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.
BMC Med Imaging. 2021 May 18;21(1):85. doi: 10.1186/s12880-021-00617-0.
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.
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.
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.
心包积血是指心包腔内血液积聚。尽管罕见，但它可能发生在多种情况下，如心脏手术后。心包积血的临床诊断不可靠；因此，心脏影像学在识别这种情况方面起着关键作用。我们报告了一例多发心包积血病例，该病例在心脏手术后评估中被偶然发现。我们强调了诊断挑战以及多模态心脏成像在心包积血评估中的关键特征。
一名 35 岁无症状男性，一个月前接受了房间隔缺损（ASD）的心脏手术修补，来院进行常规经胸超声心动图评估。在右心室（RV）游离壁侧可见心包内血肿。在右心房（RA）附近可见另一个边界不清的肿块。该肿块被怀疑是心包积血，需与心腔内血栓相鉴别。心脏计算机断层扫描（CT）显示两个肿块的 CT 值为 30-40 HU，但 RA 侧肿块边界仍不清楚。还发现轻度上腔静脉（SVC）受压和多个纵隔淋巴结病。这些发现既不典型于心包积血，也不典型于心腔内血栓；因此，考虑了另一个心包肿瘤的鉴别诊断。由于患者拒绝进行开胸活检，我们进一步进行了心脏影像学检查。锝-99 （Tc-99）聚合白蛋白（MAA）和 Sestamibi 单光子发射计算机断层扫描（SPECT）/CT 显示充盈缺损但无放射性增加，因此排除了心腔内血栓。心脏磁共振成像（MRI）显示心包内肿块 T1 信号强度低，T2 信号加权成像强度不均匀增高，无钆增强证据，诊断为亚急性心包积血。随访期间，患者无症状，6 个月后心包积血消失。
心包积血应被视为心脏手术后心包肿块的原因。当影像学表现不典型时，必须进一步进行多模态心脏成像以明确诊断。对于无症状且血流动力学稳定的患者，应考虑进行仔细和周密的随访。
