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BPRIG 1998 Abstracts
FLAIR in the Paediatric Brain: Experience with a low field MR System
PURPOSE To assess the strengths and weaknesses of the fluid attenuated inversion recovery (FLAIR) sequence in paediatric neuroimaging.
MATERIALS AND METHODS: Review of paediatric brain scans which include a FLAIR sequence. All scans performed on a Picker 0.23T Outlook system.
Comparison is made with standard sequences to assess any advantage or disadvantage in using FLAIR sequences to identify pathology.
CONCLUSIONS: FLAIR sequences are useful in several pathologies, particularly intraventricular tumours and brain injury. In some circumstances they are not helpful, such as evaluation of the premature brain.
Appropriate uses of FLAIR sequences will be illustrated, and some inappropriate uses.
THE ROLE OF THE PLAIN FILM AND RENAL TRACT ULTRASOUND IN THE MANAGEMENT
OF CHILDREN WITH UROLITHIASIS
S L Smith, J M Somers, N Broderick, K Halliday
Dept of Radiology, Nottingham City Hospital, Hucknall Road, Nottingham, UK
Both the Royal College of Radiologists and the Royal College of Paediatrics and Child Health recommend the use of plain abdominal radiographs in the initial management of children with possible urinary tract calculi. In our institution renal tract ultrasound is the primary imaging modality. The aim of this study was to assess the relative efficacy of plain abdominal radiographs and detailed renal tract ultrasound examination in the diagnosis of urolithiasis.
We performed a retrospective study of patients aged 15 years and under with urinary tract calculi who presented at our hospital between April 1993 and June 1998. We reviewed the record of 27 patients (20 males, 7 females), all of who had proven renal tract calculi.
The mean age at presentation was 6.5 years with a range of 2 to 15 years. 8 patients (30%) presented with abdominal pain and 4 (15%) with unexplained urinary tract infection. Plain films were performed as the first investigation in 8 patients (30%) and ultrasound in 7 patients (26%). In a further 8 (30%) ultrasound was performed as the initial investigation and a plain radiograph was obtained at the same attendance.
10 patients (37%) were treated with lithotripsy and a further 10 (37%) by surgery 1 (4%) received no active intervention and 3 (12%) had both lithotripsy and surgery. All patients were followed up with ultrasound and a proportion had further plain films
All renal calculi (100%) visible on plain films were demonstrated on ultrasound. Furthermore ultrasound frequently detected more calculi than were visible on plain radiographs and gave a better indication of their size and distribution. Detailed ultrasound also provided other significant information, such as renal size, the presence or absence of cortical scarring and any underlying structural abnormalities, which were not apparent on plain films. There was one false positive ultrasound diagnosis of a renal calculus that was not demonstrated on plain films.
EVALUATION OF FACTORS WHICH INFLUENCE IMAGE QUALITY AND DOSE
AN APPRAISAL OF THE CEC GUIDELINES
J.V. Cook K. Shah, S. Pablot,
Queen Marys’ Hospital for Children, Carshalton.
J. Kyriou, A. Pettett and M. Fitzgerald,
Radiological Protection Centre, St. George’s Hospital.
The CEC Guidelines are an attempt to define what characteristics a radiologist would deem necessary to produce an X-ray image which was of diagnostic quality. The criteria published are a combination of positioning and resolution criteria with doses given, above which corrective action should be considered.
3000 dose readings were taken at 2 general hospitals and 2 hospitals for children and compared. Approximately 100 representative radiographs were then selected at each centre and image quality assessed according to the CEC criteria. Over 90% of the radiographs met the criteria, although this did not always match the subjective assessment of the 2 paediatric radiologists involved. The CEC criteria were expanded to include other positional data and graded. These extended criteria more accurately differentiated between the 4 hospitals and reflected the radiologists views.
Dose readings were within an acceptable range at all 4 hospitals but it was found that the general hospitals could reduce their doses further by improving their positioning techniques whereas the children’s hospitals could reduce their doses by producing diagnostic images rather than aesthetically high quality images for all indications, eg reducing the use of a grid and using faster screen film systems in some follow up examinations.
The CEC guidelines on quality criteria were our initiative and as a result of this study, changes were instituted at one of the children’s hospitals which have resulted in dose savings of up to 50% compared with the initial data and CEC published data without significant loss of quality.
The guidelines of Queen Mary’s Hospital for Children have been published and illustrative examples will be demonstrated.
Imaging of the Nose and Paranasal Sinuses Relevant to
FESS (functional endoscopic sinus surgery)
Recently there has been increased demand for cross-sectional imaging of the nose and paranasal sinuses. The is largely due to the introduction of FESS a new, minimally invasive therapy for sinus disease.
Coronal CT imaging is required, axial images may be helpful in a minorith of patients. Anatomical diagrams and clinical images are presented to demonstrate the anatomy relevant to FESS.
Imaging Paranasal Sinus Pathology
Plain films of the paranasal sinuses have been the mainstay of imaging for many years and are know to have many pitfalls. The advent of CT and MR has allowed the accurate delineation of a wide range of pathologies. These include congenital abnormalities such as choanal atresia, inflammatory disease such as polyps, complex fractures including blow-out and tripod fractures and both benign and malignant tumours. Examples of each lesion will be discussed.
