Download View Presentation Document

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