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154
4 Ultrasound of the Neck
a
b
c
Fig. 4.16 Thyroiditis – Basedow/Graves’ disease. ( a ) Inhomogenously enlarged gland. ( b ) CDS
demonstrates massive hypervascularisation (“thyroid inferno”). ( c ) Improved delineation of para-
thyroid gland by CDS in these conditions
a
b
c
Fig. 4.17 Hypothyreosis. ( a ) Axial view: hyperechoic enlarged neonatal thyroid gland in neo-
natal hypothyreosis, callipers for standard measurements of lobe ( 2 , 3 ) and isthmus ( 1 ). ( b )
CDS of the same glands as in ( a ) impressive hypervascularity. ( c ) Goitre with focal nodule
( arrow ), T Trachea
Nodular Goitre
Usually enlarged gland.
• Defi ned by formation of nodules, commonly surrounded by anechoic structures
(increased regional vascularisation – use CDS).
4.3 Pathologic Findings
155
ab
Fig. 4.18 US in different forms of goitre. ( a ) Huge thyroid tumour-like enlargement (+ +) with
focal regressive changes ( arrow ) in familiar Mediterranean fever, dual image technique display.
( b ) Extended view US: huge thyroid adenoma, also focal regressive/degenerative nodule
• Central regressive changes make nodular fi ndings inhomogenous.
• Potentially cysts with fl uid-fl uid level and even calcifi cations, often irregularly
distributed throughout both lobes.
Amyloid Goitre
Usually signifi cant enlargement with multiple nodular pseudotumors (amyloid
tumours) throughout gland, associated with regressive changes (e.g. familiar
Mediterranean fever) (Fig.
4.18a ).
Adenoma/Carcinoma
Focal tumours – adenomas usually produce hormone and lead to hyperthyroidism.
• Single or multiple nodes with varying echotexture and usually sharp margins.
• Varying echotexture – depends on extent of central regressive changes
(Fig. 4.18b ).
• Clear diagnosis cannot be achieved by US.
• Signs of malignancy/carcinoma: infi ltrative behaviour, unclear margins, vascular
disruption and regional nodes. Rare in childhood.
NOTE : US mostly nonspecifi c, diagnosis usually made by combining US fi ndings,
history, laboratory data and potentially scintigraphy and/or biopsy results – hormone status and scintigraphy irreplaceable, sometimes US-guided fi ne needle
biopsy (though less frequently in children than in adults).
4.3.4 Salivary Glands (Parotid, Sublingual,
Submandibular Gland)
4.3.4.1 Inflammation
US: Inhomogenous altered echogenicity and enlargement, nonspecifi c:
• Often from viral infection (mumps, Epstein Barr, CMV) (Fig. 4.19 ). Multiple
intraparotid lymph nodes may be present. Hypervascularisation on CDS.
• Bacterial infection rare (neonates, immunosuppressed), may cause abscesses and
potentially exhibit intracavitary gas (bright echoes with reverberation artefacts
and acoustic shadowing).
156
4 Ultrasound of the Neck
Fig. 4.19 Intra- and paraparotid lymphatic follicle. Lymphatic tissue inside (+ +) and aside
the parotid gland, recognisable by its typical sonomorphologic features
• Chronic infection: recurrent sialadenitis, granulomatous disease (Sjögren’s syn-
drome, tuberculosis, sarcoidosis, cat scratch disease, etc.) and immunocompro-
mised children (HIV). Inhomogenous appearance, enlargement, patchy
hypoechoic granulomas; may exhibit lymphoid follicles and chronic ductal
enlargement with irregular contour (Fig.
4.20 ).
4.3.4.2 Cysts
Most commonly ranula (mucoid retention cyst) arising from obstructed excretory
ducts.
Clue to diagnosis: position and course of somewhat tubular complex liquid structure
that may contain some low-level echoes.
DDx – other cysts (see above).
4.3.4.3 Calcifications/Sialolithiasis
Think of underlying disease (e.g. cystic fi brosis with duct concrements).
