739

Case Report

....

CT Diagnosis of Acute Pericardial Tamponade After Blunt

Chest Trauma
American Journal of Roentgenology 1989.152:739-741.

Laurence Goldstein,1 Stuart E. Mirvis,1 Irene S. Kostrubiak,1 and Stephen Z. Tume?

CT has been used to diagnose injury after both blunt and The right hip was fixed in internal rotation. The abdomen was firm,
penetrating thoracic trauma [1 -4]. Applications include the and the bowel sounds were hypoactive. On admission, the hematocrit
diagnosis of mediastinal hemorrhage, subtle pneumothorax, was 52.5%. An anteropostenor chest radiograph obtalned on admis-
pulmonary laceration, parenchymal hematomas, and pleural sin was interpreted as normal.
The patient received rapid IV fluid resuscitation, with an increase
and pericardial effusions [1 -4]. Although CT is valuable for
in systemic blood pressure to 1 20/80 mm Hg. Arteriography indicated
detection and evaluation of pericardial effusions and may that the thoracic aorta was not injured. Abdominal CT with IV contrast
show signs that suggest pericardial constriction, such as a enhancement was then done to exclude intraabdominal or retroperi-
dilated inferior vena cava, a deformed ventricular contour, or toneal injuries. Initial CT sections through the lower chest revealed a
an angulated interventricular septum [5], the diagnosis of pericardial effusion with a CT density of 35-45 H, consistent with
acute pericardial tamponade following trauma is usually es- hemorrhage 1). Because of the pencardial effusion, we obtained
(Fig.
tablished by clinical signs. These signs include tachycardia, more cephalad sections through the thorax to include the entire
diminished cardiac output, increased central venous pressure, pericardial space. The superior and inferior vena cavae and the renal
elevated systemic vascular resistance, distended neck veins, veins were distended (Fig. 1). Areas of linear low attenuation paral-
leling the portal veins were thought to represent periportal lymph-
and muffled cardiac sounds. Emergency bedside cardiac so-
edema or tracking of penportal blood (Fig. 1). The rest of the CT
nography can document the presence of pericardial effusion
study was unremarkable.
before surgical intervention [2].
Because the clinical and CT findings were compatible with pencar-
We present a case of acute pericardial tamponade shown dial tamponade, the patient underwent a median stemotomy. The
by emergency CT scanning of the thorax after closed blunt pencardium was tense, and after incision, unclotted blood flowed
chest trauma. A triad of CT findings diagnostic for acute freely from the pericardial space. A 1 .5-cm laceration of the right
pericardial tamponade is illustrated. auncular appendage near the entrance of the superior vena cava was
kientified and oversewn. After pericardial blood was evacuated, the
systemic blood pressure increased to 200/1 20 mm Hg and the pulse
Case Report rate decreased from 1 30 to 90 beats per minute. Orthopedic injuries
to the right hip and acetabulum were repaired later.
A 1 9-year-old man was admitted to our trauma center after a motor The patient’s postoperative course was complicated by pneu-
vehicle accident. Four hours had elapsed from the time of injury. On monia. On a follow-up abdominal CT, obtalned 2 weeks after admis-
admission, the patient complained of pain in his chest and right hip. sion, the inferior vena cava was considerably less prominent and
Physical examination revealed an alert individual with a systolic blood appeared flattened in the anteroposterior dimension. The periportal
pressure of 1 04 mm Hg and a pulse rate of 1 40 beats per minute. lymphedema pattern in the liver had resolved (Fig. 1). After gradual
The upper thorax looked dusky, and the neck veins were distended. improvement, the patient went home 36 days after surgery.

