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Pediatric Radiology

Ildikó Várkonyi Semmelweis University 1st Dept. of Pediatrics

18.10. 2017

Aim of this lecture

Role of different imaging methods in pediatric patients

Different anatomy

Special imaging in children

Different methods, thinking, diseases

Some typical clinical settings

Bone development

Battered child

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What is different?

Age group

Anatomy

IMAGE GENTLY

Radiation protection

Contrast materials

Methods

Special investigations: head – spinal – hip sonography

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Modalities

Sonography

X-ray

CT

MRI

Scintigraphy

X ray

Radiation

Sensitivity to radiation: red marrow, gonads

Dosis cumulation

No routine investigation!

Indications, special technique

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B - Beam A - Artifacts S – Shielding

I - Immobilizaton and Indicators C – Collimation S - Structures

Contrast material

Modern CM, seldom side effects

Newborn: CM of low osmolality (dehydration)

Air as negative CM

Dynamic investigations: only with fluroscopy

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Reposition of intussusception with air

Ultrasound

Non-invasive, no side effects, no contraindications

Fast, repetable

Sections in every directions

Real time: motion

Vessels

Cheap

Limitations: bones, air, depends on sonographer

Air in portal veins, NEC

Ultrasound

Special transducers

Different sonoanatomy

Different possibilities, special regions for sonography,

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Newborn

Child

Teenager

Uterus

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Normal kidney

Adrenal gland Adrenal hemorrhage

Head sonography Through the

fontanella until 8-10. mo of life

5 MHZ convex transducer

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Coronal and sagittal sections

Width of the ventricles, hemorrhage

In the brain: haemorrhage, cysts, calcifications

Congenital anomalies

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Head sonography

Head sonography

Positive result is important, but negative does not rule out all pathologies

Dependent on sonographer

Indications Prematurity Hypoxic injury Neurological symptoms,

convulsions Sepsis Suspected congenital

anomaly

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Hydrocephalus

Cause: hemorrhage, infection

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IVH in newborn

Grade 1

SUBEPENDYMAL H.

Grade 2 Hemorrhage in the ventricles, without hydrocephalus

Grade 3 IVH + hydrocephalus

Grad 4 Parenchymal hemorrhage

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Gr 3

Gr IV.

Gr 4

Spinal sonography

7-10 MHz linear transducer Through the cartilage of

the posterior arch Anomalies, intraspinal

masses

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WK

Spinal Sono

Tethered cord

Spinal dysraphy

Conus too deep

Fixation to an intraspinal lipoma

Paresis, incontinence

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Hip sonography

Screening of hip dysplasia

6 weeks – 6 month Cartilaginous

femoral head Graf’s method: standardized Mesurement of

angles State of

development therapy

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Reinhard Graf

Scintigraphy (Nuclear medicine)

Ionising radiation (mostly gamma-ray)

Low radiation dose

Function, no morphology

Kidneys

Bones

Special

MIBG: Neuroblastoma

GERD

VUR

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Neuroblastoma

VUR

CT

Children: sedation, Radiaton (300-400x

Chest X-ray) I.v. CM

Indications CNS: hemorrhage,

trauma Chest: lungs, airways,

chest wall Abdomen Bones: Tumor, Trauma

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SDH

Lymphoma CF

MRI

No radiation No side effects Precise anatomy in each

direction +/- CM Time consuming Narcosis, sedation Claustrophobia Expensive (relatively) Metallic implantation

materials - can be contraindicated

Indications

CNS

Heart and vessels

MSK, bone marrow!

