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Cortes-Albornoz MC, Calixto C, Bedoya MA, Didier RA, Estroff JA, Jaimes C. Fetal Brain Growth in the Early Second Trimester. AJNR Am J Neuroradiol 2023; 44:1440-1444. [PMID: 37973183 PMCID: PMC10714857 DOI: 10.3174/ajnr.a8051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND PURPOSE Recent advances in fetal MR imaging technology have enabled acquisition of diagnostic images in the early second trimester. Interpretation of these examinations is limited by a lack of familiarity with the developmental changes that occur during these early stages of growth. This study aimed to characterize normal fetal brain growth between the 12th and 20th weeks of gestational age. MATERIALS AND METHODS This study was conducted as an observational retrospective analysis. Data were obtained from a tertiary care center's PACS database. All fetuses included had late fetal MR imaging (>20 weeks) or postnatal MR imaging, which confirmed normality. Each MR image was manually segmented, with ROIs placed to calculate the volume of the supratentorial parenchyma, brainstem, cerebellum, ventricular CSF, and extra-axial CSF. A linear regression analysis was used to evaluate gestational age as a predictor of the volume of each structure. RESULTS Thirty-one subjects with a mean gestational age of 17.23 weeks (range, 12-19 weeks) were studied. There was a positive, significant association between gestational age and intracranial, supratentorial parenchyma; brainstem cerebellum; intraventricular CSF; and extra-axial CSF volumes (P < .001). Growth was fastest in the supratentorial parenchyma and extra-axial CSF. Fetal sex was not associated with the volume in any of the ROIs. CONCLUSIONS This study demonstrates distinct trajectories for the major compartments of the fetal brain in the early second trimester. The fastest growth rates were observed in the supratentorial brain and extra-axial CSF.
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Affiliation(s)
- Maria Camila Cortes-Albornoz
- From the Department of Radiology (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston Children's Hospital, Boston, Massachusetts
- Department of Radiology (M.C.C.-A., C.J.), Massachusetts General Hospital, Boston, Massachusetts
- Pediatric Imaging Research Center (M.C.C.-A., C.J.), Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston, Massachusetts
| | - Camilo Calixto
- From the Department of Radiology (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston, Massachusetts
| | - M Alejandra Bedoya
- From the Department of Radiology (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston Children's Hospital, Boston, Massachusetts
- Maternal Fetal Care Center (M.A.B., R.A.D., J.A.E.), Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston, Massachusetts
| | - Ryne A Didier
- From the Department of Radiology (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston Children's Hospital, Boston, Massachusetts
- Maternal Fetal Care Center (M.A.B., R.A.D., J.A.E.), Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston, Massachusetts
| | - Judy A Estroff
- From the Department of Radiology (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston Children's Hospital, Boston, Massachusetts
- Maternal Fetal Care Center (M.A.B., R.A.D., J.A.E.), Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston, Massachusetts
| | - Camilo Jaimes
- From the Department of Radiology (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston Children's Hospital, Boston, Massachusetts
- Department of Radiology (M.C.C.-A., C.J.), Massachusetts General Hospital, Boston, Massachusetts
- Pediatric Imaging Research Center (M.C.C.-A., C.J.), Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School (M.C.C.-A., C.C., M.A.B., R.A.D., J.A.E., C.J.), Boston, Massachusetts
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Didier RA, Estroff JA. Fetal MRI: Counterpoint-3 T Is Truly Terrific If You Try! AJR Am J Roentgenol 2023; 221:584-585. [PMID: 37255037 DOI: 10.2214/ajr.23.29564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Ryne A Didier
- Maternal Fetal Care Center, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115
| | - Judy A Estroff
- Maternal Fetal Care Center, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115
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Larson AC, Sridharan A, Moon JK, Agarwal D, Chang J, Wallace KD, Forsberg F, Didier RA. Contrast-enhanced subharmonic aided pressure estimation for assessment of intracranial pressure in vivo. Pediatr Radiol 2023; 53:1640-1647. [PMID: 37062765 DOI: 10.1007/s00247-023-05637-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring in children currently requires invasive techniques. Subharmonic aided pressure estimation (SHAPE) uses contrast-enhanced ultrasound (CEUS) to measure intravascular and interstitial pressure, but utility in ICP measurements has yet to be explored. OBJECTIVE The objective of this study was to investigate SHAPE as a novel tool for noninvasive ICP measurements in fetal lambs. MATERIALS AND METHODS Eighteen fetal lambs at 107-139 days gestational age (term = 145 days) underwent subdural ICP catheter placement. The brain was imaged in the coronal plane in CEUS mode optimized for SHAPE, while infusing an US contrast agent into the fetal circulation. After SHAPE calibration, saline was infused via the subdural catheter to increase ICP. Five-second SHAPE cine clips were obtained at various ICPs. Subharmonic intensity values of the whole brain and thalami were correlated with ICP values using mixed effects linear regression analyses and the strength of the relationship was evaluated by Spearman's rank-order correlation. RESULTS Forty-nine experiments produced 723 datapoints, including SHAPE intensity values and mean ICP measurements. There was a statistically significant inverse relationship between SHAPE intensity values and ICP measurements in the whole brain and thalami (median rho value - 0.58 and - 0.56, respectively). CONCLUSION SHAPE intensity values of the brain demonstrate an inverse and statistically significant correlation with in vivo ICP measurements in an animal model.
