ultrasound imaging of vascular anomalies
TRANSCRIPT
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Ultrasound imaging of vascular anomalies:
pearls and pitfallsOscar Navarro, MD
Dept. of Medical Imaging, University of Toronto
Dept. of Diagnostic Imaging, The Hospital for Sick Children
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Declaration of Disclosure
I have no actual or potential conflict of interest in relation to this presentation
Oscar Navarro, MD
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Background
• Soft-tissue vascular anomalies are common:• Hemangiomas in 5-10% infants <12mo
• Vascular malformations 1.2-1.5% prevalence
• Most cutaneous lesions are diagnosed clinically
• Deeper lesions are difficult to diagnose clinically
• Association with other pathology or syndromes, especially overgrowth
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Indication for US
• Atypical superficial lesions or with suspicion of deeper involvement
• Palpable lesions without diagnostic visible features
• MRI better for:• Obviously large & deeper lesions
• Part of complex vascular anomalies or overgrowth syndromes
• Prior to invasive treatment
• US prior to MRI may be useful to tailor study (probably not vascular, low-flow vs. high flow)
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Technique
• Transducer selection determined by size & depth of lesion – higher frequency possible
• Use of stand-off pads & submersion in water of hands or feet
• Larger & deeper lesions combination of transducers
• Color & spectral Doppler useful but limited by patient motion & cooperation
• Compression
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Gray scale
• Margins of the mass
• Visible vessels
• Intravascular clots
• Involvement of one or more soft tissue planes
• Calcifications
• Cystic components
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Doppler US
• Useful to differentiate high from low flow lesions
• Classical categorization based on number of color pixels per cm2
• >4 high
• 2-4 moderate
• <2 low
• Compare with normal adjacent or contralateral soft tissues
• Spectral Doppler:• Differentiate arterial from venous
• Magnitude
• Resistive indices
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Get clinical history & look at the lesion
• Present at birth?
• When was it first seen?
• Growth pattern (proportional or not to child’s growth)
• Does the lesion change in appearance or size?
• Skin discoloration
• Other skin abnormalities (vesicles, hair)
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ISSVA Classification
• Last updated in 2014
• issva.org
• Vascular tumors
• Vascular malformations
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Vascular tumors
• Benign• Infantile hemangioma
• Congenital hemangiomas (RICH, PICH, NICH)
• Lobular capillary hemangioma (pyogenic granuloma)
• Tufted angioma
• Locally aggressive or borderline• Kaposiform hemangioendothelioma
• Malignant• Angiosarcoma
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Vascular malformations
• AVM, AVF → High flow
• Capillary, venous, lymphatic → Low flow
• Combined
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High flow lesion
• Mass with vessels (hemangiomas or other vascular tumors) vs mass formed by vessels (AV malformation)
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Arteriovenous malformation
6y♀: Persistent swelling over lateral malleolus for months
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Infantile hemangioma
11w♀: Left breast mass
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Congenital hemangioma
6w♂: Left upper arm mass diagnosed antenatally
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Kaposiform hemangioendothelioma
2d♂: Left thigh mass diagnosed antenatally
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Hemangioma or sarcoma? – Red flags
• First detected or rapid growth after 6-12 months
• Painful mass
• Involvement of muscles
• Lymphadenopathy
• Bone destruction
• Calcifications, hemorrhage or necrosis in non-congenital lesions
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Infantile fibrosarcoma
7m♂: Rapidly growing palmar mass
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Low flow lesions
• Capillary malformation: often minimal changes (skin/subcutaneous thickening)
• Venous malformation
• Lymphatic malformation• Macrocystic
• Microcystic
• Combined
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Venous malformation
5y♂: Slowly growing forearm mass
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Venous malformation
2y♀: Right paraspinal mass
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Venous malformation
13y♂: Mass left foot present since birth, growing with child
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Venous malformation
16y♀: Swelling posterior neck
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Venous malformation
16y♀: Swelling posterior neck
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Venous malformation
• Phleboliths are characteristic but uncommon (9-16%)
• Absence of flow does not exclude diagnosis (16%)
• Increased color Doppler signal can be apparent with compression & release of transducer – do not confuse with high flow lesions
• Arterial flow can be present
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Lymphatic malformation
3y♀: Left arm mass
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Lymphatic malformation
8m♂: left arm & chest wall mass
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Lymphatic malformation
8w♀: Growing mass in dorsum of hand since birth
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Conclusion
• US extremely useful in diagnosis & treatment monitoring of soft-tissue vascular anomalies
• High diagnostic yield when used in combination with clinical assessment
• Some lesions, especially venous malformations, can be challenging on US & may require further MRI
• Large, deep lesions or associated with overgrowth syndromes are better evaluated with MRI