Comprehensive First-Line Magnetic Resonance Imaging in Hypertension: Experience From a Single-Center Tertiary Referral Clinic

Abstract

European guidelines recommend that patients with hypertension be assessed for asymptomatic organ damage and secondary causes. The authors propose that a single magnetic resonance imaging (MRI) scan can provide comprehensive first-line imaging of patients assessed via a specialist hypertension clinic. A total of 200 patients (56% male, aged 51±15 years, office BP 168±30/96±16 mm Hg) underwent MRI of the heart, kidneys, renal arteries, adrenals and aorta. Comparisons were made with other imaging modalities where available. A total of 61% had left ventricular hypertrophy (LVH), 14% had reduced ejection fraction, and 15 patients had myocardial infarcts. Echocardiography overdiagnosed LVH in 15% of patients and missed LVH in 14%. Secondary causes were identified in 14.5% of patients: 12 adrenal masses, 10 renal artery stenoses, seven thyroid abnormalities, one aortic coarctation, one enlarged pituitary gland, one polycystic kidney disease, and one renal coloboma syndrome. This comprehensive MRI protocol is an effective method of screening for asymptomatic organ damage and secondary causes of hypertension.

Figure 1

Magnetic resonance imaging of target organ damage in hypertension. (A) Left ventricular (LV) midcavity steady‐state free precession (SSFP) short‐axis cine image at end‐diastole (Ai) LV four‐chamber/horizontal long‐axis SSFP cine image at end‐diastole (Aii) images from the same patient showing elevated indexed LV mass consistent with LV hypertrophy. (B) LV midcavity SSFP cine image at end‐diastole from another patient demonstrating LV hypertrophy (Bi) LV short‐axis midcavity magnitude inversion recovery myocardial late gadolinium enhancement image showing evidence of patchy midwall replacement myocardial fibrosis (Bii, indicated by arrow). These findings raise the possibility of previously undiagnosed hypertrophic cardiomyopathy in this case. (C and D) Phase‐sensitive inversion recovery (PSIR) images showing late gadolinium enhancement of (C) a lateral, subendocardial infarction, and (D) an inferolateral (circumflex territory), subendocardial infarction (indicated by arrows).

Figure 2

Secondary causes of hypertension demonstrated on magnetic resonance imaging. (A) Maximal intensity, arterial phase, coronal image (time‐resolved imaging with stochastic trajectories‐magnetic resonance [TWIST‐MR] angiography) showing left ostial renal artery stenosis (indicated by arrow) with left accessory renal artery inferior to main renal artery. (B) TWIST‐MRA showing right accessory renal artery (incidental finding, indicated by arrow). (C) Single left malrotated and inferiorly positioned kidney in a patient with renal coloboma syndrome (delayed‐phase coronal image from TWIST‐MRA showing arterial and venous phase imaging). (D) Multiple low signal, well‐defined entities in both renal cortices on nephrographic phase imaging from coronal TWIST‐MRA, which represent renal cysts in a patient with polycystic kidney disease (see arrows). (E) Maximum‐intensity projection sagittal image showing coarctation of the aorta just distal to the left subclavian artery (marked by arrow) and numerous collateral vessels. (F) Right benign adrenal nodule (see arrow). (G) Bilateral adrenal pheochromocytomas in a patient with multiple endocrine neoplasia type IIa (see arrows). (H) Large left thyroid nodule (see arrow). (F, G, and H) Axial half‐Fourier acquisition single‐shot turbo spin‐echo (HASTE) images.