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 Bibliografische Information der Deutschen Bibliothek The Deutsche Bibliothek lists this publication in Deutsche Nationalbibliographie; detailed bibliographic data is available in the internet at http://dnb.ddb.de. This work is subject to copyright. 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Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. SPIN 11770107 Typesetting: TypoStudio Tobias Schaedla, Heidelberg Printing: Grosch! Druckzentrum GmbH, Heidelberg 18/5135 – 5 4 3 2 1 0 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