Intravenous contrast-enhanced sonography in children and adolescents - a single center experience

Martin Stenzel, Martin Stenzel

Abstract

Compared to adult patients, ultrasonography in children and adolescents is much more common, due to lack of ionizing radiation, and its wide availability. With the introduction of contrast-media for use in ultrasonography, one major drawback of the method could be overcome. In Europe, SonoVue(®) is the only widely available agent, which due to improved stability makes it possible to image normal and diseased tissue perfusion and vascularization with high accuracy. Inability to hold the breath and voluntary body movement of the patient is less of an obstacle compared to color Doppler techniques and makes the method very attractive for use in children, which, depending on age, may not be very cooperative. Use of intravenous contrast-medium in minors is currently very limited for several reasons: availability, lack of recommendation in national and international guidelines, and lack of official licensing. The article will touch medical indications, technique, safety considerations, and perspective of intravenous use of contrast-media in children and adolescents, including data from a 6-year period in 37 patients.

Purpose: The purpose of the study was to collect data on ultrasonographic examinations, expanded by intravenous administration of the contrast agent SonoVue(®) in children and adolescents. Besides assessing diagnostic yield, data on adverse medication effects was collected.

Materials and methods: The study includes contrast-enhanced ultrasound examinations in 37 children at a single institution. Indications for the examinations were tumor lesions, infections, traumatic organ injuries, and parenchymal organ ischemia. Parents of the patients and adolescent patients were informed about the off-label use of the contrast agent. Thirty-nine examinations were performed, the average age of the patient was 11.1 years (range 1 to 17 years).

Results: All of the examinations yielded additional diagnostic value, always expanding results from B mode and color coded sonography. Overall, most examinations were done to assess the liver (n=16), followed by the kidney in 10 cases. The different etiologies were encountered in the following order: tumor (n=22), infection (n=9), trauma (n=5), ischemia (n=4). Most examinations were performed to evaluate a hepatic lesion (n=12). There was one incident recorded that fit the criteria of a possible adverse effect. In an 8-year-old girl nausea was noted, that started 15 minutes after the end of the examination and resolved spontaneously. In none of the patients medical treatment for adverse effects was necessary.

Conclusion: Ultrasonography in children, enhanced by intravenous use of contrast medium is feasible and allows for further evaluating cystic and solid tumors, and organ perfusion. Given that proper medical equipment and correct ultrasound machine settings are used, it is a robust method without diagnostic failures. In this small-sized case series there were no severe adverse effects, however, off-label use in children needs to be addressed.

Keywords: children; contrast-enhanced ultrasonography; intravenous route; off-label use; safety.

Figures

Fig. 1
Fig. 1
Case 1: The hepatic cyst is marked by the big arrows. The small arrows mark the septae. In power Doppler perfusion of the septae cannot be demonstrated (A). Strong enhancement of the septae proves perfusion (B)
Fig. 2
Fig. 2
Case 2: The arrows mark the focal liver lesion. The asterisk marks the gall bladder lumen. B-mode shows a slightly hyperechoic mass (A). In power Doppler mode there is a central perfusion (B). 27 sec after contrast-medium application there is strong enhancement in the periphery (C). 148 sec after contrast-medium application the lesion fills in and shows mostly homogenous enhancement (D)
Fig. 3
Fig. 3
Case 3: The big arrows mark a focal liver lesion. The small arrow marks the center of the lesion. The asterisks depict intrahepatic vessels. In B-mode sonography the lesion is isoechogenic to normal liver tissue, although there is a partial hyperechogenic rim (A). 61 sec after contrast-medium application the lesion shows a stronger enhancement compared to the surrounding liver tissue. The very center shows a medium-sized vessel (B). Besides the central vessel, there is a small area lacking perfusion, in keeping with a central scar (C). Video shows the central scar and typical vessel (video 1 – available on the website www.jultrason.pl)
Fig. 4
Fig. 4
Case 4: Dual display of contrast-enhanced mode (left side), and fundamental B-mode (right side). Arrows mark the outer margin of the lesion. The metastasis is not detectable in B-mode. In contrast-enhanced mode there is homogenous reduced perfusion in the late phase, in keeping with a metastasis (video 2 – available on the website www.jultrason.pl)

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Source: PubMed

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