The British Journal of Radiology, 83 (2010), 194205

REVIEW ARTICLE

Imaging the pericardium: appearances on ECG-gated 64-detector

row cardiac computed tomography
1
S M OLEARY, 1P L WILLIAMS, 1M P WILLIAMS, 2A J EDWARDS, 1C A ROOBOTTOM, 1G J MORGAN-
HUGHES and 1N E MANGHAT

1
Department of Clinical Radiology, Derriford Hospital, Plymouth PL6 8DH, UK, and 2Department of Clinical Imaging, The
Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, UK

ABSTRACT. Multidetector row computed tomography (MDCT) with its high spatial and
temporal resolution has now become an established and complementary method for
cardiac imaging. It can now be used reliably to exclude significant coronary artery
disease and delineate complex coronary artery anomalies, and has become a valuable
problem-solving tool. Our experience with MDCT imaging suggests that it is clinically
useful for imaging the pericardium. It is important to be aware of the normal anatomy
of the pericardium and not mistake normal variations for pathology. The pericardial
recesses are visible in up to 44% of non-electrocardiogram (ECG)-gated MDCT images.
Abnormalities of the pericardium can now be identified with increasing certainty on
64-detector row CT; they may be the key to diagnosis and therefore must not be
overlooked. This educational review of the pericardium will cover different imaging
techniques, with a significant emphasis on MDCT. We have a large research and clinical Received 9 December 2008
experience of ECG-gated cardiac CT and will demonstrate examples of pericardial Revised 23 July 2009
recesses, their variations and a wide variety of pericardial abnormalities and systemic Accepted 2 August 2009
conditions affecting the pericardium. We give a brief relevant background of the
DOI: 10.1259/bjr/55699491
conditions and reinforce the key imaging features. We aim to provide a pictorial
demonstration of the wide variety of abnormalities of the pericardium and the pitfalls 2010 The British Institute of
in the diagnosis of pericardial disease. Radiology

The rapid technological development of multidetector The pericardial recesses

row computed tomography (MDCT) with its greatly
improved spatial and temporal resolution and sophisti- The pericardium surrounds the heart and extends
cated ECG-gated image acquisition software has led to cranially to cover the pulmonary trunk, superior vena
the more widespread use of dedicated cardiac imaging. cava (SVC) and ascending aorta. The normal pericardial
Not only does this technology enable assessment of the sac is made up of an inner visceral and outer parietal layer
coronary arteries [1, 2], but the same acquired data set with a serosal lining; the space between them constitutes
also provides imaging detail of the overall cardiac the pericardial cavity. On CT this is seen as a thin line of
morphology including the normal and diseased pericar- fibrous tissue; the visceral pericardium cannot be visual-
dium, features of which may also be readily appreciated ised separately. The higher-attenuation pericardium is
on the non-ECG-gated thoracic CT [3]. It is important for distinguished in relation to the low-attenuation medias-
the general radiologist to be familiar with both normal tinal fat anteriorly and epicardial fat posteriorly. On MRI,
and variant pericardial anatomy and with that of the the pericardium is depicted by a thin rim of low signal on
pericardial recesses, which can mimic some pathological both T1 and T2 weighted images.
processes. Several disease processes, either primary or Several studies have examined the normal thickness of
secondary, can affect the pericardium. This review aims the pericardium on CT and MRI and at autopsy. The
to illustrate normal pericardial anatomy, diagnostic pericardial thickness varies over different parts of the
pitfalls, commonly encountered abnormalities (some of heart; it is at its thinnest over the left ventricle. Bull et al,
which may be quite subtle) and some more unusual [4] reported that when using 1 mm high-resolution CT
entities. (HRCT) the upper limit of the thinnest part of the
pericardium was 0.7 mm and when using 10 mm CT
slices it was 1.2 mm. The upper limit of normal for the
thickest part of the pericardium is 2 mm [58]. The
pericardial sac contains up to 50 ml of clear fluid [9] and
forms a protective layer around the heart, acting as a
Address correspondence to: S OLeary, Department of Clinical
Radiology, Derriford Hospital, Plymouth PL6 8DH, UK. E-mail:
barrier against local inflammation and limiting its
[email protected] movement within the mediastinum.

194 The British Journal of Radiology, March 2010

Review article: Imaging the pericardium

As MDCT resolution has improved, the pericardial pericardial recess, which has a more cranial extension.
recesses can be identified as defined anatomical struc- This can take a variety of shapes including triangular,
tures that are visible in up to 44% of thin-section scans crescent-shaped or oval and can be seen to extend up
[10]. They are cavities found between the outer fibrous into the right paratracheal region (Figure 2b).
and inner serous layers of the pericardium and can best N The right lateral extension is seen insinuating between
be understood by subdividing them according to the part the ascending aorta and SVC. Basile et al [11]
of the pericardial cavity from which they arise. The three demonstrated this recess to be present in 6.6% of
main sites of origin are the transverse sinus, the oblique patients when the chest is imaged using 16-MDCT.
sinus and the pericardial cavity proper (Figure 1) [3].
In continuity with the transverse sinus inferiorly is the
inferior aortic recess. This is a caudal extension from the
The transverse sinus transverse sinus seen extending anterior to the left
atrium.
This space is located posterior to the ascending
Also in continuity with the transverse sinus are the right
aorta and pulmonary trunk and cranially to the left
and left pulmonic recesses. These extend from the
atrium; a number of recesses take origin from this space
transverse sinus inferolaterally, lying caudal to the
(Figure 1). Arising superiorly from the transverse sinus
is the superior aortic recess. This, in turn, has three pulmonary arteries (Figure 2d).
subdivisions:

