Radiological Imaging of the Neonatal Chest (eBook)

Foreword 5
Preface 6
Table of Contents 7
1 Embryology and Anatomy of the Neonatal Chest 9
1.1 Embryology 9
1.1.1 Introduction 9
1.1.2 Early Embryonic Development 9
1.1.3 Embryology of the Airway and Lungs 10
1.1.3.1 The Maturation of the Lungs 10
1.1.3.2 The Blood Supply of the Lungs 11
1.1.4 Embryology of the Heart 11
1.1.4.1 The Primitive Heart Tube 11
1.1.4.2 Early Chamber Formation 11
1.1.4.3 Development of the Heart Wall 12
1.1.4.4 Folding of the Heart 12
1.1.4.5 Development of the Atria 12
1.1.4.6 Development of the Atrial Septum 12
1.1.4.7 Development of the Ventricles, the Atrioventricular Canals, the Valves and the Outflflow Tracts 13
1.1.5 Embryology of the Oesophagus 13
1.1.6 Embryology of the Diaphragm 13
1.1.7 Embryology of the Thoracic Wall 14
1.1.7.1 Vertebrae 14
1.1.7.2 Ribs 14
1.1.7.3 Sternum 14
1.1.7.4 Intercostal Muscles and Dermis 15
1.2 Anatomy of Neonatal Chest Radiology 15
1.2.1 Introduction 15
1.2.2 Airway and Lungs 15
1.2.3 Heart and Great Vessels 15
1.2.4 Thymus 16
1.2.5 The Chest Wall and Diaphragm 17
References 18
2 Update on Clinical Management of Neonatal Chest Conditions 19
2.1 Introduction 19
2.2 Ventilatory Support 19
2.2.1 Continuous Positive Airway Pressure 20
2.2.2 Continuous Mandatory Ventilation 22
2.2.3 High Frequency Ventilation 26
2.2.4 Extracorporeal Membrane Oxygenation 30
2.2.5 Liquid Ventilation 34
2.3 New Drug Therapies 37
2.3.1 Surfactant 37
2.3.2 Nitric Oxide 42
2.4 Prenatal Medicine 45
2.5 Conclusion 48
Reference 48
3 Computed and Digital Radiography in Neonatal Chest Examination 54
3.1 General Considerations 54
3.1.1 Indications 54
3.1.2 Radiographic Technique 55
3.1.3 Expected Findings, Normal Variants and Artefacts 56
3.1.3.1 The Normal Neonatal Chest Radiograph 56
3.1.3.2 Nasogastric, Replogle and Endotracheal Tubes 57
3.1.3.3 Umbilical Arterial/Venous Catheters 59
3.1.3.4 Extracorporeal Membrane Oxygenation Catheters (ECMO) 59
3.1.3.5 Chest/Mediastinal Drains 60
3.1.3.6 Normal Variants and Artefacts 60
3.2 Digital Radiographic Systems 60
3.2.1 Acquisition Techniques 60
3.2.1.1 Introduction 60
3.2.1.2 Digitising Analogue Images 61
3.2.1.3 Computed Radiography (CR) 61
3.2.1.4 Direct Digital Radiography (DR) 62
3.3 Digital Image Optimisation 62
3.3.1 Image Display 62
3.3.1.1 Hard Copy Versus Soft Copy 62
3.3.1.2 DICOM 63
3.3.1.3 Matrix Size of Digital Systems and Monitors 64
3.3.2 Image Processing 64
3.3.2.1 Introduction 64
3.3.2.2 Pre-processing 64
3.3.2.3 Post-processing 65
3.3.2.3.1 Non-Linear Grey-Scale Enhancement 65
3.3.2.3.2 Edge Enhancement 65
3.4 Digital Image Quality 67
3.4.1 Introduction 67
3.4.2 Image Quality and Radiation Dose Considerations 68
3.4.3 Strategies for Dose Reduction andImage Optimisation 70
3.5 Computer-Aided Diagnosis 70
References 71
4 Hyaline Membrane Disease and Complications of Its Treatment 74
4.1 Introduction 74
4.2 Pathophysiology 74
4.3 Radiographic Findings and New Treatments 75
4.4 Air Leaks 80
4.5 Atelectasis 81
4.6 Pneumonia 82
