Pericardial Cyst: Symptoms, Types, Causes and Treatment

Pericardial cysts, though rare, are clinically significant entities that can present a diagnostic and therapeutic challenge. Most often, they are discovered incidentally during imaging for unrelated reasons, but in some cases, they can produce symptoms or complications that necessitate medical attention. In this article, we take a deep dive into what pericardial cysts are, their symptoms, types, underlying causes, and current treatment approaches—drawing on the latest evidence and case experiences.

Symptoms of Pericardial Cyst

Pericardial cysts are notorious for their silent nature; many people live with one without ever knowing it. However, when symptoms do occur, they can mimic other, more common cardiac or respiratory conditions, leading to diagnostic confusion. Understanding the symptom profile of pericardial cysts is essential for timely identification and management.

Symptom	Description	Typical Presentation	Source(s)
Chest Pain	Discomfort, may be pleuritic or atypical	Sudden or persistent	1 2 3 4
Cough	Persistent, unexplained cough	Acute or chronic	1 2 4
Dyspnea	Shortness of breath, sometimes severe	With exertion or at rest	1 2 3 4 6
Dysphagia	Difficulty swallowing (rare)	If cyst compresses esophagus	4
Arrhythmia	Irregular heartbeat, potentially life-threatening	With large cysts	6
Asymptomatic	No symptoms, found incidentally	On imaging	1 2 4 5 9

Table 1: Key Symptoms

Overview of Symptom Presentation

Pericardial cysts most commonly present without symptoms, only coming to light during imaging for unrelated health issues such as chest pain or abdominal complaints 1 2 4 5 9. However, when symptoms do occur, they can range from mild discomfort to severe, life-threatening events.

Common Manifestations

• Chest Pain: This can be pleuritic (sharp pain with breathing) or atypical, often leading to confusion with more serious cardiac events like myocardial infarction or pulmonary embolism 1 2 3.
• Cough and Dyspnea: These are due to the cyst causing pressure on nearby airways or lung tissue, resulting in persistent cough or shortness of breath 1 2 4.
• Dysphagia: Though rare, very large cysts can compress the esophagus, leading to swallowing difficulties 4.
• Arrhythmias: In exceptional cases, especially with very large cysts, compression of cardiac structures can precipitate abnormal and potentially dangerous heart rhythms 6.

Asymptomatic Cases

The majority of pericardial cysts are completely asymptomatic and are discovered by chance during imaging studies such as chest X-ray (CXR), computed tomography (CT), or magnetic resonance imaging (MRI) 5 9. This "silent" nature underscores the importance of imaging in diagnosis.

Types of Pericardial Cyst

Not all pericardial cysts are the same. Their classification is based on location, etiology, and specific features, which can have important implications for diagnosis and management.

Type	Distinguishing Feature	Frequency/Significance	Source(s)
Congenital	Present from birth	Most common	5 6 9
Acquired	Develops later (infection/trauma)	Rare	5
Hydatid	Parasitic origin (Echinococcus)	Very rare	7
Location-based	Cardiophrenic angle, mediastinum	Cardiophrenic most common	1 4 11
Pericardial Diverticulum	Communication with pericardial space	Uncommon	9

Table 2: Types of Pericardial Cyst

Congenital vs. Acquired

• Congenital Cysts: These arise due to developmental anomalies during the formation of the pericardium. They are, by far, the most common type 5 6 9.
• Acquired Cysts: Much less common, these can result from infections (like tuberculosis), trauma, or post-surgical changes 5.

Hydatid (Parasitic) Cysts

• Hydatid Cysts: Caused by the Echinococcus parasite, these are exceptionally rare and usually occur in areas where hydatid disease is endemic. Management often requires a multidisciplinary approach 7.

Anatomical Location

• Cardiophrenic Angle: Most pericardial cysts are found in the right or left cardiophrenic angles—the recesses where the heart meets the diaphragm 1 4 11.
• Other Mediastinal Locations: Less commonly, cysts may appear in the anterior, posterior, or superior mediastinum, or near the heart itself 1 4 11.

Pericardial Diverticulum

• Diverticulum vs. Cyst: Pericardial diverticula are similar to cysts but communicate with the pericardial space, sometimes making distinction difficult without surgical exploration 9.

Causes of Pericardial Cyst

Understanding what causes pericardial cysts helps guide both diagnosis and risk assessment. Most are congenital, but other etiologies must also be considered.

