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Pediatric MRI Cahoon Final PDF
Pediatric MRI Cahoon Final PDF
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Glenn D Cahoon
The Royal Children's Hospital
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1A 1B
1 Longer TR and TE times are generally required when imaging very young children. The high water content in neonatal brains, coupled with the lack
of fatty myelin results in a reduction in contrast-to-noise ratio (CNR) and grey/white matter differentiation. Restore pulses on T2w imaging can improve CSF
contrast and allow shorter TR times to reduce scan time.
Magnetic resonance imaging (MRI) exam- in the MR setting, and some of the have their own subtle nuances that alter
inations of children require a particular different techniques that may be as patients mature. In our facility we rou-
set of skills and expertise in order to suc- employed to overcome these difficulties. tinely scan patients from the early fetal*
cessfully obtain diagnostic images with While some technical modifications stages right through to young (and not so
minimal distress to the patients and their are described, the focus is on practical young) adults with complex congenital
family. There have been many develop- recommendations that can assist young conditions. Each of these fields, and
ments in MRI in recent years, which children to comply with the MR proce- stages of development requires their own
have lead to a dramatic increase in the dure, and minimize the use of anesthe- specialized skills, knowledge, and equip-
number and types of referrals we are now sia with this vulnerable population. ment to be performed appropriately,
seeing for pediatric MR examinations. Pediatric MR imaging can be considered however, there is a number of common
This paper provides an overview of the a series of subspecialties. Each area, challenges and techniques that apply to
challenges that pediatric patients raise neurology, cardiac, MSK, oncology, all imaging pediatric patients.
chest and abdominal imaging. Increased Techniques in scanning to comply with the MRI procedure,
flow rates lead to artifacts from blood children without sedation and also helps to prepare these children,
vessels and cerebrospinal fluid (CSF) by familiarizing them with the environ-
pulsations, creating difficulties with Preparation ment, sounds, and equipment, while
spine and Time-of-Flight (TOF) vessel At our institution we begin scanning teaching them skills (such as breathing,
imaging [5]. Differences and evolution without sedation from about five years relaxation, or distraction) to cope with
in pediatric physiology may also lead of age, although some positive out- the actual procedure (Fig. 2). Use of
wto changes in the mechanism of injury, comes have been obtained with patients the ‘mock’ magnet has led to a marked
or the types of injuries that occur in as young as three years. Adequate prep- reduction in the numbers of patients
children, such as growth plate injuries aration of children for the MRI procedure who have required anesthetic [7] and
and osteo-chondral defects (OCD) [6]. has been vital in achieving these results. reduced the time required for the diag-
Our facility employs the services of edu- nostic scan [8]. Several pediatric facili-
Behavioral cational play therapists who use a range ties in various countries have introduced
Sedation or anesthetic is commonly of resources to assist children to comply a mock procedure in their facilities in
required for younger children or those with the procedure, such as brochures, recent years [9].
with significant behavioral problems. MRI toys and storybooks, discussions with
Factors such as temperament, stress, parents, and, most importantly, the Communication
pain, and illness play an important role ‘mock MRI’ procedure. Specialist staff and equipment are clearly
in patient compliance, creating difficul- helpful in assisting children to comply
ties in establishing definitive age limits Simulation with an MR scan. However, for technolo-
for identifying which children will require The ‘mock MRI’ procedure involves chil- gists, an awareness of how to talk to chil-
these procedures [7]. Encouraging chil- dren undergoing a simulated scan with dren and adolescents at different stages
dren to co-operate for an MRI examina- the assistance of a play therapist prior of development and the use of psycho-
tion and identifying those who cannot to the actual diagnostic scan. It acts as logical techniques, such as distraction and
are arguably the most significant chal- both a screening tool, to assist in identi- relaxation, can be the critical factor deter-
lenges in pediatric MRI. fying children who are likely to be able mining whether a young person is will-
ing, or able, to carry out the procedure.
Many children are withdrawn or uncom-
3
municative when nervous about a medi-
cal procedure, and taking the time to
help the child to feel safe and secure in
the environment is important. Compli-
ance with preschool children may be
facilitated by engaging in pretend play,
where the child can be encouraged to
frame the experience in familiar and non-
threatening ways [10]. Nonverbal com-
munication comprises a significant pro-
portion of a child’s interaction with the
world at this stage, and young children
can pick up on their parents’ anxiety or
the technologist’s impatience through
nonverbal clues. They may not under-
stand these feelings and can interpret
them as anger or fear of the examination.
