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Imaging Findings in Cardiac Tamponade with Emphasis on CT1

Article  in  Radiographics · November 2007

DOI: 10.1148/rg.276065002 · Source: PubMed

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EDUCATION EXHIBIT 1595

Imaging Findings in
Cardiac Tamponade
with Emphasis on CT1
CME FEATURE C. Santiago Restrepo, MD ● Diego F. Lemos, MD ● Julio A. Lemos, MD
See accompanying Enrique Velasquez, MD ● Lisa Diethelm, MD ● Ty A. Ovella, MD
test at http://
www.rsna.org Santiago Martinez, MD ● Jorge Carrillo, MD ● Rogelio Moncada, MD
/education Jeffrey S. Klein, MD
/rg_cme.html

LEARNING
Cardiac tamponade is a life-threatening condition that results from
OBJECTIVES
FOR TEST 2 slow or rapid heart compression secondary to accumulation of fluid,
After reading this
pus, blood, gas, or tissue within the pericardial cavity. This condition
article and taking can be associated with multiple causes including trauma, inflamma-
the test, the reader
will be able to: tion, scarring, or neoplastic involvement of the pericardial space among
䡲 Describe the others. The main pathophysiologic event leading to tamponade is an
pathophysiology and
clinical manifesta- increase in intrapericardial pressure sufficient to compress the heart
tions of cardiac tam- with resultant hemodynamic impairment, which leads to limited car-
ponade.
diac inflow, decreased stroke volume, and reduced blood pressure.
䡲 List the imaging
findings of develop- These events result in diminished cardiac output, which manifests
ing or impending clinically as a distinctive form of cardiogenic shock. Although cardiac
cardiac tamponade
and its differential tamponade is a clinical diagnosis, imaging studies play an important
diagnostic consider- role in assessment and possible therapeutic intervention. Computed
ations.
tomographic (CT) findings associated with cardiac tamponade include
䡲 Discuss how the
underlying patho- pericardial effusion, usually large, with distention of the superior and
physiologic events inferior venae cavae; reflux of contrast material into the azygos vein
correlate with the
imaging manifesta- and inferior vena cava; deformity and compression of the cardiac
tions of cardiac tam- chambers and other intrapericardial structures; and angulation or bow-
ponade.
ing of the interventricular septum. Familiarity with the clinical and
pathophysiologic features of cardiac tamponade and correlation with
TEACHING
the associated CT findings are essential for early and accurate diagno-
POINTS sis.
See last page ©
RSNA, 2007

Abbreviation: IVC ⫽ inferior vena cava

RadioGraphics 2007; 27:1595–1610 ● Published online 10.1148/rg.276065002 ● Content Codes:

1From the Department of Radiology, University of Texas Health Sciences Center, San Antonio (C.S.R.); the Department of Radiology, Fletcher Allen
Health Care and University of Vermont, FAHC/MCHV Campus, Patrick 1, Room 117, 111 Colchester Ave, Burlington, VT 05401-1473 (D.F.L.,
J.A.L., J.S.K.); the Departments of Cardiology (E.V.) and Radiology (T.A.O., R.M.), Louisiana State University Health Science Center, New Or-
leans; the Department of Radiology, Ochsner Clinic Foundation, New Orleans (L.D.); the Department of Radiology, Duke University, Durham, NC
(S.M.); and the Department of Radiology, Universidad Nacional de Colombia, Bogotá (J.C.). Recipient of a Certificate of Merit award for an educa-
tion exhibit at the 2004 RSNA Annual Meeting. Received January 10, 2006; revision requested March 22; final revision received May 15, 2007; ac-
cepted May 21. All authors have no financial relationships to disclose. Address correspondence to D.F.L. (e-mail: Diego.Lemos@vtmednet.org).
©
RSNA, 2007
1596 November-December 2007 RG f Volume 27 ● Number 6

Figure 1. Suggested diagnostic algorithm for evaluation of patients suspected to have cardiac tamponade.

