Normal penile Doppler study

- Baseline Cavernosal Artery Measurement: 0.4 mm

- Post-Papaverine Cavernosal Artery Measurement:1.1 mm

- Color Doppler PSV (Peak Systolic Velocity): Increased from 10 cm/s to 30 cm/s over 20 minutes

- Diastolic Flow: Increased from 0 to 10 cm/s before returning to 0

- Left Cavernosal Artery PSV: Slightly lower at 25 cm/s compared to the right side

Penile Doppler ultrasound images:

Before papaverine  injection:

After papaverine injection:

After some time:

After some more time:

*Interpretation:

- The increase in cavernosal artery diameter post-papaverine suggests a normal response, facilitating improved blood flow.

- Color Doppler results indicate a healthy increase in PSV, reflecting improved arterial blood flow during the assessment.

*Left vs. Right Cavernosal Artery PSV:

- The marginal difference in PSV between the left and right cavernosal arteries may not be clinically significant, but it's worth noting.

*Prognosis:

- The overall findings, including increased PSV and diastolic flow, suggest a normal penile Doppler ultrasound, indicating good vascular responsiveness.

*Management:

- Given the normal findings, addressing potential psychological factors and lifestyle modifications could be explored for comprehensive management.

- Consultation with a urologist may be beneficial for a more detailed assessment and to discuss potential treatment options for erectile dysfunction.

Note: specific patient cases should be discussed with healthcare professionals for accurate diagnosis and management.

LVF with pleural effusion and MR

Echo Findings in an Elderly Patient with Dyspnea and a Past History of Myocardial Infarction

*Introduction:

An elderly patient with dyspnea and a past history of myocardial infarction underwent echocardiography. The echocardiogram findings included:

* Left ventricle wall motion abnormality (WMA) affecting the LAD artery territory

* Reduced ejection fraction (EF) of 33%

* Moderate mitral regurgitation (MR)

* Bilateral pleural effusion

*Findings:

* Left ventricle WMA affecting LAD artery territory: This finding indicates that there is damage to the LAD artery, which is the main artery that supplies blood to the left ventricle. The damage is causing the left ventricle to not pump as well as it should.

* Reduced EF of 33%: An EF of 33% is considered to be low. This means that the left ventricle is not pumping as much blood as it should with each heartbeat.

* Moderate MR: MR is a condition in which the mitral valve does not close properly, allowing blood to leak back into the left atrium. Moderate MR means that the leak is significant.

* Bilateral pleural effusion: Pleural effusion is a condition in which there is excess fluid in the space around the lungs. Bilateral pleural effusion means that there is excess fluid in the space around both lungs.

*Prognosis:

The prognosis for patients with these findings is variable. Some patients will improve with medical treatment, while others will develop heart failure. The prognosis is worse for patients with more severe findings, such as a very low EF or severe MR.

*Management:

The management of patients with these findings depends on the severity of the findings. Patients with mild findings may be treated with medical therapy, such as beta-blockers or ACE inhibitors. Patients with more severe findings may require more aggressive treatment, such as surgery or heart transplantation.

*Images of echocardiography:

[Image of Reduced ejection fraction (EF)]

[Image of Moderate mitral regurgitation (MR)]

[Image of Bilateral pleural effusion]

*In brief:

* The patient has left ventricle WMA affecting the LAD artery territory.

* The patient has a reduced EF of 33%.

* The patient has moderate MR.

* The patient has bilateral pleural effusion.

* The prognosis for the patient is variable.

* The management of the patient will depend on the severity of the findings.

Watch the video 📹 of this case:

Echo video of this case

I hope this blog post has been informative

Aortic Aneurysm with Thrombus

Ultrasound Imaging Findings: Aortic Aneurysm with Thrombus

CT scan images:

Ultrasound images:

Color Doppler imaging:

1. Patient Profile:

   - Elderly patient 

   - Aortic aneurysm detected on ultrasound imaging

2. Aneurysm Dimensions:

   - Length: 5 cms

   - Width: 4.3 by 4.7 cms

   - Lumen diameter: 2 cms

3. Thrombus Presence:

   - Thrombus measures 1.8 cms

   - Located in the left half of the aneurysm

4. Implications of Thrombus:

   - May pose a risk of embolization or clot dislodgment. 

