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6/30/2014 PEDIATRIC RADIOLOGY UPDATE 2014 Medical Imaging • 2013 Imaging Informatics Summit & Data Registries Forum October 2013 • The Image Gently ALARA CT Summit February 2014 • SPR Annual Meeting May 2014 Leveraging radiologists’ tools and expertise to optimize patient care from the time imaging is first considered until referring physicians and patients fully understand the imaging results and Imaging 3.0 Evolution in Patient Care Why Imaging 3.0? We believe a significant imaging care occurs prior to and following exam interpretation. However, for a number of reasons, most radiologists are not providing all of that care. If we did, results would be recommendations “ CLINICAL DECISION SUPPORT ACR APPROPRIATENESS CRITERIA EVIDENCE BASED GUIDELINES ESTABLISHED BY MULTI-SPECIALTY COMMITEES ACR.ORG Improved patient safety and outcomes More cost effective care Increased radiologists’ relevance to the healthcare system A measurable role for radiologists in improving population health A calculation of radiology’s value in reducing per capita cost To assist referring providers in making the most appropriate imaging decision for a specific condition 10 Diagnostic categories 11 Pediatric conditions ” 1 6/30/2014 UTILIZES ACR APPROPRIATENESS CRITERIA EMBEDS THEM IN THE CPOE RANKS THE MOST APPROPRIATE TEST FOR THE INDICATION GIVEN CDS FUJI DOES NOT BLOCK ORDERS CERNER DOES TRACK ORDERS ALLOWS FOR REAL TIME EDUCATION AND RESOURCE MANAGEMENT Head Trauma — Child Variant 3: Moderate or severe head injury (GCS ≤13) or minor head trauma with high-risk factors (eg, altered mental status, clinical evidence of basilar skull fracture). Excluding nonaccidental trauma. Head Trauma — Child Variant 2: Minor head injury (GCS >13), <2 years of age, no neurologic signs or high-risk factors (e.g., altered mental status, clinical evidence of basilar skull fracture). . Radiologic Procedure Rating Comments Refer to variant 4 if there is concern for nonaccidental trauma. This procedure is not indicated if CT with reformations is to be performed. X-ray head 3 RRL* Radiologic Procedure ☢ Rating 7 MRA head without contrast 4 CTA head with contrast 4 O MRA head without and with contrast 3 O X-ray head 2 CT head without and with contrast 2 CT head with contrast 2 MRI head without and with contrast 2 O Arteriography cerebral 2 ☢☢☢☢ US head 1 FDG-PET/CT head 1 Tc-99m HMPAO SPECT head 1 O Consider this procedure if vascular injury is suspected. ☢☢☢ 3 RRL* ☢☢☢ 9 MRI head without contrast This procedure has shown to be low yield in the absence of signs or symptoms. It may be considered if clinical assessment, which can be difficult at this age, is uncertain or indeterminate. CT head without contrast Comments CT head without contrast O MRA is preferred to this procedure. It may be used for problem solving. ☢☢☢☢ Refer to variant 4 if there is concern for nonaccidental trauma. MRI head without contrast 3 MRA head without contrast 2 CTA head with contrast 2 CT head without and with contrast 1 CT head with contrast 1 MRI head