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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5795_Библиотеки_им_академика_М_И_Перельмана.pdf
198
a bc
Fig. 10.19 Intra- and paraparotid lymphatic follicle. Lymphatic tissue inside (++) and aside the
parotid gland, recognisable by its typical sonomorphologic features
Fig. 10.20 Parotid gland pathology. (a) Parotitis: enlargement, irregular echotexture. (b) Dilated
parotid duct (arrow), P parotid gland. (c) Abscess (necrosis) formation in bacterial parotitis
M. Riccabona
• Bacterial infection rare (neonates, immunosuppressed) may cause abscesses and
potentially exhibit intracavitary gas (bright echoes with reverberation artefacts
and acoustic shadowing).
• Chronic infection: recurrent sialadenitis, granulomatous disease (Sjögren’s syndrome, tuberculosis, sarcoidosis, cat scratch disease, etc.) and immunocompromised children (e.g. HIV). Inhomogenous appearance, enlargement, patchy
hypoechoic granulomas; may exhibit lymphoid follicles and chronic ductal
enlargement with irregular contour (Fig.10.20).
10.3.4.2 Cysts
Most commonly ranula (mucoid retention cyst) arising from obstructed excretory ducts.
Clue to diagnosis: position and course of somewhat tubular complex liquid struc-
ture that may contain some low-level echoes.
DDx—other cysts (see above).
10.3.4.3 Calcifications/Sialolithiasis
Think of underlying disease (e.g. cystic brosis with duct concrements).
Most commonly in submandibular gland, with dilated duct and swelling:
• DDx: postinammatory remnant or remnant of thrombosed/regressed
haemangioma.
10 Ultrasound oftheNeck inChildhood
199
Fig. 10.21 Parotid haemangioma.
Inhomogenously structured, spheric parotid
gland—with multiple vessels throughout the
gland on CDS, otherwise appearance rather
unspecic
a
b
10.3.4.4 Tumours
Rare, mostly benign, but occur in childhood, most commonly in parotid gland—
particularly haemangioma/lymphatic malformation (“cystic hygroma”) (Fig.10.21).
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, adenocarcinoma and mixed tumours.
• Malignancy indicated by irregular margins and heterogeneous echogenicity with
regional nodes and vascular encasement. Diagnosis requires tissue sampling.
10.3.5 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.
Pathologic ow patterns also found in feeding or draining vessel of adjacent
pathology (brain death, brain oedema, inammation, high-ow haemangioma and
vascular malformation)—the respective criteria apply.
10.3.5.1 Arteriosclerosis
Rare, in older children, associated with obesity.
Findings: Arterial wall thickening, altered intima-media complex, more or less
echogenic disruption of normal wall texture, swelling and/or disrupted intimal surface. Wall calcications practically never occur in children (except after trauma/surgery—e.g. after arteriovenous ECMO with carotid cannulation and reconstruction).
200
a
c
M. Riccabona
b
de f
Fig. 10.22 Carotid wall thickness measurement and carotid stiffness: Wall thickness measurement in an overview image (a), with magnication of image (a) showing inaccuracies in calliper
placement (b). Proper measurement in a zoomed high-resolution image without harmonic imaging
reveals a reduction of wall thickness measurement of 25% (c, from 8 to 6mm!). Stiffness/elasticity
measurement calculated as a ratio from the difference of systolic (d) versus diastolic (e) vessel
diameter (f); some use circumference or cross-sectional area. This example however also demonstrates the variability of vessel diameter measurements depending on heart cycle as a source of
error; other factors such as intravascular volume or medication may also inuence this measurement
Criteria not different from adults—not discussed, rarely clinically applied
(mostly for research).
Note The younger the child, the more difcult are intima/media and wall thickness measurements (US reaches resolution limits). Use high-frequency high-resolution linear transducers, also M-Mode; avoid compounding and harmonic imaging— these techniques may
reduce spatial resolution and be aware of intrinsic measurements limitations.
Early precursors of arteriosclerosis may be depicted by assessing vessel stiffness
and pulsatility, though in childhood due to very small distances often equivocal in
the individual case (and depending on many inuencing factors such as volume
load, blood pressure, etc.)—even if group statistics show a difference and partially
even cut-off values are suggested (Fig.10.22).
10.3.5.2 Dissection
Typically found after trauma, rarely spontaneously in syndromes (e.g. Marfan syndrome).
US Findings
• Intima ap in vessel lumen, wall haematoma, perivascular haematoma (may be
difcult to differentiate from thrombosed dissection lumen), potentially vessel
occlusion (Fig.10.23).
10 Ultrasound oftheNeck inChildhood
Fig. 10.23 CCA dissection. (a) Grey scale depicts dissection membrane, with true (1++) and
false (2+ +) lumen. (b) CDS demonstrates ow in main lumen (3+ +), thrombosed dissection
lumen (1++) with wall and haematoma (5++)
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CDS
• Colour ow signal difference between real and false lumen. Often beginning/end
of dissection not visualised. Particularly in VA, also higher ICA and lower CCA
segments US unreliable; however, spectral analysis may hint towards altered
ow by upstream/downstream stenosing component.
Note US can nd dissection, but has restrictions in excluding the condition.
10.3.5.3 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 arteriovenous ECMO).
CDS
• Turbulent and accelerated ow at stenosis. For grading stenosis use typical pre-/
poststenotic ow patterns on spectral analysis (Fig.10.24).
• For grading (distance/cross-sectional surface/circumference measurements, or
spectral ow analysis), same criteria apply as in adults (Table10.2).
Asymmetric size and ow, particularly of VA, can be normal variant. Try to
Note
assess inuence of cervical vessel pathology on brain perfusion (Fig.10.24e, f).
