G Model EURR-6746; No. of Pages 2
ARTICLE IN PRESS European Journal of Radiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Radiology journal homepage: www.elsevier.com/locate/ejrad
Diagnostic ultrasonography in neonates, infants and children—Why, when and how夽 Michael Riccabona ∗ Department of Radiology, Division of Paediatric Radiology, University Hospital LKH Graz, Auenbruggerplatz 34, A-8036 Graz, Austria
a r t i c l e
i n f o
Article history: Received 2 April 2014 Accepted 16 April 2014
Ultrasonography (US) has become the mainstay of paediatric imaging. This is not only due to considerations concerning radiation protection and ALARA principles, which of course implies shifting as many examinations as possible towards the non-irradiating modality which US constitutes. Ultrasound has undergone a remarkable evolution from its initial “orienting” images to a vast potential of a sophisticated modern imaging technique. Furthermore neonates, infants and children of specific conditions are perfectly suitable for performing US: Little fat and fibrous tissue, higher water content of the tissue and smaller structures enable not only good sound penetration and improved image quality but also application of higher frequencies that allow for higher special resolutions. Thus all the benefits of high-resolution US not only using high frequencies but also other modern techniques such as image compounding, harmonic imaging and speckle reduction filters, can – in paediatric patients – be applied to organs which often are not accessible with this techniques in adulthood, such as the kidney or the liver and spleen. Therefore high resolution US is no longer a technique only applicable to small part imaging, but particularly in neonates and infants has become standard routine for everyday US of abdominal organs and for brain US. Due to the specific anatomy and immaturity of childhood many areas can be perfectly assessed by US that are not suitable for US assessment in adulthood, such as the neonatal brain using the open fontanelles as a sonographic window, or the neonatal spinal cord using the non-ossified posterior arches of
夽 Disclosure: The author is member of the Kretz European advisory board on 3DUS, and has ongoing cooperation with GE (and its subcompany Kretz), and Siemens Medical for development and clinical adaptations of paediatric US devices and transducers. Furthermore, a cooperation of our paediatric radiology division with Toshiba aims at improving paediatric CT applications with a particular focus on radiation protection and reduction. ∗ Tel.: +43 316 385 14202; fax: +43 316 385 14202. E-mail address: [email protected]
the virtual bodies to penetrate; mediastinal US is enabled by the physiologically large thymus, or sonographic assessment of nonossified skeletal structures particularly the epiphysis which is still a cartilaginous and thus can even be better assessed by US than by CT or plain films (e.g., for hip dysplasia, slipped epiphysis). Furthermore, most modern techniques such as US-elastography, contrast-enhanced US or 3D-/4D-US can also be applied to paediatric conditions and further enhance US potential. The introduction of new creative approaches such as the perineal access or filling techniques such as a diagnostic saline enema during an US investigation of the bowel have further widened US applications to areas that have been considered inadequate for sonographic diagnostics; today also therapeutic procedures are guided and monitored by US such as a range of biopsies and punctures or reduction of intussusception and meconium ileus. All this needs dedicated equipment with a range of transducers as well as specific training and education – not only in terms of handling the US device, but also concerning knowledge of paediatric conditions, the normal findings, and typical paediatric pathology which may differ from adults, as well as the implications on therapy and management. Furthermore, as children are often less cooperative, a completely different approach to scanning with often longer investigation time has to be accepted. All these leads to higher costs which are often not reflected in the reimbursement contracts. Additionally, particularly in some countries without established paediatric radiology, paediatric US is performed by paediatricians and paediatric surgeons or orthopaedists as well as a range of subspecialties such as (paediatric) pulmonologists, rheumatologists, gastroenterologist, nephro-urologists or neonatologists. Often these only the focus on their specific field of interest and no profound general US knowledge is available in these scenarios due to a somewhat restricted education, training and knowledge. Together with these aspects, additional systemic and economic health care problems induce another major major setback for US in paediatrics: it is the restricted availability of high
http://dx.doi.org/10.1016/j.ejrad.2014.04.010 0720-048X/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Riccabona M. Diagnostic ultrasonography in neonates, infants and children—Why, when and how. Eur J Radiol (2014), http://dx.doi.org/10.1016/j.ejrad.2014.04.010
G Model EURR-6746; No. of Pages 2
ARTICLE IN PRESS
2
M. Riccabona / European Journal of Radiology xxx (2014) xxx–xxx
level diagnostic US 24 hour a day, seven days a week throughout the year – which, however, would be the undisputable prerequisite for properly making use of the US potential and helping to reduce the need for more burdening, particularly irradiating imaging. This specific paediatric edition therefore tries to summaries in short reviews the huge US potential and the applicability of US throughout the paediatric age group and all systems and organs – hopefully encouraging the reader to take on this challenge and invest in increasing their US skills for optimally serving our small patients. This, however, also implies lobbying for proper equipment, adequate reimbursement, and sufficient staff and examiners. Eventually this will grant an enriching daily diagnostic work not
of less satisfaction as MRI or CT, also allowing for a fulfilling engagement for our small patients health. And it does not claim paediatric US exclusively for paediatric radiologists – this battle is long lost, many subspecialties are using US for many queries throughout childhood. But it should help that, whoever performs US in neonates, infants and children, has profound skills and knowledge as well as a proper device including the necessary transducers, and that paediatric radiology will be able to stay on top to offer expertise and education in all aspects of paediatric sonography to all who need and want to learn or improve – for the benefit of our small patients.