Most commonly in submandibular gland, with dilated duct and swelling:
• DDx: postinfl ammatory remnant or remnant of thrombosed/regressed haemangioma.
4.3.4.4 Tumours
Rare, mostly benign, but occur in childhood, most commonly in parotid gland – particularly haemangioma/lymphatic malformation (“cystic hygroma”) (Fig. 4.21 ).
Look the same as anywhere else.
• Others include pleomorphic adenoma (usually a hypoechoic spherical mass with
sharp borders and less vascularity, sometimes resembling a large lymph node),
rhabdomyosarcoma, mucoepidermoid and acinar cell carcinoma, adenocarci-
noma and mixed tumours.
• Malignancy indicated by irregular margins and heterogeneous echogenicity with
regional nodes and vascular encasement. Diagnosis requires tissue sampling.
4.3 Pathologic Findings
157
a
b
c
Fig. 4.20 Parotid gland pathology. ( a ) Parotitis: enlargement, irregular echotecture. ( b ) Dilated
parotid duct ( arrow ), P parotid gland. ( c ) Abscess (necrosis) formation in bacterial parotitis
Fig. 4.21 Parotid haemangioma. Inhomogenously structured, spheric parotid gland – with mul-
tiple vessels throughout the gland on CDS, otherwise appearance rather unspecifi c
4.3.5 Cervical Vessels
Vascular pathology in children far less common than in adults. Only occurs after
interventions, after trauma, or in systemic vascular disease, and rarely as a congenital anomaly.
158
4 Ultrasound of the Neck
Pathologic fl ow patterns also found in feeding or draining vessel of adjacent
pathology (brain death, brain oedema, infl ammation, high-fl ow haemangioma and
vascular malformation) – the respective criteria apply.
4.3.5.1 Arteriosclerosis
Rare, in older children, associated with obesity. Arterial wall thickening and more
or less echogenic disruption of normal wall texture as well as swelling and disrupted intimal surface. Also observed after trauma or intervention (e.g. after arteriovenous ECMO with carotid cannulation and reconstruction). Criteria are not
different from adults – not discussed, rarely clinically applied (mostly for
research).
NOTE : The younger the child, the more diffi cult are intima and wall thickness
measurements (US reaches resolution limits). Use high-frequency high-resolution
linear transducers, also M-Mode avoid compounding and harmonic imaging – they
reduce spatial resolution.
4.3.5.2 Dissection
Typically found after trauma, rarely spontaneously in syndromes (e.g. Marfan
syndome)
US Findings:
• Intima fl ap in vessel lumen, wall haematoma, perivascular haematoma (may be
diffi cult to differentiate from thrombosed dissection lumen), potentially vessel
occlusion (Fig. 4.22 ).
CDS :
• Perfusion difference between real and false lumen. Often beginning/end of dis-
section not visualised. Particularly in VA, also higher ICA and lower CCA seg-
ments US unreliable; however, spectral analysis may hint towards altered fl ow by
upstream/downstream stenosing component.
NOTE : US can fi nd dissection, but has restrictions in exclusion.
4.3.5.3 Stenosis
Extremely rare in childhood.
US Findings
• Narrowed lumen/diameter. Plaques rarely exist in children, rather wall pathology
arises from systemic vascular disease or postoperative conditions (e.g. after
AV-ECMO).
CDS
• Turbulent and accelerated fl ow at stenosis, typical pre-/poststenotic fl ow patterns
on spectral analysis used for grading stenosis (Fig. 4.23 ).
• For grading (distance/cross sectional surface/circumference measurements, or
spectral fl ow analysis), same criteria apply as in adults (Table 4.2 ).
NOTE : Asymmetric size and fl ow, particularly of VA, can be normal variant.
Try to assess infl uence of cervical vessel pathology on brain perfusion
4.23e, f ).
(Fig.
