First-Pass Perfusion and T1-weighted Dixon Imaging as Emerging Biomarkers of Pericardial Disease
André Vaz1, Danilo de Oliveira Santana Ramos2, Júlia Tupinambá Del Rey Crusoé3
1Radiology department; Instituto do Coração do Hospital de Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
Abstract:
Pericardial assessment with cardiac MRI relies on three complementary pillars: anatomic evaluation, functional characterization, and tissue characterization. Tissue characterization traditionally depends on T2-weighted triple inversion recovery imaging for helping to detect edema and late gadolinium enhancement for helping to identify inflammation or fibrosis. However, these techniques have important limitations, including the susceptibility of T2-weighted triple inversion recovery to motion artifacts and the potential overestimation of pericardial enhancement on conventional, non-fat-suppressed late gadolinium enhancement images due to adjacent epicardial and epipericardial fat. This imaging essay demonstrates the added value of two complementary and widely available sequences, first-pass perfusion and postcontrast T1-weighted Dixon, for pericardial tissue characterization. First-pass perfusion depicts early contrast media uptake which reflects microvascular hyperemia, a physiologic hallmark of active inflammation, and thus may help differentiate active from inactive disease and support clinical decision-making. Although previously applied to detect subepicardial hyperemia in myocarditis, the potential role of first-pass perfusion in pericardial evaluation remains incompletely explored. T1-weighted Dixon imaging provides robust fat suppression through chemical shift reconstruction, increasing the specificity of pericardial enhancement and reducing misinterpretation caused by adjacent adipose tissue. The aim of this imaging essay is to present the potential role of first-pass perfusion and T1-weighted Dixon imaging in improving pericardial tissue characterization and differentiating active inflammatory, chronic, and inactive ("burned-out") stages of pericardial disease, thereby aligning imaging findings more closely with clinically relevant phenotypes. Keywords: MR Imaging, MR Perfusion, Cardiac, Mediastinum, Pericardium Supplemental material is available for this article. © RSNA, 2026.
