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Do you need a DGH paediatric neuroradiologist?: A survey of DGH workload

Do you need a DGH paediatric neuroradiologist?: A survey of DGH workload. Ahmed Iqbal Alexander C Maclennan Consultant Radiologist, RAH, Paisley alex.maclennan@doctors.org.uk. Study Aims. Assess DGH workload in paediatric neuroradiology Implications for training

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Do you need a DGH paediatric neuroradiologist?: A survey of DGH workload

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  1. Do you need a DGH paediatric neuroradiologist?: A survey of DGH workload Ahmed Iqbal Alexander C Maclennan Consultant Radiologist, RAH, Paisley alex.maclennan@doctors.org.uk

  2. Study Aims • Assess DGH workload in paediatric neuroradiology • Implications for training • Implications for delivering a service to DGH paediatricians

  3. Study Details • Retrospective RIS review • US, CT & MRI Brain & Spine • To age 16 • Mid 2006 to 2009 (3 years) • 3 DGHs in ‘Clyde’ • Patient age , OP/IP, indication, findings, reporting radiologist

  4. ‘Clyde’ (1) • Part of Greater Glasgow & Clyde HB • Area, north and south of River Clyde to west of Glasgow, covered by 3 DGHs • 420,000 population • 17 WTE radiologists cover all 3 sites • 1 radiologist sub specialty training (ACM) • 2 radiologists with paediatric ‘interest’ • US & CT all sites; 2 MRI but no GA or monitoring in MRI

  5. ‘Clyde’ (2) • 10.5 WTE paediatricians • VOL - minor injuries unit and OP paediatrics • IRH - A&E, OP and day ward paediatrics • RAH - A&E, OP & IP paediatrics, maternity & neonatal units • 3600 annual births • Ventilate from 24 weeks in NICU (4 beds) • RHSC Yorkhill & INS are within 20 miles

  6. 3 year US, CT & MRI workload • US: 92,481 overall; 5,526 paeds; 527 neuro so paed US is 6% overall and neuro 10% • CT: 63,528 overall; 629 paeds; 408 neuro so paed CT is 1% overall and neuro is 65% • MRI: 22,617 overall; 884 paeds; 448 neuro so paed MRI is 4% overall and neuro is 50%

  7. US Brain (1) • 465 exams; 72 portable in NICU; 153 RAH departmental IP; 240 OP all 3 sites • All performed by 3 radiologists • Tend to be day 3 and six week scans. • Main indications: 116 PVL screen; 49 increasing OFC; 43 seizures or ‘jittery’; 39 IUGR or dysmorphic; 32 ? IVH; 15 apnoeas or events (overall >80%) • Main Findings: 268 normal (59%); 40 suboptimal but probably normal (9%); 143 abnormal (32%)

  8. US Brain (2) • 37 increased VCR/ hydrocephalus; 23 IVH; 20 caudothalamic groove cyst/ old GM haemorrhage; 13 PVL; 13 mineralising vasculopathy; 4 multiple cerebral abscesses (same child); 4 porencephalic cyst; 9 BESS; 2 HIE ( 1 echogenic basal ganglia, 1 obliterated ventricles); 1 holoprosencephaly; 1 cystic encephalomalacia • Portable exams require dexterity and knowledge of normal preterm appearances. Range of main indications and findings limited

  9. US Spine • 62 exams; 14 IP; 52 RAH; 10 IRH & VOL • All performed by 3 radiologists • Generally scanned before 1 month old • Main indications: sacral dimple & hairy patch • Main Findings: 42 normal (68%); 10 suboptimal but probably normal (16%); 10 abnormal (16%) • 3 Neuroepithelial cysts; 1 filum terminale lipoma; 1 thoracic meningocoele; 1 diastomatomyelia • Range of indications and findings limited

  10. CT Brain (1) • 399 exams; 316 A&E or IP; 83 OP • 3 radiologists reported 103 (26%). Most of radiologists reported 10 to 25 exams in 3 years. • Tend to be older children with trauma • Main indications: 118 head injury; 93 headache ; 55 seizure; 39 ?infection (brain, orbit & sinus); 35 vomiting; 32 decreased GCS or confusion; 17 ?NAI; 17 syncope or collapse; 10 stroke; 9 psychosis; 8 alcohol or drug OD (overall >85%) • Main Findings: 253 normal (63%); 5 failed scan; 141 abnormal (35%)

  11. CT Brain (2) • 29 skull fracture; 20 acute extraaxial haematoma; 16 contusions; 13 pneumocephalus (usually tiny amounts); 12 intracerebral haematoma; 11 facial or orbital fracture 11; 10 significant sinus opacification; 10 midline shift or increased ICP; 8 depressed skull fracture; 5 SAH; 4 cerebral oedema; 5 orbital cellulitis; 4 focal infection; 5 tumour ( overall >80%) • Exam that on call general DGH radiologists have to interpret. Many relevant findings are similar to adults. Important to understand certain paediatric presentations and CT appearances, especially non accidental injury.

