by Aadil Ahmed and Mala Modi Soboleski D, Therialt C, Acker A. Unnecessary irradiation to non - thoracic structures during pediatric chest radiogra- phy. Pediatr Radiol 2006; 36: 22 – 25. This article highlights the fact that our present positioning techniques for paediatric chest radiographs result in unnecessary radi- ation exposure to non-thoracic structures. Pearls: • Infants and young children have a higher sensitivity than older children and adults to radiation exposure and the potential for harmful side-effects. • The ratio of radiation exposure to non- thoracic structures increases as the age of the patient decreases. • ± 43% of the length of the chest radio- graphs in this study was of non-thoracic structures and it was also demonstrated that no significant additional information was obtained by including the neck or abdomen in chest radiographs done for cardiorespiratory pathology. Defining new landmarks for position- ing/ collimation is necessary to eliminate this problem and also to satisfy the ALARA (as low as reasonably acceptable) principle. Fung E, Ganesan V, Cox TSC. Complication rates of diagnostic cerebral arteriography in children. Pediatr Radiol 2005; 35: 1174 – 1177. Cerebral arteriography (CA) in children is investigated, and the differences between adults and children in terms of local and neurological complications are compared. This article is particularly relevant as most CA articles either have an adult bias, or are relatively outdated – and there have been significant technological advances. CA is useful in the evaluation of cerebral arteriovenous malformations and aneurysms and has a continuing role to play in the detec- tion and characterisation of arteriopathies in children with arterial ischaemic stroke, for example, moyamoya syndrome, embolic dis- ease and inflammatory processes. Pearls: • CA can be technically challenging in a small infant with extra adipose tissue so that local complications may be more common than in adults. • Conversely, the absence of co-morbid fac- tors, such as diabetes and hypertension, or of widespread arterial disease, means that neurological complications are likely to be less common in children than in adults. • CA is a superior technique to standard MRA sequences as it provides dynamic information regarding the cerebral circula- tion. • CTA is more freely available, and its value has been proven in adults, even though it uses both iodinated contrast and ionizing radiation • A comparative study of helical CTA, MRA and DSA in children has demonstrated that helical CTA is superior to MRA in the identification of the intracranial vascula- ture (venous and arterial) and is almost as good as DSA. The author and his group performed CAs under GAs which in itself can be a deter- rent, as well as the fact that patients require a 2-day admission. This retrospective study carried out in a tertiary care institution concluded that CA has a continuing role to play in evaluating cerebrovascular pathologies in kids. In experienced hands neurological com- plications are rare and local complications are not uncommon (around 5% in this study) but are not usually serious (the com- monest being groin haematomas and bleed- ing at the puncture site). By Savvas Andronikou A doctor was struck from the General Medical Register in the UK after he pleaded guilty to making indecent images of children. A panel found that he downloaded images from the internet deliberately. ‘The public inter- est includes protecting patients and main- taining public confidence in the profession and maintaining proper standards of profes- sional behaviour and conduct.’ Children’s rights must be protected on their behalf and medical practitioners including radiologists should be instrumental in bringing injustices to light particularly with regard to abuse and sexual abuse. Child pornography is sexual abuse! Reference: GMC Newsletter Issue 5 December 2005. On Saturday 25 February the first work- shop for paediatric imaging in South Africa took place in Johannesburg under the aus- pices and sponsorship of the College of Radiology of South Africa and the Paediatric Imaging Society of South Africa (PISSA). This was organised by Mala Modi and her team of registrars (Lee Kramer and Jeanie Jennings). Over 75 doctors attended this compact course which answered practical issues relating to procedure performance. These included MCUG, contrast swallow/ meal, tube oesophagogram, ultrasound for UTI, head ultrasound and imaging of hyper- trophic pyloric obstruction. There was also a speak-off on the current management of intussusception by Dr Aadil Ahmed of Baragwanath Hospital and Professor Savvas Andronikou of Tygerberg