Pediatr Radiol (2012) 42 (Suppl 3):S403–S578 DOI 10.1007/s00247-012-2383-5
Founded in 1963 The European Society of Paediatric Radiology 49th Annual Meeting and 35th Postgraduate Course
th
st
May 28 –June 1 2012 The Hilton Hotel Athens, Greece
Table of contents Programme at a glance ESPR General information Officers of the Board Honorary members Gold Medallists Jacques Lefebvre awards Poster awards Young Researcher awards President’s awards Past Presidents and meeting sites Future ESPR meetings European Courses of Paediatric Radiology (ECPR) European Courses of Paediatric Neuroradiology (ECPNR) ESPR 2012 Gold Medallist ESPR 2012 Honorary Members 2012 Jacques Lefebvre lecture Congress Organisation Welcome address Programme Task Forces pages Abstracts of oral presentations Abstracts of poster presentations Author index for abstracts Continuing Medical Education In memory of Clément Fauré
This supplement was not sponsored by outside commercial interests; it was funded entirely by the publisher.
Programme at a Glance
S404
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S405
General Information—European Society of Paediatric Radiology
Officers 2011–2012 President Past President 1st Vice President 2nd Vice President 3rd Vice President General Secretary Treasurer Counsellor for Northern Europe Counsellor for Southern Europe Pediatric Radiology Managing Editor JESPeR delegate Webmaster Head of Education Committee Secretariat
ESPR Executive Assistant
Maria I. Argyropoulou (Ioannina, Greece) Catherine M. Owens (London, United Kingdom) Eva Kis (Budapest, Hungary) Rutger J. Nievelstein (Utrecht, Netherlands) Michael Riccabona (Graz, Austria) Catherine M. Owens (London, United Kingdom) Catherine Adamsbaum (Paris, France) Karen Rosendahl (Bergen, Norway) Paolo Tomà (Roma, Italy) Guy Sebag (Paris, France) Samuel Stafrace (Aberdeen, UK) Rick Van Rijn (Amsterdam, Netherlands) Jean-François Chateil (Bordeaux, France) Catherine M. Owens Department of Radiology Great Ormond Street Hospital for Sick Children Great Ormond Street, London, WC1N 3JH, UK Amanda Dehaye (Pau, France) ESPR-office@espr-org
Honorary members of the Society
1964 John Caffey (USA)
1987 D.C. Harwood-Nash (USA)
1964 Lutz Schall (Germany)
1987 Hooshang Taybi (USA)
1965 Sven R. Kjelberg (Sweden)
1988 Herbert Kaufmann (Germany)
1965 Edward B. D. Neuhauser (USA)
1989 Bryan Cremin (South Africa)
1966 Jacques Lefebre (France)
1989 Klaus D. Ebel (Germany)
1973 Hardy M. Geffert (Hungary)
1989 Helmut Fendel (Germany)
1973 Ksawery Rowinsky (Poland)
1989 Elizabeth Sweet (Scotland)
1974 Frederic Silverman (USA)
1990 Donald Kirks (USA)
1975 Ulf G. Rudhe (Sweden)
1991 Alan Chrispin (England)
1979 John Kirkpatrick (USA)
1991 Edmund Franken (USA)
1979 Arnold Lassrich (Germany)
1991 Daniel Nussle (Switzerland)
1979 Jacques Sauvegrain (France)
1991 Beverly Wood (USA)
1982 Clement Fauré (France)
1992 Walter Berdon (USA)
1982 Andes Giedion (Switzerland)
1993 Javier Lucaya (Spain)
1983 Eberhard Willich (Germany)
1993 Wilhelm Holthusen (Germany)
1984 Roy Astley (England)
1994 Noemie Perlmutter (Belgium)
1987 Jean Bennet (France)
1994 Hans Ringertz (Sweden)
1987 Ole Eklof (Sweden)
1994 Donald Shaw (England)
1987 Charles A. Gooding (USA)
1996 Robert Lebowitz (USA)
1987 John Holt (USA)
1996 Bela Lombay (Hungary)
1987 Andrew Poznanski (USA)
1997 Yan Briand (France)
S406
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
1997 Philip Small (England)
2007 Gabriel Benz-Bohm (Germany)
1997 N. Thorne Griscom (USA)
2007 Pedro Daltro (Brazil)
1998 Alan Daneman (Canada)
2007 Richard Fotter (Austria)
1998 Gabriel Kalifa (France)
2008 Jose Fonseca-Santos (Portugal)
1999 Michael Grunebaum (Israel)
2008 Ingmar Gassner (Austria)
2000 Paul Thomas (Ireland)
2008 Tom Slovis (USA)
2000 Noel Blake (Ireland)
2008 Rita Teele (New Zealand)
2000 Peter Kramer (Netherlands)
2009 Reinhart Schumacher (Germany)
2000 Gunnar Stake (Norway)
2009 Nicholas Gourtsoyiannis (Greece)
2001 Janet Strife (USA)
2009 Ines Boechat (USA)
2001 Robert Brasch (USA)
2009 Steve Chapman (United Kingdom)
2001 Max Hassan (France)
2009 Jochen Troeger (Germany)
2001 Yacob Bar-Ziv (Israel)
2010 Ernst Richter (Germany)
2002 Sven Laurin (Sweden)
2010 Veronica Donoghue (Ireland)
2003 Aldo Pelizza (Italy)
2010 Freddy Avni (Belgium)
2003 Giampiero Beluffi (Italy)
2010 François Diard (France)
2003 Helen Carty (England)
2010 Paola Toma (Italy)
2003 Bruce Parker (USA)
2011 Rose de Bruyn (United Kingdom)
2004 Christine Hall (England)
2011 Goya Enriquez (Spain)
2004 Andrzej Marcinski (Poland)
2011 Cristian Garcia (Chile)
2005 Ulrich Willi (Switerland)
2011 Paul Kleinman (USA)
2005 Jean-Philippe Montagne (France)
2011 George Tayor (USA)
2005 Giuseppe Farielo (Italy) 2006 Francis Brunelle (France)
Gold Medallists
2006 Laurent Garel (Canada)
2007 Javier Lucaya
2006 Morteza Meradji (Netherlands)
2008 Gabriel Kalifa
2006 Alan E. Oestreich (USA)
2010 Ulrich Willi
2007 Marianne Spehl (Belgium)
2011 Richard Fotter
Jacques Lefebvre Awards 1977
Ringertz H. (Sweden)
The width of cranial sutures in neonates: an objective method of assessment
1978
Garel L. (France)
Xanthogranulomatous pyelonephritis in children: 19 cases
1979
Brauner M. (France)
Metrizamide myelography in infants with brain injury to the brachial plexus
1980
Spehl-Robberech M. (Belgium)
Ultrasonic study of the pancreas in cystic fibrosis
1981
Garel L. (France)
The renal sinus: an important anatomical landmark in children
1982
Couture A. (France)
Ultrasonographic exploration of cerebral malformations
1983
Brunelle F. (France)
Percutaneous cholecystography in children
1984
Veyrac C. (France)
Ultrasound of normal and pathologic choroid plexus
1985
Avni F. (Belgium)
Ultrasonic demonstration of abnormal and atypical gallbladder content in newborns
1986
Pariente D. (France)
Biliary tract involvement in children with Langerhans cell Histiocytosis
1987
Sellier N. (France)
Focal cortical dysplasia: a rare cause of epilepsy
1988
Deeg K. H. (Germany)
Pulsed Doppler sonographic measurement of normal values for the flow velocities in cerebral arteries of healthy infants
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S407
1989
Winkler P. (Germany)
Major pitfalls in the Doppler examination of cerebral vascular system
1990
Garel C. (France)
Laryngeal ultrasonographic study in infants and children. Pathological findings
1991
Pracros J. P. (France)
Systemic study of superior mesenteric vessels in abdominal ultrasound
1992
Hollman A. (UK)
Colour Doppler imaging of the acute paediatric scrotum
1993
Chami M. (France)
Ultrasound contribution in the analysis of the newborn infant normal foot and club foot: preliminary study
1994
Adamsbaum C. (France)
Vermian agenesis without posterior fossa cyst
1995
Sebag G. (France)
Magnetic resonance angiography of paediatric renal transplants with quantification of allograft blood flow
1996
Rohrschneider W. (Germany)
US, CT and MR imaging. Characteristics in nephroblastomatosis: evaluation of 23 Patients
1997
Hertz-Pannier L. (France)
Non-invasive preoperative motor mapping in children with brain functional MRI
1998
Nicaise N. (Belgium)
Dynamic Gd-DTPA-enhanced T1W turbo field echo imaging: Interest in paediatric renal evaluation
1999
Rypens F. (Belgium)
Fetal lung volume estimation by MRI: normal values and potential use
2000
Ziereisen F. (Belgium)
Doppler assessment of pulsatility index (PI) of the uterine artery in girls around puberty
2001
Lidegran M.K (Sweden)
MRI and echocardiography in assessment of ventricular function in atrially corrected transposition of the great arteries
2002
Cassart M. (Belgium)
The assessment of fetal uronephropathies by MR imaging
2003
Boddaert N. (France)
18F-Fluoro-L-Dopa PET scan of focal forms of hyerinsulinism of infancy
2004
Jourdan C. (Germany)
US evaluation of intima-media thickness (IMT) and elastic properties distensibility, stiffness and incremental modulus of elasticity of the common carotid artery as a marker of early vascular damage in children with chronic renal failure and reference values
2005
Kellenberger C.J. (Switzerland)
Cardiovascular MRI for investigating Newborns and Infants with Congenital Heart Disease
2006
Phalla O. (France)
Detection of coronary complications after arterial switch operation for transposition of the great arteries: first experience with 65-slice CT in children
2007
Sporcq C. (Belgium)
Reappraisal of the sonographic characteristics of the fetal and newborn kidney: introducing the cortico-medullary ratio
2008
Damasio M. B. (Italy)
Which is the best imaging modality to capture bone erosions in juvenile idiopathic arthritis?
2009
McDonald K. (UK)
DWI to assess chemotherapy response in solid tumors
2010
Ording-Müller L.S. (Norway)
Development of the wrist. Normal standards based on MRI for 6–15 year old
2011
Duran C. (Spain)
Voiding urosonography: normal and abnormal appearance of the urethra
Poster Awards 1994
Gomes H. (France)
Neonatal hip sonography from anatomy to sonography
1995
Schmit P. (France)
Imaging of cystic mesenchymal hamartomas of the liver. Review of 13 patients
1997
Schmit P. (France)
Congenital hepatic vascular malformations in children
1998
Brisse H. (France)
In utero MRI. Normal gyral development of the human brain
2000
Valle M. (Italy)
High-frequency ultrasound detection of the brachial plexus in newborns and infants
2001
Rohrschneider W. K (Germany)
Static dynamic MR-urography—simultaneous morphological and functional evaluation of the urinary tract
S408
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
2002
Owens C.M (UK)
The utility of MRI in the assessment of symptomatic adenoidal hypertrophy and rhinosinusitis in children. pre and post medical therapy
2003
Schumacher R. (Germany)
Sonographical anatomy of the anal sphincter complex (ASC) and levator ani muscle in neonates and infants
2004
Mentzel H.-J. (Germany)
Comparison of whole body STIR MRI and 99mTc-methylene diphosphonate scintigraphy in the examination of children with suspected multifocal bone lesions
2005
Enriquez G (Spain)
Prenatal assessment of lung hypoplasia in congenital diaphragmatic hernia: correlation between volumetric MRI and biometric ultrasound measurements
2006
de Maupeou F. (France)
Whole body imaging in malignant bone tumours in children: preliminary results
2007
Punwani S. (UK)
Effects of reducing radiation dose on lung nodule detection
2008
Chateil J.-F. (France)
Imaging of acquired spinal cord lesions and spinal canal pathology in children
2009
Barez MG. (Spain)
Spectrum of imaging findings in the brachial apparatus anomalies
2010
Brun M. (France)
Diffusion tension imaging in attention deficit disorders in children treated for posterior fossa tumours: preliminary results
2011
Fonda C. (Italy)
3T arterial spin labelling (ASL) in pediatric patients
Young Researcher Awards 2003
Brun M. (France)
Phonological Decoding in Dyslexic Children: Activation Pattern of FMRI
2004
Barnacle A.B (UK)
Image-guided percutaneous biopsy of soft tissue masses in children
2005
Raissiki M. (Greece)
Eye-lens Bismuth Shielding in Pediatric Head CT Examinations
2006
Sorge I. (Germany)
Reduction of radiotherapy in children with early stages of Hodgkin’s lymphoma, influenced by a new imaging and FDG-PET based strategy
2007
Alison M. (France)
In vivo targeting of macrophagic activity with MRI contrast agent (USPIO) in an experimental model of neonatal brain lesions
2008
Herrmann J (Germany)
Capsular arterial collateralisation after paediatric liver transplantation
2010
Arthurs O. (UK)
MR Voiding cystourethrography for vesico-ureteric reflux in unsedated infants
2011
Gupta N (UK)
Predictors of vesicoureteric reflux in infants with UTI using NICE criteria
President’s Awards 2004
Kilian A.K. (Germany)
Prenatal magnetic resonance (MR) lung volumetry of congenital diaphragmatic hernia (CDH): comparison with the clinical outcome and the necessity of extracorporeal membrane oxygenation (ECMO)
2005
Larke A. (Ireland)
MRI findings as an indication of underlying genetic lesions in congenital malformations of the brain
2007
Duran C. (Spain)
Voiding cystosonography for the study of the urethra
2008
Calder A. (UK)
Computed tomography compared with ultrasound and chest radiography in children with pleural empyema
2009
Senocak E. (Turkey)
MRI and DWI findings in children with hemophagocytic lymphohistiocytosis: tendency for symmetricity
2010
Franchi-Abella S. (France)
Congenital portosystemic shunt: complications and outcome after closure: about 19 pediatric cases
2011
Punwani S. (UK)
MRI vs. PET/CT for detection of focal splenic lesions in paediatric and adolescent lymphoma at initial staging
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Past Presidents and Meeting Sites 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Jacques Lefebvre, Paris, France Ulf Rudhe, Stockholm. Sweden John Sutcliffe, London, England Herbert Kaufmann, Basel, Switzerland Arnold Lassrich, Hamburg, Germany Ksawery Rowinsky, Warsaw, Poland Guido Lannacone, Rome, Italy Gregers Rhomsen, Copenhagen, Denmark Jacques Sauvegrain, Paris, France Roy Astley, Birmingham, UK Per-Erik Heikel, Helsinki, Finland Klaus Knapp, Madrid, Spain Ole Eklof, Stockholm, Sweden Andreas Geidion, Lucerne, Switzerland Noemi Perlemutter-Cremer, Brussels, Belgium Klaus Dieter Ebel, Koln, Germany The Dutch Group of Paediatric Radiologists, The Hague, Netherlands Gunnar Stake, Oslo, Norway Antonin Rubin, Prague, Czechoslovakia Clement Fauré, Paris, France Gianfranco Vichi, Florence, Italy Elizabeth Sweet, Glasgow, Scotland Javier Lucaya, Barcelona, Spain Denis Lallemand (ESPR) and Derek Harwood-Nash (SPR), Toronto, Canada Daniel Nussle, Montreux, Switzerland Noel Blake, Dublin, Ireland Hlemut Fendel, Munich, Germany Hans Ringertz (ESPR) and Donald Kirks (SPR), Stockholm, Sweden Bela Lombay, Budapest, Hungary Donald Shaw, London, UK Fred Avni, Brussels, Belgium Peter Kramer, Utrecht, Netherlands Paul Thomas (ESPR) and Kenneth Fellows (SPR), Boston, USA Ulrich Willi, Lugano, Switzerland Basilos Theodoropoulos, Rhodes, Greece Jacob Bar-Ziv and Gabriel Kalifa, Jerusalem, Israel Jose Fonseca Santos, Lisbon, Portugal Francis Brunelle (ESPR) and Janet Strife (SPR), Paris, France Tore Nordhus, Bergen, Norway Paolo Tomà, Genoa, Italy Jochen Troeger, Heidelberg, Germany
S409
2005 2006 2007 2008 2009 2010 2011
Veronica Donoghue, Dublin, Ireland Richard Fotter (ESPR) and George Taylor (SPR), Montreal, Canada Goya Enriquez, Barcelona, Spain Stephen Chapman, Edinburgh, UK Mithat Haliloglu, Istanbul, Turkey Jean-François Chateil, Bordeaux, France Catherine M. Owens (ESPR) and Dorothy Bulas (SPR), London, United Kingdom
Future ESPR Meetings 2013
Budapest, Hungary, June 3–7
Future SPR Meetings 2013
San Antonio, Texas, May 14–18
2014
Washington, DC, May 13–17
2015
Seattle, Washington, April 27–May 1
European Courses of Paediatric Radiology (ECPR) 1992
F. Brunelle, Biarritz, France
1993
P. Tomà, Genoa, Italy
1994
G. Enriquez, Barcelona, Spain
1995
C. Raybaud, Marseille, France
1996
G. Benz-Bohm, Koln, Germany
1997
H. Carty, Liverpool, UK
1998
C. Adamsbaun, G. Sebag, Montpellier, France
1999
P. Tortori-Donati, Genoa, Italy
2000
R. Fotter, Graz, Austria
2001
S. Laurin, Lund, Sweden
2002
B. Lombay, Budapest, Hungary
2003
E. Martin-Fiori, T Huisman, Zurich, Switzerland
2004
T. Berrocal, Madrid, Spain
2005
M. Spehl, C. Christophe, Brussels, Belgium
2006
J.-N. Dacher, Rouen, France
2007
R. Schumacher, Mainz, Germany
2008
K. Chong, London, UK
2009
R. R. van Rijn, A. Smets & E. Deurloo, Netherlands
2010
C. Fonda, Firenze, Italy
2011
I. Barber, Spain
2012
H-J Mentzel, Germany
European Courses of Paediatric Neuroradiology (ECPNR) Course run jointly by the ESPR, the ESNR and the ESMNR 2011
M. Argyropolou (ESPR), Andréa Rossi (ESNR), Nadine Girard (ESMRN)
S410
Curricula vitae of Gold Medal award recipient, Honorary Member and Jacques Lefevbre lecturer ESPR 2012 Gold Medal Award The ESPR gold medal is an exceptional award recently instituted to recognise a lifetime’s work and outstanding achievements in Paediatric Radiology within Europe. Four recipients have received it thus far: Professor Javier Lucaya (Spain), Professor Gabriel Kalifa (France), Professor Ulrich Willi (Switzerland) and Professor Richard Fotter (Austria). This year’s award will be presented to Professor Francis Brunelle (France). Professor Francis Brunelle, M.D., France
Professor Francis Brunelle was born on May 29th, 1949. His parents were professors of philosophy, and of Greek, Latin, and French. He graduated from Cochin Medical School in Paris in 1972, and served as a volunteer military surgeon in Togo (Africa), establishing the first nursing school in Togo during his stay. He trained as a paediatrician, neonatologist, and then branched into diagnostic radiology during his residency, whilst acquiring a master’s degree in biochemistry. He went on to spend a year as a visiting fellow in Alex Margulis’ department, University of California, San Francisco, where he trained with Harry Genant, Roy Filly, Hans Newton and David Norman in neuroradiology. On his return to France, he became an Associate Professor of radiology in Dr. Chaumont’s department, Bicetre Hospital, Paris. Professor Daniel Alagille, a world specialist in paediatric liver, inspired him to develop diagnostic and interventional radiology in this domain. Most of today’s abdominal interventional techniques were developed during this period.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
In 1981, he spent 4 months in Derek Harwood-Nash’s department, HSC Toronto, where he trained in paediatric neuroradiology, writing a seminal paper entitled, “Brain vascular malformations in children.” In 1985, Prof Brunelle became a Professor of Radiology at Necker Enfants-Malades Hospital, which proved to be the turning point of his career. Professor Hirsch, a pioneer of paediatric neurosurgery, and Doctor Jean Aicardi, one of the leading figures in paediatric neurology, inspired him to develop diagnostic and interventional neuroradiology techniques in children. He established the first paediatric neuroradiology course in France, which rapidly became the European Course of Paediatric Neuroradiology, now held in conjunction with the European Society of Paediatric Radiology and the European Society of Neuroradiology. In addition, he developed the syllabus for and organised the first European Course of Paediatric Radiology in 1992. His research interests developed within the field of neurogenetic diseases in children and autism. Later, he was (as always) at the forefront of research involving new techniques the department was a pioneer in MRI foetal imaging, the first foetal MRI was performed in 1987. Prof. Brunelle’s brilliance and pioneering spirit has enabled an extra ordinary academic career. He has written 322 peer-reviewed papers and 3 books, amongst them Imaging Children (with Carty, Stringer and Kao). He is a former President of the Medical Board in Necker; Editor of Paediatric Radiology; Secretary of the French College of Radiologists (CERF); and Counsellor of the Minister of Health (2004–2007). He served as President (co-president Janet Strife) of the International Paediatric Radiology (IPR) meeting in Paris in 2001, and Director and Chairman of the Imaging Department at Necker. He continues his inspirational career as one of the founders of a renovation plan for Necker Hospital, due for official opening in July 2012. Prof. Brunelle is one of the three authors behind the drafting of Necker Hospital’s medical strategy. He is also one of the two founders of a university diploma, “Management for Doctors” and a coach in “Management of Change”. Amongst his many civic and medical honours, Prof Brunelle has been made a Knight of the Legion of Honour, and a City counsellor of Sceaux. Prof. Brunelle has 6 children and is much beloved by them and his wife Anne, an architect. MA, CMO
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
ESPR 2012 Honorary Member Corinne Veyrac, M.D., (France)
Doctor Corinne Veyrac was born in Rouen, France, on 31st December 1951. She pursued her medical studies in Rouen University from 1968 to 1975, and moved to the University Hospital of Montpellier for her residency (1975 to 1981). She originally trained in Clinical Paediatrics (1975 until 1981), then in Paediatric Radiology (1981 to 1983). Dr Veyrac joined the pediatric radiologists (JL Ferran and A Couture) in the University Hospital of Montpellier in 1983, where she commenced her career as an inspirational teacher, mentor and patient advocate within Paediatric Radiology, and contributed to the creation of the Department of Pediatric Radiology, led by Alain Couture. Doctor Veyrac is a pioneer and world leader in paediatric ultrasonography, her main areas of interest include neonatal brain sonography, urogenital and abdominal sonography. Doctor Veyrac joined the European Society of Pediatric Radiology (ESPR) in 1982, and the French Society of Pediatric and Perinatal Imaging (SFIPP) in the same year. Her participation in external teaching includes courses organized by the MASU (Rabat, Nairobi and Damas), the ESR (through the ESOR Galen Foundation: Athens, Warsaw and Sofia) and the SPR (Orlando and Sao Paulo). Dr Veyrac has delivered approximately 140 lectures in national and international congresses.
S411
She has published 50 peer-reviewed publications, and 32 book chapters in 18 different textbooks; including her major publications in: Echographie cérébrale du foetus au nouveau-né. Imagerie et hémodynamique (with A. Couture and C. Baud), Transfontanellar Doppler Imaging in Neonates (with A. Couture) and Gastrointestinal Tract Sonography in Fetuses and Children (with A. Couture, C. Baud, JL. Ferran and M. Saguintaah). Dr Veyrac is a leader in clinical excellence, with a steely determination to deliver the best quality of care to children within her sub-speciality. She has devoted herself tirelessly, unselfishly and with passion to her work, and in doing so she is a woman who has captured the hearts and minds of paediatric radiologists worldwide. Her modesty and selflessness have inspired her many pupils; as a dedicated and gifted teacher, and a mentor to several generations of students. Thus her efforts to further the sub-speciality will endure, carried forward by brilliant young paediatric radiologists compelled to follow her example. Any biography would be incomplete without a personal anecdote to describe her spirit of adventure, as beneath her modest exterior she is a legendary adventurer. During a working trip to Syria, whilst on a narrow mountain road, her car ran headlong into a truck. Her crazy driver, perhaps recognizing the amazing determination and strength of character of his passenger, somehow kept the vehicle on the road. Although she turned from pink to green, and her life flashed before her eyes, Dr Veyrac thankfully survived unhurt..... To her profound distress, two subsequent French radiologists, taking the same route 2 years later, did not. Her commitment, and her compassion, has been uplifting to all who have had the pleasure to know her. Outside her working circles, Corinne Veyrac is a devoted and loving mother to her children Nathalie and Nicolas, and a wonderful wife to her husband, Michel, who shares her passion for gastroenterology. We all wish Dr Corinne Veyrac a blissful retirement, amongst the flowers she tends and loves, Her boundless energy will now be spent on her favourite passions—cooking, baking, and…. football (another focus of her brilliant expertise!) MA/CMO/CA/JFC/PP
S412
2012 Jacques Lefebvre Lecturer
Prof. Nicholas Gourtsoyiannis, M.D., PhD., FRCR (Hon.), FRCSI (Hon.) Professor Emeritus, University of Crete/Greece Professor Gourtsoyiannis was born in Amphissa, Greece, in 1943. He obtained his medical degree from Thessaloniki University in 1967 and his doctoral thesis from Athens University in 1977. After a three-year internship in Internal Medicine at the Red Cross Hospital of Athens, he completed a three-year residency in Radiology at Evagelismos Hospital in Athens, followed by a 2-year fellowship at the Radcliffe Infirmary in Oxford (1977–1979). He served the Hellenic Air Forces Hospital in Athens between 1975 and 1987, where he was appointed head of the Radiology Department in 1981. He was elected Associate Professor of Radiology of the University of Crete in 1986, and was Professor and Chairman of the Department of Radiology from 1990 to 2010. He served as the first Medical Director at the University Hospital of Crete (1997–1999) and spent two terms as Dean of the Faculty of Medicine of the University of Crete (1999– 2001 and 2001–2003). He was appointed Professor emeritus of the University of Crete in 2010.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Professor Gourtsoyiannis is the founding father of the Hellenic College of Academic Radiology. He has served as its President from 1997 until 2001 and holds the title of its Honorary President. He is also a founding member of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). He was President of two of the annual ESGAR meetings (1990, 1996), President of the Society (1997–2000), and President of the joint European (ESGAR) and American (SGR) Abdominal congress in 2006. His greatest interest has been in the radiology of diseases of the small intestine, and he has made major contributions to the evaluation of small bowel imaging with MR. His work in Radiological-Pathologic Correlation spurred him on to mastermind ECR’s Categorical Course and Syllabi in this discipline, introducing Radiological-Pathologic Correlation at ECR. An active researcher, he has published more than 250 scientific articles in international peer-reviewed journals and he has written or co-written 40 book chapters. He has served on the Editorial Board of numerous journals, including European Radiology, Abdominal Imaging, Investigative Radiology, Acta Radiologica and Magnetic Resonance in Medical Science. He has also been the editor of Hellenic Radiology and a reviewer for several national and international scientific journals on medical imaging and gastrointestinal diseases. He is the editor or co-editor of 4 books, Imaging of Small Bowel Tumors (Elsevier, 1997), Small Bowel Imaging (Springer-Verlag, 2003), RadiologicPathologic Correlations (Springer-Verlag, 2005), and Clinical MRI of the Abdomen (Springer-Verlag, 2011). Nicholas Gourtsoyiannis has been visiting professor at 27 Universities and he has delivered more than 400 invited lectures, and over ten eponymous ones, worldwide. In recognition of his international achievements and the excellence of his work, he has been awarded honorary membership by the following societies: the Radiological Society of North America, the British Institute of Radiology, the French Society of Radiology, the Radiological Society of Switzerland, the Austrian Society of Radiology, the Italian Society of Medical Radiology, the Royal Belgian Radiological Society, the Argentinean Society of Radiology, the Bulgarian Association of Radiology, the Association of Bosnia and Herzegovina Radiologists, the Serbian Society of Radiology, the Turkish Radiological Society, the Hungarian Society of Radiology, the Nordic Radiological Society, the Swedish Society of
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Radiology, the Polish Society of Medical Radiology, the Iranian Society of Radiology, the Portuguese Society of Radiology, the Romanian Society of Radiology, Spanish Society of Radiology, the German Society of Radiology, the Chinese Society of Radiology, and the European Society of Paediatric Radiology. He has also received honorary fellowships from the Royal College of Radiologists (UK) and the Royal College of Surgeons (Ireland), and he is a member of the Russian Academy of Medical Sciences. He is the recipient of the 2000 Gold Medal of ESGAR, the 2001 Olson Medal of Sweden, the 2003 Schinz Medal of Switzerland, the first Gold Medal of the Hellenic Society of Radiology in 2004, the Boris Rajewsky Medal of the EAR in 2007, and the Gold Medal of the European Society of Radiology in 2008.
S413
He was President of ECR in 2003 and chairman of the ECR Executive Committee in 2004. From 1999 to 2003 he was Chairman of the Subspecialties Committee of the EAR and from 2004 to 2007 he was President of the European Association of Radiology (EAR). He introduced the Electronic Presentation Online System (EPOS™) and the European School of Radiology (ESOR), and he masterminded the creation of the European Society of Radiology (ESR). Nicholas Gourtsoyiannis was the first President of the European Society of Radiology (ESR, 2006 to 2007). He is now the Scientific/Educational Director of the European School of Radiology (ESOR) and the President of the International Society of Radiology (ISR). He and his wife Emmy have two children, Christos and Sofia.
S414
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Congress Organisation
President Maria I. Argyropoulou Secretary Efthymia Alexopoulou Scientific Committee Loukas Astrakas Areti Charissiadi Savvas Defteraios Christiana Hadjigeorgi Paraskevi Kosta Panagiotis Nikolopoulos Marina Papadaki Frederika Papadopoulou Georgia Papaioannou Maria Raissaki Loukia Tzarouchi Vassilios Xydis Anastasia Zikou Organising Committee President Efthymia Alexopoulou Committee Maria Arvaniti Maria Badouraki Maria Chasiotou Nikos Evlogias Christiana Hadjigeorgi Christina Kalogeropoulou Maria Katsikari Chrissoula Koumanidou Ioannis Nikas Panagiotis Nikolopoulos George Pitsoulakis George Tsimitselis Marina Vakaki Maria Zarifi
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S415
Conference Secretariat
102, Michalakopoulou str. Tel: +30 210 7711673 Fax: +30 210 7711289 WebSite: www.prctravel.gr E-mail:
[email protected] The organizers acknowledge the support of the following organizations Institutional partners Hellenic Radiological Society Industrial and Commercial partners Agfa HealthCare Bayer HealthCare Pharmaceuticals Bracco Suisse SA EOS Imaging GE Medical Systems Hellas LMT Lammers Medical Technology GmbH PharmaZac Philips Medical Systems The ESPR would also like to thank all further sponsors and exhibitors for their support. This supplement was not sponsored by outside commercial interests. It was funded entirely by the publisher.
S416
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Dear Colleagues, Dear friends It is my great honour and privilege to welcome you to Athens for the 35th Postgraduate Course & 49th Annual Meeting of the European Society of Pediatric Radiology. The foundation of Athens goes back some 3,000 years, since then the city has lived through times of glory and times of decline. The times of glory have given birth to philosophy, literature, science, arts and politics, defining the matrix and momentum for modern western civilization. Today, decline wears a global mantle, yet the goddess Athena still watches over us from her Parthenon, and shares her wisdom and days of glory with us all. Days of Glory, the ESPR 2012 days. ESPR 2012 begins with the postgraduate course, covering topics on cardiothoracic, skeletal, gastrointestinal, genitourinary, neuro and interventional radiology. Highly qualified paediatric radiologists, all excellent teachers, will explore the theoretical aspects of each thematic area, whilst sharing practical ‘tips’ garnered from years of experience. The JESPeR lecture is dedicated to Tuberculosis, building up A to Ω familiarity with all the key imaging findings of this disease. During the congress, high-quality research undertaken since last year’s meeting will be communicated as oral or poster presentations. Of particular interest are the task force sessions, where updates and guidelines relating to the imaging of different systems and radioprotection issues will be presented. Practical issues are extremely important, but knowledge of the theory behind our imaging applications is at the core of good science and practice. Thus a comprehensive review of state of the art imaging of the brain and spine will be presented in the Symposium: Brain and Spinal MR: from the technique to application. Knowledge is acquired not only to be used, but more importantly, to be imparted to future generations. Thus the experience, wisdom and knowledge of world-renowned paediatric radiologists will be offered to junior and senior pediatric radiologists alike during the session “The top ten lessons learnt from my life”. Education is the corner stone of science, and the creation of educational opportunities is the on-going task of the European family of radiology. The ESPR lecture is given by the father of the European School of Radiology, Professor Nicholas Gourtsoyiannis, and is dedicated to the European experience of striving for education in radiology. Hippocrates is the father of western medicine, and the Hippocratic Oath defines ethics in medical practice. “The Application of Hippocratic Principles to Pediatric Radiology” will be presented by a famous American paediatric radiologist (albeit European in his heart), Professor Bruce Parker. Thank you for coming to Athens, and thank you for being part of this venture. We shall doubtless prove once again that our democratic societies, in the manner of this city’s ancient Acropolis, promote and protect good science, thus paying homage to Athens’ timeless splendour, that resists the rigours of time. Sincerely
Prof Maria I Argyropoulou President ESPR2012
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S417
ESPR 2012, ATHENS 35th POSTGRADUATE COURSE May 28th–May 29th
Monday 28 May 08:45 Introduction & welcome 09:00–10:30 Chest and Heart Chaired by: C Bakoula, V Donoghue 09:00 Neonatal Chest: What the neonatologist needs to know from the pediatric radiologist G Enriquez Civicos, Bracelona/ES 09:30 Top ten lesions of the pediatric lung H Ducou le Pointe, Paris/ FR 10:00 Morphological and functional assessment of congenital heart disease with MRI N Kelekis, Athens /GR 10:30 Coffee Break 11:00–12:30 Gastrointestinal Chaired by: N Evlogias, M Anooshiravani 11:00 Congenital malformations of the GI tract: How to use imaging V Donoghue, Dublin/IE 11:30 Biliary atresia: Investigation and management D Pariente, Paris /FR 12:00 Inflammatory bowel disease: advances in imaging E Alexopoulou, Athens/GR 12:30 Lunch 13:30–15:00 Skeletal Chaired by: M Arvaniti, H Ducou le Pointe 13:30 How to image musculoskeletal infection M Raissaki, Iraklion/GR 14:00 Arthritis in children; How to start and when to finish with imaging K Rosendahl, Bergen/NO 14:30 Benign Bone Lesions: How far should we go with imaging? K Oudjhane, Toronto/CA
15:00 Coffee Break 15:30 Special lecture Chaired by: MI Argyropoulou, A Gouliamos Imaging the pediatric brain: the past, the present, the future F Brunelle, Paris/FR 16:00–17:30 Genito-urinary System Chaired by: M Papadaki, P Toma 16:00 Urinary tract infection revisited F Avni, Brussels/BE 16:30 MR Urography: How to do it and when to use it C Kanavaki, Geneva/CH 17:00 Voiding dysfunction in children M Riccabona, Gratz/AU 17:30 Special Lecture Chaired by: I Nikas, JF Chateil Spinal trauma: when and how to image P Sundgren, Lund/SE Tuesday 29 May 08:30–10:00 Fetal Chaired by: S Andronikou, C Adamsbaum 08:30 All about fetal brain: from A to Ω N Girard, Marseille/FR 09:00 Urogenital anomalies: US/ MRI F Avni, Brussels/BE 09:30 The liver, the pancreas and the spleen: US/MRI M Cassart, Brussels/BE 10:00 Special Lecture Chaired by: F Avni Fetal imaging: Should we measure and what C Garel, Paris/FR
S418
10:30 Coffee Break 11:00–12:30 Oncology: Don’t forget the fundamentals and learn about the future Chaired by: H Brisse, E Stiakaki 11:00 Bone tumors G Papaioannou, Athens/GR 11:30 Hematologic malignancies RA Nievelstein, Utrech/NL 12:00 Brain tumors T Huisman, Baltimore/USA 12:30 Lunch 13:30–15:00 Neuroimaging from A to Ω Chaired by: A Zikou, A Rossi 13:30 US of the brain C Veyrac, Montpellier /FR 14:00 All about Stroke JF Chateil, Bordeaux/FR 14:30 Non accidental injury C Adamsbaum, Paris/FR
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
15:00 Coffee Break 15:30–17:00 Skull base Chaired by: M Katsikari, N Girard 15:30 Fetal head and neck: Pre-postnatal imaging correlation E Vasquez, Barcelona/ES 16:00 The petrous bone A Rossi, Genova/IT 16:30 The pituitary gland C Garel, Paris/FR 17:00 Special lecture Chaired by: F Brunelle, D Pariente Liver vascular anomalies: imaging, treatment and pitfalls J Dubois, Montreal/CA 17:30 JESPeR lecture Chaired by: C Hadjigeorgi, S Stafrace Tuberculosis from A to Ω S Andronikou, Cape Town/ZA
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S419
35th Postgraduate Course Presentations
Neonatal chest: what the neonatologist needs to know from the pediatric radiologist Goya Enriquez Pediatric Radiology Department, Hospital Infantil Vall d’Hebron, Barcelona/Spain Chest X-ray continues to be the first radiologic examination performed to assess chest lesions in neonates and it requires a meticulous technique. Proper positioning of the patient and X-ray tube is extremely important to avoid a distorted chest image. Upward angulation of the tube can result in a bizarre configuration of the ribs, whereas lordotic patient positioning produces an abnormally prominent cardiac apex, simulating right ventricular hypertrophy. If the infant is rotated to one side the upper lung may appear hyperlucent and be misinterpreted as a pathologic finding. To ensure that the chest is not rotated, the operator should verify that the ribs and the medial borders of the clavicles are symmetrical. It is also essential to know that the features of films obtained in expiration often simulate cardiomegaly or increased lung density, mimicking pulmonary disease. Hence, the chest examination must be performed in appropriate inspiration, which can only be determined with the experience of reading numerous radiographs. The nasogastric tube is the chosen nutritional technique in premature infants. It is essential to check the position of feeding tubes because it can provide important diagnostic information regarding esophageal atresia and traumatic esophageal pseudodiverticulae. Inability to properly advance an oral tube may indicate esophageal atresia. Traumatic pharyngeal perforation should be suspected when the feeding tube is seen outside the esophagus in unexpected locations. These iatrogenic lesions can occur when the tube comes into contact with the fragile pharyngeal wall tissue, causing cricopharyngeal spasm and perforation. The endotracheal tube position should also be checked. Improperly positioned tubes can cause lobar or lung atelectasis or hyperaeration, or lead to long-term complications of tracheal stenosis or granuloma formation. Furthermore, visualization of the tracheobronchial tube in the stomach while the lungs are well aerated in a newborn is the key to establishing the diagnosis of tracheal agenesis.
Clinical conditions leading to respiratory distress in the first days of life can be divided into two groups: those that can be treated medically and those requiring surgery. The radiologic patterns of several medical conditions, such as hyaline membrane disease, also known as respiratory distress syndrome (RDS), transient tachypnea (TRDN), meconium aspiration and neonatal pneumonia, have been extensively reported. Ultrasound is particularly useful in the diagnosis of RDS and some authors speculate that it may serve as a screening method for early administration of surfactant in preterm infants with this condition. A huge increase in lung echogenicity (“white lung”) is the US diagnostic hallmark. Pulmonary lymphangiectasis is a less common condition that also produces severe respiratory distress. It can occur as an isolated abnormality, as a part of generalized lymphangiectasis or associated with heart lesions (hypoplastic left heart syndrome, anomalous venous return or pulmonary vein atresia). The lymphatic vessels are dilated in this condition and appear as nodular or somewhat reticular images on plain films. Positive-pressure ventilation is often a part of the treatment for these conditions and related complications such as interstitial emphysema, pneumothorax, and pneumomediastinum can be recognized on plain films. The variety of air-leak patterns produced should not be interpreted as pulmonary malformations. Interstitial blebs can simulate lung adenomatoid malformation and air in the anterior portion of the chest seen in patients in supine position (“anterior pneumothorax”) may simulate lobar emphysema. In patients with pneumomediastinum, air sometimes elevates the thymus, producing the so-called “angel wings” or “spinnaker sail” sign, simulating a mediastinal mass. Congenital lung malformations are usually detected prenatally, and most newborns are asymptomatic at birth and show normal chest plain films. To postnatally confirm the malformation, US, CT, or MRI should be performed. On US, an echogenic mass with systemic vascularization is seen in cases of pulmonary sequestration, whereas abnormal aeration with increased and heterogeneous parenchymal echogenicity is common in cystic adenomatoid malformation. In asymptomatic patients, contrast-enhanced CT or MRI can be performed later on (6–8 months) for complete characterization of the malformation. There is considerable debate in the
S420
literature on the management of patients with these congenital malformations. Most authors agree that solid sequestrations can regress spontaneously, and conservative management is recommended. However, cystic or hybrid lesions usually persist and may increase in size or develop infection; therefore surgical management may be more appropriate. Last, conditions causing respiratory distress in the neonatal period requiring surgery usually manifest on plain films as mediastinal displacement to the contralateral side. Congenital diaphragmatic hernia is a major surgical emergency in the newborn. The prenatal assessment, which mainly focuses on the degree of pulmonary hypoplasia and determines the postnatal management, is based on US and MRI study. In more severe cases, prenatal tracheal plug placement can be applied to increase the volume of the affected lung. The differential diagnosis of diaphragmatic hernia should be established, particularly with congenital adenomatoid malformation and pulmonary lymphangiomatosis. Top ten lesions of the pediatric lung H. Ducou le Pointe Department of Pediatric Radiology, Hôpital d’Enfants ArmandTrousseau, Paris/France Selecting 10 pediatric lung lesions is a hard challenge! Our choice was based on some of the lesions most commonly found in children, or lesions concerned by a new classification. Respiratory distress in newborn infants can be related to numerous causes. Hyaline membrane disease, also called respiratory distress syndrome, remains one of the major causes of death in live-born infants. Hyaline membrane disease affects premature infants. It is the clinical expression of surfactant deficiency in neonates. Infants are usually symptomatic within minutes following birth. Neonates present with non-specific tachypnea, grunting and cyanosis. Classic radiologic findings are observed in untreated patients and reflect generalized acinar collapse. Chest radiograph demonstrates underaeration of the lungs and diffuse consolidation (fine granular appearance) with air bronchograms. Mechanical ventilation and exogenous surfactant therapy have modified the radiological appearance of the disease. Bronchopulmonary dysplasia remains a long-term consequence of this disease. The incidence has not changed significantly, but the severity in infants born before 28 weeks of gestation is less important due to improved management and treatment. Pediatric diffuse lung disease, also called interstitial lung disease (ILD), encompasses a heterogeneous group of uncommon disorders characterized by impaired gas exchange and widespread pulmonary parenchymal pathology. It is now widely accepted that the idiopathic interstitial lung disease described in adults is not applicable to children. A new and specific pediatric classification was proposed in 2007 by the Child Research Cooperative group. This new classification is largely based on clinicopathologic findings. Radiologists must be aware of this classification so as to work with clinicians and pathologists and define characteristic imaging patterns. Genetic disorders of
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
surfactant should be highlighted. They currently represent a well known cause of chronic diffuse lung disease in the neonatal period and childhood. Most frequent genetic defects involve adenosine triphosphate binding cassette A3 (ABCA3), surfactant protein B (SP-B), surfactant protein C (SP-C) and thyroid transcription factor 1 (TTF-1). Congenital pulmonary malformations also represent a challenging topic. Their classification depends on investigators’ specialties. Some investigators classify congenital pulmonary malformations according to embryological considerations (the lesions are defined as lesions of defective budding, differentiation and separation of the primitive foregut). Other investigators consider that congenital pulmonary malformations result from airway obstruction with secondary pulmonary dysplastic changes. Vascular theory has also been supported. Some authors have developed a very practical approach based on morphological findings in radiology and pathology. Three groups have been defined: parenchymal lesions, vascular lesions and a combination of both. Three malformations need highlighting: congenital lobar emphysema, congenital pulmonary airway malformations and pulmonary sequestrations. Congenital lobar emphysema may cause respiratory distress in the neonatal period. Classification of congenital pulmonary airway malformations, previously known as congenital cystic adenomatoid malformations, has been updated to include 5 types by Stocker 2002. This new classification highlights two points: the term “adenomatoid” should not be used any longer, as it refers to one of the 5 types only. Moreover, the term “cystic” refers to 3 types only (1, 2 and 4). Pulmonary sequestrations combine parenchymal and vascular lesions. They are classified into two types (intralobar and extralobar). They are mostly located in lower lobes. Children with intralobar sequestration usually present with recurrent infections in the lower lobes. Extralobar pulmonary sequestration is diagnosed during the neonatal period and presents as a lung mass. This malformation is characterized by a systemic arterial supply. The pulmonary tissue of intralobar pulmonary sequestration has roughly the same appearance as that of CPAM and up to 50% of extralobar pulmonary sequestrations are associated with type 2 CPAM. Pneumonia is a very frequent infection in children (more than 150 million pediatric cases reported each year, according to the estimation of the World Health Organization). Numerous types of infectious agents are responsible for pneumonia in children. The radiological findings are rarely specific. Frontal chest radiographs are frequently the only required imaging modality. The lateral view is useful for visualizing hilar lymph nodes. CT is useful in pulmonary complications, in case of tuberculosis or in immunocompromised children. Bronchiolitis is a major cause of morbidity in children younger than 2 years of age. Respiratory syncytial virus is the most common cause of bronchiolitis. X-ray findings are related to a small airways obstruction (hyperinflation, peribronchial thickening, subsegmental atelectasis). Performing chest Xrays rarely impacts on the treatment and X-ray is recommended only for severe cases. Lung abscess is a complication of pneumonia. Lung abscesses used to be related to congenital pulmonary malformations with primitive lung abscesses being less frequent. Due to prenatal diagnosis, these malformations are now commonly
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
treated before infectious complications occur. Recognizing the primitive nature of lung abscesses at diagnosis is challenging even when a chest CT is performed. In our experience, the CT should be performed much later, after the acute episode, so as to detect an underlying pulmonary malformation. The prognosis of lung abscesses in children is usually good without sequelae. Pediatric tuberculosis remains a worldwide challenge. About 1 million annual cases occur in children younger than 15 years of age. The great majority (95%) of infected children will not develop the disease, and a disseminated form of the disease is more frequent in children younger than 2 years of age. The association between chronic pneumonia and hilar lymphadenopathies should raise suspicion for tuberculosis. Chests radiographs remain very effective for detecting parenchymal lesions and lymphadenopathies. CT is useful in case of equivocal chest X-ray, complicated presentation or disseminated disease. In immunocompromised children, chest CT is helpful for the evaluation of lung infection, particularly when X-ray does not contribute. CT findings in keeping with pulmonary fungal infection are characterized by nodules with poorly defined margins. Cavitation of the nodules and ground-glass opacity surrounding the nodules strongly suggest this diagnosis. Cavitation occurs in half of all cases and is characterized by the air-crescent sign. The halo sign is related to haemorrhage around a nodule or to inflammatory infiltration within the lung parenchyma. This sign may also be observed in other diseases such as viral infections and bacterial abscesses. Cystic fibrosis is caused by mutation in the CFTR gene and remains the most common cause of pulmonary insufficiency in children. Low-dose high-resolution technique computed tomography is the technique of choice (the gold standard) for the evaluation of lung disease in cystic fibrosis. However, there are concerns about the cumulative radiation dose in these patients. MRI seems to be a valuable technique to replace CT in the near future for the evaluation of cystic fibrosis. Recently, an MR-scoring system based on morphological and functional data was suggested for annual follow up. Reference Stocker JT: Congenital pulmonary airway malformation: a new name and an expanded classification of congenital cystic adenomatoid malformation of the lung. Histopathology 2002, 41:424–431. Morphological and functional assessment of congenital heart disease with MR N. L. Kelekis 2nd Department of Radiology, General University Hospital “ATTIKON” National and Kapodistrian University of Athens, Athens/Greece Introduction: Advances in diagnostic modalities and treatment have led to increased survival in patients with congenital heart disease (CHD) through adulthood. Diagnosis and follow-up in patients with CHD relies greatly on imaging studies. Until relatively recently, these relied principally on plain X-rays, echocardiography and angiography, the latter two being almost exclusively practiced by cardiologists. Nowadays, multislice CT
S421
and MRI play an evolving role in the management of patients with CHD. Morphology: A morphologic systematic approach to CHD includes assessment of the atrial situs in conjunction with abdominal and thoracic anatomy, atrioventricular connections, morphology of the ventricles, ventriculoarterial connections and anatomy of the great vessels, venous connections to the cardiac chambers, and finally the presence of valvular abnormalities, as well as abnormal communications such as atrial or ventricular septal defects. Specific anatomical features of various cardiac components used in morphological assessment of CHD are described below. The normal position with the cardiac apex situated in the lower anterior left hemithorax is described as levocardia; the term dextrocardia refers to the cardiac apex being on the right, while the rare mesocardia consists of a centrally positioned heart with both the base and the apex along the midline with the former more cranial and the latter more caudal (such as in mammalian quadripeds). The position of the apex is independent from the situs of the heart, lungs and viscera. The situs of viscera and lungs does not depend on the position of the cardiac apex (levo-, meso-, or dextrocardia). It always correlates with the position of the morphological right or left atrium. There are five categories, determined by the position of the morphologically right or left atrium:
1. Situs solitus (right atrium on the right) 2. Situs inversus or mirror image (right atrium on the left) 3. Right isomerism (asplenia, bilateral right atria and morphological right main bronchi)
4. Left isomerism (polysplenia, bilateral left atria and morphological left main bronchi)
5. Situs ambiguous (inability to accord atrial characterization) Regarding the external topography of the heart, the atrioventricular groove defines the plane of the base of the heart (4 cardiac valves) and defines the short-axis plane of the heart, containing the right coronary artery and left circumflex artery in the right and left atrioventricular grooves respectively. The left anterior coronary artery courses along the anterior interventricular groove, while the posterior descending coronary artery courses along the inferior interventricular groove. As a general rule, morphological right chambers are more coarsely trabeculated and morphological left chambers smoother in their interior surfaces. The morphological right atrium is a right posterolateral chamber. Its posterior aspect receives the two caval veins and has a veinlike appearance, in keeping with its embryologic origin from the venous sinus (sinus venosus), while the coronary sinus enters the right atrium anteriorly (Thebesian valve) in front of the inferior vena cava ostium (Eustachian valve). It has a wide-based pyramidal-shaped appendage, contains the limbs of the septum secundum (oval fossa limbs), and has free-wall and septal components. A prominent C-shaped ridge of muscle forms the terminal crest (or crista terminalis), which
S422
separates the two regions and forms one of the tracts for internodal conduction. The right atrium is characterized by the presence of numerous pectinate muscles, which arise from the terminal crest and travel as parallel ridges along the anterior aspect of the free wall. The interatrial septum, when viewed from the right, has an interatrial component and an atrioventricular component (RA-LV). The interatrial portion is relatively small and contains the oval fossa, which consists of a horseshoe-shaped muscular rim (limb), containing a pathway of internodal conduction, and a central thin fibrous membrane (valve of the oval fossa). The morphological left atrium receives the pulmonary veins, has a narrow-based finger-like appendage and contains the remnants of the septum primum, while it does not have a crista terminalis or pectinate muscles but rather demonstrates a smooth internal surface. The atrioventricular valves always accompany their reciprocal ventricles. The tricuspid valve has three cusps, three papillary muscles with a septal cusp and papillary muscle, and is separated from the pulmonary valve by a muscular infundibulum. It may, however, have a conal, rather than septal, papillary muscle. The mitral valve has two cusps and two papillary muscles with an absence of septal attachments and has a fibrous continuity with the aortic valve. In congenital heart disorders, there may be a single common atrioventricular valve. The ventricles consist of three well-developed parts: the inflow tract, the body and the outflow tract, which is of conotruncal origin. In congenital heart disorders, hypoplastic ventricles may consist of one or two of the above parts, or a single ventricle may be present. The morphological right ventricle has coarse trabeculations. The most prominent of the septomarginal trabeculae is termed the moderator band, which contains part of the electrical conduction system and is one of the most important right ventricular landmarks on imaging studies. The right ventricle has a muscular infundibulum, three papillary muscles (usually anterior, posterior and septal), and a tricuspid valve, with its diaphragmatic cusp closer to the apex. The morphological left ventricle has a cylindrical shape and smooth interior surface with small and thin trabeculae mainly at the apex, two papillary muscles (anterior and posterior), and a bicuspid mitral valve with fibrous continuity between it and the aortic valve. The semilunar valves connect the ventricles to the great arteries. They consist of an annulus, cusps, and commissures without tensor apparatus (tendinous cords and papillary muscles). Behind each cusp there is an outpouching of the great artery, known as a sinus of Valsalva, that imparts a tribulbous, or cloverleaf, shape to the arterial root. The junction between the sinus portion of a great artery and its distal tubular portion forms a prominent ridge, the sinotubular junction. From the right and left aortic sinuses, adjacent to the pulmonary artery and proximal to this junction, arise the right and left coronary arteries respectively, while the third sinus is termed the noncoronary sinus.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Function: MR imaging in addition to morphology provides functional parameters such as volumes and function of cardiac chambers throughout the cardiac cycle, ventricular mass and flow through aorta, pulmonary artery, atrioventricular valves and virtually any vessel, permitting non-invasive quantification of flow and volumes, and pulmonary to systemic flow ratio (Qp/Qs), thus yielding a comprehensive assessment of patients with CHD. MRI is superior to ultrasonography in situations with poor acoustic windows such as postoperative or obese patients, conduits calcified or not, always providing objective anatomic and functional data. It is, however, a time-consuming and expensive modality and inferior to ultrasonography in the assessment of valve leaflets and small vegetations. Assessment of right ventricular function, including volume, mass, ejection fraction, hypertrophy, systolic and diastolic function, is of relevance in the diagnosis and follow-up of many clinical situations; primarily in congenital heart disease such as in tetralogy of Fallot, or systemic right ventricle in various conditions, such as congenitally-corrected transposition of the great arteries, transposition of the great arteries following atrial switch operations, and single right ventricle. MRI, using breath-hold multislice-multiecho gradient echo acquisitions, reliably measures RV volume throughout the cardiac cycle, and provides ejection fraction, wall motion and right ventricular mass measurements. Using phasecontrast flow-encoded gradient echo acquisitions’ maximum velocities in the pulmonary and tricuspid valve, pulmonary and tricuspid blood flow can be quantified. MRI is the only modality able to quantify the regurgitant volume, which is of importance in patients with surgically-corrected tetralogy of Fallot. The combination of pulmonary regurgitant and tricuspid flow reflects the diastolic function of the right ventricle, while ejection fraction and end systolic volume estimate the systolic function of the ventricle. Assessment of LV volumetric, velocity, and flow parameters permits evaluation of the functional status of the LV, which is often impaired in conditions affecting primarily the RV. Future perspectives include improved anatomical imaging at 3 T, efforts to adequately visualize valve leaflets, real-time velocity-encoded sequences and the development of single whole-heart scanning with cine and flow sequences encoded in the three directions. Congenital malformations of the GI tract: how to use imaging. V Donoghue, Children’s University Hospital, Temple Street, Dublin/ Ireland. There is a large spectrum of congenital abnormalities that affect the GI tract. The abnormalities that present in the newborn and early infant period are the most symptomatic and some represent true emergencies. In the adolescent period the abnormalities are often discovered incidentally at imaging or during surgical exploration. Some congenital lesions are suspected on routine antenatal ultrasonography and small bowel dilatation, polyhydramnios and
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
hyperechogenic intestinal contents are the most common findings. These findings may only occur late in pregnancy, and are sometimes transient and non-specific. The normal signal characteristics of the bowel contents on MR examination of the fetal GI tract have been reported. However, the extent of the bowel loop dilatation and the changes of the MR signal characteristics have been shown not to be sufficiently characteristic to accurately determine the type and location of bowel obstruction. There is therefore a requirement for postnatal imaging in the vast majority of congenital lesions. As intrinsic bowel obstruction at the various levels is the most common congenital abnormality, plain radiography and contrast examinations remain the most important imaging studies required. The instances where a contrast examination is required will be discussed together with the type of examination and contrast agents used. Where obstruction due to meconium ileus is diagnosed, the role of the paediatric radiologist includes the therapeutic use of high-osmolar contrast medium. Ultrasonography is particularly helpful in evaluating lesions extrinsic to the bowel such as duplication cysts. Congenital tumours of the GI tract are extremely rare and most commonly involve the liver. Cross-sectional MR or CT imaging is often required to help characterize the abnormality and to evaluate its extent. Nuclear medicine imaging may be helpful in the diagnosis of Meckel’s diverticulum but is otherwise not required. In all instances, close collaboration with paediatric surgeons is advisable. Biliary atresia: investigation and management D Pariente and S Franchi-Abella Pediatric Radiology department Hôpital de Bicêtre Hôpitaux Universitaires Paris Sud, Paris/France Despite continuous progress in imaging and knowledge, the diagnosis of biliary atresia remains a challenge and its management will eventually conclude end up with liver transplantation in most cases. Imaging has a role to play in the initial investigation of a cholestatic neonate and in the evolution of the disease. We would like to present our experience as a Reference Centre for this disease in France, and compare it with the current literature. Biliary atresia (BA) is an obliterative cholangiopathy of neonates that affects varying lengths of both extra and intrahepatic bile ducts. Its origin is still unknown, most likely multifactorial, but its onset is most probably antenatal. Its incidence varies around the globe, being rare in Europe (approximately 40 cases per year in France) and much more frequent in the Pacific area. Up to 20% of cases are syndromic forms, associated with other congenital anomalies, the most common being the splenic malformation syndrome. If left untreated, BA has a progressive course to cirrhosis and end-stage liver failure. The treatment of choice is the Kasai portoenterostomy, performed as early as
S423
possible. Liver transplantation is indicated in case of failure and BA accounts for half of the indications for liver transplantation in children. The diagnosis of BA should be considered in every infant presenting with persistent cholestasis (conjugated hyperbilirubinemia), acholic stools, dark urine and hepatomegaly. Differential diagnosis includes all other causes of extrahepatic lesions, in which there is dilatation of bile ducts, and intrahepatic medical causes. These latter are often grouped in the literature under the term of “neonatal hepatitis,” but in fact correspond to a large variety of causes that are infectious, metabolic, ischemic and genetic diseases. Ultrasonography (US), with high-frequency transducer and colour Doppler, remains the best radiologic investigation, and the most specific parameters that have to be carefully searched for are, in our experience, a blind macro or microcyst at the porta hepatis, elements of the splenic malformation syndrome, the presence of a triangular cord sign and an abnormal gallbladder, atretic or with irregular and hyperechoic contour and walls. However, the many pitfalls must be recognised and the diagnosis of BA should not be completely ruled out on US unless there are dilated bile ducts. Other investigative studies that could be helpful before surgery are ERCP and percutaneous cholecystography when the gallbladder is large enough to be punctured. Scintigraphy, MRI and biopsy have limitations, in our experience. After Kasai procedure, complications may occur in the course of the disease, in some cases hastening liver transplantation; they mainly include cholangitis, portal hypertension with gastrointestinal bleeding and ascites, acute liver ischemia, hepatopulmonary syndrome, and rarely hepatocellular carcinoma. US is still the best screening modality, but MDCT with contrast enhancement has replaced angiography for the thorough assessment of hepatic vasculature before palliative surgery or interventional radiology, or in a pretransplantation work-up, particularly in the syndromic forms of BA, in which anatomical anomalies are frequent. MRI is the examination to perform for better characterization of a regenerative nodule, in cases of increased alpha fetoprotein level or for a global evaluation of the bile ducts and bile lakes. In conclusion, although many aspects of BA remain poorly understood, there is evidence that early diagnosis and prompt surgery are needed to provide children with the best chance to survive with their native liver and avoid liver transplantation. Therefore, it is essential for the paediatric radiologist to be aware of all the anatomic variants of BA and the limitations of every study. Inflammatory bowel disease: advances in imaging 2nd Department of Radiology, General University Hospital "ATTIKON" National and Kapodistrian University of Athens, Athens/Greece Introduction: The diagnosis of inflammatory bowel disease (IBD) in children and adolescents is based on the integration of clinical, biological, endoscopic, histological and radiological
S424
data. Histological examination of endoscopic samples remains the gold standard. However, the application of small bowel imaging in the IBD context has evolved in recent years. The goals of imaging are primarily to determine the extent of small bowel involvement, assess complications and define candidates for surgery. Imaging techniques are divided into conventional and cross-sectional. Conventional imaging (barium studies): The small bowel follow through (SBFT) was, and probably remains, the commonest examination of the small bowel, with a sensitivity and specificity of 90% and 96% respectively for the diagnosis of Crohn disease. However ulcers, erosions and polyps are frequently reported as missed. The method still plays a major role in the diagnosis of small bowel obstruction in children, due to the high radiation dose of CT. Recently either the use of the Patency Capsule in children or the low dose Multi-Detector CT (MDCT) has tended to replace this last indication for SBFT. Small bowel enteroclysis has limited use in children, due to both its high radiation dose and the stress and discomfort it causes. Both barium studies are unable to demonstrate extraluminal disease, and have the disadvantage of high radiation dosage. Ultrasonography (US): In children with unknown IBD, US is considered to be the first choice imaging technique and is performed before endoscopy. The absence of bowel wall thickening has a strong negative predictive value. The main advantages of the technique are availability, low cost, lack of radiation and good tolerance by the pediatric patient. Disadvantages to be considered include: the examination is operator-dependent and not reproducible; the difficulty in examining the whole GI tract; US challenges in obese children; and situations of excessive gas distension of the bowel. Bowel wall thickening, location and length of the disease, echogenicity of the bowel wall, the presence or not of normal stratification, ulcers, bowel stiffness, stricture or distention can often be detected with US. Additional information regarding the surrounding fat and the presence or absence of mesenteric nodes can also be obtained. In children, the sensitivity for IBD varies from 74– 93% and the specificity from 78–93%. Bowel wall thickness is one of the most important signs of IBD, with different thickness values used as a threshold for a positive diagnosis. The sensitivity and specificity of US is dependent on the threshold of bowel wall thickness used. For the terminal ileum, the cut off measurement varies between 1.5–3 mm, whereas for the colon it varies between 2–3 mm. Color Doppler US can provide information about the disease activity. The estimation of “vessel density” appears to be an indicator for disease activity whereas measurement of the Resistive Index (RI) of the Superior Mesenteric Artery has been proposed by some authors as an alternative indicator. In the followup, US has a place in monitoring medical treatment and in detecting complications (abscess, fistula or stenosis) in cases with relapse. Computed tomography (CT) has become a widely used technique in adults for small bowel investigation, either by CT enterography or by CT enteroclysis. According to a recent study, the radiation dose from SBFT is on average half the dose
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
of abdomen/pelvis MDCT in pediatric populations with Crohn disease. Therefore for radiation protection reasons, MDCT is avoided by most pediatric radiologists. However it remains an examination of choice for abscess drainage, to obtain accurate images of the exact extension and to select the most appropriate access route for drainage. MDCT is also utilized to detect other, usually acute, complications of the disease such as bowel obstruction, peritonitis, post-operative leaks, perforation and anastomotic complications. Magnetic resonance imaging (MRI) of the small bowel is a recent technique, which is now widely applied in adult populations and to a significant degree in children. It is performed either as MR enterography or as MR enteroclysis. In children, due to its simplicity and the lack of radiation exposure (no requirement to advance a catheter in the jejunum under fluoroscopic guidance), MR enterography is the preferred technique. However, problems such as imaging artifacts due to bowel peristalsis and motion or poor cooperation from the child taking the oral contrast agent can cause an examination to be of poor quality. For these reasons the technique is applied in older children, preferably above the age of 7. The sensitivity and specificity of MR enterography has been reported as 81 % and 100% respectively. According to our protocol, requirements are that the child is given a bowel cleansing preparation 3 days prior to examination followed by a a low residue diet (ample fluids, no milk products) and nil-by-mouth on the day of the examination. Several oral contrast agents can be used for bowel distension, Manitol solution is currently used in our practice. The IV injection of glucagon or buscopan provides further improvement of image quality as bowel motion is suppressed. Examination is performed with the patient in the prone position. The MR sequences should include a combination of fast axial and coronal T1- and T2-weighted sequences to cover the entire gastrointestinal tract. Typically thin slice (3–4 mm) plain and fatsuppressed 2D or 3D T2-weighted true fast imaging with steady-state in the free precession (true FISP) sequences and 3D T1-weighted fat-saturated unenhanced and contrastenhanced gradient-echo sequences (slice thickness 2.5–3 mm) are acquired. The field of view (FOV) and matrix are optimized for each individual patient on the basis of body size. The fatsaturation technique increases contrast resolution by reducing the chemical shift–induced black boundary artifacts along the bowel wall. Injection of IV gadolinium–based contrast agents further increases detection of active inflammation. MR findings to look for include the following: a) Bowel loop appearance (fixed, dilated, strictured, pseudo sacculation appearance), b) Bowel wall (thickness, focal lesions such as ulceration, pseudopolyps and mural abscess, type of signal on T2-W sequences and pattern of enhancement after IV contrast injection) c) Extramural signs (fibrofatty proliferation, “comb sign,” fistula, abscess, mesenteric nodes). Controversies exist concerning the prediction of disease activity due to the lack of a gold standard examination to compare with, the different MR techniques used and the fact that acute and chronic lesions may coexist in the same bowel loop. Diffusion-weighted image (DWI) sequences
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
with high b-values open new horizons in the detection and quantification of bowel wall inflammation and searching for extramural disease. In the adult population, detection of IBD with DWI sequences has a sensitivity of 95% and specificity of 82% (reported to be the highest sensitivity but lowest specificity, compared to previous techniques). According to some authors, the real role of this sequence is in the detection and, more interestingly, the differentiation between fibrosis and persistent inflammation. In conclusion US should be the first choice examination in children with suspected IBD and should be performed before endoscopy, while MR enterography is the technique of choice in children with known IBD, for the investigation of the small bowel and the whole GI tract, as it is a reproducible and well tolerated examination, lacking radiation and providing excellent information about bowel disease. CT should be kept for use in cases in which MRI is contraindicated or in acute-emergency situations, when US is inadequate. SBFT now has a questionable role, as it appears to have been widely replaced by MRI enterography in the pediatric population, despite its lower cost. It should be applied in younger children in whom performing MR enterography is impossible. How to image musculoskeletal infection in children M Raissaki, MD. University of Crete, Heraklion/Greece Classification of pediatric musculoskeletal infection: Musculoskeletal infections in children can be classified as osteomyelitis, septic arthritis and soft tissue infection depending on the anatomic location of the primary focus. In acute Osteomyelitis subacute or chronic. The source of the infection is usually hematogenous, while direct spread from a penetrating wound or adjacent infected structures may also occur. Congenital osteomyelitis may be due to syphilis or viral agents (rubella, cytomegalovirus (CMV), varicella). Acquired infection may be due to bacteria, mycobacteria (tuberculosis), on rare occasions to fungi and may also be idiopathic in chronic recurrent multifocal osteomyelitis. Staphylococcus aureus, Streptococcus, Salmonella, Meningococcus, Hemophilus Influenzae and Enterobacter are the main pathogens. Role of Imaging: In children, clinical presentation may be typical. Localized hyperemia, tenderness, pain, swelling and limitation of movement, often coupled with positive radiographs, abnormal laboratory and/or ultrasound examinations may suffice to establish diagnosis and initialize treatment. However, assessment of these children may be difficult, especially when they present systemically unwell; with a nonspecific limp, persistent pain or in cases when the disease has been altered by antibiotic administration. It is in these children that urgent imaging should establish the diagnosis and avoid delay in treatment and subsequent complications. In cases of marked tenderness and diffuse soft-tissue swelling, accurate mapping of infection is important for the surgeon
S425
who will invariably administer antibiotics but does not wish to open a joint with the potential of introducing infection if the focus is in the metaphysis, or to drill the bone unnecessarily if the infection is in fact in the joint. Therefore, imaging is often able to confirm the suspected diagnosis of musculoskeletal infection, to evaluate the site and extent of disease and to determine the most appropriate mode of therapy. Imaging findings in osteomyelitis and septic arthritis: The rational use of imaging in children with suspected osteomyelitis should be based on an understanding of the strengths and limitations of the different techniques. Skeletal scintigraphy provides evidence of infection within 14–72 h while plain radiographs will demonstrate no change for 7–14 days. In acute osteomyelitis all three phases of bone scans using 99-m technetium (99Tcm) methylene diphosphonate (MDP) show increased uptake with the abnormal “hot” area being well defined and matched. The combination of osteomyelitis and cellulitis produces increased bone and soft-tissue uptake in later phases. The normal growth plate has a linear appearance on scintigraphy with a sharply demarcated transition to the shaft uptake. In metaphyseal infection, loss of this sharp demarcation is accompanied by a flare of increased activity in the shaft. In septic arthritis there is increased uptake around the joint in both early and later phases and no focal osseous lesion on the static images. A fourth phase scan, 24 h after injection, may prove useful as osteomyelitis usually provokes further increased activity. Radiographs are important for the exclusion of trauma or tumor. Features of osteomyelitis on plain film radiography comprise osteopenia in the early course of the disease, softtissue swelling and fat plane loss and/or displacement, followed by development of an ill-defined area of bone destruction. A permeative or sclerotic pattern is a characteristic of subacute or chronic osteomyelitis, where pus penetrates the cortex via a cloaca and may elevate the periosteum or extend beneath it, causing vascular deprivation and dense periosteal reaction, known as involucrum. Sequestra are seen as devitalized bone within osteopenic areas. A Brodie’s abscess is seen as an elongated radiolucent lesion in the long bones, measuring 1–4 cm in length with surrounding sclerosis, occasionally simulating an osteoid osteoma. Plain films have a limited value for the diagnosis of joint effusion in septic arthritis; however they may demonstrate fat plane displacement around joints, epiphyseal lucency due to local hyperemia and dislocated or subluxed joints. High-resolution ultrasound has been increasingly utilized for the demonstration of periosteal reaction and subperiosteal abscess formation in long bones before radiographically detectable changes, of joint effusion with or without synovial hyperemia in suspected septic arthritis and for guidance of drainage. CT accurately accesses features of osteomyelitis such as sequestrum, involucrum, cloaca and abscess. Increased bone marrow density is due to purulent material replacing normal fatty marrow. CT is not performed routinely in pediatric
S426
osteomyelitis, due to increased radiation burden and is reserved for the evaluation of the subacute and chronic stages of infection, as well as for particular sites of osteomyelitis including sterno-clavicular junction and hidden areas in the pelvis or shoulder. MRI offers excellent contrast resolution and delineation of morphological changes in bone marrow, joints and soft tissue and is especially useful for children with pelvic or vertebral osteomyelitis. Its sensitivity in diagnosing early osteomyelitis is equal to scintigraphy and is considered the modality of choice in many centers. Disadvantages include increased scanning time, the need for sedation, and increased cost. In practice, MRI could be reserved for difficult clinical diagnoses and for optimal preoperative planning. Imaging findings of acute osteomyelitis include areas of low signal intensity on T1-weighted sequences turning bright on T2-weighted sequences representing edema, inflammation and/or purulent material, the latter not enhancing following contrast material administration intravenously. Subperiosteal fluid collections and abscesses may appear as non-enhancing or rim-enhancing areas respectively, while cellulitis as ill-defined areas of enhancing strands, exhibiting low signal intensity on T1-weighted sequences turning bright on T2-weighted sequences. In addition to bone abnormalities, myositis or pyomyositis contiguous to the site of osteomyelitis is readily detected. Diffusion imaging may prove useful in outlining areas of soft-tissue abscesses. Joint effusion
Table 1
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
with synovial enhancement is a non-specific sign of arthritis and the diagnosis of septic arthritis can only be confidently made coupled with bone marrow changes and the relevant clinical/laboratory findings. Differential diagnosis of osteomyelitis comprises septic arthritis, cellulitis, acute rheumatic fever, and indolent fractures. Malignant conditions that may mimic osteomyelitis both clinically and radiologically include Langerhans cell histiocytosis, Ewing sarcoma, leukemia, osteosarcoma and metastatic neuroblastoma. Imaging findings should always be interpreted considering all pertinent clinical and laboratory data. Pathways for imaging suspected musculoskeletal infection: When osteomyelitis is suspected (Table 1), an AP and lateral radiograph of the affected region is performed and if positive, prompt treatment is initiated, while scintigraphy and MRI may be needed for management planning. If radiographs are negative, and the area in question is the long bones, a positive ultrasound prompts initiation of treatment while a negative ultrasound indicates further investigation with scintigraphy and/or MRI. In cases of spinal or pelvic involvement in neonates with negative scintigraphy and unresponsive to treatment after 48h, MRI is indicated. CT is reserved for preoperative planning in cases of chronic osteomyelitis and for differentiating cortical lesions. Ultrasonography is being increasingly utilized for the diagnosis and monitoring of musculoskeletal infection in children.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
When septic arthritis is suspected (Table 2), radiographs exclude osteomyelitis and other diagnoses. A positive radiograph and a negative ultrasound for effusion suggest osteomyelitis. The pres-
S427
ence of effusion under the appropriate clinical and laboratory context indicate aspiration or surgical debridement while followup is done with X-rays or MRI, depending on the clinical course.
Table 2
Arthritis in children: how to start and when to finish imaging K Rosendahl Department of Pediatric Radiology, Haukeland University Hospital, Bergen/Norway Arthritis, i.e. inflammation of a joint, usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances or other causes, occurs in various forms. In children, reactive arthritis (secondary to viral infections, f.i.), bacterial arthritis and juvenile idiopathic arthritis (JIA) are most common. JIA is a heterogeneous condition encompassing all forms of chronic arthritis of unknown origin, >6 weeks’ duration and with onset before 16 years of age. It is characterized by chronic synovial inflammation, with potential risk of developing progressive joint destruction and serious functional disability. The reported incidence varies from 0.6 to one in 1,000 children, and JIA thus represents an important cause of acquired disability in the paediatric age group. During the last decade, new, potent therapeutic agents have become available to children with JIA, underscoring the need for accurate monitoring of therapeutic response on both disease activity and structural damage to the joint, the latter being considered the gold standard in treatment efficacy studies.
Thus, the role of the (paediatric) radiologist is first to aid in making a correct diagnosis, and in cases of JIA, to monitor disease activity / treatment effect and occasionally to provide markers for chronic change for use in clinical trials. Diagnosis: In children presenting with one “swollen” joint, initial imaging should include a radiograph to exclude bone involvement (osteomyelitis > 10–12 days’ duration? tumour? other?) and an ultrasound scan to look for joint effusion and/ or synovial hypertrophy. Findings should be interpreted in light of symptoms, clinical and laboratory findings, and if consistent with reactive arthritis, no further imaging is needed as part of the initial workup. However, if bacterial arthritis cannot be excluded, an ultrasound-guided aspiration should be performed, preferably after discussion with an orthopaedic surgeon. On the other hand, if the initial examinations are normal, a limited MRI examination (STIR and T1-w sequences) might be considered to exclude osteomyelitis. If the initial examinations are suggestive of JIA, an additional MRI would include pre- and post Gd sequences to assess disease activity and the full disease extension. A stepwise approach as outlined here, rather than going directly for an MRI, has proved efficient in our practice, as a number of problems can be solved based on the initial radiograph and ultrasound scan.