4.7 Pulmonary Haemorrhage 82
4.8 Neonatal Chronic Lung Disease 83
4.9 Conclusion 85
References 86
5 Transient Tachypnoea of the Newborn 87
5.1 Introduction 87
5.2 Pathophysiology and Clinical Course 87
5.3 Radiographic Findings 88
5.4 Conclusion 89
References 89
6 Meconium Aspiration 90
6.1 Introduction 90
6.2 Pathophysiology of Meconium Passage 91
6.3 Pathophysiology of Meconium Aspiration Syndrome 91
6.4 Infl ammation 93
6.5 Signs and Symptoms 94
6.6 Management of the Infant with Meconium Aspiration Syndrome 96
6.6.1 Conventional Mechanical Ventilation 96
6.6.2 High-frequency Ventilation 97
6.6.3 Surfactant Therapy 97
6.6.4 Inhaled Nitric Oxide 97
6.6.5 Extracorporeal Membrane Oxygenation 97
6.6.5.1 ECMO Technique 98
6.6.5.2 Duration of ECMO Support 98
6.7 Long-term Pulmonary Sequelae of MAS 99
6.8 Conclusion 100
References 100
7 Diagnostic Imaging of Neonatal Pneumonia 103
7.1 Introduction 103
7.2 Clinical Considerations 103
7.3 Radiological Considerations 104
7.4 Aetiologic Agents 105
7.4.1 Transplacental Infection 105
7.4.2 Perinatal Infections 107
7.4.2.1 Clinical Considerations 107
7.4.2.2 Radiological Considerations 108
7.4.2.3 Specififi c Agents 108
7.4.2.3.1 Bacterial 108
7.4.2.3.2 Viral 109
7.4.2.3.3 Others 110
Chlamydia Trachomatis 110
Ureaplasma Urealyticum 111
7.4.3 Postnatal/Nosocomial Infections 112
7.5 Conclusion 113
References 113
8 Antenatal Imaging of Chest Malformations 116
8.1 Introduction 116
8.2 General Concepts 116
8.2.1 Basics of Lung Embryology, Fetal Lung Development and Pathology 116
8.2.2 Pathogenesis, Nosology and Classifi cation 118
8.3 Prenatal Imaging 118
8.3.1 Sonography of the Fetal Chest 118
8.3.2 Bronchopulmonary Malformations 120
8.3.3 Pulmonary Hyperplasia (CHAOS) 121
8.3.4 Congenital Lobar Overinfl ation 121
8.3.5 Pleural Eff usion 121
8.3.6 Mediastinal Abnormalities 129
8.3.7 Congenital Diaphragmatic Hernia (CDH) 129
8.3.8 Pulmonary Hypoplasia 132
8.4 Post-Natal Issues 132
8.4.1 Post-Natal Investigations 132
8.4.2 Management of Asymptomatic Patients with Prenatally Recognized CLL 132
8.5 Conclusion 138
References 138
9 Postnatal Imaging of Chest Malformations 142
9.1 Abnormalities of Oesophageal Development 142
9.1.1 Oesophageal Atresia and Tracheo-Oesophageal Fistula 142
9.1.2 Postoperative Imaging after Repair of Tracheo-Oesophageal Fistula 146
9.2 Abnormalities of Lung Bud and Vascular Development 146
9.2.1 Agenesis and Aplasia of the Lung 146
9.2.2 Pulmonary Hypoplasia 146
9.2.2.1 Alveolar Capillary Dysplasia 147
9.2.2.2 Absent Pulmonary Artery 147
9.2.2.3 Absent Pulmonary Vein 147
9.2.2.4 Pulmonary Artery Sling 147
9.2.2.5 Pulmonary Venolobar Syndrome (Scimitar Syndrome) 147
9.2.3 Horseshoe Lung 149
9.2.4 Congenital Lobar Emphysema (CLE) 149
9.2.5 Bronchial Atresia 150
9.2.6 Congenital Cystic Adenomatoid Malformation (CCAM) 150
9.2.7 Sequestration 153
9.2.9 Oesophageal Bronchi 156
9.2.10 Bronchogenic Cysts 157
9.2.11 Hybrid lesions–Bronchopulmonary Foregut Malformation 158
9.2.12 Neuroenteric Cysts 158
9.2.13 Pulmonary Vascular Malformation 158
