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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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