S428
Juvenile idiopathic arthritis Disease activity: In children with JIA, monitoring disease activity is important to make informed choices for further treatment. But stop for a second; which is the best marker for disease activity— the amount of joint effusion, the degree of synovial hypervascularity or a combination of the two? The fact is that we really don’t know. If the amount of joint effusion is an important marker, an ultrasound would do for most joints. However, if the degree of synovial hypervascularity is a more important marker, a post contrast magnetic resonance imaging (MRI) scan would be more appropriate—although its accuracy and clinical validity have been questioned. Chronic change: Joint damage evaluation in JIA is traditionally performed by radiographic scoring methods assessing joint space narrowing and erosions, but are however quite insensitive, in part due to the growing skeleton. Wrist disease has been associated with a more severe course of arthritis and a poorer functional outcome, and is the only joint in which suitable radiographic measures of disease progression have been reported. Much effort has been spent recently on validating existing scoring systems or devising new ones, of which the Adapted Version of the Sharp/van der Heijde Score has gained most acceptance. The value of MRI, as an advanced method to evaluate both disease activity and disease damage in adults with rheumatoid arthritis, is under active investigation by a research consortium called Outcome Measures in Rheumatology Clinical Trials (OMERACT). However, the results drawn from OMERACT studies are not directly applicable to children, because adult rheumatoid arthritis is different from JIA and the growing skeleton of children requires a different approach. Indeed, in children, ossification is incomplete and joint space width varies with age. Thus, despite technical progress in the imaging of cartilage (development of ultra-short TE sequences, driven equilibrium, Fourier transform [DEFT] imaging, and steady-state free precession [SSFP] sequences for the detection of subtle surface irregularities and tiny focal defects of the articular cartilage, diffusion-weighted techniques to assess degradation of collagen fibres, delayed gadolinium-enhanced cartilage imaging [dGEMRIC] to detect changes in cartilage proteoglycan content and T2 relaxation time mapping to detect integrity of collagen in the extracellular matrix), the potential helpfulness of these techniques has yet to be seen. The same goes for sophisticated analysis of 3-D image data to provide articular surface contour mapping and 3-D rendering as well as volumetric quantification of articular cartilage to evaluate the progression and response to treatment in patients with chronic arthritis. Progress in the assessment of synovitis, including dynamic contrast-enhanced MRI to assess the degree of inflammation, is also flawed, with methodological difficulties, although voxelby-voxel analysis of signal intensity versus time curves has proved more accurate than the region-of-interest (ROI) approach in adults with RA. Another technique for assessment of inflammation using a semiautomated segmentation program technique of dynamic contrast-enhanced MRI (DCE-MRI) has also been described. Thus, although MRI is a potential powerful imaging tools to assess joint inflammation and the progression of joint damage, standardized, validated, and feasible assessment systems are lacking.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Conclusion: For a correct diagnosis, a stepwise approach as that outlined above may be helpful. In JIA, US and MRI may aid the assessment of disease activity and extension, although, unlike for rheumatoid arthritis, there is no widely used MR wrist scoring system for JIA. Benign bone lesions: how far should we go with imaging? K Oudjhane MD MSc Department of Pediatric Radiology, Hospital for Sick Children University of Toronto, Toronto/Canada Diagnosis of bone neoplasms in children is a challenge and a source of apprehension, as bone lesions are commonly seen in pediatric patients. Radiography frequently gives rise to the initial encounter with a bone abnormality, but more and more bone lesions are detected on CT and MR examinations. The presence of patient symptoms, one of which is pain, warrants the careful collection of imaging information as specific radiographic features may influence the clinical decision: biopsy versus clinical monitoring. An appropriate clinical approach from a radiologist’s point of view entails 3 steps: the clinical step, involving the gathering of important clinical data; a second stage of meticulous radiographic analysis of the abnormality and consideration of differential diagnosis from a few mimickers; and the third step, based on an evaluation of the aggressiveness of the bone lesion, which cross-sectional imaging may characterize further, with bone biopsy remaining an eventuality (Table 1). At a clinical level, specific bone tumors are prevalent in specific age groups. In general, bone lesions have equal sex predilection; however giant cell tumor, enchondroma, have a female / male ratio of 1.5, fibrous dysplasia of 1.2. The presence of symptoms (mainly pain) in addition to the radiographic abnormality, suffices to warrant further imaging. A possible complication is a pathologic fracture. If pain is experienced at night, and is unresponsive to NSAID, osteoid osteoma is likely. A benign-looking enchondroma may need biopsy if pain forms part of the clinical picture, in order to exclude chondrosarcoma. Systemic signs such as cafe au lait spots associated with a bone tumor may lead to the diagnosis of fibrous dysplasia and McCune-Albright syndrome. A family history may reveal possible NF1, or multiple hereditary exostosis. The radiographic analysis first takes into account the location of the lesion, both in the skeleton and within a specific bone. The radiographic elements to study include the size of the lesion, its matrix nature (osteoid, chondroid, fibrous or other), the appearance of its margins, the status of the cortical bone, the presence of periosteal reaction and the association of a soft-tissue mass. The rate of growth / degree of aggressiveness is best depicted at its margins and in the morphology of the osteolysis. Lodwick classification is still useful for forming a global assessment: geographic pattern type I (A/B/C), moth-eaten type II, permeative type III. Depending on the lesion’s site, considering potential mimickers is a necessary step to exclude possible normal anatomic variants such as a venous channel foramen or a dorsal defect of the patella. The herniation pit of the femoral neck should not be taken as osteoid osteoma. An asymmetric ischio-pubic synchondrosis may mimic an expansile bone tumor. Pseudotumors may be present as physiologic lucencies in the bone (greater tuberosity of humerus head, proximal end of ulna, neck-body junction of the calcaneum).
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Traumatic injuries of stress fractures may be discussed, along with possible osteoid osteoma. Post traumatic pseudotumors of the bone may include cortical lucencies and osteochondral lesions of the elbow (capitellum, trochlea). The issue becomes more complex, as simple bone cysts that have undergone a pathologic fracture are no longer so straightforward, imaging-wise. An infectious process is a great simulator of bone tumors, be it as an acute, sub acute or chronic form of osteomyelitis. Chronic recurrent multifocal osteomyelitis (CRMO) should be considered when the preferred location is at the metaphyses of long bones and the medial clavicle. A miscellaneous group of differential diagnoses include osteonecrosis, intra-osseous ganglia, regional osteoporosis, bone stigmata of secondary hyperparathyroidism, hemophiliac pseudotumor and melorheostosis. Appreciation of the degree of aggressiveness of a bone lesion will ultimately guide the pattern of further imaging and the follow-up and treatment options. The bone lesion may be considered at a latent benign stage (stage 1 of Enneking classification), active benign (stage 2) or aggressive benign stage (stage 3). Stage 1 lesions need no additional workup or treatment; regular follow-up is required, however. An active / aggressive bone lesion may only be best depicted on MRI. Hence, after conventional radiography, MRI is considered the next best modality because of its higher sensitivity in detecting marrow-based lesions, identifying other diagnoses such as radiographically occult fracture and osteonecrosis, and defining the extent of bone marrow disorders and possible soft-tissue involvement. MRI may suggest a histologic diagnosis as in intra-osseous lipoma or aneuysmal bone cyst. CT is preferable to MRI for assessing the matrix pattern of the bone lesion and depicting cortex-based abnormalities as in osteoid osteoma with more clarity. Bone scintigraphy is useful in the case of multifocal disease (polyostotic fibrous dysplasia, for example). Whole-body MR is an elegant method of assessing the bone marrow of the entire body without ionizing radiation. A Local / regional cross-sectional imaging is preferable before any biopsy. No biopsy is advised when clear radiographic diagnosis is made of a non-ossifying fibroma or enchondroma. Benign conditions such as infection can have an aggressive pattern. Percutaneous biopsy is usually image-guided. The indications of cross-sectional imaging are variable depending on the matrix nature of the lesion. Boneforming tumor may require CT assessment, as is the the case for osteoma with frontal sinus obstruction and an osteoid osteoma (often missed on MR). MRI will be of clinical help for a local complication of spinal osteoblastoma. MRI is useful to assess cartilage-forming bone tumors such as an epiphyseal chondroblastoma (diagnosis and local extent), an enchondroma (differential with chondrosarcoma), chondromyxoid fibroma, and an osteochondroma (complication, cartilage cap thickness threshhold). MRI is not required in non-ossifying fibroma or simple fibrous dysplasia. CT is best to define the matrix of fibrous dysplasia. MRI appearances are characteristic in lipoma, cystic lesions (ABC with fluid /fluid levels), giant cell tumor (pattern of dynamic contrast enhancement), Langerhans cell histiocytosis (T1 signal higher than muscle signal, T2 signal abnormality and degree of enhancement and soft-tissue involvement in the acute phase) and osteofibrous dysplasia of the tibia. On MR, soft tissue disease in a bone process is a concern, reflecting the extension of an infection, Langerhans disease or a malignant disorder.
S429
In summary, a diagnostic strategy for a bone lesion is needed to ensure effective management and follow-up. The frequency of unrecognized infections and incidental trauma must be borne in mind. The patient’s age, the location of the abnormality and the various imaging features are key elements in zooming in on the differential diagnosis. After initial radiographic evaluation, additional imaging may be needed. Advanced imaging is critical in differentiating aggressive lesions and usually helps in guiding biopsy. Table 1: Benign bone lesions: step-by-step imaging approach
A- Clinical Evaluation: – –
Symptomatic or not Pathologic fracture
B- Radiographic Analysis: Benign vs malignant (slow growing vs aggressive)
– – – – – – –
Location of the lesion Characteristics: size, margins, matrix, cortex, periosteal reaction Lodwick classification Differential Diagnosis: The mimickers Normal variants Traumatic injuries Infection Miscellaneous
C- Advanced Cross-Sectional Imaging: – – –
The modalities : MRI, CT, bone scintigraphy Enneking classification To biopsy or not
D- Follow-up / Monitoring of therapy
Paediatric neuroradiology: past, present, and future F Brunelle, M Zylbovicius, D Grevent, N Boddaert Imaging department Necker-Enfants-Malades Hospital, Paris/France A child is not merely a small adult. This aphorism cited by John Caffey and Derek Harwood Nash speaks volumes. What were they trying to say? The aphorism can be understood in many ways: pathologies affecting children differ from those of adults. The child is a developing person, and pathologies have a deep impact on his or her development, especially that of the brain. This concept of neoteny is an important one. Indeed, the small man is basically immature when compared to other mammals that walk and run soon after delivery, such as horses. This fragility has been held up as one of the reasons why humans have developed their brain and skills. The brain reaches maturity at about 7 years of age. During this period of maturity, the child acquires most of the knowledge to be used for the rest of his or her life.
S430
The process of brain maturation has been well documented using MRI, and the pattern of “myelinisation” is now widely known. Any diseases involving the brain will affect this process of maturation. Trauma, hydrocephalus, brain tumour and vascular anomalies all affect brain development.. Thus in children, it is mandatory to diagnose and treat them early. The Past Now that I have reached the status as a man of the past, let me share my memories of being a medical student with Jean Aicardi. The first tool we had to diagnose hydrocephalus was “transillumination.” A lamp was applied to the head of the child and the light would diffuse into the dilated ventricle, giving a “venetian lantern” effect. Ultrasound, like light, uses the same basic physical principles of diffusion, refraction and reflection. Air was the only injectable media we had to elucidate the cause of obstruction within the ventricular system. It was introduced via a lumbar puncture or directly through a fontanel, sometimes even through the sub occipital approach! Third ventricle ventriculostomy was performed on a special table under general anaesthesia in the radiology department. The ventricles were punctured with a trocar and a drop of lipiodol or contrast medium was injected to visualize the floor of the third ventricle.The basilar artery was very close…as we all know! One of the big revolutions was the invention of iso osmolar contrast media, the first to replace air in the visualisation of CSF spaces. In the 1980s, several papers were published and a book on CT metrizamide in children was brought out by the Toronto school. New diagnosis were discovered, notably “thick filum” syndrome, using metrizamide, was first injected into the subarachnoid spaces and then the CT performed; hydrocephalus and external hydrocephalus were studied using this method. In parallel, transfontanellar ultrasound was developed, partially by radiologists, along with neonatologists. This was one of the earliest examples of sharing an imaging technique with nonradiologists. Intracranial haemorrhages of the premature were diagnosed and classified. Prognosis was established accordingly. Thus one of the very first fields in which imaging not only made a “diagnosis” but tried to establish a prognosis, came into being. Antenatal imaging started slowly with ultrasound. Corpus callosum agenesis and mild ventricular dilatation were “seen” during antenatal care. Then MRI appeared. Today; Paediatric neuroradiology today is MRI. MRI development changed our perception of neuro-images. We discovered a “direct” vision of the brain anatomy. Before MRI, we were seeing the anatomy indirectly, even with the CT scanner. A large number of papers have gone on to describe paediatric brain anatomy. MRI in medical school is used to teach anatomy. Neuroradiologists were accustomed to “reading” CT scans of the brain on axial planes. Books were published to teach “axial” anatomy. The
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
3D nature of MRI images allowed oblique, curvilinear and surface 3D reconstructions. Sonographists learned a lot from MR images, mainly from antenatal MR images of the brain. Anomalies of the posterior fossa began to be diagnosed by antenatal MRI, rapidly followed by ultrasounds. Joint meetings involving mixing obstetricians, radiologists and neonatologists flourished. Because of the natural anxiety of parents when a malformation was diagnosed, imagers started trying to establish a prognosis. A diagnosis alone was no longer sufficient. To answer these new types of questions, we had to change our way of thinking:
& & &
Build up “database” cohorts of patients Follow them up over a long period of time, because in paediatrics only long-term follow-up is significant. Collaborate with obstetricians, paediatricians, neurosurgeons
The term “imaging” progressively replaced “radiology.” Development of antenatal imaging also changed our understanding of the malformations we were used to seeing during postnatal care. Cerebellar clefts are now known to be secondary to antenatal cerebellar haemorrhage. The term cerebelloschisis was used to describe malformations similar to schizencephaly. Patterns of the white matter maturation were established; these patterns are now well known to all paediatric neuroradiologists and paediatric neurologists. One has to bear in mind that 25 years ago, they did not even exist. It was purely research at that time. The outbreak of enormous chapters on “leucodystrophies” and metabolic diseases of the brain began. Understanding of hydrocephalus progressed rapidly with sequences that show not only the CSF spaces, but also their dynamics. MRI was the technique of choice to perform a third ventricular ventriculostomy in the event of aqueduct stenosis. The basilar artery was seen better than with pneumoencephalography! MRI images served as an aid for neurosurgeons. Images were loaded in computers that piloted robots holding an operating microscope. “MRI aided neurosurgery” was born. Functional MRI using the “BOLD (blood oxygenation level dependent contrast) effect” allowed us to map the functional region of the brain prior to surgery with precision. Motor, visual and language areas were localized prior to surgery in cases of brain tumours in close proximity. 3D reconstruction enabled us to measure and monitor volumes of CSF and their changes in hydrocephalus. There was a major shift towards 3D instead of 2D, to functional images instead of anatomy. An everyday example in our department would be an emergency case of a child with headaches and vomiting. A CT scan performed in a county hospital reveals a brain tumour. An emergency MRI is performed in sterile conditions with gadolinium injection. A perfusion study is conducted for research as well as spectroscopy. The MRI data are sent to the operating room computer, to aid the neurosurgeon. A new MRI is performed the following day, “day one,” to check the completeness of the resection. Statistical analysis of the brain morphology has changed our diagnostic power. Visual inspection of the brain is difficult, as
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
many inter-individual variations exist. Pediatric neuroradiologists always dreamt of being able to diagnose small anomalies of brain structure, particularly in patients with epilepsy or mental retardation. MRI is now the first examination of choice for epilepsy and mental retardation. CT is only performed to check for the presence of calcification. Voxel-based morphometry (VBM) now allows us to statistically compare, voxel by voxel, any individual brain with normals ones. A large number of papers were published on structural anomalies of white and grey matter in patients with genetic syndromes and autism. Such results could not have been reached by simple visual analysis of MRI. Spectroscopy, due to its ability to measure several chemicals in the brain, led to a giant step being taken in the diagnosis of metabolic disease such as mitochodriopathies, creatine deficiency and others. MRI is now used as a “screening” tool for these. Brain iron measurement is also a very powerful tool in classifying iron deposition diseases. Tomorrow Several techniques are currently used for research; tomorrow, they will be routine. Some techniques will probably serve as research tools for a longer period, as they are non-automatic, and therefore timeconsuming. A routine technique should be simple to use and rapid with results, to obtain and display for communication purposes. This is true for tractography, which is now available as a technique, but remains cumbersome. Tractography is useful in some cases of brain tumours, for visualizing the relationships between the tumour and the pyramidal tract. It is still, however, difficult to use for optic nerve gliomas, where it would be useful to separate the normal optic nerve fibres from the tumour. This technique demonstrates abnormal organization of the white matter in several brain malformations, corpus callosum agenesis, Joubert syndrome etc. Arterial spin labelling ASL is a relatively new technique in paediatric neuroradiology. It uses “tagging” of spins in the carotid arteries. These “tagged” spins are then sampled in the brain and a quantitative measurement of brain perfusion is obtained. The real revolution is twofold: this technique does not require any injection of tracers, contrast medium or radio nuclides. To keep things short, as a whole chapter could be and surely will be written on this technique, it replaces SPECT and PET images. It is now used by our team for epilepsy. It shows a per critic hyperperfusion and an inter critic hypo perfusion. It allows the precise localization of epileptic foci. This technique will merely replace all the techniques necessitating contrast injection: brain tumour perfusion, AVMs, head and neck angiomas, perfusion studies in brain ischemia (sickle cell disease, moyamoya diseases, stroke etc.…) and more. We discover a new application almost every day. Imaging genetics This is a brand new concept in neuroradiology. The goal is to try to correlate and fuse three medical approaches. The first is clinical, the second is genetics and the third is neuroimaging.
S431
To be clear, the initial approach was to correlate clinical findings with brain anatomy. This approach was successful, but relatively rough. An example is Joubert syndrome, in which it was discovered that the brain findings were heterogeneous in a relatively well identified syndrome. Then descriptions emerged that the genetics of Joubert syndromes were heterogeneous as well. It became clear that this approach was not efficient enough. Comparisons were made with groups of patients that either displayed the same anatomy, or the same clinical findings, or the same genetic anomaly. The concept of “endophenotype” to describe a homogeneous group of brain anatomy anomalies was born. This approach transpired to be very powerful in the analysis of genetic syndromes, mitochondriopathies and other malformations. We now know that patients with mental retardation and a thick corpus callosum should be tested for genetic anomalies with CGH array (x % of anomalies found). Integrated imaging or “whole imaging” The future of imaging in neuropaediatrics could be called global imaging. We will soon observe a fusion of all modalities to demonstrate not only anatomy but networks, function, bio dynamics, electroencephalography and MEG. To date, it is still difficult to merge all the modalities. Brain perfusion with ASL while EEG is recorded is just getting off the ground in our institution. Resting state studies will have an important impact on the understanding of mental retardation and autism, for example. At present, we can merge antenatal MRI and ultrasounds. We can thus see the vessels on Doppler in real time, along with a precise anatomy. Cardiac gating of the foetus will allow us to understand the CSF dynamics of arachnoids cysts, amongst others. We anticipate that it will become possible to image neurotransmittors, synaptogenesis, genes and protein expression in the brain. Dynamic networking will follow. An entire area of research has opened. The exploration of the brain is the new “terra incognita” to discover. This will be an endless quest, I think. Conclusion: In 30 years of professional life, neuroradiology has evolved dramatically. The novelties that appear on an almost yearly basis (CT, US, MRI) incite us to pursue our daily work with enthusiasm and passion. The paediatric environment is very special, and an emotional one; we are treating the future of the world. We are not only dealing with a patient, but with a whole family. This experience is incredibly rich, as it provides insight into the deepest foundations of humanity. As it is said: “to save one child is to save the world” Urinary tract infection revisited F E Avni, M Cassart, M Hall, K Ismaili ULB—Erasme Hospital Departments of Imaging and pediatric nephrology Brussels/Belgium Urinary tract infection (UTI) is one of the commonest bacterial diseases in children, with 5% of girls and 2% of boys affected.
S432
However, a lack of agreement continues to exist with respect to the role of imaging following a first febrile UTI (or suspicion of). Guidelines vary greatly in the literature. For instance, in children younger than 2 years old, the focus is directed towards detection of vesico-ureteric reflux (VUR) and therefore on the necessity to perform voiding cysto-urethrography (VCU). For some other authors, VCU should only be performed if ultrasound (US) or radionuclide renal scan (RRS) are abnormal. The reasons for the lack of consensus are probably related to:
– – –
The poor correlation between the severity of UTI and the presence and degree of VUR The debated role of VUR in the development of renal scars The debated yield of any imaging test in improving the longterm prognosis
The present course is intended to summarize current knowledge and propose guidelines for the evaluation of UTI. In the acute phase, the role of imaging is primarily intended to demonstrate parenchymal damage and the presence of VUR. Once the treatment is initiated, imaging should provide information whenever the clinical progression is unfavorable. In the long term, imaging should identify if renal scars have developed. It should be noted that for each imaging technique, there are arguments for and against their use. 1. Should ultrasound be performed? Most authors agree that a sonographic examination should be performed as the first imaging technique in the case of febrile UTI. High resolution transducers should be used with settings suited to the child’s size. The technique allows re-evaluation and detailed analysis of prenatally detected anomalies or detection of unrecognized congenital malformations. It may show lithiasis and pyonephrosis. These findings would prompt supplementary examinations (and adapted treatment). Interestingly, the demonstration of ureteral dilatation is apparently the best predictor of the presence of VUR. Clearly, ultrasound is able to demonstrate other abnormalities potentially associated with UTI such as signs of dysplasia, parenchymal abnormalities, abnormal color Doppler and evidence of previous infection. The significance of a normal sonographic examination is another controversial area. For many authors, a normal ultrasound examination does not exclude parenchymal damage and/or VUR whereas others (in recent articles) stress that in cases of normal ultrasound, the risk of significant disease is minimal and therefore a complementary examination is unnecessary. Ultrasound should also be performed whenever the response to antibiotic therapy is unsatisfactory and or a complication is suspected. Again, the technique is able to demonstrate renal abscesses but a normal ultrasound is not sufficient to exclude disease (see below). Finally, the role of ultrasound for the detection of late complications of UTI such as renal scars is also debated, with most authors concluding that the technique lacks sensitivity and specifity for this purpose.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
2. Should a systematic VCU be performed? Most authors agree that a systematic VCU should be avoided, and the indications should be restricted to patients with risk factors (Table 1). Furthermore, the age of the patient should guide whether to perform a VCU. One would be keener to perform VCU under the age of 6 months (or even 2 years) whereas in school age girls with suspicion of UTI, the priority would be to assess voiding dysfunction. VCU (and RRS) must be performed in cases of recurrent UTI. The choice of technique depends on local expertise. Cystosonography should be the first choice due to its lack of radiation; yet the use of sonographic contrast is not permitted universally in children and is relatively expensive. For the time being, VCU remains the gold standard in spite of its higher radiating dose, potential for acquired infection and pain. Therefore, one should optimize the technique reducing irradiation and pain as much as possible. 3. Should a systematic radionuclide renal scan be performed? Although RRS is the presently accepted gold standard for detecting acute and late parenchymal lesions, there is no consensus on its use or on the best time to perform this examination. In this debate, some authors favor a systematic use of DMSA scan in the acute phase of febrile UTI. Yet, in many places, it is not possible to perform this examination during nights or weekends. Furthermore, the technique involves irradiation and therefore, many authors prefer a more restricted approach, limiting the use of RRS to patients at risk, namely those with abnormal ultrasound or with high grades of VUR. RRS is presently considered as the gold standard for the detection of renal scars and should be performed 6 months after the initial episode of UTI to verify their presence. 4. What is the role of CT and MR imaging? In children with UTI, CT should not be used as part of the initial armament of examination. The technique can be helpful in cases of unfavorable clinical progression and high suspicion of renal abscess not previously demonstrated by ultrasound, particularly if MR imaging is not available. MR imaging could become the gold standard examination for the assessment of both uncomplicated and complicated UTI, utilising the various sequences, with and without gadolinium injection. The technique allows for a detailed evaluation of both the renal parenchyma and cavities; whenever necessary functional information can be provided as a result of Gd injection. More recently, diffusionweighted sequences have proved useful for the detection of renal abscesses. MR imaging can detect renal scars and other long-term complications of UTI. In conclusion: Controversies, especially in the choice of imaging techniques for patients with febrile UTI, remain unresolved. Based on the present knowledge, it seems reasonable to base our imaging evaluation on ultrasound first. A completely normal sonographic examination (and no risk factors) would render further investigations unnecessary. An abnormal sonographic examination (or presence of risk factors) should lead to VCU. In case of high grades reflux or unfavorable prognosis, RRS or MR imaging should be performed.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Table 1 Risk factors for vesico-ureteric reflux indicating voiding cysto urethrogram
– – –
Abnormal prenatal ultrasound Age<6 months Abnormal ultrasound
& & & & & & & – – – – –
Hydronephrosis Ureteral dilatation Hypoplasia/dysplasia Duplication Bladder abnormalities Renal agenesis Lithiasis Siblings with VUR Septicemia Chronic renal failure Bacteria other than E Coli Abnormal DMSA scan
MR urography in children: how to do it and when to use it A Kanavaki1, S Hanquinet1, P-H Vivier2 1 Department of Pediatric Radiology, Children's University Hospital of Geneva, Geneva/Switzerland 2 Department of Pediatric Radiology, University Hospital of Rouen, Rouen/France Current imaging methods of the urinary tract include US, contrastenhanced voiding US, VCUG, CT and MRI. MR urography (MRU) combines anatomic and functional imaging in a single non-irradiating study. Technique Patient preparation: For optimal image quality, the patient’s motion has to be minimized. Sedation is performed according to the local institution’s protocol (usually performed for children under 6 years old). The patient is installed in a supine position. A bladder catheter is usually unnecessary. The relationship between gadolinium (Gd) concentration and signal intensity is nonlinear. This relationship is relatively linear at low concentration, whereas T2* predominately effects at higher concentration. As a result, hydration and furosemide are important for keeping the Gd concentration low in its linear regimen. Children can be hydrated per os, by administrating 250–300 ml of water (or juice) 30 min before the MR study. Sedated children are hydrated intravenously, in order to correct the NPO (nil per os) deficit. The following hydration protocol has been suggested by Grattan-Smith et al. 2008: 4 cm3/ kg/h for the first 10 kg of the patient’s weight, 2 cm3/ kg/h for the next 10 kg of the patient’s weight, 1 cm3/ kg/h for each kg above 20 kg patient’s weight. Furosemide is important not only for diminishing the T2* effect of high Gd concentration, but also for distending the urinary tract. The dose of furosemide ranges between 1 mg/kg in infants and 0.5 mg/kg in older children, to a maximum dose of 20 mg. The timing of furosemide’s injection varies between the different dynamic protocols (F-20, F-15, F0). Gadolinium, if needed, is injected with a dose of 0.05 mmol/kg. Due to the immaturity of the renal system, contrast injection should
S433
be avoided in children less than 2 months old. The risk of nephrogenic systemic sclerosis (NSF) means that the need for MRU should always be reconsidered, as unenhanced MR examinations can sometimes prove sufficient. Patients at risk of developing NSF (i.e. renal disease, liver transplants) must be identified. In patients with renal disease or impaired renal function, GFR must be measured: when GFR is <30 ml/min, the need for injection must be discussed at an individual level. In all cases with an increased risk of NSF, only macrocyclic compounds of Gd should be injected. Image acquisition: Surface phased-array body coils are used. Pre-contrast imaging includes 2D axial and coronal TSE T2-weighted sequences from kidneys to bladder. Next, a heavily T2 weighted (2D or 3D) acquisition through the whole urinary tract is performed. This sequence provides a urogram without contrast injection, with the possibility of maximum-intensity projections (MIP) and volume-rendered reconstructions of the urinary tract. After injection of Gd, a 3D GRE T1-weighted dynamic sequence is performed, in a coronal plane, including the aorta and the kidneys. The images are acquired continuously for the first 5 min and then every 15–30 s for the following 10–15 min. When MR angiography (MRA) is needed, Gd can be re-injected after the dynamic acquisition (e.g. search for a polar artery). Finally, a 3D T1 sequence, with high spatial resolution, is performed, in order to examine renal parenchyma as well as the enhanced urinary tract. Two software programmes designed specifically for functional analysis can be downloaded for free: CHOPfMRU (www.chop-fmru.com) and Image J with its MR Urography plugin (http://rsb.info.nih.gov/ij/) Indications for performing MRU: The main indications for MRU are congenital genitourinary anomalies, hydronephrosis, renal infection (acute pyelonephritis and renal scarring) and renal transplant dysfunction. MRI limitations: The need for sedation in children younger than 6 years old can render MRU challenging at times. On the other hand, MRI is not always available in all centers. Finally, there is a lack of standardization of the method to date. Conclusion: MR urography combines anatomical and functional imaging in a single examination. It is useful in the evaluation of complex urinary tract malformations, hydronephrosis and infection. The need for sedation of young children is one of the major drawbacks. Patient preparation is the key for optimal quality imaging. Reference J. Damien Grattan-Smith, Stephen B. Little and Richard A. Jones: MR urography in children: how we do it. Pediatric Radiology 2008, Volume 38, Supplement 1, 3–17 Functional disorders of the lower urinary tract in childhood: an update M Riccabona Department of Radiology Division of Pediatric Radiology University Hospital Graz Graz/Austria The International Children’s Continence Society has proposed a standardized classification of lower urinary-tract dysfunction in
S434
children with two main dysfunctions: urge syndrome (bladder instability) and dysfunctional voiding (staccato voiding, fractionated voiding, lazy bladder syndrome) (Table 1). However, transitional phases between urge syndrome and dysfunctional voiding occur. Additionally, functional incontinence may be associated with recurrent urinary tract infection (UTI) starting with detrusor hyperactivity and hold manoeuvres, with a gradual progression to fractional and incomplete voiding (i.e., dysfunctional voiding). The typical neurogenic bladder based on anatomical pathology is a different type and will not be covered. The objective of this presentation is to discuss the variances in terminology, categories and incidence with its impact on imaging based on the one common pathophysiologic denominator: impaired coordination between the smooth muscle of the urinary bladder and the striated muscle of the external urethral sphincter leading to repeated pathologically high intravesical pressure during bladder filling and/or voiding. All this basically arises due to abnormal uninhibited detrusor contractions resulting from a lack of inhibition through the central nervous system with all its negative consequences for the bladder, the ureterovesical junction with the ureteric orifices and potential secondary vesico-ureteric reflux (VUR), the ureters, and the kidneys. Additionally there is a strong causal correlation between dysfunctional voiding and UTI (Table 2), with significant age and gender-dependent differences due to different anatomical fetal development and maturation processes (Table 3). Imaging methods and findings Voiding Cystourethrography (VCUG): A slightly modified VCUtechnique allows depiction of unstable detrusor contractions enabling the diagnosis of an unstable bladder with high reliability; the accuracy (sensitivity 93 %, specificity 91 %) is similar to urodynamic techniques. As this VCUG-information regarding bladder-sphincter dysfunction may significantly impact further treatment and management of affected patients, the high diagnostic accuracy and subsequent therapeutic thinking efficacy justifies the potential hazards from VCUG, even considering the radiation exposure, potential discomfort and invasiveness. Therefore, if a VCUG is performed, all the comprehensive diagnostic power of this invasive and irradiating technique should be used, including not only anatomic assessment or VUR evaluation, but also, and in particular, depiction of potential bladder-sphincter dysfunction. The simultaneous combination of VCUG with an urodynamicmanometric study is called “videourodynamics” and is used mostly for severe forms or the classical neurogenic bladder, e.g., in children with myelomeningocele. Ultrasound (US): All children with (persistent) lower urinary tract dysfunction and/or (recurrent) UTI should undergo a comprehensive urinary tract US that consists of a pre- and post void assessment of the bladder and the kidneys. Typical findings in children with bladder dysfunction are a thickened bladder wall, trabeculation, potentially (pseudo-) diverticula, abnormal bladder shape and size / capacity, open bladder neck, residual urine, dilatation of the ureter and / or renal pelvicalyceal system—commonly with a thickened urothelium indicating either infection, obstruction or VUR, and potential kidney
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
damage indicated by abnormal renal size, altered renal parenchymal echogenicity / structure, calyceal clubbing or perfusion defects. A proper investigation technique with age-adapted equipment accompanied by mandatory preparations such as hydration is essential to yield reliable results. Thus US can enable—together with clinical and anamnestic data—a strict selection of patients in whom more invasive studies such as VCUG or urodynamic tests are justified. Imaging algorithm and strategy: Initially, clinical data together with patient history and a voiding calendar will help indicate imaging studies. In all children with respective symptoms, a non-invasive urodynamic assessment using urine flow measurement, potentially complemented by simultaneous with electromyography of the pelvic floor (“free flow cystometry”), should be part of the standard protocol, as well as a comprehensive urogenital tract US. As urine flow measurements cannot be reasonably accomplished in the first years of life, infants and younger children who do not respond to conservative treatment and show persistent symptoms should undergo a complete urodynamic study. If any form of dysfunctional voiding, urge incontinence or other signs of bladder instability is suspected or abnormal US findings raise the suspicion of a bladder dysfunction, a (“modified”) VCUG should be performed. In children with associated (recurrent) UTI the imaging algorithm has to follow the respective recommendations. Furthermore, for these particular patients, special attention has to be given to all findings that may indicate lower urinary tract dysfunction. In patients with severe lower urinary tract dysfunction with and without recurrent UTI and associated severe constipation, spinal MRI may be considered for evaluation of a potential occult spinal dysraphism causing a neurogenic bladder. Finally, a reasonable time period should be allowed between functional assessment of the lower urinary tract and successful treatment of any UTI (i.e. 6 weeks) in order to avoid false-positive results. Summary and conclusion: The common pathophysiological cause of all lower urinary tract dysfunctions is detrusor-sphincter dyscoordination during bladder filling and/or voiding causing functional urinary and leading to high intravesical pressure. Clinical manifestations are voiding symptoms and/or incontinence and anatomical manifestations are urinary tract distortion, VUR and pelviureteric dilatation. There is a close relationship between UTI and constipation. Basic imaging consists of US of the urinary tract; in order not to miss signs of functional bladder disorders in neonates, infants and children the (paediatric) radiologist has to be familiar with the respective findings and procedural requisites. (Modified) VCUG and videourodynamic studies are more invasive procedures using ionising radiation; they should not be used as a screening procedure, but only are indicated in thoroughly selected patients. Aetiology is as yet unclear, probably multifactorial, and may differ by age and gender. As little evidence is available due to the lack of systematic and recent large studies on the impact of different diagnostic tools in terms of diagnostic and therapeutic thinking efficacy, treatment decisions remain difficult and future large prospective and randomized multicenter studies are necessary to clarify divergent results of the few existing outcome studies.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S435
Tables Table 1. Voiding Disorders—Definition and Symptoms Normal voiding (toilet trained children 0 as in healthy adults)
&
2 groups discriminated:
–
&
–
Bladder instability—VUR frequently on 1 side only, scarring and/or upper urinary tract abnormalities rare Stable bladder, poorly contracting during voiding + overactivity of external urethral sphincter—bilateral VUR, renal scaring and/or upper urinary tract abnormalities common
&
Definition: no involuntary or uninhibited detrusor contractions during bladder filling, no contractions at full bladder even with physiologic urge Coordinated relaxation of external urethral sphincter when voiding 0 low intravesical pressure also during emptying
Detrusor-sphincter dysfunction during bladder filling (unstable bladder):
Table 3: Lower Urinary Tract Dysfunction in Neonates, Infants and Preschool Children
&
&
&
& &
Primary abnormality 0 failure to voluntarily suppress involuntary detrusor contractions Includes all stages—from minor unstable detrusor contractions at large filling volume to high amplitude unstable detrusor contractions at less filling, potentially combined with urge Compensation by voluntary constriction of external urethral sphincter to stay dry, causing increased intravesical pressure Leads to (urge) incontinence (clinically daytime wetting) or “hidden instability” with less specific voiding symptoms (clinically frequency and urge, UTI with/without VUR, constipation and/or fecal soiling)
Detrusor-sphincter dysfunction during micturition (dysfunctional voiding)
& & & & & – – –
Definition: Overactivity of urethral closure mechanism during voiding Most severe form in childhood 0 Hinman Sy, non-neurogenic neurogenic bladder Less common (clinically fecal retention/soiling, emotional disturbance, psychosocial problems) Imaging findings: Bladder trabeculation, diverticula, VUR and upper tract dilatation, large post void residual urine volume Three main forms: Staccato voiding—caused by bursts of pelvic floor activity during voiding, resulting in bladder pressure peaks with interrupted urinary flow Fractionated voiding—caused by detrusor muscle hypoactivity, voiding 0 several unsustained detrusor contractions, low voiding frequency, large bladder capacity Lazy bladder syndrome—long standing dysfunctional voiding and resulting detrusor decompensation, voiding achieved by abdominal pressure; leads to large residual urine volume
Table 2. UTI and VUR
& &
Basic phenomenon: bladder-sphincter dysfunction strongly correlated with recurrent UTI, may hinder spontaneous VUR resolution Voiding dysfunction 0 significant risk factor for UTI/VUR development/perpetuation, associated with development of new renal scars
& &
Typical phenomena: considerably greater rise in detrusor pressure and increased activity of pelvic floor with micturition, low bladder capacity, high frequency bladder instability, high voiding pressure and later constantly decreasing detrusor hypercontractility in male infants with gross bilateral VUR/UTI; pronounced dyscoordinated voiding pattern in male newborns with fetal hydronephrosis Covert instability—after short stable filling phase, the first unstable detrusor contraction is immediately transformed into premature and forceful micturition contraction Clinical presentation more severe in infants than in older children—many VURs in baby-boys may result from transient fetal urethral and/or upper tract obstruction, injuring nephrons during fetal development and causing congenital reflux nephropathy and/or dysplasia
Imaging pediatric spine trauma: when and how P Sundgren Department of Diagnostic Radiology, University of Lund, Lund/Sweden Spinal injuries are generally less common in children than in adults. The most frequent to occur are cervical spine injuries, accounting for 60– 80% of all pediatric spine trauma. The etiology varies depending on the age of the child, with motor vehicle accidents being the most common cause of pediatric cervical spine injury, but obstetric trauma, fall, pedestrians struck by vehicles, sports, and diving accidents accounting for many injuries as well. The specific biomechanics of the pediatric cervical spine lead to a different distribution of injuries with distinct clinical and radiological features compared to adults. Upper cervical spine injuries, seldom below C3, are most commonly observed in young children, whereas lower cervical spine injuries are mainly observed in older children. The incidence of subluxation without fracture of the cervical spine is high in children under 8 years old. Spinal cord injury without radiographic abnormality (SCIWORA), observed on plain radiographs or CT, occurs predominantly in children and represents approximately 15–25% of all pediatric cervical spine injuries. MRI shows spinal cord edema, hemorrhage and/or ligamentous injury. Hyperextension or flexion of the immature and inherently elastic spine allows for significant intersegment movement and transient soft disc protrusion, resulting in distraction injuries, and/ or ischemic injury of the spinal cord. The elasticity of the spine allows it to stretch up to 5 cm before rupture, whereas the spinal cord, which is anchored to the brachial plexus superiorly and the cauda equina inferiorly, ruptures after 4–6 mm of traction.
S436
When and how to image A normal clinical examination might not require any imaging. Plain radiographs, CT and MRI are the modalities used for imaging spine trauma in children. In smaller children a twoview (lateral and AP) of the spine is usually enough to identify subluxations or fractures. In the teenagers, lateral oblique and open-mouth views can be added. Sometimes a swimmers’ view is indicated to evaluate the cervicothoracic junction. Multidetector CT (MDCT) allows whole spine examination in a very short space of time, producing reformatted images in multiple planes with different algorithms and thus allowing more accurate diagnosis of bone and soft-tissue injuries. Typically, a high-resolution CT imaging protocol begins with submillimeter overlapping partitions to create an isotropic dataset that yields identical spatial resolution in any reconstructed plane. Axial data can be reformatted into thicker sections, possibly at 1.25– to 2–mm thickness in the C1-C2 region, 2–3 mm thin slices in the rest of the cervical spine and 3–4 mm thin slices in the thoracic and lumbar spine. Multiplanar reformatted (MPR) sagittal and coronal images of the entire spine are typically produced automatically from the scanning console or a nearby workstation. Reconstructions should always be performed with both bone and soft tissue algorithms. A shortcoming of CT is the inability to evaluate spinal cord injury. If there is the slightest clinical suspicion of spinal cord or ligamentous injury, an MRI should be performed. The initial MRI shows spinal cord edema and hemorrhage and determines the level and extent of the injury. A follow up MRI helps to rule out posttraumatic sequelae such as syringohydromyelia, myelomalacia and cord atrophy. The MRI protocol for acute cervical spine trauma should include 3 mm thick sagittal T1-(T1W) and T2weighted (T2W) and short tau inversion recovery (STIR) sequences and 3-mm thick axial T2*-weighted gradient echo (GRE) images without contrast. In the thoracic and lumbar spine, 4-mm thick sagittal T1W, T2W, and STIR sequences and axial 4-mm thick T1W, T2W, and T2*GRE images without contrast are recommended. 3D volumetric axial GRE or T2weighted partitions at 1–2 mm thickness are useful in the cervical region. Fat-saturated T2-weighted images are valuable for evaluating ligamentous and soft tissue injuries, and T2*-weighted GRE for evaluating small hemorrhage or blood products in the spinal cord. A limitation of conventional MRI is the inability to differentiate between spinal cord edema and axonal injury. Advanced MRI, especially diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI) and fiber tractography have shown promising results with regard to the visualization of the disrupted continuity of white matter tracts and may play an important role in the diagnostic workup of spinal cord injury in the near future. All about fetal brain N Girard Marseille, France Introduction Ultrasound scan (US) is still the primary imaging technique used during the embryonic and fetal period with assessment of
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
the whole fetus, placenta, and amniotic fluid. In most countries, US is serially performed at 12 weeks, during the second trimester, and finally during the third trimester. The use of fetal MRI has spread widely due to the development in fast imaging and the safety of fetal MRI. MRI provides improved anatomical details where ultrasound is difficult. In contrast to US, the identification of the cortex and subarachnoid spaces is not affected by calvaria on MRI. Midline structures such as the aqueduct, the pineal body, the cerebellum and the corpus callosum are extremely well identified. MRI also provides accurate depiction of the morphological and signal changes of normal brain development and fetal brain disorders. Moreover, MRI gives insight to mechanisms of injury through diffusion-weighted imaging (DWI), in the microstructure of brain tissue by diffusion tensor imaging (DTI) and in biochemical composition through proton magnetic resonance spectroscopy (MRS). Fetal brain MRI is performed in patients with a suspected anomaly that requires further clarification for management. MRI can be performed as early as 18–20 weeks of gestational age (GA) after abnormal sonography. Below this age, US picks up obvious abnormalities while MRI resolution is poor due to the brain anatomy that displays thin cerebral mantle and enlarged ventricles. MRI is performed routinely after 28 weeks (32 in some centres) in patients with familial history, suggesting a risk for fetal brain damage or if a previously normaly US scan becomes abnormal at a later date. Selection of cases for MRI is therefore made after referral to a specialist fetal management team, with repeat US scan, multidisciplinary assessment, and radiologists aware of technical limitations and pitfalls. MRI is performed at a neuroradiological unit at a tertiary care facility after US performed by a dedicated neurosonographer, optimally in the late-second or third trimester as intracranial anomalies can be missed in the second trimester. The primary indications of fetal brain MRI arise from abnormal fetal US in most cases, such as ventricular dilatation and suspicion of malformation: this later indication mostly includes abnormal morphology from total commissural agenesis, cystic posterior fossa, and abnormal biometry such as microcephaly. Pregnancy with a risk of brain damage represents the last primary indication of MRI, especially twin-twin transfusion syndrome (TTTS), intrauterine growth retardation (IUGR), thrombocytopenia, maternal hypoxia, and maternal infection mostly from toxoplasmosis and cytomegalovirus (CMV) infections. MRI is usually obtained in theses pregnancies, whether US is considered normal or not. Knowledge of the general rules of fetal maturation is extremely important. Indeed, anatomy and the effects of maturation on the MR signal change according to gestational age. Therefore, the MRI features of a definite pathology will change accordingly. Moreover, the image itself may be confusing because different pathologies can display similar images, especially in young fetuses from 20 to 25 weeks. MRI features of the normal developing brain over gestational age The normal developing brain displays changes in morphology that are well seen on T1- and T2-weighted images, changes in signal that are well identified on T1-, T2- and diffusion-weighted images, changes in microstructure that are depicted by DTI, and changes in biochemical maturation that is assessed by MRS.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Changes in brain morphology include the increase in brain volume and weight, the changes in surface configuration, which are due to the developing sulcation, changes in ventricular shape, and decrease in the volume of subarachnoid spaces. These changes are mostly seen during the fetal period and will be illustrated by fetal brain MRI. The developing gyration is changing dramatically throughout the last half of gestation, moving from an agyric brain to a convoluted pattern. Gyration has almost reached its definitive shape by week 34–35. The sylvian fissure is the last to be achieved and is dependant upon the development of the frontal and temporal operculum. An open insula can be considered as a marker of different abnormal clinical conditions such as inborn error of metabolism (especially aminoacidopathies) and malformations of cortical development. In the posterior fossa, the primary fissure, the posterolateral fissure and the superior posterior fissure are seen at 20 weeks. The secondary fissure and the horizontal fissure are identified at 22 weeks. The convoluted pattern of the cerebellum is well clearly seen from 30 weeks on and is always identified beyond 33 weeks. MR evaluation of gyration in vivo shows discrepancy with histology, with time delay on MRI. Computerized software has been developed to identify volumetric brain growth more precisely, and the cortical folding over GA through cortical surface rendering: however these post-processing techniques are not available in a clinical setting and cannot be used for medical decision-making. The germinal matrices volume increases between 13 and 26 weeks of GA. One-half of its volume is lost between 26 and 28 weeks of GA, and gradually regresses. Disruption or nodular appearance of the ventricular wall coincides with ependymal reactions to injury, especially subependymal hemorrhage, ventricular dilatation, infection or inflammation. Subependymal heterotopias also manifest as ventricular nodules, and are often bilateral with a regular distribution. Although lateral ventricles appear relatively enlarged during the 2nd and early 3rd trimesters, the ventricular size is quite constant throughout pregnancy from 20 to 40 weeks and the normal ventricular size at the atria level on the axial plane is known to be of 7.6 ±0.6 mm from US studies. However, the generally admitted upper level is 10 mm, with trends toward 12 mm. The subarachnoid spaces are also prominent during the 2nd and early 3rd trimester. A decrease in volume is seen from 30 weeks onwards. However, prominence of the subarachnoid spaces still persists in some fetuses at the parieto-occipital and temporal pole levels, not to be misinterpreted as cerebral atrophy, and is thought to reflect the vacuolisation of the primary meninges. Signal changes are related to the changing brain composition over GA. The effects from brain composition changes on the MR signal are a shortening of T1 (bright signal on T1-W images) and T2 (dark signal on T2-W images), due to the decrease of water content mainly in the white matter, the increase in cell density and the MR properties of lipids of myelin. The high cell density and the cell-packing observed in the cortex, the basal ganglia, the germinal matrix and the white matter are responsible for a multilayered pattern of the cerebral hemisphere seen in utero. This pattern is characterized by high signal intensity on T1-W images and low signal on T2-W images of the cortical ribbon, the germinal matrix and periventricular zone, the intermediate layers within the white matter, and basal ganglia, whereas the low cell density white matter areas display a low signal on T1 and high signal on T2 images.
S437
The white matter underlying the cortex with low cell-packing density is called the subplate. The multilayered pattern is transient and well identified up to 30 weeks of GA on MRI. Absence of the intermediate layers prior 30 weeks of GA on fetal MRI coincides with white matter damage, whatever the cause of the damage. A thick intermediate layer with a thin subplate below 25 weeks is usually seen in agyria-pachygyria. Persistent bands of cells beyond 31 weeks are seen in pachygyria. Signal changes from brain myelination are detected early in utero and are seen in the posterior brainstem at 20 weeks as high signal on T1 and low signal on T2, in the posterior limb of the internal capsule at 33 weeks as a high signal on T1, and in the optic tracts and in the white matter underlying the central area at 35 weeks as high signal on T1 and low signal on T2. Diffusion-weighted imaging is sensitive to changes in cell density and myelination, and show signal changes before T1 and T2 sequences in a short period of time (about 1 min 30 s). In the literature, ADC mappings have emerged with regards to normal brain development; however, b values are disparate from one study to the other, making comparisons difficult, especially between in utero and ex utero subjects at similar GA, which do not show similar microstructure and chemistry obtained from ADC and MRS respectively. DTI permits calculation of FA, radial and longitudinal diffusivity, and fiber tracking. Currently DTI is possible and feasible in utero with an acceptable acquisition time. Fiber tracking is more difficult to achieve because of the low FA compared to ex utero studies, so that the thresholds have to be changed. However, it shows the main tracts nicely, such as corpus callosum, pyramidal tracts, and optic radiations. Numerous studies in fetal specimens have emerged in the literature, as well as in ex utero reports, with acquisition times that cannot be performed in utero. Nevertheless these studies are of importance because post-mortem MRI can be a valuable adjunct to fetal autopsy. It is known from fetal specimens that FA varies with GA in a non-monotonic manner in the cortex of cerebral hemispheres. FA changes are thought to represent radial organization of neuronal cells then followed by loss of radial orientation. A similar course of FA is seen in the cortex of cerebellar hemispheres from 20 weeks of GA onward. DTI can also identify 3 phases during brain maturation of the white matter in vivo in utero: a first stage that is thought to correspond to axonal organization, a second stage that is thought to relate to glial maturation and a third stage that is thought to represent myelination. It also shows that processes of maturation of different parts of the brain develop at different times, at different speeds, and at a variable speed for a given structure because the rate of myelination in a particular pathway may change over time. Feasibility of H MRS was demonstrated in the early 2000s and may be considered as an additional tool for evaluation of normal brain maturation. H MRS depicts changes in brain metabolism over GA: normal brain maturation in utero is characterized by a significant decrease in myo-Inositol and Choline (Cho), a significant increase in N-acetylaspartate (NAA) and Creatine (Cr), and a tendency to a decrease in lipids. Lactate may be part of the normal metabolic spectra in premature newborns. However, the pathological significance of a lactate peak found in the fetal brain remains unclear. Elevated lactate have been reported in a limited study of IUGR (3 cases). Nevertheless, more studies are needed to confirm
S438
that higher levels of lactate will be found in cases that go on to have lower Apgar scores. Lactate is found, in our experience, in cases of abnormal clinical context, irrespective of morphology. Elevated lactate is seen in numerous conditions and is identified, in our experience, in cases with isolated ventriculomegaly, infections, malformations, brain injury, extracerebral malformation, and in pregnancy at risk unrelated to infection. Further data are needed, especially from follow up when morphology is considered normal, to understand the significance of elevated lactate in the different clinical conditions, and to assess accurate quantification that could bear prognosis information. Abnormal developing brain Acquired fetal brain anomalies refer to brain damage from fetal hypoxia, a pregnancy at risk of brain damage, and any external agent that can be infectious or inherited. Developmental brain anomalies refer to brain malformations, which are considered of genetic origin. However, an overlap is seen when an external agent is responsible for brain malformation, such as in congenital infection. Brain malformations are characterized by their specific morphological changes, whereas criteria of brain injury consist of a presence of abnormal signal (such as hemorrhage), irregular ventricular wall, an absence of the normal signal, and a lack of brain layering in young fetuses. These criteria, however, may overlap because a brain malformation may be associated with brain injury (i.e. vascular malformation and brain injury) or with abnormal signal such as in lipoma and tuberous sclerosis. Many CNS malformations can be seen in utero: however, commissural abnormalities, posterior fossa cysts, and polymicrogyria (PMG) are the most frequent malformations encountered in utero. Some malformations may be difficult to identify, such as partial commissural agenesis, polymicrogyria (PMG) below 26 weeks of GA, lobar holoprosencephaly, and histogenetic disorders of the posterior fossa. Limitation of MRI is seen in cases of partial corpus callusum agenesis (CCA) associated with interhemispheric cyst, which, through its mass effect, can prevent detection of associated cortical malformations (especially PMG) until after delivery and shunting. DWI and DTI are extremely helpful in showing hypoplastic corpus callosum (CC), partial agenesis of CC, or agenesis of the hippocampic commissure, provided the fetus is not moving. Absence of the septum is also part of commissural agenesis. Septo-optic dysplasia includes absence of the septum, hypoplastic optic nerves, hypoplasia-aplasia of olfactory bulbs, and sometimes pituitary gland abnormalities. This abn o r m a l i t y i s u s u a ll y d i a g n o s e d w h e n a s s e s s i n g m i l d ventriculomegaly. Causes of PMG include congenital infection (particularly cytomegalovirus infection), localized or diffuse in utero ischemia, or mutations. PMG may be uni or bilateral. From mid- to end of the third trimester, MRI features are familiar and similar to what is known from the ex utero period as packed and serrated microgyri, with an irregular cortex-white matter junction. Aberrant sulci, atrophy and white matter abnormalities such as gliosis are also seen. In young fetuses, however, the identification of the malformation is difficult and sometimes impossible around week 20–21. MRI appearances include the absence of the normal signal of the cortex, the presence of sulci at the surface of the brain that are not expected according to the GA, and the irregular surface of the cerebral hemisphere. It may be necessary in young fetuses to
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
repeat MRI several weeks after the initial referral in order to get more familiar images of PMG. DWI can depict abnormal ADC values in the white matter underlying the cortical malformation related to abnormal organization and increased cell density in the developing white matter (particularly heterotopic neurons). On FA map, the normal high anisotropy of the cortex below 28 weeks is not seen in the malformed cortex. Disturbances of histogenesis in the posterior fossa are uncommon. Severe hypoplasia, which is of poor prognosis, manifests as small cerebellar hemispheres with shallow brainstem and absence of the anterior bulging of the pons. Cerebellar hypoplasia may be seen with normal bulge of the pons, especially when unilateral, making the distinction from necrosis challenging. This challenge may be achieved with diffusion images that are helpful in showing necrosis. Hypoplasia-aplasia of the cortico-spinal tract (CST) is a rare malformation that is usually found at autopsy while not identified on MRI because the brainstem looks normal. DTI seems promising in such cases, particularly when fiber tracking shows the absence of organized fibers within the brainstem. Acquired fetal brain disorders include fetal hypoxia as defined by US, congenital infections (mainly toxoplasmosis and cytomegalovirus infections), brain damage due to malformation such as vascular brain malformation and heart malformation, pregnancies at risk of fetal brain damage, inherited metabolic diseases (especially mitochondrial diseases), and tumors. Acquired fetal brain disorders represent the third most frequent indication of fetal brain MRI following ventricular dilatation and suspected central nervous system (CNS) malformation. Cerebral insults during the early months of gestation result in either death or malformation. After the 6th fetal month, the cellular responses become comparable to the mature brain. Vulnerability differs between gray and white matter in fetuses of 20–40 weeks. Neuronal necrosis is uncommon compared to white matter damage that is prevalent. White matter astrocytosis as hypertrophic astrocytes is prevalent compared to focal necroses of white matter. Gray matter hypotensive lesions most commonly occur in the upper brainstem and thalami, followed by convexity borderzone lesions causing sclerotic microgyria. The fetal brain response to injury is unique and consists of acute and chronic response, seen alone or in combination. Chronic and combination chronic-acute responses are more common than the acute response alone. Factors leading to pregnancy at risk of brain damage are numerous and include maternal factors (toxic conditions such as carbon monoxide poisoning, fetal alcohol syndrome, cocaine exposure, maternal hypoxia such as trauma, sepsis among others, maternal/fetal coagulation disorders such as thrombocytopenia, alloimunization), obstetric (mechanic) factors (such as placenta praevia, placental abruption, umbilical cord accident) and fetal factors (such as multiple pregnancy especially monochorionic twin pregnancy and intrauterine growth retardation). Advanced MRI techniques are helpful to detect acute hemorrhage, abscess, acute lesions of hypoxic-ischemic origin, while isolated ventriculomegaly and white matter gliosis are still the most challenging clinical condition. Acute response of the fetal brain consists of hemorrhage, white matter damage as edema and acute stage of leukomalacia, infarction, venous thrombosis, and abscess. Acute changes are also seen
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
in the fetal posterior fossa and necrosis of the cerebellum is probably the most common finding. Hemorrhages are encountered in hypoxic fetuses, in ascending intrauterine infections as a result of procoagulant activity and endothelial cell damage mediated by cytokines, in CMV infections as a result of thrombocytopenia, in disorders of coagulation and in trauma. White matter edema is probably more frequent than focal necrosis (leukomalacia) and manifests in the subcortical white matter of frontal and parietal lobes. Absence of the intermediate layer of the white matter can be the only MRI finding in young fetuses. Diffusion images can help identifying white matter edema of cytotoxic and vasogenic type but its role in utero is currently unknown. Selective neuronal necrosis is not as common as in the neonatal period but may be seen, particularly in cases of twin-twin transfusion syndrome (TTTS) in monochorionic pregnancy. Diffusion images are needed to depict such lesions in order to show the typical cytotoxic changes. Thalami and basal ganglia involvement can also be identified as a result of profound maternal hypoxia-ischemia. Abscesses are uncommon in utero, and are usually tiny and difficult to identify. They are mostly encountered in toxoplasmosis and CMV infections. Most commonly, the diagnosis of abscess is made retrospectively because of calcification, either isolated or multiple, and scattered within the white matter. DTI and fiber tracking may help to identify the consequence of a focal brain injury on the organization of white matter tracts. The chronic response of the fetal brain is more common than the acute response. It includes ventricular dilatation, thickened/irregular germinal matrix or ventricular wall, white matter gliosis, loss of volume (atrophy), parenchymal cystic cavity, ependymal cyst, calcification, and malformation, especially of the cortex such as PMG. Ventricular dilatation is a common sign of the chronic response, and is most likely unilateral in brain injury compared to bilateral ventriculomegaly caused by malformation or of genetic origin. It is usually associated with other brain damage, particularly of the germinal matrix or of white matter. However, the challenge increases when ventricular dilatation is isolated and mild. Progression of the dilatation should be documented by serial US and/or MRI to ensure best medical management. Advanced MRI techniques are employed to identify further brain damage criteria. The inositol over creatine ratio was shown to be significantly lower in fetuses with hydrocephalus compared to normal controls, although unconfirmed in larger series. DTI seems promising, showing abnormal organization of white matter tracts. However large series are needed to evaluate its role, especially for medical decisionmaking. White matter gliosis is not currently identified with MRI. White matter gliosis consists of hypertrophic astrocytes with fibrillary gliosis that spread diffusely in the white matter, especially in deep frontal or parietooccipital white matter. Cases with white matter gliosis at autopsy usually manifest with mild ventriculomegaly and irregular ventricular wall. DTI could help identify such damage but its role is not known in utero. Correlation between increased ADC and the presence of vasogenic edema and astrogliosis has been reported in white matter ischemic lesions. Proton spectroscopy may show increase in creatine that is a marker of astrocyte. Outcome of white matter gliosis is not well known and may lead to psychomotor retardation, behavior disturbances and epilepsy.
S439
Fetal urogenital anomalies: the complementary role of Ultrasound and MR imaging F E Avni, M Cassart, K Ismaili, Ma Hall Department of Medical Imaging and Perinatal Nephrology CUB Erasme Hospital, Brussels/Belgium Introduction Since the era of obstetrical ultrasound began, most cases of fetal urogenital anomalies are detected in utero. The largest group corresponds to fetuses with congenital malformations of the urinary tract. Fetal uropathies encompass heterogeneous groups of diseases with variable degrees of severity. To date, despite numerous publications, several questions remain controversial regarding diagnosis, workup and prognosis. The present course aims to summarize the approach to fetal urinary tract dilatation. 1. Sonographic assessment of urinary tract dilatation in the fetus The aim of antenatal diagnosis of uropathies is to detect the anomaly, determine the diagnosis as precisely as possible and subsequently assess the prognosis in order to counsel parents and physicians so that postnatal management can be adequately prepared. Obstetrical ultrasound provides answers to most (but not all) questions. Various criteria have been published in the literature for assessing dilatation, and are used in daily practice. Most teams rely on the measurement of the AP diameter of the renal pelvis on a transverse scan of the fetal kidney. For this purpose, 4 mm in the second trimester and 7 mm in the third trimester are considered the best thresholds. Other evidence for dilatation includes a visible fetal ureter (usually above 2 mm) and an enlarged bladder (above 3 cm height on a sagittal scan during the 2nd trimester or 5 cm during the 3rd trimester. The severity of a dilatation will be graded through its diameter as mild (below 10 mm), moderate (10–15 mm) and severe (above 15 mm). As stated above, the degree of dilatation is the first parameter to identify; the level of potential obstruction should be determined thereafter so as to render the diagnosis more precise. As expected, uretero-pelvic junction obstruction, uretero-vesical junction obstruction, complicated duplex kidneys, bladder outlet obstruction and vesico-ureteric reflux (VUR) are the most common differential diagnoses to consider. Besides the dilatation, additional signs of severity include abnormal renal parenchyma (thinned, hyperechoic or containing cysts), calyceal dilatation, irregular renal contours, and small size kidneys. Nonetheless, the most reproducible US sign indicating “impaired” fetal renal function is the finding of a mar kedl y d ecr eased amo un t of am nio tic f lu id (oligohydramnios). Once an uropathy has been characterized, a detailed fetal survey is mandatory in order to detect other system malformations and provide a complete diagnosis and precise prognosis. 2. The role of fetal MR imaging Fetal MR imaging has mainly been used for assessing the central nervous system and fetal chest malformations. Using this technique for evaluating the fetal abdomen, and especially the urinary tract, is more recent. MR imaging can provide exquisite details of the fetal anatomy and helps to provide a better understanding of complex malformations than sonography. Conversely, thanks to a larger field of view and multi-
S440
planar approach, the technique can visualize larger masses than ultrasound. Nonetheless, MR imaging is usually complementary to a sonographic examination, and should not be performed without information provided by a meticulous US. The general indications of fetal MR imaging are mainly circumstances in which the contribution of ultrasound is limited, such as maternal obesity or low lying presentation. In case of uropathies, fetal MR imaging can provide additional information regarding the presence and location of the kidneys and the status of the parenchyma. T2 weighted sequences are optimal for these assessments. The technique lacks direct evaluation of renal function. ADC values and diffusion weighted sequences may provide such information in the near future. Another interesting application of renal fetal MRI is the evaluation of complex genito-urinary or uro-digestive malformations. Due to its multi-planar approach, fetal MR imaging is able to assess complex genital or genitor-urinary malformations such as cloacal abnormalities and/or genital tract obstructions. In cases of urodigestive malformation (e.g. anal atresia with urinary tract fistula), the signal of the meconium changes. This is best demonstrated on T1-weighted sequences. 3. Post natal management of fetal uropathies Due to the antenatal diagnosis and evaluation, the paediatrician is informed about the diagnosis and can adapt the post natal management accordingly. Imaging plays a central role and the workup has been standardized (Table 1). The follow-up will also be based on imaging findings. One question that remains controversial is whether we have been able to influence and improve long-term renal function in patients with congenital uropathies.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
There is growing evidence that the group of congenital anomalies of the kidneys and urinary tract (CAKUT) are due to polygenic disease processes and therefore renal damage is already present at birth. Nonetheless, further modulation and compromise are the consequences of acquired postnatal damage, mainly secondary to infection and obstruction. The long-term prospective follow-up of CAKUT is mandatory to understand the benefits of antenatal diagnosis and post natal management. Few data exist to date. Furthermore, there have been publications on patients with VUR and posterior urethral valves. It has been shown that in the majority of patients, VUR resolves spontaneously. Yet whenever the renal function is already impaired at birth, it cannot be significantly improved. Fortunately there will be a certain degree of glomerular maturation that does improve the renal function to a certain extent (unless both kidneys are affected). In the case of PUV, it has been shown that prenatal diagnosis has little impact on mortality or end-stage renal failure in the first decade of life. This appears to be largely pre-determined by renal dysplasia and the severity of intra-uterine obstruction. Yet there are findings that suggest that the long-term prognosis of PUV of intermediate severity might be improved by prenatal diagnosis. Conclusion: Obstetrical ultrasound plays a central role for the detection of congenital uropathies. Fetal MR imaging provides useful additional information. The standardization of defining urinary tract dilatation and post natal management have clearly opened up the way to a better understanding of their natural history. If progress is to continue, our capacities to assess renal function in the fetus must improve, so that treatment and management can be adapted at birth. We also need long-term follow-up data confirming that such an approach is effective.
Table 1 Post natal workup of congenital uropathies (From ESUR-ESPR working group)
The liver, the pancreas and the spleen: US and MRI M Cassart, Department of Medical Imaging, ULB Erasme Hospital Brussels/Belgium
Introduction: Abdominal imaging of the fetus relies on ultrasound (US) and magnetic resonance imaging (MRI). These two techniques are complementary in the management of fetal abdominal
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S441
anomalies. In this particular course, we will focus on abdominal solid organs, including the liver, the pancreas and the spleen. We will depict their normal aspect and the most common anomalies encountered in daily clinical practice.
hepatic veins. The prognosis is better in this context. Associated vascular, cardiac, anatomical and genetical anomalies should be excluded.
The fetal liver The fetal liver is easy to visualise on US scans at every gestational age. Located in the right flank, it appears less echogenic than the adjacent lung, from which it is separated by the thin hypoechogenic diaphragm. On routine US, we look for the size of the liver, measured on a mid clavicular sagital slice, and its parenchymal homogeneity. The vascularisation of the liver is also checked (ombilical vein, arantius canal, sus hepatic veins draining into the inferior vena cava). The gallbladder is always seen in the second trimester, its visualisation rate decreases slightly in the third trimester (80–90%). Its position, content and aspect are examined. Hepatic or hepatobiliary anomalies are rare in fetuses. Different pathologic situations are considered, such as hepatomegaly, hepatic tumors, vascular malformations, parenchymal calcifications and biliary tract anomalies.
Liver calcifications, when depicted, should be located with precision in the parenchyma, on the liver capsula or in vascular structures. Intraparenchymal scattered punctate foci may be secondary to congenital infections (TORCH) or, more rarely, to tumors (see above). Capsular calcifications, associated with meconial pseudo cyst or other gastro intestinal anomalies or not, are consistent with meconium peritonitis. A few isolated vascular calcifications may induce localized ischemic infarcts.
–
Hepatomegaly
Hepatomegaly is defined as a global enlargement of the organ. In the various aetiologies, the most common are congenital infections (TORCH) and congestive heart failure. More rarely, chromosomal anomalies such as trisomy 21 may be associated with myeloproliferative disorders or congenital leukemia, which is responsible for a huge liver enlargement. Storage disorders are rare but often fatal, resulting in fetal demise. Beckwith-Wiedemann syndrome, associated with nephromegaly, macroglossia and omphalocele should also be excluded.
–
Liver tumors
A large variety of benign and malignant tumors derive from mesenchymal tissues. Liver tumors may present with various sonographic appearances. The differential diagnosis of fetal echogenic liver tumors includes vascular lesions, such as hemangioendothelioma, that may lead to Kasabach-Merritt sequence. Predominantly cystic or mixed lesions are more consistent with the diagnosis of simple hepatic cyst or mesenchymal hamartoma. These latter two tumors are benign. Solid malignant lesions include hepatoblastoma and metastasis of neuroblastoma.
–
Liver vascular malformations
Liver vascular malformations are numerous; although rare, ductal agenesis is the most commonly encountered. The ductus venosus is located between the left ombilical vein and the inferior vena cava. It allows a prioritary oxygenated blood supply to the heart, brain and kidneys through the foramen ovale. Ductal agenesis in encountered in 0.6% of fetuses with cardiac evaluation and is associated with 65% of cardiac anomaly. The vascular patterns in such a situation include extra hepatic shunts with an umbilical vein most commonly shunting the liver and directly connected to the right auricle or the inferior caval vein. Cardiac failure and hydrops may be the consequences of such a malformation. Intra hepatic shunts represent 30% of cases and correspond to a direct connection of the umbilical vein into the portal circulation or sus
–
–
Hepatic calcifications
Gallbladder and biliary tract anomalies
The gallbladder presents numerous variants in size, shape and position (left sided). These different aspects mainly represent normal variants without physiological consequences. The gallbladder, normally anechoic during fetal life, may contain sludge or stones that usually spontaneously resolve after birth. The non-visualisation of the gallbladder should be transitory and without pathological significance, but may also be associated with biliary tract malformations such as choledochal cysts and potential biliary atresia. In this context, the prognosis is poor if untreated, leading to cholestasis, biliary cirrhosis and secondary liver failure. The fetal pancreas The pancreas is a small, retroperitoneal hyperechogenic organ. It is not routinely visualised in daily practice but if searched for, it may be seen in 55% and 90% of pregnancies respectively in the second and third trimester. Fetal congenital anomalies involving the pancreas are exceedingly rare. Pancreatic cysts, arising from a developmental anomaly of the pancreatic ductal system, may be encountered in polycystic diseases, Ivemark or Zellweger syndromes or in Beckwith-Wiedemann syndrome. The fetal spleen The normal fetal spleen is isoechogenic to the liver and slightly hypointense on T2 weighted sequences. In cases of hepatomegaly, the size of the spleen should be checked. If a splenomegaly is depicted, infectious, neoplasic or syndromal etiologies (see above) should be suspected. The spleen may also contain cystic lesions. They are usually isolated and benign. Their antenatal diagnosis allows a prompt and adequate neonatal work-up in order to prevent further complications (rupture, haemorrhage). Normally, secondary to embryologic development, the internal organs have a specific location: the situs solitus. This normal situs may be totally inverted, the situs inversus, or partially inverted, the situs ambiguus. In some cases named left heterotaxia, the fetus has two left sides (two left lungs, two left auricle), and is associated with polysplenia. In cases of right heterotaxia, the spleen is generally absent. Theses situations are better depicted by MRI than US. Fetal imaging: should we measure and what? C Garel, Department of Radiology,
S442
Hôpital d’Enfants Armand-Trousseau, Paris/France Fetuses are not directly visualized and physical examination is not possible. Therefore, imaging plays a pivotal role in fetal evaluation and is based on a biometrical and morphological approach. The role of biometry has been gradually increasing during the last decade. For example, a literature search for the terms “biometry” and “fetus” yields about 1,900 articles (1,600 articles when “biometry” and “prenatal diagnosis” are used). In daily practice, measurements are obtained with ultrasonography (US). Biometrical analysis encompasses several tasks:
– – –
assessing gestational age and fetal growth, measuring certain parameters that may have a prognostic impact, in some pathological settings, measuring certain parameters that may contribute to the diagnostic evaluation.