4.3 Pathologic Findings
159
ab
Fig. 4.22 CCA dissection. ( a ) Gray scale depicts dissection membrane, with true (1+ +) and false
(2+ +)lumen. ( b ) CDS demonstrates fl ow in main lumen (3+ +), thrombosed dissection lumen
(1+ +) with wall and haematoma (+5 5)
ab c
def
Fig. 4.23 Cervical artery stenosis/occlusion. ( a ) Narrowing of CCA after ligation and reconstruc-
tion for ECMO cannulation. ( b ) CDS demonstrates narrowing and aliasing of fl ow in the short-
distance high-grade stenosis. ( c ) Long segment narrowing in a postinterventional hypoplastic ACC
section. ( d ) Inverted fl ow on brain US – coronal section of basal vessels CDS (coronal image),
indicated by blue colour coding, into proximal part of distally occluded ICA. ( e ) Parasagittal trace
analysis confi rms inverted fl ow direction. ( f ) Collateralisation by circle of Willis – with inverted
fl ow in the ipsilateral ACA 1 segment, both contralateral ACA segments are coded in the same
colour
4.3.5.4 Other Vascular Anomalies
Vascular tumours and anomalies – extremely rare in neck.
Irregularities seen in systemic vascular disease (e.g. Takayasu arteritis, fi bromuscular dysplasia).
Some degree of asymmetry may be normal; variations in origin form aortic arch
exist as normal variants (e.g. common left trunk, separate origin of left VA from arch).
US and CDS Findings: Vessel irregularities (wall as well as diameter) with regional
ectasia, aneurysm formation, stenotic aspects. Respective CDS and fl ow profi le
alterations depend on degree of stenosis, size of aneurysmal component, etc.
160
Table 4.2 Grading of stenosis
4 Ultrasound of the Neck
Abbreviation: V
maximum systolic peak velocity
syst max
Grading of stenosis depending on amount of narrowing – based on a normal adult vessel, similar
relations however apply to children, only with smaller diameters and lower velocities, i.e.:
Grade V = nearly occluded vessel, minimal residual, atypical low and turbulent fl ow may still be
depictable
Grad IV = 2–10 % of normal vessel diameter, very lower systolic fl ow – but only slightly higher
systolic fl ow velocity
Grade II = 10–20 % of normal vessel diameter, low systolic fl ow – but up to fi vefold higher systolic
fl ow velocity
Grade II = 20–40 % of normal vessel diameter, only little impairment of systolic fl ow volume, but
higher and turbulent systolic fl ow velocity
Grade I = only mild narrowing with up to 70 % of normal vessel diameter, no impairment of fl ow
volume and mild increase of maximum systolic fl ow velocity, often considered “nonsignifi cant”
a b
Fig. 4.24 Cervical venous thrombosis. ( a ) Thrombosed cervical vein – noncompressible, no fl ow
even on aCDS. ( b ) Catheter causing thrombosis ( arrow )
4.3 Pathologic Findings
161
4.3.5.5 Thrombosis and Occlusion
Occurs practically only in veins, usually secondary to catheterisation, compression
or infl ammation.
US Criteria (as in All Other Veins)
• Lack of vein compressibility, potentially some echogenic components within
lumen that do not move (echogenicity varies with age of thrombus) (Fig. 4.24 ).
CDS:
• Lack of fl ow, lack of spectral response to respiratory manoeuvres. Spectral anal-
ysis used to confi rm CDS fi ndings, helpful for differentiating potential collater-
alisation due to distal obstruction by depicting altered fl ow pattern/inverted fl ow
direction and pathologic fl ow response to respiration/compression manoeuvres.
NOTE : Try to follow vessel as far as possible to see potential site of obstruction,
beginning/end of thrombus, relation to catheter or compression, as well as origin of
collateralising vessel.
