Bedside Ultrasound for the Diagnosis of Abnormal Diaphragmatic Motion in Children After Heart Surgery.

OBJECTIVE: To assess the utility of bedside ultrasound combining B- and M-mode in the diagnosis of abnormal diaphragmatic motion in children after heart surgery. DESIGN: Prospective post hoc blinded comparison of ultrasound performed by two different intensivists and fluoroscopy results with electromyography. SETTING: Tertiary university hospital. SUBJECTS: Children with suspected abnormal diaphragmatic motion after heart surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Abnormal diaphragmatic motion was suspected in 26 children. Electromyography confirmed the diagnosis in 20 of 24 children (83.3%). The overall occurrence rate of abnormal diaphragmatic motion during the study period was 7.5%. Median patient age was 5 months (range, 16 d to 14 yr). Sensitivity and specificity of chest ultrasound performed at the bedside by the two intensivists (91% and 92% and 92% and 95%, respectively) were higher than those obtained by fluoroscopy (87% and 83%). Interobserver agreement (k) between both intensivists was 0.957 (95% CI, 0.87-100). CONCLUSIONS: Chest ultrasound performed by intensivists is a valid tool for the diagnosis of diaphragmatic paralysis, presenting greater sensitivity and specificity than fluoroscopy. Chest ultrasound should be routinely used after pediatric heart surgery given its reliability, reproducibility, availability, and safety.

[Optimization of radiological scoliosis assessment]. / Optimización del estudio radiológico de la escoliosis.

Most scoliosis are idiopathic (80%) and occur more frequently in adolescent girls. Plain radiography is the imaging method of choice, both for the initial study and follow-up studies but has the disadvantage of using ionizing radiation. The breasts are exposed to x-ray along these repeated examinations. The authors present a range of recommendations in order to optimize radiographic exam technique for both conventional and digital x-ray settings to prevent unnecessary patients' radiation exposure and to reduce the risk of breast cancer in patients with scoliosis. With analogue systems, leaded breast protectors should always be used, and with any radiographic equipment, analog or digital radiography, the examination should be performed in postero-anterior projection and optimized low-dose techniques. The ALARA (as low as reasonable achievable) rule should always be followed to achieve diagnostic quality images with the lowest feasible dose.

Optimización del estudio radiológico de la escoliosis / Optimization of radiological scoliosis assessment

La mayoría de las escoliosis son idiopáticas (80%) y ocurren más frecuentemente en adolescentes y en el sexo femenino. La radiografía simple es el método de imagen de elección, tanto en el estudio inicial como en el seguimiento evolutivo, pero tiene el inconveniente de utilizar radiaciones ionizantes. Las mamas quedan en el campo de exposición durante estos estudios repetidos. Los autores presentan una serie de recomendaciones para optimizar la técnica de las exploraciones y los equipos radiográficos, tanto analógicos como digitales, para evitar dosis de irradiación innecesarias a los pacientes y reducir el riesgo de cáncer de mama en los pacientes con escoliosis. Cuando se utilizan equipos analógicos siempre debe utilizarse protector mamario plomado y, en todos los equipos, sean analógicos o digitales, hay que realizar la radiografía en proyección posteroanterior y con técnicas optimizadas de baja dosis. Hay que seguir siempre el principio ALARA (as low as reasonable achievable) para obtener imágenes diagnósticas de calidad con la dosis lo más baja posible (AU)

Most scoliosis are idiopathic (80%) and occur more frequently in adolescent girls. Plain radiography is the imaging method of choice, both for the initial study and follow-up studies but has the disadvantage of using ionizing radiation. The breasts are exposed to x-ray along these repeated examinations. The authors present a range of recommendations in order to optimize radiographic exam technique for both conventional and digital x-ray settings to prevent unnecessary patients' radiation exposure and to reduce the risk of breast cancer in patients with scoliosis. With analogue systems, leaded breast protectors should always be used, and with any radiographic equipment, analog or digital radiography, the examination should be performed in postero-anterior projection and optimized low-dose techniques. The ALARA (as low as reasonable achievable) rule should always be followed to achieve diagnostic quality images with the lowest feasible dose (AU)

Tracheobronchomegaly following intrauterine tracheal occlusion for congenital diaphragmatic hernia.