Therefore, while certain measurements are mandatory, others should be used in particular settings only. Assessing gestational age and fetal growth During the first trimester, the crown-rump length (CRL) is considered the best parameter for early dating of pregnancy. The bi-parietal diameter BPD and the femur length (FL) are usually also measured. During the second and third trimesters, measurements of the BPD, the head circumference (HC), the abdominal circumference (AC) and the FL are commonly used for estimating and monitoring fetal weight and several formulae are available. Numerous charts and references exist and it is crucial to be aware of the method that has been employed, particularly how the callipers should be placed (for instance outer, inner or middle measurement of the skull). It has also been suggested that customised fetal charts should be used, adjusted for ethnicity and maternal and fetal factors. The transverse cerebellar diameter (TCD) is another important biometrical parameter and it should be measured during the second and the third trimesters for two reasons: there is a significant relationship between TCD and gestational age, and TCD measurement is a good marker for cerebellar growth. There are many parameters that do not undergo measurement in routine circumstances but may aid in the diagnosis and prognosis of rarer conditions. An exhaustive list of these less-used parameters cannot be provided as they are too numerous and illustrate only some conditions. In the literature, a large volume of normal reference data are available for various parameters. Some of them are not relevant; some of them may be helpful in very rare conditions. Sometimes, even if the biometric assessment is not always useful in itself, it may serve to focus attention on the particular organ concerned (for instance the eyes when inter or intra-orbital diameter is measured). It must always be kept in mind that the biometrical analysis has no meaning when being used without taking into account the morphological approach. Certain biometrical parameters may have a prognostic impact Measurement of the nuchal translucency is recommended during the first trimester between 11 weeks and 13 weeks+6 days. This parameter is part of the first-trimester screening test that also takes into account serum markers and maternal age.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
During the second and third trimesters, the amount of amniotic fluid is usually evaluated subjectively. In case of suspected oligohydramnios or polyhydramnios, it is recommended to measure the diameter of the larger pocket and /or to evaluate the amniotic index. The cerebral lateral ventricles and the renal pelvises are not routinely measured and are evaluated subjectively. When they appear to be too large, they should be measured properly as they may indicate a cerebral or a urological damage and thus may have a prognostic impact. The long bones are not routinely measured with the exception of the femur and, for certain sonographers, the humerus. However, when the FL and the humerus length are decreased below the 3rd centile, it may be useful to measure the other long bones. When all these parameters are markedly decreased and when associated abnormalities (spine, pelvis, ribs…) are present, the diagnosis of osteochondrodysplasia is likely. In fetal cardiac US, in case of ventricular and/or vessel disproportion, the chambers and vessels should be measured. As an example, right-side dominance may predict coarctation and the size of the aortic arch should be assessed. Certain biometrical parameters may participate in the diagnostic evaluation In daily practice, many parameters are not routinely measured and receive subjective evaluation only. When particular pathological settings are suspected, certain parameters can be measured, which may help with diagnosis assessment. In the literature, normal ranges have been established for a wide variety of biometrical parameters. The following list of organs or parameters is not exhaustive: the corpus callosum, the vermis, the nasal bones, the inter (intra) orbital diameter, various facial angles, the thyroid, the thymus, the lungs, the cardiothoracic ratio, the kidneys, the bladder, and the penis. Numerous norms are available in Doppler analysis including the umbilical artery, the middle cerebral artery, the uterine artery, the ductus venosus (various indexes), the mitral and tricuspid valve E/A ratios, the peak of maximum velocity of the aorta and main pulmonary artery, and the splenic artery. Biometrical reference data have also been established in MRI of the brain, the eyes, the lungs. Comparison between US and MRI biometrical values has been made studied. The biometric analysis is undoubtedly an important part of the fetus evaluation. Numerous reference data are available in the literature. Most of them should not be used routinely. During the past decade, the number of articles dedicated to fetal biometry has markedly increased. However, it should be emphasized that the morphological approach remains crucial and should always be considered the most important step in the diagnostic process. The fetus must not be reduced to a series of numbers, and biometry must be considered but a tool. Bone Tumors G. Papaioannou Department of Imaging, Mitera Maternity and Children's Hosptial, Athens/Greece The purpose of this presentation is to review the basic imaging features of different modalities that will lead to the diagnosis and characterization of a bone tumor in the pediatric population, keeping the radiograph as a gold standard and highlighting the specific clues that other
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
modalities offer to narrow the spectrum of differential diagnosis, accurately map the extent of the lesion and help planning of operating strategies, including limb-salvage. The value of modern imaging in evaluating response to treatment will be underlined and possible future applications will be mentioned. Conventional high-quality radiographs still remains the key imaging examination on which to base the diagnosis of a bone tumor, despite the technical advent and superiority of other imaging modalities, such as CT and MRI. Bone lesions include benign and malignant neoplasms, reactive focal abnormalities, metabolic abnormalities and miscellaneous tumor-like entities. They are highly common in children; up to 42% occur in the first two decades of life and more than half are benign. There is an accepted age-range for bone tumors that includes patients younger than 20 years, 20–40 years and older than 40 years. In children, the most common benign bone lesions include osteochondroma, non-ossifying fibroma, Langerhans cell histiocytosis, unicameral bone cyst and aneurismal bone cyst. The most common (more than 90%) primary malignant bone tumors in children include osteosarcoma and Ewing sarcoma. In cases of a bone tumor, essential features that will narrow the differential diagnosis and lead to correct, if not single, diagnosis are: the patient’s age, the location of the lesion and the radiographic features as seen on conventional, high-quality radiographs. Complicated features that may alter the typical imaging patterns and create confusion are pathologic fractures occurring mainly in benign but also in malignant bone lesions and causing extensive bone edema and blood product accumulation around them, osteomyelitis, and secondary aneurismal bone cysts. In such cases the differential diagnosis needs to be broadened, the diagnostic approach should include team work and each member (clinician, radiologist and pathologist) should contribute and provide sufficient information in order to target the correct diagnosis as accurately as possible. Routine radiographs remain the optimal imaging technique for primary bone tumors and are usually sufficient in lesions with typically nonaggressive features. Nonaggressive features include a narrow zone of transition, an intact— although thinned—cortex, matured periostitis and lack of associated soft-tissue mass. The radiologist plays an important role in assisting clinicians to call for further imaging in an appropriate manner, especially when the radiographs appear normal but the child’s symptoms persist, when a possibly aggressive lesion is demonstrated, or even when a nonaggressive lesion is suspected but its biologic features suggest rapid growth and surgical resection is advised. MRI is the study of choice in these instances, bearing in mind that lytic bone lesions and bone marrow lesions may often go undetected on plain radiographs. Its anatomical detail is superior to that of scintigraphy. The radiologist needs to analyze the lesion in an organized fashion and pay attention to specific radiographic features. These features were originally described for conventional radiographs, but can also be applied to CT images. They cannot apply to MRI images, however, as the latter overestimates the aggressiveness of some benign lesions, which produces marked marrow and soft-tissue edema. The decision to perform a CT in a child should be carefully weighted in order to avoid unnecessary radiation exposure, but appears to be useful in certain anatomical areas, such as pelvis or spine, where overlapping structures make interpretation of plain films difficult. CT presents superiority over plain films in determining the exact location of a lesion within the bone, more accurately
S443
evaluating changes in the cortex and demonstrating a nondisplaced pathologic fracture or early periosteal reaction. MRI, albeit currently one of the most advanced modalities, is often nonspecific in cases of bone tumors, as most of them demonstrate low T1 and high T2 signal. When MRI is applied to address certain issues, such as local extension of the tumors, delineation of certain imaging features such as marrow edema, fluid-fluid levels, soft-tissue involvement and invasion of adjacent neurovascular structures or joint space, optimization of the protocols is essential and this is usually achieved with the active involvement of a pediatric radiologist. Determining which lesions can be ignored or deserve further characterization and biopsy is a decision in which the radiologist plays major role. Staging of primary bone tumors is better achieved with MRI or CT in certain types, like osteoid osteoma or evaluation of matrix mineralization, which characterizes cartilage forming tumors. In high suspicion of metastatic disease, bone scintigraphy reveals the extension of involvement. When staging an aggressive-looking bone tumor, the radiologist plays an important role in detecting and highlighting certain features, such as tumor size, transcompartmental extension, and skip metastates, all of which should be mentioned in the report. The initial MRI should be performed prior to any biopsy procedure, to avoid misinterpretations due to secondary intramedullary edema and determine the biopsy path using a large field of view. Current treatment strategies for localized forms of primary malignant bone tumors focus on neoadjuvant chemotherapy designed to treat micrometastatic disease and reduce primary tumor volume to facilitate limb salvage in the subsequent surgical procedure ensuring complete resection. The role of imaging in these cases focuses on a precise evaluation of local extension prior to surgery, accurate assessment of response to chemotherapy and ideally on identification of prognostic factors. In tumor surveillance postoperatively, both CT and MRI have a role; subtle areas of new lysis at a bone-cement interface detected accurately by CT, early T2 signal changes on MRI and the presence of soft-tissue mass are all indicative of recurrence, which is ultimately confirmed by biopsy; dymanic MRI study may help evaluate response to treatment in inoperable forms. Quantitative models in dynamic MRI and 18FDG-PET are being developed in order to demonstrate early prognostic criteria, which could be decisive in future protocols. Imaging in haematological malignancies R Nievelstein, T Kwee Department of Pediatric Radiology University Medical Center Utrecht, Wilhemina Children’s Hospital Utrecht/Netherlands Haematological malignancies, in particular leukemia and malignant lymphoma, are among the commonest pediatric malignant disease entities. Despite its limited role in leukemia, cross sectional imaging plays an essential role in the diagnosis and follow-up of malignant lymphoma. At the time of diagnosis, imaging facilitates tumor staging, the planning of therapy and the
S444
determination of prognosis. During follow-up, the role of imaging includes therapy response monitoring as well as evaluation of disease and therapy-related complications (i.e. thromboembolic and neurological events). As extensive (whole-body) disease involvement is common in haematological malignancies, imaging modalities which can encompass the entire body are crucial, in particular for staging and therapy monitoring purposes. Whole-body (WB) imaging can be achieved with computed tomography (CT) and positron emission tomography (PET), or a combination of both techniques (PET/CT). More recently, WB magnetic resonance imaging (WB-MRI) has become feasible, thanks to the development of parallel imaging techniques and multi-channel phased array coils. WB-MRI provides excellent tissue contrast, detailed morphological information, and, very importantly, does not use any ionizing radiation. Moreover, the recent developments in WB diffusion-weighted imaging (DWI) and focused dynamic contrast-enhanced imaging make functional imaging with MRI possible. In this short contribution, the applications and recent technical developments of the most important (WB) crosssectional imaging techniques will be discussed, with special emphasis on their strengths and limitations (Table 1). Until recently, CT has been the mainstay of structural imaging evaluation in oncology. In cases of the haematological malignancies, CT mainly plays a role in the diagnosis and follow-up of malignant lymphomas, whereas for the other haematological malignancies, the role of CT is limited to the evaluation of pulmonary disease or (disease and therapy related) complications. With the current multidetector CT technique, volumetric WB-CT can be performed within a few seconds, allowing for detection of lymph nodes and extranodal lesions of 5 mm or less throughout the body. An important limitation of CT is the fact that identification of nodal involvement is almost entirely based on size criteria. As the short-axis diameter proved to be the most reproducible, it is accepted as the most helpful measurement with a short-axis diameter greater than or equal to 10 mm being considered as positive for lymphomatous involvement. Other criteria include normal-sized but prominent lymph nodes in an abnormal location or cluster, particularly when they are rounded in shape. General criteria for extranodal involvement in malignant lymphoma include areas of abnormal attenuation in liver, spleen, bone or other extranodal sites, and presence of nodules or infiltration in the lung. CT is known to be insensitive for bone marrow involvement. The recent integration of CT with 18 F-fluoro-2-deoxy-D-glucose (FDG) PET has changed the imaging evaluation of haematological malignancies considerably. FDG-PET/CT makes it possible to combine the anatomical information of CT with the functional information of FDG-PET. Moreover, in addition to the more accurate localization of foci of increased FDG uptake, the reconstruction of attenuationcorrected PET images makes semiquantitative evaluation of the FDGPET images possible by measuring standardized uptake values (SUV) of suspected foci. FDG-PET has proven to be a powerful method for the detection of lymphomatous involvement of lymph nodes and extranodal regions in patients with malignant lymphoma, independent of size criteria. Furthermore, FDG-PET is able to determine whether a residual mass contains active tumor or not. Several studies already have shown the sensitivity and specificity of PET/CT in staging and (early) response assessment of malignant lymphoma are superior to those of diagnostic CT alone. Limitations of FDG-PET/
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
CT include detection of non FDG-avid indolent lymphomas, detection of central nervous system and bone marrow localisations, and differentiation between infectious, inflammatory and malignant processes. PET/CT plays almost no role in the diagnosis and follow-up of leukemia, as tumor load and response can be adequately monitored in blood, bone marrow, and liquor. The only exception is the possibility to detect extramedullary localizations with PET using FDG (and, since recently, using the proliferation marker 3′-deoxy-3′-18 F-fluorothymidine (FLT)) in acute myeloid leukemia, in particular the detection of so called sanctuary regions (i.e. CNS, eye, and testis) where it will be more challenging to reach adequate chemotherapy levels. Finally, there are some recent publications suggesting that PET/CT might play a role in the diagnosis and response assessment of Langerhans cell histiocytosis (LCH), but (large scale) systematic studies are still lacking. Thanks to its high spatial resolution, excellent soft-tissue contrast, and absence of ionizing radiation, MRI has become an attractive alternative imaging modality for the detection of parenchymal and bone marrow abnormalities, especially in the pediatric population. Moreover, the recent development of faster imaging techniques (parallel imaging acquisition), higher gradient field strengths, matrix coils and table movement techniques have made WB-MRI clinically feasible for staging and follow-up of malignancies. Commonly applied sequences for WB MRI include a T1-weighted turbo spin echo sequence (without and, less commonly, with intravenous contrast material) for anatomical detail, and a fluid-sensitive, fat-suppressed T2-weighted sequence for improved lesion detection. The images are usually obtained in the coronal plane, although images in axial and sagittal planes can be of additional value. As WB-MRI is sensitive to susceptibility artifacts and motion artifacts, the chest and abdomen should be scanned with breath-holding or respiratory triggering. By adding DWI to the (conventional) WB-MRI sequences, both anatomical and functional information can be provided within a single examination. The recent development of the diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) technique has facilitated the use of DWI in a whole-body setting under free-breathing. Because background signal is suppressed by the WB DWIBS technique, nodal and extranodal (malignant) lesions will be highlighted, as these lesions often have a prolonged T2 relaxation and decreased diffusivity. Furthermore, the ability of DWI to quantify diffusion by means of apparent diffusion coefficient (ADC) measurements may help to characterize (malignant) lesions and assess treatment response. WB-MRI already proved to be a valuable tool in the diagnosis and staging of malignant lymphoma. A major advantage of MRI is the good visualization of the bone marrow, thereby facilitating the detection of bone marrow involvement. On the other hand, as the signal characteristics of benign and malignant lesions on conventional MRI and DWI do show considerable overlap, assessment of nodal involvement is still mainly based on size criteria. In addition, the involvement of extranodal regions is still mainly based on the detection of signal abnormalities or mass lesions in soft tissues, bone marrow, parenchymal organs, and serosal cavities. The role of DWI (including ADC measurements) in distinguishing benign form malignant (lymphomatous) lesions is the subject of current research, as is its potential application in early response and end of
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
treatment assessment. WB-MRI has been used for the evaluation of Langerhans cell histiocytosis (LCH), especially its skeletal localizations. However, again (large scale) systematic studies of its role in diagnosis and follow up are still lacking. As applies to other imaging modalities, WB-MRI will not be routinely used in the diagnosis and follow-up of leukemia. However, there are some recent reports that suggest a potential role for WB-MRI in the early detection of acute leukemia in selected cases without peripheral blood abnormalities. Furthermore, WB-MRI might be a valuable imaging tool for the detection of extramedullary localizations in acute myeloid leukemia.
S445
In conclusion, CT and FDG-PET(/CT) are currently the mainstay for evaluating haematological malignancies. CT allows for WB imaging with a high spatial resolution and high scan speed, whereas FDG-PET adds functional information. WB-MRI (with DWI) is a promising alternative imaging tool that can be used to extract both anatomical and functional information from tumors. However, the value of WB DWI and ADC measurements for tumor characterization and tumor response assessment still has to be established. In this scope, the development of an integrated PET/MRI system is a promising approach in order to further optimize the imaging of haematological malignancies.
Table 1: Comparison of features of CT, FDG-PET/CT, and WB MRI for the evaluation of haematological malignancies. Feature
Diagnostic CT
FDG-PET/CT
WB MRI (± DWI)
Image acquisition
Axial
Axial
Coronal (optional: axial, sagittal)
CE-CT
Low-dose CT (attenuation correction and anatomical location)
T1-weighted, T2-weighted (FS), DWI (DWIBS acquisition)
Image reconstruction
Coronal and sagittal MPR
Fused axial and coronal reformatted FDG-PET and CT images
3D MIP of FDG-PET component
WB coronal reconstruction DWIBS
(optional: CE T1-weighted) WB coronal reconstruction T1/T2
3D MIP of DWIBS Ionizing radiation
Yes
Yes (x-ray and FDG)
No
Image quality
Good spatial resolution
FDG-PET component: lower spatial resolution
High spatial resolution (T1/T2)
Less soft tissue contrast compared to MRI High lesion-to-background signal (DWIBS)
Good soft tissue contrats (T1/T2)
Assessment
Qualitative: visual lesion detection
Qualitative: visual lesion detection on FDG-PET
Qualitative: visual lesion detection at T1/T2/DWIBS
Quantitative: SUV measurement at FDG-PET (optional)
Quantitative: ADC measurements at DWIBS (optional)
Major indications
Malignant lymphoma: staging and follow-up
Malignant lymphoma: follow-up, (staging)
Malignant lymphoma: staging, (follow-up)
Complications (disease and therapy related)
AML; detection of extramedullary localizations
Langerhans cell histiocytosis: staging, (follow-up)
Major limitations
Relies on size criteria for lymph node involvement
Lesion detection in areas of high physiologic FDG uptake limited
Low sensitivity for bone marrow involvement
Discrimination from infectious and inflammatory processes
Limited specificity for bone marrow lesions
Detection of (non FDG-avid) indolent lymphomas limited
Thoracic and abdominal regions prone to susceptibility and motion artifacts
Promising future developments
Dual-energy CT (bone marrow imaging)
Langerhans cell histiocytosis: staging and follow-up Anatomical MRI relies on size criteria for lymph node involvement
WB MRI at 3 T (increased image quality and lesion conspicuity) Development of hybrid PET/MRI systems (decreases radiation exposure, enhances functional tumor assessment) USPIO-enhanced MRI (improved assessment of lymphoid tissue and bone marrow)
S446
ADC: Apparent diffusion coefficient; CE: Contrast-enhanced; CT: computed tomography; DWI: Diffusion-weighted imaging; DWIBS: Diffusion-weighted whole-body imaging with background body signal suppression; FDG-PET: 18 F-fluorodeoxyglucose positron emission tomography; FS: Fat-saturated; MIP: Maximum intensity projection; MPR: multiplanar reconstruction; MRI: Magnetic Resonance Imaging; SUV: Standardized uptake value; USPIO: Ultrasmall supermagnetic iron oxide Brain tumors in children T A G M Huisman, A Poretti Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore/USA Introduction A frequently used phrase is: “Children are not small adults.” This phrase is valid for pediatric radiology in general and pediatric neuroradiology in particular. Pediatric central nervous system (CNS) tumors have multiple characteristic features that differ significantly from their adult counterparts. What are the main differences between children and adults?
& & & & & &
Clinical symptoms Histology and incidence of tumors CT and MRI imaging characteristics Treatment options Prognosis Neuronal and functional plasticity
Clinical symptoms are determined by various factors, including the age of the child. Each age group has a typical incidence of different kind of tumors (e.g. medulloblastoma in young male children). In addition, the predominant location of histological similar tumors differ between children and adults. Moreover, the ongoing development of the brain and skull (e.g. progressing myelination, open versus closed sutures) determines clinical symptoms. Neonates and young children with a brain neoplasm frequently present with macrocephaly and surprisingly minimal focal neurological deficits. Non-specific symptoms such as failure to thrive and delayed motor development occur. Increased intracranial pressure (ICP) is rarely the leading symptom because of the open cranial sutures. These relatively minor clinical symptoms frequently delay diagnosis and consequently brain tumors are usually large at initial presentation in these age groups. In older children, the classic signs of ICP (nausea, headache, early morning vomiting, diplopia, ataxia) are more frequently encountered because of the progressive fusion of the cranial sutures and fontanels. In addition, focal neurological symptoms become more apparent with older age and are more tightly linked to the primary location of the tumor. Clinical symptoms may include motor or sensory deficits, endocrinological disorders or seizures. The age at time of presentation and the gender of the affected child help to narrow the differential diagnosis. Each age group has its typical tumors; in addition certain tumors are more frequent in boys than in girls. The most frequent posterior fossa tumors are juvenile pilocytic astrocytomas (JPA) (35%), primitive neuro-ectodermal tumors (PNET)/medulloblastoma (25%), brainstem gliomas (25%) and ependymomas (12%). In the
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
supratentorial brain the most frequent tumors include the astrocytomas (30%) followed by craniopharyngeomas (15%) and hypothalamic/optic pathway gliomas (15%). The distribution of supra- versus infratentorial tumors also varies with age. In the first 2 years of life, supratentorial tumors are more frequent than infratentorial tumors; between 2 and 10 years of age, infratentorial tumors outweigh supratentorial tumors while in children 10 years and older, supra- and infratentorial tumors are more or less equally frequently observed. Functional prognosis in children may be better because of the larger functional plasticity at younger age. Treatment options may be more limited, however, because of the higher vulnerability of the developing pediatric brain for the potential deleterious effects of the various treatments. Radiotherapy in particular is frequently contraindicated in very young patients. In addition, radiotherapy may induce secondary neoplasm later in life. Infratentorial tumors The most frequent posterior fossa tumors in children are the cerebellar astrocytoma, PNET/medulloblastoma, brainstem glioma and ependymoma. Many other less frequent tumors may be seen, including atypical teratoid rhabdoid tumor (ATRT), hemangioblastoma, cerebellar gangliocytoma, etc. We will focus, however, on the most frequently encountered tumors.
1. Cerebellar astrocytomas can be subdivided into the more frequent juvenile pilocytic astrocytoma (JPA) and the less common fibrillary and anaplastic astrocytomas, as well as glioblastoma multifome. JPA is a unique form of astrocytoma which manifests rather benign behavior and has a good prognosis if the tumor is recognized early and completely resected. Pilocytic astrocytomas may be seen in neurofibromatosis (NF1) patients. The so-called “epicenter” of the tumor is frequently within the cerebellar vermis, followed in frequency terms by the cerebellar hemisphere. Most children present with a long history of slowly progressing symptoms of increased intracranial pressure or unilateral/asymmetric cerebellar signs. Pilocytic astrocytomas are usually well demarcated, have a solid, strong contrast enhancing tumor component and a cystic component which does not or minimally enhance. The cyst may be significantly larger than the solid tumor nodule. Calcifications are seen in approximately 20% of cases, perifocal vasogenic edema is usually mild or minimal. The tumor typically compresses or displaces adjacent structures including the brainstem and fourth ventricle, resulting in a supratentorial hydrocephalus. Next to the “benign” pilocytic astrocytomas, each grade of astrocytomas (WHO I-IV) may be encountered in the posterior fossa. Lesions may start as a low-grade tumor and de-differentiation into higher grade astrocytomas with time. High-grade or anaplastic astrocytomas may show diffuse infiltrative, ill-defined tumor components. Due to their close proximity to the fourth ventricle and subarachnoid space, they are at risk for leptomeningeal cerebrospinal fluid (CSF) seeding. Consequently spinal metastatic disease should be ruled out. Unfortunately, grade III and IV astrocytomas have a poor prognosis. 2. Medulloblastomas are also known as infratentorial PNET. The majority of lesions originate from the vermis (75–90%); 10– 15% are primarily located within the cerebellar hemispheres
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
(lateral medulloblastoma). In the vermian location, the tumor is located dorsally to the fourth ventricle; the anterior medullary velum and fourth ventricle are pushed anteriorly. Most clinical symptoms are related to an obstructive hydrocephalus as well as tumor infiltration of adjacent cerebellar structures. The tumor is most frequently encountered in the first decade of life (75%) and boys are three times more frequently affected than girls. The lesion is typically hyperdense on CT due to its high cellularity. On MR examination, the tumor is solid, predominantly T1hypointense and T2-iso- or hyperintense. Depending on the histological subtype, various degrees of contrast enhancement are noted. The most important imaging clue for diagnosis is the location of the tumor dorsally to the fourth ventricle, which helps to differentiate the lesion from fourth ventricle ependymomas. However, in advanced stages, the tumor may invade the fourth ventrical, making differentiation difficult. If the fourth ventricle is invaded, CSF seeding of the neuroaxis must be excluded. Spinal imaging should preferably be performed preoperatively, because a mild postoperative leptomeningeal enhancement may mimic tumor seeding. 3. Brainstem gliomas can be classified upon their primary location into (a) diffuse infiltrative brainstem glioma (also known as pontine glioma), (b) exophytic glioma of the medulla oblongata, and (c) tectal glioma. Clinical symptoms are determined by the primary location and degree of infiltration or compression of adjacent functional centers. Gliomas usually develop and grow slowly over a long time period before they become symptomatic. A sudden increase in size is usually an indication for increasing malignant degeneration. Patients may present with isolated or combined cranial nerve palsies as well as ataxia. Because these gliomas grow slowly, hydrocephalus is only encountered late in the course of the disease. Most gliomas are recognized between three and 10 years of age. Long-term prognosis of the diffuse infiltrative brainstem glioma is poor. These brainstem gliomas have a low sensitivity for chemotherapy and the young age of most patients as well as the central location of the tumor usually prevents high dose radiotherapy or surgical exploration/resection. The exophytic glioma of the medulla oblongata has a much more favorable prognosis. Histologically they usually belong to the group of pilocytic astrocytomas and they are more accessible to surgical resection. Tectal gliomas usually have an excellent prognosis, may remain stable for many decades and usually only require symptomatic treatment. The proximity to the Sylvian aqueduct usually results in an obstructive hydrocephalus which can be treated by a ventriculo-peritoneal shunt or a third ventriculostomy. On MRI, most gliomas are T1-hypointense, T2hyperintense and show no or minimal contrast enhancement. Tectal gliomas are usually characterized by a “thick/ bulky” quadrigeminal plate. The exophytic glioma of the medulla oblongata typically appears with a large exophytic component attached to the medulla oblongata. The MR imaging features of the diffuse infiltrative brainstem
S447
glioma are considered to be sufficient to establish diagnosis. Typically, the lesion is centered in a diffuse enlarged pons, preserved fiber tracts may be seen as linear signal intensities within the lesion (especially well seen on T2weighted imaging), the basilar artery is typically embraced and depending on the grade of malignancy, multifocal areas of contrast enhancement may be observed. These gliomas may extend into the lower brainstem as well as into the mesencephalon and diencephalon. 4. Ependymomas typically originate from the ependymal lining of the fourth ventricle (60–70%). In contrast to the medulloblastoma, the “epicenter” of an ependymoma is within the fourth ventricle. Ependymomas rarely infiltrate the vermis, brainstem or cerebellum. Ependymomas typically respect the boundaries of the ventricular system and extend along the various outlet channels of the fourth ventricle (foramen of Luschka and Magendie) along the brainstem into basal cisterns and spinal canal (toothpaste tumor). CSF seeding may occur early due to the intraventricular location. Clinically, most children present with signs of an obstructive hydrocephalus or compression of the brainstem and cranial nerves. On imaging, ependymomas are solid, T1-iso or hypointense, T2-iso- or hyperintense with a variable degree of contrast enhancement. Calcifications are seen in 50 %, cysts in 20% and hemorrhage in 10 % of cases. Supratentorial tumors The most frequent supratentorial tumors include the astrocytoma, craniopharyngeoma, optic pathway gliomas and supratentorial ependymomas and PNET’s. Metastatic disease is rare.
1. Astrocytomas (WHO I-IV) are the most frequent supratentorial tumors in children (30%). Clinical symptoms are determined by the primary location, degree of infiltration and compression of functional centers. Focal functional deficits may be seen next to epileptic seizures and more general signs of increased intracranial pressure. Most pediatric astrocytomas are low grade, however grade IV glioblastoma multiforme occur. Pilocytic astrocytomas are much rarer in the supratentorial brain compared to the posterior fossa. Next to white matter locations, astrocytomas may also be located within the thalami and basal ganglia. On CT and MRI, depending on their WHO grade, the imaging appearance may differ. Lowgrade astrocytomas are T1-hypointense and T2hyperintense with no or minimal contrast enhancement or mass effect. High-grade gliomas typically show an intense, inhomogeneous contrast enhancement with areas of necrosis within the center of the tumor. Diffusion-weighted imaging may be helpful to differentiate between a necrotic tumor and abscess. 2. Craniopharyngeomas are seen in 15% of children. They are most frequently seen between 10 and 14 years of age and are typically located in the sellar/suprasellar region along the axis between hypothalamus and pituitary gland. These tumors most likely originate from residual pluripotent cells during the development of the hypothalamus/
S448
pituitary gland. Clinical symptoms are related to compression of the optic chiasm/optic pathway, pituitary gland/ hypothalamus or infiltration of the connection between hypothalamus and pituitary gland. Craniopharyngeomas are easily identified on CT/MRI. They are usually heterogeneous with solid and cystic components, as well as variable degree of calcifications and contrast enhancement. The sella may be enlarged. 3. Optic pathway gliomas represent a separate group of astrocytomas and are usually seen in NF1-patients. Histologically, they represent pilocytic astrocytomas. Non- or minimally enhancing optic nerve gliomas can be seen next to T2hyperintense, strongly enhancing hypothalamic/chiasmatic tumors. These tumors may be stable for many years but typically present with slowly progressive blindness and pituitary/hypothalamic dysfunction. 4. Supratentorial ependymomas and PNET are rare tumors in childhood. Of all ependymomas, only 20–40% are located within the supratentorial brain. Supratentorial ependymomas are most frequently located within the periventricular white matter; intraventricular ependymomas are much rarer. Local compression may result in trapped ventricles with asymmetrical hydrocephalus. Supratentorial PNET’s are also rare, accounting for less than 5% of all Supratentorial tumours. They are usually large on initial presentation, heterogeneous and may be located within the white matter as well as in the ventricles. Differentiation from other rare tumors like ATRT or intraventricular meningeomas may be challenging.
Brain ultrasound (US) in the neonate C. Veyrac, M. Saguintaah, O. Prodhomme, C. Baud, A. Couture Department of Pediatric Radiology. Arnaud de Villeneuve Hospital. Montpellier/FRANCE
US plays a major role in the detection and management of brain disease in the neonate. The morphological study remains invaluable; it not only uses a convex probe through the traditional anterior fontanel approach, but may also utilize additional techniques. High-frequency probes assist in detecting superficial cortical ischemic damage, differentiating cortical and subcortical involvement, following the change in echostructure of a peripheral lesion, recognizing abnormal gyration or parenchymal deorganisation, and locating extra cerebral collections. Areas that are remote from the anterior fontanel can be displayed through accessory windows: i.e. the mastoid fontanel to image the cerebellum, fourth ventricle and peduncles, and the posterior fontanel to image the parenchyma posterior to the lateral ventricles and finally any cranial suture near a peripheral lesion. Use of color Doppler guides with pulsed Doppler permits detection of colored CSF flow in the aqueduct of Sylvius (intraventricular hemorrhage or ventriculitis) as well as a demonstration of the patency of cerebral arteries and veins.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Pulsed Doppler aids the prediction of the increased risk of intraventricular hemorrhage or severe ischemia in the first postnatal days, following post-hemorrhagic or post-meningitis progressive ventricular dilatation. US examinations may be repeated at bedside in the Intensive Care Unit. US and MRI are complementary tools that should be integrated in the management of the neonate: US for screening and early follow-up, MRI for the complete evaluation and long-term follow-up. Stroke in children: 2012 key points J-F Chateil1, B Husson2, P Bessou1 1 CHU de Bordeaux, Service d’imagerie anténatale, de l’enfant et de la femme, Bordeaux/France 2 CHU Bicêtre, AP-HP, Service de radiologie pédiatrique, Le Kremlin-Bicêtre, Paris/France Ischemic stroke is increasingly recognized as a significant cause of neurological morbidity in children. Etiologies and risk factors are multiple and markedly different from those in adults, particularly in relation to neonatal stroke and infarction in older children. Clinical recognition is difficult as often the presentation mimics other, more frequent neurological disorders. Therefore imaging studies are essential to confirm a positive diagnosis, give etiologic and prognostic direction and assist in the therapeutic approach. Risk factors and causes In newborns, the estimated incidence is 2.5/10,000. Definitive causes of neonatal stroke are as yet unknown, although multiple risk factors have been evinced including inherited or acquired prothrombotic risk factors, coagulopathies and placental pathology. After the neonatal period, the incidence ranges from 0.2 to 1.5/10,000. Many specific causes can be identified, some classic—embolic cardiac diseases, Moyamoya vasculopathy or sickle cell disease. Others have been more recently described as transient cerebral arteriopathy with or without infection (varicella). Arterial dissection with or without trauma, metabolic diseases (MELAS, CADASIL syndromes) and general or primitive CNS vasculitis are less frequent. Although several risk factors often exist, the etiology cannot be identified in 2546% of cases. Cerebral venous thrombosis is also responsible for ischemic stroke in neonates (hypoxic encephalopathy or infection) and in older children (otitis media, mastoiditis, and sinusitis, connective-tissue disorders or chemotherapy). Diagnosis Diagnostic delay is predominately caused by insufficient recognition of stroke symptoms. In neonates, clinical symptoms are non-specific; seizures are a major symptom without motor deficit. Neurological signs may appear during or after the first year of life and the diagnosis is made retrospectively. In older children, a focal neurological deficit, with or without seizures, and a decreased level of consciousness, is the most common presentation. Visual or sensory impairment and ataxia are encountered in vertebra-basilar territory stroke.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Alternatively, acute neurologic deficits, “stroke mimics,” can be related to benign or more severe disorders, of non-vascular origin. Neuro-imaging is mandatory in all cases. Brain MRI should be the first-choice examination in the acute phase. If MRI is not available in the emergency setting, CT is useful to exclude hemorrhage, but may not detect any abnormality. A typical protocol includes T1, Flair and T2-weighted sequences, diffusion imaging, T2* (or susceptibility-weighted imaging) and MR angiography (MRA). A non-contrast T1-weighted axial sequence with fat saturation at the cervical level is useful to demonstrate a crescentic hemorrhage at the vessel wall, suggestive of arterial dissection. MRA, in most cases, is performed with time-of-flight sequences, without dynamic contrast infusion. It is sensitive enough to provide an adequate and sufficient evaluation at the initial stage of arterial brain diseases in childhood. Segmental contrast arterial wall enhancement and the absence of wall hematoma could be presumptive of transient cerebral arteriopathy. Diagnosis of craniocervical arterial dissection may be difficult. Vertebral artery dissections represent a greater diagnostic challenge than carotid dissections. The segment V2-V3 is often involved, without hematoma within the vessel wall. Isolated dissection of the posterior cerebral artery is rare. Conventional catheter cerebral arteriography should be considered in situations in which MRA is normal, when small-artery diseases are suspected, or uncertainties persist regarding the differential diagnosis of internal carotid artery lesions. Basal ganglia infarction may occur without overt angiographic abnormalities. It is often related to either occult intrinsic arteriopathy limited to lenticulostriate arteries or to thromboembolic disease of the carotid arteries with rapid dissolution of emboli. For venous thrombosis, the optimal technique for establishing the diagnosis is MR venography, using 2D or 3D acquisition. Susceptibility-weighted imaging with contrast-enhanced sequences may also be useful. Brain perfusion sequences during contrast infusion is difficult to obtain in neonates, but may be useful in older children to assess ischemic penumbra regions. Arterial spin labeling (ASL) can be performed without contrast injection, to evaluate regional brain perfusion. Experience is limited in children’s stroke and only brain perfusion studies are available for Moyamoya disease. Increased venous contrast using susceptibility-weighted imaging has also been reported in ischemic stroke, although few reports have compared increased venous contrast areas with perfusion change areas. Other proposed techniques include phase-sensitive imaging, flow-sensitive alternating inversion recovery and BOLD (blood oxygenation level dependent contrast) imaging to study the cerebrovascular reactivity and identify patients for surgical revascularization. Alternative imaging techniques Cranial ultrasonography coupled with transfontanellar Doppler is a powerful tool for a noninvasive diagnosis of stroke and venous thrombosis in neonates. Transcranial Doppler may be useful for the assessment of cerebral blood flow velocities in
S449
the circle of Willis in patients with sickle cell anemia and for the diagnosis and follow-up of chronic vasculopathies, such as Moyamoya disease. Prognosis and follow-up Recurrence of stroke in patients with a history of neonatal infarct is very rare. Children with neonatal infarct present with motor impairment at early school age in 30-40% of cases. Prognostic factors detected with diffusion imaging include involvement of the internal capsule and “Wallerian degeneration” of the pyramidal tract. In older children, concomitant ischemic lesions in the basal ganglia, internal capsule and cortex have often been associated with hemiparesis. Recurrence within 5 years has been observed in two thirds of cases with vascular abnormalities (arterial stenosis). In posterior fossa stroke, persistent cognitive deficits can be observed. The lateralization of functions depends upon the cognitive function measured. Dissociation between the lateralization of different language or visual search tasks may occur, and is observed with functional imaging. Nonaccidental trauma. Intracranial injury resulting from child abuse C Adamsbaum 1, B Husson 1, C Rey-Salmon 2 1 CHU Bicêtre, AP-HP, Service de radiologie pêdiatrique, Le Kremlin-Bicêtre, Paris/France 2 Unité Médico Judiciaire, Hôpital Hôtel Dieu, AP-HP, Paris/ France Child abuse is a problem of special concern. Radiologists play a key role in the early diagnosis of “abusive head trauma” (AHT) also called “nonaccidental head injury” (NAHI) or shaken baby syndrome (SBS). The frequency of abuse is difficult to estimate as no one actually knows how many cases go permanently undetected. Child abuse deaths occur mainly from head injuries, and infants who survive often present with severe neurological sequelae. Thus a rapid identification of the diagnosis of AHT is required to safeguard the child and relatives from further injuries. The symptoms and signs of abuse are various and may range from coma to completely asymptomatic children. The main symptoms are seizures (around 60 %) occurring in male infants (sex ratio 1:3), younger than 1 year. Confessions of violent and repetitive shaking are rare at the time of diagnosis. Changing elements of the history provided, previous injuries, bruising in non-ambulatory children and delay in seeking care evoke a high index of suspicion. Associated suggestive lesions must be searched for with care, but may be missing i.e. retinal haemorrhages are present in around 90 % of cases, ecchymoses in around 45 % of patients. The latter are often multiple and located in unusual sites as face, neck, axilla, thorax and/or buttocks in non ambulatory children. Fractures must be investigated with high-detail skeletal survey, but they are actually seen in less than one third of patients. CT is the first diagnostic examination to be used for patients with acute injury. It can reveal not only intracranial haemorrhage, but also fractures (3D reconstructions needed) and soft tissue swelling with a high degree of sensitivity. CT scan allows
S450
assessment of the diagnosis of AHT by demonstrating typical multifocal subdural haematomas located over the cerebral hemispheres, in the interhemispheric fissure and in the tentorium. The predominance of the hyperdensities at the vertex is highly suggestive of the diagnosis of AHT and often corresponds to venous thrombosis that are secondary to the venous ruptures. Contusions and shearing injuries may be encountered, but hypoxic-ischemic changes are considerably more frequent. CT should be repeated after a time interval if the findings are doubtful or if there is a discrepancy with the neurological picture. MRI (including T1, T2, T2*, diffusion sequences and cervical spine examination) is required to fully determine intracranial injury as it can exquisitely demonstrate hypoxic-ischemic injuries by showing areas of cytotoxic oedema. To date, MRI allows the best prognostic evaluation. Thus MRI is recommended in all of symptomatic children by the first week, after CT. MRI should be primarily performed only in totally asymptomatic children in proximity to an index case, to look for subacute injuries and scars. Enlarged subarachnoid spaces can correspond to the evolution of a true subdural hematoma and if an acute increase of the head circumference is noticed a few weeks before imaging, the diagnosis of chronic subdural hematoma should be given priority consideration. Datation is imprecise and overall of no use at the time of the diagnosis of AHT. The pattern of a subdural haematoma is influenced by numerous factors as haemoglobin level or previous hematoma. For example, a hyperdensity may correspond to a bleeding dating from few hours to approximately 10 days; in addition, an heterogeneous pattern may be due to a suracute hematoma; moreover, an old subdural hematoma can become heterogeneous by spontaneous re-bleeding. MRI is not significantly more accurate than CT for dating the hematomas. Nevertheless, MRI can help for dating the parenchymal injuries as diffusion sequences can disclose cytotoxic edema that indicates recent lesions, dating less than around 1 week. However, considering the datation of injuries, the main point is to determine the presence of “age-different” lesions. This not only provides a strong argument for the diagnosis but also suggest repetitive violence and thereby, a high risk for further injury unless protective action is undertaken. In all patients, the radiological reporting has to describe the anomalies, rule out any differential diagnoses (subdural effusions during meningitis, vascular malformations in which the bleeding predominates around the malformation, coagulopathies or glutaric aciduria) and clearly communicate the suspicion of AHT to clinicians. A strong collaboration between radiologists and clinicians is crucial for the hospitalisation of the child as soon as the diagnosis is suspected, and reporting to protection services as soon as the diagnosis of AHT is confirmed, or even highly probable. Brain imaging and skeletal survey must be performed in all siblings younger than 2 years, living in the same conditions as the index case. Fetal head and neck: pre-postnatal imaging correlation E Vasquez Pediatric Radiology Department Hospital Infantil Vall d’Hebron, Barcelona/Spain The diagnosis of prenatal head and neck anomalies requires a meticulous imaging approach using both ultrasound (US) and
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
magnetic resonance (MR) imaging techniques. In addition to diagnostic purposes, the imaging findings will provide a guide to prenatal planning and fetal or neonatal surgical treatment. US is a noninvasive technique that has become a standard component of prenatal care. Advances such as 3D imaging enable postprocessing to provide surface-rendered images of the fetal head and neck region, and cinematic sequences. Fetal MR imaging provides complete evaluation of the anomalies noted on US, confirms inconclusive US findings, detects other anomalies that may change the fetal prognosis or maternal management, and aids in planning fetal surgery if necessary. It has an important current role in evaluating various craniofacial and cervical lesions. In this presentation, the main conditions involving the fetal head and neck region will be reviewed with particular emphasis on technical protocols, differential diagnosis and implications for perinatal management. Conditions such as craniofacial malformations (craniosynostosis, nasal anomalies, cephaloceles, cleft palate, ear or eye anomalies, tracheal agenesis), vascular conditions (hemangioma, lymphatic malformations), and tumors (teratoma, nasal glioma) will be shown, with the main clues for pre- and postnatal management. Prenatal ultrasound diagnosis of craniosynostosis may be suspected when the cephalic index, cranial shape or face shape are abnormal, usually only after the second trimester in most cases. 3D US is an optional step to enhance display of the cranial sutures and obtain 3D volume reconstruction of the fetal head and face, improving the fetal bonding and prenatal counseling. MR imaging proved to be of value in the prenatal diagnosis of craniosynostosis, and in the detection of associated brain abnormalities, which is an important predictive factor. Fetal karyotype is recommended, including gene mapping for fibroblast growth factor receptors (FGFRs) to reach an appropriate molecular diagnosis. Lymphangiomas, which are located in the neck and the lower face in 75–80% of cases, are the main vascular conditions seen prenatally in this region. As the mass enlarges during gestation, it may lead to airway compression, with high morbidity and mortality. Assessment of the extension of the mass and direct visualization of both the larynx and trachea is difficult on US. Fetal MR imaging shows the fluid-filled airway (amniotic fluid), provides a better estimation of the severity of airway obstruction, possible extension into the thorax, involvement of diverse head and neck regions (tongue, parotid gland, orbits), and establishes the relationship between the mass and the neck vessels. Congenital hemangioma (CH) is the infantile hemangioma that develops prenatally and is completely developed at birth, with no subsequent postnatal increase in size. Two courses have been identified within this tumor population: rapidly involuting CH (RICH), which generally involutes spontaneously, and noninvoluting CH (NICH). The head and neck region is the second most commonly affected by teratomas. They are often large, bulky masses originating in the cervical, palate, or nasopharyngeal areas and containing both cystic and solid elements. Calcifications, seen in only half the cases, are diagnostic. Polyhydramnios is a common, important associated finding in cervical and oral teratomas and is the result of a direct mass effect. Cervical teratomas can cause dramatic hyperextension of the fetal neck, resulting in malpresentation and dystocia. They may be associated with other malformations in 6% of cases, mainly with cleft palate because the tumor prevents palate closure. A teratoma is termed
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
“epignathus” when it is located in the oral cavity. Most epignathi are unidirectional and protrude from the mouth but some protrude bidirectionally and affect the brain tissue. Exclusion of intracranial extension is part of the preoperative management. By filling up the mouth and nasal cavity, epignathi cause substantial obstruction of the upper airways, and are a lifethreatening condition at the time of delivery. Prenatal diagnosis is the most important step for meticulous perinatal planning. A substantial improvement in survival can now be achieved by using the ex utero intrapartum treatment (EXIT) procedure. Aberrant embryogenesis leads to three main congenital midline nasal masses: nasal dermoid, anterior cephalocele, and nasal glioma. Accurate antenatal diagnosis is important because the prognosis and management of these lesions are completely different. Cephaloceles commonly cause hypertelorism and a broad nasal bridge. Demonstration of the boney defect with continuity of herniated tissue and/or fluid with the brain is crucial to the diagnosis and is better seen with MR imaging. Associated CNS anomalies may be also identified. Nasal glioma comprises of dysplastic, neuroglial and fibrovascular tissue, with a fibrous stalk representing a relic of the intracraneal connection in 15% of cases. The lesion tends to grow during gestation, and appears postnatally as a well circumscribed, bluish or reddish mass that is often misdiagnosed initially as capillary hemangioma. Although nasal glioma may show a vascular component, it can be easily differentiated from the high flow vessels seen in proliferative infantile hemangioma by MR imaging. Our experience suggests that MR imaging complements US in the accurate diagnosis of fetal head and neck abnormalities, and better evaluates the fetal airway for deciding in utero therapy, delivery planning and perinatal management. Petrous bone imaging in children A Rossi, MD Neuroradiology Department, G. Gaslini Children’s Hospital, Genoa/ Italy Background: Hearing loss (HL) is a frequent reason for CT and MR imaging studies performed in children. However, a generic request of neuroimaging studes for “HL” is not sufficient. The radiologist should require the clinician to specify whether HL is unilateral (and which side is involved) or bilateral, and whether it is sensorineural (SNHL), conductive (CHL), or mixed. This will influence the imaging approach, which is primarily based on a combination of CT and MRI for SNHL or mixed HL, and on CT for CHL. Sensorineural hearing loss (SNHL) In SNHL, CT detects only approximately 20% of causes. Thus, MRI is often the first-line imaging study. The MRI protocol should always include thin-slice (1 mm or less), heavily T2-weighted images obtained with adequate techniques (ie T2 DRIVE, CISS, FIESTA), which allow for a superb delineation of the membranous labyrinth of the inner ear, inner acoustic canal (IAC) with the VIIVIII cranial nerve complex, and cerebellopontine angle cistern. These sequences can be reformatted on any plane, but direct inplane acquisition offers significant advantages in terms of spatial resolution. Because the acoustic lemniscus projects to the Heschl’s
S451
gyrus in the temporal lobe, MRI studies in patient with SHNL should not focus on the inner ear only, but include the whole pathway. Contrast material may be administered where applicable. Unilateral SNHL is usually caused by acoustic schwannomas in adults. However, this lesion is uncommon in children except for bilateral schwannomas in the setting of neurofibromatosis type II. Unilateral enhancing mass lesions involving the pediatric IAC are rare and usually of other histologies, including capillary hemangiomas in PHACE syndrome. Most cases of uni- or bilateral SNHL in children are caused by malformations of the inner ear. These, in turn, depend on the timing of the derangement in the development of the inner ear, which starts at 23 days with the formation of the otic placode, proceeds with the otic pit (24 days) and otic vesicle (27 days) stages, and subsequently with the appearance of the vestibular and cochlear pouches and, finally, of the semicircular canals, of which the lateral is the last one to appear. The adult size and configuration is reached by the middle of the fetal period (20–22 weeks), and any derangement at intermediate stages will result in a different kind of malformation. Early stage derangement, including the Michel aplasia (complete aplasia of the inner ear) and the common cavity, are relatively rare. Midstage derangements are more common and include the incomplete partition types I (cystic appearance of cochlea and vestibule) and II, formerly known as Mondini malformation (1.5 cochlear turns, dilated vestibule and vestibular aqueduct). Although CT adequately depicts these malformations, MRI has the advantage of the absence of ionizing radiation and the possibility to assess the presence of the cochlear nerve, a critical issue for management planning which cannot be resolved by CT alone. Moreover, MRI must be used to look for associated abnormalities and syndromic complexes, in particular the CHARGE association which it also comprises. Among other abnormalities, orbital colobomas which must be scrutinized during the same MRI study. Among causes of SNHL in children, the large vestibular aqueduct syndrome (LVAS) is the most common. In LVAS, HL is initially mild, worsens stepwise, and deteriorates with trauma or intercurrent disease, CT and MRI show a markedly enlarged vestibular aqueduct, mono-or bilaterally; MRI also shows the dilated endolymphatic sac protruding into the cerebellopontine angle cistern. Conductive hearing loss (CHL) Causes of CHL can be categorized into congenital (i.e. malformations) and acquired (i.e. otitis and otomastoiditis). Congenital aural aplasia (CAA) is the main cause of congenital CHL. It is characterized by stenosis (types 1 and 2) or atresia (types 3 and 4) of the external acoustic canal, and it is very commonly associated with anomalies of the middle ear and mastoid. This is due to the common embryological origin of the anterior part of the external ear, incus and malleus from the first branchial arch, and the posterior part of the external ear and the stapes from the second branchial arch. CAA is unilateral in 70% of cases, and bilateral in the remainder; it can be isolated or syndromic (Goldenhar, Klippelfeil, Treacher-Collins, and other syndromes). In CAA, CT must be used to carefully scrutinize for associated ossicular anomalies which include incudomalleal fixation and stapes dislocation. The course of the facial nerve must also be carefully evaluated, especially looking for dehiscent courses which may cause problems during ontological surgery.
S452
Acquired CHL is mainly cause by otitis, otomastoiditis, and related complications. Acute otitis/otomastoiditis is caused by pharyngeal germs which colonize the middle ear through the Eustachian tuba. Acute otitis/otomastoiditis is a clinical diagnosis that does not require imaging studies for confirmation; the clinical course is usually short, and the process terminates because of the host’s immune system, the infection-resistant properties of the mucosal linings, and antibiotic treatment. However, a small proportion of untreated or inadequately treated patients may experience complications which can be a threatening disease and must be diagnosed promptly. Intratemporal complications include incipient mastoiditis, in which infection is restricted to the mucoperiosteal compartment, and coalescent mastoiditis, in which the bone is involved. From this stage, extratemporal complications may ensue, including Bezold’s abscesses, sigmoid sinus thormbophlebitis, cerebellar abscess, and Lemierre syndrome. Contrast-enhanced CT is required in the study of complicated mastoiditis to rule out these potentially life-threatening complications; MRI plays a complementary role for confirmation of the diagnosis. Chronic otomastoiditis is caused by the persistence of inflammation in the middle ear cavity leading to mucosal thickening and occlusion of the Eustachian tube. This, in turn, causes retraction of the tympanic membrane at the pars flaccida with development of chronic inflammation which, eventually, may lead to the formation of a cholesteatoma. The Prussak space at the anterior epitympanic recess is the most common location for acquired cholesteatomas, although other locations in the tympanic cavity and petrous bone cells are also possible. Cholesteatomas are characterized on CT as discrete masses causing bone resorption (typically with amputation of the scutum) and ossicular demineralization. Labrynthine or facial nerve fistulae must be carefully ruled out since they may be the source for recurrent meningitides. In doubtful cases, MRI is useful to discriminate a cholesteatoma from aspecific inflammation; a cholesteatoma gives restricted diffusion and does not enhance with contrast material administration. MRI is also useful in the post-surgical follow-up in operated cases. Conclusions In conclusion, neuroimaging is a powerful tool for the characterization, management planning, and follow-up of both congenital and acquired petrous bone pathology in children. A careful history-taking and correlation with the clinician are of paramount importance to correctly choose the imaging technique and recognize the various conditions. Profound knowledge of anatomy and embryology is necessary to properly address this difficult, fascinating area. The pituitary gland in children C Garel1, J Léger2 1. Department of Radiology, Hôpital d’Enfants Armand-Trousseau, Paris/France 2. Department of Endocrinology, Hôpital Robert-Debré, Paris/France Magnetic resonance imaging is the imaging gold standard for evaluating the pituitary gland. Detailed MRI analysis is essential and must include the analysis of both the neuro- and adenohypophysis and the pituitary stalk. Depending on a
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
child’s age and clinical symptoms, particular pathologies can be predicted. In neonates The adenohypophysis demonstrates marked T1 hyperintensity and has a similar appearance to the neurohypophysis. The pituitary gland is convex, sometimes pear-shaped. Unexplained hypoglycaemia at birth may reveal growth hormone deficiency (GHD) and should prompt a search for hypothalamopituitary (HP) axis abnormalities such as ectopic posterior lobe (EPL) and non-visible stalk. MRI of the HP axis is also necessary in cases of midline cerebral or cranio-facial malformation. In children The adenohypophysis demonstrates an intermediate T1 intensity. The bright spot of the neurohypophysis is usually clearly visible. The pituitary height ranges from 3 to 6 mm prepubertally. The maximum transverse diameter of the pituitary stalk should not exceed 2 mm. The diagnosis of GHD is suggested by short stature or persistent growth failure. GHD may be isolated (IGHD) or associated with multiple pituitary hormone deficiencies (MGHD). Different gene mutations have been reported to be associated with GHD, exhibiting various clinical and imaging phenotypes with possible associated cerebral and facial malformations. In most cases, GHD is idiopathic. There is no correlation between the size of the pituitary gland and the severity of the endocrine defect. The adenohypophysis may be normal or hypoplastic, more commonly observed in IGHD. In patients with MGHD, severe hypoplastic adenohypophysis is observed more frequently and is associated with EPL either with a nonvisible (EPL located at the median eminence) or a hypoplastic (EPL located anywhere along the stalk) pituitary stalk. Associated cerebral and non cerebral malformations may be present in up to 52% of cases. In children and adolescents Clinically, craniopharyngioma present most frequently with headaches, visual field defects, decreased visual acuity, nausea/vomiting, growth failure and delayed puberty. The median age at presentation is 10 years. The adamantinomatous tumours are predominantly cystic (T1-hyperintense) and intraor supra-sellar in location. The squamous-papillary tumours are mainly solid and located predominantly in the supra-sellar compartment. The cystic portion is T1-hypointense. Solid portions enhance after contrast administration. With Computed Tomography (CT), calcifications are observed in up to 93% of cases. Clinically children with a Rathke cleft cyst (RCC) may present with headache and visual symptoms. According to the series, a variable percentage of cases are incidental findings. The median age at presentation is also highly variable according to the series, ranging from 4 to 16 years. The RCCs become symptomatic when they are large (about 16 mm). The RCCs arise in the region of the pars intermedia between the adeno- and the neurohypophysis. They may be intra-sellar only or may also have a supra-sellar extension. Small intra-sellar cysts (<3 mm) cannot be differentiated from pars intermedia cysts. Over time, protein concentration increases within
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
RCCs, resulting in an increase in T1 intensity. No calcification or solid enhancement is observed. The RCCs may spontaneously increase or decrease in size, and may even involute. In some cases, it may be difficult to differentiate with imaging RCCs from craniopharygiomas. In adolescents The adenohypophysis undergoes physiological enlargement and its height may reach 10–12 mm in girls and 8 mm in boys. In case of pubertal failure, the MR appearance of the HP axis is usually normal, depending on the aetiology. Hypogonadotrophic hypogonadism may be associated with congenital olfactory deficit in Kallmann’s syndrome. MRI can show absent or hypoplastic olfactory bulbs and sulci. In central precocious puberty, the pituitary gland is usually enlarged within the pubertal range. MRI can demonstrate possible associated lesions such as a hypothalamic hamartoma, hydrocephalus, a supra-sellar arachnoid cyst or a chiasm glioma. Adenomas Pituitary adenomas are rare in teenagers and are much more frequent in adults. Most adenomas are secreting tumors and at diagnosis are already quite large. Prolactinomas are the most common, while ACTH- and GH-secreting tumors are rarer. The ACTH-secreting adenomas are more commonly observed in prepubertal children. Clinical symptoms are mostly related to the consequences of mass effect and/or endocrine dysfunction: headache, visual impairment, secondary amenorrhea or oligomenorrhea, growth arrest, delayed puberty, obesity and galactorrhea. Typically, adenomas demonstrate an iso-or slightly hypo- T1 intensity and an iso-or slightly hyper- T2 intensity. Haemorrhage may be responsible for changes in intensity. Scanning must be performed immediately after contrast administration as adenomas enhance initially less than normal pituitary parenchyma and therefore exhibit relative hypointensity. Lesions smaller than 3–4 mm may be difficult to detect. At any age Central diabetes insipidus (CDI) is rare in children. Loss of the neurohypophysis bright spot is the imaging hallmark of CDI. It is observed in all cases except for familial CDI and chronic neurogenic hypernatremia. Idiopathic CDI represents up to half of cases of CDI. Identified causes include Langerhans’ cell histiocytosis (LCH), intracranial tumors (germinomas, craniopharyngiomas and post-resection, post-traumatic CDI and lymphocytic infundibuloneurohypophysitis. Tuberculosis and sarcoidosis are exceptional in children. The size of the adenohypophysis is variable. Pituitary enlargement is strongly suggestive of germinoma. Hypoplastic adenohypophysis is common and often associated with pituitary stalk thickening (PST). PST is observed in almost one third of children with CDI and may be observed in any part of the stalk. It may change in size over time and resolve spontaneously. The natural course of CDI with PST is unpredictable. MRI should be repeated and tumor markers (β-human chorionic gonadotropin and α-fetoprotein) should be studied in the cerebrospinal fluid. The appropriate timing for a diagnostic neurosurgical procedure is discussed according to the follow-up clinical and imaging data.
S453
Liver vascular anomalies: imaging and treatment J Dubois Department of Medical Imaging, CHU Sainte-Justine-Mother and Child University Hosptial Center Montreal/Canada Despite recent literature addressing the classification of vascular anomalies, improper terminology is often used, leading to inappropriate description of imaging studies and, sometimes, to the misdiagnosis of vascular anomalies. For instance, in adults the term “liver hemangioma” continues to be erroneously applied instead of “venous malformation.” Based on vascular anomalies’ classification by Mulliken and Glowacki in 1982, vascular anomalies are divided into vascular tumors (cellular proliferation and hyperplasia) and vascular malformations (lesions that arise by dysmorphogenesis and exhibit normal endothelial turnover). This classification is reported for skin and soft tissue but can be applied for organ involvement as well. The most frequent liver vascular tumors in infancy are infantile hemangiomas. Congenital hemangiomas (RICH: rapidly involuting congenital hemangiomas), hemangioendotheliomas and sarcomas are other vascular tumors rarely seen. Vascular malformations are classified as slow- and high-flow malformations. Slow-flow malformations include capillary malformations, venous malformations, lymphatic malformations, capillary-venous malformations, and capillary-lymphatic-venous malformations, and as high-flow malformations, including arteriovenous fistula and arteriovenous malformations (AVM). Liver hemangioma Liver hemangioma includes infantile and congenital hemangioma. The differentiation is indeed often impossible to make because: a) there is no biopsy in most instances to look for Glut-1 marker, b) contrary to skin lesion it is usually not known if the hepatic lesion is present at birth or not, and c) we do not even know if liver hemangioendothelioma exists or not in the pediatric age group. Infantile hemangioma is the most frequent pediatric tumor affecting 4–5% of infants, characterized by rapid postnatal proliferation from 3 to 12 months, followed by a variable period of stability, and finally, by a period of slow involution (2 to10 years). Subtype classification of liver hemangiomas includes: focal lesions, multifocal lesions, and diffuse lesions. FOCAL LESIONS are frequently found at birth or on prenatal ultrasound. Most focal liver hemangiomas are asymptomatic and occur in the absence of skin hemangioma. They can be associated with mild thrombocytopenia and anemia. The Glut-1 (glucose transporter isoform) marker is negative. This focal liver hemangioma usually corresponds to cutaneous RICH. RICH characteristically regresses in an accelerated fashion by 12 to 14 months and does not stain positive for Glut-1, a marker of common infantile hemangioma. On US, a well-defined hypo- or hyperechoic lesion is seen. The echotexture is sometimes heterogeneous and related to the central hemorrhage or necrosis. Color Doppler US demonstrates a variety of flow patterns depending on the presence of microshunt, portosystemic or arteriovenous shunt. These shunts are clinically significant only when associated with cardiac failure. On MR, the lesion is well-defined, solitary, hypointense on T1- and hyperintense on T2weighted images without peripheral edema. Postgadolinium, the
S454
tumor shows centripetal enhancement and may contain internal vascular flow voids. Heterogeneous signal on all sequences is seen if hemorrhage, thrombosis and/or necrosis are present. Calcifications may occur in about 16% of cases. MULTIFOCAL LESIONS are frequently associated with multiple cutaneous infantile hemangiomas with Glut-1 positive marker. Many of them are asymptomatic; however depending on the presence of arteriovenous or portosystemic shunts, life-threatening complications such as congestive heart failure require immediate treatment. On US, small multifocal lesions are homogeneous and most are hypoechoic, although hyperechoic nodules may occur. The hepatic arteries and veins generally appear enlarged. Large feeding arteries and draining veins are seen in and around the vascular tumors. Direct arteriovenous or portovenous shunts may be seen. On MR, multiple nodular tumors present with T1 hypointense and T2 hyperintense signal, as well as homogeneous enhancement after gadolinium injection. Flow voids are seen due to large hepatic arteries or veins. Aortic tapering distal to the celiac trunk is a good indicator of increased hepatic flow, and a predictor of cardiac overload risk. DIFFUSE LESIONS present with numerous small lesions in the liver leading to severe hepatomegaly, abdominal compartment syndrome, hypothyroidism due to overproduction of type III iodothyronine deiodinase, cardiac failure, and mental retardation. The enlarged infiltrated liver reveals numerous hypoechoic lesions. MR imaging findings are similar to the focal and multifocal lesions. Symptomatic liver hemangiomas have been treated with propanolol and/or corticosteroids followed by interferon-α-2a or vincristine. Catheter embolization is recommended for patients with cardiac failure related to arteriovenous or portosystemic shunts in association with medical treatment. In patients with diffuse lesions, medical treatment is recommended, including the treatment of hypothyroidism. Liver transplantations are reported in life-threatening liver hemangioma. Differential diagnoses include hepatoblastoma, metastatic neuroblastoma, and mesenchymal hamartoma. Vascular malformation of the liver The most common liver vascular malformations are venous malformations (misnamed hemangiomas in adults), isolated congenital liver shunts, and shunts associated with hereditary hemorrhagic telangiectasia (HHT). VENOUS MALFORMATIONS of the liver are uncommon in children and most of them are asymptomatic. They are seen in patients with Blue Rubber Bleb nevus syndrome, which is a familial condition with multiple venous malformations of the skin associated with glomangiomas. ISOLATED CONGENITAL LIVER SHUNTS are divided in three types: the hepatic artery to the hepatic vein (arteriovenous or arteriohepatic shunt), the hepatic artery to the portal vein (arterioportal shunt) and the portal vein to the systemic circulation (portosystemic or portohepatic shunt). Liver arteriovenous malformations are very rare and most of them are associated with hemangiomas or hemangioendotheliomas with high output heart failure. Congenital arterioportal malformations are also very rare and cause portal hypertension. It is discovered in the first year of life with splenomegaly, hypersplenism and/or variceal hemorrhage. Diagnosis is done by Doppler ultrasound. Treatment is embolization of the
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
feeding artery. In cases of embolization failure, liver transplantation is an option. Congenital portosystemic shunt is a rare vascular malformation that leads to severe complications: cholestasis, liver hypertension, portosystemic encephalopathy, heart failure, liver tumors and/or hepatopulmonary syndrome. Two types are described: extrahepatic and intrahepatic. Extrahepatic shunt is represented by a direct communication of the portal trunk or one of its branches of origin to the inferior vena cava or one of its branches. Intrahepatic shunt is located between a) the portal vein or one or several of its branches, and b) the inferior vena cava or a hepatic vein including the ductus venosus. Doppler color ultrasonography is the best modality to determine the shunt. Before treatment, CT angio and/or MRA are recommended to evaluate the shunt and plan the treatment. Some intrahepatic shunts may regress spontaneously, other remain asymptomatic. After 2 years of age, because of the severity of the complications, closure of a congenital portosystemic shunt is recommended. Shunts can be closed by endovascular approach, surgery or liver transplantation. Depending on the level of portal pressure and the intrahepatic portal branches, surgery is performed in 1 step (<32 mmHg small portal branches) or 2 steps (> 32 mmHg with hypoplastic or not visible portal branches). The three types of shunt may coexist, particularly in patients with HHT. HHT or Rendu-Osler-Weber syndrome is a rare genetic disease with an autosomal dominant inheritance pattern characterized by cutaneous, visceral arteriovenous malformation involving lung, intestine, brain and/or liver. Hepatic vascular malformation is found in 41–74% of HHT affected subjects. Symptomatic liver vascular malformations occur in about 8% of HHT patients who have hepatic abnormalities. Most of the symptoms appear during adult age with the presentation of high-output heart failure, portal hypertension and biliary ischemia. Doppler ultrasonography has the highest diagnostic accuracy to characterize the type of shunt or malformation, and intrahepatic vascularization. CT-scan angio is useful to determine the size of the shunt and for the planning of embolization treatment. No treatment is recommended for patients with asymptomatic liver involvement by HHT. In symptomatic patients, medical treatment is the first choice. Endovascular treatment or surgery are performed in patients with high output heart failure, portal hypertension, and mesenteric steal syndrome. Improvement or resolution of symptoms are transient with significant morbidity and mortality related to biliary and/or hepatic necrosis. Orthotopic liver transplant has been proposed as the only definitive curative option for liver involvement in HHT.
Imaging tuberculosis in children—alpha to the omega S Andronikou Department of Radiology, Faculty of Health Sciences, University of the Witwatersrand, Cape Town/South Africa Introduction: Diagnosis of Tuberculosis (TB) in children is challenging even considering all available tests - including Mantoux, gastric aspirate microscopy, culture and gene amplification techniques. Imaging is often the only support for a clinical diagnosis of TB. Understanding pathogenesis, recognising imaging findings and
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
awareness of differences relevant to children using traditional and modern techniques is important for making decisions. Pulmonary TB The organism usually enters the lungs. Isolated intrathoracic lymphadenopathy indicates contained “primary complex disease” while lymphadenopathy in combination with parenchymal consolidation suggests uncontained pulmonary TB. Miliary disease represents blood borne TB with distant spread.
a) Plain radiographs: The radiographic hallmark of primary
b)
c)
d)
e)
pulmonary TB is mediastinal and hilar lympadenopathy. Even though widely available, plain chest radiographs have low/ moderate sensitivity and specificity for lymphadenopathy in children and also have wide inter-observer variability. Practitioners still use lateral radiographs, but this has failed to improve diagnostic accuracy. The most reliable feature of lymphadenopathy appears to be the presence of airway compression on adequately performed radiographs. CT scanning: CT is a more accurate tool for detecting lymphadenopathy. Two-thirds of TB lymph nodes show enhancement on CT scanning, characterized either by a low-density, ring-enhancing appearance; or fine curvilinear enhancement within matted group of nodes called “ghost-like enhancement.” The sub-carinal group is most commonly enlarged, but the paratracheal region, the hilar and the azygooesophageal lymph nodes are commonly involved. However CT carries a high radiation dose. MDCT, combi-scanning and post processing: Multidetectorrow spiral computed tomography (MDCT) allows for “combiscanning” and post-processing, including three-dimensional volume rendering. Combi-scanning produces a high-resolution CT during a conventional CT study without additional radiation or time spent. This is important for identifying milliary TB or the interstitial disease associated with HIV co-infection. Three dimensional volume rendering (3-D VR) has a sensitivity of 92% and specificity of 85% for detecting bronchial narrowing from lymphadenopathy and may demonstrate significant obstruction of airways inaccessible to bronchoscopy. MRI: MRI is attractive for paediatric mediastinal imaging but anaesthesia for MRI presents a risk in children with comorbidities, and long-term neurodevelopmental complications. T2 and short T1 inversion recovery (STIR) sequences are useful for detecting lymphadenopathy showing a characteristic low signal of TB necrosis in lymphadenopathy and areas of lung necrosis. Ultrasound: Because ultrasound is cheap, easy to use, mobile, and carries no radiation risk, it offers a “point-of-care” solution for TB diagnosis. TB lymphadenopathy is easily detectable in accessible areas such as the abdomen, neck and axilla. Diagnosis of PTB (pulmonary tuberculosis) using abdominal lymphadenopathy as a surrogate for mediastinal lymphadenopathy results in a 6% improvement in the rate of lymphadenopathy detection, playing an adjunctive role in developing countries. Recent work using ultrasound of the mediastinum in children via the suprasternal approach diagnosis showed lymphadenopathy in 67 % of children with normal chest radiographs.
S455
Things you may not know a) Lymphobronchial TB and its complications: Lymphobronchial tuberculosis describes tuberculous lymphadenopathy involving the airways: the resulting compression occurs in 38% of children with TB. Evolutionary changes occur in the parenchyma distal to the airway compression—starting as consolidation / collapse, progressing through “drowned lung” to necrosis and eventual cavitating lung destruction. CT of children with lymphobronchial TB shows that airway compressions are more severe in infants and most commonly involve the bronchus intermedius (causing parenchymal complications on the right). Imaging can direct endoscopic or transthoracic airway decompression and prevent lung destruction.
b) Multi-drug-resistant tuberculosis (MDR TB): Imaging plays a role in identifying lesions contributing to drug resistance such as large cavities, which harbor mycobacteria within an area where there is limited drug penetration. Patients with drug-resistant TB more commonly show multiple cavities and bronchiectasis. Demonstration and localization of cavities on CT is important for planning surgery. Extrapulmonary TB A. CNS TB: CNS TB: Tuberculosis can affect the brain and spinal cord both focally and diffusely. It is also a common imaging referral for acquired epilepsy/seizure and the commonest cause for bacterial meningitis in developing countries. a) Focal TB lesions of the CNS: Tuberculomas are the commonest focal CNS TB lesions resulting in seizure (>95 %). They are typicallly iso- or hyperdense centrally on CT, and are usually < 2 cm in size with ring or discoid enhancement and moderate surrounding oedema. On MRI the characteristic feature is low signal on T2. On T1 they are iso-intense to cortex and ring or discoid enhancement is seen. An alternative lesion is a tuberculous abscess which is rare (<5 %), and is > 2 cm in size, has a low density centre with ring enhancement. On MRI it has low signal on T1 and high signal on T2 and is therefore inseparable from pyogenic abscesses and tumours. Tuberculosis meningitis (TBM) may also present as focal basal enhancement with or without associated infarction/border zone necrosis and even meningeal-based tuberculomas. b) TB meningitis: CT diagnosis of TBM requires a combination of basal enhancement, hydrocephalus and infarction. However, hyperdensity in the basal cisterns on non-contrast scans is the most specific feature for TBM (100%) but is not widely used. The most sensitive feature of TBM is basal enhancement (89%). Objective criteria of basal enhancement on CT in children with suspected TBM have been described to improve detection. These include the “Y-sign,” “double lines,” “nodular enhancement,” “join the dots,” ‘contrast filling the cist e r n s ’ , a n d ‘ a s y m m e t r y. M R I d e m o n s t r a t e s b a s a l enhancement with greater sensitivity than CT and determines prognosis more accurately by detecting acute infarction. CT has equal capability of detecting hydrocephalus, which solidifies its role in the acute setting for distinguishing those patients who would benefit from neurosurgical drainage.
S456
Things you may not know a) Miliary TBM: Miliary tuberculosis is not an incidental MRI finding in TBM and suggests that it plays an integral part in the pathogenesis. A miliary distribution of nodules has been demonstrated in 88% of children with confirmed TBM on enhanced MRI. These nodules are leptomeningeal in all patients and are sometimes also located deep in the parenchyma. b) Brainstem disease: A significant percentage of children with TBM have ischemic brainstem lesions only demonstrated with MRI scanning. These brainstem ischemic lesions correlate with severe clinical deficit on presentation and poor long-term outcome. c) Cranial nerve enhancement: Cranial neuropathies occur in up to 27% of children with TBM. The optic, oculomotor and abducens nerves are frequently affected. Gadolinium enhanced MRI may demonstrate cranial nerve enhancement of these. Early diagnosis of optochiasmic arachnoiditis in particular is important as some patients benefit from neurosurgical decompression or thalidomide therapy. d) Borderzone necrosis: Borderzone necrosis (BZN) in TBM occurs in brain parenchyma adjacent to meningeal inflammation. Diffusion-weighted imaging (DWI) has confirmed BZN in 50% of patients with TBM (mainly involving the temporal lobes). The severity and extent of basal enhancement in the middle cerebral artery cisterns correlates with the presence of BZN. e) Absent posterior pituitary bright spot: the syndrome of inappropriate antidiuretic hormone secretion (SIADH) contributes to the morbidity and mortality in children with tuberculous meningitis (TBM). T1-weighted MRI shows absence of the normal posterior pituitary bright spot in 55% of children with TBM. There is no significant correlation, however, with serum sodium status or the severity of the disease, but there is a correlation between absent posterior pituitary bright spot and developmental outcome at 6 months. f) HIV complicating TB: HIV infection predisposes children to tuberculosis, increases the risk of progression to active disease and increases the risk for extrapulmonary involvement, including TBM. HIV related immune dysfunction, however, prevents the production of thick exudates that cause parenchymal infarctions and CSF flow obstruction. It could be said therefore that HIV maybe “protective” to some of the common complications related to TBM. When antiretroviral treatment is started and immunity is restored, the severity of TBM meningitis will begin to manifest and this may be matched by more prominent imaging findings, including the development of detectable complications. g) Automated diagnosis of TBM: A CAD (computer-aided diagnostic tool) for predicting TBM in children with
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
symptoms is desirable for any CT scan facilities in developing countries lacking pediatric radiologists, and for developed countries with radiologists who have little expertise in diagnosing infectious diseases for their immigrant populations. Automated detection of TBM features such as basal enhancement, pre-contrast cisternal density, hydrocephalus and infarctions is currently possible. B. Abdominal TB Abdominal TB manifests with lymphadenopathy (most common), ascites, multifocal organ lesions, omental “cakes,” bowel wall thickening and complex masses involving a combination of bowel, lymph nodes and omentum. Lymphadenopathy is commonest in the para-aortic region and porta hepatis and may show low density with rim enhancement or calcification on CT. Mesenteric nodes show a typical stellate appearance on axial images through splaying the mesenteric vessels and displacing bowel to the periphery. Organ lesions may be solitary or multiple, may be low density and ring-enhanced or may be calcified. Ultrasound is excellent for diagnosing ascites and some of the other features but CT detects all the features in one study to better advantage. Retroperitoneal disease affects the adrenals and kidneys with calyceal and ureteric stricturing, papillary necrosis and cavitation and eventually fibrosis, calcification and autonephrectomy. Pelvic involvement including the ovaries is also encountered. MRI has some advantages, especially for substituting intravenous pyelography in the evaluation of the renal collecting system and the ureters. C. Muskuloskeletal TB Musculoskeletal involvement by TB is rare in comparison to other TB locations. It most commonly involves the spine but can also involve large weight-bearing joints, long bones, the skull and the soft tissues. When diagnosis depends on imaging appearances alone, there is always a differential diagnosis, including other infections and malignancies. Awareness of TB as a possible cause of vertebral body lesions, large joint arthritis / synovitis, long bone lesions and soft-tissue collections will allow clinicians to consider TB as a diagnosis and will sometimes be characteristic enough to allow for a trial of therapy, thereby avoiding biopsy. Conclusion: TB can involve any part of the body and therefore a wide variety imaging studies may be requested from a radiologist. Understanding the pathogenesis and complications of the disease allows for more accurate and timely diagnosis which can prevent destruction of vital organs including the lungs and brain, and which can result in the death of a child. It is our responsibility to diagnose this disease, whether for our own populations or those from other countries, to help combat this ancient, prevalent and deadly disease.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S457
49th Annual Meeting of the European Society of Paediatric Radiology Wednesday 30 May 2012 Registration, 08:00–18:00. ESPR Officers Meeting, 08:30–10:30. Room: Santorini. Pediatric Radiology Journal Meeting, 10:45–12:00. Room: Santorini. Opening Ceremony, 13:00–13:30. Room: Terpsichore A. Scientific Session 1: Chest-Cardiovascular, 13:30–15:30. Room: Terpsichore A. Chaired by : E Alexopoulou, G Enriquez Civicos 13:30–13:37
1 - SP: Does lateral view improve the accuracy of chest radiographs in identifying lung metastases in children with Wilms tumour? Cheng Xie1, Øystein Olsen2, Catherine Owens2 1
13:37–13:44
University of Birmingham; 2Great Ormond Street Hospital, London (United Kingdom)
2 - SP: Assessment of neonatal chest radiograph quality; a comparison between three health professional groups Hayley Danielle Cameron, Samuel Stafrace Royal Aberdeen Children’s Hospital (United Kingdom)
13:44–13:54
3 - LP: Assessing progression in cystic fibrosis: a novel approach Robert Cleveland1, David Zurakowski1, Dubhfeasa Slattery2, Andrew Colin3 1 3
13:54–14:04
Children’s Hospital, Boston (United States); 2Childrens University Hospital, Dublin (Ireland); Miller School of Medicine, Miami (United States)
4 - LP: Differences in the pattern of structural lung abnormalities on CT in patients with cystic fibrosis and pancreatic sufficiency and insufficiency Natalia Simanovsky, Malena Cohen-Cymberknoh, Eitan Kerem, Nurith Hiller Hadassah Medical Center, Jerusalem (Israel)
14:04–14:14
5 - LP: The complementary role of high resolution computed tomography and flexible bronchoscopy in childhood chronic cough Aggeliki Nikopoulou, Konstantinos Douros, Argyro Mazioti, Gerasimos Kremidas, Ioannis Arapakis, Georgios Velonakis, Konstantinos Priftis, Efthymia Alexopoulou Attikon Hospital, University Of Athens (Greece)
14:14–14:21
6 - SP: Interstitial lung disease in children: high-resolution CT findings in 14 patients proven histopathologically Xinyu Yuan, Huizhong Chen, Jizhen Zou, Rongyan Huang Capital Institute of Pediatric, Beijing (China)
S458
14:21–14:31
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
7 - LP: Computed Tomography demonstration of the complications and associations of lymphobronchial Tuberculosis in children Susan Lucas1, Savvas Andronikou1, Pierre Goussard 2, Robert Gie2 1
14:31–14:41
University of the Witwatersrand, Johannesburg; 2Stellenbosch University (South Africa)
8 - LP: Incidence and acute complications of asymptomatic central venous catheter-related deep venous thrombosis in critically ill children Cicero Silva1, Philip Spinella2, Simon Li3, Matthew Pinto3, Petronella Stoltz4, Joana Tala5, Mary Card1, Veronika Northrup1, Kenneth Baker1, Thomas Goodman1, Lei Chen1, Edward Faustino1 Yale University School of Medicine, New Haven; 2Washington University, St. Louis; 3Maria Fareri Children’s Hospital, Valhalla 4Connecticut Children’s Medical Center, Hartford 5Yale-New Haven Children’s Hospital, New Haven (United States)
1
14:41–14:48
9 - SP: Interrupted aortic arch: CT findings Tetyana Yalynska, Raad Tammo, Ievgeniia Iershova, Nadya Rokitska, Oleksandr Kondrachuk Ukrainian Children’s Cardiac Centre, Kyiv (Ukraine)
14:48–14:55
10 - SP: The role of CT in pediatric patients with congenital heart disease: new clinical and radiological perspectives using high-pitch dual source spiral acquisition Aurelio Secinaro1, Benedetta Leonardi1, Silvia Cacaci2, Giacomo Pongiglione1, Paolo Tomà1 1
14:55–15:02
Bambino Gesù Pediatric Hospital, Rome; 2Policlinico Gemelli, Rome (Italy)
11 - SP: Cardiovascular magnetic resonance (CMR) in patient with repaired tetralogy of Fallot: the gold standard in assessment of injectable pulmonary V-valve implantation and follow up Aurelio Secinaro1, Benedetta Leonardi1, Stefano Marianeschi2, Giacomo Pongiglione1, Paolo Tomà1 1
15:02–15:09
Bambino Gesù Pediatric Hospital, Rome; 2Niguarda Hospital, Milan (Italy)
12 - SP: Gd-free MRA in coarctation—can ce-MRA be replaced? Peter Kalmar, Erich Sorantin Medical University Graz (Austria)
15:09–15:16
13 - SP: Imaging congenital heart disease (CHD) in paediatric patients by high field open (HFO) 1.0 Tesla MRI scanner: a pictorial essay Dimitra Loggitsi1, Georgia Papaioannou1, Ioannis Spandonis2, Nikolaos Kritikos1, Aphrodite Tzifa1 1
15:16–15:23
Mitera Maternity and Children’s Hospital, Athens; 2Philips Healthcare (Greece)
14 - SP: Antenatal cardiac sonography: a systematic approach Manish Bajaj1, Mukesh Garg1, Tushar Chandra2, Amit Gupta3 Geetanjali Medical College, Udaipur, (India); 2Childrens Hospital of Wisconsin (United States); 3 Ravindra Nath Tagore Medical College, Udaipur (India) 1
15:23–15:30
15 - SP: Use of multidetector CT for asessing anatomical relation of tracheobronchial and cardiovascular anomalies associated with left pulmonary artery sling Xihong Hu, Guoying Huang, Mier Pa Children’s Hospital of Fudan University, Shanghai (China) R16: 64-slice multidetector computed tomography assessment of coronary artery lesions in children with Kawasaki disease: initial experience Xihong Hu, Guoying Huang, Mier Pa, Qiong Yao Children’s Hospital of Fudan University, Shanghai (China)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S459
Task Force 1: Uroradiology, 13:30–15:15. Room: Terpsichore B. Coffee break, 15:30–16:00. Room: Terpsichore D. Scientific Session 2: Urogenital, 16:00–18:00. Room: Terpsichore A. Chaired by : M Raissaki, K Darge 16:00–16:07
17 - SP: Unilateral hydronephrosis: morphological findings in MR urography Kassa Darge, Leslie LeCompte, Melkamu Adeb, Dmitry Khrichenko, Sarah Lambert, Pasquale Casale The Children’s Hospital of Philadelphia (CHOP) (United States)
16:07–16:17
18 - LP: Unilateral hydronephrosis: functional results in MR urography Kassa Darge, Leslie LeCompte, Melkamu Adeb, Dmitry Khrichenko, Sarah Lambert, Pasquale Casale The Children’s Hospital of Philadelphia (CHOP) (United States)
16:17–16:24
19 - SP: Morphological and functional assessment of pediatric urinary tract abnormalities by MRU George Hadjidekov, Violeta Groudeva University Hospital Lozenetz, Sofia (Bulgaria),
16:24–16:34
20 - LP: Supranormal differential renal function in unilateral hydronephrotic kidney: insights by functional MR Urography Claire Sanavi, Jean-Nicolas Dacher, Jérome Caudron, Michael Dolores, Agnès Liard, Pierre-Hugues Vivier University Hospital of Rouen (France)
16:34–16:41
21 - SP: Functional MR urography for assessment of obstructive and reflux uropathies Martin Stenzel, Martin Freesmeyer, Ioannis Diamantis, Ulrike John, Hans-Joachim Mentzel University Hospital Jena (Germany)
16:41–16:51
22 - LP: Contribution of URO-MRI and laparoscopy to the management of challenging urological pathology in children Beatrice Damasio, Chiara Mattiuz, Girolamo Mattioli, Sara Costanzo, GianMarco Ghiggeri, Gian Michele Magnano Istituto Giannina Gaslini, Genoa (Italy)
16:51–16:58
23 - SP: Does an additional sequence during MR Urography provide more information regarding pyelonephritic changes in children? Katerina Dailiani, Thomas G Maris, Maria Bitsori, Sofia Koukouraki, Maria Raissaki University Hospital of Heraklion (Greece)
16:58–17:05
24 - SP: Acoustic radiation force impulse (ARFI) quantification of the renal parenchymal stiffness in paediatric patients with vesicoureteral reflux: preliminary results Costanza Bruno, Salvatore Minniti, Giuliana Caliari, Roberto Pozzi Mucelli University Hospital of Verona (Italy)
17:05–17:12
25 - SP: Diffusion-weighted imaging of the kidneys in patients with haemolytic uremic syndrome (HUS): initial findings. Jochen Herrmann, Ulrich Wenzel, Stephanie Galler, Jun Oh, Markus Kemper, Sebastian Loos, Knut Helmke, Gerhard Adam, Christian R. Habermann University Clinic Hamburg-Eppendorf (Germany)
17:12–17:19
26 - SP: Adequacy of paediatric renal tract ultrasound requests and reports Nishentha Govender, Savvas Andronikou, Matthew Goodier University of Witwatersrand, Johannesburg (South Africa)
S460
17:19–17:26
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
27 - SP: Ultrasonography of inguinal abnormalities in girls: experience acquired through 178 cases Magali Saguintaah, Olivier Prodhomme, Julie Bolivar Perrin, Catherine Baud Montpellier University Hospital (France)
17:26–17:33
28 - SP: Rare causes of pelvic pain in infancy and adolescence: hydrosalpinx vs isolated tubal torsion Cinzia Orazi, Paola Marchetti, Maria Chiara Lucchetti, Roberta Lombardi, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy)
17:33–17:43
29 - LP: Disorders of sexual development (DSDs): the role of imaging Cinzia Orazi, Massimiliano Silveri, Marco Cappa, Paolo MS Schingo, Carla Bizzarri, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy)
17:43–17:53
30 - LP: Multiplanar contrast-enhanced US measurement of tissue perfusion in a rabbit model of testicular torsion Harriet Paltiel1, Carlos Estrada1, Ahmad Alomari1, Carlo Passerotti1, Richard Lee1, Gregory Clement2 1
17:53–18:00
Children’s Hospital Boston; 2Brigham and Women’s Hospital, Boston (United States)
31 - SP: Role of spinal cord MRI in bladder dysfunction where clinical examination is normal Shyam Mohan, Srikanth Boddu, John Somers, Katherine Halliday, Nigel Broderick Nottingham University Hospitals NHS Trust (United Kingdom) R32: New chances in the diagnosis of female puberty: a cut off for the uterine artery pulsatility index Pier Luigi Paesano, Caterina Colantoni, Elena Di Rosa, Gianni Russo, Stefano Mora, Alessandra Dilascio, Francesco De Cobelli, Alessandro Del Maschio San Raffaele Hospital, Milan (Italy) R33: Doppler sonographic renal resistance index in children with acute pyelonephritis Eugenia Vranou, Savas Deftereos, Aggelos Tsalkidis, Athanasios Chatzimichael, Panos Prassopoulos Democritus University of Thrace, Komotini (Greece)
Task Force 2: Functional Imaging, 16:00–16:40. Room: Terpsichore B. Welcome reception, 20:00. Pool area.
