Paediatric imaging manual : with 18 tables

167 Pages·2008·8.03 MB·English

by  Seidensticker, Peter, Tröger, Jochen

Jochen Tröger
Peter Seidensticker
Paediatric Imaging Manual
Jochen Tröger
Peter Seidensticker
Paediatric
Imaging Manual
With 273 Figures and 18 Tables
123
Jochen Tröger
Head of Department of Paediatric Imaging
Paediatric Radiology
University of Heidelberg
Im Neuenheimer Feld 153
69120 Heidelberg
Germany
Peter Seidensticker
Global Medical Aff airs Diagnostic Imaging
Bayer-Schering-Pharma AG
Müller Straße 178
13342 Berlin
Germany
Project coordination: Bayer-Schering-Pharma AG and Bayer HealthCare Pharmaceuticals, Inc., Global Medical Affairs,
Diagnostic Imaging.
ISBN 978-3-540-34964-8 Springer Medizin Verlag Heidelberg
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V
Preface
Imaging of newborns, infants, children and adolescents
Children and adolescents are not simply small adults; they suffer from different diseases and
require different treatments. The same is true where imaging is concerned. The diagnostic
strategies – using identical diagnostic instruments – are different; the care prior to, during,
and following the examination differs from that of adults.
For this reason, there exists in many countries a specialized line of advanced training for
paediatric radiology. However, students make only a peripheral acquaintance with paediatric
radiology during their studies. Understandably, paediatricians lack not only the ability to
interpret the images, but also knowledge about the importance of a finding for the next step
toward a diagnosis and thus for treatment. And in many cases, general radiologists have insuf-
ficient contact with paediatric radiology during their course of advanced training.
The aim of this book, therefore, is to provide readily available information, limited to
what is essential, for physicians doing advanced training in radiology and paediatrics and for
advanced students concerning the most important aspects of imaging in newborns, children,
and adolescents.
The diagnostic strategies used for children differ from those used for adults in many
respects. One of the most important aspects is radiation protection, as children are particu-
larly sensitive to ionizing radiation and, with their longer life expectancy, can also expect to
accumulate a higher dose from natural and artificial – above all medical – causes. The latter
increase the individual risk (malignant disease) as well as the genetic risk.
The best radiation protection is the avoidance of an examination employing ionizing
radiation (X-rays, CT scan). This is accomplished, on the one hand, by establishing strict
indications (for example, no X-rays following trauma to the cranial vault or no imaging of the
paranasal sinuses in case of acute sinusitis) and, on the other hand, if possible, by substituting
ultrasonography or magnetic resonance imaging for X-rays or computer tomography.
In addition to the aspect of radiation protection, however, there is also a physical reason
for the great value of ultrasonography in paediatric radiology. High frequencies allow for high
diagnostic quality but entail less penetration depth. Given the lesser body volume of children,
higher frequencies can be used in them. This is one of the reasons why ultrasonography is of
greater value in paediatric radiology than in adult radiology. Therefore, diagnostic flow charts
generated from adult imaging may not be applied 1:1 to paediatric radiology. Several examples
will serve to substantiate the high and still increasing value of ultrasonography in paediatric
and adolescent medicine.
For the diagnosis of urinary flow disorder ultrasonography has replaced excretory urogra-
phy in many areas, with the result that excretory urography has become a rare examination in
paediatric radiology. Hip sonography has replaced the X-ray for diagnosing hip dysplasia or
luxation in an infant. MRI can replace CT in most cases of abdominal tumors. Kidney func-
tion can also be analyzed be means of functional MRI (MRI with determination of function).
The list of these changes in diagnostic practice could be continued.
A further aspect of radiation protection concerns the number of X-ray images made and
the way in which an examination with ionizing radiation is performed. In paediatric radio-
logy, a p.a. or an a.p. image of the thorax provides sufficient clinically necessary information
in 70–80% of cases. The request for X-rays should therefore not state »thorax at two levels«
but rather »thorax p.a.«; the decision to take a further image can be made on the basis of the
VI Preface
reading of the first image, if necessary. Fluoroscopic examinations must almost always be car-
ried out using the radiation-reducing pulsed X-ray. For this it is entirely possible to accept a
reduction in image quality, as long as the diagnostic certainty is not diminished.
