Blunt traumatic rupture of the pericardium with cardiac herniation: two cases diagnosed using computed tomography

Abstract

Traumatic ruptures of the pericardium with cardiac herniation are infrequent, and their radiological pattern little familiar, so that they are often missed preoperatively. Few reports have emphasised the use of a CT scan as a tool for diagnosis and CT scan signs have not been well documented. We report on two cases of traumatic herniation of the heart for which a CT scan brought a major contribution for diagnosis. We describe the presence of an empty pericardial sac on CT slices which allowed us to diagnose the cardiac herniation. These observations demonstrate that CT scans can contribute to the diagnosis of pericardial rupture with cardiac herniation.

Blunt traumatic rupture of the pericardium with cardiac herniation

“…9 In retrospect, it was a "bruit de moulin," which is described as the splashing or waterwheel murmur of hemopneumopericardium and is created by the heart beating in a pericardium filled with both air and blood. 1,4,6 The patient's blood pressure normalized with 2 litres of crystalloid and 4 units of packed red blood cells. Initial supine chest x-ray revealed a mid-thoracic spine fracture, a left-sided hemopneumothorax and subtle pneumopericardium and pneumomediastinum ( Fig.…”

“…1,4,5 It is usually not an isolated injury and is difficult to diagnose in the acute multiple trauma setting. 1,3,6,7 Rupture usually occurs in the left pleuropericardium but can also occur in the diaphragmatic portion of the pericardium, the right pleuropericardium or the superior mediastinal pericardium. 1,8 Pericardial rupture without cardiac herniation is usually not diagnosed initially and is found incidentally either in the course of surgery for associated injuries or at a later date.…”

“…1,8 Pericardial rupture without cardiac herniation is usually not diagnosed initially and is found incidentally either in the course of surgery for associated injuries or at a later date. 1,6 Cardiac herniation through the pericardial defect may occur at any time after the initial injury and has been reported to occur up to 5 years post injury. 4 If cardiac herniation occurs, a previously stable patient may develop sudden cardiogenic shock with signs and symptoms mimicking cardiac tamponade.…”

Coronary Artery Bypass Surgery in Undiagnosed Traumatic Pericardial Rupture—25 Years Later

“…A CT scan may show a pericardial effusion or an empty pericardial sac (pericardium in its normal position with a displaced heart in one of the hemithoraces). 4 An echocardiogram may show pericardial effusion. Non-return of the lavage fluid following pericardial lavage with normal saline through subxyphoid pericardial window is very diagnostic of pericardial tears.…”

A pictorial review of traumatic pericardial injuries

“…compressive pneumothorax, haemothorax, air trapping in the lung or atelectasis) should also act as a warning sign for potential cardiac herniation [14–16]. It is also important to bear in mind that there are reports of delayed presentation of cardiac herniation as herniation has also been described following the institution or discontinuation of positive pressure ventilation [17]. Other findings that may suggest cardiac herniation include an unusual cardiac silhouette contour and a change in cardiac position after intercostal drain insertion [18].…”