Pericardial cyst occurs rarely, with one person affected in 100,000 [1] [2]. The cysts constitute less than ten percent of mediastinal masses and about a third of mediastinal cysts [3]. They range in size from about 2 cm to almost 30 cm [4], with a layer of mesothelial cells lining them [2]. The cysts are usually congenital [1], and originate from the pericardial coelom as the result of abnormal embryonic development [5]. They are most often found at the right cardiophrenic angle [2]. Alternative names include springwater cyst because the fluid inside the cysts has been characterized as crystal clear [5]. Otto Pickhardt performed the first resection of a pericardial cyst and found an orange-sized, shiny cyst [5] [6].

Most patients are asymptomatic and the cysts are discovered on radiographs or echocardiograms obtained for unrelated reasons. Symptoms, if they occur, are most often caused by compression of neighboring structures. The most frequent symptoms of pericardial cysts are chest pain, dyspnea, and cough.

Rare but serious complications can arise. One of these is cardiac tamponade, which is usually caused by rupture of the cyst inside the pericardium [6], or by hemorrhage from the cyst [7] [8]. Chest pain and signs of respiratory tract infection have been reported [9]. Pulmonary stenosis, right ventricular outflow obstruction, and infection of the cyst can also occur [10]. Giant cysts have been described, one that slowly grew to a size that held two and a half liters of fluid [11], and another that resulted in the unusual symptom of recurrent syncope because of compression of the right ventricle [12]. A pericardial cyst may infrequently erode adjacent structures, such as the superior vena cava [13], or partially erode into the right ventricular wall [14]. The cysts can occasionally resolve without intervention.

• Chest Discomfort

  We report a young girl who presented to us with chest discomfort and had a paracardiac mass on chest radiograph. Computerised tomographic (CT) scan of the thorax was suggestive of pericardial cyst. Hydatid serology was negative. The cyst was excised. [ncbi.nlm.nih.gov]

  She had experienced 30 years of atypical chest discomfort. The symptoms did resolve by a surgical procedure, removing the pericardium. Please feel free to download Dr. Money’s case report and literature review to read more. [pcaofhagerstown.com]

  Case reports Case 1 A 48-year-old woman sought care for chest discomfort, generalized fatigue, and dyspnoea with minimal exertion. The symptoms were of 10 months' duration. After exercise, her dyspnoea typically lasted for about 2 or 3 h. [academic.oup.com]

• Spontaneous Hemorrhage

  Spontaneous hemorrhage into a pericardial cyst is an extremely rare event, and to our knowledge this is the first case in which a pericardial cyst has been shown to cause recurrent syncope. [ncbi.nlm.nih.gov]

  Cardiac tamponade is usually due to intra-pericardial rupture of the cyst, although tamponade due to spontaneous hemorrhage into the cyst has also been reported[2,4]. [ctsnet.org]

• Aspiration

  We describe four patients with symptomatic pericardial cysts who were treated with either echocardiographically guided percutaneous aspiration or video-assisted thoracoscopic surgery, or both; thoracotomy; or conservative therapy. [ncbi.nlm.nih.gov]

  Percutaneous aspiration of a pericardial cyst: an acceptable treatment for a rare disorder. Heart. 2007 ; 93 : 22. Crossref Medline Google Scholar [circ.ahajournals.org]

  The patient underwent echocardiography-guided percutaneous aspiration of the pericardial cyst, during which 1100 mL of serous fluid was removed. [academic.oup.com]

• Persistent Cough

  Symptomatic pericardial cysts present with dyspnoea, chest pain, or persistent cough. [ncbi.nlm.nih.gov]

  If present, symptoms are usually due to compression of adjacent organs and include atypical chest pain, dyspnea, and persistent cough[2]. [ctsnet.org]

  Symptoms, when present, are usually due to compression of adjacent organs and in-clude atypical chest pain, dyspnoea and persistent cough [5]. [documents.tips]

