AJR 2003; 181:1109-1113
© American Roentgen Ray Society
Anatomy of Pericardial Recesses on Multidetector CT: Implications for Oncologic Imaging
Mylene T. Truong1,
Jeremy J. Erasmus,
Gregory W. Gladish,
Bradley S. Sabloff,
Edith M. Marom,
John E. Madewell,
Marvin H. Chasen and
Reginald F. Munden
1 All authors: Department of Diagnostic Radiology, University of Texas M. D.
Anderson Cancer Center, Box 57, 1515 Holcombe Blvd., Houston, TX 77030.
Received March 11, 2003;
accepted after revision April 29, 2003.
Address correspondence to M. T. Truong.
Introduction
The pericardium, consisting of a fibroserous sac that encloses the heart,
is routinely imaged on CT
[1–4].
Multidetector technology, in allowing rapid acquisition of volumetric data in
high resolution and multiplanar reformation, has improved anatomic imaging.
Imaging with narrow collimation results in improved delineation of
cardiovascular anatomy and routine visualization of the pericardial recesses.
The pericardial space normally contains a small amount of fluid (15–20
mL), and the fluid-filled recesses and sinuses can be misinterpreted as
adenopathy or abnormality of an adjacent mediastinal structure. In oncologic
imaging, staging and prognostic implications of fluid in a pericardial recess
misinterpreted as adenopathy can significantly alter management and therapy.
We review the anatomy of the pericardium with emphasis on the pericardial
recesses that can potentially be misinterpreted as adenopathy.
Materials and Methods
Multidetector CT (MDCT) of the chest was performed in all patients on a
LightSpeed QX/i scanner (General Electric Medical Systems, Milwaukee, WI) with
3.75-mm collimation or 1.25-mm collimation, 120 kVp and 200–320 mA.
Nonionic contrast material (120–150 mL) was injected at a rate of
3–5 mL/sec. Multiplanar reformations were performed on a Vitrea 2
workstation (Vital Images, Minneapolis, MN).
Anatomy
The pericardium consists of an outer fibrous component and an inner
double-layered serous sac that surrounds the heart. The visceral layer, or
epicardium, surrounds the heart and great vessels, and the parietal layer
lines the fibrous component. The reflections of the serosal layers are
arranged around two complex tubes. One tube encloses the aorta and pulmonary
trunk. The second tube encloses the superior vena cava, the inferior vena
cava, and the four pulmonary veins. The transverse sinus is the passage
between these two pericardial tubes and is divided into the superior and
inferior aortic recesses and the right and left pulmonic recesses
[5]. The oblique sinus is the
cul-desac located behind the left atrium
(Fig. 1).
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Fig. 1. —Drawing of interior of serosal pericardial sac seen from
front after section of large vessels at their cardiac origin and removal of
heart. Aorta (A) and pulmonary trunk (P) are enclosed in one tube. Superior
vena cava (SVC), inferior vena cava (IVC), and pulmonary veins
(asterisks) are enclosed in other tube forming inverted J. Cul-de-sac
within curve of J is oblique sinus located behind left atrium. Transverse
sinus is complex interconnecting passage between these two tubes. Double layer
of serous pericardium (arrow) separates transverse sinus and oblique
sinus. 1 = superior aortic recess of transverse sinus, 2 = right pulmonic
recess of transverse sinus, 3 = left pulmonic recess of transverse sinus, 4 =
postcaval recess, 5 = right pulmonary venous recess, 6 = left pulmonary venous
recess, 7 = oblique sinus. (Drawing by Lang N; printed with permission from
Department of Visual Arts, M. D. Anderson Cancer Center)
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Transverse Sinus
Superior Aortic Recess
The transverse sinus is situated inferior and posterior to the aorta and
the pulmonary trunk, above the left atrium. The superior extent of the
transverse sinus is the superior aortic recess. The posterior portion of the
superior aortic recess manifests on CT as a well-defined crescentic fluid
collection adjacent to the posterior wall of the ascending aorta usually at
the level of the left pulmonary artery
(Fig. 2). Cephalad extension of
this recess into the high right paratracheal region can be mistaken for
adenopathy or a bronchogenic cyst
[6] (Fig.
3A,
3B).
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Fig. 2. —48-year-old man with non–small cell lung cancer of
right upper lobe. Axial contrast-enhanced multidetector CT scan shows superior
aortic recess (asterisk) posterior to ascending aorta (A) at level of
left pulmonary artery (LPA). Although this recess can be misinterpreted as
enlarged lymph node, location and appearance are characteristic. Note right
hilar mass (M) invading mediastinum.
