0:02

Hello and welcome to Noon Conference hosted by MRI Online

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Noon Conference connects the global radiology community

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to learn alongside top radiologists from around the world.

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and previous noon conferences

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by creating a free MRI online account today.

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We are so honored to welcome Dr. Grace Mitchell back

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to the noon conference stage

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for a lecture entitled Pediatric Ultrasound Cases

0:31

Vascular Anomalies.

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Dr. Mitchell is a pediatric radiologist at Children's Mercy

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Hospital and an associate professor of radiology at MKC.

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She earned her M-D-M-B-A from Tufts University,

0:43

completed an internal medicine internship at Kearney

0:46

Hospital and a diagnostic radiology residency at

0:49

Baystate Medical Center.

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She further specialized

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with a fellowship in pediatric radiology at Cincinnati

0:55

Children's Hospital Medical Center in 2015.

0:58

Passionate about radiology education.

1:00

Dr. Mitchell also serves as the associate program director

1:03

for the UMKC diagnostic radiology residency

1:07

and the site director

1:08

for all diagnostic radiology residency rotations at

1:11

Children's Mercy Hospital.

1:13

At the end of the lecture, please join her in a q

1:15

and A session where she will address questions you may

1:18

have on today's topic.

1:19

Please remember to use that q

1:21

and a feature to submit your questions so we can get to

1:23

as many as we can before our time is up.

1:25

With that, we are ready to begin today's lecture.

1:28

Dr. Mitchell, please take it from here.

1:31

We are gonna be talking about pediatric ultrasound cases

1:33

today we're gonna focus primarily in the first part on

1:37

vascular anomalies and then I have a pokey

1:39

of additional cases pertinent to pediatric imaging

1:42

that I hope you will find useful.

1:44

I have no financial disclosures.

1:48

And as a more detailed overview, like I mentioned,

1:50

we're gonna review vascular anomalies

1:52

and in particular discuss the differences between vascular

1:56

tumors and vascular malformations.

1:59

We'll touch upon a newer topic in pediatric imaging,

2:02

which is contrast enhanced ultrasound.

2:05

We'll also talk about ultrasound

2:07

and its use with malrotation

2:08

and makeup ulu in pediatric patients.

2:12

And then a couple of miscellaneous topics that I have found,

2:15

excuse me, when working with my trainees

2:18

that sometimes are a little bit elusive to them, including

2:20

what the pre pubertal uterus looks like on ultrasound

2:23

and then also neonatal spine.

2:30

As a quick introduction

2:31

before we get into our cases, I wanna make you aware

2:33

of a society, if you are not already aware,

2:36

called the I-S-S-V-A, the International Society

2:40

for the Study of Vascular Anomalies.

2:42

And you can go online to their website

2:43

and find this document.

2:45

But what I really wanna highlight is the main

2:48

category categorization system of vascular anomalies.

2:52

So what they do is they, uh, categorize the whole of

2:57

vascular anomalies into two main subcategories,

3:02

vascular tumors and vascular malformations.

3:05

And the reason I point this out is you'll see as we go

3:08

through the cases is that broadly speaking,

3:10

all the vascular anomalies that we see can fit into one

3:13

of these two categories, but it can sometimes be a little

3:15

bit confusing how to categorize them, particularly

3:18

because older nomenclature sort

3:21

of misrepresented some of them.

3:24

So you don't really need to read the rest of this chart.

3:26

All I want you to get out from this slide is

3:27

that we have tumors and we have malformations, uh,

3:31

in another portion of this same document.

3:32

Again, you don't need to read this whole side,

3:34

but I just want to highlight a couple

3:36

things that we'll talk about today.

3:38

And within the vascular tumor category,

3:41

you wanna keep in mind the entities infantile hemangioma

3:45

and congenital hemangioma

3:47

and just know those two entities in the back of your mind

3:50

and we'll go through some more details a little later.

3:52

And then the one other thing I wanna make you aware

3:55

of is a diagnosis called kapoof formm heman endothelial.

3:58

And this is a more aggressive tumor in childhood.

4:01

Again, just keep it in the back of your mind

4:04

and know those for future reference.

4:07

All right, let's get right into our cases.

4:09

This is case number one.

4:11

So we have an ultrasound with a gray scale image on the left

4:15

and a color doppler image on the right.

4:17

And this is on the cheek of a young child.

4:19

This is actually um, a baby a nine month old.

4:21

And you can see that we've got this non-specific

4:23

heterogeneous lobular mass.

4:25

It's got a little bit difficult to see some of the margins,

4:27

but that might just be the angle where we are.

4:30

But what's really important here is

4:32

that you can see on the color image

4:33

that there's just diffuse vascularity,

4:35

very dense vascularity often described

4:38

as a Christmas tree light appearance.

4:41

And when uh, waveforms were sampled,

4:44

which I don't have shown here,

4:45

these showed arterial waveforms.

4:48

Oh, I do have it shown here actually.

4:50

So you can see some arterial waveforms within this mass.

4:54

So this is a classic appearance for an infantile hemangioma.

4:58

What's really important to know

5:00

and history is key with these cases is

5:02

that this is not present at birth.

5:04

So when the baby is born, this lesion is not present

5:08

previously termed the capillary or strawberry hemangioma.

5:11

We now refer to it as the infantile hemangioma.

5:14

It can have deeper extension and that,

5:16

and that is why sometimes they come to us for imaging.

5:19

Usually when cutaneous lesions are found,

5:21

especially if they are multiple,

5:23

they might end up being seen by pediatric dermatology

5:26

and if they order imaging it's

5:27

because they wanna evaluate for any deeper extension.

5:32

And this follows a really predictable pattern.

5:34

There is a proliferative phase

5:36

that's rapid usually over the span of weeks

5:38

and these can get quite large.

5:40

And then there's an eventual evolution phase,

5:42

which is spontaneous, uh, with fatty replacement.

5:45

And this can take months to years.

5:48

During the proliferative phase, as we saw with our case,

5:51

there's high VE vessel density

5:53

with this Christmas tree light appearance on color doppler.

5:59

When you sample these,

6:00

you can see low resistance arterial waveforms

6:02

and you don't see AV shunting.

6:05

The evolution phase usually starts somewhere

6:07

around 12 months of age

6:09

and you, as you would expect,

6:11

there's decreased vessel density,

6:13

increased arterial resistance of the waveform

6:16

and just less of this bright color that we see

6:18

during the proliferative phase.

6:21

These do not need to be treated necessarily if they're

6:24

small, but if there's any vital compromise

6:26

or skin ulceration, they can be treated.

6:28

Patients can be placed on a beta blocker, but

6:30

otherwise they will fa follow their natural

6:32

natural evolution.

6:36

Here's a companion case

6:37

of another Hema infantile hemangioma.

6:39

This did not have the typical cutaneous findings.

6:42

So the dermatologist sent the the baby to us.

6:45

You can see that there's a sort of bluish discoloration

6:47

of the upper arm on this baby where the arrow is.

6:50

So we got ultrasound images

6:52

and these initial gray scale images show a non-specific

6:55

heterogeneous but predominantly echogenic mass we see in

6:59

trans and long planes with some more hypo coic components.

7:04

When we put color doppler on, we see high vessel density,

7:07

again, that Christmas tree light appearance

7:10

with arterial waveforms and these were higher resistance.

7:15

This is a different kid, another companion case

7:17

of an infantile hemangioma.

7:19

This baby actually underwent an MRI in when it was first

7:22

diagnosed and you can see on the T two fat saturated image

7:25

this lobular large cheek mass

7:27

that's predominantly T two hyperintense.

7:29

On the dynamic contrast imaging, we can see

7:31

that we're in the arterial phase

7:33

and we see some early arterial enhancement.

7:35

And on the post contrast fat saturated image, we see

7:37

that there is diffuse enhancement as well

7:39

as some prominent flow voids.

7:41

This baby went on to get an ultrasound later.

7:44

Um, the MRI was done in about six months of age

7:47

and then a few years later they got a follow-up ultrasound.

7:50

And you can see what's left is this sort

7:52

of ill-defined heterogeneous solid appearing mass

7:56

that still got some uh, color doppler,

7:58

but we see higher higher resistance arterial waveforms.

8:02

And this was a pathology proven infantile hemangioma.

8:07

All right, next case.

8:10

This is a gray scale cine of the upper abdomen

8:13

through the liver and you can see that there are multiple

8:18

hypoechoic lesions scattered throughout the liver.

8:20

Here's one over here.

8:21

There was a larger one up here and we see multiple of them.

