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Pneumopericardium is the presence of air in the pericardial sac, a rare but potentially life-threatening condition. It may result from trauma, medical intervention, infection, or fistulous communication with air-filled structures.

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Etiology

Clinical Presentation

Radiology

◦ Pneumopericardium **confined to pericardial contours**
◦ Pneumomediastinum often tracks superiorly into neck or anterior mediastinum |

| CT | Best modality for diagnosis • Demonstrates: ◦ Air limited to the pericardial sac ◦ No extension into mediastinum (unless coexistent pneumomediastinum) ◦ May show underlying cause: trauma, fistula, surgery • Air-fluid levels may be seen if hemorrhage or effusion coexists | | MR | Rarely used in acute setting • Air seen as signal voids on all sequences • MRI valuable in chronic or complicated cases (e.g., associated masses, infections) |

![A 27-year-old man was admitted to the hospital after a fall from approximately 10 m. He had multiple bone fractures, head trauma (Glasgow Coma Scale: 4/15), bilateral pulmonary contusions and pneumothoraces. We placed bilateral tube thoracostomies, and treated his other injuries. 1 day later, because of severe haemodynamic instability (hypotension and low cardiac output with high central venous pressure), we did transoesophageal echocardiography and found right ventricular compression in the absence of a pericardial effusion. Repeat chest radiographs (figure, left) showed the existing bilateral lung contusions and a new lucent outline of the heart (arrows). Computed tomography of the chest confirmed the diagnosis of post-traumatic pneumopericardium (figure, right, black arrow), bilateral pneumothoraces (white arrows) and lung contusion. The pneumopericardium resolved after we repositioned the left-sided interthoracic tube.

Gerard I, Verhelst D. Pneumopericardium. The Lancet. 2002;360(9335):771-771. doi:https://doi.org/10.1016/s0140-6736(02)09898-7](attachment:05660b55-16ea-45e7-b17a-6d057d397ec4:gr1_lrg.jpg)

A 27-year-old man was admitted to the hospital after a fall from approximately 10 m. He had multiple bone fractures, head trauma (Glasgow Coma Scale: 4/15), bilateral pulmonary contusions and pneumothoraces. We placed bilateral tube thoracostomies, and treated his other injuries. 1 day later, because of severe haemodynamic instability (hypotension and low cardiac output with high central venous pressure), we did transoesophageal echocardiography and found right ventricular compression in the absence of a pericardial effusion. Repeat chest radiographs (figure, left) showed the existing bilateral lung contusions and a new lucent outline of the heart (arrows). Computed tomography of the chest confirmed the diagnosis of post-traumatic pneumopericardium (figure, right, black arrow), bilateral pneumothoraces (white arrows) and lung contusion. The pneumopericardium resolved after we repositioned the left-sided interthoracic tube.

Gerard I, Verhelst D. Pneumopericardium. The Lancet. 2002;360(9335):771-771. doi:https://doi.org/10.1016/s0140-6736(02)09898-7

Pediatric imaging:

![a Chest X-ray demonstrating circular pneumopericardium, b Chest X-ray after insertion of pericardial tube (pigtail)

Meyer, S., Ruffing, S., Geipel, M. et al. Something is up in the air: pneumothorax and pneumopericardium in a 29-week preterm infant. Wien Med Wochenschr 174, 211–212 (2024). https://doi.org/10.1007/s10354-023-01021-9](attachment:f1d5f02c-0171-4e33-b5b1-d2f1d55a61b4:10354_2023_1021_Fig1_HTML.webp)

a Chest X-ray demonstrating circular pneumopericardium, b Chest X-ray after insertion of pericardial tube (pigtail)

Meyer, S., Ruffing, S., Geipel, M. et al. Something is up in the air: pneumothorax and pneumopericardium in a 29-week preterm infant. Wien Med Wochenschr 174, 211–212 (2024). https://doi.org/10.1007/s10354-023-01021-9

Differentials

Management

Further reading: