Pericardial deseases

BY DR. TARIQ MASOOD

Pericardial effusionConstrictive pericarditis.Pericardial cystHematomasNeoplasmCongenital absence of pericardium

Pericardial effusionCauses;Myocardial infarction,most commonCollagen vascular disease,especially LupusTrauma,Surgical or accidentalMetastatic diseaseTuberculosis, uncommon except in AIDSViral infection,Coxsackie A and B virusUremia,18% in acute uremia

Plain x raySuggestive but not usually diagnostic"Water bottle configuration" (major DDX is

cardiomegaly)Loss of retrosternal clear space"Fat-pad sign“(produced by separation of

retrosternal from epicardial fat line >2 mm)Uncommon but specific

Rapidly enlarging cardiac silhouette with normal pulmonary vascularity

Pericardial effusion on both frontal chest radiograph and axial CT. Red arrow points to fat outside of pericardium. Green arrow points to pericardial space which is 8 mm in this patient (<4 mm is normal.)  The  yellow arrow  points to fat outside of heart and the blue arrow to the myocardium.

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CTMay detect small effusions (50cc)

Fluid-filled space surrounding the myocardium Early effusions accumulate posteriorly first.

EchocardiogramStudy of choiceEcho-free fluid between the visceral and

parietal pericardiumEarly effusions accumulate posteriorly first> 1cm is usually defined as a “large” effusion

PericarditisAcuteChronicRecurrentConstrictive

Acute pericarditis;Acute pericarditis is dry, fibrinous or effusive,

independent from its etiology. 

Chronic pericarditisChronic ( 3 months) pericarditis includes effusive

(inflammatory or hydropericardium in heart failure), adhesive, and constrictive forms.

curable causes are tuberculosis, toxoplasmosis, myxedema, autoimmune, and systemic diseases.

Constrictive pericarditisConstrictive pericarditis is a rare but severely

disabling consequence of the chronic inflammation of the pericardium, leading to an impaired filling of the ventricles and reduced ventricular function.

Increased pericardial thickness is considered an essential diagnostic feature of constrictive pericarditis.

Tuberculosis, mediastinal irradiation, and previous cardiac surgical procedures are frequent causes of the disease

NCCT thorax showing the thickened pericardium

Chest CT of a patient with clinical constrictive pericarditis and with no calcification on chest radiograph. Areas of pericardial calcification are evident (horizontal arrows), but in other areas (anterior face, vertical arrow) the pericardium had a normal appearance.

Axial and coronal black-blood images of a patient with constrictive pericarditis after CABG. Arrows point to the thickened pericardium.

Pericardial CystCongenital pericardial cysts are uncommon; they may be unilocular or multilocular, with

the diameter from 1–5 cm. Inflammatory cysts comprise pseudocysts as

well as encapsulated and loculated pericardial effusions, caused by rheumatic pericarditis, bacterial infection, particularly tuberculosis, trauma and cardiac surgery.

 Echinococcal cysts usually originate from ruptured hydatid cysts in the liver and lungs. cysts are detected incidentally on chest x ray as an oval, homogeneous radiodense lesion, usually at the right cardiophrenic angle. 

Echocardiography is useful, but additional imaging by computed tomography (density readings) or magnetic resonance is often needed.

Axial CT of the chest reveals a well-defined cystic structure measuring approximately 3.5 cm in diameter located in the right cardiophrenic angle, abutting the right heart border. This is most likely a pericardial cyst

Modified 4-chamber view showing the pericardial cyst ( ) without ★compression of the left ventricle

Pericardial Neoplasm

Differential Diagnosis of Pericardial Masses

A high-density mass was noted (arrows) adjacent to the right cardiac border, compromising and displacing the heart toward the left. A biopsy was performed, and it was shown to be a pericardial mesothelioma

Pericardial Teratoma

Mixeddensity mass with caicification on the right side of middle mediastinum

Pericardial MetastasisMetastatic pericardial disease commonly presents

as hemorrhagic effusion. Tumor nodules may enhance after intravenous  contrast administration.

Most frequent CT features of pericardial metastases include, in order of decreasing frequency:

pericardial effusionprepericardial lymph nodespericardial thickening and enhancementnodules 

Squamous cell carcinoma with pericardial metastasis.

Computed tomography of the chest performed after the administration of contrast material revealed multiple pericardial masses with central necrosis compatible with metastatic disease.

Congenital absence of pericardiumCongenital defects of the pericardium

comprise partial left (70%), right (17%) or total bilateral (rare) pericardial absence. Additional congenital abnormalities occur in 30% of patients.

 Most patients with a total pericardial absence are asymptomatic.

Homolateral cardiac displacement and augmented heart mobility impose an increased risk for traumatic aortic dissection.

 Partial left side defects can be complicated by herniation and strangulation of the heart through the defect (chest pain, shortness of breath, syncope or sudden death).

Axial T1 MRI of the heart revealing the partial defect of the left pericardium.

On magnetic resonance imaging, T2-weighted gradient-echo (*) axial , and coronal views showed left pterolateral rotation and displacement of the heart, with the apex located in a posterior position.

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