N The anterior extension is seen anteriorly between the The oblique sinus
ascending aorta and pulmonary trunk, taking a
characteristic triangular shape (Figure 2a). The oblique sinus is the most posterior pericardial
N The posterior extension, or superior pericardial recess, space (Figure 1). This space lies behind the left atrium
is seen directly behind the ascending aorta, taking a and is inferior to the transverse sinus, from which it is
characteristic crescent shape (Figure 2c); an important separated by pericardial reflections. Arising from the
variant of this recess is the high-riding superior oblique sinus is the posterior pericardial recess. This

Figure 1. Line drawing illustrating

the relative positions of the transverse
and oblique sinuses; the majority of
the pericardial recesses take their
origin from these spaces. Note the
pericardial reflection between the
two spaces. The pulmonic venous
recesses are also illustrated.

The British Journal of Radiology, March 2010 195

 S M OLeary, P L Williams, M P Williams et al

(a) (b)

(c) (d)

Figure 2. (a) The anterior extension of the superior aortic recess. (b) A coronal reformation demonstrating the right
paratracheal position of a high-riding superior pericardial recess. (c) The posterior extension of the superior aortic recess. (d) The
left pulmonic recess.

extends superiorly behind the right pulmonary artery Pericardial effusions can be imaged using a variety of
and medial to the bronchus intermedius. modalities. The plain chest radiograph may suggest a
pericardial effusion only in the context of a rapidly
enlarging cardiac silhouette. Echocardiography is highly
sensitive and specific in detecting pericardial effusions,
Pericardial effusion and indeed effusions may be easily seen on subcostal
The pericardium normally contains a small amount of views obtained during conventional abdominal ultra-
fluid (between 15 and 50 ml) [9]. Gradual fluid build-up sound examination. CT or MRI is indicated if the
may be accommodated by the pericardium to the extent effusion is suspected to be complicated by haemorrhage
of volumes greater than 1 litre [12], although rapid (Figure 4), loculations, pericardial inflammation, thick-
accumulation (Figure 3) is far more problematic; tamp- ening or constriction [4, 14]. Accurate localisation of
onade can be caused by a volume of 250 ml within a effusions can be facilitated and guide intervention and
previously normal pericardial sac [13]. The aetiology of a also allow further characterisation of the fluid. If the
pericardial effusion is obstruction of lymphatic or attenuation value on CT is greater than that of water,
venous drainage from the heart, which can be caused then an effusion is more likely to be due to haemoper-
by a number of disease processes: the commonest are icardium, malignancy, purulent exudates or hypothyr-
cardiac and renal failure, followed by infection, neopla- oid-associated effusion [15, 16].
sia and myocardial infarction. Any cause of acute On MRI, a haemorrhagic effusion is characterised by
pericarditis, although initially causing a dry and fibrin- high signal on T1 weighted images and low signal on T2
ous inflammatory reaction, will lead to subsequent weighted cine images [17]. The size and extent of the
development of a pericardial effusion. pericardial effusion may also be better assessed using CT

196 The British Journal of Radiology, March 2010

Review article: Imaging the pericardium

effusion is secondary to a malignancy there may also be

associated pericardial irregularity and nodularity (see
later).

Pericarditis without constriction

Pericarditis is essentially a fibrotic inflammatory
reaction of the pericardium brought on by a large
number of conditions, including radiation therapy, post
cardiac surgery or post myocardial infarction (Dresslers
syndrome), or by drugs, uraemia, infection (e.g. viral,
bacterial tuberculosis), and hypothyroidism [16, 20].
There is thickening of the pericardium associated with
a pericardial effusion, but without constriction of the
myocardium (Figure 5). The pericardial fat may also be
of increased, ill-defined attenuation, in keeping with
inflammatory change.
All causes of pericarditis can lead to subsequent
constriction [17]. Inflammation of the pericardium
causes enhancement on post-intravenous (iv) contrast
CT and also post-gadolinium MRI. In a study by Masui
Figure 3. Pericardial effusion. Here, there has been a rapid et al [21] there was 88% correlation between pericardial
accumulation of pericardial fluid, particularly on the left thickness at surgery and MR images. Pericarditis may
side, which is compressing the cardiac chambers and creating affect only part of the pericardium, making it important
a tamponade. to visualise and scrutinise the entire pericardium [12].
Ben-Horin et al [22] described the case of a patient with
known systemic lupus erythematosus who presented
or MRI than with transthoracic echocardiography; the with pleuritic chest pain; conventional methods of
smallest amount of pericardial fluid that can be detected investigation did not detect a pericardial effusion,
by CT is approximately 10 ml [18]. A pericardial space whereas CT demonstrated a localised area of pericar
greater than 5 mm anterior to the right ventricle is dial inflammation leading to the diagnosis of lupus
equated to at least a moderate effusion [19]. When the pericarditis.