Thursday 31 May 2012 Registration, 08:00–17:30. Scientific Session 3: Digestive, 08:00–10:00. Room: Terpsichore A. Chaired by : C Koumanidou, E Kis 08:00–08:07
34 - SP: Umbilical vein catheter tip—slight lateral shift can indicate liver perforation Alan Oestreich Cincinnati Children’s Hospital (United States)
08:07–08:17
35 - LP: Liver stiffness measurement using supersonic shear imaging: feasibility and comparison with liver biopsy in the assessment of liver fibrosis in children Stéphanie Franchi-Abella, Lucie Corno, Monique Fabre, Emmanuel Gonzales, Danièle Pariente Hôpital Bicêtre, Paris (France)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
08:17–08:27
S461
36 - LP: Detection of primary sclerosing cholangitis (PSC)-type lesions in children with inflammatory bowel disease via MRCP: a relative risk measures analysis Polis Xenophontos1, Themistoklis Spyridopoulos2, Nikos Economopoulos1, Konstantina Spyrou1, Christina Kontopoulou1, Christina Tsompanlioti1, Eleftheria Roma3, Efthymia Alexopoulou1 General Hospital Attikon, Athens; 2Penteli’s Children Hospital, Athens; 3 “Agia Sofia” Children’s Hospital, Athens (Greece)
1
08:27–08:34
37 - SP: Secretin has uncertain value in pediatric MRCP Andrew Trout, Alexander Towbin, Daniel Podberesky Cincinnati Children’s Hospital (United States)
08:34–08:41
38 - SP: Imaging and interventional radiology in congenital porto-systemic shunts Aikaterini Kanavaki, Mehrak Anooshiravani, Barbara Wildhaber, Valerie Mc Lin, Sylviane Hanquinet, Sylvain Terraz University Hospital of Geneva (Switzerland)
08:41–08:48
40 - SP: Has ultrasound reduced the need for radioisotope scans in the investigation of neonatal conjugated jaundice? Terry Humphrey, William Ramsden, Patricia McClean, Sanjay Rajwal, Suzanne Davison, Naved Alizai Leeds Children’s Hospital (United Kingdom)
08:48–08:55
41 - SP: Ultrasonographic diagnosis of gastric or duodenal ulcers in children Kwanseop Lee Hallym University Hospital, Chuncheon (Republic of Korea)
08:55–09:02
42 - SP: Ultrasound exclusion of malrotation in babies with duodenal atresia/stenosis Shadi Abdar Esfahani1, David Yousefzadeh2 1
09:02–09:12
Massachusetts General Hospital, Boston; 2University of Chicago (United States)
43 - LP: External manual reduction with US assistance: a new procedure for pediatric idiopathic ileocolic intussusception Jose Vazquez, Margarita Montero, Maria Doniz, Manuel Ortiz Complejo Hospitalario Xeral Cies, Vigo (Spain)
09:12–09:19
44 - SP: Deep sedation during pneumatic reduction in intussusception Anat Ilivitzki, Luda Gluzman, Ahuva Engel Rambam Medical Center, Haifa (Israel)
09:19–09:23
45 - SP: Transient self-limiting intussusception of the small-bowel: more frequent than suspected? Cinzia Orazi, Maria Barbieri, Paola Marchetti, Laura Cursi, Paolo MS Schingo, Andrea Magistrelli, Antonino Reale, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy)
09:23–09:30
46 - SP: MR imaging of the normal appendix in children with suspected inflammatory bowel disease Arzu Kovanlikaya, Daniel Rosenbaum, Madhu Mazumdar, Allison Dunning, Paula Brill NewYork Presbyterian Hospital, Weill Cornell Medical College, New York (United States)
S462
09:30–09:40
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
47 - LP: Faecal incontinence following correction of anorectal malformations: MR and rectal manometry correlations Sergio Salerno, Jessica Giordano, Anna Caruso, Livia Bruno, Antonio Lo Casto Policlinic Hospital, University of Palermo (Italy)
09:40–09:50
48 - LP: Diffusion-weighted MRI of abdominal and soft tissue abscess formations in children and young adults Henning Neubauer, Isabel Platzer, Verena Mueller, Thomas Meyer, Johannes Liese, Herbert Koestler, Dietbert Hahn, Meinrad Beer University Hospital Wuerzburg (Germany)
09:50–10:00
49 - LP: Imaging investigation of liver structure and hepatic perfusion changes in pediatic patients with chronic diffuse liver diseases Boris Tarasyuk, Iryna Dykan, Elena Polischuk Scientific and Practical Center of Radiology NAMS (Ukraine) R50: Evaluation of hepatic diffusion and perfusion values in healthy children by means of multi-b DWI Sara Savelli, Antonio Ciccarone, Marco Esposito, Anna Perrone, Marco Di Maurizio, Claudio Fonda Meyer Children’s Hospital, Florence (Italy)
Task Force 3: Child Abuse, 08:00–09:00. Room: Terpsichore B. Coffee break, 10:00–10:30. Room: Terpsichore D. Special Lecture, 10:30–11:00. Room: Terpsichore A. Chaired by : G Sebag, G Chrousos The application of Hippocratic Principles to Pediatric Radiology Bruce Parker, San Francisco/USA Symposium: Brain and spinal MR: from the technique to application, 11:00–13:00. Room: Terpsichore A. Chaired by : F Brunelle, E Sorantin 11:00–11:30
Optimizing imaging protocols C Malamateniou, London/UK
11:30–12:00
Diffusion tensor imaging of the head and Spine T Huisman, Baltimore/USA
12:00–12:30
Functional MRI: How and when to do it P Brader, Vienna/AU
12:30–13:00
A primer in in-vivo and ex-vivo MR Spectroscopy LG Astrakas, Ioannina/GR
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S463
Lunch, 13:00–14:00. Room: Thalia. Satellite Symposium Bracco, 13:00-13:30 Room: Terpsichore A. Mini Course, 14:00–15:00. Room: Terpsichore A. Chaired by : G Sebag 14:00–14 :20
How to write a pediatric radiology original article: tips & tricks
14:20–14 :40
How to write a pediatric radiology case report: tips & tricks
Ø Olsen, London/UK V Donoghue, Dublin/IE 14:40–15 :00
2010 Pediatric Radiology survey R Van Rijn, Amsterdam/NL
ESPR Lecture, 15:15–16:00. Room: Terpsichore A. Chaired by : C Owens Strives for International Radiology Education: The European Experience N Gourtsoyiannis Athens/GR Coffee break, 16:00–16:30. Room: Thalia, Terpsichore D. ESPR General Assembly, 16:30–17:30. Task Force 4: Oncology, 17:30–19:00. Room: Terpsichore B. Scientific Session 4: Musculoskeletal, 17:30–19:30. Room: Terpsichore A. Chaired by : P Kosta, K Rosendahl 17:30–17:40
51 - LP: Conventional MRI sequences are inaccurate when assessing bone destruction in children with juvenile idiopathic arthritis Lil-Sofie Ording Muller1, Peter Boavida2, Beatrice Damasio3, Karen Lambot4, Clara Malattia (Ospedale Gaslini, Genova), Laura Tanturri (Ospedale Pediatrico Bambino Gesù), Karen Rosendahl5 University Hospital North Norway, Tromsø (Norway); 2Homerton University Hospital NHS Foundation Trust, London (United Kingdom); 3Ospedale Gaslini, Genoa (Italy); 4Hopital Necker, Paris (France), 5 Haukeland University Hospital, Bergen (Norway)
1
17:40–17:50
52 - LP: Juvenile idiopathic arthritis with dry synovitis: clinical and imaging aspects in a cohort of 6 patients Karen Lambot1, Lien De Somer2, Sylvain Breton1, Carine Wouters2, Brigitte Bader-Meunier1, Francis Brunelle1 1
Hopital Necker, Paris (France); 2University Hospitals Leuven (Belgium)
S464
17:50–18:00
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
53 - LP: A new MR quantitative approach to assess inflammation and damage in children with juvenile dermatomyositis Chiara Mattiuz1, Beatrice Damasio2, Luca Nocetti3, Clara Malattia2, Silvia Pederzoli1, Gian Michele Magnano1 1
18:00–18:10
Istituto Giannina Gaslini, Genvoa; 2Ospedale Gaslini, Genova; 3Policlinico di Modena (Italy)
54 - LP: Juvenile dermatomyositis: MRI findings regarding acute inflammation and damages Karen Lambot, Sylvain Breton, Catherine Bourget, Caroline Elie, David Grevent, Laureline Berteloot, Christine Barnerias, Christine Bodemer, Brigitte Bader-Meunier, Francis Brunelle Hôpital Necker-Enfants Malades, Paris (France)
18:10–18:20
55 - LP: The utility of DWI sequences in the diagnosis of non-traumatic acute musculoskeletal pain Afshin Alavi, May-ai Seah, Shema Hameed, Maria Nordlander, Risha Hathi, Joanna Danin St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom)
18:20–18:30
56 - LP: Garches muscle whole-body MRI (WB-MRI) protocol: pattern recognition in early onset neuromuscular disorders Robert-Yves Carlier1, Daniela Avila-Smirnow1, Dominique Monpoint1, Brigitte Estournet1, Pierre Carlier2, Susana Quijano-Roy1 1
18:30–18:40
Hôpital Raymond Poincaré, Paris; 2Hôpital Pitié Salpêtrière, Paris (France)
58 - LP: Rib fractures in metabolic bone disease of prematurity Michael Jackson, Simon McGurk, Maeve McPhillips Royal Hospital for Sick Children, Edinburgh (United Kingdom),
18:40–18:50
59 - LP: Associations between femoroacetabular impingement and hip dysplasia as demonstrated radiographically. Preliminary results. Lene B Laborie, Ingvild Engesaeter, Trude G Lehmann, Lasse B Engesaeter, Karen Rosendahl University of Bergen and Haukeland Hospital (Norway)
18:50–19:00
60 - LP: The paediatric cervical spine: a guide to image interpretation in major trauma Maria Nordlander, Shema Hameed, Afshin Alavi, May-ai Seah, Joanna Danin St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom)
19:00–19:10
61 - LP: Radiography of scoliosis: comparative dosimetry and evaluation of image quality between a dynamic flat detector and a slot-scanning system Marianne Yvert1, Abou Diallo1, Pierre Bessou1, Muriel Brun1, Jean-Luc Réhel2, Jean-François Chateil1 1
19:10–19:20
University Hospital Pellegrin, Bordeaux; 2IRSN Fontenay aux Roses (France)
62 - LP: Replacing conventional spine radiographs with dual energy x-ray absorptiometry (DXA) in children with suspected reduction in bone density Lucy Summers1, Penny Broadley2, Isla Lang2, Amaka Offiah2 1
19:20–19:30
University of Sheffield; 2Sheffield Children’s Hospital NHS Foundation Trust (United Kingdom)
63 - LP: Novel assessment of fracture risk in children using finite element (FE) analysis of lateral spine dual energy absorptiometry (DXA) scans. Lucy Summers1, Chuhee Lee1, Lang Yang1, Amaka Offiah2 1
University of Sheffield; 2Sheffield Children’s Hospital NHS Foundation Trust (United Kingdom)
R64: Pediatric Knee: MR imaging in non-traumatic conditions Manish Bajaj1, Tushar Chandra2, Amit Gupta3, Shalini Bajaj1 Geetanjali Medical College (India); 2Childrens Hospital of Wisconsin (United States); 3Ravindra Nath Tagore Medical College, Udaipur (India)
1
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
S465
Concert, 20:00. Agios Dionysios Aeropagitis Church Friday 1 Jun 2012 Registration, 08:00–17:30. Scientific Session 5: Oncology-Miscellaneous, 08:00–10:00. Room: Terpsichore A. Chaired by : S Defteraios, RA Nievelstein 08:00–08:10
65 - LP: Whole-body MRI, including DWI, compared to FDG-PET/CT for staging malignant lymphoma Malou Vermoolen1, Ignasi Barber2, Claudio Granata3, Annemieke Littooij4, Goya Enriquez2, Bart De Keizer1, Erik Beek1, Judit Adam5, Jozsef Zsiros5, Thomas Kwee1, Marc Bierings1, Rutger Jan Nievelstein1 University Medical Center Utrecht (Netherlands); 2Hospital Universitari Vall d’Hebron Barcelona (Spain); Ospedale Giannina Gaslini Genova (Italy); 4KK Women’s and Children’s Hospital Singapore (Singapore); 5 Academic Medical Center Amsterdam (Netherlands)
1
3
08:10–08:17
66 - SP: Imaging findings in posttransplantation lymphoproliferative disorder in children - 8 cases Ildikó Várkonyi, Anna Nyitrai, Éva Kis Semmelweis University Budapest (Hungary)
08:17–08:27
67 - LP: Imaging findings in progressive transformation of germinal centers: a retrospective study of 23 patients Heba Takrouri, Jeffrey Traubici, Furqan Shaikh The Hospital for Sick Children, Toronto (Canada)
08:27–08:34
68 - SP: Radiological information for rhabdomyosarcoma (RMS) patients in the European pediatric soft tissue Sarcoma Study Group (EpSSG). Kieran McHugh1, Gianluca de Salvo, Michael Stevens, Gianni Bisogno 1
Great Ormond Street Hospital, London (United Kingdom); 2University of Padua (Italy); 3Bristol Children’s Hospital (United Kingdom); 2University of Padua (Italy) 08:34–08:41
69 - SP: Radiological information on non-rhabdomyomatous soft tissue sarcomas (NRSTS) within the European pediatric soft tissue Sarcoma Study Group (EpSSG). Kieran McHugh1, Gianluca de Salvo2, Michael Stevens3, Gianni Bisogno2 Great Ormond Street Hospital, London (United Kingdom); 2University of Padua (Italy); 3Bristol Children’s Hospital (United Kingdom); 2University of Padua (Italy) 1
08:41–08:48
71 - SP: Diffusion imaging findings of pediatric brain tumors Amit Agarwal, Kanupriya Vijay Pennsylvania State University (United States)
08:48–08:55
72 - SP: Infantile hepatoblastoma: comparative analysis of ultrasonographic and surgical pathology manifestations Xinyu Yuan, Yingzi Su, Fengsen Bai, Jizhen Zou Capital Institute of Pediatrics, Beijing (China),
08:55–09:02
73 - SP: US-guided percutaneous needle biopsy as the main diagnostic tool in pediatric oncology Anat Ilivitzki, Maya Abu Gazala, Ayelet Ben Barak, Sergey Postovsky, Marc Arkovitz, Nira Arad, Diana Gaitini, Miriam Ben Arush Rambam Health Care Campus, Haifa (Israel)
S466
09:02–09:09
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
74 - SP: Improvement of the efficacy of radiation oncology by using new imaging technology Vasiliki Diakatou, Dimitrios Demenagas, Evrydiki Patriki, Christina Lappa, Apostolia Christakaki, Zoi Pemma, Neratzoula Kallia, Maria Andreou, Adam Kouvelis, Maria Synodinou Panagiotis & Aglaia Kyriakou Children’s Hospital, Athens (Greece)
09:09–09:19
75 - LP: High-pitch spiral CT: scan time and patient dose for abdominal oncologic imaging Andrea Magistrelli, Vittorio Cannatà, Roberta Lombardi, Marco Cirillo, Teresa Corneli, Mauro Rebuzzi, Paolo Tomà Bambino Gesù Pediatric Hospital, IRCCS, Rome (Italy)
09:19–09:26
76 - SP: Chest and abdomen iterative CT: threshold image quality in pediatric protocols Antonio Ciccarone1, Sara Savelli1, Marco Di Maurizio1, Annamaria Didona2, Giovanna Zatelli3, Claudio Fonda1 Meyer Children’s University Hospital; 2University of Florence; 3Azienda Sanitaria Firenze, Florence (Italy)
1
09:26–09:36
77 - LP: Comparison between conventional autopsy and post-mortem MRI in fetuses: preliminary results—GRRIF (Groupe Radiopédiatrique de Recherche en Imagerie Foetale) Eléonore Blondiaux1, Marie Cassart2, Marie Brasseur-Daudruy3, Marianne Yvert4, Céline Rozel5, Marianne Alison6, Anne Larroque7, Antoinette Gelot1, Christina Antal1, Marie Gonzales1, Catherine Garel1 Hôpital Armand Trousseau, Paris; (France), 2Hôpital Erasme, Bruxelles (Belgium), 3University Hospital, Rouen (France); 4University Hospital Pellegrin, Bordeaux (France), 5University Hospital of Rennes (France); 6Hôpital Robert Debré, Paris (France); 7 University Hospital of Lyon (France) 1
09:36–09:43
78 - SP: Paediatric Trauma Imaging: the challenges faced in a major trauma centre Shema Hameed, Maria Nordlander, Nadeeja Koralage, May-ai Seah, Rebecca Salter, Afshin Alavi, Joanna Danin St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom)
09:43–09:50
79 - SP: Radiology beyond imaging—are we in safe hands? An audit of hand hygiene Joan Adiotomre, Patricia Fenton, Thuzar Win Sheffield Childrens Hospital (United Kingdom)
09:50–10:00
80 - LP Pediatric hematologic malignancies: is hypoechoic periportal cuffing the tip of the iceberg? Marina Vakaki, Anastasia Garoufi, George Karapostolakis, Despina Grigoraki, Xristos Argiris, Kleanthie Kalogerakou, Chris Koumanidou “P & A.Kyriakou” Children’s Hospital, Athens (Greece) R81: Post-transplant lymphoproliferative disease in children: main diagnostic challenges. Silvia Rocha, Natally Rocha, Andrea Ferme, Marcia Matsuoka, Bety Chisman, Gisele Almeida Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil)
Task Force 5: Neuro, 08:00–08:30. Room: Terpsichore B. Coffee break, 10:00–10:30. Room: Terpsichore D. Launch of the ESPR Research Committee, 10:30–12:00. Room: Terpsichore B. Scientific Session 6: Head & Neck-Antenatal, 10:30–13:00. Room: Terpsichore A. Chaired by : S Ryan, JF Chateil 10:30–10:40
82 - LP: Inferior vermian hypoplasia—preconception, misconception Ashley Robinson BC Children’s Hospital, Vancouver (Canada)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
10:40–10:47
S467
83 - SP: Fetal MRI of posterior fossa in a high-field open magnet Georgia Papaioannou, Dimitra Loggitsi, Ilias Kampas, Panagiotis Trimis, Nikolaos Kritikos Mitera Maternity and Children’s Hospital, Athens (Greece)
10:47–10:57
84 – LP: Clinical predictors of punctate white matter lesions in premature babies Areti Charisiadi, Aikaterini Drougia, Persefoni Margariti, Eleni Evaggelidou, Anastasia Zikou, Aikaterini Ntoulia, Loukia C Tzarouchi, Styliani Andronikou, Maria I Argyropoulou University of Ioannina (Greece)
10:57–11:07
85 - LP: Correlation between MR imaging of the brain and biochemical abnormalities of children with oxidative phosphorylation disorders Pablo Caro, Veronica Donoghue, Stephanie Ryan, Ahmad Monavari Temple Street Children’s Hospital, Dublin (Ireland)
11:07–11:14
86 - SP: Relationship between body growth and regional gray matter volume changes in extremely premature small for gestational age babies Loukia C Tzarouchi, Aikaterini Drougia, Anastasia Zikou, Areti Charisiadi, Paraskevi Kosta, Loukas Astrakas, Styliani Andronikou, Maria I Argyropoulou University of Ioannina (Greece)
11:14–11:21
87 - SP: Paediatric brain cortical abnormalities: DTI and TBSS analysis Claudio Fonda, Antonio Ciccarone, Marco Esposito, Marzia Mortilla Meyer Children’s Hospital, Florence (Italy)
11:21–11:31
88 - LP: Corpus callosum thickness on MRI as a surrogate marker of white matter volume in children with HIV and its correlation with developmental scores Savvas Andronikou1, Christelle Ackermann2, Barbara Laughton2, Els Dobbels2, Steve Innes2, Reghana Taliep2, Ronald van Toorn2, Mark Cotton2, Bruce Spottiswoode3, John Pettifor1 University of the Witwatersrand, Johannesburg; 2University of Stellenbosch; 3University of Cape (South Africa)
1
11:31–11:38
89 - SP: Can apparent diffusion coefficient (ADC) predict the clinical aoutcome in drowned children? Adrian Hrusca1, Andreea Rachisan1, Erich Sorantin2, Siegfried Rödl2 Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca (Romania); 2Medical University Graz (Austria)
1
11:38–11:48
90 - LP: Feasibility study to assess clinical applications of 3T Cine MR coupled with synchronous audio during speech in evaluation of velopharyngeal insufficiency (VPI) in children Pallavi Sagar, Katherine Nimkin Massachusetts General Hospital (United States)
11:48–11:55
91 - SP: Pediatric brain MRI with susceptibility weighted imaging (SWI) at 1.5 and 3T Sara Savelli, Marzia Mortilla, Anna Perrone, Claudio Fonda Meyer Children’s Hospital, Florence (Italy)
11:55–12:05
92 - LP: Intraoperative MRI (IoMRI) of brain tumors in children: feasibility and results, comparison with post-operative follow-up imaging Guilherme Cassia, Jean-Pierre Farmer, Jose-Luis Montes, Jeffrey Atkinson, Josee Melancon, Christine Saint-Martin Montreal Children’s Hospital (Canada)
12:05–12:15
93 - LP: Improved detection of postlaminar optic nerve infiltration with MRI in children with retinoblastoma—initial results Selma Sirin, Marc Schlamann, Norbert Bornfeld, Markus Holdt, Sophia Goericke University Hospital Essen (Germany)
S468
12:15–12:22
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
94 - SP: Syndromic and complex craniosynostosis: volumetric analysis of the fossa posterior and the cerebellum Bianca Rijken, Irene Mathijssen, Maarten Lequin Academic medical Center, Rotterdam (Netherlands)
12:22–12:29
95 - SP: Diagnostic value of three-dimensional ultrasonographic imaging of neonatal brain Kriengkrai Iemsawatdikul, Preeyacha Pacharn, Nucharee Chotipanvittayakul, Chirawat Sudla Siriraj Hospital, Bangkok (Thailand)
12:29–12:36
96 - SP: Dynamic magnetic resonance (MR) study of the hypothalamo-pituitary region in patients with Langerhans cell histiocytosis (LCH) Janice Ip, Wendy WM Lam, PT Cheung, SY Ha, GCF Chan Queen Mary Hospital, HKSAR (Hong Kong)
12:36–12:46
97 - LP: Ectopic thymic tissue in thyroid loggia: description of 87 cases in pediatrics Pier Luigi Paesano, Elena Di Rosa, Caterina Colantoni, Giovanna Weber, Marianna Di Frenna, Alessandro Del Maschio San Raffaele Hospital, Milan (Italy)
12:46–12:53
98 - SP: Ultrasound to diagnose orbital complications of ethmoid sinusitis. A series of 73 children. Anne Geoffray, Myriam Guesmi, Beatrice Leloutre, Corinne Boyer, Claire Grech, Carole Leroux, Marco Albertario, Claude Maschi Fondation Lenval, Nice; University Hospital of Nice; University Hopistal Lenval, Nice (France)
12:53–13:00
99 - SP: Can ultrasonography be considered trustworthy in diagnosing maxillary sinusitis in children? Otilia Fufezan1, Vasiliki Bizimi2, Carmen Asavoaie3, Diana Feier3, Paraschiva Chereches Panta1 IIIrd Pediatric Clinic, Cluj-Napoca; 2General University Hospital Attikon (Greece); 3Emergency County Hospital, Cluj-Napoca (Romania) 1
R100: MR Venogram evaluation of cerebral venous sinuses in children: Pearls and Pitfalls Madhu kumar Singhal1, Tushar Chandra2, Manish Bajaj3; Amit Gupta1 1 3
Ravindra Nath Tagore Medical College (India); 2Childrens Hospital of Wisconsin (United States); Geetanjali Medical College (India);
R101: Imaging of term and preterm infants using a 3 Tesla MR-compatible incubator—initial experiences Selma Sirin, Britta Huening, Ursula Felderhoff-Mueser, Bernd Schweiger University Hospital Essen (Germany) Task Force 6: Dose, 12:30–13:00. Room: Terpsichore B. Lunch, 13:00–14:00. Room: Thalia. Satellite Symposium Philips, 13:00–14:00. Room: Terpsichore A. Top ten lessons from my life, 14:00–16:00. Room: Terpsichore A. Chaired by : B Parker 14:00–14:25
The fetus F Rypens, Montreal/CA
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
14:25–14:50
S469
The pediatric brain F Brunelle, Paris/FR
14:50–15:15
The pediatric chest C Owens, London/UK
15:15–15:40
The abdomen P Toma, Vatican/VA
15:40–16:00
The bones K Oudjane, Toronto/CA
Coffee break, 16:00–16:30. Room: Terpsichore D. Scientific Session 7: Dose—Safety, 16:30–18:00. Room: Terpsichore A. Chaired by : C Owens, J Kalef Ezra 16:30–16:40
102 - LP: Evaluation of dose and image quality of neonatal chest x-rays when using an incubator detector tray Thorsten Köhler, Thomas Angell Augdal, Arne Erikson, Grete Anita Hansen, Ellen Marie Husby, Lena Mari Dale Jakobsen, Bodil Lura, Lil-Sofie Ording Mueller University Hospital of Northern Norway, Tromsø (Norway)
16:40–16:50
103 - LP: Pediatric radiation doses from multi-detector CT exams: preliminary results from the first 2011 Italian national survey Claudio Granata1, Federica Palorini2, Daniela Origgi2, Domenica Matranga3, Sergio Salerno3 Ospedale Giannina Gaslini, Genoa; 2Istituto Europeo di Oncologia, Milan; 3Policlinic Hospital, University of Palermo, Palermo (Italy)
1
16:50–17:00
104 - LP: Overscanning in Pediatric Chest CT—an unrecognized source of excess radiation Erich Sorantin1, Sabine Weissensteiner1, Adrian Hrusca2, Andreea Rachisan2 Medical University Graz (Austria); 2Iuliu Hatieganu University of Medicine & Pharmacy, Cluj-Napoca (Romania) 1
17:00–17:10
105 - LP: CT of the Chest Abdomen in children: dose optimisation to single or two series acquisition? Carolyn Young Great Ormond Street Hospital (United Kingdom)
17:10–17:20
106 - LP: The newly released DR detector (Canon CXDI-70C Wireless) maintains diagnostic image quality at a reduced radiation dose in pediatric examination Helle Precht1, Claus Bjørn Outzen1, Poul Ravn2, Dorthe Ulrik Knudsen2, Lene Bak2 1
17:20–17:30
Conrad Research Center; 2Odense University College Lillebelt, Kolding, (Denmark)
107 - LP: Assessment of the potential for pediatric DR dose reduction using customized multifrequency image processing Sosamma Methratta1, Lynn La Pietra2, Jacquelyn Whaley2, Steven King1, Michael Hess1, Arabinda Choudhary1, Michael Moore1, James Brian1, Michael Hulse1 The Milton S. Hershey Medical Center, Hershey, PA; 2Carestream Health, Inc., Rochester, NY (United States)
1
17:30–17:40
108 - LP: A review of current local dose-area product levels for pediatric fluoroscopy in a referral center compared with international standards Andrea Magistrelli, Vittorio Cannatà, Marco Cirillo, Roberta Lombardi, Saverio Malena, Paolo Tomà Bambino Gesù Pediatric Hospital, IRCCS, Rome (Italy)
S470
17:40–17:50
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
109 - LP: Knowledge of ionizing radiation risk between resident and fellow in paediatrics. A questionnaire study. Sergio Salerno1, Roberta Puccio1, Paola Marchese1, Andrea Magistrelli2, Paolo Tomà2 1
17:50–18:00
Policlinic Hospital, University of Palermo, Palermo; 2Bambino Gesù Pediatric Hospital, Rome (Italy)
110 - LP: The SECURE study: observational post-marketing study on the safety of meglumine gadoterate—interim analysis of 972 children Jean-Pierre Pracros, Jacqueline de la Garanderie Hôpital Femme Mère Enfant, Bron (France), R111: Optimization of radiation dose using adaptive statistical iterative reconstruction (ASIR) in children’s CT imaging. Triantafillia Makri, Anastasia Hranioti, Vasilis Syrgiamiotis, Christiana Hadjigeorgi “Agia Sofia” Children’s Hospital, Athens (Greece)
Task Force 7: Hips, 16:30–17:00. Room: Terpsichore B. Close of Congress and Call to Budapest, 18:00–18:15. Room: Terpsichore A. Annual Dinner, 20:00.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
ESPR TASK FORCES AND SUB-MEETINGS PAGES 1 - Meeting of the ESPR Uro-radiology task force (1 h 45 mins) Wednesday, 30th May 2012, 13:30–15:15 In cooperation with the ESUR working group on paediatric uroradiology. Members: Riccabona M (head), Avni F, Blickman H, Damasio B, Darge K, Dacher JN, Lobo ML, Ording-Mueller LS, Papadopoulou F, Vivier PH, and Willi U. Chair: Riccabona M./Avni FE. Introduction & update on task force activities, 10’, Riccabona M. Graz/Austria Discussion 5′ A. Imaging in childhood nephropathies and renal parenchymal disease, 20′, F. Avni, Brussels/Belgium Discussion 5 min B. Renal biopsy in children (Riccabona M, Willi U), 20′ M. Riccabona, Graz/Austria Discussion 5 min C. How to image the neonatal genitalia (Lobo ML, Riccabona M, Gassner I), 20′, ML. Lobo, Lisbon/Portugal Discussion 5 min D. Imaging in childhood urolithiasis and nephrocalcinosis revisited, 20′, K. Darge, Philadelphia/USA Discussion 5′ 2 - Meeting of the Functional Imaging Task Force (40 mins) Wednesday, 30th May 2012, 16:00–16:40 Chaired by Peter Brader
S471
B. Forming a group of paediatric radiologists who will cooperate in generating ESPR endorsed guidelines for imaging child abuse. C. Starting international studies on imaging in child abuse. Suggestions for collaborative research are welcome and initiators will be given time to present their study proposals. 4 - Meeting of the Oncology Task Force (90 mins) Thursday, 31st May 2012, 17:30–19:00 Chaired by Hervé Brisse Programme A. Radiological features of malignant supra-tentorial glial tumors: Pr Nathalie Boddaert (Hôpital Necker-EnfantsMalades, Paris, France) B. Conventional and advanced imaging of posterior fossa tumors: Pr Thierry Huisman (Johns Hopkins Hospital, Baltimore, USA) C. Molecular and functional imaging of brain tumors: Pr Peter Brader (Medizinische Universität, Wien, Austria) D. Response assessment guidelines for multicenter trials: Dr Hervé Brisse (Institut Curie, Paris, France) E. Diagnostic cases 5 - Meeting of the Neurology Task Force (30 mins) Friday, 1st June 2012, 08:00–08:30 Chaired by Maria Argyropoulou Members: Catherine Adamsbaum, Steve Chapman, JeanFrançois Chateil, Veronica Donoghue, Rutger Jan Nievelstein, Andrea Rossi, Guy Sebag, Elida Vazquez, Thekla Von Kalle
Programme A. Whole-body diffusion-weighted imaging—an update: Nievelstein Rutger Jan, Utrecht (25′) B. Functional Imaging Taskforce—Vision and mission statement, an update: Brader Peter (15′ plus discussion) 3 - Meeting of the Child Abuse Task Force (60 mins) Thursday, 31st May 2012, 08:00–09:00 Chaired by R. Van Rijn & Amaka Offiah The second taskforce child abuse meeting will have an informal character. During this meeting we aim to present and discuss the following items: A. The results of an ESPR on-line questionnaire on the use of imaging protocols for imaging child abuse.
Programme: The Role of Neuroimaging in Pediatric Headache. A systematic review (20 min presentation, 10 min discussion) George Alexiou, Maria I Argyropoulou, Medical School, University of Ioannina, Greece 6 - Launch of the ESPR Research Committee (90 mins) Friday, 1st June 2012, 10:30–12:00 Chaired by Karen Rosendahl A. Definition, vision and mission statement for this new ESPR Committee: Karen Rosendahl B. The different arms of ESPR research falling under the committee’s coordination
S472
– –
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
European Excellence Network for Paediatric Radiology Research (with example of Optimizing IV Contrast for CT): Erich Sorantin EIBIR
C. Illustrations of other on-going multicentre research projects: how they currently operate, and how they will fit under the committee’s future coordination – –
Hodgkins (Rutger Jan Nievelstein: 10 mins) Juvenile Idiopathic arthritis (London, Paris, Rome, Genova, Bergen, Tromsø): Karen Rosendahl
D. Next steps 7 - Meeting of the ESPR CT Dose task force (30 mins) Friday, 1st June 2012, 12:30–13:00 Chaired by Eric Sorantin & Catherine Owens Programme An update on the phantom study, Graz, and an outline of the next steps 8 - Meeting of the ESPR Developmental Dysplasia of the Hip task force (30 mins) Friday, 1st June 2012, 16:30–17:00 Chaired by K. Rosendahl & P. Tomà Programme A. The recommendations for US screening, as published on the ESPR web site in 2011 B. Extension of the task force’s aims to include MSK ultrasound
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
List of abstracts, ordered by session Wednesday, May 30 Scientific Session 1: Chest-Cardiovascular 1 - SP Does lateral view improve the accuracy of chest radiographs in identifying lung metastases in children with Wilms tumour? Cheng Xie1, Øystein Olsen2, Catherine Owens2 1 University of Birmingham; 2Great Ormond Street Hospital, London (United Kingdom) Purpose - Objective. Current guidelines recommend chest radiographs in both AP and lateral views for detection of pulmonary metastases in children with Wilms tumour. The purpose of this study was to investigate any contribution to diagnostic accuracy of the lateral view in the evaluation of pulmonary metastases in children with Wilms tumour. Material and methods. This retrospective study included 142 consecutive children diagnosed with Wilms tumour from September 1994 to June 2011. Chest radiographs of 19 children with and 59 without lung nodules on corresponding chest CTs (reference standard) were reviewed independently by two paediatric radiologists, masked to the CT findings. AP and lateral views were independently reviewed for (a) pulmonary nodules and (b) diagnostic quality using two scoring charts. Results. AP radiographs detected 95 % (18/19) of children with pulmonary metastasis. One examination was identified as ‘CT-only lesion’. Neither reviewer reported any additional findings from lateral views. Cohen kappa for inter-reviewer agreement was 0.7. Wilcoxon test showed non-significant difference (P00.1) between the nodule scores of the two reviewers. Discussion and conclusions. In our study, the lateral view did not provide significant added valuable for detection of pulmonary metastases in children with Wilms tumour, despite the additional radiation incurred to the child compared to AP alone. Our study included small number of children from a single institution; we recommend further research in this area involving multicentre populations.
2 - SP Assessment of neonatal chest radiograph quality; a comparison between three health professional groups Hayley Danielle Cameron, Samuel Stafrace Royal Aberdeen Children’s Hospital (United Kingdom) Purpose - Objective. Anecdotal discussion had suggested that differences in perception of radiograph acceptability
S473
existed across different health professional groups involved with local neonatal care. This study investigated the perceived standard of radiograph acceptability across three health professional groups. Material and methods. Forty-five neonatal CXRs were randomly selected from a 4 month time period dating March 2011 and July 2011. Of these 45 radiographs, there were 15 films in each gestational category; pre 32 weeks, 32– 36 weeks and post 36 weeks. The radiographs were completely anonymised, put into a custom work-list on the local PACS and distributed to five members of each of the three health professional groups; radiologists, radiographers, and neonatologists. Assessment was performed according to 11 criteria amended from those defined by the European Commission. Results. Only in 2 radiographs was there a statistically significant difference between two of the three groups mean total marks. The radiologists had a significantly higher score than the radiographers in both these cases. No significant difference was identified between any of the three professional groups in the other 43 radiographs assessed where correlation between the groups was present. Discussion and conclusions. The study demonstrated an absence of statistically significant data to substantiate the anecdotal evidence that local professional groups have differing views of what represents an acceptable neonatal chest radiograph when assessment was performed according to a structured set of criteria.
3 - LP Assessing progression in cystic fibrosis: a novel approach Robert Cleveland1, David Zurakowski1, Dubhfeasa Slattery2, Andrew Colin3 1 Children’s Hospital, Boston (United States); 2Childrens University Hospital, Dublin (Ireland); 3Miller School of Medicine, Miami (United States) Purpose - Objective. Emphasize CXR in assessing progression of CF disease. Material and methods. 3038 CXR (456 CF patients) scored by Brasfield system were plotted against age, creating an age-based rate of decline (ABS); PFT were similarly assessed. Patients receiving TOBI were compared pre/post treatment; patients with different genotypes were compared to each other. Results. Cumulatively there was no statistical difference in rates of decline in CXR v PFT (CXR v FEV1: p0.41; CXR v FVC: p0.58). Patients pre/post TOBI revealed an 11 % decrease in the rate of decline (p0.02) v reports in FEV1 of 12–12.5 %. Different genotypes of CF produce differences in prognosis but without conclusive PFT data to confirm
S474
this, other than for categories of “pancreatic mild” and “pancreatic severe” genotypes. Subgroups of the “pancreatic severe” genotypes had statistically significant different rates of decline using the ABS. Our data show ABS is more sensitive than FEV1. Discussion and conclusions. Serial CXR is more sensitive than PFT in assessing differences in progression, especially if sample size is small. Presumably anatomic changes become apparent before producing physiologic change. We emphasize the value of “thinking out of the box” in using CXR (ABS, TOBI and genotype data are previously published). This tool does not increase cost or radiation exposure. Data can be obtained in patients too young or ill to perform PFT.
4 - LP Differences in the pattern of structural lung abnormalities on CT in patients with cystic fibrosis and pancreatic sufficiency and insufficiency Natalia Simanovsky, Malena Cohen-Cymberknoh, Eitan Kerem, Nurith Hiller Hadassah Medical Center, Jerusalem (Israel) Purpose - Objective. We aimed to evaluate differences in the severity and distribution of pulmonary manifestations and pancreatic CT changes in cystic fibrosis, in patients with and without pancreatic insufficiency (PI). Material and methods. We retrospectively evaluated changes on chest CT using the modified Brody score in 84 CF patients (39 females, 45 males; ages 4–68 years, mean 20.5) receiving care in our hospital from 2000 to 2010. Pancreatic changes were assessed on CT in 52 patients. Statistical analysis was performed of the severity of lung changes and the distribution of the pulmonary disease in the lung lobes in 28 patients with known pancreatic sufficiency (PS) and 56 PI patients. Results. Patients with PI had more severe lung disease (p0 0.001), with predominant involvement of the upper lobes (p00.002), due to bronchiectasis and bronchial wall thickening. No such distribution was demonstrated for the PS patients (p00.133). More PI patients demonstrated atrophic changes in the pancreas (84.6 %) than PS patients (30.4 %). Pancreatic cysts and calcifications were noted exclusively in PI patients. Atrophic changes in the pancreas correlated with the severity of the lung disease (p00.002), and the patient’s age (p00.001). Discussion and conclusions. Lung disease is more severe in CF patients with pancreatic insufficiency, with predilection of pathology to the upper lung lobes. Our research suggests that in clinical studies evaluating lung function in CF, pancreatic status should be considered as a confounding variable.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
5 - LP The complementary role of high resolution computed tomography and flexible bronchoscopy in childhood chronic cough Aggeliki Nikopoulou, Konstantinos Douros, Argyro Mazioti, Gerasimos Kremidas, Ioannis Arapakis, Georgios Velonakis, Konstantinos Priftis, Efthymia Alexopoulou Attikon Hospital, University Of Athens (Greece) Purpose - Objective. Childhood wet cough exceeding 6 weeks duration can gradually lead from a protracted bacterial infection to symptomatic irreversable bronchiectasis if appropriate therapy is not followed. Using the Bhalla scoring system to evaluate the High Resolution Computed Tomography(HRCT) findings, we then tried correlating them with the Flexible Bronchoscopy (FB) and bronchoalveolar lavage(BAL) findings. Material and methods. Ninty-three children (0.6–16.4 years), with wet cough(>6 weeks), were studied. All patients underwent blood tests, chest x-ray(s), HRCT, and FB/BAL. HRCTs were evaluated with the Bhalla scoring system and the bronchoscopic findings were categorized according to severity into five groups (I–V). Results. On bronchoscopy visible abnormalities were found in 91 children (97.8 %), while positive HRCTs were found in 70(75.2 %). A positive correlation was found between the Bhalla score and the cough duration (>00.23, p00.028). The Bhalla score correlated positively with type-III (OR: 5.44, 95 %CI: 1.92–15.40, p00.001) and type IV (OR: 8.91, 95 %CI: 2.53–15.42, p00.001) bronchoscopic groups; it also correlated positively with the neutrophils’ percentage in the BAL (>00.23, p00.036). Discussion and conclusions. HRCT detected airway wall thickening and bronchiectasis and the severity of the findings correlated positively with the length of clinical symptoms and the intensity of neutrophilic inflammation in the airways. However, HRCT was less sensitive than FB/BAL in detecting airway abnormalities. The two modalities should be considered complementary in the evaluation of prolonged wet cough.
6 - SP Interstitial lung disease in children: high-resolution CT findings in 14 patients proven histopathologically Xinyu Yuan,Huizhong Chen, Jizhen Zou, Rongyan Huang Capital Institute of Pediatric, Beijing (China) Purpose - Objective. To assess the high-resolution computed tomography (HRCT) features of childhood interstitial lung disease (ChILD). Material and methods. Fourteen patients with ChILD proven histopathologically were enrolled in the current
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
study. Among them, there were 10 boys and 4 girls, aged from 1y3m to 13y1m (the median age was 6y). The final diagnoses of this series included nonspecific interstitial pneumonia, NSIP (NSIP) (n06), lymphocytic interstitial pneumonia (LIP) (n03), pulmonary alveolar proteinosis (PAP) (n02), respiratory bronchiolitis interstitial lung disease (RB-ILD) (n01), acute interstitial pneumonia (AIP) (n01), and Eosinophilic Pneumonia (EP) (n01). Results. The most common HRCT patterns of NSIP included reticulation, ground-glass opacity and peribronchiolar thickness (6/6, 100 %). Nodules were always present on the HRCT of children with LIP (3/3, 100 %). In the two PAP patients, there was the specific sign, named “crazy-paving sign”, (2/2, 100 %) could be found. The nodules with hazy margin in EP were different from that in LIP. Nodule, reticulation and GGO were present in the boy with AIP. The reticulation, GGO, consolidation and peribronchiolar thickening were present in RB-ILD patient. Through the analysis with logistic regression, the nodule was regarded as the specific negative-pattern for NSIP (P00.047, OR0−2.71) in our study. Discussion and conclusions. HRCT scanning is the primary imaging modality for ChILD. So far, however, there is no sign that could be identified as the specific pattern for any subsets of childhood interstitial lung disease.
7 - LP Computed Tomography demonstration of the complications and associations of lymphobronchial Tuberculosis in children Susan Lucas1, Savvas Andronikou1, Pierre Goussard2, Robert Gie2 1 University of the Witwatersrand, Johannesburg; 2Stellenbosch University (South Africa) Purpose - Objective. Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children. The aim was to describe the CT findings of LBTB in children, the parenchymal complications and associated abnormalities. Material and methods. CT scans of 98 children with LBTB were retrospectively reviewed. Lymphadenopathy, bronchial narrowing, parenchymal complications and associations were documented. Results. : Infants comprised 51 % of patients. The commonest lymphadenopathy was subcarinal (97 % of patients). Bronchial compressions (259 in total) were present in all patients, of which 23 % were severe/complete stenoses and 28 % affected bronchus intermedius. Parenchymal complications were present in 94 % of patients, including consolidation (88 %), breakdown (42 %), air trapping (38 %), expansile pneumonia (28 %), collapse (17 %) and bronchiectasis (9 %),
S475
all predominantly right-sided (63 %). Associations included oval focal bodies, miliary nodules, pleural disease and intracavitory bodies. Discussion and conclusions. The most important CT finding of children with LBTB is visible airway compression as a result of lymphadenopathy. CT of children with LBTB showed that airway compressions were more severe in infants and most commonly involved bronchus intermedius. Numerous parenchymal complications were documented, all showing rightsided predominance. Several associations were identified.
8 - LP Incidence and acute complications of asymptomatic central venous catheter-related deep venous thrombosis in critically ill children Cicero Silva1, Philip Spinella2, Simon Li3, Matthew Pinto3, Petronella Stoltz 4, Joana Tala 5, Mary Card1, Veronika Northrup1, Kenneth Baker1, Thomas Goodman1, Lei Chen1, Edward Faustino1 1 Yale University School of Medicine, New Haven; 2Washington University, St. Louis; 3Maria Fareri Children’s Hospital, Valhalla 4 Connecticut Children’s Medical Center, Hartford 5Yale-New Haven Children’s Hospital, New Haven (United States) Purpose - Objective. Asymptomatic central venous catheter (CVC)-related deep venous thrombosis (DVT), detected only by ultrasound, is significantly more common than symptomatic CVC-related DVT. The clinical significance of asymptomatic CVC-related DVT is unknown. We determined the incidence and acute complications of asymptomatic CVC-related DVT in critically ill children. Material and methods. Muiticentric prospective cohort. Sequential pediatric intensive care unit (PICU) patients with newly inserted un-tunneled CVC were included. Patients underwent DVT assessment with Doppler ultrasonography of the central vein where the CVC was inserted, on the day of enrollment and at study exit (CVC removal, day 28 after CVC insertion, PICU discharge or prior to demise). Patients were divided in two groups: with no DVT (A) and with DVT (B) at study exit. Mortality adjusted duration of mechanical ventilation was used as a surrogate for pulmonary embolism, the main complication of DVT. Results. Asymptomatic CVC-related DVT was diagnosed in 16 (15.8 %) children. Mortality-adjusted duration of mechanical ventilation was similar between the 2 groups (23± 7 days in children with no DVT vs. 22±9 in children with DVT, P00.24). Discussion and conclusions. Asymptomatic CVC-related DVT is common in critically ill children. However, the acute complications in children with DVT are similar to children with no DVT.
S476
9 - SP Interrupted aortic arch: CT findings Tetyana Yalynska, Raad Tammo, Ievgeniia Iershova, Nadya Rokitska, Oleksandr Kondrachuk Ukrainian Children’s Cardiac Centre, Kyiv (Ukraine) Purpose - Objective. Interrupted aortic arch (IAA) is an uncommon congenital anomaly, characterized by a lack of luminal continuity between the ascending and descending thoracic aorta. It represents a critical ductus-dependent congenital heart disease, which without surgery is associated with high mortality in the neonatal period. The purpose of this study was to determine the accuracy of CT in the diagnosis of the IAA. Material and methods. Thirty-seven neonates (from 2 h to 1 month) with suspected or proven IAA after echocardiography underwent non-gated CT. 9 patients underwent CT before and after surgery. Nonionic iodinated contrast material (300 mg ml) was injected at a rate varying from 1.5 ml/s to 2.5 ml/s. Results. Type A of IAAwas in 19 patients (51,4 %); type B had 18 patients (48,6 %), 8 of them had an aberrant right subclavian artery and 2 had right aortic arch. Associated abnormalities included: patent arterial duct (n037), atrial septal defect (n0 7), ventricular septal defect (n016), aortopulmonary window (n04), truncus arteriosus (n03), double outlet right ventricle with ASD and VSD (n02), transposition of the great arteries (n01). 3 neonates had DiGeorge syndrome. Surgery was done in 34 of 37 patients; CT findings were confirmed surgically. Discussion and conclusions. CT as a non-invasive technique provided the critical anatomic information required for preoperative assessment of the IAA in pediatric patients.
10 - SP The role of CT in pediatric patients with congenital heart disease: new clinical and radiological perspectives using high-pitch dual source spiral acquisition Aurelio Secinaro1, Benedetta Leonardi1, Silvia Cacaci2, Giacomo Pongiglione1, Paolo Tomà1 1 Bambino Gesù Pediatric Hospital, Rome; 2Policlinico Gemelli, Rome (Italy) Purpose - Objective. To investigate the diagnostic accuracy, clinical advantages and radiation exposure of high-pitch dual source CT in pediatric patients compared with cardiac catheterization. Material and methods. Twenty patients (4 females and 16 males, aged between 3 months and 15 years) underwent cardiovascular CT and invasive catheterization at our institution. All CT scans were performed with a second-generation dual-source CT system (Somatom Definition Flash, Siemens Healthcare, Forchheim, Germany), permitting data acquisition
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
at a high-pitch (3.2–3.4). Diagnostic accuracy was assessed in terms of image quality and anatomical definition (course/ caliber of great vessels and origin/proximal course of coronary arteries) using invasive catheterization as a standard reference. Radiation dose values were calculated using the dose length product (DLP). We assessed the clinical advantages as the need for sedation/general anaesthesia. Results. Diagnostic accuracy was achieved in 90 % of the patients. Mean DLP value was 49 (standard deviation of +/− 17.3) with a mean time of exposure of 0.35 ms (standard deviation of +/− 0.09 ms). All scans were performed unsedated during free-breathing. Discussion and conclusions. High-pitch dual source CT protocol in pediatric patients with congenital heart disease provides a non-invasive high diagnostic accuracy with low radiation exposure. It could be a promising tool to support cardiac catheterization in pediatric age.
11 - SP Cardiovascular magnetic resonance (CMR) in patient with repaired tetralogy of Fallot: the gold standard in assessment of injectable pulmonary V-valve implantation and follow up Aurelio Secinaro1, Benedetta Leonardi1, Stefano Marianeschi2, Giacomo Pongiglione1, Paolo Tomà1 1 Bambino Gesù Pediatric Hospital, Rome; 2 Niguarda Hospital, Milan (Italy) Purpose - Objective. Severe pulmonary regurgitation, progressive dilatation and dysfunction of the right ventricle are the most frequent late morbidity after tetralogy of Fallot repair. Consequently pulmonary valve replacement is often indicated in these patients. Biointegral Injectable Pulmonary Valve (IPV) is an innovative, less invasive technique, often performed off a cardiopulmonary bypass. However, not all patients with severe pulmonary regurgitation are suitable for IPV insertion and CMR is fundamental in assessing pulmonary trunk dimensions, right ventricular volume and pulmonary regurgitation. Material and methods. We performed a full CMR on three patients, pre and 6 months post IPV insertion. The suitability of an IPV approach required a pulmonary trunk length of more than 20 mm and a diameter of between 15 and 31 mm. Using the 3D SSFP navigator sequence, we measured the diameters at the following sites: right ventricular patch, pulmonary valve and pulmonary bifurcation and the length of the pulmonary trunk. Results. Three patients had implanted IPV. Post IPV insertion CMR showed that all three patients demonstrated an improvement in the right ventricle end-diastolic volume. In all patients, the IPV was continent and fully assessable at CMR. Discussion and conclusions. CMR is a necessary tool before IPV insertion, both to exclude contraindications and to
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
determine the need for cardiopulmonary bypass. CMR is a safe and effective method in the follow up of patients with repaired tetralogy of Fallot treated with IPV.
12 - SP Gd-free MRA in coarctation—can ce-MRA be replaced? Peter Kalmar, Erich Sorantin Medical University Graz (Austria) Purpose - Objective. Coarctation of the aorta (CoA) accounts for 5–10 % of all congenital heart defects. MRA represents an accepted imaging modality for monitoring vessel size in detection of late complications such as aneurysm formation. New MRA developments enable Gd-free angiographic imaging (native-MRA). The purpose of this study was to compare contrast enhanced MRA (ce-MRA) with native-MRA in the follow-up of CoA patients. Material and methods. In 18 patients (6 female, 12 male, aged 12 to 35 years) orthogonal to vessel direction were reconstructed in ce-MRA and native-MRA cross sections on the following positions: aortic bulb (1), ascending aorta (2), just before origin of brachiocephalic trunk (3) and left carotid artery (4), before (5), inside (6) and after coarctation (7), descending aorta (8). Vessel area and perimeter served as parameters for vessel size and were derived from region of interests (ROIs) defined by manual outlining of the vessel periphery. For ceMRA and native-MRA in all corresponding positions, both parameters were compared by paired Student t-test. Results. Differences (area and perimeter) on corresponding positions were (1) 3.4 % and 2.0 %, (2) 2.8 % and 1.3 %, (3) 2.7 % and 1.4 %, (4) 4.1 % and 2.1 %, (5) 3.7 % and 1.9 %, (6) 4.6 % and 2.6 %, (7) 3.1 % and 1.2 %, (8) 4.6 % and 3.2 % (p>> 0.05). Discussion and conclusions. Our results show that measurements of vessel size using native-MRA are equivalent to ce-MRA (no statiscally significant difference) whilst proving faster and less invasive. 13 - SP Imaging congenital heart disease(CHD) in paediatric patients by high field open (HFO) 1.0 Tesla MRI scanner: a pictorial essay Dimitra Loggitsi1, Georgia Papaioannou1, Ioannis Spandonis2, Nikolaos Kritikos1, Aphrodite Tzifa1 1 Mitera Maternity and Children’s Hospital, Athens; 2Philips Healthcare (Greece) Purpose - Objective. MR imaging is a well-established modality for the evaluation and monitoring of CHD. Advanced cardiac MRI (cMRI) is traditionally performed in closed bore
S477
MR scanners of 1.5Tesla. To our knowledge this is the first study concerning cMRI in paediatric patients with CHD performed in HFO 1.0Tesla magnet. Material and methods. During an 11-month period 45 paediatric patients aging from 6-days to 18-years old (mean age0 8.49 year, m:f028:17, mean BSA01.07 kg/m2) underwent cMRI in a HFO 1.0Tesla MRI scanner (Panorama, Philips). The indications for the examination included Tetralogy of Fallot, transposition of great arteries, aortic malformations, pulmonary atresia/stenosis, aortic valve disease, single ventricle, cor triatriatum, ASD, Kawasaki disease. cMRI consisted of Black-blood sequences, Cine imaging, Velocity-encoded phase contrast mapping, Gadolinium-enhanced MR angiography and 3D SSFP wholeheart when possible. Results. In all patient,s morphology and anatomy was assessed. Biventricular volumetry and function was evaluated (mean LVEDVI070.4 ml/m2, LVESVI023.7 ml/m2, LVEF065.1 %, RVEDVI0102.2 ml/m2, RVESVI044.7 ml/ m2, RVEF055.4 %), as well as aortic and pulmonary valve function and Qp/Qs measurement. In patients with aortic valve disease or malformations of the aortic arch LV wall mass was calculated (meanLV wall mass02,02gr/kgr). Discussion and conclusions. Advanced cMRI is an invaluable tool in the evaluation of CHD with high reproducibility. HFO 1.0Tesla MRI provides functional assessment and excellent image quality comparable to 1.5Tesla conventional MRI scanners. 14 - SP Antenatal cardiac sonography: a systematic approach Manish Bajaj1, Mukesh Garg1, Tushar Chandra2, Amit Gupta3 1 Geetanjali Medical College, Udaipur, (India); 2Childrens Hospital of Wisconsin (United States); 3Ravindra Nath Tagore Medical College, Udaipur (India) Purpose - Objective. This educational exhibit aims to: 1.Describe embryology of Heart and normal fetal circulation, 2.Illustrate the optimal sonographic technique for antenatal evaluation of heart, 3.Discuss the normal appearance of heart on routine sonographic views, 4.Illustrate imaging features of common congenital heart diseases on antenatal ultrasound, 5.Elucidate common pitfalls in interpreting fetal cardiac sonography Material and methods. Transabdominal ultrasound was performed to evaluate fetal heart for detection of anomalies using routine 3–5 MHz transducer. Four chamber and other standard views of fetal heart were obtained. Examples of normal ultrasound anatomy and common pathologies will be depicted along with differential diagnoses. Results. Obtaining standard views of the heart on antenatal ultrasound is a relatively simple approach that allows assessment of the major cardiac anomalies. A knowledge of normal embryology of heart appearance on prenatal ultrasound is very important to detect cardiac anomalies.
S478
Discussion and conclusions. Structural abnormalities of the heart are not uncommon. Incorporating a proper sonographic technique using standard views during routine antenatal scans can go a long way in shortening the learning curve and thus help in timely diagnoses and deciding upon appropriate management and counselling. Awareness of the common pitfalls is of utmost importance in this respect.
15 - SP Use of multidetector CT for asessing anatomical relation of tracheobronchial and cardiovascular anomalies associated with left pulmonary artery sling Xihong Hu, Guoying Huang, Mier Pa Children’s Hospital of Fudan University, Shanghai (China) Purpose - Objective. The study was to demonstrate the role of multidetector computed tomography (MDCT) in diagnosing and assessing anatomical relationships with tracheobronchial tree in LPAS. Material and methods. Fourteen patients (ten infants, four children) with LPAS were evaluated. They ranged in age from 3 days to 4 years (median age, 7 months) and in weight from 3.0 to 18.0 kg (median weight, 9 kg). MDCT was performed to determine the tracheobronchial and cardiovascular anatomy and identify tracheobronchial stenosis. Results. According to the Wells classification of LPAS, there were three cases of type IA, five cases of type IIA and six cases of type IIB. All patients had substantial tracheobronchial stenosis and ten cases of type II had a long segment of tracheobronchial stenosis. MDCT found pulmonary abnormalities including right upper pulmonary hypoplasia (n02), and right pulmonary hyperlucent (n01). Cardiacovascular abnormalities included PDA (n02), DORV (n01), TOF (n02), VSD (n03), ASD (n02), RPA stenosis (n01), LPA stenosis (n01). Nine patients had reanastomosis of the left pulmonary artery. Discussion and conclusions. We concluded that MDCT were ideal noninvasive imaging modalities for assessing the anatomical relationships of the tracheobronchial tree and cardiovascular in LPAS.
R16 64-slice multidetector computed tomography assessment of coronary artery lesions in children with Kawasaki disease: initial experience Xihong Hu, Guoying Huang, Mier Pa, Qiong Yao Children’s Hospital of Fudan University, Shanghai (China) Purpose - Objective. To evaluate the value of 64-slice multidetector computed tomography (MDCT) as a non-
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
invasive diagnostic modality in the young children suspected of coronary artery aneurysm due to Kawasaki disease. Material and methods. Twenty patients (mean age 4.0 years, range 0.6 to7 years) with Kawasaki disease suspected of coronary artery aneurysm underwent 64-slice MDCT ECG-gated coronary angiography from 2007 to 2011. The data of twenty patients who were younger than 4 years old was acquired without breath holding. Two pediatric radiologists independently assessed image quality and the diameter of all coronary segments were measured. The number, position, shape and size of each coronary artery aneurysm were observed and compared with those of echocardiography (ECHO) performed previously. Results. There is no significant difference in inter-observer and intra-observer. A total of 60 branches permitted visualization with diagnostic image quality. A total of 31 coronary artery aneurysms were identified. Ten tumors were small, fourteen were medium and seven were giant. The affected branches included 17/20 of LAD, 1/20 of LCX; 13/20 of RCA. Calcification was found in two cases and one case with thrombosis; five stenotic segments were found. ECHO failed to detect 6 tumors in LAD, 1 in LCX and 2 in RCA, and those included 6 small aneurysms. Discussion and conclusions. 64-slice MDCT is a useful modality for assessing young children with Kawasaki disease.
Scientific Session 2: Urogenital 17 - SP Unilateral hydronephrosis: morphological findings in MR urography Kassa Darge, Leslie LeCompte, Melkamu Adeb, Dmitry Khrichenko, Sarah Lambert, Pasquale Casale The Children’s Hospital of Philadelphia (CHOP) (United States) Purpose - Objective. To review morphological findings in MR urography (MRU) of high-grade unilateral pelvicalyceal dilatation (PCD) with a contralateral normal kidney. Material and methods. A retrospective morphologic evaluation of 22 cases, 10 males/12 females (0.1–17.3 years) with high-grade unilateral PCD was conducted. The MRU studies were carried out according to a standard protocol. Pre-contrast sequences included fat saturated axial/coronal T2 and 3D T2 urogram. Following parameters were evaluated: PCD grade, pelvic/calyceal neck diameter (mm), ureteropelvic junction (UPJ) angle relative to a horizontal reference line, crossing vessels, corticomedullary differentiation (CMD), parenchymal thickness and T2 parenchymal signal intensity.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Results. Distribution of the PCD was 4 grade 3, 10 grade 4 and 8 grade 5. Mean intrarenal pelvic, extrarenal pelvic and calyceal neck diameters were in mm 25.5, 35.7, and 15.8 mm, respectively The average UJP angle in the dilated systems was 32 (−34–58) versus 27 (5–50) on the contralateral side. A crossing renal vessel was identified in 3/16. Decrease in CMD was seen in 7, with parenchymal thinning identified focally in 3 and diffusely in 17. Increased T2 signal was found subjectively in 4/20 dilated systems and qualitatively in 7/20. Discussion and conclusions. Multiple morphological features need to be assessed in the evaluation of hydronephrosis on the MRU. It is essential to incorporate these findings in subsequent combined interpretation with the functional part of the MRU.
18 - LP Unilateral hydronephrosis: functional results in MR urography Kassa Darge, Leslie LeCompte, Melkamu Adeb, Dmitry Khrichenko, Sarah Lambert, Pasquale Casale The Children’s Hospital of Philadelphia (CHOP) (United States) Purpose - Objective. To review functional results of MR urography (fMRU) in high-grade unilateral pelvicalyceal dilatation (PCD) with a contralateral normal kidney. Material and methods. A retrospective evaluation of functional results in 16 cases, 8 males/8 females (0.1-17.0 years) with high-grade unilateral PCD was conducted. The fMRU studies were carried out according to a standard protocol and post-processing using the CHOP-fMRU software. Fifteen minutes after diuretic administration, a dynamic coronal 3D fat saturated T1 sequence was performed over 15 min. A sagittal 3D T1 and delayed single coronal T1, both fat saturated, followed. The following functional features were evaluated: visualization of the ureter, presence of contrasturine level and swirling of contrast in the dilated renal pelvis. The functional results included calyceal transit time (CTT), renal transit time (RTT), time-to-peak (TTP), parenchymal volume (PV), differential renal functions (volumetrictovDRF, Patlak-pDRF and volumetric PatlaktovpDRF). Results. The ureter was visualized in 10, 3 during the dynamic sequence, 4/9 during supine delay and 3/7 only in prone position. A contrast-urine level was present in 14 and swirling in 6. A significant (p<0.05) difference between the normal and dilated pelvicalyceal systems was noted with the TTP (2′25″/3′ 14″), pDRF (56.8 %/43.2 %) and vpDRF (58.3 %/41.7 %). Discussion and conclusions. Awareness of multiple functional features and range of calculated results is important in subsequent combined interpretation of the fMRU with the morphological findings.
S479
19 - SP Morphological and functional assessment of pediatric urinary tract abnormalities by MRU George Hadjidekov, Violeta Groudeva University Hospital Lozenetz, Sofia (Bulgaria), Purpose - Objective. Magnetic resonance urography presents attractive imaging modalities in paediatrics, providing wide diagnostic information in a single protocol. Our study is designed to evaluate the diagnostic value of MRU in children with various urogenital anomalies and the renal function using different post-processing functional software. Material and methods. Ninety six children (7 days–18 years old) were examined. In 54 of them, a static T2 MRU was completed by excretory T1 MRU after gadolinium administration and functional analysis was carried out using two functional analysis softwares “CHOP-fMRU” and “ImageJ” software. Results. MRU visualized the suspicious renal anomalies and the whole urinary tract with excellent image quality in all children. In ureteropelvic obstruction, MRU was confirmatory to the other imaging techniques, but better evaluated the end-ureteral anomalies. The renal transit times, renal volumes and volumetric differential renal function were assessed separately by “CHOP-fMRU” and “ImageJ” with excellent agreement with 99mTc-DTPA and among them. Full correlation between MRU data and the conclusive diagnosis was determined by surgery. Discussion and conclusions. MRU overcomes a lot of the limitations facing conventional imaging modalities and has a potential to become a leading modality in pediatric uroradiology. Even minor kidney dysfunction can be detected by functional analysis software. Synthesis of both anatomical and functional criteria in MR urography enables the selection of the best candidates for surgical treatment.
20 - LP Supranormal differential renal function in unilateral hydronephrotic kidney: insights by functional MR Urography Claire Sanavi, Jean-Nicolas Dacher, Jérome Caudron, Michael Dolores, Agnès Liard, Pierre-Hugues Vivier University Hospital of Rouen (France) Purpose - Objective. To retrospectively assess supranormal differential renal function (DRF) in unilateral hydronephrotic kidney by functional MR Urography (fMRU). Material and methods. The ethics committees waived the need for informed consent. A retrospective analysis was performed of all patients undergoing fMRU since January 2008 to November 2011. DRF was measured by both the
S480
area under the curve method and Rutland-Patlak plot. Glomerular DRF per unit of volume and kidney volumes were analyzed. Kidney volumes were compared with nomograms. Results. Three children with a left ureteropelvic junction obstruction were included. Two patients also underwent a renal scintigraphy that confirmed the supranormal DRF on the hydronephrotic side. Glomerular DRF per unit of volume was slightly higher on the dilated side but remained within normal range (<55 %). Dilated kidney volumes were always higher on the dilated side (>55 %). The combination of both findings explained the imbalance. Discussion and conclusions. The data support a nonhyperfunctioning dilated kidney and a non-hyperfunctioning non-dilated kidney. The supranormal DRF on the dilated side could be simply explained by a slight kidney volume asymmetry in association with a higher DRF per unit of volume that remains within normal physiological range.
21 - SP Functional MR urography for assessment of obstructive and reflux uropathies Martin Stenzel, Martin Freesmeyer, Ioannis Diamantis, Ulrike John, Hans-Joachim Mentzel University Hospital Jena (Germany) Purpose - Objective. In congenital anomalies of the kidney and urinary tract (CAKUT) the role of MRI for classification is expanded by obtaining functional data. MAG3 scintigraphy is considered gold standard for functional analysis. Material and methods. From 04/2010 to 01/2012 20 patients from one university hospital were examined by a standardised MR urography (MRU) in a 1.5 Tesla scanner after i.v. hydration and furosemide i.v. The data was processed by a dedicated software (CHOP-fMRU). Results were compared with Tc99m MAG3 scintigraphy. Results. Twenty patients (5 female, 15 male; age 5 weeks to 18.4 years) had both MR urography and MAG3 scintigraphy (1 to 484; average 48 days). All patients had isolated or combined CAKUT (6 duplex kidneys; 7 proximal, 11 distal ureteral stenoses; 8 subvesical obstructions; 10 VUR). Split renal function values differed by an average 8.2 % (min 1 %, max 18 %). Curve types after O’ Reilly were available in 36 kidneys (4 kidneys were multicystic dysplastic with no residual organ function). There was a relevant discrepancy in one case only (norml in scintigraphy, relevant obstruction in MRU). Discussion and conclusions. X-ray excretion urography was replaced by earlier MRU. The CHOP-fMRU examination protocol is very robust and reliable and able to give as much information as MAG3 scintigraphy. It is now possible to receive information on morphology, excretion, and split renal function with one examination.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
22 - LP Contribution of URO-MRI and laparoscopy to the management of challenging urological pathology in children Beatrice Damasio, Chiara Mattiuz, Girolamo Mattioli, Sara Costanzo, GianMarco Ghiggeri, Gian Michele Magnano Istituto Giannina Gaslini, Genoa (Italy) Purpose - Objective. To point out the joint role of both magnetic resonance urography (MRU) and laparoscopy as useful tools in overcoming challenging urologic scenarios in children. Material and methods. Three cases are presented with comparative MR and laparoscopic images. All patients presented underwent MRU using a 1,5 T Magnet and respective standardised protocols prior to laproscopy. Results. Case 1: A 12-year-old boy presented with right proximal ureteral obstruction and kinking on renal US and IVU. After surgical retroperitoneal adhaesiolysis and the positioning of a ureteral JJ stent, MRU diagnosed a retrocaval ureter. The patient underwent laparoscopic transperitoneal ureteroureterostomy. Case 2: In a 12-year-old boy with recurrent left flank pain and ipsilateral hydroureteronephrosis on renal US, MRU revealed a pelvic U-shaped left ureteral kinking. Laparoscopy diagnosed and revealed an obstructing obturator hernia of the left ureter. Case 3: A 17year-old boy treated elsewhere for right PUJO, with relapse of right hydronephrosis and flank pain. MRU revealed residual PUJO from a crossing vessel, subsequently corrected through retroperitoneoscopy. Discussion and conclusions. MRU is a precious tool for solving challenging scenarios, revealing excellent anatomic information with no radiation exposure. Laparoscopy then can confirm diagnosis and provides a less invasive treatment option. Teamwork between the radiologist and urologist is essential.
23 - SP Does an additional sequence during MR Urography provide more information regarding pyelonephritic changes in children? Katerina Dailiani, Thomas G Maris, Maria Bitsori, Sofia Koukouraki, Maria Raissaki University Hospital of Heraklion (Greece) Purpose - Objective. To compare T1w and HASTE-IR sequences pre- and post-gadolinium in the diagnosis of pediatric acute pyelonephritis and scarring. Material and methods. Two readers independently graded T1w and HASTE-IR sequences pre- and post-gadolinium administration in 21 MRI scans performed in 19 children
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
referred for complex UTI(n011), suspected tumor (n02) and urologic abnormalities(n05). The upper, middle and lower area of each kidney was graded separately for acute pyelonephritis and scarring respectively: 1 0 definitely normal, 2 0 rather normal, 3 0 inconclusive, 4 0 rather abnormal, 5 0 definitely abnormal. DMSA scans performed within 1 week were considered the gold standard. P up to 0.05 was significant. Results. Twenty acute pyelonephritis changes and 12 scars were identified in 126 renal areas with DMSA. Acute pyelonephritis detection ranged from 6 to 20, depending on the sequence. Following gadolinium, T1w and HASTE-IR sequences detected 7.1 % and 5.6 % more lesions, respectively. Sensitivities for T1w, and Haste-IR pre and post gadolinium sequences were pre: 30 %, 60 %, post: 75 %, 90.5 %, specificities pre:100 %, 96.1 %, post:91.9 %, 91.4 %, positive predictive values pre:100 %, 75 %, post:65.2 %, 67.9 %, negative predictive values pre:83.1 %, 92.6 %, post:94.8 %, 98 %. Average interobserver agreement [kappa (k) statistics] ranged from k00.74 for pre-gad to k00.83 for post-gad sequences. Discussion and conclusions. The addition of Haste-IR post gadolinium sequence in the MRU protocol increases the detection and characterization of acute pyelonephritis lesions vs scarring in children with suspected acute pyelonephritis.
