Download Pericardial recesses. Anatomy and morphology with MDCT

Pericardial recesses. Anatomy and morphology with MDCT
Poster No.:
C-1399
Congress:
ECR 2012
Type:
Educational Exhibit
Authors:
D. Durany , M. vargas , J. C. Quintero , S. Vizcaya , A. Mariscal ,
1
2
3
5 1
4
2
4
3
A. Olazábal ; Badalona barcelona/ES, baalona/ES, O Pereiro
4
5
de Aguiar (OURENSE)/ES, Badalona/ES, Barcelona/ES
Keywords:
Artifacts, Staging, Diagnostic procedure, CT, Thorax, Lymph
nodes, Cardiac
DOI:
10.1594/ecr2012/C-1399
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Learning objectives
To show radiological features of pericardial recesses by MDCT axial, coronal and sagittal
sections in order to avoid confusing them with mediastinal lymphadenopathy or other
lesions.
Background
The pericardium is a "wrapper" around the heart and root of great vessels in the
mediastinum. It facilitates the cardiac activity of the heart by decreasing the friction with
the rest of surrounding mediastinal structures forming a defensive barrier to possible
inflammation/infection of the heart.
It has saccular morphology and has two main components: outer fibrous layer or fibrous
pericardium and serous internal sac or serous pericardium. The latter consists of two
layers: the epicardium or visceral pericardium and parietal pericardium.
The parietal pericardium is located between the external fibrous layer and the pericardial
cavity. At 2-3 cm from the exit of the thoracic great vessels (ascending aorta, main
pulmonary artery and superior vena cava), the parietal pericardium turns on itself
touching the adventitia of large vessels and forming the visceral pericardium.
The space between the parietal pericardium and visceral pericardium is the pericardial
cavity, which normally may contain from 15 to 50 ml of serous fluid.
The visceral pericardium is intimately linked to the epicardial fat and cardiac surface.
At CT the pericardium is visualized as a linear image of less than 2 mm of thickness.
The pericardium is easily recognizable at CT because it is outlines by mediastinal fat
(anteriorly) and epicardial fat (posteriorly). The presence of mediastinal fat helps to
visualize the pericardium and pericardial recesses.
Pericardial recesses are formed by extensions of the pericardial cavity when the visceral
layer adapts to the entry of vessels into the heart or between them.
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Pericardial recesses on MDCT are structures of low-attenuation near water (10-30UH),
well defined, without walls or peripheral rings that limit them, in the typical locations of
each of them. There's no intravenous contrast enhancement and they can be viewed
even without the presence of pericardial effusion. Fig.1, Fig.2, Fig.3.
Sometimes pericardial recesses have an interface pericardial fat adjacent to vascular
structures that allow proper characterization. This is particularly common in the upper
recesses.
Another important feature of the pericardial recesses is their morphology, being very
variable depending on the amount of fluid, location and in different spatial planes
(multiplanar reconstructions: axial, coronal and sagittal) according to anatomical spaces.
They can show different shapes: linear, crescent, punctate, ovoid, round, triangular,
rhomboid; and some of them are more characteristic of certain recesses.
Images for this section:
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Fig. 1: Attenuation in Hounsfield units of a pericardial recess.
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Fig. 2: PET-CT. Pericardial recesses do not show contrast enhancement or metabolic
activity.
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Fig. 3: PET-CT. Coronal image showing no contract enhancement and absence of
metabolic activity.
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Imaging findings OR Procedure details
When the pericardium embraces several vessels entering and leaving the heart, it forms
two tubular structures. The first one is the one that includes the aorta and pulmonary
artery. The second is around the four pulmonary veins and both venae cavae, the superior
and inferior. Fig. 4.
Between the first and second tubular structure is a passage called the transverse sinus.
Below the second tubular structure, there is a pouch called the oblique sinus, behind the
left atrium. Fig. 5.
The transverse sinus lies below and behind the ascending aorta and main pulmonary
artery and above the left atrium. Fig. 6.
The cranial extension of the transverse sinus creates superior aortic recess fitting directly
into the aorta. The superior aortic recess has anterior, posterior and lateral subdivisions.
The anterior portion of superior aortic recess extends in front of the ascending aorta and
main pulmonary artery, adapting to the cleft between them (triangular). Fig. 7, Fig. 8.
Laterally, it presents an extension to the aortic-pulmonary window, forming the recess of
the aortic-pulmonary window (with a peak in the front). Fig.9, Fig. 10, Fig. 11.
The posterior portion of the superior aortic recess is usually detected as a crescent behind
the posterior wall of the ascending aorta. It can be detected an extension of the recess to
the right paratracheal region (between the ascending aorta and the superior vena cava).
