Imaging Pearls ❯ Cardiac ❯ Pericardium and Pericardial Disease
|
-- OR -- |
|
- Dystrophic calcification is the most common type and usually occurs following myocardial infarction. This condition is characterized by the deposition of calcium in the injured myocardium in the setting of normal calcium and phosphorus levels. The prevalence of dystrophic calcifications is estimated to be about 8% in myocardial infarctions older than 6 years . Other causes of dystrophic calcification include trauma, radiation , infectious and/or inflammatory causes, and neoplastic pathology. Rarely, there have been reports where the primary disorders originate from the adjacent myocardial tissue, as recognized in cases like exuberant and extensive mitral annulus calcification , or pericardial calcifi- cation extending into the surrounding myocardium.
Extensive myocardial calcifications in a dialysis patient: A porcelain heart manifesting with abdominal pain
Moezedin Javad Rafiee, et al.
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 5 2 3 – 5 3 0 - Calcium deposition in otherwise healthy myocardium, indicating a systemic disruption in calcium metabolism. The locations and patterns of this type of calcification vary. It can ap- pear faint or dense and usually presents as nodular and/or amorphous. The deposition may be widespread or localized, affecting a single heart chamber or all of the cavitie . This form is most commonly seen in chronic kidney disease (CKD) with an estimated prevalence of 59% in postmortem studies of those patients with CKD on maintenance hemodialysis [. Other causes include acute kidney disease (AKD), in- creased bone turnover, oxaluria , primary or secondary - hyperparathyroidism related to dietary deficiency of calcium and Vitamin D (11), and other Vitamin D-related disorders [4] . There are multiple CKD and dialysis-related factors contributing to dystrophic calcification, including elevated phosphorus levels, and secondary or tertiary hyperparathyroidism which results in hypercalcemia and culminates in an abnormal calcium and phosphorus homeostasis manifesting as a high product of Calcium-Phosphorus (Ca x PO4) with a normal range is less than 55 mg/dL , as well as side effects of treatment with calcium-containing phosphate binders and vitamin D analogs.
Extensive myocardial calcifications in a dialysis patient: A porcelain heart manifesting with abdominal pain
Moezedin Javad Rafiee, et al.
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 5 2 3 – 5 3 0 - Cardiovascular disease accounts for more than 50% of deaths in patients with end-stage renal disease (ESRD) receiving dialysis . There are various factors that have been suggested to contribute to elevated risk, but recently roles of dialysis-specific pathogenetic factors such as hyperphosphatemia, hypercalcemia that lead to high levels of serum calcium x phosphorus product(Ca x PO4), and hyperparathyroidism in the development of coronary artery calcification, myocardial calcification and aortic valve calcification has been raised. Regmi et al found that elevated product of serum calcium and phosphorus (Ca x PO4) exceeding 55 mg/dL is an independent risk factor for cardiovascular events in CKD patients.
Extensive myocardial calcifications in a dialysis patient: A porcelain heart manifesting with abdominal pain
Moezedin Javad Rafiee, et al.
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 5 2 3 – 5 3 0 - The patterns and specific localizations of these calcifications can provide clues into the underlying cause. Generally, dystrophic calcifications have a tendency to be localized and linear, whereas metastatic calcifications may present as dif- fuse, globular, or coarse amorphous patterns. Atrial involvement is usually associated with rheumatic heart disease along with mitral valve engagement, but it can also occur in cases of metastatic calcifications. Various pathologies like vascular, valvular, pericardial, and tumoral calcification can mimic myocardial calcification. The morphology and distribution of calcification play a crucial role in discerning the precise anatomical location. For instance, coronary calcifications appear as linear or tram-track patterns along their typi- cal anatomical path, while pericardial calcifications exhibit a curvilinear pattern, often globally involving the pericardium. The application of cardiac CT scans is pivotal for distinguish- ing calcifications situated within the myocardium from those in extramyocardial locations.
Extensive myocardial calcifications in a dialysis patient: A porcelain heart manifesting with abdominal pain
Moezedin Javad Rafiee, et al.