Introduction thickened, or inelastic, one of three pericardial

Cardiac tamponade is one condition in the spec-
trum of pericardial compressive syndromes.
When material accumulates within the pericardial
cavity or when the pericardium becomes scarred,
compressive syndromes may develop. These in-
clude cardiac tamponade, constrictive pericarditis
(the result of scarring and consequent loss of elas-
ticity of the pericardium), and effusive-constric-
tive pericarditis (a variant characterized by con-
RG f Volume 27 ● Number 6
strictive physiology with a coexisting pericardial
effusion, usually with tamponade) (1).
Cardiac tamponade is a hemodynamic state
that results from the slow or rapid accumulation
of fluid, pus, blood, gas, or benign or malignant
neoplastic tissue within the pericardial cavity. It
can be acute or subacute, but other variants in-
cluding low pressure (occult) and regional tam-
ponade may also occur. The incremental increase
in the intrapericardial volume raises the intraperi-
cardial pressure, resulting in compression of the
heart, which restricts the filling of the cardiac
chambers with resultant severe hemodynamic
impairment and eventually reduced cardiac out-
put (1–3).
Echocardiography is considered the imaging
technique of choice for assessment of pericardial
effusion and tamponade. However, in equivocal
cases or when echocardiography is not feasible,
additional imaging studies including computed
tomography (CT) or magnetic resonance (MR)
are necessary (Fig 1). Cross-sectional techniques
may provide morphologic signs of developing or
impending tamponade that have significant he-
modynamic correlates. Furthermore, additional
information with assessment of the entire chest
including associated abnormalities in the medias-
tinum, lungs, and adjacent structures is possible
due to the larger field of view compared with that
of echocardiography. Radiologists should be
aware of the imaging findings of tamponade with
cross-sectional techniques in order to allow early
diagnosis and prompt, life-saving interventions.
In this article, we briefly review the anatomy,
pathophysiology, and clinical manifestations of
cardiac tamponade, with a particular focus on the
CT findings of this life-threatening condition.
Anatomy
The pericardium is a double-walled sac consisting
of an external fibrosa layer and beneath it a serosa
layer. The serosa is a complete closed sac that
reflects on itself and covers the heart with some
extensions to enclose portions of the juxtacardiac
Restrepo et al 1597
great vessels and the inner aspect of the fibrosa.
The serosa directly covering the surface of the
heart is the visceral pericardium (also known as
the epicardium). The fibrosa together with the
reflections of the serosa internally attached to it is
known as the parietal pericardium. The space
between the visceral and parietal pericardium is
the pericardial cavity. This pericardial cavity nor-
mally contains a small amount of pericardial fluid
(15–50 mL) produced by the mesothelial cells
that line the serosa. A number of pericardial si-
nuses and recesses between the reflections of the
pericardium serve as a potential space to accom-
modate a limited amount of additional pericardial
fluid, which contributes and augments the peri-
cardial reserve volume (4 –7).
Pathophysiology
Cardiac tamponade is a condition characterized
hemodynamically by decreased intracardiac vol- Teaching
umes and increased diastolic filling pressures. In- Point
crease of the intrapericardial pressure producing
external cardiac compression is the critical event
in the development of tamponade. Under normal
physiologic conditions, the intrapericardial pres-
sure is equal to intrapleural pressure and there-
fore negative. The elevation of the intrapericardial
pressure is the result of rapid or slow accumula-
tion of fluid, gas, or tissue within the pericardial
cavity. As the pericardial contents initially in-
crease, the pericardial space accommodates the
expanding volume of material without an increase
in pressure or compromise of the cardiac cham-
bers until the limit of the pericardial reserve vol-
ume is reached. As the pericardial contents con-
tinue increasing, the limit of pericardial stretch is
exceeded and there begins to be compromise of
the cardiac chambers, which become smaller.
This effectively reduces myocardial diastolic
compliance and therefore limits blood inflow,
ultimately leading to equalization of the mean
 1598 November-December 2007 RG f Volume 27 ● Number 6

Figure 2. Pericardial pressure-volume curves. As the pericardial effusion initially increases, the pericardial space
accommodates the expanding volume of fluid without a significant increase in pressure or compromise of the cardiac
chambers until the limit of the pericardial reserve volume is reached. Left: In rapidly increasing pericardial effusion,
after the pericardial reserve volume limit is reached, the limit of parietal pericardial stretch is then quickly exceeded
even with as little as 200 mL of fluid, causing a steep rise in pressure with beginning of compromise of the cardiac
chambers, which become smaller. The curve becomes even steeper as smaller increments in fluid cause a dispropor-
tionate increase in the pericardial pressure; this process effectively reduces myocardial diastolic compliance and
therefore limits blood inflow, ultimately leading to equalization of the mean diastolic pericardial and cardiac chamber
pressures, which results in decrease of stroke volume, reduction of arterial blood pressure, diminished coronary blood
flow, and finally reduced cardiac output. Right: In pericardial effusions with a slower filling rate, it takes longer to
exceed the limit of pericardial stretch and the pericardium can accommodate volumes as large as 1500 mL without
hemodynamic compromise; however, once the limit of pericardial stretch is exceeded, even small increments in peri-
cardial volume may provoke full-blown tamponade (3).

