BSPR 2009 Abstracts & Posters
Trying to measure outcomes in paediatric radiology - Play therapy preparation for micturating cystography
Roseanne O’Shea (Msc Student) and Professor Christine Eiser (Supervisor), Department of Psychology, Sheffield University
Dr Iwan Roberts, Consultant Radiologist, Sheffield Childrens Hospital
Routine investigations (such as MCUG) can produce significant distress and pain for the patient, as well as anxiety and discomfort for a parent. Preparing a child for the procedure aims to reduce this distress through play therapy - an explanation of what the procedure involves, familiarisation with the equipment and modelling of the procedure using dolls.
This retrospective study (MSc dissertation) assessed the psychological outcomes of MCUG in children who had received play therapy. Using a variety of adapted questionnaires, parents were asked to recall their overall satisfaction, their behaviour during the procedure (both the parent and the child) and any subsequent behavioural change.
The study found high parental satisfaction with staff and appropriateness of play therapy. Dissatisfaction was expressed by the lack of anxiety relief play therapy offered parents. Highly positive correlations were found between parent and child distress as well as parental self-efficacy and child coping. Negative correlation was found between satisfaction and parental distress.
These results lead to a discussion about the best way to help prepare parents and children for routine procedures. At a time when financial pressures could affect clinical quality, this paper illustrates what outcomes might be measured and how this can be achieved.
Subdural hemorrhage, intradural hemorrhage and hypoxia in the pediatric and perinatal post-mortem: Are they related?
E H Whitby, A Sprigg, M Cohen
Aim: The aim of this study was to describe the occurrence of subdural haemorrhages(SDH), Intradural hameorrhages (IDH) and hypoxia in pediatric and perinatal deaths using a combined approach of post mortem magnetic resonance imaging (PM MRI), autopsy examination and histology.
Material and Methods: 42 cases (age range 1 day to 4 years, mean 6.9 months) underwent PM MRI and autopsy of the central nervous system. The MRI images were assessed for the presence of SDH, hypoxia and any structural abnormality. The autopsy was perfomed following standard procedures and included sampling of the falx.
Results : SDH and Macroscopic SDH was seen in 11 cases on PM MRI and at autopsy, 10 had fetures of hypoxia. IDH was seen histologically in 35 cases overall: diffuse in 17, focal in 18. 12 of the 17 cases with diffuse IDH were less than a week old and 14/17 were associated with hypoxia.
Conclusion: IDH and SDH are not uncommon findings in the perinatal and pediatric post mortem. SDH was associated with a diffuse IDH. Diffuse IDH this was also frequently associated with hypoxia. Focal IDH was not associated with hypoxia (on MRI and/or on histology) in the majority of cases.
What is the role of a Skeletal survey in the diagnosis of suspected non-accidental injury in infants aged two years and under?
Dr Owen Forbes (FY2), Dr Jean Herbison, Dr Andrew Watt
The aim of this study is to investigate how valuable the skeletal survey is in the diagnosis of non-accidental injury (NAI) in children aged two years and below. Also incorporated into the study is the value of CT head as part of the skeletal survey.
All children aged two years and below who underwent skeletal survey for suspected NAI between January 2004 and April 2008 at Royal Hospital for Sick Children Yorkhill were included in the study. Cases were split into two groups: 1) Infants aged 0-1 year; 2) Children aged 1 year - 2 years. For each of the 120 cases a record was made of: presenting complaint; reason for skeletal survey request; skeletal survey result; and the extent of subsequent involvement of the child protection team plus follow up. Cases were considered to be ‘positive’ if a previously unknown fracture was demonstrated as part of the survey. CT head reports were also analysed and outcomes were allocated to one of four categories:
A) Not done B) No bleed C) Unilateral bleed D) Bilateral / multiple bleed. The results obtained were compared between groups 1 and 2.
The most common presenting complaint was found to be ‘bruising’ and the most common reason for a skeletal survey request was ‘unexplained injury’. Of the 120 skeletal surveys carried out during the study period 15% revealed a new fracture (positive result), with ‘rib fractures’ and ‘metaphyseal fracture’ being most frequent. In group 1) 16 % of skeletal surveys were positive, compared to 15 % in group 2. CT head scans were done in 88% of cases. In group 1) 23% of CT scans demonstrated a bleed of some form. No cases were found in group 2) demonstrating a bleed. One in four children were placed on the Child protection register following skeletal survey for suspected NAI. Almost half of the children were discharged to either grandparent or foster care.
In conclusion, 1 in 7 skeletal surveys carried out on children with suspected NAI aged two or below are positive. This suggests that skeletal survey is a valuable tool for use as part of the investigations into suspected NAI. There is evidence for the use of CT head images as part of skeletal survey in infants below one. However there appears to be less value in the use of CT head as part of skeletal survey in children 1-2 years old. Metaphyseal fractures and rib fractures are the two most common findings in positive skeletal surveys. Most children included in the study were not placed on the child protection register following investigation, with the aid of skeletal survey, for possible NAI.
Retrospective study to look at radiological signs of fracture healing in young children
Prosser IM, Evans A, Harrison S, Morris S, Kemp A, Maguire S, Lawson Z
To define a timetable of radiological features of fracture healing in children, determine the accuracy of dating and level of agreement between radiologists.
Digital x-rays of children =5years with accidental fractures of known age (with follow-up films) were reviewed independently by three Paediatric Radiologists, blinded to clinical details, evaluating six features of fracture healing and estimating fracture age.
