Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5790_Библиотеки_им_академика_М_И_Перельмана.pdf
5.9 Acquired Paediatric Heart Diseases
Fig. 5.18 Hypertrophic
obstructive cardiomyopathy –
parasternal long axis view.
Massive hypertrophy (↔) of
interventricular septum (IVS)
and left ventricular posterior
wall (LVPW). LA left atrium,
Ao Aorta
185
IVS
AO
LVPW
Fig. 5.19 Endocarditis – apical four-
chamber view. Endocarditic vegetation
attached to mitral valve (→). LA left atrium,
LV left ventricle
5.9.4 Pericarditis/Pericardial Effusion
LA
LV
LA
US findings: anechoic space surrounding (and compressing) heart (Fig. 5.20).
Compression of RA and RV wall indicates beginning tamponade.
5.9.5 Kawasaki Disease
Associated with coronary artery aneurysms or ectatic coronary arteries:
• From second week of illness.
• Best seen in parasternal short axis view at base of heart.
• Pericardial effusion, valve regurgitations and LV dysfunction common.
• Follow-up studies mandatory – particularly in patients with coronary artery involvement.
186
Fig. 5.20 Pericardial effusion with
tamponade – apical four-chamber view.
Significant compression of heart by anechoic
surrounding pericardial fluid (—). LV left
ventricle, LA left atrium, RV right ventricle,
RA right atrium
5 Basics of Paediatric Echocardiography
RA
LV
LA
RV
5.9.6 Intracardiac Thrombi
In children, intracardiac thrombi mainly associated with intravascular catheters,
dilated CMP, atrial dilatation (atrial flutter or fibrillation) and prosthetic valves.
5.9.7 Cardiac Tumours
Primary tumours of heart – rare in infants and children, most of them benign:
• Rhabdomyoma: homogenous, echo-bright mass(es) in both ventricles and highly
associated with tuberous sclerosis.
• Fibroma: predominantly single intramuscular tumour of left ventricle.
• Myxoma: globular and heterogenous tumours, usually attached to atrial septum.
When tumour found:
• Exact evaluation of entire heart - to rule out multiple lesions.
• Evaluation of hemodynamic consequences (e.g. congestive heart failure or valve
obstruction).
• Evaluate for systemic condition; sometimes additional imaging needed.
5.10 Complementing Investigations
5.10.1 Cardiac Catherisation and Angiography
Diagnostic cardiac catheter angiography necessary if:
• Exact hemodynamic evaluation essential (shunt volume, pulmonary pressure/
resistance…).
5.11 When to Do What
• Echocardiographic assessment of morphology (e.g. lung perfusion, coronary
anatomy) not satisfying.
• In most cases of congenital heart disease, preoperative echo sufficient – diagnos-
tic catheterisation not needed.
• Today role has changed: Over 50 % of cardiac catheterisations in children are
therapeutic interventional procedures.
187
5.10.2 Cardiac MRI and CT
• Have become more important during the last two decades.
• Can provide additional morphologic and functional information.
• Can provide more detailed topographic relation to other intrathoracic structures.
• 3D reconstruction helpful in preoperative evaluation of complex anatomy.
• Carefully select indications.
5.11 When to Do What
5.11.1 Imaging in Typical Clinical Scenarios
5.11.1.1 Typical Orientating Examination
Particularly in newborns and infants in emergency situation or in (N)ICU.
e.g. echocardiographic differential diagnosis of a cyanotic newborn, echocardiographic evaluation of critically ill child.
• Most relevant malformations easily depictable.
• Always include apical four-chamber view and view at IVC entrance to RA in
every US of upper abdomen.
• Include transabdominal/apical heart view during FAST in ER (e.g. pericardial
effusion, poor contractility).
• Typical course of basic orienting investigation and minimal requirements for ori-
enting assessment.
– Start with apical and/or subcostal four-chamber view.
– Continue through parasternal long and short axis.
– End with suprasternal view of the aorta.
5.11.1.2 Typical Clinical Queries
• Child with murmur: clinical examination and echocardiography.
• Child with cyanosis: clinical examination and echocardiography.
• Child with syncope: clinical examination, exact history; echocardiography only
necessary in case of pathologic ECG or murmur.
• Child with chest/heart pain and sensations: clinical examination, ECG and
echocardiography.
NOTE: Cardiac reasons for chest pain rare in children.
188
5 Basics of Paediatric Echocardiography
5.11.2 Trauma and Emergency
In chest trauma – orientating four-chamber view often sufficient:
• Assess global function.
• Rule out pericardial effusion.
• Severe traume = indication for ce-CT(A).