Hospital, which is mirrored in this publication. There was also an interactive session on interpretation of neonatal ICU films including tube and line placement and recognition. The workshop was free to delegates and PISSA is grateful to the President of the College of Radiologists for its new educational initiative in sponsor- ing the airfare for Professor Andronikou to run the course. Aadil Ahmed and Mala Modi, Dept of Radiology, University of the Witwatersrand and Chris Hani Baragwanath Hospital Intussusception is the invagination of a segment of bowel (the intussusceptum) into the contiguous segment (the intus- suscipiens). The peak incidence is between 6 months and 2 years.1 Most cases are idio- pathic, but in a small number there is a pathological lead point. Common sites are ileocolic and ileoileocolic.1,2 The classic clini- cal triad of abdominal pain, red currant jelly stool and palpable abdominal mass is present in less than 50% of children.2 Journal review by Savvas Andronikou Figs 1 and 2 demonstrate the contrast meal in a child with alleged ‘bile-stained’ vomiting. The second part of the duodenum shows a loop to the right of the spine prior to crossing to the left of the spine, suggesting malrotation. A false- positive diagnosis was made by the reporting registrar because a normal duodeno-jejunal flex- ure is expected to be located to the left of the spine, behind the stomach at the level of the duo- denal bulb. The above images are consistent with a duodenum inversum or a duodenum reflex- um.1 This subtle variation of normal demon- strates the distal duodenum to ascend to the right of the spinal column up to the level of the duodenal bulb and crossing the spine horizon- tally where it is fixed in a normal location by the ligament of Treitz. It may result in delayed gastric emptying which gives rise to the presenting symptoms but is not associated with midgut volvulus. An accurate diagnosis is imperative to avoid unnecessary surgery.1 1. Long FR, Kramer SS, Markowitz RI, Taylor GE, Liacouras CA. Intestinal malrotation in children: tutorial on radi- ographic diagnosis in difficult cases. Radiology 1996; 198: 775-780. Pediatric Radiology October 2005; 35: 947-979. The minisymposium consists of 2 articles on the evaluation of vascular rings and slings and the imaging thereof. A vascular ring refers to any vascular or ligamentous anomaly that encircles the trachea or oesophagus. There are 2 groups: complete and incomplete. Complete vascular rings include double aortic arch, right aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum. Incomplete vascular rings include pulmonary artery sling and innominate artery compressive syndrome. The first article written by M Oddone et al. is: ‘Multi-modality evaluation of the abnormali- ties of the aortic arches in children: techniques and imaging spectrum with emphasis on MRI’. A fantastic article discussing embryology and classification as well as the imaging with chest radiography, barium oesophagography and MRI. Each subtype is then comprehensively described under separate sections with great images and additional line diagrams. The second article, written by M Hernanz- Schulman, is ‘Vascular rings: a practical approach to imaging diagnosis’. This article also discusses imaging techniques in detail and includes modalities such as ultra- sound and multislice CT. Specific subtypes are also described in detail with superb images. The articles combined are 30 pages but well worth the read. by Nicky Wieselthaler Girst TM, Thornton FJ. MRA in children: tech- nique, indications and imaging findings. Pediatric Radiology 2005; 25: 26-39. This article explains the conventional MRA tech- niques that can be used in children as well as contrast-enhanced 3D MRA with rapid T1 spoiled gradient-recalled echo (FSPGR). Injection parameters and indications are dis- cussed in detail. Rating: ***. Comment: very educational and practical. Taylor Chung. MRA of the body in pediatric patients: experience with a contrast-enhanced time resolved technique. Pediatric Radiology 2005; 35:3-10. This article compares CT angiography with other available modalities and techniques. It also provides valuable and practical scan parameters that can be used in practice. Dose-specific para- meters are discussed with useful suggestions for radiation reduction. Applications in paediatric practice are listed. by Savvas Andronikou • ESPR – 2005 The European Society for Pediatric Radiologists held its Annual Conference in Dublin. The mem- bers of PISSA who attended (S Andronikou and N Wieselthaler) presented 2 papers and 1 paper which were well received. The long papers were delivered by S Andronikou on behalf of Carey