We analysed 78 fractures in 63 children. The earliest feature was soft-tissue swelling present in 58% of fractures on day 1, disappearing by day 29. Periosteal reaction was first noted at day 5, and present in 81.5% of fractures between days 17-29. Hard callus and bridging were first seen at day 19 and present in 98% by 24-71 days. Remodelling was noted at day 31. The level of agreement between radiologists was high. Accuracy at estimating fracture age was best at =1week (84-98%) and least at 2-3 weeks (20-48%) when casts limited interpretation.
The most consistent and accurate dating was for acute fractures (<day 5). Of six recognised features of fracture healing, five in combination are the most informative. Further analysis of these in combination will be conducted.
Antenatally detected Unilateral Renal Agenesis and Multicystic Dysplastic Kidney: Is routine DMSA scintigraphy of any value following confirmation of diagnosis on Postnatal Ultrasound Scan?
Chatora G, Broderick N, Halliday K, Somers J
It is standard practice in most centres to perform postnatal ultrasound and DMSA scintigraphy in patients with Unilateral Renal Agenesis, (URA) and Multicystic Dysplastic Kidney, (UMDK) identified antenatally. I reviewed our experience over a 21 year period to determine whether DMSA scintigraphy provided any additional diagnostic information over ultrasound.
Materials and Methods
Records of all patients who had DMSA scintigraphy for antenatal diagnosis of URA or UMDK between December 1987 and December 2008 were reviewed retrospectively.
124 patients, were identified, 75 male, (60%) 49 female, (40%), aged 2 to 340 (median 101) days.
All patients had undergone postnatal ultrasound examination, mean interval between the studies, being 86 days. 30 patients had URA (24.2%), 92 had UMDK, (74.2%) and 2 had a pelvic kidney (1.6 %). 12 patients, (9.6%) had contralateral renal abnormalities.
In 116, (93.6%) cases, both examinations gave identical results. In 1 case, (0.8%) DMSA identified a pelvic kidney missed on ultrasound. Ultrasound demonstrated significant abnormalities of the solitary functional kidney, such as hydronephrosis, not evident on DMSA in 7 cases, (5.6%).
Conclusion NHS Evidence | library.nhs.uk
DMSA scintigraphy does not routinely provide any additional information over that obtained from ultrasound alone. Ultrasound also provides superior information regarding the solitary functional kidney.
3D MR Urography in Paediatrics
Dr Emma Cheasty ST2 Radiology Manchester Training Scheme
Dr Abdu Shabani Consultant Paediatric Radiologist
MR urography is increasingly used in paediatrics as an effective alternative to intravenous urography and scintigraphy in selected subsets of patients.
The aim of this study is to review the common urological problems in children, discuss the imaging sequences used for optimal 3D MR urography and illustrate the common anomalies identified by these techniques.
Materials and method
A retrospective study was conducted looking at 9 years of MR urography in a tertiary paediatric referral centre. Clinical notes and images reviewed to determine; patient cohort, pre and post scan care, anomalies identified and imaging sequences used.
MR urography demonstrated multiple anomalies including; duplication system with ectopic ureteric insertion, detecting causes of obstruction; examples of which are crossed renal vessels with or without PUJ and/or VUJ obstruction. Other unexpected abdominal and/or pelvic pathology were also identified.
3D MR urography is extremely useful in evaluation of common and uncommon paediatric urological problems. It provides a superior understanding of the anomaly than intravenous urography and scintigraphy with the benefit of no radiation exposure. MR urography is increasingly replacing conventional urography in children
Prevalence of late onset renal scarring in children
Mvere M, Broderick N, Halliday K, Somers J
Objective. The purpose of this study was to investigate the incidence of new renal scarring in patients above the age of 4 years.
Methods. We retrospectively reviewed the formal radiology reports of 1372 children aged 2 to 18 years investigated for a confirmed urinary tract infection between 1995 and 2008 in order to identify children developing new renal scars after the age of 4 years. Of these 1372 patients, 61 (4.5%) patients developed new renal scarring after the age of 4 years. Results. 13 (21%) of the patients were male and 48 (79%) were female. Mean age at which new renal scarring was detected was 8.8 years (range 4-18 years). The majority of the new renal scars were initially detected by ultrasound scan in 45 patients (73.8%). DMSA detected new renal scars in 8 patients (13%), MAG 3 scan in 6 patients (9.8%) and a couple of patients (3.2%) by IVU
Conclusion. The incidence of late onset renal scarring in our study was 4.5%. Girls were more prone to late onset renal scarring than boys.
Role of magnetic resonance imaging (MRI) of lumbosacral spine in the evaluation of paediatric population with isolated bladder dysfunction.
Boddu SR; Broderick N; Haliday K; Somers J
Purpose: To evaluate the role of MRI of the spinal cord in the evaluation of children with complicated voiding dysfunction with normal cutaneous and neurological examination.
Materials and Methods: Retrospective study involving all the paediatric patients with presumed bladder dysfunction referred to the department of radiology at a tertiary referral centre during 1995-2009. We reviewed a total of 54 patients. The details of neurological and cutaneous evaluation were obtained from patient case notes. Patients with abnormal neurological examination, cutaneous stigmata (lipoma, haemangioma and sacral pit), obvious clinical spinal dysraphism and ano-rectal abnormalities were excluded from the study population. Based on the inclusion and exclusion criteria, 38 patients (n=38) are included in the study population. Patients had prior evaluation with renal tract ultrasound and bladder pressure studies and final evaluation with MRI. T1 and T2 weighted axial and sagittal acquisitions of lumbosacral spine were acquired using 1.5-Tesla scanner. Images were reviewed by consultant paediatric or neuroradiologists.