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Affiliation(s)
- Abby C Larson
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - James K Moon
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Divyansh Agarwal
- Perelmen School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Chang
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryne A Didier
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Perelmen School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Khalek N, Gebb JS, Soni S, Hwang R, Teefey CP, Didier RA, Moldenhauer JS. Optimal timing for selective cord occlusion in monochorionic pregnancies complicated by selective fetal growth restriction. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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De Bie FR, Didier RA, Halline C, Sridharan A, Larson A, Kotzur T, Hayes K, Chang J, Khan S, Russo FM, Deprest J, Hedrick H, Partridge E. Nitrofen rat model of congenital diaphragmatic hernia demonstrates increased lung stiffness using shear wave elastography. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Gebb JS, Hwang R, Soni S, Teefey CP, Rychik JR, Didier RA, Moldenhauer JS, Khalek N. Recipient cardiac dysfunction does not increase risk for demise after laser for Twin-Twin Transfusion Syndrome. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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De Bie FR, Halline C, travis Kotzur, kevin Hayes, Chang J, Larson A, sameer Khan, Didier RA, Sridharan A, Russo F, Deprest J, Hedrick H, Partridge E. Prenatal treprostinil improves the pulmonary hypertensive phenotype in the nitrofen model of congenital diaphragmatic hernia. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Lawrence KM, Coons BE, Sridharan A, Davey MG, Flake AW, Didier RA. Contrast-Enhanced Brain Ultrasound Perfusion Metrics in the EXTra-Uterine Environment for Neonatal Development (EXTEND): Correlation With Hemodynamic Parameters. J Ultrasound Med 2021; 40:2571-2579. [PMID: 33512029 DOI: 10.1002/jum.15642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/31/2020] [Accepted: 01/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Contrast-enhanced ultrasound (CEUS) can provide quantitative perfusion metrics and may be useful to detect cerebral pathology in neonates and premature infants, particularly in extrauterine environments. The effect of hemodynamics on cerebral perfusion metrics is unknown, which limits the clinical application of this technology. We aimed to determine associations between systemic hemodynamics and concurrently measured brain perfusion parameters in an animal model of extrauterine support. METHODS Nine fetal lambs were transferred to an extrauterine support device. Lumason® ultrasound contrast (0.1-0.3 ml) was administered via the umbilical vein and 90-second cine clips were obtained. Time-intensity-curves (TICs) were generated and time-dependent and area-under-curve (AUC) parameters were derived. Associations between brain perfusion metrics and hemodynamics including heart rate (HR) and mean arterial pressure (MAP) were evaluated by multilevel linear mixed-effects models. RESULTS Eighty-six ultrasound examinations were performed and 72 examinations were quantifiable. Time-dependent measurements were independent of all hemodynamic parameters (all p ≥.05). Oxygen delivery and mean blood flow were correlated with AUC measurements (all p ≤.01). Physiologic HR and MAP were not correlated with any measurements (all p ≥.05). CONCLUSION Detected aberrations in time-dependent CEUS measurements are not correlated with hemodynamic parameters and are thought to reflect the changes in cerebral blood flow, thus providing a promising tool for evaluation of brain perfusion. CEUS brain perfusion parameters are not correlated with physiologic HR and MAP, but AUC-dependent measurements are correlated with oxygen delivery and blood flow, suggesting that CEUS offers additional value over standard monitoring. Overall, these findings enhance the applicability of this technology.
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Affiliation(s)
- Kendall M Lawrence
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA
| | - Barbara E Coons
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA
| | - Anush Sridharan
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marcus G Davey
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryne A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Didier RA, Oliver ER, Rungsiprakarn P, Debari SE, Adams SE, Hedrick HL, Adzick NS, Khalek N, Howell LJ, Coleman BG. Decreased neonatal morbidity in 'stomach-down' left congenital diaphragmatic hernia: implications of prenatal ultrasound diagnosis for counseling and postnatal management. Ultrasound Obstet Gynecol 2021; 58:744-749. [PMID: 33724570 DOI: 10.1002/uog.23630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/15/2021] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the influence of stomach position on postnatal outcome in cases of left congenital diaphragmatic hernia (CDH) without liver herniation, diagnosed and characterized on prenatal ultrasound (US), by comparing those with ('stomach-up' CDH) to those without ('stomach-down' CDH) intrathoracic stomach herniation. METHODS Infants with left CDH who underwent prenatal US and postnatal repair at our institution between January 2008 and March 2017 were eligible for inclusion in this retrospective study. Detailed prenatal US examinations, fetal magnetic resonance imaging (MRI) studies, operative reports and medical records of infants enrolled in the pulmonary hypoplasia program at our institution were reviewed. Cases with liver herniation and those with an additional anomaly were excluded. Cases in which bowel loops were identified within the fetal chest on US while the stomach was intra-abdominal were categorized as having stomach-down CDH. Cases in which bowel loops and the stomach were visualized within the fetal chest on US were categorized as having stomach-up CDH. Prenatal imaging findings and postnatal outcomes were compared between the two groups. RESULTS In total, 152 patients with left CDH were initially eligible for inclusion. Seventy-eight patients had surgically confirmed liver herniation and were excluded. Of the 74 included CDH cases without liver herniation, 28 (37.8%) had stomach-down CDH and 46 (62.2%) had stomach-up CDH. Of the 28 stomach-down CDH cases, 10 (35.7%) were referred for a suspected lung lesion. Sixty-eight (91.9%) cases had postnatal outcome data available for analysis. There was no significant difference in median observed-to-expected (o/e) lung-area-to-head-circumference ratio (LHR) between cases with stomach-down CDH and those with stomach-up CDH (41.5% vs 38.4%; P = 0.41). Furthermore, there was no difference in median MRI o/e total lung volume (TLV) between the two groups (49.5% vs 44.0%; P = 0.22). Compared with stomach-up CDH patients, stomach-down CDH patients demonstrated lower median duration of intubation (18 days vs 9.5 days; P < 0.01), median duration of extracorporeal membrane oxygenation (495 h vs 223.5 h; P < 0.05), rate of supplemental oxygen requirement at 30 days of age (20/42 (47.6%) vs 3/26 (11.5%); P < 0.01) and rate of pulmonary hypertension at initial postnatal echocardiography (28/42 (66.7%) vs 9/26 (34.6%); P = 0.01). No neonatal death occurred in stomach-down CDH patients and one neonatal death was seen in a patient with intrathoracic stomach herniation. CONCLUSIONS In infants with left CDH without liver herniation, despite similar o/e-LHR and o/e-TLV, those with stomach-down CDH have decreased neonatal morbidity compared to those with stomach herniation. Progressive or variable physiological distension of the stomach over the course of gestation may explain these findings. Stomach-down left CDH is mistaken for a lung mass in a substantial proportion of cases. Accurate prenatal US characterization of CDH is crucial for appropriate prenatal counseling and patient management. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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MESH Headings
- Adult
- Cephalometry
- Female
- Fetus/diagnostic imaging
- Fetus/pathology
- Head/diagnostic imaging
- Head/pathology
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/embryology
- Infant, Newborn, Diseases/pathology
- Lung/diagnostic imaging
- Lung/embryology
- Lung/pathology
- Magnetic Resonance Imaging
- Male
- Morbidity
- Pregnancy
- Retrospective Studies
- Stomach/diagnostic imaging
- Stomach/embryology
- Stomach/pathology
- Ultrasonography, Prenatal
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Affiliation(s)
- R A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E R Oliver
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - P Rungsiprakarn
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Debari
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Adams
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - H L Hedrick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Khalek
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L J Howell
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B G Coleman
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Didier RA, Biko DM, Hwang M, Unnikrishnan S, Woźniak MM, Yusuf GT, Sridharan A. Emerging contrast-enhanced ultrasound applications in children. Pediatr Radiol 2021; 51:2418-2424. [PMID: 33791840 DOI: 10.1007/s00247-021-05045-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/27/2021] [Accepted: 03/01/2021] [Indexed: 11/25/2022]
Abstract
Ultrasound contrast agent (UCA) use in radiology is expanding beyond traditional applications such as evaluation of liver lesions, vesicoureteral reflux and echocardiography. Among emerging techniques, 3-D and 4-D contrast-enhanced ultrasound (CEUS) imaging have demonstrated potential in enhancing the accuracy of voiding urosonography and are ready for wider clinical adoption. US contrast-based lymphatic imaging has been implemented for guiding needle placement in MR lymphangiography in children. In adults, intraoperative CEUS imaging has improved diagnosis and assisted surgical management in tumor resection, and its translation to pediatric brain tumor surgery is imminent. Because of growing interest in precision medicine, targeted US molecular imaging is a topic of active preclinical research and early stage clinical translation. Finally, an exciting new development in the application of UCA is in the field of localized drug delivery and release, with a particular emphasis on treating aggressive brain tumors. Under the appropriate acoustic settings, UCA can reversibly open the blood-brain barrier, allowing drug delivery into the brain. The aim of this article is to review the emerging CEUS applications and provide evidence regarding the feasibility of these applications for clinical implementation.
