Enlarging, atypically located pericardial cyst. Recent experience and literature review

Pericardial Cyst at an Unusual Location: The Role of CT Imaging

The pericardial cyst is a benign, uncommon congenital cystic lesion of pericardial origin located in the anterior and middle mediastinum. Most commonly, pericardial cysts are located in the right anterior cardiophrenic angle. Computed tomography (CT) and magnetic resonance imaging (MRI) of the chest are the non-invasive imaging modalities for the diagnosis of the pericardial cyst. Here we present a case of a 55-year-old male who presented with coughing and chest pain for two weeks. A chest X-ray revealed a soft-tissue opacity mass in the left lower zone. A CT of the chest showed a fluid-density cystic lesion in close proximity to the pericardium, located along the left posterior cardiophrenic angle, an uncommon location for a pericardial cyst.

Unusual cause of mediastinal tumor: A case of calcified pericardial cyst

Pericardial cysts are rare benign intrathoracic lesions, and calcified pericardial cysts are even more uncommon. Most pericardial cysts are asymptomatic, but patients may present with chest pain, dyspnea and any complications of pericardial effusion. We present a case of a left-sided calcified pericardial cyst, highlighting its rarity and symptoms in relation to its location.

An Incidental Finding of a Large Pericardial Cyst

A pericardial cyst is a rare and benign cause of a mediastinal mass. They are frequently asymptomatic and are usually incidental findings on imaging. Symptoms may include persistent cough, atypical chest pain, dysphagia, and dyspnea. Diagnosis is usually established with the aid of imaging, including a chest x-ray, a computed tomography (CT) scan, and magnetic resonance imaging (MRI). Therapeutic options include surgical resection or aspiration for large and/or symptomatic cysts, whereas conservative management with routine follow-up is advised for small or asymptomatic cysts. We herein describe the case of a 48-year-old lady, who presented with clinical features suggestive of acute cholecystitis, with an incidental finding of a pericardial cyst, measuring approximately 10.1 cm x 8.7 cm x 10.7 cm. The patient underwent video-assisted thoracoscopic surgery (VATS) for excision of the pericardial cyst. She had an uneventful recovery and was discharged on the second post-operative day. At six months, there was no evidence of disease recurrence.

Cardiovascular magnetic resonance of cardiac tumors and masses

Cardiac masses diagnosis and treatment are a true challenge, although they are infrequently encountered in clinical practice. They encompass a broad set of lesions that include neoplastic (primary and secondary), non-neoplastic masses and pseudomasses. The clinical presentation of cardiac tumors is highly variable and depends on several factors such as size, location, relation with other structures and mobility. The presumptive diagnosis is made based on a preliminary non-invasive diagnostic work-up due to technical difficulties and risks associated with biopsy, which is still the diagnostic gold standard. The findings should always be interpreted in the clinical context to avoid misdiagnosis, particularly in specific conditions (e.g., infective endocarditis or thrombi). The modern multi-modality imaging techniques has a key role not only for the initial assessment and differential diagnosis but also for management and surveillance of the cardiac masses. Cardiovascular magnetic resonance (CMR) allows an optimal non-invasive localization of the lesion, providing multiplanar information on its relation to surrounding structures. Moreover, with the additional feature of tissue characterization, CMR can be highly effective to distinguish pseudomasses from masses, as well as benign from malignant lesions, with further differential diagnosis of the latter. Although histopathological assessment is important to make a definitive diagnosis, CMR plays a key role in the diagnosis of suspected cardiac masses with a great impact on patient management. This literature review aims to provide a comprehensive overview of cardiac masses, from clinical and imaging protocol to pathological findings.

Pericardial pseudocyst along atrioventricular groove

Cystic lesions in relation to the pericardium are a rare congenital lesion with an estimated incidence of 1 per 100,,000. Pericardial cysts may be classified as congenital or acquired. Here, we present a case of a pericardial pseudocyst having a horseshoe configuration along the atrioventricular groove in a middle-aged subject with no previous relevant medical history. The patient underwent open surgery for the same with histopathological diagnosis being established. This paper highlights the differentials for a cystic pericardial lesion in imaging in addition to the histopathological entity of a pericardial pseudocyst.

Anesthetic and surgical considerations of giant pericardial cyst: Case report and literature review

Introduction

Pericardial cysts are considered as a rare congenital abnormality, mostly found incidentally. The estimated incidence of pericardial cyst is 1:100,000 and represent approximately 6% of all mediastinal masses. Patients can present with symptoms similar to acute chest pain or right-sided heart failure or can be asymptomatic.

