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Cardiac Herniation Due to Blunt Trauma: Early Diagnosis Facilitated by CT

Loyola University Medical Center Maywood, IL 60153

Pericardial rupture with cardiac herniation from blunt trauma is a highly lethal injury. Most patients succumb to cardiac or associated traumatic injuries before arrival at a hospital [1]. Diagnosis in survivors is often delayed because initial chest radiography results are normal or show nonspecific abnormalities before cardiac herniation through the pericardial tear. In the 25-year-old man we present here, CT led to early diagnosis. Brought to the trauma ward after a motorcycle crash, he was alert, tachycardic, and hypotensive, with left-sided chest pain. Chest radiography (Fig. 8A) showed lung consolidation, pneumothoraces, and mediastinal deviation. Immediately after radiography, single-detector CT showed herniation of the heart into the right hemithorax (Figs. 8B and 8C). The patient underwent reduction of the herniated heart, oversewing of lung lacerations, and splenectomy. Postoperative chest radiography showed the heart in the normal anatomic position (Fig. 8D).

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —25-year-old man with cardiac herniation after motorcycle accident. Admission chest radiograph shows bilateral pneumothorax, extensive subcutaneous gas, bilateral lung consolidation, and deviation of heart and mediastinum to right.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —25-year-old man with cardiac herniation after motorcycle accident. Chest CT 3 hours after admission shows pneumopericardium with heart protruding through pericardial defect into right hemithorax. CT image through heart shows pericardium with pneumopericardium and heart deviated into right hemithorax. Note bilateral pneumothoraces, mediastinal and body-wall gas, and lung consolidation. Asterisk indicates air-filled partially empty pericardial sac, usually occupied by heart. Arrows indicate pericardial wall.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —25-year-old man with cardiac herniation after motorcycle accident. More caudal CT image shows pericardium with pneumopericardium and marked deviation of heart into right hemithorax. Asterisk indicates air-filled partially empty pericardial sac, usually occupied by heart. Arrows indicate pericardial wall.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8D —25-year-old man with cardiac herniation after motorcycle accident. Chest radiograph after surgery shows normal situs of heart. Bilateral chest tubes, endotracheal tube, and nasogastric tube are in place. Bilateral pneumothoraces have resolved. There is still extensive body-wall gas.

Pericardial tears with cardiac herniation from blunt trauma are rare, comprising less than 1% of more than 20,000 patients admitted to one trauma center from 1979-1989 [2]. Most such patients die before arrival at a hospital, and those who do survive to hospitalization have a mortality rate as high as 43% [2, 3]. Pericardial tears range from short and insignificant to long tears that may lead to cardiac herniation. Tears 8-12 cm in length are associated with cardiac herniation, 90% of which occur along the left pleuropericardium [1]. Fewer than 20% of all tears are diaphragmatic; these rarely lead to cardiac herniation [2, 3]. Patients with short tears may remain asymptomatic, whereas those with long tears may initially be asymptomatic, only to develop cardiogenic shock after cardiac herniation.

Short tears are seldom diagnosed based on radiography or echocardiography. Echocardiography has been found useful by some authors, but others report low sensitivity even with long tears [1-3]. The utility of focused abdominal sonography for trauma (FAST) has not been documented. Most tears without cardiac herniation are diagnosed at thoracotomy or autopsy; this occurred in 15 (91%) of 16 patients in one study [2].

Patients with longer tears without cardiac herniation may have pneumopericardium and enlargement, distortion, and displacement of the heart on radiographs, but these signs are nonspecific unless there is gross displacement of the heart unaccounted for by another abnormality. Abnormalities of the cardiac axis may be shown by ECG with cardiac herniation but are nonspecific.

In one study, pericardial tear was complicated by cardiac herniation in six (27%) of 22 patients; five were diagnosed at surgery, and one was diagnosed based on radiography [2]. It is noteworthy that in another study, nine (90%) of 10 patients with cardiac herniation had normal pulse rates and normal results on admission chest radiographs but developed cardiogenic shock within hours. Two such patients were diagnosed during emergent surgery. Chest radiographs acquired an average of 9 hours after admission were diagnostic of cardiac herniation in seven patients [3].

CT has shown pericardial tears before cardiac herniation and herniation itself [1, 4]. Signs of a tear include focal pericardial discontinuity; pneumopericardium; and interposition of lung between the aorta and pulmonary artery, heart and diaphragm, or right atrium and right ventricular outflow tract— signs similar to congenital absence of the pericardium. The primary sign of herniation is cardiac displacement when no large pleural effusion, atelectasis, or tension pneumothorax accounts for this displacement. Other signs are cardiac deformity due to protrusion through a tear and pneumopericardium. Pneumopericardium is nonspecific, but a large volume of unilateral gas within the pericardium is more diagnostic, as in our patient, and has been termed the empty pericardial sac [4] (Figs. 8B and 8C). This report and a few others document the contribution of CT to the earlier diagnosis of this highly lethal injury.

References

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1. Farhataziz N, Landay M. Pericardial rupture after blunt chest trauma. J Thorac Imaging 2005;20 : 50-52[CrossRef][Medline]
2. Fulda G, Rodriguez A, Turney SZ, Cowley RA. Blunt traumatic pericardial rupture: a ten-year experience 1979 to 1989. J Cardiovasc Surg 1990; 31:525 -530[Medline]
3. Carrillo EH, Heniford BT, Dykes JR, McKenzie ED, Polk HC Jr, Richardson JD. Cardiac herniation producing tamponade: the critical role of early diagnosis. J Trauma 1997;43 : 19-23[Medline]
4. Schir F, Thony F, Chavanon O, Perez-Moreira I, Blin D, Coulumb M. Blunt traumatic rupture of the pericardium with cardiac herniation: two cases diagnosed using computed tomography. Eur Radiol2001; 11:995 -999[CrossRef][Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Wielenberg, A. J. Articles by Bova, D. Search for Related Content PubMed PubMed Citation Articles by Wielenberg, A. J. Articles by Bova, D. Social Bookmarking                      What's this?