Case report: pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI

Pericardial rupture following blunt chest trauma is rare, and is not usually diagnosed pre-operatively. If pericardial rupture is not recognized and treated promptly, it may be fatal owing to cardiac herniation. We report a case of traumatic herniation of the heart for which a CT scan and MRI made a major contribution to the diagnosis.     

CT diagnosis of cardiac and pericardial injuries

The purpose of this retrospective study was to determine the CT findings diagnostic of cardiac and pericardial injury, including signs of pericardial tamponade, in patients suffering from blunt and penetrating trauma. A search of the CT radiology database at a level I trauma center was performed to identify cases in which injury to the heart or pericardium was diagnosed, as well as to identify cases of pericardial tamponade. All cases were reviewed to ascertain the specific CT findings, and medical records were reviewed to assess the influence of CT findings on management and to assess for clinical evidence of pericardial tamponade. Eighteen patients had direct CT evidence of cardiac or pericardial injury, including nine cases of pneumopericardium, eight cases of hemopericardium, and one case of intrapericardial gastric herniation. Four of these patients were found to have direct cardiac injuries. Three additional cases with CT evidence of pericardial tamponade were identified, two secondary to cardiac compression by an anterior mediastinal hematoma and one following repair of left ventricular rupture. Of 11 patients with CT evidence of tamponade, only three were suspected clinically. Cardiac and pericardial injuries are usually diagnosed surgically and are often clinically unsuspected, particularly in blunt trauma. As CT is increasingly utilized as a general screening test for thoracic/abdominal trauma, these injuries may be first suspected on the basis of CT findings, and knowledge of the CT findings of cardiac injury or tamponade is crucial.     

Delayed levorotation of the heart in traumatic pericardial rupture

Traumatic pericardial rupture, with complicating cardiac herniation, is an extremely uncommon condition with a high mortality rate. We are reporting our experience with a case of blunt trauma to the chest, secondary to high-impact motor vehicle collision. The preoperative diagnosis of ascending aortic transection was made on subsequent imaging studies for which surgical repair was elected. Upon thoracotomy, a posterior pericardial tear was found to be associated with laterally displaced cardiac axis. Delayed levorotation of the cardiac axis in traumatic pericardial rupture is an uncommon finding and needs to be recognized in a timely manner.     

心脏原发恶性肿瘤CT及MRI表现

目的:了解心脏原发恶性肿瘤的CT、MRI表现,旨在提高诊断及鉴别诊断。材料和方法:12例经病理证实心脏恶性肿瘤的CT及MRI资料进行回顾性分析。其中5例行胸部CT平扫加增强扫描。9例做心脏MR检查,其中7例行动态增强扫描。结果:发生部位以右心房最多见(6/12)。跨心腔生长或累及邻近大血管及心包常见(10/12)。伴有心包和胸腔积液(9/12)。肿瘤多以中度不均匀强化为主,血管肉瘤内见同血管强化一致条状影,横纹肌肉瘤呈后期明显均匀强化。肿瘤MR信号以T1WI等略低信号,T2WI为混杂高信号表现为主,而恶性纤维组织细胞瘤T2WI呈明显低信号较特征。结论:心脏恶性肿瘤具有一般恶性肿瘤侵袭性生长之特点,CT、MRI评价病变范围、组织特征具有优势,有助于诊断及治疗方案实施,进一步组织学定性、鉴别有困难。     

Traumatic diaphragmatic hernia into the pericardium: verification of diagnosis by computed tomography.

Computed tomography (CT) is a useful modality in the evaluation of mediastinal abnormalities and in the assessment of mediastinal masses for fat content. A case of posttraumatic herniation of the omentum and large bowel into the pericardial sac is presented. The mediastinal configuration, depicted on a CT scan, is thought to be diagnostic of this extremely rare abnormality.     

Rapid-acquisition computed tomography demonstration of chronic calcified pericardial constriction

Dynamic imaging by a new ultrafast computed tomography scanner of a patient with chronic calcified pericardial constriction is presented. Images of the heart throughout the cardiac cycle demonstrate compression of the right ventricle by calcified pericardium. Hemodynamic data was derived from the scan study to support the diagnosis of pericardial constriction, which was confirmed on cardiac catheterization.     