24 - SP Acoustic radiation force impulse (ARFI) quantification of the renal parenchymal stiffness in paediatric patients with vesicoureteral reflux: preliminary results Costanza Bruno, Salvatore Minniti, Giuliana Caliari, Roberto Pozzi Mucelli University Hospital of Verona (Italy) Purpose - Objective. To evaluate the tissue stiffness of the renal parenchyma in paediatric patients with chronic renal disease, by means of ARFI. Material and methods. Twenty-eight children (age range:8 to 16) with vesicoureteral reflux (>_gradeIII), either primary (18 cases) or secondary(10), underwent scintigraphy and ultrasound with ARFI. The results were compared with those obtained in 12 age-matched healthy controls. The results of ARFI were expressed as speed (m/sec)of wave propagation through the tissue: the stiffer a tissue the faster the wave propagation. A global ARFI value was calculated for each kidney through the sum of the values obtained at the upper, middle and lower third. The t-test per paired data was adopted. P values 0.05 were considered statistically significant. All data are reported as mean ± standard deviation.
S481
Results. The ARFI values obtained in the affected kidneys of the patients with renal disease (17.6± 4.5 m/s) were significantly higher than those measured in the contralateral unaffected kidneys of the same patients (13.2±4.76 m/s:p 0.017) and those measured in the kidneys of the healthy controls (9.3±0.18 m/s:p 0.001). The difference between the ARFI values in the unaffected kidneys of the patients with renal disease (13.2±4.76 m/s) and the kidneys of the healthy controls (9.3±0.18 m/s) was statistically significant too(p 0.04). Discussion and conclusions. These preliminary data demonstrate that ARFI quantification can provide reliable information about the severity of renal damage.
25 - SP Diffusion-weighted imaging of the kidneys in patients with haemolytic uremic syndrome (HUS): initial findings. Jochen Herrmann, Ulrich Wenzel, Stephanie Galler, Jun Oh, Markus Kemper, Sebastian Loos, Knut Helmke, Gerhard Adam, Christian R. Habermann University Clinic Hamburg-Eppendorf (Germany)) Purpose - Objective. To evaluate kidney function in patients with HUS using diffusion-weighted imaging (DWI) in comparison to healthy volunteers. Material and methods. Between Mai-Dec 2011, eight children (mean age 8y) and fifteen adults (mean age 33.3y) with acute diarrhea-positive HUS were evaluated using DWI focused on the kidneys. For comparison, age and sex matched volunteers were investigated. Echo-planar DWI was performed with a 1.5T system. Results. Mean ADC values (x 103 mm2/s) of the renal cortex were significantly lower in patients with HUS compared to healthy controls (adult patients, ADC cortex 1.79±0.23 vs. 2.02±0.1, p-value<0.001). Medullary ADC values were less markedly decreased (adult patients, ADC medulla 1.8±0.17 vs. 1.9±0.11, p value 0.013). Corticomedullary differences were lower in patients with HUS compared to controls (ADC, 0.008±0.12 vs. 0.14±0.06, respectively; p<0.001). Patients with low cortical ADC values ranging below the level of the medulla displayed a band-like hypointensity of the cortex (4/15 adults and 5/8 children). ADC values differed in patients with estimated glomerular filtration rate above and below 30 ml/min (p< 0.05). Discussion and conclusions. DWI is a useful tool for functional evaluation of kidneys in patients with renal failure. Our quantitative DWI study presenting first results in patients with HUS shows characteristic changes of renal diffusivity with a marked reduction of ADC values of the renal cortex.
S482
26 - SP Adequacy of paediatric renal tract ultrasound requests and reports Nishentha Govender, Savvas Andronikou, Matthew Goodier University of Witwatersrand, Johannesburg (South Africa) Purpose - Objective. According to current guidelines, US is the most important modality for imaging urinary tract infections (UTI) in children. Objectives: (1) To assess the adequacy of paediatric renal US requests and reports in a general radiology department, and correlate the request adequacy and the performing radiologist’s experience with report adequacy, (2) To determine the yield of abnormal findings. Material and methods. Retrospective review of renal US requests. The information was scored: requests 0 to 3 (3 as highest adequacy) and reports 0 to 21 (21 as highest adequacy). Correlation tests used included Spearman’s correlation, the Kruskal-Wallis test, the Chi-square test of independence and the Fisher exact test. Results. Mean report adequacy score was 6.67/21. Trainees did 87 % of all scans and performed better (score 6.76) than the staff radiologists (score 6.08). Hydronephrosis was the most common abnormality. There was no correlation between request or reporter rank and reporting adequacy. Discussion and conclusions. Renal US requests and reports are inadequate. To improve reporting standards for trainees and specialists, a renal ultrasound reporting template was designed for use.
27 - SP Ultrasonography of inguinal abnormalities in girls: experience acquired through 178 cases Magali Saguintaah, Olivier Prodhomme, Julie Bolivar Perrin, Catherine Baud Montpellier University Hospital (France) Purpose - Objective. To describe the US examination technique used to explore the normal and pathological aspects of the inguinal area in girls Material and methods. We retrospectively studied 178 cases of inguinal US in girls (from 0 to 10 years) referred for inguinal lump. Bilateral sagittal and axial scans were performed, at rest and with abdominal hyperpressure. Ovaries were always evaluated. The results were correlated with surgical data or clinical follow-up. Results. The inguinal canal (canal of Nuck) obliterates at birth or during the first year. When obliterated, it is neither visible nor measurable. An open canal is at risk of hernia. A hernia may contain the ovary, the fallopian tube or the uterus (infant), bowel or omentum (girl). A high anteriorly located
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
ovary near an open canal suggests intermittent ovarian hernia. In irreducible ovarian hernia, signs of ischemic ovarian damage are: large ovary, thickened stroma, echogenic thickened surrounding tissues, blurred margins, normal or decreased vascularisation. The cyst of the canal of Nuck can be large, septated, with a dumbbell, cyst-in-cyst aspect. Other abnormalities should be recognized: adenitis, lymphocele… In bilateral gonadal hernias, a testicular pattern may reveal a disorder of sexual differenciation. Discussion and conclusions. US is useful to establish the etiological diagnosis of a groin lump, and helps to determine the necessity for urgent surgery (ovarian hernia with ischemic damage).
28 - SP Rare causes of pelvic pain in infancy and adolescence: hydrosalpinx vs isolated tubal torsion Cinzia Orazi, Paola Marchetti, Maria Chiara Lucchetti, Roberta Lombardi, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy) Purpose - Objective. Acute pelvic pain in infancy and adolescence can be caused by several different conditions. Fallopian tube diseases are only rarely involved. Hydrosalpinx indicates dilation of the fallopian tube with accumulation of fluid content, due to distal occlusion. Besides local infection or compression (e.g. hemorrhagic corpus luteum), congenital anomalies or adhesions (previous inflammatory conditions or abdominal surgery) may also be possible underlying factors. The enlarged salpinx bears the risk of torsion, even without involvement of the ovary. Material and methods. We report on imaging findings in 18 infants and adolescent patients, not sexually active, affected by hydrosalpinx, and in 2 patients in whom hydrosalpinx was associated with isolated tubal torsion. Results. US and MRI demonstrated an enlarged and tortuous fallopian tube, separated from the ovary, with variably thickened tubal walls and fluid contents. MRI allowed further characterization of the contents, whether fluid, hematic, or dense. The vascular pattern of the tubal walls and the uterus and adnexa were also clearly shown. Discussion and conclusions. US is the first imaging technique in the evaluation of the female genital tract, and allows the evaluation of a dilated fallopian tube. MRI can add useful information about the characteristics of the contents and of the vascular supply. Early recognition and correct discrimination between medical and surgical causes of hydrosalpinx are important in order to avoid unnecessary surgery and subsequent harmful adhesions.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
29 - LP Disorders of sexual development (DSDs): the role of imaging Cinzia Orazi, Massimiliano Silveri, Marco Cappa, Paolo MS Schingo, Carla Bizzarri, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy) Purpose - Objective. Anomalies in sexual differentiation can lead to disorders of sexual development (DSDs), usually presenting in the perinatal period with a spectrum of genital ambiguity or isolated anomalies. In other cases, DSDs can be associated with an apparently normal male or female phenotype, the diagnosis becoming evident only at puberty. DSDs should be suspected in infertility and “salt losing” diseases, in family histories of such pathologies, including neonatal death, and in all cases of discordance between prenatal genetic sex and phenotypic sex. Material and methods. We report on imaging findings in our series of 161 consecutive DSD patients (63 affected by congenital adrenal hyperplasia), observed between 2002 and 2011. Results. Our experience confirms that ultrasonography (US) is the first level imaging modality in the evaluation of the genital tract. The pelvis, the scrotum, the inguinal, perineal, renal and adrenal regions should be assessed. Magnetic Resonance Imaging (MRI) allows better spatial and structural definition and should include the pelvis, the perineum and the urinary tract. Genitography and voiding cystourethrography are used to determine internal ductal anatomy. Endoscopic examination (genitoscopy) often outpaces genitography, providing more detailed assessment. Discussion and conclusions. The management of DSDs is a challenge for clinicians and a multidisciplinary team is advisable. Imaging plays an important role in the appropriate gender assignment, which is necessary for healthy physical and psychological development.
30 - LP Multiplanar contrast-enhanced US measurement of tissue perfusion in a rabbit model of testicular torsion Harriet Paltiel1, Carlos Estrada1, Ahmad Alomari1, Carlo Passerotti1, Richard Lee1, Gregory Clement2 1 Children’s Hospital Boston; 2 Brigham and Women’s Hospital, Boston (United States) Purpose - Objective. To assess correlation between multiplanar contrast-enhanced US-derived measurements of tissue perfusion with radiolabeled microsphere-derived measurements in a rabbit model of testicular torsion. Material and methods. Contrast-enhanced US was performed in 5 groups of 6 rabbits during intravenous infusion
S483
of US microbubbles before and after unilateral testicular torsion and contralateral orchiopexy. The degree of torsion per group was 0, 180, 360, 540, or 720. Disruptionreplenishment data were acquired preoperatively, immediately postoperatively, and after 4 and 8 h. At each time point 7 datasets were acquired: 2 sagittal measurements per testis, and 3 transverse measurements of both testes. An automated technique analyzed the time history of US image intensity. A linear least squares method fit the initial rise phase of the mean signal for each time curve. Slope of fit and intervention/control ratios were calculated. Individual measurements were averaged to compare means of transverse, sagittal, and combined sagittal/ transverse measurements. Standard deviation of the residuals assessed error in fit. US data were compared with radiolabeled microsphere intervention/control perfusion ratios. Results. Combined sagittal/transverse US perfusion ratios demonstrated correlation coefficients of 0.85 (immediate postop), 1.00 (4 h), and 0.99 (8 h) with p-values of 0.07, <0.001, and <0.001, respectively, compared with radiolabeled microsphere intervention/control perfusion ratios. Discussion and conclusions. Multiplanar contrast-enhanced US measurements of tissue perfusion demonstrate excellent correlation with radiolabeled microsphere measurements, and hold promise for future clinical applications of this technique.
31 - SP Role of spinal cord MRI in bladder dysfunction where clinical examination is normal Shyam Mohan, Srikanth Boddu, John Somers, Katherine Halliday, Nigel Broderick Nottingham University Hospitals NHS Trust (United Kingdom) Purpose - Objective. To evaluate the role of MRI of spinal cord in the evaluation of children with complicated voiding dysfunction with normal cutaneous and neurological examination. Material and methods. A retrospective study involving paediatric patients with presumed bladder dysfunction referred to the department of radiology at a tertiary referral centre during 1995–2009. We reviewed a total of 54 patients. The details of neurological and cutaneous evaluation were obtained from case notes. Patients with abnormal neurological examination, cutaneous stigmata (lipoma, haemangioma and sacral pit), obvious clinical spinal dysraphism and ano-rectal abnormalities were excluded from the study. Based on these criteria, 38 patients (n038) were included in the study population. Patients had prior evaluation with renal tract ultrasound and bladder pressure studies and final evaluation with MRI. T1 and T2 weighted axial
S484
and sagittal acquisitions of lumbosacral spine were acquired using 1.5-Tesla scanner. Images were reviewed by consultant paediatric or neuroradiologists. Results. Bladder pressure studies confirmed several patterns of voiding dysfunction (Detrusor instability: 13; Hypertonia: 8; Hyporeflexia: 13 and Detrusor-sphincter dysinergia: none of the patients had abnormal findings on MR imaging of the lumbosacral spine. Discussion and conclusions. In the background of normal cutaneous and neurological assessment, MRI lumbosacral spine is of no added value in the evaluation of paediatric population with isolated bladder dysfunction. We recommend a prospective study to confirm this evidence. The data for 2009 to 2011 is being collected and will be ready shortly.
R32 New chances in the diagnosis of female puberty: a cut off for the uterine artery pulsatility index Pier Luigi Paesano, Caterina Colantoni, Elena Di Rosa, Gianni Russo, Stefano Mora, Alessandra Dilascio, Francesco De Cobelli, Alessandro Del Maschio San Raffaele Hospital, Milan (Italy) Purpose - Objective. The diagnosis of puberty is still controversial: clinical signs, laboratory tests and ultrasound uterine diameters often do not give reliable parameters for the assessment of the pubertal stage. The role of estrogen in the uterine vascular resistances and in the subsequent uterine development is widely established. Our aim is to confirm pulsatility index (PI) as a valid non-invasive parameter in the pubertal assessment and to find an accurate cut-off value. Another goal is to validate it in the evaluation of GnRH-agonists-treatment (GnRH) in patients with precocious puberty (PP). Material and methods. Two hundred sixteen females with disorders of pubertal development and 38 females with PP in GnRH were submitted to color-Doppler-ultrasound for the determination of PI. Results. PI values (mean ± SD) were: 3.2±0.97 in pubertal patients (11±1 years); 3.4±1.13 in PP (8±1 years); 6.5± 1.57 in pre-pubertal ones (8±2 years), with p<0.0001. For PI04.5 as a cut-off, sensibility was 94 %, specificity 100 %, PPV 100 %, NPV 94 % and overall accuracy 97 %. Mean PI values were 3.1±0.89 before GnRH and 5.7±1.57 after treatment (p<0.0001). For these groups, sensibility was 95 %, specificity 89 %, PPV 88 %, NPV 94 % and overall accuracy 91 %. Discussion and conclusions. Considering 4.5 as cut-off value, PI represents a valid parameter for the diagnosis of puberty (puberty is assessed for PI<4.5) and can be used for the evaluation of the efficacy in GnRH-agonists treatment in patients with precocious puberty.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
R33 Doppler sonographic renal resistance index in children with acute pyelonephritis Eugenia Vranou, Savas Deftereos, Aggelos Tsalkidis, Athanasios Chatzimichael, Panos Prassopoulos Democritus University of Trace, Komotini (Greece) Purpose - Objective. To determine the values of Doppler resistance indices (RIs) in intrarenal arteries in children with acute pyelonephritis in order to differentiate acute pyelonephritis from lower urinary tract infection (UTI). Material and methods. Twenty seven consecutive children (male: 11, female:16) between 0 and 3 year old (mean age:18,22 months+/−12,26SD) with clinical signs of febrileUTI were included to our study. RI was measured from the renal arteries with Doppler ultrasound (US) in the first 72 h in all patients. The renal involvement evaluation was estimated by initial US of the parenchyma, 99mTc-DMSA scintigraphy in the first 7 days after admission, in correlation with clinical and laboratory examination. All children underwent voiding cysteourethrography after successful treatment. Results. Kidneys with DMSA findings of acute pyelonephritis (upper-UTI) had a mean RI of 0.74+/−0.03 (sensitivity: 81 %, specificity: 88 %). The mean RI was 0.69+/−0.01 in patients with lower-UTI. Patients with vesicoureteral reflux and scars in follow-up DMSA also had higher RI values. The mean RI-values were significantly higher in patients with upper UTI (p<0.001). There was also a highly significant correlation between RI-values and the severity of DMSA revealed renal lesions (p<0.001). Discussion and conclusions. RI-values were increased significantly in children with febrile UTI when renal parenchymal involvement (assessed by DMSA) was present. This might allow identification of patients at risk for severe renal lesions that require more aggressive therapy, investigation, and follow-up than those with lower-UTI.
Thursday, May 31 Scientific Session 3: Digestive 34 - SP Umbilical vein catheter tip—slight lateral shift can indicate liver perforation Alan Oestreich Cincinnati Children’s Hospital (United States) Purpose - Objective. To alert on the importance of recognizing a slight lateral shift of umbilical vein catheter tip because it may indicate liver perforation.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Material and methods. Case report of a newborn infant in whom 2.5 mm rightward shift on plain images (with respect to the inferior vena cava/right atrium junction) of the umbilical vein catheter tip at the diaphragm level was associated with penetration of the catheter into the liver. Results. From the first supine frontal image, a 2.5 mm shift was present, but not recognized. The shift later was as high as 3.7 mm. No lateral had been obtained. Several days later ultrasound and MRI revealed fluid and destruction in the liver centered at the tip’s former location. Recognition of such a lateral shift could have lead to an immediate ultrasound instead, which could then have lead to the proper diagnosis much earlier. Discussion and conclusions. The little known finding may be crucial for a baby’s well being. The complications of liver penetration by umbilical vein catheters is well known, but the importance of slight variation in the tip position on frontal plain images has not be emphasized, so is reported here.
35 - LP Liver stiffness measurement using supersonic shear imaging: feasibility and comparison with liver biopsy in the assessment of liver fibrosis in children Stéphanie Franchi-Abella, Lucie Corno, Monique Fabre, Emmanuel Gonzales, Danièle Pariente Hôpital Bicêtre, Paris (France) Purpose - Objective. Supersonic Shear Imaging (SSI) is a new non-invasive method to measure liver stiffness. The aim of this study is to evaluate the accuracy of SSI for the diagnosis of liver fibrosis by comparing its results with the METAVIR score on liver biopsy. Material and methods. Fifty-two children were prospectively included. The mean age was 4 years (1 month to 17 years). Twenty-three had liver transplantation, 13 biliary atresia, 5 others chronic cholestasis, 12 miscellaneous. All had liver biopsy with METAVIR fibrosis score. Results. The METAVIR score was F0 in 5 cases, F1 in 22, F2 in 9, F3 in 7, F4 in 9. The areas under the ROC for the prediction of significant (F2) or advanced fibrosis (F3) were 0.877 and 0.866 respectively. The correlation between stiffness by SSI and METAVIR score was lower in liver graft recipients (0.47) compared to other patients (0.70 to 0.87). Ten patients had discordance between liver stiffness and the METAVIR score and venous congestion or cholestasis was present on biopsy in 7. Discussion and conclusions. Liver stiffness measurement by SSI is feasible in children and related to liver fibrosis in most cases. Further studies are necessary to evaluate the accuracy of this technique in each group of pathology and to better understand the pitfalls.
S485
36 - LP Detection of primary sclerosing cholangitis (PSC)-type lesions in children with inflammatory bowel disease via MRCP: a relative risk measures analysis Polis Xenophontos 1 , Themistoklis Spyridopoulos 2 , Nikos Economopoulos1, Konstantina Spyrou1, Christina Kontopoulou1, Christina Tsompanlioti1, Eleftheria Roma3, Efthymia Alexopoulou1 1 General Hospital Attikon, Athens; 2Penteli’s Children Hospital, Athens; 3 “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. 1. To detect and classify primary sclerosing cholangitis (PSC)-type lesions in children with inflammatory bowel disease (IBD) via magnetic resonance cholangiopancreatography (MRCP). 2. To investigate the effectiveness of several data in detecting such lesions. Material and methods. Demographic, laboratory and magnetic resonance enterography (MRE) data (1) were collected from 73 IBD children. The Ponsioen’s classification for PSC (modified for MRCP studies) was used as a radiological diagnostic guide (2). In order to estimate relative risk (RR) measures, we performed logistic regression analyses. Results. Eleven children presented with PSC-type lesions at MRCP. Ponsioen’s combined score for PSC was 2 in seven cases, 3 in three cases and 4 in one case. A greater RR of a PSC-positive MRCP was revealed for AST, ALT and GGT abnormality at initial diagnosis of IBD, and AST, ALT, GGT, direct and total bilirubin abnormality at the time of MRCP. A linear relationship was demonstrated between the RR and the values of AST, ALT, ALP and GGT at initial diagnosis of IBD, and the values of AST, ALT, ALP, GGT, direct and total bilirubin at the time of MRCP. Discussion and conclusions. The modified Ponsioen’s classification is easily applicable for detecting and discussing PSC-type lesions. AST, ALT and GGT were the most consistent laboratory parameters in estimating the relative possibility of presenting with such lesions at MRCP.
37 - SP Secretin has uncertain value in pediatric MRCP Andrew Trout, Alexander Towbin, Daniel Podberesky Cincinnati Children’s Hospital (United States) Purpose - Objective. Secretin reportedly improves visualization of the pancreatic duct in magnetic resonance cholangiopancreatography (MRCP) by stimulating pancreatic exocrine function. Based upon our clinical experience, we were skeptical of the added diagnostic value in our pediatric population.
S486
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Material and methods. A retrospective study was performed evaluating all MRCPs with secretin completed at our hospital over 15 months. Pre and post-secretin images were separated, de-identified and randomized. One observer measured the pancreatic, common, intra- and extrahepatic bile ducts at multiple locations. Two other observers reported subjective image quality and visibility of the same duct segments. Results. Twenty MRCPs were performed in 17 pediatric patients. Secretin administration resulted in a mean increase in pancreatic duct diameter of approximately 0.3 mm (p0 0.0113–0.0255, 95 % CI: 0.04–0.54 mm) at all locations. There was no significant change in the diameter of the common duct or common bile duct but the diameter of the central intrahepatic ducts significantly increased with secretin (p<0.05). Image quality was not substantially different with secretin but visualization of pancreatic duct segments was improved (of 80 segments, 43 and 40 were seen presecretin versus 51 and 56 post-secretin). Discussion and conclusions. While there was a statistically significant change in pancreatic duct diameter and improved duct visualization following secretin administration, the small absolute diameter change and the unexpected change in intrahepatic biliary duct diameter calls the true significance of these changes into question.
diagnosis of CPSS with a very good outcome. One asymptomatic patient has so far been managed conservatively. Discussion and conclusions. CPSS is a rare condition and may be related to intrauterine growth retardation, galactosemia, cholestasis and hepatic encephalopathy. It may lead to hepatic tumours, hepatopulmonary syndrome and pulmonary hypertension. Ultrasonography is the first modality for diagnosis, with further work-up by contrast-enhanced CT/MRI, and angiography if necessary. Early detection and management, including interventional radiology, is valuable for the clinical outcome.
38 - SP
Purpose - Objective. Ultrasound diagnosis of Biliary Atresia (BA) was found to have an accuracy of 98 %¹ within our institution. Our practice has been to perform radioisotope scans in conjunction with ultrasound in the work up of infants with conjugated jaundice. This study’s aim was to assess if radioisotope scans are always needed. Material and methods. We reviewed the imaging data of 336 consecutive patients investigated for conjugated jaundice at our institution over a 10 year period and compared this with the final diagnosis. Results. There were 89 surgically proven cases of BA, all detected by ultrasound. Of these, 79 had an isotope scan, all non-excreting. Of 247 Non BA cases, 156 had an isotope scan, and 60 of these were non-excreting. Ultrasound reported no features of BA in 225 cases. In 22 cases where ultrasound showed some abnormal features associated with BA, 5 demonstrated excretion on isotope scan. Discussion and conclusions. In cases where ultrasound gave a strong positive diagnosis of BA, it removed the need for radioisotope scan. Radioisotope scan can sometimes exclude BA in those infants in whom the US appearances are not entirely normal, but there remain a small number of diagnostically challenging cases in whom imaging alone cannot give the final diagnosis. 1 Humphrey T M and Stringer M D. Biliary Atresia: US Diagnosis. Radiology: 2007; 244: 845–851 Conflict of interest. None
Imaging and interventional radiology in congenital porto-systemic shunts Aikaterini Kanavaki, Mehrak Anooshiravani, Barbara Wildhaber, Valerie Mc Lin, Sylviane Hanquinet, Sylvain Terraz University Hospital of Geneva (Switzerland) Purpose - Objective. To review clinical and radiological manifestations of five children with congenital portosystemic shunts (CPSS), as well as treatment and outcome. Material and methods. Between 2008 and 2011, five patients (age range, 12 days to 25 months) were admitted in our institution with a diagnosis of CPSS, established by US (5), CT (5) and MRI (4). Clinical presentation was hepatopulmonary syndrome (2), hepatoblastoma (1) and liver failure (4). Three patients underwent angiography for further evaluation. Results. In our series, three CPSS were extrahepatic, whereas two were intrahepatic. Three CPSS were closed by endovascular procedures, with a technical success of 100 %. One patient died 1 week after the procedure from brain haemorrhage. In one patient, a new small (<2 mm) intrahepatic shunt was detected on 24-hours US follow-up; the third patient developed partial portal vein thrombosis, treated by anticoagulation. Two patients were respectively transplanted 2 months and 1 year after
39 - SP
Withdrawn
40 - SP Has ultrasound reduced the need for radioisotope scans in the investigation of neonatal conjugated jaundice? Terry Humphrey, William Ramsden, Patricia McClean, Sanjay Rajwal, Suzanne Davison, Naved Alizai Leeds Children’s Hospital (United Kingdom)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
41 - SP Ultrasonographic diagnosis of gastric or duodenal ulcers in children Kwanseop Lee Hallym University Hospital, Chuncheon (Republic of Korea) Purpose - Objective. In children, the diagnosis of gastric or duodenal ulcer is limited, especially in younger children. But evaluation of the stomach using ultrasonography in children is relatively easy to access due to thin body habitus. Moreover, most of the gastric ulcers are located in the antrum, where sonographic evaluation is especially good. The purpose of this presentation is to evaluate the sonographic findings of gastric or duodenal ulcers in children. Material and methods. We evaluated eight children who were diagnosed as gastric or duodenal ulcer on initial ultrasonography and confirmed on endoscopy (6 children) or upper GI study (2 children). Results. Sonographic findings were wall thickening of the stomach or duodenum with echogenic spots in the thickened wall. Thickened bowel wall was from 8 mm to 16 mm, of which the mean diameter was 11.1 mm. Seven were gastric ulcers and one was a duodenal ulcer. Seven gastric ulcers were all located in the antrum. Six children were male and two were female. The age of the children was from 1 year to 17 years old. The mean age was 7.4 years. Discussion and conclusions. Ultrasonographic findings of gastric or duodenal ulcers were wall thickening with echogenic foci in the thickened wall. Initial sonographic diagnosis of the stomach in children could render early diagnosis and proper treatment possible.
42 - SP Ultrasound exclusion of malrotation in babies with duodenal atresia/stenosis Shadi Abdar Esfahani1, David Yousefzadeh2 1 Massachusetts General Hospital, Boston; 2University of Chicago (United States) Purpose - Objective. 28–38 % of babies with duodenal atresia (DA) and duodenal stenosis (DS) have malrotation and congental heart disease (CHD), requiring prioritization of which anomaly should be managed first. Material and methods. Three cases of DA and one case of DS all had abdominal radiographs and one had UGI. Position of third portion of duodenum (D3) were assessed by ultrasound (US). Rightward manual abdominal compression was used to align the shifted superior mesenteric artery (SMA) with aorta (AO). One with cloacal anomaly had pelvic US and MRI.
S487
Results. Duodenal bulb was variably distended in all. Gas was seen distal to the second bubble in initial study in one with a severe post-bulbar DS by UGI.US showed the D3 between AO and SMA, excluding malrotation/midgut volvulus. In one, rightward manual abdominal compression corrected the rightward shifted SMA/SMV and aligned them with AO for obtaining longitudinal images. Pelvic US showed distended recto-sigmoid due to an imperforate anus. Axial MRI showed D3 between AO and mesenteric vessles. Discussion and conclusions. In view of a high likelihood of malrotation with DA/DS and since malrotation cannot be excluded by UGI in DA, US exclusion of malrotation eliminates the fear of impending bowel ischemia and rationalizes gastric and duodenal decompression by nasogastric suctioning and postponing immediate surgery for DA/DS until the associated CHD is managed first.
43 - LP External manual reduction with US assistance: a new procedure for pediatric idiopathic ileocolic intussusception Jose Vazquez, Margarita Montero, Maria Doniz, Manuel Ortiz Complejo Hospitalario Xeral Cies, Vigo (Spain) Purpose - Objective. An additional, new, simple, effective and safe maneuver for the radiologist in the nonsurgical reduction of pediatric ileocolic intussusception. Material and methods. For a 30-month period, we performed the procedure on 14 occasions on a total of 12 patients (6 boys, 6 girls). Age range was 6–34 months, mean 22. Symptom duration range 3–48 h, mean 12. Inclusion criteria: children with idiopathic ileocolic intussusception. Exclusion criteria: shock, peritonitis or perforation. The procedure is performed under sedation, usually moderate, to diminish abdominal wall muscle tone, provide patient comfort and facilitate the maneuver. A photographic sequence and a clinical video of the maneuver will be shown. Results. Procedure was uneventfully performed on 14 occasions on 12 patients (two patients with recurrences). Sedation was moderate in 12 procedures and deep in 2 older patients. Complete reduction was achieved exclusively by external manual reduction in 11 instances (79 %). In the remainder 3, partial reduction (to the cecum) was obtained. Enema was subsequently performed, completely reducing two. One patient finally underwent surgical reduction. Overall nonsurgical reduction rate: 93 %. All patients had a rapid and painless recovery. Discussion and conclusions. External manual reduction with US assistance is a radiation-free, clean, simple, safe and effective
S488
maneuver for the radiologist. It adds an initial step in the nonsurgical management of intussusception. Multicenter further research is proposed to validate the procedure and its results. Conflict of interest. None.
44 - SP Deep sedation during pneumatic reduction in intussusception Anat Ilivitzki, Luda Gluzman, Ahuva Engel Rambam Medical Center, Haifa (Israel) Purpose - Objective. Pneumatic reduction under fluoroscopic guidance is a routine procedure. The awake child may become combative, this may lengthen the study and raise the radiation dose. We use deep sedation during the procedure to overcome these difficulties. We aim to summarize our experience with deep sedation during fluoroscopic reduction in intussusception and assess the added value and complication rate of deep sedation during enema reduction. Material and methods. All pediatric patients with intussusception who underwent attempted pneumatic reduction in our hospital between January 2004 and June 2011 were enrolled in this retrospective study. Anesthesiologist sedated the patients using Propofol. The fluoroscopic studies, US studies and the charts of these patients were reviewed retrospectively by pediatric radiologist. Results. One hundred thirty-one enemas for attempted reduction were performed in 119 patients, 121 were successful (92.36 %), 10 failed (8.2 %). 2 perforations (1.5 %) occurred during reduction attempt. Average fluoroscopic time was 1.5 min. No complications post-sedation were recorded. Discussion and conclusions. In our experience, deep sedation with Propofol added no complication to the pneumatic reduction. The short fluoroscopic time with sedation reduced the amount of radiation the child received. The high success rate in our study raises the possibility of pharmacologic aid in the reduction due to bowel relaxation.
45 - SP Transient self-limiting intussusception of the small-bowel: more frequent than suspected? Cinzia Orazi, Maria Barbieri, Paola Marchetti, Laura Cursi, Paolo MS Schingo, Andrea Magistrelli, Antonino Reale, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy) Purpose - Objective. Isolated small-bowel intussusception can present in a transient, self-limiting manner, unassociated to the idiopathic ileo-colic form, with nonspecific
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
abdominal symptoms, and may also be incidentally detected during US examinations performed for other reasons. Material and methods. We report on US findings in 33 patients, mean age 3.7 year, presenting with cyclic, crampiform abdominal pain, and sometimes diarrhea and vomiting. Video recording was usually associated. Results. US demonstrated the well-known evocative aspect of intussusception involving small bowel loops. The intussuscepted segment was usually small and short, mostly less than 3,5 cm, without wall swelling; peristaltic movements were clearly appreciable. No lead point was appreciable, but adjacent mesenteric lymphnodes were sometimes slightly enlarged. In a few cases, the intussusception reduced spontaneously during the US examination. In other cases it persisted up to the following 24–48 h, but mostly with weak symptoms. Reduction was sonographically documented. Discussion and conclusions. Transient self-limiting intussusception of the small-bowel is a little-known condition in the pediatric population that does not always manifest symptoms. It can be discovered in children complaining of abdominal pain, but symptoms are not specific. A causal relationship remains uncertain. It can presumably be related to abnormal gastro-intestinal motility or concomitant inflammatory aspecific conditions. Conservative management with US monitoring rather than immediate surgery is advisable.
46 - SP MR imaging of the normal appendix in children with suspected inflammatory bowel disease Arzu Kovanlikaya, Daniel Rosenbaum, Madhu Mazumdar, Allison Dunning, Paula Brill NewYork Presbyterian Hospital, Weill Cornell Medical College, New York (United States) Purpose - Objective. To determine the detection rate of the normal appendix in children with suspected IBD on oral and IV contrast-enhanced MRI. Material and methods. Imaging of 58 patients (mean age014.3 years) undergoing MR enterography for suspected IBD were retrospectively reviewed. Patients were given oral Volumen according to the MR enterography protocol, and were classified as having IBD involving the right lower quadrant, IBD distant from the right lower quadrant, and normal patients. Two observers interpreted the results by consensus. Detection rate was defined as the percentage of times the appendix was visualized on at least one sequence. Results. The normal appendix was detected in 28 cases (48 %). Patients in whom the appendix was detected had significantly higher body mass index compared to patients
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
in whom the appendix was not seen (p0.0025). Presence and location of IBD, age, and gender had no significant association with the detection rate. Discussion and conclusions. The overall detection rate of the normal appendix in children on oral and IV contrast-enhanced MRI was 48 %, and was unaffected by the presence and location of IBD. This rate is comparable to previously reported detection rates of the normal appendix on non-enhanced MRI. These results suggest that in MR protocols designed to evaluate the appendix, patients may be spared the delay and discomfort of oral contrast administration, increasing the feasibility of MR imaging of appendiceal pathology in the emergency setting.
47 - LP Faecal incontinence following correction of anorectal malformations: MR and rectal manometry correlations Sergio Salerno, Jessica Giordano, Anna Caruso, Livia Bruno, Antonio Lo Casto Policlinic Hospital, University of Palermo (Italy) Purpose - Objective. Faecal incontinence is a frequent complication in patients treated for severe anorectal malformations. We compare the functional parameter of the rectal manometry to the morphological MR data. Material and methods. Nine patients with faecal incontinence were submitted to rectal manometry and MR blind. Rectal manometry measured the resting anal pressure and maximum anal pressure during contraction. MR was conducted with T1 and T2 weighted images in axial, sagittal oblique and coronal planes. The following parameters were evaluated in MR: muscle thickness, shape and symmetry (dividing the muscular plane in 4 zone: right anterior, right posterior, left anterior etc.), and associated sacrum or genitourinary anomalies. Results. 4/9 patients with low-grade anorectal incontinence on rectal manometry showed on MR anmild asymmetry of the muscles (less than 30 % in thickness compared with the other zone), with a prevalence of 1 or, more commonly, 2 different zones. 5/9 with high-grade anorectal incontinence grades revealed a severe muscle asymmetry (more than 50 %) and a prevalence of 2 different zones. 2/9 patients showed genitourinary associated malformation, 4/9 sacral anomalies. Discussion and conclusions. Pelvic MR is a useful tool to determinate postoperative malformation in children presenting faecal incontinence, evaluating muscle quality, position and eventual associated sacral or genitourinary malformation with a significant correlation with rectal manometry.
S489
48 - LP Diffusion-weighted MRI of abdominal and soft tissue abscess formations in children and young adults Henning Neubauer, Isabel Platzer, Verena Mueller, Thomas Meyer, Johannes Liese, Herbert Koestler, Dietbert Hahn, Meinrad Beer University Hospital Wuerzburg (Germany) Purpose - Objective. To evaluate the detectability and imaging characteristics of abscess formations on diffusionweighted MRI (DWI) in children and young adults. Material and methods. Seventeen patients (11 females, age 13±6 years, range 1–21 years) with suspected abdominal or soft-tissue abscess underwent routine MRI including diffusion-weighted free-breathing single-shot echo planar imaging. Seventeen randomly chosen age-matched patients with non-purulent abdominal free fluid collections served as a control. Mean ADC was measured for abscess, muscle, liver, spleen and kidney tissue as well as for various body fluids. Results. All abdominal (n09) and soft tissue (n08) fluid collections were identified on diffusion-weighted images. Twelve of 13 confirmed abscess formations showed an ADC below 1.0 *10–3 mm2/s with a mean value of 0.80± 0.38 *10–3 mm2/s. One tuberculous soft-tissue abscess had a higher ADC of 1.85 *10–3 mm2/s. There were no falsepositive findings in the control group. Discussion and conclusions. Diffusion-weighted MRI reliably detects fluid collections in paediatric patients and distinguishes between abscess and non-purulent fluid. DWI facilitates free-breathing rapid image acquisition without the need of i.v. contrast application and constitutes a particularly useful choice in paediatric imaging.
R49 Imaging investigation of liver structure and hepatic perfusion changes in pediatic patients with chronic diffuse liver diseases Boris Tarasyuk, Iryna Dykan, Elena Polischuk Scientific and Practical Center of Radiology NAMS (Ukraine) Purpose - Objective. The problem of imaging diagnostics of chronic liver diseases in children needs urgent addressing due to prevalence of viruses and metabolic injuries of the liver. Material and methods. Non-invasive diagnosis by high frequency ulrtasound (10 MHz), dopplerography and CT perfusion (CT Perfusion-3 software; GE Medical Systems) was used for liver chronic diseases evaluation in 166 pediatric patients (chronic virus hepatitis B - 76, C-51,
S490
autoimmune hepatitis - 9, Wilson’s disease – 30), in children aged from 5 to 17 years (mean age 9±2,3 years). A control group was composed of 31 patients of the same age, without liver injury signs according to biochemical blood analyses, who passed examination unrelated to liver disease. Puncture biopsy verification of chronic liver diseases was in 45 cases Results. The main US signs were: liver capsule induration and sinuosity, 3–5 mm noduls appearance in liver parenchyma, portalisation of blood flow spectrum in hepatic veins (3–4 branching) and RI increasing in arteria hepatica propria; the main perfusion changes were: increase of blood flow, decrease of mean transit time and capillary permiability surface. Discussion and conclusions. These results made it possible to take an accurate and adequate therapeutic decision in each case of chronic hepatitis.
R50 Evaluation of hepatic diffusion and perfusion values in healthy children by means of multi-b DWI Sara Savelli, Antonio Ciccarone, Marco Esposito, Anna Perrone, Marco Di Maurizio, Claudio Fonda Meyer Children’s Hospital, Florence (Italy) Purpose - Objective. Little evidence for the measurement of liver diffusion has been reported in children. Our aim was to evaluate the variability of hepatic diffusion and perfusion parameters and ADC in a group of healthy pediatric patients. Material and methods. From May 2009 on, 15 consecutive pediatric healthy patients without liver diseases scheduled for a liver MR examination were enrolled in our study. All the patients underwent liver MRI with DWI images with thirteen b values. DWI sequence was validated on a phantom. Hepatic diffusion and perfusion coefficients and fraction of perfusion were obtained by fitting a bi-exponential model on a region of interest (ROI) basis. In each ROI, we also computed the ADC value at b500 and b1000. Results. In the whole liver, the statistical distributions of D and f are symmetrical while F is non symmetrical. The mean values and standard deviations in our population were: 916×10-6 mm2/s and 95×10-6 mm2/s (D), 0.25 and 0.06 (f), 82000 × 10-6 mm2/s and 44000 × 10-6 mm2/s (F), 1528×10-6 mm2/s and 246×10-6 mm2/s (ADC@b500), 1061×10-6 mm2/s and 138×10-6 mm2/s (ADC@1000). Discussion and conclusions. The D parameter exhibits the best reproducibility and has the shortest standard deviation
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
in this pediatric population, thus suggesting a promising use of D in the evaluation of liver diffusivity.
Scientific Session 4: Musculoskeletal 51 - LP Conventional MRI sequences are inaccurate when assessing bone destruction in children with juvenile idiopathic arthritis Lil-Sofie Ording Muller1, Peter Boavida2, Beatrice Damasio3, Karen Lambot4, Clara Malattia (Ospedale Gaslini, Genova), Laura Tanturri (Ospedale Pediatrico Bambino Gesù), Karen Rosendahl5 1 University Hospital North Norway, Tromsø (Norway); 2 Homerton University Hospital NHS Foundation Trust, London (United Kingdom); 3Ospedale Gaslini, Genoa (Italy); 4Hopital Necker, Paris (France), 5Haukeland University Hospital, Bergen (Norway) Purpose - Objective. MRI is sensitive for early bone destruction in children with juvenile idiopathic arthritis (JIA). However, bony depressions resembling erosions are frequently seen on MRI of the carpal bones in healthy children as well. The accuracy of MRI in detecting early bony destruction is therefore questionable. We compared findings on MRI of the wrist in both healthy children and children with JIA to investigate true disease markers. Material and methods. Eighty-four healthy children and 74 children with JIA had an MRI of the wrist performed. We compared the number and localisation of bony depressions at the wrist between the two groups, using the OMERACTdefinition of an erosion; Aa cortical breech with typical signal characteristics seen in at least one plane on a T1 weighted image. Results. No significant difference in the total number of bony depressions in the carpal bones was seen between healthy children and children with JIA at any age. Depressions are found in similar locations in the two groups, except for a few sites, where bony depressions were seen exclusively in the JIA- group. Discussion and conclusions. T1 weighted images are inaccurate in differentiating true erosions from normal findings of bony depressions unless they appear in certain locations. More specific imaging tools need developing to avoid overdiagnosing of bone destruction in patients with JIA.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
52 - LP Juvenile idiopathic arthritis with dry synovitis: clinical and imaging aspects in a cohort of 6 patients Karen Lambot1, Lien De Somer2, Sylvain Breton1, Carine Wouters2, Brigitte Bader-Meunier1, Francis Brunelle1 1 Hopital Necker, Paris (France); 2University Hospitals Leuven (Belgium) Purpose - Objective. Dry synovitis is considered to be a rare form of juvenile idiopathic arthritis, incompletely understood and following a potentially destructive course, little described in the literature. We describe the clinical and radiological manifestations of dry synovitis. Material and methods. A retrospective study of 6 patients, in 2 pediatric rheumatology centers, with progressive articular limitations, without palpable synovitis and with radiologic articular damages. Neuromuscular conditions were excluded. Clinical and imaging (X-rays and MRI of wrist and/or pelvis) data were reviewed. Results. Six children (2 boys and 4 girls) aged from 3 to 15 years (median 9.7 years) presenting delayed motor development and/or progressive articular stiffness were included. Clinical examination showed a symmetric and polyarticular involvement without obvious clinical signs of synovitis. All patients had osteopenia, advanced bone age, irregular bone contours and/or erosions. Synovial thickening was present in 5/6 patients and bone erosions in 4/6 patients. Bone edema was variably present. Despite treatment, articular limitations persisted and imaging showed progressive articular damage. Discussion and conclusions. Dry synovitis can be considered as a descriptive term referring to the development of prospective symmetric polyarticular limitations. MRI reveals subclinical inflammation and destructive changes earlier than X-ray. The exact nature of this entity and a possible contribution of a metabolic or intrinsic bone disorder into its pathogenesis remain to be determined.
53 - LP A new MR quantitative approach to assess inflammation and damage in children with juvenile dermatomyositis Chiara Mattiuz1, Beatrice Damasio2, Luca Nocetti3, Clara Malattia2, Silvia Pederzoli1, Gian Michele Magnano1 1 Istituto Giannina Gaslini, Genvoa; 2Ospedale Gaslini, Genova; 3Policlinico di Modena (Italy)
S491
Purpose - Objective. To assess reliability and validity of a new MR quantitative approach to evaluate inflammation and damage in children with juvenile deratomyosotis (JDM) Material and methods. JDM patients (n06 years 9±1) and healthy children (n06;years:9±5) underwent 1.5T MR examination of muscle’s tissue. Water transversal relaxation times (T2*water) and intravoxel fat water percentage were calculated using a sequence with multiple fat water in-phase and out-phase echo times (TR0500 ms FA030° 32 echo times, first TE02.3 ms delta TE02.3 ms, slice thk03 mm, FOV0250 mm, matr 512×512), acquired on axial plane on the vastus lateralis muscle. For each patients T2*water, T2*fat and Intravoxel Fat Water percentage maps were calculated, and values from regions of interest (ROIs) defined on the vastus lateralis muscle were measured by two readers. A unpaired T-test was used for statistical analysis, P<0.05 was considered statistically significant. Results. A statistically significant difference for T2*water and intravoxel fat water percentage values resulted between JDM patients (40±6 ms and 6.9±5.6 %) and healthy subjects (31 ± 6 ms and 1.6 ± 1.1 %) respectively; P-values resulted <0.01 for T2*water and <0.05 for intravoxel fat water percentage. I Discussion and conclusions. We provided good results in terms of reliability and validity of T2* mapping technique with a new MR quantitative approach We also report for the first time the quantitative analysis of fat water percentage in JDM
54 - LP Juvenile dermatomyositis: MRI findings regarding acute inflammation and damages Karen Lambot, Sylvain Breton, Catherine Bourget, Caroline Elie, David Grevent, Laureline Berteloot, Christine Barnerias, Christine Bodemer, Brigitte Bader-Meunier, Francis Brunelle Hôpital Necker-Enfants Malades, Paris (France) Purpose - Objective. To establish and to assess a Magnetic Resonance Imaging (MRI) scoring method for acute inflammation and damage findings in juvenile dermatomyositis (JD). Material and methods. Between 1998 and 2009, children with JD referred to our institution for proximal thighs MRI were included retrospectively. The MRIs were analysed twice by two musculoskeletal paediatric radiologists with a 6 week interval. Inflammatory activity was scored,
S492
including muscle oedema (0 0 none, 1 0 mild and 2 0 severe), fascial, subcutaneous fat and skin oedema (qualitative scale). Damage was scored including calcinosis in muscles, fascias, subcutaneous fat and skin (qualitative scale), muscle and fat atrophy (qualitative scale) and muscle fatty infiltration (0 0 none, 1 0 mild and 2 0 severe). Results. Twenty children were included (median age, 7.1 years; range, 1.3–15.8; 6 boys and 14 girls). 45 MRIs were analysed, of which 10 were performed in the 2 months following diagnosis. The most common MRI findings were muscle oedema (80 %) for inflammatory activity, and muscle fatty infiltration (24 %) for damage. Both intra- and inter-observers agreements’ were excellent with regard to the global score (Intraclass Correlation Coefficient [ICC], from 0.95 [CI 95 %, 0.87–0.98] to 0.97 [0.94–0.99] and 0.88 [0.74–0.95], respectively). Inter-observer ICC were also excellent with regard to inflammatory and damage subscores (0.84 [0.73–0.91] and 0.89 [0.66–0.97], respectively). Discussion and conclusions. MRI is a reliable, objective and re-useable tool for analysing inflammatory activity and damage during JD.
55 - LP The utility of DWI sequences in the diagnosis of non-traumatic acute musculoskeletal pain Afshin Alavi, May-ai Seah, Shema Hameed, Maria Nordlander, Risha Hathi, Joanna Danin St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom) Purpose - Objective. According to statistics compiled from our Paediatric Accident and Emergency Department, 26 % of patients admitted last year were musculoskeletal cases. Many such studies have produced similar outcomes. Whilst trauma is the main cause, the most common non-traumatic aetiologies are infection and infarction. There are less frequent non-traumatic entities, including malignancies which can be presented with acute musculoskeletal pain. Although the diagnostic role of DWI in oncology is widely accepted, its diagnostic value in other fields is controversial. The purpose of our respective study was to evaluate the value of DWI in the diagnostic of non-traumatic acute musculoskeletal events. Material and methods. In this retrospective study, we reviewed the MRI studies and medical records of 132 children with acute non-traumatic musculoskeletal pain. Subsequently, we correlated the clinical outcomes with the results of the DWI sequences in order to verify its diagnostic value.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Results. One hundred thirty-two Children were admitted to our hospital with non-traumatic acute musculoskeletal pain. All of these patients had at least 1 MRI, including DWI sequences, and 109 patients had abnormal findings in the DWI sequences. There was a significant correlation between the DWI findings and the clinical outcomes. Discussion and conclusions. Our study showed that DWI sequences are the most effective sequences for the detection of the musculoskeletal hot spots, especially in multifocal processes.
56 - LP Garches muscle whole-body MRI (WB-MRI) protocol: pattern recognition in early onset neuromuscular disorders Robert-Yves Carlier1, Daniela Avila-Smirnow1, Dominique Monpoint1, Brigitte Estournet1, Pierre Carlier2, Susana Quijano-Roy1 1 Hôpital Raymond Poincaré, Paris; 2Hôpital Pitié Salpêtrière, Paris (France) Purpose - Objective. To evaluate the technical feasibility and diagnostic correlation of a paediatric WB-MRI Material and methods. One hundred five patients with known or suspected inherited neuromuscular disorder and 11 relatives were explored using a WB protocol on a 1.5-Ts MRI system. Axial and coronal head to toe T1w slices were obtained in all cases and axial STIR slices in most of the cases. Involvement scoring in T1 slices was performed using the Mercuri classification for 92 muscles. Results. WB-MRI was abnormal in 67 % of patients and in 27 % of non-complaining relatives. WB-MRI identified a recognisable pattern in 32 % of the series, which was consistent with the molecular diagnosis in 96 % of the examinations. Identification of a particular pattern consistent with a genetic defect was much higher in patients with rigid spine syndrome (RSS) (60 %), distal hyperlaxity syndrome (HLX) (41 %), and myopathy without RSS or HLX (32 %) than in the group of miscellaneous neuromuscular disorders. In addition, WB-MRI revealed distinct muscle involvement in different regions of the body not previously described. Discussion and conclusions. In inherited myopathies, muscle weakness is often diffuse but data in the literature is mostly limited to lower limbs (sequential MRI). WB-MRI is applicable in children with a broad spectrum of neuromuscular disorders and useful in the diagnosis of early-onset neuromuscular disorders, with a particular interest for inherited myopathies associated with RSS and HLX.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
57 Withdrawn
58 - LP Rib fractures in metabolic bone disease of prematurity Michael Jackson, Simon McGurk, Maeve McPhillips Royal Hospital for Sick Children, Edinburgh (United Kingdom), Purpose - Objective. Metabolic bone disease of prematurity (MBDP) is a recognised cause of rib fractures in infants. Studies from the 1980s and 1990s suggested such fractures were reasonably common in premature infants. More recent data from 2009 (Smurthwaite et al.) suggested rib fractures are infrequent and should be considered suggestive of nonaccidental injury (NAI). It has been suggested that fracture rates have decreased as a result of more sophisticated neonatal care. Material and methods. Cases of rib fractures identified on chest radiograph in infants under the care of the neonatal unit were collected retrospectively over a 12 month period. Results. Six cases were identified. All were premature infants in which rib fractures were identified as incidental findings. Birth gestational age range 24+5 to 31 weeks (mean 27.5 weeks). In every case the child had been under medical care since birth, with no clinical concern of NAI or inappropriate handling. In one case persistent mild hypocalcaemia was present but no significant disturbance in bone biochemistry was identified in the other infants. Discussion and conclusions. The incidence of rib fractures in this population is unknown. Nevertheless, the number of cases accumulated within a relatively short time period suggests such fractures are more frequent than previously suggested. In the abscence of additional evidence, rib fractures in the context of MBDP should not be considered indicative of NAI.
59 - LP Associations between femoroacetabular impingement and hip dysplasia as demonstrated radiographically. Preliminary results. Lene B Laborie, Ingvild Engesaeter, Trude G Lehmann, Lasse B Engesaeter, Karen Rosendahl University of Bergen and Haukeland Hospital (Norway) Purpose - Objective. We examined possible associations between acetabular immaturity/dysplasia (DDH) and
S493
femoroacetabular impingement at skeletal maturity in healthy young adults. Material and methods. Four thousand six adolescents were invited to a population-based clinical and radiological follow-up study on DDH. 2059 (52 %) were included. Acetabular roof shape indicating immaturity or dysplasia was assessed subjectively from an erect, pelvic anteroposterior (AP) view. The pistol grip deformity, a focal femoral neck prominence and a flattening of the lateral femoral head, all associated with cam-type impingement, and the posterior wall sign, an excessive acetabular coverage and the crossover-sign, all associated with pincer-type impingement, were assessed subjectively from AP/frog-leg views. The associations between DDH and impingement were examined using chi-square statistics. Results. Radiographs of 2,059 adolescents (58 % females), (mean age 18.6, SD 0.6) were analysed. When based on the left hip, 67/867(7.7 %) males and 143/1192(12.0 %) females had acetabular immaturity/dysplasia. In males, a positive posterior wall sign was seen in 147/867 (17.0 %) of the total cohort, and in 19/67 (28.4 %) of those with an immature/dysplastic hip (p0.017). In females, a laterally flattened femoral head was seen in 60/1192 (5.0 %), and in 13/143 (9.1 %) of immature/dysplastic hips (p0.025). Discussion and conclusions. Acetabular immaturity/dysplasia was associated with a positive posterior wall sign in males (marker for pincer-impingement), and with a laterally flattened femoral head in females (marker for cam-impingement).
60 - LP The paediatric cervical spine: a guide to image interpretation in major trauma Maria Nordlander, Shema Hameed, Afshin Alavi, May-ai Seah, Joanna Danin St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom) Purpose - Objective. Radiological assessment of the paediatric c-spine in major trauma is a recognised challenge. Children demonstrate a variable and unique range of injuries compared to adults, owing to the complex biomechanics of the paediatric c-spine. We share our experiences as one of the largest major trauma centres in London, performing over 500 paediatric c-spine radiographs and almost 100 CTs per year. Material and methods. We aim to discuss: • Embryological development and anatomy of the paediatric cervical spine. • Normal anatomical variants that may be mistaken for fractures. • Commonly encountered mechanisms of injury per age group, with descriptions of associated c-spine injuries. •
S494
A step-by-step guide to image interpretation, with a description of normal parameters. Results. Utilising high quality radiographic and CT images, with original illustrations, we will guide the reader to confident interpretation of the paediatric c-spine. Normal parameters, including cervical spine lines, atlanto-dental distance, basion-dens interval and Wackenheim’s clivus line, will be described. We present normal anatomical variants that may be mistaken for fractures, including epiphyseal variants, incomplete ossification of synchondroses and apophyses, C3 vertebral body jwedging and pseudosubluxations. Discussion and conclusions. Interpretation of c-spine imaging in children is a recognised challenge. Accurate analysis depends on an understanding of mechanisms of injury, thorough clinical assessment, knowledge of normal anatomy, developmental background and anatomical variants, as well as the normal parameters within the upper cervical spine.
61 - LP Radiography of scoliosis: comparative dosimetry and evaluation of image quality between a dynamic flat detector and a slot-scanning system Marianne Yvert1, Abou Diallo1, Pierre Bessou1, Muriel Brun1, Jean-Luc Réhel2, Jean-François Chateil1 1 University Hospital Pellegrin, Bordeaux; 2IRSN Fontenay aux Roses (France) Purpose - Objective. To compare a Dynamic Flat Panel Detector (DFP) and a Slot-Scanning System (SSS) in terms of radiation exposure, image quality, accuracy of Cobb angles measurements in children and adolescent scoliosis assessment. Material and methods. An experimental study was performed with a CDRAD phantom to assess the quality of each device. A clinical, prospective observational dosimetric and qualitative comparative study was carried out, including 57 young patients (median age 11.4 years old), with an entire postero-anterior spinal X-ray required as part of the evaluation of scoliosis. 26 patients were exposed with DFP, 31 patients with SSS. A statistical analysis of dosimetric data was undertaken: dose area product (DAP) and skin entrance dose, measured by thermoluminescent dosimeters localized in the cervical, thoracic and sacral area, were compared. Diagnostic quality (phantom and clinical studies) was assessed through an independent evaluation of images performed by three observers. A statistical analysis of quality score and interobserver reproducibility was carried out. Results. DAP calculated according to body mass index of the patient was identical in the two systems (p<0.05). Skin entrance dose was significantly higher with DFP compared to SSS in thoracic and pelvic regions (p<0.05), but higher in the cervical region (p<0.05). Image quality scores of the
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
SSS were significantly better than DFP, in both phantom and clinical evaluations (p<0.05). Discussion and conclusions. SS System can achieve a higher image quality-to-dose ratio for scoliosis imaging, especially in most sensitive areas (breast, pelvic organs).
62 - LP Replacing conventional spine radiographs with dual energy x-ray absorptiometry (DXA) in children with suspected reduction in bone density Lucy Summers 1, Penny Broadley2, Isla Lang2, Amaka Offiah2 1 University of Sheffield; 2Sheffield Children’s Hospital NHS Foundation Trust (United Kingdom) Purpose - Objective. Children have a greater lifetime risk of radiation-induced complications than adults. In children with osteogenesis imperfecta (OI), conventional radiographs assess spine morphometry, while spine DXA assesses bone density; DXA is now used in adults for both. The objective; to establish whether iDXA can replace spine radiographs for vertebral morphometry assessment in children. Material and methods. An 18 month prospective recruitment of 250 children aged 5–15 years. 200 children with and 50 without suspected reduction in bone density will have lateral spine radiographs and DXA on the same day. Three observers will independently assess images (blinded to corresponding results) using a modified ABQ technique. A random sample of 100 will be interpreted twice. Diagnostic accuracy and inter and intra-observer reliability of DXA will be compared to radiography; the gold standard. Aspects of this study include DXA accuracy, patient/carer experience, radiation dose of DXA compared to radiographs and health economic evaluation. Results. After 1 month, we have recruited 9 patients and anticipate approximately 65 patients by ESPR 2012. In April 2012, we plan on undertaking an interim analysis of images for 40 children with and a quarter (12) of the total children without suspected reduction in bone density. Discussion and conclusions. Interim results, which we hope to present at ESPR, may provide an indication for potential of iDXA to replace spine radiographs in assessing vertebral morphometry in children with suspected reduced bone density. R63 Novel assessment of fracture risk in children using finite element (FE) analysis of lateral spine dual energy absorptiometry (DXA) scans. Lucy Summers1, Chuhee Lee1, Lang Yang1, Amaka Offiah2 1 University of Sheffield; 2Sheffield Children’s Hospital NHS Foundation Trust (United Kingdom)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. Infants presenting with multiple unexplained fractures have two major differential diagnoses: osteogenesis imperfecta (OI) and child abuse. No reliable method exists to exclude reduced bone density in children less than 5 years. Finite element (FE) analysis of adult hip DXA scans predicts fracture risk. The objective: to test the hypothesis that FE analysis of spine DXA scans in children correlates with bone mineral density (aBMD). Material and methods. A prospective pilot study involving 50 consecutive children over the age of 5 years presenting for DXA scans. FE analysis of the images will be performed using a specially developed software programme. Index of fracture risk (IFR) will be determined for each vertebral level (T4 to L4) and for the entire spine (T4 to L4). Correlation coefficients between IFR and aBMD will be calculated. Local REC approval obtained. Results. After 1 month we have recruited 9 patients and will reach our goal of 50 by March 2012; all results will be compiled prior to the ESPR conference in May. Discussion and conclusions. If our results are promising, the next steps will be to conduct prospective studies to: 1.Correlate IFR with age, gender, and aBMD. 2.Compare IFR in different groups of children (normal, reduced bone density, OI) less than 5 years. 3.Perform longitudinal studies comparing IFR with number of fractures. 4.Determine normative IFR values in children less than 5 years of age.
R64 Pediatric Knee: MR imaging in non-traumatic conditions Manish Bajaj1, Tushar Chandra2, Amit Gupta3, Shalini Bajaj1 1 Geetanjali Medical College (India); 2Childrens Hospital of Wisconsin (United States); 3Ravindra Nath Tagore Medical College, Udaipur (India) Purpose - Objective. This educational exhibit aims to: 1.Describe the normal anatomy of the knee on MR imaging in the pediatric age group and common variations in anatomy 2. Discuss normal evolution of the marrow pattern on MRI in the pediatric age group 3. Illustrate the imaging features of common tumors, tumor-like conditions, infections, inflammatory pathologies involving the knee 4. Emphasize the common pitfalls in evaluating the pediatric knee. Material and methods. Pediatric patients with atraumatic knee conditions were evaluated using 1.5T MRI. Standard MR imaging protocols were used to image the knee in three orthogonal planes. Plain and post contrast T1W images were used to evaluate infections, tumors and tumor-like conditions. Results. MRI provides many advantages in an evaluation of the knee, compared to other modalities, particularly in the pediatric age group. These include lack of ionizing radiation,
S495
multiplanar imaging, excellent resolution and improved evaluation of the soft tissues, marrow, cartilage, muscle, and ligaments around knee. Certain pathologies have a characteristic appearance on MR imaging that can be virtually diagnosed, even in the absence of a histopathology. Discussion and conclusions. Interpreters of pediatric knee MRIs must be aware of normal variations in the anatomy of the knee as well as the normal evolution of the bone marrow signal with age and incidental findings unique to this group. Certain tumors and tumor like-conditions favor children and have classical MR appearances. Optimal interpretation of these pathologies is very important for timely intervention and management.
Friday, June 1 Scientific Session 5: Oncology-Miscellaneous 65 - LP Whole-body MRI, including DWI, compared to FDG-PET/CT for staging malignant lymphoma Malou Vermoolen1, Ignasi Barber 2 , Claudio Granata 3 , Annemieke Littooij4, Goya Enriquez2, Bart De Keizer1, Erik Beek1, Judit Adam5, Jozsef Zsiros5, Thomas Kwee1, Marc Bierings1, Rutger Jan Nievelstein1 1 University Medical Center Utrecht (Netherlands); 2Hospital Universitari Vall d’Hebron Barcelona (Spain); 3Ospedale Giannina Gaslini Genova (Italy); 4KK Women’s and Children’s Hospital Singapore (Singapore); 5Academic Medical Center Amsterdam (Netherlands) Purpose - Objective. Whole-body magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI), is emerging as a radiation-free method for oncological staging. This study aimed to compare whole-body MRI, including DWI, to 18F-fluorodeoxyglucose positron emission tomography with low-dose computed tomography (FDG-PET/CT) for staging newly diagnosed malignant lymphoma. Material and methods. Twenty-five children (male/female, 14/11; mean age, 12.9 years; age range, 5–16 years) with malignant lymphoma prospectively underwent whole-body MRI (T1-weighted and T2-STIR [n025], and DWI [n024]) and FDG-PET. Whole-body MRI and FDG-PET/CT were evaluated by different observers, who were blinded to the other imaging modality. Ann Arbor stages according to whole-body MRI (without and with DWI) were compared to those of FDG-PET/CT. Results. Staging results of whole-body MRI without DWI were equal/higher/lower to those of FDG-PET/CT in 15, 8, and 2 of 25 patients respectively. Staging results of whole-body MRI with DWI were equal/higher/lower to those of FDG-PET/
S496
CT in 16, 7 and 1 of 24 patients respectively. Sites of discrepant staging between MRI and FDG-PET/CT were lymph node stations (n06), spleen (n02), lung (n01) and pleura (n01). Discussion and conclusions. Our results indicate that staging using whole-body MRI (without and with DWI) is equal to staging using FDG-PET/CT in little over half of patients. Overstaging by whole-body MRI relative to FDG-PET/CT was more frequent than understaging.
66 - SP Imaging findings in posttransplantation lymphoproliferative disorder in children - 8 cases Ildikó Várkonyi, Anna Nyitrai, Éva Kis Semmelweis University Budapest (Hungary) Purpose - Objective. Post-transplantation lymphoproliferative disorder (PTLD) is a secondary disease of transplanted patients, which can be lethal or have a good response to reduction of immunsuppressive therapy. We present the various presentations of this entity in 8 children. Material and methods. PTLD was diagnosed in 8 transplanted children (7M, 1F), mean age: 11,75 years old, 3 renal transplanted, 3 lungtransplanted and 2 livertransplanted. PTLD presented between 2 months and 4 years after transplantation. Results. Six patients had abdominal, 5 thoracal, 1 axillar manifestations. Imaging findings included pulmonary nodules, mediastinal, axillary and abdominal lymphadenopathy, hilar mass, liver and renal nodules, splenomegaly and bowel wall thickening. Diagnosis was made based on X-ray, sonography and completed by CT and MRI. The final diagnosis had to be made on histology. 3 patients died, 2 are tumorfree, 3 are in remission. Discussion and conclusions. Presenting symptoms of PTLD are aspecific, often mimicking infection. First step imaging studies include chest X-ray and abdominal sonography. Neck, chest and abdominal CT or MRI are mandatory for detecting all sites of the disease, staging and determining the best localization of biopsy.
67 - LP Imaging findings in progressive transformation of germinal centers: a retrospective study of 23 patients Heba Takrouri, Jeffrey Traubici, Furqan Shaikh The Hospital for Sick Children, Toronto (Canada) Purpose - Objective. Progressive transformation of germinal centers (PTGC) is a rare, benign reactive adenopathy that leads to abnormal nodal enlargement. A rare but
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
consistent association of PTGC to Hodgkin lymphoma has been seen. Although PTGC was first described almost three decades ago, it is still relatively unknown to radiologists. The purpose of our study is to describe the radiological features of PTGC in our series. Material and methods. All patients with PTGC over a 13year period (1998–2011) at a tertiary children’s hospital were identified from a pathology database. All imaging studies were retrospectively reviewed. Studies were performed after surgical resection of nodes were excluded. Results. PTGC was diagnosed in 23 pediatric patients, aged 15 months to 17 years, male to female 1.3:1. The most common site of involvement was head and neck nodes. A total of 14 relevant ultrasounds were studied. Sonographic findings included lymph node enlargement, loss of oval shape, loss of fatty hilum and hyperaemia in 86 %, 100 %, 86 % and 84 % respectively. Multiple scattered, hypoechoic nodules were demonstrated in 12 scans (86 %). 17 patients had CT scans, all showed non-specific nodal enlargement. PET scans were performed in 8 patients with avid FDG uptake in all studies. Discussion and conclusions. Although not specific to the disease, PTGC should be considered in the differential diagnosis of lymphadenopathy with multiple hypoechoic nodules. Ultrasound can aid in the choice of nodes for biopsy.
68 - SP Radiological information for rhabdomyosarcoma (RMS) patients in the European pediatric soft tissue Sarcoma Study Group (EpSSG). Kieran McHugh1, Gianluca de Salvo, Michael Stevens, Gianni Bisogno 1 Great Ormond Street Hospital, London (United Kingdom); 2 University of Padua (Italy); 3Bristol Children’s Hospital (United Kingdom); 2University of Padua (Italy) Purpose - Objective. To review the radiological data accrued within EpSSG. Material and methods. Relevant information was extracted from the CINECA website. Results. Radiology reports are uploaded in 475/783 (64 %). Images are uploaded in 56 (7.5 %), but these are not DICOM images. Routine CT of the chest was not performed in 15/743 (2 %). 62/728 patients in the RMS 2005 study had lung nodules not considered metastases, with 53 cases from the UK, Holland, France and Italy. Routine PET-CT is variable with highest frequency in France—95/204 (46.6 %) of the French patients had PET-CT. Routine technetium bone scan was performed in 650/743 (93 %), and lower frequency in countries which tend to do PET-CT. CT abdomen/pelvis was not performed in 12/41 cases of lower limb primary RMS, but the numbers who had
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
abdominal MRI are unknown. 5/107 paratesticular tumours had neither CT nor MRI evaluation of the abdomen. Regarding CT/ MRI of the primary site, 333/743 (44.8 %) had both CT and MRI examinations of the primary. In 71/743 (9.6 %), however, neither CT nor MRI were performed, but the number who had excision surgery prior to diagnosis is unknown. In the enrolled patients, 3 diameters (and tumour volume) at diagnosis are available in 579 (74 %). 3 diameters are available in 298 (55 %)at response evaluation, but these are not all the same patients. Discussion and conclusions. Lessons learnt and new recommendations will be presented.
69 - SP Radiological information on non-rhabdomyomatous soft tissue sarcomas (NRSTS) within the European pediatric soft tissue Sarcoma Study Group (EpSSG). Kieran McHugh1, Gianluca de Salvo2, Michael Stevens3, Gianni Bisogno2 1 Great Ormond Street Hospital, London (United Kingdom); 2 University of Padua (Italy); 3Bristol Children’s Hospital (United Kingdom); 2University of Padua (Italy) Purpose - Objective. To review the radiological data accrued within the EpSSG study for patients with NRSTS. Material and methods. Relevant information was extracted from the CINECA website. Results. The radiology reports are uploaded in 334/493 (71.4 %) of patients. Images, which are JPEGs not DICOM files, are uploaded in 21 (4.5 %). CT chest has been performed in 356/468 (76 %) patients. 30/326 (9.2 %) had equivocal lung nodules not considered metastases, with the highest percentage of equivocal cases clearly occurring in Holland. 71 PET-CT studies were performed in 468 patients (15.2 %). 36/91 (28.4 %) French patients had PET-CT. Tc99m-MDP bone scans were done in 261/468 (55.8 %), which appears to be a relatively high percentage as many NRSTS tumours never metastasise to bone. Regarding CT and MRI of the primary site, 59/468 (12.6 %) had neither, whilst 154/468 (32.9 %) had both. Further clarifications on the histopathological sub-types is planned, with a more detailed evaluation of the cohort of children with synovial sarcoma in particular. Data on 3D and 1D measurements is currently being analysed, and will be available at the meeting. Discussion and conclusions. Recommendations for further studies and lessons learnt will be presented.
70 - LP Withdrawn
S497
71 - SP Diffusion imaging findings of pediatric brain tumors Amit Agarwal, Kanupriya Vijay Pennsylvania State University (United States) Purpose - Objective. To discuss the diffusion imaging findings of common pediatric brain tumors and how the apparent diffusion coefficient values (ADC) can help in tumor characterization Material and methods. We retrospectively selected 57 cases of pediatric brain tumors, with surgical and histopathological results, and reviewed the diffusion and ADC findings Results. There is a difference in ADC values of most of the pediatric brain tumors that can be used to narrow the differential in the radiologic impression. ADC values were significantly higher in pilocytic astrocytomas (1.62 +/− 0.3) (mean +/− SD) than in ependymomas (1.21 +/− 0.2) and medulloblastomas (0.56 +/− 0.19) Ependymomas demonstrated significantly higher ADC values than medulloblastomas Discussion and conclusions. Diffusion imaging including ADC values can be useful to narrow down the differential and demarcate common pediatric brain tumors
72 - SP Infantile hepatoblastoma: comparative analysis of ultrasonographic and surgical pathology manifestations Xinyu Yuan, Yingzi Su, Fengsen Bai, Jizhen Zou Capital Institute of Pediatrics, Beijing (China), Purpose - Objective. To investigate the diagnostic value of color Dopplar ultrasonography in infantile hepatoblastoma compared with the findings of surgery and pathological examination. Material and methods. A total of 18 infants with pathologically confirmed hepatoblastoma were enrolled in this study. The findings of hepatoblastoma observed by ultrasonography were analysed comparatively with those observed by surgery and pathology. Results. Compared with surgery, 17 cases were accurately located by ultrasonography. One case of single lesion in the left lobe of liver was misdiagnosed as multiple lesions involving the left and right lobes. The accuracy was 87.50 %. No statistical difference was found between the tumor volume obtained by ultrasonography and surgery (t0 0.765, P00.470). The tumor morphology of ultrasonography was consistent with that of surgery, and the sensitivity and specificity were both 100 %. There was consistency between ultrasonography and pathology regarding calcification or ossification (K00.750, P00.028) and cysts (K0
S498
0.714, P00.035) in tumors. The sensitivity and specificity was 80.00 % and 100 % in the visualization of calcification or ossification in each method respectively, and 66.74 %and 100 % in displaying cysts respectively. There was no consistency in displaying the boundary, capsule and necrosis in tumors between ultrasonography, surgery and pathology (K00.60, 0.231, 0.263, all P>0.05). Discussion and conclusions. Ultrasonography is an effective method for illustrating the localization and the shape of hepatoblstoma. Furthermore the calcification or ossification and cysts in tumors can be accurately displayed with high sensitivity and specificity.
73 - SP US-guided percutaneous needle biopsy as the main diagnostic tool in pediatric oncology Anat Ilivitzki, Maya Abu Gazala, Ayelet Ben Barak, Sergey Postovsky, Marc Arkovitz, Nira Arad, Diana Gaitini, Miriam Ben Arush Rambam Health Care Campus, Haifa (Israel) Purpose - Objective. Traditionally in pediatric oncology, biopsies were incisional. The alternative of percutaneous imaging guided biopsies, though promising, is not yet the procedure of choice worldwide. We retrospectively reviewed our experience in the procedure in the pediatric population and assessed its accuracy rate, safety and availability. Material and methods. We retrospectively studied US guided FNB on the pediatric population performed in our hospital between 11.2003 and 11.2011. Core biopsies were sent for pathology, molecular biology and genetic studies. Data collection included demographics, clinical data, imaging and pathologic reports. Long term follow up included clinical evaluation, imaging, and pathology taken from definitive operations. Results. Two hundred thirteen biopsies were performed on 191 patients; 17 were excluded, for there was no question of malignancy. Of the remaining 196 biopsies, 156 were carried out to establish diagnosis, and 40 in search of tumor recurrence or progression. 65 % of patients were biopsied within a day of the request for biopsy. The sensitivity of our US guided FNB is 97.1 %, specificity 100 % and the accuracy 97.9 %. We had no complications related to sedation, and 2 related to the biopsy: bleeding from biopsy site in one case and seeding of tumor cells in another. Discussion and conclusions. We find US guided FNB for suspected malignancy in the pediatric population to be highly available, safe and very accurate, potentially the future procedure of choice.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
74 - SP Improvement of the efficacy of radiation oncology by using new imaging technology Vasiliki Diakatou, Dimitrios Demenagas, Evrydiki Patriki, Christina Lappa, Apostolia Christakaki, Zoi Pemma, Neratzoula Kallia, Maria Andreou, Adam Kouvelis, Maria Synodinou Panagiotis & Aglaia Kyriakou Children’s Hospital, Athens (Greece) Purpose - Objective. In paediatric radiotherapy it is particularly important to minimise all potential late radiation effects. The children’s and adolescents’ radiotherapy department at “Panagiotis & Aglaia Kyriakou” Children’s Hospital, in Athens, uses new equipment and improved methods of imaging, thus confirming maximum high doses of radiation to the target and sparing normal tissues, in an attempt to improve tumour control and reduce toxicity. Material and methods. Seventy-nine children have been irradiated since January 2011 in our department. The radiotherapy process begins by placing the child in the CTSimulator-GE LightSpeed RT16. After accurate immobilization and depending on the pre-treatment imaging, new CT slices are acquired. The CT based virtual simulation for children provides us with data about the tumour and organs at risk in relation to the external reference points we had previously placed on the skin. CT/MRI fusion is used for radiotherapy planning of brain tumours. After the child has been positioned for treatment on our linear accelerator— Elekta Synergy, a verification of patient’s positioning acquired by a CT scanner, mounted on the linac and online corrections, is performed if necessary. Results. Incorporating imaging technology offers a more precise definition of target volume whilst saving normal tissues. Discussion and conclusions. Imaging is an integral part of high precision paediatric radiotherapy.
