Spectrum, Applicability and Diagnostic Capacity of Contrast-Enhanced Ultrasound in Pediatric Patients and Young Adults after Intravenous Application - A Retrospective Trial

Purpose: To investigate the spectrum, applicability and diagnostic capacity of intravenous contrast-enhanced ultrasound imaging (CEUS) in a pediatric population. Materials and Methods: From 08/2005 to 11/2015, n = 40 pediatric patients and young adults from 0 - 26 years (Ø 11.4 ± 7.5) and 3.0 - 85.3 kg (Ø 40.8 ± 25.6) with n = 55 investigations received n = 79 IV applications of ultrasound contrast agent (UCA). UCA dose and side effects were documented. Scanned organs were the liver (n = 42), spleen (n = 9), kidney (n = 3), and testis (n = 1). Histology, surgery or reference imaging was compared to CEUS and clinical follow-up. Results: The UCA dose < 20 kg was 0.4 ± 0.3 ml, (0.05 ± 0.02 ml/kg) and > 20 kg was 1.0 ± 0.4 ml (p< 0.0001) (0.02 ± 0.01 ml/kg, p< 0.0001). Adverse effects occurred in 2/79 applications (2.5 %). Agreement CEUS/gold standard resulted in 32/34 investigations. For liver diagnostics (gold standard: MRI, CT, histology, serology), n = 11 malignant and n = 15 benign focal liver lesions were included. The specificity was 100 % (95 % CI: 0.77 - 1.00), the sensitivity was 82 % (95 % CI: 0.48 - 0.98), the positive predictive value was 100 % (95 % CI: 0.69 - 1.00) and the negative predictive value was 88 % (95 % CI: 0.62 - 0.98, p< 0.0001). In n = 2 reference imaging misdiagnosed and CEUS was in accordance with clinical follow-up. All splenic/renal lesions were diagnosed correctly. In n = 1 an insufficient testicular perfusion was ruled out. The observation time was 30.4 ± 30.5 months. Conclusion: CEUS is a well-tolerated and diagnostically equivalent modality in pediatric care, providing fundamental advantages compared to currently approved imaging modalities for these age groups.

[Partial homonymous hemianopia of traumatic origin after riding a high-speed amusement ride]

Amusement park injuries have become more common in recent years. Especially neurological symptoms dominate clinical findings. In this article, the case of a 15-year-old child with homonymous hemianopia due to an atypical intracranial bleeding with subdural hematoma after a giant swing ride is described for the first time.

Application of Dual-Source-Computed Tomography in Pediatric Cardiology in Children Within the First Year of Life

PURPOSE

To assess fields of application and value of dual source computed tomography (DSCT) for diagnostics and therapy in patients with congenital heart disease during their first year of life. Evaluation of image quality, surgical use and radiation exposure of 2nd and 3 rd generation DSCT.

MATERIALS AND METHODS

DSCT was applied in 118 cases between January 2012 and October 2014 for diagnostics of congenital heart defects. 2nd generation was used in 91 cases until April 2014 and 3 rd generation in 27 cases during the period thereafter. 3 D reconstructions of the image data were created for clinical diagnostics and planning of interventions. Image quality was assessed using a 4-point-scale. The visibility of the mammary arteries was analyzed, and signal-to-noise-ratio (SNR) and contrast-to-noise-ratio (CNR) were calculated. The usefulness of 3D-reconstructions for surgical planning was rated using a 5-point-scale. Radiation exposure and contrast dye consumption were determined. All cases were analyzed retrospectively.

RESULTS

DSCT was successfully used in 118 cases. All image data obtained were interpretable. More than 60 percent of cases did not show any artifacts. The mammary arteries were visible down to the diaphragmatic arch in more than 80 percent of cases. Diagnostic value and surgical benefit were evaluated as "useful" or as "essential" in all cases. Median radiation dose was 0.4 mSv and 0.27 mSv for the 2nd and 3 rd generation DSCT, respectively. Consumption of contrast dye was 2 ml/kg in all cases.

