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Hemopericardium in the acute clinical setting: Are we ready for a tailored management approach on the basis of MDCT findings?

  • Cardiac radiology
  • Published:
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Abstract

The clinical spectrum of pericardial effusions varies from innocuous serous fluid to life-threatening hemopericardium. A misdiagnosis may be made by similar clinical presentation of acute chest pain/hypotension. Echocardiography is the first-line test for diagnosis of pericardial effusion and its etiology, but sometimes there are different drawbacks to the correct cardiovascular ultrasound diagnosis. Radiologists are reporting an increasing amount of thoracic Multidetector CT examinations at the emergency department. Multidetector CT has now become an established and complementary method for cardiac imaging, and diseases of the pericardium can now be quickly identified with increasing certainty. The aim of this review is to discuss the hemopericardium key Multidetector CT features in acute clinical setting which indicate the need to proceed with predominantly medical or surgical treatment, however, being able to identify forms of bleeding pericardial effusion for which only “a watch and wait strategy” and/or deferred treatment is indicated. In the emergency care setting, radiologists must be aware of different findings of hemopericardium in order to address a tailored and timely management approach.

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Authors and Affiliations

  1. Department of Diagnostic Imaging, Section of General Radiology, Azienda Ospedali dei Colli, Monaldi Hospital, Via Leonardo Bianchi, Naples, Italy

    Tullio Valente, Giacomo Sica, Giorgio Bocchini & Gaetano Rea

  2. Department of Precision Medicine, University of Campania L. Vanvitelli, Naples, Italy

    Maria Pignatiello & Salvatore Cappabianca

  3. Department of Diagnostic Imaging, Pineta Grande Hospital, Castelvolturno, Italy

    Mariano Scaglione

  4. Department of Radiology, Tesside University, Middlesbrough, UK

    Mariano Scaglione

  5. James Cook University Hospital, Middlesbrough, UK

    Mariano Scaglione

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  1. Tullio Valente
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 All the authors declare that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

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 This retrospective Review Article has been conducted on already available data. The data have been collected over the years, formal consent of each patient is impossible to obtain, and images of the entire CT examinations are available in our Company PACS system (Azienda dei Colli, Naples, Italy).

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Supplementary electronic material(s)

MDCT findings of hemopericardium in acute pericarditis (tuberculous etiology). 24-year-old- African man admitted at emergent department with unexplained severe dyspnea, palpitations, fever, and weight loss. Urgent pericardiocentesis yields 650 ml of a sanguineous effusion with a predominantly lymphocytic exudate, monocytes and foam cells; tubercle bacilli were found by polymerase chain reaction (PCR) and culture of pericardial fluid. Axial MDCT shows a large pericardial high density effusion, diffuse enhancement of the thickened pericardium (>7 mm), enlargement of right posterior mediastinal lymph nodes, bilateral lower pulmonary artery embolism, and contrast reflux to the inferior vena cava and suprahepatic veins (AVI 5716 kb)

Hemorrhagic pericarditis (confirmed on surgery) mimicking an ascending aorta acute intramural hematoma on TEE. 58-year-old man with acute (2 days) onset of sharp anterior chest pain, physical signs of pericardial friction rub without ECG changes and fever. 2D subxiphoid view shows blood (maximum thickness 7 mm) sticking to the posterior wall of ascending aorta suggesting type A acute intramural hematoma (IMH) (AVI 11283 kb)

2D long-axis view confirms blood (maximum thickness 7 mm) sticking to the posterior wall of ascending aorta suggesting type A IMH (AVI 11257 kb)

Arterial phase MDCT examination shows a normal aorta, high attenuation effusion in superior aortic recesses, and mild linear enhancement of the pericardial leaflets (AVI 11768 kb)

Delayed phase MDCT examination shows a normal aorta, high attenuation effusion in superior aortic recesses, and a progressive enhancement of the thickened pericardial leaflets due to inflammation, consistent with a hemorrhagic pericarditis diagnosis (AVI 10527 kb)

ECG-gated MDCT findings in complicated infective native mitral valve endocarditis. 52-year-old woman with fever, shortness of breath and mild leg edema. Axial ECG-gated examination shows huge vegetation attached to the ventricular side of posterior mitral leaflet protruding in the left ventricular chamber, mild bloody pericardial effusion, and an abnormal large perivalvular neocavity posterior to the left atrium, enhancing concomitantly with the cardiac lumen (AVI 9811 kb)

Type A aortic dissection complicated by hemopericardium, cardiac tamponade and end-organ ischemia in a 40- year-old woman with Marfan syndrome and a one-day complaint of fatigue, non-postural dizziness, and posterior pulsatile neck pain. Axial non-ECG-gated chest MDCT angiography shows acute type A aortic dissection with a severe involvement of the epiaortic vessels, and hemopericardium (AVI 12850 kb)

MDCT manifestations of hemopericardium in primary cardiac neoplastic disease. 73-year-old man with right side heart failure, chest pain, cough, and shortness of breath by cardiac angiosarcoma (AS). Contrast-enhanced chest MDCT examination show a heterogeneous mass involving the the inlet of the superior vena cava, right atrial chamber (cardiac angiosarcoma predilection site), and interatrial septum with extension into the left atrium. There is a loculated hemorrhagic pericardial effusion adjacent to the right atrial free wall, pericardial thickening posteriorly, and a right pleural effusion. Primary cardiac AS is the most aggressive cardiac tumor and can occur at any age but is more common in those 30–40 years of age (AVI 8928 kb)

68-year-old woman after blunt motor vehicle traumatic aortic injury with HP and posterior mediastinal hematoma. MDCT axial examination shows outward contour deviations, so-called pseudoaneurysm, at the level of proximal descending and isthmus of the aorta, without contrast medium extravasation (Vancouver simplified grade III of blunt aortic injury). On the left coexist posterior mediastinal hematoma and hemothorax, on the right mediastinal and pericardial hematoma. The patients early underwent a successful TEVAR (AVI 5069 kb)

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Valente, T., Pignatiello, M., Sica, G. et al. Hemopericardium in the acute clinical setting: Are we ready for a tailored management approach on the basis of MDCT findings?. Radiol med 126, 527–543 (2021). https://doi.org/10.1007/s11547-020-01303-x

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