CT and MRI of the Pericardium - Society of Thoracic Radiology

CT and MRI of the Pericardium
Mark L. Schiebler, MD
Outline
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CT and MR of
The Pericardium
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Mark L. Schiebler, M.D.
Jeffrey Kanne, M.D.
Stanley Siegelman, M.D.
Christopher J. François, MD
Anatomy and function of the pericardium
• Two layers
• Visceral – serous membrane
consisting of single layer of
mesothelial cells adherent to
epicardial surface of heart
• Parietal – acellular, fibrous
membrane consisting
g of collagen
g
and elastin fibers surrounding
most of the heart
Serous visceral
pericardium
Pericardial fluid
Fibrous parietal
pericardium
• Pericardium extends superiorly to
cover proximal portions of the
great vessels
• Left atrium predominately
outside of the pericardium
Broderick, L. S. et al. Radiographics 2005;25:441-453
Normal Anatomy
Congenital variants (Embryology)
Pitfalls
Pericardial effusions and pericarditis
Pericardial masses
Constrictive pericarditis
Summary
CME question
Anatomy and Function of the pericardium
• Normal thickness = 2 mm
-space between visceral and
parietal pericardial surfaces
• Normal fluid d 50 mL
• Normal Function
• Maintain position of heart
• Lubricated surface between stationary
chest wall and moving heart
• Barrier to infection
• Restrains cardiac chamber volumes
“negative systolic pericardial pressure”
Pericardial defects
Pericardial defects
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• DDx =
• Congenital
• Trauma
• Iatrogenic
• Congenital absence of the pericardium
• Partial » complete
• Most commonly affects left side of pericardium
• Heart is more mobile
• Leftward shift of heart
• Lung between aorta and main pulmonary artery
• Associated with other congenital heart disease (ASD, PDA)
Post Surgical Pericardial absence
Congenital absence of pericardium (2)
*
*
Leftward shift and rotation of cardiac apex (*)
Interpositioning of lung (red arrow) between aorta (A) and pulmonary artery (P)
Portion of pericardium adjacent to right atrium (RA) is visible (green arrow)
Rajiah P and Kanne J, J Cardiovasc Comp Tomogr,Vol 4, Issue 1 ; 3-18
Psychidis-Papakyritsis, P. et al. Am. J. Roentgenol. 2007; 189: W312-W314.
Pericardial recesses
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Pitfalls
• Knowledge of location important in
distinguishing normal pericardial
recesses from mediastinal
lymphadenopathy and masses1
1Groell,
Normal Variants that Simulate Disease
1. Fluid in recesses
a. Superior aortic pericardial recess
(may mimic aortic dissection)
Broderick, L. S. et al. Radiographics 2005;25:441-453
R. et al. Radiology 1999;212:69-73
Normal Variants that Simulate Disease
1. Fluid in recesses
b. Pulmonary Vein Serosal sleeve
(may simulate mass or LN)
Broderick, L. S. et al. Radiographics 2005;25:441-453
359
Normal Variants that Simulate Disease
1. Fluid in recesses
c. Oblique Sinus(may simulate mass or LN
1. Fluid in recesses
d. Transverse sinus (simulates LN)
Broderick, L. S. et al. Radiographics 2005;25:441-453
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Truong MT et al AJR 2003.181,4:1109-1113
Normal Variants that Simulate Disease
Pericardial Cysts
Pericardial cysts
Benign
Formed from persistence of a blind ending
parietal pericardial recess
60% Asymptomatic
May communicate with the pericardial space
Location
70%
22%
8%
Pericardial Cysts
Right CPA
70%
Right CPA
Left CPA
22%
Right CPA
Left CPA
Mediastinal
Asymptomatic Pericardial cyst adjacent to LV
Well circumscribed
fluid density and
fluid signal mass
adjacent to LV.
LV This
is a less common
location. Crosssectional imaging is
needed to establish
the Dx.
Left CPA
Slide Courtesy of Christopher J François, M.D.
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Pericardial cyst in right cardiophrenic angle
Symptomatic Pericardial cyst adjacent to LV
T2 weighted MRI
Slide Courtesy of Christopher J. François, M.D.
