Pericarditis MRI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Homa Najafi, M.D.[2]


On MRI, normal pericardium appears as a thin dark band that is bordered by a bright band on both sides on T1 weighted spin imaging. These surrounding bright bands are associated with the surrounding epicardial and pericardial fat. Following the administration of gadolinium, pericardium may appear thick and inflamed in the setting of pericarditis. Lower intensity signal is observed in constrictive pericarditis than in acute pericarditis. Comprehensive visualization of the LV endocardium and the physiologic consequences of abnormal pericardial thickening can also be obtained without exposure to ionizing radiation.

Normal Pericardium on Cardiac MRI

The low water content pericardium appears as a thin dark band that is bordered by a bright band on both sides on T1 weighted spin imaging. These surrounding bright bands are associated with the surrounding epicardial and pericardial fat. The thickness of the normal pericardium is 2 to 4 mm.

Inflamed Pericardium on Cardiac MRI

Following the administration of gadolinium the pericardium is enhanced due to inflammation.

Constrictive Pericarditis on Cardiac MRI

Pericardial thickening on cardiac MRI has become the diagnostic modality of choice in the assessment of constrictive pericarditis with a sensitivity of 88%, the specificity of 100%, and diagnostic accuracy of 93%. The pericardium is of a lower intensity signal in constrictive pericarditis than in acute pericarditis.[1]

Other signs of pericardial constriction on cardiac MRI include the following:

Pericardial Effusion on Cardiac MRI

A pericardial effusion is black on spin echo images and in contrast is bright on gradient echo images. Small to moderate sized pericardial effusion occupy the space anterior to the right ventricle and are usually 5 mm or greater. A large pericardial effusion is often circumferential.

Insight into the composition of the pericardial effusion can be gleaned based upon the following characteristics:

  • Transudates: Low signal on T1-weighted images but high signal on T2-weighted and gradient echo images.
  • Exudates: Intermediate signal on both types of sequences.
  • Hemorrhagic effusions: Wide range of signal intensity on spin-echo sequences that is dependent upon the age of the effusion.

Cardiac Tamponade on Cardiac MRI

Cardiac tamponade is characterized by the diastolic collapse the right-sided chambers and sometimes the left-sided chambers on cine images.

Detection and Assessment of other Pericardial Pathologies on Cardiac MRI

Cardiac MRI is useful in the detection and assessment of the following pericardial pathologic processes:

  • Pericardial cysts
  • Metastasis to the pericardium
  • Primary tumors of the pericardium
  • Intracardiac tumors such as myxomas, lipomas, and teratomas.
  • Pericardial calcification: Calcification is not well distinguished from pericardial thickening on CMR. Calcium appears black on CMR and may be difficult to distinguish from pericardial thickening. Cardiac CT is the preferred imaging modality to assess for pericardial calcification.

2010 ACCF/ACR/AHA/NASCI/SCMR Expert Consensus Document on Cardiovascular Magnetic Resonance (DO NOT EDIT)[2]

Pericardial Disease (DO NOT EDIT)[2]

CMR may be used as a noninvasive imaging modality to diagnose patients with suspected pericardial disease. CMR can provide a comprehensive structural and functional assessment of the pericardium as well as evaluate the physiological consequences of pericardial constriction.

2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)[3]

Recommendations for the general diagnostic work-up of pericardial diseases

Class I
1. In all cases of suspected pericardial disease a first diagnostic evaluation is recommended with:



transthoracic echocardiography

chest X-ray

– routine blood tests, including markers of inflammation (i.e., CRP and/or ESR), white blood cell count with differential count, renal function and liver tests and myocardial lesion tests (CK, troponins).

2. CT and/or CMR are recommended as second-level testing for diagnostic workup in pericarditis.

3. Pericardiocentesis or surgical drainage are indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis.

4. Further testing is indicated in high-risk patients (defined as above) according to the clinical conditions. (Level of Evidence: C)

Recommendations for the diagnosis and management of pericarditis associated with myocarditis

Class I
1. In cases of pericarditis with suspected associated myocarditis, coronary angiography (according to clinical presentation and risk factor assessment) is recommended in order to rule out acute coronary syndromes.

2. Cardiac magnetic resonance is recommended for the confirmation of myocardial involvement.

3. Hospitalization is recommended for diagnosis and monitoring in patients with myocardial involvement.

4. Rest and avoidance of physical activity beyond normal sedentary activities is recommended in non-athletes and athletes with myopericarditis for a period of 6 months. (Level of Evidence: C)

Recommendations for the diagnosis of constrictive pericarditis

Class I
1. Transthoracic echocardiography is recommended in all patients with suspected constrictive pericarditis.

2. Chest X-ray (frontal and lateral views)with adequate technical characteristics is recommended in all patients with suspected constrictive pericarditis.

3. CT and/or CMR are indicated as second-level imaging techniques to assess calcifications (CT), pericardial thickness, degree and extension of pericardial involvement.

4. Cardiac catheterization is indicated when non-invasive diagnostic methods do not provide a definite diagnosis of constriction. (Level of Evidence: C)


  1. Hatle LK, Appleton CP, Popp RL (1989). "Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography". Circulation. 79 (2): 357–70. PMID 2914352.
  2. 2.0 2.1 American College of Cardiology Foundation Task Force on Expert Consensus Documents. Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA; et al. (2010). "ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 121 (22): 2462–508. doi:10.1161/CIR.0b013e3181d44a8f. PMC 3034132. PMID 20479157.
  3. Adler, Yehuda; Charron, Philippe; Imazio, Massimo; Badano, Luigi; Barón-Esquivias, Gonzalo; Bogaert, Jan; Brucato, Antonio; Gueret, Pascal; Klingel, Karin; Lionis, Christos; Maisch, Bernhard; Mayosi, Bongani; Pavie, Alain; Ristić, Arsen D.; Sabaté Tenas, Manel; Seferovic, Petar; Swedberg, Karl; Tomkowski, Witold (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN 0195-668X.

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