Radiographic Findings by Diagnosis: Pericardial and Pleural Diseases




Key Points


The presence of many pericardial disorders may be suggested by the chest radiograph.




  • Pericardial effusion: enlargement of the cardiopericardial silhouette (CPS)



  • Pericardial tamponade




    • Enlargement of the CPS



    • Systemic and pulmonary venous engorgement




  • Constrictive pericarditis




    • May or may not have pericardial calcification



    • Atrial, especially left atrial enlargement



    • Systemic and pulmonary venous engorgement




  • Pericardial cysts: cardiodiaphragmatic angle (left greater than right) or midline mediastinal rounded mass



  • Pneumopericardium: air stripe and parietal pericardial stripe





Acquired Pericardial Disease


Pericardial Effusion


A pericardial effusion ( Figs. 16-1 to 16-15 ) is often suggested on the frontal chest radiograph by a smoothly distended, “flasklike” CPS. More than 500 mL of fluid must be present before the change in the CPS is fairly obvious. A flasklike appearance may be caused by myocardial disease as well; scrutiny of the hilar vessels may distinguish the two. In the presence of pericardial effusion, the hilar vessels are covered (the pericardium runs up onto them and obscures them). In the presence of myocardial disease, the hilar vessels are unusually prominent as they are distended under higher than usual pressure.




Figure 16-1


Anteroposterior radiograph of a patient with a moderate-sized pericardial effusion that has rendered the heart more rounded in shape. The pulmonary venous markings are increased and the azygous vein has dilated, consistent with the tamponade physiology with which the patient had presented.



Figure 16-2


Posteroanterior and lateral chest radiographs of a patient with a large pericardial effusion. The cardiothoracic ratio is prominently increased, and the shape is globular, with flasklike tapering superiorly as the pericardial effusion has run up the pericardial sleeve over the aorta and pulmonary artery.



Figure 16-3


Large pericardial effusion. The cardiothoracic ratio is increased, and the shape, although partially obscured by a large left-sided pleural effusion, is globular.



Figure 16-4


Chest radiographs and corresponding contrast-enhanced computed tomography (CT) axial images. There is cardiomegaly in all four of the chest radiographs. Between the upper and the lower chest radiographs, there has been collapse of the right upper lobe. The CT scans reveal that the cardiomegaly is due to a moderate-sized pericardial effusion that can be seen both around the heart on the left lower image and extending up the pericardial sleeve of the great vessels along the aorta and the pulmonary artery seen on the right lower image. Bronchogenic carcinoma with right upper lobe collapse and malignant pericardial and pleural effusions is seen.



Figure 16-5


A patient with advanced pulmonary hypertension. The left images are prior to the development of a pericardial effusion. Note the prominent pulmonary arteries and large right atrium and ventricle. The right images reveal the development of a moderate-sized pericardial effusion; the cardiopericardial silhouette has increased in size.



Figure 16-6


There is mild rounding of the heart silhouette on the chest radiographs. The flasklike shape of the heart due to the moderate-sized pericardial effusion extending up the vascular sleeves of the pericardial space is more apparent on the coronal computed tomography image.



Figure 16-7


Chest radiographs and computed tomography scans of a patient with a large pericardial effusion. Note the typical flask shape of the cardiopericardial silhouette, as well as the dialysis catheter and central venous lines.



Figure 16-8


Posteroanterior and lateral chest radiographs of a patient with a large pericardial effusion. Note the enlarged cardiopericardial silhouette with globular shape.



Figure 16-9


The upper radiographs are in the context of pericardial tamponade. The cardiothoracic ratio is increased and the cardiopericardial silhouette is globular with superior tapering (flasklike). There is a right pleural effusion. The lower images show that despite removal of a liter of fluid, the cardiothoracic ratio is actually not prominently smaller. The drainage catheter, inserted apically, is not associated with a left-sided pneumothorax or new pleural effusion (left image after drain insertion and right image after drain removal).



Figure 16-10


Posteroanterior and lateral chest radiographs and approximately corresponding echocardiographic images of a patient with pericardial tamponade. The cardiothoracic ratio is prominently increased, and the shape is globular. The echocardiographic images depict the proportion of the cardiomegaly that is due to fluid.



Figure 16-11


Chest radiograph of a patient with pericardial tamponade. The cardiothoracic ratio is prominently increased, and the shape is globular. There is a double shadow superiorly on the left due to fluid within the pericardial space at the arch level.