49 yo female with shortness of breath and altered
diastolic filling of left ventricle at echocardiography
Pericardial effusions and
pericarditis
Pericardial effusions
• Presentation
• Often asymptomatic
• Chest pain
• When present, usually due to
tamponade
• Dyspnea
• Physical examination
• Elevated jugular venous pressure
• ECG – reduced voltage
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Pericardial effusions
• Causes
• Idiopathic
• Infectious
• Viral, bacterial, mycobacterial, fungal
• Inflammatory
• Connective tissue disease
ost yoca d a infarction
a ct o
• Post-myocardial
• Trauma
• Iatrogenic, non-iatrogenic, radiation
• Drugs
• Neoplastic
• Primary or secondary
• Other
• Hypothyroidism, Amyloidosis, hemodialysis/uremic
• Hemorrhage
Pericardial effusions
• Chest x-ray
• Usually normal
• With moderate and larger pericardial effusions, change in
size of cardiac silhouette
g suggestive
gg
of etiology
gy
• Finding
• Echocardiography
• Less sensitive than CT and MR for detecting small effusions
• Tamponade
• Early diastolic collapse of RV and RA
• Exaggerated respiratory variation in R and L venous and
valvular flow
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Pericardial effusion - Uremic
• CT and MRI
• More sensitive than
echocardiography for small effusions
• Better
B tt characterization
h
t i ti off fluid
fl id
• Cine MRI motion (bSSFP) and flow
(phase contrast) analysis similar to
echocardiography
CXR
Globular
CV Silhouette
Mild PV HTN
Azygous not
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Pericardial effusions
J Collins and EJ Stern. Chest Radiology: The Essentials.
2nd ed. Lippincott Williams & Wilkins, 2008.
Pericardial effusion
At time of presentation
Cine MRI of Pericardial effusion
3 months prior
Pericardial effusion in acute STEMI
bSSFP 4 chamber Cine MRI
showing epicardial fat (short
arrow) and pericardial fluid
(long arrows). MI is shown
as increased T2* signal
intensity (lightening bolt)
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DCE 4 chamber MRI showing pleural
fluid enhancement (arrow) without
pericardial enhancement and the
enhancing MI (lightening bolt) with
subendocardial no-reflow zone.
Pericardial hematoma from RCA graft after CABG causing tamponade
Severe compression of
right atrium and ventricle
Pericardial hemorrhage due to aortic rupture
Pericarditis
• Causes of pericarditis
• Idiopathic
• Infectious
• Viral, bacterial, mycobacterial, fungal
• Inflammatory
• Connective tissue disease
• Post-myocardial infarction
• Trauma
• Iatrogenic, non-iatrogenic, radiation
• Drugs
• Neoplastic
• Primary or secondary
High density pericardial fluid = hemorrhage
• Presentation
• Chest pain
• Often sharp and pleuritic
• Substernal
• Relieved by leaning forward
• Dyspnea
• Fever
• Physical examination
• Pericardial rub with auscultation
Pericarditis
• CT and MRI
• Pericardial thickening
• Pericardial enhancement
• Cine imaging may show decreased
pericardial mobility
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Pericarditis
Pericarditis
• Chest x-ray
• Usually normal
• With moderate and larger pericardial
effusions, change in size of cardiac
silhouette
• Pneumopericardium suggests gasproducing organism or fistula
• Echocardiography
• Usually normal
• Effusions unusual with idiopathic
pericarditis
Infected Pericardial effusion
*
*
*
*
*=19 HU
26 yo Male with staphylococcus aureus pyopericarditis.
Note heterogeneous density of pericardial fluid and the
thickened and enhancing visceral pericardium (arrow).
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Pneumopericardium from purulent pericarditis
Pericardial defect caused by pancreatico-pericardial fistula
:
Fistulogram:
Contrast in pericardium
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J Collins and EJ Stern. Chest Radiology:
The Essentials. 2nd ed. Lippincott Williams
& Wilkins, 2008.
Drain in pancreatic pseudocyst
François, CJ et al. Abdominal Imaging. 2005; 30: 761-767.