Let's break down the various grades and types of aortic aneurysms:

Types of Aortic Aneurysms:

1. Abdominal Aortic Aneurysm (AAA):

   - Located in the abdominal aorta

   - Commonly associated with atherosclerosis

   - May be asymptomatic until rupture

2. Thoracic Aortic Aneurysm (TAA):

   - Occurs in the thoracic (chest) portion of the aorta

   - Can involve the ascending or descending aorta

   - May be associated with genetic conditions (e.g., Marfan syndrome)

3. Thoracoabdominal Aortic Aneurysm:

   - Extends from the thoracic to the abdominal aorta

   - Requires careful management due to the involvement of multiple aortic segments

4. Fusiform Aneurysm:

   - Affects the entire circumference of the aorta

   - Results in a gradual, symmetrical bulging

5. Saccular Aneurysm:

   - Localized bulging on one side of the aorta

   - More prone to rupture than fusiform aneurysms

**Grades of Aortic Aneurysms:

1. **Small Aneurysm:

   - Diameter less than 3 cm

   - Often monitored regularly without immediate intervention

2. **Moderate Aneurysm:

   - Diameter between 3 and 5.5 cm

   - Requires close monitoring and consideration for intervention based on individual factors

3. **Large Aneurysm:

   - Diameter greater than 5.5 cm

   - Higher risk of rupture, often requiring surgical intervention

4. **Ruptured Aneurysm:

   - Life-threatening emergency

   - Immediate surgery is typically necessary

5. **Dissecting Aneurysm:

   - Involves a tear in the inner layers of the aortic wall

   - Can be classified as Stanford Type A (involving the ascending aorta) or Type B (confined to the descending aorta)

Understanding the type and grade of the aortic aneurysm is crucial for determining the appropriate management strategy.

5. Prognosis:

   - Guarded prognosis due to the presence of thrombus

   - Risk of rupture increases with the aneurysm size and thrombus presence

6. Management Options:

   - Monitoring: Regular follow-up to track changes in aneurysm size and thrombus status

   - Medication: Anticoagulants to prevent further thrombus formation and reduce embolization risk

   - Surgery: Consideration for intervention based on aneurysm size, patient's health, and rupture risk

   - Lifestyle Modifications: Emphasis on blood pressure control, smoking cessation, and healthy living to mitigate risk factors

7. Patient Education:

   - Importance of compliance with medications and follow-up appointments

   - Recognition of warning signs for potential complications

8. Collaborative Care:

   - Involvement of a multidisciplinary team including cardiologists, vascular surgeons, and primary care physicians

Regular monitoring and timely intervention are crucial for optimizing the patient's outcome.

For more visit:

Ultrasound images of aortic aneurysms

Ultrasound video of aortic aneurysms

Submandibular Sialolithiasis: A Case Report

# Submandibular Sialolithiasis: An ultrasound Case Report

#Introduction

Sialolithiasis is a condition in which stones (calculi) form in the salivary glands or ducts, blocking the flow of saliva. It is the most common disease of the salivary glands, accounting for approximately 50% of all major salivary gland pathology¹. The submandibular gland is the most frequently affected site, followed by the parotid gland². Sialolithiasis can cause pain, swelling, infection, and reduced salivary function³.

Case study:

In this case report, we present a patient with acute onset pain and swelling of the right submandibular region due to a large calculus in the proximal Wharton's duct.

#Case Presentation:

A 45-year-old male presented to the emergency department with a history of sudden onset pain and swelling of the right submandibular region that started 12 hours ago. He reported that the pain was severe, throbbing, and radiating to the ear and neck. He also complained of dry mouth and difficulty swallowing. He denied any fever, chills, trauma, or previous episodes of similar symptoms. He had no history of smoking, alcohol consumption, or systemic diseases. His physical examination revealed a tender, firm, and enlarged right submandibular gland with overlying erythema. There was no palpable mass or lymphadenopathy. His oral cavity was dry and his tongue was coated. His vital signs were normal.