• Ejection Murmur

  The jugular venous pressure was elevated and a grade 2/6 systolic ejection murmur was found. The lungs were clear. Abdominal examination revealed hepatomegaly and ascites. A clinical diagnosis of right sided heart failure was made. [panafrican-med-journal.com]

  The patient had elevated jugular venous pressure, bilateral pitting pedal edema, engorged superficial veins in lower limb, ascites, hepatomegally, left varicocele and a grade 2/6 systolic ejection murmur over the precordium. [interventional-cardiology.imedpub.com]

Imaging methods include plain radiography, echocardiography, computed tomography (CT) scans, and magnetic resonance imaging (MRI). Computed tomography is regarded as the method of choice, because it is helpful in determining the location of lesions, and detects pericardial thickening, and other defects [2] [15]. CT can distinguish masses derived from mediastinal structures from those arising outside the mediastinum. CT scans can also differentiate cystic structures from solid ones. In problematic cases, injection of contrast material into the cyst may aid in the diagnosis [2]. Most pericardial cysts show well-defined, non-enhancing attenuation on CT scans [15]; however, protein content in the cysts interferes with attenuation. Hemorrhagic cysts show hyperattenuation.

MRI is also helpful in diagnosis and follow-up examinations. It yields a high signal intensity on T2 weighted images, and a low signal intensity on T1 weighted images. This is altered in cysts containing a high concentration of protein. Diffusion weighted images may be useful in certain cases [16].

Ultrasound techniques are not the generally favored method for diagnosing pericardial cysts, although echocardiography can be a useful tool for determining the location of the cyst, and for differentiating it from other structural anomalies [2]. Echocardiography has the advantage over CT in that no ionizing radiation is involved [1].

• Mediastinal Mass

  Patient with a mediastinal mass may be diagnosed incidentally or following evaluation for the symptoms due to compressive effects on the adjoining structures. Pericardial cysts account to 6% of mediastinal masses. [ncbi.nlm.nih.gov]

  Echocardiography Mediastinal mass Pericardial cyst Transoesophageal echocardiography Transthoracic echocardiography Cardiology and Cardiovascular Medicine Radiology Nuclear Medicine and imaging Cite this Apa Standard Harvard Vancouver BIBTEX RIS Najib [mayoclinic.pure.elsevier.com]

  Pericardial cysts represent 6% of mediastinal masses. See the differential diagnosis of caridophrenic angle masses here. About radiologypics I am a radiology physician from California, USA. [radiologypics.com]

  Surgical resection or aspiration may be performed for symptomatic selected cases 6-7. pericardial diverticulum 9 As general differential on cross sectional imaging cystic mediastinal masses On a chest radiograph also consider: pericardial fat pad thymic [radiopaedia.org]

• Anterior Mediastinal Mass

  View Article PubMed Google Scholar Uchiyama A, Shimizu S, Murai H, Ohshima A, Konomi H, Ogura Y, Ishikawa N, Yamashita H, Matsumoto S, Kuroki S, Tanaka M: Infrasternal mediastinoscopic surgery for anterior mediastinal masses. [casesjournal.biomedcentral.com]

• Right Axis Deviation

  The electrocardiography detected sinus tachycardia of 104 beats per minutes, right axis deviation, an incomplete right bundle-branch block and no conduction disturbances. A chest X ray was normal. [panafrican-med-journal.com]

  The electrocardiography detected right axis deviation and incomplete right bundle-branch block. In echocardiography the inferior vena cava and hepatic veins were dilated without respiratory variation in size of the inferior vena cava. [interventional-cardiology.imedpub.com]

• Staphylococcus Aureus

  View Article PubMed Google Scholar Hoque M, Siripurapu S: Methicillin-resistant Staphylococcus aureus-infected pericardial cyst. Mayo Clin Proc. 2005, 80 (9): 1116-1116. [casesjournal.biomedcentral.com]

  Hoque M, Siripurapu S (2005) Methicillin-resistant Staphylococcus aureus-infected pericardial cyst. Mayo ClinProc 80: 1116. [interventional-cardiology.imedpub.com]

