular function was mildly impaired as assessed by SAX Cine. Ejection fraction was 34%.

Overall findings were consistent with TS and aided definitive counseling of the expectant parents. Postnatal observation in the NICU was planned based on multisystem findings as well as plans for postnatal follow up with cardiology.

Learning Points from this Case:

Baby A was confirmed to have a large cardiac rhabdomyoma in the interventricular septum, combined with central nervous system findings consistent with TS. Fetal MRI assisted with postnatal care planning by providing a more definitive design for what the child’s future medical needs would be. Baby A started on sirolimus postnatally, the larger ventricular rhabdomyoma has become significantly smaller, not causing any obstruction, and the baby has had no neurologic/developmental issues. The child has been followed by cardiology from birth.

Imaging both hearts and brains of twins at 36 weeks initially was a daunting task. We found it was feasible to image two CNS and one heart in approximately 90 minutes. The scan contributed to prenatal counseling.

Figure 2. Mass in interventricular septum seen in SAX view and TS seen in the brain prenatal sagital and postnatal sagital.

Figure 1. Coronal HASTE image showing the position of the fetuses and their chest.