8:26

Some representative color Doppler images show

8:31

that we have diffuse vascularity within them

8:36

and this was true of all of them.

8:39

And so this is a case

8:40

of the same entity infantile hemangioma,

8:43

but within the liver these babies oftentimes have cutaneous

8:48

hemangiomas and so the dermatologists will also send them

8:51

to us for screening evaluation of their liver.

8:54

And we look for hepatic hemangiomas there.

8:57

Usually if they have the infantile type, he angio

8:59

and if they have liver lesions, they're typically multiple

9:02

and they're usually small to medium in size.

9:05

If they uh, diffusely replace the liver, uh,

9:09

that's another subtype and it could cause enlargement

9:11

and again, diffuse replacement.

9:14

Typically when you have more discreet lesions, they're round

9:17

and well-defined frequently hypo coic initially,

9:20

but definitely variable appearance particularly

9:23

during the InMotion stage.

9:25

And similar with vascularity, it really depends on

9:27

what stage, whether proliferative or involuting.

9:32

If you happen to do contrast enhanced ultrasound,

9:35

which we'll talk about later in the talk, you're gonna look

9:37

for early arterial hyper enhancement portal ISO enhancement.

9:41

And there's variable washout again,

9:42

depending on the stage of the lesion.

9:46

This is a companion case and this one was interesting

9:48

because it turned out to be an infantile hemangioma

9:51

but it's larger and it's solid.

9:53

So I mentioned that for the infantile type more typically

9:55

they're multiple, but this one happened to be solid.

9:58

This was uh, an infant, a five week old

10:00

that had multiple cutaneous um, infantile hemangiomas

10:05

and they actually had a screening ultrasound at 10 days old

10:08

that was normal and then ultimately had a follow-up

10:10

ultrasound that showed this lesion.

10:12

So consistent with the infantile type where they're not born

10:14

with the lesion, then this baby went on

10:17

to have follow-up ultrasounds

10:19

and we can see sometime later that this is what was left

10:22

of the lesion with sort of um, echogenic more linear kind

10:26

of scarring with with no more internal vascularity.

10:30

And this is even later, a few years later where

10:32

that's gotten even smaller and there's

10:34

no internal vascularity.

10:35

The typical of the infantile hemangioma

10:39

here is a different case.

10:41

This is another CNA clip

10:42

where we're gonna show gray scale on the left

10:44

and color doppler on the right.

10:45

Oops. And

10:49

what we see here is this heterogeneous lesion posteriorly

10:53

with mixed hyper coic and hypoechoic components.

10:57

We can see on the color doppler that there doesn't seem

11:00

to be a whole lot of internal enhancement.

11:02

It seems to be predominantly peripheral and maybe septal.

11:06

This was actually an incidental finding in a baby

11:08

that had an ultrasound for a different reason

11:12

and they got a follow up ultrasound a year and a half later.

11:14

And you can see this is what's left of the lesion.

11:16

It's much smaller and there isn't really any associated

11:19

uh, vascularity anymore.

11:21

Now this baby actually did get interval workup.

11:24

They didn't just have these two ultrasounds.

11:26

So just for comparison, I'll show you that at two weeks old

11:28

after that initial ultrasound, they got a CT scan.

11:31

And you can see here on this contrast enhanced axial CT

11:34

image that we've got this large lobular lesion

11:36

that has predominantly peripheral enhancement.

11:39

They also underwent an MRI.

11:40

So you can see on this T two image that it's heterogeneous

11:43

but predominantly hyper uh, intense.

11:46

And they also got post contrast imaging which pretty much

11:48

mirrors that of the CT scan

11:50

with this peripheral enhancement.

11:52

And we can see here we're in the arterial

11:53

phase like we saw before.

11:57

And so this was a congenital hemangioma also in the liver.

12:01

And just like in anywhere else in the body,

12:04

this is gonna be present perinatally,

12:06

but um, as opposed to the infantile hemangiomas

12:09

that are not present when they're born.

12:11

So these are perinatal,

12:13

they do not proliferate beyond birth.

12:15

So that's a major difference between this

12:17

and the infantile hemangioma where

12:20

as we mentioned in the infantile hemangioma you have this

12:22

predictable proliferation phase

12:24

and then involution phase,

12:26

these congenital hemangiomas instead are defined by how

12:30

and whether or not they involute.

12:32

The most common is what's called the rich, which stands

12:35

for rapidly involuting congenital hemangioma.

12:38

And this is the most common particularly in the liver.

12:41

And these usually completely involute

12:43

by a little over a year in age.

12:45

The others are less common.

12:47

The niche which is non involuting

12:49

and the pitch be partially involuting congenital

12:52

hemangiomas, unlike the infantile he

12:57

hemangiomas that are most typically multiple in the liver,

13:00

the congenital hemangiomas in the liver are commonly

13:02

solitary and large.

13:04

As we saw in this most recent case.

13:06

They may present with a mild transient consumptive

13:09

coagulopathy depending on how big they are.

13:12

And on imaging on ultrasound,

13:14

they can be quite heterogeneous as we saw in our case.

13:17

But typically they have peripheral vascularity

13:20

and little to no central vascularity,

13:22

which makes it quite different from the

13:24

infantile hemangioma.

13:25

In the proliferative phase there may

13:27

or may not be associated calcifications,

13:29

which you can see on imaging as well.

13:32

And in these kids, if you were

13:33

to do contrast enhanced ultrasound, you would expect

13:35

that early arterial hyper enhancement peripherally

13:38

with portal hyper enhancement maintaining and no washout.

13:45

And so here's a companion case.

13:47

This is a CA with contrast enhanced ultrasound.

13:50

Again, we'll talk about this later,

13:51

but this is the re regular gray scale cine

13:54

and this is contrast enhanced ultrasound.

13:56

And so we can see background liver here

13:58

and the lesion is actually here, which is really hard

14:00

to tell on the gray scale alone.

14:02

But once we give contrast, you can see immediately you have

14:05

that peripheral enhancement of the lesion um,

14:08

that persists over time

14:10

and on later imaging as you go

14:12

through there's no real washout.

14:16

And so this happened to be a newborn, um,

14:18

with cutaneous hemangiomas

14:19

and ended up getting this ultrasound.

14:23

So as a review of everything we just talked about,

14:26

when you're thinking about angios in kids, you really need

14:28

to understand the difference between

14:30

infantile and congenital.

14:31

Infantile in general is more common

14:35

and is defined by not being present at birth,

14:38

whereas the congenital is perinatal.

14:41

Infantile has a predictable proliferative phase followed

14:44

by an evolution phase, whereas congenital is defined by

14:48

its evolution if at all, with the most common being rapid.

14:53

And then if you have hepatic lesions in addition

14:55

to cutaneous lesions, typically with the infantile,

14:58

they're multiple and typically with the congenital,

15:00

they'll they're solitary.

15:03

And if you have the hepatic lesions in infantile

15:06

hemangiomatosis, you would expect

15:08

to see cutaneous lesions in the vast majority of patients.

15:11

Whereas with the congenital,

15:13

although they are associated with cutaneous lesions,

15:15

is not nearly as common

15:21

some things to be aware of.

15:22

So depending on the patient

15:24

and what the lesions look like,

15:26

you might have a differential if you're not totally sure if

15:28

you're looking at a heman genoma for example,

15:30

could it be some sort of metastatic disease

15:33

with neuroblastoma being more common in this

15:35

or being possible in this age group?

15:38

Although usually you're not gonna diagnose neuroblastoma

15:40

by the liver mets initially,

15:41

you're usually gonna have something else

15:43

that's gonna lead you to that diagnosis.

15:45

Hepatoblastoma is the most common malignant liver tumor in

15:49

patients in this age group but

15:51

or in young children I should say.

15:53

But it's uncommon in newborns

15:55

and if you were to draw an A FP,

15:57

it would be elevated in hepatoblastoma

15:59

and it would not be with hepatic angios.

16:03

Mesenchymal hematoma is another possibility.

16:05

It can have a wide variety

16:06

of appearances ranging from completely cystic

16:09

to completely solid appearing.

16:11

Uh, it is an uncommon tumor

16:13

so I wouldn't put it at the top of my list.

16:15

Um, and you might see growth with that.

16:17

Uh, that might help differentiate between a hemangioma

16:22

probably not gonna be on the same differential all

16:23

that often, but it's something to

16:24

have in the back of your mind.

16:28

A couple more things that are important to note.

16:31

So we just talked about all the things that we look

16:34

for in hepatic angios.

16:37

What is really important is I did not say

16:41

anything about the typical cavernous he angios that many

16:45

of us learn about uh, in our training.