BACKGROUND: Fetuses with severe congenital diaphragmatic hernia (CDH) and pulmonary hypoplasia may benefit from fetal endoluminal tracheal occlusion (FETO). Enlargement of the main bronchi and trachea appears to be a common complication of FETO. OBJECTIVE: To retrospectively evaluate the trachea and main bronchi of infants who underwent FETO for CDH and compare diameters with age-matched references. MATERIAL AND METHODS: Postnatal and follow-up chest radiographs were performed in seven children with unilateral CDH treated by FETO. Additional CT was performed in six of these (one neonate died before CT could be performed). Images were acquired from 3 days to 23 months of age. For each child, radiographs and CT images with optimal visualisation of the airways were selected for retrospective analysis. Tracheal and bronchial morphology was assessed by two experienced paediatric radiologists, and the diameters of these structures measured and compared with age-matched references. RESULTS: Mean diameters of the trachea and main bronchi were above the age-matched normal range in all patients, regardless of the side of the hernia or the degree of lung hypoplasia. CONCLUSION: Enlargement of the trachea and main bronchi appears following FETO and persists at least to the age of 5 years.

Correlation between US and MRI for prenatal lung volumetry in diaphragmatic hernia, and use of Doppler to identify the ipsilateral lung cap.

BACKGROUND: Pulmonary hypoplasia is a common cause of neonatal death. OBJECTIVE: To describe the correlation between relative fetal lung volume (RFLV) and lung-to-head ratio (LHR) in fetuses with unilateral diaphragmatic hernia. Additionally, to describe identification of the ipsilateral lung cap by power Doppler. MATERIALS AND METHODS: Single-institution study of consecutive fetuses with diaphragmatic hernia. LHR (by US) and RFLV (by MRI) were correlated in fetuses with and without an ipsilateral lung cap seen at MRI. In four, color/power Doppler was used to follow the pulmonary artery of the ipsilateral lung to identify the compressed cap. RESULTS: The study included 48 fetuses of 20-38 weeks' gestational age (mean, 26 weeks). Mean LHR was 1.52 (range, 0.6-3) in fetuses with a lung cap and 1.15 (range, 0.6-2.58) in fetuses without (P = 0.043). Mean RFLV was 47.4% (range, 18-80%) in fetuses with and 32.9% (range, 14-57%) in fetuses without a lung cap (P = 0.005). RFLV and LHR correlated (r = 0.41, P = 0.01 in those with a cap; r = 0.50, P = 0.05 in those without). Power Doppler identified the ipsilateral lung cap and pulsed Doppler confirmed pulmonary vascularization in four of four fetuses. CONCLUSION: LHR underestimates lung volume in fetuses with an ipsilateral lung cap. Power Doppler may be useful for identifying the cap.

White hemithorax in children.

The aim of this pictorial review is to introduce the radiologist to the differential diagnosis of a white hemithorax in children, to provide significant information on the diagnostic work-up, and to promote radiation-free techniques whenever possible. There are many causes of white hemithorax in children and it can be due to a variety of chest disorders. In most cases, plain chest radiographs and ultrasound will suffice. However, additional information provided by, e.g., CT or MRI is sometimes required.

Gray-scale and color Doppler sonography of scrotal disorders in children: an update.

Ultrasonography (US) is well suited to the study of pathologic conditions of the scrotum in children. US provides excellent anatomic detail; when color Doppler and power Doppler imaging are added, testicular perfusion can be assessed. Gray-scale, color Doppler, and power Doppler US were used to study a spectrum of scrotal disorders in 750 boys aged 1 day to 17 years. The entities studied included processus vaginalis-related disorders (cryptorchidism, inguinal-scrotal hernia, and hydrocele); varicocele; acute scrotum (epididymo-orchitis, torsion of the testicular appendages, and testicular torsion); scrotal tumors; testicular microlithiasis; scrotal trauma; and systemic diseases with scrotal involvement. When combined with the results of clinical and physical examination, the information obtained with US is sufficient to enable diagnosis in most cases of scrotal disease. Moreover, color Doppler imaging is essential for differentiation between processes such as epididymo-orchitis or torsion of the testicular appendages and testicular torsion, which have similar clinical manifestations (pain, swelling, and redness) but are managed differently.