# Ultrasound Findings

An ultrasound examination of the right submandibular region was performed using a high-frequency linear transducer. The ultrasound showed a calculus of 8 mm in diameter in the proximal Wharton's duct with mild dilation of the duct (Figure 1 to 5). The calculus appeared as a hyperechoic structure with posterior acoustic shadowing. The submandibular gland parenchyma was normal in echotexture and vascularity. There was no evidence of abscess formation or sialadenitis.

[Figure 1 to 5]: Ultrasound image showing a calculus (arrow) in the proximal Wharton's duct with mild ductal dilation:

# Etiology

The exact etiology of sialolithiasis is unknown, but several factors have been proposed to contribute to its formation. These include:

- Dehydration: Reduced fluid intake or increased fluid loss can lead to decreased salivary flow and increased concentration of calcium and phosphate in saliva⁵.

- Smoking: Tobacco use can alter the composition and pH of saliva, as well as cause inflammation and fibrosis of the salivary ducts⁶.

- Diet: High intake of calcium or oxalate-rich foods can increase the risk of sialolithiasis by increasing the saturation of these minerals in saliva⁷.

- Medications: Certain drugs, such as antihistamines, diuretics, anticholinergics, and beta-blockers, can reduce salivary secretion and cause xerostomia.

- Infections: Bacterial or viral infections can cause inflammation and obstruction of the salivary ducts, as well as alter the pH and viscosity of saliva.

- Anatomical factors: The submandibular gland is more prone to sialolithiasis than other salivary glands because of its longer and tortuous duct, its alkaline and mucinous saliva, and its dependent position that favors gravity-dependent sedimentation.

For more visit:

Ultrasound imaging of salivary glands

# Management of sialolithiasis

The management of sialolithiasis depends on the size, location, number, and symptoms of the calculi. The main goals are to relieve pain, restore salivary flow, prevent infection, and remove the calculi. The possible treatment options include:

- Conservative measures: These include hydration, massage, heat application, sialogogues (substances that stimulate salivary secretion), antibiotics (if infection is present), and analgesics (for pain relief). These measures can be effective for small or distal calculi that can be spontaneously expelled.

- Sialendoscopy: This is a minimally invasive technique that involves inserting a small endoscope into the salivary duct to visualize and remove the calculi using micro-instruments or laser. This technique has high success rates and low complication rates for calculi located in the proximal or middle part of the duct.

- Extracorporeal shock wave lithotripsy (ESWL): This is a non-invasive technique that uses high-energy sound waves to break up the calculi into smaller fragments that can be flushed out by saliva. This technique can be used for large or multiple calculi that are not amenable to sialendoscopy.

- Surgery: This is the last resort for sialolithiasis that is refractory to other modalities or complicated by recurrent infections or glandular damage. The surgical options include ductal incision, calculus extraction, ductal dilation, or gland excision. Surgery has higher risks of complications, such as nerve injury, bleeding, infection, and salivary fistula.

# Prognosis of sialolithiasis in this case:

The prognosis of sialolithiasis is generally good, especially if the condition is diagnosed and treated early. Most patients achieve complete resolution of symptoms and restoration of salivary function after appropriate treatment. However, some patients may experience recurrence of sialolithiasis, especially if the underlying etiological factors are not addressed. The recurrence rate ranges from 5% to 15%. Recurrence can be prevented by maintaining adequate hydration, avoiding smoking, eating a balanced diet, and practicing good oral hygiene.

# Conclusion

Sialolithiasis is a common and benign condition that can cause pain and swelling of the salivary glands. Ultrasound is a useful imaging modality for diagnosing and evaluating sialolithiasis. The treatment options vary depending on the size, location, number, and symptoms of the calculi. The prognosis is generally good with timely and appropriate management. Recurrence can be prevented by modifying the risk factors and following up regularly.

(1) Sialolithiasis | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/sialolithiasis.

(2) Salivary Stones: Causes, Symptoms & Treatment - Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/24344-sialolithiasis.

(3) Submandibular Gland: Anatomy, Function, Conditions - Verywell Health. https://www.verywellhealth.com/submandibular-gland-5101463.

(4) Sialolithiasis - Wikipedia. https://en.wikipedia.org/wiki/Sialolithiasis.