MRI of Infectious Pericarditis
Axial cine SSFP
Axial post-contrast FSPGR
Pericardial thickening
SA delayed CE
Pericardial enhancement
The
Continuum
from
Calcific pericarditis
to
Constrictive pericarditis
Note both the visceral (yellow arrow)
and parietal pericardial (white arrow) enhancement
Calcific pericarditis
Pericardium is immobile and
may limit diastolic filling of LV
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Calcific pericarditis – CXR and CT
Common Clinical Findings of
Constrictive Pericarditis
Constrictive pericarditis
• End-stage of any inflammatory process affecting the
pericardium
• Most common causes in US include infection, post-surgical,
and radiation
• TB was most common cause
• Can occur months to years after initial incident
• Patients present with right sided heart-failure and normal LV
systolic function
• DDx = restrictive cardiomyopathy
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•
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Increased Jugular venous distension
Hepatomegaly
Dyspnea
Edema
Ascites
Pleural Effusion
Fatigue
Imaging Findings of
Constrictive pericarditis
Post acute pericarditis
Post heart surgery (CABG)
Uremia
Connective Tissue Ds
Post Traumatic
Drug toxicity ( procainamide, hydrazaline, methylsergide)
XRT
Malignant (melanoma)
Infection (TB, Histoplasmosis, Coccidiomycosis, Purulent)
Post MI/ post Dressler’s Syndrome
Asbestosis
• Chest x-ray
• Pericardial calcifications
• DDx = calcification of LV aneurysm
• Right atrial enlargement
• Pulmonary vascular congestion and redistribution when LV
pressures are increased
• Pleural Fluid
• Distended Azygous Vein (>1cm)
Constrictive pericarditis
• CT and MRI
• Pericardial thickening (t
t 4mm)
• Global or focal
• Calcifications (CT » MRI)
• Cine:
• Septal “bounce” reflecting abnormal RV filling (!
! 85%)
• Real-time cine imaging can be helpful to elicit abnormal
septal motion with Valsalva.
• Ancillary findings:
• Atrial enlargement, dilated HV and IVC, ascites
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Causes of Constrictive Pericarditis
• Echocardiography
• Pericardial thickening and immobility
• Interventricular septal “bounce” at inspiration
• Dilated HV and IVC
Constrictive pericarditis
Real time MRI of
a patient with
constrictive
pericarditis showing
straightening of the
interventricular
septum with
inspiration due to the
increased volume
entering the right
heart.
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Constrictive pericarditis
Cine MRI of
a patient with calcific
constrictive pericarditis
Of the right atrium and
Right ventricle (RV) showing
aneurysmal dilation of
non involved RV and
bowing of the adjacent
Intraventricular septum.
M-mode recording showing a respiratory shift of the
interventricular septum toward the left ventricle with inspiration
ventricle with expiration as a result of exaggerated ventricular inter...
N
O
R
M
A
L
Verhaert D et al. Circ Cardiovasc Imaging 2010;3:333-343
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Copyright © American Heart Association
Right atrial Pressure volume loop
late atrial filling of Rt ventricle
-The “a” wave
Early atrial filling of Rt ventricle
- The “e” wave
Power and Turf In Medicine
“ The currency in medicine is patients and
Radiology doesn’t have any. We (Radiologists)
y strong
g and close ties
have to build extremely
with our referring physicians or we will have
nothing to offer.”
Carl Ravin, M.D.
Founding Member of STR
President, Private Diagnostic Clinic
Duke University
Take home point
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Take home point
You can measure inflow across the TV with MRI
using breath hold 2D PC pulse sequences.
Thus measurement of the “e to a” wave ratio
is possible to do in less than 3 minutes.
Normal e to a wave velocity profile in diastole
With constrictive pericarditis the velocity
of the atrial Kick (a-wave) is larger than
the early diastolic filling (e-wave) filling which
is opposite of the normal situation.
Reversal of e to a wave velocity profile with
constrictive pericarditis
e
a
a
e
Physiology of Constrictive Pericarditis
Constrictive pericarditis in patient with rheumatoid arthritis (1)
! 85%)
Septal “bounce” reflecting abnormal diastolic RV filling (!
This is due to the fact that RV filling pressure in diastole
exceeds LV diastolic filling pressure and thus as the higher
pressure RV fills in diastole, it moves the septum towards the
lower pressure LV
LV.
This is not to be confused with septal straightening during
systole, which is a sign of elevated RV pressures greater
than systolic LV pressures. This occurs with pulmonary
hypertension and PV stenosis.
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Constrictive pericarditis in patient with rheumatoid arthritis (2)
Pericardial masses
Slide Courtesy of Christopher J Francois, M.D.
Pericardial masses
• Pericardial tumors
• Metastases >> primary pericardial tumors
• Metastases to pericardium :
•
•
•
•
Direct extension from mediastinal malignancies
Lymphatic spread from thoracic malignancies
Hematogenous spread from any malignancy
May have hemorrhage
Pericardial masses
• Pericardial tumors
• Primary pericardial neoplasms can be benign or malignant
• Benign: lipoma, teratoma, fibroma, hemangioma
• Malignant: mesothelioma, lymphoma, angiosarcoma
• Malignant neoplasms tend to be larger, more ill-defined, and
heterogeneous
• Melanoma, Adenocarcinoma (lung, breast, gastric)
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Myocardial tagging
Primary Pericardial Lymphoma (rare)
Irregular, long T2,
infiltrating,
heterogeneous
mass in AV groove
surrounding aorta
and
d main
i
pulmonary artery
Can be performed with many types of pulse sequences.
Gridded (waffle Iron) or single plane saturation bands
started at each R wave (electrical systole).
Evolution of bulk myocardial motion can be ascertained
over the R-R’ interval.
Adherent myocardium to the pericardium or a pericardial
mass is shown by tag persistence between the two areas
T1 SE
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Slide Courtesy of Christopher J Francois, M.D.
T2 SE
Myocardial tagging
Primary pericardial lymphoma
Irregular,
heterogeneously
dense, mass
surrounding aorta and
left main coronary
artery and invading
main pulmonary artery
Early systole
Mid systole
Pericardial tumor mass is not adherent to ventricle as shown
by sheer in the myocardial taglines
Primary pericardial undifferentiated sarcoma
Slide Courtesy of C.J. Francois, M.D
Pericardial metastases from lung cancer
Large, heterogeneous, pericardial
mass adjacent to LA appendage and
main pulmonary artery
Irregular, lobular isodense,
isointense, hypermetabolic
intracavitary RV mass extending
into RVOT
CECT
PA
T1 TSE
SSFP
FDG 18 PET
FDG-18
PA
T2 TSE
T2 TSE
Slide Courtesy of Christopher J. Francois, M.D.
Slide Courtesy of Christopher J Francois, M.D.
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Summary
• Normal pericardium made up of two layers and is d 2mm in
thickness
• CXR, CT, and MRI have very important roles in diagnosis and
evaluation of patients with pericardial disease
• Pericardial effusions have many causes
• Etiology may or may not be evident on CT/MRI
• Pericarditis presents as pericardial thickening and
enhancement
• Pericardial effusion may or may not be present
Radiology
Drs. Lynn Broderick, Scott Nagle, Cris Meyer,
Donald Yandow, Thomas Grist, Scott Reeder
Cardiology
Drs. Jon Keevil, Mary Zasadil, Mark Sasse,
Nancy Sweitzer, Annie Kelly
• Constrictive pericarditis can be distinguished from restrictive
cardiomyopathy with CT or MRI
• Pericarditis (r
r calcification)
• Septal bounce with cine imaging
• Real-time cine SSFP with inspiration/expiration
i
di l masses
• P
Pericardial
• Metastases » primary pericardial neoplasms
• Pericardial cysts most common @ right cardiophrenic angle
• Congenital absence of pericardium is usually partial rather than
complete
• Left ! right
CME QUESTION: PERICARDIAL DISEASE
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Thank you
Summary
1. Constrictive pericarditis is best shown by which MRI
sequence:
a. Arterial Spin Labeling
b. Double Inversion Recovery
c. Fast Spin Echo T2
e. Short Time Inversion Recovery (STIR)
f. bSSFP Cine Images with myocardial tagging
Thoracic Surgery
Drs. Tracey Weigel, Nilto DeOlivera
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CT and MRI of the Pericardium
Mark L. Schiebler, MD
This syllabus will provide an overview of the current state of the art of CT and MRI of the pericardium with current pertinent references from the literature. We will begin with a discussion of the embryology and the normal appearance of this
ancillary but important structure in the chest and then we will discuss the various imaging appearances of the common
diseases that affect this structure. We will discuss how MRI can be used to determine the presence and physiological significance of constrictive pericarditis. We will conclude with a review of the common pitfalls associated with the various
pericardial recesses.
