docDysplasia - Society for Pediatric Radiology
download 
Report Transcription
Dysplasia - Society for Pediatric Radiology
Pediatric MR Urography: Clinical Applications Jonathan R. Dillman, MD, MSc Associate Professor Department of Radiology Cincinnati Children’s Hospital Medical Center Disclosures • No relevant conflicts of interest • Use of gadolinium contrast agents for urinary tract imaging <2 years of age is off-label • This talk would not be possible without the physicians, technologists, and patients of University of Michigan/C.S. Mott Children’s Hospital Objective • To review common MRU applications in children and adolescents Pediatric MRU – My Approach 1. MR Hydrography: – SSFSE with fat-sat – T2W FSE with fat-sat – 3D T2W FSE (with 3Ds) 2. Postcontrast MRU: – Dynamic 3D T1W SPGR • 15 minutes, post-furosemide – Delayed 3D T1W SPGR (with 3Ds) • 3-planes, high-resolution Where Can We Add Value? 1. Complex renal/urinary tract anatomy – Often duplex systems 2. Certain UPJO/hydronephrosis cases – – – – – Intermittent UPJO – crossing vessel? Duplex lower moiety hydronephrosis Post-pyeloplasty pain Discordant US/NM studies Surgical planning (e.g., robot cases?) More Added-Value? 3. Certain hydroureter cases – Obstructing vs. non-obstructing megaureter/UVJO? – Megaureter/UVJO vs. ectopic 4. Detailed assessment of renal parenchyma – Dysplasia – Scarring vs. pyelo 5. Day and night wetness (ectopic ureter?) 6. Other renal/GU mysteries Complex Renal/ Urinary Tract Anatomy Complex Anatomy – Example #1 History: 2 month-old girl --- antenatal hydronephrosis Complex Anatomy – Example #1 Diagnosis: Right Duplex Kidney with Ureterocele Disproportion & Massive Lower Moiety Pelvicaliectasis from UPJO Complex Anatomy – Example #2 History: 4 month-old girl --- antenatal hydronephrosis UPJ Obstruction/ Hydronephrosis Unexplained Hydronephrosis History: 3 year-old boy --- antenatal hydronephrosis Intermittent Flank Pain History: 8 year-old boy --- hx/o hydronephrosis Intermittent Flank Pain History: 8 year-old boy --- hx/o hydronephrosis Intermittent Flank Pain T1W+ History: 8 year-old boy --- hx/o hydronephrosis T1W+ UPJO due to Crossing Vessel History: 7 year-old girl --- intermittent flank pain UPJO due to Crossing Vessel History: 17 year-old boy --- intermittent flank pain Duplex System – UPJO? History: 8 year-old boy --- hydronephrosis Duplex System – UPJO? Courtesy of M. DiPietro (Lebowitz Collection) UPJO – Post-Op History: 16 year-old girl --- flank pain post pyeloplasty Hydroureter Megaureter – Obstructing? History: 2 year-old girl --- left hydroureteronephrosis Megaureter – Obstructing? History: 1 year-old girl --- right hydroureteronephrosis Megaureter – Obstructing? History: 3 year-old boy --- left hydroureteronephrosis Megaureter/UVJO – Anatomy? History: 6 year-old boy --- left antenatal hydronephrosis Megaureter/UVJO – Anatomy? History: 7 month-old girl --- antenatal hydronephrosis Assessment of Renal Parenchyma Assessment of Renal Parenchyma Dysplasia History: 3 month-old girl --- Left UPJ obstruction? Assessment of Renal Parenchyma Dysplasia History: 1 month-old boy --- in utero hydronephrosis Assessment of Renal Parenchyma Dysplasia History: 3 month-old girl --- antenatal hydronephrosis Assessment of Renal Parenchyma Dysplasia History: 3 month-old girl --- antenatal hydronephrosis Renal Dysplasia – Predictable? Risdon RA, et al. Pediatr Radiol 1975; 3:213-225 Assessment of Renal Parenchyma Reflux (Scarring & Pyelo) History: 8 year-old girl --- fevers, history of VUR Assessment of Renal Parenchyma Reflux (Scarring) History: 12 year-old boy --- UTIs, history of VUR Day and Night Wetness/ Ectopic Ureter? Day and Night Wetness Ectopic Ureter? History: 10 year-old girl --- day/night wetting Day and Night Wetness Ectopic Ureter? Diagnosis: Left Duplex Kidney with InfraHistory: sphincteric 10 year-old girl --day/nightUreter wetting Insertion Ectopic Day and Night Wetness Ectopic Ureter? History: 3 year-old girl --- day/night wetting Day and Night Wetness Ectopic Ureter? History: 8 year-old girl --- “solitary kidney”, wetting More Ectopic Ureter History: 14 year-old boy --- “solitary kidney”, pelvic pain More Ectopic Ureter History: 2 day-old girl --- solitary kidney, no urine output More Ectopic Ureter History: 3 week-old girl --- antenatal hydronephrosis Where Do They Insert? Courtesy of M. DiPietro (Lebowitz Collection) Unsolved Mysteries History: 13 year-old boy with remote history of highgrade right kidney injury – abnormal follow-up US 2 years prior … History: 13 year-old boy with remote history of highgrade right kidney injury – abnormal follow-up US History: 13 year-old boy with remote history of highgrade right kidney injury – abnormal follow-up US Diagnosis: Obstructed Right Upper Pole Calyces due to Infundibular Stricture Complementary Case 16 year-old boy with horseshoe kidney & remote left moiety grade IV injury following blunt trauma Complementary Case 9 year-old boy --- incidental upper pole hydronephrosis during appendicitis work-up Conclusions • MRU at 3T is a POWERFUL diagnostic tool with many applications in children • Permits successful marriage of structural & functional assessment without ionizing radiation • Potential to limit # of diagnostic studies, lower costs, and improve outcomes? – Need more research! ... “Tailored MRU”?
