Pericarditis CT scan

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Homa Najafi, M.D.[2]


On CT, pericardial fluid adds to the thickness of pericardium as both have the similar signal intensities. In pericarditis, pericardium can generate an intermediate signal intensity and may enhance after gadolinium administration. In pericardial effusion, hemorrhagic effusions can be differentiated from a transudate or an exudate based on signal characteristics (high signal on T1-weighted images) or density (high-density clot on CT). CT is superior to MRI in the visualization of pericardial calcification which is often seen in the patient with pericardial constriction. CT imaging also helps in detecting the presence of tumors and the extent of metastasis of the neoplasm.

CT scan

Normal Pericardium on CT

There is normally 15 to 50 mL of fluid in the pericardial sac which may contribute to the apparent thickness of the pericardium since they both have the same signal intensity.

Pericarditis on CT

In the presence of acute pericarditis, the pericardium can generate an intermediate signal intensity and may enhance after gadolinium administration.

Pericardial Effusion on CT

If the fluid is free-flowing and not loculated, it will first accumulate at the posterior lateral aspect of the all sleepleft ventricle in the supine position. It can be hard to differentiate a small pericardial effusion from pericardial thickening of about 4 mm, since both entities generate a similar signal. In the presence of acute pericarditis, the pericardium can generate an intermediate signal intensity and may enhance after gadolinium administration.

Estimation of the amount of fluid is possible to a limited extent based on the overall thickness of the crescent of fluid. Hemorrhagic effusions can be differentiated from a transudate or an exudate based on signal characteristics (high signal on T1-weighted images) or density (high-density clot on CT). Pulsation artefacts may cause local areas of low signal in a hemorrhagic effusion.

Images courtesy of RadsWiki

Cardiac MSCT: Pericardial effusion

Pericardial Effusion as an Incidentoloma on CT

A pericardial effusion is often incidentally noted on CT scans obtained for other indications.

Advantages of CT over Echocardiography in the Assessment of Pericardial Effusion

Both MRI and CT have an advantage over echocardiography insofar as they can detect loculated effusions as well as generalized effusions.[1][2] CT is superior to MRI in the assessment of pericardial calcification.

Constrictive Pericarditis on CT

The signs of constrictive pericarditis on CT include:

Pericardial Tumor on CT

A pericardial cyst is most commonly located at the right cardiophrenic angle. On T1, it appears either as a low signal or an intermediate signal due to high protein content, or with a characteristic light-bulb appearance on T2.

There are several rare tumors that may arise within the pericardium including mesothelioma and angiosarcoma. Malignant primary tumors have many overlapping imaging features and generally cannot be differentiated from one another. The role of cross-sectional imaging is to establish a diagnosis and to define the extent of the lesion (invasion of cardiac structures, veins, pericardium, etc.). Sometimes lesions may have helpful signal characteristics to suggest a specific diagnosis, e.g., high-signal fat on T1 or low-density fat on CT in lipoma or liposarcoma.

Pericardial Metastases on CT

Secondary tumors are much more common than primary tumors. Lung cancer may invade the mediastinal and cardiac structures directly or indirectly. The most common secondary tumors affecting the heart are:

Metastatic pericardial disease commonly presents as hemorrhagic effusion. Tumor nodules may enhance after intravenous gadolinium administration.

Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Limitations of CT

  • Need for contrast administration.
  • Exposure to ionizing radiation.
  • Difficulty in differentiating fluid from thickened pericardium.

2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)[3]

Recommendations for the general diagnostic work-up of pericardial diseases

Class I
1. In all cases of suspected pericardial disease a first diagnostic evaluation is recommended with:



transthoracic echocardiography

chest X-ray

– routine blood tests, including markers of inflammation (i.e., CRP and/or ESR), white blood cell count with differential count, renal function and liver tests and myocardial lesion tests (CK, troponins).

2. CT and/or CMR are recommended as second-level testing for diagnostic workup in pericarditis.

3. Pericardiocentesis or surgical drainage are indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis.

4. Further testing is indicated in high-risk patients (defined as above) according to the clinical conditions. (Level of Evidence: C)

Recommendations for the diagnosis of constrictive pericarditis

Class I
1. Transthoracic echocardiography is recommended in all patients with suspected constrictive pericarditis.

2. Chest X-ray (frontal and lateral views)with adequate technical characteristics is recommended in all patients with suspected constrictive pericarditis.

3. CT and/or CMR are indicated as second-level imaging techniques to assess calcifications (CT), pericardial thickness, degree and extension of pericardial involvement.

4. Cardiac catheterization is indicated when non-invasive diagnostic methods do not provide a definite diagnosis of constriction. (Level of Evidence: C)


  1. Chotas HG, Dobbins JT, Ravin CE (1999) Principles of digital radiography with large-area, electronically readable detectors: a review of the basics. Radiology 210:595-599
  2. Ohnesorge BM, Becker CR, Flohr TG, Reiser MF (2001) Multislice CT in cardiac imaging. Springer-Verlag
  3. Adler, Yehuda; Charron, Philippe; Imazio, Massimo; Badano, Luigi; Barón-Esquivias, Gonzalo; Bogaert, Jan; Brucato, Antonio; Gueret, Pascal; Klingel, Karin; Lionis, Christos; Maisch, Bernhard; Mayosi, Bongani; Pavie, Alain; Ristić, Arsen D.; Sabaté Tenas, Manel; Seferovic, Petar; Swedberg, Karl; Tomkowski, Witold (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN 0195-668X.

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