(5) Sialolithiasis Symptoms, Diagnosis, and Treatments - Verywell Health. https://www.verywellhealth.com/everything-you-need-to-know-about-sialolithiasis-1192027.

(6) undefined. https://doi.org/10.53347/rID-2044.

(7) undefined. https://radiopaedia.org/articles/2044.

Ultrasound Case of the Week: Ovarian Cyst with Mural Nodule

Ultrasound Case of the Week: Ovarian Cyst with Mural Nodule

In this post we discuss a challenging case of a 50 year old female patient who presented with pelvic pain and irregular menstrual bleeding. She underwent a transvaginal ultrasound examination, which revealed a 4 cm cystic mass in the right adnexa with a 0.9 cm mural nodule. The cystic mass had thin walls and no septa, and the mural nodule was non-calcified and non-vascular. The left ovary was normal, and there was no ascites or lymphadenopathy.

Ultrasound images of the ovarian cyst:

Transabdominal ultrasound image shows an innocuous looking simple ovarian cyst. But endocavity ultrasound says otherwise. 🙄 

#Differential Diagnoses:

The differential diagnoses for an ovarian cyst with a mural nodule include:

- Ovarian mucinous cystic tumor with mural nodules: This is a rare type of ovarian tumor that consists of a cystic component lined by mucinous epithelium and solid nodules composed of anaplastic or sarcomatoid cells. The mural nodules are usually non-calcified and non-vascular, and may show papillary projections. This tumor has a high risk of malignant transformation and recurrence.

- Ovarian mucinous cystadenocarcinoma: This is a malignant epithelial ovarian tumor that is filled with mucin and may have thick septa, papillary projections, or mural nodules. The mural nodules are usually vascular and may show calcifications. This tumor has a poor prognosis and may spread to other organs.

- Ovarian endometrioid carcinoma: This is a malignant epithelial ovarian tumor that is associated with endometriosis and may have a cystic or solid appearance. The cystic component may have hemorrhagic fluid and mural nodules that are vascular and may show calcifications. The mural nodules may also have squamous differentiation or clear cell features. This tumor has a moderate prognosis and may invade the uterus or the fallopian tubes.

- Ovarian mature cystic teratoma: This is a benign germ cell ovarian tumor that contains elements from all three germ layers, such as skin, hair, teeth, bone, cartilage, or fat. The cystic component may have sebaceous fluid and mural nodules that are calcified and non-vascular. The mural nodules may also have immature components or somatic malignancies. This tumor has a low risk of malignancy and recurrence.

- Hydrosalpinx: This is a dilated fallopian tube filled with serous fluid due to inflammation, infection, or obstruction. It may mimic an ovarian cystic mass on ultrasound, especially if the longitudinal folds are not seen. The mural nodules may represent incomplete septa or debris within the tube. This condition is usually benign but may cause infertility or pelvic pain.

#Diagnostic Approach

To narrow down the differential diagnoses, we need to consider the following factors:

- Patient's age: The patient is 50 years old, which is postmenopausal for most women. This increases the likelihood of malignant tumors over benign ones.

- Patient's symptoms: The patient had pelvic pain and irregular menstrual bleeding, which are suggestive of hormonal imbalance or endometrial pathology. This may favor endometrioid carcinoma over other tumors.

- Cyst size: The cyst is 4 cm in diameter, which is relatively small for most ovarian tumors. However, this does not exclude malignancy, as some tumors can be small but aggressive.

- Cyst morphology: The cyst has thin walls and no septa, which are favorable features for benignity. However, the presence of a mural nodule raises suspicion for malignancy.

- Mural nodule characteristics: The mural nodule is non-calcified and non-vascular, which are features that can be seen in both benign and malignant tumors. However, the absence of calcifications and vascularity makes mucinous cystadenocarcinoma less likely. The size of the nodule is also important, as larger nodules (>1 cm) are more likely to be malignant than smaller ones (<1 cm).

- Other findings: The absence of ascites or lymphadenopathy is reassuring for benignity. However, these findings can be absent in early stages of malignancy.

Based on these factors, we can rank the differential diagnoses as follows:

- Ovarian endometrioid carcinoma: This is the most likely diagnosis, as it fits the patient's age, symptoms, cyst morphology, and mural nodule characteristics. It also has a moderate prognosis and may require surgery and chemotherapy.

