Pictorial Essay Computed tomography of the pericardium and pericardial disease Prabhakar Rajiah, MBBS, MD, FRCR a, * , Jeffrey P. Kanne, MD b a Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA and b Division of Cardiothoracic Imaging, Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA KEYWORDS: CT; Effusion; Inflammation; Pericardium; Tumor Abstract. The spectrum of pericardial abnormalities includes congenital absence, pericardial cyst, per- icarditis, effusion, constriction, tamponade, retained foreign body, and neoplasms. Because of it high spatial and temporal resolutions, multiplanar reconstruction capability, and large field of view, com- puted tomography (CT) is a very useful tool in the comprehensive anatomical and functional evaluation of the pericardium. Knowledge of normal pericardial anatomy, anatomic variants, and imaging appear- ances of various pericardial abnormalities is essential for accurate diagnoses and characterization. In this pictorial review, the CT appearances of the normal pericardium and pericardial abnormalities are discussed and illustrated. Ó 2010 Society of Cardiovascular Computed Tomography. All rights reserved. Introduction Computed tomography (CT) scanning provides a com- prehensive anatomic and functional evaluation of the pericardium because of its high spatial and contrast reso- lution, fast acquisition (5–10 heart beats), multiplanar reconstruction capabilities, and large field of view. CT attenuation values can be used for tissue characterization, especially calcification, which is suggestive of constrictive pericarditis in patients with constrictive or restrictive physiology. Functional cine images are useful in evaluation of wall motion abnormalities in pericardial constriction and tamponade. The main disadvantages of CT are the use of ionizing radiation and the frequent need for intravenous administration of iodinated contrast material. Although echocardiography is often the first imaging test used in the evaluation of suspected pericardial diseases, it is limited by operator skill and the inability to image the entire pericardium because of restricted acoustic windows, espe- cially for pathology in unusual locations. Moreover, ech- ocardiography does not accurately assess pericardial thickening. In current clinical practice, CT is used when echocardiography is nondiagnostic or difficult to interpret and to characterize pericardial masses, including when there is contraindication to magnetic resonance imaging (MRI). Normal pericardium The pericardium envelops not only the heart but also the proximal portions of the ascending aorta, pulmonary artery, left pulmonary veins, and superior vena cava (SVC). The pericardium has an outer fibrous layer and an inner serous layer. The fibrous pericardium forms a flask-shaped, tough Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: radprabhakar@gmail.com Submitted July 7, 2009. Accepted for publication January 1, 2010. 1934-5925/$ -see front matter Ó 2010 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2010.01.004 Journal of Cardiovascular Computed Tomography (2010) 4, 3–18