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Fig. 3A. —42-year-old woman with breast cancer. Axial contrast-enhanced
multidetector CT scan at level of left brachiocephalic vein (LBV) shows
cephalad extension of superior aortic recess adjacent to trachea. This
"high-riding" variant (arrow) can be misinterpreted as
adenopathy when slice thickness precludes seeing anatomic contiguity.
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Fig. 3B. —42-year-old woman with breast cancer. Coronal reformation
confirms contiguity of fluid collection with superior aortic recess
(arrow) of transverse pericardial sinus. A = aorta, S = superior vena
cava, PA = pulmonary artery.
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The anterior portion of the superior aortic recess passes anterior to the
aorta and pulmonary artery, forming a characteristic cleft as it indents
between the great vessels.
The anterior portion of the superior aortic recess includes the area
occasionally described as the aortopulmonary window recess
[7] (Fig.
4A,
4B). Differentiation of this
recess from aortopulmonary window adenopathy is facilitated by the typical
location and appearance. Fluid in this pericardial space has a
well-circumscribed contour with a beaklike extension as it drapes in front of
the aorta and pulmonary artery. Although visual analysis can often
differentiate pericardial fluid from aortopulmonary window adenopathy,
measurement of attenuation values can be useful.
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Fig. 4A. —21-year-old woman with Ewing's sarcoma of zygoma. T = thymus.
Axial contrast-enhanced multidetector CT (MDCT) scan shows focal
fluid-attenuation (4-H) structure (arrow) adjacent to aortic arch
mimicking enlarged lymph node.
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Fig. 4B. —21-year-old woman with Ewing's sarcoma of zygoma. T = thymus.
Axial contrast-enhanced MDCT scan shows pericardial fluid (long
arrow) mimicking aortopulmonary window adenopathy. Contiguity of these
two collections with pericardial fluid anterior to aorta and pulmonary trunk,
seen on 3.75-mm images, was less apparent on 7.5-mm images. Fluid collection
forms beak (short arrow) directed anteriorly communicating with
anterior portion of superior aortic recess (not shown). Note this appearance
is useful in differentiating pericardial recess from adenopathy when
contiguity is not apparent. A = aorta.
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Inferior Aortic Recess
The inferior aortic recess (Fig.
5A,
5B,
5C) is a crescentic
diverticulum between the right lateral aspect of the ascending aorta and the
right atrium. The caudal extent of this recess is at the level of the aortic
valve annulus.
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Fig. 5A. —78-year-old man with invasive thymoma. Axial
contrast-enhanced multidetector CT (MDCT) scan obtained at level of lower
aspect of right pulmonary artery (RPA) shows intrapericardial tumor extension
(asterisks) in inferior portion of transverse sinus between superior
vena cava (S) and ascending aorta (A). Malignant pleural effusion (P) is
present.
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Fig. 5B. —78-year-old man with invasive thymoma. Axial
contrast-enhanced MDCT scan obtained at level of left atrium (LA) shows
inferior aortic recess (asterisks), caudal extent of transverse sinus
located between right atrium (RA) and aortic root (A). This recess is
distended by malignant pericardial effusion and tumor implants with
soft-tissue attenuation. P = malignant pleural effusion.
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Fig. 5C. —78-year-old man with invasive thymoma. Coronal reformation
shows superior (arrows) and inferior (arrowheads) aortic
recesses of transverse sinus. Note craniocaudal extent of transverse sinus. T
= thymoma, A = aorta, PA = pulmonary artery, RA = right atrium.
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Right and Left Pulmonic Recesses
The right and left pulmonic recesses form the lateral extent of the
transverse sinus (Fig. 6A,
6B,
6C). The right pulmonic recess
is inferior to the proximal right pulmonary artery. This recess is bounded by
the reflection of serous pericardium extending from the right pulmonary artery
to the superior vena cava. The left pulmonic recess is bounded superiorly by
the left pulmonary artery; inferiorly by the left superior pulmonary vein; and
medially by the ligament of Marshall, a vestigal fold of the remnant left
superior vena cava..
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Fig. 6A. —64-year-old woman with retroperitoneal mesothelioma. A =
aorta, PA = pulmonary artery. Axial contrast-enhanced multidetector CT scan
shows left pulmonic recess (arrow) of transverse sinus
(asterisk). Pericardial fluid is also seen anterior to aorta and
pulmonary artery forming characteristic cleft as it indents between great
vessels (arrowheads).
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Fig. 6B. —64-year-old woman with retroperitoneal mesothelioma. A =
aorta, PA = pulmonary artery. Sagittal reformation obtained through right
ventricular outflow tract shows transverse sinus (asterisk) located
inferior to pulmonary artery and superior to left atrium (LA).