CONCLUSION

DSCT is a modern and extremely helpful technique for diagnostics and planning of interventions in patients with complex congenital heart defects. Extracardiac vascular structures in particular can be depicted three-dimensionally at high resolution. The use of iterative reconstruction with 3 rd generation DSCT yielded image quality similar to that of 2nd generation DSCT at considerably reduced radiation exposure level compared to 2nd generation DSCT. 3 rd generation DSCT is a low risk, accurate and extremely fast technique for diagnosing unstable patients with CHD.

KEY POINTS

Expanded scope of indications for DSCT in diagnosing critically ill infants. Effective radiation dose is considerably lower than 0.5 mSv. Extremely rapid image acquisitions with high image quality. Possibility of optimized 3D-based surgical planning

Cardiac MRI in Children and Adolescents Who Have Undergone Surgical Repair of Right-Sided Congenital Heart Disease: Automated Left Ventricular Volumes and Function Analysis and Effects of Different Manual Adjustments

PURPOSE

To evaluate automated segmentation and the effects of different manual adjustments regarding left ventricular parameter quantification in cardiac magnetic resonance (MR) data on children and adolescents who have undergone surgical repair of right-sided congenital heart disease (CHD).

MATERIALS AND METHODS

Dedicated software (syngo.via, Siemens AG) was used to automatically segment and/or manually adjust the end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), myocardial mass (MM) and ejection fraction (EF) before/after manual apex/base adjustment (ADJ-step 1) and after manual apex/base/myocardial contour adjustment (ADJ-step 2; reference standard). MR data of 40 patients (13.1 ± 3. y, 4 - 17 y) with repaired CHD with decreased pulmonary blood flow (CHD-DPBF) were evaluated. Intra- and inter-rater reliability was determined for 10 randomly selected patients.

RESULTS

The software correctly detected the left ventricle in 38/40 (95%) patients. EDV after automated segmentation: 119.1 ± 44.0 ml; after ADJ-step 1: 115.8 ± 9.5 ml; after ADJ-step 2: 116.2 ± 39.4 ml. The corresponding results for ESV were 52.0 ± 18.5/49.6 ± 6.9/49.7 ± 16.4 ml; for SV 67.1 ± 28.5/66.2 ± 25.4/66.5 ± 25. ml; for EF 55.5 ± 7.3/56.7 ± 6.6/56.7 ± 6.3%; for MM 83.7 ± 35.9/76.2 ± 8.3/74.6 ± 27.2 g. Significant differences were found for ESV/MM/EF comparing the automated segmentation results with these after ADJ-step 1 and ADJ-step 2. No significant differences were found when comparing all results of ADJ-step 1 and ADJ-step 2 or when comparing EDV/SV results. Intra- and inter-rater reliability was excellent. The mean time effort was 63.4 ± 6.9 s for the automated segmentation, 74.2 ± 8.9 s for ADJ-step 1 and 269.5 ± 39.4 s for ADJ-step 2.

CONCLUSION

Automated left ventricular volumes and function analysis in children and adolescents with surgically treated CHD proved to be feasible with excellent intra- and inter-rater reliability. Automated segmentation with manual apex/base adjustment provided clinically acceptable results.

KEY POINTS

Automated left ventricular volume and function analysis in children and adolescents with surgically treated right-sided heart disease is feasible with excellent intra- and inter-rater reliability. Automated segmentation with manual apex/base adjustment provides clinically acceptable results. Additional manual myocardial contour adjustment does not significantly improve the results.

Risk of cancer incidence before the age of 15 years after exposure to ionising radiation from computed tomography: results from a German cohort study

