Doppler ultrasound in preoperative and/or post treatment assessment of infantile hemagiomas

Transcription

1 Doppler ultrasound in preoperative and/or post treatment assessment of infantile hemagiomas Poster No.: C-1654 Congress: ECR 2014 Type: Educational Exhibit Authors: E. D. Nedelcu; Bucharest/RO Keywords: Vascular, Ultrasound-Colour Doppler, Efficacy studies, Hemangioma DOI: /ecr2014/C-1654 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Learning objectives Infantile hemangioma of the skin or various small parts became an important chapter of diseases because of increasing number of patients and severity of cases. Particular facts are related to patient's age - toddler or child 1-3 year old, determining: Restless patient (needing sedation for MRI) Particularities for the treatment : - plastic surgery for young tissue, cosmetic results needed in time - appropriate doses and length of classic drug treatment - Propranolol / Cortisone. Ultrasonography is important in choosing between those methods. Managing treatment is the task of the team - plastic surgeon, dermatologist, pediatrician and radiologist. In the side bar there are five cases, highlighting the facts presented. Case 1 - fig lip hemangioma involution with propranolol treatment Case 2- fig lip hemangioma, progression without propranolol treatment Case 3 - fig ulcerated hemangioma of he buttock Case 4- fig giant hemangioma of the supraclavicular fossa Case 5- fig complex vascular malformation of the arm Images for this section: Page 2 of 28

3 Fig. 1: Inferior lip hemagioma, 4 months baby, B mode First evaluation- may Page 3 of 28

4 Fig. 2: Same case, color Doppler mode Page 4 of 28

5 Fig. 3: Arterial like wave form and high velocity, proven by pulsed Doppler Page 5 of 28

6 Background Resuming literature, imaging for infantile soft tissues hemangiomas relates mainly to MRI or stipulates that no imaging is necessary. Also, they mention a lot of cases of spontaneous regression. On our part, this is a very rare condition - so all spots must be considered for treatment. Those very few considering ultrasonography necessary, don't mention several facts: technique necessary programs tips for babies serial examination most important, the types of flow, related to mass pressure, determining therapeutic approach - surgery vs propranolol / corticosteroids treatment. If not correct applied, ultrasonography can be dangerous (inconclusive or wrong results) and MRI preferred. So, some points must be highlighted / the goals for ultrasonography are: Positive and differential diagnosis - hemangioma vs some other space occupying lesion Determining intralesional pressure, using color and pulse Doppler Mapping the vascular pedicles for the surgical planning Achieving 3D reconstructions, good both for clinician - to better understand, and radiologist, to complete the description and follow-up. Standard examination in B mode This is the first part of the examination, proving a lot of information: Extension in depth Hypodermic extension Page 6 of 28

7 Shape, margins, borders of the lesion, facts useful for surgeon Direct identification of the lump In real time, determining spontaneous contrast in suspected venous cavities can add to characterize cavernous intramuscular anomalies, otherwise difficult to be seen. Without Doppler mode, there is no hemangioma diagnosis, because vessels cannot be seen solely in B mode. Color Doppler mode Correct setting (low scale), and proper setting (for superficial), must be used, otherwise vessels can be missed. This is a perfect method to describe: Presence, size, shape of the vessels ( corkscrew like), intralesional distribution- ex. proximity to the skin of vital organs Presence and distribution of pedicles, size, shape, length - preoperative mapping Connection to major vessels - ex. jugular, subclavicular vein, facial artery suggest abstention to surgical therapy Pulsing nature - seen in real time - gives indirect clues of the pressure Artifacts are important to be known and avoided: Too much gain - means possible false vessels to be described - this artifact can be avoided analyzing the shape of the colored spots. Mirror artifact - important when the lesion is bordering a bony plane possible false vessels crossing the bone! Moving artifact - colored spots inside a liquid cavity do not necessarily means that there is flow inside - see lymphatic lakes. Pulsed Doppler mode The known rules for the correct examination are difficult to be achieved when the patient is a baby (correct angle or gate setting). Page 7 of 28

8 Anyway, errors in velocities estimation are not too big, meaning no changing of the therapy. For example, usually there is a difference of mainly 30cm/s, between 70 and 100 cm/s, but that means anyway a high pressure lesion, comporting a high risk of intraoperator bleeding. According to my experience, there are no arterial or venous hemangiomas, but there are high pressure or low pressure hemangiomas: High pressure means arterial like curve, similar to normal low resistance vessels, velocities between 50 and 100cm/s (or more). Low pressure means mainly venous like curve, low velocities, minimum 2 cm/s. Under correct Propranolol treatment, high pressure can transform in low pressure, and surgical or laser therapy can then be applied. The idea of malformed vessels can well be understood by one examining vessels in Parks Weber syndrome, noting the change of the curve of a small vein into a typical artery - a malformed one. Pulsed Doppler mode can describe also pressure inside the pedicles, by placing the sample inside the area already identified by color mode. This information can affect therapeutic decision, too. In fact, the above mentioned pressure levels are indirect findings from Doppler data: Objective - extended from velocities range and spectral curve analysis Subjective - counting vessels density in color Doppler mode and noting the pulsatility in real time. 3D Power Doppler images The procedure cannot be done for every patient given that a calm baby/child is needed. If it can be obtained, useful points are: For the clinician, to understand better the size of the vascular ball and its connections For the radiologist, to better depict the pedicles and the reducing in size of the ball and if necessary, proving the decrease in vessel number. Page 8 of 28

9 The images are gorgeous when there are a lot of vessels. If not, 3D is still useful given that it proves the coronal plane. This cannot be obtained otherwise. Images for this section: Fig. 4: Here shown 3D image, power Doppler included, proving the vascular ball and its connections. Also, the vicinity with the tongue is well seen Page 9 of 28