Ultrasound of the Chest
Michael Riccabona
Contents
6.1 Requisites ........................................................................................................................ 190
6.1.1 Transducers .......................................................................................................... 190
6.1.2 Positioning ........................................................................................................... 190
6.1.3 Indications ........................................................................................................... 190
6.1.4 How to Perform Chest US ................................................................................... 191
6.2 Normal Findings .............................................................................................................. 191
6.2.1 Chest Wall............................................................................................................ 191
6.2.2 Breast ................................................................................................................... 191
6.2.3 Pleural Space ....................................................................................................... 192
6.2.4 Diaphragm ........................................................................................................... 192
6.2.5 Lung ..................................................................................................................... 192
6.2.6 Mediastinum ........................................................................................................ 193
6.2.7 CDS ..................................................................................................................... 195
6.3 Pathology of Chest Wall .................................................................................................. 195
6.3.1 Aplasia, Variations of Ribs .................................................................................. 195
6.3.2 Congenital Malformations ................................................................................... 195
6.3.3 Traumatic Changes .............................................................................................. 195
6.3.4 Chest Wall Tumours ............................................................................................ 196
6.3.5 Breast ................................................................................................................... 196
6.3.6 Role of US and Additional Imaging .................................................................... 198
6.4 Pathology of Pleural Space ............................................................................................. 198
6.4.1 Pleural Effusion ................................................................................................... 198
6.4.2 Empyema ............................................................................................................. 198
6.4.3 Other Pleural Pathology ...................................................................................... 200
6.4.4 Role of Imaging ................................................................................................... 200
6.5 Pathology of Diaphragm ................................................................................................. 201
6.5.1 Diaphragmatic Hernia ......................................................................................... 201
6.5.2 Diaphragmatic Motion Disturbance .................................................................... 202
6.5.3 Role and Potential of Imaging ............................................................................. 202
6
M. Riccabona
Division of Pediatric Radiology, Department of Radiology,
University Hospital Graz, Auenbruggerplatz 3, Graz 8036, Austria
e-mail: michael.riccabona@klinikum-graz.at
M. Riccabona, Pediatric Ultrasound,
DOI 10.1007/978-3-642-39156-9_6, © Springer Berlin Heidelberg 2014
189
190
6.6 Lung Pathology ............................................................................................................... 203
6.6.1 Pneumonia ........................................................................................................... 203
6.6.2 Lung Abscess....................................................................................................... 203
6.6.3 Atelectasis............................................................................................................ 204
6.6.4 Respiratory Distress Syndrome (RDS)/Hyaline Membrane Syndrome .............. 205
6.6.5 Sequestration ....................................................................................................... 206
6.6.6 Congenital Cystic Adenomatoid Malformation (CCAM) ................................... 207
6.6.7 Cysts .................................................................................................................... 207
6.6.8 Infarction ............................................................................................................. 208
6.6.9 Tumours and Space-Occupying Lesions ............................................................. 210
6.7 Other Miscellaneous and Rare Applications ................................................................... 210
6.7.1 US for Interstitial Lung Disease .......................................................................... 210
6.7.2 US for Pneumothorax ........................................................................................ 211
6.8 Additional Imaging ......................................................................................................... 211
6 Ultrasound of the Chest
6.1 Requisites
6.1.1 Transducers
Chest Wall
High-resolution linear arrays, plenty of US gel (stand-off pad sometimes helpful)
Deeper Structures
Sector and curved linear arrays – small surface helpful to properly insonate through
intercostal space for suffi cient penetration into deeper structures
Frequency depends on age and depth of targeted structure
6.1.2 Positioning
Depends on area of interest: prone, supine, decubitus
• For jugular access extend head and neck, potentially put pillow below
shoulders
NOTE : For standardised assessment and measurement of pleural effusions stan-
dardised upright positioning (sitting) helpful – also improves comparability with
chest radiographs.
6.1.3 Indications
• Pleural and pericardial effusions
• Equivocal opacities on plain fi lm
– e.g. tumour, malformation, cyst, pneumonia and effusion
• Diaphragm and diaphragmatic motion
6.2 Normal Findings
• Pathology of chest wall (soft tissue, cartilage, breasts etc.)
• Assessment of mediastinal structures
– Particularly thymus, central vessels
• Echocardiography addressed separately (see Chap. 5 )
191
6.1.4 How to Perform Chest US
For large vessels: typical cardiologic planes
• Jugular, parasternal and intercostal access
For other chest areas:
• Upper abdomen with transdiaphragmatic access through liver and spleen
• Subxiphoid access
• Jugular access
• Intercostal access
NOTE : In neonates and infants, ossifi cation of chest wall is not completed – access
through cartilaginous parts of sternum and ribs.
Documentation: Basic minimum documentation of all scanned areas is advisable,
even if normal. If lesion, image in longitudinal and axial sections:
• Additional sections should be obtained if necessary and with pathology
• Try to document all relevant structures with some neighbouring reference
structure
• Proper labelling, potentially using pictograms, is extremely helpful
NOTE : Even if only chest US is requested, orienting overview of cardiac struc-
tures or potential effusion (and upper abdominal “sonoscope” – brief survey
of particularly upper abdomen) is helpful. Detailed course of investigation depends
on individual query.
