Enlarged Cardiac Silhouette

Gregory Kicska, MD, PhD

DIFFERENTIAL DIAGNOSIS

Common

Less Common

Rare but Important

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Pericardial space fluid: Globular enlargement
Cardiac chamber enlargement: Characteristic contour abnormality such as filling of retrosternal clear space in right ventricle enlargement
Pericardial mass: Focal contour irregularity

Helpful Clues for Common Diagnoses

Ischemic Cardiomyopathy
- Sub-endocardial fat or calcium, left ventricle (LV) wall thinning in coronary distribution, dense coronary calcifications
- MR shows subendocardial or transmural delayed enhancement in coronary artery distribution
Valvular Disease
- Valvular calcifications most common
- MR cine or phase contrast shows flow jets
Heart Failure Exacerbation
- Coexistent signs of pulmonary edema
Pericardial Effusion
- New globular heart enlargement on radiograph, fluid-density pericardial fluid on CT
- Hemopericardium suggested by high-density pericardial fluid or neoplasm history (lung, breast, melanoma)

Helpful Clues for Less Common Diagnoses

Nonischemic Dilated Cardiomyopathy
- Dilated LV, thin wall, EF < 40%
- Either no delayed enhancement present or enhancement is not subendocardial
Pericardial Mass
- Pericardial cyst: Circumscribed fluid density at right more than left cardiophrenic angle
- Pericardial fat pad: Fat density most commonly at right cardiophrenic angle

Helpful Clues for Rare Diagnoses