without and with contrast 1 O MRA head without and with contrast 1 O ☢☢☢☢ ☢☢☢☢ ☢☢☢ Arteriography cerebral 1 ☢☢☢☢ US head 1 O FDG-PET/CT head 1 Tc-99m HMPAO SPECT head 1 ☢☢☢☢ ☢☢☢☢ Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate O ☢ ☢☢☢☢ ☢☢☢ O ☢☢☢☢ ☢☢☢☢ *Relative Radiation Level *Relative Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Radiation Level 2 6/30/2014 RADIOLOGY DATA REGISTRIES SSDE per exam (mGy) CT ABDOMEN CT ABDOMEN ANGIO W IVCON CT ABDOMEN PELVIS CT ABDOMEN PELVIS ENTERO W IVCON CT ABDOMEN PELVIS KIDNEY CALC WO IVCON CT ABDOMEN PELVIS W IVCON CT ABDOMEN PELVIS WO IVCON CT ABDOMEN PELVIS WO THEN W IVCON Age Group 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 1: Site 100486 25th 75th %'ile Median %'ile DIR Standing . . . . . . . Below 25th %'ile 25th-75th %'ile . . . . . . . . . . . . . . . . . Below 25th %'ile Below 25th %'ile Below 25th %'ile Below 25th %'ile . Below 25th %'ile . . Above 75th %'ile . 2: All DIR sites 25th 75th %'ile Median %'ile N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 . . . . . . . . . . . . . . . . . 36 19 41 69 . 3 . 0 1 . . . . . . . . 2 3 . . . . . . . . . . . . . . . . . 2 3 6 7 . 1 . . 22 . . . . . . . . 2 6 . . . . . . . . . . . . . . . . . 3 4 6 8 . 1 . . 22 . . . . . . . . 2 9 . . . . . . . . . . . . . . . . . 4 6 9 10 . 11 . . 22 . N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 12 14 20 39 0 3 4 7 11 10 57 54 82 180 2 3 7 18 20 2 0 7 41 188 130 396 710 1133 2436 12 27 76 170 602 1 6 6 6 7 8 . 4 4 5 7 5 6 6 7 8 11 10 11 12 13 7 . 8 8 8 5 4 5 7 8 8 4 6 8 10 17 9 7 8 12 16 . 8 12 9 18 6 6 7 9 15 12 11 12 13 14 9 . 11 11 11 19 6 8 10 12 13 6 9 12 15 17 17 .. 8 .. 10 .. 19 .. 20 .. . .. 8 .. 20 .. 16 .. 26 .. 12 .. 8 .. 9 .. 14 .. 27 .. 13 .. 13 .. 14 .. 14 .. 17 .. 11 .. . .. 13 .. 16 .. 16 .. 30 .. 9 .. 11 .. 14 .. 19 .. 19 .. 10 .. 14 .. 19 .. 21 .. 17 .. 5: Sites of type Children's 25th Media 75th N %'ile n %'ile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 7 5 1 2 6 2 2 2 3 7 16 11 . . . . . 23 160 187 264 250 2 7 12 17 30 . . . . . . . 4 4 5 6 4 8 8 9 8 11 10 11 12 13 . . . . . 3 3 4 5 6 4 1 4 5 5 . . . . . . . 8 12 9 10 4 9 13 12 12 12 11 12 13 13 . . . . . 4 4 6 7 8 6 3 5 6 6 . . . . . . . 8 20 16 18 4 10 16 14 17 13 13 14 14 15 . . . . . 7 7 8 11 12 8 5 7 7 7 . DIAGNOSTIC REFERENCE LEVELS-DRL Hit the sweet spot! 25-75% SSDE per exam (mGy) CT ABDOMEN CT ABDOMEN ANGIO W IVCON CT ABDOMEN PELVIS DIR CT ABDOMEN PELVIS ENTERO W IVCON Can be used across Institutions CT ABDOMEN PELVIS KIDNEY CALC WO IVCON CT ABDOMEN PELVIS W IVCON CT ABDOMEN PELVIS WO IVCON CT ABDOMEN PELVIS WO THEN W IVCON Age Group 1: Site 100486 25th 75th %'ile Median %'ile DIR Standing 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 . . . . . . . Below 25th %'ile 25th-75th %'ile . . . . . . . . . . . 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 3-6 7-10 11-14 15-18 0-2 . . . . . . Below 25th %'ile Below 25th %'ile Below 25th %'ile Below 25th %'ile . Below 25th %'ile . . Above 75th %'ile . 2: All DIR sites 25th 75th %'ile Median %'ile N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 . . . . . . . . . . . . . . . . . . 