Presentation

A 46-year-old female who is known to have hypertension and hypothyroidism presented to the breast clinic with left breast mass that was proved by core needle biopsy as proliferative breast lesion. During the preoperative assessment, the patient reported progressive shortness of breath and cough over the last two years and bilateral lower limb edema. Her preoperative chest X-ray showed a well-defined oval like opacification at the right cardiophrenic angle that was proved by chest computed tomography imaging as a cystic mass od most likely a pericardial origin. A huge pericardial cyst originating from the right diaphragmatic surface was excised through a mini-sternotomy incision with smooth postoperative recovery. The patient-reported significant improvement in her symptoms and her lifestyle during her follow up.

Discussion

Pericardial cysts represent 6%-7% of all mediastinal masses with an estimated incidence of 1:100,000. About 70% of pericardial cysts originate at the right cardiophrenic angle and less frequently at the left cardiophrenic angle, they are usually suspected when the chest x-ray shows an enlarged contour of the right heart border. Mediastinal cysts have many differential diagnoses and the preoperative decision might be challenging in many cases. Pericardial cysts appear as oval, thin-walled homogeneous masses on cardiac computed tomography. The choice between surgical intervention and conservative follow up is related mainly to the size and symptoms that are induced by the cyst.

Conclusion

As pericardial cysts are rarely diagnosed pathology, a high index of suspicion is essential for diagnosis. Surgical resection is indicated when they are huge, enlarging in size or symptomatic. Morbidity and mortality risks following pericardial cyst excision are very low.

Video-Assisted Thoracoscopic Treatment of Coelomic Cysts

Background: Coelomic cysts are uncommon benign cyctic lesions of the mediastinum. Complete resection of the cyst with surgical treatment is indicated depending on whether the patient is symptomatic or whether the cyst grows during follow-up, or whether the diagnosis is uncertain. Surgical treatment prevents complications, relieves symptoms, and establishes diagnosis. Video-assisted thoracoscopic surgery (VATS) is the best method for excision of these cysts. This approach is safe and effective, has low morbidity, and shortens the length of hospital stay Objectives: We aimed to analyze our experience with coelomic cysts through VATS, reviewing clinical, radiological, and pathological features, early and long-term results of surgical management. Patients and Methods: Between January 2011 and December 2018, 20 patients with coelomic cysts who underwent VATS at our clinic were included in the study. Results: The study included 11 female and 9 male patients with a mean age of 45.6 years. Symptoms were present in 17 patients and 3 were asymptomatic. The average cyst diameter was 5.4 cm (range 2-8 cm). Fourteen of them were right sided, the others were left sided. There were no operative mortality and complications. Postoperatively there were no complications, in all cases course was uneventful, all of them were discharged after a mean of 3 days (range 2-6 days). Conclusions: Considering the low complication rate and hospital stay, excision of coelomic cysts through VATS is extremely safe and comfortable, so it should be considered the primary therapeutic procedure.

Pericardial Cyst: Cause of Sudden Cardiac Death?

Cardiovascular disease is the leading cause of sudden death in the world. The etiology of sudden cardiac death involves a wide range of diseases, but seldom pericardial cysts. A pericardial cyst is an uncommon cyst usually located in the middle mediastinum and rarely in the posterior part. They are usually harmless and asymptomatic. Here, we present a case of a 63-year-old woman who presented with dyspnea and hoarseness, but died suddenly after a CT scan was attempted. The detailed forensic pathologic and histologic examination revealed a pericardial cyst located in the posterior mediastinum. Toxicology and biochemistry tests, including tryptase, found no competing cause of death.

Inflammation and Rupture of a Congenital Pericardial Cyst Manifesting Itself as an Acute Chest Pain Syndrome

We present the case of a 63-year-old woman with a remote history of supraventricular tachycardia and hyperlipidemia, who presented with recurrent episodes of acute-onset chest pain. An electrocardiogram showed no evidence of acute coronary syndrome. A chest radiograph revealed a prominent right-sided heart border. A suspected congenital pericardial cyst was identified on a computed tomographic chest scan, and stranding was noted around the cyst. The patient was treated with nonsteroidal anti-inflammatory drugs, and the pain initially abated. Another flare-up was treated similarly. Cardiac magnetic resonance imaging was then performed after symptoms had resolved, and no evidence of the cyst was seen. The suspected cause of the patient's chest pain was acute inflammation of a congenital pericardial cyst with subsequent rupture and resolution of symptoms.