腰骶椎椎间盘突出的影像诊断

目的：通过回顾性分析，探讨腰骶椎椎间盘突出的非创性影像诊断及相关问题。材料与方法；报告200例腰骶椎椎间盘突出者的影像学表现，其中67例经手术证实。全部病例摄有X线平片及CT扫描，21例做了MRI检查。结果：对腰骶椎椎间盘突出的诊断，MRI和CT显示优于传统X线检查。但MRI在鉴别诊断方面又比CT稍胜一筹。结论：MRI虽然敏感性高，但检查费用昂贵，故对本症的诊断，应首选CT检查。     

颈椎间盘膨出或突出症CT平扫诊断的限度(附75例分析)

目的 探讨CT平扫诊断颈椎间盘膨或突出症的限度。方法 收集75例做颈椎间盘平扫的病例，根据诊断结果进行分析。结果 CT平扫诊断颈椎间盘膨或突出症阳性率仅为8％(6／75)，诊断骨质增生45．33％(34／75)。结论 当CT平扫异常警诊断与临床表现不符时，CTM也许会提高正确诊断率。     

Imaging the pericardium: appearances on ECG-gated 64-detector row cardiac computed tomography

Multidetector row computed tomography (MDCT) with its high spatial and temporal resolution has now become an established and complementary method for cardiac imaging. It can now be used reliably to exclude significant coronary artery disease and delineate complex coronary artery anomalies, and has become a valuable problem-solving tool. Our experience with MDCT imaging suggests that it is clinically useful for imaging the pericardium. It is important to be aware of the normal anatomy of the pericardium and not mistake normal variations for pathology. The pericardial recesses are visible in up to 44% of non-electrocardiogram (ECG)-gated MDCT images. Abnormalities of the pericardium can now be identified with increasing certainty on 64-detector row CT; they may be the key to diagnosis and therefore must not be overlooked. This educational review of the pericardium will cover different imaging techniques, with a significant emphasis on MDCT. We have a large research and clinical experience of ECG-gated cardiac CT and will demonstrate examples of pericardial recesses, their variations and a wide variety of pericardial abnormalities and systemic conditions affecting the pericardium. We give a brief relevant background of the conditions and reinforce the key imaging features. We aim to provide a pictorial demonstration of the wide variety of abnormalities of the pericardium and the pitfalls in the diagnosis of pericardial disease.The rapid technological development of multidetector row computed tomography (MDCT) with its greatly improved spatial and temporal resolution and sophisticated ECG-gated image acquisition software has led to the more widespread use of dedicated cardiac imaging. Not only does this technology enable assessment of the coronary arteries [1, 2], but the same acquired data set also provides imaging detail of the overall cardiac morphology including the normal and diseased pericardium, features of which may also be readily appreciated on the non-ECG-gated thoracic CT [3]. It is important for the general radiologist to be familiar with both normal and variant pericardial anatomy and with that of the pericardial recesses, which can mimic some pathological processes. Several disease processes, either primary or secondary, can affect the pericardium. This review aims to illustrate normal pericardial anatomy, diagnostic pitfalls, commonly encountered abnormalities (some of which may be quite subtle) and some more unusual entities.     

心脏转移癌的CT诊断

目的：分析和总结心脏转移癌的CT表现特征,为早期诊断和治疗提供帮助。方法对42例经临床病理确诊的心脏转移癌的CT图像以及临床资料进行分析。主要观察指标包括：心包增厚、心包积液、心肌及心腔内有无肿块等。结果42例患者中累及心包者36例（85．7％）、累及心肌者7例（16．7％）、累及心腔者12例（28．6％）。结论心脏转移癌在CT表现上多为心包积液、心包增厚、纵隔淋巴结肿大、心肌及心腔内肿瘤等。CT对心脏转移癌的诊断有帮助,但最终确诊仍需依靠病理学检查。     

Pericardial fibrosarcoma demonstrated by Ga-67 scintigraphy

A case of malignant fibrosarcoma originated from pericardium was reported. A 31 year-old female who complained of general fatigue and back pain showed dilated cardiac shadow in chest X-ray. Cardiac blood pool scan with 99mTc-RBC revealed avascular mass in pericardial cavity which push the heart up and left side. It was suspected to be malignant, since the mass had increased 67Ga uptake. CT and MRI also demonstrated that the tissue characterization of the pericardial mass was irregular, and the mass compressed venous return. The large mass originated from pericardium caused the right sided cardiac failure. In 12 years ago, she had a history of operation which resected benign hemangioma in the same space (pericardium). We could suspect the malignant transformation between the two rare pericardial tumors; benign hemangioma and malignant fibrosarcoma.     