- Ovarian mucinous cystic tumor with mural nodules: This is the second most likely diagnosis, as it also fits the patient's age, cyst morphology, and mural nodule characteristics. However, it is a rare tumor and has a high risk of malignancy and recurrence. It may also require surgery and chemotherapy.

- Ovarian mature cystic teratoma: This is the third most likely diagnosis, as it is a benign tumor that can have a cystic component and mural nodules. However, it is more common in younger women and the mural nodules are usually calcified and non-vascular. It may also have other components such as hair or teeth that can be seen on ultrasound. It usually requires surgery but has a low risk of recurrence.

- Hydrosalpinx: This is the fourth most likely diagnosis, as it can mimic an ovarian cyst on ultrasound. However, it is more common in women with a history of pelvic inflammatory disease or tubal ligation. It also has longitudinal folds that can be seen on ultrasound. It may cause infertility or pelvic pain but does not require surgery unless symptomatic.

- Ovarian mucinous cystadenocarcinoma: This is the least likely diagnosis, as it is a malignant tumor that usually has thick septa, papillary projections, or mural nodules that are vascular and calcified. It also has a poor prognosis and may spread to other organs. It requires surgery and chemotherapy.

#Prognosis and Management

The prognosis and management of the patient depend on the final diagnosis, which can be confirmed by MRI or biopsy. However, based on the ultrasound findings, we can assume that the patient has a malignant ovarian tumor that requires surgical removal and possibly chemotherapy. The prognosis will depend on the stage of the tumor, which can be determined by imaging or pathology. The survival rates for ovarian cancer vary depending on the type and stage of the tumor, but generally range from 10% to 90%.

The management of the patient will also depend on her fertility status and preferences. If she wishes to preserve her fertility, she may opt for conservative surgery that spares the uterus and the contralateral ovary. However, this may increase the risk of recurrence or metastasis. If she does not wish to preserve her fertility, she may opt for radical surgery that removes the uterus, both ovaries, both fallopian tubes, and any other affected organs or tissues. She may also need adjuvant chemotherapy to reduce the risk of recurrence or metastasis.

You may find this ebook interesting:

Ebook atlas of sonography of uterine fibroids

For Indian readers:

Sonography of uterine fibroids Atlas format

I hope you enjoyed this blog post. Please leave your comments or questions below. Thank you for reading!

: Ovarian Mucinous Cystic Tumor with Mural Nodules. https://www.ncbi.nlm.nih.gov/medgen/269341.

: Ovarian mucinous borderline tumor with anaplastic carcinomatous nodules .... https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-022-01010-3.

: Ovarian cystic neoplasms | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/ovarian-cystic-neoplasms-1.

: Hydrosalpinx | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/hydrosalpinx.

: The Radiology Assistant : Roadmap to evaluate ovarian cysts. https://radiologyassistant.nl/abdomen/unsorted/roadmap-to-evaluate-ovarian-cysts.

Hashimoto's thyroiditis- fibrotic stage

Fibrotic stages of Hashimoto's thyroiditis in a young adult with hypothyroidism

Hashimoto's thyroiditis is an autoimmune disorder that causes inflammation of the thyroid gland. Over time, this inflammation can lead to scarring and fibrosis of the thyroid gland, which can impair its function. This can lead to hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone.

Case study:

In this young adult with hypothyroidism, the likely diagnosis is the fibrotic stage of Hashimoto's thyroiditis. This condition is characterized by a small, fibrotic thyroid gland. On ultrasound, the thyroid gland appears hypoechoic (darker than surrounding tissue) and heterogeneous (with a non-uniform texture). The thyroid gland may also appears atrophic (shrunken).

Here are three ultrasound images of fibrotic stage of Hashimoto's thyroiditis:

[Image 1: Ultrasound image of a small, hypoechoic thyroid gland with a heterogeneous echotexture.] 

[Image 2: Ultrasound image of a small, fibrotic Rt lobe thyroid gland with dense echogenic fibrous septa.] 

[Image 3: Color Doppler ultrasound image of a small, fibrotic thyroid gland with normal vascularity.]