Conservative versus surgical treatment for complex neonatal ovarian cysts: outcomes study.

OBJECTIVE: Prenatally diagnosed complex ovarian cysts are most often managed surgically in an attempt to save the ovary. Nevertheless, published surgical results disclose that most patients undergo oophorectomy or salpingo-oophorectomy. We assessed whether a surgical or conservative approach was more appropriate by comparing the long-term outcome of infants treated by both methods. A hypothesis for the cause of complex cysts is presented. CONCLUSION: Clinical evidence questions the use of surgery for asymptomatic complex ovarian cysts. Histologic analysis suggests gonad maldevelopment as the origin of complex neonatal ovarian cysts.

Posterior fontanelle sonography: an acoustic window into the neonatal brain.

BACKGROUND AND PURPOSE: Sonographic brain studies are classically performed through the anterior fontanelle, but visualization of posterior supratentorial and infratentorial structures is poor with this approach. Posterior fontanelle sonography is recommended for better assessment of these structures. Our purpose was 1) to determine whether sonography of the brain through the posterior fontanelle (PF) improves visualization of brain lesions when added to the routine anterior fontanelle (AF) approach and 2) to describe standardized PF coronal and sagittal sections. METHODS: In this prospective study (conducted from February 1999 to January 2001), PF sonography was added to AF sonography in 165 consecutive premature neonates with a birth weight of < 2000 g. Sonograms were recorded in digital format for re-evaluation at the end of the study. Lesions were grouped as congenital, infectious, hemorrhagic, or hypoxic-ischemic. The chi2 test for paired data and the kappa coefficient were used to compare diagnoses with AF alone and diagnoses with AF plus PF. RESULTS: PF sonography was performed in 164 of 165 patients. Results were normal in 86 and abnormal in 78. The single posterior fossa malformation detected in this series was best delineated with the PF approach. PF sonography increased the diagnostic rate of grade II hemorrhage by 32%. Cerebellar hemorrhage (two patients) and cerebellar abscesses (one patient) were diagnosed by using the PF approach. PF sonography did not contribute to the diagnosis of periventricular leukomalacia. CONCLUSION: Study of the neonatal brain with the addition of PF sonography afforded greater accuracy in detecting intraventricular hemorrhage compared with AF sonography alone, especially when the ventricle was not dilated. The PF approach better defines posterior fossa malformations.

Second malignancies in pediatric patients: imaging findings and differential diagnosis.

Therapeutic advances in the treatment of pediatric neoplasms have improved the prognosis but have also increased the risk of developing rare second malignant neoplasms (SMNs). Primary neoplasms that are often associated with SMNs include lymphoma, retinoblastoma, medulloblastoma, neuroblastoma, and leukemia. The most common SMNs are central nervous system (CNS) tumors, sarcomas, thyroid and parotid gland carcinomas, and leukemia, particularly acute myeloblastic leukemia. Genetic predisposition, chemotherapy, and especially radiation therapy are implicated as pathogenic factors in SMN. All survivors of childhood cancer should have lifelong follow-up, preferably with magnetic resonance imaging, which does not require ionizing radiation and provides greater anatomic detail and resolution in the head and neck region and the CNS. A new or progressive lesion may represent recurrence of the primitive neoplastic process, late radiation injury, or, more infrequently, an SMN. Differential diagnosis can be very difficult, and outcome is often fatal. Treatment protocols should be modified to reduce the risk for SMN without compromising the effectiveness of initial therapy. Clinicians should individualize treatment for patients who are genetically predisposed to SMN. In addition, radiologists should be familiar with the long-term consequences of antineoplastic therapy to facilitate diagnosis and anticipate adverse outcomes.