Makenzie and Stefan Przybojewski and dealt with physeal bar and objective features of basal enhancement in TBM respectively. The main focus and keynote speakers dealt with increasing scientific evidence of the decreasing importance of vescicoureteric reflux. Abstracts were published in a supplement issue of Pediatric Radiology. • ESPR/ IPR 2006 In 2006 there is a combined meeting of North American, European and Oceanic societies of Pediatric Radiologists at IPR in Montreal. Abstracts have already closed. PISSA has entered 4 abstracts including long papers on radiograph- er reporting in CT brain and correlation of infants with outcome in TBM. • ISR 2006 Jan Labuschagne has secured this massive International Conference to be held at the Cape Town ICC in September 2006. Good news for PISSA is that there is a dedicated Pediatric Tract for Thursday 14 September, Friday 15 September and Saturday 16 September with over 8 hours of talks and over 30 invited international speakers just for the Pediatric Tract. These will be from Europe, the USA, Canada, Australia, Asia and Africa and include the likes of J Barkovich, Susan Blaser, Steven Chapman, Francis Brunelle, Alan Daneman, Marilyn Siegel, Isky Gordon, Kieran McHugh and Douglas Jamieson. One session is dedicated to neuroimaging, one to abdominal imaging and one to TB/HIV in children. The last day will be jam-packed with internationally renowned TB/HIB experts. Abstracts for posters and long papers are wel- come: docsav@mweb.co.za. Check out the pro- gramme: www.isr2006.co.za. Baby Steps into Pediatric Neuro Imaging. S Andronikou, N Wieselthaler, E Kader (2004) SAMA Health and Medical Publishing Group (Cape Town). A product of PISSA, this national collaboration is finally in print, but has already run out of print! The massive demand has prompted another print of 200 books for 2006. Feedback has shown this to be an excellent quick reference, particularly for the myelin maturation and stan- dardised US imaging of the head. PISSA intends to produce its next book ‘A Guide to Pediatric Imaging Procedures’ some- time in 2006. The RSSA and College of Radiologists are col- laborating to produce a free Imaging Atlas for Radiologists and Clinicians. The publishing team of PISSA is heading the project even though most of the atlas will deal with adult anatomy. An excellent chapter in Paediatric Imaging Anatomy is in progress and will form an integral part of the book. The RSSA has donat- ed over R120 000 for the publication which is sanctioned by the College of Radiologists of South Africa. A pre-exam course is held annually by the College of Radiology. This year paediatric imag- ing was given as much emphasis as imaging of all the other body systems and the conference was a huge success. Vivas, spot tests and long cases were added to the programme of physics and written question preparation lectures. The next course will be held in Cape Town in 2006. Enquiries contact the organiser: Dr Savvas Andronikou at docsav@mweb.co.za. The October 2005 College of Radiology exams have just taken place. Paediatric imaging was a focus of 2 written questions and 2 of the 10 long cases. It also formed a large proportion of the oral exam as one examiner asked only paediatric radiology-related questions. Written by S Andronikou & N Wieselthaler 36 SA JOURNAL OF RADIOLOGY • December 2005 Specialty Corner Produced by: PISSA Figs 1 and 2. Images demonstrating the course of the duodenum, consistent with duo- denum inversum. Case of the day An unusual duodenal C- loop Journal review – Hermes Conference News Books Pre-exam Course College of Radiology Newspaper2 11/25/05 1:50 PM Page 36 Contributors: A Ahmed, M Modi, S Andronikou, A Erlank News: indecent ‘imag- ing’ of children Workshop on paediatric fluroscopic imaging and paediatric ultrasound technique Controversy and con- sensus on the manage- ment of intussuscep- tion. Guidelines to diagnosis and manage- ment for suggested safe practice – a literature review 33 SA JOURNAL OF RADIOLOGY • March 2006 speciality corner.indd 33 3/27/06 3:26:35 PM 34 SA JOURNAL OF RADIOLOGY • March 2006 Imaging diagnosis 1. Sonography is reported to be sensitive. A 100% negative predictive value has been reported in some series and is used as the modality of choice for diagnosis and exclu- sion in many centres. Intussusception has a characteristic appearance. A 3 - 5 cm soft-tis- sue mass is demonstrated, more often on the right side of the abdomen, and usually found just deep to the abdominal wall. The ‘crescent in doughnut’ sign and ‘pseudokidney’ sign have been described. Sonography is also use- ful in documenting the presence or absence of a pathological lead point or excluding