Pericardial Thickening
Gregory Kicska, MD, PhD
DIFFERENTIAL DIAGNOSIS
Common
Small Pericardial Effusion (Mimic)
Malignancy
Infectious-Idiopathic Pericarditis
Less Common
Cardiac Surgery
Uremic Pericarditis
Radiation-induced Pericarditis
Rare but Important
Connective Tissue Disease
Post Myocardial Infarction
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Pericarditis often accompanied by effusion, which significantly aids in diagnosis
Hemorrhagic effusion: Malignancy, post myocardial infarction most common
Large simple effusion: Infection, idiopathic, and malignancy most common
Symptomatic effusion: Malignancy and acute pericarditis most common
Large effusion without significant thickening makes infectious cause unlikely
Determination of pericardial thickening
Abnormally thickened pericardium > 4 mm with > 6 mm highly specific
LV pericardium thinner than RV, > 2 mm may represent abnormal thickening
Thickening may be focal, commonly adjacent to atrioventricular groove
MR imaging features
Normal pericardium, low T1W, low T2W, no enhancement
Abnormal pericardium, low T1W, high T2W, post-contrast enhancement
Pericardial thickening in presence of heart failure symptoms is very suggestive of constrictive pericarditis
Coexistence of pericardial calcifications further increases suspicion for constrictive pericarditis
Imaging features suggesting constriction
IVC: Descending aorta ratio > 2; SVC: Descending aorta ratio > 1, coronary sinus dilation, and ascites
Biatrial enlargement with normal-sized, tubular-shaped ventricles
Septal bounce with respiratory variation in septal wall motion
Helpful Clues for Common Diagnoses
Small Pericardial Effusion (Mimic)
Small pericardial effusion on CT can mimic thickening
Presence of pulmonary edema, pleural effusions suggest small pericardial effusion is present
Observe fluid in pericardial recess or pooling in dependent pericardium
High T2W, low T1W signal on MR if simple effusion
Pericardial fluid differentiated from soft tissue on inversion recovery sequences
Fluid is dark on phase preserved images, bright on magnitude images, indicating long T1
Hemorrhagic effusions demonstrate high T1W and absence of enhancement
Malignancy
Most commonly from lung cancer, breast cancer, and lymphoma
In patients with history of malignancy, ˜ 50% of pericardial thickening is due to other causes (most commonly idiopathic)
˜ 5% of presenting pericarditis is due to undiagnosed malignancy
Nodular pericardium, often enhancing
MR shows high T2W signal
Infectious-Idiopathic Pericarditis
Pericardial friction rub, fever, and response to NSAIDs
Pericardial thickening with enhancement and possible effusion
May result in rapid accumulation of serous or serosanguineous pericardial fluid, increasing risk of tamponade
Idiopathic pericarditis
Diagnosis of exclusion, thought to be most often due to undiagnosed viral infection
Infectious pericarditis
In developed world, viral and bacterial etiologies are most common
Although rare in developed world, tuberculosis remains major cause for pericarditis in developing countries
Tuberculous disease of pericardium also presents with mediastinal lymphadenopathy
Helpful Clues for Less Common Diagnoses
Cardiac Surgery
Post pericardiotomy syndrome – Febrile illness secondary to inflammatory reaction involving pleura and pericardium
Patients have history of surgery opening pericardium
Aseptic loculated, simple and hemorrhagic effusions all occur
Uremic Pericarditis
Occur in patients with chronic renal dysfunction on dialysis or patients with acute renal failure
Fibrinous pericarditis caused by accumulated toxins, resolves after dialysis
Associated with hemorrhagic effusions
Radiation-induced Pericarditis
Radiation pericarditis only seen with > 40 Gy of mediastinal radiation, most commonly delivered in lymphoma and lung cancer treatment
Current radiotherapy protocols for breast cancer does not cause pericarditis, unlike older treatment protocols
Radiation pericarditis can occur within weeks to decades after exposure
Subset may present decades later with recurrent effusions and progressive fibrosis and thickening
Associated with rapid accumulation of pericardial fluid and collagen deposition causing pericardial fibrosis, mostly in parietal pericardium
Fibrosis will often be present in adjacent tissue
Pleural thickening and calcifications will be sharply demarcated, contained within radiation field
Connective Tissue Disease
Most commonly rheumatoid arthritis and systemic lupus
Most common cardiac manifestation of systemic lupus erythematosus, with 50% developing pericardial effusion at some point
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