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 5 2 3 – 530 
Extensive myocardial calcifications in a dialysis patient: A porcelain heart manifesting with abdominal pain
Moezedin Javad Rafiee, et al.
R a d i o l o g y Cas e R e p o r t s 1 9 ( 2 0 2 4 ) 523-530
- "Pericardial cysts are rare with an incidence of about 1 in every 100,000 persons and one in 10 pericardial cysts may actually be a pericardial diverticulum. Pericardial cysts and diverticula share similar developmental origin and may appear as an incidental finding in chest roentgenogram in an asymptomatic patient. CT scan is considered as best modality for diagnosis and delineation of the surrounding anatomy. Cardiac MRI is recommended in the evaluation of the compressive effects caused by the pericardial cysts. The authors recommend echocardiography for serial follow up and image guided aspiration of the pericardial cyst in presence of compressive effects leading to cardiovascular and airway symptoms.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370 - "Cystic lesions within the pericardial space are a rare entity and comprise 7% of the mediastinal masses and 33% of mediastinal cysts. The incidence of a pericardial cyst is 1 in 100,000 populations and most of the pericardial cysts presenting as mediastinal opacity are detected incidentally.They are usually found in the third or the fourth decade of the life and male and female are affected equally.In 70% of the cases, these cysts are located in right cardiophrenic angle, in 22% cases in the left cardiophrenic angle and in 8% cases are located in the posterior or the anterior-superior part of the mediastinum.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370 - “Most of the cases (50–75%) are asymptomatic and are diagnosed incidentally during radiological investigations ordered as routine investigation for other causes of illness. Symptoms may appear due to compression of the nearby structures, such as heart, great vessels, oesophagus and the tracheobronchial tree.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370 - “Computerised tomography scan (CT scan) is considered as the best modality for the diagnosis as it provides an excellent delineation of the pericardial anatomy and can aid in the precise localization and characterization of various pericardial lesions, including effusion, pericardial thickening, pericardial masses, and congenital anomalies helping in surgical decision making. Inaccuracies in diagnosis arise when the cyst is in an unusual location, or the protein content of the cyst fluid is high.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370
- "Pericardial cysts are rare with an incidence of about 1 in every 100,000 persons and one in 10 pericardial cysts may actually be a pericardial diverticulum. Pericardial cysts and diverticula share similar developmental origin and may appear as an incidental finding in chest roentgenogram in an asymptomatic patient. CT scan is considered as best modality for diagnosis and delineation of the surrounding anatomy. Cardiac MRI is recommended in the evaluation of the compressive effects caused by the pericardial cysts. The authors recommend echocardiography for serial follow up and image guided aspiration of the pericardial cyst in presence of compressive effects leading to cardiovascular and airway symptoms.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370 - "Cystic lesions within the pericardial space are a rare entity and comprise 7% of the mediastinal masses and 33% of mediastinal cysts. The incidence of a pericardial cyst is 1 in 100,000 populations and most of the pericardial cysts presenting as mediastinal opacity are detected incidentally.They are usually found in the third or the fourth decade of the life and male and female are affected equally.In 70% of the cases, these cysts are located in right cardiophrenic angle, in 22% cases in the left cardiophrenic angle and in 8% cases are located in the posterior or the anterior-superior part of the mediastinum.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370 - “Most of the cases (50–75%) are asymptomatic and are diagnosed incidentally during radiological investigations ordered as routine investigation for other causes of illness. Symptoms may appear due to compression of the nearby structures, such as heart, great vessels, oesophagus and the tracheobronchial tree.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370 - “Computerised tomography scan (CT scan) is considered as the best modality for the diagnosis as it provides an excellent delineation of the pericardial anatomy and can aid in the precise localization and characterization of various pericardial lesions, including effusion, pericardial thickening, pericardial masses, and congenital anomalies helping in surgical decision making. Inaccuracies in diagnosis arise when the cyst is in an unusual location, or the protein content of the cyst fluid is high.”
Current concepts of diagnosis and management of pericardial cysts.
Kar SK1, Ganguly T2.