  12. CT Spine • 9 exams; all IP • All performed for trauma • All normal

  13. MRI Brain (1) • 344 exams; 126 IP; 317 RAH; 27 IRH • 289 reported by 2 radiologists (84%). Remaining exams, in older children, reported by multiple other radiologists • Feed & sleep to age 6 months, then from 5 years onwards. • Main indications: 127 headache; 89 seizure; 46 focal signs; 38 visual upset; 30 dysmorphic; 21 severe vomiting; 17 gait upset; 21 severe vomiting; 16 precocious puberty; 15 developmental delay; 10 behavior change (overall >80%)

  14. MRI Brain (2) • Main Findings: 225 normal (65%); 35 limited or suboptimal (10%); 12 failed; 72 abnormal (21%) • 7 MS or ADEM (3 patients); 10 UBO or enlarged VR space; 10 focal gliosis; 9 WM delay/ absent PLIC; 4 infarct; 4 SDH; 4 grey matter heterotopia; 2 holoprosencephaly; 1 cystic encephalomalacia; 4 tumour; 3 NF1; 3 ADEM; 5 PVL (overall <60% of findings) • The range of indications, apart from trauma, is broadly similar to CT. The range of findings is much more broad. Many congenital and aquired pathologies are seen with no typical group of pathologies seen.

  15. MRI Spine (1) • 104 exams; 12 IP; 92 OP • 84 reported by 2 radiologists (about 80%). Remaining exams, in older children, reported by several other radiologists • Main indications: 62 neck or back pain; 14 gait abnormalities; 14 scoliosis; 12 focal signs; 8 paraesthesia; 4 torticollis; 2 ?transverse myelitis

  16. MRI Spine (2) • Main Findings: 69 normal (66%); 5 limited or suboptimal; 1 failed; 30 abnormal (29%) • Main findings: 10 juvenile disc disease or Scheurmann’s Disease; 5 syrinx; 4 annular disc bulges; 4 spinal dysraphism (2 low cord, 1 filum terminale lipoma, 3 Chiari 1; 1 diatomatomyelia); 2 caudal regression; 3 demyelination; 1 old fracture; 1 tumour. • Range of indications and findings limited, probably because rarely performed. Likely that the spectrum of congenital and aquired pathologies would be seen, as with MRI brain.

  17. Tumefactive ADEM IRT1 6 year old girl Drowsy and mild left weakness T1+C T2 FSE FLAIR

  18. Cystic encephalomalacia 10 year old with quadriplegic cerebral palsy and status epilepticus

  19. Semilobar holoprosencephaly High resolution US ‘Feed and Sleep’ HASTE 2 month old with facial dysmorphism and seizures

  20. Developing porencephalic cyst Left Grade IV haemorrhage at D3 US. 28 weeks preterm Left porencephalic cyst at term corrected

  21. Bilateral SDH in NAI 6 month old with Decreased GCS Facial bruising and Retinal haemorrhage Emergency CT D1 skeletal survey D16 MRI

  22. Prenatal unilateral PVL ‘Feed & Sleep’ IRT1 Term infant with unilateral ‘ventriculomegaly’ on antenatal US scan

  23. Conclusion (1) workload • Paediatric neuroradiology is a small part of overall DGH workload but accounts for half of paediatric CT & MRI. • Paediatric CT brain is part of on call for general DGH radiologists. • The 5 to 10 US & MRI per week can be delivered by a small number of interested DGH radiologists.

  24. Conclusion (2) training • US & CT training should be possible in an intensive 3 or 6 month block. • All DGH radiologists need to recognise non accidental injury on CT brain • MRI is more problematic, because of the wide range of pathologies, and probably can not be mastered in 6 months of general paediatric or neuroradiology training.

  25. Conclusion (3) Service • A paediatric neuroradiology service can be provided in a DGH. • There are sufficient numbers of US & possibly MRI to maintain skills in a small cohort of interested DGH radiologists • All DGH radiologists need to maintain skills in interpreting emergency paediatric CT brain • Developing an interest or training in MRI requires either continued mentoring by links to a tertiary centre or a DGH appointment with sessions at a tertiary centre (a common model in paediatrics).

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