Transcript Selected Topics in Rehabilitation and Radiology

Selected Topics in
Rehabilitation and Radiology
Neuroimaging of CP
Neuroimaging of MS, ADEM, GBS
More on MRI
Some “rare birds” you can learn to recognize
Osteopenia/Osteoporosis
Interventional/GI
Rehabilitation and Radiology
OBJECTIVES
Demystify/explain fancy new neuroimaging
techniques at a basic level
 Get a few more board questions right
 Choose well from available options, and
know when to consult your radiologist
 Recognize and respect contraindications
 Recognize limitations and appropriately
apply findings to patient management
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Cerebral Palsy
Who remembers the definition?
 Do they still have “idiopathic” as most
common etiology on the boards?
 The most common etiologic sequence and
result is _________________________?
 Indications for neonatal imaging
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screening, therapeutics, prognostics,
Indications for diagnostic imaging when
they come to our clinics
American Academy of Neurology
Practice Parameters
Available on line –
http://www.aan.com/professionals/practice/
index.cfm?a=0&fc=1
 Mar 2004Diagnostic Assessment of the
Child with Cerebral Palsy
 Jun 2002Neuroimaging of the Neonate
 Sep 2003Utility of MRI in Suspected MS
 Jun 1993Magnetic Resonance Imaging in
the Evaluation of Low-Back Syndrome
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Imaging of the Neonate
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Ultrasound on all < 30 weeks preterm infants
once between 7-14 days, again between 36-40
weeks
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MRI slightly better at picking up cystic white matter
lesions
Will pick up IVH, PVL, ventriculomegaly
Non-contrast CT for sick term babies
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MRI between days 2-8 if not conclusive; diffusion
weighted if available
Pick up major hemorrhages, BG/thalamic
Research on MRS promising
Imaging for Cerebral Palsy
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Get MRI if etiology not clearly established.
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Genetic and metabolic testing if:
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Positive clinical findings (dysmorphology)
Specific brain malformations
Normal brain structurally and deterioration, episodic
nature, + FH, no etiology
Skip the EEG unless possible seizures
Check hearing, vision, nutrition, cognition, speech
Consider coagulopathy workup for early CVA
Myelination – Delayed vs abnormal
(PVL vs leukodystrophy)
Hypoplasia Corpus Callosum +
Septo-Optic Dysplasia (mild)
Hypoplasia Corpus Callosum +
Septo-Optic Dysplasia (mild)
Vermian and CC hypoplasia
Term baby, smart, bulbar-CP like picture
Metabolic errors – Agenesis CC
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Amino acid
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glycine synthase
maternal phenylketonuria
methyl malonic acidemia
Mitochondrial
pyruvate dehydrogenase
pyruvate decarboxylase
fumarase
Organic Acid
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non-ketotic hyperglycinemia
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glutaric acidemia
congenital disorder of
glycosylation
3-hydroxyisobutyric
aciduria
Peroxisomal
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Zellweger
Refsum
adrenoleukodystrophy
Metabolic errors - Cerebellar
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Menkes syndrome
Smith-Lemli-Opitz
syndrome
Shapiro syndrome
fetal alcohol syndrome
acrocallosal
ectodermal dyplasia
Lhermitte Duclos Disease
(PTEN mutations)
Pontocerebellar
hypoplasia
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CGDS - congenital
glycosylation defect,
(carbohydrate-deficient
transferrin)
Joubert
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recessive, several genes
discovered
hypotonia
episodic hyperpnea/apnea
abnormal eye movements
facial, other dysmorphisms.
developmental delay
cerebellar ataxia
Glutaryl-CoA dehydrogenase
deficiency
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encephalopathic crises
extrapyramidal symptoms
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Treatment:
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Glucose/electrolyte IV for acute illness
Carnitine supplementation
Low protein, lysine restricted diet
Neuroimaging:
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frontotemporal and basal ganglia atrophy
subependymal pseudocysts
delayed myelination
chronic subdural effusions and hematomas
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Could be msitaken for child abuse
Other associations
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HIE, NEC, sepsis with either CC or vermian
Congenital infections with cerebellar
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Toxoplasmosis
Rubella
Dandy-Walker and variants
Chromosomal - trisomy 8, 13, 18, 21
Peroxisomal disorders and fatty acid oxidation
defects can produce migration defects
Folate and neural tube defects
HIE vs Metabolic
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HIE - end of term gestation hyperintense signal, atrophy of
putamen and thalamus, associated
with static esxtrapyramidal CP
Signal abnormalities, atrophy in the
putamen, globus pallidus, or
caudate associated with geneticmetabolic diseases
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J Pediatr. 1997 Aug;131(2):240-5, "Brain
magnetic resonance imaging in suspected
extrapyramidal cerebral palsy: observations
in distinguishing genetic-metabolic from
acquired causes," Hoon AH Jr, Reinhardt
EM, Kelley RI, Breiter SN, Morton DH,
Naidu SB, Johnston MV.