9.2.14 Chylothorax 158
9.2.15 Abnormalities in Situs 158
9.3 Abnormalities of the Diaphragm 159
9.3.1 Congenital Diaphragmatic Hernia: Bochdalek Type 159
9.3.2 Congenital Diaphragmatic Hernia: Morgagni Type 160
9.3.3 Eventration of the Diaphragm 160
9.3.4 Accessory Diaphragm 163
References 163
10 Congenital Anomalies of the Neonatal Upper Airway 166
10.1 Introduction 166
10.2 Nasal Anomalies 166
10.3 Oral Airway Anomalies 167
10.4 Laryngomalacia 168
10.5 Laryngeal Malformations 168
10.6 Upper Airway Cysts/Masses 170
10.7 Tracheomalacia 173
10.8 Congenital Tracheal Stenosis 175
10.9 Conclusion 177
References 177
11 Computed Tomography of the Central and Peripheral Airways 179
11.1 Introduction 179
11.2 Central Airways 179
11.2.1 Indications and Clinical Presentations 180
11.2.2 Purposes of Imaging 180
11.2.2.1 Non-CT Imaging Techniques 180
11.2.2.1.1 Chest Radiography 180
11.2.2.1.2 Contrast Oesophagography 180
11.2.2.1.3 Bronchoscopy 180
11.2.2.1.4 Contrast Bronchography 180
11.2.2.1.5 Magnetic Resonance Imaging 181
11.2.2.2 CT Techniques 181
11.3 Extrinsic Airway Compression:Vascular Rings 181
11.3.1 Anatomical and Embryological Considerations 181
11.3.2 Classifi cation and Terminology 183
11.3.3 Complete Vascular Rings 183
11.3.3.1 Double Aortic Arch 183
11.3.3.2 Right Aortic Arch with Left-Sided Ligamentum 185
11.3.3.3 Other Complete Rings 186
11.3.4 Incomplete Vascular Rings 186
11.3.4.1 Pulmonary Sling 187
11.3.4.2 Innominate Artery Compression 187
11.3.4.3 Other 188
11.4 Extrinsic Airway Compression: Other Vascular Anomalies 189
11.4.1 Absent Pulmonary Valve Syndrome 189
11.4.2 Major Aortico-Pulmonary Collateral Artery (MAPCA) 189
11.5 Extrinsic Airway Compression: Non-Vascular 190
11.6 Intrinsic Airway Abnormalities 190
11.6.1 Tracheobronchomalacia 191
11.6.2 Tracheal Stenosis 191
11.6.2.1 Congenital Tracheal Stenosis 191
11.6.2.2 Acquired Tracheal Stenosis 193
11.7 Peripheral Airway 193
11.7.1 Congenital Bronchial Anomalies 193
11.7.1.1 Anatomical Variants 193
11.7.1.1.1 Tracheal Bronchus 193
11.7.1.1.2 Accessory Cardiac Bronchus 194
11.7.1.2 Bronchial Atresia 194
11.7.2 Lung Malformations 195
11.7.2.1 Congenital Lobar Overinflflation 195
11.7.2.2 Congenital Cystic Adenomatoid Malformation 196
11.8 Conclusions 196
References 196
12 Ultrasound of the Neonatal Thorax 198
12.1 Introduction 198
12.2 Technique 198
12.2.1 Imaging Approach to the Mediastinum 199
12.2.2 Imaging Approach to Pleura, Diaphragm and Lung 201
12.3 Mediastinum 201
12.3.1 Thymus, Trachea, Oesophagus 201
12.3.1.1 Thymus 201
12.3.1.2 Trachea 202
12.3.1.3 Oesophagus 204
12.3.2 Heart and Great Vessels 206
12.3.2.1 Imaging Approach 206
12.3.2.2 Congenital Vascular Anomalies 208
12.3.2.3 Cardiac Tumours 209
12.4 Diaphragm 209
12.4.1 Diaphragmatic Hernias 209
12.4.2 Diaphragmatic Eventration 216
12.4.3 Diaphragmatic Palsy 216
12.5 Lung and Pleura 216
12.5.1 Congenital Lung Disease 216
12.5.1.1 Congenital Cystic Adenomatoid Malformation 216
12.5.1.2 Congenital Lobar Emphysema 218
12.5.1.3 Bronchogenic Cyst 219