2 3 . . . . . . . . . . . . . . . . . . 2 6 . . . . . . . . . . . . . . . . . . 2 9 . . . . . . . . . . . . . . . . . 36 19 41 69 . 3 . 0 1 . . . . . . . 2 3 6 7 . 1 . . 22 . . . . . . . 3 4 6 8 . 1 . . 22 . . . . . . . 4 6 9 10 . 11 . . 22 . N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 12 14 20 39 0 3 4 7 11 10 57 54 82 180 2 3 7 18 20 6 6 6 7 8 . 4 4 5 7 5 6 6 7 8 11 10 11 12 13 9 7 8 12 16 . 8 12 9 18 6 6 7 9 15 12 11 12 13 14 17 . 8. 10 . 19 . 20 . .. 8. 20 . 16 . 26 . 12 . 8. 9. 14 . 27 . 13 . 13 . 14 . 14 . 17 . 2 0 7 41 188 130 396 710 1133 2436 12 27 76 170 602 1 7 . 8 8 8 5 4 5 7 8 8 4 6 8 10 17 9 . 11 11 11 19 6 8 10 12 13 6 9 12 15 17 11 . .. 13 . 16 . 16 . 30 . 9. 11 . 14 . 19 . 19 . 10 . 14 . 19 . 21 . 17 . 5: Sites of type Children's 25th Media 75th N %'ile n %'ile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 7 5 1 2 6 2 2 2 3 7 16 11 . . . . . . 4 4 5 6 4 8 8 9 8 11 10 11 12 13 . . . . . . 8 12 9 10 4 9 13 12 12 12 11 12 13 13 . . . . . . 8 20 16 18 4 10 16 14 17 13 13 14 14 15 . . . . . 23 160 187 264 250 2 7 12 17 30 . . . . . . 3 3 4 5 6 4 1 4 5 5 . . . . . . 4 4 6 7 8 6 3 5 6 6 . . . . . . 7 7 8 11 12 8 5 7 7 7 . Louis K. Wagner, Ph. D. WHAT DOES RADIOLOGY DO? BENEFIT/RISK IN MEDICAL IMAGING RADIOLOGY ADVANCES HEALTHCARE THROUGH MEDICAL IMAGING BENEFIT/RISK SHOULD BE AS HIGH AS REASONABLY ACHIEVABLE AHARA 3 6/30/2014 AHARA Chose and design the exam to provide the highest medical benefit to risk for the patient R. PAUL GUILLERMANN, MD DEPARTMENT OF PEDIATRIC RADIOLOGY A PERSONALIZED PERSPECTIVE Consider the benefit not just the risk Consider the underlying health condition of the patient BUT Always consider alternatives: MRI US PERSONALIZED CT Patient size • Anatomic region • Clinical indication Often occurs in chronic patients • Inherent disease and life expectancy Shunt patients - rapid MRI • ? Radiosensitivity • BUT! Each risk CT exam does carry Linear no threshold model CONSIDER Is it indicated? Is benefit worth the risk? Ultrasound MRI RISK OF REPETITIVE CT SCANNING • ? Risk perception/preference SUNK COST BIAS Prior investment should not affect future decisions Previous radiation exposure is a sunk cost Risk associated with future radiation exposure is independent of prior exposure Shortened life expectancy Risk NOT cumulative ? Inherent disease fatal before radiation induced cancer develops Not performing an indicated CT due to prior radiation is irrational and more likely to cause harm than good IBD – MRI for follow up Cancer ? MRI for follow up PERSONALIZATION OF RADIO-SENSITIVITY DNA repair capacity of individuals varies and may be the primary determinate of outcome at low dose exposure rather than dose! Risk factors Ataxia-Telangiectasia ? Caffeine ? IV Contrast The presence of iodinated contrast agents amplifies DNA radiation damage in computed tomography 1.Caroline Pathe1,†, 2.Katharina Eble1,†, 3.Daniel Schmitz-Beuting1, 4.Boris Keil 1,2, 5.Bjoern Kaestner1, 6.Maximilian Voelker1, 7.Beate Kleb1, 8.Klaus J. Klose1 and 9.Johannes