(a) (b)

Figure 4. (a) This patient sustained a previously unsuspected iatrogenic left ventricular injury during a mitral valve
annuloplasty, and presented with cardiac tamponade secondary to a rapidly accumulating haemorrhagic pericardial effusion.
(b) 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.

The British Journal of Radiology, March 2010 197

 S M OLeary, P L Williams, M P Williams et al

reduced diastolic filling of one or both ventricles, with a

normal-thickness pericardium.
Constriction causes small tubular-shaped ventricles,
with distortion of the ventricular septum (Figure 6a). The
septum becomes flattened or sigmoid in shape and can
exhibit the phenomenon of septal bounce. This phenom-
enon is seen on echocardiography, which reveals the
septum moving in an atypical manner. As the pericar-
dium limits ventricular filling, one ventricle fills at the
expense of the other with subsequent septal movement;
the right atrium, inferior vena cava (IVC) and hepatic
veins become dilated (Figure 6b).
CT and MRI can aid the diagnosis of constrictive
pericarditis requiring clinical and radiological concordance.
Figure 5. Anterosuperior pericardial thickening and fatty A thickened pericardium on its own does not therefore
inflammatory change is seen in this patient who presented indicate constrictive pericarditis. Once the pericardium is
with acute chest pain and no clinical evidence of myocardial thicker than 6 mm [19] and the patient is clinically in heart
infarction. The patient had pericarditis. failure, constrictive pericarditis is very likely.
Masui et al [21] demonstrated that MRI has an
It should be noted, however, that subtle increases in accuracy of 93% when differentiating between constrict-
pericardial thickness in the absence of surrounding ive pericarditis and restrictive cardiomyopathy, using
inflammatory change could simply result from a small pericardial thickening of greater than 4 mm as the
amount of pericardial fluid and not from thickening. In deciding factor. MRI has also been shown to be better
the context of a correlative clinical history, and if there is than CT at differentiating between pericardial fluid and
doubt on CT, then T1/T2 MRI could be performed to thickened pericardium [11], and these modalities may
confirm the presence of fluid or thickening. therefore be seen as complementary. Pericardial con-
striction may just be limited to the right heart or the right
atrioventicular groove [23], with pericardial thickening
Constrictive pericarditis present only over the right atria and ventricles [19]. CT is
very sensitive in demonstrating calcification of the
Constrictive pericarditits is a diagnosis requiring a pericardium, unlike MRI, which is also suggestive of
combination of clinical signs and imaging. It is also of constrictive pericarditis if found in the right clinical
paramount importance to distinguish constrictive setting (Figure 7).
pericarditis from restrictive cardiomyopathy; although About 50% of cases show some degree of calcification
clinical signs, transthoracic echocardiography and car- [21] which, if present, excludes restrictive cardiomy-
diac catheterisation findings are very similar, the treat- opathy. Enhancement of the pericardium on post-
ments are different. contrast CT and MRI indicates inflammation [24].
Constrictive pericarditis is caused by a thickened or Johnson et al [25] noted that constrictive pericarditis
fibrotic pericardium, which in turn has a multifaceted can present with vague abdominal symptoms. If the
aetiology (Table 1). This is contrasted with restrictive abdominal CT shows dilated hepatic veins/IVC, ascites
cardiomyopathy, in which there is restrictive filling or or liver cirrhosis then the pericardium should be

Table 1. Causes of constrictive pericarditis and restrictive cardiomyopathy

Constrictive pericarditis Restrictive cardiomyopathy

Causes Post-cardiac surgery Idiopathic endomyocardial fibrosis

Mediastinal radiotherapy Amyloidosis
Infection viral, bacterial (e.g. TB) Loeffler endomyocarditis
Hydatid disease Haemochromatosis
Uraemia Malignancy
Connective tissue disease Carcinoid
Malignancy
Haematoma
Clinical signs Heart murmur uncommon Mitral and tricuspid regurgitation
Hepatomegaly Bilateral pleural effusions
Peripheral oedema Ascites
Peripheral oedema
2-D Echocardiography Normal ventricular size Normal or reduced ventricular size
Pericardial thickening Non-dilated left ventricle with normal contraction
Pericardial effusion may be visualised Marked dilatation of both atria
Cardiac catheterisation Square root sign of ventricular diastolic pressure Square root sign of ventricular diastolic pressure
Increased right heart pressure
Treatment Complete pericardectomy Low dose diuretics
Permanent pacemaker
Cardiac transplantation

198 The British Journal of Radiology, March 2010

Review article: Imaging the pericardium

(a) (b)