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Affiliation(s)
- Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Unnikrishnan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Magdalena M Woźniak
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - Gibran T Yusuf
- Department of Radiology, King's College Hospital, Denmark Hill, London, UK
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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Sridharan A, Hwang M, Kutty S, McCarville MB, Paltiel HJ, Piskunowicz M, Shellikeri S, Silvestro E, Taylor GA, Didier RA. Translational research in pediatric contrast-enhanced ultrasound. Pediatr Radiol 2021; 51:2425-2436. [PMID: 33991196 DOI: 10.1007/s00247-021-05095-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/21/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
The role of contrast-enhanced ultrasound (CEUS) imaging is being widely explored by various groups for its use in the pediatric population. Clinical implementation of new diagnostic or therapeutic techniques requires extensive and meticulous preclinical testing and evaluation. The impact of CEUS will be determined in part by the extent to which studies are oriented specifically toward a pediatric population. Rather than simply applying principles and techniques used in the adult population, these studies are expected to advance and augment preexisting knowledge with pediatric-specific information. To further develop this imaging modality for use in children, pediatric-focused preclinical research is essential. In this paper we describe the development and implementation of the pediatric-specific preclinical animal and phantom models that are being used to evaluate CEUS with the goal of clinical translation to children.
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Affiliation(s)
- Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shelby Kutty
- Taussig Heart Center, Johns Hopkins University, Baltimore, MD, USA
| | - M Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Harriet J Paltiel
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Sphoorti Shellikeri
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Elizabeth Silvestro
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - George A Taylor
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Harvard Medical School, Boston, MA, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Hwang M, Back SJ, Didier RA, Lorenz N, Morgan TA, Poznick L, Steffgen L, Sridharan A. Pediatric contrast-enhanced ultrasound: optimization of techniques and dosing. Pediatr Radiol 2021; 51:2147-2160. [PMID: 32955599 DOI: 10.1007/s00247-020-04812-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/08/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022]
Abstract
When performing contrast-enhanced ultrasound (CEUS), ultrasound (US) scanner settings, examination technique, and contrast agent dose and administration must be optimized to ensure that high-quality, diagnostic and reproducible images are acquired for qualitative and quantitative interpretations. When carrying out CEUS in children, examination settings should be tailored to their body size and specific indications, similar to B-mode US. This review article details the basic background knowledge that is needed to perform CEUS optimally in children, including considerations related to US scanner settings and US contrast agent dose selection and administration techniques.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Susan J Back
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Norbert Lorenz
- Children's Hospital, Dresden Municipal Hospital, Teaching-Hospital of Technical University, Dresden, Germany
| | - Trudy A Morgan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Laura Poznick
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Ludwig Steffgen
- Trainings-Zentrum Ultraschall-Diagnostik LS GmbH, Mainleus, Germany
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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Didier RA. Reply. Ultrasound Obstet Gynecol 2021; 58:788. [PMID: 34724267 DOI: 10.1002/uog.24780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- R A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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Ntoulia A, Anupindi SA, Back SJ, Didier RA, Hwang M, Johnson AM, McCarville MB, Papadopoulou F, Piskunowicz M, Sellars ME, Darge K. Contrast-enhanced ultrasound: a comprehensive review of safety in children. Pediatr Radiol 2021; 51:2161-2180. [PMID: 34716453 DOI: 10.1007/s00247-021-05223-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/10/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022]
Abstract
Contrast-enhanced ultrasound (CEUS) has been increasingly used in pediatric radiology practice worldwide. For nearly two decades, CEUS applications have been performed with the off-label use of gas-containing second-generation ultrasound contrast agents (UCAs). Since 2016, the United States Food and Drug Administration (FDA) has approved the UCA Lumason for three pediatric indications: the evaluation of focal liver lesions and echocardiography via intravenous administration and the assessment of vesicoureteral reflux via intravesical application (contrast-enhanced voiding urosonography, ceVUS). Prior to the FDA approval of Lumason, numerous studies with the use of second-generation UCAs had been conducted in adults and children. Comprehensive protocols for clinical safety evaluations have demonstrated the highly favorable safety profile of UCA for intravenous, intravesical and other intracavitary uses. The safety data on CEUS continue to accumulate as this imaging modality is increasingly utilized in clinical settings worldwide. As of August 2021, 57 pediatric-only original research studies encompassing a total of 4,518 children with 4,906 intravenous CEUS examinations had been published. As in adults, there were a few adverse events; the majority of these were non-serious, although very rarely serious anaphylactic reactions were reported. In the published pediatric-only intravenous CEUS studies included in our analysis, the overall incidence rate of serious adverse events was 0.22% (10/4,518) of children and 0.20% (10/4,906) of all CEUS examinations. Non-serious adverse events from the intravenous CEUS were observed in 1.20% (54/4,518) of children and 1.10% (54/4,906) of CEUS examinations. During the same time period, 31 studies with the intravesical use of UCA were conducted in 12,362 children. A few non-serious adverse events were encountered (0.31%; 38/12,362), but these were most likely attributable to the bladder catheterization rather than the UCA. Other developing clinical applications of UCA in children, including intracavitary and intralymphatic, are ongoing. To date, no serious adverse events have been reported with these applications. This article reviews the existing pediatric CEUS literature and provides an overview of safety-related information reported from UCA uses in children.