Necessary CT examinations must be performed according to a protocol adapted to the
child’s age, with a lesser dose.
Active radiation protection is of essential importance for children and adolescents. The
protective measures should not lead to a reduction in diagnostic reliability, however. X-rays
and CT remain an indispensable component of imaging for children. Without them, modern
medicine, in particular emergency medicine, would be unthinkable. Thus it is not a matter
of preventing the application of ionizing radiation, but of its responsible use where necessary
and of substitution with non-ionizing radiation where possible. The ALARA principle states:
»As Low As Reasonably Achievable«, in other words, the lowest dose possible and the largest
necessary.
This book was written intentionally as a concise work of reference. We have done without
technical details and without descriptions of examination procedures.
An important difference in comparison to radiology for the adult lies in the diagnostic and
therapeutic consequences that many findings entail. For instance, a sharply delimited zone of
enhanced radiation transparency without soft-tissue swelling, lying decentralized in the meta-
physis of a long bone of a 9-year-old asymptomatic child (X-ray imaging following trauma) is
simply a nonosteogenic fibroma: Neither section imaging nor clinical monitoring is necessary,
and by no means is a biopsy required. In a further example, a movable cystic space-occupying
lesion with or without small floating particles next to or above the urinary bladder in a girl
represents an ovarian cyst with or without internal bleeding. This finding frequently recedes
spontaneously. These are only a few of many possible examples.
This book was written by several authors from various countries. The culture of examina-
tion often differs even within a country. We have intentionally avoided comparing examina-
tions or expounding at length upon the differences in each case. Both methods are always logi-
cal and justifiable. The diagnosis of vesicorenal reflux in Heidelberg by means of an ultrasound
examination is well-founded; elsewhere an X-ray examination – naturally using extremely
radiation saving pulsed fluoroscopy – is favored. The scientific discussion has not yet been
concluded. However, it should not be allowed to become a purely economic discussion.
We thank the authors for the high-quality manuscripts they provided. We also thank
Springer-Verlag – and especially Mr. Henquinet – for their patient, very competent work as
publishers.
Finally, working as a doctor requires continuous training and obtaining a specialization is
an important aspect of that process. We are pleased that this publication has been rated by the
state Medical Association of Baden-Württemberg with 4 CME points.
Jochen Tröger Peter Seidensticker
Heidelberg Berlin
VII
Contents
1 Radiation bio effects and dose reduction 3.8 Intracranial cystic lesions in children . . . . . . . . . . . . . . .30
strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3.9 Cystic lesions of the head and neck in children . . . . .33
Donald P. Frush 3.10 Spinal cord neoplasm in children . . . . . . . . . . . . . . . . . .36
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
1.2 Mechanisms of radiation injury . . . . . . . . . . . . . . . . . . . . .1
1.3 Doses of medical radiation . . . . . . . . . . . . . . . . . . . . . . . . .1 4 Thoracic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
1.4 Risks of medical radiation . . . . . . . . . . . . . . . . . . . . . . . . . .2 Donald P. Frush
1.5 Strategies for radiation dose management . . . . . . . . . .2 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 4.2 Imaging modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
4.3 Congenital abnormalities/neonatal anomalies . . . . .42
4.4 Infectious/inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . .48
2 C ontrast media: posology, risks and side 4.5 Mass or mass-like conditions . . . . . . . . . . . . . . . . . . . . . .52
effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4.6 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Magdalena M. WoŹniak 4.7 Toxic/metabolic and thoracic evaluation
2.1 General information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 of systemic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
2.1.1 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
2.2 Posology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.2.1 Barium preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 5 Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
2.2.2 MRI contrast agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Jochen Tröger