Figure 6. (a) Axial sections through the heart in a four-chamber view in a young Asian male patient with constrictive non-
calcified tuberculous pericarditis (see later). The image demonstrates diffuse pericardial thickening, small-volume pericardial
effusion, a flattened interventricular septum and a small right pleural effusion. (b) Axial sections through the upper abdomen in
the same patient, showing ascites, hepatomegaly and dilatation of the hepatic inferior vena cava and hepatic veins with reflux
of intravenous contrast.

carefully inspected, as in their experience the majority of and 54% thin enhancing rims. The most common position
patients will have an abnormal pericardium. was the right atriouentricular (AV) groove, in 77%,
calcification was present in 27% of cases and the abscesses
were shown to have a low attenuation core and may
Tuberculous disease of the pericardium contain septations. The diagnosis was confirmed by
examination of the aspirated fluid or the demonstration
Tuberculosis (TB) is an important cause of pericardial of other extracardiac manifestations of the disease.
effusion worldwide. Cherian et al [26] looked at the Pericardial abcesses have been reported to be caused
features differentiating tuberculous pericardial effusion by a variety of other conditions, including infective
from chronic idiopathic effusion and found three pericarditis after blunt and penetrating trauma, thermal
important features: injuries [31, 32], endocarditis [33], sepsis [34] and
oesophago-mediastinal fistula [35].
N Mediastinal lymphadenopathy was present in all
patients with TB and absent in those with chronic
idiopathic effusion.
Pericardial cysts
N Thinning of the pericardium was not a feature in TB.
N Pericardial tamponade occurred in 64% of both groups. Pericardial cysts are rare congenital defects; however,
they are the most common benign pericardial mass [36].
TB is the commonest cause of constrictive pericarditis in These cysts are formed during early development when a
developing countries, with 50% of patients developing portion of the pericardium is pinched off; they can be found
constriction despite treatment [27, 28]. Associated find- anywhere in the mediastinum, but by far the commonest
ings in TB constrictive pericarditis are pericardial thicken- position is at the right cardiophrenic angle [12]. Pericardial
ing, effusion, lymphadenopathy and calcification. The cysts usually have thin, smooth walls without internal
calcification tends to be thick, irregular, amorphous and in septations (Figure 8) and attach to the pericardium directly
the AV grooves (Figure 6). This can be compared with the or by a pedicle [36]. The majority of these cysts are an
eggshell calcification seen in viral or uraemic pericarditis. incidental finding on the chest radiography.
Tamponade is a frequent complication of TB constric- Pericardial diverticula are clinically identical to cysts
tive pericarditis, but patients do well with appropriate and can be hard to distinguish from bronchogenic or
therapy [29]; abscess formation is a rare complication. thymic cysts if in an unusual location [37]. CT will confirm
Gulati et al [30] demonstrated 15 abscesses in 13 patients the diagnosis of a pericardial cyst by clearly demonstrating
out of a group of 120 known to have constrictive the position and extent of the lesion; fluid density and
pericarditis. TB was found to be the cause in all cases; characterisation of the mass; a clearly defined ovoid mass;
91% of the abscesses on CT demonstrated smooth walls and absent enhancement with iv contrast [38].

The British Journal of Radiology, March 2010 199

 S M OLeary, P L Williams, M P Williams et al

(a) (b)

(c) (d)

Figure 7. Volume-rendered MDCT (c, d) demonstrates in three dimensions florid, irregular, amorphous, pericardial calcified
plaques causing constrictive pericardial disease. Areas of non-calcified pericardial thickening can also be appreciated in the four-
chamber (c, d) and two-chamber planes (a, b) above. In this case, CT aided in surgical resection.

MRI demonstrates four key features: low signal on T1 should be resected [39]. The reported complications of
weighted images; homogeneously high signal on T2 pericardial cysts are cardiac compression [39], infection of
weighted images; no enhancement with iv gadolinium; the cyst with or without cardiac erosion [40] and rupture
and, occasionally, a high signal on T1 weighted images of the cyst [41]. There are no reported cases of malignant
owing to the high protein content of the fluid [38]. degeneration. An important identifying characteristic of
Pericardial cysts may be aspirated under image gui- pericardial cysts is their tendency to alter their size and
dance and, if the fluid is clear and watery, the diagnosis is shape with respiration or body position [37].
confirmed. If there is doubt over the diagnosis, the patient Cystic appearances of the pericardium may also be
is symptomatic or a complication arises, then the cyst due to hydatid cysts. Cardiac involvement is very rare,

200 The British Journal of Radiology, March 2010

Review article: Imaging the pericardium

differentiation of these diagnoses, as haematomas do

not enhance [50]. Pericardial haematomas can further
complicate matters by causing tamponade.

