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Pericardial Cyst

Cysts Pericardial

Pericardial cyst is a rare and benign abnormality. Many patients harboring pericardial cysts are asymptomatic. However, serious, even fatal, complications can arise, such as cardiac failure. Small cysts and asymptomatic cases may be managed conservatively. Surgical resection is recommended if the cysts are large or compress neighboring organs, or the symptoms are troubling or dangerous.


Presentation

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.

Asymptomatic
  • Subsequently, the patient has been asymptomatic for nine years and appears to be in complete remission. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • Many patients harboring pericardial cysts are asymptomatic. However, serious, even fatal, complications can arise, such as cardiac failure. Small cysts and asymptomatic cases may be managed conservatively.[symptoma.com]
  • They are usually asymptomatic and diagnosed incidentally on echocardiography or chest X-ray.[ncbi.nlm.nih.gov]
  • While most pericardial cysts are asymptomatic, some patients may present with compression symptoms. We present the case of a 22-year-old man who presented with a right pericardial cyst that caused compression of the right ventricle.[ncbi.nlm.nih.gov]
  • Most are asymptomatic and a common incidental finding on routine chest radiograph. We report a case of large pericardial cyst presenting with severe excruciating chest pain in a Nigerian man.[ncbi.nlm.nih.gov]
Chest Discomfort
  • Abstract A 47-year-old woman presented with shortness of breath, chest discomfort, and hoarseness. She was found to have an enlarged cardiac silhouette on plain chest radiography.[ncbi.nlm.nih.gov]
  • Abstract 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.[ncbi.nlm.nih.gov]
  • Herein, we present a case of pericardial cyst compressing the left atrium complicated by a pericardial effusion and pleural effusion in a 62 year-old man with chest discomfort and dyspnoea.[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]
  • In asymptomatic patients, no treat-ment is necessary.Case descriptionA 72-year-old woman presented to our outpatient clinic for dyspnoea and chest discomfort with minimal exertion. Her blood pressure was 100/80 mmHg.[documents.tips]
Persistent Cough
  • Symptomatic pericardial cysts present with dyspnoea, chest pain, or persistent cough.[ncbi.nlm.nih.gov]
  • Even the majority are asymptomatic ( 50%), the localization and relation to adjacent structures lead the role of the clinical manifestations (persistent cough, dyspnoea, chest pain...).[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]

Workup

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
  • Abstract 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]
  • Abstract Pericardial cysts are rare congenital abnormalities with a reported incidence rate of 1:100,000, accounting for about 7.6% of all mediastinal masses.[ncbi.nlm.nih.gov]
  • KEYWORDS: cardiac; cardiomegaly; chest pain; echocardiogram; echocardiography; emergency department; emergency radiography; emergency radiology; focused cardiac ultrasonography; mediastinal mass; pericardial; pericardial cyst; point-of-care; ultrasound[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]
  • The cysts constitute less than ten percent of mediastinal masses and about a third of mediastinal cysts. They range in size from about 2 cm to almost 30 cm, with a layer of mesothelial cells lining them.[symptoma.com]
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]

Treatment

  • Although definitive diagnosis and management were not accomplished at the bedside in this case, an abnormal finding on FOCUS prompted further investigation and timely treatment. Copyright 2016 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Surgery is the preferred choice of treatment in these patients.[ncbi.nlm.nih.gov]
  • The only treatment for pericardial cysts is surgical excision and patients recover fully with no complication.[ncbi.nlm.nih.gov]
  • We present a patient with a symptomatic intra-pericardial cystic lesion with intermittent syncope who underwent treatment using a laparoscopic approach, thus minimizing pain and allowing quick recovery.[ncbi.nlm.nih.gov]
  • As the cyst was stable, conservative treatment was adopted. The usefulness of echocardiography for the diagnosis and follow-up of pericardial cysts is discussed. Copyright 2012 Wiley Periodicals, Inc.[ncbi.nlm.nih.gov]

Prognosis

  • Signal characteristics are those of fluid and include 4 : T1: typically low signal (occasionally can be high signal if contains proteinaceous material) T2: high signal T1 C (Gd): no enhancement Treatment and prognosis They are benign lesions.[radiopaedia.org]
  • This cyst generally presents a favorable prognosis, although its natural history is not completely known. 3 The literature reports cases ranging from spontaneous disappearance to recurrence after surgical resection, as well as serious, even fatal complications[revespcardiol.org]

Etiology

  • A pericardial cyst is a rare finding and is frequently congenital in etiology. Pericardial cysts are most commonly incidental findings and have no clinical significance.[healio.com]
  • A concept of etiology and report of cases. J Thorac Surg 1950;20:494–504. PubMed Google Scholar 4. Kutlay H, Yavuzer I, Han S, et al. Atypically located pericardial cysts. Ann Thorac Surg 2001;72:2137–2139. PubMed CrossRef Google Scholar 5.[link.springer.com]
  • Pericardial and bronchogenic cysts share the second most common etiology after lymphomas[1]. The presented case is of a symptomatic pericardial cyst.[ctsnet.org]
  • Most are congenital, although several acquired cases with an infectious, inflammatory, or traumatic etiology have been described.[revespcardiol.org]

Prevention

  • In order to prevent complications, the giant pericardial cyst was excised outside of the pericardium with median sternotomy.[ncbi.nlm.nih.gov]
  • In order to prevent complications, the giant pericardial cyst was excised outside of the pericardiumwith median sternotomy.[journals.co.za]
  • Diagnosis is confirmed with computed tomography or magnetic resonance imaging, and surgical treatment is indicated for symptomatic patients. 1, 2 Watchful observation may be feasible for asymptomatic patients, but outcome data are lacking and thus preventive[westjem.com]
  • The indications for resection of pericardial cysts include large size, symptoms, patient concern, uncertainty of malignant potential, and prevention of the life threatening emergencies.[ctsnet.org]
  • The indications for resection of pericardial cysts are large size, symptoms, patient concern, uncertainty of malignant potential, and prevention of the life threatening emergencies.[keralamedicaljournal.com]

References

Article

  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.

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Last updated: 2018-06-22 08:16