pericardial abnormal findings
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Diagnostic Radiology ofDiagnostic Radiology ofCardiovascular SystemCardiovascular System
Chen, Shaoqiong
Acknowledgement : most of the slices are refer to the ppt provided by Dr. Biling Liang is gratefully
acknowledged
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Basic X-ray featuresBasic X-ray features
Heart dislocation
Heart enlargement
Abnormal pulmonary blood flow
Changes of aorta
Pericardial abnormal findings
methods
normal
abnormities
diseases
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Basic X-ray featuresBasic X-ray features
Changes of pericardiumChanges of pericardium
Normal pericardium
Pericardial anomalies
Pericardial effusionAcute pericarditis
Pericardial thickening 、 calcification
Chronic pericarditis
Constrictive pericarditis
methods
normal
abnormities
diseases
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Basic X-ray featuresBasic X-ray features
Changes of pericardiumChanges of pericardium
Normal pericardium
methods
normal
abnormities
diseases
Normal pericardium
Inner serous layer is the epicardium Outer fibrous layer is pericardium Space between the two is pericardial space Normally contains about 20-50cc of fluid Fat covers outside of heart and outside of pericardium sandwiching pericardial space between the two layers
Normal thickness of pericardium (parietal pericardium and fluid in space) is 2-4 mm
Requires about 150-250cc before cardiac tamponade occurs
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Basic X-ray featuresBasic X-ray features
Changes of pericardiumChanges of pericardium
Normal pericardium
Pericardial anomalies
Pericardial effusionAcute pericarditis
Pericardial thickening 、 calcification
Chronic pericarditis
Constrictive pericarditis
methods
normal
abnormities
diseases
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Pericardial effusionPericardial effusionX-ray appearance：
Direct sign：Heart shadow generally enlarge bilaterally “water-bottle” or “flask” shape, globularContour of cardiac border disappearPulsation of the cardiac border weaken or disappear, but the aortal pulsation is normal
Indirect sign：Vena systemica return obstructed, right ventricle output decreased
Superior vena cava widenDecreased lung markings
Aortal shadow smaller
Cardiac tamponade – impedes diastolic filling
methods
normal
abnormities
diseases
Tuberculosis rheumatism
uraemia virus neoplasm
Fluid: Transudation exudation blood
Pericardial effusionPericardial effusion
Pericardial effusion on both lateral chest radiograph and axial CT. Red arrow points to fat outside of pericardium. Green arrow points to pericardial space which is 8 mm in this patient (<4 mm is normal.) The yellow arrow points to fat outside of heart and the blue arrow to the myocardium.
Pericardial effusionPericardial effusion
Pericardial effusionPericardial effusion
methods
normal
abnormities
diseases
“water-bottle” “flask” shape Globular shape
Pericardial effusionPericardial effusionmethods
normal
abnormities
diseases
general enlarge
bilaterally
Widened SVCWidened SVC
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Pericardial effusionPericardial effusion
erect positionerect position supine positionsupine position
methods
normal
abnormities
diseases
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Pericardial thickening 、 calcificationthickening：
Pericardium near the diaphragm (ventricular face) thicken obviously but the atrium aera and the root of the great vessels less thickenEpicardial fat pad ‘sign’ (+)
Lat. / PA view: anterior pericardial stripe ＞ 2mm
Hemodynamic change:Right ventricle compression ： venous return obstructed, vena cervicalis and vena cava dilatationLeft ventricle compression ： left atrium and pulmonary venous pressure increased, so the left heart output decreased
methods
normal
abnormities
diseases
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Constrictive pericarditisConstrictive pericarditisX-ray ：
Direct sign：The heart shadow size is normal or little, midium enlarged
A side or both sides of heart borders straighten, the demarcation among each arcus is undefined; contour: triangle , globular
Heart pulsation weaken or disappear; the portion without thickened can bulge, and it’s pulsation enhanced
Pericardial calcification ： eggshell, barred, patching,
Pleural thickening, adhesion
Indirect sign ： VP ↑Superior vena cava dilatation
Pulmonary venous hypertension
methods
normal
abnormities
diseases
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Constrictive pericarditisConstrictive pericarditismethods
normal
abnormities
diseases
Pericardial calcification
Constrictive pericarditisConstrictive pericarditis - - RA enlargementRA enlargement
Constrictive pericarditisConstrictive pericarditis - RA enlargement - RA enlargement
Constrictive pericarditisConstrictive pericarditis - - RA enlargementRA enlargement
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Diagnostic Radiology ofDiagnostic Radiology ofCardiovascular SystemCardiovascular System