Radiological findings of partial expression pentalogy of Cantrell and other multiple congenital anomalies: A rare case report

Pentalogy of Cantrell is a rare syndrome of anomalous malformation. In the present case, the syndrome was initially diagnosed as a complete pentad, including a supra-umbilical abdominal wall defect, a sternal defect, pericardial defects, an anterior diaphragmatic defect, and heart malformation. Diagnosis required several imaging modalities, including computed tomography (CT) and magnetic resonance imaging (MRI). In this case report, we present an 8-month-old female patient with a thoracic wall defect with ectopia cordis and a bilateral cleft lip and palate. In addition, a head CT scan showed craniosynostosis, hypogenesis of the corpus callosum, and tonsillar cerebellar herniation. Thoracoabdominal CT revealed herniation of the transverse colon up to the subcutaneous layer, diaphragmatic hernia, atrial septal defects (ASD), ventral septal defects (VSD), and a persistent left superior vena cava (PLSVC). A multidisciplinary approach is required for the optimal management of this syndrome. We describe a female infant who presented with pentalogy of Cantrell syndrome and include the findings from postnatal CT imaging.     

Impending cardiac herniation: the snow cone sign

Two cases of cardiac herniation and volvulus that occurred after right pneumonectomy are presented. Both asymptomatic patients demonstrated an unusual bulging contour to the right side of the heart on radiographs obtained in the recovery room, before complete herniation and volvulus occurred. In an autopsy preparation, a similar right contour was produced after partial cardiac herniation through a pericardial defect. The hemispheric contour from partial cardiac herniation resembles the shape of a snow cone. Clinical awareness of this sign of impending herniation is important, so risk factors known to produce herniation may be modified.     

Constrictive pericarditis following inactivated virus COVID-19 vaccine: a case report with review of the literature

Cardiac adverse effects of the COVID-19 vaccine are very rare, myocarditis and pericarditis are the most common amid them, and constrictive pericarditis (CP) is reported to be restricted to a few cases following mRNA COVID-19 vaccines. We report a case of a 72-year-old male patient who developed symptoms of right-sided heart failure, which started after 8 days of receiving the third dose of inactivated virus COVID-19 vaccine and his diagnostic tests comprising transthoracic echocardiography, chest CT scan, cardiac magnetic resonance were in favor of CP. Ultimately, invasive cardiac catheterization confirmed the diagnosis of CP. Due to the lack of satisfactory response to corticosteroid therapy, pericardiectomy was performed, which gave rise to symptom relief progressively and substantially. Considering the temporal course of the patient''s symptoms and exclusion of other possible etiologies based on the patient''s medical history and diagnostic evaluation, immunization with the COVID-19 vaccine was recognized as a culprit for developing CP. Despite being a scarce phenomenon, the COVID-19 vaccine could have a tendency to provoke pericardial inflammation in so far as causing CP. Hence, physicians should have a high index of suspicion in these circumstances and accelerate the diagnostic investigation.     

Correlations between anatomy and computerized tomography findings in transtentorial cerebral herniation

The diagnosis of transtentorial brain herniation has long relied on encephalography, then arteriography. Computerized tomography (CT) is a safer method which permits a more precise and earlier visualization of temporal and central herniations and herniation of the culmen cerebelli, which are the three varieties of transtentorial herniation. In an attempt to evaluate the reliability of CT images of herniation, the authors have conducted a study of anatomy-CT correlations, using autopsy specimens of brains with these three types of transtentorial herniation. Temporal herniation was well studied, irrespective of the CT reference plane. Direct visualization of temporal uncus herniation and filling of the homolateral perimesencephalic cistern was regularly obtained. Central herniation was better visualized when the occipito-temporal was used as reference. The disappearance of perimesencephalic cisterns on CT sections through the widest part of the tentorial incisura is the best element of diagnosis. Herniation of the culmen is easily studied on the conventional orbito-meatal plane. Provided CT scans are performed with the technique they recommend, the authors consider that this examination is reliable for the diagnosis of transtentorial herniation. Some variations in the anatomy of the incisura may explain why the clinical consequences of herniation are varied. CT perfectly shows the configuration of this notch and therefore may be helpful in predicting the prognosis.     