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Affiliation(s)
- Aikaterini Ntoulia
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Sudha A Anupindi
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan J Back
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ann M Johnson
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Maria E Sellars
- Department of Radiology, King's College Hospital, London, UK
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Hwang M, Barnewolt CE, Jüngert J, Prada F, Sridharan A, Didier RA. Contrast-enhanced ultrasound of the pediatric brain. Pediatr Radiol 2021; 51:2270-2283. [PMID: 33599780 DOI: 10.1007/s00247-021-04974-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/10/2020] [Accepted: 01/14/2021] [Indexed: 12/16/2022]
Abstract
Brain contrast-enhanced ultrasound (CEUS) is an emerging application that can complement gray-scale US and yield additional insights into cerebral flow dynamics. CEUS uses intravenous injection of ultrasound contrast agents (UCAs) to highlight tissue perfusion and thus more clearly delineate cerebral pathologies including stroke, hypoxic-ischemic injury and focal lesions such as tumors and vascular malformations. It can be applied not only in infants with open fontanelles but also in older children and adults via a transtemporal window or surgically created acoustic window. Advancements in CEUS technology and post-processing methods for quantitative analysis of UCA kinetics further elucidate cerebral microcirculation. In this review article we discuss the CEUS examination protocol for brain imaging in children, current clinical applications and future directions for research and clinical uses of brain CEUS.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Carol E Barnewolt
- Department of Radiology, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Jörg Jüngert
- Department of Pediatrics, Friedrich-Alexander University Erlangen - Nürnberg, Erlangen, Germany
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.,Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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16
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Sridharan A, Lawrence KM, Martin-Saavedra JS, Davey MG, Flake AW, Didier RA. Quantitative contrast-enhanced ultrasound of the brain on twin fetal lambs maintained by the extrauterine environment for neonatal development (EXTEND): initial experience. Pediatr Radiol 2021; 51:103-111. [PMID: 32870357 DOI: 10.1007/s00247-020-04797-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/09/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND With the development of an artificial environment to support the extremely premature infant, advanced imaging techniques tested in this extrauterine system might be beneficial to evaluate the fetal brain. OBJECTIVE We evaluated the feasibility of (a) performing contrast-enhanced ultrasound (CEUS) and (b) quantifying normal and decreased brain perfusion in fetal lambs maintained on the extrauterine environment for neonatal development (EXTEND) system. MATERIALS AND METHODS Twin premature fetal lambs (102 days of gestational age) were transferred to the EXTEND system. Twin B was subjected to sub-physiological flows (152 mL/kg/min) and oxygen delivery (15.9 mL/kg/min), while Twin A was maintained at physiological levels. We administered Lumason contrast agent into the oxygenator circuit and performed serial CEUS examinations. We quantified perfusion parameters and generated parametric maps. We also recorded hemodynamic parameters, serum blood analysis, and measurements across the oxygenator. Postmortem MRIs were performed. RESULTS No significant changes in hemodynamic variables were attributable to CEUS examinations. On gray-scale images, Twin B demonstrated ventriculomegaly and progressive parenchymal volume loss culminating in hydranencephaly. By CEUS, Twin B demonstrated decreased peak enhancement and decreased overall parenchymal perfusion when compared to Twin A by perfusion parameters and parametric maps. Changes in perfusion parameters were detected immediately following blood transfusion. Postmortem MRI confirmed ultrasonographic findings in Twin B. CONCLUSION In this preliminary experience, we show that CEUS of the brain is feasible in fetal lambs maintained on the EXTEND system and that changes in perfusion can be quantified, which is promising for the application of CEUS in this extrauterine system supporting the premature infant.
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Affiliation(s)
- Anush Sridharan
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Kendall M Lawrence
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Juan S Martin-Saavedra
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Marcus G Davey
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryne A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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17
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Didier RA, Martin-Saavedra JS, Oliver ER, DeBari SE, Bilaniuk LT, Howell LJ, Moldenhauer JS, Adzick NS, Heuer GG, Coleman BG. Fetal Intraventricular Hemorrhage in Open Neural Tube Defects: Prenatal Imaging Evaluation and Perinatal Outcomes. AJNR Am J Neuroradiol 2020; 41:1923-1929. [PMID: 32943419 DOI: 10.3174/ajnr.a6745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/16/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Fetal imaging is crucial in the evaluation of open neural tube defects. The identification of intraventricular hemorrhage prenatally has unclear clinical implications. We aimed to explore fetal imaging findings in open neural tube defects and evaluate associations between intraventricular hemorrhage with prenatal and postnatal hindbrain herniation, postnatal intraventricular hemorrhage, and ventricular shunt placement. MATERIALS AND METHODS After institutional review board approval, open neural tube defect cases evaluated by prenatal sonography between January 1, 2013 and April 24, 2018 were enrolled (n = 504). The presence of intraventricular hemorrhage and gray matter heterotopia by both prenatal sonography and MR imaging studies was used for classification. Cases of intraventricular hemorrhage had intraventricular hemorrhage without gray matter heterotopia (n = 33) and controls had neither intraventricular hemorrhage nor gray matter heterotopia (n = 229). A total of 135 subjects with findings of gray matter heterotopia were excluded. Outcomes were compared with regression analyses. RESULTS Prenatal and postnatal hindbrain herniation and postnatal intraventricular hemorrhage were more frequent in cases of prenatal intraventricular hemorrhage compared with controls (97% versus 79%, 50% versus 25%, and 63% versus 12%, respectively). Increased third ventricular diameter, specifically >1 mm, predicted hindbrain herniation (OR = 3.7 [95% CI, 1.5-11]) independent of lateral ventricular size and prenatal intraventricular hemorrhage. Fetal closure (n = 86) was independently protective against postnatal hindbrain herniation (OR = 0.04 [95% CI, 0.01-0.15]) and postnatal intraventricular hemorrhage (OR = 0.2 [95% CI, 0.02-0.98]). Prenatal intraventricular hemorrhage was not associated with ventricular shunt placement. CONCLUSIONS Intraventricular hemorrhage is relatively common in the prenatal evaluation of open neural tube defects. Hindbrain herniation is more common in cases of intraventricular hemorrhage, but in association with increased third ventricular size. Fetal closure reverses hindbrain herniation and decreases the rate of intraventricular hemorrhage postnatally, regardless of the presence of prenatal intraventricular hemorrhage.