75 - LP High-pitch spiral CT: scan time and patient dose for abdominal oncologic imaging Andrea Magistrelli, Vittorio Cannatà, Roberta Lombardi, Marco Cirillo, Teresa Corneli, Mauro Rebuzzi, Paolo Tomà Bambino Gesù Pediatric Hospital, IRCCS, Rome (Italy) Purpose - Objective. To evaluate the dose-length-productbased (DLP) CTDI volume and the effective dose (E) during standard abdominal CT of pediatric oncologic patients using a high-pitch scan protocol in a second generation dualsource CT scanner.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Material and methods. We retrospectively evaluated all abdominal CT examinations performed on our dual-source CT system (Somatom Definition Flash, Siemens) with the same protocol (100/120 kV depending on children-size; pitch 2.7; rotation time 0.28 sec) and the automated tube current modulation (CARE DOSE 4D; 80/100 reference mAs depending on children size). Results were compared between dual-source scans at high pitch (0 2.7) and other existing conventional pitch mode techniques. None of the patients were sedated for the CT examination, and no breathing instructions were given (the avarage acquisition time was 0.5–1.5 s). Dose values were calculated from the DLP/CTDI provided in the patient protocol/dose reports. Results. All scans were performed without complications, with an optimal image quality due to a significant reduction in motion artefacts. Dose values were within the same range in the patient examinations (Flash: CTDIvol 4–11.46 mGy, DLP 133–693.85 mGy*cm—Spiral: CTDIvol 9.1–11.78 mGy, DLP 24.61–432.09 mGy*cm) although z-overscanning increased with the increase of detector width and pitch-value. Discussion and conclusions. High-pitch abdominal CT is a robust method to provide highest image quality, rendering sedation for the examination of infants, small or uncooperative children unnecessary, whilst maintaining low radiation-dose values.
76 - SP Chest and abdomen iterative CT: threshold image quality in pediatric protocols Antonio Ciccarone1, Sara Savelli1, Marco Di Maurizio1, Annamaria Didona2, Giovanna Zatelli3, Claudio Fonda1 1 Meyer Children’s University Hospital; 2University of Florence; 3Azienda Sanitaria Firenze, Florence (Italy) Purpose - Objective. To conduct a critical evaluation of new CT protocols with iterative reconstruction and Z-Dom enabled for chest and abdomen studies in pediatric patients. iDose4 (Philips Healthcare) is an innovative iterative reconstruction technique that enables significant improvements in image quality and radiation dose reduction. Material and methods. Our study takes into account 5 patient’s sizes that fall in a range of 5 weight brackets (kg): 3–8; 8–12; 12–18; 18–26; 26–36,and previous work where optimized CT protocols has been shown modulating mAs for weight range on the basis of low contrast analysis in water cylinder phantoms. Quantum noise (SD), signal to noise ratio (SNR), contrast to noise ratio (CNR) and dose efficiency (noise derivative) were evaluated. The scores refer to the noise perceived by the radiologist and the
S499
diagnostic quality of radiograph. Radiologists were asked to accord a score to the low contrast tissue separation between muscle and. Aligned rank and Wilcoxon’s signed rank tests were used for statistical analysis. Results. Radiologists reported no loss of clinically-relevant image quality. We were able to quantify the real perception of improvement in CT dose reduction, often introducing iterative reconstruction as our low contrast detectability threshold. Discussion and conclusions. Iterative CT protocols have to be re-written with the size of patient in mind, factoring in not only the patient’s weight, but also body thickness and the medical question at stake.
77 - LP Comparison between conventional autopsy and post-mortem MRI in fetuses: preliminary results - GRRIF (Groupe Radiopédiatrique de Recherche en Imagerie Foetale) Eléonore Blondiaux 1, Marie Cassart2, Marie BrasseurDaudruy 3 , Marianne Yvert 4, Céline Rozel 5 , Marianne Alison6, Anne Larroque7, Antoinette Gelot1, Christina Antal1, Marie Gonzales1, Catherine Garel1 1 Hôpital Armand Trousseau, Paris; (France), 2 Hôpital Erasme, Bruxelles (Belgium), 3University Hospital, Rouen (France); 4University Hospital Pellegrin, Bordeaux (France), 5 University Hospital of Rennes (France); 6Hôpital Robert Debré, Paris (France); 7 University Hospital of Lyon (France) Purpose - Objective. To prospectively compare the results of post-mortem fetal MRI with the results of conventional autopsy. Material and methods. After parental consent, 31 fetuses underwent MRI on a 1.5T MR scanner prior to conventional autopsy. MRI results were compared with pathological findings and classified into four subgroups: perfect agreement between both techniques (group 1), minor discrepancies with no substantial impact on diagnosis or prognosis (group 2), major discrepancies significantly impacting on diagnosis or prognosis (group 3) and advanced autolysis with limited autopsy but informative MR images (group 4). Results. The study group consisted of 25 fetuses electively terminated for anomalies seen on prenatal sonography, 5 in utero fetal death and one neonatal death, with a mean gestational age of 30 weeks (range, 19–39 weeks). Termination of pregnancy was performed for neurological (n013), chromosomal (n02), urogenital (n05) and cardiac and thoracic (n05) anomalies. There were 12 cases (38.7 %) classified in Group 1, 10 (32.3 %) in Group 2, 6 (19.4 %) in Group 3 and 3 (9.7 %) in Group 4. The major discrepancies
S500
concerned cardiac anomalies (n03) and oesophageal atresia (n02). A vermian posterior lobe dysgenesis in the context of a complex cloacal malformation was missed by MRI. Discussion and conclusions. Although conventional autopsy remains the reference standard for post-mortem examination of fetuses, MR may be an alternative when autopsy is refused.
78 - SP Paediatric Trauma Imaging: the challenges faced in a major trauma centre Shema Hameed, Maria Nordlander, Nadeeja Koralage, May-ai Seah, Rebecca Salter, Afshin Alavi, Joanna Danin St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom) Purpose - Objective. In the advent of dedicated major trauma centres with multidisciplinary teams, the paediatric patient should be considered independently due to a differing and variable range of injuries. Greater concern over ionising radiation means the decision to perform CT beyond initial assessment should be tailored to individual needs. We aim to share our experiences over the past year as the second the largest major trauma centre in London. Material and methods. We will present: • 200 cases correlating clinical assessment, radiographic and US findings, with justification for further imaging. • A retrospective review of requirements for CT by correlating imaging findings with the age and mechanism of injury, thereby proposing correct utilisation of trauma imaging. • Protocols utilised for minimisation of radiation exposure. • A pictorial review of interesting cases with clinical outcomes. Results. Out of 2000 major trauma cases presenting in our institution over the past year, 200 were children. Common mechanisms of injury include road traffic accidentsR, direct penetrating trauma and significant falls. Over 60 % of children received a head CT (30 % abnormal), 45 % cervical spine CT (all normal), and 30 % body CT (60 % abnormal). Discussion and conclusions. The challenge faced in major trauma is a sound understanding of the differing injury patterns between children and adults. Vast experience is therefore required to guide imaging and ensure minimal radiation exposure. We will discuss appropriate imaging strategies for variable clinical scenarios.
79 - SP Radiology beyond imaging—are we in safe hands? An audit of hand hygiene Joan Adiotomre, Patricia Fenton,Thuzar Win Sheffield Childrens Hospital (United Kingdom)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. Healthcare-associated infections (HCAI) in Europe cost €7 billion annually, extend hospital stays plus contribute to thousands of deaths. Radiology departments are increasingly busy and with the growing prevalence and detrimental effects of HCAI, hand hygiene within radiology is important to reduce spread throughout hospitals. We aim to audit compliance departmentally. Material and methods. We prospectively audited the 5 moments of hand hygiene using the Trust audit tool, aiming for a minimum standard of 90 % compliance. All staff within fluoroscopy and USS plus Radiology Consultants on NICU were observed anonymously (69 observations). Results were analysed using Excel. Results. There were large variations in compliance across different areas, staff groups and the moments of hand hygiene. Overall we achieved 100 % compliance in moment 2 but only 0–64 % in the others. Discussion and conclusions. This was the first anonymous radiology hand hygiene audit and is reflective of true practice. NICU raises high awareness of the importance of hand hygiene and 100 % compliance was achieved by the same employees in Fluroscopy/USS, which were less compliant areas. Many missed opportunities occurred when staff, not directly involved in procedures, acted as patient comforters. Compared with the rest of the Trust, our results appear poor, however they are similar to the early trust results. Awareness has been raised departmentally: we will re-audit to complete the audit cycle and present our findings.
R80 Pediatric hematologic malignancies: is hypoechoic periportal cuffing the tip of the iceberg? Marina Vakaki, Anastasia Garoufi, George Karapostolakis, Despina Grigoraki, Xristos Argiris, Kleanthi Kalogerakou, Chris Koumanidou “P & A. Kyriakou” Children’s Hospital, Athens (Greece) Purpose - Objective. Hypoechoic periportal cuffing (HPC) has rarely been mentioned in pediatric patients and its significance is unrecognized. The aim of this retrospective study was to emphasize the importance of HPC. Material and methods. During the last 10 years, 16 children aged 6 months–10 years, sonographically examined for various symptoms, demonstrated the sonographic sign of HPC. Results. In all cases, a hypoechoic area encasing the portal vein and its intrahepatic branches was noted. Coexisting sonographic findings included: hepatosplenomegaly (n08), upper abdominal and/or retroperitoneal lymphadenopathy (n09), and renal foci (n04). The sonographic finding of HPC was the first sign pointing towards the hematologic
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
malignancy. The final diagnosis was: Langerhans histiocytosis (n02) juvenile xanthogranuloma (n02), acute lymphoblastic leukemia (n09), and acute myeloid leukemia (n03). In all children, the sonographic reexamination 2 days– 1 week after the initiation of chemotherapy did not show the above sonographic finding. HPC was attributed to transient lymphedema due to blockage of small lymphatic vessels or to direct periportal infiltration by malignant cells. Discussion and conclusions. Recognition of the extremely rare HPC is of outmost importance in the diagnostic investigation of children with various atypical symptoms. According to our experience, it is always associated with hematologic malignancies. Therefore, further investigation should be turned to this direction, avoiding lost time. Furthermore, its disappearance soon after chemotherapy initiation should be considered an early sign of treatment response.
R81 Post-transplant lymphoproliferative disease in children: main diagnostic challenges. Silvia Rocha, Natally Rocha, Andrea Ferme, Marcia Matsuoka, Bety Chisman, Gisele Almeida Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil) Purpose - Objective. The purpose of this paper is to describe the main clinical and radiological features of posttransplant lymphoproliferative disease in children (PTLD) and its differential diagnosis. Material and methods. Ultrasound, computed tomography and magnetic resonance exams of the patients treated in our service during the year of 2011 were described. Results. The initial clinical presentation of PTLD is nonspecific and often indistinguishable from infection and rejection. However, any digestive symptoms and graft dysfunction,should raise suspicions. The intra-abdominal compartment is the most often affected. When PTLD is suspected, abdominal ultrasonography study should be performed and the most frequent findings are hepatomegaly and lymphadenopathy. Chest CT and brain MRI may be requested when there is a suspicion of these systems being involved. Discussion and conclusions. PTLD meets a group of diseases that occur in patients with immunosuppression after solid organ transplantation. It is characterized by abnormal proliferation of lymphocytes, often associated with active infection by the Epstein Barr virus and/or in response to immunosuppressive therapy, being more common in the pediatric age group. Imaging methods play an important role in early detection of PTLD, including the guidance of
S501
invasive procedures, helping to optimize clinical management in order to achieve reduction of morbidity and mortality.
Scientific Session 6: Neuro-Antenatal 82 - LP Inferior vermian hypoplasia—preconception, misconception Ashley Robinson BC Children’s Hospital, Vancouver (Canada) Purpose - Objective. To propose and provide evidence for an alternative concept regarding development of the cerebellum, and to dispel several misconceptions regarding both normal and abnormal cerebellar development, with specific reference to the cerebellar vermis. Material and methods. Examples of cerebellar and vermian anatomy by both sonography and fetal MRI were retrospectively reviewed in both fetuses and in pre-term neonates between 8 and 40 weeks gestation. This was correlated with already established knowledge of cerebellar embryology, phylogeny, somatotopic mapping and functional MRI. Results. The evidence indicates that the cerebellar vermis probably does not develop in a cranio-caudal direction, but rather in a ventral to dorsal direction, and therefore the concept of inferior vermian hypoplasia is probably incorrect. Discussion and conclusions. As a result of terminology such as “closure of the 4th ventricle”, “craniocaudal growth of the vermis”, “craniocaudal diameter” and the numbering of the cerebellar lobules from superior to inferior, we have the preconception that the vermis grows from superior to inferior. There is then an incorrect assumption that partial agenesis always involves the inferior lobules, whereas the evidence suggests that in many cases it is the central lobules that are actually deficient. In these cases “neo-vermian hypoplasia” may be a more accurate description.
83 - SP Fetal MRI of posterior fossa in a high-field open magnet Georgia Papaioannou, Dimitra Loggitsi, Ilias Kampas, Panagiotis Trimis, Nikolaos Kritikos Mitera Maternity and Children’s Hospital, Athens (Greece) Purpose - Objective. To present our experience in imaging abnormalities of fetal posterior fossa in a high-field open magnet (HFO) 1.0 Tesla.
S502
Material and methods. One hundred forty-eight fetal CNS MRI scans were performed during a 4-years period in a HFO Magnet. Of these scans, 36 included sonographic referrals for possible posterior fossa anomalies. 4 women were scanned twice and one represented a twin pregnancy. The mean gestational age was 25 weeks. Results. In 21/36 cases, MRI confirmed the sonographic findings, demonstrating additional anomalies in 15/21 cases (71.4 %). There was disagreement between MRI and sonographic results in 15/36 cases. Overall, MRI results worsened fetal prognosis in 17/36 cases (47.2 %). Repeat scan when performed confirmed the morphological deterioration of the identified anomalies in 66.7 % cases and revealed new abnormalities in 33.3 %. One fetus was born prematurely and eventually developed clinical and imaging signs of Joubert syndrome. Discussion and conclusions. Imaging of fetal posterior fossa remains a technical challenge, especially when the MRI scan is performed prior to the 24th week of gestation. Fetal MRI has the potential of revealing sonographically occult anomalies. During the 3rd trimester several pathologies become evident in addition to the anticipated normal development of the posterior fossa structures, making early consultation of these entities sometimes confusing and inaccurate.
84 - LP Clinical predictors of punctate white matter lesions in premature babies Areti Charisiadi, Aikaterini Drougia, Persefoni Margariti, Eleni Evaggelidou, Anastasia Zikou, Aikaterini Ntoulia, Loukia C Tzarouchi, Styliani Andronikou, Maria I Argyropoulou University of Ioannina (Greece) Purpose - Objective. Punctate white matter lesions (PWML) have been demonstrated in premature babies with either ischemic or hemorrhagic brain disease. The purpose of the study was to define independent clinical predictors for the development of PWML. Material and methods. Fifteen premature babies (gestational age-GA: 29.5±1.8 weeks) with PWML on MRI and 22 age and sex matched controls were enrolled in the study. Brain ultrasound demonstrated germinal matrix or intraventricular hemorrhage (GMH/IVH) in 12 and periventricular leukomalacia (PVL) in one. A chi-square test was used to evaluate the relationship between PWML and clinical parameters (eg sex, birth weight, mechanical ventilation, oxygen administration, patent ductus arteriosus, hypotension, antenatal steroid administration to the mother, and early or late infection). A binary
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
logistic regression analysis was used to define independent clinical predictors of PWML. Results. A correlation was found between PWML and birth weight, oxygen administration, patent ductus arteriosus, hypotension, steroid administration and early infection. An independent positive predictor of PWML was early infection (B01.97, p00.017) and a negative predictor was antenatal steroid administration (B0−2.70, p00.028). Discussion and conclusions. The only clinical parameter related to an increase in the appearance of PWML is early infection, while antenatal steroid administration seems to avert it.
85 - LP Correlation between MR imaging of the brain and biochemical abnormalities of children with oxidative phosphorylation disorders Pablo Caro, Veronica Donoghue, Stephanie Ryan, Ahmad Monavari Temple Street Children’s Hospital, Dublin (Ireland) Purpose - Objective. To correlate brain MR features with the biochemical defect in oxidative phosphorylation disorders in children. Material and methods. All children with biopsy or genetic proven oxidative phosphorylation disorders and who had MRI of the brain over a 10 year period were identified. MR findings were correlated with the biochemical defects. Results. Of 150 patients with mitochondrial disorders, 60 had brain MR performed including children with isolated and combined complex deficiencies, Alpers disease, Kearns-Sayre syndrome, Leigh’s disease and MELAS. Thirty MR scans were essentially normal. MR spectroscopy showed a lactate peak in four of 33 patients. Basal ganglia abnormality (n010) was commonest in Leigh disease and complex 1 deficiency. Delayed myelination (n04) and ventricular dilatation (n09) were commonest in complex 4 deficiencies. Deep white matter changes (N013), was found in a similar proportion in each type of defect. Superficial white matter abnormality (n06) was commonest in complex 3 deficiency. Cortical abnormalities (n05) and cerebellar abnormalities (n06) were commonest in deficiencies one and four. Midbrain abnormalities were seen in 3 patients including both with Leigh disease. Discussion and conclusions. MR findings are not specific enough to distinguish between these types of disorders. Half of the children showed no MR abnormality. However, we have identified a relationship between some of the MR findings and the type of biochemical defect.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
86 - SP Relationship between body growth and regional gray matter volume changes in extremely premature small for gestational age babies Loukia C Tzarouchi, Aikaterini Drougia, Anastasia Zikou, Areti Charisiadi, Paraskevi Kosta, Loukas Astrakas, Styliani Andronikou, Maria I Argyropoulou University of Ioannina (Greece) Purpose - Objective. Extremely low birth weight and/or low gestational age has been associated with alterations in brain development. The purpose of the study was to assess whether early body growth catch-up reflects regional grey matter volume (rGMv) changes by evaluating small for gestational age (SGA) extremely premature babies (gestational age?32 weeks) at term equivalent age. Material and methods. Twenty five extremely premature infants (GA: 29.8±2.1 weeks) with normal brain US studies and normal MRI at term equivalent age (41.5+1.6 weeks) were enrolled. Thirteen were appropriate for gestational age at birth and at term (AGA), 5 SGA at birth and AGA at term (SGA+) and 7 SGA at birth and term(SGA-). T1-weighted high resolution 3D images were segmented using the SPM 5 and volumes of 90 individual GM areas were calculated using the IBASPM toolbox. Two-tailed Student’st-test was performed to test for differences in rGMv between groups. Results. There was no difference in rGMv between AGA and SGA+ (body growth catch-up at term). In SGA- (persistent body growth restriction at term), areas of late maturation (frontal cortex, caudate nucleus) presented lower rGMv. There was no difference in rGMv between AGA and SGA- in GM areas of early maturation (occipital cortex, thalami). Discussion and conclusions. In extremely premature babies, body growth catch-up is associated with rGMv catch-up at term equivalent age. RGMv changes start from areas with great potential for early maturation.
87 - SP Paediatric brain cortical abnormalities: DTI and TBSS analysis Claudio Fonda, Antonio Ciccarone, Marco Esposito, Marzia Mortilla Meyer Children’s Hospital, Florence (Italy) Purpose - Objective. The cortical brain abnormalities presents altered corticale and subcortical fractional anisotropy
S503
(FA) on DTI. the white matter in cortical abnormalities are evaluted with DTI and Tract-Based-Spatial-Statistics Material and methods. Sixty-seven patienst (1–14 year old range) with different pattern of cortical alterations, diffuse (11) and focal (59) were studied with MR imaging at 3 T scaner (Achieva Philips medical system, Best, Nederland) and 8 channel head coil. 3D T1w images, conventional T1 and T2 (TSE an FLAIR) sense, multiplanar acquisitions were collected. DTI acquisition with sense echo planar with 16 directions was performed in axial plane, dti was processed in FSL. 7 templates for coregisterng different size of the pediatric brain were built. Mean Diffusivity (MD) and fractional anisotropy (FA) were quantified together. An analysis of single fiber orientation for each voxel with a bayesian algorithm was made. Results. The cortical abnormalities differ for hystopathology, extension, localization and consequent white matter connection with other brain structures. Different fa were collected, the reductions of fa, associated with elevation of diffusivity (D) in altered contiguous and distl area, were recorded. Abnormal tract were founded in 43 % of cases. Discussion and conclusions. Anatomical abnormalities are evalutated with precision, using 3T morphological acquisistion. DTI and tractography are generally evaluated in clinical setting with FACT analysis. DTI with TBSS evaluate the altered FA pattern with more accuracy, and consequently allow more precise evaluation of the abnormal connection in cortical brain abnormalities.
88 - LP Corpus callosum thickness on MRI as a surrogate marker of white matter volume in children with HIV and its correlation with developmental scores Savvas Andronikou 1 , Christelle Ackermann 2 , Barbara Laughton2, Els Dobbels2, Steve Innes2, Reghana Taliep2, Ronald van Toorn2, Mark Cotton2, Bruce Spottiswoode3, John Pettifor1 1 University of the Witwatersrand, Johannesburg; 2University of Stellenbosch; 3University of Cape (South Africa) Purpose - Objective. To determine whether the thickness of the CC is a surrogate marker of white matter volume in children with HIV and to correlate mean overall and regional thickness developmental scores. Material and methods. A retrospective MRI analysis in children with HIV related neurology and controls. A custom tool divided the midline CC contour into 40 radial thickness
S504
segments. White matter volumes were determined using MATLAB and statistical parametric mapping software. Mean overall and segmental CC mean thickness was correlated against WM volume and Griffiths scoring tests. Results. Provisional results: 44 children (22 boys; 22 girls) (mean 2.5; range 0.7 to 4.1 years) with HIV neurology were included. 23 have received an initial evaluation. Overall mean CC thickness: 4.9 mm (3.5 to 7.2 mm). Segmental thickness means (ranges): Premotor 3.9 mm (1.6 to 7.2 mm); motor 5.1 mm (3.5–8 mm); sensory 6.6 mm (4.1 to 8.7 mm); visual 6.8 mm (4.1 to 8.9 mm). White matter mean volume was 661 ml (219 to 1,045 ml). Mean developmental scores were ‘low average’ (mean General Griffiths Quotient of 83; range 67 to 101). Subquotient means: locomotor 83 (50 to 116); language 80 (57 to 118). Results of controls and correlations: pending. Discussion and conclusions. Objective volumetric assessment of white matter in children with HIV involves postprocessing white mid-sagital. MRI allows for corpus callosum (CC) thickness measurement as a surrogate marker of this. Conflict of interest. No conflict
89 - SP Can apparent diffusion coefficient (ADC) predict the clinical aoutcome in drowned children? Adrian Hrusca1 , Andreea Rachisan 1 , Erich Sorantin2 , Siegfried Rödl2 1 Iuliu Hatieganu University of Medicine and Pharmacy, ClujNapoca (Romania); 2Medical University Graz (Austria) Purpose - Objective. To examine if spatial distribution of reductions in apparent diffusion coefficient (ADC) is associated to clinical outcome in drowned children. Material and methods. This was a retrospective study of 7 children (10 examinations), suffering from an hypoxicischemic (HI) event, who underwent diffusion-weighted magnetic resonance imaging (DWIs). Ten subjects with normal DWIs served as controls. Mean patients age was 6,22 years; 1 female (14,28 %). The neurological outcome of the patients is divided into: 4 children with Apallic syndrome and 3 deaths. ADC maps were segmented into the following regions: frontal, occipital, parietal and temporal lobes (grey and white matter), basal ganglia, pre- and postcentral area, pons and cerebellum. We analysed the differences between the drowned children and control group regarding to clinical data, the DWIs abnormalities and the ADC values. Results. The restricted diffusion abnormalities in the frontal white matter were significantly different
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
between the drowned children (62,62) and control group(80,00). Discussion and conclusions. The ADC reduction is a good prognosticator for poor outcome in drowned children and can be a valuable tool for clinical assessment.
90 - LP Feasibility study to assess clinical applications of 3T Cine MR coupled with synchronous audio during speech in evaluation of velopharyngeal insufficiency (VPI) in children Pallavi Sagar, Katherine Nimkin Massachusetts General Hospital (United States) Purpose - Objective. To develop an MR protocol during phonation and compare it to nasopharyngoscopy (NP) and videofluoroscopy (VF) in children with known VPI. Material and methods. Five children with VPI, 8–16 years old, who had NP and VF were included. 3T Siemens scanner was used. Protocol included isotropic T2 weighted 3D SPACE and 2D FLASH cine sequences of airway during phonation. Audio was captured by a MR compatible optical microphone. Audio files and cine images were automatically merged by FFmpeg software program installed on the host computer creating a movie with synchronized sound. This was copied to a USB flashdrive and reviewed on a personal computer. Static images were reviewed on a picture archiving and communication system. Results. VPI was indentified in all 5 cases. Location and severity of the gap, closure pattern, Levator Veli palatini (LVP) sling were seen in all. MR was superior in visualizing the integrity the LVP. MR was unable to identify hemipalatal weakness in 1 case. In another case of stress induced VPI, occurring during clarinet playing, MR demonstrated a prominent gap during phonatory tasks. There was satisfactory correlation between MR, NP and VF. Discussion and conclusions. Cine MR of airway during speech is a non-invasive, well-tolerated diagnostic imaging tool that has the potential to serve as a guide prior to and after surgical correction of VPI. Creation of a movie allowed correlation between palatal movement and specific phonatory tasks.
91 - SP Pediatric brain MRI with susceptibility weighted imaging (SWI) at 1.5 and 3T Sara Savelli, Marzia Mortilla, Anna Perrone, Claudio Fonda Meyer Children’s Hospital, Florence (Italy)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. Susceptibility weighted imaging (SWI) is a new technique that exploits susceptibility differences in differt tissues, to provide a different type of tissue contrast. The purpose is the evaluation in brain microbleedings and larger bleeedings Material and methods. Eighty-nine pediatric patients (1 day to 15 years old) were studied leading to different brain pathologies. MRI was performed using either 1.5T and 3T magnet (Achieva Philips) Among these patients, 71 also received a conventional Gradient Echo T2* sequences Results. Our experience corfirms a greater sensibility of SWI than GRE in detecting the microbleeding (93 %) SWI is much more helpful in patients younger han 1 year of age since it can distinguish haemorrhagic and non hemorrhagic puntuate white matter lesions detected as hyperintensities on T1W images. It is more accurate in distinguishing petechial haemorrhages and ischemic foci in patients with germinal matrix heamorrhages Discussion and conclusions. SWI is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue mascetic susceptibility effects. It is extremely sensistive to even minute amounts of blood products (heamosiderin, feritin) deoxigenated blood, calcium, iron and small vein depiction. It is particularly suited fror vascular imaging, espcially in cerebral ischemaia, and in shearing traumatic lesions. Conflict of interest. No disclosure
92 - LP Intraoperative MRI (IoMRI) of brain tumors in children: feasibility and results, comparison with post-operative follow-up imaging Guilherme Cassia, Jean-Pierre Farmer, Jose-Luis Montes, Jeffrey Atkinson, Josee Melancon, Christine Saint-Martin Montreal Children’s Hospital (Canada) Purpose - Objective. To evaluate the feasibility of the IoMRI and the accuracy of the images obtained during surgery, when compared to the 3 months post-operative follow-up MRI. Material and methods. Our study includes thirty-five patients (40 surgeries) out of a total of 58 who underwent Neurosurgery with IoMRI, between November/09 and April/11. 22 male and 14 female (mean age 9.6±5.8 years) underwent IoMRI before and during surgery, both under anesthesia. Images were analyzed by a senior pediatric neuroradiologist and the operating neurosurgeon. Results. Post-op IoMRI showed gross total resection in 22 (55 %) of the 40 surgeries. 19/22 (86 %) were confirmed in the follow-up. In 13/40 (32 %) surgeries, subtotal resection was performed, with the follow-up MRI showing stable residues in 6/13 (46 %), residual growth in 3/13 (23 %)
S505
and absence of residue in 3/13 (23 %). 5/40 (12 %) surgeries were planned to be partial, owing to case specificities. Overall sensitivity and specificity to diagnose completeness of resection was, respectively, 77 % and 86 %. Discussion and conclusions. IoMRI for pediatric brain tumor appears to be efficient in terms of assessing tumor resection and size of tumor residue. This technique, helpful to neurosurgeons in safely performing a complete resection of tumors, avoids delayed post-operative baseline imaging, as well as prolonged or repeat post-operative sedation of young patients. Main limitations in image interpretation were related to either inadequate protocol or blood within the surgical bed.
93 - LP Improved detection of postlaminar optic nerve infiltration with MRI in children with retinoblastoma - initial results Selma Sirin, Marc Schlamann, Norbert Bornfeld, Markus Holdt, Sophia Goericke University Hospital Essen (Germany) Purpose - Objective. Retinoblastoma is the most common intraocular tumor in children. The aim of this retrospective study (2007–2011) was to access the improvement of diagnostic accuracy of MRI for the detection of postlaminar optic nerve infiltration (pONI). Material and methods. MR imaging was performed on a 1.5T MR scanner (Magnetom Symphony/Avanto/Aera, Siemens, Erlangen, Germany) with the use of a head coil and one or two additional surface coils (117 vs. 43 patients). A standardized examination protocol was applied in all cases, which adjusted parameters and additional sequences over the time. Histopathological correlation was available for all 160 enrolled patients. Qualitative image analysis was performed by two senior neuroradiologists in consensus. Results. Histopathological analysis revealed 15 eyes with pONI out of the total of 160 patients (median age 1.7 years, 105 uni-/55 bilateral retinoblastoma, 70 girls/90 boys). When using the single surface coil (117 patients, 121 enucleated eyes), 6 of the 11 eyes with histopathologically proven pONI were correctly identified by MRI (sensitivity 54 %, specificity 88 %). When applying the double surface coils (43 patients/44 enucleated eyes), 3 out of 4 cases with pONI were correctly identified by MRI (sensitivity 75 %, specificity 100 %). The image quality improved with new MR scanners and sequences. Discussion and conclusions. Our initial results indicate an improvement in the diagnostic accuracy in the detection of pONI with new MR-scanners/-sequences and the utilization of double surface coils.
S506
94 - SP Syndromic and complex craniosynostosis: volumetric analysis of the fossa posterior and the cerebellum Bianca Rijken, Irene Mathijssen, Maarten Lequin Academic medical Center, Rotterdam (Netherlands) Purpose - Objective. Patients with craniosynostosis syndromes are at risk of maldevelopment of the fossa posterior (FP), including a Chiari I malformation, disturbances in cerebral spinal fluid and venous blood flow as well as possible overcrowding of the FP. To understand their pathophysiology, we started to investigate the volume of the FP and cerebellum and their ratio, in patients and controls. Material and methods. Measurements were performed in T1-weighted 3D-MR images of 91 craniosynostosis patients (mean07.2 years, range: 0–18 years). Control data were collected from MRI’s of 23 patients without any brain anomalies (mean04.8 years, range: 0–15 years). Results. The cerebellum in Crouzon patients is smaller (mean0107.11 ml vs mean0120.30 ml, p<0.05) while the FP illustrates a trend towards a smaller volume (mean0 167.82 ml vs mean0146.91 ml, p00.06) compared to controls. Saethre-Chotzen patients have a smaller cerebellum than controls (mean0114.12 ml vs mean0120.3 ml, p< 0.05). Volumes in Muenke and Apert syndrome, as well as in complex craniosynostosis, equal normal. Discussion and conclusions. Patients with Crouzon and Saerthre-Chotzen syndrome demonstrate a smaller cerebellum than controls, with an early deterioration of their growthcurve. Since the volume ratio never exceeds the normal ratio, no overcrowding of the FP occurs in our patient group.
95 - SP Diagnostic value of three-dimensional ultrasonographic imaging of neonatal brain Kriengkrai Iemsawatdikul, Preeyacha Pacharn, Nucharee Chotipanvittayakul, Chirawat Sudla Siriraj Hospital, Bangkok (Thailand) Purpose - Objective. The primary purpose of this study is to compare image quality and diagnostic capability between two-dimensional cranial sonography and three-dimensional cranial sonography. The other purpose is to compare scanning time between these two modalities. Material and methods. Both 2DUS and 3DUS were performed and evaluated in 160 neonates prospectively. Image quality, diagnostic capability and scanning time were graded separately between each modality by two pediatric radiologists.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Results. The 2DUS demonstrated significantly higher image quality in most of intracranial regions except in the area of midbrain (p00.07). 2DUS also showed better demonstration of intracranial lesions such as intraventricular hemorrhage, hydrocephalus, cerebral white matter lesion, cerebellar abnormality and extracranial lesion. However, there was no significant difference in diagnostic capability between these two modalities. Discussion and conclusions. Although 3DUS’s image quality is not better than that of 2DUS, its diagnostic capability is nonetheless comparable. Patients may therefore benefit from its faster scanning time and post processing techniques, which may enhance image interpretation.
96 - SP Dynamic magnetic resonance (MR) study of the hypothalamo-pituitary region in patients with Langerhans cell histiocytosis (LCH) Janice Ip, Wendy WM Lam, PT Cheung, SY Ha, GCF Chan Queen Mary Hospital, HKSAR (Hong Kong) Purpose - Objective. To study magnetic resonance (MR) changes in the hypothalmo-pituitary region in LCH patients with or without pituitary hormone deficiency. Material and methods. Thirteen patients with biopsyproven LCH were prospectively recruited. Non-contrast MR study of pituitary region was performed, followed by dynamic sagittal fast gradient echo (FSPGR) examination. Computerized reconstruction of enhancement pattern of straight sinus, posterior and anterior pituitary were done. Non-LCH patients matched for age who had undergone similar study were included as controls. Urinary concentration test and other endocrinological workup were applied. Results. Ten patients without LCH had normal MR study. Seven out of 13 studied patients (7 months to 29 years old) had endocrinopathies and MR changes including absent posterior pituitary T1 bright spot (7/7) and thickened pituitary stalk (3/7). All patients (6/6) with diabetes insipidus (DI) had delayed in contrast enhancement. Two patients had both thickened stalk and delayed contrast enhancement while one had additional enhancing hypothalamic mass. Five LCH patients without endocrinopathy had normal MR findings and were comparable to the control. Discussion and conclusions. Absence of a posterior hyperintense signal is the most consistent MR finding, but is nonspecific. Presence of thickened stalk and/or delayed contrast enhancement are more specifically associated with endocrinological manifestion in LCH. Delayed enhancement is even more sensitive than thickened stalk in DI cases. Dynamic study may therefore offer additional evidence of hypothalamic-pituitary involvement in LCH.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
97 - LP Ectopic thymic tissue in thyroid loggia: description of 87 cases in pediatrics Pier Luigi Paesano, Elena Di Rosa, Caterina Colantoni, Giovanna Weber, Marianna Di Frenna, Alessandro Del Maschio San Raffaele Hospital, Milan (Italy) Purpose - Objective. Ectopic thymic tissue in thyroid loggia is the consequence of aberrant migration during embryogenesis. Systematic description of these incidental findings does not exist in the literature, so non-recognition is rather common. Material and methods. We report 87 cases (53 females) that came to our attention from August 1996 to January 2012 (mean age: 5,7 years). None had palpable nodule. A total of 109 incidental findings were retrospectively analysed. Results. Thymic inclusion appears as a hypoechoic area, with regular linear or punctuate internal hyperechoic echoes, unvascularized. Thymic inclusion can be totally surrounded by normal thyroid tissue (25/87), or thin branches from thymus may be present, appearing as “thymic extroflession” (57/87). 5/87 presented both. Right extroflession appeared the most frequent observation. Follow up was performed in 37/87: up to 1 year from diagnosis (12/37), up to 2 year from diagnosis (12/37), beyond 2 years in 13/37 and up to 4 years from diagnosis in 6/13. Morphology, size, echogenicity and vascularization were described for all the findings (109). Both inclusions and extroflessions maintained these features unchanged. Discussion and conclusions. The lack of progression seen both in thymic inclusions and in thymic extroflessions confirmed the benign features of these incidental findings, that must be recognized in order to avoid further diagnostic assessment.
98 - SP Ultrasound to diagnose orbital complications of ethmoid sinusitis. A series of 73 children. Anne Geoffray, Myriam Guesmi, Beatrice Leloutre, Corinne Boyer, Claire Grech, Carole Leroux, Marco Albertario, Claude Maschi Fondation Lenval, Nice; University Hospital of Nice; University Hopistal Lenval, Nice (France) Purpose - Objective. Ethmoidal inflammation, a frequent condition in young children, may expand into the orbit.
S507
Diagnosis of retroseptal orbital involvement, sometimes suggested on clinical findings, requires imaging. Our purpose was to evaluate the efficiency of Ultrasound to diagnose this complication. Material and methods. We retrospectively reviewed the charts of 73 children with ethmoid sinusitis seen between January 2007 and December 2011. There were 41 males, 32 girls, age ranges from 7 months to 13.4 (mean 5 years). They all presented with periorbital swelling and possible orbital complication of ethmoid sinusitis. Results. Ultrasound was requested in 68, CT in 5. There were 41 normal initial ultrasound. The five CT done as initial exam were normal. There were 27 abnormal ultrasounds, showing an intra orbital abcess under the medial rectus muscle in 26, an anterior abscess in the canthus angle in one. In 10 of these cases, CT (7) MR (3) were also perfomed and were concordant with ultrasound findings, except in one case where the abcesses were more important on MRI than expected on ultrasound. In our series, the predictive positive value of ultrasound was 100 %, the negative predictive value was 95 %. Discussion and conclusions. Ultrasound of the orbit should be preferred to other imaging techniques when there is clinical suspicion of orbital complication of ethmoid sinusitis. It is easy to perform, efficient, requires neither sedation nor radiation. Conflict of interest. none
99 - SP Can ultrasonography be considered trustworthy in diagnosing maxillary sinusitis in children? Otilia Fufezan1, Vasiliki Bizimi2, Carmen Asavoaie3, Diana Feier3, Paraschiva Chereches Panta1 1 IIIrd Pediatric Clinic, Cluj-Napoca; 2General University Hospital Attikon (Greece); 3Emergency County Hospital, Cluj-Napoca (Romania) Purpose - Objective. The aim of this study is to demonstrate the use of ultrasonography in the diagnosis of maxillary sinusitis in children. Material and methods. The study was prospectively conducted and included 73 patients (146 maxillary sinuses) who underwent an ultrasound and a radiograph of the maxillary sinuses. Inclusion criteria: presence of signs and symptoms suggestive of maxillary sinusitis, uncontrolled or partially controlled asthma, age over 4. Exclusion criteria: inability to perform both examinations in the same day or at least 1 day apart, sinusal anomalies. The ultrasound was performed with a pediatric convex probe, the patient sitting down and facing the examiner. The presence of fluid collections and
S508
mucosal thickening were evaluated. The X-ray was obtained using Water’s view projection and was examined for sinusal opacification, air-fluid levels or mucosal thickening. Results. A diagnosis agreement between the two techniques was found in 120 maxillary sinuses (82.2 %). Compared to the X-ray, ultrasonography had a 93.2 % sensitivity and a 97.3 % specificity in detecting fluid collections. The error of the ultrasound compared to the X-ray, evaluated in a divided interpretation, was low for the normal aspect (2.05 %) and for the fluid collection (5.47 %), but high (60.1 %) for the mucosal thickening. Discussion and conclusions. Ultrasonography may be considered a trustworthy alternative to other more invasive techniques currently used in evaluating fluid collections of the maxillary sinus among the pediatric population.
R100 MR Venogram evaluation of cerebral venous sinuses in children: Pearls and Pitfalls Madhu kumar Singhal1, Tushar Chandra2, Manish Bajaj3; Amit Gupta1 1 Ravindra Nath Tagore Medical College (India); 2Childrens Hospital of Wisconsin (United States); 3Geetanjali Medical College (India); Purpose - Objective. The aim of this exhibit is to: 1. Review normal anatomy and development of the cerebral venous sinuses. 2. Compare various techniques of MR Venogram, including Phase Contrast (PC), Time of Flight (TOF) and Post contrast MR Venogram. 3. Discuss the role of MR Venogram in the evaluation of various cerebral venous sinus abnormalities encountered in the pediatric age group. 4. Emphasize the diagnostic pitfalls of MR Venogram in assessment of cerebral venous sinuses. Material and methods. We will present venous sinus abnormalities on MR Venograms performed on 1.5T MRI system at our institute during the past 3 years. Results. An overview of various congenital variants and pitfalls on MR Venogram including hypoplasia or absence of sinuses, developmental dominance, persistent occipital sinus, falcine sinus, arachnoid granulations, flow gaps, slow flow etc. will be provided. The role of various techniques for evaluation of pediatric venous sinus thrombosis will be elucidated. Discussion and conclusions. Its capacity to show cerebral venous sinuses without intravenous contrast and the absence of ionising radiation make MR imaging a very useful tool for assessing cerebral venous system in the pediatric age group. Understanding the normal anatomy, variants of the cerebral venous system and the pitfalls of MR Venogram in children is critical for proper diagnosis and clinical decision making. Conflict of interest. none
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
R101 Imaging of term and preterm infants using a 3 Tesla MR-compatible incubator - initial experiences Selma Sirin, Britta Huening, Ursula Felderhoff-Mueser, Bernd Schweiger University Hospital Essen (Germany) Purpose - Objective. MR imaging of term and preterm infants becomes an increasingly standard procedure, but there are limitations due to instable conditions, especially in preterm infants. Material and methods. MR imaging was performed in a 3 Tesla (T) MR scanner (Magnetom Skyra, Siemens, Erlangen, Germany) with a MR-compatible incubator with a compatible 3T head coil (LMT nomag, Luebeck, Germany). 62 examinations of 46 children were carried out by use of the incubator (17 examinations of term, 45 of preterm infants), 15 examinations (12 patients, 4 term, 8 preterm) with 3 T and a standard head coil without incubator served as controls. During transfer and imaging, patients were monitored by neonatologists, qualitative image analysis was performed by an experienced pediatric radiologist. Results. Except for one child with known intermittent apnoea, where MR imaging had to be stopped because of apnoic attacks, all examinations were performed without complications. We found a reduction of motion artifacts (only 16 of 398 performed sequences (4 %) were classified non diagnostic, without incubator 6/93 (7 %)) despite reduced sedation. With the use of the incubator 3 T compatible head coil, the SNR was improved by a factor of 2,2. No problems occurred during transfer of infants to/from the examination. Discussion and conclusions. Our initial experiences indicate an improvement in diagnostic quality by using a 3 Tesla compatible incubator for the imaging of term and preterm infants.
Scientific Session 7: Dose - Safety 102 - LP Evaluation of dose and image quality of neonatal chest xrays when using an incubator detector tray Thorsten Köhler, Thomas Angell Augdal, Arne Erikson, Grete Anita Hansen, Ellen Marie Husby, Lena Mari Dale Jakobsen, Bodil Lura, Lil-Sofie Ording Mueller University Hospital of Northern Norway, Tromsø (Norway) Purpose - Objective. Repeat x-ray examinations are stressful for a sick baby. Incubators with customised detectortrays are developed to protect the child from unnecessary
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
handling. However, concerns have been raised as to whether using the tray requires increased exposure values. Our aim is to evaluate the dose and image quality when using the incubator tray compared to placing the detector directly underneath the child. Material and methods. An Anthropomorphic NeoNatal Chest Phantom, Model 610, Gammex-RMI LTD, with normal lung and IRDS, with and without pneumothorax, will be used. Image quality, degree of magnification and dose will be evaluated for 200 x-rays using Canon wireless portable detector, CXDI-80C and combinations of kV (40–80) and mAs (0,32– 2,5) with constant focus-to-patient distance, in two situations: I. Detector placed directly under the phantom II. Detector placed in the X-ray tray, with the phantom in a standard ‘nest’ of blankets and mattress using a Giraffe Omnibed, GE Healthcare, 2006. Dose will be measured with an Unfors Xi-detector. Two radiologists, blinded for image settings, will evaluate the image- quality independently, according to the quality criteria in Gammex-users Guide. Results. Our study is ongoing and we wish to present the results at ESPR 2012. Discussion and conclusions. To date, systematic evaluations of the incubator-trays are lacking.
103 - LP Pediatric radiation doses from multi-detector CT exams: preliminary results from the first 2011 Italian national survey Claudio Granata1, Federica Palorini2, Daniela Origgi2, Domenica Matranga3, Sergio Salerno3 1 Ospedale Giannina Gaslini, Genoa; 2Istituto Europeo di Oncologia, Milan; 3 Policlinic Hospital, University of Palermo, Palermo (Italy) Purpose - Objective. To provide the first nation-wide evaluation of exposure levels from pediatric examinations with multi-detector computed tomography (MDCT) scanners in Italy. Material and methods. All Italian radiology departments executing MDCT studies in children were asked to collect data from typical scanning investigations (trauma, infection, staging) in three anatomical regions (head, thorax, abdomen). For each examination, the participating centers recorded the delivered dose in term of CTDIvol and DLP, previously verified with standard quality assurance tests. The main scanning parameters (tube voltage, current, tube rotation time, slice thickness, beam collimation, scan length, pitch, filtration) were also collected to check dosimetric data consistency and for future detailed analysis. The survey was endorsed by SIRM (Società Italiana di Radiologia Medica).
S509
Results. We show preliminary results from 908 pediatric examinations performed from January to June 2011 with MDCT scanners (16 to 64 slices) in 25 radiology units. Dividing the data by three age groups (1–5, 6–10 and 11– 15 years) the 75th percentiles of CTDIvol (mGy) and DLP (mGy*cm) distributions, respectively, are: 30, 56, 56 and 494, 964, 985 for the “head” protocol; 2.9, 3.8, 6.4 and 72, 124, 196 for “thorax”; 5.8, 7, 14 and 195, 396, 725 for “abdomen”. Data exhibit high inter-center discrepancy. Discussion and conclusions. The current pediatric MDCT imaging practice in Italy was evaluated. These results allow the development of diagnostic reference levels and optimization of dose delivered to children.
104 - LP Overscanning in Pediatric Chest CT—an unrecognized source of excess radiation Erich Sorantin1, Sabine Weissensteiner1, Adrian Hrusca2, Andreea Rachisan2 1 Medical University Graz (Austria); 2Iuliu Hatieganu University of Medicine & Pharmacy, Cluj-Napoca (Romania) Purpose - Objective. Computed Tomography (CT) is regarded as high dosage examination in which several dose-increasing factors are known. Overscanning, meaning that some of the area scanned is not necessary for reporting (eg in chest neck and abdomen area), has not yet been recognized as a source of excess radiation. The aim of the study is the quantify and analyze the amount of overscanning in pediatric chest CT. Material and methods. Seven hundred thirty-nine chest CTs from 90 patients (mean age 14.9, 1,18–24.7 years) were analyzed. Total scan length was calculated as the difference of CT table positions at the start and end. The table position of lung apex and basis was determined, and the difference to the scan start and end postition calculated to the sum of both represented the overscanned length. For normalization, the overscanned length was expressed as percentage of the total scan length. Using ANOVA factors such as team (1: more CT experience, 2:less CT experience), scoutview (one or two planes) and patients age were investigated. Results. Overscanning was 14.5±6.9 % (1.02–43.5 %) in all examinations, (team1: 12.96±6.9 %, team2: 14.99±6.9 p<0.05). ANOVA identified age (overscanning decreased with age) and team as statistically significant factors. Discussion and conclusions. Overscanning represents an avoidable source of considerable excess radiation in pediatric chest CT. A mean of about 15 % of dose can be saved. Patient age and radiographer experience are important factors.
S510
105 - LP CT of the Chest Abdomen in children: dose optimisation to single or two series acquisition? Carolyn Young Great Ormond Street Hospital (United Kingdom) Purpose - Objective. Standard protocols for CT chest and abdomen usually utilize a single series acquisition for ease of planning, speed of coverage and to maximise contrast enhancement. But this can lead to over-exposure of the thorax as the imaging parameters used are set for optimal image quality in the abdominal region. Using two separate series with different scanning parameters reduces radiation dose to the sensitive organs in the thorax (breast tissue and thyroid). Material and methods. Children under 6 years old were imaged using either a single series or 2 series acquisition protocols with automated dose modulation activated. The resultant effective mAs per slice and effective dose were analysed and compared between both imaging protocols. Results. Estimated effective dose for single series acquisition chest and abdomen was 4.2 ± 0.1 mSv, and 3.7 ± 0.5 mSv for the two series acquisition. A significant difference was noted in the effective mAs per slice (p<0.01) in the chest ranging between 45-85mAs for single series and 28-51mAs in 2 series acquisition. No significance difference was noted in either the effective mAs per slice or estimated effective dose in the abdomen, (p 0.3 and p 0.2 respectively). Discussion and conclusions. It may be more convenient to perform chest and abdominal CT scans in a single series acquisition but the radiation burden to the chest is significantly higher.
106 - LP The newly released DR detector (Canon CXDI-70C Wireless) maintains diagnostic image quality at a reduced radiation dose in pediatric examination Helle Precht1, Claus Bjørn Outzen1, Poul Ravn2, Dorthe Ulrik Knudsen2, Lene Bak2 1 Conrad Research Center; 2Odense University College Lillebelt, Kolding, (Denmark) Purpose - Objective. Canon has recently released a new Digital Radiography (DR) detector; which has a smaller pixel size and a higher fill factor than previous detectors. Theoretically, a higher fill factor results in increased sensitivity whilst still maintaining image quality in accordance with the ALARA principle. This is
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
relevant in the paediatric population that is sensitive to radiation doses and contains anatomical structure that requires high image quality. The purpose: to investigate whether there is potential dose savings associated with using the new detector at chest and bone examination of paediatric patients, and still produce optimum image quality. Material and methods. A technical CDRAD phantom was used, where the analyzed images gave results as objective IQF values. A human neonate’s chest phantom and a bone phantom were used and the images analyzed by three specialized radiologists using the Visual Grading Analysis (VGA). Images were taken at different kV and mAs level. Results. The IQF value was statistically significantly higher for the new detector at all exposure values as the VGA showed great potential for improving image quality and possibilities for dose reduction. Discussion and conclusions. Optimum image quality could be maintained at a lower dose on the new detector for pediatric chest and bone examinations. Exposure index values were clearly higher on the new detector at all kV levels, as the sensitivity is approximately 42 % higher, which will benefit image quality.
107 - LP Assessment of the potential for pediatric DR dose reduction using customized multi-frequency image processing Sosamma Methratta1, Lynn La Pietra2, Jacquelyn Whaley2, Steven King 1 , Michael Hess 1 , Arabinda Choudhary 1 , Michael Moore1, James Brian1, Michael Hulse1 1 The Milton S. Hershey Medical Center, Hershey, PA; 2 Carestream Health, Inc., Rochester, NY (United States) Purpose - Objective. To investigate the potential for lowering radiation exposure to pediatric patients. Material and methods. Clinical pediatric Cesium Iodide (CsI) digital radiographs were categorized by exam type and patient age: <1, 1–5, 6–10, or 11–18 years. Exams were selected chronologically from each age category covering chest, abdomen, cranium, cervical spine, and femur. A validated noise-add model simulated dose-reduced images from each original representing 720, 900, 1440, 2280, and 3600 equivalent film-speed exposures. A post-processing site preference for a multi-frequency rendering algorithm was established on training exams and used to render 100 exams for the reader study. Reduced exposure simulations were derived, representing one of the lower equivalent filmspeed levels. Images and corresponding indications were presented to five radiologists on a diagnostic quality monitor. Readers rated each exam as Exemplary[4], Diagnostic[3], Limited[2], or Non-diagnostic[1].
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Results. Mean ratings for simulations representing 720 [mean:3.02 (95 % CI:2.89–3.15)] and 900 equivalent film speeds [2.90 (2.77–3.03)] were not statistically different from Diagnostic or [3]. Image quality ratings for images simulating 1440, 2280, and 3600 speed exposures were statistically worse than diagnostic. Image quality degraded more rapidly with decreasing exposure for the <1 year bracket (p<0.01) when compared with the older age groups. The <1 year bracket was statistically different from all other age brackets. Discussion and conclusions. Diagnostic quality pediatric images may be captured with CsI DR using exposures as low as 900 speed.
108 - LP A review of current local dose-area product levels for pediatric fluoroscopy in a referral center compared with international standards Andrea Magistrelli, Vittorio Cannatà, Marco Cirillo, Roberta Lombardi, Saverio Malena, Paolo Tomà Bambino Gesù Pediatric Hospital, IRCCS, Rome (Italy) Purpose - Objective. To assess dose-area product (DAP) values in pediatric fluoroscopy and to revise local diagnostic reference levels (DRLs). Material and methods. Data were collected prospectively on consecutive patients from November 2010 to December 2011. For each examination performed, the patients name, date, DAP (cGycm2), examination type and radiologist’s name were recorded. All studies were performed on a Siemens Iconos R200 unit. The DAP meter is calibrated by our radiation physicists on a yearly basis and a tolerance of 3 % was considered acceptable. Views obtained were tailored to the individual clinical question but basic views were obtained in all patients, sometimes including a mixture of grabbed images and spot exposures. Results. DAP measurements for the five most commonly performed examinations (1763 cases on 1,973 total exams) are presented. DAPs (75th centile) for upper gastrointestinal studies and micturating cystograms are substantially lower than the international literature reference doses. DAPs for emergency exams are also lower than that reported in literature, but higher if compared to our diagnostic studies. Discussion and conclusions. The small DAP values in all examinations demonstrate the substantial reduction in dose and consequent risk that can be achieved when both equipment performance and operator technique are optimized. Different institutions could have differing practices, but nonetheless radiologists should be aware of the range of DAPs achievable and that international literature don’t necessarily represent best practice.
S511
109 - LP Knowledge of ionizing radiation risk between resident and fellow in paediatrics. A questionnaire study. Sergio Salerno1, Roberta Puccio1, Paola Marchese1, Andrea Magistrelli2, Paolo Tomà2 1 Policlinic Hospital, University of Palermo, Palermo; 2 Bambino Gesù Pediatric Hospital, Rome (Italy) Purpose - Objective. Radiological investigations are increasing in paediatric population, partly due to the use of MDCT. Considering that the paediatric population is more sensitive to radiation risks, we tried to asses radiation protection knowledge among paediatric residents and fellows in two mayor hospital an University Hospital and a tertiary referred paediatric centre, using a simple anonymous questionnaire. Material and methods. The analysis was conducted using a 12 multiple-choice questionnaire posted to all resident and fellow in paediatrics. 65 questionnaires were administered to the paediatricians in training. The questionnaire aimed to analyse the knowledge in risks and awareness in exposing infants and children to common radiological investigation. The data were than elaborated using a non-parametric analysis with the program SPSS for Windows®. Results. 51/65 (78.4 %) questionnaires were fully completed. With a generous pass mark of 50 %, only 67 % of the junior doctor showed sufficient knowledge. In more detail, just 26.5 % knew the ALARA principle; 38 % of the doctors thought that an orthopantomography could be easily done in pregnancy just wearing a protection shield. 46 % believed that MR has a significant radiation dose. Discussion and conclusions. The study demonstrates an urgent need to improve knowledge of radiation protection and relative risks during paediatric training. This concern is shared by some juniors, of whom more than 75 % consider their preparation in radiation protection to be inadequate.
110 - LP The SECURE study: observational post-marketing study on the safety of meglumine gadoterate - interim analysis of 972 children Jean-Pierre Pracros, Jacqueline de la Garanderie Hôpital Femme Mère Enfant, Bron (France), Purpose - Objective. To prospectively assess the safety profile of meglumine gadoterate (Gd-DOTA) and the overall incidence of nephrogenic systemic fibrosis (NSF). Material and methods. A worldwide post-marketing study (PMS) is conducted to collect safety data in 40,000 patients (adults and children) with or without renal insufficiency who had routine contrast-enhanced magnetic resonance (MR)
S512
imaging using Gd-DOTA. For each patient, risk factors at inclusion, indications for MR imaging, and conditions of use of the contrast material are recorded. For any patient identified as renally impaired at the time of inclusion (i.e., estimated creatinine clearance or estimated glomerular filtration rate <60 mL/min/1.73 m²), at least a 3-month follow-up is performed in order to detect any suspicion or occurrence of NSF. Results. As of November 16, 2011, the cut-off date for the interim safety analysis, this ongoing PMS included data from 972 children (mean age: 9.9 years; range: 0–17 years; male, 51.9 %). MR examinations were mainly performed to image the central nervous system (>75 %). The main risk factors were central nervous system disorders (20.6 %) and allergies (7.1 %). No adverse events were observed. Moderate to severe impaired renal function was reported in 3 children (0.3 %). No suspicion of NSF was notified. Discussion and conclusions. This interim safety analysis confirms the very good safety profile of Gd-DOTA in children.
R111 Optimization of radiation dose using adaptive statistical iterative reconstruction (ASIR) in children’s CT imaging. Triantafillia Makri, Anastasia Hranioti, Vasilis Syrgiamiotis, Christiana Hadjigeorgi “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. The purpose of this study was to evaluate the radiation doses given from our department during CT procedures and the effect of ASIR on radiation dose and image quality in children. Material and methods. A hundred and forty two patients from 0 to 15 years old underwent head, chest and abdomen CT examinations, on a GE BrightSpeed Elite 16CT scanner, according to age-based examination protocols, using Auto mA, 40 % ASIR for head protocols and 60 % ASIR for chest and abdomen CT protocols. Dosimetric values from each study were recorded. Low dose protocols using 80 % ASIR were used, in order study the effect of ASIR on dose and image quality. Anatomical images were obtained and assessed for noise and total quality. Results. The average values of CTDIvol and DLP for different age groups were estimated and found to be comparable to similar studies. Using 80 % ASIR, a significant reduction of dose was found, while the image quality was at the same level. The radiologists’ assessments showed that 80 % ASIR is helpful for a further reduction of patient dose, especially for returning patients who undergo multiple CT scans. Discussion and conclusions. Our study showed that 80 % ASIR can be used in children in order to secure lower doses and diagnostic image quality. Further evaluation is needed in order for low dose protocol use to become standardized practice.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Posters Abdomen 112 Early imaging findings of tyrosinemia type I in an infant Dafni Katsiba, Anna Charsoula, Chrystalla Dimitriou, Parthena Kampouridou, Stauroula Karyda, Mairoula Arvaniti General Hospital of Thessaloniki “G. Gennimatas” (Greece) Purpose - Objective. To describe the imaging findings of tyrosinemia type I before the clinical manifestations of the disease. Material and methods. A 7-month-old infant was presented in the Emergency Pediatric Department with fever and respiratory distress. Clinically, respiratory infection findings, purulent conjunctivitis and eczema were observed. Laboratory tests revealed elevated hepatic enzymes and alpha-fetoprotein (AFP) levels, abdominal US and subsequently MRI examination were performed. Results. On imaging examinations, focal liver lesions as well as diffuse renal involvement were observed. Tyrosinemia type I was the final diagnosis confirmed by the pattern of the organic acids in urine. Discussion and conclusions. Type I is the most severe type of tyrosinemia and early diagnosis and management is crucial.
113 Hepatic peliosis in a 7.5 year-old boy with cystic fibrosis Christiana Hadjigeorgi, George Pitsoulakis, Maria Nezi, Stavros Doudounakis “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. Hepatobiliary manifestations of cystic fibrosis compromise a spectrum of disorders. Histological evidence of liver damage has been recorded at all ages, from preterm babies until adult life. Peliosis hepatitis is a rare benign entity that is characterized by oval or irregular, multiple blood-filled cavities within the liver parenchyma. The aim of this study is to report the radiological appearances of peliosis hepatitis in a case of a boy with cystic fibrosis. Material and methods. Pre- and postcontrast CT and MRI examinations of the abdomen were performed in our department in a 7.5 year-old boy with cystic fibrosis causing hepatomegaly. Results. Abdominal CT and MRI showed an enlarged liver with diffusely heterogenous parenchyma and multiple cystic lesions. Discussion and conclusions. Although peliosis hepatitis is a rare condition in children with non-specific imaging findings, it is important to consider it in the differential diagnosis of liver masses.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
114 Rare portal vein absence in a boy Maria Gavra, Christiana Hadjigeorgi, Vassiliki Dermetzoglou, Christina Liakou, Theoni Petropoulou, Maria Zarifi, Basil Theodoropoulos “Agia Sofia” Children’s Hospital (Greece) Purpose - Objective. Congenital absence of the portal vein is a rare condition. We present the clinical and imaging features of a child with an absence of intrahepatic portal veins and a portosystemic shunt. Material and methods. A 4-month-old boy was admitted to the hospital with jaundice and epistaxis. Clinical examination revealed a palpable liver and spleen. The patient had abnormal coagulation tests, elevated transaminases, hyperprothrombinemia and hyperbilurinemia. An abdominal ultrasound, computed tomography (CT) and computed tomographic angiography (CTA) were performed. Results. Abdominal ultrasound did not identify the portal vein in the porta hepatitis. CT and CTA with contrast demonstrated the absence of intrahepatic portal veins. The superior mesenteric and splenic vein was joined to form a large fistulous tract which drained into the vena cava, superior to the level of renal veins, bypassing the liver. There was a dilatation of the azygous, hemiazygous veins, vertebral venous plexus, lumbar and iliac veins. The absence of the portal vein was classified as type 1 according to Abernethy classification. There was also an anatomic variation because the common hepatic artery originated from the superior mesenteric artery instead of the celiac trunk. There were no signs of biliary atresia and no lesions within the liver. Discussion and conclusions. Computed tomography is a non-invasive, sensitive technique in identifying and classifying the congenital absence of the portal vein with the aim of guiding management.
115 Congenital extra-hepatic porto-systemic shunt: Abernethy malformation Silvia Rocha, Luciana Panizza, Toulouse Leusin, Andrea Ferme, Lisa Suzuki, Antonio Leal, Uenis Tannuri Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil) Purpose - Objective. This paper aims to present one clinical case of Abernety malformation, a rare condition, characterized by congenital porto-systemic shunt, portal vein agenesia, congenital heart defect and hepatic tumor.
S513
Material and methods. Presentation of a clinical case and literature review. Results. Female, 7 years, with previous cardiac surgery to correct a congenital heart defect. In August/2011 she had an episode of urinary tract infection and underwent an abdominal ultrasonography, which reveled a liver mass and the absence of the portal vein. She was referred to our service for an investigation of the hepatic mass, undergoing an Abdominal CT angiogram that confirmed sonographic findings and showed splenic-renal shunt. Hepatic biopsy was also performed. Diagnosis: Abernethy malformation - congenital heart defect, portal vein agenesia with portosystemic shunt and hepatic mixed tumor, presenting areas of adenoma and focal nodular hyperplasia. Discussion and conclusions. Extra-hepatic porto-systemic shunts classification was proposed by Morgan and Superina as follows: type 1 (blood from splenic and mesenteric veins drains directly into a systemic vein), subdivided into 1a (splenic and mesenteric veins do not join before shunting into the systemic vein) and 1b (splenic and mesenteric veins form a single trunk which drains into the inferior vena cava (IVC)) and type 2 (normal/hypoplasic portal vein with partial shunt to the IVC). Associated liver tumors, usually benign, are thought to be related to hepatic “arterialization”.
116 Sonographic liver and bladder changes caused by Schistosomiasis in treated rural schoolchildren in Zambia: a follow- up study. Rodney Strahan1, Michal Schneider-Kolsky2 Southern Health, Clayton; Monash University, Melbourne (Australia) Purpose - Objective. To assess the efficacy of Prazequantel to treat Schistosomiasis mansoni and haematobium changes in the liver and bladder of school children. Material and methods. Liver and renal tract ultrasounds were performed on 763 school children at Chitokoloki Day School in Zambia in 2010. All the students, regardless of infection status, were treated with Prazequantel unless contraindicated. Fourteen months later in 2011, 704 children from the same school were again investigated with ultrasound scans. Of those, 405 students were follow-ups from the previous year. Periportal thickening in the liver was documented on ultrasound as either normal, 2SD-4SD or >4SD according to height adjusted tables. Bladder wall lesions were categorized as either normal, irregular, thickened, a mass or pseudopolyp. Results. Of those followed-up: 55 % of the periportal thickening (2SD–4SD and >4SD) resolved completely and 15.8 % improved (>4SD to 2SD–4SD), giving 70.8 % which showed
S514
improvement. There were 22 bladder wall lesions in 2010 and 11 in 2011. 100 % of the followed-up bladder lesions in 2010 resolved. 75 students (18.5 %) developed periportal thickening and there were 2 new bladder lesions between the 2 studies. Possible causes will be discussed. Discussion and conclusions. Mass treatment of school children in endemic countries is effective. 70 % of periportal thickening improvement, especially in >4SD children, equates with the expected 70–90 % parasitological response to treatment. Although small numbers, 100 % of bladder wall lesions resolved.
117 Imaging of primary pediatric hepatic tumors: our experience over the past 10 years Amira Dhouib, Mehrak Anooshiravani, Laura Merlini, Aikaterini Kanavaki, Barbara Wildhaber, Sylviane Hanquinet University Hospital, Geneva (Switzerland) Purpose - Objective. To illustrate radiological aspects of pediatric primary liver tumors, a rare finding in children. Material and methods. We reviewed data of 16 patients presenting with primary liver tumors from January 2002 to December 2011. Nine boys and seven girls with a mean age of 3 years and 11 months (ranging from 1 day to 16 year) underwent US (16), CT (13), MRI (10). One patient had prenatal MRI. Results. Six had underlying pathologies: BeckwithWeidmann syndrome, congenital hepatic fibrosis, congenital porto-systemic shunt, alagille syndrome, spherocytosis, surgical mesenterico-caval shunt. The tumors were: hepatoblastoma (6), hemangioma (3), focal nodular hyperplasia(2), hamartoma (2), embryonic sarcoma (1), myofibroblastic tumor (1), hepatocarcinoma (1). Diagnosis was based on histology in all cases except in hemangiomas. The different imaging findings will be described. Discussion and conclusions. Primary pediatric hepatic tumors are rare; malignant lesions being twice as frequent as benign neoplasms. The knowledge of imaging characteristics of the most common as well as the rare types of hepatic tumors, sometimes associated with underlying congenital pathologies, is important in pediatric radiology practice.
118 Hepatic neoplasms in school-aged children Silvia Rocha, Luciana Panizza, Bety Chisman, Andrea Ferme, Lisa Suzuki, Luiz Antonio Oliveira Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. This paper aims to present: a) hepatic neoplasms that are more prevalent in school-aged children (from 6 to 12 years of age), covering epidemiological features and image patterns reported in the literature, and b) the incidence of these tumors in the population of our medical service in the last 8 years. Material and methods. Image patterns are described and illustrated by US, CT and MRI records of cases diagnosed in our department, with histological confirmation. Results. Primary hepatic neoplasms in the pediatric population include injuries that are exclusive to this age, such as hepatoblastoma, and others that are also found in adults. Hepatoblastoma occurs almost exclusively in children under 5 years of age. In older children and adolescents, prevailing liver tumors include: undifferentiated embryonal sarcoma, hepatocellular carcinoma, fibrolamellar carcinoma, hemangioendothelioma epithelioid, adenoma and focal nodular hyperplasia. Discussion and conclusions. Primary tumors of the liver in children, although rare, require early diagnosis and treatment. The knowledge of different types of hepatic neoplasms that can occur in children and adolescents, besides hepatoblastoma, their prevalence and imaging patterns, are essential tools to guide the imaginologist in his/her task, for findings of a hepatic mass.
119 Fibrolammellar hepatocellular carcinoma has high metastatic potential in a child: imaging findings of an atypical case Emrah Ozcan, Bilal Battal, Yalcin Bozkurt, Murat Kocaoglu Gulhane Military Medical School, Ankara (Turkey) Purpose - Objective. To present imaging findings of 13year-old girl with atypical fibrolammellar hepatocellular carcinoma (HCC). Material and methods. A case of a 13-year-old girl who had abdominal swelling and pain evaluated by abdominal ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). Results. An US examination revealed a hypoechoic hepatic mass at the left liver lobe that extended to midline. Multiple periportal and aortocaval lymphadenopathies were also noted. CT examination showed a mass lesion which enhanced heterogeneously, had hyperdense small calcifications and a non-enhancing central scar-like hypodense area. On CT examination of the thorax, we also revealed multiple metastatic nodules in the lungs. On MRI, the lesion was hypointense on T1- and hyperintense on T2-weighted images. After intravenous injection of paramagnetic contrast agent, the lesion was heterogeneously enhancing on early phase
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
and slightly hyperintense on late phase images. We also saw central scar and multiple linear septations, these were hypointense on T2-weighted images and did not enhance on late phase contrast enhanced T1-weighted images, unlike focal nodular hyperplasia. After percutaneous biopsy, the lesion histopathologically diagnosed as fibrolammellar HCC. Discussion and conclusions. Fibrolammellar HCC is usually seen at young adults and teenagers, and has not a great metastatic potential. But in some cases, like the one presented here, the fibrolammellar HCC may be seen in childhood period and has important metastatic potential which may be an indicator for worse prognosis.
120 MRCP at 3T in Children: quality, diagnostic ability and utility in pediatrics athology including primary sclerosing cholangitis Abeer Almehdar, Govind Chavhan, Rahim Moineddin, Simon Ling The hospital for sick children, university of Toronto, Toronto, Ontario (Canada) Purpose - Objective. The aims of this study were to assess the diagnostic quality of MRCP at 3T in children and assess its diagnostic ability in answering clinical queries and its accuracy in the diagnosis of PSC in particular. Material and methods. Retrospective study was approved by the REB. Consecutive MRCPs performed at 3 T between January 2008 and June 2011 were reviewed for the indications, findings, diagnosis, normal variants, quality and artifacts. Patients’ charts were reviewed for the demographics, clinical presentations, final diagnosis and management. Analysis was performed, based on final diagnosis assigned by pathology or combination of clinical, lab, imaging features and follow up. Results. There were 82 MRCPs performed at 3T. 41 were good quality, 34 were suboptimal but diagnostic and 5 were non-diagnostic. Out of 82 MRCP, 61 answered the clinical queries, 10 were equivocal and 11 did not answer the clinical query. Calculated P value demonstrated significant association between the MRCP quality and its ability to answer the clinical query. 29/82 MRCPs were done to rule out PSC. Sensitivity, specificity, accuracy, PPV and NPV for the diagnosis of PSC were 82.4 %, 100 %, 87.5 %, 100 % and 70 % respectively. Discussion and conclusions. 3T MRCP has a good ability to diagnose various pathology. Significant correlation between MRCP quality and its ability to answer the clinical query is identified. There is no significant superiority of the MRCP at 3T when compared to previous studies done on 1.5T for the diagnosis of PSC.
S515
121 MR Elastography of the liver in patients status-post fontan procedure: preliminary results Alexander Towbin, Daniel Wallihan, Suraj Serai, Daniel Podberesky Cincinnati Children’s Hospital and Medical Center (United States) Purpose - Objective. The Fontan procedure is used to improve outcomes in patients with single ventricle physiology. With many Fontan patients now reaching adulthood, one of the factors that affects long-term prognosis is hepatic congestion and cirrhosis. Currently, liver biopsy is the goldstandard for assessing liver fibrosis. MR elastography (MRE) is a relatively new imaging technique that quantitatively measures liver stiffness and thus provides a measure of fibrosis. The purpose of this study was to evaluate the feasibility of liver MRE in patients status-post Fontan procedure. Material and methods. A retrospective study was performed evaluating all hepatic MREs in patients with a history of Fontan procedure. The standard hepatic MRE protocol used in our department was employed. Liver stiffness values were calculated using post-processing software. Results. Two patients were included in this study: females aged 12 and 15, 8 and 13 years post Fontan surgery, respectively. The liver stiffness values were elevated in both patients at 3.4kPa and 3.5kPa (normal: 1–2.93kPa), suggesting the presence of moderate fibrosis. Discussion and conclusions. Liver MRE is feasible in patients status-post Fontan procedure who are undergoing surveillance cardiac MRI. We hypothesize that liver stiffness values may be significantly elevated in these patients due to chronic venous congestion. Further investigation with histologic correlation is needed to determine the etiology and longterm sequela of elevated liver stiffness in this population.
122 Acoustic radiation force impulse imaging (ARFI): normal values of liver stiffness in healthy children. Teresa Cañas (MD), María Miralles (MD), Teresa Fontanilla (MD), Araceli Maciá (Phd) University Hospital of Madrid (Spain) Purpose - Objective. To describe normal values of liver stiffness in healthy children using a non-invasive techniche called acoustic radiation force impulse imaging (ARFI). Material and methods. We perform a prospective study with healthy children between 0 and 12 years old. We make four age groups (first month of life, between second month and first year, from 1 year and 7 years, between 7 years and
S516
14 years old). Anthropometric data are collected: age, gender, weight and the body mass inde. ARFI is performed with Virtual Touch software using ACUSON 2000. Share wave velocities of several regions within the liver are measured. SPSS 15.0 is used for statistical analysis Results. We present our preliminary results for normal values of liver stiffness using ARFI, in a pilot sample of 15 children from each age group (60 children) Discussion and conclusions. A wide spectrum of pediatric diseases can lead to hepatic fibrosis. It is vital for prognosis to estimate the degree of fibrosis. The gold standard is liver biopsy, an invasive procedure, with significant risks. It is therefore important to evaluate liver stiffness with a noninvasive technique. Transient elastography is a non-invasive technique that has validity in adults with HVC, but has some limitations. It is not an imaging method, and could be the wrong choice for patients with ascites or fat liver. Most of these limitations are settled by ARFI, which is integrated in conventional ultrasound.
123 Pancreatic injuries in children: imaging, management and outcome Cecilia Lanza, Vittoria Galeazzi, Lucia Amici, Giovanni Pieroni, Manuela De Vivo, Valeria Bolli Ospedali Riuniti Ancona-Salesi Hospital (Italy) Purpose - Objective. Blunt pancreatic injuries in children have to be evaluated by an early imaging modality, in order to perform acute assessment of the lesions. Primary conservative treatment is advocated while clinic, biologic and imaging follow-up is required to detect complications, the management of which can be endoscopic, percutaneous or surgical. We describe the imaging, management and outcome of eight consecutive children with pancreatic injuries. Material and methods. We reported 8 consecutive cases of pancreatic injuries with an age ranging from 3 to 8 years (median age: 5 years). All patients underwent abdominal ultrasonography (US) and CT scan in the initial evaluation and MRI and US during follow-up. Results. Imaging showed 4 corporeal fractures, 2 caudal fractures and 2 between the corporeal and the caudal portions. The associated lesions were splenic, hepatic and renal. Two patients with grade III pancreatic injuries developed psudocysts, demonstrated by magnetic resonance cholangio-pancreatography. Any case management was chirurgical. In two cases of pseudocysts gastro-cystostomy, stent was attempted. Discussion and conclusions. The presence of ductal disruption in pancreatic trauma is a major indicator of severity leading to higher morbidities and prolonged hospital stay. However, the adoption of early interventional approach in
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
selected cases of documented grade III pancreatic trauma could result in shorter hospitalization.
124 Multimodality imaging evaluation of cystic masses at splenic hilum in children Young Ah Cho, Hye-Kyung Yoon, Jae Yeon Hwang, Chong Hyun Yoon, Jin Seung Lee Asan Medical Center, Seoul (Republic of Korea) Purpose - Objective. To review the imaging appearances of common and uncommon pediatric cystic masses at splenic hilum using multi-modality imaging evaluation. Material and methods. Multi-modality imaging of pediatric cystic masses at splenic hilum will be reviewed. Common and uncommon cystic masses at splenic hilum will be divided into three categories based on their region of origin, such as solid organs, mesentery/omentum and bowel. Important clinical aspects, characteristic imaging features, and key points that allow differentiation among various cystic masses in children will be discussed. Results. Cystic masses at splenic hilum are not uncommon and can be symptomatic or incidental findings in pediatric patients. Imaging evaluation can provide precise information regarding their location, appearance, size, and pathologic features. Discussion and conclusions. This exhibit will help the reader in improving detection and characterization of the cystic masses at splenic hilum in children.