diastolic pericardial and cardiac chamber pres-
sures (Fig 2) (3).
The initial effects of the increase in pericardial
pressure are on the thinner, more compliant right
cardiac chambers and eventually for all chambers
with limited diastolic chamber filling, which re-
sults in decreased stroke volume, reduction of
arterial blood pressure, diminished coronary
blood flow, and finally reduced cardiac output
(3,8,9).
The rate of accumulation is more significant in
Teaching establishing cardiac tamponade than the ultimate
Point size or composition of the pericardial contents
(10). In the acute setting, the pericardium is rela-
tively stiff and noncompliant. Accordingly, acute
or rapidly developing pericardial effusions can
abruptly increase the intrapericardial pressure and
produce cardiac tamponade with as little as 100 –
200 mL of pericardial fluid. On the other hand,
over time the pericardium can stretch and be-
come more compliant. Therefore, slow or gradual
accumulation of pericardial fluid of up to 1000 –
1500 mL can be tolerated without hemodynamic
impairment (11). However, once the pericardium
has maximally distended to accommodate the
increasing pericardial contents, even small incre-
ments in intrapericardial volume will eventually
result in acute tamponade due to an abrupt in-
crease in intrapericardial pressure (2,3,10 –12).
Note that an abnormally thickened pericardium
may have a much lower threshold for increases in
pressure that lead to tamponade due to its inabil-
ity to expand normally to accommodate an in-
creasing intrapericardial volume.
The term effusive-constrictive pericarditis refers
to an uncommon pericardial syndrome character- Teaching
ized by concomitant tamponade and constriction. Point
The tamponade is caused by tense pericardial
effusion; the constriction is caused by scarring or
calcification of the visceral pericardium or epicar-
dium. Patients with effusive-constrictive pericar-
ditis may be erroneously believed to have only
tamponade; however, in the former entity the
central venous pressure typically remains elevated
after drainage of the pericardial effusion (13).
RG f Volume 27 ● Number 6
Figure 3. Cardiac tamponade secondary to tuberculosis in a 32-year-old man with acquired immunodeficiency
syndrome. (a) Chest radiograph shows significant enlargement of the cardiac silhouette with the characteristic “water
bottle” appearance. (b) Axial nonenhanced CT image of the chest shows a large pericardial effusion flattening the
anterior cardiac contour.
Clinical Findings
Although cardiac tamponade is a clinical diagno-
sis, most signs and symptoms are nonspecific
when analyzed individually. However, these
manifestations may strongly suggest tamponade
when they occur simultaneously or when consid-
ered together in the proper clinical scenario.
Tachycardia is almost always present with some
exceptions (ie, bradycardic patients in uremia and
those with hypothyroidism). Owing to the mark-
edly diminished intracardiac volumes, the stroke
volume is reduced, triggering a cascade of com-
pensatory mechanisms to maintain cardiac output
and blood pressure including sympathetic and
catecholamine stimulation, which result in in-
creased contractility, tachycardia, and vasocon-
striction (3).
Clinically significant tamponade frequently
produces hypotension. In rapidly developing tam-
ponade, patients usually are in shock with jugular
venous distention, which is a key finding in differ-
entiating it from other forms of endovascular col-
lapse. Signs of poor peripheral perfusion include
cool legs, arms, ears, and nose, as well as periph-
eral cyanosis (3,12). The Beck triad (muffled
heart sounds, hypotension, and jugular venous
distention) strongly suggests tamponade but is
present in only a minority of patients (14). Pulsus
paradoxus (an exaggerated fall in systolic blood
pressure of 10 mm Hg or more during inspira-
tion) is one of the most useful physical findings
Restrepo et al 1599
and an ominous sign of impending hemodynamic
collapse, but again it is nonspecific and may be
blunted, absent, or difficult to reproduce (12).
Other conditions that can also produce pulsus
paradoxus include massive pulmonary thrombo-
embolism, obstructive lung disease, profound
hemorrhagic shock, and other forms of severe
hypotension (3).
Imaging Findings
Chest Radiography
Conventional radiographs of the chest in patients
with cardiac tamponade may demonstrate an en-
larged cardiac silhouette with or without an epi-
cardial fat pad sign suggesting a pericardial effu-
sion; the lungs are typically clear (Fig 3) (3,8,15).
However, chest radiographs may not be useful
early in the course of the process, since at least
200 mL of pericardial fluid must accumulate be-
fore visible enlargement of the cardiac silhouette
occurs (3). Cases of acute cardiac tamponade
after blunt chest trauma with a normal-size heart
on chest radiographs have been reported in the
literature (16,17).
In patients with pneumopericardium, chest
radiographs typically show the heart surrounded
partially or completely by air with a sharply delin-
eated pericardium outlined by lucency on either
 1600 November-December 2007 RG f Volume 27 ● Number 6

Figures 4, 5. (4) Cardiac tamponade in a newborn with respiratory distress syndrome who developed pneu-
mopericardium associated with barotrauma from mechanical ventilation. Chest radiograph shows pneumoperi-
cardium with cardiac tamponade. (5) Pneumopericardium with cardiac tamponade in an adult patient with
blunt thoracic trauma. Chest radiograph shows a sharply delineated pericardium (arrowheads) outlined by air
on both sides. The small heart sign suggests the presence of tension pneumopericardium.

