CASE 13323 Published on 25.01.2016

Traumatic pericardial rupture

Section

Cardiovascular

Case Type

Clinical Cases

Authors

Joelin Teh, Fatima Zakeer, Chandra Hewavitharana

Royal Perth Hospital;
197 Wellington Street
6000 Perth;
Email:joelinteh@yahoo.com.my
Patient

64 years, female

Categories
Area of Interest Cardiovascular system, Emergency, Mediastinum, Cardiac ; Imaging Technique Conventional radiography, CT
Clinical History
A 64-year-old female motorist involved in a high-speed motor vehicle accident presents with hypoxia and hypotension.
Imaging Findings
CT chest and abdomen demonstrated significant left-sided chest and abdominal blunt trauma necessitating an emergency thoracotomy and laparotomy. A pleural drain was inserted for a large left pneumothorax. Complete rupture and fragmentation of the pericardium without myocardial contusion was identified intra-operatively. A post-operative chest radiograph in the intensive care unit showed a prominent cardiac silhouette with rotation of the cardiac axis. Subsequent CT chest one day post-operatively confirmed a change in cardiac axis with complete herniation of the heart into the left pleural cavity.
Discussion
Blunt traumatic pericardial rupture is rare, occurring in less than 0.5% of blunt trauma victims [1]. The left pleuropericardium is more commonly involved than the right side or the diaphragmatic pericardium [2]. Haemodynamic instability may arise from small or intermediate sized tears secondary to cardiac strangulation or torsion of the heart around the great vessels. Large left-sided tears, as in our case, may be asymptomatic and may not require further surgical intervention. Pre-operative diagnosis of blunt traumatic pericardial rupture is challenging and requires a high level of clinical suspicion. Imaging findings on chest radiography include a shift of the cardiac silhouette to the right or left, pneumopericardium, bowel loops within the pericardial sac and herniation and rotation of the heart into either pleural cavity [3, 4]. CT is more sensitive than chest radiography in identifying these signs, with the diagnosis almost always made during surgical exploration. Once diagnosed, concomitant cardiac injury and great vessel injury should be excluded.
Differential Diagnosis List
Blunt traumatic pericardial rupture
Congenital absence of the pericardium
Cardiac herniation
Final Diagnosis
Blunt traumatic pericardial rupture
Case information
URL: https://www.eurorad.org/case/13323
DOI: 10.1594/EURORAD/CASE.13323
ISSN: 1563-4086
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