Indian Heart J. 2017 May - Jun;69(3):364-370
- “ CT is a powerful diagnostic tool for evaluating the pericardium and its abnormalities. Knowledge of the normal recesses and sinuses is essential to avoid misdiagnosis. Functional imaging is useful in the evaluation of pricardial constriction and tamponade.”
Computed Tomography of the Pericardium and Pericardial Disease
Rajiah P et al.
J Cardiovasc Comput Tomogr (2010) 4,3-18 - Normal Pericardium: Facts
- < 2 mm thick
- Contains 15-50 ml of fluid
- Pericardial recesses can be confused with adenopathy or other masses - Cardiac Tamponade: CT Findings
- Large pericardial effusion
- Enlargement of either the SVC (diameter similar or greater than adjacent aorta) or IVC (diameter twice adjacent aorta)
- Periportal edema
- Reflux of contrast into IVC and azygous vein or enlargement of hepatic and renal veins
- Cardiac Tamponade: Causes
- Malignant pericardial effusion
- Free wall aortic rupture following a myocardial infarction
- Rupture of a coronary artery aneurysm
- Complications of endocarditis
- Cardiac neoplasms
- Dressler syndrome
- Trauma - Cardiac Tamponade: Causes
- Aortic dissection
- Aneurysm rupture
- Lung cancer
- Esophageal cancer - Cardiac Tamponade: CT Findings
- Enlargement of the SVC with a diameter similar to or greater than that of the adjacent thoracic aorta
- Enlargement of the IVC with a diameter or greater than twice that of adjacent abdominal aorta
- Periportal lymphedema
- Reflux of contrast material within the IVC
- Reflux of contrast material within the azygous vein
- Enlargement of hepatic and renal veins - “ Cardiac tamponade is a hemodynamic state that results from the slow or rapid accumulation of fluid, pus, blood, gas, or benign or malignant neoplastic tissue within the pericardial cavity.”
Imaging Findings in Cardiac Tamponade with Emphasis on CT
Restrepo CS et al.
RadioGraphics 2007; 27:1595-1610
- Pericardial Cyst: Facts
- More common in right cardiophrenic space (77%)
- Congenital in origin
- Always asymptomatic
- Attenuation usually 0-20 HU
- No enhancement on contrast enhanced studies - Primary Pericardial Metastases: Differential Dx
- Benign tumors like teratoma, lipoma, lymphangioma, neurofibroma
- Malignant tumors like mesothelioma, angiosarcoma, lymphoma and hemangioendothelioma - Metastases to the Pericardium: Causes
- Lung cancer (number one at 36%)
- Lymphoma
- Leukemia
- Breast cancer
- Esophageal cancer
- Melanoma
- Renal cell carcinoma - Pericardial Calcification: Causes
- Chronic purulent pericarditis
- TB
- Rheumatic fever
- Hemopericardium
- Prior trauma
- Radiation therapy - Cardiac Tamponade: CT Findings
- Large pericardial effusion
- Enlargement of either the SVC (diameter similar or greater than adjacent aorta) or IVC (diameter twice adjacent aorta)
- Periportal edema
- Reflux of contrast into IVC and azygous vein or enlargement of hepatic and renal veins - Normal Pericardium: Facts
- < 2 mm thick
- Contains 15-50 ml of fluid
- Pericardial recesses can be confused with adenopathy or other masses "CT is a powerful diagnostic tool for evaluating the pericardium and its abnormalities. Knowledge of the normal recesses and sinuses is essential to avoid misdiagnosis. Functional imaging is useful in the evaluation of pricardial constriction and tamponade."
Computed Tomography of the Pericardium and Pericardial Disease
Rajiah P et al.
J Cardiovasc Comput Tomogr (2010) 4,3-18- Pericardial Cyst: Facts
- Usually at right anterior costophrenic angle
- Water density on CT
- 2-3 c in size
- Homogeneous without any enhancement - Pericardial Cyst: Facts
- Usually an incidental finding
- May be confused with a Morgagni hernia or duplication cyst or occassionally a thymic cyst - Pericardial Cyst: Differential Diagnosis
- Loculated pleural effusion
- Bronchogenic cyst
- Hematoma
- Esophageal duplication cyst
- Pericardial tumor