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A pictorial review of traumatic pericardial injuries
Insights Imaging
A pictorial review of traumatic pericardial injuries
Ashok Adams
Nicos Fotiadis
Jann Yee Chin
Wayne Sapsford
Karim Brohi
Background Thoracic injuries are the third most common injuries in trauma patients with cardiac injuries amongst the most lethal. Imaging is essential in diagnosis and triage of patients with pericardial injuries, and this review aims to highlight the spectrum of imaging findings of pericardial trauma. Focussed assessment with sonography for trauma (FAST) is the preferred initial examination, being rapid and accurate. Sensitivity of FAST for pericardial fluid detection is high with reported sensitivities of 97-100%. Plain chest radiography has low sensitivity for pericardial injuries but is useful in the evaluation of associated injuries. Computed tomography (CT) is the modality of choice for stable patients and can accurately diagnose traumatic pathology of the pericardium being especially useful in identification of cardiac herniation. The spectrum of CT findings includes pericardial fluid collections, focal pericardial defects and pneumopericardium. Methods A selection of cases of pericardial trauma encountered at a level one trauma centre is presented. Operative findings were correlated with the FAST scan, plain radiography and computed tomography imaging. Conclusion The imaging findings of pericardial trauma with various imaging modalities (ultrasound, plain radiography and computed tomography) are presented in order to aid interpretation during the acute trauma setting.
Pericardium; Heart injuries; Multidetector computed tomography; Ultrasonography
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Injuries to the thorax are the third most common injuries in
trauma patients [1] and have an overall fatality rate of
approximately 10%. Cardiac injuries are among the most
lethal in thoracic trauma patients, particularly in the setting
of penetrating trauma [2]. The majority of patients who
sustain penetrating cardiac injuries die at the scene with a
reported survival rate as low as 6% [3]. The diagnosis of a
pericardial injury relies on a high degree of clinical
suspicion especially in patients with subtle imaging findings who
may be haemodynamically stable on admission but
subsequently deteriorate rapidly when a significant pericardial
effusion develops. Dedicated imaging plays a cardinal role
in the prompt management of these critically injured
patients, and the aim of this pictorial review is to highlight
the spectrum of imaging findings with a particular focus on
cross-sectional imaging.
The pericardial sac is formed by the pleuropericardial
folds that grow from the lateral body wall in a coronal
plane. These septae appear at the beginning of the fifth
week of embryonic development as broad folds of
mesenchyme that grow medially towards each other and
eventually fuse to separate the pleural and pericardial
cavities [4]. The pericardium contains the heart and
juxtacardiac portions of the great vessels, and it is
composed of an outer fibrous pericardium and an inner,
double-layered sac, the serous pericardium [5]. The
pericardial space lies between the visceral and parietal layers
of the serous pericardium and contains approximately
15?50 ml of serous fluid produced by the mesothelial
cells that line the serosa. This fluid facilitates freedom of
movement of the heart within the pericardium.
Inferiorly, the fibrous pericardium is attached to the
diaphragm?s central tendon. Anteriorly, the pericardium is
separated from the thoracic wall by lungs and pleurae, but in a
small area at the level of the 4th and 5th costal cartilages, it
is in direct contact with the posterior aspect of the sternum.
Laterally, the fibrous pericardium is related to the pleura and
the medial pulmonary surfaces with the phrenic nerve
descending between them. Posterior relations of the fibrous
pericardium include the principal bronchi, oesophagus,
descending thoracic aorta and the posterior portions of the
mediastinal surfaces of both lungs. Superiorly, the fibrous
pericardium blends externally with the great vessels, and it
is continuous with the pretracheal fascia. Through its
various attachments, the pericardium is securely anchored and
maintains its thoracic position. A number of pericardial
sinuses and recesses between the pericardial reflections
serve as a potential space to accommodate a limited amount
of fluid.
Cardiac injuries are more common in penetrating trauma
compared to blunt trauma and are fatal in a significant
percentage of patients with many found dead at the scene
[2]. The anatomic position of the heart can account to some
degree for the relative frequency of different injuries and,
depending on the phase of respiration, penetrating
abdominal injuries can also result in cardiac injury. The right and
left ventricles are injured approximately 40% of the time,
the right atrium approximately 24% of the time and the left
atrium approximately 3% of the time [6].
Pericardial tears range in size from a few millimetres to
seve (...truncated)