Migrational Defects
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Lissencephaly
Microgyria
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Pachygyria
Schizencephaly
BOTTOM LINE
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Brain malformations can be caused by
environmental or genetic factors, by creating a
toxic or energy-deficient intrauterine milieu,
changes in membrane function, or disturbing
normal expression of genes responsible for
morphogenesis.
Refer for detailed workup
 Refer urgently if having episodic or stepwise deterioration with/without illness
 Later referral may not be helpful
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Imaging of Neuro-Immunologic
Disorders
MS
 ADEM
 Transverse myelitis
 GBS and variants
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[question = “What are several conditions that
MRI is almost always the best study for?”]
Multiple Sclerosis
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Ideal criteria – 2 attacks, 2 lesions
May not fit primary progressive types versus
remitting-relapsing
If fewer of either, look for corroboration with CSF
and/or VEP studies
Poser, McDonald, newer criteria
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Location of lesions
Differential gadolinium enhancement
Differential: ADEM, CVD, HIV, sarcoid
Easy differential: Chiari I, cervical SCI
T2, gadolinium enhancement
http://www.med.ege.edu.tr/norolbil/2000/NBD12600.html
http://www.annalsofian.org
Representative axial T2- (upper left),
noncontrast T1- (upper middle), postcontrast
T1- (upper right), and fast fluid-attenuated
inversion recovery (FLAIR) (bottom row)
MRI variations you just saw
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FLAIR - special T2 sequence analysis
Fast Fluid Attenuation Inversion Recovery
 CSF subtracted out, good for MS, PVL
 May enhance edges of ventricles as artifact
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Gadolinium – MRI contrast material for T1
highly paramagnetic material
 coordinates with protons of water molecules,
changes them to a very bright signal
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More MRI variations
manipulate slice, pulse orientation and
timing, Te & Tr values, post-processing
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Spin Echo
Gradient Echo
STIR short tau inversion recovery
TSHIRT
Fast Spin Echo
Time of Flight Angiography 2D & 3D
Fat Separation (Dixon – use for fractures)
Diffusion Weighted Imaging (DWI)
Echo Planar Imaging (EPI – use for FMRI)
FMRI - BOLD
MRS (MR Spectroscopy)
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Normal spectrum of eight metabolites
Reproducible, small files
Peaks compared with creatine
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Multivoxel and 3D spectroscopy
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NAA higher, myo-inositol half
Color map superimposed on diagnostic image
Region of interest down to 2-3 mm, 4-9 min.
Works reliably only at long TEs, leaving NAA, creatine,
choline, lipid, and lactate as others decay
Gliomas (choline – cell membrane turnover)
HIE (lactate)
Dementia (low NAA, high myo-inositol)
Craniosynostosis
Post TBI with parietal fracture
Socially Responsive Child
Osteopenia
Plain film – not quanititative
 DEXA – newer versions may subtract
hardware, contractures a problem
 Ultrasound – very rough screening
 Quantitative CT
 Urinary N-telopeptide
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Teen with SMA and knee pain
GI Radiology
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KUB
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Stool pattern, pneumatosis
Barium study – upper, SBFT, lower
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Structural anomaly, IBD
Radionuclide – not as sensitive as pH
probe but useful, quanititative
 No study sensitive for gastritis, esophagitis
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GI - Interventional
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Continent cecostomy
Anterograde enema
 Brief admission, traning
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Non-surgical tube placement
NJ by fluoro in cases of SMA
 GJ – poor feeding tolerance via GT
 Limitations due to finer gauge tube – may not
be able to use crushed meds
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SMA - obstruction