Figure 16-12


The cardiothoracic ratio is increased, and the cardiopericardial silhouette shape is globular due to hemopericardium. The pulmonary artery catheter is within the right heart.



Figure 16-13


Posteroanterior and lateral chest radiographs and non–contrast-enhanced computed tomography coronal and axial views of a female patient with prior bilateral mastectomies (note axillary dissection clip) who presented with pleural effusions and pericardial tamponade due to metastatic bowel carcinoma. Note the rounded or flasklike shape of the cardiopericardial silhouette and the prominent azygous vein/superior vena cava, consistent with raised central venous pressure due to tamponade.



Figure 16-14


Upper images: Posteroanterior and lateral chest radiographs during a presentation with acute pericarditis. The lower images are at a later date during subsequent re-presentation to hospital with dyspnea and fatigue. The heart size has visibly increased within a 3-week period, with the shape becoming more globular on both the frontal and lateral radiographs. As well, the azygous vein is plethoric consistent with raised central venous pressure. The second presentation was associated with the hemodynamics of tamponade.



Figure 16-15


The upper radiographs reveal mild cardiomegaly with an increase in the left atrial and left ventricular chambers due to severe mitral insufficiency without heart failure. The middle radiographs, taken 3 months later while the patient was awaiting mitral valve surgery, reveal an increase in the size of the cardiopericardial silhouette. This was due to the development of malignant tamponade in the intervening period. The left lower radiograph is post–pigtail catheter insertion into the pericardial space. The right lower radiograph is post–pigtail catheter insertion into both pleural spaces to drain malignant pleural effusions.


In a minority of patients with pericardial effusion, on the lateral radiograph, a stripe of radiolucent epicardial fat, a “fat line,” may be visible anteriorly, suggesting fluid in the pericardial space. A stripe greater than 2 mm is abnormal. This “pericardial stripe sign” is more easily seen in adults than children (more fat!).


A prominent azygous vein, superior vena cava, or inferior vena cava suggests cardiac tamponade.


Echocardiography is the diagnostic test of choice for the evaluation of pericardial effusions. Pericardial tamponade remains a clinical diagnosis, strengthened by supportive echocardiographic findings.


Constrictive Pericarditis


In constrictive pericarditis ( Graphic 16-1 ; Figs. 16-16 to 16-23 ) , the CPS is usually nonspecifically and mildly enlarged. Occasionally, the heart is normal or small in size. The left atrium is the most frequently enlarged chamber, because its enlargement is less restricted by pericardium. The right atrial contour on the frontal chest radiograph may be flattened. Calcification of the pericardium suggests past tuberculosis, but since tuberculosis has become uncommon at most centers, 90% of cases of constrictive pericarditis are currently noncalcified. Calcification, especially diaphragmatic, is not specific for constrictive physiology; it may be seen in the absence of cardiac compression. The apical surface is less frequently calcified than the interventricular and atrioventricular grooves. The apex seldom calcifies prominently in constrictive pericarditis; this finding suggests a calcified apical aneurysm rather that constrictive pericarditis.




Graphic 16-1


Lateral projection depicting radiographic finds of calcific constrictive pericarditis. Note the mildly enlarged cardiac silhouette and the presence of plaquelike patches of pericardial calcification principally seen in the atrioventricular grooves. Pleural effusions are also depicted. Posteroanterior projection showing calcific constrictive pericarditis. Note the plaquelike pericardial calcification, which spares the left ventricular apex, mild cardiomegaly, and pleural effusion.



Figure 16-16


The cardiothoracic ratio is not increased, and there is no particular abnormality to the cardiopericardial silhouette. The lung fields are clear, although the film is overpenetrated. The left costophrenic angle is blunted. There is an extensive plate of pericardial calcification present under the heart on the posteroanterior (PA) film. The lateral radiograph reveals that the pericardial calcification is also anterior to the right ventricle and is not appreciable on the PA radiograph, where it is “en-face.”



Figure 16-17


The cardiothoracic ratio is not increased, and there is no particular abnormality to the cardiopericardial silhouette. The lung fields are clear, although the film is overpenetrated. The azygous vein is bulging over the right mainstem bronchus due to the elevation of central venous pressure from acute tamponade.



Figure 16-18


Calcified chronic organized intrapericardial hematoma. The cardiothoracic ratio is increased. There is an extensive plate of pericardial calcification present under the heart, seen on both the posteroanterior and lateral radiographs.

Apr 10, 2019 | Posted by in General Surgery | Comments Off on Radiographic Findings by Diagnosis: Pericardial and Pleural Diseases
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