16:47

So in young adult

16:50

or adult patients, frequently we find lesions on imaging

16:53

that have a typical appearance including a flash

16:56

filling enhancement.

16:57

If it's small or if it's larger.

17:00

We have this typical phrase

17:01

that we use nodular discontinuous, centripetal enhancement.

17:05

And those are in fact not hemangiomas.

17:08

We call 'em mo hemangiomas all the time.

17:10

And the literature is rife with articles

17:13

and textbooks that call these hemangiomas

17:15

and even say that they are benign tumors.

17:18

But it turns out, um, under pathologic investigation

17:21

by the pathologists under the microscope,

17:23

those lesions are in fact not hemangiomas.

17:26

Those are venous malformations.

17:29

So they're in the complete other category within the

17:32

I-S-S-V-A vascular anomalies.

17:34

They're not tumors at all, they're malformations.

17:37

And I think this is really important to know

17:39

because as pediatric radiologists we're usually quite aware

17:42

of this because we have those other infantile

17:43

and congenital hemangiomas that we diagnose.

17:46

Um, and we really wanna work to change the working lexicon

17:49

of radiologists including adult radiologists.

17:52

So I would beseech you as you go forward in your practice,

17:55

not to call those adult liver lesions with

17:59

that typical imaging appearance hemangiomas,

18:01

but rather call them venous malformations.

18:04

This is also true for these guys.

18:06

So even though this is not in the liver,

18:07

this is a vertebral body.

18:09

We have these really typical cent lesions on CT

18:11

that we also see on MR sometimes

18:13

and they're frequently called vertebral hemangiomas.

18:16

These are not hemangiomas,

18:18

these are also venous malformations.

18:20

And so if I see either of these types of lesions on any

18:22

of my patients, what I will do in the impression

18:25

of my report is say, uh, hepatic venous malformation

18:30

parentheses previously termed cavernous

18:32

angio and parentheses.

18:34

And that way people reading my report who might not be aware

18:37

of this new lexicon will understand what I'm talking about.

18:40

But going forward we can use the correct terminology.

18:44

Other things that are not omas

18:46

that sometimes get called omas, meaning other things

18:49

that are not in fact tumors, vascular tumors

18:52

that get called tumors, uh,

18:54

we already mentioned the hepatic angio

18:56

but also venous angios.

18:58

What you really mean if you say

18:59

that is a venous malformation.

19:01

And so that's the term we should be using.

19:03

Similarly, lymph angios are really lymphatic malformations

19:07

and that is the term we should be using there.

19:09

So hopefully that made sense.

19:12

We'll move on to our next case.

19:15

This is an ultrasound of of the third digit of a child

19:19

and we can see that our tech has labeled the

19:21

proximal interphalangeal joint here.

19:22

So this is a long image. This is the proximal phalanx,

19:25

this is the middle phalanx.

19:27

We don't see the distal phalanx

19:28

and we see this just sort

19:29

of non-specific soft tissue thickening dorsally,

19:32

but we've got quite a bit of vascularity

19:34

with arterial waveforms.

19:36

And this patient also had a radiograph

19:39

and we can see that there's this diffuse soft tissue

19:40

thickening corresponding to all of this over here.

19:44

And then importantly we can see that there is erosion of

19:47

that distal phalanx.

19:49

And so this turned out to be a capor Heman endothelial

19:53

and I include this because this is a much more aggressive,

19:56

usually locally invasive tumor.

19:58

It can be heterogeneous, it can be quite infiltrative,

20:01

it can be vascular, it can be variable in its vascularity.

20:05

And this is a tumor of infancy.

20:07

So it's something to put in the back

20:08

of your mind if you're um, getting an ultrasound of a sort

20:11

of non-specific vascular thing

20:13

but has aggressive features, usually it's cutaneous, um,

20:17

can be trans spatial within the soft tissues.

20:20

Interestingly, visceral and osseous involvement is uncommon

20:24

even though in this patient I showed you OSUs involvement,

20:26

but I did show it to you

20:27

because I wanted to demonstrate

20:29

how this is clearly more aggressive

20:30

because it's causing erosion of that bone.

20:33

It's also very important to be aware

20:35

that this entity can be associated

20:37

with cassock merit syndrome and that's obviously important

20:40

because that can be fatal.

20:42

Unlike the congenital hemangiomas that can be associated

20:45

with a mild transient consumptive coagulopathy,

20:49

they should not be associated with Casa Mart, whereas these,

20:52

the Capor hagio endothelial list can.

20:56

Here's a companion case of a different kid.

20:58

This was a nine week old baby that presented

21:00

with abdominal distension.

21:01

They got an abdominal ultrasound

21:03

and immediately they saw a lot of free fluid in the abdomen.

21:06

This was tapped and found to be frank Hemoperitoneum.

21:10

And what I wanna draw your attention to, that's sort

21:12

of subtle, but notice that there's this non-specific kind

21:16

of heterogeneous soft tissue

21:18

that's uplifting this kidney, the right kidney.

21:21

And so this patient went on to have a contrast enhanced ct.

21:24

We can see this axial image showing free fluid,

21:27

which was the hemoperitoneum.

21:29

And then we see this heterogeneously

21:31

enhancing soft tissue mass.

21:32

It's pushing up that kidney sort

21:34

of indistinct from the uh, abdominal wall.

21:37

And you can see some abnormal enhancement extending along

21:39

the abdominal wall anteriorly.

21:41

And so this was found to be a compost formm.

21:43

He angioli and this patient did have casa backer syndrome.

21:48

Alright, next case. So here's a gray scale image.

21:53

Uh, the soft tissues of the leg of a teenager.

21:56

So there's a 13-year-old

21:58

and we can see multiple koic cystic spaces.

22:03

And then we got doppler imaging that shows diffuse

22:07

vascularity with arterial waveforms.

22:10

What's important here is

22:11

that this patient also has associated pulsatile puls

22:15

fity with this mass.

22:18

Uh, what I don't show here is that there's also

22:20

venous waveforms in this mass in addition

22:22

to the arterial waveforms.

22:24

And this is a very typical appearance

22:26

of an arterial venous malformation.

22:28

This same patient underwent an MRI

22:32

and here you can see sagittal and coronal dynamic images.

22:36

So here's anterior lower leg posterior,

22:38

here's right here's left and this is the arterial phase

22:41

where you can see that there's immediate enhancement

22:44

into this tangle of vessels.

22:46

And then there's further enhancement

22:47

of venous components on the venous phase here.

22:51

And so again, this is an A VM,

22:53

which is a congenital high flow vascular malformation high

22:57

flow because it's got arterial components

22:59

and this is defined as a direct arterial venous connection

23:02

or lesion with connections without capillaries.

23:07

This typically has that tangle of vessels

23:09

where those abnormal arteries and veins are connected.

23:12

We see low resistance arterial flow

23:14

because it just flows straight into those veins

23:17

and those veins will have arterial waveform

23:19

arterialized wave forms.

23:21

Note that on the Doppler imaging, it might

23:26

remind you of that Christmas tree appearance

23:29

of the hemangiomas, um, in little babies.

23:32

But quite different in

23:34

that on the gray scale imaging we don't

23:35

see a solid appearing mass.

23:36

We see large cystic appearing spaces.

23:42

This is a different case.

23:43

So this is a gray scale

23:45

and color doppler set of images of a kidney

23:48

and we can see that there's this large tubular

23:51

vessel fills with color.

23:53

And then here's another one that's a little bit smaller

23:55

and the technologist sampled them with waveforms

23:57

and the handily labeled for us

23:59

that these showed venous waveforms over here

24:00

and this one showed arterial waveforms.

24:02

And if you look carefully the doppler, there seems

24:05

to be a little bit of communication in between the two.

24:08

This was uh, a young adult who had had a prior renal biopsy.

24:13

And so here's an image from the time of the biopsy where in

24:17

that same region we see some vessels

24:18

but it does not have that same enlarged appearance

24:21

of the vein or the artery.

24:23

And so this is a post-procedural arteriovenous fistula.

24:28

The AV S can be acquired or congenital,

24:31

although acquired is far more common.

24:34

And this is also a type of lesion

24:35

with direct arterial venous connection without capillaries.

24:38

But unlike the AVMs, there's no tangle of vessels.

24:42

Uh, but similarly

24:44

because of the direct AV connection we see low resistance

24:46

arterial flow and arterialized venous wave forms.

24:53

Moving on to the next case.

24:55

Here's a color Doppler image of

24:58

the lower extremity of a 10 year olds.