Professionals who work with children
typically take steps to ensure that both
their verbal communication and body
3 Mock MRI simulator – this procedure identifies patients that are able to comply with
the requirements of an MRI examination, as well as prepare them for the clinical scan,
saving unnecessary appointments and valuable scanner time.
Engage with the child Get down on their level Use simple language Maintain eye contact
Frame the experience Help them verbalize Involve the child’s past Smile
their experience experiences / play
Empower the child Offer limited choices Praise good behavior Be positive “I know you can do this”
language are reassuring and convey calm- video screen) is helpful in maintaining choose an IV site. Active distraction
ness and confidence (Table 1). Positive the patient in one position. Active tech- techniques can be helpful, and there are
reinforcement, where the child is praised niques which require patient participa- several aids available to assist with the
for their efforts at each step, can be very tion such as relaxation breathing, guided pain, such as local anesthetic creams,
helpful. imagery, or complex puzzle tasks, are ice, or nitrous oxide.
School age children are able to engage useful in relaxing children before MRI or
more actively in the procedure, and may performing interventions such as intra-
respond well to efforts to increase their venous cannulation and general anes- Protocols and sequences
perceived control. Medical examinations thetic (GA) inductions. Protocol based scanning can be difficult
often take the locus of control away in presenting pediatric patients, as the
from the patient, and this is particularly required sequences differ dramatically
true in pediatrics where someone else Successful use of depending upon pathology, patient age,
usually makes the decisions for the intravenous (IV) contrast compliance, and the clinical questions
patient. Empowering children by offer- IV cannulation is a major cause of anxi- being asked. It is often necessary for the
ing some choice in how they can have ety in young patients presenting for technologist or radiologist to screen the
the scan can be helpful. This is particu- MRI examination. Limiting the use of IV examination as it progresses and tailor
larly important during adolescence; a contrast in pediatric examinations can the sequences for the patient and pathol-
period of rapid social and physical often mean the difference between a ogy. A wide field-of-view scan can be
changes [10], when increased autonomy successful awake scan and a rebook for helpful to obtain an overview to screen
is important, yet can be hampered by sedation. This requires the support of for other pathologies, particularly in
serious illness. Adolescents are less likely the radiologists to make decisions regard- children who are difficult to examine
than children or adults to blindly follow ing whether the benefits of contrast are clinically. Children can be unpredictable
instructions, and may be reluctant to worth the potential distress to the patient. in how long they will remain still, so it
accept or comply with the scan in the Where contrast is necessary, it is often is important to prioritize sequences with
absence of a flexible approach, where the helpful to separate the procedures of the highest diagnostic yield such as T2,
technologist is sensitive to their concerns. IV placement and the MR exam by either FLAIR, and diffusion. Scanning in multi-
placing the cannula before the examina- ple planes or using 3D sequences can
Distraction and relaxation tion or offering a break between the help delineate disorders as well as mini-
Distraction can be a powerful tool for pre and post contrast scans. Many mize the chance of pathology being
reducing anxiety and increasing patient children respond well to being able to missed through partial voluming or inter-
compliance. Distraction techniques slice gap.
can be either active or passive. Passive Often it is necessary to modify a proto-
techniques such as audiovisual aids are col or sequence when imaging children
useful during the scan when patients are of different sizes or capabilities. It is
required to lie still in the bore. Having important to strike a balance between
a point of interest (such as a parent or optimum image resolution and scan time.
4A 4B
4C 4D
When modifying pulse sequences, the ■ Utilize recovery pulses, where avail- Scanning techniques
following suggestions may be helpful: able, to achieve reduction in TR times
■ Select pulse sequences that closely and to collect the images in multiple Coil selection
match the FOV required and the coil concatenations. When combined with Novel uses of MR coils are possible and
being used. The less changes you need interleaving this dramatically reduces often necessary in pediatric imaging.
to make to a sequence, the less chance the chance of crosstalk when using Choosing a coil that closely matches the
for error. minimal slice gaps. FOV you are imaging is important in
■ Concentrate on maintaining voxel size ■ Use the shortest TE that will maintain extracting the maximum signal from your
and signal-to-noise when changing image contrast to boost signal and patients. Use of multichannel arrays is
field-of-view or matrix size, and consider reduce image blur. desirable when available to take advantage
using interpolation to maintain signal of parallel imaging techniques (Fig. 4).