2.2.3 Ultrasound contrast agents . . . . . . . . . . . . . . . . . . . . . . . . .8 5.1 Hepatobiliary system, spleen, pancreas . . . . . . . . . . . .63
2.3 Contra-indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Hyun Soo Ko
2.3.1 Iodine contrast agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 5.1.1 Hepatobiliary system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
2.3.2 Barium preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 5.1.2 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
2.3.3 MRI contrast agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 5.1.3 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
2.3.4 Ultrasound contrast agents . . . . . . . . . . . . . . . . . . . . . . . .9 5.2 Urogenital tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80
2.4 Adverse reactions to contrast agents and their Jens-Peter Schenk
management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 5.2.1 Renal dysmorphology and anomalies . . . . . . . . . . . . . .80
2.4.1 Types of adverse reactions . . . . . . . . . . . . . . . . . . . . . . . .10 5.2.2 Cystic renal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
2.4.2 Treatment of adverse reactions to contrast 5.2.3 Obstructive uropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86
material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5.2.4 Urinary tract infections . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
2.5 Remember! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 5.2.5 Renal parenchyma disease . . . . . . . . . . . . . . . . . . . . . . . .94
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 5.2.6 Nephrocalcinosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
5.2.7 Renal vein thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
5.2.8 Renal tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
3 Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 5.2.9 Diseases of the suprarenal gland . . . . . . . . . . . . . . . . . .99
Thierry A.G.M. Huisman 5.2.10 Female gonads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
3.1 Developmental anomalies of the central 5.2.11 Male gonads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
nervous system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 5.2.12 Congenital genital anomalies . . . . . . . . . . . . . . . . . . . .106
3.2 Hypoxic-ischemic encephalopathy in neonates . . . .15 5.2.13 Persistence of urachus . . . . . . . . . . . . . . . . . . . . . . . . . . .107
3.3 Intracranial haemorrhage in neonates . . . . . . . . . . . . .18 5.3 Gastro-intestinal tract . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
3.4 Cerebral infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Michael Kimpel
3.5 Traumatic head injury in children . . . . . . . . . . . . . . . . . .22 5.3.1 Oesophagus (Oesophageal atresia and tracheo-
3.6 Supra- and infratentorial tumours in children . . . . . .25 esophageal fistula) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
3.7 Non accidental traumatic brain injury in children, 5.3.2 Obstructions of the stomach and duodenum . . . . .108
child abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 5.3.3 High intestinal obstruction . . . . . . . . . . . . . . . . . . . . . . .110
VIII Contents
5.3.4 Low intestinal obstruction . . . . . . . . . . . . . . . . . . . . . . . .111
5.3.5 Rotation anomalies of the midgut . . . . . . . . . . . . . . . .114
5.3.6 Achalasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
5.3.7 Gastro-esophageal reflux . . . . . . . . . . . . . . . . . . . . . . . .117
5.3.8 Foreign body ingestion . . . . . . . . . . . . . . . . . . . . . . . . . .119
5.3.9 Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
5.3.10 Hypertrophic pyloric stenosis . . . . . . . . . . . . . . . . . . . .123
5.3.11 Necrotizing enterocolitis . . . . . . . . . . . . . . . . . . . . . . . . .123
5.3.12 Inflammatory bowel disease . . . . . . . . . . . . . . . . . . . . .124
5.3.13 Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
5.3.14 Gastro-intestinal tumours and tumour-like
lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
6 Musculoskeletal system . . . . . . . . . . . . . . . . . . . . 133
Harvey Teo, David Stringer
6.1 Common bone dysplasias . . . . . . . . . . . . . . . . . . . . . . . .133
6.1.1 Achondroplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
6.1.2 Thanatophoric dysplasia . . . . . . . . . . . . . . . . . . . . . . . . .134
6.1.3 Asphyxiating thoracic dysplasia . . . . . . . . . . . . . . . . . .135
6.1.4 Osteogenesis imperfecta . . . . . . . . . . . . . . . . . . . . . . . . .136