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Affiliation(s)
- R A Didier
- Department of Radiology (R.A.D., J.S.M-S., E.R.O., S.E.D., L.T.B., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - J S Martin-Saavedra
- Department of Radiology (R.A.D., J.S.M-S., E.R.O., S.E.D., L.T.B., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - E R Oliver
- Department of Radiology (R.A.D., J.S.M-S., E.R.O., S.E.D., L.T.B., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - S E DeBari
- Department of Radiology (R.A.D., J.S.M-S., E.R.O., S.E.D., L.T.B., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - L T Bilaniuk
- Department of Radiology (R.A.D., J.S.M-S., E.R.O., S.E.D., L.T.B., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - L J Howell
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Surgery (L.J.H., J.S.M., N.S.A., G.G.H.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J S Moldenhauer
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery (L.J.H., J.S.M., N.S.A., G.G.H.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery (L.J.H., J.S.M., N.S.A., G.G.H.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - G G Heuer
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery (L.J.H., J.S.M., N.S.A., G.G.H.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - B G Coleman
- Department of Radiology (R.A.D., J.S.M-S., E.R.O., S.E.D., L.T.B., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Fetal Diagnosis and Treatment (R.A.D., E.R.O., S.E.D., L.T.B., L.J.H., J.S.M., N.S.A., G.G.H., B.G.C.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (R.A.D., E.R.O., L.T.B., J.S.M., N.S.A., G.G.H., B.G.C.), University of Pennsylvania, Philadelphia, Pennsylvania
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18
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McGovern PE, Hornick MA, Mejaddam AY, Lawrence K, Schupper AJ, Rossidis AC, Baumgarten H, Vossough A, Didier RA, Kim A, Partridge EA, Hwang G, Young K, Peranteau WH, Davey MG, Flake AW. Neurologic outcomes of the premature lamb in an extrauterine environment for neonatal development. J Pediatr Surg 2020; 55:2115-2123. [PMID: 32014247 DOI: 10.1016/j.jpedsurg.2019.12.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/14/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE Neurologic injury remains the most important morbidity of prematurity. Those born at the earliest gestational ages can face a lifetime of major disability. Perinatal insults result in developmental delay, cerebral palsy, and other profound permanent neurologic impairments. The EXTracorporeal Environment for Neonatal Development (EXTEND) aims to transition premature neonates through this sensitive period, but it's impact on neurologic development requires analysis. METHODS Fetal sheep were maintained in a fluid-filled environment for up to 28 days. Physiologic parameters were measured continuously; tissues were subsequently fixed and preserved for myelin quantification, glial cell staining, and structural assessment via magnetic resonance. Surviving animals were functionally assessed. RESULTS No evidence of fetal brain ischemia or white matter tract injury associated with the EXTEND system was detected, and the degree of myelination was regionally appropriate and consistent with age matched controls. No evidence of neurologic injury or immaturity was visible on magnetic resonance; animals that transitioned from the system had no persistent neurologic deficits. CONCLUSIONS No evidence of major neurologic morbidity was found in animals supported on the EXTEND system, though more work needs to be done in order to verify its safety during critical periods of neurologic development.
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Affiliation(s)
- Patrick E McGovern
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew A Hornick
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ali Y Mejaddam
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kendall Lawrence
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander J Schupper
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Avery C Rossidis
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heron Baumgarten
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryne A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aimee Kim
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Grace Hwang
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen Young
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marcus G Davey
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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19
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Oliver ER, DeBari SE, Didier RA, Johnson AM, Khalek N, Peranteau WH, Howell LJ, Adzick NS, Coleman BG. Two's Company: Multiple Thoracic Lesions on Prenatal US and MRI. Fetal Diagn Ther 2020; 47:642-652. [PMID: 32599594 DOI: 10.1159/000507783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestrations (BPS), and CPAM-BPS hybrid lesions are most commonly solitary; however, >1 lung congenital lung lesion may occur. OBJECTIVES To assess the frequency of multiple congenital thoracic anomalies at a high-volume referral center; determine prenatal ultrasound (US) and magnetic resonance imaging (MRI) features of these multifocal congenital lung lesions that may allow prenatal detection; and determine the most common distribution or site of origin. METHODS Database searches were performed from August 2008 to May 2019 for prenatally evaluated cases that had a final postnatal surgical diagnosis of >1 congenital lung lesion or a lung lesion associated with foregut duplication cyst (FDC). Lesion location, size, echotexture, and signal characteristics were assessed on prenatal imaging and correlated with postnatal computed tomographic angiography and surgical pathology. -Results: Of 539 neonates that underwent surgery for a thoracic lesion, 35 (6.5%) had >1 thoracic abnormality. Multiple discrete lung lesions were present in 19 cases, and a lung lesion associated with an FDC was present in 16. Multifocal lung lesions were bilateral in 3 cases; unilateral, multilobar in 12; and, unilobar multisegmental in 4. Median total CPAM volume/head circumference ratio for multifocal lung lesions on US was 0.66 (range, 0.16-1.80). Prenatal recognition of multifocal lung lesions occurred in 7/19 cases (36.8%). Lesion combinations were CPAM-CPAM in 10 cases, CPAM-BPS in 5, CPAM-hybrid in 2, hybrid-hybrid in 1, and hybrid-BPS in 1. Of 5 unilateral, multifocal lung lesions, multifocality was prenatally established through identification of a band of normal intervening lung or intrinsic differences in lesion imaging features. CONCLUSIONS Although less common, multiple thoracic abnormalities can be detected prenatally. Of multifocal lung lesions, the most common combination was CPAM-CPAM, with a unilateral, multilobar distribution. Prenatal recognition is important for pregnancy counseling and postnatal surgical management.