25:00

They had a palpable lump.

25:02

We can see this non-specific Y shaped hypoechoic structure

25:06

with a few dots of color in it.

25:09

So this patient went on to get an MRI

25:11

and we can see here on the dynamic post contrast imaging

25:14

that we're in the venous phase

25:16

and we can see this sort of non-specific vascular channel.

25:21

But because it's a venous phase,

25:22

we know that that must be a vein.

25:26

And this is a venous malformation.

25:28

So this is a malformation

25:30

that just has venous cha cha channels.

25:33

So this is a congenital low flow vascular malformation

25:36

because it's made up of veins.

25:37

And if it's not already obvious, the category

25:41

of malformations vascular malformations are simply

25:44

lesions made up of abnormal vessels.

25:46

So if it's a venous malformation, it's made up

25:48

of abnormal veins

25:51

and if you have a superficial lesion,

25:53

you can get this bluish discoloration

25:54

that can be usually seen on clinical exam.

25:58

And then on imaging you generous, you can have a variety

26:01

of appearances and it can be quite heterogeneous including a

26:04

mix of venous channels like we saw.

26:06

And then sometimes intermixed genic fat.

26:11

The color flow can be poor if it's quite slow flow.

26:14

So the color flow might be quite spotty

26:18

or even seemingly absent.

26:20

But one thing you can do if this is on your differential is

26:22

have the patient uh, perform a Valsalva maneuver

26:25

and you can expect to see increased flow as a result.

26:30

And you may or may not see vollis on imaging.

26:33

And as we see in other types of slow flow veins

26:36

because of the slow flow in the vascular malformations

26:39

or sorry in the venous malformations, you might see

26:42

associated with these as well.

26:44

And these can be focal

26:45

or extensive meaning you could see just a focal lesion

26:48

somewhere or you can have really infiltrative

26:51

extensive lesions as well.

26:54

Here's a companion case

26:55

of just a single representative ultrasound image

26:58

of the antecubital fossa in a patient

27:00

and you can see that there's this dominant vessel which one

27:03

sampled showed venous waveforms,

27:05

but we went on to get the MRI

27:07

and you can see that this is actually quite an extensive

27:09

network of abnormal veins.

27:11

So here's the T two fat saturated image

27:13

and here's the post contrast fat saturated saturated image

27:16

showing all these T two hyperintense vascular channels

27:21

that extend throughout the forearm, wrist, hand fingers.

27:24

And we can see that there is enhancement

27:27

of all these channels so consistent

27:28

with a venous malformation.

27:30

And then this patient also went on to have

27:32

or at some point had a radiograph.

27:35

We can see soft tissue thickening related

27:37

to all those venous channels.

27:39

And then we have these tiny little freis

27:41

as well securing the diagnosis of venous malformation.

27:47

Here's another case. This is a patient

27:50

who was about three years old and had jaw swelling.

27:53

And so we got an ultrasound image again, we see big,

27:56

large cystic spaces, not unlike the initial gray scale image

28:00

of the A VM case that I showed you,

28:04

but when we put on color it looks very

28:06

different than the AV M case.

28:08

Specifically we don't see any internal

28:10

vascularity of these cystic spaces.

28:12

We have a little bit of vascularity kind of in the um, walls

28:15

or the septa, but that's it.

28:18

This patient went on to have an MRI

28:20

and we can see on these two T two fat rated images

28:24

that we have these large lobular cystic spaces.

28:26

Here's a fluid, fluid level

28:29

and then on the post contrast imaging we can see

28:31

that there is again peripheral wall and septal enhancement

28:34

but no internal enhancement.

28:36

And so this is very typical of a lymphatic malformation,

28:39

meaning this is a a lesion that is made up

28:43

of abnormal lymphatic channels.

28:47

Another congenital low flow vascular malformation

28:50

just like the venous malformation except in this case

28:52

they're made up of lymphatic channels.

28:54

And these can be subdivided into macrocystic which are the

28:58

more common and microcystic.

29:00

So this case here shows a, an example of macrocystic.

29:04

You can sometimes see fluid, fluid levels

29:06

or an on ultrasound swirling debris.

29:08

If you get a semi clip again you may see rim

29:11

or sation vascularity but not internal vascularity.

29:15

It's generally soft And compressible with the transducer

29:19

microcystic can be a little bit more difficult

29:21

because if these cysts are really,

29:23

really tiny then the sound beam can bounce around

29:26

between their um,

29:28

reflective walls without showing the antico central

29:30

portions 'cause they're so small.

29:32

And so it can make the whole lesion actually look solid

29:35

'cause you're just getting bright echoes throughout.

29:38

Um, again, as those sound beams bounced between the walls

29:41

of those tiny cysts and it can also make it look vascular

29:43

because those walls might have vascularity even though

29:46

internally they don't.

29:47

This is not unlike what can happen uh,

29:49

with autosomal recessive polycystic kidney disease as well

29:52

where the kidney parenchyma can be replaced by these tiny,

29:55

tiny cysts but it just makes it look like the kidney is

29:58

enlarged and really genic when in fact there are these tiny

30:01

microscopic cysts

30:02

that we can't resolve on our gray scale imaging.

30:06

Here's a new case. So this is a gray scale

30:10

and color doppler image of a 6-year-old with a leg mass.

30:13

We can see sort of non-specific tubular

30:16

and circular hypo coic or koic structures.

30:21

Not really a well-formed mass around it.

30:25

And we can see that there's some color flow within some

30:27

of those tubular structures.

30:28

And then we also see that some

30:30

of them don't seem to have color flow.

30:31

And this was a persistent real finding

30:33

for the ones that did have color flow.

30:34

We see venous waveforms.

30:38

And so this turned out

30:39

to be a mixed venal lymphatic malformation.

30:42

So a lesion with features of both a venous malformation

30:46

and a lymphatic malformation.

30:47

This patient went on to get an MRI

30:49

and we can see that there's this large lesion that's got uh,

30:53

T two hyperintense components

30:55

but also layering uh,

30:56

debris levels on the T two fat satter fat saturated image.

31:00

And then on the post contrast fat saturated image, we see

31:03

that some portions seem to enhance but other portions don't.

31:06

And just to compare to the pre contrast fat saturated image

31:10

to ensure that these are not inherently T one bright

31:13

structures, they're not, they're truly enhancing again,

31:17

features of venous uh malformation as well as features

31:20

of lymphatic malformation.

31:22

And then you may have also noticed this very hypo intense

31:25

structure which is in fact a lebo lith.

31:28

Again, that would be typical of the venous malformation.

31:32

So in these mixed lesions where you have both venous

31:35

and lymphatic malformations, you can have imaging findings

31:37

of both and sometimes it can be really difficult

31:39

to tell on imaging 'cause it might not follow all the

31:42

classic imaging findings and it might not be known uh,

31:45

unless they go to pathology.

31:46

But something to think about if you see features

31:48

of both vascular channels with flow

31:51

and vascular channels without flow,

31:53

this might be what you're looking at.

31:56

All right, so that was our whirlwind tour into a review

32:00

of the pediatric vascular anomalies.

32:02

If you remember nothing else, just remember

32:04

that there is this ISS VA with their classification system

32:08

and that you really wanna think about vascular anomalies

32:10

as either tumors which are truly neoplastic,

32:13

whether they're benign or malignant.

32:15

And then there are the mal malformations, which are simply

32:18

abnormal vessels that are not neoplastic

32:22

but they're just abnormally formed.

32:23

For some reason, history is really important.

32:27

So you may have noticed that with the hemangiomas,

32:29

those were all babies, uh, whereas a lot

32:31

of the other malformation cases I

32:32

showed you, they were older children.

32:34

So if you have an older child, it's not gonna be hemangioma.

32:37

And then its growth pattern can also be really important in

32:39

differentiating some of these.

32:41

Oftentimes with these lesions we can diagnose them

32:44

with ultrasound, but we may need to go on to CT

32:46

or MRI to evaluate for deeper extension or other lesions.

32:52

And a lot of uh, dedicated p pediatric hospitals have

32:57

vascular anomalies clinics to treat these made up of, uh,

33:00

multidisciplinary teams including radiologists,

33:02

pediatric radiologists, pediatric dermatologists surgeons,

33:05

um, pediatric, uh, interventional radiologists

33:08

who will often treat some of these.

33:10

So if you have a patient with one of these, uh,

33:12

they will be well-served if you have a local children's

33:14

hospital with a dedicated pediatric

33:16

vascular anomalies clinic.

33:19

All right, so this slide is a queue just to let us know

33:23

that we're gonna be switching topics.