6.1.5 Osteopetrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
6.2 Developmental dysplasia of the hip . . . . . . . . . . . . . .138
6.3 Infection and inflammatory . . . . . . . . . . . . . . . . . . . . . .140
6.3.1 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
6.3.2 Septic arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
6.3.3 Juvenile idiopathic arthritis . . . . . . . . . . . . . . . . . . . . . . .142
6.4 Neoplasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
6.4.1 Evaluation of tumour and tumour-like bony
lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
6.4.2 Langerhan cell histiocytosis . . . . . . . . . . . . . . . . . . . . . .145
6.5 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
6.5.1 Paediatric fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
6.5.2 Non-accidental injury . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
6.5.3 Slipped capital femoral epiphysis . . . . . . . . . . . . . . . . .149
6.6 Rickets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150
6.7 Osteochondroses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
6.7.1 Legg-Calve-Perthes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
6.8 Muscle disorders in children . . . . . . . . . . . . . . . . . . . . . .153
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
CME-Instructions . . . . . . . . . . . . . .inside back cover
IX
List of Contributors
Donald P. Frush Peter Seidensticker
Chief, Division of Pediatric Radiology Global Medical Aff airs Diagnostic Imaging
Professor of Radiology and Pediatrics Bayer-Schering-Pharma AG
Faculty, Medical Physics Program Müller Straße 178
Division of Pediatric Radiology 13342 Berlin
1905 McGovern-Davison Children’s Health Center Germany
Box 3808 Department of Radiology
Duke University Medical Center David Stringer
Erwin Road Head of Department of Diagnostic Imaging
Durham, North Carolina 27710 Professor of Radiology
USA KK Women’s and Children’s Hospital
100 Bukit Timah Road
Thierry A.G.M. Huisman Singapore 229899
Professor of Radiology and Pediatrics Singapore
Director Pediatric Radiology
Johns Hopkins Hospital Harvey Teo
600 N Wolfe Street Department of Diagnostic Imaging
Baltimore, MD 21287 KK Women’s and Children’s Hospital
USA 100 Bukit Timah Road
Singapore 229899
Michael Kimpel Singapore
Paediatric Radiology
University of Heidelberg Jochen Tröger
Im Neuenheimer Feld 153 Head of Department of Paediatric Imaging
69120 Heidelberg Paediatric Radiology
University of Heidelberg
Hyun Soo Ko Im Neuenheimer Feld 153
354/ 51 Hope Street 69120 Heidelberg
Trilogy Residences Germany
Spring Hill QLD 4000
Australia Magdalena M. Woźniak
Department of Paediatric Radiology
Jens-Peter Schenk Medical University of Lublin
Paediatric Radiology Al. Raclawickie 1
University of Heidelberg 20-059 Lublin
Im Neuenheimer Feld 153 Poland
69120 Heidelberg
Germany
X
List of Abbreviations
AAP American Academy Of Pediatrics PW Doppler Pulsed Wave Doppler
ALARA As-Low-As-Reasonably-Achievable PWI Perfusion-Weighted Imaging
AP Anterior-Posterior RDS Respiratory Defi ciancy Syndrom
AV Arterio-Venous RI Resistive Index
CBF Cerebral Blood Flow SPECT Single Photon Emission Computed Tomography
CBV Cerebral Blood Volume SPGR Spoiled Gradient Echo
CDI Colour Doppler Imaging SPIR Selective Partial Inversion Recovery
CF Cystic Fibrosis STIR Short Inversion Recovery
CNS Central Nervous System Tc Technetium
CT Computer Tomography Tc99m MDP Technetium 99m Methylene Disphonate
DTI Diff usion Tensor Imaging TNF Tumour Necrosis Factor
DWI Diff usion-Weighted Imaging TSE Turbo Spin Echo
ECG Electro Cardiogramm US Ultrasonography
ECMO Extracorporal Membrane Oxygenation VCUG Voiding Cystourethrogram
ED Eff ective Dose VCUS Contrast-Enhanced Voiding Cysturo-
ERCP Endoscopic Retrograde Cholangio- sonography
Pancreaticography VIBE Volumetric Interpolated Breath-Hold
FLAIR Fluid-Attenuated Inversion-Recovery Examination (Mr)
FNH Focal Nodular Hyperplasia VUR Vesicoureteral Refl ux
Gd-DTPA Gadoliniumdiethylenetriamine-Penta-
Acetic Acid
GI Gastro-Intestinal
GN Glomerulonephritis
HCC Hepatocellular Carcinoma
HIV Human Immunodefi ciency Virus
HRCT High-Resolution CT
IL Interleukin
IVC Inferior Vena Cava
IVP Intravenous Pyelogramm
LIH Last-Image-Hold
MDCT Multidetector CT
MIBG Meta-Iodobenzylguanidine
MR Magnetic Resonance
MRA Magnetic Resonance Angiography
MRCP Magnetic Resonance Cholangio-
Pancreaticography
MRI Magnetic Resonance Imaging
MRS Magnetic Resonance Spectroscopy
MRU Magnetic Resonance Urography
mSv Millisievert
NEC Necrotizing Enterocolitis
NSF Nephrogenic Systemic Fibrosis
PNET Primitive Neuroectodermal Tumours
PVL Periventricular Leucomalacia