Pericardial Effusion

How do you distinguish cardiomegaly from pericardial effusion?

There is pulmonary congestion in CHF and pulmonary oligemia in pericardial
effusion.
Shape of the heart is helpful
o Water bottle appearance in pericardial effusion.
Displacement of precardiac fat line in pericardial effusion .
What are the Common Causes for pericardial effusion?
Idiopathic
Infection
Autoimmune (SLE, rheumatoid arthritis, scleroderma)
Dressler's and postpericardiotomy syndromes
Neoplasm (lymphoma, lung or breast metastasis)
Drug-induced (procainamide, hydralazine, phenytoin)
Uremia
Myxedema
Congestive heart failure
Trauma
How would you evaluate a patient suspected to have pericardial effusion by
Imaging studies?
CXR, US, CT amd MR have roles in the evaluation of pericardial effusion.
CXR:
In patients with a large pericardial effusion (at least 250 ml), the chest radiograph
usually demonstrates
Symmetrically enlarged cardiopericardial silhouette.
The appearance has been characterized as the flask or water bottle
configuration.
The normal great vessels contours are smoothed out and the hilar vessels are
obliterated.
The cardiophrenic angles show acute rather than obtuse angles.
On the lateral view there may be loss of retrosternal clear space.
Another clue is the rapid change in heart size or presence of cardiomegaly
without the radiographic findings of congestive heart failure (pulmonary edema,
etc.)
Posterior displacement of epicardial fat pad by effusion.
Pulmonary olegemia.

Enlarged cardiac silhouette could be pericardial effusion or cardiac enlargement. Lateral
chest radiograph shows sign indicating effusion. Dorsally displaced epicardial fat pad
(arrows) indicates that the cardiac silhouette is due to pericardial effusion.
3D Echocardiography: is the radiologic modality of choice for evaluating
pericardial effusions.

Pericardial
Effusion
Echocardiogra
m showing
fluid
surrounding
the heart.

If performed in patients with good acoustic windows, echocardiography will
accurately detect all pericardial effusions and provide important information about
their size and hemodynamic importance.
Echocardiography is less reliable than MRI or CT in detecting pericardial
thickening or small loculated effusions, but it is still extremely useful in these
conditions.
Echo free space around heart.
o Accumulation of pericardial fluid creates an anechoic space between the
posterior left ventricular wall and the anterior parietal pericardium. In larger
effusions, a similar echo-free space exists between the anterior right
ventricular wall and the anterior parietal pericardium and chest wall.
The technique is semi quantitative: very small effusions (50 -100 ml) are imaged
only posteriorly, with separation of pericardial and epicardial echoes only in
systole; small to moderate effusions (100 - 300 ml) are imaged only posteriorly
throughout the cardiac cycle; and large effusions (300 ml) are imaged both
anteriorly and posteriorly. Because of the oblique pericardial sinus, the echo-free
space disappears behind the left atrium unless massive pericardial effusion is
present.
Diastolic collapse of right ventricle.
Dilated inferior vena cava.
Case of cardiac tamponade:
CT : is valuable for detecting loculated pericardial effusions and in detecting
pericardial thickening

Epicardial fat pad is displaced posteriorly by pericardial effusion. Low density fluid
density around heart.
MRI
may be able to characterize the fluid as serous or hemorrhagic (because of
characteristic changes in signal intensity).