Case-of-the-Week

Case of the Week

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AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.

Case-of-the-Week Information

The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

You can change the size and the format of the image or video loops by using the links below the image or video loop.

= Windows Media Video	= MP4 Video
= QuickTime	= WebM Video
= Flash	= Ogg Video
= JPG Image	= GIF Image
Video Sizes
1X = 200x150 pixels 2X = 400x300 pixels	3X = 600x450 pixels 4X = 800x600 pixels

Loop Text Key
Preop	Preop TEE or TTE
Intraop	An Intraop TEE
IntraopPreOp	Intraop TEE or TTE before Operation
IntraopPostOp	Intraop TEE or TTE after Operation
IntraopEnd	Intraop TEE or TTE at End of Anesthesia
Post Op	Postop TEE or TTE

Case of the Month Information Table

IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE

Abnormal Pericardium

Case#: 22

AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits

Presentation:
54 y.o. female who had a 'rub' heard on auscultation. A CT scan was performed and she was referred to the operating room. What is the diagnosis? Please review the diagnosis and differential.

Loops:

Case Discussion/CME Questions

The patient has a pericardial cyst near the right atrium. Pericardial cysts occur at a rate of 1:100,000. Pericardial cysts may occur from the failure of fusion of the mesenchymal lacunae that form from the pericardial sac. Pericardial cysts occur in the right and left cardiophrenic angle (70% and 22% respectively) and also anterior and posterior superior mediastinum. The cysts can be quite large and cause obstructive symptoms such as chest pain, cough, dyspnea, tamponade, sudden death, but, 75% cause no symptoms. Hemorrhage can occur inside the cyst. Cysts can rupture, and if the cyst ruptures into the pericardium, acute tamponade can occur. RVOT outflow obstruction, compression of cardiac chambers, erosion into adjacent structures, pulmonary artery stenosis, congestive heart failure, and atrial fibrillation are all possible complications.

The differential diagnosis is be:

Thymus
Lymphoma
Lung Cancer
Other

Pericardial cysts represent 6% of mediastinal masses and 33% of mediastinal cysts. Other cysts are:

Bronchogenic 34%
Enteric 12%
Thymic/Others 21%
Pericardial 6%

In the middle of the mediastinum, 61% of masses are cysts. The size of the cyst can range from very small to a large, dumbell shaped cyst.

Pezzano reported on 4 patients with pericardial cysts. He found that M-Mode was not helpful but 2D mode was helpful in locating the cyst and, in one case, found a teratoma along with the cyst. Butz reported a case where echocardiography was used to drain a large cyst. The cyst, in this case, was compressing lung tissue along with compression of the left ventricle. The cyst originated along the left cardiophrenic angle.

Treatment of pericardial cysts frequently involves observation with serial CT scans. Symptomatic or large cysts may be drained or resected. Anterior cysts can be drained by mediastinoscopy whereas, other cysts will require thoracotomy, thoracoscpy, or daVinciâ‚Äû¢ robotic assisted surgery.

Please answer the following questions correctly to obtain your CME.

Web Links/References

Pericardial Cyst
Giant, Dumbbell-Shaped Pericardial Cyst
Value of two-dimensional echocardiography in the diagnosis of pericardial cysts
Echocardiography-Guided Percutaneous Aspiration of a Large Pericardial Cyst
Pericardial cyst: case reports and a literature review.
A Giant Pericardial Cyst in an unusual Localization
Giant Pericardial Cysts
A Giant Pericardial Cyst
Rupture of Pericardial Cyst

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of University of Nebraska Medical Center, Center for Continuing Education and JLS Interactive, LLC.

The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is approved by the American Society of Radiologic Technologists (ASRT) as sonography-related continuing education (CE). Credit(s) issued for successful completion of ASRT-approved CE activities are accepted by the American Registry of Diagnostic Medical Sonography, American Registry of Radiological Technologists, Cardiovascular Credentialing International and Canadian Association of Registered Diagnostic Ultrasound Professionals. Contact the applicable registry for additional information / restrictions on their acceptance of ASRT CE credit.