side (Fig 4) (17). In patients with tamponade due
to pneumopericardium, termed tension pneumo-
pericardium, a substantial decrease in the size of
the cardiac silhouette may be observed on radio-
graphs, the so-called small heart sign (Fig 5) (17–
19). In addition, chest radiographs may show not
only pneumopericardium but also the presence of
coexistent pneumothorax or pneumomediasti-
num. Traumatic or congenital communications
(ie, fenestrations) between the pleural space and
the pericardium with a one-way valve mechanism
may have a role in the development of tension
pneumopericardium, particularly if there is asso-
ciated pneumothorax without pneumomediasti-
num and no evidence of any penetrating pericar-
dial wound (20).
Echocardiography
Echocardiography is the imaging technique of
choice for diagnosis of pericardial effusion and
cardiac tamponade. It is readily available and por-
table, lacks ionizing radiation, and is highly sensi-
tive for detection of pericardial effusion. It is also
very specific for diagnosis of pericardial tampon-
ade if the characteristic imaging findings are iden-
tified. Some of the echocardiographic findings
Teaching described in cardiac tamponade include cardiac
Point chamber compression, inferior vena cava (IVC)
plethora, Doppler flow velocity paradoxus, com-
pression of the pulmonary trunk, compression of
the thoracic IVC, paradoxical motion of the inter-
ventricular septum, and swinging motion of the
heart in the pericardial sac (Fig 6) (3,8,21–25).
As mentioned earlier, the thinner more compli-
ant right-sided chambers are usually the first to be
compressed in the setting of cardiac tamponade.
Right atrial and right ventricular collapse are the
most commonly used clues for tamponade at
echocardiography; however, neither of them is
100% sensitive or specific for tamponade (3,8).
Right atrial collapse, which occurs in late dias-
tole or early systole, reflects increased intraperi-
cardial pressure inverting the right atrial wall in-
ward when the right atrial pressure is lowest. This
echocardiographic sign has a reported sensitivity
of 55%– 60% and specificity of 50%– 68% for
tamponade. Right atrial collapse is more specific
if the inward movement lasts for at least 30% of
the cardiac cycle. Right ventricular collapse,
which occurs in early diastole, is a less sensitive
(38%– 48%) but more specific (84%–100%) find-
ing for cardiac tamponade; however, it has been
considered a late sign. Collapse of the left atrium,
which takes place in late diastole, may occur in
approximately 25% of patients and is highly spe-
cific for tamponade. Left ventricular collapse also
has low sensitivity and usually occurs under spe-
cific circumstances such as localized postsurgical
tamponade (3,8,21,22).
Another echocardiographic sign for tamponade
is a distended IVC or IVC plethora. Normally,
the proximal IVC decreases by more than 50% in
diameter after a deep inspiration or a sniff. In
tamponade, by definition the right atrial pressure
is elevated and the IVC typically is distended and
will not decrease in diameter with these maneu-
vers. However, IVC plethora is not a specific find-
ing for tamponade and may be present in other
RG f Volume 27 ● Number 6 Restrepo et al 1601

Figure 6. Cardiac tamponade in a 50-year-old man with a 3-week history of malaise and dys-
pnea. (a) Parasternal short-axis echocardiographic view shows a large circumferential pericardial
effusion (PE) surrounding the left ventricle (LV). (b) Subcostal long-axis echocardiographic view
shows diastolic collapse of the right atrium (RA) as well as a dilated and plethoric IVC. PE ⫽ peri-
cardial effusion. Cardiac arrest later developed, and the patient required emergent pericardiocen-
tesis.

conditions causing elevated right atrial pressure
(8).
Abnormal Doppler flow has a good correlation
with clinical features of tamponade, with a higher
sensitivity (75%) than right ventricular collapse
and a much higher specificity (91%) than right
atrial collapse (23). Marked respiratory variation
in Doppler velocities, the so-called Doppler flow
velocity paradoxus, is a pattern of reciprocal
variation in the left- and right-sided transvalvular
inflow velocities. Normally, there is no significant
respiratory variation in early diastolic filling ve-
locities across the tricuspid and mitral valves. In
tamponade, however, there may be an exagger-
ated “paradoxical” increase in right-sided inflow
velocities with an exaggerated decrease in left-
sided inflow velocities (8,24). Unfortunately, this
“flow velocity paradoxus” is not specific for tam-
ponade either.
Other recently described echocardiographic
signs in tamponade include compression of two
intrapericardial structures, the pulmonary trunk
and the thoracic IVC. The pulmonary trunk is an
entirely intrapericardial short and wide vessel.
The short intrathoracic segment of the IVC is
extrapericardial in its posterior aspect but is cov-
ered by pericardium on its anterior aspect. This is
the reason why in pericardial effusion with tam-
ponade, there is indentation of the right atrium at
the level of the IVC junction anteriorly but not
posteriorly (25).
One mechanism of pulsus paradoxus is also
visible at echocardiography when both the ven-
tricular and atrial septa move sharply to the left
with an increase in right chamber volumes at the
expense of the left chambers. The reverse occurs
in expiration. This paradoxical motion of the
septa occurs because each side of the heart fills at
the expense of the other due to the fixed intraperi-
cardial volume (8,12).
The mechanism of electrical alternans, an elec-
trocardiographic finding, is due to the swinging
motion of the heart within the pericardial sac,
another visible echocardiographic sign. Typically,
the extremes of oscillation of the heart can be
seen, particularly in large effusions. Unfortu-
nately, while electrical alternans is a highly spe-
cific sign of tamponade on an electrocardiogram,
a swinging heart is neither sensitive nor specific
for tamponade at echocardiography (3,8,12).
Computed Tomography
Echocardiography remains the primary method of
evaluating pericardial disease, in particular peri-
cardial effusion. An advantage of CT of the chest
over echocardiography in the evaluation of sus-
pected pericardial disease is the larger field of
view inherent in CT, which allows assessment of
the entire chest and detection of associated ab-
normalities in the mediastinum, lungs, and adja-
cent structures. CT is also less operator depen-
dent, and owing to the improved temporal resolu-
tion of multidetector CT, the acquisition of high-
quality motion-free images of the pericardium is
possible, particularly in patients with limited
breath-hold capacity. In addition, multidetector
CT scanners may offer retrospective cardiac gat-
ing, thus allowing acquisition of cine CT images,
1602 November-December 2007 RG f Volume 27 ● Number 6