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Fig. 6C. —64-year-old woman with retroperitoneal mesothelioma. A =
aorta, PA = pulmonary artery. Coronal reformation shows right (black
arrow) and left (white arrow) pulmonic recesses that form
lateral extent of transverse sinus. LA = left atrium.
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Postcaval Recess
The postcaval recess, a diverticulum of the pericardial cavity proper,
extends along the lateral aspect of the superior vena cava, forming the right
lateral extension of the superior aortic recess
[8] (Figs.
1 and
7). The postcaval recess is
bounded by the right pulmonary artery and the right superior pulmonary
vein.
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Fig. 7. —69-year-old man with rectal cancer. Axial contrast-enhanced
multidetector CT scan delineates fluid in postcaval recess (long
arrow) and posterior (arrowheads) to ascending aorta.
Pericardial fluid also extends anterior (short arrows) to aorta (A)
and pulmonary artery (PA) as well as in left pulmonic recess
(asterisk) of transverse sinus. S = superior vena cava.
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Oblique Sinus
The oblique sinus, superior and posterior to the left atrium and
posteromedial to the left superior pulmonary vein, is separated from the
transverse sinus by a double reflection of serous pericardium (Figs.
8 and
9). Fluid in the oblique sinus
can simulate abnormalities in the esophagus, descending thoracic aorta, and
subcarinal and bronchopulmonary lymph nodes.
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Fig. 8. —61-year-old man with non–small cell lung cancer. Axial
contrast-enhanced multidetector CT scan obtained at level of main pulmonary
artery (PA) shows oblique sinus (asterisk) anterior to esophagus (E)
and superior to left atrium. Note difference in attenuation between fluid in
oblique sinus and adjacent mediastinal lymph nodes (arrow). A =
aorta, B = blastic metastasis in thoracic vertebral body.
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Fig. 9. —48-year-old man with non–small cell lung cancer. Axial
contrast-enhanced multidetector CT scan obtained at level of main pulmonary
artery (PA) shows that fluid in oblique sinus (asterisk) and adjacent
lymph node (arrow) are similar in attenuation and can lead to
misinterpretation of pericardial sinus as adenopathy. A = aorta.
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Right and Left Pulmonary Venous Recesses
The right and left pulmonary venous recesses are located between the
superior and inferior pulmonary veins projecting superiorly and medially
posterior to the left atrium, indenting the side walls of the oblique sinus
(Figs. 1 and
10). As the pulmonary veins
penetrate the fibrous pericardium to enter the left atrium, a serosal sleeve
of pericardium invests the veins (Fig.
11). At the level of the inferior pulmonary vein, pericardial
fluid in the sleeve can be misinterpreted as adenopathy. Fluid in the sleeve
can be seen anterior and posterior to the vein, whereas adenopathy typically
occurs on one side of the vein and narrows the vein.
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Fig. 10. —67-year-old woman with thyroid cancer. Axial
contrast-enhanced multidetector CT scan shows fluid in superior aortic recess
(white asterisk) posterior to ascending aorta (A) and in left
pulmonary venous recess (black asterisks) medial and posterior to
left superior pulmonary vein (V). Note small amount of fluid is also seen in
left pulmonic recess posterior to pulmonary artery (PA). E = esophagus, N =
bronchopulmonary lymph node.
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Fig. 11. —64-year-old woman with pancreatic cancer. Axial
contrast-enhanced multidetector CT scan shows fluid in serosal sleeve
(white arrows) surrounding right inferior pulmonary vein (V) as it
drains into left atrium (LA). Typical location and appearance—that is,
anterior and posterior to vein, and well-circumscribed contour— are
useful in preventing misinterpretation as adenopathy. Focal fluid collection
is not associated with pericardial effusion. Note pericardium (black
arrows) anterior to right ventricle (RV) is normal.
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Conclusions
In summary, the capability of MDCT to obtain volumetric data with high
resolution and decreased respiratory and cardiac motion artifacts results in
the routine visualization of the pericardial recesses, even in the absence of
abnormal pericardial fluid accumulation. Because misinterpretation of the
pericardial recesses as a mediastinal abnormality can have important clinical
ramifications, a comprehensive understanding of pericardial anatomy is
essential. In oncologic imaging, misinterpretation of pericardial fluid as
adenopathy can lead to inaccurate clinical staging and inappropriate
management and therapy. Knowledge of the anatomy of pericardial recesses
together with better visualization with narrow collimated images and
multiplanar reformation enables improved diagnostic accuracy.
Acknowledgments
We thank Brooke Lening for photography, Nicholas Lang for medical
illustration, and Gloria Mendoza for manuscript preparation.
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Introduction
Materials and Methods