Pericardial Masses, Cysts and Diverticula: A Comprehensive Review Using Multimodality Imaging

Pericardial masses/tumors, cysts, and diverticula are quite rare. Presentation is variable and often patients may be asymptomatic with pericardial involvement initially only detected at time of autopsy. When patients do present with symptoms they are often non-specific and often mimic other conditions of the pericardium such as pericarditis, pericardial effusion, constriction or tamponade. Therefore, echocardiography and cross-sectional imaging are essential in identifying and characterizing pericardial disease. Imaging findings vary in specificity depending on the type of tumor. The purpose of this review is to describe the role of multi-modality imaging and characteristic findings in patients with pericardial masses/tumors, cysts, and diverticula.

Pleuropericardial cyst torsion: case report

Pericardial cysts account for 12-18% of all mediastinal masses. They are usually asymptomatic and incidentally detected. However, when large, they can cause symptoms. Most pericardial cysts are located in the right cardiophrenic angle, but they can be anywhere in the mediastinum. We reported a pleuropericardial cyst torsion after physical stress, a very rare complication of this condition. The diagnosis was made by computed tomography and confirmed by video-assisted thoracoscopy.

Unusual coexistence of pulmonary sclerosing hemangioma and pericardial cyst

Pulmonary sclerosing hemangioma is an uncommon tumor, thought to be a benign neoplasm. Pericardial cysts are also uncommon benign abnormalities, most often found incidentally on chest radiography. We describe the case of a 51-year-old woman in whom both lesions were incidentially detected on a routine chest radiograph. Enucleation of the pulmonary sclerosing hemangioma and simultaneous resection of the pericardial cyst were undertaken.

[Pleuropericardial cyst rupturing into the pericardium causing tamponade]

Pleuropericardial cysts of the mediastinum are rare lesions, usually congenital but exceptionally acquired. They are often asymptomatic, but complications can occur. We report below the case of a 35-year-old man who presented with an acquired right-sided para-tracheal mesothelial cyst that ruptured into the pericardium and was responsible for clinical tamponade. Although the majority of mesothelial cysts are asymptomatic, only a strict clinical and radiological follow-up can provide an indication for surgical resection. This should be reserved for symptomatic patients or for those facing an uncertain diagnosis.

Atypically located pericardial cyst compressing the left ventricle during the whole cardiac cycle: a case report

We report the uncommon case of a pericardial cyst with unremitting compression of the left ventricle during the whole cardiac cycle, but normal ejection fraction. On CT scan, the cyst was found at an atypical location, lateral to the pulmonary artery, the ascending aorta, and the right ventricular outflow tract in the left anterior mediastinum. The radio-density of the cyst was 41 Hounsfield units (HU), higher than other cases reported in the literature. As the cyst was stable, conservative treatment was adopted. The usefulness of echocardiography for the diagnosis and follow-up of pericardial cysts is discussed.

Imaging of an atypical pericardial cyst

Pericardial cysts are uncommon mediastinal lesions that are usually congenital in origin. Patients are usually asymptomatic and the cysts are generally discovered on routine radiography for unrelated purposes. This case illustrates a symptomatic presentation of a haemorrhagic pericardial cyst in which radiographic, echocardiographic and multislice (MRI and CT) imaging were performed. The imaging findings were not typical of pericardial cysts leading to a diagnostic quandary despite the varied imaging techniques. In conclusion, it is important to appreciate that the imaging findings of pericardial cysts can be varied. Radiologists and clinicians alike should be aware of this variability.

Atypically located pericardial cyst in a patient who underwent off-pump myocardial revascularization

Pericardial cysts are rare benign mediastinal lesions and most commonly located at the cardiophrenic angle. We present a case of an atypically located pericardial cyst in a patient who underwent myocardial revascularization. A 61-year-old man with acute myocardial infarction was scheduled for coronary artery bypass grafting (CABG). Preoperative chest computed tomography revealed a homogenous cystic lesion in the superior mediastinum. The mass was located between the ascending aorta, the superior vena cava, and the left innominate vein. It was growing to the anterior of the aorta and to the right anterior paratracheal area. The density of the mass was close to that of water; thus, the contrast medium failed to enhance its visualization. A concomitant resection of the mass and the CABG was scheduled. After a medial sternotomy and bypass graft harvest, a median pericardectomy was performed. The surgeon found the cystic mass along the roof of the pericardium and located between the ascending aorta and superior vena cava. There was no adhesion between the mass and cardiovascular components. The mass was resected en bloc; therefore, off-pump CABG was completed. Histopathological examination of the resected specimen confirmed diagnosis of a pericardial cyst.