Pericardial defects
Pericardial defects are rare, with the most common
cause being congenital absence. Defects can also result
from surgery or trauma (Figure 9).
With congenital absence of the pericardium there is
premature atrophy of the cardinal vein leading to poor
nourishment of the left pleuro-pericardial membrane.
This leads to failure of the pericardium to develop [51].
These defects are three times commoner in men and are
usually detected in the early 20s. The commonest defect
is complete absence of the left side of the pericardium;
this then allows lung tissue to be interposed between the
main pulmonary artery and aorta. Bulging of the left
Figure 8. Non-gated contrast-enhanced chest CT image in atrial appendage can then occur through the defect. As a
the axial plane. At the right cardiophrenic angle there is an
ovoid structure with attenuation value in keeping with fluid
consequence of all these abnormalities the heart rotates
density that does not enhance with contrast. The structure to the left [38]. There may unusually be right-sided
proved to be a pericardial cyst, following aspiration. defects, diaphragmatic defects or total bilateral absence
of the pericardium.
Congenital pericardial defects are associated with
accounting for 0.22% of all hydatid cyst-related cases congenital abnormalities such as bronchogenic cysts,
[42], with the pericardium involved in only 1015% of ventricular septal defect (VSD), patent ductus arteriosus
these cases [43]. CT is the main diagnostic test and (PDA), mitral stenosis, diaphragmatic hernia or seques-
illustrates the overall extent of the disease. The classical tration. Most pericardial defects are asymptomatic,
findings of a hydatid pericardial cyst are the presence of especially if they do not have any associated defects.
a homogeneous cystic mass that is clearly defined with Imaging of pericardial defects usually begins with an
thin walls, evidence of trabeculations, and the presence incidental finding on the chest radiograph. There may be a
of daughter cysts [43, 44]. Hydatid cysts of the focal bulge in the region of the main pulmonary artery or
pericardium can cause complications, with case reports
of right ventricular outflow obstruction [39] and circu-
latory collapse [43].

Pericardial haematoma
Pericardial haematomas are essentially the result of
trauma. They may be due to blunt trauma, causing a
haemopericardium that subsequently organises to create
a haematoma, or can arise iatrogenically during cardiac
surgery, cardiac catheterisation, paracentesis or central
line insertion.
Features of pericardial haematoma on CT are not
documented in the literature. The blood is of high
attenuation initially, which decreases over time. As the
haematoma progresses it organises and may become
fibrotic and calcify. Haematomas do not enhance with iv
contrast medium.
On MRI the appearances vary according to the age of
the haematoma: in the acute phase they are homo-
geneously of high signal [45, 46], whereas between 1 and
4 weeks of maturity (the subacute phase) the signal
becomes heterogeneous, with areas of high signal on
both T1 and T2 weighted images [45, 47]. Chronic Figure 9. Gated contrast-enhanced axial image.This patient
has undergone aortic valve replacement and grafts. There is
haematomas demonstrate low signal intensity foci that
mediastinal fibrosis (black arrow) (seen as thickened soft
correspond to calcification or fibrosis; on T1 weighted tissue anterior to the right ventricle and just posterior to the
images there is a dark peripheral rim [48, 49]. sternum), which could be mistaken for a thickened pericar-
Haematomas may be confused with pseudoaneurysms dium when the pericardium is in fact absent. The right heart
of the ventricles or coronary arteries or can be mistaken is enlarged and the septum is bowed (white arrow), which
for tumours. The use of iv gadolinium allows the are also findings in constrictive pericarditis.

The British Journal of Radiology, March 2010 201

 S M OLeary, P L Williams, M P Williams et al

lung interposed between the left hemi-diaphragm and the

heart. There can also be levoposition of the heart. The
diagnosis can be confirmed on CT or MRI, in which the
absence of the pericardium can be more clearly defined [12].
Complications of congenital pericardial defects
include herniation and entrapment of the cardiac
chamber, particularly the left atrial appendage, leading
to ischaemic necrosis [36]; to alleviate this, surgical
closure or enlargement of the defect may be necessary
[38]. A further complication is that following a pneumo-
thorax there is likely to be a pneumomediastinum.

Pericardial tumours
Metastatic disease of the pericardium is much com-
moner than that of primary pericardial malignancy.
Metastases are present at autopsy in 1012% of patients
with known neoplasia [47, 48]. If discovered pre-
autopsy, they are associated with a poor prognosis [52].
The primary tumours most likely to metastasise to the Figure 11. An axial section through the heart in a patient
pericardium are lung, breast (Figure 10), melanoma and with end-stage lung cancer demonstrates a soft tissue mass
infiltrating the pericardium and myocardium on the left
lymphoma [47, 48].
poterolateral wall. A small volume of ascites can also be seen
Metastatic spread to the pericardium happens late in around the spleen.
the disease and is usually associated with recurrent
disease. A third of cases are from carcinoma of the lung, pericardial effusion; pericardial enhancement after iv
and a third of lung cancer cases have pericardial contrast administration [54]; and the possible presence
infiltration at autopsy (Figure 11) [17]. of a mass in the pericardium (Figure 12).
Direct extension of primary tumours from the medi- Both benign and malignant primary tumours of the
astinum or lung to the pericardium is a common mode of pericardium are rare. Malignant primaries include
spread [4]. Other modes of spread are through the mesothelioma, sarcoma, liposarcoma and lymphoma,
lymphatic system, haematogenously or transvenously [53]. with mesothelioma and sarcoma being the more com-
Four key features of pericardial malignancy are mon [17]. Mesothelioma accounts for 50% of all
apparent on CT: an irregular, thickened nodular pericar- pericardial primary tumours [55] and may present as a
dium (although this may also occur with an inflammatory pericardial effusion with pericardial nodules or plaques.
pericardiopathy; follow-up imaging may be required); a Sarcoma, liposarcoma and lymphoma manifest as large
pericardial masses (Figure 12) with a haemorrhagic
effusion; imaging alone cannot give a definitive diag-
nosis, therefore biopsy becomes necessary.
Benign tumours of the pericardium include fibroma,
teratoma, haemangioma and lipoma. Teratomas tend to
present as a mass with either fat or calcium within them,
which can readily be demonstrated on CT. Lipomas
demonstrates high signal on T1 weighted images and a
low attenuation (negative Hounsfield units) on CT.
Fibromas have poor vascularisation and therefore have
either no enhancement or irregular enhancement after iv
contrast [49, 56].