10 Fig. 5: Same image, rotated, to be better understood by the surgeon. Cranial is up. Page 10 of 28

11 Fig. 6: 3D image. Coronal plane is seen down left, proving all the vascular connections and the real shape of the vascular ball Page 11 of 28

12 Fig. 7: December, after 6 month of Propranolol treatment, B mode. Decrease in size of the affected inferior lip. Sagittal image Page 12 of 28

13 Fig. 8: Same case, color Doppler, proving, residual vascular asymmetry - some more vessels onto the inferior lip. Note marked improved of the condition. Page 13 of 28

14 Fig. 9: Here it is another case, similar location - inferior lip. 6 months baby Color Doppler is proving the size of the vascular ball. One can note moving artifacts caused by sucking Page 14 of 28

15 Fig. 10: One month later, marked increase in size of the ball. Propranolol treatment proved to be toxic for this baby. One can note an inferior vascular pedicle, well depicted Page 15 of 28

16 Fig. 11: After trying to calculate correctly the velocity in the inferior pedicle, the child got bored. Thus, it wasn't possible to obtain 3D images. Page 16 of 28

17 Fig. 12: It is a case of ulcerated hemangioma of the left buttock, B mode. A lot of sterile gel is enough to obtain correct image. Infiltrated hyperechoic fat can be seen profound to the superficial lesion, because of the infection. Skin irregular contour can also be noted. Page 17 of 28

18 Fig. 13: A lot of superficial vessels can be seen in Doppler mode. Note the very superficial position of the vessels, explaining the ulcerative event. The lesion is unfortunately permanently exposed to urine - note the patient it is a baby in diapers. Very difficult to manage the case. Page 18 of 28

19 Findings and procedure details One must know there are some particularities of this examination, which makes it difficult. There are some requirements and tips: A top machine with a high frequency probe, color Doppler with low scale, digital soft, 3D soft, archiving mode. I'm using a Siemens S2000 machine. For very superficial skin lesion, a lot of gel will be enough to ensure near field good images in B mode and Color Doppler. A PACS, for comparing images. Assessing the decreasing number of vessels as a result of Propranolol therapy is one of the major advantages of the method. High speed in examining, to avoid babies moving and child boredom. Prepare to place the probe in very different anatomical areas - tips of the fingers, lips, eyes, buttocks, vulva. For ulcerated regions be aware that placing the probe creates pain so the baby is crying. Don't forget to use a sterile probe. Images for this section: Page 19 of 28

20 Fig. 14: Supraclavicular fossa mass, 4 month baby, B mode. Note the blurred contour and the extension in depth. Page 20 of 28

21 Fig. 15: Color Doppler shows rapidly the extent of the malformed vessels and the very important connection with brahio-cephalic trunk Page 21 of 28

22 Fig. 16: Pulsed Doppler counts the high velocity malformed vessels Page 22 of 28

23 Fig. 17: Superb synthetic 3D image, showing better real number of vessels and the typical corkscrew or brush like Page 23 of 28

24 Conclusion Ultrasonography, both for me and my team, is sufficient to diagnose and follow up small parts hemangiomas of the babies and children: Enough morphologic and functional data are obtained for the setting of the appropriate treatment No sedation is necessary Can be used to monitor treatment efficacy A cutting edge machine and interdisciplinary team are needed. Many thanks to my team - prof. Enescu, dr. Jurjiu and dr. Calapod, from G. Alexandrescu Children's Hospital Bucharest. Images for this section: Page 24 of 28

25 Fig. 18: Panoramic image of 3 years old boy, complaining about superficial progressive increasing lumps of the arm. Additional, increase in arm's diameter was noted and some spots. It's a case of venous varicosities, superficial and intramuscular, completed by and malformed tiny superficial vessels ( a sort of Klippel Trenaunay Weber Syndrome). It is a complex case, deeper and greater extension than supposed was found. Page 25 of 28

26 Fig. 19: Color Doppler examination, depicting high velocity varicose veins, souse for the tiny superficial vessels (arterial like signal, not shown here) Page 26 of 28

27 Fig. 20: 3D image. Coronal plane shows better the network of malformed vessels See also moving artifacts. Page 27 of 28

28 Personal information References 1. Ecographie pediatrique - indication, techniques et resultats Rose de Bruyn, Elsevier, edition francaise, 2007; p Ecografie clinica musculo-scheletala - Daniela Fodor Editura Medicala, 2009; p.88, 279, Textbook of radiology and imaging, D. Sutton, Churchill Livingstone, 2003 Haemangioma of the soft tissues -1428, 1429, 1430, Diagnostic Ultrasound- Carol Rumack & all, Elsevier Mosby, 2005, pediatric hemangiomas, 1874, 1968, 1969, 1689, 1761, Ultrasonography in vascular diagnosis-w.schaberle - Springer, page 45. Ultrasonografie vasculara, Dudea S, Badea, R, Editura medicala, 2004, p 62, 623 Ultrasound -a logical approach - B. Goldberg, Lippincott Raven, 2000, p 289,290 Ecografia vasculara, intre examenul clinic si angiografie, Dana Elena Nedelcu, ed. Yes, Bucuresti, 2009, p.74 Propranolol vs corticosteroids for infantile hemangiomas - a multicenter retrospective analysis; C Price, C Lattouf, Arc. Dermatologia Infantile Hemangioma ; Richard J Antaya, MD; Chief Editor: William D James, MD; Medscape, 20 may Infantile Hemangiomas, Eun-Kyung Mary Kwon, Marcia Seefeldt, Beth A. Drolet Am J Clin Dermatol. 2013;14(2): Page 28 of 28