Pediatric Contrast Enhanced Ultrasoundjeffline.jefferson.edu/jurei/conference/pdfs/contrast/4... ·...
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4/8/2019 1 Pediatric Contrast Enhanced Ultrasound Ryne A. Didier, MD The Children’s Hospital of Philadelphia Philadelphia, PA, USA Disclosures • Lumason® is FDA-approved for ceVUS and IV administration for pediatric liver lesions • Other applications are “off-label” • Other ultrasound contrast agents are “off-label” for pediatric applications Disclosures • No financial disclosures • Preclinical research • Vuebox™ post-processing software from Bracco Diagnostics Inc. (in-kind donation) • Definity® ultrasound contrast agent from Lantheus Medical Imaging Inc. (in-kind donation) Safety • Systematic review – Sonovue and Optison • 19 studies (2004-2015) • 502 children, 655 IV CEUS examinations • Additional studies: • 546 children, 665 IV CEUS examinations Rosado E and Riccabona M 2016 J US Med; 35:487-496 Safety: to date • 1048 children, 1320 IV CEUS examinations • 2 severe adverse events (0.0015) • 11 minor adverse events (0.008) • 3 of these had follow-up studies where the reaction did not occur Why do CEUS in children? • Risks of other imaging modalities • CT – requires radiation • MRI – often requires sedation or gadolinium • Renal failure or contrast allergy • Benefits of ultrasound • Parents can stay with child • Improved temporal resolution • Can be done at bedside – even the ICU • Ease of scheduling • Well tolerated
Transcript of Pediatric Contrast Enhanced Ultrasoundjeffline.jefferson.edu/jurei/conference/pdfs/contrast/4... ·...
4/8/2019
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Pediatric Contrast Enhanced
UltrasoundRyne A. Didier, MD
The Children’s Hospital of PhiladelphiaPhiladelphia, PA, USA
Disclosures
• Lumason® is FDA-approved for ceVUS and IV administration for pediatric liver lesions• Other applications are “off-label”
• Other ultrasound contrast agents are “off-label” for pediatric applications
Disclosures
• No financial disclosures
• Preclinical research• Vuebox™ post-processing software from Bracco Diagnostics Inc. (in-kind donation)
• Definity® ultrasound contrast agent from Lantheus Medical Imaging Inc. (in-kind donation)
Safety
• Systematic review – Sonovue and Optison
• 19 studies (2004-2015)
• 502 children, 655 IV CEUS examinations
• Additional studies:
• 546 children, 665 IV CEUS examinations
Rosado E and Riccabona M 2016 J US Med; 35:487-496
Safety: to date
• 1048 children, 1320 IV CEUS examinations
• 2 severe adverse events (0.0015)
• 11 minor adverse events (0.008)• 3 of these had follow-up studies where the reaction did not occur
Why do CEUS in children?
• Risks of other imaging modalities• CT – requires radiation
• MRI – often requires sedation or gadolinium
• Renal failure or contrast allergy
• Benefits of ultrasound• Parents can stay with child
• Improved temporal resolution
• Can be done at bedside – even the ICU
• Ease of scheduling
• Well tolerated
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US Contrast Administration
• Reconstitute contrast
• Inject intravenously
• 180° or “in-line”
• 90° destroys contrast
Perpendicular Injection
• Decreased in vitro enhancement
• Optison and Lumason
• Increased with time
Kramer MR et al 2018 Ped Radiol 48: 101-108
Equipment
• 3-way stopcock
• Peripheral IV
• Central line• Catheter connector
• Huber needle
Technique
• Personnel:• Sonographer
• Injector
• Ultrasound:• Sonographer
• Radiologist present
• Contrast Injection:• Nurse
• Sonographer
• Radiologist
Technique
• Greyscale and color Doppler
• Focal Lesion
• Screening• Trauma
• Infection
• Additional lesions
Focal Lesion
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1 mo boy, vomiting, palpable liver. Mass on US 1 mo boy, vomiting, palpable liver. Mass on US
1 mo boy, vomiting, palpable liver. Mass on US Screening
Right kidney and Liver
9 mo girl, dresser drawer fell on abdomenNORMAL NORMAL
9 mo girl, dresser drawer fell on abdomen
Left kidney and Spleen
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NORMAL
9 mo girl, dresser drawer fell on abdomen
Left kidney and Spleen
NORMAL
9 mo girl, dresser drawer fell on abdomen
Pancreas
Trauma
CEUS > USCEUS = CECT
SensitivityUS 45%CEUS 86%CECT 100%
7 yo girl, presents 3 days after fall
7 yo girl, presents 3 days after fall
Liver
11 yo girl, fall 15 ft out of a tree
Spleen
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11 yo girl, fall 15 ft out of a tree 16 yo boy, kneed in abdomen during baseball game
perinephric collection
2 days later Hb 11 g/dL 8 g/dL
Right Kidney Right Kidney
active bleeding
Right Kidney
1 month follow up
Right Kidney
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Focal Liver Lesions
• Retrospective: 7 years
• Patients: 305
• 11.7 years old (0.1-18)
• 147 focal liver lesions (48%)
Yusuf GT et al 2017 AJR 208:1-7
Pediatric CEUS
49.7% (73) patientsNo CT/MR – CEUS diagnostic
6 mo girl, incidental liver lesion
Liver
Hepatoblastoma
15 yo girl, osteosarcoma, disseminated Candida
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Liver
Spleen
4 yo girl, complex medical history, liver nodules
Liver
Liver
19 yo man, relapsed Ewing sarcoma. Liver lesion seen on spine MRI
Liver
0:20 0:60 1:20
Metastasis
Liver
7 yo girl with history of bladder exstrophy
Left Kidney
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Left Sag Left TRV
Left Kidney
Renal Cell Carcinoma
Left Kidney
Indeterminate Renal Lesions
• CEUS more sensitive than CT• Blood flow in hypovascular structures
• Blood flow in septations and solid component
Barr RG et al 2014 Radiology 271:133-142
16 yo boy back pain and urinary incontinence
Right Kidney Right Kidney
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Right Kidney Cystic nephroma
12 d boy bright red blood in diaper
Left Kidney
Left Kidney
Renal Infection
• Pyelonephritis: hypoechoic
• Abscess: Anechoic
Fontanilla T et al 2012 Abdom Imaging 37:639-646
Renal Scar
• Pilot study
• Renal CEUS versus DMSA scintigraphy
• CEUS detects scars in reflux nephropathy
Hains DS et al 2017 Kidney Int Rep 2:420-424
11 yo boy with recurrent pyelonephritis
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Power Doppler
2 days after CT
Left Kidney Left Kidney
2 week follow up
Left Kidney
11 yo girl with fever and abdominal pain
SAG TRV
Right Kidney Right Kidney
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1 month follow up
Right Kidney
17 yo girl, fever, R CVA tenderness, AKI
Right Kidney
Left Kidney Left Kidney
Procedural Tips
• Avoid vascularity
• Target viable tissue
• Increase lesion conspicuity
• Consider in place of fluoroscopic techniques
1 yo girl with liver mass
FNH
Liver
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13 yo girl, left flank pain, upper pole renal cyst
Left Kidney Left Kidney
Left Kidney- Prone Bladder
Summary
• Safe
• Avoids risks• Radiation
• Sedation
• Many diagnostic and procedural applications
Thank You
Ryne Didier, MD