Various stages of Hashimoto's thyroiditis as seen on ultrasound:

• Early stage: The thyroid gland may be enlarged and have a heterogeneous echotexture, with hypoechoic and hyperechoic areas. There may be increased vascularity.
• Micronodular stage: Small, hypoechoic nodules (1-6 mm in diameter) are seen throughout the thyroid gland. This is a highly characteristic finding of Hashimoto's thyroiditis.
• Atrophic stage: The thyroid gland is shrunken and has a decreased echogenicity. This is seen in advanced cases of Hashimoto's thyroiditis.

Other ultrasound findings that may be seen in Hashimoto's thyroiditis include:

• Echogenic septations
• Lobulated contour
• Geographic hypoechogenicity without discrete nodules

Prognosis

The prognosis for the fibrotic stages of Hashimoto's thyroiditis is generally good. However, the condition is chronic and progressive, and may eventually lead to hypothyroidism that requires lifelong treatment with thyroid hormone replacement therapy.

Management

Management of the fibrotic stages of Hashimoto's thyroiditis is focused on treating the hypothyroidism. This is done with thyroid hormone replacement therapy, which typically involves taking a daily dose of levothyroxine (Levothroid, Synthroid).

In addition to thyroid hormone replacement therapy, there are a number of other things that people with the fibrotic stages of Hashimoto's thyroiditis can do to manage their condition, including:

• Eating a healthy diet
• Getting regular exercise
• Avoiding stress
• Avoiding smoking and excessive alcohol consumption

Download this concise ebook on Thyroid diseases ( US edition):

Thyroid disease ebook

Indian edition:

Thyroid disease ebook

Epicardial fat

What is epicardial fat?

- Epicardial fat pad is a normal structure that lies between the myocardium and the visceral pericardium¹.

- It is more prominent in obese patients and can be associated with coronary artery disease, diabetes, arrhythmias, and other cardiac conditions⁶.

- Ultrasound imaging: can show the epicardial fat as echogenic tissue around the right heart, especially on the subcostal view³.

- The following are two examples of ultrasound images showing the epicardial fat pad:

Image 1: A subcostal view of the heart showing a prominent epicardial fat pad (arrow) as a bright layer around the right ventricle (RV). The liver (L) is seen below the heart. The left ventricle (LV) and the pericardium (P) are also visible.

Image 2: Another subcostal view of the heart showing a large epicardial fat pad (arrow) extending from the right atrium (RA) to the apex of the right ventricle (RV). The liver (L) is seen below the heart. The left ventricle (LV) and the pericardium (P) are also visible.

- The prognosis and management of epicardial fat pad depend on the underlying cardiac condition and the presence of symptoms⁶.

- In most cases, conservative treatment with weight loss, exercise, and medications can reduce the amount of epicardial fat and improve cardiac function⁸.

- In rare cases, surgical removal of epicardial fat may be indicated for symptomatic patients.

For an ebook on interesting ultrasound imaging cases, on Amazon Kindle, you can download this:

Assorted ultrasound cases ebook, atlas format

Assorted ultrasound cases ebook Indian download link

(1) Pericardial fat pads | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/pericardial-fat-pads-2.

(2) Epicardial Adipose Tissue: A Predictor of Coronary Artery Disease. https://www.healthline.com/health/coronary-artery-disease/epicardial-adipose-tissue-coronary-artery-disease.

(3) Potential Errors in the Diagnosis of Pericardial Effusion on Trauma .... https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2000.tb00472.x.

(4) Understanding Epicardial Fat | Premier Health. https://www.premierhealth.com/your-health/articles/health-topics/understanding-epicardial-fat.

(5) Epipericardial fat necrosis | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/epipericardial-fat-necrosis-1?lang=us.

(6) Epicardial fat pad | Radiology Case | Radiopaedia.org. https://radiopaedia.org/cases/epicardial-fat-pad.

(7) What does pericardial fat pad mean? - Studybuff.com. https://studybuff.com/what-does-pericardial-fat-pad-mean/.

(8) Pericardial effusion | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/pericardial-effusion.

(9) Pericardial cyst - Wikipedia. https://en.wikipedia.org/wiki/Pericardial_cyst.