Imaging methods
normal appearances
abnormities
diseases
methods
normal
abnormities
diseases
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Common disease Common disease of heart and great vessels of heart and great vessels
Rheumatic heart disease
Mitral stenosis
Mitral regurgitation
Ischemic heart disease Ischemic heart disease
Coronary artery diseaseCoronary artery disease
Congenitial heart disease
ASDASD
Tetralogy of FallotTetralogy of Fallot
method
normal
abnormities
diseases
22/231
Rheumatic heart diseaseRheumatic heart disease
Involved valve：Mitral valve 、 Aortic valve 、 Tricuspid
valve
Pathology：Mitral valve stenosisMitral valve stenosis: Valve ring
cicatricle contraction
Mitral valve insufficiencyMitral valve insufficiency:
methods
normal
abnormities
diseases
Mitral StenosisRheumatic Valvular Heart Disease
● Rheumatic heart disease causes mitral stenosis in 99.8% of cases
Right Ventricular Hypertrophy
Stenotic mitral valve
© Frank Netter, MD Novartis®
• Mitral stenosis occurs
• Left atrial pressure
• Left atrium enlarges
• Cephalization
• PIE
• PAH develops
• PVR increases
• RV enlarges
• Pulmonic regurg develops
• Tricuspid annulus dilates
• Tricuspid insufficiency
• RV failure
Time course of MS in adult
© Frank Netter, MD Novartis®
● Pulmonary venous and capillary pressure
Normal 5-10 mm Hg
Cephalization 10-15 mm
Kerley B Lines 15-20
Pulmonary Interstitial Edema 20-25
Pulmonary Alveolar Edema > 25
Effect of Mitral Stenosis On Lungs
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Mitral stenosis hemodynamics
Mitral valve stenosis
Left atrial output obstructed
LV engorge insufficientlyLA pressure increase & dilate
Pulmonary venous hypertension, interstitial pulmonary edema
RV burden increase & enlarge
aortic knob shrink
LV and aortic knob shrink
methods
normal
abnormities
diseases
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Mitral stenosisMitral stenosisX-ray appearance：
Cardiac type：“mitral configuration”LA & RV enlarged
------- pulmonary artery segment Convexity
LV shrink, Straightening of left heart border
------- Aortic knob shrink
valvular calcification
Pulmonary venous hypertension, interstitial pulmonary edema
Hemosiderin deposited ： 1-2mm nodular shadow
methods
normal
abnormities
diseases
LA enlargementPA – right border ： Double density of left atrial enlargement,,doublePA – left border ： left atrial appendage enlargement Lat & RAO ： esophagus compressed Elevation of left mainstem bronchus RV enlargementpulmonary artery segment Convexity Lat ： contact between the front surface of heart and the sternum (anterior chest wall) >1/3
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Mitral stenosisMitral stenosis
Four arus, diplopia, Pulmonary venous hypertension
methods
normal
abnormities
diseases
LA enlargement PA – right border ： double density PA – left border ： left atrial appendage enlargement Lat & RAO ： esophagus compressed
Mitral stenosisMitral stenosis
LALALVLV
RVRV
LA
LV
LVLV
LALA
Valve calcification
LatLat
Cor Cor
Mitral stenosisMitral stenosis
LALA
LVLV
LALALVLV
LALA
RVRV
LVLVRARA
RVRV
Mitral stenosisMitral stenosis
LALA
LVLVLVLV
LALA
RVRV
RARA
Mitral stenosisMitral stenosis
LA,RV enlarge, Hemosiderin pigmentation
methods
normal
abnormities
diseases
RV enlargementpulmonary artery segment Convexity Lat ： contact between the front surface of heart and the sternum (anterior chest wall) >1/3
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Mitral stenosisMitral stenosismethods
normal
abnormities
diseases
Mitral stenosisMitral stenosis
LA enlarge ： esophagus compression, diplopiaRV enlarge: heart touch the anterior chest wall ＞ 1/3
methods
normal
abnormities
diseases
LA enlargementPA – right border ：double densityPA – left border ： left atrial appendage enlargementLat & RAO ： esophagus compressed
Mitral stenosisMitral stenosismethods
normal
abnormities
diseases
PV hypertension enlarged MPA Cephalization
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Mitral stenosis --- Mitral stenosis --- Hemosiderin deposited
methods
normal
abnormities
diseases
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Mitral stenosis—pulmonary interstitialMitral stenosis—pulmonary interstitial edema-- Kerley’s B-line edema-- Kerley’s B-line
methods
normal
abnormities
diseases
Perpendicular to the chest wallPerpendicular to the chest wall
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Common disease Common disease of heart and great vessels of heart and great vessels
Rheumatic heart disease
Mitral stenosis
Mitral regurgitation
Ischemic heart diseaseIschemic heart disease
Coronary artery diseaseCoronary artery disease
Congenitial heart disease
ASDASD
Fallot 4Fallot 4
method
normal
abnormities
diseases
Coronary artery diseaseCoronary artery disease
Myocardium O2 supply insufficient
Caused by severe coronary artery stenosis
Atherosclerosis , spasm , thrombosis
Myocardial infarction
Coronary artery CTA
MIP
With Contrast Medium
VRT Recon.