Received November 10, 1988; accepted after revision December 27, 1988
I Department of Diagnostic Radiology, University of Maryland Medical System, 22 S. Greene St., Baltimore, MD 21201 . Address reprint requests to S. E. Mirvis.
2 Maryland Institute for Emergency Medical Services Systems, thiiversity of Maryland Medical System, 22 S. Greene St., Baltimore, MD 21201.
AJR 152:739-741, April 1989 0361-803X/89/1524-0739 © American Roentgen Ray Society
 740 GOLDSTEIN ET AL. AJR:152, April 1989
American Journal of Roentgenology 1989.152:739-741.

Fig. 1.-CT of pericardial tamponade.

A, Enhanced CT scan through mldcardiac level shows small pericardial effuslon(arrows). Density was between 35 and 45 H compatiblewith hemorrhagic
fluid. Also note small, bilateral, pleural effuslons and Increased density around descending aorta consistent with mediastlnal hemorrhage. Thoraclc
aortogram revealed no Injury.
B, Axial scan at level of proximal great vessels shows distended superior vena cava (arrow) approximating size of aortic root.
C, Scan at midhepatic level shows diffuse low density paralleling petal venous structures (arrows), most suggestive of periportal lymphedema due to
high venous hydrostatic pressure. Note markedly distended inferior vena cava (arrowhead).
D, Scan at more caudal level shows dIstended right renal vein (arrow). Left renal vein, partially shown, was also markedly dilated.
E, Scan through upper abdomen obtained 2 weeks after admission shows anatomic changes after correction of cardiac tamponade. Inferior vena cave
is considerably lass prominent and narrowed in anteroposterlor dimension (arrow). Periportai lymphedema has resolved.

Discussion gency bedside cardiac sonography to confirm the presence

of pericardial fluid.
Acute cardiac rupture after blunt chest trauma is a rare and In this patient, despite suggestive physical signs, pericardial
often fatal injury. Most often the left ventricle is involved, tamponade was not considered likely, and the patient re-
resulting in rapidly fatal pericardial tamponade [6]. Rupture of mained hemodynamically stable with IV administration of fluid.
the atria after blunt chest trauma is rare [6]. Bleeding into the Emergency aortography and abdominal CT were performed
pericardium from the lower-pressure atria can produce a to exclude other injuries. In our institution, abdominal CT
slower accumulation of pericardial blood, which permits sur- scanning is started at the lower thorax to exclude pneumo-
vival long enough to reach a medical facility. Typically, diag- thorax, pleural effusions, parenchymal lung injury, and peri-
nosis of cardiac tamponade depends on recognition of a cardial effusion. CT showed pencardial effusion with a density
physiologic pattern of tachycardia, elevated central venous compatible with blood. Continued scanning through the ab-
pressure, elevated systemic vascular resistance, muffled car- domen revealed distension of the inferior vena cava and renal
diac sounds, distended neck veins, and diminished cardiac veins and periportallow density compatible with lymphedema.
output. Recognition of these findings may lead to prompt Increased pericardial pressure most likely resulted in in-
pericardiotomy or pericardiocentesis, perhaps after emer- creased central venous pressure with distension of the inferior
 AJR:152, April 1989 CT OF ACUTE PERICARDIAL TAMPONADE 741

vena cava and renal veins and development of periportal the pathophysiologic pattern of tamponade may not be fully
lymphedema. We think that the long time from initial injury to developed or may be masked by rapid IV administration of
CT scanning permitted development of periportal lymphe- fluid, use of vasopressors to maintain systemic blood pres-
dema. Although the superior vena cava also appeared en- sure, or more apparent injuries. The triad of CT findings of
larged in this patient, it was less distended then the inferior hemorrhagic pericardial fluid, distended central veins (e.g.,
vena cava. Doppman et al. [5] have observed that superior the vena cavae or renal veins), and periportal lymphedema
vena caval distension is not as striking a finding as inferior should suggest the diagnosis and lead to therapeutic inter-
vena caval distension on CT studies of patients with constric- vention.
tive pericarditis.
Although a similar CT appearance for periportal tracking of
blood after has been described [7], we think that
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