Abdomen

Mediastinum

MR Urography

MR Angiography,

MRCP

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Fetal MRI

If sonography fails Planned postnat.

interventions, or need for abortion

Congenital anomalies

Early rupture of membranes

Lack of growth

Twins

Known genetic disorder

Routine fetal MRI 20-30 min

Moving artefacts

Claustrophobia

No MRI in the 1st trimester

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Fetal CNS 145 abnormal CNS-sonography MRI - 50% other decision of the mother - changed diagnosis in 32%, - Changed handling in 19%. (Levine et al. 2003) T2 , occipital MMC, 20th w GA, good prognosis

PRÄNATALE DIAGNOSTIK Fetale Magnetresonanztomographie W. Blaicher1, P. Husslein1, A. Messerschmidt2, A. Pollak2, G. Kasprian3, C. Herold3

FRAUENARZT 48 (2007) Nr. 12

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SOME EXAMPLES WHAT DO WE DIFFERENTLY?

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Mediastinal mass? CT? MRI?

Healthy ! Normal thymic shadow !

Sonography: homogeneous structure in the anterior mediastinum

Visible on chest X-ray until 3 y of age

Variations in form and size

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Diseases – seen only in children

Respiratory distress (IRDS)

Premies

Surfactant-deficiency

Alveolar atelectasis

Grade I-IV

6-12 hours after birth

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Foreign body aspiration

The most FB are radiolucent Expiration: overdistension of the affected side Fluoroscopy: mediastinal shift to the normal side in expiration Bronchoscopy is urgent

inspir exspir

Different methods: e.g. pleural effusion

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liver Lung

Investigations adapted for children

Sonography

VCUG

CE- voiding urosonograohy

Scintigraphy

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Dilatation of renal pelvis, suspected VUR

VCUG (Voiding cystouretrography

Fluoroscopy

Diluted CM via catheter into the bladder

REFLUX?

Yes! prophylaxis

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CE VCUG

Sonovue® – US-CM

Microbubbles: 1-10 mikrometer

Reflux in the filling phase or under micturition

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Eur Radiol Suppl (2004) 14[Suppl 8]:P11–P15

CEUS

Scintigraphy

Dynamic renal scintigraphy

Obstruction?

VUR?

Follow-up (less radiation then VCUG)

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MR-Urography

PRO -s

1. NO radiation

2. No CM (T2W, turbo SE: fluids , nice anatomy

3. With CM ( T1w GE + Gad) dynamic: kidney function

CON-s:

Time consuming

Expensive

Sedation

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GI tract

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10-15 minutes

30-60 minutes

6 hours

24 hours

Newborn with ileus

Air as CM!

Too little: proximal obstruction

Too much: distal obstruction

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Double bubble :duodenal atresia

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Hirschsprung’s disease

Hirschsprung’s disease

No ganglia in the colon (aganglionosis)

Obstipation since birth

Abdominal distension

Barium enema, biopsy

Surgery

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Small bowel atresia

Something , we do the other way

Premie with abdominal distension

Bloody stool

NEC?

Pneumatosis – air in the bowel wall

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Is there an indication for surgery? Perforation?

Free air in the abdomen?

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Laterolateral with horizontal beam Perforation, free air

Newborn , biliary vomiting

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Malrotation

Volvulus

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BONE DEVELOPMENT AND ITS CONSEQUENCES

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www.fotosearch.com

DIAPHYSIS

METAPH

EPIPHYSIS

Epiphyseal fractures

Under 16 y : 6-18% of all extremity fractures

Complications: Growth anomalies in 25-33%

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Rickets

Vitamin- D deficiency

Failure in the bone mineralisation

Hyperplastic noncalcified cartilage

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OSTEOMYELITIS

Hematogenous infections

Staphylococcus aureus 70-90%

First in the bone marrow of the metaphysis

‹ 18. mo anastomosis between meta- and epiphysis

Later: growth plate is a barrier

Small children septic arthritis – growth disturbancies, deformities

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OSTEOMYELITIS

4 weeks

6 months

Typical pediatric fractures: green stick, bowing etc.

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Child abuse, battered child Typical pattern of

injuries Metaphyseal

fractures Ribs, Sternum,

Scapulae Multiple fractures of

different ages Periosteal reaction,

epiphyseolysis, complex skull

fractures

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Battered child, Child abuse

Discrepance between history and injury

CNS and visceral injuries

Shaken baby

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It is better that baby cries

than the baby dies.

Scintigraphy

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