Results: In all the study population (n=38) bladder pressure studies confirmed several patterns of voiding dysfunction (13 -detrusor instability; 8 hypertonia; 13 - hyporeflexia; 4 - detrusor-sphincter dysinergia. None of the patients had abnormal findings on MR imaging of the lumbosacral spine.
Conclusion: In the background of normal cutaneous and neurological assessment, lumbosacral spine MRI is of no added value in the evaluation of a child presenting with isolated bladder dysfunction. We recommend a large prospective study to confirm this evidence.
Implementation of the NICE guidelines for imaging children with urinary tract infection - the Leicester experience
Dr Adam Thomas, Dr Andrew Rickett
The NICE guidelines for UTI were implemented in July 2007. Preceding this, two months of imaging referrals were assessed as to whether they would be rejected under the new NICE guidance. This group were followed up over 2 years with no significant abnormality detected. 101/103 (98%) requests received were imaged under the old guidelines. 2/101 (1.94%) investigations yielded an abnormal result
Six months later a second 2 month collection showed a significant reduction in accepted referrals: 73.8 vs 98%, 24.2% reduction (95% confidence interval 13.9
35.1%, p<0.0001). The number of investigations performed had fallen to 62 (39.6% reduction, 95% CI 29.4 49.8%, p<0.0001).
Two years after implementation a third data collection revealed the following: Referrals ‘appropriate’ to guidelines: 51/56 (91%), difference from old guideline = 7% (CI -0.8 17.9%, p = 0.10). Number of investigations performed: 51 = 49.5% reduction (CI 38.8 59.6%, p<0.0001). Over the two years the abnormal scan rate has increased from 2/101 (1.94%) to 6/51 (11.7%) = 9.8% increase (0.98 22.0%, p = 0.03).
Imaging workload has decreased by approximately 50%. ‘Appropriate’ clinical referrals rate has returned to baseline within two years of implementation. Number of positive/abnormal scans has significantly increased.
NICE Guidelines for the management of childhood UTI (2007)- have they changed paediatric imaging practice?
Briard R, Moorthy I, Vara A, Dikomite J, Dizdarevic S.
Departments of Paediatric Radiology, Nuclear Medicine and Radiology Information Technology,
Brighton and Sussex University Hospitals, Brighton and Sussex Medical School
Aim: To assess whether the referral pattern for UTI imaging has altered following publication of NICE clinical guideline 54 (August 2007). (1)
Background: Our Department has historically offered open access for KUB ultrasonography to General Practitioners referring children following UTI.
Methods: We audited imaging referrals before and after NICE Guidelines, against NICE recommendations, comparing request numbers and indications in the year from 01.04.2007 to 31.03.2008, with 01.04.2008 to 31.03.2009, in the same catchment area.
Results: We showed a decrease of 32% in requests for KUB ultrasonography, 43% decrease in VCUGs and 35% decrease in DMSA scans. Post- NICE, the majority of requests were in line with NICE recommendations.
Conclusion: Our data suggest that NICE guidelines have changed clinical practice. We discuss possible reasons for, and implications of this trend in terms of resource utilisation and service implications, it’s impact on patients, and long and short term morbidity, referring to relevant recent literature. (2,3)
1. NICE clinical guideline 54. Urinary tract infection in children. August 2007
2. Coulthard MG. Is reflux nephropathy preventable, and will the NICE childhood UTI guidelines help?ArchDisChild 2008;93:196-199.
3. Marks SD, Gordon I, Tullus K.Imaging in urinary tract infections: time to reduce investigations. Pediatr Nephrol 2008;23:9-17.
Specific Identification of Solid Tumours at Ultrasound - a retrospective review
Dr Sarah Watson, Dr Haran Jogeesvaran, Dr Alistair Calder
OBJECTIVE: To compare ultrasound diagnosis with subsequent histology in children referred with suspected solid tumours. Imaging of selected cases is also presented, including discrepancies.
METHOD: 66 patients referred for ultrasound by the oncologists at a regional paediatric centre were identified. The radiology reports were reviewed to determine how often a specific diagnosis or differential diagnosis was suggested. These were then compared with the histological reports from biopsy or surgery.
RESULTS: In 78% of cases the organ of origin was correctly identified at ultrasound.In 53% of cases a specific diagnosis or differential diagnosis was suggested. Where a specific diagnosis was suggested 73% were confirmed by histology.
CONCLUSION: There is a high correlation between diagnosis at ultrasound and subsequent histology.
DISCUSSION: In some cases the radiologist may intentionally avoid suggesting a specific tumour type as affixing a diagnosis prematurely may alter the patient’s subsequent management. A descriptive diagnosis of the tumour characteristics together with the organ of origin may be more helpful than suggesting specific histological diagnoses.
Ultrasounded Guided Core Biopsy Of Suspected Tumours in Paediatric Population – Yorkhill Experience
Dr. Imran Khan, Dr. Sanjay Maroo
We evaluated the ability of ultrasound-guided core biopsy to obtain sufficient tissue from suspected pediatric tumors for a definitive diagnosis.
Materials and Methods
23 patients underwent ultrasound-guided biopsy of suspected tumours from 2006 till March 2009. One patient was excluded because of lack of availability of histopathology report on the system. A single radiologist performed all procedures. Data collected included the site/organ, the caliber of the biopsy needle and the histological diagnosis.