33:24

So if you need to take a quick stretch

33:26

and move around, I'm gonna pull up the questions real quick,

33:29

the q and a just to see if there's any questions

33:31

specifically about this first section.

33:40

And I don't see any questions at the moment.

33:43

So, oh,

33:48

actually someone just popped something up.

33:50

Let's see. So someone said I am an endocrinologist

33:52

and I have a five-year-old son diagnosed

33:54

with a venous malformation at 10 months.

33:56

Is there any role for elastography?

33:57

Well that's, oh, sorry, these are two different questions.

34:00

Sorry, they're just popping up on my screen now.

34:03

Um, yeah, so I'm not sure if the first one

34:06

had a question as well.

34:07

Oh, sorry, now it popped up.

34:09

The question is what is the approach for this diagnosis?

34:11

So I guess to, it sort

34:13

of depends on whether you have a confirmed diagnosis or not

34:16

and what, what the location is.

34:18

So if you have a confirmed diagnosis of a diagnosis

34:20

of a venous malformation, um, I would recommend uh, talking

34:25

to your local pediatric institution if you have one, so

34:29

that you can um,

34:31

get the whole multiple multidisciplinary team involved.

34:34

And if there are treatment options, depending on if

34:36

how big it is and if it's causing any symptoms

34:39

and where it is, um, I think it'll be helpful to have

34:42

that whole team uh, talk

34:43

to you depending again on if it is fully venous malformation

34:47

or if there might be a lymphatic component,

34:49

IR might be able to sclerosis.

34:51

So it really depends on some of the details,

34:52

but that's where I would start any role for elastography.

34:55

Um, so we do use elastography

34:58

for certain things in pediatric imaging.

35:00

We have not been typically using them in my experience

35:03

for these sorts of lesions

35:04

'cause much of the time we can often, um,

35:07

diagnose without elastography.

35:09

Um, in our patient population we're usually using

35:12

elastography, um, either if they're being evaluated

35:15

for hepatocellular disease, um,

35:18

whether it's hepatic steatosis

35:20

or more rarely in kids cirrhosis.

35:23

Um, but also in our sick kids who might have, um,

35:28

uh, sorry I'm having a momentary brain lapse,

35:31

but um, kids who undergo bone marrow transplant are

35:36

risk for um, ugh, it'll come to me later,

35:39

but they're at risk for, uh, a process

35:42

that can very quickly cause liver stiffening

35:44

and in then we'll we will do cystography

35:46

but not usually for these vascular anomalies.

35:49

Um, in older children,

35:52

when you find a hyper epigenic lesion in the liver,

35:54

what you do next.

35:56

Um, so it depends partially on what sort

36:01

of resources you have.

36:02

So if you have a hyper coic lesion, a couple things

36:04

that I would do.

36:05

So number one, you always can throw on color, um,

36:08

and get arteri, uh, see if there are any wave forms.

36:11

Um, just as a starting point,

36:13

if you have contrast enhanced ultrasound at your

36:16

institution, that's another thing that you can do.

36:18

I'll talk more about that in the next section.

36:20

Um, but it's also important to know how old they are

36:23

and um, if you have any comparative imaging to,

36:27

to help you along, oh, I'm sorry,

36:28

you said an older children in the question.

36:30

So, um, if it's an older child

36:32

and you find this incidental lesion, um, I would try

36:35

and do contrast enhanced ultrasound if you

36:37

are able to do it.

36:39

Uh, otherwise, unless it's very obviously benign like just a

36:43

liver cyst, then you're probably gonna have to go onto CT

36:46

or MRI with IV contrast.

36:48

And typically for uh, MRI, we would use vist,

36:51

which is a type of contrast that is partially excreted

36:54

by the hepatobilliary system.

36:56

It can help differentiate different types of liver lesions.

37:01

All right,

37:07

so why don't we move on to our next section

37:13

and that is to talk more about contrast enhanced ultrasound.

37:16

So I referenced this a couple times earlier

37:20

and there are a number of articles out there.

37:22

There are always more and more coming out.

37:25

And initially when we started uh,

37:27

seeing research about contrast enhanced ultrasound, it was

37:30

focusing on the liver, but more work is being done

37:32

on additional organs.

37:34

And so this is FDA approved at the moment

37:37

for focal liver lesions in kids also use an echocardiography

37:41

and then you can also use it for reflux.

37:43

So essentially doing A-V-C-U-G,

37:44

but ultrasound

37:46

that is not something our institution currently has

37:48

experience with, but it is being done.

37:51

And so what is the agent that we use?

37:53

So in the US the brand name is Lumon, it's called vu

37:57

and other parts of the world, there are a couple other types

38:00

of agents that are currently off-label in the US

38:04

and the whole concepts

38:05

between the ultrasound contrast agents, unlike CT

38:09

or MRI, is that these are microbubbles.

38:11

And so there's some sort of inert gas at the central core

38:15

of it and then that is surrounded by shell made

38:18

of phospholipid or protein.

38:20

And what's great about this is that in art,

38:22

gas ultimately is exhaled by the patient.

38:25

Um, and that's how it's eliminated from the body.

38:28

And then the shell is excreted by the hepatobiliary system.

38:31

There's no soft tissue deposition as we know can occur

38:35

with um, gadolinium.

38:38

And the way this works is that under the ultrasound, um,

38:43

probe or under, uh, the signal from the ultrasound,

38:47

these microbubbles can trend, uh, con contract and expand

38:52

and um, with that interaction with the sound beam.

38:55

And so that leads

38:57

to non-linear signal returning back to the transducer.

39:00

And that's how you get your quote

39:01

enhancement on the imaging.

39:04

Uh, in general, we want to keep the mechanical index low

39:08

because if it's high

39:09

that can actually burst the micro bubbles

39:11

and so then you no longer will have, uh, data

39:13

that can help you look at the enhancement.

39:16

But occasionally we intentionally will burst the

39:18

microbubbles and you can use this, you can do this, um,

39:21

with uh, either using flash mode

39:24

or doppler, it can burst them

39:26

and you might choose to do this if for some reason you need

39:28

to give a second dose of contrast

39:30

and you wanna get rid of all the previous dose of contrast

39:33

so it doesn't confuse your um, imaging.

39:36

And so that's one way you can do it.

39:37

And again, that gas just gets exhaled by the patient

39:40

and you can very safely give a second dose.

39:44

Um, so in general using the ultrasound contrast agents is

39:48

very safe in patients and including pediatric patients.

39:52

It's not excreted by the kidneys.

39:54

Remember that, uh, gas is exhaled

39:55

and the shell is excreted by the hepato biliary system.

39:58

You don't need sedation to get the images.

40:01

So that's helpful. A very good safety profile

40:04

with very low percentage of adverse events.

40:08

These are some images from one of the articles

40:10

that I showed earlier, and this is just showing

40:12

what turned out to be a congenital hemangioma.

40:14

There's this large lesion in the liver

40:16

and we can see over the next several images, which are span

40:19

between I think two to eight seconds between images B

40:22

through F and you can see this, uh,

40:24

diffuse enhancement in those first few seconds.

40:26

And then this is a delayed image a couple minutes later

40:28

showing retention of that contrast.

40:30

So this is background liver over here

40:33

with some contrast in the

40:34

vessels, and then that's the lesion.

40:38

This is from that same paper.

40:39

Another example of what turned out to be a an FNH, um,

40:43

focal nodular hyperplasia.

40:45

So we have this large lesion in the liver

40:48

and right away on the early post contrast images,

40:51

you can see that there is uh, d there is, uh, enhancement

40:55

of a central portion that typical central scar.

40:59

So the imaging characteristics are very similar to

41:02

what you're used to on CT or MRI.

41:04

With IV contrast, we're just using a different agent

41:06

and we see on the delayed image

41:08

that there's retention of contrast.

41:09

Again, typical of an FNH,

41:15

this is the case that I showed earlier in the first section

41:17

of the talk from our institution, just to show you again,

41:19

here's that background liver.

41:21

Here's the lesion that looks very similar

41:23

to the liver just on the gray scale.

41:24

And when we give contrast immediately we see that

41:28

peripheral enhancement

41:31

and retention of enhancement over time.

41:34

So this was our congenital hemangioma case

41:36

that I had showed you earlier, some

41:40

practical considerations.

41:41

So this is all well and good,

41:43

but you can't just simply go back to your department

41:46

and tell the technologist, Ooh,

41:47

let's do contrast enhanced ultrasound.

41:48

There are a few things that you need

41:50

to get in place before you can do this.