Fig. 12, Fig. 13.
The lower extention of transverse sinus originates the inferior aortic recess. The latter
is located between the superior vena cava and right atrium on one side and ascending
aortic root on the other.
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The lateral extention of the transverse sinus originates the left and right pulmonic
recesses. The right pulmonic recess is below the proximal right pulmonary artery and
above the left atrium. Fig. 14, Fig. 15.
The left pulmonary recess is bounded by the left pulmonary artery at the top, left superior
pulmonary vein below and medially by the ligament of Marshall (remnant of the left
superior vena cava). Fig. 16, Fig. 17, Fig. 18.
Pericardial recesses, previously described, can mimic different conditions, the most
common of these are the lymph nodes, but also aortic disease (dissection or thrombus),
related to thymus or congenital (bronchogenic cyst).
The oblique sinus is located in the posterior portion of the left atrium, anterior to the
esophagus, separated from the transverse sinus by a double layer of pericardium
(it may contain a fat plane between the two sheets of pericardium). The cranial
portion of the oblique sinus is the posterior pericardial recess located between the
distal right pulmonary artery and the intermediate bronchus. It can be confused with
lymphadenopathy and esophageal disorders or injuries of the descending aorta. Fig. 19,
Fig. 20, Fig. 21.
There are two recesses not belonging to any of the above groups.
Postcaval recess is a diverticulum of the pericardial cavity itself, which fits directly into
the superior vena cava. Inferiorly, it continues with the cleft between the right pulmonary
artery and right superior pulmonary vein. Fig. 22.
The pulmonary veins recesses are usually located between the upper and lower veins
of the right and left or accompanying them on their course. In inferior pulmonary veins,
pericardial fluid may accompany the veins in front and behind them. There is no fatty
tissue between the vascular structures and recess. Fig. 23, Fig. 24, Fig. 25.
Images for this section:
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Fig. 4: Pericardium embracing heart vessels.
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Fig. 5: Transverse and oblique sinus.
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Fig. 6: Transverse sinus.
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Fig. 7: Anterior extension of superior aortic recess. Pericardial effusion.
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Fig. 8: Anterior extension of superior aortic recess. No pericardium effusion.
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Fig. 9: Axial view. Recess of the aortic-pulmonary window with oval morphology.
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Fig. 10: Sagittal view. Recess of the aortic-pulmonary window with elongated
morphology.
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Fig. 11: Coronal view. Recess of the aortic-pulmonary window with fusiform morphology.
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Fig. 12: Axial view. Posterior portion of superior aortic recess with crescent morphology.
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Fig. 13: Coronal view. Posterior portion of superior aortic recess with fusiform
morphology.
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Fig. 14: Axial view. Right pulmonic recess.
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Fig. 15: Coronal view. Right pulmonic recess.
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Fig. 16: Axial view. Left pulmonic recess with elongated morphology.
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Fig. 17: Coronal view. Left pulmonic recess with ovoid morphology.
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Fig. 18: Sagital view. Left pulmonic recess with oval morphology.
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Fig. 19: Axial view. Posterior pericardial recess with oval morphology.
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Fig. 20: Sagittal view. Posterior pericardial recess with elongated morphology.
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Fig. 21: Coronal view. Posterior pericardial recess with ovoid morphology.
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Fig. 22: Postcaval recess.
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Fig. 23: Axial view. Right pulmonary venous recess with nodular morphology.
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Fig. 24: Sagittal view. Right pulmonary venous recess with crescent morphology.
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Fig. 25: Coronal view. Right pulmonary venous recess with ovoid morphology.
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Conclusion
In the radiological study of oncological patients with MDCT is essential to recognize
pericardial recesses in order to avoid misunderstandings that could lead to diagnostic
and therapeutic errors and mistakes.
MDCT (multidetector row computed tomography) with multiplanar reconstruction allows
the rapid acquisition of scans, reducing heart and breathing motion artifacts, and due to
greater anatomic resolution, it allows to recognize the several pericardial recesses in the
absence of pericardial effusion.
A comprenhensive knowledge of anatomy, the locations and typical morphological
features of the pericardial recesses allow proper characterization.
Pericardial recesses are common "pitfalls" in the diagnosis and staging of cancer patients
in which the interpretation of a pericardial recess as a mediastinal lymph node can change
neoplasia staging and alter their prognosis and treatment.
Pericardial recesses are presented as images of variable morphology in the different
planes of space, low attenuated to fit the cardiovascular structures.
These structures are easily recognizable and they must not be confused with mediastinal
lymphadenopathy or tumors that have a different CT appearance
Familiarity of general radiologists with pericardial recesses should be recomended to
avoid diagnostic errors.
Personal Information
[email protected]
References
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