6.2 Normal Findings
6.2.1 Chest Wall
Below typical multilayer structures of skin and subcutaneous tissue, large chest and
intercostal muscles seen
Ribs seen as echogenic surfaces with shadowing in ossifi ed parts, hypoechoic in
cartilaginous aspects (see Fig. 1.8 ):
• Continuity of ribs/sternum easy to follow, subtle alterations depictable – helpful
for diagnosis of fractures/fi ssures – to be differentiated from physiologic gaps
such as additional ossifi cation centres, syndesmoses or synchondroses
Below chest wall:
• Echogenic surface – reverberation echoes caused by air-fi lled lungs
• In more medial position – cardiac and mediastinal structures
192
6 Ultrasound of the Chest
6.2.2 Breast
Breast appearance varies with age, depending on hormonal status:
• Neonatally breast tissue seen, may appear large, eventually regresses
• In (pre)puberty breast tissue increases, typical change in echotexture
• Eventually typical adult breast US features
NOTE : Some minimal breast tissue even in male neonates physiologic; thereafter
no breast tissue should be seen at any stage of development in boys.
6.2.3 Pleural Space
Usually pleural space not accessible by US
Visualisation of both pleural sheets only achieved by high-resolution linear
arrays if some effusion present
NOTE : The two pleural surfaces move independently from each other.
6.2.4 Diaphragm
Seen as un-/hypoechoic muscular structure – particularly at origin and insertion
Majority of diaphragm usually only indirectly visible – by aerated lung surface:
• Movement/shape of diaphragm assessed using this pseudosurface
• With pleural effusion, even smaller parts of diaphragm visible
• Documentation of diaphragmatic motion: M-Mode, video clip (Fig. 6.1 )
6.2.5 Lung
Normal lung is aerated and only seen indirectly by surface (echogenic structure with
reverberation echoes that change with respiration)
• Parts beyond aerated lung surface not visualised
NOTE : As soon as US can penetrate lung tissue, some pathology must be expected
(e.g. atelectasis, consolidation, effusion, other non-aerated space- occupying
process).
Respiratory motion of lung surface used to differentiate normal aerated lung from
pneumothorax, where no motion of refl ecting surface/air space can be noted:
• Also seen in air-fi lled bronchogenic cysts and severe obstructive hyperinfl ation
• Documentation by video clip or M-Mode
Basal parts of lungs best seen by transabdominal access:
• Should be part of any standard abdominal US (as effusion, atelectasis and
pneumonia may cause abdominal complains, particularly in young children)
6.2 Normal Findings
acb
Fig. 6.1 Diaphragm and diaphragmatic motion: ( a ) Normal diaphragmatic respiratory motion on
M-Mode – the echogenic border represents air-fi lled base of lung, not diaphragm itself, the inhomogeneous spots are minimal peripheral atelectatic areas. ( b ) No diaphragmatic motion, conspicu-
ously documented by M-Mode, after surgery and postoperative pleural effusion in diaphragmatic
palsy. ( c ) M-Mode under respirator therapy: M-Mode trace refl ects effect of mechanical ventila-
tion and not patients’ own respiratory motion
6.2.6 Mediastinum
6.2.6.1 Anterior Mediastinum/Thymus
Mainly Thymus (Fig. 6.2 ):
• Physiologically large in neonates, then eventually regresses
• Shape and size variable
• Echogenicity: hypoechoic, mixed, with some septa (“dot-dash pattern”)
• Behaviour of soft tissue: not compressing or displacing other structures,
particularly vessels
• Size of thymus diffi cult to assess, reliable age-related normal values not
available
• CDS: some internal vascularity
Value of US :
• Differentiate from other mediastinal or chest masses (unclear opacifi cation on
chest fi lm)
• Demonstrate normal echogenicity and behaviour in relation to surrounding
structures of a large thymus
• Additionally: ideal acoustic window to deeper structures
NOTE : Large thymus at unusual age may point at diffuse infi ltration or thymus hyperplasia; infi ltration and tumours will cause increased stiffness and thus subsequent impression or displacement of surrounding structures or crossing vessels.
193
6.2.6.2 Middle Mediastinum
Contains – among others – large vessels, trachea, potential nodes may be visualised
by US (Fig. 6.3 ):
• Particularly feasible in neonates and infants
194
6 Ultrasound of the Chest
a
c
Fig. 6.2 Thymus: ( a ) Anterior mediastinum, axial section, linear transducer: Large neonatal
thymus, serving as window to deeper structures such as the great vessels. Note non-ossifi ed
sternum with central ossifi cation centre. ( b ) Sagittal section, anterior and middle mediastinum,
linear transducer in trapezoid format, paramedian view: Large neonatal thymus. Note anechoic
non-ossifi ed parts of ribs and large, uncompressed vessels; behind one can see a feeding tube in the
oesophagus. ( c ) Left anterior mediastinum, axial section, sector transducer: Enlarged thymus with
inhomogeneous echogenicity in a child with Hodgkin lymphoma. ( d ) Right anterior mediastinum,
axial section, linear transducer in trapezoid format: US in mediastinitis, abscess-like pseudotumorous infl ammatory lesions with nodular appearance in the mediastinum
b
b
d
Fig. 6.3 Middle mediastinum: vessels and lymph nodes. Parasternal (jugular) sagittal view, sector
transducer: thoracic aortic arch, supra-aortic vessels, two enlarged mediastinal lymph nodes ( dotted circular lines )