other abdominal pathology. The presence of free fluid is a common finding and is not a contraindication to reduction. Non-visu- alisation of blood flow in the intussusception by colour Doppler is not a contraindication to reduction, but cautious reduction should be undertaken.2 2. No reported study has demonstrated plain radiographs to be as good as sonog- raphy, however, its importance, especially a horizontal beam radiograph, in detecting free air, cannot be overemphasised.1,2 Some characteristic signs include the ‘meniscus’ sign and the ‘target’ sign. 3. A diagnostic enema was considered the gold standard until the value of sonography was recognised. It is more invasive, requires radiation exposure and may not demon- strate the presence of other intra-abdominal pathology. Radiological management The major advantages of radiological man- agement are decreased invasiveness and mor- bidity, lower costs and shorter hospital stays.3 The general contraindications include: (i) clinical evidence of dehydration, shock or peritonitis; and (ii) radiographical evidence of a perforation with free air. Pneumatic reduction will be discussed as this technique is used in many centres worldwide as well as in our institution, and is generally considered the optimal tech- nique.3-5 • The patient must be fully resuscitated with an IV line in situ. • Informed consent must be obtained from a parent or guardian. • The local paediatric surgeon should be aware of the procedure and a doctor trained in paediatric resuscitation should be in the room. • Fluoroscopically guided reduction is used due to ease of use and familiarity. • Ultrasound guidance has the advantage of no radiation, but can be technically chal- lenging, and recognition of perforation may also be difficult. • Methods to improve reduction success are variable and of limited use with no signifi- cant increase in reduction rates: • Medications: (i) antispasmodics are not routinely indicated; (ii) sedation is of ques- tionable value, may have an unpredict- able response and has the disadvantage of masking the patient’s condition; and (iii) consider analgesia as an alternative.3,4 • Delayed repeated attempts; the time inter- val varies from 30 minutes to 24 hours and is only applicable in a minority of patients and depends on local and clinical circumstances. • The catheter used is a local decision, but a large-bore tube or catheter is suggested • Meticulous strapping of buttocks is sug- gested, as a good anal seal is of utmost importance in maintaining a sustained pressure. • The initial attempt should be at pressures of 60 - 80 mmHg. • Three attempts of 3 minutes each are usu- ally sufficient and safe. • It is generally recommended that each attempt at reduction should be for a maxi- mum of 3 minutes, with approximate 3- minute intervals between attempts (Rule of 3’s).1,4,5 • Increasing pressure with subsequent attempts, to a maximum pressure of 120 mmHg is recommended.4,5 • A pressure release valve with a cut-off at 120 mmHg is an alternative in the absence of a pressure manometer. • Successful reduction is usually defined as free flow of air into the distal ileum. If no reflux of air into the ileum is seen, the patient may be observed and management decided on the child’s clinical state. • Complications: (i) the major complication is bowel perforation, a large pneumoperi- toneum can be relieved by needle puncture of the abdomen to prevent the rare compli- cation of tension pneumoperitoneum; (ii) hypovolaemic shock requiring resuscita- tion; and (iii) the risk of bacteraemia. • In some instances sonography may play a role, post reduction or attempted reduc- tion: (i) to confirm reduction; (ii) to assess for pathological lead point; and (iii) to delineate the presence of unreduced com- ponent. • Regular audits of intussusception figures should be undertaken. Successful reduc- tion rates of > 50% should be aimed for.4 1. Dahnert W. Radiology Review Manual. 5th ed. Lippincott Williams and Wilkins, 2003:835 – 837. 2. Daneman A, Navarro O. Intussusception: A review of diagnos- tic approaches. Pediatr Radiol 2003; 33: 79 - 85. 3. Daneman A, Navarro O. Intussusception: An update on the evolution of management. Pediatr Radiol 2004; 34: 97 - 108. 4. British Society of Paediatric Radiology. Guidelines for Intussusception Reduction. 2003. 5. Rosenfeld K, McHugh K. Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better. Clin Radiol 1999; 54: 452 - 458. By S Andronikou, A Erlank, M Strachan, G Dekker: Radiology Department, Tygerberg Hospital and University of Stellenbosch In view of your review article on air reduction of intussusception, we would like to comment as follows: Precautions and Preparations • If you do use ultrasound for the diagnosis, be confident about a positive diagnosis; if you are confident about the diagnosis of exclusion of an intussusception do not proceed with any procedure. • No positive ultrasound finding for intus- susception is a contraindication for air reduction. • Only proceed to air reduction if a paedi- atric surgeon and adequate resuscitation equipment are available on site. • Check films for features of bowel perfora- tion (free air) and for features of colitis (mural air) and cancel the procedure if present. • Insist on attendance of surgical staff. • Insist on intravenous access. • Have large-bore needles available – place in the attending surgeon’s hands. • We do not wait for fluid resuscitation because we lose valuable time. • Do not sedate the patient; it only confuses patient monitoring. Some advice on the procedure itself • Use a balloon catheter (24 F) to get a good seal and keep it neat1 (Figs 1a and b) Comments on intussus- ception reduction – the Tygerberg Hospital experience Fig. 1a. A little finger which is accepted for PR examinations in young children is much larger than a 24F Foley catheter. speciality corner.indd 34 3/27/06 3:26:36 PM • Store an image before air is going in – it helps to see the central gas paucity later when confused about free flow into the small bowel (Fig. 2) • Prone position helps hand grasp seal • Be prepared for direction of sigmoid when prone (Figs 3 - 5) • Do not infuse air until watching with fluoroscopy • Rotate tasks with many people • Try hard. Procedure rules • There are no rules • Try as many times as you like • Come back as may times as you like • 120 mmHg is not an absolute; you can go more but we do not recommend this; do not panic about small elevations above this. Caution • When perforation occurs remember the air is white on fluoroscopy – take a spot film to look for free air (Fig. 6); deflate the bal- loon; turn the patient; stick needles in the abdomen and resuscitate the patient • Move fast because diaphragms are high in the chest due to high pressure. Why are we not succeeding? • We do not try long enough or hard enough • Our patients present late (anecdotal suc- cess rate in the UK is about 90% and in SA about 60%) • Perforation probably happens in patients with bowel necrosis and not from too- high pressures. 1. McAlister WH, Parker B. Apropriateness criteria for imaging and treatment decisions. Expert panel on pediatric imaging. Possible acute or chronic sinusitis. Radiology 1998; 206: 595-598. According to regulation 17 of the regulations relating to the specialties and subspecialties in medicine, which were published in gov- ernment notice no. R590 of June 2001, any specialist may treat any person who comes to him or her directly, without referral by another medical practitioner. In essence this means that a patient can present to a radiolo- gist and request a CT scan. The radiologist is the best person to decide on the appropriate investigation, and this may seem completely logical and ethical. There are many pitfalls, however when the radiologist has not or cannot perform the full clinical examination and take the complete history into account. Appropriate use of this regulation is for example for mammography, which is usually a screening test. Referral of a patient to the clinical specialist can occur if pathology is identified. Fig. 1b. The balloon that is inflated in the rec- tum acts as a seal to prevent air leakage. Fig. 2. We recommend this preliminary film which shows the amount of central gas prior to reduction attempt and is a valuable record when the free flow into the small bowel is not actually visualised. Fig. 3. An early image stored as a ‘grab’ is of low quality but is sufficient to demonstrate the intussusception being forced back by the column of air. Note that air on fluoroscopy is ‘white’ and that the sigmoid is in a ‘mirror image’ position because the procedure is performed prone by our team. Fig. 4. Later during the procedure the intus- susceptum is driven even further. Note that this image was recorded as a spot film result- ing in a high quality image. Note the reversed position of the sigmoid once again, due to prone positioning. Fig. 6. Full exposure has been performed and the image contrast reversed to demon- strate free air in the recognisable ‘black’ form after perforation. Reportage: Can the radiologist consult directly with the patient? Fig. 5. Post reduction, there has been free flow of air into the small bowel indicating success of the procedure. Comparison with the initial image (Fig. 2) is useful. 35 SA JOURNAL OF RADIOLOGY • March 2006 speciality corner.indd 35 3/27/06 3:26:40 PM