10 patients were males, 12 females. Majority of the biopsies were carried out using an 18-gauge needle (18 patients) with only 4 patients undergoing the procedure with a 16-gauge needle. The most common site/tumour was an abdominal mass (6 patients) followed by kidney (4 patients), liver (4 patients) and mediastinal mass (3 patients). Other sites included chest wall mass (2/22), lung (1/22), right thigh mass (1/22) and parapharyngeal mass (1/22). The minimum number of cores obtained by radiologist was 1 and the maximum number was 16.
The radiologist felt that the procedure had been successful on all but one patient. Though samples were taken in the latter, the biopsy site (chest wall mass) was difficult to access and the patient developed haemothorax and cardiac arrest. All other patients had a successful biopsy according to the radiologist’s report with only one patient developing a small haematoma following renal biopsy.
However, to further confirm success, histopathology reports were analyzed. According to the histopathology reports, the sample provided was diagnostic in 20 patients (91%). The size of the core was mentioned in the histopathology reports of 18 patients with largest core at 20 mm and the smallest at 2 mm (average 13.5 mm)
Ultrasound-guided core biopsy is a safe and reliable means of obtaining sufficient tissue to make a confident histological diagnosis of malignant pediatric tumors in a high percentage of patients. Our findings are comparable to other experiences quoted in the literature.
Incidence of Avascular necrosis in ALL patients
S Moholkar, K Johnson, M Velangi ,W Hogler
Department of Radiology, Haematology Oncology and Endocrinology, Birmingham Children's Hospital
Avascular necrosis is increasingly being recognised as a complication of acute lymphoblastic leukaemia (ALL) treatment, especially since dexamethasone was included in ALL treatment protocols. Clinical symptoms of avascular necrosis usually present during ALL maintenance therapy but often lag behind the MRI features. MRI is considered the gold standard for detection of avascular necrosis, which predominantly occurs at the weight-bearing lower extremities.
We endeavour to document the incidence of symptomatic avascular necrosis in children on ALL therapy at our institution.
Retrospective review of the oncology database over the last 3 years to identify children on ALL therapy with review of their Magnetic Resonance Imaging .Children over 8 years of age who are more likely to develop avascular necrosis were included in the study.
36 patients included in the review 16 patients had MRI scans for detection of avascular necrosis.
During and after ALL treatment, children should be routinely asked about musculoskeletal pain with low threshold for performing MRI if there is clinical suspicion. National guidelines for ALL treatment should include screening MRI for early detection of avascular necrosis.
Audit on Ultrasound-guided liver biopsy in children
A.Neelakantan, S. Maroo
US-guided percutaneous liver biopsy is an established and effective diagnostic tool. The risk of complications are not insignificant, even when performed by an expert, and there is evidence to suggest that the risk of major complications such as bleeding requiring intervention may be higher in children than in adults(1)
1. An adequate tissue sample should be achieved at the first attempt in 95% of cases.
2. Zero mortality
3. Morbidity -defined as complications requiring intervention, either surgical or medical e.g. blood transfusion, surgery etc. – <5% (2,9,11)
1.97% of tissue samples were adequate, as stated in the pathologist’s report
(1/30 i.e. 3% was non-diagnostic)
3.6% (2/30) - Major bleed requiring blood transfusion and ITU support
Utility of MRI in Suspected Scaphoid Injury
R. Isaac, S. Moholkar, K. Johnson
MRI has been shown to be both sensitive and specific in diagnosing occult scaphoid fracture.
Whilst initial imaging involves standard scaphoid radiographs, there is wide variation in imaging protocols for patients with negative radiographs and a high index of clinical suspicion.
Retrospective review of the radiology database over the last 5 years. 108 patients identified in whom MR wrist was performed following fall on to outstretched hand.
In addition to occult scaphoid fractures, a number of other clinically significant abnormalities were identified.
In appropriate clinical circumstances, early imaging of suspected scaphoid fracture with MR can provide definitive diagnosis and guide appropriate therapy. In the event of a negative scan, unnecessary wrist immobilisation can be prevented.
At our institution early MR has replaced follow up scaphoid series in patients with suspected scaphoid fracture and normal initial radiographs.
How useful is the Meckel's Scan in the 21st Century?
M Steven, A Sabharwal, A Watt
Introduction: A Technetium 99 radioisotope scan is regarded as the test of choice for investigating possible Meckel’s diverticulum. We hypothesised that the diagnostic yield from such scans is relatively low.
Methods: We retrospectively analysed our radiology and theatre databases between January 2000 and October 2009 and performed a case-note analysis.
Results: 190 Meckel’s scans were performed. 10 were reported as positive, 3 indeterminate and 177 negative. 35 children underwent surgery; 12 girls and 23 boys. The median age at surgery was 4 years (0.05-13.6 years). 14 had painless rectal bleeding, 9 had abdominal pain and rectal bleeding and 12 had abdominal pain. 13 had associated vomiting. 3 were found to have intussusception and one volvulus. All 3 with an indeterminate scan underwent negative laparoscopy. All ten with positive scans proceeded to theatre and in all but one a Meckel’s was found. Four patients with a negative scan had a laparoscopic-assisted Meckel’s diverticulectomy. 69% of patients underwent emergency procedures and, therefore, only 17 had a pre-operative Meckel’s scan. Interestingly, all false-negatives had heterotopic gastric mucosa on pathology.
Conclusion: In the current laparoscopic era this begs the question as to whether the Meckel’s scan is still truly the investigation of choice.
