Kleine Perikardzyste 44M - CR pa und CT nativ axial - 001 - Annotation

A pericardial cyst is an uncommon benign dilatation of the

pericardial sac The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...

surrounding the heart. It can lead to symptoms by compressing nearby structures, but is usually asymptomatic. Pericardial cysts can be congenital or acquired, and they are typically diagnosed with radiologic imaging. Management of pericardial cysts can include follow-up imaging, percutaneous aspiration, or surgical resection.

Presentation

Pericardial cysts most often are

asymptomatic In medicine, any disease is classified asymptomatic if a patient tests as carrier for a disease or infection but experiences no symptoms. Whenever a medical condition fails to show noticeable symptoms after a diagnosis it might be considered asy ...

, with 50 to 75% of patients experiencing no symptoms. The presentation of symptomatic cysts depends on the cyst location and effects on nearby structures, including the heart, lungs, and esophagus. Symptoms can include chest pain, cough, shortness of breath,

palpitations Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart. Symptoms include a rapi ...

, syncope, recurrent

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...

congestive heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...

, difficulty swallowing, and weight loss.

Causes

Pericardial cysts can be

congenital A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...

or acquired, with the majority being congenital. Congenital pericardial cysts happen due to an abnormality in the development of the

that creates a bulge which is walled off to form a cyst. Acquired pericardial cysts can be caused by inflammation from surgery,

pericarditis Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sit ...

, trauma,

echinococcosis Echinococcosis is a parasitic disease of tapeworms of the ''Echinococcus'' type. The two main types of the disease are ''cystic echinococcosis'' and ''alveolar echinococcosis''. Less common forms include ''polycystic echinococcosis'' and ''unic ...

tuberculosis Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, in ...

metastasis Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, ...

, or

hemodialysis Hemodialysis, also spelled haemodialysis, or simply dialysis, is a process of purifying the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as creatinin ...

. The inflammation can lead to a walled-off pocket of fluid that is a pericardial cyst.

Diagnosis

Since pericardial cysts are often asymptomatic, the most common diagnosis is through incidental finding on a chest x-ray. Differentiation of pericardial cysts from

diverticula In medicine or biology, a diverticulum is an outpouching of a hollow (or a fluid-filled) structure in the body. Depending upon which layers of the structure are involved, diverticula are described as being either true or false. In medicine, t ...

is usually impossible as both the lesions have similar radiological appearance. The lone differentiating feature is the presence of communicating tract between pericardium and the cyst cavity in the diverticula, unlike the fully walled off pericardial cyst. When patients have symptoms,

transthoracic echocardiogram A transthoracic echocardiogram (TTE) is the most common type of echocardiogram, which is a still or moving image of the internal parts of the heart using ultrasound. In this case, the probe (or ultrasonic transducer) is placed on the chest or abdo ...

is one of the first tests used to look for a pericardial cyst. CT or

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...

may also be used to diagnose pericardial cysts. On CT and MRI a pericardial cyst will commonly appear as a round, fluid-filled structure surrounded by thin walls. Diagnosis of a pericardial cyst can also be made before birth using ultrasound. The differential diagnosis for a suspected pericardial cyst includes a bronchial cyst,

pericardial effusion A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of t ...

teratoma A teratoma is a tumor made up of several different types of tissue, such as hair, muscle, teeth, or bone. Teratomata typically form in the ovary, testicle, or coccyx. Symptoms Symptoms may be minimal if the tumor is small. A testicular terato ...

lymphangioma Lymphangiomas are malformations of the lymphatic system characterized by lesions that are thin-walled cysts; these cysts can be macroscopic, as in a cystic hygroma, or microscopic. The lymphatic system is the network of vessels responsible for ...

, pericardial fat,

congenital diaphragmatic hernia Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm. The most common type of CDH is a Bochdalek hernia; other types include Morgagni hernia, diaphragm eventration and central tendon defects of the diaphragm. Malformation of ...

, neuroenteric cyst, and congenital cyst from the primitive

foregut The foregut is the anterior part of the alimentary canal, from the mouth to the duodenum at the entrance of the bile duct. Beyond the stomach, the foregut is attached to the abdominal walls by mesentery. The foregut arises from the endoderm, deve ...

Management

Pericardial cysts that are small and cause no symptoms can be followed with repeat imaging through

echocardiogram An echocardiography, echocardiogram, cardiac echo or simply an echo, is an ultrasound of the heart. It is a type of medical imaging of the heart, using standard ultrasound or Doppler ultrasound. Echocardiography has become routinely used in th ...

, CT, or MRI to assess for changes. Pericardial cysts that are large or cause symptoms may be candidates for percutaneous aspiration, ethanol sclerosis, or surgery. Percutaneous aspiration removes the fluid from inside the cyst, and ethanol sclerosis uses the injection of ethanol into the cyst after aspiration to decrease the likelihood of cyst recurrence. Percutaneous aspiration with ethanol sclerosis is typically the first treatment for pericardial cyst that requires management. Surgery can remove a pericardial cyst through a

thoracotomy A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...

, sternotomy,

mediastinoscopy Mediastinoscopy is a procedure that enables visualization of the contents of the mediastinum, usually for the purpose of obtaining a biopsy. Mediastinoscopy is often used for staging of lymph nodes of lung cancer or for diagnosing other conditio ...

, or video-assisted thoracic surgery. The type of surgery is chosen based on the size and location of the pericardial cyst.

Prognosis

With most pericardial cysts having no symptoms, the prognosis is very good. The cysts can resolve without intervention. If percutaneous aspiration is performed, the recurrence rate of pericardial cysts is about 30-33%. Although pericardial cysts are benign, the location of cysts can rarely cause life-threatening emergencies by compressing the heart or lungs.

Epidemiology

Pericardial cysts have an incidence of 1 in 100,000. Pericardial cysts make up 6-7% of all

mediastinal The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...

masses. They can present at any age, but are most commonly diagnosed between the third and fifth decade of life. Females and males have approximately equal incidences of pericardial cysts.

History

Pericardial cysts were first reported on during

autopsies An autopsy (post-mortem examination, obduction, necropsy, or autopsia cadaverum) is a surgical procedure that consists of a thorough examination of a corpse by dissection to determine the cause, mode, and manner of death or to evaluate any d ...

in the 19th century by pathologists. As the field of

radiology Radiology ( ) is the medical discipline that uses medical imaging to diagnose diseases and guide their treatment, within the bodies of humans and other animals. It began with radiography (which is why its name has a root referring to radiat ...

progressed, pericardial cysts could be identified in living patients. In 1931, the first surgical resection of a pericardial cyst was performed by Otto Pickhardt at

Lenox Hill Hospital Lenox Hill Hospital (LHH) is a nationally ranked 450-bed non-profit, tertiary, research and academic medical center located on the Upper East Side of Manhattan in New York City, servicing the tri-state area. LHH is one of the region's many unive ...

in New York using a

thoracoscopy Thoracoscopy is a medical procedure involving internal examination, biopsy and/or resection/drainage of disease or masses within the pleural cavity, usually with video assistance. Thoracoscopy may be performed either under general anaesthesia o ...

. In 1943, Greenfield and his colleagues coined the term "spring water cysts" for pericardial cysts since the cysts contain clear fluid.

References

Cysts Pericardial disorders {{pathology-stub