125 Abdominal pain and wandering spleen in young children: a rare cause of abdominal pain. Veli Ermis, Hakan Gençhellaç, Mehmet Yadigar Kirici, Osman Temizöz, Ercüment Ünlü, Nermin Tunçbilek, Sedat Tuncel, Bekir Cagli, Nasrin Guaenni Trakya University, Edirne (Turkey) Purpose - Objective. A wandering spleen is a rare form of developmental anomaly arising from either a congenital or acquired laxity of the suspensory ligaments of the spleen. Acute splenic torsion of a wandering spleen is a potentially fatal surgical emergency case, and its correct and early identification continues to represent a challenge, especially in children. Material and methods. A young 11 year old female was admitted to the emergency service for acute abdominal pain. The past medical history was abdominal fullness and intermittant abdominal pain for the last 4 months.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Ultrasound showed absence of spleen in its LUQ and heretogeneus hypoechoic mobile mass 14×12 cm in the left lower quardrant. Splenic vein flow could not be visualized at doppler usg. CT and MRI scan confirmed a wandering spleen. Results. Splenectomy was performed. The patient was discharged in good general conditions. Discussion and conclusions. Splenopexy must be performed each time the organ regains good vascularity after its detorsion. Detorsion and splenopexy may be considered a reasonable surgical option even in these patients, when there is no evidence of infarction and thrombosis. Splenectomy was the standard recommended treatment for a wandering spleen. Although rare, splenic torsion should be recognized as a cause of acute abdomen.
126 CT image guided biopsy as an alternative in the diagnosis of abdominal solid organ’s lesions. Evanthia Botsa 1 , Ioannis Koutsogiannis 2 , Paraskevi Konstantopoulou1, Evaggelia Sotiropoulou3, Loukas Thanos1 1 Sotiria General Hospital Athens; 2 Aglaia Kyriakou Children’s Hospital, Athens; 3Bioclinic of Athens (Greece) Purpose - Objective. To determine that CT-guided fine needle biopsy is an effective and safe technique for the evaluation of abdominal organs lesions, even in inaccessible locations. Material and methods. A total of 36 patients underwent a biopsy procedure. Patients’ age ranged from 5 to 16 years old. Treated lesions were located in the liver (15), pancreas (3), kidney (8), spleen (4) and lymph nodes (6). Each patient was positioned according to the location of the lesion. The choice of the needle route was made depending on the lesion depth and the vital organs surrounding it. All biopsies were performed under conscious sedation. For FNA procedures, we used 22G needles, and for core biopsies 18G needles. At least 2 to 4 tissue samples were taken in every biopsy. All material obtained was sent for culture, cytological and histopathological examination. Results. Sufficient and proper material for histologic examination was obtained in 32 of our cases. Two out of four patients underwent the procedure for a second time in order to obtain adequate tissue sample and another two patients had a surgical operation. Diagnosis was set after the pathologist’s evaluation. No major complications occurred. Discussion and conclusions. CT-guided percutaneous biopsy plays a useful role in the diagnosis and management of young patients with abdominal lesions. Most biopsies can be safely and rapidly performed under sedation. Appropriate technique and awareness of possible complications are essential for success.
S517
127 Late presentation of extrinsic duodenal pressure, by ectopic vessels; an interesting case report Maria Katsikari, Maria Michalakou, Agapios Petridis, Evaggelia Manopoulou, Kanella Sotirakou Euroclinic Paidon, Athens (Greece) Purpose - Objective. To demonstrate an unusual reason for continued vomiting of a 13 year-old girl Material and methods. A young girl had been suffering from chronic vomiting, 1–2 h after every meal, since birth. In the past year, the content was often undigested food, sometimes consumed days earlier. The child had been referred to a pediatric surgeon who, among other tests, ordered an abdominal ultrasound, with unremarkable results, and a barium meal, the results of which led to the operating table. Results. The ultrasound examination came up negative. The barium meal examination revealed an important prestenotic dilatation of the 1st, 2nd and 3rd part of duodenum, with multiple deficits of the contrast, consistent with the presence of food particles. During the operation, the cause of the obstruction was revealed to be the presence of ectopic gastric vessels, extrinsingly pressuring the duodenum, leading to lateral gastrojejunum anastomosis. A Barium meal, 1 month postoperatively, was greatly ameliorated and 1 year postoperatively, the girl was completely asymptomatic Discussion and conclusions. Congenital duodenal stenosis is uncommon and rarely goes undetected past infancy. In this case the patient, despite consulting with many physicians and undergoing numerous examinations, remained undiagnosed for years.
128 A rare coexistence of intestinal rotation and duplication anomalies. Dafni Katsiba, Chrysi Nalmpantidou, Charikleia Mavridou, Aikaterini Monti, Niki Lamnatou, Mairoula Arvaniti General Hospital of Thessaloniki “G. Gennimatas” (Greece) Purpose - Objective. To present a rare combination of midgut malrotation and multiple gastrointestinal tract duplication anomalies. Material and methods. During the evaluation of a 26month old boy for severe malnutrition, GIT follow through, abdominal US and subsequently CT were performed. In his past history, two surgical interventions are mentioned: the excision of an esophageal gastroenteric cyst postnatally and the excision of two parts of duplicated ileus presenting as GIT hemorrhage at the age of 5,5 months. Results. On imaging evaluation, three duplication cysts of duodenum, jejunum and ileum were observed. On GIT
S518
follow through, rotation and fixation intestinal abnormalities were also revealed. All imaging findings were surgically confirmed. Discussion and conclusions. Although rare, GIT rotation and duplication abnormalities may coexist.
129 Umbilico-enteric fistula: a rare cause of neonatal umbilical mass Janice Ip, Peter Hui, Wendy WM Lam, Lawrance CL Lan Queen Mary Hospital, HKSAR (Hong Kong) Purpose - Objective. Congenital umbilical anomalies are common presentations in paediatric patients and mostly classified as persistent umbilical cord structures or failure of umbilical ring closure. Vitelline duct anomalies, urachal anomalies and umbilical herniations comprise the main group of these disorders. Among these disorders, only congenital urachal cyst is common. All anomalies associated with the vitelline duct are rare. Material and methods. In this article, we report a presentation of umbilico-enteric fistula due to persistent vitelline duct, in a neonate; with a brief review of the embryology, anatomy and classification of vitelline duct malformations. The differential diagnosis and management options are also discussed. Results. A pink nodular umbilical protrusion was noted in a 2-week-old infant after sloughing of the umbilical stump. It was progressively enlarging and discharging serous material. Initial ultrasonography of the umbilical zone ruled out the presence of an urachus duct. Fluoroscopic examination was followed. Contrast was instilled into the sinus opening at the stoma-like umbilical polyp. Free passage of contrast through the umbilicus into bowel loops was noted. No abnormal bowel dilatation or herniation was noted. No contrast opacification of urinary bladder or contrast spillage into peritoneum was seen. Discussion and conclusions. Features were in keeping with failed vitelline duct obliteration, with umbilico-enteric fistula, which was confirmed intra-operatively.
130 The “double-wall” sign identified in an omental cyst complicated with torsion in an infant: a pitfall in the sonographic diagnosis of enteric duplication cysts Anna Charsoula, Dafni Katsiba, Dimitris Rafailidis, Styliani Kakani, Katerina Prodromou, Georgios Koutsoumis, Mairoula Arvaniti General Hospital of Thessaloniki “G. Gennimatas” (Greece)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. The sonographic “double wall” sign is considered pathognomonic for the diagnosis of a duplication cyst. We report a case of a torted omental cyst in an infant that demonstrated a false-positive “double wall” sign. Material and methods. A 4-month-old female infant was admitted to the pediatric surgery department for investigation of an abdominal cystic mass that was detected prenatally. MRI, scintigraphy and abdominal ultrasound were performed and based on sonographic findings, diagnosis of a duplication cyst was made. The infant was operated and pathologic examination of the excised cyst was made. Results. The mass appeared hyperintense on T1 and T2weighted MR images, extended from the liver to the pelvis and displacing the right colon centrally. Scintigraphy was negative for ectopic gastric mucosa. Ultrasound revealed a large, unilocular cyst that contained complex hemorrhagic fluid: both diffuse low-level echoes and echogenic movable debris. Based on the double-layered appearance throughout the cystic wall (inner hyperechoic rim, outer hypoechoic layer) diagnosis of a duplication cyst was made. However, a torted omental cyst was found intraoperatively. Histopathological examination revealed a necrotic hemorrhagic cyst. Cystic wall consisted of fibrous connective tissue and dystrophic microcalcifications. Discussion and conclusions. There are reported cases, such as this, of complicated cysts or cystic-like masses where the demonstrated “double wall” sign does not represent gut mucosa—muscularis propria, but is explained when correlated with pathologic findings.
131 Long-segment aganglionosis in newborn infants; clinical manifestations and imaging findings Gye Yeon Lim1, Hee Jung Lee2 1 St. Mary’s Hospital, The Catholic Univesity of Korea, Seoul (Korea); 2Keimyung University Dongsan Hospital, Daegu (Korea) Purpose - Objective. We describe the clinical and radiologic features of long-segment aganglionosis identified in newborn infants to increase the index of suspicion regarding diagnosis in this unusual disease. Material and methods. We retrospectively reviewed the clinical and imaging findings of long-segment aganglionosis defined as aganglionosis extending proximal to the ileocecal valve, in 19 newborn infants. Results. Two patients had associated neurocristopathy. Plain radiographs showed diffuse, gaseous distention of bowel loops with gas-fluid levels in 63 % of the patients. 37 % of the patients showed sharply defined, marked, dilated segments of small bowel. Intraluminal calcification was
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
not noted in any of our patients. Findings of spasmodic colon (75 %), question-mark colon (65 %), delayed evacuation of contrast (90 %), ileal reflux (50 %), intraluminal filling defect (50 %), microcolon (35 %), and normal shaped colon (35 %) were found when enemas were performed. A colonic transition zone was noted in 25 % of the patients. The location of the transition zone from the normal to the aganglionic segment was in the distal ileum (47 %), from the middle ileum to the middle portion of the jejunum (32 %), or proximal jejunum (21 %) which were proven histopathologically at laparotomy. Discussion and conclusions. The imaging findings of longsegment aganglionosis varied according to the length of the aganglionic small bowel and age at presentation of the patients. Therefore, awareness of this combination of varied imaging findings may help to ensure a rectal biopsy for a timely diagnosis as well as to facilitate optimal treatment of this unusual condition.
132 Acquired tracheoesophageal fistula after battery impaction Argyro Mazioti, Anastasia Polychronakou, Achilleas Attilakos, Dimitrios Filippiadis, Konstantinos Priftis, Efthymia Alexopoulou Attikon University Hospital, Athens (Greece) Purpose - Objective. To demonstrate imaging findings of an acquired tracheoesophageal fistula (TOF) after battery impaction and its potential complications in a 3.5 years old girl. Material and methods. A neck X-ray revealed the impacted battery at the level of the thoracic inlet. The battery was immediately removed by endoscopy. Three days later, the girl presented with laryngitis-bronchitis, while she was drowning during liquid swallowing. Esophagoscopy, bronchoscopy, chest-CT scan and video-fluoroscopy were performed, showing a TOF at the previous site of the battery impaction. As there was no clinical improvement, after surgical repair, a repeat chest-CT was ordered. Results. Initial esophagoscopy was normal, whereas bronchoscopy and chest-CT revealed findings consistent with acute and chronic airway and lung inflammation. Despite medical treatment, the girl still suffered from recurrent infections and drowning, so video-fluoroscopy was ordered, showing a TOF at the previous site of the battery impaction. The fistula was surgically repaired, but as there was no significant improvement, a repeat chest-CT was performed 1 year later, which revealed a recurrent TOF, lung bronchiectasis and post-inflammatory pulmonary changes. Further surgical treatment was considered.
S519
Discussion and conclusions. According to the literature acquired, TOF is extremely rare, but presents dangerous complications post battery ingestion, with a high rate of post operative recurrence. So, close clinical and imaging follow up is suggested in order to avoid irreversible lung changes. 133 Omentum torsion in children; diagnosis and follow-up Bojan Vucinic, Goran Djuricic, Marija Mandic University Children’s Hospital, Belgrade (Serbia) Purpose - Objective. To present the characteristic appearence of torsion of the great omentum in children on US and CT and follow-up. Material and methods. In the period of 5 years we diagnosed 11 cases of torsion of the right segment of the omentum. We perfomed diagnostic procedure on 8 patients-US, 5 of 8-CT, and 3 patients underwent surgery. Results. US examination showed a painful, non-compressible hyperechogenic mass adhered to the parietal peritoneum. CT performed in 5 patients showed and confirmed fatty lesion presence. The follow-up US procedure was performed weekly over a period of 6 months and showed a gradual decrease in volume and hyperechogenicity of the lesion. In three cases, CT showed a decrease and lesion disappearance in 3 months and in two cases, in 6 months. Discussion and conclusions. Our investigation showed that torsion of the omentum is more common than believed. Characteristic US and CT presentation enable a correct diagnosis and proper conservative treatment of this disorder. 134 Omental infarction in a child with Down syndrome. A case report Natalia Barmpaliou, Sylvie Kaiser Children’s Hospital, Korolinska University Hospital (Sweden) Purpose - Objective. Omental infarction (OI), idiopathic or associated with omental torsion, is a rare cause of acute abdominal pain in children that usually mimics acute appendicitis with right lower quadrant pain. Material and methods. A 3,5 year-old-boy with Down syndrome (DS) was admitted to our hospital complaining of abdominal pain of 2 days duration, inducing him to avoid walking. The child had a low-grade fever up to 38C and no history of vomiting. There was no previous history of abdominal surgery. CRP 43. The child underwent abdominal ultrasound and enhanced CT study. Results. Ultrasonography revealed a highly hyperechoic mesentery in the right iliac fossa and showed a normal appendix.
S520
Enhanced CT scan was performed and this revealed the presence of a ca 6×1, 5×1, 5 cm inflammatory lipomatous omentum along the normal caecum and ascending colon. The mass was covered by an inflamed thickened peritoneum. At surgery, the fixed greater omentum was identified laparoscopicaly in the right abdominal cavity and an approximately 11 cm long infarcted omental segment was resected. There was no torsion of the omentum. The appendix was normal, macroscopically. Discussion and conclusions. OI is rare because of the presence of abundant collateral vessels. Establishing a preoperative diagnosis is clinically difficult because it often mimics acute appendicitis. In most cases, the diagnosis is done by the radiologist and mainly after cross-sectional imaging, although even sonography findings can be highly suggestive of OI.
135 Ultrasonography diagnosis of acute appendicitis in a 6month-old infant coexisting with ileal obstruction caused by an omental band Natalia Kokhanovsky Alicia Nachtigal, Nadir Reindorp, Abdel-Rauf Zeina Medical School of the Technion, Hillel Yaffe Medical Center and Hospital, Hadera (Israel) Purpose - Objective. Acute appendicitis is an extremely rare condition in infants younger than 12 months. An exact early clinical diagnosis is critical for the outcome and remains very difficult in this age group. Material and methods. Herein, we describe the case of successful diagnosis by ultrasonography of acute appendicitis in an infant boy who had an unclear clinical presentation on admission. This diagnosis was confirmed by surgery. An additional finding at the time of surgery was another rare condition-an omental band, causing ileal obstruction. Results. We present the ultrasonographic findings and provide appropriate discussion. Discussion and conclusions. The case presented here exemplifies the benefits of sonography as an extremely useful method for true, early diagnosis of acute appendicitis in young infants.
136 Intraperitoneal focal fat infarction in children: little-known and unknown locations and sonographic appearances Marina Vakaki 1 , Ioannis Koutsogiannis 1 , George Karapostolakis1, George Pitsoulakis2, Magdalini Smarda1, Chris Koumanidou1 1 “P & A. Kyriakou” Children’s Hospital, Athens (Greece); 2 “Agia Sofia” Children’s Hospital, Athens (Greece)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. Intraperitoneal focal fat infarction (IFFI) includes various acute abdominal clinical conditions with a common pathologic denominator, which is focal fatty tissue necrosis. Although IFFI can occur in several anatomic locations, the clinical signs, aetiology, radiological features and natural history are always the same. In most cases the spontaneous clinical evolution is favorable. Radiologists are unfamiliar with this under-recognized entity and its imaging findings, whereas the literature is very limited. The purpose of this retrospective study is to describe the sonographic features of IFFI in various anatomic locations and to emphasize the role of sonography in its diagnosis. Material and methods. The abdominal sonograms of 10 children with IFFI diagnosis performed during the last 3 years were retrospectively reviewed. Results. The sonographic findings of the more common IFFI, such as omental infarction/torsion (n 05), and epiploic appendage torsion (n04), as well as the extremely rare torsion of a lipomatous appendage of the hepatic falciform ligament (n01), are illustrated. The key sonographic features are highlighted. The differential diagnosis is discussed. Furthermore, the normal anatomy and sonographic appearance of the fatty abdominal structures usually implicated in IFFI are presented. Discussion and conclusions. IFFI is an uncommon, poorly recognized spectrum of entities. An accurate imaging diagnosis of IFFI should be an important challenge for the Pediatric Radiologist with the major goal to avoid unnecessary surgery.
137 Significance of sonographic detection of portal venous gas in neonates Damjana Ključevšek, Mojca Tomažič, Martin Thaler, Maja Podkrajšek, Anton Kenig University Children’s Hospital, Ljubljana (Slovenia) Purpose - Objective. Ultrasound (US) is a sensitive method for detection of portal venous gas (PVG), which is generally considered as a sign of severe disease. There are two main reasons why PVG is now recognized more frequently: the growing use of US as a diagnostic tool, and the improvement of US image resolution. Therefore, the significance of PVG as a US sign should be evaluated. Material and methods. In 13 neonatus, 11 boys and 2 girls, age 3–19 days, mean 9.2 days, PVG was discovered during diagnostic US examination of the abdomen. Results. Clinically 3 children were asymptomatic; 2 of them had congenital heart disease and one suffered from ischemic encephalopathy. 10 symptomatic children had blood in the stool and 3 of them were generally ill: 3 had necrotising enterocolitis (NEC), 3 had enterocolitis caused by calyci virus or E.coli and 4 children suffered from a disease not related to
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
abdominal distress. All were treated by parenteral feeding and some of them received antibiotic therapy. Discussion and conclusions. PVG is often discovered during US examination. It is not necessarily related to NEC, but it can be associated with congenital heart disease, enterocolitis and ischemia, and can be found in patients with umbilical catheter etc. PVG must always be evaluated in association with clinical status and other US findings. 138 A large endoperitoneal abscess complicating subacute appendicits Themistoklis N. Spyridopoulos, Athanasia Stratigopoulou, Konstantinos Tsilikas, Ioannis Papadopoulos, Evaggelia Anagnostaki, Nikolaos Evlogias Penteli’s Children Hospital, Athens (Greece) Purpose - Objective. We present an interesting pediatric surgical case who presented to our Emergency Department with a history of 10 days of abdominal pain and low grade fever. Material and methods. Clinical, laboratory and imaging findings are presented. Results. A 7 year old girl presented with a history of 10 days fever, nausea and loss of appetite. Clinical investigation revealed diffuse abdomen tenderness and blood neutrophil leucocytosis. Abdomen X-ray was unremarkable.. Ultrasound showed many circumscribed, fluid-filled formations in the lower abdomen and pelvis. An urgent pelvic CT scan, after per rectum and IV contrast material (CM) administration, demonstrated a 10 cm endoperitoneal, lobulated abscess in the lower pelvis. An enlarged appendix with irregular borders was identified in contact with the abscess; it also contained an appendicolith. Per rectum CM administration made it easy to distinguish the abscess from surrounding bowel loops. Many mesenteric and local enlarged nodes were also noted, along with wall thickening of focal large bowel’s loops. CT scan delineated the abscess’ location and extent, which facilitated the surgical procedure. Discussion and conclusions. Acute appendicitis is the most common condition requiring emergency abdominal surgery in the pediatric population. Its subacute route may present with subtle clinical symptoms, and thus be complicated. Clinicians and radiologists should be suspicious in order to make the right diagnosis. 139 T2W versus T1W Gadolinium-enhanced MR enterography sequences in the evaluation of pediatric Crohn’s disease Polina Pavicevic University Children’s Hospital, Belgrade (Serbia and Montenegro)
S521
Purpose - Objective. To compare, retrospectively, oral contrast-enhanced T2W (SSh SE and Spair)and (BFFE) with postcontrast T1W (THRIVE)sequences in children with Crohn’s disease Material and methods. Thirty-two children with Crohn’s disease underwent MR imaging after SSh TE and BFFE and THRIVE sequences were performed before and after intravenous injection of gadolinium contrast agent. Preexamination evaluation included echosonographic, and clinical-biochemical scoring of disease activity. Presence and extent of Crohn’s disease lesions and complications were reported and correlated with endoscopic, radiologic, and clinical data. Results. T2Wsequences were 93 % accurate, 97 % sensitive, and 79 % specific for detection of ileal lesions. Agreement between T1 and T2W images ranged from 0.77 for ileal lesions to 1.00 for colic lesions. T2W enabled detection of 16 of 19 strictures, 7of 9 enteroenteric fistulas, and all adhesions and abscesses; T1W enabled detection of 13 of 19 strictures, 16 of 24 enteroenteric fistulas, and all adhesions and abscesses. Complications leading to surgery were found in 12 (20 %) children; these were assessed correctly with either T1- or T2-W images. T2-weighted signal intensities of the wall and mesentery correlated with biologic activity (P<.001, r of 0.774 and 0.712, respectively) Discussion and conclusions. T2W can depict Crohn’s disease lesions and help assess mural and transmural inflammation with the same accuracy as postcontrast T1W. Combination of postcontrast T1- and T2W sequences is useful in the assessment of Crohn’s disease. 140 Illustrative and educational multimodality review of pediatric abdominal Burkitt lymphoma at the time of initial diagnosis Marina Vakaki1, George Pitsoulakis2, Katerina Terzaki1, Xristos Argiris1, Despina Grigoraki1, Chris Koumanidou1 1 “P & A. Kyriakou” Children’s Hospital, Athens (Greece); 2 “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. To review the various abdominal and pelvic findings of pediatric Burkitt Lymphoma (BL) at the time of diagnosis, emphasizing the key-role of imaging (US, CT, MRI) in the prompt and correct diagnosis, with significant consequences to the BL prognosis. Material and methods. The initial abdominal sonograms and CT and/or MRI examinations of 22 children (19 boys, 3 girls), aged 5–12 years, with abdominal BL, were reviewed. The clinical presentation varied, though atypical abdominal pain was the main symptom in most cases. Results. The gastrointestinal tract was involved in 12 patients, kidneys in 5, omentum/peritoneum in 9, liver in 2, gallbladder in 6, spleen in 3, pancreas in 3, ovaries in one girl and testes in
S522
2 boys. Ascites and mesenteric or/and retroperitoneal lymphadenopathy coexisted in most cases. The terminal ileum was the commonest primaryl location of BL. Secondary intussusception due to BL mass was revealed in 4 patients. The imaging findings are illustrated. The role of sonography as first-line imaging method in the suggestion of the possible diagnosis of BL is emphasized. Discussion and conclusions. Although pediatric abdominal BL has a wide variety of imaging appearances and definitive diagnosis relies on histopathology, imaging findings can strongly suggest the diagnosis. Pediatric Radiologist should be familiar with them, to recognize them and request further diagnostic work-up for earlier diagnosis and initiation of appropriate therapy.
141 Benign cystic lesions of the pediatric abdomen: multimodality radiologic imaging features Bilal Battal, Murat Kocaoglu, Yalcin Bozkurt Gulhane Military Medical School, Ankara (Turkey) Purpose - Objective. To list a broad spectrum of benign cystic lesions that affect various organs and structures in pediatric abdomen, and to identify the multimodality imaging features of benign cystic lesions originating from the pediatric abdomen. Material and methods. The imaging examinations performed by our radiology department of the pediatric patient with benign abdominal cystic lesion were evaluated retrospectively. Results. In the evaluated radiologic examination, various benign cystic lesions originating from abdominal structures and organs were identified including simple cyst, hydatid cyst, liver mesenchymal hamartoma, pancreatic pseudocyst, cystadenoma, abscess, peritoneal inclusion cyst, mesenteric cyst, omental cyst, intestinal duplication cyst, tailgut cyst, lymphangioma, ovarian cyst, endometrioma. Discussion and conclusions. A broad spectrum of benign cystic lesions can occur in the abdomen. Therefore, the diagnosis and differentiation of abdominal benign cystic lesions relies on a multimodality imaging approach including ultrasonography (US), computed tomography (CT) and magnetic resonance (MR) imaging. US is an excellent noninvasive technique in the evaluation of cystic lesions. If US findings are inadequate or suggest a complex lesion, CT and MR imaging can be used as a problem-solving technique.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
142 Various diseases of abdominal calcification in pediatrics: pictorial review Yun-Woo Chang, Hyun Sook Hong Soonchunhyang University Hospital, Seoul (Republic of Korea) Purpose - Objective. The purpose of this exhibit is to review and classify abdominal calcifications in pediatrics and to discuss the disease characteristics according to patient’s age and anatomical locations of the calcification. Material and methods. We retrospectively review various diseases of pediatric abdominal calcification; divided into two groups—neonate and older children. Results. In neonates, meconium peritonitis, hepatoblastoma, neuroblastoma, teratoma, gallstone, nephrocalcinosis are included. In older children, appendicolith, medullary sponge kidncy, immature teratoma, sclerosing stromal tumor of ovary, renal stone, foreign body are included. Discussion and conclusions. Abdominal calcifications in pediatrics will be detected on pediatric imaging. The patient’s age and anatomical location of calcification should be considered. Knowledge of the disease spectrum of abdominal calcifications may be helpful for differential diagnosis and recommendation of further evaluation.
143 Ultrasonography of emergent gastrointestinal diseases in pediatric age Choon Sik Yoon, Mi Jung Lee, Myung-Joon Kim, Mu Suk Lee Gangnam Severance Hospital, Seoul (Republic of Korea) Purpose - Objective. To understand the imaging strategy for the evaluation of emergency diseases of the pediatric gastrointestinal tract, and to understand the characteristic findings for each specific disease. Material and methods. Many diseases, including congenital anomalies, can cause gastrointestinal tract emergencies in the pediatric age group. Ultrasonography is a screening imaging modality for abdominal pathologies in pediatric patients. We will demonstrate ultrasonographic findings in important and specific diseases, including various bowel obstructions, gastrointestinal bleeding, infectious conditions and others. Results. We identified specific ultrasonographic findings in many emergency gastrointestinal diseases of pediatric
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
patients. It is very important to improve both ultrasonographic skill and experience of pediatric gastrointestinal emergencies; ultrasonography can diagnose the specific disease and differentiate between surgical and non-surgical cases. Discussion and conclusions. In the pediatric age group, ultrasonography plays an important role in diagnosis and treatment of emergent gastrointestinal diseases.
S523
145 You are performing an abdominal sonogram: don’t miss diaphragmatic and juxtadiaphragmatic pathology! Marina Vakaki1, Ioannis Koutsogiannis1, Despina Grigoraki1, Kleanthi Kalogerakou1, Xristos Argiris1, George Pitsoulakis2, Chris Koumanidou1 1 “P & A. Kyriakou” Children’s Hospital, Athens (Greece); 2 “Agia Sofia” Children’s Hospital, Athens (Greece)
144 Incidental findings during abdominal ultrasonography in pediatric patients Hippocratis Moschouris1, Eirini Papadaki2, Anastasios Protopapas1, Marina Papadaki1 1 Tzanion General Hospital, Piraeus; 2Ag. Anargyroi Oncology Hospital, Kifissia (Greece) Purpose - Objective. Incidental findings during abdominal ultrasonography are rare but, when detected, care should be taken for the patient management. The aim of this study is to present the frequency and nature of incidental findings and to discuss whenever further investigation or follow-up is mandatory. Material and methods. Three thousand eight hundred patients aged 2-days to 18 years underwent abdominal ultrasonography. Indications and diagnosis varied but were unrelative with findings that will be discussed. Results. A total of 96 incidental findings were recorded (2,53 %): hepatic haemangioma (3), hepatic cyst (1), hepatic calcification (3), hepatic nodule (1), choledochal cyst (1), cholelithiasis (3), simple renal cyst (3), polycystic renal disease (2), cystic nephroma (1), renal hypoplasia (4), renal agenesis (2), duplex collecting systems (patient <4 years old) (20), pelvi-ureteric junction obstruction (6), ureterocele (1), nephrocalcinosis (1), horseshoe kidney (2), renal ectopia (3), angiomyolipoma (1), adrenal cyst (2), adrenal calcification (3), splenomegaly (5), splenic cystic lesions (4), splenic haemangioma (1), splenic nodular lesions (1), neuroblastoma (1), ovarian cysts (11), polycystic ovaries (3), uterus bicorne (1), duplication cyst (1), situs inversus (1), peritoneal cysts (3), suspitious lymph node (1). Discussion and conclusions. The frequency of occurence of incidental findings during abdominal ultrasonography is estimated at 2,53 %. Their importance varies depending on their nature, the clinical history and patient’s age. They rarely lack clinical importance, and usually require followup and/or further investigation.
Purpose - Objective. A lot of abdominal sonograms are performed routinely for various reasons in daily practice. The technique of the examination and the indications are well-known. However, the diaphragm, infra- and supradiaphragmatic areas are not usually examined, and their abnormalities either are missed or erroneously diagnosed. The purpose of this educational presentation is to emphasize the necessity of careful evaluation of the diaphragm and juxtadiaphragmatic regions, and to present characteristic cases of pathologic conditions, sonographically identified. Material and methods. In this exhibit, various congenital and acquired diaphragmatic and juxtadiaphragmatic sonographic abnormalities are illustrated. The presented cases are collected from our 11-year database. Results. They include different types of congenital diaphragmatic hernia, diaphragmatic eventration, diaphragmatic mesothelial cysts, subpulmonic effusions, pneumonic consolidations, juxtadiaphragmatic abscesses, pulmonary sequestration, tumors (diaphragmatic or pleural metastases, infiltrating thoracic and abdominal neoplasms), etc. The importance of diaphragmatic domes’ movement assessment and comparison in real time is analyzed. Discussion and conclusions. The diaphragm is affected by various types of pathologic conditions in children. Therefore, the diaphragm and juxtadiaphragmatic areas are important anatomic regions that should be routinely evaluated in every abdominal sonographic examination in order to avoid missing obvious diagnoses.
146 Ultrasound characteristics and vascular features of lymphadenopathy in pediatric patients Hippocratis Moschouris 1, Eirini Papadaki2, Eustathios Hahamis2, Georgios Nikas2, Marina Papadaki1 1 Tzanion General Hospital, Piraeus; 2Ag. Anargyroi Oncology Hospital, Kifissia (Greece)
S524
Purpose - Objective. Lymphadenopathy is a common problem in the pediatric polulation. The purpose of this study is to highlight the specific characteristics of the lymph nodes. Material and methods. Five hundred fifty-two children, aged 2–18 years, were examined by ultrasonography and colour-power Doppler technique. Specific characteristics were examined: size, shape, appearance of the nodal hilum, echotexture of the cortex, pattern of vascularity. Results. Diagnosis of reactive lymphadenopathy was established in 528 patients. For nodes >1,5 cm L/S ratio exceeded 2.0. Hilum was centrally located in 526/528 patients with reactive cervical/inguinal lymphadenopathy and eccentric/ lacking in 2 patients with granulomatous infections. Lack of hilum presence was common in patients with reactive abdominal lymphadenopathy (62/300 patients). Cortex was homogeneous in all but 6 patients. A hilar flow with central vascular pattern was recognised in 94 % of these patients. Malignant involvment was proved in 24 patients. Diameter exeeded 2 cm in all cases and L/S ratio was <2.0 in 19 patients. Hilum was thin with eccentric cortical widening in 16 patients, completely lacking in 8patients. Lymphomatous nodes (6/24) had a thick, uniformely hypoechoic cortex (5/6) while a more heterogeneous and echogenic cortex was revealed in 16/18 patients with metastatic disease. A mixed capsular-hilar vascularity was demonstrated in all cases. Discussion and conclusions. Ultrasonography is a valuable tool when investigating pediatric patients with lymphadenopathy. Follow-up studies can monitor response to treatment and orientate to a diagnostic biopsy in selected cases.
147 Abdominopelvic CT in pediatric blunt trauma: can the noncontrast scan be eliminated? Jee-Eun Kim Gil Medical Center, Gachon University of Medicine and Science, Incheon, (Republic of Korea) Purpose - Objective. Computed tomography (CT) is invaluable in the emergency department. To determine the value of performing noncontrast scan in addition to contrast abdominopelvis CT in the evaluation of pediatric blunt trauma. Material and methods. Among 81 children who had undergone abdominopelvis CT (APCT) for abdominal trauma, 29 children who had undergone noncontrast scan in addition to contrast enhanced scan were included in the study. We retrospectively evaluated the traumatic injury in both pre and post contrast CT images. Results. Solid organ injuries were noted in 13 organs of 11 patients. All injuries were detected in postcontrast scan; 5
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
did not show in noncontrast scan. In 3, injuries were not evident, but could be assumed. In the remaining 3, injuries were very extensive, so detectable by both pre and post contrast scan. 2 patients with active bleeding on postcontrast scan were not detectable on noncontrast scan. 2 patients had multiple pelvic bone injuries, one of them had a hematoma in the pelvic muscles, detectable on noncontrast scan. 5 had small pelvic ascites. 11 had evidence of injury on CT scan Discussion and conclusions. Traumatic injuries were detected on noncontrast scan only when injuries were very extensive. Moreover noncontrast scan were not able to demonstrate active bleeding. Therefore, the need for a noncontrast scan is questioned.
148 CT findings of abdominal complications in children secondary to ventriculoperitoneal shunts Maria Sidiropoulou, Anthoula Morihovitou, Nikolaos Barmpas, Tania Hrysopoulou, Panagiota Pardali, Vasiliki Georgopoulou, Eirini Kazantzidou, Efthymia Zafeiriadou Hippokration General Hospital, Thessaloniki, (Greece) Purpose - Objective. Ventriculoperitoneal shunt (VPS) is a therapeutic procedure used for the treatment of hydrocephalus. We report a series of two children that developed abdominal complications secondary to VPS, emphasizing the role of CT imaging. Material and methods. Our study included a 13-month-old boy with Arnold-Chiari II malformation, and a 6 year-old boy with a history of posthemorrhagic hydrocephalus. Both children were managed with VPS. Results. Case 1:A 13-month-old boy was admitted for routine check-up. Abdominal radiograph raised the suspicion of VPS dislocation. CT performed revealed a 4.5-cm-diameter multilocular cystic lesion with thin septa of the right lobe of the liver. The peritoneal tip of the VPS was located at the periphery of the lesion, diagnostic sign of a hepatic cerebrospinal fluid pseudocyst. Case 2: A 6-year-old boy presented with mild abdominal pain and fever. He had undergone VPS revision 6 weeks before. Brain CT depicted hydrocephalus. Abdominal CT demonstrated a loculated left subdiaphragmatic fluid collection. Smaller subhepatic and perisplenic fluid collections were also present. Follow-up CT performed 6 weeks after documented presence of VPS catheter within an intraperitoneal abscess in the left peritoneal cavity. Grampositive cocci grew from abscess fluid drainage. External drainage tube was inserted for treatment. Discussion and conclusions. CT plays a significant role in evaluating the broad spectrum of abdominal complications due to VPS.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Head - Neck - Antenatal 149 CT and MRI opportunities in the diagnosis of violations of neuronal migration, differentiation, proliferation and hystogenesis Lyudmila Myronyak, Irina Dykan, Anna Skorokhoda Scientific and Practical Center of Radiology NAMS (Ukraine) Purpose - Objective. To explore CT and MRI use in diagnosis of CNS congenital anomalies caused by impaired neuronal migration, proliferation, differentiation, and hystogenesis. Interest in The clinical management of this group of malformations is of interest as 90 % of cases are accompanied by pharmaco- resistant epilepsy. These malformations of CNS require clinical and genetic counseling, to determine prognosis, treatment strategy, and to calculate the risk of having offspring with the same pathology. Material and methods. We examined 197 children (age 1.5 monthes–14 years) suffering from epilepsy on devices Light Speed VCT CT and MRI Magnetom Vision Plus (1,5 T) before and after IV administration of contrast agents. Results. MRI is more informative than CT in detecting structural changes in the cortex and white matter, the definition of multiplicity, location and distribution process for violations of neuronal migration, differentiation, proliferation, hystogenesis (focal cortical dysplasia was found in 4 patients, lissencephaly 9, cortex heterotopia - 11 with 3 - hemimegalencephaly, 2 microcephaly, 11 - fakomatozis). The above abnormality on CT was detected in only 32 % of cases. Informativeness of CT imaging abnormalities increased with the related violation of histogenesis involving the presence of tumors, dysplastic defects of the underlying bone, expansive extension of internal auditory canals (NF I, II), and cortical subendymal calcifications (tuberous sclerosis, Shturge-Weber syndr). Discussion and conclusions. MRI should be a compulsory part of the algorithm evaluation of patients with epilepsy, even in the absence of focal neurological symptoms.
150 Vanishing white matter disease, MRI Imaging over 3 years Nasreen Mahomed, Werner Steyn, Savvas Andronikou, John Rhodda University of the Witwatersrand, Johannesburg (South Africa) Purpose - Objective. Vanishing White Matter Disease or Childhood Ataxia with Central Nervous System
S525
Hypomyelination is a rare, ‘new leucoencephalopathy’ with only 148 cases reported in the literature. It is, however, the most prevalent inherited childhood white matter disorder, (autosomal recessive). We present a child with Vanishing White Matter Disease who had the typical progressive neurologic findings and demonstrates classic progressive deterioration on MRI over 3 years. The aim of this poster is to demonstrate the progressive MRI features of Vanishing White Matter Disease and differentiate this condition from other childhood white matter disorders. Material and methods. Materials: Serial MRI over 3 years Results. MRI is usually diagnostic, demonstrating abnormal signal of most of the cerebral white matter and progressive rarefaction and cystic degeneration (with low signal on FLAIR and proton density sequences) of affected white matter over time. A radiating stripe like pattern of the affected white matter on T1 weighted, FLAIR and proton density sequences represents remaining normal white matter strands. Discussion and conclusions. The disease is linked to mutations in the 5 subunits of the EIF2B genes, which has an important regulatory mechanism in protein synthesis. The diagnosis can be made with the presence of typical clinical findings, characteristic MRI findings, and identifiable mutations in one of five causative genes. The classical and most prevalent phenotype, has its onset in childhood at the age of 1–5 years.
151 Vein of Galen malformation in a neonate. Anthoula Morihovitou, Maria Sidiropoulou, Dimitrios Kyriakou, Spyridon Papadopoulos, Sofia Tsismalidou, Agisilaos Notidis, Efthymia Zafeiriadou Hippocration General Hospital, Thessaloniki (Greece) Purpose - Objective. The vein of Galen malformation (VGM) is a venous ectasia secondary to an arteriovenous shunt, draining either directly into the vein of Galen or into a tributary. It is thought to result from the development of an arteriovenous connection between primitive choroidal vessels and the median prosencephalic vein of Markowski. The purpose of our study is to present a case of VGM in a neonate investigated by MR imaging. Material and methods. A 2-day-old, full-term female, was admitted to the neonatal intensive care unit with high-output congestive heart failure. Results. MR imaging revealed a markedly dilated vein of Galen supplied by enlarged thalamostriate, pericallosal and posterior choroidal arterial feeders. The dilated vein of Galen demonstrated continuity with the straight sinus and the torcular of Herophilus, which were also enlarged. The
S526
transverse and sigmoid sinuses were mildly dilated. Persistence and dilatation of the occipital sinuses were also present. Signal flow void was seen in arteries and veins on T2WI. FLAIR did not show cerebral ischemic changes. T1WI demonstrated signal flow void of vessels but also vessels of intermediate signal due to flow direction changes. Thrombus was not noted. Hydrocephalus was not depicted. Discussion and conclusions. Endovascular therapy is the treatment of choice for VGM performed in appropriate time by experienced neurointerventional radiologists.
152 Vein of Galen aneurysmal malformation (VGAM)—ultrasound appearance Maria Karagianni, Euaggelia Varchalama, Iraklis Chrisatzas, Magdalini Smarda, Eleni Georgiadou, Athanasios Mourikis, Nikolaos Tsirakis, Ioannis Dermitzakis General Hospital of Nikaia-Piraeus Athens (Greece) Purpose - Objective. The presentation of an interesting case of a neonate with a vein of Galen aneurysmal malformation. Material and methods. A premature female neonate was admitted to the neonatal ICU of our hospital 3 h after birth, with respiratory distress, extremity cyanosis, poor peripheral circulation and a full-systolic murmur 3/6. The transcranial ultrasound showed a cyst-like serpentine formation of midline without any dilatation of the lateral ventricles, but with a constant low flow velocity on Color Doppler ultrasound. This finding was confirmed by brain MRI/MRA/MRV, showing many dilatated vessels with no signs of flow in the area of the midbrain, leading to the dilatated vein of Galen. Results. Apart from the above, a lot of foci of pathological signal intensity were found on the periventricular white matter of the cerebrum (acute and subacute ischemic lesions), likely due to blood interception from the malformation. Discussion and conclusions. VGAM is a rare arteriovenous communication developed between the 6th-11th week of pregnancy, related to prematurity and responsible for neonatal high output heart failure. There is a common coexistence of ischemic lesions of the cerebrum because of infarctions or interception. A hydrocephalus may also be noted because of impedance to the flow of cerebrospinal fluid. This congenital abnormality is associated with high neonatal mortality, whereas the intra-arterial embolization of the branches supplying the communication suggests the only way of treatment.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
153 Microstructural changes of white matter tracts in Tuberous Sclerosis Complex: a diffusion tensor imaging study Anastasia Zikou, Loukia C Tzarouchi, Meropi Tzoufi, Iliada Nakou, Maria I Argyropoulou University of Ioannina (Greece) Purpose - Objective. There is evidence of microstructural changes in the normal appearing white matter (WM) of patients with Tuberous Sclerosis Complex (TSC). The purpose of the study was to evaluate major WM tracts in patients with TSC by using Diffusion Tensor Imaging. Material and methods. Seven children with an established diagnosis of TSC (mean age: 6.7±4.8 years) and twelve control subjects (mean age: 7.8±4.8 years) were enrolled in the study. Using a multi-slice, spin-echo planar diffusion weighted sequence, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were measured bilaterally in 24 fiber tracts by applying the region-of-interest method. A multivariate general linear model was applied to assess differences between children with TSC and control subjects when adjusting for the effect of age and sex. A p<0.05 was considered statistically significant. Results. Significantly decreased FA values were observed in children with TSC in the external capsule bilaterally when compared to controls. Increased ADC values were observed in the superior corona radiata bilaterally and in the right corticospinal tract Discussion and conclusions. Patients with TSC have decreased anisotropy and increased diffusivity in major WM tracts, probably related with axonal myelin packing, gliosis and myelination defects.
154 Chiari malformation in patient suffered from Pfeiffer’s syndrome: important aspects in pre-operative imagings Peter Hui, Janice Ip, Wendy Lam Queen Mary Hospital, HKSAR (Hong Kong) Purpose - Objective. Pfeiffer’s syndrome is a condition associated with premature fusion of multiple cranial sutures, cloverleaf skull (Kleeblatschädel deformity), prominent ptosis, thumb and first toe abnormalities, variable syndactyly, and mutated genes for type 1 or 2 fibroblast growth factor receptor. These children, especially types 2 and 3 the more
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
severe forms, generally do poorly because of significant neurologic and cognitive defects, and many die very young. Material and methods. Poster Results. We present a term female infant with Pfeiffer syndrome, who was noted to have progressive Chiari I malformation, with classical imaging features illustrated. Important aspects in pre-operative imaging will be discussed, with brief review of literature. Discussion and conclusions. It is well-known that there is an association between Chiari I malformation and some congenital craniosynostosis syndromes. It is an acquired and progressive finding in multisutural and syndromic craniosynostosis, occurring in 70 % of patients with Crouzon’s syndrome, 75 % with oxycephaly, 50 % with Pfeiffer’s syndrome and 100 % with the Kleeblattschädel deformity. Chiari I malformation can develop rapidly in the face of increased intracranial pressure and craniosynostosis, despite reconstructive craniotomies and ventriculoperitoneal shunt insertion.
S527
Discussion and conclusions. With the advent of MR imaging, there has been a revolution in identification and characterization of malformations of the brain. Abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their imaging appearances. However, an accurate diagnosis is essential for proper treatment planning and genetic counselling. Therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose various posterior fossa abnormalities.
156 Cerebral aneurysmal hemorrhage in a child: a case report Maria Boviatsi1, Maria Varela1, George Alexiou1, Alexandros Andreou2, Ioannis Nikas1, Basil Theodoropoulos1 1 “Agia Sofia” Children’s Hospital, Athens; 2Hygeia Hospital, Athens (Greece)
155 What lies beneath the tentorium: MR evaluation of posterior fossa in children Amit Gupta1, Tushar Chandra2, Manish Bajaj3, Ravishankar Pillenahalli Maheshwarappa1 1 Ravindra Nath Tagore Medical College, Udaipur (India); 2 Childrens Hospital of Wisconsin, Madison (United States); 3 Geetanjali Medical College, Udaipur (India) Purpose - Objective. 1) Review embryology and development of cerebellum. 2) Describe normal anatomy of posterior fossa structures. 3) MR appearance of spectrum of abnormalities involving posterior fossa in children, including developmental abnormalities, tumours, cysts and miscellaneous conditions. 4) To describe associated supratentorial and/or spinal imaging findings wherever relevant Material and methods. This pictographic presentation displays the imaging features of cases encountered in our clinical practice on 1.5 Tesla magnetic resonance (MR) imaging, pertaining to posterior fossa in children. Results. MR imaging with its multidimensional imaging capability, excellent resolution and lack of ionising radiation is far superior to computed tomography (CT) in the detection of subtle morphologic abnormalities. However, there is still confusion regarding the classification, terminology, and spectrum of disease expression and this is where neuroembryology is of great help. In this exhibit we present a series of cases encountered in our clinical practice highlighting the above fact.
Purpose - Objective. Intracranial arterial aneurysms in children are very rare. The clinical and neuroradiological findings in a child with subarachnoid and intraventricular hemorrhage related to posterior communicating artery aneurysm are presented. Material and methods. A 12-year-old boy was admitted in the emergency department of our hospital, because of a sudden onset of severe headache and brief loss of consciousness during an athletic activity. A brain computed tomography (CT) without contrast was carried out immediately Then a brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) and a digital subtraction angiography (DSA) were performed. Results. The CT and MRI demontrated subarachnoid hemorrhage (SAH) in the basal cisterns and the sylvian fissures and intraventricular hemorrhage of the 4th ventricle. The MRA showed an aneurysm of the left posterior communicating artery. Fifteen hours from the insult, the DSA confirmed the presence of a saccular aneurysm, size <10 mm, and embolization with platinum coils in the same session was performed. Three weeks post-admission the patient was discharged home neurologically intact. A follow up MRA 4 months postembolization showed comlete obliteration of the aneurysm. Discussion and conclusions. Acute and severe SAH in children due to ruptured aneurysm has been reported very sporadically. Timely and accurate diagnosis (CT, DSA, MRA) of SAH due to a ruptured aneurysm, and immediate therapeutic intervention (endovascular coiling) is associated with excellent outcome.
S528
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
157
Purpose - Objective. The numbers of extremely preterm children (EPT) are increasing, and little is known regarding long term radiology outcome. The aim of the study was to evaluate cerebral MRI pathology in EPT (gestastional age (GA) <28 weeks) and preterm children (28–37 weeks) compared to term born controls. Material and methods. A regional cohort of 30 11-year old EPT and103 preterm children examined at 18 years, both with matched controls (age, gender), underwent an MRI examination. All scans were evaluated by the same experienced neuro radiologist. Pathology in ventricular size, bulk of white matter, focal white matter lesions and size of corpus callosum was registered. Results. Pathology was found in all four areas in both preterm and control groups. The pathology score increased with decreasing gestational age, with highest rate for the EPT OR: 9 (95 % CI 3 to 27, p00.001). For preterms with GA 28–35 weeks the rate of total pathology score was fourfold (OR: 4 95 % CI 2 to 8, p<0.001). For preterms with GA over 35 weeks, no statistical significant difference was found compared to their term peers. Discussion and conclusions. EPT share the same morphological pathology in MRI scans as very preterm children, but at higher rates. Even term born controls have some of the same MRI findings, but at a lower degree. No specific cerebral MRI pattern for premature children was found.
CODAS (Cerebral, Ocular, Dental, Auricular, Skeletal) syndrome: detailed description of radiological findings and new feature on brain MRI Ok-Hwa Kim1, Tae-Joon Cho2, Gen Nishimura3, Andrea Superti-Furga4, Sheila Unger4, Jong Hee Chae2 1 Ajou University Hospital, Suwon (Republic of Korea); 2 Seoul University Hospital, Seoul (Republic of Korea); 3 Kiyose Children’s Hospital, Tokyo (Japan); 4University of Lausanne, Lausanne (Switzerland) Purpose - Objective. CODAS syndrome is a very rare constellation of congenital anomalies with only four cases reported to date. The characteristic features are craniofacial anomalies, congenital cataracts, dental anomalies, malformed ears, and multiple epiphyseal dysplasia. Material and methods. We present two children affected with CODAS syndrome to provide in detail the radiological manifestations. In addition, a new finding observed on MRI of the brain is discussed. Results. Patient 1 was a 3.5 year old Korean boy presenting with genu valgum. At the age of 3 months bilateral cataracts with strabismus had been discovered. Radiographs at age 2 years showed non ossification of femoral heads, short and broad femoral neck with notch-like depression at the metaphyses. The knees showed non ossification of the distal femoral epiphyses and V-shaped indentation of the femoral metaphyses. Lateral spine radiograph showed coronal cleft. Brain MRI showed marked cerebellar hypoplasia with prominent cerebellar folia. Patient 2 was a 2.5 years old girl presenting with delayed development and gait disturbance. At birth, flat face with crumpled ears were found. At age 2 months, bilateral cataracts were discovered. Brain MRI at age 10 months revealed mild cerebellar hypoplasia. Neurologic examination revealed a cerebellar pattern of ataxia. Radiographs shows absent ossification of the femoral heads and delayed carpal bone ages. Discussion and conclusions. Our presentation broadens the phenotypic variability of CODAS syndrome as a distinct epimetaphyseal dysplasia.
158 Extremely preterm children: cerebral MRI pathology Silja Griffiths1, Stein Magnus1, Trond Markestad1, Kling Chong2, Kenneth Hugdahl1, Morten Odberg3, Irene Elgen1 1 Haukeland University Hospital, Bergen (Norway); 2Great Ormond Street Hospital, London (United Kingdom), 3 Department of Youth and Adolescence Psychiatry, Helse mFonna (Norway)
159 Microstructural changes of white matter tracts in small for gestational age very preterm infants evaluated at term equivalent Loukia C Tzarouchi, Aikaterini Drougia, Anastasia Zikou, Paraskevi Kosta, Loukas Astrakas, Styliani Andronikou, Maria I Argyropoulou University of Ioannina (Greece) Purpose - Objective. Very preterm infants suffer a wide range of neurodevelopmental disabilities. The purpose of the study was to assess the relationship between body growth and white matter (WM) microstrusture maturation, in very low-birth weight, extremely preterm infants. Material and methods. Twenty seven extremely premature infants (gestational age:29.11±1.9 weeks) with normal brain US studies and normal MRI at term equivalent age(41.1± 1.03 weeks) were enrolled in the study. Using a diffusion weighted sequence, fractional anisotropy (FA) was measured bilaterally in 16 fiber tracts with the region-ofinterest method. The effect of sex and the relationship between somatometric measurements (birth and body weight, crown to heel length and head circumference) and FA was evaluated using a general linear model. Two-tailed student ttest was used to assess differences between small for gesta-
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
tional age (SGA) and appropriate for gestational age (AGA) infants. Results. A positive correlation was found between body weight and FA in the anterior corona radiata, the posterior limb of internal capsule, the external capsule, the inferior fronto-occipital fasciculus, the superior longitudinal fasciculus, the middle cerebellar peduncles and the fornix. Decreased FA was observed in the superior longitudinal fasciculus and the fornix in SGA infants(p<0.05). Discussion and conclusions. In extremely premature infants, body growth correlates with changes in WM microstrusture. Compromised growth at term equivalent age is associated with microstructural abnormalities in areas related to attention, language, memory and executive functioning.
160 Sonographic findings of periventricular leukomalacia in preterm infants: compared with MR findings Yun-Jung Lim Inje University Haeundae Paik Hospital, Busan (Republic of Korea) Purpose - Objective. To illustrate the sonographic findings of periventricular leukomalacia (PVL) in preterm infant and highlight the clues in the sonographic diagnosis of PVL in preterm infant Material and methods. From April 2011 to January 2012, ultrasonography (US) and MR imaging were performed in 35 preterm infants. 7 infants with US obtained by two radiologists were excluded. In 28 preterm infants, initial and serial US were performed by one pediatric radiologist (mean gestational age, 28 weeks; male: female016:12). The grade, extent, margin, and heterogeneity of periventricular echogenicity (PVE) and change on serial US were evaluated. US findings were compared with MR findings at termequivalent age. The diagnostic performance of each US finding was accessed. Results. Five preterm infants proved to be PVL. 4 of 5 infants were sonographically diagnosed as cystic PVL. In 4 infants with PVL, initial US findings were increased grade and extent of PVE, heterogeneity, and sharp margin of PVE. In remaining 1 infant, serial US showed abnormalities and MR imaging showed noncystic PVL. Increased grade of PVE, defined as increased echogenicity more than those of choroid plexus, showed the best performance in US diagnosis of PVL (sensitivity, 80 %; specificity, 96 %; accuracy, 93 %). Discussion and conclusions. The sonographic findings of PVL are already well known. Meticulous US may be reliable in the diagnosis of PVL.
S529
161 Congenital methemorrhagic hydrocephalus—porencephaly in a neonate with isoimmune thrombocytopenia, considered as hydroanencephaly on prenatal ultrasound Magdalini Smarda, Faidra Kokori, Nikolaos Michalopoulos, Vasilios Nikolaou, Dimitra Chaini, Eleni Barbagianni, Maria Karagianni, Ioannis Dermitzakis General Hospital of Nikaia, Piraeus (Greece) Purpose - Objective. The presentation of the head ultrasound findings in a female neonate with unexpected severe thrombocytopenia at birth. Material and methods. Here is the case of a 28 year old second gravida woman with normal pregnancy until the 32nd week, confirmed by prenatal ultrasound and other medical examinations. At that point, during the scheduled fetal ultrasound, a hydroanencephaly was found and because of that, the obstetrician proceeded to birth provocation. The female neonate was born having a birth weight of 2230 gr. and was in no need for life support at birth time. However, it presented the clinical signs of hydrocephalus such as increased head circumference (38 cm.), separated sutures and the “sunset eye sign”, as well as other symptoms (paleness, petechiae and ecchymoses on its torso and extermities). Results. The brain ultrasound revealed a hydrocephalus (haemorrhagic) with porencephalic cysts on both sides, the blood testing showed: severe thrombocytopenia (platelets: 3000/mm3), negative infection markers, negative TORCH and VDRL and normal karyotype. Discussion and conclusions. Since the mother already had two miscarriages without thrombocytopenia or taking any medication, the most suspected diagnosis was that of Neonatal Isoimmune Thrombocytopenia. So, the mother was finally checked for antiplatelet antibodies and turned out to be positive. The neonate passed away on the 3rd day of life, due to her underlying disease.
162 Late-type hemorragic disease of neonate and intracranial hemorrhage Mehmet Yadigar Kirici, Hakan Gençhellaç Veli Ermis, Osman Temizöz, Osman Simsek, Ercüment Ünlü Trakya University, Edirne (Turkey) Purpose - Objective. In this study we present a case of intracranial hemorrhage in a premature infant due to Vitamin K deficiency. Preterm neonates tend to develop intraventricular or periventricular hemorrhage if there is a trauma or hemorrhagic diathesis, such as Vitamin K deficiency.
S530
Intraparenchimal hemorrhage is uncommon but in our case, both CT and MRI scans showed hemorrhage in the subdura, subarachnoidea and the parenchyma. Vitamin K deficiency was determined as the only cause. Material and methods. A 1970 gr male infant was delivered by cesarean after 34 weeks gestation. The infant was healthy until he was 3 months old when he suddenly developed seizures, beginning with clonic movements on the right upper and lower extremity. He was admitted to emergency services with complaints ofconfusion, vomiting and a tense fontanel. CT and MRI examinations showed intracranial hemorrage in the parenchyma, subdura and subarachnoidea. Results. In spite of conservative treatment, convulsions continued and he developed intracranial shift, the patient was taken for surgery. The hematoma was aspirated by craniotomy. Some days after the operation the patient was discharged in good general condition, with weight gain, normal blood count and electrolyte levels. Discussion and conclusions. The treatment of intracranial haematoma disease is surgery. Early diagnosis and treatment are essential for prognosis.
163 Periventricular region: normal appearance and common diseases in children Manish Bajaj1, Tushar Chandra2, Amit Gupta3, Shalini Bajaj1 1 Geetanjali Medical College, Udaipur (India); 2Childrens Hospital of Wisconsin, Madison (United States); 3Ravindra Nath Tagore Medical College, Udaipur (India) Purpose - Objective. This educational exhibit aims to: 1. Illustrate the normal appearance of periventricular region on MRI and describe its status in temporal sequence of myelination 2.Present a pictorial review of the common pathologies affecting the periventricular region 3.Describe imaging findings characteristic of various disorders affecting anterior versus posterior periventricular region and thus formulate a plan to reach specific diagnosis Material and methods. This exhibit displays the spectrum of disorders affecting periventricular region on 1.5T MRI using standard protocol for brain imaging. Post contrast study was performed wherever necessary. Results. A plethora of pediatric brain disorders including developmental diseases, myelination disorders, metabolic conditions and neoplasms involve periventricular region. Coexistent findings in other areas of brain help in narrowing the differentials. Discussion and conclusions. Many disease processes and abnormalities affecting the periventricular region can be diagnosed on the basis of anterior versus posterior predominance of the abnormality detected. A thorough knowledge
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
of normal myelination, variant anatomy, mimics and other associated findings is necessary to reach the specific diagnosis of pathological processes affecting the periventricular region.
164 Grey areas in imaging of white matter: normal myelination or disease? Amit Gupta1, Manish Bajaj2, Tushar Chandra3, Ravishankar Pillenahalli Maheshwarappa1 1 Ravindra Nath Tagore Medical College, Udaipuri (India); 2 Geetanjali Medical College, Udaipur (India), 3Childrens Hospital of Wisconsin, Madison (United States) Purpose - Objective. The aim of this exhibit is to: 1. Describe the normal sequence of myelination in the pediatric brain. 2. To differentiate the normal pattern of myelination from the pathological processes involving the white matter. 3. Illustrate the MR appearances of common mimics, leukodystrophies and ischemia. Material and methods. This educational exhibit displays the temporal sequence of myelination on 1.5 Tesla magnetic resonance (MR) imaging in normal infants. Imaging mimics of normal myelination and appearances of common leukodystrophies will be discussed. Results. The myelination of the brain progresses in a predetermined manner in caudocranial direction. The increase in signal intensity on T1W images precedes the decrease in intensity on the T2W images. Therefore T1W images are more useful in monitoring the myelination during first 6 months, while T2W images become more important later on. Leukodystrophies have characteristic imaging appearance and distribution which helps in narrowing the differentials. Discussion and conclusions. Myelination occurs in highly predictable and a very orderly pattern. However various disease processes in pediatric age group tend to be confused with this normal development process. Therefore it mandates the radiologist to have a thorough knowledge of the temporal sequence of myelination so as to correctly diagnose various white matter diseases in children.
165 Preservation of white matter integrity on fractional anisotropy maps in encephalopathic neonates with normal-appearing MR Imaging post hypothermia therapy Christabel Lee 1, Neha Kwatra2, Gilbert Vezina2, Zarir Khademian2 1 Georgetown University Hospital, Washington DC; 2Children’s National Medical Center, Washington DC (United States)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. We evaluated white matter integrity in encephalopathic neonates using diffusion tensor imaging (DTI). Material and methods. Diffusion tensor imaging (DTI) was performed on 36 encephalopathic neonates post hypothermia therapy. Twelve healthy term equivalent prematurely born neonates without neurological deficits, US, CT or MR abnormalities were recruited as controls. The neonates were categorized into three groups based on the FA and ADC: neonatal encephalopathy with normal conventional MRI findings (NNE), neonatal encephalopathy with abnormal conventional MRI findings (ANE) and controls. Regions of interests were drawn in frontal, parietal, occipital and temporal white matter, corpus callosum, and posterior limb of the internal capsule. Results. Twelve neonates had normal findings (NNE) and 24 neonates had abnormal (ANE) MRI findings. There were no statistical differences in FA between control and NNE group. Short term clinical outcomes of the NNE group were within normal limits except for 3 who had no follow up notes available. There was significant reduction in FA in all measured white matter regions in the ANE neonates compared to NNE. No significant differences in ADC were detected between ANE and NNE. Discussion and conclusions. Encephalopathic neonates with normal conventional MRI findings did not have detectable white matter changes on FA. ANE had significant abnormal white matter changes on FA in all measured regions of the brain.
166 The alteration of gray matter volume in children with mental retardation? The differences between the patients presented with operation deficit predominantly and those presented with language deficit mainly Xinyu Yuan, Shuochun Wu, Jiangxi Xiao, Sheng Xie Capital Institute of Pediatric, Beijing (China) Purpose - Objective. To detect brain structural difference in children with mental retardation (MR) presenting with operation deficit (OD) predominantly or language deficit (LD) predominantly, compared to children with typical normal development. Material and methods. MRI on 1.5T scanner was obtained from 9 children with mental retardation presenting with predominant OD and 11 children with predominant LD mental retardation, as well as the age-matched control children without intellectual disabilities. VBM analysis was applied to compare the two groups. Statistically, the total gray matter volume was compared between the two groups. Results. Compared to controls, the MR of predominant OD children showed significantly increased gray matter volume in the posterior cingulated gyrus, left superior prefrontal gyrus, left cuneus, left middle prefrontal gyrus and the body
S531
of left caudate nucleus. Meanwhile, the MR of LD predominant children showed significantly increased gray matter volume in bilateral thalami, the left superior temporal gyrus, the left inferior frontal gyrus, and the left cerebellum. The total gray matter volume on MR of OD and LD children was significantly increased relative to the controls, respectively. (OD vs Control: 1.030×106 mm3 vs 0.984×106 mm3, P0 0.006; LD vs Control: 1.002×106 mm3 vs 0.957×106 mm3, P00.009). Discussion and conclusions. There are differences between the MR children presented with OD and with LD in the alteration of gray matter volume, compared with control.
167 Basal Ganglia and/or thalamic changes in full-term neonates with hypoxic-ischemic encephalopathy: neurosonography and CT/MRI Correlation Choon Sik Yoon, Mi Jung Lee, Myung-Joon Kim, Mu Suk Lee Gangnam Severance Hospital, Seoul (Republic of Korea) Purpose - Objective. To evaluate US findings of basal ganglia and thalamus in term infants with hypoxic-ischemic encephalopathy and to correlate them with identified patterns, follow-up findings, and prognosis. Material and methods. We reviewed the US findings of 13 full-term infants who were suspected to have hypoxicischemic encephalopathy. All the patients were examined by neurosonography within 1 week of onset. All cases also had follow-up neurosonography (n 011), follow-up CT scans (n04), or MRI (n07). We retrospectively analyzed and grouped the identified patterns into three types: diffuse, unilateral, and focal pattern. Results. Nine patients with diffuse pattern showed bilaterallyincreased echogenecities at the basal ganglia, thalamus and surrounding brain parenchyma, and slit ventricle suggesting brain edema on early neurosonography. Follow-up neurosonography showed increased echogenecity, ventriculomegaly, and multicystic encephalomalacia. One patient with unilateral pattern, caused by thromboembolism, showed increased echogenecity on the right basal ganglia, thalamus and cerebral hemisphere. Three patients with focal pattern were confirmed to have lacunar infarction through follow-up studies. Among nine patients with diffuse pattern, one patient died within 2 days after onset, two were discharged against advice and six have severe neurologic handicap. One patient with unilateral pattern has a moderate neurologic handicap and three patients with focal pattern are within a normal neurological developmental course. Discussion and conclusions. Identified patterns of basal ganglia and thalamus in term infants with hypoxicischemic encephalopathy correlates with the prognosis.
S532
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
168
Material and methods. A 7-year-old boy who had drug resistant seizures and had been using okscarbazepin (a molecular analog of carbamazepin) for 2 years was referred to our hospital. The patient was evaluated by a complete history, physical and neurological examination and cranial MR examination to evaluate the central nervous system. Results. Cranial MR imaging performed a month after withdrawal of carbamazepine showed an oval lesion with slightly hypointense on T1-weighted and hyperintense on the T2-weighted images causing expansion in the posterior part of body and splenium of the corpus callosum. The lesion also showed hyperintense signal on diffusion trace images and low signal on apparent diffusion coefficient (ADC) maps suggesting restricted diffusion. MR imaging taken 2 months later showed that the corpus callosum lesion disappeared and no other pathological findings developed. Discussion and conclusions. Transient lesions in the splenium of the corpus callosum can be seen and are due to different etiologic factors, especially among antiepileptic drug users and patients with epilepsy. Knowing this fact is very important as it can help us avoid invasive examination and treatments.
Posterior reversible encephalopathy syndrome (PRES) in a child with neuroblastoma Maria Raissaki, Alekos Marinos, Nikos Katzilakis, Eftichia Stiakaki, Maria Kalmanti University Hospital of Heraklion, University of Crete (Greece) Purpose - Objective. PRES is associated with abruptly increased blood pressure, is characterized by edematous lesions at the posterior parietal and occipital lobes and is uncommon in children. Our objective is to describe the imaging findings of PRES and discuss its pathogenesis in relation to the clinical and imaging findings of the abdominal tumor. Material and methods. A 2.5-years-old female presented with abdominal distention and palpable mass. Ultrasound and abdominal CT were performed. During treatment for neuroblastoma she developed hypertension resistant to double medication and subsequent headache, vomiting, visual disturbance and blindness. Brain MRI was performed. Results. Abdominal US, CT and follow up MRI disclosed a large adrenal mass associated with hemorrhagic peritoneal metastases, hemoperitoneum and stretching of the right renal artery. Brain MRI following transfusions and chemotherapy, showed cortical and subcortical hyperintense lesions located posteriorly at the occipital and the parietal lobes, exhibiting restricted diffusion. Patient’s neurological symptoms resolved following hypertension control. Discussion and conclusions. Diagnosis of PRES should be considered in cases of cortical/subcortical lesions located posteriorly in the brain, especially when there is a relevant history of hypertension in an oncologic pediatric patient. The combination of chemotherapy-related dysfunctional vascular endothelium, renal compression and renal artery stretching causing hypertension, may predispose to PRES. Restricted diffusion does not indicate irreversibility.
169 Transient lesion in the posterior part of the body and splenium of the corpus callosum due to carbamazepine withdrawal: 3T MR imaging findings of a case Bilal Battal, Yalcin Bozkurt, Murat Kocaoglu, Emrah Ozcan Gulhane Military Medical School, Ankara (Turkey) Purpose - Objective. To present clinical and 3T magnetic resonance (MR) and diffusion-weighted (DW) imaging findings of a 7-year-old boy with transient signal changes and expansion in the posterior part of the body and splenium of the corpus callosum identified incidentally after withdrawal of carbamazepine.
170 Is diffusion weighted imaging necessary in obtaining correct diagnosis in leukemic pediatric patients with acute neurologic deficit? Maria Boviatsi, Christiana Hadjigeorgi, Maria Hasiotou, Basil Theodoropoulos, Vassilios Papadakis “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. To present conventional magnetic resonance imaging (MRI) with Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) map in a child with Leukemia who developed acute focal neurologic deficit. Material and methods. A 14 y/o female was admitted with the diagnosis of Acute Lymphocytic Leukemia without CNS involment. Following completion of the treatment, while in bone marrow aplasia and afebrile, she developed dysarthria, right sided facial nerve paresis and aphasia. Within 12 h from symptom onset, she underwent conventional MRI of the brain. DWI and ADC map were also obtained. Results. Conventional spin-echo T1-weighted, T2-weighted and FLAIR images did not show any signal abnormality. DWI showed marked hyperintensity in the subcortical white matter in the left parietal lobe. The ADC of this region was markedly decreased, suggesting the presence of cytotoxic edema. With the presumed diagnosis of ischemic arterial episode, she was placed on anticoagulant therapy and steroids. Within 48 h, there was complete symptom resolution. MRI 12 days later, showed mild hyperintensity in the DWI
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
and FLAIR and normal ADC map. There were no signs of hemorrhage and no contrast enhancement. No known thrombophilic condition was proven. Discussion and conclusions. Diffusion-weighted MRI is more sensitive than conventional spin-echo techniques, in detecting early brain alterations in acute symptomatology and can be an important tool in obtaining correct diagnosis and has to be included in the MRI protocols of leukemic patients.
171 Choriod plexus papilloma transformed Jean Siador-Alcober DALTA Medical Center, University of Perpetual Help Manila (Philippines) Purpose - Objective. To present a case of choroid plexus carcinoma Material and methods. The patient is a 9-year old female who was referred to Radiation-Oncology Department following re-excision of a brain tumor that revealed choroid plexus carcinoma from a previous report of choroid plexus papilloma. Results. Initial EEG showed focal slowing of the right temporal area. Contrast-enhanced CT scan revealed a large, heterogeneously enhancing, elongated lesion in the right parietal lobe with peripherally located cystic attenuation compatible with necrosis and/or cystic degeneration. Confirmatory MRI showed mixed solid and cystic mass. CT angiogram showed feeders from the right anterior choroidal artery. Excision biopsy revealed choroid plexus papilloma. Three months after, repeat CT scan showed a minimally enhancing, hyperdensity in the right temporoparietal lobe showing interval increase in size. With findings conclusive of recurrence, she again underwent craniectomy with findings of atypical choroid plexus carcinoma, grade III. Radiotherapy was advised. Discussion and conclusions. Neoplasms of the choroid plexus are very rare and arise anywhere this tissue exists. With high index of suspicion, the detection of an intracranial abnormality on imaging study should immediately cause the radiologist to evaluate if the presenting signs and symptoms are due to a mass. Protocol must include enhanced imaging and biopsy thereby minimizing an incorrect approach that might result in greater morbidity than when tumors are classified and removed when smaller, if detected earlier.
172 Atypical meningiomas in children: report of 2 rare cases. George Alexiou, Maria Boviatsi, Kalliopi Stefanaki, Dimitrios Panagopoulos, George Sfakianos, Neofytos Prodromou “Agia Sofia” Children’s Hospital, Athens (Greece)
S533
Purpose - Objective. Meningiomas are rare in children, accounting for approximately 2.2 % of intracranial tumors. We present two cases of large supratentorial atypical meningiomas in children that were conceived by in vitro fertilization. Material and methods. A 4-year-old boy was admitted because of headache and episodes of vomiting over the previous 2 weeks. On clinical examination there was macrocrania, left facial nerve palsy and mild left sided hemiparesis. Fundoscopy revealed bilateral papilledema. Brain MRI demonstrated right frontotemporal mass with peritumoral edema and midline shift, hypointense on T1w and hyperintense on T2w images and strong heterogeneous enhancement. The second case was a 5-year-old boy with episodes of focal seizures. A brain MRI demonstrated a right parietal mass isointense on T1w and hyperintense on T2w images with a strong heterogeneous enhancement. Results. The patients were operated and complete tumor removal was achieved. Histopathology revealed the presence of atypical meningiomas. Both cases exhibited increased Ki67 index and positive staining for progesterone receptors. A mean 2 year follow-up period revealed no tumor recurrence and both patients were in excellent condition. Discussion and conclusions. Atypical meningiomas although rare constitute a challenging problem. Surgery is the definitive form of therapy and is usually associated with favorable prognosis. Nevertheless, long-term follow-up is mandatory.
173 Rare case of intracranial embryonal RMS with aggressive meningeal spread despite multimodal therapy Norbert Utz, Nina Bauer, Thomas Imschweiler, Thorsten Rosenbaum, Martin Scholz, Marcus Katoh University Children’s Hospital, Helios-Klinikum Krefeld (Germany) Purpose - Objective. We present the case of a 6-year-old boy with an intracranial manifestation of embryonal rhabdomyosarcoma (RMS) located in Meckels cave and in the left cerebellopontine angle. Cerebral fluid analysis and neuroimaging of the brain showed no evidence for leptomeningeal involvement at diagnosis. The lesions weres initially diagnosed as benign tumor (dumbell-neurinoma), since intracranial RMS usually do not have any characteristic imaging features and because of the location and the configuration of the tumor. The patient presented with signs of increased intracranial pressure so a partial resection of the tumor in the Meckels cave and a total resection of the affected area in the cerebellopontine angle was performed. Four weeks after the end of multimodal therapy the patient developed repeated episodes of headaches. MRI scan revealed extensive intracranial and spinal leptomeningeal tumor spread. In addition, a few days later he developed paraplegia.
S534
Material and methods. Case report Results. Based on rare cases reported in the literature and our own observation it shound be kept in mind that intracranial RMS can lead to an aggressive meningeal tumor spread despite multimodal therapy and therefore should be considered in contemporary staging imaging protocols. Discussion and conclusions. Early evidence of spinal leptomeningeal tumor spread may lead to improved radiation protocols which may have an impact in the quality of life in this group of patients.
174 “Lumps on the skull”; differential diagnosis of usual palpable findings Maria Michalakou, Maria Katsikari, Evaggelia Manopoulou, Kanella Sotirakou Euroclinic Paidon, Athens (Greece) Purpose - Objective. The description of common causes of calvarian palpable lesions, in pediatric population Material and methods. During the last 3 years, 45 children, aged 1.5 month to 14 years, with good clinical presentation, were referred for the investigation of a “head lump”. 7 underwent only skull X-ray, 34 ultrasound examination, and in 4 cases both examinations were performed Results. : In 5 cases there were no abnormal findings and the palpable finding was considered to be exaggerated bony tubercle mainly in occipital area. In 12 of cases it was due to an epidermoid/dermoid cyst, whereas in 1 case it was due to eosinophillic granuloma. During our survey 11 palpable “lumps” were due to the presence of haemangioma (with or without discoloration) and 5 (in older patients) were found to be simple sebaceous cysts. In 6 cases the findings were consistent with cephalohematoma whereas occipital “lump” in 5 children was caused by occipital lymph nodes Discussion and conclusions. In children the differential diagnosis of a solitary palpable mass is considered mainly benign and includes eosinophilic granuloma, epidermoid/dermoid, haemangioma and cephalohematoma. Other more trivial causes, like sebaceous cysts, lymph nodes (even in atypical places) and simple bone protrusions, must also be taken into consideration, and the use of simple imaging methods like ultrasound and X-ray is invaluable
175 Investigation of paediatric head injury Anup Mathew, Philip Borg, Raj Jayarajasingam, Thuzar Win Sheffield Teaching Hospitals NHS Trust (United Kingdom)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. NICE guidelines for head-injury, recommend CT-head be performed within 1 h of request. Skull radiographs(SXR)are not recommended in trauma. Our aim was to measure compliance of Radiology Department with guidelines. Material and methods. Retrospective review of A&E CT requests for trauma cases during a 4-month period in 2010. Based on the results, re-audit during a similar period in 2011 was performed. Time of request,time of study,time of provisional (PR) and validated report (VR) were noted, along with significant findings and number of SXR requested. Results. Seventy-five CT-head requests were made during the study period in 2010(80 during 2011). 100 % were done within 1 h(96 % in 2011). PR was issued within 1 h in 57 %(58 % in 2011). In 24 %, no PR was issued or time was not recorded (25 % in 2011). VR was issued within 24 h in 38 % (51 % in 2011); 26 % (12 % in 2011) were issued more than 72 h later. SXR were requested in 23 % (7 % in 2011). Significant findings (fracture,haemorrhage) were recorded in 21 % in both phases of the study. Skull fracture on X-ray, scalp haematoma, low GCS and vomiting seem to correlate with a positive scan. Discussion and conclusions. Significant improvement observed in issuing of VR and reduction observed in SXR requests. No improvement seen in inadequate and delayed PRs. For provision of optimum care in this potentially critical condition, a more proactive and robust approach is needed towards issuing reports. Regular feedback and reaudit seem to improve the indicators.