The Role of Imaging in the Management of Salivary Gland Masses in Children
H. Al-Hashimi, S. Abbas, R. Fitzgerald, R. Hayes
Department of Radiology and Paediatric Surgery, Our Lady’s Hospital for Sick Children, Crumlin, Dublin 12
Mass lesions involving the salivary glands in children are uncommon. They occur in <5% of the paediatric patients. Occasionally lesions which are clinically felt to involve the salivary glands, on imaging are shown to be separate from the gland. Due to the complex regional anatomy of the salivary glands, there can be risks associated with salivary gland surgery in particular risk to facial nerve in parotid surgery. The objective of this study was to assess the role of imaging in the management of children with salivary gland masses. We reviewed all radiological examinations performed on 35 children <15 years who were referred between January 1994 and June 1998 for radiological investigation of a salivary gland mass. Investigation included plain films, ultrasound, sialography, computed tomography and MRI. We found that imaging played an important role in the management of salivary gland masses. In the first instance, it helped distinguish between lesions arising from or adjacent to the gland. It also provided vital information regarding regional anatomy and tissue characterisation of these lesions thereby helping in diagnosis and surgical planning.
PROTOCOLS Are they worth the paper they are written on?
Dr D Horton, Dr C C Dobson
Department of Radiology, Hull Royal Infirmary, Anlaby Road, Kingston upon Hull, East Yorkshire, HU3 2JZ
Protocols and investigation plans are an increasing part of the working practice of all radiologists. They offer an opportunity to provide a uniform service to agreed standards, particularly in a health service under pressure from health targets and league tables. The best protocols are written and agreed by all the participants. However, this collective ownership is no guarantee that all will run smoothly.
In our institution, a large DGH, we created a protocol for the investigation of UTIs in children based on the work of the BPRIG. This was agreed by all paediatricians at a rare meeting when all were present. The protocol was put into place in June 1996. Subjectively all seemed to be going well, as for the first time there was uniformity and a documented evidence base to the investigation of these children. We wished to obtain objective figures and so audited the investigation of UTI in children under 7 years of age.
We reviewed all request cards and results for ultrasound and MCU investigations between 01.07.1996 and 31.6.1997 and radionuclide studies between 01.06.1996 and 01.01.1998 to allow for their longer waiting lists.
There were 303 urinary tract ultrasound scans in the study period. We restricted the audit to those where UTI was the only indication. The study population was 134 children, 56 under the age of 2 years. The full protocol will be discussed. By the protocol all under 2s should have MCU and DMSA as well as their U/S. The 2-7 age group should have DMSA as well as U/S.
Results and Discussion
The full results will be given and discussed though the main finding was that the investigations met the agreed protocols in 30% of the under 2s and 37% of the 2-7 age group.
This was a significant shortfall. The paediatricians believed this was due to inappropriate entry into the protocol by inexperienced juniors, whose requests were cancelled by the consultant at the next outpatient attendance. We assessed this by re-auditing those children with an abnormal U/S, who should have completed the protocol whoever entered them into it.
The completion of the protocol increased to just 46% of the under 2s and 38% of the 2-7 age group.
The reasons why the protocol should fail in such a spectacular way are still unclear. The bureaucracy of organising separate investigations must play some part however. The paediatricians are examining there own practices whilst we in the radiology department are preparing to take complete control of the protocol by organising the whole thing “in house” for a trial period, which will then be re-audited. The new system will be outlined.
The UTI protocol was the most discussed and widely agreed of all the protocols running in the department. These results do not bode well for the success of the others.
Even widely agreed and “owned” protocols may fail.
Close audit is essential.
Imaging protocols may only work if the radiology department take full control of them.
AUDIT OF ADHERENCE TO PAEDIATRIC ONCOLOGY IMAGING PROTOCOLS.
Dr S Hegarty, Dr J Fairhurst
Department of Paediatric Radiology, Southampton University Hospitals NHS Trust
Over a three year period, 36 patients with a childhood cancer presented to our hospital. The radiological investigations at presentation were reviewed, to determine how closely they conformed to those laid down in the treatment protocols drawn up by the United Kingdom Children’s Cancer Study Group.
We found that there was failure to comply fully with any imaging protocol. Adherence to protocol determined by imaging modality ranged from 91% for abdominal ultrasound, to 56% for MRI.
The reasons for this include not only limited resources, as in the case of MRI imaging, but also some overlap in the diagnostic information obtained by different imaging modalities. In the interests of keeping the dose of ionising radiation low in children, particularly in those requiring multiple imaging investigations, review of the imaging protocols would be useful.
How Useful are Cervical Spine Radiographs in Paediatric Trauma?
D.M.G. Buckley, N.J. Broderick, K.E. Halliday, J.M. Somers
Department of Radiology, Queens Medical Centre, Nottingham, UK
Aim: To assess the value of cervical spine radiographs performed for trauma in children aged ten years and under.
Methods: All cervical spine examinations carried out in patients aged ten and under in the Children’s A&E Department of Queens Medical Centre, Nottingham in 1997 were reviewed. Radiographs performed for reasons other than trauma were excluded. Films were assessed for technical quality and radiological abnormality. In cases where the film was not available the report was reviewed.
Results: 251 examinations were performed. Of these the plain films of 196 were reviewed. There was no evidence of any fracture or significant spinal cord injury. In the remaining 55 review of their reports or clinical course also revealed no significant injury. 33% of lateral films, 34% of peg views and 12% of AP films were repeated or technically inadequate.
Conclusion: No significant injury was identified in this study despite 251 examinations being performed. These films are often difficult to obtain and this is reflected in the high proportion of technically inadequate examination. It is recommended that cervical spine radiographs should only be performed in children who have sustained a high force injury or those with definite clinical signs or symptoms