41:51

There's certainly doable, you just need to, um,

41:54

you just can't do it without preparation.

41:56

So one thing to be aware of is obviously the patients are

41:59

gonna need venous access.

42:00

So, um, there needs to be a mechanism to be able to do

42:03

that at your institution.

42:04

You will need two team members in the room with the patient.

42:07

So you need one person who actually injects the contrast

42:10

and then you need the other person to obtain the images.

42:13

It cannot be the same person doing both.

42:16

You also understandably will need specific software

42:19

to be able to run this as well.

42:22

You always wanna perform the gray scale first,

42:25

particularly if they don't have previous ultrasound imaging.

42:28

For example, if you have a patient who had a CT scan

42:31

and had an incidental liver lesion, if they come

42:34

to you here, you do this gray, gray scale first.

42:37

And you might find for example,

42:38

that it's a completely benign cyst,

42:40

in which case you don't even need to give the contrast

42:42

and you can skip that whole portion.

42:44

And that's one reason why gray scale first is helpful.

42:47

Another reason is to know that if, uh,

42:51

if a patient has some sort

42:52

of underlying hepatocellular disease, whether um,

42:55

it's cirrhosis or portal hypertension, uh, being able to see

43:00

that with the gray scale imaging will be helpful to know

43:03

because that can actually affect, um,

43:05

the differential diagnosis

43:07

or any focal lesions that you're imaging.

43:13

When you get the imaging.

43:15

You might've noticed on the example I showed you on

43:17

that syne clip, you keep the transducer in the same place

43:20

throughout all phases of imaging.

43:22

So you're not doing a sweep from top

43:24

to bottom of the lesion.

43:26

You can do that on your gray scale certainly

43:27

and get documentation,

43:29

but you need to pick a spot with your transducer

43:31

and then when you give contrast,

43:32

you keep the transducer there

43:34

and you see what that lesion does in

43:36

that spot over the multiple phases.

43:41

All right, so that was just a very quick overview

43:43

of contrast enhanced ultrasound.

43:44

It's time for another stretch

43:45

and I will look at any questions that we might have.

43:48

Is it safe to give in a pregnant patient?

43:50

That's a great question.

43:51

Um, I will, I will double check the articles

43:55

to make sure I'm not saying this wrong,

43:56

but I am pretty sure that this would be safe.

43:58

Uh, I don't think,

44:01

I don't think there would be contraindication,

44:04

but that is something I would have to double check

44:05

for you since not as many

44:08

of our pediatric patients are pregnant.

44:10

Um, but it's a great question. All right.

44:18

Okay, let's move on to the next topic.

44:21

Okay, so malrotation and midgut vois.

44:25

So this is, uh, these are diagnoses that you probably are,

44:28

have some familiarity with whether

44:30

or not you, you do a lot of pediatric imaging,

44:33

hopefully it's something that you are aware of.

44:35

Um, but the reason we bring it up is increasingly we're

44:38

seeing more literature with respect

44:40

to diagnosing these on ultrasound, whereas

44:42

that not did not used to be, uh, the case so often.

44:46

So as a quick review, um, here is

44:51

what normal anatomy looks like.

44:53

So we're talking about the GI tract of course,

44:56

and so we normally have the stomach

44:58

and then duodenum should follow a very predictable course

45:01

where the second portion comes down.

45:02

And then the third portion comes across midline.

45:05

Uh, and then the duodenal juvenile junction is usually

45:08

approximately at the level of duodenal bulb,

45:10

maybe a little higher than this.

45:11

Um, and then that connects with the rest of the small bowel

45:14

and then eventually leads to the cecum,

45:16

which is again usually in the right lower quadrant.

45:19

And these structures,

45:20

the duodenal al junction are usually held

45:22

and fixed in place with some, um, attachments and ligaments.

45:26

So the ligament of trites up here

45:27

and then another attachment at the sequel base here.

45:29

And that holds everything in place.

45:31

And so people who have normal rotation are not at risk

45:35

for midgut ulu

45:36

because they are, their bowel is held in place

45:40

and not at risk for twisting if you have malrotation.

45:44

That in and of itself is not a surgical emergency,

45:48

but what that means is during embryogenesis,

45:50

for whatever reason, the bowel did not rotate normally, uh,

45:53

and it settled in some abnormal position.

45:55

And there's a, a spectrum of

45:57

how abnormally rotated it could be.

45:59

In this particular example, we see that a lot

46:02

of the colon is kind of on the left side

46:03

with the seum in the right upper quadrant.

46:06

Uh, but regardless it's abnormal.

46:07

So we see that the duo just goes straight down in this

46:10

example, it does not cross midline

46:12

and everything is held together with

46:14

what are called lads bands.

46:15

And so what that means is the body is trying

46:18

to hold everything in place

46:19

because the bowel iss not rotated.

46:21

Normally, you can't put the ligament of trites

46:23

where it's supposed to be and you

46:24

can't put this where it's supposed to be.

46:25

So it just tries to hold everything

46:26

as in place as best as it can.

46:29

Now these lads bands can,

46:31

however, as much as the body is trying

46:34

to hold everything in place, these bands can cause symptoms.

46:36

So the most common reason why we have outpatients come

46:40

to our department for upper GI studies is

46:43

to rule out malrotation.

46:44

And so these are kids who are not necessarily acutely sick,

46:47

but they might have sort of vague, uh, abdominal pain

46:51

or vomiting maybe associated

46:52

with eating or a little after eating.

46:54

And that can occur because these bands can cause an

46:57

extrinsic compression on the bowel.

46:58

And so, um, they can develop these symptoms,

47:02

but they're not acutely in need of surgery.

47:05

But they might ultimately need, um, if they're found

47:07

to have malrotation, to have these bands cut.

47:10

And that's called the lads procedure.

47:13

But what can happen is if you have malrotation,

47:15

then you are at risk of midgut vols.

47:18

So malrotation is simply the bowel not in the right place,

47:22

but vulu is when you get a secondary twisting as much

47:25

as the bowel, as much as the body tries

47:26

to hold everything in place with these lads bands,

47:28

it doesn't always, and sometimes you can get this abnormal

47:31

twisting, and this is a surgical emergency

47:34

because not only does the bowel lumen get obstructed

47:37

by the twisting, but all the mesenteric vessels

47:40

that are also getting swept up into this twist,

47:42

which are not shown in this picture,

47:43

those also get obstructed.

47:45

And so very quickly you can develop ischemia or infarction.

47:48

And so these babies, uh,

47:49

or these patients, usually babies need

47:52

to go to the or right away.

47:53

And for this reason, uh,

47:55

radiologists will come into the middle

47:56

of the night classically to do an upper gi, uh,

47:59

to see whether or not they might have makeup ulis so

48:01

that they can go to the or if necessary.

48:03

The classic history isus vomiting in a baby.

48:07

And so here's an example of an upper gi

48:10

and you can see this is a frontal image on the left

48:12

and a lateral image on the right.

48:13

And we see a distended stomach with air and contrast.

48:17

I'll just pause for a moment just to mention that

48:20

although not present in this patient,

48:22

I would recommend anytime you have a baby

48:24

with bill is vomiting

48:26

and they're worried about mid gut ulu drop an NG tube,

48:29

whether you do it or somebody in the er does it

48:31

drop an NG tube for a couple reasons.

48:33

One is you can, if they're truly obstructed,

48:35

they're not gonna wanna take a bottle and drink for you.

48:38

And so you can re relieve, um, at least some

48:42

of their discomfort by

48:43

removing whatever's backed up in the stomach.

48:45

Number two, if you have a tube

48:46

and you just attach a syringe with contrast in it,

48:49

you can control exactly

48:50

how much contrast goes in rather than trying to get them

48:53

to drink when they don't feel

48:54

like drinking because they're vomiting.

48:56

Um, and I find in these newborns, generally speaking,

48:58

you don't need more than about five to 10 milliliters

49:01

to get a diagnostic study.

49:03

They really don't need very much.

49:05

Additionally, you can start them on their right side down,

49:07

meaning they're decubitus on their right side, so that

49:10

as soon as you inject contrast through that tube,

49:12

it'll hopefully start emptying out

49:15

the stomach into the dito and you can get your images.

49:18

This was a newborn, four days old.

49:21

And um, we can see that there's contrast.

49:23

Some contrast gets into the duodenum,

49:25

here's the duodenal bulb, and then something funny is

49:27

happening over here and a little bit

49:29

of contrast squeaks out over here.

49:32

Whatever is happening though is not normal.

