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Dynamic Contrast-Enhanced MR Lymphangiogram of the Central Lymphatic System in Children: Overcoming the challenges in a non-hybrid environment
Mei Yu Poon1, Chi Yan Iris Chung1, Kin Fen Kevin Fung1, Wing Kei Carol Ng1, and Yee Ling Elaine Kan1
1Radiology, Hong Kong Children’s Hospital, Hong Kong SAR, Hong Kong

Synopsis

Keywords:

Motivation: Performing dynamic contrast-enhanced MR lymphangiogram (DCMRL) in children require general anesthesia. In a non-hybrid environment, the nodal puncture for DCMRL is often performed in the angiography suite. Transporting a pediatric patient under general anesthesia with needles to an MRI environment presents unique challenges.

Goal(s): Develop a safe and effective workflow for DCMRL in non-hybrid setting.

Approach: Meticulous planning and collaborations between radiology and anesthesiology teams ensure safe execution of DCMRL. Using contrast-enhanced ultrasound (CEUS) also improve the logistic of intranodal DCMRL by minimizing patient transfer.

Results: Careful coordination between Radiology and Anesthetic team results in successful and safe intranodal and intrahepatic DCMRL. .

Impact: The ability to perform DCMRL in non-hybrid environment has significant implications for accurate diagnosis of lymphatic diseases, enabling improved treatment planning and better patient outcomes.

Background

The lymphatic system was once considered a "forgotten" circulation 1,2 due to its complex anatomy and challenges in visualizing it with contrast agents. Recent advancements in magnetic resonance imaging (MRI) have revolutionized our understanding and assessment of lymphatic diseases. Dynamic contrast-enhanced MR lymphangiogram (DCMRL) 3-9 has emerged as a powerful technique for evaluating the central lymphatic system, providing a comprehensive assessment of lymphatic morphology and flow dynamics along with conventional T2-weighted and post-contrast T1-weighted images. Challenges of performing intranodal and intrahepatic DCMRL in units without hybrid Angio-MR suite include patient transport and risk of needle dislodgement. This logistical hurdle is further compounded in the pediatric population as most children receiving DCMRL would be under general anesthesia.

Indications

Two patient groups that benefit most from MR lymphangiogram are children with congenital heart diseases and Fontan circulation 8,10, who may experience impaired lymphodynamics and manifestations such as chyle blockage, reflux, or leaks in the thorax or abdomen, as well as patients with central conducting lymphatic anomaly (CCLA) within complex lymphatic malformation 7,9.

Procedure

During the imaging procedure, a gadolinium-based contrast agent (GBCA) is injected slowly into the lymphatic system while performing a dynamic scan. Access sites commonly include bilateral inguinal nodes, liver or mesenteric nodes. Needle position is conventionally confirmed by fluoroscopy. In units without hybrid Angio-MR suite, this requires patient transport from angiography suite to MR scan room under general anesthesia. This transportation and positioning of the DCMRL patient require meticulous planning and collaboration between the radiology department and anesthesiology team to ensure patient safety and procedural success. In DCMRL requiring intranodal injection only, our centre has adopted an approach to use CEUS only for confirmation of intranodal needle position at MR preparation room, shortening patient transport and reducing risk of needle dislodgement. 3-9, 11, 12.

Conclusion

MR lymphangiogram employing DCMRL has revolutionized lymphatic imaging, shedding light on the once "forgotten" circulation. Through careful technique, thorough preparations, and effective collaborations, we are able to bring this technique to units without hybrid Angio-MR suite, enabling accurate diagnosis and improved patient care.

Acknowledgements

Deep gratitude to my colleagues from the MRI, Angio, Ultrasound, and Anesthesiology teams for their invaluable inputs in planning and executing the DCMRL procedure seamlessly and safely. The collaboration and dedication made a significant impact.

References

1. Itkin M. (2016). Invited Commentary: Lymphatic (or "Forgotten") Circulation Has to Be Rediscovered. RadioGraphics, 36(7), 2212-2213.

2. Tomasulo CE, Dori Y, Smith CL. (2023). Understanding the next circulation: lymphatics and what the future holds. Current Opinion in Cardiology, 38(4), 369-374.

3. Ramirez-Suarez KI, Tierradentro-Garcia LO, Smith CL, et al. (2022). Dynamic contrast-enhanced magnetic resonance lymphangiography. Pediatric Radiology, 52, 285-294.

4. Chavhan GB, Lam CZ, Greer MC, Temple M, Amaral J, Grosse-Wortmann L. (2020). Magnetic Resonance Lymphangiography. Radiol Clin North Am, 58(4), 693-706.

5. Chavhan GB, Amaral JG, Temple M, Itkin M. (2017). MR Lymphangiography in Children: Technique and Potential Applications. Radiographics, 37(6), 1775-1790.

6. Dori Y, Smith CL, DeWitt AG, Srinivasan A, Krishnamurthy G, Escobar FA, Biko DM. (2020). Intramesenteric dynamic contrast pediatric MR lymphangiography: initial experience and comparison with intranodal and intrahepatic MR lymphangiography. European Radiology, 30(10), 5777-5784.

7. Nriagu BN, Adams DM, Srinivasan A, Krishnamurthy G, Smith C, Dori Y, Snyder K. (2023). Multicompartment Dynamic Contrast Magnetic Resonance Lymphangiography in Diagnosis of Complicated Lymphatic Anomaly. Lymphatic Research and Biology, 21(2), 135-140.

8. Lemley BA, Biko DM, Dewitt AG, Glatz AC, Goldberg DJ, Saravanan M, O'Byrne ML, Pinto E, Ravishankar C, Rome JJ, Smith CL, Dori Y. (2021). Intrahepatic Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography: Potential Imaging Signature for Protein-Losing Enteropathy in Congenital Heart Disease. J Am Heart Assoc, 10(19), e021542.

9. Pieper CC, Wagenpfeil J, Henkel A, et al. (2022). MR lymphangiography of lymphatic abnormalities in children and adults with Noonan syndrome. Scientific Reports, 12, 11164.

10. Kreutzer J, Kreutzer C. (2017). Lymphodynamics in Congenital Heart Disease. Journal of the American College of Cardiology, 69(19), 2423-2427.

11. Wagenpfeil J, Kupczyk PA, Henkel A, Geiger S, Köster T, Luetkens JA, Schild HH, Attenberger UI, Pieper CC. (2022). Ultrasound-guided needle positioning for nodal dynamic contrast-enhanced MR lymphangiography. Scientific Reports, 12(1), 3621.

12. Fung KFK, Chen HR, Ng WKC, Che KYJ, Poon MY, Kan YLE. (2023). Feasibility of contrast-enhanced ultrasound in confirming intranodal needle position for dynamic contrast-enhanced magnetic resonance lymphangiography in children. Pediatric Radiology, 53(10), 2137-2143.

Proc. Intl. Soc. Mag. Reson. Med. 32 (2024)
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DOI: https://doi.org/10.58530/2024/5126