Saboe A., Sanjaya F., Soeriadi R.E.A., Maryani E., Kusumawardhani N.Y., Cool C.J., Astuti A.
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran – Hasan Sadikin General Hospital, Jl. Pasteur No. 38, Bandung, 40161, Indonesia; Department of Nuclear Medicine and Molecular Imaging, Faculty of Medicine, Universitas Padjadjaran – Hasan Sadikin General Hospital, Bandung, Indonesia; Cardiothoracic Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Padjadjaran – Hasan Sadikin General Hospital, Bandung, Indonesia; Cardiovascular Imaging Division, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran – Hasan Sadikin General Hospital, Bandung, Indonesia
Background: Pericardial hematoma is blood accumulation in the pericardial space. Although rare, it could arise in various conditions, such as after cardiac surgery. Clinical diagnosis of pericardial hematoma is implausible; thus, cardiac imaging plays a pivotal role in identifying this condition. We presented a case of multiple pericardial hematomas, which was found as an incidental finding in post-cardiac surgery evaluation. We highlighted the diagnostic challenge and the key features of multi-modality cardiac imaging in pericardial hematoma evaluation. Case presentation: An asymptomatic, 35-years old male, who underwent surgical closure of secundum atrial septal defect (ASD) one month ago, came for routine transthoracic echocardiography evaluation. An intrapericardiac hematoma was visualized at the right ventricle (RV) ‘s free wall side. Another mass with an indistinct border was visualized near the right atrium (RA). This mass was suspected as pericardial hematoma differential diagnosed with intracardiac thrombus. Cardiac computed tomography (CT) scan showed both masses have an attenuation of 30–40 HU; however, the mass’s border at the RA side was still not clearly delineated. Mild superior vena cava (SVC) compression and multiple mediastinal lymphadenopathies were also detected. These findings are not typical for pericardial hematomas nor intracardiac thrombus; hence another additional differential diagnosis of pericardial neoplasm was considered. We pursued further cardiac imaging modalities because the patient refused to undergo an open biopsy. Single-photon emission computer tomography (SPECT)/CT with Technetium-99 m (Tc-99 m) macro-aggregated albumin (MAA) and Sestamibi showed filling defect without increased radioactivity, thus exclude the intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) reveals intrapericardial masses with low intensity of T1 signal and heterogeneously high intensity on T2 signal weighted imaged and no evidence of gadolinium enhancement, which concluded the diagnosis as subacute pericardial hematomas. During follow-up, the patient remains asymptomatic, and after six months, the pericardial hematomas were resolved. Conclusion: Pericardial hematoma should be considered as a cause of pericardial masses after cardiac surgery. When imaging findings are atypical, further multi-modality cardiac imaging must be pursued to establish the diagnosis. Careful and meticulous follow-up should be considered for an asymptomatic patient with stable hemodynamic. © 2021, The Author(s).
Diagnosis; Diagnostic investigation; Multi-modality cardiac imaging; Pericardial hematoma; Pericardial mass
BMC Medical Imaging
Publisher: BioMed Central Ltd
Volume 21, Issue 1, Art No 85, Page – , Page Count
Journal Link: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85106167865&doi=10.1186%2fs12880-021-00617-0&partnerID=40&md5=69282f4d88d49bc270d478dac6d1304d
Type: All Open Access, Gold, Green
Tower-Rader, A., Kwon, D., Pericardial masses, cysts and diverticula: a comprehensive review using multi-modality imaging (2017) Prog Cardiovasc Dis, 59 (4), pp. 389-397; Restrepo, C.S., Vargas, D., Ocazionez, D., Martínez-Jiménez, S., Betancourt Cuellar, S.L., Gutierrez, F.R., Primary pericardial tumors (2013) Radiographics, 33 (6), pp. 1613-1630; Hutchison, S.J., (2009) Pericardial diseases: clinical diagnostic imaging atlas with DVD, , Elsevier Health Sciences, New York; Klein, A.L., Abbara, S., Agler, D.A., Appleton, C.P., Asher, C.R., Hoit, B., American Society of Echocardiography clinical recommendations for multi-modality cardiovascular imaging of patients with pericardial disease: Endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography (2013) J am Soc Echocardiogr, 26 (9), pp. 965-1012. , e15; (2009) Improving Therapeutic Decisions, , Seminars in nuclear medicine, Elsevier; Wang, Z.J., Reddy, G.P., Gotway, M.B., Yeh, B.M., Hetts, S.W., Higgins, C.B., CT and MR imaging of pericardial disease (2003) Radiographics, 23, pp. S167-S180; Sridhara, S., Lichtenwalter, C., Mazdeh, S., Yeneneh, B.T., Positive