Figures 7, 8. (7) Dilatation of the superior vena cava in a 74-year-old woman with cardiac
tamponade after revascularization surgery. Axial contrast-enhanced CT image obtained infe-
rior to the aortic arch shows an abnormally dilated superior vena cava (straight arrow) with a
diameter similar to that of the adjacent aorta (arrowhead). There is also reflux of contrast
material within the azygos vein (curved arrow). (8) Dilatation of the IVC in a 20-year-old
man with a pericardial effusion and signs and symptoms of cardiac tamponade. Contrast-
enhanced CT image of the chest shows an abnormally dilated IVC (straight arrow) with a
diameter greater than twice that of the adjacent abdominal aorta (arrowhead). The coronary
sinus (curved arrow) also appears prominent.

which provide valuable information about the
function and dynamics of the heart and pericar-
dium. Another advantage of CT over other mo-
dalities is its ability to demonstrate pericardial
calcification, allowing measurement of its thick-
ness, location, and extent (6 – 8).
Some of the reported limitations of echocardi-
ography are generally not present with CT, in-
cluding the high rate of false-positive findings due
to adjacent pathologic conditions that may simu-
late pericardial effusions (ie, pleural effusions,
lower lobe atelectasis, pericardial and intracardiac
masses, or other mediastinal lesions). Other limi-
tations include the difficulty of identifying clotting
or clots within the pericardium at echocardiogra-
phy as well as differentiation of small fluid collec-
tions from pericardial thickening, differentiation
of fluid in the anterior and posterior spaces around
the heart from epicardial fat, and identification of
loculations in complex pericardial collections
(8,26,27).
CT provides valuable information about the
possible nature of pericardial effusions based on
the attenuation measurements of the collection.
Pericardial fluid with relatively low attenuation
values close to that of water likely represents a
simple serous effusion from underlying heart fail-
ure, renal failure, or nonhemorrhagic carcinoma-
tous involvement. Attenuation values greater than
that of water suggest hemopericardium, malig-
nancy, purulent exudates, or myxedematous effu-
sion associated with hypothyroidism. Low attenu-
ation values with measurements close to that of
fat have been reported in cases of chylopericar-
dium (28,29).
CT also allows differentiation of pericardial
thickening from pericardial fluid owing to the oc-
casional presence of nodular areas of increased
attenuation in pericardial thickening, the typical
anterior location of the thickened pericardium,
lack of change at decubitus positioning, and peri-
cardial enhancement with administration of con-
trast material (26). Occasionally, this differentia-
tion can be difficult, particularly in cases of small
pericardial collections (27,28).
Some of the reported CT findings in tampon-
ade include enlargement of the superior vena cava Teaching
with a diameter similar to or greater than that of Point
the adjacent thoracic aorta (Fig 7), enlargement
of the IVC with a diameter greater than twice that
of the adjacent abdominal aorta (Fig 8), peripor-
tal lymphedema (Fig 9), reflux of contrast mate-
rial within the IVC (Fig 10), reflux of contrast
material within the azygos vein, and enlargement
of hepatic and renal veins (10,30 –34). Unfortu-
nately these findings seen individually are not spe-
cific for tamponade, but the constellation of find-
RG f Volume 27 ● Number 6 Restrepo et al 1603

Figure 9. Cardiac tamponade in a 23-year-old man with a history of intravenous drug abuse who presented with
chest pain and shortness of breath. (a) Contrast-enhanced CT image obtained at the level of the ventricles shows a
large pericardial effusion deforming the cardiac contours. Note the dilated IVC (arrow) and the slightly dilated azy-
gos vein (arrowhead). The fluid was an inflammatory exudate, and cultures were negative. (b) Contrast-enhanced
CT image of the upper abdomen shows periportal fluid (arrows) due to distended periportal lymphatic vessels.

cardiac tamponade but also in patients with

Figure 10. Cardiac tamponade in a 59-year-old man
who presented to the emergency department with
shortness of breath. Axial CT image shows a large peri-
cardial effusion with a compressed small heart and re-
flux of contrast material into the IVC (arrow). A mod-
erate-sized right pleural effusion and very small left
pleural effusion are also seen. The patient had clinical
and hemodynamic findings consistent with pericardial
tamponade.
ings should strongly suggest the diagnosis, par-
ticularly in the presence of a large pericardial
effusion.
For example, periportal lymphatic distention
or lymphedema has been described not only in
chronic congestive heart failure, blunt abdominal
trauma with or without liver injuries, cirrhosis,
hepatitis, liver transplants, and hepatic or retro-
peritoneal malignancies (34,35). Similarly, reflux
of contrast material into the IVC occurs not only
in the setting of cardiac tamponade but can be
seen in individuals with intrinsic cardiac disease
such as tricuspid regurgitation, patients with hy-
povolemic or cardiogenic shock, and those with
pulmonary embolism, among others (32,33,36).
Azygos vein reflux can occur in a variety of condi-
tions that raise the central venous pressure, in-
cluding massive pulmonary embolism, cor pul-
monale, ischemic right-sided heart failure, pulmo-
nary arterial hypertension, tumoral obstruction of
the main pulmonary artery, and bilateral pneu-
mothoraces, as well as in patients with acute re-
spiratory distress syndrome receiving positive
pressure ventilation (32,33,37,38).
An additional CT finding that should suggest
pericardial tamponade is the so-called flattened
heart sign (39). This sign occurs when the in-
creased intrapericardial pressure is sufficient to
produce transient reversal of the transmural left
ventricular pressure during diastole, thereby pro-
ducing a change in the contour of the anterior
aspect of the heart with resultant hemodynamic
changes (39). This CT sign is characterized by
flattening of the anterior surface of the heart with
decreased anteroposterior diameter and can occur
1604 November-December 2007 RG f Volume 27 ● Number 6