Coregistration of (Whole Body) MRI & SPECT Mibg in the staging of neuroblastoma
Christie McComb, Michael Bradnam, John Foster, Elaine Thompson, Shona Morris, Hugh Wallace, Dermot Murphy, Andrew Watt
Conventional Staging of neuroblastoma requires the use of both morphological imaging such as CT and\or MRI as well as functional imaging in the form of Mibg scanning. It is difficult sometimes to relate the Mibg findings to the morphological findings provided by cross sectional imaging. This study attempted to address these issues by using automated co registration of Mibg with MRI to assess feasibility and clinical utility.
MRi scanning was performed on 1 1.5T Philips Intera scanner using abdominal & whole body protocols. Mibg imaging was acquired on Siemens & Philips dual head gamma camersas using planar and SPECT imaging. SPECT data was reconstructed into an axial data set and then fused with the MRI data set using the Hermes nuclear medicine software from nuclear diagnostics. A clinical assessment of the accuracy (poor, average, good, excellent) was made and any specific points of interest were noted.
14 scans in 8 patients were analysed. Co registration was excellent in 7, good in 5 and average in 2. Co registration was more accurate when whole body mri data set was used rather than abdomen only. Additional clinical information with regards to differential activity within different parts of the primary tumour was noted as well as the presence and absence of nodal and marrow uptake.
Automated co registration of SPECT Mibg with MRI is feasible. Best results were obtained with whole body mri data sets. Additional information with regards to differential activity within the primary tumour & nodes was identified.
Is there life in the old dog yet?(Another look at radiographic tomography)
Ian J Kenney
Getting rid of structures overlying an area of interest has always been a problem, resulting in a large variety of projections, techniques, and of course now largely solved by cross sectional imaging and ultrasound. Thus comventional tomorgaphy bit the dust. Recently however, digital imaging and microproscessing power have combined to make radiographic tomography worth another look. I hope to illustrate where it might be of use in a modern paediatric imaging department.
Nair S, Forbes K.
Mitochondrial disorders are caused by a wide range of mitochondrial DNA mutations and can have an equally wide clinical presentation. We retrospectively reviewed all our cases and the possible imaging findings at presentation and progressive changes over time seen in this heterogeneous patient group. We describe the basic principle of mitochondrial disorders and the respiratory chain, describe various mitochondrial disorders and their presentation, typical/atypical imaging findings, differential diagnosis and follow up imaging.
Methods and material:
MRI offers an important diagnostic tool in suggesting these disorders. We retrospective review of all our cases from 1999-2009.
MRI offers an important diagnostic tool in suggesting these disorders and may potentially help differentiating specific clinical syndromes eg MELAS, Kearns-Sayre syndrome and Leigh syndrome. We review and show the use of MRS and DWI. Differential diagnosis will be considered.
We describe typical and atypical MR findings with reference to both clinical syndromes and genetic classification. The peers will become familiar with the neuroimaging findings seen with mitochondrial disorders and be able to identify features that may suggest particular clinical subtypes.
Institutional Experience with Cardiac MRI following Tetralogy of Fallot Repair.
Dan Kusuma, Sanjay Maroo
Tetralogy of Fallot is the most common cyanotic congenital heart disease, accounting for approximately 6-10% of all cases of congenital heart disease.
Following surgical correction, patients invariably develop pulmonary regurgitation with resultant right ventricular dysfunction, arrhythmias and increased mortality. Restoring pulmonary valve function has been shown to decrease RV size and improve symptoms.
To assess the severity of right ventricular dysfunction and pulmonary arterial flow abnormalities.
Retrospective study of CMR findings and physiological parameters in post-operative patients with Tetralogy of Fallots performed at the RHSC from 2005 - 2009.
Right ventricular dysfunction was measured qualitatively through the detection of interventricular septal wall movement dyskinesia and quantitatively by measuring end-diastolic volume, ejection fraction and by studying flow through the atrioventricular valves. Pulmonary arterial flows were measured using regurgitant fractions and identification of aneurysmal or stenotic segments.
21 scans were included in our study. 3 patients were unable to tolerate the prolonged scanning times and a further 3 patients had metallic pulmonary arterial stents in-situ.
The majority of patients demonstrate right ventricular dysfunction and varying degrees of pulmonary regurgitation.
The oral presentation will include a short synopsis of classic MR findings in post-operative Tetralogy of Fallots as demonstrated in our study participants.
10 year audit cycle of intussusception reduction: Poor performance or a changing spectrum of disease?
KJ Taylor-Robinson, M Jayawardena, LJ Abernethy
In a tertiary paediatric referral centre we had an impression of a fall in the incidence of intussusception in recent years. There was also a suspicion of a poorer success rate for pneumatic intussusception reduction. To evaluate this we repeated an audit first performed in 1999 -2001.
43 consecutive cases who had attempted pneumatic intussusception reduction (Dec 2006 to May 2009) were identified by prospectively completed audit forms and retrospective search of the radiology information system. The results were compared with summary data from a previous audit in 2001 and to targets in BSPR draft guidelines from April 2003.
The results confirmed our suspicions: we found a significant fall in incidence over the last decade and that the current overall success rate for pneumatic reduction was 56%, well below both the previous audit (> 70% success) and the BSPR target of >65-70%.
We present a breakdown of the results, including population characteristics, seasonal distribution, duration of symptoms, underlying pathology and clinical outcomes and speculate as to the cause of these trends. We also raise practical questions regarding the appropriateness of performance targets for air enema reduction of intussusception.
Use of post gadolinium MR scans in the assessment of paediatric syringomyelia-our experience
Dr Vidula Godhamgaonkar, Dr Caren Landes
T1W post gadolinium sequence has been widely recommended in the MR assessment of paediatric syringomyelia. It has been recommended primarily to exclude an underlying cystic neoplasm in the spinal cord on the basis of the finding that a neoplasm shows enhancement on post gadolinium MR scan. An idiopathic syrinx lacks this enhancement.