Pitfalls in diagnosing pericardial disease

When diagnosing pericardial disease, there are many
things to consider in order to avoid potential pitfalls.
Figure 10. Non-gated contrast-enhanced chest CT axial Normal superior pericardial recesses can mimic aortic
image. This patient was known to have breast cancer and dissection and intramural haematoma (Figure 13) and
had undergone radiotherapy; the lung demonstrates a linear enlarged lymph nodes (Figure 14).
area of fibrosis consistent with this. On further imaging the
pericardium has become nodular and thickened (black
When considering these differential diagnoses, the
arrow) and enhances with contrast. There are also lung Hounsfield attenuation number should be confirmed; for
(white arrowhead) and liver deposits consistent with meta- pericardial recesses, this number will be equivalent to
static disease; however, without a biopsy it is impossible to that of water and will also be in continuity with the
tell whether the pericardial change is secondary to meta- pericardial space. Small volumes of pericardial fluid may
static spread or radiation. be confused with pericardial thickening even on CT, and

202 The British Journal of Radiology, March 2010

Review article: Imaging the pericardium

(a) (b)

Figure 12. (a) ECG-gated contrast-enhanced cardiac CT images demonstrate a large, heterogeneously enhancing, pericardial
mass on the antero-inferior border of the heart causing right heart compression and elevated right heart pressure. The patient
initially presented with right heart failure. The tumour was entirely resected and proved to be a sarcoma on histology. (b) the
same patient CT in the axial plane.

Figure 13. In the context of a patient presenting with acute

chest pain radiating to the back, CT angiography of the aorta
demonstrates a volume of fluid within normal limits within
the posterior extension of the superior pericardial recess Figure 14. This patient with a history of thyroid malignancy
mistaken for ascending aortic intramural haematoma. Note underwent CT which demonstrated a well-defined fluid
the crescent-shaped fluid density immediately posterior to density within an atypical high-riding superior aortic recess.
the aorta, which on multiplanar reformatting was found to This was initially misdiagnosed as an enlarged lymph node
be continuous with the pericardial cavity. and subsequently found at surgery to be a pericardial recess.