• Right Bundle Branch Block

  The electrocardiography detected sinus tachycardia of 104 beats per minutes, right axis deviation, an incomplete right bundle-branch block and no conduction disturbances. A chest X ray was normal. [panafrican-med-journal.com]

  The electrocardiography detected right axis deviation and incomplete right bundle-branch block. In echocardiography the inferior vena cava and hepatic veins were dilated without respiratory variation in size of the inferior vena cava. [interventional-cardiology.imedpub.com]

• Incomplete Right Bundle Branch Block

  The electrocardiography detected sinus tachycardia of 104 beats per minutes, right axis deviation, an incomplete right bundle-branch block and no conduction disturbances. A chest X ray was normal. [panafrican-med-journal.com]

  The electrocardiography detected right axis deviation and incomplete right bundle-branch block. In echocardiography the inferior vena cava and hepatic veins were dilated without respiratory variation in size of the inferior vena cava. [interventional-cardiology.imedpub.com]

1. Kar SK, Ganguly T, Dasgupta S, Mitra M, Bhattacharya R. Pericardial Cyst: A Review of Historical Perspective and Current Concept of Diagnosis and Management. Interv Cardiol J. 2015;1:1-8.
2. Patel J, Park C, Michaels J, Rosen S, Kort S. Pericardial cyst: case reports and a literature review. Echocardiography. 2004;21(3):269-272.
3. Cohen AJ, Thompson L, Edwards FH, Bellamy RF. Primary cysts and tumors of the mediastinum. Ann Thorac Surg. 1991;51: 378-384.
4. Braude PD, Falk G, McCaughan BC, Rutland J. Giant pericardial cyst. Aust N Z J Surg. 1990;60(8):640–641.
5. Schweigert M, Dubecz A, Beron M, Ofner D, Stein HJ. The tale of spring water cysts: a historical outline of surgery for congenital pericardial diverticula and cysts. Tex Heart Inst J. 2012;39(3):330-334.
6. Bandeira FC, deSa VP, Moriguti JC, et al. Cardiac tamponade: An unusual complication of pericardial cyst. J Am Soc Echocardiogr. 1996;9(1):108–112.
7. Shiraishi I, Yamagishi M, Kawakita A, Yamamoto Y, Hamaoka K. Acute cardiac tamponade caused by massive hemorrhage from pericardial cyst. Circulation. 2000;101(19):E196-197.
8. Borges AC, Gellert K, Dietel M, Baumann G, Witt C. Acute right-sided heart failure due to hemorrhage into a pericardial cyst. Ann Thorac Surg. 1997;63(3):845-847.
9. Elamin WF, Hannan K. Pericardial cyst: an unusual cause of pneumonia. Cases J. 2008;1: 26.
10. Hoque M, Siripurapu S. Methicillin-resistant Staphylococcus aureus-infected pericardial cyst. Mayo Clin Proc 2005;80:1116.
11. Satur CM, Hsin MK, Dussek JE. Giant pericardial cysts. Ann Thorac Surg. 1996;61: 208-210.
12. Ilhan E, Altin F, Ugur O, et al. An unusual presentation of pericardial cyst: recurrent syncope in a young patient. Cardiol J. 2012;19: 188-191.
13. Mastroroberto P1, Chello M, Bevacqua E, Marchese AR. Pericardial cyst with partial erosion of the superior vena cava. J. Cardiovas Surg. 1996;37(3):323–324.
14. Chopra PS1, Duke DJ, Pellett JR, Rahko PS. Pericardial cyst with partial erosion of the right ventricular wall. Ann Thorac Surg. 1991;51:840–841.
15. Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW, Higgins CB. CT and MR imaging of pericardial disease. Radiographics. 2003;23 Spec No:S167-80.
16. Raja A, Walker JR, Sud M, et al. Diagnosis of pericardial cysts using diffusion weighted magnetic resonance imaging: A case series. J Med Case Rep. 2011;5:479.