Figures 11–14. (11) Cardiac tamponade in a 44-year-old man with a history of lung cancer who presented with
progressive shortness of breath, tachycardia, and tachypnea. Axial nonenhanced CT image obtained at the level of
the ventricles shows a pericardial effusion, which produces abnormal flattening of the anterior surface of the heart
(arrowhead). (12) Pneumopericardium with tamponade physiology in a 28-year-old man after blunt trauma. Con-
trast-enhanced CT image obtained at the level of the ventricles shows pneumopericardium with compression of the
anterior surface of the heart (black arrowheads). There is associated left pneumothorax (white arrowhead). Left basi-
lar atelectasis and a left pleural effusion are also seen. (13) Immunoblastic T-cell lymphoma with pleural and pericar-
dial involvement in a 30-year-old man who presented with cardiac tamponade. Contrast-enhanced CT image shows
decreased anterior-posterior diameter of the heart due to significant compression of the anterior (arrow) and poste-
rior (arrowhead) cardiac surfaces by neoplastic tissue. There are associated bilateral pleural effusions. (14) Non-
Hodgkin lymphoma in a 62-year-old man who presented with cardiac tamponade. Nonenhanced CT image shows
abnormal concave deformity of the anterior wall of the right ventricle, compression of the anterior epicardial fat (ar-
rowhead), and a moderate-sized pericardial effusion. The patient died shortly after this examination was performed.

secondary to the presence of fluid (Fig 11), air
(Fig 12), or tissue (Fig 13) compressing the car-
diac chambers (39). In severe cases, inversion
with concave chamber deformity may be seen
(Fig 14). Compressive deformity of the cardiac
chambers, particularly the thinner and more com-
pliant right-sided chambers, typically manifests at
CT as straightening of the right cardiac contour
(Fig 15).
Compression of the coronary sinus (an intra-
pericardial structure) may be another sign of im-
pending cardiac tamponade. This is a similar phe-
nomenon to the previously described compres-
sion of the pulmonary trunk (an entirely intraperi-
cardial vessel) and the short intrathoracic seg-
ment of the IVC (which is extrapericardial poste-
riorly but is covered by pericardium anteriorly).
This sign was appreciated in a patient with coro-
nary perforation during a percutaneous coronary
intervention with resultant tamponade (40). Al-
though this sign was documented with angiogra-
phy, CT can also demonstrate an abnormal coro-
nary sinus; therefore, the radiologist should be
able to identify this finding and its significance in
the proper scenario, particularly in the presence
of simultaneous pericardial effusion.
Another CT finding that can be observed in
cardiac tamponade is angulation or bowing of the
RG f Volume 27 ● Number 6 Restrepo et al 1605

Figure 15. Cardiac tamponade in a 34-year-old man

Figure 16. Cardiac tamponade in a 38-year-old man
with acquired immunodeficiency syndrome. Contrast-
after a motor vehicle collision. Contrast-enhanced CT
enhanced CT image shows a pericardial effusion and bi-
image shows abnormal bowing of the interventricular
lateral pleural fluid collections. Note the straightening of
septum (arrowhead) toward the left ventricle. There is
the anterior and right lateral cardiac contours (arrow), as
an associated large pericardial effusion.
well as the collapsed anterior right ventricle (arrowhead).

Figure 17. Cardiac tamponade in a 61-year-old man with a pericardial metastasis. (a) Contrast-enhanced CT im-
age obtained at the level of the ventricles shows a large pericardial fluid collection with a single solid metastatic nod-
ule (arrowhead). A left pleural fluid collection is also noted. (b) Contrast-enhanced CT image shows periportal fluid
in the porta hepatis (curved arrow) and a hypoattenuating collar surrounding the intrahepatic portion of a distended
IVC. The distended IVC demonstrates a fluid– contrast material level (straight arrow), which is due to refluxed con-
trast material from the right atrium layering within the dependent portion of the IVC. Note the small liver metastases
and left paraaortic node metastasis.