Right ventricular shotgun pellet embolism: Case report and radiological aspect

Pellet embolism to the heart following gunshot injuries is an unusual event that requires a fast diagnosis. Imaging assessment is necessary to locate the projectiles and look for associated injuries. We present a case of a 41-year-old woman admitted after sustaining 2 gunshot wounds in the abdomen and left thigh, with the initial computed tomography (CT) scan showing a metallic object next to the right ventricle. Further radiological evaluation included transthoracic echocardiography and electrocardiogram-gated cardiac CT scan which confirmed the diagnosis of a migrating pellet to the right ventricle, entrapped within the trabeculations. Electrocardiogram-gated cardiac CT has a major role in detailed evaluation of bullet embolism to the heart cavities and guides the management.     

Rupture of the pericardium with luxation of the heart after blunt trauma

This report describes a patient who presented to our hospital in stable condition without signs of circulatory or respiratory failure following previous surgery for blunt abdominal trauma. The diagnosis of rupture of the pericardium with luxation of the heart was suggested on chest X-ray and CT. Left anterior thoracotomy revealed a 6-cm longitudinal left pericardial tear with herniation of the heart into the mediastinum.     

Detection of postcardiotomy bacterial pericarditis with gallium-67 citrate

A 46-year-old man who had undergone apical cardiac aneurysmectomy with a ventriculotomy graft and implanted automatic cardioverter-defibrillator electrodes, presented with fever, left-sided pleuritic chest pain, and a draining sinus. A Ga-67 scan was performed to aid in determining whether the infection was limited to the chest wall or if it had penetrated deeper to the cardiac structures. Uptake of gallium within the cardiac region, in association with minimal rib uptake of Tc-99m MDP, strongly supported the existence of infection within the pericardium. CT scan demonstrated a pericardial collection which under CT-guided aspiration proved to be purulent. Definitive surgical drainage was performed, and the patient was discharged 4 weeks postoperatively. Ga-67 imaging can provide an accurate and relatively rapid means of localizing infection in the postcardiotomy patient. A thorough bibliography of pericardial gallium uptake is provided.     

Significance of incidental pericardial effusion on computed tomography in cardiac trauma: A report of two cases

We describe computed tomographic (CT) findings in two patients with cardiac injury who required emergency surgery. Chest CT revealed an unexpected low-density area, indicating pericardial effusion. We emphasize that, given the situation of trauma, an incidental low-density area covering more than two slices along the inferior border of the heart suggests pericardial effusion, which may be caused by cardiac injury.     

Computed tomography of cardiac and pericardial tumors

Computed tomography (CT) scans in 30 patients with neoplastic involvement of the heart and pericardium were retrospectively reviewed. Computed tomography was compared with echocardiography in three of four patients with large primary cardiac tumors and in three patients with metastatic pericardial disease. Computed tomography was superior to echocardiography in determining tumor extent and site of origin of a right atrial sarcoma, as well as in assessing tumor extent and presence of pulmonary arterial hypertension in a left atrial malignant fibrous histiocytoma and a left atrial myxoma. Pericardial effusions were detected by echocardiography in two out of three patients with metastatic pericardial disease, but the malignant nature of the effusion was not recognized; in all three cases CT showed nodular pericardial thickening. Of the 23 patients with evidence on CT of direct extension of anterior mediastinal masses, bronchogenic carcinoma or mesothelioma to the pericardium 21 had nodular pericardial thickening and 2 diffuse thickening; only 6 had pericardial effusion. We conclude that CT is useful in the characterization of large primary cardiac tumors that are incompletely visualized with echocardiography. Computed tomography is superior to echocardiography in assessing tumor involvement of the pericardium because pericardial effusions are often absent; CT is also superior in identifying nodular pericardial thickening.