10.3.5.4 Other Vascular Anomalies
Vascular tumours and anomalies—extremely rare in neck.
Irregularities seen in systemic vascular disease (e.g. Takayasu arteritis, bromus-
cular 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).
202
Fig. 10.24 Cervical artery stenosis/occlusion. (a) Narrowing of CCA after ligation and recon-
struction for ECMO cannulation. (b) CDS demonstrates narrowing and aliasing of ow in the
short-distance high-grade stenosis. (c) Long segment narrowing in a postinterventional hypoplastic
ACC section. (d) Inverted 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 spectral trace analysis conrms inverted ow direction. (f) Collateralisation by circle
of Willis—with inverted ow in the ipsilateral ACA 1 segment, both contralateral ACA segments
are coded in the same colour
M. Riccabona
US and CDS Findings
Vessel irregularities (wall as well as diameter) with regional ectasia, aneurysm formation, stenotic aspects. Respective CDS and ow prole alterations depend on
degree of stenosis, size of aneurysmal component, etc.
10.3.5.5 Thrombosis andOcclusion
Occurs practically only in veins, usually secondary to catheterisation, compression
or inammation.
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.10.25).
10 Ultrasound oftheNeck inChildhood
203
CDS
• Lack of ow, lack of spectral response to respiratory manoeuvres. Spectral analysis used to conrm CDS ndings, helpful for differentiating potential collateralisation due to distal obstruction by depicting altered ow pattern/inverted ow
direction and pathologic 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.
Table 10.2 Grading of stenosis
Abbreviation: V
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 ow may still be
depictable
Grad IV= 2–10% of normal vessel diameter, very lower systolic ow—but only slightly higher
systolic ow velocity
Grade II=10–20% of normal vessel diameter, low systolic ow—but up to vefold higher systolic
ow velocity
Grade II=20–40% of normal vessel diameter, only little impairment of systolic ow volume, but
higher and turbulent systolic ow velocity
Grade I=only mild narrowing with up to 70% of normal vessel diameter, no impairment of ow
volume and mild increase of maximum systolic ow velocity, often considered “nonsignicant”
maximum systolic peak velocity
syst max
204
Fig. 10.25 Cervical venous thrombosis. (a) Thrombosed cervical vein—noncompressible, no
ow even on aCDS. (b) Catheter causing thrombosis (arrow)
M. Riccabona
Basics ofPaediatric Echocardiography
MartinKöstenberger, AndreasGamillscheg,
andMichaelRiccabona
Abbreviations
Ao Aorta
AS Aortic stenosis
ASD Atrial septal defect
AVSD Atrioventricular septum defect
CMP Cardiomyopathy
CoA 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
11
M. Köstenberger · A. Gamillscheg (*)
Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine,
Medical University Graz, Graz, Austria
e-mail: martin.koestenberger@medunigraz.at; andreas.gamillscheg@medunigraz.at
M. Riccabona
Department of Radiology, Division of Pediatric Radiology, Medical University Graz
and University Hospital Graz, Graz, Austria
e-mail: michael.riccabona@medunigraz.at
© Springer Nature Switzerland AG 2020
M. Riccabona (ed.), Pediatric Ultrasound,
https://doi.org/10.1007/978-3-030-47910-7_11
205
206
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
M. Köstenberger et al.
11.1 Introduction
US = most important non-invasive tool for evaluation of the child’s cardiovascular system, provides exact morphological diagnosis and enables haemodynamic
assessment in most cases—often avoiding invasive diagnostic heart
catheterisation.
11.2 Equipment Needs andSpecific Considerations
11.2.1 Transducers
Large variety of (mostly sector) transducers necessary to full all imaging requirements—as age and size of patients from preterm infants to adolescents:
• 8–10–12MHz transducer for good near-eld resolution in premature/newborn
infants, in this age also linear transducers can be used.
• 5–2MHz transducer for far-eld penetration and high-ow velocities in older
children/young adults.
11.2.2 Standard US Techniques
• M-mode.
• Two-dimensional ultrasound (2DUS).
• Continuous wave Doppler (CW-Doppler).
• Pulsed wave Doppler (PW-Doppler).
• Colour Doppler sonography (CDS).
11.2.3 Patient Position
Ideally transthoracic echocardiography performed in reclined position with patient
lying left side down—to avoid interference from lung tissue (especially in older
children). A supporting pillow helpful.
For suprasternal views use hyperextended neck to gain access.
11 Basics ofPaediatric Echocardiography
207
11.2.4 Sedation
Transthoracic echocardiography mostly feasible without sedation. However, sometimes sedation undispensable and essential to obtain accurate diagnostic information.
11.3 Standard Planes andStandardised Course
ofExamination
Four basic planes: Transducer positioned to four echocardiographic windows to
obtain planes (Fig.11.1):
• Long-axis plane parallel to major axis of left ventricle (LV).
• Short-axis plane orthogonal to major axis of LV.
• Coronal plane through cardiac apex (four-chamber view).
• Suprasternal view (aortic arch).
– Parasternal area near to sternum in second, third or fourth intercostal space.
– Region of cardiac apex.
– Subcostal region.
– Suprasternal notch.
Long- or short-axis plane can be generated in each of these areas. Moreover,
additional views are obtained by tilting transducer from right to left, from superior
to inferior, or rotating clockwise and counterclockwise.
Ideally every examination should follow standardised protocol:
• Dene visceral situs, describe relationship between descending aorta and inferior vena cava (IVC).
• Specify position and morphology of atria.
Fig. 11.1 Schematic drawing of typical
transducer positions for echocardiography.
Suprasternal, parasternal, intercostal, apical and
subcostal window, with respective transducer
orientation