12.5.1.4 Bronchial Atresia 219
12.5.1.5 Pulmonary Sequestration 219
12.5.1.6 Scimitar Syndrome 219
12.5.2 Pleura 221
12.5.2.1 Pleural Fluid 221
12.5.2.2 Pneumothorax 221
12.6 Use of Chest Ultrasound in Neonatal Intensive Care 221
References 223
13 Ultrasound in Congenital Heart Disease 227
13.1 Introduction 227
13.2 History of Ultrasound 228
13.3 Physics of Ultrasound 228
13.4 Echocardiographic Planes in Congenital Heart Disease 228
13.4.1 Subcostal Views 228
13.4.2 Four-Chamber View 229
13.4.3 Parasternal Views 229
13.4.4 Suprasternal Views 232
13.4.5 Right Parasternal Window (the Fifth Imaging Plane) 232
13.5 Segmental Cardiac Anatomy 232
13.5.1 Abdominal Situs – Cardiac Location 233
13.5.2 The Cava and the Atria 233
13.5.3 Caval Veins and Right Atrium 233
13.5.4 Atrial Septum 233
13.5.5 Left Atrium and Pulmonary Veins 233
13.5.6 Atrioventricular Arrangement 234
13.5.7 Ventricular Morphology 234
13.5.8 Ventricular Septum 234
13.5.9 Conal Morphology 234
13.5.10 Ventriculo-Arterial Relationship 234
13.5.11 The Aortic Arch and Coronary Arteries 235
13.6 Doppler Echocardiography 235
13.7 Echocardiographic Tools Available for Analysis of Ventricular Function 235
13.8 Left Ventricular Systolic Dysfunction 236
13.8.1 Dimension-Derived Indices 236
13.8.1.1 Doppler-Derived Indices 237
13.8.2 The Stress–Velocity Index 237
13.8.3 Doppler Tissue Imaging (DTI) and Strain Rate Imaging 238
13.9 Left Ventricular Diastolic Dysfunction 239
13.9.1 Doppler-Derived Indices 239
13.9.2 Color M-Mode Flow Propagation Velocity (Vp) 241
13.10 Global Left Ventricular Dysfunction 241
13.11 Right Ventricular Dysfunction 242
13.12 Univentricular Hearts and Assessment of Ventricular Function 243
13.13 Tissue Harmonic Imaging 243
13.14 Fetal Echocardiography 243
13.15 Transoesophageal Echocardiography 243
13.16 Conclusions 243
References 243
14 Magnetic Resonance Imaging in Congenital Heart Disease 248
14.1 Introduction 248
14.2 Techniques 248
14.2.1 General Setting 248
14.2.2 Pulse Sequences 249
14.3 Clinical Indications 252
14.3.1 Thoracic Vasculature 252
14.3.2 Ventricular Size 257
14.3.3 Tumours 257
14.4 Conclusion 257
References 257
15 Chest Radiography in Congenital Heart Disease 260
15.1 Introduction 260
15.2 Clinical Information 261
15.3 Chest Radiography 261
15.3.1 Technical Considerations 261
15.3.2 Evaluation 262
15.3.2.1 Lung Vessels 263
15.3.2.2 Aeration 264
15.3.2.3 The Heart 266
15.3.2.4 Lung Parenchyma 267
15.3.2.5 Large Airways 267
15.3.2.6 Oesophagus 270
15.3.2.7 Aorta and Pulmonary Trunk 270
15.3.2.8 Skeleton 270
15.3.2.9 Arrangement of the Organs 272
15.4 Conclusion 273
References 273
16 Angiocardiography and Intervention in Congenital Heart and Great Vessel Disease 274
16.1 Introduction 274
16.2 Different Modes of Visualization 275
16.2.1 Ultrasonography 275
16.2.2 Fluoroscopy 276
16.2.3 Angiocardiography 276
16.2.3.1 Technique 277
16.2.3.2 Complications 277
16.2.4 Other Imaging Modalities 278
16.3 Intervention in Congenital Heart Disease 278
16.4 Transposition of the Great Arteries 279