interventricular septum. This CT finding corre- Specific Causes of Pericardial

lates with the paradoxical motion of the septum
frequently observed on echocardiograms of pa-
tients with tamponade physiology (8,41,42) (Fig
16). However, this finding is not specific for tam-
ponade, as septal shifting can be seen in other
processes that occur with either pressure or vol-
ume overload of the right ventricle or both. Be-
sides cardiac tamponade, septal “bounce” has
been reported in other conditions including con-
strictive pericardial disease (41– 44), as well as
in conditions producing right ventricular dys-
function such as massive pulmonary embolism
(45,46).
Tamponade as Demonstrated at CT
As previously mentioned, CT may help in the
differentiation of malignant from benign causes of
pericardial effusion. Malignant pericardial disease
is suggested by several CT criteria, including peri-
cardial effusions with high CT attenuation values
(usually ⬎20 HU), localized or diffuse pericardial
thickening, masses arising from or contiguous
with the pericardium, and obliteration of the nor-
mal tissue planes between a paracardiac mass and
the heart or pericardium (47) (Figs 17, 18). Note
1606 November-December 2007
Figure 18. Cardiac tamponade in a 65-year-old
woman with a history of Merkel cell carcinoma of the
skin and a metastasis to the pericardium. Contrast-en-
hanced CT image shows a large pericardium-based
mass (arrowhead) compressing the anterior surface of
the heart. A moderate amount of pericardial fluid (ar-
row) and large left pleural fluid collections are also
noted.
that not all cases of tamponade in the setting of
malignant pericardial disease are due to associ-
ated effusion, as hemodynamic impairment can
occur in patients with pericardial malignancy as a
result of compression of cardiac chambers by tu-
mor masses alone (Fig 19).
There is a wide spectrum of cardiac pathologic
conditions associated with tamponade, including
free-wall cardiac rupture after myocardial infarc-
tion (48), rupture of a ventricular aneurysm (49),
rupture of a coronary aneurysm (50), complica-
tions after thrombolytic therapy such as hemo-
pericardium (51) and ventricular wall hematoma
(52), Dressler syndrome (53), complications of
endocarditis (54), and cardiac neoplasms (55).
Trauma can produce cardiac tamponade by
several different mechanisms. Penetrating trauma
can result in hemopericardium and tamponade. A
posttraumatic anterior mediastinal hematoma,
such as may be seen after blunt injury with sternal
fracture, or a postsurgical hematoma after coro-
nary artery bypass surgery (56,57) (Fig 20) are
additional causes. Rarely, intrapericardial hernia-
tion of subdiaphragmatic intestinal contents after
blunt abdominal trauma can compress the heart
and produce cardiac tamponade (58,59) (Fig 21).
CT assessment of structures adjacent to the
heart including mediastinal structures and the
lungs may suggest the nature of pericardial effu-
sion with or without tamponade. Pericardiac me-
diastinal structures that are well assessed at CT
include the aorta and great vessels, esophagus,
and thymus. Lung cancer can result in tampon-
RG f Volume 27 ● Number 6
Figure 19. Pericardial metastasis in a 62-year-old
woman who presented with tamponade physiology.
Contrast-enhanced CT image shows innumerable solid
nodular metastatic deposits projecting within the peri-
cardial cavity. Note the absence of pericardial fluid.
There are bilateral pleural fluid collections.
Figure 20. Extracardiac tamponade in a 62-year-old
man with coronary artery disease who underwent coro-
nary artery bypass graft surgery. He presented 2 weeks
after the intervention with clinical findings suggestive of
tamponade. Contrast-enhanced CT image shows an
anterior mediastinal fluid collection (arrowheads) that
compresses and deforms the anterior surface of the
heart, predominantly the right ventricle.
ade via metastatic pericardial or cardiac involve-
ment (60). Aortic pathologic conditions that can
result in tamponade include aortic dissection and
aneurysm rupture (34,61,62) (Fig 22). Mediasti-
nal pathologic conditions that can cause tampon-
ade include mediastinal malignancy producing
direct cardiac compression, such as lymphoma or
small cell lung cancer. Examples of esophageal
pathologic conditions that may produce tampon-
ade include esophageal malignancy (63) and
esophageal perforation (64). Other reported
causes of tamponade that have been described at
CT include abscess formation (Fig 23).
RG f Volume 27 ● Number 6 Restrepo et al 1607

Figure 21. Pericardial tamponade in a 63-year-old woman with a delayed posttraumatic diaphragmatic
hernia. (a) Contrast-enhanced CT image obtained at the level of the ventricles shows intrapericardial
herniation of the colon (arrows), which produces tamponade. (b) Sagittal reformatted contrast-enhanced
CT image shows the pericardial defect (white arrowheads) and the herniating bowel loop with air (white
arrow) compressing the anterior aspect of the heart (black arrowheads). Note the free edge of the dia-
phragm (black arrow). Pericardiocentesis demonstrated fecal material. The patient was taken to the oper-
ating room for repair of the hernia and resection of necrotic bowel found within the pericardial sac.

Figure 22. Type A aortic dissection with cardiac tamponade in a 74-year-old woman. (a) Contrast-enhanced mul-
tisection CT image shows a dilated ascending aorta that contains an intimal flap (arrowhead). (b) Axial CT image
shows a pericardial effusion (arrows) and compression of the right ventricle.