T. Heverhagen1,* Article first published online: 5 DEC 2011 DOI: 10.1002/cmmi.453 4 6/30/2014 SIEMENS X-CARE BISMUTH SHIELDS Statement approved by AAPM Board of Directors, Feb 2012 – Policy Date: 02/07/2012 AAPM Position Statement on the Use of Bismuth Shielding for the Purpose of Dose Reduction in CT scanning Policy Text: Bismuth shields are easy to use and have been shown to reduce dose to anterior organs in CT scanning . However, there are several disadvantages associated with the use of bismuth shields, especially when used with automatic exposure control or tube current modulation . Other techniques exist that can provide the same level of anterior dose reduction at equivalent or superior image quality that do not have these disadvantages. The AAPM recommends that these alternatives to bismuth shielding be carefully considered, and implemented when possible . SPR 2014 Alternatives to bismuth shields X-Care Automated Tube Current Modulation x, y, z Is the examination indicated? ALARA /? AHARA ?BRAS- Turns out yes PET/MR State of the art and future trends NEUROIMAGING WHY PET/MR? Seizures Lesions may be subtle Know the location of focus ?EMR Focal Cortical Dysplasia Combines advantages of multiple modalities Increased Cortical Thickness Blurring of Cortical-WM Junction Anatomy Perfusion Indications Heavy T1 Diffusion Cancer Multiple Planes Flow Function Staging Restaging Treatment Response Therapy Significantly lower radiation exposure than PET/CT Biopsy Surgery Thin Images Include FLAIR, T2 Planning Refractory Magnetization Transfer T1 Susceptibility GRE/SWI PET/MR Epilepsy 5 6/30/2014 ACUTE ISCHEMIC STROKE NEONATAL HIE CHILDHOOD STROKE ACUTE Neonatal Acute Ischemic Stroke Child Acute Ischemic Stroke Neonatal Cerebral Sinovenous Thrombosis Child Cerebral Sinovenous Thrombosis Dehydration Head & neck Infections Trauma Tumor Therapy Clotting Disorders ISCHEMIC STROKE CHILDHOOD Chickenpox-”Transient Cerebral Narrowing of Proximal MCA Arteriopathy” Basal Ganglia Infarct Within Months of Infection Multimodality Evaluation MRI MRA/CTA Catheter Angiography MRU MR UROGRAPHY MRU ANATOMIC T2 DYNAMIC CONTRAST ENHANCED IMAGING NONCONTRAST T2 FUNCTIONAL DIFFERENTIAL RENAL FUNCTION INDIVIDUAL KIDNEY GFR SIGNAL INTENSITY VS TIME CURVES Utricle Abnormal urethra 2 y/o 2009 Urinary Tract Obstruction T2 Post Pyeloplasty Evaluation From Prostatic Urethra Incontinence Ambiguous Genitalia “Vagina Like “ MRU Clinical Indications Ectopic Ureter Renal Scarring and Dysplasia Renal Masses Anatomic Definition of Congenital Anomalies MIDLINE SAGITAL 6 6/30/2014 Driver LIVER MR ELASTOGRAPHY • MR ELASTOGRAPHY INDICATIONS DISTINGUISH STEATOHEPATITIS FROM SIMPLE STEATOSIS STAGING FIBROSIS IN CHRONIC LIVER DISEASE BENIGN VS MALIGNANT TUMOR PEDIATRIC ADNEXAL MASSES Active Driver Passive Driver THE END Ovarian Torsion Ovaries are usually seen on CT If is not ENLARGED it is NOT torsed In a female of menstruating age normal ovarian follicles can be up to 5 cm No need to do CT after US for torsion if Ovaries are not enlarged No Need to do CT after US for ovarian Cysts < 5 cm 7