The British Journal of Radiology, March 2010 203

 S M OLeary, P L Williams, M P Williams et al

MRI might still be needed for further characterisation. 9. Edwards ED. Applied anatomy of the heart. In: Giulaini ER,
Some disease processes, such as systemic lupus ery- Fuster V, editors. Cardiology: fundamentals and practice.
thematosus, may affect only a portion of the pericardium 2nd edn. St. Louis, MO: Mosby-Year Book, 1991:4751.
and therefore the entire pericardium must be scrutinised, 10. Kodama F, Fultz PJ, Wandtke JC. Comparing thin-section
and thick-section CT of pericardial sinuses and recesses.
again highlighting the importance of pericardial anato-
AJR Am J Roentgenol 2003;181:11018.
mical knowledge and normal variation. 11. Basile A, Bisceglie P, Giulietti G, Calcara G, Figuera M, Mundo
Any process that causes thickening, nodularity or E, et al. Prevalence of high riding superior pericardial
masses of the pericardium can be confused with recesses on thin-section 16-MDCT scans. Eur J Radiol
metastatic disease, such as radiation pericarditis [13], 2006;59:2659.
tuberculous pericarditis (Figure 6) and severe acute 12. Breen JF. Imaging of the pericardium. J Thorac Imaging
pericardial inflammation following radiation therapy 2001;16:4754.
for the treatment of a primary malignancy. 13. Posner MR, Cohen GI, Skarin AT. Pericardial disease in
Pericardial effusions should be assessed for size and patients with cancer: the differentiation of malignant from
idiopathic and radiation-induced pericarditis. Am J Med
attenuation on CT. Observed values greater than water
1981;71:40713.
suggest that the effusion is caused by haemorrhage, 14. Isner JM Carter BL, Bankoff MS, Konstam MA, Salem DN.
malignancy, infection or hypothyroidism. Computed tomography in the diagnosis of pericardial heart
disease. Ann Intern Med 1982;97:4739.
15. Tomoda H, Hoshiai M, Furuya H, Oeda Y, Matsumoto S,
Tanabe T, et al. Evalution of pericardial effusion with
Conclusion computed tomography. Am Heart J 1980;99:7016.
MDCT has augmented our ability to identify and 16. Kamath S, Roobottom C. Hyperdense pericardial effusion
characterise the pericardium, allowing us to differentiate in dermatomyositis and contrast induced nephropathy.
between the normal anatomy and pathology with a Emergency Radiol 2005;11:1779.
17. Hancock EW. Neoplastic pericardial disease. Cardiol Clin
precise relationship to other anatomical structures. This
1990;8:67382.
review illustrates how ECG-gated cardiac MDCT, with 18. Ovchinnikov VI. Computerized tomography of pericardial
submillimetre spatial resolution, should be considered as diseases. Vestn Rentgenol Radiol 1996;1:105,
part of the diagnostic armamentarium in the context of 19. Frank H, Globits S. Magnetic resonance imaging evaluation
suspected pericardial disease. of myocardial and pericardial disease. J Magn Reson
Imaging 1990;10:61726.
20. Song H, Choi YW, Jang IS, Jeon SC, Park CK, Lee IS, Lee JS.
Pericardium: anatomy and spectrum of disease on com-
Acknowledgments puted tomography. Curr Probl Diagn Radiol 2002;31:
The authors would like to thank The Royal College of 198209.
21. Masui T, Finck S, Higgins CB. Constrictive pericarditis and
Radiologists Research Fellowship Award for funding Dr
restrictive cardiomyopathy: evaluation with MR imaging.
N Manghat to study The clinical applications of cardiac Radiology 1992;182:36973.
CT and General Electric Medical Systems for software 22. Ben-Horin S, Portnoy O, Pauzner R, Livneh A. Localized
applications support. pericardial inflammation in systemic lupus erythematosus.
Clin Exp Rheumatol 2004;22:4834.
References 23. Higgins CB. Acquired heart disease. In: Higgins CB, Hricak
H, Helms CA, editors. Magnetic resonance imaging of the
1. Kini S, Bis KG, Weaver L. Normal and variant coronary body. Philadelphia, PA: Lippincott-Raven, 1997:40960.
arterial and venous anatomy on high-resolution CT 24. Stephen WM. Imaging pericardial disease. Radiol Clin
angiography. AJR Am J 2007;188:166574. North Am 1989;27:1113.
2. Cury RC, Nieman K, Shapiro MD, Nasir K, Cury RC, Brady 25. Johnson KT, Julsrad PR, Johnson CD. Constrictive pericar-
TJ. Comprehensive cardiac CT study: evaluation of cor- ditis at abdominal CT: a commonly overlooked diagnosis.
onary arteries, left ventricular function and myocardial Abdom Imaging 2008;33:34952,
perfusion is it possible? J Nuc Cardiol 2007;14:22943. 26. Cherian G, Uthaman B, Habashy AG, Salama AL, George S.
3. Broderick LS, Brooks GN, Kuhlman JE. Anatomic pitfalls of Large pericardial effusion: the differentiation of tubercu-
the heart and pericardium. Radiographics 2005;25:44153. lous from chronic idiopathic effusion. J Assoc Physicians
4. Bull RK, Edwards PD, Dixon AK. CT dimensions of the India 2003;51:8803.
normal pericardium. Br J Radiol 1998;71:9235. 27. Lin JH, Chen SJ, Wu MH, Lee PI, Chang CI. Fibrinofibrous
5. Truong MT, Erasmus JJ, Gladish GW, Sabloff BS, Marom pericarditis mimicking a pericardial tumour. J Formos Med
EM, Madewell JE, et al. Anatomy of pericardial recesses on Assoc 2000;99:5961.
multidetector CT: implications for oncologic imaging. AJR 28. Kawecka-Jazcz K. Pericarditis: classification, etiology,
2003;181:110913. pathogenesis. Folia Med Cracov 1991;32:1522.
6. Bogaert J, Duerinck AJ. Appearance of the normal pericar- 29. Cherian G, Uthaman B, Salama A, Habashy AG, Khan NA,
dium on coronary MR angiograms. J Magn Reson Imaging Cherian JM. Tuberculous pericardial effusion: features,
1995;5:57987. tamponade and computed tomography. Angiology 2004;55:
7. Delile JP, Hernigou A, Sene V, Chatellier JC, Challander P, 43140.
Plainjosse MC, et al. Maximal thickness of the normal 30. Gulati GS, Sharma S. Pericardial abscess occurring after
human pericardium assessed by electron beam computed tuberculous pericarditis: image morphology on computed
tomography. Eur Radiol 1999;9:11839. tomography and magnetic resonance imaging. Clin Radiol
8. Deepak, Talreja DR, Edwards WD, Danielson GK, Schaff 2004;59:5149.
HV, Tajik AJ, Tazelaar HD, et al. Constrictive pericarditis in 31. Johnson MA, Hirji MK, Hennig RC, Williams D. Pericardial
26 patients with histologically normal pericardial thickness. abscess: diagnosis using two-dimensional echocardiog-
Circulation 2003;108:1852. raphy and CT. Radiology 1986;159:41921.