16.4.1 Transcatheter Intervention 280
16.5 Tetralogy of Fallot 280
16.6 Pulmonary Atresia withVentricular Septal Defect 282
16.7 Pulmonary Atresia withIntact Ventricular Septum 282
16.8 Tricuspid Atresia 284
16.9 Single Ventricle 284
16.10 Hypoplastic Left Heart Syndrome (HLHS) 285
16.11 Balloon Dilatation of Valvar Stenoses 286
16.11.1 Pulmonary Valve Stenosis 286
16.11.2 Aortic Valve Stenosis 286
16.11.3 Mitral Valve Stenosis 287
16.12 Treatment of Stenoses in Arteries or Veins – Balloons and Stents 289
16.12.1 Pulmonary Artery Banding 289
16.12.2 Peripheral Pulmonary Artery Stenosis 290
16.12.3 Supravalvular Aortic Stenosis 291
16.12.4 Coarctation of the Aorta 291
16.12.5 Stenosis in Veins 294
16.12.5.1 Vena Cava 294
16.12.5.2 Pulmonary Vein Stenosis 294
16.12.6 Stent in Ductus Arteriosus 295
16.13 Closure of Atrial Septal Defects 296
16.13.1 Fenestrations in Fontan’s Operation 298
16.14 Closure of Ventricular Septal Defects 298
16.15 Closure of Arteries and Arteriovenous Connections 300
16.15.1 Persistent Arterial Duct 300
16.15.2 Systemic to Pulmonary Artery Shunts and Collaterals 303
16.15.2.1 Surgical Shunts 303
16.15.2.2 Systemic MAPCAs 303
16.15.2.3 Arteria Mammaria Interna 303
16.15.2.4 Bronchial Arteries 304
16.15.3 Anomalies of the Coronary Arteries with a Shunt 304
16.15.4 Lung Sequester 305
16.15.5 Intrapulmonary Arteriovenous Fistula 305
16.15.6 Large Arteriovenous Malformations in Other Locations 307
16.16 Closure of Veins 309
16.16.1 Postoperative Abnormal Venous Connections 310
16.17 Removal of Intracardiac orIntravascular Foreign Body 311
16.18 Conclusion 315
References 315
17 Computed Tomography in Congenital Heart Disease 317
17.1 Introduction 317
17.2 Technical Considerations 318
17.2.1 Spatial and Temporal Resolution 318
17.2.2 Radiation Dose Considerations 319
17.2.3 Scanning Technique for MDCT Angiography for Infants and Small Children 321
17.3 Complementary Role of MDCT and MRI for Cardiac Imaging 325
17.4 Clinical Applications 326
17.4.1 Aortic Arch Anomalies 326
17.4.1.1 Coarctation 326
17.4.1.2 Interrupted Aortic Arch 327
17.4.1.3 Truncus Arteriosus and Aortopulmonary Window 328
17.4.2 Coronary Artery Anomalies 328
17.4.2.1 Anomalous Coronary Artery 328
17.4.2.2 Kawasaki Disease 330
17.4.3 Pulmonary Vasculature 331
17.4.3.1 Pulmonary Artery Anomalies 331
17.4.3.2 Pulmonary Vein Anomalies 331
17.4.4 Airway Compromise in Patients with CHD 337
17.4.5 Postoperative Congenital Heart Disease 338
17.5 Conclusion 342
References 343
18 Chest Wall Abnormalities which Cause Neonatal Respiratory Distress 345
18.1 Introduction 345
18.2 Anatomic, Pathophysiologic, and Nosologic Considerations 345
18.3 Thanatophoric Dysplasia (OMIM 187600) 347
18.4 Osteogenesis Imperfecta (OMIM 166210) 349
18.5 Hypophosphatasia (OMIM 241500) 349
18.6 Short-Rib Dysplasia Group 349
18.7 Metaphyseal Dysplasia with Pancreatic Insufficiency and Cyclic Neutropenia (Shwachman-Bodian-Diamond, OMIM 260400) 350
18.8 Achondrogenesis II and Hypochondrogenesis (OMIM 200610) 351
