Download Identifying pericardial recesses on computed tomography : is it

Identifying pericardial recesses on computed tomography :
is it important?
Poster No.:
C-0954
Congress:
ECR 2016
Type:
Educational Exhibit
Authors:
S. Thakar , C. B. Kulkarni , S. moorthy , K. P. sreekumar ;
1
1
2
2
2
2
MUMBAI, Maharashtra/IN, kochi/IN
Keywords:
Cardiac, Anatomy, Lymph nodes, CT, Contrast agent-intravenous,
Education, Normal variants, Education and training
DOI:
10.1594/ecr2016/C-0954
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Learning objectives
This poster aims
•
•
•
•
To illustrate the basic anatomy of the pericardial recesses
To depict the importance to differentiate it from mediastinal
lymphadenopathy
To emphasize on points to differentiate between the two
To emphasize the impact of pericardial recesses on onco-imagng
Background
The complex configuration of the pericardial cavity can be described in rather simple
words as 'two interconnecting spaces surrounding the heart and the great vessels'.
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•
•
The pericardial cavity has several recesses which can be demonstrated on
CT and MR imaging. Accurate knowledge of the cross sectional anatomy of
the pericardium and its recesses is essential for the differentiation of fluid
filled recesses from various mediastinal lymphnodes.
The capability of MDCT to obtain high resolution images results in routine
visualization of pericardial recesses, even in absence of abnormal
pericardial fluid accumulation.
Misinterpretation of the pericardial recess as a mediastinal abnormality or
lymphadenopathy or vice versa can have important clinical ramifications
especially in onco-imaging. Occasional prominence of one or more recess in
comparison to others increases the probability of misinterpretation
Findings and procedure details
The pericardium encloses the heart and the juxtacardiac parts of great vessels and
consists of two components :
•
•
Fibrous (outer) pericardium
Serosal (inner) pericardium
Fibrous pericardium
- A complex collagenous tissue that completely surrounds the heart without being
attached to it.
Page 2 of 15
- Superiorly : It is continuous with the adventitia of great vessels and with the pretracheal
fascia
- Inferiorly : It is attached to the central tendon of the diaphragm
- Anteriorly : It is attached to the sternum by the superior and the inferior pericardial
ligaments and is covered by the parietal mediastinal pleura
Serosal pericardium
- A single layer of flat cells on a thin subserosal layer of connective tissue
- A closed sac with parietal and visceral layer which are continuous with each other
- The visceral layer or the epicardium, covers the heart and vessels and is reflected on
to the parietal layer which lines the internal surface of the fibrous pericardium
- A thin film of pericardial fluid fills up the potential space in between these two layers
except at the arterial and the venous attachments where the two merge
The reflections of the serosal layer are arranged as two tubes :
•
•
•
One encasing the aorta and the pulmonary trunk: The pericardial cavity
proper
Other encasing the superior and the inferior vena cava and the pulmonary
veins : The oblique sinus
The passage between the two tubes : The transverse sinus
As the pericardium extends along the great vessels, the pericardial cavity proper,
transverse and the oblique sinuses form recesses
Transverse sinus (TS)
- Located posterior to the ascending aorta and the pulmonary trunk and superior to the
left atrium
Superior aortic recess (SAR)
- Transverse sinus extends upwards along the ascending aorta to form the superior aortic
recess which is further divided into
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•
•
Posterior portion (P-SAR)
Anterior portion (A-SAR)
Lateral portion (L-SAR)
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Posterior portion (P-SAR)
- A well defined crescent shaped collection adjacent to the posterior wall of ascending
aorta at the level of left pulmonary artery
- It is closely related to and thus mimics :
•
•
Pre carinal lymph nodes
Sub carinal lymph nodes
- It may extend cephalad along the right para tracheal region and thus mimics:
•
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Paratracheal lymphnode
Bronchogenic cyst
Anterior portion (A-SAR)
- Present anterior to ascending aorta and the pulmonary artery insinuating between them
with a characteristic triangular shape.
