Pediatric Pericardial Effusion

  • Etiology: Accumulation of fluid (serous, chylous, blood) in pericardial space
  • Imaging CXR:
    — Water bottle heart due to large amount of fluid in the pericardial space
    — Epicardial fat sign is good sign of fluid – see pericardial fluid between outer mediastinal fat and inner epicardial fat
  • DDX:
  • Complications:
    — Pericardial space normally has 15-50 cc of fluid
    — Gradual accumulation of fluid in pericardial space can result in more fluid (1500 cc) without serious tamponade
    — Rapid accumulation of 100-200 cc of fluid in pericardial space can cause cardiac tamponade due to diastolic dysfunction
  • Treatment: Cardiocentesis
  • Clinical: In unexplained code in NICU patient need to rule out cardiac tamponade from upper extremity PICC line eroding into pericardial space as etiology of code

Radiology Cases of Pericardial Effusion

Radiology Cases of Chylous Pericardial Effusion

CXR of pericardial effusion
CXR AP shows normal pulmonary vasculature and an enlarged water bottle-shaped heart.
CXR and CT of chylous pericardial effusion
CXR AP (above) shows the heart to be enlarged and to have a water bottle shape. Axial CT with contrast of the chest (below) shows a large amount of high density fluid in the pericardial space.

Radiology Cases of Pericardial Effusion Due To Subclavian Venous Catheter Malposition in the Pericardial Space

CXR of pericardial effusion due to malposition of central line in the pericardial space
CXR AP (left) shows the tip of the newly placed left subclavian venous catheter to project deep within the right atrium while the cardiac silhouette is normal in size. CXR AP 2 days later (right) shows the catheter tip unchanged in position while the cardiac silhouette has increased markedly in size in the interval. Cardiocentesis returned TPN.
CXR of pericardial effusion due to catheter perforation into pericardial space
CXR AP obtained after left subclavian line placement (above) shows the tip of the line in the right atrium. CXR AP obtained 3 days later during the episode of cardiac decompensation (below) shows interval enlargement of the cardiac silhouette. ECHO showed the subclavian line had perforated into the pericardial space resulting in a hemopericardium.

Radiology Cases of Pericardial Effusion Due to Gunshot

CXR and CT of pericardial effusion
CXR AP shows an enlarged cardiac silhouette, bilateral pleural effusions and radioopaque pellets in the right thorax near the hilum and left axilla. Axial and coronal CT with contrast of the chest shows a large amount of fluid in the pericardial space.

Radiology Cases of Pericardial Effusion Due to Histoplasmosis

CXR and US of pericardial effusion due to histoplasmosis
AXR (above left) shows hepatomegaly and an enlarged cardiac silhouette. CXR (above right) shows a water-bottle appearance to the cardiac silhouette and bilateral pleural effusions and bilateral hilar lymphadenopathy. Transverse US of the heart (below) shows a large anechoic fluid collection in the pericardial space.
CXR and CT of pericardial effusion due to histoplasmosis
CXR AP (above left) shows a large cardiac silhouette and an abnormal contour to the right superior mediastinum. Coronal CT with contrast of the chest (above right) shows a huge fluid collection in the pericardial space and a conglomeration of cystic lymph nodes in the right superior mediastinum. Axial CT (below) shows the pericardial fluid collection completely surrounding the heart and left lower lobe atelectasis.