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Affiliation(s)
- Edward R Oliver
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA, .,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, .,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Suzanne E DeBari
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryne A Didier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ann M Johnson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William H Peranteau
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Beverly G Coleman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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20
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Oliver ER, Heuer GG, Thom EA, Burrows PK, Didier RA, DeBari SE, Martin-Saavedra JS, Moldenhauer JS, Jatres J, Howell LJ, Adzick NS, Coleman BG. Myelomeningocele sac associated with worse lower-extremity neurological sequelae: evidence for prenatal neural stretch injury? Ultrasound Obstet Gynecol 2020; 55:740-746. [PMID: 31613408 DOI: 10.1002/uog.21891] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/12/2019] [Accepted: 09/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine whether the presence of a myelomeningocele (MMC) sac and sac size correlate with compromised lower-extremity function in fetuses with open spinal dysraphism. METHODS A radiology database search was performed to identify cases of MMC and myeloschisis (MS) diagnosed prenatally in a single center from 2013 to 2017. All cases were evaluated between 18 and 25 weeks. Ultrasound reports were reviewed for talipes and impaired lower-extremity motion. In MMC cases, sac volume was calculated from ultrasound measurements. Magnetic resonance imaging reports were reviewed for hindbrain herniation. The association of presence of a MMC sac and sac size with talipes and impaired lower-extremity motion was assessed. Post-hoc analysis of data from the multicenter Management of Myelomeningocele Study (MOMS) randomized controlled trial was performed to confirm the study findings. RESULTS In total, 283 MMC and 121 MS cases were identified. MMC was associated with a lower incidence of hindbrain herniation than was MS (80.9% vs 100%; P < 0.001). Compared with MS cases, MMC cases with hindbrain herniation had a higher rate of talipes (28.4% vs 16.5%, P = 0.02) and of talipes or lower-extremity impairment (34.9% vs 19.0%, P = 0.002). Although there was a higher rate of impaired lower-extremity motion alone in MMC cases with hindbrain herniation than in MS cases, the difference was not statistically significant (6.6% vs 2.5%; P = 0.13). Among MMC cases with hindbrain herniation, mean sac volume was higher in those associated with talipes compared with those without talipes (4.7 ± 4.2 vs 3.0 ± 2.6 mL; P = 0.002). Review of the MOMS data demonstrated similar findings; cases with a sac on baseline imaging had a higher incidence of talipes than did those without a sac (28.2% vs 7.5%; P = 0.007). CONCLUSIONS In fetuses with open spinal dysraphism, the presence of a MMC sac was associated with fetal talipes, and this effect was correlated with sac size. The presence of a larger sac in fetuses with open spinal dysraphism may result in additional injury through mechanical stretching of the nerves, suggesting another acquired mechanism of injury to the exposed spinal tissue. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E R Oliver
- Perelman School of Medicine, University of Pennsylvania, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - G G Heuer
- Perelman School of Medicine, University of Pennsylvania, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E A Thom
- The George Washington University Biostatistics Center, Washington, DC, USA
| | - P K Burrows
- The George Washington University Biostatistics Center, Washington, DC, USA
| | - R A Didier
- Perelman School of Medicine, University of Pennsylvania, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E DeBari
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J S Martin-Saavedra
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Jatres
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N S Adzick
- Perelman School of Medicine, University of Pennsylvania, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B G Coleman
- Perelman School of Medicine, University of Pennsylvania, PA, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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21
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McGovern PE, Lawrence K, Baumgarten H, Rossidis AC, Mejaddam AY, Licht DJ, Grinspan J, Schupper A, Rychik J, Didier RA, Vossough A, Spray TL, Peranteau WH, Davey MG, Flake AW, Gaynor JW. Ex Utero Extracorporeal Support as a Model for Fetal Hypoxia and Brain Dysmaturity. Ann Thorac Surg 2019; 109:810-819. [PMID: 31541634 DOI: 10.1016/j.athoracsur.2019.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Congenital heart disease (CHD) is associated with abnormal fetal brain development, a phenomenon that may be related to decreased cerebral oxygen delivery in utero. We used an artificial womb model to test the hypothesis that decreasing fetal oxygen delivery would reproduce physiologic changes identified in fetuses with CHD. METHODS Experimental (hypoxemic) fetal lambs (mean gestational age, 111 ± 3 days; n = 4) and control animals (112 days; n = 5) were maintained in the artificial womb for a mean of 22 ± 6 days. Oxygen delivery was reduced to 15.6 ± 1.0 mL/kg/min in the hypoxemia animals versus 21.6 ± 2.0 mL/kg/min in the control animals. Blood chemistry analysis and sonographic evaluation were performed daily. An additional control group (n = 7) was maintained in utero and harvested for analysis at gestational age 134 ± 4 days. RESULTS Physiologic variables were monitored continuously, and no statistical differences between the groups were identified. Fetal oxygen delivery and arterial partial pressure of oxygen were remarkably lower in the experimental group longitudinally. Increased umbilical artery and decreased middle cerebral artery resistance resulted in a lower cerebral to umbilical resistance ratio, similar to the brain sparing effect observed in human fetuses with CHD. Experimental brains were smaller than control brains in relation to the calvarium on magnetic resonance. CONCLUSIONS Sustained hypoxemia in fetal sheep leads to altered cerebrovascular resistances and loss of brain mass, similar to human fetuses with CHD. This unique model provides opportunities to investigate the pathologic process underlying CHD-associated brain dysmaturity and to evaluate potential fetal neuroprotective therapies.
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Affiliation(s)
- Patrick E McGovern
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kendall Lawrence
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heron Baumgarten
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Avery C Rossidis
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ali Y Mejaddam
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Judith Grinspan
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexander Schupper
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryne A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William H Peranteau
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marcus G Davey
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan W Flake
- The Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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22
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Didier RA, Sridharan A, Lawrence K, Coleman BG, Davey MG, Flake AW. Contrast-Enhanced Ultrasound in Extracorporeal Support: In Vitro Studies and Initial Experience and Safety Data in the Extreme Premature Fetal Lamb Maintained by the Extrauterine Environment for Neonatal Development. J Ultrasound Med 2019; 38:1971-1978. [PMID: 30560564 DOI: 10.1002/jum.14885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To evaluate the effects of ultrasound contrast agent (UCA) administration on hemodynamic parameters and support equipment in in vitro and in vivo models of extracorporeal support. METHODS In vitro, incrementally increasing bolus doses of a UCA were administered proximal to a membrane oxygenator, and ultrasound cine clips were obtained. The rates of microbubble destruction across the oxygenator and over time were calculated from time-intensity-curves. Measurements across the membrane oxygenator were recorded and compared by a repeated-measures analysis of variance. In vivo, 7 premature fetal lambs were transferred from placental support to the extrauterine environment for neonatal development. Contrast agent boluses were administered for contrast-enhanced ultrasound (CEUS) examinations. Hemodynamic parameters and serum laboratory values were evaluated before and after the examinations by paired t tests. For oxygenator staining, oxygenator membranes from the in vitro circuit, study animals (n = 4), and control animals (n = 4) were stained for the adherent UCA. RESULTS In vitro, with all doses (0.1-4 mL), there was no difference in measured parameters across the oxygenator (P ≥ .09). Contrast agent destruction (3%-14%) across the oxygenator was observed at the first pass with a progressive decline in contrast intensity over time. In vivo, there was no difference in hemodynamic parameters or serum laboratory values (P ≥ .08) with any CEUS examination (n = 17). For oxygenator staining, all oxygenator membranes were negative for UCA with lipid staining. CONCLUSIONS The UCA had no detectable effect on the oxygenator or measured parameters in in vitro and in vivo studies, thus providing additional safety data to support the use of CEUS in the setting of extracorporeal support.