We have incorporated a T1W post gadolinium sequence routinely in our scanning protocol for a paediatric syrinx. On most occasions, however, there is no evidence of enhancement related to the syrinx. They are commonly associated with Chiari I malformation.
We are currently reviewing all the spinal MRI scans done at out institution over past 2 years which showed a syrinx at the first presentation.
We have included incidentally found syringes as well as symptomatic syringes in the review. We have excluded scans showing complicated syringes and subsequent follow up scans done for idiopathic syringes.
We are reviewing whether these scans revealed any enhancement on post gadolinium scanning and also any other significant spinal pathology. We intend to test the hypothesis of appropriateness of routine use of post gadolinium MR sequence in the assessment of paediatric syringomyelia in our review.
This is a currently ongoing project with data collection in progress.
SPECT DMSA with MPR reconstruction in the assessment of childhood renal tract abnormalities
Michael Bradnam, Elaine Thompson, Shona Morris, Andrew Watt
Conventional DMSA imaging of childhood renal tract abnormalities is performed using static planar views of the kidneys from the front, rear and obliques. This method is reliable and reproducible but by its nature gives a projectional view of renal parenchymal uptake. SPECT imaging as part of the protocol provided additional information with regards to functioning renal parenchyma. The purpose of this study was to identify whether the routine use of a SPECT acquisition added any useful further information
A SPECT acquisition was added to the standard DMSA protocol of frontal, rear and oblique projections for a period of 3 months to assess feasibility. Following this, the oblique projections were removed from the protocol. SPECT image data was motion corrected & reconstructed into an axial data set using the Hermes nuclear medicine software and then the exams were reported via PACS. SPECT data was routinely viewed using MPR reconstruction on PACS.
907 DMSA scans were performed in the study period of January-September 2009. Patient demographics & failure rates were unchanged compared to the pre-study period. SPECT failed in xx patients. Significant movement artefacts were seen in <10% of exams. SPECT was useful in identifying structural anomalies such as duplex kidneys, but was not reliable enough for the diagnosis of scars on its own. Scars were only diagnosed when there was an abnormality on both imaging methods.
SPECT acquisition of DMSA data is feasible in all ages groups. It provides a useful adjunct to planar imaging in allowing 3d interrogation of the renal parenchyma. This is useful in the presence of structural anomalies of the renal tract. Movement artefacts were encountered and SPECT tended to overestimate scarring when compared with planar imaging but was helpful in confirming scarring in cases where planar imaging was inconclusive.
Scoliosis : The role of plain radiographs
Dr Lauren K Harris, STR Radiology, Edinburgh
Dr Kaseem Ajilogba, Consultant Paediatric Radiologist, RHSC Edinburgh
Mr Thanos Tsikiros, Consultant Orthopaedic Surgeon, RHSC Edinburgh
Key learning objectives:
1. Evaluation of the initial scoliosis radiograph
2. Terminology used in evaluating scoliosis radiographs
3. Illustrated aetiologies of scoliosis
4. Review of the radiographic indications for further imaging
Scoliosis is the presence of one or more lateral rotatory curves of the spine in the coronal plane. Although defined as a side-to-side deformity, it is a 3-dimensional rotational deformity. Imaging plays a crucial role in confirming the diagnosis of scoliosis, with plain film radiography the mainstay in assessment. Idiopathic scoliosis is the most common type of scoliosis, accounting for 80% of cases however should be considered idiopathic only after other occult causes have been excluded.
The initial radiograph is used to confirm the clinical diagnosis of scoliosis and is usually the best opportunity to identify congenital, dysraphic or developmental abnormalities, as subsequent deterioration of the curve with rotation can hinder detection. Furthermore it is used to assess the curves and their severity, to monitor progression, to assess skeletal maturity, and to determine a patient's suitability for surgery.
With illustrated examples, we review the terminology and evaluation of the scoliosis radiograph.
Angles, lines and measurements - what the orthopaedic surgeon really wants to know regarding the assessment of paediatric lower limb plain radiographs.
Dr. K S Lutchmeesingh, Dr. S Negus, Dr. N Mohan
A pictorial view of the angles, lines and measurements used when describing a paediatric lower limb plain radiograph.
Explanation of those which are clinically useful for the orthopaedic surgeons are given, together with an overview, and brief explanation of the pathologies commonly encountered.
Complications of Umbilical Catheters and Peripherally Inserted Central Catheters.
Dr.Lekha Potti and Dr.Bozena Starzyk
Umbilical catheters and peripherally inserted central catheters (PICC) are increasingly used in neonatal intensive care for prolonged administration of parenteral fluids, medications and for blood sampling. Correct positioning of the lines is highly important to minimise complications. Complications of incorrect positioning include thrombosis, perforation leading to extravasation of intravenous fluids, pleural, peritoneal and more seriously pericardial effusions and cardiac tamponade.
Plain film radiographs must be used to ascertain the course and position of the tips of the lines.
We wish to discuss the normal anatomical course and ideal location of the tips of long lines, umbilical arterial and venous catheters. We also illustrate examples of complications of malpositioned PICC and umbilical catheters.
Congenital abnormalities of the neonatal thorax: a pictorial review
Deganello A., Allen P., Sellars M.
There are a number of congenital abnormalities that can affect the neonatal thorax involving the respiratory, gastrointestinal and cardiovascular systems. These abnormalities are often extremely difficult to diagnose clinically and therefore the role of imaging remains vital.