Cause	Mechanism	Commonality	Source(s)
Congenital	Incomplete fusion of pericardial tissue	Most common	5 6 9
Infection	Post-infectious cyst formation	Rare	5 7
Trauma	Following chest injury or surgery	Rare	5
Parasitic	Echinococcus granulosus infection	Very rare (hydatid cyst)	7

Table 3: Causes of Pericardial Cyst

Developmental (Congenital) Origin

The vast majority of pericardial cysts are congenital. They result from abnormal development during the embryonic formation of the pericardium—specifically, from incomplete coalescence of the fetal pericardial lacunae (small embryonic cavities) 6 9. This developmental “misfire” leaves behind a fluid-filled sac.

Acquired Causes

• Infection: Rarely, pericardial cysts can form following significant infections in the chest, such as tuberculosis or bacterial infections 5 7.
• Trauma: Surgical procedures or blunt chest trauma can sometimes trigger the formation of a cyst as the body attempts to wall off injury or inflammation 5.

Parasitic Infection

• Hydatid Disease: In regions where Echinococcus is prevalent, hydatid cysts can form in the pericardium. These are not only rare but also require special attention due to the risk of rupture or spread 7.

Treatment of Pericardial Cyst

Once a pericardial cyst is identified, the next step is determining the best management strategy. Treatment depends on symptoms, cyst size, location, and potential for complications.

Treatment Option	Indication	Outcomes/Notes	Source(s)
Observation	Asymptomatic, small cysts	Periodic imaging follow-up	4 5 9
Percutaneous Aspiration	Symptomatic or large cysts	Minimally invasive, recurrence possible	1 8 10 11
Ethanol Sclerosis	Refractory cysts, post-aspiration	Reduces recurrence, safe	10
Surgical Resection	Symptomatic, large, or complicated cysts	Definitive, minimal recurrence	1 4 11
Video-Assisted Thoracoscopic Surgery (VATS)	Minimally invasive resection	Rapid recovery, good results	1 4 11

Table 4: Treatment Approaches

Observation and Follow-Up

• When to Observe: Asymptomatic and small cysts can often be safely observed with regular imaging (such as echocardiography or CT) every 1–2 years 4 5 9.
• Rationale: Many pericardial cysts remain static or may even resolve spontaneously 5.

Percutaneous Aspiration

• Technique: Fluid is aspirated from the cyst under imaging guidance (often echocardiographic or CT) 1 8 11.
• Advantages: Minimally invasive; useful for temporary relief, especially in high-risk surgical candidates.
• Limitations: Risk of recurrence, infection, or incomplete drainage 1 8.

Ethanol Sclerosis

• Indication: Used after aspiration for cysts that tend to recur.
• Mechanism: Injection of ethanol into the cyst after aspiration causes the cyst wall to scar and collapse, reducing recurrence 10.
• Evidence: Successful outcomes and no recurrence at 6 months in reported cases 10.

Surgical Resection

• Open Thoracotomy: Standard for large, symptomatic, or complicated cysts. Involves surgical excision through the chest wall 1 4 11.
• VATS (Video-Assisted Thoracoscopic Surgery): Minimally invasive, offering shorter recovery times and excellent outcomes 1 4 11.
• Outcomes: Both approaches are highly effective, with minimal recurrence and low complication rates 4 11.

Choosing the Right Approach

Treatment choice is individualized, taking into account:

• Symptom severity
• Cyst size and location
• Risk of complications (e.g., cardiac tamponade, arrhythmia)
• Patient comorbidities and surgical risk 1 4 11

Conclusion

Pericardial cysts, while rare and often silent, can pose significant diagnostic and management challenges. Awareness of their varied symptoms, types, causes, and treatment options is crucial for clinicians and patients alike.

Key points from this article:

• Most pericardial cysts are asymptomatic and discovered incidentally on imaging 1 2 4 5 9.
• Symptomatic cysts usually cause chest pain, cough, or dyspnea, and rarely, life-threatening complications like arrhythmias 1 2 3 4 6.
• The majority are congenital, but acquired and parasitic causes (hydatid cysts) exist 5 6 7 9.
• Observation is appropriate for small, asymptomatic cysts, while symptomatic or large cysts may require aspiration, ethanol sclerosis, or surgical removal 1 4 5 8 10 11.
• Both open and minimally invasive surgical techniques offer excellent outcomes with low recurrence 4 11.

Early recognition, appropriate imaging, and tailored management remain the cornerstones of optimal care for patients with pericardial cysts.