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Anatomy
The normal pericardial sac can be envisioned in a very simplistic manner as a bursal like structure that is draped like a
ball of dough applied to the anterior surface of the heart and rolled to the posterior surface leaving a bare area at the left
atrium. The pericardium has two components: an outer fibrous layer providing structure and a serous layer that is responsible for fluid production.1 The serous layer has both a visceral and parietal surface that is a single cell layer thick. This
visceral lining on the epicardial surface is not visible by imaging methods. The parietal layer composed of the parietal
serous layer and a second fibrous component usually measures a <2mm thick on imaging. Often what can be seen by CT
and MRI is material or fluid in the pericardial space between the two layers. There is normally around 15-50 ml of a clear
serous plasma ultra-filtrate present. Pericardial thickening is defined as any area greater than 4mm in AP dimension on
CT or MRI. This “pericardial thickening” is in fact the summation of visceral layer, material or fluid in the pericardial
space and also the parietal fibrous layer.
Function
The function of the pericardium is multifactorial: 1) provide a barrier to infection from mediastinal and pleural surfaces,
2) provide a lubricated space (like a bursa for a tendon) for the heart to contract in that is sheltered from the (reasonably)
stationary chest wall,2 3) provide a defined space for the atria to be filled while the ventricles contract, acting as a backbone to prevent atrial collapse and allowing for blood to be “pulled into” the atria. The atria can act like individual bellows that fill with new blood as their respective ventricles empty in systole because of the “negative systolic pericardial
pressure”, 4) fixation of the heart in the mediastinum, 5) limits acute dilation of the chambers, 6) prevent acute atrioventricular valve (AV) annular stretching in the setting of acute left or right ventricular end diastolic pressure overload, thus
limiting potential acute AV regurgitation, 7) coordinate, in the short term, right and left ventricular stroke volumes when
there is elevated peripheral vascular resistance (e.g. elevated systemic blood pressure).
Embryology
The embryology of the pericardium is important in understanding the common congenital variants that the clinical imager
is likely to encounter. Congenital absence most commonly is partial and on the left. Complete congenital absence is rare.
This is thought to be related to regression of the left common cardinal vien, which in turn devascularizes the pleuropericardial membrane, resulting in loss of that portion of the pericardium.3 This disorder may also be associated with many
intra-cardiac defects that include: Atrial septal defects, patent ductus arteriosis, Tetralogy of Fallot, and mitral stenosis.3
Partial absence of the pericardium can be seen as a lack of the normal thin pericardial membrane at CT or MRI over those
regions that have enough epicardial fat. For the left atrial appendage and portions of the left ventricle that are not perpendicular to the plane of imaging, the pericardium may be difficult to see. Clues to this diagnosis includes shift of the mediastinal structures, focal bulging of a structure (e.g. the left atrial appendage or left ventricle), and interposition of lung
either between the heart and the hemidiaphragm or between the pulmonary artery and aorta.4-5 Rarely, herniation of the
left atrial appendage through a focal pericardial defect can result in torsion with subsequent strangulation. Surgical repair
is usually indicated for significant torsion of the heart or an epicardial structure because of sizeable pericardial defect.6
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Pericardial Diseases
There are a number of pathologies that involve the pericardium. This presentation will highlight the common etiologies
that affect this portion of the chest.