Please cite this article in press as: Riccabona M. Diagnostic ultrasonography in neonates, infants and children—Why, when and how. Eur J Radiol (2014), http://dx.doi.org/10.1016/j.ejrad.2014.04.010
ARTICLE IN PRESS European Journal of Radiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Radiology journal homepage: www.elsevier.com/locate/ejrad
Diagnostic ultrasonography in neonates, infants and children—Why, when and how夽 Michael Riccabona ∗ Department of Radiology, Division of Paediatric Radiology, University Hospital LKH Graz, Auenbruggerplatz 34, A-8036 Graz, Austria
a r t i c l e
i n f o
Article history: Received 2 April 2014 Accepted 16 April 2014
Ultrasonography (US) has become the mainstay of paediatric imaging. This is not only due to considerations concerning radiation protection and ALARA principles, which of course implies shifting as many examinations as possible towards the non-irradiating modality which US constitutes. Ultrasound has undergone a remarkable evolution from its initial “orienting” images to a vast potential of a sophisticated modern imaging technique. Furthermore neonates, infants and children of specific conditions are perfectly suitable for performing US: Little fat and fibrous tissue, higher water content of the tissue and smaller structures enable not only good sound penetration and improved image quality but also application of higher frequencies that allow for higher special resolutions. Thus all the benefits of high-resolution US not only using high frequencies but also other modern techniques such as image compounding, harmonic imaging and speckle reduction filters, can – in paediatric patients – be applied to organs which often are not accessible with this techniques in adulthood, such as the kidney or the liver and spleen. Therefore high resolution US is no longer a technique only applicable to small part imaging, but particularly in neonates and infants has become standard routine for everyday US of abdominal organs and for brain US. Due to the specific anatomy and immaturity of childhood many areas can be perfectly assessed by US that are not suitable for US assessment in adulthood, such as the neonatal brain using the open fontanelles as a sonographic window, or the neonatal spinal cord using the non-ossified posterior arches of
夽 Disclosure: The author is member of the Kretz European advisory board on 3DUS, and has ongoing cooperation with GE (and its subcompany Kretz), and Siemens Medical for development and clinical adaptations of paediatric US devices and transducers. Furthermore, a cooperation of our paediatric radiology division with Toshiba aims at improving paediatric CT applications with a particular focus on radiation protection and reduction. ∗ Tel.: +43 316 385 14202; fax: +43 316 385 14202. E-mail address: [email protected]
the virtual bodies to penetrate; mediastinal US is enabled by the physiologically large thymus, or sonographic assessment of nonossified skeletal structures particularly the epiphysis which is still a cartilaginous and thus can even be better assessed by US than by CT or plain films (e.g., for hip dysplasia, slipped epiphysis). Furthermore, most modern techniques such as US-elastography, contrast-enhanced US or 3D-/4D-US can also be applied to paediatric conditions and further enhance US potential. The introduction of new creative approaches such as the perineal access or filling techniques such as a diagnostic saline enema during an US investigation of the bowel have further widened US applications to areas that have been considered inadequate for sonographic diagnostics; today also therapeutic procedures are guided and monitored by US such as a range of biopsies and punctures or reduction of intussusception and meconium ileus. All this needs dedicated equipment with a range of transducers as well as specific training and education – not only in terms of handling the US device, but also concerning knowledge of paediatric conditions, the normal findings, and typical paediatric pathology which may differ from adults, as well as the implications on therapy and management. Furthermore, as children are often less cooperative, a completely different approach to scanning with often longer investigation time has to be accepted. All these leads to higher costs which are often not reflected in the reimbursement contracts. Additionally, particularly in some countries without established paediatric radiology, paediatric US is performed by paediatricians and paediatric surgeons or orthopaedists as well as a range of subspecialties such as (paediatric) pulmonologists, rheumatologists, gastroenterologist, nephro-urologists or neonatologists. Often these only the focus on their specific field of interest and no profound general US knowledge is available in these scenarios due to a somewhat restricted education, training and knowledge. Together with these aspects, additional systemic and economic health care problems induce another major major setback for US in paediatrics: it is the restricted availability of high
http://dx.doi.org/10.1016/j.ejrad.2014.04.010 0720-048X/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Riccabona M. Diagnostic ultrasonography in neonates, infants and children—Why, when and how. Eur J Radiol (2014), http://dx.doi.org/10.1016/j.ejrad.2014.04.010
G Model EURR-6746; No. of Pages 2
ARTICLE IN PRESS
2
M. Riccabona / European Journal of Radiology xxx (2014) xxx–xxx
level diagnostic US 24 hour a day, seven days a week throughout the year – which, however, would be the undisputable prerequisite for properly making use of the US potential and helping to reduce the need for more burdening, particularly irradiating imaging. This specific paediatric edition therefore tries to summaries in short reviews the huge US potential and the applicability of US throughout the paediatric age group and all systems and organs – hopefully encouraging the reader to take on this challenge and invest in increasing their US skills for optimally serving our small patients. This, however, also implies lobbying for proper equipment, adequate reimbursement, and sufficient staff and examiners. Eventually this will grant an enriching daily diagnostic work not
of less satisfaction as MRI or CT, also allowing for a fulfilling engagement for our small patients health. And it does not claim paediatric US exclusively for paediatric radiologists – this battle is long lost, many subspecialties are using US for many queries throughout childhood. But it should help that, whoever performs US in neonates, infants and children, has profound skills and knowledge as well as a proper device including the necessary transducers, and that paediatric radiology will be able to stay on top to offer expertise and education in all aspects of paediatric sonography to all who need and want to learn or improve – for the benefit of our small patients.
Please cite this article in press as: Riccabona M. Diagnostic ultrasonography in neonates, infants and children—Why, when and how. Eur J Radiol (2014), http://dx.doi.org/10.1016/j.ejrad.2014.04.010