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Affiliation(s)
- Ryne A Didier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anush Sridharan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kendall Lawrence
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Beverly G Coleman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marcus G Davey
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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23
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Didier RA, DeBari SE, Oliver ER, Gebb JS, Howell LJ, Hedrick HL, Adzick NS, Coleman BG. Secondary Imaging Findings Aid in Prenatal Diagnosis and Characterization of Congenital Diaphragmatic Hernia: Role of an Abnormal Orientation of Vascular Structures and Gallbladder Position. J Ultrasound Med 2019; 38:1449-1456. [PMID: 30244484 DOI: 10.1002/jum.14823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/23/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To determine whether an abnormal orientation of the abdominal or hepatic vasculature and an abnormal gallbladder position on prenatal ultrasound (US) imaging are associated with intrathoracic liver herniation and postnatal outcomes in cases of congenital diaphragmatic hernia (CDH). METHODS Children who underwent prenatal US examinations and postnatal CDH repair at our institution were eligible. Prenatal US images were reviewed, and the orientation of the superior mesenteric artery (SMA) and hepatic veins as well as gallbladder position were recorded. Findings were correlated with prenatal US measurements (lung-to-head ratio and calculated observed-to-expected lung-to-head ratio) and postnatal outcomes, including intrathoracic liver herniation, an extracorporeal membrane oxygenation (ECMO) requirement, and mortality. RESULTS A total of 175 patients met inclusion criteria. The SMA was shown in 168 cases and had a cephalad orientation in 95.4% (161 of 168), which was not associated with outcome measures and represented bowel herniation. A cephalad orientation of the hepatic veins was identified in 52.6% (90 of 171) and was associated with intrathoracic liver herniation, an ECMO requirement, and mortality (P < .01). In right-sided CDH, the gallbladder was intrathoracic in 91.3% (21 of 23). In left-sided CDH, an abnormal gallbladder position was seen in 51.3% (76/152) and was associated with intrathoracic liver herniation, an ECMO requirement, mortality, and lower lung-to-head ratio and observed-to-expected lung-to-head ratio values. When combined, abnormal hepatic vein and gallbladder positions showed good sensitivity and specificity in predicting intrathoracic liver herniation (area under the curve, 0.93). CONCLUSIONS Abnormal SMA, hepatic vein, and gallbladder positions can be used to improve prenatal characterization of CDH. Accurate depiction of these structures on prenatal US images may aid in patient counseling and postnatal management.
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Affiliation(s)
- Ryne A Didier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Suzanne E DeBari
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juliana S Gebb
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Beverly G Coleman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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24
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Oliver ER, DeBari SE, Adams SE, Didier RA, Horii SC, Victoria T, Hedrick HL, Adzick NS, Howell LJ, Moldenhauer JS, Coleman BG. Congenital diaphragmatic hernia sacs: prenatal imaging and associated postnatal outcomes. Pediatr Radiol 2019; 49:593-599. [PMID: 30635693 DOI: 10.1007/s00247-018-04334-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/19/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The presence of a hernia sac in congenital diaphragmatic hernia (CDH) has been reported to be associated with higher lung volumes and better postnatal outcomes. OBJECTIVE To compare prenatal imaging (ultrasound and MRI) prognostic measurements and postnatal outcomes of CDH with and without hernia sac. MATERIALS AND METHODS We performed database searches from January 2008 to March 2017 for surgically proven cases of CDH with and without hernia sac. All children had a detailed ultrasound (US) examination and most had an MRI examination. We reviewed the medical records of children enrolled in our Pulmonary Hypoplasia Program. RESULTS Of 200 cases of unilateral CDH, 46 (23%) had hernia sacs. Cases of CDH with hernia sac had a higher mean lung-to-head ratio (LHR; 1.61 vs. 1.17; P<0.01), a higher mean observed/expected LHR (0.49 vs. 0.37; P<0.01), and on MRI a higher mean observed/expected total lung volume (0.53 vs. 0.41; P<0.01). Based on a smooth interface between lung and herniated contents, hernia sac or eventration was prospectively questioned by US and MRI in 45.7% and 38.6% of cases, respectively. Postnatally, hernia sac is associated with shorter median periods of admission to the neonatal intensive care unit (45.0 days vs. 61.5 days, P=0.03); mechanical ventilation (15.5 days vs. 23.5 days, P=0.04); extracorporeal membrane oxygenation (251 h vs. 434 h, P=0.04); decreased rates of patch repair (39.0% vs. 69.2%, P<0.01); and pulmonary hypertension (56.1% vs. 75.4%, P=0.03). CONCLUSION Hernia sac is associated with statistically higher prenatal prognostic measurements and improved postnatal outcomes. Recognition of a sharp interface between lung and herniated contents may allow for improved prenatal diagnosis; however, delivery and management should still occur at experienced quaternary neonatal centers.
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Affiliation(s)
- Edward R Oliver
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA.
| | - Suzanne E DeBari
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
| | - Samantha E Adams
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryne A Didier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
| | - Steven C Horii
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Teresa Victoria
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Beverly G Coleman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, USA
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25
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Lawrence KM, McGovern PE, Mejaddam A, Rossidis AC, Baumgarten H, Kim A, Grinspan JB, Licht DJ, Didier RA, Vossough A, Radaelli E, Rychik J, Song L, Peranteau WH, Davey MG, Flake AW, Gaynor JW. Chronic intrauterine hypoxia alters neurodevelopment in fetal sheep. J Thorac Cardiovasc Surg 2019; 157:1982-1991. [PMID: 30745051 DOI: 10.1016/j.jtcvs.2018.12.093] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 12/16/2018] [Accepted: 12/31/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We tested the hypothesis that chronic fetal hypoxia, at a severity present in many types of congenital heart disease, would lead to abnormal neurodevelopment. METHODS Eight mid-gestation fetal sheep were cannulated onto a pumpless extracorporeal oxygenator via the umbilical vessels and supported in a fluid-filled environment for 22 ± 2 days under normoxic or hypoxic conditions. Total parenteral nutrition was provided. Control fetuses (n = 7) were harvested at gestational age 133 ± 4 days. At necropsy, brains were fixed for histopathology. Neurons were quantified in white matter tracts, and the thickness of the external granular layer of the cerebellum was measured to assess neuronal migration. Capillary density and myelination were quantified in white matter. Data were analyzed with unpaired Student t tests or 1-way analysis of variance, as appropriate. RESULTS Oxygen delivery was reduced in hypoxic fetuses (15.6 ± 1.8 mL/kg/min vs 24.3 ± 2.3 mL/kg/min, P < .01), but umbilical blood flow and caloric delivery were not different between the 2 groups. Compared with normoxic and control animals, hypoxic fetuses had reduced neuronal density and increased external granular layer thickness. Compared with normoxic and control animals, hypoxic fetuses had increased capillary density in white matter. Cortical myelin integrity score was lower in the hypoxic group compared with normoxic and control animals. There was a significant negative correlation between myelin integrity and capillary density. CONCLUSIONS Chronic fetal hypoxia leads to white matter hyper-vascularity, decreased neuronal density, and impaired myelination, similar to the neuropathologic findings observed in children with congenital heart disease. These findings support the hypothesis that fetal hypoxia, even in the setting of normal caloric delivery, impairs neurodevelopment.