Murphy’s sign in pericardial hematoma from a right atrial tear (2018) Cureus, 10 (10), pp. 1-6; Fernandes, A., Cassandra, M., Pinto, C., Oliveira, C., Antunes, M., Gonçalves, L., Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery (2015) Revista Portuguesa De Cardiologia, 34 (9), pp. e1-e3; Huang, H.D., Garcia, M., Alam, M., Misra, A., Lakkis, N., Tabbaa, R., Post-operative intrapericardial hematoma presenting as isolated right atrial tamponade (2014) J Cardiol Cases, 9 (2), pp. 48-49; Ortega, J.R., San Román, J.A., Rollán, M.J., García, A., Tejedor, P., Huerta, R., Atrial hematoma in cardiac postoperative patients and the diagnostic use of transesophageal echocardiography (2002) Rev Esp Cardiol, 55 (8), pp. 867-871; Zhou, W., Srichai, M.B., Multi-modality imaging assessment of pericardial masses (2017) Curr Cardiol Rep, 19 (4), p. 32; Herzog, E., (2014) Management of pericardial disease, , Springer, Berlin; Fyke, F.E., Tancredi, R.G., Shub, C., Julsrud, P.R., Sheedy, P.F., Detection of intrapericardial hematoma after open heart surgery: the roles of echocardiography and computed tomography (1985) J Am Coll Cardiol, 5 (6), pp. 1496-1499; Motwani, M., Kidambi, A., Herzog, B.A., Uddin, A., Greenwood, J.P., Plein, S., MR imaging of cardiac tumors and masses: a review of methods and clinical applications (2013) Radiology, 268 (1), pp. 26-43; Lilly, L.S., Braunwald, E., (2012) Braunwald’s heart disease: a textbook of cardiovascular medicine, , Elsevier Health Sciences, New York; Makis, W., Ciarallo, A., Hickeson, M., Rush, C., Novales-Diaz, J.A., Derbekyan, V., (2011); Makis, W., Ciarallo, A., Hickeson, M., Rush, C., Novales-Diaz, J.A., Derbekyan, V., Spectrum of malignant pleural and pericardial disease on FDG PET/CT (2012) Am J Roentgenol, 198 (3), pp. 678-685; McCarthy, C.J., O’Neill, A.C., McEvoy, S.H., Kilcoyne, A., Butler, M.W., Keane, M.P., Poststernotomy lymphadenopathy: prevalence, size, and location on chest CT (2013) Diagnostic Intervent Radiol (Ankara, Turkey), 19 (3), pp. 208-212; McCarthy, A., Mohan, S., Saeed, A., Kumaran, M., Mediastinal lymphadenopathy, a review of nodal anatomy, pathology and sampling techniques (2014) Imaging, 23 (1), p. 20120003; Bateman, T.M., Advantages and disadvantages of PET and SPECT in a busy clinical practice (2012) J Nucl Cardiol, 19 (1), pp. 3-11; Zanglis, A., Andreopoulos, D., Baziotis, N., Trapping of technetium-99m albumin macroaggregate and other four radiopharmaceuticals by blood clots in vitro (2007) Hell J Nucl Med, 10 (1), pp. 24-25. , PID: 17450246; Nishimura, T., Misawa, T., Park, Y.-D., Uehara, T., Hayashida, K., Hayashi, M., Visualization of right atrial thrombus associated with constrictive pericarditis by indium-111 oxine platelet imaging (1987) J Nucl Med, 28 (8), pp. 1344-1347. , COI: 1:STN:280:DyaL2s3ot1KktA%3D%3D, PID: 3112332; Restrepo, C.S., Vargas, D., Ocazionez, D., Martínez-Jiménez, S., Cuellar, S.L.B., Gutierrez, F.R., Primary pericardial tumors (2013) Radiographics, 33 (6), pp. 1613-1630; Zhu, A., Lee, D., Shim, H., Metabolic positron emission tomography imaging in cancer detection and therapy response (2011) Semin Oncol, 38 (1), pp. 55-69. , COI: 1:CAS:528:DC%2BC3MXksVagsb0%3D; Zanglis, A., Andreopoulos, D., Dima, M., Sidiropoulou, A., Baziotis, N., A large intra-atrial thrombus detected during a lung perfusion scan with technetium-99m macroaggregated albumin injected through the subclavian venous line (2006) Hell J Nucl Med, 9 (3), pp. 184-186. , PID: 17160161; Gandhi, S.J., Babu, S., Subramanyam, P., Shanmuga, S.P., Tc-99m macro aggregated albumin scintigraphy—indications other than pulmonary embolism: a pictorial essay (2013) Indian J Nuclear Med IJNM, 28 (3), pp. 152-162; Reyhan, M., Aydin, M., Yapar, A.F., Bolat, F.A., Tercan, F., Atypical carcinoid tumor detected incidentally on Tc-99m sestamibi myocardial perfusion scintigraphy (2004) Clin Nucl Med, 29 (2), pp. 129-131; Desai, S.P., Yuille, D.L., Visualization of a recurrent carcinoid tumor and an occult distant metastasis by technetium-99m-sestamibi (1993) J Nuclear Med, 34 (10), pp. 1748-1751. , COI: 1:STN:280:DyaK2c%2FhsFCgsw%3D%3D; Maffioli, L., Steens, J., Pauwels, E., Bombardieri, E., Applications of 99mTc-sestamibi in oncology (1996) Tumori J, 82 (1), pp. 12-21. , COI: 1:STN:280:DyaK283gtFaitg%3D%3D; Dvorak, R.A., Brown, R.K.J., Corbett, J.R., Interpretation of SPECT/CT myocardial perfusion images: common artifacts and quality control techniques (2011) Radiographics, 31 (7), pp. 2041-2057; Hirai, S., Hamanaka, Y., Mitsui, N., Isaka, M., Kobayashi, T., Chronic expanding hematoma in the pericardial cavity after cardiac surgery (2003) Ann Thorac Surg, 75 (5), pp. 1629-1631
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