Basics of Paediatric Echocardiography
Andreas Gamillscheg, Bernd Heinzl,
and Michael Riccabona
Contents
5.1 Introduction ..................................................................................................................... 164
5.2 Equipment Needs and Specific Considerations............................................................... 165
5.2.1 Transducers ......................................................................................................... 165
5.2.2 Standard US Techniques ..................................................................................... 165
5.2.3 Patient Position ................................................................................................... 165
5.2.4 Sedation ............................................................................................................... 165
5.3 Standard Planes and Standardised Course of Examination............................................. 165
5.4 Normal 2D Echocardiogram Findings ............................................................................ 166
5.4.1 Parasternal Views ................................................................................................ 166
5.4.2 Apical Views ....................................................................................................... 167
5.4.3 Subcostal Views .................................................................................................. 169
5.4.4 Suprasternal View ............................................................................................... 169
5.5 Other Techniques ............................................................................................................ 170
5.5.1 M (Motion)-Mode Echocardiography ................................................................. 170
5.5.2 Doppler Sonography ........................................................................................... 171
5.5.3 Other Calculations and Functional Parameters ................................................... 171
5.6 Special Echocardiographic Techniques ........................................................................... 172
5.6.1 Transoesophageal Echocardiography (TEE) ....................................................... 172
5.6.2 Three-Dimensional (3D) Echocardiography ....................................................... 172
5.6.3 Tissue Doppler Imaging (TDI)............................................................................ 172
5.6.4 Contrast-Enhanced US ........................................................................................ 172
5.7 Normal Values ................................................................................................................. 172
5.8 Pathologic Findings ......................................................................................................... 173
5.8.1 Congenital Heart Defects with Left-to-Right Shunt ........................................... 173
5.8.2 Obstructions of Left Ventricular Outflow ........................................................... 177
5
A. Gamillscheg () • B. Heinzl
Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine,
University Hospital Graz, Auenbruggerplatz 34/2, Graz 8036, Austria
M. Riccabona
Division of Pediatric Radiology, Department of Radiology,
University Hospital Graz, Auenbruggerplatz 34, Graz 8036, Austria
e-mail: michael.riccabona@klinikum-graz.at
M. Riccabona, Pediatric Ultrasound,
DOI 10.1007/978-3-642-39156-9_5, © Springer Berlin Heidelberg 2014
163
164
5.8.3 Obstructions of the Right Ventricular Outflow ................................................... 179
5.8.4 Miscellaneous Congenital Heart Defects ............................................................ 181
5.9 Acquired Paediatric Heart Diseases ................................................................................ 184
5.9.1 Cardiomyopathies (CMP) ................................................................................... 184
5.9.2 Acute Myocarditis ............................................................................................... 184
5.9.3 Acute (Infective) Endocarditis ............................................................................ 184
5.9.4 Pericarditis/Pericardial Effusion ......................................................................... 185
5.9.5 Kawasaki Disease ............................................................................................... 185
5.9.6 Intracardiac Thrombi .......................................................................................... 186
5.9.7 Cardiac Tumours ................................................................................................. 186
5.10 Complementing Investigations ........................................................................................ 186
5.10.1 Cardiac Catherisation and Angiography ........................................................... 186
5.10.2 Cardiac MRI and CT ......................................................................................... 187
5.11 When to Do What............................................................................................................ 187
5.11.1 Imaging in Typical Clinical Scenarios .............................................................. 187
5.11.2 Trauma and Emergency .................................................................................... 188
5 Basics of Paediatric Echocardiography
Abbreviations
Ao Aorta
AS Aortic stenosis
ASD Atrial septal defect
AVSD Atrioventricular septum defect
CMP Cardiomyopathy
Co A Aortic coarctation
CW-Doppler Continuous wave Doppler
PW-Doppler Pulsed wave Doppler
DORV Double outlet right ventricle
IAS Interatrial septum
IVS Interventricular septum
LA Left atrium
LV Left ventricle
PA Pulmonary atresia
PDA Patent ductus arteriosus
PS Pulmonary stenosis
PV Pulmonary vein
RA Right atrium
RV Right ventricle
TAPVR Total anomalous pulmonary venous return
TGA Transposition of the great arteries
TOF Tetralogy of Fallot
UVH Univentricular heart
VSD Ventricular septum defect
5.1 Introduction
Most important non-invasive tool for evaluation of the child’s cardiovascular system, provides exact morphological diagnosis and enables hemodynamic assessment
in most cases – often avoiding invasive diagnostic heart catheterisation.