Pericardial effusion

Dr Henry Knipe and A.Prof Frank Gaillard et al.

Pericardial effusions occur when excess fluid collects in the pericardial

space (a normal pericardial sac contains approximately 30-50 mL of fluid).

Epidemiology
There is no single demographic affected, as there are many underlying causes of
a pericardial effusion.

Clinical presentation
Clinical presentation of pericardial effusions does not relate so much to the size
of the effusion but rather the speed at which the fluid has accumulated, as slow
gradual accumulation allows the pericardium to stretch and accomodate much
larger volumes of fluid . 4

Regardless of volume, symptoms relate to impaired cardiac function due to

intrapericardial pressure approximating intracardiac pressure leading to impaired
filling of low pressure chambers, particularly the right atrium.

Dyspnoea and reduced exercise tolerance will be early signs, progressing to

severe impaired cardiac output and death in severe cases (e.g. cardiac
tamponade).

Pathology
Aetiology
idiopathic
inflammatory
o post myocardial infarction: Dressler syndrome
o connective tissue disorders
infectious
o viral
o bacterial
o tuberculosis
post surgical / trauma
 pulmonary arterial hypertension 7

radiotherapy
malignancy
o primary, e.g pericardial mesothelioma
o metastatic
endocrine
o hypothyroidism 3

Radiographic features
Plain radiograph
a very small pericardial effusion can be occult on plain film
there can be globular enlargement of the cardiac shadow giving a water bottle
configuration
lateral CXR may show a vertical opaque line (pericardial fluid) separating a
vertical lucent line directly behind sternum (epicardial fat) anteriorly from a
similar lucent vertical lucent line (pericardial fat) posteriorly; this is known as
the Oreo cookie sign 5

widening of the subcarinal angle without other evidence of left atrial

enlargement may be an indirect clue 2

a differential density sign at cardiac borders has been suggested , but its
9

specificity is limited

Echocardiography
Echocardiography is the method of choice to confirm the diagnosis, estimate the
volume of fluid and most importantly assess the haemodynamic impact of the
effusion.

CT
The generally accepted thickness of a normal pericardium, measured on CT
scans and on MR images is often taken at 2 mm . 6

CT makes the diagnosis extremely easy, but is usually obtained to try and clarify
the cause of an effusion rather than to confirm the diagnosis. Pericardial
effusions are a frequent incidental finding in unwell hospitalised patients.
Fluid density material is seen surrounding the heart. Careful inspection of the
region is necessary to ensure that no invasive mass can be identified.

Estimating volume
Depth of the effusion can be used to estimate the likely volume of fluid, provided
the fluid is relatively evenly spread throughout the pericardium (global effusion) .
4

Clearly this does not apply to localised effusions.

<5 mm: 50-100 mL

5-10 mm: 100-250 mL
10-20 mm: 250-500 mL
>20 mm: >500 mL

Treatment and prognosis

If small, asymptomatic and clinically not-suspect then conservative management
is usually favoured.

If large, symptomatic or there is clinical concern of the underlying cause (e.g.

infection, malignancy) then pericardiocentesis can be performed to drain the
fluid. A Seldinger technique is employed, usually under
ultrasound/echocardiographic guidance, to insert a drain into the pericardial
space . 4

In cases where effusions are recurrent and symptomatic (e.g. malignancy)

then pericardial fenestration can be performed.

Differential diagnosis
haemopericardium: has higher attenuation on CT and often a different clinical
context
cardiomegaly: can sometimes mimic an effusion

sumber : https://radiopaedia.org/articles/pericardial-effusion