Radiographic, Ultrasound, CT and MRI findings in pericardial effusion

1. PERICARDIAL
EFFUSION
Dr. P.Sandeep

2. Pericardium Anatomy



Sac like membrane that surrounds heart and proximal great
vessels
Pericardial fluid- 15-50ml
Attachments
Base
1.
•
Anterior
2.
•

Pericardiophrenic ligaments
Superior and inferior Sternopericardial
Ligaments
Consists of
Fibrous
Serous
1.
2.
a.
b.
Visceral
Parietal

3. 
Reflections
1.
2.

1.
Sinuses
Transverse Sinus
a.
b.
2.
3.
Superior
Posterior
Superior aortic recess
Inferior aortic recess
Oblique Sinus
Recess of pericardial cavity
a.
b.
Post caval recess
Right and left Pulmonary venous recess

4. Innervation and Vascular supply

Innervation
1.
2.

Arterial supply
1.
2.

Vagus and Sympathetic Trunk
Phrenic nerves
Thoracic aorta- Sup. Phrenic a. & Coronary a
Internal thoracic a.- Pericardiophrenic a. &
Musculophrenic a.
Venous:
1.
2.
Azygous system
Internal thoracic v.

5. Imaging

Radiography
•

Echocardiography
•
•

Imperceptible
Modality of choice for initial evaluation
Cannot asses entire pericardium
CT/MR
•
•
•
•
Normal thickness- 2-4 mm
Most visible anterior to right ventricle- fat lining
Increased thickness near diphragm
MR:
•
•
Low signal on T1 & T2- normal pericardium
Outlined by bright signal - fat

9. Pericardial Effusion

Abnormal amount of fluid in the pericardial space (>50
ml)
Causes:
1.
idiopathic
2.
inflammatory
1.
2.
3.
4.
5.
6.
post myocardial infarction - Dressler syndrome
connective tissue disorders
infectious - Viral, Bacterial, tuberculosis
post surgical / trauma
radiotherapy
malignancy - primary or metastatic

10. Clinical presentation:
 Does not relate so much to the size of the effusion
but rather the speed at which the fluid has
accumulated.
 Regardless of volume, symptoms relate to
impaired cardiac function due to intrapericardial
pressure approximating intracardiac pressure
leading to impaired filling of low pressure
chambers, particularly the right atrium.
 Dyspnea and reduced exercise tolerance will be
early signs, progressing to severe impaired
cardiac output and death in severe cases.

11. Imaging
Radiograph
 Non specific and normal until volume of fluid > 250
ml.
 Rapidly enlarging cardiac silhouette with normal
pulmonary vascularity
 water bottle configuration -globular enlargement of
the cardiac shadow.
 Oreo cookie sign/Fat-pad sign
 separation of retrosternal from epicardial fat line
>2 mm

12. water bottle configuration

14. Oreo cookie sign

15. Echocardiography

1.
2.
3.


Primary imaging modality for the evaluation of
pericardial effusion
Confirm the diagnosis
Estimate the volume of fluid
Assess the hemodynamic impact of the
effusion.
Echo-free fluid between the visceral and
parietal pericardium
> 1cm is usually defined as a “large” effusion

17. Diastolic collapse of the right ventricular (RV) free wall and systolic collapse of the right
atrial (RA) free wall were suggestive of cardiac tamponade

18. Cross-sectional imaging

CT and MR imaging are indicated when
loculated or hemorrhagic effusion or
pericardial thickening is suspected or when
findings at echocardiography are inconclusive

19. Computed Tomography





A pericardial space greater than 5 mm anterior to the
right ventricle is equated to at least a moderate
effusion
Small effusions first collect dorsal to left ventricle and
along left atrium
Larger effusions collect ventral and lateral to right
ventricle
Halo sign- larger effusions may envelop the
myocardium
Loculation most often form along right anterolateral
pericardium

20. Estimating volume
 Depth of the effusion can be used
to estimate the likely volume of fluid, provided
the fluid is relatively evenly spread throughout
the pericardium (global effusion). Does not
apply to localised effusions.
 < 5 mm : 50-100mL
 5-10 mm : 100-250mL
 10-20 mm: 250-500mL
 > 20 mm
: > 500mL

21. Oreo cookie sign

22. Halo Sign

25. Attenuation coefficients rarely helpful in
narrowing differential diagnosis
 Attenuation close to that of water (0 to 25 HU)
- simple effusion.
 Attenuation > water (>25 HU) suggests
malignancy, hemopericardium, purulent
exudate, or effusion associated with
hypothyroidism
 low attenuation - chylopericardium

27. Iatrogenic left ventricular injury during a mitral valve annuloplasty
The inferior left ventricle wall has ruptured secondary to acute myocardial
infarction causing a haemopericardium and cardiovascular compromise. Note
the contrast extravasation and the subendocardial myocardial perfusion defect.

28. MRI





Similar morphologic features to those depicted
on CT
Transudates: low signal intensity T1WI
Exudates: Intermediate signal intensity T1WI
Chylous and hemorrhagic effusions: High
signal intensity T1WI
Cine sequences may reveal hemodynamic
consequences of pericardial effusion;
compression / deformity right atrium signifies
hemodynamic significance

29. Transudate
MRI is low signal on T1-weighted and high signal
intensity on T2-weighted images

30. Management



conservative management-If small,
asymptomatic and clinically not-suspected.
Pericardiocentesis -If large, symptomatic or
there is clinical concern of the underlying
cause (e.g. infection, malignancy etc..)
Pericardial fenestration-In cases where
effusions are recurrent and symptomatic (e.g.
malignancy)