Normal Coronary artery CTA
前降支和旋支 前降支和对角支
前降支和旋支 心底部冠脉供血
正常冠脉MIP
重建
正常冠状动脉
CT：119148
Ischemic heart diseaseIschemic heart disease
methods
normal
abnormities
diseases
LV enlargement PA – cardiac apex extending to left and down left ventricle segment extended,rounded,expand to left Lat ： retrocardiac space become narrowed or disappeared, esophageal space disappeaered
Aorta enlarged
Ischemic heart diseaseIschemic heart disease
methods
normal
abnormities
diseases
cardiomegalycardiomegaly
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Multi-slice spiral CTmethods
normal
abnormities
diseases
Plain scan
Calcification in the coronary A. wall
Coronary artery CTA
Negative prediction 100％
positive prediction 80 ～ 88％
Coronary artery calcification & soft plaque
Coronary artery soft plaque
Coronary artery stenosis
DSA
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Myocardial infarctionMyocardial infarction
methods
normal
abnormities
diseases
Real time : infarcted Real time : infarcted myocardium non-enhancedmyocardium non-enhanced
Delay enhancement in the Delay enhancement in the infarcted myocardiuminfarcted myocardium
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Common disease Common disease of heart and great vessels of heart and great vessels
Rheumatic heart disease
Mitral stenosis
Mitral regurgitation
Ischemic heart disease Ischemic heart disease
Coronary artery diseaseCoronary artery disease
Congenitial heart disease
ASDASD
Fallot 4Fallot 4
method
normal
abnormities
diseases
56/231
Congenital heart diseaseCongenital heart disease
Classification：Hemodynamics ： left to right shunt, right to left shunt, no shunt
Clinic ： cyanotic, non- cyanotic
X-ray: increased pulmonary blood flow , pulmonary oligemia, LBV no change
pathological changes：Atrial septal defect （ ASD）Ventricualr septal defect （ VSD）Tetralogy of Fallot （ F4）Patent ductus arteriosus （ PDA）Pulmonary stenosis （ PS）
method
normal
abnormities
diseases
ASD
Right atrium open looking into left atrium through ASD
Normal
© Frank Netter, MD Novartis®
fossa ovalis
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ASD----hemodynamicsASD----hemodynamics
RA LA
RA flow ↑ RV flow ↑ PBF↑
RA hypertrophydilatation
RV hypertrophydilatation
pulmonary hypertension
Right heart failure
methods
normal
abnormities
diseases Left → right shuntLeft → right shuntBut
depend on theP. Vscular resistance
• Discontinuity in the atrial septum with systolic signal void consistent with L->R shunt on atrial level
• Right atrium is mildly dilated; RV, LV and LA size are normal
SCMRAuckland MRI
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ASDASD
Clinicmostly adult
SM on the 2th-3rd intercostal of the left sternal border
Change of hemodynamics
X-ray appearanceCardiomegaly , “mitral configuration”
RA & RV↑, RA↑ ↑ obviously
Pulmonary artery segment bulge ， hilum angiectasia, hilum dance
pulmonary blood flow↑ ↑. PAH in later stage
LA do not enlarge, LV and aorta shrink
methods
normal
abnormities
diseases
4 type:Ostium primum , ostium secundumSinus venosus , coronary sinus
Fossa Ovalis defect80~90%
Atrial septal defect
ASD
RA
RA
ASDaorta shrink
RA & RV↑, RA↑ ↑ obviously
RA
RV
PA
Aorta
svc
ASD
RA & RV↑, RA↑ ↑ obviously
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ASDASD
Enlargement of RA
methods
normal
abnormities
diseases
RA
RV
PA
Aorta
svc
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ASDASDmethods
normal
abnormities
diseases
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ASDASD
Preoperative Postoperative
methods
normal
abnormities
diseases
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ASDASD
Pulmonary hypertensionPulmonary hypertension
methods
normal
abnormities
diseases
RA
RV
PA
Aorta
svc
ASD
Prominent pulmonary vessels
Prominent MPA
Normal left atrium
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Tetralogy of FallotTetralogy of FallotMost common CHD with hematoasthenia and cyanosis Including four anomalies :
Pulmonary stenosisVentricular septal defectAortic overridingHypertrophy of the RV
Radiologic findings
Cardiac apex displaced upward “coer en sabot”
PA segment concave Decreased vasculature R aortic arch in 25%
methods
normal
abnormities
diseases
70/231
Fallot’s tetralogyFallot’s tetralogymethods
normal
abnormities
diseases
Tetralogy of Fallot
Tetralogy of Fallot
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Tetralogy of FallotTetralogy of Fallotmethods
normal
abnormities
diseases
F4
Aortic overriding Pulmonary stenosis right→ left shunt RV hypertrophy
LA
RV
MR:41655
F4
MR:41655
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