18.9 Cerebro-Costo-Mandibular Syndrome (OMIM 117650) 352
18.10 Dyssegmental Dysplasia 353
18.11 Spondylocostal Dysostosis (OMIM 277300) 353
References 354
Subject Index 355
List of Contributors 359

"12.3.2.2 Congenital Vascular Anomalies (p. 207)

Congenital vascular anomalies such as right aortic arch with aberrant left subclavian artery, double aortic arch, aberrant left pulmonary artery and anomalous pulmonary venous return including scimitar syndrome are known to have a great impact on related extra cardiac systems (Berrocal et al. 2004). Not only cardiologists but also the paediatric radiologists are, therefore, compelled to acquire profound knowledge about normal as well as aberrant vascular anatomy of the mediastinum.

Because this section is focused on ultrasound we ask the kind reader to refer to other articles in this volume for a more detailed insight into the subject. In right aortic arch with aberrant left subclavian artery, a right aortic arch is present together with a right descending aorta (Fig. 12.8), in contrast to the commonly asymptomatic left aortic arch with aberrant right subclavian artery (Fig. 12.9). The aberrant left subclavian artery originates from a Kommerell diverticulum, an enlargement of the take off of the subclavian artery (Moes and Freedom 1993).

The ductus arteriosus is commonly on the left side and extends from this diverticulum to the left pulmonary artery leading to a vascular ring that may cause tracheo- oesophageal compression in cases where the ductus or ligamentum arteriosum is tight (Berdon 2000). The trachea is displaced to the left. Ultrasound evaluation reveals a right aortic arch and a left carotid artery as a solitary vessel. The presence of an aberrant left subclavian artery is then suspected and demonstrated on a slightly oblique transverse scan. The retro-oesophageal Kommerell diverticulum can be con? rmed by delineating the oesophagus.

A double aortic arch shows two arches with the right arch usually being a little larger and slightly higher than the left (Fig. 12.10). The upper descending aorta may be right- or left-sided. Suprasternal sagittal scans demonstrate both arches and their common carotid and subclavian arteries. A clue to diagnosis is that each arch gives rise to only two main vessels. One will notice that the carotid and subclavian arteries are symmetrically arranged on a high transverse scan. With slight clockwise rotation of the transducer the left arch is imaged on the left side of the oesophagus.

Rotation of the transducer in the other direction will reveal the right arch on the right side of the oesophagus. Both arches are displayed in cross-section in a suprasternal coronal plane. The complete vascular ring may be shown on a transsternal axial scan. In anomalous left pulmonary artery also known as pulmonary artery sling, the left pulmonary artery arises from the posterior aspect of the right pulmonary artery and courses behind the trachea and in front of the oesophagus to reach the left lung."