and resolution. The day optimizing
throughput (Dot) engines on the newer Volume imaging
Siemens scanners can be used to auto- 3D imaging can be utilized in all areas of
mate many of these decisions. the body. The use of 3D sequences per-
mits reformatting, which can be helpful
5A 5B
5 Volume imaging: Reformatting of 3D imaging is useful in the investigation of complex congenital conditions. The curved reformat of
the T1-weighted MPRAGE sequence allows appreciation of the disorganised left cerebral cortex, and helped in identification of a region of
polymicrogyria which was the seizure focus in this 12-year-old girl.
6A 6B
6C 6D
6E 6F
6 Motion correction – syngo BLADE can be used to provide a limited study in uncooperative patients (6A, 6B), but is particularly useful in
imaging posterior fossa lesions in pediatric patients where complex and high flow from CSF and vascular structures cause artifacts that may
obscure some lesions (6C, 6D). High parallel imaging factors can also be utilised with multiple excitations to average out motion artifacts
(6E None, 6F PAT3).
7A 7B
7 Images of a 1-month-old who presented with acute seizures. T2w, T1w and diffusion-weighted imaging were unremarkable. Susceptibility-
weighted imaging (7A) shows increased venous drainage in the right temporal-parietal region. (7B) The same patient imaged 48 hours later after
seizure control with phenobarbital showing normalization of the cerebral flow. The sensitivity of syngo SWI is being increasingly utilized in the
pediatric population.
8A 8B
8 Venous angioma as imaged on syngo SWI (8A) and T2w sequences (8B). The ability to obtain this level of detail has allowed us to reduce our
reliance on intravenous contrast agents to delineate these lesions.
9A 9B
9C 9D
9 These images are of a patient with a pineal cyst causing obstruction of the cerebral aqueduct with associated enlargement of the lateral and
third ventricles. The sensitivity to flow of the T2w SPACE sequence can be used to demonstrate the obstruction in the pre surgical images (9A)
as well as the increased retrograde flow through the foramen of Monro. The post surgical image (9B) shows the reduction in the size of the cyst
as well as the restored flow to the cerebral aqueduct. The 3D sequence can be easily reformatted to show the site of the fenestration of the third
ventricle (9C, 9D arrows). Third ventricultomies have been traditionally difficult to demonstrate with standard 2D and phase contrast imaging,
however, with a single 3D acquisition we can now easily answer all of the questions of the neurosurgeon.
of MRI are ideal for displaying complex nation in this population. MRI in children 12 Von Kalle T, et al. (2010) “Diagnostic Relevant
congenital anomalies of the genito- can be extremely challenging physically, Reduction of Motion Artifacts in the Posterior
Fossa by syngo BLADE Imaging” MAGNETOM
urinary tract. This information can be mentally, and emotionally, even for a
Flash 43(1/2010):6-11.
used to predict outcome and select seasoned pediatric technologist; however, 13 Forbes KP, et al. (2003) “Brain Imaging in the
patients that are most likely to benefit these very challenges are also what make Unsedated Pediatric Patient: Comparison of
from surgical intervention [18]. pediatric imaging such an interesting Periodically Rotated Overlapping Parallel Lines
and rewarding field for MR technologists. with Enhanced Reconstruction and Single-Shot
MR enterography Fast Spin-Echo Sequences” American Journal of
Neuroradiology 24:794-798.
Crohn’s disease is a serious and lifelong Acknowledgments
14 Shenoy-Bangle A, Nimkin K, Gee MS (2010)
condition affecting the digestive system. I would like to thank the patients and “Pediatric Imaging: Current and Emergent
It affects primarily the ileum and colon staff of the Royal Children’s Hospital, Trends” Journal of Postgrad Medicine 56:98-102.
causing inflammation, ulceration and Melbourne, for their inspiration, advice, 15 Zhen Wu, Sandeep Mittal, Karl Kish, Yingjian Yu,
J. Hu, Mark Haake (2009) “Identification of Calci-
can lead to abscess formation or fistulae and support in compiling this paper.
fication with Magnetic Resonance Imaging Using
to other organs. Approximately 30% of Susceptibility-Weighted Imaging: A Case Study”
patients with Crohn’s disease will pres- Journal of Magnetic Resonance Imaging 29(1):
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