204 The British Journal of Radiology, March 2010

Review article: Imaging the pericardium

32. Sato TT, Geary RL, Ashbaugh DG, Jurkovich GJ. Diagnosis 45. Seelos KC, Funari M, Chang JM, Higgins CB. Magnetic
and management of pericardial abscess in trauma patients. resonance imaging in acute and subacute mediastinal
Am J Surg 1993;165:63741. bleeding. Am Heart J 1992;123:126972.
33. Suzuki S, Tajimi T, Takeshita A, Nakamura M, Kinoshita K, 46. Vilacosta I, Gomez J, Domnguez J, Domnguez L, Banuelos
Tokunaga K. Isolated right heart purulent pericarditis C, Ferreiros J, et al. Massive pericardiac hematoma with
forming a large mediastinal mass. Chest 1988;93:6678. severe constrictive pathophysiologic complications after
34. Capov I, Wechsler J, Sumbera M, Pavlik M, Jedlicka V. insertion of an epicardial pacemaker. Am Heart J 1995;130:
Pericardial abscess a rare complication of sepsis. Acta 1298300.
Chir Hung 1999;38:1921. 47. Meleca MJ, Hoit BD. Previously unrecognised intrapericar-
35. Muto M, Ohtsu A, Boku N, Tajiri H, Yoshida S. dial hematoma leading to refractory abdominal ascites.
Streptococcus milleri, infection and pericardial abscess Chest 1995;108:17478.
associated with oesophageal carcinoma: report of two cases. 48. Brown DL, Ivey TD. Giant organized pericardial hematoma
Hepatogastroenterology 1999;46:17824. producing constrictive pericarditis: a case report and
36. Smith WHT, Beacock DJ, Goddard A, Bloomer TN, review of the literature. J Trauma 1996;41:55860.
Ridgway JP, Sivananthan UM. Magnetic resonance evalu- 49. Funari M, Fujita N, Peck WW, Higgins CB. Cardiac tumors:
ation of the pericardium. Br J Radiol 2001;74:38492. assessment with Gd-DTPA enhanced MR imaging.
37. Pader E, Kirschner P. Pericardial diverticulum. Dis Chest J Comput Assist Tomogr 1991;15:9538.
1969;55:3446.
50. Higgins CB, Sakuma H. Heart disease: functional evalu-
38. Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW,
ation with MR imaging. Radiology 1996;199:30715.
Higgins CB. CT and MR imaging of pericardal disease.
51. Broadbent JC, Callahan JA, Kincaid OW, Ellis FH.
Radiographics 2003;23:S16780.
Congenital deficiency of the Pericardium. Dis Chest 1966;
39. Ng AF, Olak J. Pericardial cyst causing right ventricular
50:23744.
outflow tract obstruction. Ann Thorac Surg 1997;63:11478.
40. Chopra PS, Duke DJ, Pellett JR, Rahko PS. Pericardial cyst 52. Mukai K, Shinkai T, Tominaga K, Shimosato Y. The
with partial erosion of the right ventricular wall. Ann incidence of secondary tumours of the heart and pericar-
Thorac Surg 1991;51:8401. dium: a 10 year study. Jpn J Clin Oncol 1988;18:195201.
41. King JF, Crosby I, Pugh D, Reed W. Rupture of pericardial 53. Schoen FJ, Berger BM, Guerina NG. Cardiac effects of
cyst. Chest 1971;60:61112. noncardiac neoplasms. Cardiol Clin 1984;2:65770.
42. Perez-Gomez F, Duran H, Tamames S, Perrotet JL, Blanes 54. Funari M, Fujita N, Peck WW, Higgins CB. Cardiac
A. Cardiac echinococcosis: clinical picture and complica- tumours: assessment with Gd-DTPA enhanced MR im-
tions. Br Heart J 1973;35:I326I331. aging. J Comput Assist Tomogr 1991;15:9538.
43. Gossios K, Passas G, Kontogiannis D, Kakadellis J. 55. Grebenc ML, Christenson MLR, Burke AP, Green CE, Galvin
Mediastinal and pericardial hydatid cysts: an unusual cause JR. Primary cardiac and pericardiac neoplasms: radiologic-
of circulatory collapse. AJR Am J Roentgenol 2003;181:2856. pathologic correlation. Radiographics 2000;20:1073.
44. Zidi A, Zannad-Hantous S, Mestiri I, Ghrairi H, Baccouche 56. Hoffmann U, Globits S, Frank H. Cardiac and paracardiac
I, Djilani H, et al. Hydatid cyst of the mediastinum: 14 case masses: current opinion on diagnostic evaluation by
reports. J Radiol 2006;87:186974. magnetic resonance imaging. Eur Heart J 1998;19:55363.

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