49:34

We do not see the normal, um, descending portion

49:36

of the duodenum going like this,

49:38

and we certainly don't see it going across

49:39

midline up to the level of the bulb.

49:41

We turn them lateral, we can see air in the duodenal bulb,

49:44

and we can see contrast in a dilated, uh, duodenum.

49:48

And it comes to what's, uh, called a little beak.

49:51

This is a beaking appearance

49:52

and that is where the obstruction is happening.

49:54

So the twist is happening right over here somewhere.

49:57

Um, and so it's causing obstruction

49:58

of the more proximal bowel.

50:00

And in this particular patient, a tiny amount

50:02

of contrast manages to get through the twist.

50:04

And so we'll see a little bit of contrast more distally,

50:06

but importantly we see that it's going anteriorly, um,

50:09

which is abnormal.

50:10

The duodenum is a retroperitoneal structure, so in addition

50:14

to normally the duodenum is

50:15

supposed to go in this direction.

50:17

Additionally, on a normal upper gi,

50:21

the duodenum should remain retroperitoneal.

50:24

So this is a baby who had malrotation with midgut ulu.

50:30

Now, like I said, that was the more classic thing

50:32

that we did, which was to do upper gi,

50:35

but again, increasingly there's more literature suggesting

50:38

that we can make this same diagnosis with ultrasound.

50:40

Uh, and that's helpful because sometimes, uh, if you have,

50:44

uh, a hospital that does not have 24 7 radiology

50:47

or a pediatric radiologist, um,

50:49

but you do have in-house ultrasound texts, you might be able

50:52

to get your answer with ultrasound.

50:54

So on ultrasound, we would hope to see the same things

50:58

that we show on upper gi.

51:01

So you look to see whether that third portion

51:03

of the duodenum, uh, goes intraperitoneal instead

51:05

of remaining retroperitoneal.

51:07

What you can also do on ultrasound

51:08

that you can't do on upper GI is

51:10

to actually look at the vessels themselves.

51:12

And so if you see an abnormal S-M-V-S-M-A orientation,

51:17

that along with abnormal intraperitoneal D three,

51:20

that could be, that could be present at either mal

51:23

rotation or makeup ulu.

51:24

These don't diagnose makeup ulu alone.

51:26

But, um, it is helpful to be paying attention to them

51:29

because as I'll tell you in a minute,

51:31

there's some other things to look out for.

51:34

Remember that just like the IVC is normally on the

51:36

patient's, right, and the aortas on the left, similarly,

51:39

the SMV should be to the right of the SMA.

51:42

And so if that's switched, that's gonna give you an idea

51:44

that we're dealing with something like this.

51:47

If you additionally see dilation of the more proximal bowel,

51:51

if you scan, if you do kind of a sweep through the abdomen

51:54

and you see bowel

51:56

and vessels swirling on your ultrasound,

51:58

that's gonna tell you that that's, that's swirl is abnormal.

52:00

That's the twist of the volvulus.

52:03

If you see, if you actually can see the SMA itself get cut

52:07

off because it's obstructed,

52:08

or if you see post volvulus SMV dilation,

52:10

those are all indicative

52:12

of a volvulus superimposed on mal rotation.

52:14

And if you see mesenteric edema, that would,

52:16

although nonspecific in the presence

52:18

of these other findings, is gonna be highly suggestive

52:21

of makeup ulus.

52:23

And then of course, ultrasound is beneficial in

52:25

that it doesn't emit any radiation.

52:27

It's quite portable, and again, it might be more accessible,

52:30

um, depending on the institution where you are in.

52:33

So here's an example of a gray scale transverse

52:35

image to the upper abdomen.

52:36

And we're seeing the aorta here as labeled

52:38

by the technologist as it's just the takeoff of a celiac.

52:41

Here's the SMA and here's the SMV, and that's abnormal.

52:44

The SMV should be over on this side.

52:46

And then here's a color image of the same,

52:48

it's the same thing showing the aorta S-M-A-S-M-V abnormal.

52:53

Now again, this picture alone doesn't tell you

52:55

that there's ulous.

52:56

It tells you at the very least there's mal rotation.

52:59

But in this patient, we went on to get a semi clip

53:02

and you'll actually see those vessels starting to twist,

53:06

really obvious twisting of these vessels.

53:08

And so this was a case of midgut ulous.

53:15

All right, that was malrotation, midgut, ulous.

53:18

So we'll take another stretch real quick.

53:27

All right, so let's move on

53:32

to our last section, which would be pretty quick.

53:36

All right, a couple miscellaneous items, things

53:39

that I just think might be helpful if, if you're not used

53:41

to looking at pediatric imaging.

53:43

This one's really quick. What does the pre pubertal

53:46

uterus look like in kids?

53:48

Um, and this, there's a really simple way to do this.

53:50

So you wanna look at a long image of the uterus,

53:54

and you wanna look at the AP diameter

53:56

of the cervix relative to the fundus.

53:59

In pre pubertal patients.

54:02

The AP diameter of the cervix is gonna be

54:03

wider than that of the fundus.

54:05

So here is a long image of the pelvis,

54:09

this is the bladder, here's the uterus.

54:10

And we can see the fundus is up here.

54:12

And you can see that the, uh, you can just see qualitatively

54:17

that the AP diameter of this cervix looks wider than that

54:20

of the fundus,

54:21

and that is typical as opposed

54:23

to the post pubertal uterus in this patient.

54:26

You can see there's the fundus there

54:28

and clearly the AP diameter

54:29

of the whole fundus is wider than that of the cervix.

54:32

And that is a quick

54:33

and easy way to determine whether

54:36

a patient is pre puberty or not.

54:40

So I just knocked my microphone over. Sorry about that.

54:47

Okay, that was it for pre-pubertal uterus.

54:49

And the last thing I'll talk about here is

54:51

spinal ultrasound.

54:52

So the most common reason we get spinal ultrasounds, um,

54:56

in babies are for a history of sacral dimple.

54:59

And a couple things to be aware of.

55:01

Not all sacral dimples need to be imaged.

55:04

So the ones that should get ultrasound are some sort

55:06

of imaging are ones that are deep, uh,

55:09

or especially if you can't see the base,

55:11

if they're larger than about five millimeters, if they're

55:15

above the gluteal cleft, greater than two

55:17

and a half centimeters from the a**l verge,

55:21

or if there's any other marker of some sort

55:22

of spinal abnormality like a hair tft, a skin tag, some sort

55:27

of skin discoloration, or even a vascular anomaly such

55:30

as a hemangioma in that location.

55:34

Simple dimples, as I mentioned,

55:36

do not require further workup.

55:37

They really don't need ultrasounds

55:39

because the chance of there being anything wrong

55:40

with a spine are incredibly low.

55:42

They're very common.

55:43

If you see a visible intact base that's shallow,

55:46

or if it's small and

55:47

or if it's small, less than five millimeters,

55:49

they don't need to go on to get ultrasound.

55:53

So here's an example of a normal spinal ultrasound.

55:56

So these patients are scanned prone,

55:59

so up here is their back,

56:00

and then this would be more anterior,

56:02

and the text will label the vertebral bodies for you.

56:05

They usually start down at the

56:07

Coxs and they work their way up.

56:08

So you can see these are, these vertebral bodies

56:10

are already labeled for us.

56:11

This is the back of the T 12 vertebral body.

56:13

This is the back of the L one, et cetera up here.

56:16

These are the spinous processes, so you can see

56:18

that they're causing some shadowing.

56:20

So you can imagine as the kids get bigger

56:22

and their bony structures get bigger,

56:24

they're gonna shadow out the entire spinal canal.

56:27

So we can't really do ultrasound past six

56:29

months of age for this reason.

56:32

And what we see here is the distal spinal cord all the way

56:35

down to the tip of the conus right here.

56:37

And this is a normal appearance. It's typically hypo coic.

56:40

The central canal can have a couple different appearances.

56:43

In this case, there's a te amount

56:45

of fluid in the central canal that's the height

56:48

or the an coic portion centrally.

56:50

And then the walls are what are hyper coic.

56:53

If there's no fluid, demonstrable fluid in there,

56:55

then those two walls coopt

56:57

and it looks like just a single hyper coic

56:59

line that is normal.

57:01

And then all these echogenic things coming off here

57:03

are the nerve roots.

57:06

Keeping in mind that this patient, that the patients are,

57:09

uh, imaged prone, um,

57:11

if you have a non tethered normal cord, you would expect it

57:14

to just kind of fall dependently,

57:16

which would be anterior in this case.

57:21

Uh, and this is kind of one of those panoramic views

57:24

where we stitch together several images

57:26

to give you one long image.