The aim of this cohort study was to assess the risk of developing cancer, specifically leukaemia, tumours of the central nervous system and lymphoma, before the age of 15 years in children previously exposed to computed tomography (CT) in Germany. Data for children with at least one CT between 1980 and 2010 were abstracted from 20 hospitals. Cancer cases occurring between 1980 and 2010 were identified by stochastic linkage with the German Childhood Cancer Registry (GCCR). For all cases and a sample of non-cases, radiology reports were reviewed to assess the underlying medical conditions at time of the CT. Cases were only included if diagnosis occurred at least 2 years after the first CT and no signs of cancer were recorded in the radiology reports. Standardised incidence ratios (SIR) using incidence rates from the general population were estimated. The cohort included information on 71,073 CT examinations in 44,584 children contributing 161,407 person-years at risk with 46 cases initially identified through linkage with the GCCR. Seven cases had to be excluded due to signs possibly suggestive of cancer at the time of first CT. Overall, more cancer cases were observed (O) than expected (E), but this was mainly driven by unexpected and possibly biased results for lymphomas. For leukaemia, the SIR (SIR = O/E) was 1.72 (95 % CI 0.89-3.01, O = 12), and for CNS tumours, the SIR was 1.35 (95 % CI 0.54-2.78, O = 7). Despite careful examination of the medical information, confounding by indication or reverse causation cannot be ruled out completely and may explain parts of the excess. Furthermore, the CT exposure may have been underestimated as only data from the participating clinics were available. This should be taken into account when interpreting risk estimates.

[Diagnosis of appendicitis using harmonic ultrasound imaging]

INTRODUCTION

Harmonic Imaging (HI) is a new Ultrasound (US) modality with high contrast and spatial resolution. Aim of this study was to compare fundamental imaging (FI) and HI in the diagnosis of appendicitis.

PATIENTS AND METHODS

In 50 children (male : female, 25 : 25; mean age: 9.9 years) prior to an appendectomy US of the right lower quadrant was performed in both FI and HI (Tissue Harmonic Imaging - THI - Sonoline Elegra, Siemens, 7.5 MHz linear). The images were compared with respect to delineation of surrounding, contour, wall and content of the appendix.

RESULTS

In 43 / 50 (86 %) patients diagnosis of appendicitis was confirmed histologically (sensitivity 98 %, specificity 94 %). In 37 / 43 patients the appendix was depicted using FI. With HI this number was 40 / 43. HI was significantly better in delineating the contour, wall, mucosa and content of the appendix (p < 0.01). HI also exceeded in demonstrating free fluid, mesenterial lymph nodes and surrounding echogenicity.

CONCLUSION

HI of appendicitis provides images with significantly better quality than FI. When both imaging options are available harmonic imaging modality should be the preferred choice for scanning the appendix.

[Color-coded duplex sonography (angiodynography) in comparison with phlebography]

To verify the suspected diagnosis of deep thrombosis in the pelvic and/or the leg veins or to clarify the causes of pulmonary embolism, 84 patients were examined prospectively by color-coded duplex-sonography. The findings in the 103 legs examined were subsequently compared to those of an ascending phlebography. The deep veins from the region of the vena iliaca communis down to the lower leg were visualized, and blood flow, lumen and compressibility were checked. This procedure enabled the identification of totally occluding thrombi as well as partial thrombi with the circumfluent blood. The sensitivity of thrombus identification was 92.9%, the specificity was about 97% in the different segments. The results show that color-coded duplex sonography is a sensitive diagnostic instrument for follow-up in conservative therapy. Also, in postthrombotic changes, fresh clots can be identified for the most part. Color-coded duplex sonography can replace phlebography in most cases, if special attention is paid to regions which are difficult to visualize, such as the pelvic veins, the Hunter's channel and the veins of the lower leg.

Indications and results after Strecker-stent-application in iliac and SFA

We report on a study which has been performed during two consecutive time intervals on patients with complicated arterial obliterations, who were treated with percutaneous endoprostheses in order to stabilize the results obtained by the preceding balloon angioplasty. Eighty patients participated at this study, and 136 stents were implanted. A detailed analysis of the reocclusions respectively the stenoses shows that the precise placement of the stents and also the length of the stent in relation to the lesion is of utmost importance, in order to avoid reocclusions. The Strecker stents were lege artis placed in both time groups, and the increased occurrence of reocclusions, especially in the femoropopliteal region, was mainly due to the fact that only one stent length was available. Restenoses in the second group are, thus, considerably lower between 6 and 12 months, as the use of an adequate stent length was possible by then. The medical supplementary treatment of lege artis placed stents in the iliac arteries has no additional influence on the patency rate, while the medication with anticoagulants seems to have a rather positive effect on the patency rate in the femoro-popliteal region. The results, which have been obtained up to now, show that definite improvements are to be achieved by the use of stents, provided that their indication is being handled with utmost care.