Retrospective study of cumulative diagnostic radiation exposure during childhood in patients with spina bifida

Establishing proof of concept for sonolucent cranioplasty and point of care ultrasound imaging after posterior fossa decompression for Chiari malformation

BACKGROUND

Evaluation after posterior fossa decompression for Chiari malformation can require repeated imaging, particularly with persistent symptoms. Typically, CT or MRI is used. However, CT carries radiation risk and MRI is costly. Ultrasound is an inexpensive, radiation-free, point-of-care modality that has, thus far, been limited by intact skull and traditional cranioplasty materials. Ultrasound also allows for imaging in different head positions and body postures, which may lend insight into cause for persistent symptoms despite adequate decompression on traditional neutral static CT or MRI. We evaluate safety and feasibility of ultrasound as a post-operative imaging modality in patients reconstructed with sonolucent cranioplasty during posterior fossa decompression for Chiari malformation.

METHODS

Outcomes were analyzed for 26 consecutive patients treated with a Chiari-specific sonolucent cranioplasty. This included infection, need for revision, CSF leak, and pseudomeningocele. Ultrasound was performed point-of-care in the outpatient clinic by the neurosurgery team to assess feasibility.

RESULTS

In eight months mean follow up, there were no surgical site infections or revisions with this novel sonolucent cranioplasty. Posterior fossa anatomy was discernable via transcutaneous ultrasound obtained point-of-care in the clinic setting at follow up visits.

CONCLUSION

We demonstrate proof of concept for ultrasound as a post-operative imaging modality after posterior fossa decompression for Chiari malformation. With further investigation, ultrasound may prove to serve as an alternative to CT and MRI in this patient population, or as an adjunct to provide positional and dynamic information. Use of sonolucent cranioplasty is safe. This technique deserves further study.

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

BACKGROUND

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE

To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS

Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS

Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION

Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

Ionizing Radiation Exposure in Pediatric Patients With Intestinal Failure

BACKGROUND

Children with intestinal failure (IF) are frequently exposed to imaging studies using ionizing radiation. Due to many advancements in care of pediatric patients with IF, the number of patients living with this condition is growing. This burden of disease as pertains to pediatric IF patients has not been previously described.

METHODS AND RESULTS

10 patients in a multidisciplinary clinic for IF were included in a retrospective review of ionizing imaging studies. Ages ranged from 2-6 years old. The average number of studies performed exposing patients to ionizing radiation was 69.1 (±41.0). A majority of the studies were plain radiographs. Fluoroscopy studies were common. The Computed tomography scans were less common. An average of 31% (±25.7%) of these studies were obtained before the first discharge from the hospital.

CONCLUSIONS

While survival and outcomes of IF patients continue to improve, it is important to consider the impact of radiation-related exposure to which this population is frequently subjected. Long-term follow-up will be necessary to determine whether or not this translates to increased risks or complications in this already vulnerable patient population.

Minimizing Medical Radiation Exposure by Incorporating a New Radiation "Vital Sign" into the Electronic Medical Record: Quality of Care and Patient Safety

There is a clearly perceived and imminent need to decrease unnecessary and detrimental exposure to medical ionizing radiation. We propose a new radiation "vital sign" that incorporates cumulative radiation exposure to create a risk score on the basis of an individualized assessment of potential harm from additional exposure to medical radiation. We propose to then tie the risk score to real-time, evidence-based, clinical decision support for procedures that use ionizing radiation. Additionally, we offer recommendations that minimize unnecessary or low-yield uses. Preference is given to approaches and modalities that use less or no ionizing radiation and that are medically appropriate, acceptable to, and safer for patients.