SCORCH 2018 Bone, Brain & Vessels

Transcription

1 To complete the SAM assessment, please use one of the methods below: Complete a paper version of the exam Go to: Open your smartphone camera and scan this QR Code (QR Code will prompt a pop-up to open survey)

2 Question 1 What marrow pattern suggests recurrent leukemia? A. Flame shaped B. Sharp boarders C. Iso-intense to muscle on T1 weighted imaging D. Wispy margins

3 Question 2 The fallen fragment sign is: A. Indication the lesion has many parts B. Indication the lesion is unstable C. Indication the lesion is cystic D. Indication lesion is solid

4 Question 3 What is the most important reason for radiologists to understand the ISSVA classification and use the proposed terminology? A. Makes it easier to do literature searches in PubMed when we all use the same terminology. B. Inappropriate terminology in our reports may lead to patients undergoing inappropriate therapy. C. There is no good reason to do this because the referring clinicians don t read our reports anyway. D. Makes it easier to do longitudinal study type research on these patients.

5 Question 4 Which of the following is the correct terminology for what has historically been termed hemangiomas involving the facial nerve and vertebral bodies? A. Venous malformations B. Cavernous hemangiomas C. Kaposiform hemangioma D. Pyogenic granuloma

6 Question 5 Transcranial Doppler can be used to assess which of the following conditions: A. Stroke risk in Sickle Cell patients. B. Vasospasm following aneurysm rupture. C. Increased intracranial pressure D. All of the above

7 Question 6 Which of the following is considered abnormal in a child with sickle cell disease? A. MCA TAMV > 200 cm/sec B. MCA TAMV < 70 cm/sec C. ACA TAMV > 170 cm/sec D. All of the above

8 1. What marrow pattern suggests recurrent leukemia? A. Flame shaped B. Sharp boarders C. Iso-intense to muscle on T1 weighted imaging D. Wispy margins Rationale: Marrow patterns in the developing skeleton are the bane of the pediatric radiologist. Separating normal marrow patterns from disease is challenging. Developing red marrow tends to appear wispy and feathery or flame-shaped on MRI. Tumors tend to have a well-marginated boarder and/or intense bone marrow edema. Surrounding bone destruction also can help separate out aggressive marrow processes from normal marrow. Therapies that stimulate red marrow production can produce a variety of bizarre marrow patterns that need to be separated from metastasis and infection. Reference: JH Kan et al. MRI diagnosis of bone marrow relapse in children with ALL. Pediatric Radiology January 2008, Volume 38, Issue 1, pp 76 81

9 2. The fallen fragment sign is: A. Indication the lesion has many parts B. Indication the lesion is unstable C. Indication the lesion is cystic D. Indication lesion is solid Rationale: A fallen fragment of bone represents a pathologic fracture of an internal component of a bone cyst. It is a sign of a non-aggressive cystic bone lesion. The fragment moves around in the fluid components of the cyst. This sign helps separate a non-aggressive bone cyst from a more ominous solid lesion with pathologic fracture. In a solid bone lesion the fragment is confined (does not move). Reference:

10 3. What is the most important reason for radiologists to understand the ISSVA classification and use the proposed terminology? A. Makes it easier to do literature searches in PubMed when we all use the same terminology. B. Inappropriate terminology in our reports may lead to patients undergoing inappropriate therapy. C. There is no good reason to do this because the referring clinicians don t read our reports anyway. D. Makes it easier to do longitudinal study type research on these patients. Reference: ISSVA Classification of Vascular Anomalies 2014 International Society for the Study of Vascular Anomalies Available at "issva.org/classification".

11 4. Which of the following is the correct terminology for what has historically been termed hemangiomas involving the facial nerve and vertebral bodies? A. Venous malformations B. Cavernous hemangiomas C. Kaposiform hemangioma D. Pyogenic granuloma Reference: ISSVA Classification of Vascular Anomalies 2014 International Society for the Study of Vascular Anomalies Available at "issva.org/classification".

12 5. Transcranial Doppler can be used to assess which of the following conditions: A. Stroke risk in Sickle Cell patients. B. Vasospasm following aneurysm rupture. C. Increased intracranial pressure D. All of the above Rationale: TCD can provide a noninvasive assessment of the cerebral vasculature and has been utilized in a variety of clinical setting for over 30 years. All three scenarios in options A,B and C can be evaluated by TCD. Children with sickle cell disease have 6-17% risk of stroke. Identifying regions of stenosis allows preventive therapies such as transfusion, hydroxyurea or bone marrow transplantation to be used on those at highest risk for stroke. TCD is a safe reliable cost effective screening method to help identify children at risk. B is correct Following a rupture of an intracranial aneurysm, vasospasm may develop peaking days after the hemorrhage. Patients with severe vasospasm resulting in elevated PSV can develop deficits due to cerebral infarction. TCD has become an important tool in detecting vasospasm prior to deficits occurring with a high specificity ( %). C is correct As intracranial pressure increases, diastolic intracranial flow will decrease. Increased pulsatility ( PI/RI) can suggest the presence of elevated intracranial pressure and can be used to differentiate ventriculomegaly secondary to atrophy vs hydrocephalus. Reference: LaRovere K, Obrien N, Tasker R Current Opinion and Use of TCD in traumatic Brain Injury in the PICU J of Neurotrauma

13 6. Which of the following is considered abnormal in a child with sickle cell disease? A. MCA TAMV > 200 cm/sec B. MCA TAMV < 70 cm/sec C. ACA TAMV > 170 cm/sec D. All of the above Rationales: Various parameters can suggest a child with sickle cell is at risk for stroke. The STOP study demonstrated that a cut off of 200 cm/sec TAMV in the MCA and/or distal ICA was statistically significant in the identification of children at high risk for stroke. B is also correct. There are nuances in interpreting TCD velocities and associated stroke risk. A low TCD in the MCA, distal ICA or ACA is < 70cm/sec using appropriate technique could suggest abnormal low velocities due to stenosis and may be prudent to get additional studies such as a brain MRI/MRA. C is also correct. While isolated ACA stenosis is rare, several cases have been reported in the literature. As the angle of insonation of the ACA is often greater than 60 degrees, a lower cut off of 170 cm/sec has been suggested in the evaluation of ACA disease. References: J Pediatr Hematol Oncol Oct;35(7): doi: /MPH.0b013e318279caae.Adams RJ, McKie VC, Brambilla D, et al..stroke prevention trial in sickle cell anemia.control Clin Trials.1998;19: [Context Link]

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