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Affiliation(s)
- Kendall M Lawrence
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Patrick E McGovern
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ali Mejaddam
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Avery C Rossidis
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Heron Baumgarten
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aimee Kim
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Judith B Grinspan
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ryne A Didier
- Division of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Arastoo Vossough
- Division of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Enrico Radaelli
- Division of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pa
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Limei Song
- Division of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - William H Peranteau
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Marcus G Davey
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Alan W Flake
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa.
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26
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Didier RA, Chow JS, Kwatra NS, Retik AB, Lebowitz RL. The duplicated collecting system of the urinary tract: embryology, imaging appearances and clinical considerations. Pediatr Radiol 2017; 47:1526-1538. [PMID: 29043421 DOI: 10.1007/s00247-017-3904-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/22/2017] [Accepted: 05/11/2017] [Indexed: 10/18/2022]
Abstract
Duplication anomalies of the urinary collecting system are common and can be discovered and characterized with multiple imaging modalities. The embryology, imaging manifestations and clinical ramifications of duplicated ureters and renal collecting systems vary from a normal anatomical variant to urological pathology and are discussed and illustrated in this review.
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Affiliation(s)
- Ryne A Didier
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Neha S Kwatra
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Alan B Retik
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Robert L Lebowitz
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA
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27
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Didier RA, Hopkins KL, Coakley FV, Krishnaswami S, Spiro DM, Foster BR. Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis. Pediatr Radiol 2017. [PMID: 28631157 DOI: 10.1007/s00247-017-3897-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated. OBJECTIVE To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis. MATERIALS AND METHODS We included patients ages 4-18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy. RESULTS Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative. CONCLUSION Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall thickness demonstrate high sensitivities but relatively low specificities. Nonvisualization of the appendix favors a negative diagnosis.
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Affiliation(s)
- Ryne A Didier
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Katharine L Hopkins
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Fergus V Coakley
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Sanjay Krishnaswami
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.,Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - David M Spiro
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Bryan R Foster
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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Pool GM, Didier RA, Bardo D, Selden NR, Kuang AA. Computed tomography-generated anthropometric measurements of orbital relationships in normal infants and children. J Neurosurg Pediatr 2016; 18:201-6. [PMID: 27129093 DOI: 10.3171/2016.2.peds15475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to develop soft-tissue and bony anthropometric orbital measurements in a normal pediatric population based upon CT scans. METHODS This was a retrospective stratified study of children with ages ranging from birth to 36 months. Head CT images for 204 children were available and obtained with 0.625-1-mm slice widths. Soft-tissue and bone windows were reviewed. Images were oriented in the Frankfort horizontal plane, and the intercanthal (IC), bony interorbital (IO), and bony lateral orbital (LO) distances were measured. Age group stratifications were 0-3, > 3-6, > 6-9, > 9-12, > 12-18, > 18-24, > 24-30, and > 30-36 months. Patients with known syndromes or craniofacial abnormalities were excluded. Statistical analysis included the mean, SD, SEM, 95% CI, and an evaluation of IO:LO ratio. RESULTS There was an average of 25.5 patients in each age group (range 25-27 patients). All soft-tissue and bony measurements consistently showed rapid increase from 0-6 months of age, which tapered after age > 12 months. The mean IC, bony IO, and bony LO distances started at 22.22 ± 1.13 mm, 14.16 ± 0.74 mm, and 65.56 ± 1.76 mm, and at 12 months were 27.74 ± 1.01 mm, 16.21 ± 0.75 mm, and 77.98 ± 1.57 mm, respectively. The bony LO position was equivalent to the lateral canthal position and measurements. The IC distance was approximately one-third the lateral canthal distance for all age groups. CONCLUSIONS This study established and reported normal anthropometric orbital measurements in a pediatric population using fine-cut craniofacial CT. These measurements are essential when evaluating children with craniofacial anomalies.
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Affiliation(s)
- Garrett M Pool
- General Surgery, Bassett Medical Center, Cooperstown, New York; and
| | | | | | | | - Anna A Kuang
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon
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Coakley FV, Grant MJ, Behr S, Foster BR, Korngold EK, Didier RA. Imaging of invasive thymoma in the costophrenic recess presenting as thickening of arcuate ligaments of the diaphragm. Clin Imaging 2014; 38:529-531. [PMID: 24629791 DOI: 10.1016/j.clinimag.2014.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/23/2014] [Accepted: 02/03/2014] [Indexed: 11/16/2022]
Abstract
Imaging findings in a patient with invasive thymoma in the costophrenic recess are presented, in whom computed tomography (CT) and MRI revealed lateral arcuate ligament thickening. Increased fluoro-deoxy-glucose (FDG) uptake on subsequent positron emission tomography (PET)/CT was helpful in suggesting the correct diagnosis. A second patient with much more obvious invasive thymoma occurring in the costophrenic recess is presented for comparison. It is a well-known fact that thymic malignancies can metastasize to the pleura even years after resection. Rarely, they may present as focal thickening of the diaphragmatic lateral arcuate ligament.
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Didier RA, Kuang AA, Schwartz DL, Selden NR, Stevens DM, Bardo DME. Decreasing the effective radiation dose in pediatric craniofacial CT by changing head position. Pediatr Radiol 2010; 40:1910-7. [PMID: 20686761 DOI: 10.1007/s00247-010-1788-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/16/2010] [Accepted: 06/30/2010] [Indexed: 10/24/2022]
Abstract
BACKGROUND Children are exposed to ionizing radiation during pre- and post-operative evaluation for craniofacial surgery. OBJECTIVE The primary purpose of the study was to decrease effective radiation dose while preserving the diagnostic quality of the study. MATERIALS AND METHODS In this prospective study 49 children were positioned during craniofacial CT (CFCT) imaging with their neck fully extended into an exaggerated sniff position, parallel to the CT gantry, to eliminate the majority of the cervical spine and the thyroid gland from radiation exposure. Image-quality and effective radiation dose comparisons were made retrospectively in age-matched controls (n = 49). RESULTS When compared to CT scans reviewed retrospectively, the prospective examinations showed a statistically significant decrease in z-axis length by 16% (P < 0.0001) and delivered a reduced effective radiation dose by 18% (P < 0.0001). The subjective diagnostic quality of the exams performed in the prospective arm was maintained despite a slight decrease in the quality of the brain windows. There was statistically significant improvement in the quality of the bone windows and three-dimensional reconstructed images. CONCLUSION Altering the position of the head by extending the neck during pediatric craniofacial CT imaging statistically reduces the effective radiation dose while maintaining the diagnostic quality of the images.
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Affiliation(s)
- Ryne A Didier
- School of Medicine, Oregon Health and Science University, Portland, OR 97239, USA
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