- It may extend superiorly and mimics :
•
•
Aortopulmonary window lymphnode
Para aortic lymphnode
- It may extend downwards upto the right atrium where it is closely related to the thymus
and thus mimics :
•
Pre vascular lymphnodes
Lateral portion (L-SAR)
- Insinuates itself between ascending aorta and the SVC
- It is closely related to and mimics :
•
•
Para aortic lymph node
Pre vascular lymph nodes
Inferior aortic recess (IAR)
- Transverse sinus extends caudally in between the lateral aspect of the ascending aorta
and the inferior SVC or the right atrium to form the inferior aortic recess
- It extends inferiorly upto the aortic valve annulus
Pulmonic recesses
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- Transverse sinus extends laterally to form the right and the left pulmonic recesses
Right pulmonic recess
- Inferior to the right pulmonary artery and superior to the left atrium
Left pulmonic recess
- Bounded superiorly by left pulmonary artery, inferiorly by the left superior pulmonary
vein and medially by the ligament of marshall (vestigial remnant of left SVC)
- It is closely related to and mimics
•
Inferior tracheobronchial lymphnodes
Transverse
(TS)
# Pre carinal lymph
nodes
# Sub carinal lymph
nodes
# Paratracheal
lymph nodes
# Bronchogenic
cyst
sinus Superior
aortic Posterior SAR
recess (SAR)
(p SAR)
# AP window lymph
nodes
# Para-aortic lymph
nodes
# Prevascular
lymph nodes
Anterior SAR
(a SAR)
Right lateral SAR
(r SAR)
Transverse sinus (TS)
Left pulmonic recess
# Para-aortic lymph
nodes
# Prevascular
lymph nodes
# Inferior tracheobronchial
lymph nodes
Oblique sinus
- The oblique sinus is postero-superior to the left atrium and posteromedial to the left
superior pulmonary vein
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Posterior pericardial recess
- The right superolateral extension of oblique sinus is the posterior pericardial recess
- It is closely related to and mimics
•
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Subcarinal lymph nodes
Tracheo-bronchial lymph nodes
Oblique sinus (OS)
Posterior pericardial recess # Subcarinal lymph nodes
# Tracheo-bronchial lymph
nodes
Pericardial cavity proper
- The recesses arising from the pericardial cavity proper are
•
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Right and left pulmonary venous recesses
Post caval recess.
Pulmonary venous recesses
- Formed by the pericardium investing the pulmonary veins as they penetrate the fibrous
pericardium to enter the left atrium
- Located between the superior and inferior pulmonary veins along the lateral cardiac
borders
- Closely related to and mimic
•
Bronchopulmonary lymph nodes
Post caval recess
- Lies posterior to the SVC towards the right
Pericardial cavity proper
Pulmonary
recesses
venous # Bronchopulmonary
lymph nodes
Images for this section:
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Fig. 2: Classification of Pericardial recesses
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
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Fig. 3: Anatomy of pericardial sinuses and recesses
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
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Fig. 4: Anatomy of pericardial sinuses and recesses
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
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Fig. 5: r-SAR & a-SAR mimicking pre vascular & para-aortic lymph node
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
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Fig. 6: Posterior-Superior aortic recess mimicking : Paratracheal lymph node (when
cranially extended) and Pre-carinal lymph node
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
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Fig. 7: Left pulmonic recess mimicking AP window lymphnode
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
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Fig. 8: Oblique sinus & its posterior pericardial recess mimicking sub-carinal lymphnodes
© Department of Radiology, Amrita Institute of Medical sciences and Research centre,
Kochi / India 2015
Page 13 of 15
Conclusion
# Pericardial recesses mimic various mediastinal lymphnodes
# Following are the differentiating features on cross sectional imaging
Pericardial recess
Lymphnodes
# Beaking, sharp margins
# Rounded margins
# Spread along the vessels
# Indent the vessels
# No post contrast enhancement
# Post contrast enhancement
(except necrotic lymphnodes)
#Multiplanar reformatting and thin slice reconstruction helps to better differentiate
recesses from lymphnodes
Personal information
Dr Saket Thakar
MD Radiology
Maharashtra, India
Email: [email protected]
References
1.Mylene T. Truong, Jeremy J. Erasmus, Gregory W. Gladish, Bradley S. Sabloff, Edith
M. Marom, Jhon E. Madewell, Marvin H. Chasen, Reginald F. Mundane. Anatomy of
Page 14 of 15
Pericardial Recesses on Multidetector CT : Implications for Oncologic Imaging. AJR
2003;181:1109-1113 0361-803X/03/1814-1109.
2.Reinhard Groell, MD. Gottfried J Schaffler, MD. Rainer Reinmueller, MD. Pericardial
Sinuses and Recesses : Findings at Electrocardiographically Triggered Electron-Beam
CT. Radiology 1999; 212:69-73.
3.Lynn S. Broderick, MD . Gregory N. Brooks, MD, PhD . Fanet E. Kuhlman, MD, MS.
Anatomic Pitfalls of Heart and Pericardium. RadioGraphics 2005; 25:441-453.
4.S M O'Leary, P L Williams, M P Williams, A J Edwards, C A Roobottom, G J
Morganhughes, N E Manghat. Imaging the pericardium : appearences on ECG-gated 64detectorrow cardiac computed tomography. The British Journal of Radiology, 83 (2010),
194-205.
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