They are important causes of morbidity in newborns and with the advancement of neonatal surgery, imaging both antenatally and postnatally can assist in earlier accurate diagnoses to allow the evaluation of therapeutic options and planning of surgery.
We present a pictorial review covering a range of congenital thoracic abnormalities seen in our everyday practise including diaphragmatic hernias, atresias and various cystic abnormalities but excluding cardiovascular abnormalities. The anatomy and embryology are illustrated where relevant and we include examples of images from modalities including plain film, ultrasound, CT scans and MRI scans including antenatal images.
The radiological findings are described and the pertinent radiological features are highlighted to increase confidence in reporting of such conditions.
Ultrasonic Appearances Of An Ingested Coin Lodged Within An Ileostomy.
Dan Kusuma, Greg Irwin
Natural elimination occurs in the majority of paediatric patients who have ingested foreign bodies. The most common site of obstruction for a foreign body such as a coin is at the oesophagus where intervention may be necessary. These are commonly monitored plain radiographic imaging. To the authors’ knowledge, ultrasound has never been described as a tool for localising lodged foreign bodies within the small bowel and stoma sites. We present a case of a penny coin lodged within the lumen of an ileostomy of a 4 year-old who had previous subtotal colectomy and the relevant imaging findings.
Fluoroscopically-Guided Insertion of Feeding Gastrojejunostomy with Venting Gastrostomy: Two Case Presentations
LL Millar, E Stenhouse, S Maroo
Enteral feeding via gastrostomy or gastrojejunostomy is the preferred method for nutritional support in patients unable to tolerate oral diet or requiring supplementary intake. Radiologically-guided percutaneous retrograde placement of gastrostomy and gastrojejunostomy tubes has become an established procedure. Benefits include decreased morbidity and mortality, improved cost-effectiveness and shorter procedure times compared to the surgical alternative.
We present the cases of two children (aged 4 and 13 years) with complex medical conditions requiring establishment of enteral feeding. Both patients underwent fluoroscopically guided combined insertion of gastrostomy and gastrojejunostomy. We discuss our experience of this procedure with annotated fluoroscopic images and discuss the merits of these combined procedures.
Chondroblastoma is a rare benign cartilaginous lesion primarily affecting older children and adolescents.
ER, GI, AH (Path), DR (Ortho)
Chondroblastoma is a rare benign cartilaginous lesion primarily affecting older children and adolescents.
We present a case where the diagnosis of chondroblastoma proved to be evasive despite extensive workup with imaging and tissue biopsy.
A nine year old girl initially presented to Accident & Emergency with non traumatic left shoulder pain. Clinical examination and initial imaging were unremarkable. A complex, partially enhancing left humeral metaphyseal lesion was demonstrated on subsequent MRI, consisting of areas of presumed active disease and necrosis
Findings felt most in keeping with osteomyelitis. Initial biopsy, under fluoroscopic guidance, of the most enhancing region of the lesion yielded histology consistent only with inflammatory change. Following a second MRI scan, which demonstrated little change in the extent of the lesion, a repeat biopsy of the most enhancing area was performed under CT guidance. However, this also yielded unremarkable histology.
Antibiotic therapy was continued but increasing clinical concern grew over the lack of clinical improvement and persisting shoulder pain. An open biopsy was performed, sampling tissue from the enhancing and non-enhancing portions of the humeral lesion. Surprisingly, the tissue from the presumed necrotic material on MRI yielded positive histology, consistent with chondroblastoma.
Biopsy of lesions of equivocal nature on imaging should therefore not only sample areas of presumed active disease, but also regions of apparent necrosis or inactivity to avoid misleading histology which can be falsely reassuring and result in delayed or poorly targeted therapy.
Ultrasound as first line assessment of paediatric lumps , bumps and soft tissue swelling in a general hospital setting
Kate Kingston, Julie Cooper, Anna Murphy
Ultrasound is our modality of choice for the initial assessment of superficial lesions in the paediatric population. It is quick, non-invasive, with no radiation dose or requirement for general anaesthetic. Interaction with child and carer allows the operator to gain a detailed history, provide reassurance and alleviate anxiety.
Our department is receiving an increasing number of requests, mainly from GPs, for evaluation of paediatric lumps and bumps.
The purpose of this pictorial essay is to raise awareness amongst radiologists to the wide spectrum of lesions encountered in children. We will provide examples that overlap with the adult population, such as hernias, ganglia and other cystic lesions, but concentrate on lesions more common in, or unique to children. We will provide examples of congenital and developmental lesions: dermoid; epidermoid; vascular and lymphatic malformations and pathologies such as fibromatosis colli, pilomatrixoma and other soft tissue tumours encountered in a general hospital setting. We will include correlation with other imaging modalities, such as MRI and CT where appropriate.
In our experience, there is a time effective triage element to ultrasonic assessment of these lumps and bumps. The dynamic scan allows us to ascertain the presence of a lesion, its location and morphological characteristics. The radiologist is well placed to guide the referrer towards the most appropriate future management of the patient, be it: reassurance from the GP; more complex imaging investigations; referral for surgical opinion or evaluation by a paediatric soft tissue sarcoma centre.
The abbreviated MCUG
Clague G, Mackenzie S
Micturating cystourethrography is commonly required to diagnose and assess vesicoureteric reflux in infants with a history of UTI or evidence of upper urinary tract dilatation on ultrasound. The standard technique of performing an MCUG employs frontal in addition to oblique views of the bladder, lower ureters and urethra. We have assessed two different techniques used in our department, one includes oblique images, the other omits them.