57:27

So again, this is normal.

57:29

So the, uh, technologists can start at the coys,

57:32

which is usually not ossified at this age,

57:34

but the lowest most sacral

57:37

vertebral body should have some ossification.

57:39

So this would be labeled S 5, 4, 3, 2, 1,

57:43

and then L five, et cetera.

57:44

And again, we can see all these normal structures

57:47

and as I mentioned, oftentimes we're looking

57:49

for sacral dimple.

57:50

So it's very important that they get dedicated imaging, um,

57:53

of that region of the sacral dim dimple,

57:56

which is usually right above the coccyx.

57:58

And what you're looking for is any evidence of

58:02

continue some sort of communication between the dimple, uh,

58:04

and certainly if there's any kind of skin tag

58:06

or vascular anomaly

58:07

and seeing if there's any deeper connection towards the

58:10

spine or particularly intraspinal In this case,

58:14

there's nothing, there's no tract, there's nothing.

58:16

There's just the dimple and a totally normal

58:18

looking cox and spine.

58:22

Now here's another case, a different case

58:23

where we see the long view

58:25

with our labeled vertebral bodies.

58:27

And when we pay particular attention to the coys, you'll see

58:30

that it extending from the region

58:32

of the dimple is this little thin curve linear tract.

58:36

Uh, and we see this sometimes

58:38

and what's important here is

58:39

that this ends at the tip of the Cox.

58:41

It does not actually go intraspinal.

58:43

And we can see in this kid that here's the tip of the conus

58:45

and I'll show you another picture in a moment.

58:47

But um, this has very little, if no clinical significance,

58:51

um, occasionally later in life maybe they can develop, uh,

58:55

py phylon IAL cyst or something.

58:58

Um, maybe that can get inflamed, but

59:00

otherwise should have no bearing in terms of, um,

59:02

neurologic symptoms.

59:06

Completely incidentally, this patient also had a filer cyst.

59:09

You don't see it so well up here. It's hiding back in here.

59:11

But you can see the distal spinal cord.

59:14

Here's the tip of the conus.

59:15

And then there's this, um, koic filer cyst.

59:18

Again, usually these are of no clinical significance there.

59:21

They had, I don't know the exact

59:23

percentage, but they're fairly common.

59:24

We see them and usually, um, they are not symptomatic most

59:29

of the time when we do ultrasound.

59:32

We can also do C images both in transverse

59:35

and long view to make sure that the nerve roots are moving.

59:37

And this is one of the great things about dynamic imaging.

59:39

So you can see we're at the level

59:41

of the distal cord in trans view.

59:42

There's that, um, central canal

59:44

and you can see these little nerve roots hopping

59:47

around very happily, especially if the baby

59:49

starts moving their legs.

59:50

You'll see them really bouncing around.

59:52

Same thing on the long image.

59:53

You should see free movement of the nerve roots

59:55

and that's something that we put in our reports, whether

59:57

or not nerve roots, nerve root motion is seen and is normal.

60:00

Um, because if not, then you might be, uh,

60:03

looking at a tethered cord.

60:05

And sometimes that can be difficult if the spinal cord,

60:08

the distal spinal cord, even if it's on a normal level,

60:11

it might be functionally tethered for some reason.

60:13

And this might be a clue to that.

60:19

All right, a couple quick click

60:20

cases and then we'll wrap up.

60:21

So, um, this is a different patient

60:23

who has an abnormally low spinal cord.

60:25

You could see it's coming all the way down

60:26

to the lower lumbar level

60:28

and it seems to be tethered dorsally.

60:30

Again, these patients are prone,

60:32

so if anything it should be falling.

60:33

Um, ventrally, not dorsally. So it's a tethered cord.

60:36

This is a baby that had on radiograph

60:37

and ab abnormal, um, angulated sacrum.

60:41

They actually had carino triad.

60:43

And you can see on these, um, T two

60:45

and post contrast spinal images, it's hard to see here,

60:47

but they actually had a presacral,

60:49

sacral sacral cidal teratoma with, um, in addition

60:52

to their tethered cord, they had this little bit

60:54

of intraspinal fat coming from their lesion.

60:57

There's a different kid, uh,

60:59

where the distal spinal cord looks abnormally blunted.

61:02

And so here's the MRI showing the very typical appearance,

61:05

um, of codal regression syndrome.

61:07

Notice on the radiograph

61:08

that the distal sacrum does not have

61:11

ossified vertebral bodies.

61:12

As I mentioned, even in a newborn,

61:14

they should have at least some ossification centers down

61:16

to the lowest sacral vertebral body.

61:18

So that's, um, hypoplastic in, in accordance

61:21

with the AL regression syndrome.

61:24

All right, quick wrap up of everything.

61:27

We talked about some things to think about.

61:29

Do you have a patient with a vascular anomaly

61:31

but they're not a pediatric patient?

61:33

It's probably not hemangioma those things in the liver.

61:36

Uh, venous malformations,

61:39

do you need dynamic contrast imaging

61:40

for some reason in a pediatric patient in particular,

61:43

consider contrast enhanced ultrasound,

61:46

theus vomiting and a neonate.

61:47

You might be able to do ultrasound

61:49

for midgut VUIs rather than an upper gi if you're looking

61:52

for signs of uh, puberty

61:54

and a female look at their uh, uterus

61:56

to see whether the cervix

61:58

and the fundus, what their ratio is compared to each other.

62:00

And then if you have a patient with a sacral dimple,

62:02

make sure you pay particular attention

62:04

for a tract from the dimple, um,

62:06

or any kind of intraspinal lesion.

62:09

That was our whirlwind of cases, vascular anomalies

62:12

and pop of other things.

62:14

Thank you for joining me.

62:16

I know, uh, we are wrapping up

62:17

so I'm gonna quickly look at our questions

62:19

to see if there's anything, um, I can answer.

62:22

Here's a question about ultrasound.

62:24

Can it be an alternative to upper GI to confirm ulus

62:27

or should we proceed to upper GI for all cases?

62:29

Well, I would say right now we're in an in-between time I

62:31

think this is gonna take education for radiologists,

62:34

technologists and also the surgeons for them

62:36

to get comfortable with the idea of using ultrasound.

62:39

But um, eventually one would hope we could use just

62:41

ultrasound and not need to do upper gi, upper GI at all.

62:45

In reality, we might not be there at all institutions,

62:47

but uh, this might be a mul multidisciplinary kind of, uh,

62:50

effort to move over to making that the norm.

62:54

Um, how to differentiate

62:56

between simple dimple versus clinically

62:57

important dimple by ultrasound.

62:58

So the main things for our purposes if we're doing the

63:01

ultrasound is to look for all the things I mentioned.

63:03

So any evidence of a tethered cord, um,

63:05

or any intraspinal lesions

63:06

or any extension of some sort

63:07

of tract from the dimple intraspinal.

63:12

Um, when do you recommend an MR for a low lining conus?

63:15

So the conus is not posterior displaced in the nerve roots.

63:17

So it depends probably on how low if you're borderline kind

63:21

of like L three-ish, which most people consider borderline

63:23

and everything else looks normal

63:25

and the nerve roots are moving, I wouldn't worry about it.

63:31

Dorsal dermal sinus? Yes. So dorsal dermal dermal sinus?

63:35

Uh, yes. You would probably need to go on to MR MRI if

63:37

that's a consideration.

63:38

'cause that's gonna have intraspinal extension.

63:40

You would need IV contrast for that.

63:42

All right, I'm gonna end it there.

63:44

I hope this was helpful for you.

63:46

I hope you learned a few new things

63:48

and we'll see you next time.

63:51

Dr. Mitchell, that was awesome.

63:52

Thank you so much for all those cases

63:55

and for answering all those questions.

63:56

We really appreciate your time.

63:59

Thank you so much for having me. Take care.

64:01

Absolutely. Yeah. And thank you so much for everyone else

64:03

for engaging and asking such great questions.

64:06

We appreciate you being on today's NOOM conference.

64:09

And don't forget, you can access the recording

64:11

of today's conference

64:12

and all our previous noom conferences

64:14

by creating a free MRI online account.

64:16

We will also email out a link to the replay later today.

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Be sure to join us next week on Wednesday,

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September 11th at 12:00 PM Eastern, where Dr.

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Ssh Ani will deliver a lecture entitled MRI

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and Prostate Cancer, a case-based approach.

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You can register for that@mrionline.com

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and follow us on social media

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for updates on future NOOM conferences.

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Thanks again for learning with us and have a great day.