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Pericardial fluid
Uremia
Dressler syndrome
Acute Right heart failure
Infection: Viral and bacterial
Malignant
Pericardial cysts
Non physiologically significant
Physiologically significant
Common Locations
Pericarditis ( importance of DCMR in showing extent7-8)
Viral
Bacterial
Malignancy
Trauma
Intra-Pericardial malignancy
Common-Melanoma, Lung, Gastric, Breast
Rare- Angiosarcoma, Synovial Cell
Extra-Pericardial malignancy or Infection
Adjacent lung masses
Constrictive pericarditis ( importance of MR showing location and physiological importance)
Old Infection - TB
Prior surgery
Utilization of CT and MR in Constrictive Pericarditis
Constrictive pericarditis (CP) is defined as contact between the visceral and parietal surfaces of the pericardium such
that there is a limitation in cardiac chamber movement. This is commonly an incomplete process and is typically associated with either thickening of the pericardium or calcification. While CT shows pericardial thickening and calcification9,
motion of the heart will only be seen with retrospectively gated cCTA exams, which tend to have at least 10 mSv of radiation exposure. MRI in this setting is very useful. Cine tagged images show direct contact between the pericardium and
ventricle by a lack of sheer between those two attached structures.10 In the normal situation, there will be motion present
between the myocardial tag lines and the pericardial tag lines. In those regions of constrictive pericarditis, there is no
sheer of the myocardial tags observed between the heart chambers involved and the adjacent pericardium. This is now
seen as only one structure that moves in unison. While the pericardium does not mind this “marriage” too much, the heart
complains bitterly about this “shotgun wedding” and may scream out loud about it the only way it knows how- by changing its output resulting in the classic but non-specific symptom of: shortness of breath that worsens with exercise.
Depending on how much of the wall of each respective the chamber is involved, the lack of its ability to fully expand will
frequently change the diastolic filling pressure of that portion of the heart.
For simplicity, consider a patient with CP involving both ventricles. With each inspiration, venous inflow to the right
heart increases as the bellows of the diaphragm and intercostals muscles increase lung and pleural space volume with a
concomitant decrease the intrathoracic pressure. As there is now a concrete sac enclosing both ventricles, the ability to
expand with this influx of volume from the Right Atrium and systemic venous system is limited; thus, the right ventricle
(RV) pushes the intraventricular septum away from it. 11The diastolic filling pressure of the RV with CP now exceeds the
diastolic pressure of the left ventricle (LV) leading to paradoxical motion (from right to left) of the interventricular septum.12-14 Furthermore, limited filling ( decrease in stroke volume) of the LV , when severe, can cause pulsus paradoxicus .15 In this situation, limited filling of the left heart causes systemic blood pressure to drop with a loss of a palpable
peripheral pulse at inspiration. While this entity was first described with calcific pericarditis,15 there are many other causes including cardiac tamponade, acute pulmonary thromboembolism, and severe obesity.15
Key Point
MRI (breath hold, phase contrast complex difference, flow imaging) is able to show changes in atrial filling patterns that
are highly suggestive of constrictive physiology. Specifically the early atrial filling wave (e wave) is blunted in its flow
and velocity, while the atrial kick or secondary wave (a wave) of atrial filling is enhanced. This is typically associated
with an increase in the diastolic filling pressure of the right ventricle (RVEDP). It is this increase RVEDP that results in
the change in septal movement that can be exaggerated with inspiration.
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Common Pitfalls
A major issue when dealing with the pericardium is the errant diagnosis of lymphadenopathy that is simply related to
fluid in a pericardial recess.1,16 Knowing the common locations where this can occur is very helpful in limiting this perceptual error and preventing needless intervention.
Transverse sinus-simulates LN17
High riding superior pericardial sinus18- simulates LN
Inferior sleeve of pulmonary veins-simulates LN19
Superior pericardial sinus – simulates aortic dissection or LN18,20-23
Oblique Sinus – simulates LN1
Summary
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The radiologist is able to make the initial diagnosis of pericardial disease with confidence using CT and MRI. While CT
is excellent for routine screening of pericardial disorders and the detection of pericardial calcification; MRI is superior in
quantifying the degree of adherent pericardium and can provide detailed functional information.
References for MR and CT of Pericardium
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23.
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