90 MCUG examinations performed between November 2006 and November 2008 by radiologists using oblique projections were used. The images of each were presented as a slideshow to 3 Consultant Radiologists but the oblique images from each series was omitted. The images were viewed on departmental PCs individually and re-reported, the new reports were then compared to the originals. 81.5% of the new reports correlated exactly with the originals.
During our study, only one case of grade 1 reflux was missed by not viewing the oblique images. This degree of reflux does not warrant intervention in our institution and we therefore believe that performing oblique views during this examination are unnecessary, their omission resulting in a quicker examination with a lower radiation dose.
Non-thyroidal tissue on ultrasound of the neck in infants with congenital hypothyroidism due to lingual ectopia: the Morag phenomenon
Morag Attaie, Jeremy Jones, David Neumann, Sanjay Maroo and Malcolm Donaldson
Thyroid imaging is of proven help in establishing a diagnosis of congenital hypothyroidism in infants. Ultrasonography often shows tissue in the thyroid fossa when radio-isotope reveals only ectopic uptake.
Our hypothesis was that the use of ultrasonography alone could lead to the mistaken diagnosis of normal or dysplastic thyroid in cases of radio-isotope-proven thyroid ectopia.
Materials and methods
We undertook a detailed retrospective review and analysis of imaging and concurrent biochemistry in infants with thyroid ectopia, confirmed by radio-isotope scan.
Eighteen infants had thyroid ectopia; ten of the original ultrasound reports had suggested that cervical thyroid tissue was present. Review showed bilateral tissue in the thyroid fossa in all which was non-thyroidal in nature since, apart from showing no isotope uptake, it exhibited some or all of the following typical features: hyperechogenicity; heterogeneity; small size; poor vascularity; and anechoic and/or hypoechoic cysts. Also, extension of the tissue both around and behind the large cervical blood vessels was a universal finding.
Considerable experience is required to interpret neonatal thyroid ultrasonography. We caution against diagnosing a dysplastic/hypoplastic thyroid gland in situ on the basis of ultrasound alone, particularly if the tissue exhibits any of the non-thyroidal features described.
Spectrum of renal tumours in Children- A Pictorial Representation
S Moholkar, A Rickett
Objective: To describe the experience at our institution of renal tumours over a 10 year period
Background : Wilms tumour accounts for approximately 90% of renal tumours in children. Rare causes include clear cell sarcoma,rhabdoid tumour, renal cell carcinoma, mesoblastic nephroma and nephroblastomatosis. We describe the imaging features of the above.
Materials and Methods: Retrospective Review of Imaging and oncology records over a 10 year period at our tertiary referral centre.
Results : 23 cases identified. 19 had histological diagnosis of Wilms tumour, 1 child had clear cell sarcoma, , 1 renal medullary carcinoma,1 nephroblastomatosis, 1 mesoblastic nephroma.
Despite the good prognosis of renal neoplasms 2 of the children with Wilms tumour ( 8.6%) and the children with sarcoma and renal carcinoma died soon after diagnosis.(2)
1) LH. Lowe, BH. Isuani, RM. Heller et al. Pediatric Renal Masses: Wilms Tumor and Beyond1 Radiographics; 2000;20:1585-1603.
2) P Pickhardt, G Lonergan,C Davis et al.Infiltrative renal lesions : Radiological-pathological correlation ; Radiology 2000; 20:215-243
3) GJ Lonergan, MI Martinez-Leon, GA Agrons, H Montemarano and ES Suarez Nephrogenic rests, nephroblastomatosis, and associated lesions of the kidney; Radiographics 1998;18: 947-968
Clinical Presentation and Radiological Findings in Paediatric Penile Metastatic Crohn’s Disease
Cowell GW, O’Toole S, Howatson A, Irwin GJ
Crohn’s disease is widely described as a chronic, granulomatous inflammatory disorder of the alimentary tract, though much less commonly may affect other parts of the body, termed metastatic disease. A case of initial presentation with penile lymphoedema of paediatric metastatic Crohn’s disease of the penis is described in a previously fit and well fourteen year old boy, with subsequent more classical findings of an ileocolitis. Clinical, radiological and pathological findings are outlined, in addition to a review of the available literature.
Optimising Contrast-Enhanced (CE) Magnetic Resonance Angiography (MRA) In Infants and Children.
Since the early 1990s CE MRA has become a widely used angiography technique. The clinical application of CE MRA in paediatrics has lagged behind that of the adult population. Imaging techniques need to be careful tailored to produce the required spatial resolution which is necessary to visualise proportionally smaller vascular structures whilst maintaining a high temporal resolution which is essential for rapid circulation rates.
To improve current CE MRA image technique, a review of previously performed examinations was undertaken to identify suboptimal studies. Follow up studies were performed with modified parameters and correct coil selection to improve spatial resolution, temporal resolution and signal to noise (SNR),. All imaging was performed on a Philips Intera 1.5 with Release 12 software upgrade and high performance gradients.
SNR was improved when using a compact 5 element phased array coil with a slice thickness of 2 mm, whilst good temporal resolution was achieved with combination of larger voxels and parallel imaging techniques. High spatial resolution was demonstrated with smaller voxels and slice thickness of 1.3 mm.
When imaging non anaesthetised patients a scanning protocol with reduced acquisition time is required to minimise breath holding.
CE MRA imaging can now be performed much more rapidly on faster MR systems with high performance gradients. Paediatric examinations require very specific parameter selection and access to a range of phased array coils. Using current techniques, CE MRA can be performed safely even in infants and children, yielding clinically relevant data.