Diagnosis of pericardial cysts using diffusion weighted magnetic resonance imaging: A case series

Introduction

Congenital pericardial cysts are benign lesions that arise from the pericardium during embryonic development. The diagnosis is based on typical imaging features, but atypical locations and signal magnetic resonance imaging sequences make it difficult to exclude other lesions. Diffusion-weighted magnetic resonance imaging is a novel method that can be used to differentiate tissues based on their restriction to proton diffusion. Its use in differentiating pericardial cysts from other pericardial lesions has not yet been described.

Case presentation

We present three cases (a 51-year-old Caucasian woman, a 66-year-old Caucasian woman and a 77-year-old Caucasian woman) with pericardial cysts evaluated with diffusion-weighted imaging using cardiac magnetic resonance imaging. Each lesion demonstrated a high apparent diffusion coefficient similar to that of free water.

Conclusion

This case series is the first attempt to investigate the utility of diffusion-weighted magnetic resonance imaging in the assessment of pericardial cysts. Diffusion-weighted imaging may be a useful noninvasive diagnostic tool for pericardial cysts when conventional imaging findings are inconclusive.

Right mesothelial pericardial cyst determining intractable atrial arrhythmias

Pericardial cysts are intrathoracic lesions usually considered to be congenital and less frequently to be acquired. They are normally found incidentally upon chest radiography, computed tomography (CT)-scan or echocardiography. They are usually asymptomatic and have a benign behavior although sometimes they can cause clinical symptoms and diagnosis can be uncertain. We present, herein, the case of a 51-year-old male with a history of atrial arrhythmia resistant to transcatheter ablation therapies with an accidental finding of a pericardial cyst adherent to the lateral wall of the right atrium at the emerging superior vena cava. The patient was studied with transesophageal echocardiography, CT-scan and cardiovascular magnetic resonance with the evidence of dimensional increasing of the cyst at seriate controls. Considering this, in the absence of a definitive diagnosis and suspecting a link between the mass and the arrhythmia, the cyst was surgically removed through median sternotomy, off-pump on a beating heart. Postoperative course was unremarkable. Histopathologic examination confirmed it was a mesothelial pericardial cyst. At 12 months of follow-up the patient is doing well and he is in sinus rhythm. In conclusion, we believe that, although the majority of pericardial cysts need only radiological and clinical follow-up, surgical resection should be performed when the patient is symptomatic and when diagnosis is uncertain.

Hemorrhage into a pericardial cyst and associated right ventricular compression after blunt chest trauma

Hemorrhage into a pericardial cyst is an extremely rare event after blunt chest injury and may lead to compression of cardiac chambers. Most pericardial cysts develop adjacent to the sternum, at the right or left cardiophrenic angle; therefore a direct blow to the chest may be associated with hemorrhage into a pericardial cyst. Surgical resection is reasonable because hemorrhagic content of cysts may cause failure of percutaneous interventions. The authors present the case of 20-year-old man with a giant hemorrhagic pericardial cyst diagnosed after blunt chest injury, which caused isolated compression of the right ventricle and demonstrates clinical features of this rare pathology.

Lesions of the cardiophrenic space: findings at cross-sectional imaging

Cross-sectional imaging techniques allow excellent visualization of the cardiophrenic space. Under normal conditions, the cardiophrenic space is occupied by fat, the amount of which is usually increased in overweight individuals. It has been suggested that this fat accumulation correlates with the risk of cardiovascular disease. Several alterations originating above or below the diaphragm can affect the cardiophrenic space. Inflammatory lesions such as pericardial fat necrosis and tumoral masses are sometimes seen. Lymphoma is a major but not exclusive cause of cardiophrenic adenopathy and must be differentiated from lymphatic seeding of supradiaphragmatic and infradiaphragmatic malignancies. In patients with portal hypertension, cardiophrenic space varices are not uncommon. Other masses or pseudomasses occurring in this region include pericardial cysts, mediastinal tumors, and diaphragmatic hernia. Computed tomography and magnetic resonance imaging of the thorax are helpful in characterizing cardiophrenic lesions initially identified at plain radiography. Such characterization helps narrow the differential diagnosis when lesions are detected in this location.