Figure 23. Cardiac tamponade due to an abscess in a

patient with a history of a gunshot wound. An intraperi-
cardial purulent collection developed with regional car-
diac tamponade due to compression of the left ven-
tricle. CT image shows an intrapericardial abscess as a
low-attenuation collection surrounded by enhancing
pericardium (arrowhead).
1608 November-December 2007
MR Imaging
MR imaging allows detection of pericardial effu-
sions with high sensitivity, demonstrating fluid
collections as small as 30 mL (8). However, MR
imaging has a limited role in the setting of cardiac
tamponade owing to the emergent and life-threat-
ening nature of this condition. Nevertheless, there
are isolated reports of imminent cardiac tampon-
ade and cardiac rupture documented at MR im-
aging as an incidental finding (65,66). Some of
the previously described findings with other imag-
ing modalities can be seen with MR imaging, in-
cluding the swinging heart (65) and paradoxical
septal bounce, which can be easily seen on short-
or long-axis cine MR images (6).
MR imaging can provide information useful in
characterizing the nature of the pericardial effu-
sion in addition to the effects on cardiac function-
ing and diastolic filling. Simple transudative effu-
sions usually exhibit low signal intensity on T1-
weighted or proton density–weighted spin-echo
or double inversion images and high signal inten-
sity on T2-weighted spin-echo, fast spin-echo,
gradient-echo, or triple inversion images as well
as steady-state free precession and fast cine im-
ages. The presence of septations and debris sug-
gests a complex effusion. Hemorrhagic and pro-
teinaceous or exudative effusions generally exhibit
high signal intensity on T1- and T2-weighted im-
ages owing to the high protein content. Hemor-
rhage in the pericardial space usually exhibits low
signal intensity on gradient-echo images; how-
ever, its appearance changes with time due to the
degradation of blood products. The signal inten-
sity characteristics with other sequences depend
on the age and composition of the hemorrhagic
effusion (4,6).
Treatment
Treatment of tamponade is drainage of the peri-
cardial contents, preferably by using needle peri-
cardiocentesis with echocardiographic, fluoro-
scopic, or CT guidance. However, therapeutic
emergency pericardiocentesis without image
guidance should be performed in cases of sudden
circulatory collapse or hemodynamic instability
(3).
The success rate of echocardiography-guided
pericardiocentesis is 93% in patients with anterior
effusions larger than 10 mm and only 58% in
those with small, posteriorly located effusions.
The success rate of echocardiography-guided
pericardiocentesis in loculated pericardial effu-
sions is 96% (67). Rescue echocardiography-
RG f Volume 27 ● Number 6
guided pericardiocentesis relieved tamponade
after cardiac perforation in 99% of a series of 88
patients and was the definitive therapy in 82%
(68).
Fluoroscopy-guided pericardiocentesis and
hemodynamic monitoring have a success rate of
93.1%, in comparison to emergency pericardio-
centesis without image guidance, which has a suc-
cess rate of only 73.3% (67).
Klein et al (69) reviewed 319 CT-guided peri-
cardiocentesis procedures and reported a techni-
cal success rate of 98.4%; symptomatic improve-
ment was documented in 79% of patients with
tamponade and in 78% of patients with marked
shortness of breath without other evidence of
tamponade.
Surgical drainage is desirable in patients with
intrapericardial bleeding, purulent effusion, or
clotted hemopericardium. Patients with recurrent
tamponade (ie, malignant tamponade) may re-
quire pericardial sclerosis or a balloon pericar-
diotomy to create a communication between the
pericardium and the pleura or peritoneum (3).
Conclusions
Cardiac tamponade is a syndrome characterized
by increased intrapericardiac pressure that leads
to poor cardiac diastolic filling and decreased car-
diac output. The radiologist should be aware of
the pathophysiologic events and their correspond-
ing imaging correlates in order to identify patients
with this life-threatening condition, which re-
quires prompt intervention. Although echocardi-
ography remains the first-line imaging study in
evaluation of pericardial effusion and suspected
tamponade, CT can be a useful problem solving
technique in patients with inconclusive echocar-
diographic findings. CT evaluation of the heart,
pericardium, and surrounding structures can pro-
vide valuable information about the cause of this
condition.
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 RG Volume 27 • Volume 6 • November-December 2007 Restrepo et al

Imaging Findings in Cardiac Tamponade with Emphasis on CT

C. Santiago Restrepo, MD, et al
RadioGraphics 2007; 27:1595–1610 ● Published online 10.1148/rg.276065002 ● Content Codes:

Page 1597
Cardiac tamponade is a condition characterized hemodynamically by decreased intracardiac volumes
and increased diastolic filling pressures. Increase of the intrapericardial pressure producing external
cardiac compression is the critical event in the development of tamponade.

Page 1598
The rate of accumulation is more significant in establishing cardiac tamponade than the ultimate size
or composition of the pericardial contents (10).

Page 1598
The term effusive-constrictive pericarditis refers to an uncommon pericardial syndrome characterized by
concomitant tamponade and constriction.

Page 1600
Some of the echocardiographic findings described in cardiac tamponade include cardiac chamber
compression, inferior vena cava (IVC) plethora, Doppler flow velocity paradoxus, compression of the
pulmonary trunk, compression of the thoracic IVC, paradoxical motion of the interventricular
septum, and swinging motion of the heart in the pericardial sac (Fig 6) (3,8,21–25).

Page 1602
Some of the reported CT findings in tamponade include enlargement of the superior vena cava with a
diameter similar to or greater than that of the adjacent thoracic aorta (Fig 7), enlargement of the IVC
with a diameter greater than twice that of the adjacent abdominal aorta (Fig 8), periportal
lymphedema (Fig 9), reflux of contrast material within the IVC (Fig 10), reflux of contrast material
within the azygos vein, and enlargement of hepatic and renal veins (10,30–34).

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