Seventy-one-year-old woman followed with CMR during the course of systemic vasculitis.

CLINICAL INTRODUCTION: A 71-year-old woman was diagnosed with systemic vasculitis in 2009 and received specific therapy (corticosteroids, cytostatic agents or rituximab in differing order). A transthoracic echocardiography (TTE) in 2013 for follow-up purposes of complications showed hyperechogenic endocardium of the whole left ventricular (LV) apex and cardiac MRI (CMR) was followed to further examine this finding. Using CMR, an apical LV thrombus was detected along with abnormal signal intensities within the endocardium (figure 1A). As a consequence, the existing medication was extended by phenprocoumon to treat the LV thrombus. For tracking the pathologic image features as well as for follow-up of the LV thrombus, serial CMRs were performed at our hospital from 2013 to 2018 (figure 1A). Because of the increasing hyperintense (white arrowheads) and hypointense (red arrowheads) signal spots in cine images of the apex (figure 1A), differently weighted sequences in short-axis view were acquired in the CMR of 2018 (figure 1B).

QUESTION: Which of the following is the most likely diagnosis in CMR?Microvascular ischaemiaCircular oedemaEndomyocardial fibrosisHaemorrhageApical lipoma.