Pericardial Cyst: Case Reports and a Literature Review

Pericardial cysts are rare mediastinal abnormalities, which are usually congenital but may also be acquired after cardiothoracic surgery. Cysts frequently occur in the right cardiophrenic angle and their diagnosis is usually suspected after an abnormal chest X ray is obtained. The presence of a pericardial cyst in this typical location or, less frequently, in an unusual location, poses a diagnostic challenge in distinguishing it from other intracardiac or mediastinal abnormalities. Two-dimensional echocardiography and transesophageal echocardiography are extremely valuable in diagnosing the presence of a pericardial cyst. Although most pericardial cysts are asymptomatic, patients may present with chest pain and dyspnea. In addition, life-threatening complications such as pericardial tamponade have been reported in association with pericardial cysts. The following cases illustrate the usefulness of two-dimensional echocardiography in making an accurate diagnosis of a pericardial cyst, as well as in follow-up of these patients for the development of possible complications.

Pericardial cysts in children: surgical or conservative approach?

The authors present a case of an 11-year-old boy with a history of mild asthma and cough who underwent radiographic examination of the chest. The radiograph showed a round, discrete mass in the right cardiophrenic angle. The patient underwent thoracoscopic excision, and histologic examination found a unilocular, pericardial cyst. The possible causes of mediastinal masses and an argument for their surgical removal is presented.

Thoracoscopic resection of unusual symptomatic pericardial cysts

Pericardial cysts are mediastinal tumors that usually have a benign course. Diagnostic and therapeutic thoracoscopy are warranted for suspect mediastinal masses, unsuccessful nondiagnostic less invasive procedures, and symptomatic unusually located pericardial cysts. We report a case of thoracoscopic resection of symptomatic pericardial cysts.

Value of transesophageal echocardiography in the diagnosis of compressive, atypically located pericardial cysts

Pericardial cysts are not common and rarely cause symptoms. We report 2 cases of atypically located pericardial cysts with hemodynamic compromise because of the direct compression of the pulmonary veins and the right pulmonary artery. In the first case, transesophageal echocardiography (TEE) disclosed a round cystic mass compressing the posterior wall of the right pulmonary artery, with blood flow reduction in the right lung. Because of the symptoms, the pericardial cyst was drained and the patient had an uneventful 1-year follow-up. In the second case, a large cystic mass compressing the left atrium and the pulmonary vein outflow was clearly shown by TEE in a patient with severe respiratory distress, cyanosis, and low blood pressure. A left ventricular thoracotomy was performed with the drainage of 500 mL serous fluid from the cyst.

Atypically located pericardial cysts

Pericardial cysts are uncommon benign abnormalities and are most often found in either cardiophrenic angle. We present the cases of 3 patients with a cyst in the mediastinum and review the literature. Pathological examination confirmed the diagnosis of pericardial cyst. Clinicians should include pericardial cyst in the differential diagnosis of mediastinal masses.

Asymptomatic Pericardial Hydatid Cyst

Cardiac involvement is rare in hydatid disease, but it carries a significant risk of potentially lethal complications. Cardiac hydatid cysts are mostly intramyocardial. Pericardial hydatid cysts without myocardial involvement are much less frequent. Cardiac imaging techniques, particularly two-dimensional echocardiography, are more useful in the detection of cardiac cysts. We present an incidentally detected, asymptomatic, pericardial hydatid cyst.http://link.springer-ny.com/link/service/journals/00547/bibs/8n3p161.html

A surgical gauze appearing as a retrocardiac mass in a patient after coronary artery bypass surgery

Five years after open chest surgery because of three vessel coronary artery disease a patient was referred for progressing dyspnea and recent onset of atrial fibrillation. A retrocardiac mass was detected on chest X-ray and echocardiography. On CT-scan, the inhomogenous tumor made the diagnosis of a retained surgical gauze likely. Through a left incision the sponge was removed uneventfully and the dyspnea resolved.

Echocardiographic diagnosis of pericardial cyst

A 52-year-old woman was seen with atypical chest pain. A routine chest roentgenogram revealed an enlarged cardiac silhouette. Results of transthoracic echocardiography performed using the standard views was normal. Because of the discrepancy between the findings of chest roentgenogram and transthoracic echocardiography, a biplane transesophageal echocardiogram was obtained and revealed the presence of a pericardial cyst.

Case report: misdiagnosis of an atypical pericardial cyst presenting in a patient with chest trauma

We report a patient who presented following major trauma to the chest who had a pericardial cyst in the anterior aspect of the upper mediastinum, the high CT number of which led to a misdiagnosis. The patient underwent surgery when the pericardial cyst was excised.