Images in cardiovascular medicine. Intramyocardial spontaneous hematoma mimicking an acute myocardial infarction

An 80-year-old man affected by rheumatoid arthritis and chronic myeloid leukemia who was a smoker and hypertensive was admitted to the coronary care unit for first ST-elevation myocardial infarction. The diagnosis was suspected on the basis of the presence of chest pain associated with ST-segment elevation in leads III and aVF and a cardiac troponin T level of 0.30 ng/dL. At coronary angiography, performed 2 hours after pain onset, a 50% stenosis of the proximal right coronary artery with a translucent filling defect that suggested a parietal thrombus at the cardiac crux was found (see online-only Data Supplement Movie I); the left coronary artery had diffuse atherosclerosis in the absence of significant stenosis. Therefore, no interventional procedure was performed and the patient was treated with aspirin and clopidogrel. The echocardiogram performed soon after coronary catheterization showed an expansive lesion in the basal segment of the inferior wall characterized by echodensity intermediate between blood and tissue (Figure 1A). Myocardial contrast echocardiography documented that the expansive lesion was characterized by a reduced and irregular microvascular network compatible with both hemangioma 1 and intramyocardial hematoma 2 (Figures 1B and 2A; online-only Data Supplement Movies II and III). Magnetic Resonance Imaging further clarified the diagnosis. In fact, T2-weighted fat-suppressed images documented the presence of a hyperintense expansive lesion compatible with both hemangioma and intramyocardial hematoma (Figure 2B), but first-pass perfusion imaging showed marked signal loss in the lesion (Figure 3A), with no enhancement within the first minute (Figure 3B; online-only Data Supplement Movies IV and V). At late enhancement, a mild subendocardial perfusion defect remained only in the midventricular inferior wall. This pattern is typical of intramyocardial hemorrhage, whereas the contrast enhancement pattern of hemangioma is characterized by slow peripheral contrast uptak