Imaging of constrictive pericarditis

General considerations:
o Defined by thickening of pericardium (>4mm) impeding diastolic filling.
o Thickened pericardium may calcify (50%).
o Calcified pericardium almost always implies constriction, but not always.
o About 50% of calcified pericardiums are visible on conventional radiography.
o Calcification of the pericardium is most likely inflammatory in nature.

 Can be seen with a variety of infections, trauma, and neoplasms.
 Most common causes include:
 Viral pericarditis (most common).
 Tuberculous pericarditis.
 Uremic pericarditis.
 Post-cardiac surgery.
o Calcification most commonly occurs along the inferior diaphragmatic surface of the pericardium surrounding the ventricles.
 Thin, egg-shell like calcification is more often associated with viral infection or uremia.
 Calcification from old TB is often thick, confluent, and irregular in appearance, especially when compared with myocardial calcification.

Radiographic features:

 Plain chest radiographs may show pericardial calcification in as many as 50% of CP patients.
 The cardiac silhouette should be small in a patient with uncomplicated CP.
 CP can also coexist with cardiomyopathy, and a large heart does not exclude the disease. Other, less reliable plain radiographic findings include an abnormal cardiac contour, such as straightening of the right atrial border and, more rarely, straightening of the right and left cardiac borders, with obliteration of the normal curves, on frontal images. On fluoroscopy, diminished cardiac pulsation may be seen.
 The absence of calcification does not exclude the disease, and further testing should include an extensive workup in the echocardiography laboratory, with an assessment of the Doppler velocities across the mitral and tricuspid valves during inspiration and expiration.
Computed Tomography:
 The pericardium should be diffusely thicker than 3 mm; however, many patients do not present with this finding, and the diagnosis of CP should not be discarded if thickening is not present. The size of all 4 heart chambers should be within the normal range; however, CP can coexist with other diseases, and global or focal dilatation of the cardiac chambers does not exclude CP.
 The inflow veins to the right atrium, including the SVC, inferior vena cava (IVC), and hepatic veins, should be dilated. This finding is necessary but not sufficient to make the diagnosis of CP because it commonly occurs in the setting of congestive heart failure brought on by a variety of causes. Most often, when the hepatic veins and IVC are dilated for reasons other than CP, dilatation of 1 or all of the cardiac chambers is present and caused by systolic dysfunction or valve disease. If significant cirrhosis has already occurred, the hepatic veins may not be dilated.
 In CP, there should be poor opacification of liver parenchyma due to congestion and there should be no contrast enhancement in the portal vein.
 NB: Dilated veins can be caused by right-sided heart failure. Liver cirrhosis can mimic the CT findings of CP.
Magnetic Resonance Imaging:
 Diffuse thickening of the pericardium greater than 3 mm can be observed on multiplanar MRIs.
 ECG-triggered MRI is sensitive to constrictive disease of the pericardium because the fibrous layers are bordered by fat, which produces a distinct MRI signal. MRI can be used to measure pericardial thickness; the ideal views for measuring pericardial thickness are oriented perpendicular to the long axis of the left ventricle. MRI can also be used to measure chamber sizes at successive 50-msec delays after the R wave and to determine whether or not a filling plateau is present.
 Like echocardiography and/or Doppler imaging, velocity-encoded (VENC) MRI can be used to assess volumetric flow and regurgitant flow to the pulmonary veins and the hepatic vein. MRI can demonstrate focal abnormalities and can cover the heart to determine whether the disease encapsulates its entirety.
 MRI dynamically shows a reversed curvature of the interventricular septum clearly.
 Fast imaging can be performed during deep respiration to establish whether filling is concordant or discordant. CP restriction creates discordance with reduced left ventricular filling, which corresponds to increased right ventricular filling.
 Liver sonograms show dilated hepatic veins and abnormal pulse Doppler waveforms in the portal and hepatic veins due to outflow obstruction.
 Abdominal ultrasonographic findings are nonspecific and must be confirmed with echocardiography and cardiac catheterization results.
 Cardiac echograms show normal contraction and systolic function. Special procedures, including an assessment of Doppler velocities across the mitral and tricuspid valves during inspiration and expiration, are needed to demonstrate ventricular interdependence.
 Budd-Chiari syndrome, cirrhosis, and right-sided heart failure can mimic some of the findings of CP at liver ultrasonography.
Nuclear Imaging:
 Gated nuclear ventriculography may show rapid ventricular filling in CP. Reportedly, these findings can be used to differentiate CP from restrictive cardiomyopathy.

MRI findings of tuberculosis of the hip joint

1. The infection may originate in the synovium, the proximal femur (epiphysis, metaphysis, femoral neck, or trochanteric apophysis), the acetabulum, or the gluteal/ iliopsoas bursae.
2. Cold abscesses may be palpable in the femoral triangle, the ischiorectal fossa, or the thigh. Sinuses may occur in any of these locations.
3. The radiographic findings vary considerably depending on the primary location and degree of involvement.
4. A lesion in the acetabular roof (“wandering acetabulum”) may result in subluxation, and clinically there will be limb shortening without positioning. True pathologic dislocation may occur as well, which will be associated with both limb shortening and positioning.
5. Protrusio may be associated with lesions in the acetabular floor.
6. Coxa magna may be confused with Perthes' disease in pediatric patients.
7. Significant joint space narrowing without an osseous focus (“atrophic”) may be difficult to differentiate from rheumatoid arthritis.
8. Destruction on both sides of the joint may result in irregularity of the femoral head and incongruity (“mortar and pestle”).
9. Disease passes into 4 stages:
(A) Stage of synovitis:
- X-RAY – soft tissue swelling , haziness of articular margins & rarefaction
- USG – soft tissue swelling
- MRI – synovial effusion
(B) Stage of early arthritis:
- X-RAY – osteopenia , erosion of articular margins , ↓ joint space.
- MRI  synovial effusion , edema , minimal bone destruction
(C) Stage of advanced arthritis:
- X-RAY  further decrease in joint space.
(D) Advanced arthritis with subluxation / dislocation :
- X-RAY Furhter destruction of acetabulum , head , capsule and ligaments. Head – upwards and posteriorly. Wandering / migrating acetabulum. Mortle & pestle appearance. Reduced joint space.

Osteoporosis and osteomalacia by radiographic imaging

Osteoporosis radiographic manifestations:

1. The vertebral bodies may develop a biconcave shape or compression fractures.
2. In tubular bones the trabecular bone loss may cause the metaphyses to appear radiolucent.
3. Pathological fractures may occur at multiple sites.
4. Schmorls nodes.
5. Acute and insufficiency fractures.
6. MR imaging:
(A) In transient osteoporosis of the hip manifested as decreased signal intensity on T1-weighted sequences and increased signal intensity on T2-weighted sequences.
(B) The patient commonly has associated joint effusions in the affected hip.
(C) Chemical shift fat suppression and STIR imaging techniques can be effective in the detection of transient bone marrow oedema.

Osteomalacia radiographic manifestations:

1. Loosers zones (cortical fractures on the compression side of the bone) or Milkmans pseudofractures are strongly suggestive but not diagnostic of osteomalacia. i.e. linear lucencies oriented perpendicular to the cortical margin.
2. Decreased bone density (Osteopenia).
3. Coarsening of the trabecular pattern and cortical striations.
4. Cortical thinning.
5. MRI : insufficiency fractures seen as a hypointense lines or fissures on T1- and T2-weighted and STIR MR images.