Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma

Abstract

Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics. Keywords Pediatric blunt abdominal trauma • Contrast-enhanced ultrasound • CEUS • Follow-up • Emergency radiology • Trauma imaging SommarioIl trauma rappresenta una importante causa di morbidità e mortalità infantile ed il trauma chiuso dell'addome è responsabile di circa l' 80-90% delle lesioni addominali. Il meccanismo traumatico è abbastanza simile a quello che si verifica nell'adulto, con significative differenze fisiologiche tra le due classi di età responsabili di un sempre maggior utilizzo del management non operativo in età infantile. In caso di trauma a bassa energia l'imaging può essere effettuato con la CEUS, una tecnica diagnostica in grado di evidenziare le lesioni traumatiche addominali con un' accuratezza diagnostica molto vicina a quella della TC con mdc. Tuttavia, per alcune lesioni traumatiche, come quelle che interessano le vie urinarie, la TC con mdc resta la metodica di scelta, in ragione della sua elevata sensibilità ed accuratezza, in grado di distinguere tra un leakage retroperitoneale o intraperitoneale, guidando quindi anche il management terapeutico. Il fegato è l'organo più comunemente interessato dalle lesioni traumatiche addominali, seguito dalla milza. Le lesioni renali e pancreatiche sono piuttosto rare. In questa review gli autori si propongono di presentare i reperti di imaging più comuni in corso di trauma chiuso dell'addome infantile con CEUS e relativo confronto con la TC.

The Technique and Advantages of Contrast-Enhanced Ultrasound in the Diagnosis and Follow-up of Traumatic Abdomen Solid Organ Injuries

“…UCAs are generally well tolerated; the rate of adverse reactions is very low (1:7000 patients, 0.014%). This rate is significantly lower than the rate associated with iodinated state-of-the-art CT agents (35-95:100 000 patients, 0.035-0.095 %) [10,13]. The main contraindications for UCAs are a history of allergic reactions to the contrast agent, severe pulmonary hypertension, severe coronary artery disease, pulmonary hypertension, and unstable ischemic heart disease.…”

“…The main contraindications for UCAs are a history of allergic reactions to the contrast agent, severe pulmonary hypertension, severe coronary artery disease, pulmonary hypertension, and unstable ischemic heart disease. The use of UCAs is not authorized for pregnant or breastfeeding women [10,13]. The use of UCAs is yet to be off-label for children; however, there is a large consensus on their safety [10,14] 2.1.3.…”

Traumatic Gallbladder Perforation in Children – Case Report and Review

“…Since the contrast agent is breathed out by the lungs (laboratory testing prior to examination (i. e. kidney function) not required) and there is no ionizing radiation, CEUS is much more suited for initial examination as well as for follow-ups in trauma with conservative management in the pediatric patient [31]. However, the second-generation contrast agents are still off-label in children although several multi-centric studies have already demonstrated safety in pediatric populations [32,33].…”

Contrast-Enhanced Ultrasound (CEUS) in Non-Traumatic Abdominal Emergencies

“…A fundamental practical approach is described in the EFSUMB Guidelines [10][11][12]. CEUS application in children is currently still "off-label" except for a few indications including vesico-uereteral reflux, but it could be a very useful method in the non-ionizing imaging of young patients [6,[13][14][15][16][17]. Today, in the emergency setting, CEUS is used predominantly in the study of blunt or penetrating traumatic lesions, especially for the diagnosis and follow-up of the solid parenchymal organ (socalled "non-operative management") [8,[18][19][20][21][22].…”

“…A fundamental practical approach is described in the EFSUMB Guidelines 10 11 12 . CEUS application in children is currently still “off-label” except for a few indications including vesico-uereteral reflux, but it could be a very useful method in the non-ionizing imaging of young patients 6 13 14 15 16 17 .…”