176 Non-accidental head injury features on serial neuro-imaging with an emphasis on the causation of low density subdural collections Haseeb Chaudhary, Dr Musa Kaleem, Stavros Stivaros Royal Manchester Children’s Hospital (United Kingdom) Purpose - Objective. Non-accidental head injuries (NAHI) typically consist of extra-axial haemorrhage and ischemia with or without low density subdural collections (LDSC). Causation of LDSC is controversial and has been ascribed to represent either a chronic subdural hematoma (SDH) or acute subdural effusion (SDE). This study was particularly aimed at evaluating LDSC causation on serial neuro-imaging Material and methods. Retrospective review over 3 years (Sep 2008–Oct 2011) of all cases of suspected NAI referred for primary imaging or second opinion. All cases with abnormal CT head features were included in this study. Initial and subsequent neuro-imaging features were compared. Results. Head injury features on serial CT and MRI were identified in 20/260 (7.7 %) of total suspected NAI cohort. Acute intracranial haemorrhage was present in 14/20 (70 %) and ischemic brain changes in 8/20 (40 %) cases. LDSC
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
were present in 18/20 (90 %) and the majority were bilateral and increased in size in the initial period before stabilising. Differential MR signal intensity between the two hemispheric LDSC was observed in 16/20 (80 %) cases. Four children suffered from significant ischemic brain injury while surgical intervention for LDSC was required in 3 cases. Discussion and conclusions. We found that LDSCs were present in a significant majority of NAHI cases and were usually associated with acute extra-axial hemorrhage. Several features supported LDSC to be a result of acute injury.
177 It seems to be a trauma but it isn’t the “Raccoon” eyes sign Manuela De Vivo, Valeria Bolli, Lucia Amici, Vittoria Galeazzi, Alice Manna, Marzia Rosati, Valentina Palazzetti, Marco Olivieri University Hospital of Ancona, Umberto (Italy) Purpose - Objective. Aim of this poster is to improve the knowledge of the most obscure sign of neuroblastoma in childhood. Material and methods. In the last 6 months we have seen two babies who presented to the Emergency Department with periorbital edema:the first one and a recent limp, the second swelling and a little frontal mass, both the children had a slight palpebral ecchymosis. We have studied them with US and X-ray examination of the orbit, the hip and the knee. Results. Initially a suspicioun of child abuse was made and an abdominal US exam was performed, arriving to the correct diagnosis. Later the children were studied with CT scan and MRI. We have found an adrenal mass with hepatic metastases in both the babies. One of these also had a periorbital cellulitis without skull bone lesions, the other one had a widespread bone disease with many old metaphysal fractures. Discussion and conclusions. Neuroblastoma accounts for 8– 10 % of all childhood cancers and periorbital edema and ecchymosis are not so rare; they are probably related to obstruction of palpebral vessels with or without skull bone lesions. We must remember this sign because correct diagnosis may be delayed by the suspicious of child abuse or trauma.
178 Syndromic and complex craniosynostosis: a morphometric study of the foramen magnum. Bianca Rijken, Maarten Lequin, Irene Mathijssen Academic Medical Center, Rotterdam (Netherlands)
S535
Purpose - Objective. Patients with craniosynostosis syndromes have premature closure of multiple sutures and synchondrosis which may influence the development of the skull base. We studied the area and maximal anteriorposterior (AP) diameter of the foramen magnum (FM) in patients with different craniosynostosis syndromes before the age of 4 years (before occipital expansion) and compared them with age matched controls. Material and methods. Measurements were performed in 3D-CT scans of 44 patients with craniosynostosis syndromes and 25 trauma patients, which were used as controls. Exclusion criteria were: skull base fractures or bone disorders. All scans were aligned in sagittal, coronal and transverse plane. Results. In general, no significant difference in area or APdiameter of the foramen magnum was demonstrated between patients with craniosynostosis compared to controls. However, patients with Crouzon syndrome (n011) have a significant smaller area and AP-diameter of the FM compared to controls (mean0574.75 mm2 vs 706.65 mm2, p<0,001 and mean031.55 mm vs 34.27 mm, p00.001, respectively). Discussion and conclusions. Patients with Crouzon syndrome have a smaller FM at an early age. This may be a risk factor to develop a Chiari I malformation, since patients with Crouzon syndrome have a relatively high risk to evolve a Chiari I malformation, compared to other syndromes.
179 The jugular foramen in syndromic and complex craniosynostosis: a prospective study `J. Florisson1, M.L.C. Van Veelen1, N. Bannink1, Irene Mathijssen2, Maarten Lequin2 1 Erasmus Medical Center, Rotterdam; 2Academic Medical Center, Amsterdam (Netherlands), Purpose - Objective. Elevated intracranial pressure (ICP) is a known problem in patients with craniosynostosis whose origin is still unsolved. Cranio-cerebral disproportion, cerebellar tonsillar herniation, hydrocephalus respiratory obstruction from midface hypoplasia in syndromic forms and restriction of venous outflow through the intracranial compartment have all been mentioned as causes of elevated intracranial pressure. We investigate the influence of jugular foramen abnormalities in elevated pressure. The jugular foramen in different groups is measured and the influence of age is analyzed. The anatomical variations are illustrated. Material and methods. A prospective 3D-CT angiography study was set up with 83 patients. Syndromic craniosynostosis (41), isolated craniosynostosis (23) and healthy patients (19)
S536
were included. The inflow and outflow diameter of the jugular foramen is measured and the venous drainage was compared at 11 different points. Papilledema which was diagnosed by the opthalmologist is used as a sign of elevated ICP. Results. The syndromic craniosynostosis patients and patients with elevated ICP tend to have a larger jugular foramen compared to patients without elevated ICP. Age does have a large effect on the jugular foramen diameter. Venous drainage problems are not an indicator of elevated ICP. Very interesting abberant courses of the venous runoff were found. Discussion and conclusions. Anatomic variations are common but important findings in syndromic craniosynostosis patients. The main cause of elevated intracranial pressure in these patients is still debated and a challenge to discover.
180 MR evaluation of craniovertebral junction anomalies in children Amit Gupta1, Tushar Chandra2, Manish Bajaj3, Ravishankar Pillenahalli Maheshwarappa1 1 Ravindra Nath Tagore Medical College, Udaipur (India); 2 Childrens Hospital of Wisconsin, Madison (United States); 3 Geetanjali Medical College, Udaipur (India) Purpose - Objective. The aim of this exhibit is to: 1. Review normal anatomy and development of the structures constituting craniovertebral junction (CVJ). 2. Discuss the role of craniometry in assessment of CVJ abnormalities. 3. Emphasize the role of MR imaging as a useful alternative to CT for evaluation of various CVJ anomalies encountered in the pediatric age group. Material and methods. The pediatric patients encountered on day to day basis, with symptoms pertaining to posterior fossa and upper cervical cord were evaluated for any associated CVJ abnormality using MR imaging. Results. CT poses radiation hazards to children, which can be obviated if MR is used. MR imaging with its multiplanar capability and absence of ionising radiation can be a very useful tool for assessing CVJ anamolies in the pediatric age group. It is a robust modality providing clinically useful information regarding the status of cervical cord and the hind brain in the same study. Discussion and conclusions. Until recently, CVJ was a challenging region to a radiologist with MR imaging, and CT has been playing the lead role. But with thorough understanding of anatomy and craniometry MRI can prove to be a useful alternative for evaluating CVJ anomalies
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
181 Pediatric skull base: embryology and anatomy Tushar Chandra1, Mohit Maheshwari1, Suyash Mohan2, Dhiraj Baruah3, Sumit Singh2, Teresa C. Gross Kelly1 1 Childrens Hospital of Wisconsin, Madison; University of Pennsylvania School of Medicine, Philadelphia; 3Medical College of Wisconsin, Madison (United States) Purpose - Objective. The aim of this exhibit is to provide a succinct review of the embryology and developmental anatomy of the pediatric skull base and the pertinent diagnostic and surgical considerations. Material and methods. The exhibit will provide an overview of the embryology of the developing pediatric skull base. We will discuss the development of bony skull base, foramina, sutures and the cranial vault. Relevant cross sectional (CT and MRI) as well as graphic illustrations will be provided. Results. Growth of the skull base is slow and occurs through endochondral ossification, while the cranial vault grows rapidly through membranous ossification. The anatomy of the growing skull base is different from the adult skull. We will review the anatomy of the skull base with age and illustrate the potential diagnostic and interpretative pitfalls. Discussion and conclusions. Knowledge of the developmental anatomic relationships of the skull base provides for a better understanding of skull base abnormalities. The neurosurgical approach to pediatric skull base can also be optimized based on the anatomical maturity of the skull base, thereby improving morbidity.
182 Are there any volumetric differences of the fossa posterior and cerebellum in Crouzon patients with or without a Chiari malformation Type I? Bianca Rijken, Maarten Lequin, Irene Mathijssen Academic Medical Center, Rotterdam (Netherlands) Purpose - Objective. Patients with Crouzon syndrome have a relatively high risk of developing a Chiari malformation type I (CMI). To improve our understanding of this matter, we studied the volume of the fossa posterior (FP) and the cerebellum at different ages in Crouzon patients with and without a CMI, and compared them with each other and with aged matched controls. Material and methods. Twenty-seven patients with Crouzon syndrome (mean age of 7.9 years, range 0–17 year) underwent a T1-weighted 3D-MR scan in our craniofacial
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
center. Control data were collected from T1-weighted 3DMR scans of 23 patients, without brain anomalies (mean age of 4.8 years, range: 0–15 years). All statistical calculations were corrected for age and gender. Results. Seven (35 %) patients with Crouzon syndrome demonstrated a CMI on the 3D-MR scan. The volume of the FP and cerebellum in these patients was not different from Crouzon patients without a CMI (176.6 ml, 125.4 ml vs. 164.8 ml, 118.5 ml) or controls (176.6 ml, 125.4 ml vs. 146.9 ml, 107.1 ml). Discussion and conclusions. Thirty-five percent of the Crouzon patients developed a CMI. The volume of the FP and cerebellum in Crouzon patients with a CMI is not different from patients without a CMI or controls; therefore it has no predictive value to the development of a CMI.
183 ADC value as a predictive value in children with encephalitis Robert Marterer1, Siegfried Rödl1, Andreea Rachisan2, Adrian Hrusca2, Erich Sorantin1, Medical University of Graz (Austria); “Iuliu Hatieganu” Medicine and Pharmacy University, Cluj-Napoca (Romania) Purpose - Objective. Encephalitis is a devastating disease in childhood. MRI is the modality of choice to establish the diagnosis. Due to the inflammatory process it can be expected that ADC values are reduced in infected regions. The aim of this retrospective study was to evaluate the predictive value of ADC values. Material and methods. In 13 children the ADC values were measured in each 29 brain regions and compared with a control group (10 healthy children). The long-term outcomes were evaluated with good outcome (no long-term consequences) vs. limited outcome (neurological or other deficits). Results. The children with encephalitis had significant lower (p<0.05) ADC values in the following regions: precentral cortex (672±164 patient group vs. 790±79 control group), frontal cortex (684±175 vs. 803±58), parietal cortex (677± 137 vs. 921±89) and occipital cortex (687±107 vs. 915± 83). There was also a difference between children with good long-term outcome compared to those with limited outcome, for example parietal white matter: 739±80 (limited outcome) vs. 841±158 (good outcome). Discussion and conclusions. The study shows that the ADC values are lower in children with encephalitis and the greater the restriction, the worse the clinical long-term outcome.
S537
184 US-guided drainage of pediatric brain abscess : a powerful guiding technique Marina Vakaki 1 , Panagiotis Dimitriou 1 , I o a n n i s Koutsogiannis1, George Kannas1, George Karapostolakis1, Sokratis Hatzimichalis 1 , George Pitsoulakis 2 , Chris Koumanidou1 1 “P & A. Kyriakou” Children’s Hospital, Athens (Greece); 2 “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. Pediatric brain abscesses are rare serious infections that cause neurological problems. They require antibiotic treatment and surgical drainage. The latter is considered as the first-line treatment for abscesses larger than 2.5 cm. A method of US-guidance is presented that allows a small craniotomy approach and abscess aspiration with real-time imaging of the whole procedure. Material and methods. The procedure was performed in 2 immunocompetent children with brain abscess, 7-year and 11-year old respectively. Brain CT showed a low-attenuating ring-enhanced lesion, 2.5 cm in diameter, in the right parietal region and one subtentorial, 3 cm in diameter, retrospectively. Results. A small size craniotomy window served as the site of transducer placement and needle insertion after a sonographic evaluation of the abscess. A portable US machine with a microconvex 5–8 MHz transducer was used. Purulent material was aspirated from the abscess cavity and antibiotic was injected within it by the neurosurgeon under continuous real-time US control. There were no complications. The patients’ symptoms improved rapidly. Brain MRI one and 3 weeks after the abscess drainage showed progressive regression of the brain lesions. Discussion and conclusions. Our results demonstrate sonography to be very useful for accurate and effective brain abscess drainage without causing significant trauma to overlying parenchyma and avoiding large brain vessels. To the best of our knowledge, this is the first report of US-guided pediatric brain abscess drainage.
185 Scan time and patient dose for head-CT examination in uncooperative children using axial volumetric 128-slice CT compared to sequential CT Andrea Magistrelli, Vittorio Cannatà, Marco Cirillo, Laura Menchini, Elisabetta Genovese, Bruno Bernardi, Paolo Tomà Bambino Gesù Childrens Hospital, IRCCS, Rome (Italy)
S538
Purpose - Objective. To compare dose-length-product-based (DLP) and CT-dose index volume (CTDIvol) of sequential vs spiral head-CT examinations in pediatric trauma patients. Material and methods. We retrospectively evaluated headCT examinations performed on our dual-source CT system (Somatom Definition Flash, Siemens) with three automated tube current modulation (CARE DOSE 4D) different protocols (sequential_1:120 kV;200mAs-reference; collimation 128×0.6 mm; rotation-time 1 s; sequential_2:120 kV;200 mAs-reference;collimation 32×1.2 mm; rotation-time 1 s; spiral:120 kV;200mAs-reference; collimation 128×0.6 mm; rotation-time 1 s; pitch 0.65). None of the patients were sedated for the volumetric-CT examinations. Dose values were calculated from the DLP provided in the patient protocol/dose reports; MonteCarlo simulations were performed to assess dose distribution. Results. All scans were performed without complications with good diagnostic image quality. Despite a slight reduction of image quality in spiral-CT examination there is a significant reduction in the risk of motion artifacts as compared to conventional-CT exams. Dose values of volumetric CT are lower if compared to sequential CT exams, while the use of different collimation in sequential exams do not determine significant differences in dose values. Discussion and conclusions. Sequential-CT remains the gold-standard technique for head-CT examinations. However, it uses a fair dose of radiation and it has slow scan times, too. Spiral-CT is a robust method to avoid sedation for the examination of infants or uncooperative children, providing a good image quality and maintaining low radiation-dose values.
186 CT and MRI in diagnostic of inner ear anomalies: results of examination of 27 patients Anna Skorokhoda, Irina Dykan, Lyudmila Myronyak Scientific and Practical Center of Radiology NAMS (Ukraine) Purpose - Objective. Since the first case written by C. Mondini, CT and MRI have become essential investigative modalitiesto diagnose inner ear anomalies. According to the data from different authors, 20 % of children with sensorineural hearing loss had inner ear anomalies on CT. These patients could be potential candidates for Cochlear implantation. Material and methods. We present the results of HRCT and MRI with CISS3D examination of 27 patients (3 to14 years) with sensorineural hearing deficit (16 cases (59,3 %) bilateral, 11 cases (40,7 %) unilateral anomalies). Overall number of anomalous temporal bones was 43. Results. Anomalies of labyrinth include: bilateral labyrinth aplasia (Michel’ anomaly) - 1 (3,7 %), cochlea hypoplasia 2 (7,4 %), common cavity deformity - 1 (3,7 %), incomplete
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
partition type I - 2 (7,4 %), IP type II (Mondini anomaly) - 2 (7,4 %) cases. 4 patients (14,8 %) had large vestibular aqueduct syndrome(LVAS). Dilatation of LCC - 7 cases (20,8 %) (isolated - 4, with external auditory canal (EAC) anomaly - 2, with Mondini anomaly - 1). Narrow internal auditory canal (IAC) was diagnosed in 3 cases (11,1 %), in 2of these patients it occurred with cochlear nerve hypoplasia. Isolated wide IAC occured in 2 patients (7,4 %), in 3 cases (11,1 %) it was combined with fistulous perilymphatic —subarachnoid communicaton due to the absence of bony septae between IAC and basal turn of cochlea. Discussion and conclusions. HRCT and MRI with CISS3D are highly important diagnostic tools that provide essential information on the type of anomaly of the labyrinth, VII or VIII nerves within the IAC, which can be subsequently used as one of the factors in cochlear implantation planning.
187 Brain lesions revealed by internal auditory canal MRI in pediatric cochlear implant candidates Ji Hye Kim, Jung Won Moon, Tae Yeon Jeon, So Young Yoo, Hong Eo, Jee Hun Lee Samsung Medical Center, Sungkyunkwan University, Seoul (Republic of Korea) Purpose - Objective. To evaluate the incidence and spectrum of brain lesions and their significance in pediatric candidates for cochlear implant. Material and methods. We retrospectively reviewed preoperative internal auditory canal (IAC) MR images of 320 pediatric candidates for cochlear implant (161 boys, 159 girls; mean age, 6.7 years), which included T2-weighted axial images covering the whole brain, and intracranial and inner ear abnormalities were determined. Clinical histories including in-uteri and perinatal problem, any identified syndrome, and developmental status were evaluated by review of the medical records. Results. Eighty three (26 %) patients had brain lesions including white matter lesion (n043), cysts (n027), abnormal ventricle (n014), cortical malformation (n06), tumor (n06), and vascular malformation (n03). In addition, labyrinth anomaly (n056), abnormal IAC (n024), and abnormal 7, 8th cranial nerves (n020) were identified. Among the patients with brain lesion, in-uteri and perinatal problem was found in 45 patients, 6 syndromes were identified, and developmental delay was noted in 15 (18 %). Only 3 of 237 patients (0.1 %) without brain lesion had developmental delay (p<0.05). Discussion and conclusions. Considerable numbers of patients with hearing loss are associated with brain lesions including white matter lesions, tumors, and anomaly, which may affect neurodevelopmental status and they are expected to influence outcome of the cochlear implant.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
188 Pediatric paranasal sinuses: beyond sinusitis Manish Bajaj1, Tushar Chandra2, Amit Gupta3, Shalini Bajaj1 1 Geetanjali Medical College, Udaipur (India); 2Childrens Hospital of Wisconsin, Madison (United States); 3Ravindra Nath Tagore Medical College, Udaipur (India) Purpose - Objective. This educational exhibit aims to: 1.Describe embryology and development of paranasal sinuses 2.Depict normal anatomy of sinuses and osteomeatal unit and variants on CT scan 3.Discuss the role of various diagnostic modalities in evaluation of sinus diseases 4.Illustrate imaging features and complications of developmental abnormalities, inflammatory lesions and common neoplasms encountered in pediatric age group 5.Highlight common pitfalls in evaluating pediatric sinus CT Material and methods. Pediatric patients presenting with symptoms pertaining to sinus diseases were evaluated initially using conventional Radiography. Computed Tomography and/or MRI were used as and when required for further evaluation. Results. Plain Radiography is the best screening modality for initial evaluation. Low dose CT is the modality of choice in demonstrating pathology and is gold standard for presurgical planning. Helical acquisition with multiplanar reformatting provides the best possible depiction of pathologies. Though MRI lacks bony detail, it is a useful adjunct that does not pose radiation hazard in pediatric patients and better delineates soft tissues compared to CT. Discussion and conclusions. Knowledge of normal anatomy and common variants is pertinent to accurate diagnosis in pediatric sinus pathologies. Clinical judgement is sufficient for uncomplicated sinusitis without any need for complex investigations. However, for other pathologies, CT remains the mainstay for diagnostic work up and surgical decision making with MRI used as a supplement.
189 Intracranial and facial complications of sinusitis and otomastoiditis Amit Agarwal Pennsylvania State University (United States) Purpose - Objective. To discuss the normal imaging anatomy and the imaging appearance of complications of sinusitis and otomastoiditis. Material and methods. Sinus anatomy will be reviewed, including the structural relationships and anatomical variants which may predispose to certain complications. The
S539
imaging appearance of extrasinus complications of sinusitis and otomastoiditis will be reviewed utilizing an organized approach based on anatomical relationships. Results. Computed tomography is often the initial imaging modality used in evaluating sinusitis and otomastoiditis, and is quite good at evaluating extracranial complications. However, MR is generally a more sensitive modality for detecting intracranial complications. It is important to both utilize the best imaging modality for a specific diagnostic question and to be well versed in potential complications of sinusitis and otomastoiditis. Discussion and conclusions. Sinusitis and otomastoiditis are common diseases. Although extrasinus and particularly intracranial complications of sinusitis and otomastoiditis are relatively rare, prompt diagnosis and familiarity with the specific complications and their imaging appearances is crucial to prevent or limit neurologic complications.
190 Normal anatomic structures sonographically detected but unrecognized or misdiagnosed during the neck ultrasound examination Marina Vakaki, George Karapostolakis, Kleanthi Kalogerakou, Asteroula Papathanasiou, Elpida Vlachopapadopoulou, Vasilios Petrou, Fotini Karachaliou, Katerina Terzaki, Chris Koumanidou “P & A. Kyriakou” Children’s Hospital, Athens (Greece) Purpose - Objective. High-resolution sonography represents the initial and frequently the only imaging method for assessment of pediatric neck soft-tissue abnormalities. Knowledge of normal neck sonographic anatomy and variants is mandatory for their evaluation. Furthermore, with the advent of improved sonographic resolution, more detailed observation reveals findings either previously unreported or even unsuspected. Purpose of this educational presentation is to illustrate important sonographic pitfalls in the pediatric neck sonographic examination, and how this misinterpretation may lead to the misdiagnosis of neck pathology and potentially unnecessary investigation or inappropriate management. Material and methods. The presented sonographic examinations of the neck, including the thyroid gland, are selected from our 10-year database. Results. The sonographic appearance of normal structures and their variants is illustrated. These include cricoid and thyroid cartilage, tonsils, oesophagus, ectopic intra/extrathyroid thymic tissue, colloid intrathyroidal follicles etc. They are correlated with anatomy and/or embryology. The potential misdiagnoses are discussed. Discussion and conclusions. Recognition of these common sources of error in sonography improves the accuracy of this
S540
invaluable imaging method. Awareness of their sonographic patterns in childhood should prevent a potential diagnostic pitfall and further unnecessary investigation. To the best of our knowledge, only a few case reports in the literature describe the sonographic patterns of some of the presented anatomic structures.
191 MDCT imaging of inflammatory neck collections in children: a pictorial review Irene Borzani, Nicola Bonelli, Eliseo Ruggeri, Mauro Campoleoni, Pietro Biondetti Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan (Italy) Purpose - Objective. The aim of this pictorial exhibit is to review: 1) the anatomy of the neck compartments 2) MDCT protocol for evaluating suspected neck collections in children and 3) MDCT imaging appearance, location and extension of inflammatory collections in the neck Material and methods. A retrospective review was performed in children (<18 years old) who underwent MDCT studies of the neck between January 2009 and December 2011. Pediatric patient preparation, MDCT scanning parameters with emphasis on low radiation dose technique, and 2D/3D post-processing reconstruction techniques were investigated Results. The most common diagnostic techniques used for evaluating neck masses in children are ultrasound and CT. CT is superior to sonographic study in the demonstration of both superficial and deep neck structures, and provides better depiction of infection spread along anatomical planes. MDCT can better demonstrate the relationship between neck collections and closer anatomical structures (especially airways and vessels). These findings play an important role in the diagnosis and management of the patients, especially when surgical drainage is needed Discussion and conclusions MDCT assessment of neck collections in young children is useful to evaluate anatomical planes involvement and extension. To minimize radiation exposure CT should be reserved for patients with worsening of clinical conditions and suspicion of deep neck infection or airways compromise
192 Piriform sinus fistula: A rare finding in patients with recurrent cervical infections Evaggelia Manopoulou, Maria Katsikari, Maria Michalakou Euroclinic Paidon, Athens (Greece)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. To demonstrate the imaging findings of piriform sinus fistula extending to the thyroid gland Material and methods. Within the previous year, two patients (a 2 year-old and a 7 yeart old boy) presented to our department with signs of inflammation and painful enlargement in the left cervical region; dyscataposia was an additional symptom in the older patient. A cervical ultrasound was performed and based on the suspicion from sonographic results, a barium esophagogram was ordered Results. During the ultrasound examination a longitudinal hypoechoic area was discovered terminating in the left parathyroid space, in contact with the thyroid. In one, case the gland showed signs of local inflammation (tender during the examination, hypoechoic area with increased vascularity), whereas in the other patient two small cystic lesions (abscesses) were revealed. The barium test clearly revealed the extent of communication between the piriform sinus and thyroid gland. Antibiotic therapy was advised Discussion and conclusions. Piriform sinus fistula is an uncommon entity, a 4th brachial arch remnant, in most cases. The termination inside thyroid gland is even rarer, but it should be suspected in cases of acute suppurative thyroiditis, or thyroid abscess, given the high resistance of the gland to infections
193 An unusual location of Nasopharyngeal Angiofibroma in a 10 year old boy: Case report and review of the literature Ravishankar Pillenahalli Maheshwarappa1, Manish Bajaj2, Madhu Kumar Singhal1, Amit Gupta1 1 Ravindra Nath Tagore Medical College, Udaipur (India), 2 Geetanjali Medical College (India) Purpose - Objective. Angiofibromas are histologically benign vascular tumors, originating from the nasopharynx, near the area of sphenopalatine foramen. These neoplasms occur typically in male adolescents. Reports of primary extranasopharyngeal angiofibromas have appeared sporadically in the literature in English. Angiofibromas arising from the anterior end of the middle turbinate and near lacrimal sac have been reported. We present a case of a 10 year old boy with tumor filling the left vestibule arising from the anterior end of the inferior turbinate diagnosed as angiofibroma. Material and methods. A 10 year old boy presented with left-sided nasal obstruction and epistaxis. Endoscopic evaluation revealed a polypoid mass filling the vestibule arising from the anteroinferior portion of the left inferior turbinate. Computed tomography (CT) scan showed a soft-tissue opacity that filled the vestibule of the left nasal cavity. Endoscopic excision of the mass, postoperative and histopathological analysis was done.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Results. After the endoscopic excision of the mass, postoperative and histopathological analysis confirmed the diagnosis of an angiofibroma. Discussion and conclusions. Extranasopharyngeal angiofibromas arising from the nasal cavity are extremely rare tumors. Histopathological analysis is very important in all doubtful cases, especially in those with atypical location.
194 Ultrasonographic appearances of intrathyroid ectopic thymus Maria Raissaki1, Ioanna Tritou2, Penelope Smirnaki3 1 University Hospital of Heraklion, University of Crete; 2 Venizelio Hospital of Heraklion, Crete (Greece), 3Private practice, Heraklion, Crete (Greece) Purpose - Objective. To describe in detail the ultrasonographic findings of intrathyroid thymus. Material and methods. Thirteen euthyroid children aged 4.5–12 years (mean 5.3 years), underwent cervical Ultrasound for suspected lymphadenopathy on an iU22 Philips scanner with 17–5 MHz linear transducer. Diagnosis of intrathyroid thymus was based on comparison with visible mediastinal thymus, clinical and imaging follow-up in all patients for a mean of 8 months while MR confirmation and biopsy proof occurred in 2 and 1 patients, respectively. Results. Five right-sided and 8 left-sided lesions were identified, located posteriorly, abutting the thyroid’s periphery. Extrathyroid extension or proximity with cervical thymus occurred in 4 patients. All lesions were hypoechoic, contained fine bright spots that ranged from a few to innumerous, scattered through the lesion. A thin hypoechoic rim was noted in all lesions and was complete in 11. Speckle’s size was identical to the thymus’s internal spots. 9 lesions were ovoid, 1 wedge-shaped, 2 dumbbell, 1 drumstick like, while in 1 of the above the shape varied from ovoid to geographical, depending on the probe’s position. Discussion and conclusions. Intrathyroid ectopic thymus has a characteristic hypoechoic rim and an internal echotexture comparable to the visible mediastinal thymus. Identification of possible connections between posterior thyroid lesions and the thymus strengthens the diagnosis, obviating unnecessary investigations.
195 Pictorial overview of the spectrum of infective pathology in the paediatric orbit. Alan Quigley, Samuel Stafrace Royal Aberdeen Children’s Hospital (United Kingdom)
S541
Purpose - Objective. In this poster we aim to demonstrate the spectrum of disease, typical radiological appearances and outline the underlying pathophysiology in paediatric orbital infection. Material and methods. Cases pertaining to paediatric orbital infection in our institution over the last 5 years were retrospecively reviewed. Results. The typical CT appearances of preseptal cellulitis, postseptal cellulitis, complicated cases and important differential diagnoses are demonstrated together with the appropriate classification of this spectrum of diseases. Discussion and conclusions. More than half of orbital disease is related to infection which typically occurs secondary to spread from adjacent structures. Knowledge of the spectrum of orbital infection and the understanding of the radiological appearances is essential to guide the appropriate treatment.
196 Contribution of fetal magnetic resonance in prenatal diagnosis Luisa Battigelli 1 , Giuseppina D’Ottavio 2 , Pierpaolo Guastalla2, Floriana Zennaro 2 1 Az Ospedaliero-Universitaria di Udine, Udine; 2IRCCS Materno-Infantile Burlo Garofolo, Trieste (Italy), Purpose - Objective. Since the development of fast imaging, Magnetic Resonance Imaging (MRI) has been used to evaluate fetal anomalies. The aim of this study was to determine the role of fetal MRI in ultrasonographically (US) detected fetal structural malformations. Material and methods. One hundred thirty-eight fetuses with suspected malformations were included in this retrospective observational study. Mean gestational age was 26 week (20 to 39 weeks). All US examinations were performed by two GE ultrasound machines (Voluson 730 Expert and Voluson E8). All Magnetic Resonance examinations were performed by 0,6 T Panorama Philips using SSH, TE, T1 TSE and dynamic sequences. The benefit of Magnetic Resonance was expressed according to: no additional information, additional information or change of the diagnosis. Results. Prenatal diagnosis remained unchanged in 100 cases. MRI added information in 19 cases and changed diagnosis in 14 patients corresponding to around 10 % of the cases. Discussion and conclusions. In selected cases, MRI can be superior to sonography and has supplemental value thanks to a better anatomical localization and tissue characterization especially on thoracic mass evaluation. Nevertheless, ultrasound remains the primary fetal monitoring technique.
S542
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
197
high strength field (RF effects, susceptibility effects, chemical shift effects, dielectric effects) and their remedies. Results. The study of the fetal brain at 3T needs a dedicated 3T fetal protocol and a dedicated approach to the fetus in order to reduce artefacts. We reviewed all the sequences we used and the anatomical structures visible at fetal MRI on 3T, also commenting on the expected artifacts on 3T and the possible protocol manipulations in order to minimize them. Discussion and conclusions. The study of fetal brain at 3T is feasible and seems to be a promising tool for some fetal malformation of the CNS, due to the higher conspicuity of some fetal malformations and some type of lesions on 3T.
Diffusion weighted MRI of the fetal brain in intrauterine growth restriction Owen Arthurs, Marianne Alison, Bogdana Tilea, Nadia Belarbi, Agnes Sartor, Monique Elmaleh-Berges, Guy Sebag Hôpital Robert Debré, Paris (France) Purpose - Objective. Diffusion weighted MR imaging can quantitatively evaluate water diffusion in the fetal brain, which may alter in white matter injury, such as acute ischaemia, chronic hypoxia or abnormal maturation. Here, we assessed whether fetal brain ADC values in fetuses with severe intrauterine growth restriction (IUGR) were different to normal controls. Material and methods. We compared a group of 31 growth restricted fetuses (<10th centile for growth, with impaired uterine and umbilical Doppler flow; IUGR) to a group of 26 otherwise normal controls at the same gestation age. DWI of the fetal brain (b values 0 and 700) was performed at 1.5 T, with 8 ADC regions of interest: frontal (FWM) and occipital white matter (OWM), centrum semi ovale, basal ganglia, cerebellar hemispheres and pons. Results. IUGR fetuses had significantly lower ADC values in FWM (1.96±0.22 vs 2.11±0.2×10-3 mm2/s; p& amp;amp;lt;0.001) and Basal Ganglia (1.05±0.15 vs 1.14± 0.11; p<0.001), but not in the other areas. IUGR fetuses had a lower fronto/occipital white matter ADC ratio (0.99±0.11 vs 1.08±0.06; p<0.001) than normal fetuses. Discussion and conclusions. ADC values in IUGR fetuses are significantly lower in FWM and BG than normal controls, suggesting acute ischaemic lesions or abnormal maturation in these regions.
198 Feasibility of fetal MRI evaluation of the brain on a 3T magnet. A three-year experience Sara Savelli, Marco Di Maurizio, Anna Perrone, Marzia Mortilla, Claudio Fonda Meyer Children’s University Hospital, Florence (Italy) Purpose - Objective. 3T MR systems are expected to increase SNR which can be used for higher spatial or temporal resolution. The aim of our study is to describe our experience with fetal MRI at 3T for the evaluation of the fetal brain. Material and methods. We reviewed all our fetal MRI examinations of the brain performed on 3T in order to establish a dedicated protocol, to assess the improvements in image quality (anatomical structures visibility, conspicuity of lesions) and to discuss the special artifacts due to the
199 A comparison between second-level prenatal us and fetal MRI in an Italian population of pregnant women: a 4year retrospective review Sara Savelli1, Marco Di Maurizio1, Lucia Pasquini2, Giulia Masini 2, Anna Perrone1, Claudio Fonda1, 1 Meyer Children’s University Hospital, Florence; 2Careggi Universitary Hospital, Florence (Italy) Purpose - Objective. US is the method of choice to screen for fetal anomalies but fetal MRI has been proved to be a valid additional tool to study at risk pregnancies. Material and methods. We retrospectively reviewed all the pregnancies referred to our tertiary centre between 2007 and 2010 that performed second-level US and fetal MRI. The pathologies were divided into CNS, abdominal, thoracic, genitourinary, skeletal, maxillar, neck and gastrointestinal anomalies. Ultrasound and MRI findings were compared and with postnatal data: same diagnosis, additional MRI details, MRI correct, ultrasound correct, both incorrect. Results. Two hundred sixty-eight cases were reviewed. US and MRI were both correct in 201 cases and incorrect in 4, MRI added details in 36 and was correct in 21, US in 6. The main indication for fetal MRI remains the CNS anomalies; MRI did not add significant information in the study of the skeleton, face and GU system, but was useful for the study of abdominal masses and GI tract, added additional details in cases of congenital diaphragmatic hernia (liver, pulmonary hypoplasia) and neck masses (trachea, vessels) and can be useful in oligoamnios. Discussion and conclusions. MRI seems a valuable supplementary method to US in obtaining information in prenatal malformations. The concomitant use of the two techniques permitted a correct diagnosis and characterization of fetal anomalies in 98 % of cases in our population.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
200 Foetal MRI in antenatal diagnosis of hepatic hemangioendothelioma: A report of three cases Georgios Sgourdos, Marc Treyvaud, Leonor Alamo Centre Hospitalier Universitaire Vaudois, Lausanne (Switzerland) Purpose - Objective. To describe foetal MRI features of hepatic hemangioendothelioma and to discuss the usefulness of this imaging method in antenatal differential diagnosis. Material and methods. We reviewed three cases of foetuses with hepatic hemangioendothelioma. All cases were evaluated by prenatal US and MRI. MRI was performed on three foetuses at 35 +3, 32 +5 and 27 weeks of gestation. Prenatal MRI findings were evaluated and compared with postnatal clinical and imaging features. Results. The MRI findings of all three foetuses were similar. A large heterogeneous mass of the liver with low T1 signal intensity and high T2 signal intensity, were the main imaging features. Postnatal clinical and imaging findings were in agreement with antenatal evaluation. Discussion and conclusions. Foeatal MRI appears as a useful imaging modality to assess the anatomical extension of liver tumours. The differential diagnosis of foetal liver lesions includes hepatic hemangioendotheliomas. The MRI findings of our cases, combined with very similar results of previous studies, suggest the usefulness of foeatal MRI in the diagnosis of hepatic hemangioendotheliomas. Miscellaneous
201 Emerging applications of high-field strength whole-body MRI in paediatric imaging Shema Hameed, Maria Nordlander, Joanna Danin, May-ai Seah, Risha Hathi, Afshin Alavi St. Mary’s Hospital, Imperial College NHS Trust, London (United Kingdom) Purpose - Objective. High-field strength whole-body MRI (WB-MRI) is a rapidly growing tool in paediatric imaging. It has been shown to be an accurate modality for the detection and monitoring of systemic and malignant diseases, whilst eliminating the risks associated with ionising radiation. We will discuss its current uses, including oncological diagnosis and staging, fever of unknown origin, multifocal osteomyelitis and osteonecrosis, and systemic disorders including rheumatological diseases and rare whole-body syndromes.
S543
Material and methods. We will discuss: • Our experiences of 3T WB-MRI over the past 2 years • Imaging strategies, methodology and protocols • Variable applications of a vastly growing modality, with a pictorial review of our most interesting cases • Limitations in image interpretation • Specific 3T safety considerations in the paediatric population Results. High-field strength MRI provides superior quality images with small field of views (SFOV), and an improvement in the SNR. It provides fast imaging at a high spatial resolution, with the utilisation of multiple coil elements, synchronised signal recording, numerous independent receiving channels and motion correction algorithms. Discussion and conclusions. WB-MRI provides superior anatomical and soft-tissue detail without the radiation exposure. It has been shown to have a higher diagnostic potential over PET-CT and bone scintigraphy for the detection of metastatic spread. However its use is not solely limited to oncological imaging. We will discuss and illustrate the hugely variable emerging applications of WB-MRI.
202 Color Doppler Sonography as the initial diagnostic approach for superficial soft tissue masses in children Savas Deftereos, Eugenia Vranou, Chrisostomos Soultanidis, Panos Prassopoulos Democritus University of Thrace, Xanthi (Greece) Purpose - Objective. The purpose of this study is to estimate the value of Color Doppler Sonography (CDS) in the initial diagnostic approach of superficial soft tissue masses in children. Material and methods. Thirty-two soft tissue masses in 29 children (age range:1 month–14 years) were evaluated with CDS. Longitudinal and transverse images were obtained and the masses were described as cystic, homogeneous solid or mixed lesions and were categorized in basis of their vascularisation: hyper-, hypo- and without-flow. Results. Of the 32 masses, 9 were cystic, 7 homogeneous solid and 16 mixed masses. Ultrasound alone was diagnostic in all cystic masses, in 3 of 7 homogeneous solid masses and in 9 of 16 mixed solid masses. CDS findings raised the diagnostic suspicion to 5/7 in homogeneous solid masses and 12/16 in mixed solid masses. Pathologic correlation was reliable but not conclusive in the CDS differentiation of these masses (except cystic masses). Complete absence of detectable flow within a solid and mixed-solid mass seems to be a good criterion in favor of benign lesion (5/5). Discussion and conclusions. Ultrasonography provides immediate characterization of mass size, consistency, and anatomic location. Correlation of the imaging findings with the clinical information is crucial in the diagnostic work-up.
S544
However, on US, echogenicity and homogeneity of the lesions are nonspecific. Doppler criteria may be suggestive of malignancy but with overlap between benign and malignant lesions.
203 Subcutaneous granuloma annulare: sonographic findings of a rare entity with radiologic-pathologic correlation Marina Vakaki, Orthodoxos Achilleos, Kleanthi Kalogerakou, Ioannis Koutsogiannis, Panagiota Giamarelou, Chris Koumanidou “P & A. Kyriakou” Children’s Hospital, Athens (Greece); Purpose - Objective. Subcutaneous granuloma annulare (SGA) is a benign, usually self-limited granulomatous disease of the dermis and subcutaneous tissue, occurring almost exclusively in children. Its sonographic appearance is almost unknown with only few reports in the literature. Material and methods. We present 3 cases of SGA in the pretibial (n02) and gluteal area (n01) respectively. The children were referred for evaluation of a painless softtissue mass in the above areas. They were healthy children with no apparent history of trauma. Results. The sonographic examination revealed the presence of a subcutaneous poorly defined heterogeneous lesion, extending to the deep dermis, with low internal vasculature (color/power Doppler). In the first two cases follow-up was decided due to the typical location of the lesion and knowledge of the literature, which pointed towards the diagnosis of SGA. At the 3-month sonographic follow-up, the findings had disappeared. In the last most recent case, the large dimensions of the affected pretibial area necessitated its MRI evaluation. MRI showed an infiltrative lesion, low-intensity on T1weighted images and intermediate-intensity on T2-weighted images. Surgical excision was decided. The histologic evaluation was consistent with SGA. The X-ray, sonographic, MRI, and histologic findings are illustrated. Discussion and conclusions. The imaging diagnosis of SGA is considered difficult. However, the knowledge of its clinical characteristics, locations and imaging features can point toward the correct diagnosis avoiding anxiety and unnecessary investigation.
204 Subcutaneous fat necrosis (SCFN) in a neonate with perinatal asphyxia Xanthippi Vallianatou, Maria Karagianni, Nikolaos Ifantis, Dimitra Chaini, Euaggelia Varchalama, Faidra Kokori, Magdalini Smarda, Ioannis Dermitzakis General Hospital of Nikaia, Piraeus (Greece)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. The presentation of ultrasound findings in a neonate with subcutaneous fat necrosis due to perinatal asphyxia. Material and methods. A premature female neonate (GA: 35 weeks), with a history of severe perinatal asphyxia, presented with painful, erythroviolet, compact plaques on the neck (postauricularly and occipitally), back and submandibular area with expansion to the cheeks. The ultrasound appearance of these lesions was of a thick hyperechoic band that turned slightly heterogeneous within a few days. A couple of weeks later, there was still a hyperechoic appearance in subcutaneous fat with a slight increase in vascularity, as well as nodular compact formations up to 9 mm. Results. The above ultrasound findings were consistent with SCFN, while clinical diagnosis was finally confirmed by FNA and biopsy. The infant was discharged from hospital at the age of 1.5 months, while the follow-up revealed complete resolution of skin lesions at the age of 3.5 months. Discussion and conclusions. SCFN in neonates is a rare condition of unknown etiology, characterized by erythroviolet, compact, painful nodules or plaques. It usually presents in newborns with perinatal asphyxia, peripheral hypoxemia, hypothermia, meconium aspiration or trauma. Skin lesions are mostly located on the face, trunk, buttocks and extermities and appear right after birth, or up to several weeks later. However, it is generally considered to be a self-healing condition with a benign outcome.
205 Prolonged fever with lymphadenopathy: a West Nile Virus pediatric case Themistoklis N. Spyridopoulos, Theodora Zachari, Athanasia Stratigopoulou, Evaggelia Anagnostaki, Nikolaos Evlogias Penteli’s Children Hospital, Athens (Greece), Purpose - Objective. We present an interesting pediatric case with prolonged fever, which presented to our hospital and was finally diagnosed with West Nile Virus (WNV) infection Material and methods. Clinical, laboratory and imaging findings are presented. We also performed a literature review on WNV infections in the pediatric population. Results. A 10 years old girl presented with 10 days of fever. Laboratory tests revealed neutrophil leucocytocis, negative CRP, and no significant findings on both chest X-ray and abdomen ultrasound. Neck ultrasound showed enlarged anterior cervical nodes with normal morphology. Pharyngeal streptococcal test, EBV, CMV and toxoplasma tests were also negative. Despite therapy, fever and atypical diffuse abdomen pain persisted. Abdomen low dose CT scan
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
revealed multiple lymph nodes in the peritoneal and retroperitoneal spaces. The patient’s guardian mentioned that they had recently stayed close to a lake. Due to the possible exposure to mosquitoes, ELISA test for WNV was performed, which was positive. The girl was discharged free of symptoms after 5 days of hospitalization. Discussion and conclusions. WNV most commonly affects and tends to be more severe among adults and elderly people. It may also affect infants and children, who may be asymptomatic or present with febrile illness or in more severe cases with CNS manifestations. Known exposure to mosquitos and ELISA testing can lead to the final WNV diagnosis.
206 Imaging of post-transplant lymphoproliferative disorder in paediatric renal transplant recipients Uday Mandalia, Sîan Jenkins, Claire Lloyd Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Trust, London (United Kingdom) Purpose - Objective. To present the imaging findings of post-transplant lymphoproliferative disorder (PTLD) in paediatric renal transplant recipients and increase radiologists’ awareness of this uncommon condition. Material and methods. Retrospective review of cases of PTLD in paediatric renal transplant patients at our institution between 2005 and 2011. Results. Four male patients, aged between 7 and 16 years, were diagnosed with PTLD between 7 months and 11 years after renal transplantation. Three patients presenting with headache and vomiting had cerebral lesions on MRI. One patient with persistent cough had multifocal consolidation and pulmonary nodules on chest CT. Asymptomatic disease (splenic and pulmonary) was found at imaging in 2 patients. In 3 patients histological diagnosis was obtained by surgical or CT-guided biopsy. One patient with diffuse white matter lesions was unsuitable for biopsy; diagnosis was made on exclusion of infection and improvement in lesions with treatment for PTLD. All patients were treated with immunosuppression reduction with additional chemotherapy or immunotherapy in 2 cases. Follow-up imaging has confirmed full remission in three patients and lesion size reduction in the most recently diagnosed patient. Discussion and conclusions. PTLD in renal transplant recipients may have variable organ involvement and imaging appearances. Cerebral involvement has previously been reported as being uncommon but occurred in 75 % of our cases. PTLD is an important differential to consider in these patients. Imaging has important roles in diagnosis, assessment of disease extent, guiding biopsy and follow-up of this condition.
S545
207 Spectrum of Tuberculosis in children Amit Gupta1, Tushar Chandra2, Mohit Maheshwari2, Manish Bajaj3 1 Ravindra Nath Tagore Medical College, Udaipur (India); 2 Childrens Hospital of Wisconsin, Madison (United States); 3 Geetanjali Medical College, Udaipur (India) Purpose - Objective. 1. Define the role of current imaging modalities in diagnosing tuberculosis (TB) in children. 2. Present an imaging spectrum of tuberculosis in children with respect to pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. 3. Describe the differential diagnoses and mimics of TB in pediatric patients. 4. Emphasize the importance of timely diagnosis in guiding appropriate treatment. Material and methods. We will present common as well as rare imaging appearances of pediatric TB on plain films, Ultrasound, CT and MR. Imaging differentials will be discussed and diagnostic clues that help in specific diagnosis will be elucidated. Results. Plain films are the primary means for detection of pulmonary as well as skeletal TB, though findings may be subtle at times. Whereas CT scores over MRI in pulmonary and abdominal TB, the latter is much better in diagnosing involvement of central nervous system. In musculoskeletal and genitourinary TB, either CT or MR may be preferred based on the stage of disease and character of the lesion. Discussion and conclusions. Tuberculosis is a multisystem disease which can affect virtually any part of the body from head to toe. TB demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. Hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of TB.
208 Pediatric foreign bodies Theodore Marentis, Maria Ladino Torres University of Michigan (United States) Purpose - Objective. Pediatric patients explore the world in many ways. Sometimes this leads to the unfortunate inhalation, ingestion, or otherwise incorporation of a foreign body in the pediatric patient. We present a pictorial essay of interesting, bizarre and unexpected cases of retained foreign bodies. Material and methods. Interesting cases were catalogued as they occurred and are presented.
S546
Results. The cases -usually radiographs- will be presented as unknowns, with tiny letters that capture the nature of the incident. Discussion and conclusions. Interpreting radiographic studies can be repetitive and uneventful. When a case of a retained foreign body appears it becomes a case of the day, to be shared with others in the reading room and beyond. We are continuously impressed at what our pediatric patients will ingest.
209 Minimally invasive therapeutic techniques of fluid collections and cystic lesions in young patients Evanthia Botsa1, Ioannis Koutsogiannis2 Ioannis Tierris1, Loukas Thanos1 1 Sotiria General Hospital, Athens (Greece), 2Aglaia Kyriakou Children’s Hospital (Greece) Purpose - Objective. To determine the effectiveness and safety of CT guided percutaneous drainage of abscesses or non inflammatory fluid collections in children Material and methods. Our retrospective study included 61 patients. Their age ranged from 3 to 18 years. We treated patients with ascites; abdominal abscesses including pancreatic, pelvic, liver, renal and perirenal; splenic and psoas abscesses; pleural collections; lung empyema and cystic lesions. All procedures were performed under sedation with the use of drainage catheters trocar-pigtail or seldinger 7 F or 8 F. Results. Successful and complete drainage was obtained in 53 out of 61 patients (86.8 %). Three patients underwent a second drainage procedure successfully and five were finally treated with a surgical operation. The mean time we kept the catheter inside the collection was 2–15 days. The extraction of the catheter was made after drainage ceased or was less than 10 cc per day or in some cases after physical improvemen of the patient. All fluid samples were sent for cytologic and biochemical analysis and culture. No complications were recorded in our patients. Discussion and conclusions. Percutaneous drainage is a safe, minimal invasive, therapeutic and diagnostic technique with no major complications. Moreover, the evaluation of catheter’s right function is quite easy for pediatricians and does not require any special knowledge.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
210 Is radiofrequency ablation a safe procedure for pediatric patients? Evanthia Botsa1, Ioannis Koutsogiannis2, Ioannis Mitrakos1, Loukas Thanos1 1 Sotiria General Hospital, Athens; 2Aglaia Kyriakou Children’s Hospital (Greece) Purpose - Objective. To evaluate the efficacy and safety of Computed Tomography guided RFA as a minimally invasive treatment for pediatric malignancies and osteoid osteomas. Material and methods. During the last 3 years 36 children were treated with RFA sessions. 28 patients suffered from osteoid osteomas, 7 had liver tumors and 1 had lung tumor. RFA’s were performed under sedation. RF energy was applied for 8–12 min at 95C. A technically successful ablation was ackowledged if electrode placement was within the center of the lesion and desired temperature was achieved. In patients with osteoid osteomas, clinical success was evaluated with the Brief Pain Inventory calculated before and after the treatment (1, 4 weeks and 1 year). Patients with malignancies were evaluated radiologically after 1, 3, 6, 12 months Results. Radiofrequency procedures were technically successful in 100 %. Clinical success was achieved in 26 of the osteoid osteomas cases. Two patients had recurrence of pain and a second RFA was performed successfully. Postablation imaging performed in patients with malignancies, showed complete tumor necrosis in 7 patients and partial necrosis in 1. In 3 years of follow up, there was no recurrence of the treated tumors. Postablation syndrome occurred in 2 RFA sessions. No major complications occurred. Discussion and conclusions. CT guided RFA is a safe, efficient and minimally invasive method for treatment of osteoid osteoma and a great alternative in the treatment of malignancies.
211 CT-Simulator GE LightSpeed RT16, a CT-Sim dedicated to radiation oncology Evrydiki Patriki, Vasiliki Diakatou, Dimitrios Demenagas, Christina Lappa, Apostolia Christakaki, Neratzoula Kallia, Maria Andreou, Zoi Pemma, Adam Kouvelis, Maria Synodinou “Panagiotis & Aglaia Kyriakou” Children’s Hospital, Athens (Greece)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. CT scanners are adapted for radiotherapy planning in order to visualize internal structures and to provide the required electron density data to computer planning systems for accurate dose calculation. Material and methods. One hundred thirty-four CT scans have been performed for 79 children that have undergone radiation therapy since January 2011 at the new Children’s and Adolescents’ Radiotherapy Department of “Panagiotis & Aglaia Kyriakou” Children’s Hospital, in Athens. After the child has been placed on the flat carbon fiber table top of the CT-Simulator-GE LightSpeed RT16 identical to the linac’s one, different protocols are being used in order to optimize tumour information (full body contour in the reconstruction and scanning of relevant whole organs for dose volume histograms). Results. Incorporation of CT-Simulator-GE LightSpeed RT16 with sophisticated imaging technology offers the ability to precisely define target volume, normal tissues and margin generation Discussion and conclusions. CT scanner dedicated to radiotherapy forms the basis of modern, computer-assisted, planned three-dimensional conformal radiotherapy
212 Dosimetric evaluations in paediatric fluoroscopic procedures: the experience of the Meyer Children’s Hospital in Florence Antonio Ciccarone1, Silvia Mazzocchi2, Fabrizio Leopardi1, Francesco Rossi3, Giovanna Zatelli2, Tiziana Pellegrini1, Claudio Fonda1, 1 Meyer Children’s Hospital, Florence; 2ASF Florence’s Hospital, Florence; 3Careggi Florence’s Hospital, Florence (Italy) Purpose - Objective. The study purpose is to evaluate the patient dose for paediatric fluoroscopic procedures, related to investigation of the gastrointestinal and urinary regions. Material and methods. Fluoroscopic examinations analysed are voiding cystourethrography (VCUG) and gastrointestinal examinations made with a Philips Multidiagnost Eleva X ray arc. 100 patients were studied; their age, weight, sex, height and thickness documented. Settings were documented for each examination (protocol type, exposure mode, frame/s, additional filtration, collimation, field of view, grid), total duration of investigation, cumulative dose and DAP total. In a sample of patients the entrance dose was also measured by means of thermo-luminescence dosimeters.
S547
Results. Dose to patients are variable for age, sex, weight, height, body thickness at the entry point of the beam and the degree of patient cooperation. Mean dose indicator for each age range is always lower than typical values reported in literature [NRPB-W14]. The optimization of the exposure of patients is clearly and obviously related to the proper use of devices available, particularly through appropriate choice of filtering based on the size of the patient, protocols, and frame/ s. The proper immobilization of the patient allows effective collimationof the field of view and reduces duration of the fluoroscopy examination. Discussion and conclusions. It is fundamental to choose the best compromise between image quality and patient dose, together with constant reference to the standards of good practice.
213 Organ volume measurements: comparison between magnetic resonance imaging and autopsy findings in infants following sudden unexpected death Olivier Prodhomme1, Fabienne Seguret1, Laurent Martille2, Odile Pidoux1, Gilles Cambonie1, Alain Couture1, Caroline Rouleau3 1 Centre Hospitalier Universitaire Arnaud de Villeneuve, Montpellier; 2Centre Hospitalier Universitaire Lapeyronie, Montpellier; 3Centre Hospitalier UniversitaireVaudois, Lausanne (Switzerland) Purpose - Objective. To assess the accuracy of a semiautomated 3D volume reconstruction method for organ volume measurement by post-mortem magnetic resonance imaging (MRI) in sudden unexpected death. Material and methods. Post-mortem MRI was performed in 16 infants (1 month–1 year of age) at 1,5T using T2 and T1-weighted sequences within 48 h after death. Real volumes were recorded at autopsy by water displacement. Virtual organ volumes were estimated using the Myrian Software. The agreement between virtual and real volumes was quantified following Bland and Altman’s method. Intraand inter-observer was calculated. Results. There was a good agreement between virtual and real volumes for brain (mean difference: -0,03 % [−13,6; +7,1]), liver (+8,3 % [−9,6; +26,2]) and lungs (−5,5 % [−26,6; +37,6]). For kidneys, spleen and thymus, the MRI/autopsy volume ratio was close to 1 (0,87±0,1; 0,99±0,17; 0,94±0,25 respectively), but with a less good agreement. For heart, the
S548
MRI/autopsy volume ratio was 1,29±0,76, possibly due to the presence of residual blood within the heart. The virtual volumes of adrenal glands were significantly underestimated (p0 0,04), possibly due to their small size and conformation. The percentage of inter- and intra-observer variation was lower or equal to 10 %, except for thymus and adrenal glands. Discussion and conclusions. This MRI measurement method allows a rapid and precise estimation of brain, liver and lungs volumes. A larger study is required to confirm and extend these results. 214 Withdrawn 215 Mobile teleradiology using smartphones. Preliminary results Floriana Zennaro1, Michele Bava2, Armando Casalino3, Massimo Gregori1, Pierpaolo Guastalla1, 1 IRCCS Burlo Garofolo, Trieste; 2IT Assistant Manager Clinical Engineer/Computer Engineer/PhD student Clinical Engineering and Me; 3Project Engineer Mediko (Italy) Purpose - Objective. Teleradiology may be used in emergencies, when specialist or seniors are not available and a quick consultation is necessary. Recently, smartphones with high quality display have been marketed. The aim of our study is to evaluate if these devices can be used for radiologic consultation without diagnostic information loss. Material and methods. CT and MRi images have been chosen because of their low matrix, usually less than a smartphone display matrix. CT and MRI examination have been randomly chosen from those performed in our department in the last 2 years. Anonymized exams have been sent to smartphones using VPN encrypted connection and reported by two senior radiologists (80 % and 20 %). Apple iPhone and Nexus (Android OS) smartphones have been used for our study. Results have been collected in a database and compared with gold standard, the PACS system used in pediatric radiology department. Results. Currently 92 exams have been evaluated. No significant loss of information has been detected. Small differences in inter- and intra-operator findings have been shown and are due more to individual variations than to device inadequacy. Discussion and conclusions. Preliminary results confirm that there is no significant loss of diagnostic information in CR and MRI exams reported using smartphones. Radiologists have however reported a subjective sensation of fatigue after long sessions; the second part of our study will be focused on tablet testing.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
216 Workplace Based Assessment in Paediatric Radiology William Ramsden Leeds Childrens Hospital, Leeds (United Kingdom) Purpose - Objective. Workplace based assessment (WPBA) is now mandatory throughout UK radiology training. This study’s purpose was to investigate its usage in assessing procedural and interpretive work in paediatric radiology and compare this with adult practice. Material and methods. Semi structured interviews were undertaken with 21 radiologists (12 consultants, 9 trainees) working in two teaching hospitals. Paediatric radiologists comprised 24 % of the interviewees and their responses were separately analysed to compare their WPBA usage with adult practice. Results. Although there are similarities between paediatric and adult practice, such as predominantly developmental usage of WPBA and some desire for a consultant led process, there are also important differences. Paediatric radiologists undertook fewer WPBAs; some would only assess cases chosen prospectively in order to see the whole episode, whilst others might not record early or suboptimal assessments. Discussion and conclusions. Lesser engagement in WPBA in paediatric radiology is surprising considering there are large numbers of ‘basic’ procedures available. This may be due to some trainees’ anxiety at interacting with children and the (sometimes) unpredictable nature of paediatric work. This is reflected by some trainers highlighting the importance of assessing the whole interaction between trainee and child, and others being prepared to discard suboptimal episodes as trainees learn. This presentation will explore the reasons for the lesser use of WPBA in paediatric radiology and suggest how engagement may be improved.
217 Motion and mineralization: Non vascular application of color doppler in pediatric ultrasound Victor Wycoco, Jose Jarrin, Mary Louise Greer Sick Kids Hospital, Toronto (Canada) Purpose - Objective. Demonstrate examples of non vascular application of doppler ultrasound in a variety of pediatric settings. Material and methods. Retrospective review of 15 acute and outpatient pediatric ultrasounds in the one tertiary pediatric institution over a 4 month period; where non vascular application of color doppler was utilized. Results. Examples of potential applications shown include: characterization of renal and gall stones, micro calcification, subdural collections, presence of urinary tract reflux,
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
gastroesophageal reflux and presence of gastric outlet flow in the setting of pyloric stenosis. Discussion and conclusions. Twinkling and flash artifact have been previously described in the course of routine doppler ultrasound investigation, such as with the presence of ureteric jets and renal calculi or as pitfalls, which may lead to misdiagnosis. These non vascular doppler findings, however, could potentially be used as part of routine examination to aid in the detection of abnormalities, provide new information and increase the level of confidence in a diagnosis. Initial retrospective review of cases over a period of 4 months have identified potential non vascular applications of color doppler in characterizing motion and presence of mineralization in a pediatric setting. On this initial review we have demonstrated some examples of interesting applications of color doppler, outside of vascular imaging and there may be value in performing a prospective study where its utility can be assessed as part of routine assessment. Muskulo-Skeletal
218 The continuum of radiographic findings in the pelvis of children in four genetic or molecularly defined families of skeletal dysplasias Alistair Calder, Sophie Swinson Great Ormond Street Hospital for Children, London (United Kingdom), Purpose - Objective. The pelvic radiograph is a critical component of skeletal surveys in evaluation of children with skeletal dysplasia, demonstrating elements of both the axial and appendicular skeleton. In this review we explore the range of pelvic findings in children with skeletal dysplasias of varying severity within four genetic or molecular families. Material and methods. Pelvic radiographs are presented from children with disorders of: Fibroblast Growth Factor Receptor 3 (FGFR3) ranging from Thanatophoric Dysplasia to Hypochondroplasia; Type 2 Collagen ranging from Achondrogenesis type 2 to Stickler syndrome; Transient Receptor Potential Cation Channel V4 (TRPV4) ranging from Metatropic Dysplasia to Brachyolmia, and Lysosomal Storage Disorders, ranging from Morquio syndrome to Alpha-Mannosidosis. Results. In FGFR3 disorders, there is pelvic hypoplasia with shortened iliac bones, trident acetabulum and very narrow sacrosciatic notches. In Type 2 Collagenopaties, the pelvis is hypoplastic with rounded iliac bones. The pubic bones show delayed ossification. The acetabulum may be tilted, producing a ‘tiger’s eye’ appearance. TRPV4 mutations produce pronounced flaring of the iliac bones as well as the upper femora. The acetabula may also appear ‘flared’, producing a supra-
S549
acetabular notch. In Lysosomal Storage Disorders, the iliac wings are flared, the acetabula are shallow and the inferior portions of the iliac bones taper, producing a ‘comma-shape’. Discussion and conclusions. The pelvic radiograph is a key element of the skeletal survey for genetic disorders of bone. 219 Key signs of skeletal dysplasias on post mortem foetal radiography Alistair Calder, Sophie Swinson Great Ormond Street Hospital for Children, London (United Kingdom) Purpose - Objective. To illustrate key radiographic findings in severe and lethal skeletal dysplasias. Material and methods. We present findings from a database of over 50 foetal cases illustrating lethal and severe skeletal dysplasias. We present key findings that facilitate accurate diagnosis. Results. Absent vertebral body ossification is a key feature in all types of achondrogenesis, and also a finding in hypophosphatasia and dyssegmental dysplasia. Absent pedicular ossification is a feature of campomelic dysplasia. Platyspondyly is a key feature in thanatophoric dysplasia (TD), but also seen in type 2 collagenopathies such as hypochondrogenesis. Short ribs are a common finding in lethal dysplasias, often accounting for lethality. The shortest ribs are found in short rib polydactyly syndromes (SRPS); TD also has very short ribs. Long bone shortening is common in severe dysplasias, and is extreme in achondrogenesis and some SRPS. Curving of long bones, particularly the femora, is a common and often misleading finding, being present in many otherwise different disorders including campomelic dysplasia, TD, osteogenesis imperfecta and Stuve-Wiedemann syndrome. The hands and feet are easily overlooked and may be inadequately visualised if technique is poor: nevertheless important findings are present in the distal segments in disorders such as chondrodysplasia punctata brachytelephalangic type and in ciliopathies. Discussion and conclusions. Awareness of the key findings we illustrate will help paediatric radiologists produce accuarate diagnoses of lethal and severe dysplasias in foetuses. 220 Leg duplication with ipsilateral renal agenesis: a spectrum of congenital acrorenal malformation syndrome Ok-Hwa Kim 1 , Hyun Woo Kim 2 , Ki Seok Lee 2 , Gen Nishimura3 1 Ajou University Hospital, Suwon (Republic of Korea); 23 Yonsei University, Seoul (Republic of Korea); 3Kiyose Children’s Hospital, Tokyo (Japan)
S550
Purpose - Objective. Duplication of a leg, either partial or total, is an extremely rare anomaly, and little is known about associated malformation of internal organs and the pelvic girdle. Material and methods. We report two patients with partial leg duplication associated with ipsilateral renal genesis. Results. Patient 1 was an 18-month-old girl who had eight toes of the right foot. Radiographs showed enlargement of the right ischium and pubis. A small bony projection overlapped the tilted acetabulum was verified as an accessory ilium on CT scan. The right proximal fibula was duplicated and the foot had duplicated cuboids and seven metatarsals with eight phalanges. The right renal agenesis was confirmed by CT scan. Patient 2 was a 1-month-old girl who presented with an extra-leg attached to the posterior aspect of the left thigh. The extra-leg was composed of a hypoplastic fibula, deformed calcaneus, and talus with four metatarsals and toes. The main left leg showed absence of the fibula, short tibia without calcaneus but with three metatarsals and three phalanges. The left renal agenesis was confirmed by radionuclide DMSA renal scan. Discussion and conclusions. This presentation emphasizes the association of leg duplication with ipsilateral renal agenesis. The spectrum of aberrant skeletal development in duplicated leg should be meticulously assessed particularly using CT scan.
221 Infantile osteopetrosis complicated by rickets Korcan Aysun Gonen, Zeynep Yazici, Gokhan Gokalp, Ayse Kalyoncu Ucar Uludag University, Bursa (Turkey) Purpose - Objective. To describe 4 cases of infantile osteopetrosis complicated by rickets (osteopetrorickets) and review the relevant literature. Material and methods. Retrospective chart analysis of 4 infants with osteopetrorickets and a systematic review of the English language literature. Results. Literature review (including the current 4 cases) yielded 21 infantile cases of osteopetrorickets in total. The patients ranged in age from 2 to 12 months. In 20 patients (95 %), hepatosplenomegaly was found. Sixteen (76 %) and 8 (38 %) patients had visual and hearing impairment respectively. Serum calcium-phosphorus product was less than 30 in 19 patients (90 %). Twelve patients (60 %) were hypocalcemic, 18 (90 %) were hypophosphatemic. Serum ALP level was elevated in all patients. Parathormone was measured in 8 infants and was increased in 5 of them. In all
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
patients, radiological examination demonstrated diffuse bony sclerosis and metaphyseal cupping and fraying of long bones. Five patients (24 %) had pathologic fracture of extremities and 16 (76 %) had rachitic rosary. Discussion and conclusions. Rickets is a paradoxical complication of infantile osteopetrosis, because in patients with osteopetrosis, there is a markedly positive total body calcium balance. Diagnosis of rickets superimposed on osteopetrosis is crucial. Treatment of rickets improves the general condition of the patients and also is an important factor in the success of bone marrow transplantation. Skeletal roentgenograms are of critical importance in diagnosis of both osteopetrosis and associated rickets.
222 Post traumatic bone bruise displayed at MR imaging of adolescents’ knee Goran Djuricic1, Bojan Vucinic1, Milan Apostolovic2, Bojan Bukva1, Djordje Alempijevic2 1 University Children’s Hospital, Belgrade; 2University of Belgrade (Serbia and Montenegro) Purpose - Objective. Our aim was to determine the incidence and imaging characteristics of the bone bruise in the post traumatic adolescents’knee. Material and methods. MRI studies were performed with a 1.5T imager using a 16 elements knee coil. This retrospective study involved 96 patients with knee trauma (31 males and 65 females, aged 13–19 years). MRI was performed after an average of 38 days (range 2–65 days) following the injury. Bone bruise and osteochondral injuries to the patellar and femur cartilage in the patellofemoral joint were evaluated with an axial, sagittal and coronal proton density (PD) SPAIR sequence. Contusion location, size, and any ligamentous or meniscal injuries were recorded as well. Results. In the study 5.2 % (5/96) of patients showed bruising of the lateral femoral condyle, medial femoral condyle in 8.3 % (8/96) and 11.5 % (11/96) showed bruising of the patella. Associated injury in 4.2 % (4/96) was present at the lateral femoral condyle and the patella. Patellar and femur bruise association with lateral menisceal tears noted in 5.2 % (5/96) of patients. Lateral and medial collateral ligament injuries were detected in 4.2 % (4/96). Discussion and conclusions. Our results demonstrate that bone bruises are relatively commonly seen on MR imaging of the post traumatic adolescent knee with an incidence of 38.5 %.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
223 Limping child: besides fractures and “transient synovitis” what else? Paolo MS Schingo, Maria Barbieri, Cinzia Orazi, Andrea Magistrelli, Marco Cirillo, Sebastian Cristaldi, Valentina Savoia, Paolo Tomà Bambino Gesù Pediatric Hospital, Rome (Italy) Purpose - Objective. Painful limping in children can be due to numerous conditions, though most commonly it is related to bone and joint diseases. Besides traumatic injury, “transient synovitis” of the hip is the most frequent condition in infants, toddlers, and children up to 10 years of age. Extraskeletal pathologies are rarely identified with certainty, hence differential diagnosis problems can arise. Spinal, pelvic, neurologic, abdominal and genitourinary diseases may present with unusual clinical symptoms, including hip or leg pain. Therefore, alternative pathologies should be considered, especially in older children or adolescents. Material and methods. We report on the imaging findings in 20 patients who presented at our Emergency Department with painful limping and gait impairment. Clinical examination and investigations conducted on the abdomen, the back, the scrotum, or the neurovascular system delineated the involvement of other systems or anatomical regions. Results. US, in association with plain radiography of the pelvis and lower limbs, was the first imaging modality. MRI, CT and blood tests were performed in selected cases. We found sacro-ileitis, spondylo-discitis, avulsion of the antero-inferior iliac spine, abdominal abscesses, acute scrotal diseases, ileo-ileal intussusception, neuroblastoma, Guillain Barré and leukemia. Discussion and conclusions. In children with limp and no obvious changes in pelvis and lower limbs X-ray and sonographic imaging, we should consider different acute pathologies involving spinal, pelvic, neurologic, abdominal and genitourinary system; further investigations, therefore, are needed.
224 Traumatic fractures of the forearm: what the orthopaedic surgeon wants to know. Pablo Caro, Eoghan Laffan, Michael Dodds, Paul Connolly Temple Street Children’s Hospital, Dublin (Ireland) Purpose - Objective. Traumatic fractures of the forearm are a very common childhood presentation to the
S551
emergency department. Their subsequent treatment is quite varied, depending on the age of the child and site of the fracture. Material and methods. This poster will review the common types of fractures of the forearm and the orthopaedic criteria for treatment. We divide the fractures into 3 groups radial neck, mid-shaft and distal forearm. Results. Fifty per cent of radial neck fractures are associated with other injuries—proximal ulna or distal radioulnar injuries. Angulation of greater than 30° and/or 3 mm displacement requires reduction. In assessing mid-shaft fractures, it is important to note the straight border of the ulna and radiocapitellar line. Malalignment may suggest Monteggia or Galeazzi type fractures. Detection of rotational malalignment of the forearm will be discussed as this leads to disability (interosseous border, cortical diameter mismatch and biccipital tuberosity-radial styloid position). Plastic and greenstick fractures are treated according to age and angulation. Distal fractures are most common (80 %). Dorsal tilt up to 20° is acceptable if there is 2 years of bone growth left. Ulnar physeal injuries have a high incidence of growth disturbance (50 %). Discussion and conclusions. It is important for radiologists and emergency physicians to correctly identify and accurately describe the types of fracture, so that proper and timely management is introduced.
225 Non accidental injury—a South African experience Nasreen Mahomed, Mathew Goodier University of Witwatersrand, Johannesburg (South Africa) Purpose - Objective. Paediatric radiologist Caffey first described six infants with long bone fractures and subdural hematomas in 1946. He postulated that these injuries were inflicted and he coined the term battered child syndrome to describe metaphyseal fractures and other injuries typical of abuse. Virtually every type and location of fractures has been described in abused children and prevalence of fractures depends on the population studied. However metaphyseal and rib fractures in infants are highly specific for non accidental injury. Objectives: to determine the injury specific percentage observed in South African paediatric patients with multiple injuries investigated for non-accidental injury, to determine the incidence of underlying co-morbidity in these patients and to demonstrate the radiographic features of non accidental injury.
S552
Material and methods. Muli-modality imaging of 7 pediatric patients with multiple injuries, investigated for nonaccidental injury. Results. Injury specific percentage: rib fractures 71 %, metaphyseal fractures 43 %,long bone fractures 43 %,subperiosteal bleeds 29 %,skull fractures 71 %,surface collections 57 %,cerebral infarcts 14 %,retinal bleeds 14 %. 3 of 7 patients (43 %) had an underlying co-morbidity. Discussion and conclusions. In our South African case series, injury specific percentage correlated with international data. 43 % had an underlying co-morbidity. This correlated with a study by Ammerman and Patz. In conclusion when imaging children one should always look for the constellation of radiographic features that raise the suspicion for non accidental injury, in particular in children with chronic diseases or disabilities.
226 Osteochondritis dissecans among children and adolescents Themistoklis N. Spyridopoulos, Ioannis Papadopoulos, Ioannis Christogiannis, Athanasia Stratigopoulou, Konstantinos Filiopoulos, Nikolaos Evlogias Penteli’s Children Hospital, Athens, (Greece) Purpose - Objective. The descriptive epidemiology and outcome of pediatric cases referred to our Radiology Department and diagnosed with osteochondritis dissecans (OCD). Material and methods. Data was retrospectively collected (2006–2011) from an electronic database to include patients referred from orthopedics and diagnosed with OCD. We studied demographic characteristics (age, gender), clinical variables (lesion’s location, unilateral or bilateral location), the treatment and follow up. Results. Twenty-five cases with OCD were recorded (12 boys and 13 girls, mean age 11 year). Most frequent location was the medial femoral condyle (16/25); in 1/3 of these cases the lesions were bilateral. Ankle was the 2nd most frequent location (5/25) with 1 out of 4 with bilateral such lesions. Only two cases were surgically treated; the rest had excellent response to conservative treatment. Follow up in 18 OCD cases (3 months up to 3½years) revealed in two cases a slight limitation of affected joints’ range of motion. Discussion and conclusions. OCD shows no gender predisposition, and usually affects children around 11 years old. Its most frequent location is the medial femoral condyle. OCD may have a silent clinical route; thus, clinicians and radiologists should include this entity in the differential diagnosis in the respective cases. The majority of patients respond to conservative therapy, whereas serious cases with joint instability may require surgical reconstruction.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
227 The modified Dunn osteotomy in the treatment of severe slipped capital femoral epiphyses Delma Jarrett, Travis Matheney, Young-Jo Kim, Paul Kleinman Children’s Hospital, Boston (United States) Purpose - Objective. Background: Slipped capital femoral epiphysis (SCFE) is a common disorder affecting older children and adolescents that can have serious long term consequences. In cases of severe slip, deformity of the femoral head can result in femoroacetabular impingement (FAI) and osteoarthritis. Attempts to reduce the femoral head increase the risk of avascular necrosis (AVN). Patients may have multiple surgeries in an attempt to recontour the remodeled femoral neck, and can go on to total hip replacement. The modified Dunn osteotomy is a realignment surgery that attempts to restore normal femoral head/neck relationships via surgical dislocation of the hip. The procedure permits full exposure of the femoral neck which is then thinned via subperiosteal dissection. This allows the femoral head to be reduced without placing tension on the medial femoral circumflex artery, reducing the risk of AVN. Objective: To provide an illustrative explanation of the modified Dunn osteotomy, demonstrate the pre and post operative appearance of SCFE treated by this procedure and highlight the critical imaging findings that should be assessed by the radiologist including evidence of impingement, chondrolysis and AVN. Material and methods. Results. Discussion and conclusions. Conclusion: The modified Dunn osteotomy is an important technique that permits realignment of the femoral head in severe cases of SCFE. Continued imaging and clinical follow-up is necessary to assess the effect on future rates of FAI and osteoarthritis.
228 A rare case of chronic osteomyelitis Diana Stanescu, Mariana Coman, Elena Barbu M.S. Curie Emergency Clinical Hospital for Children, Bucharest (Romania) Purpose - Objective. To study the imaging findings of multifocal, symmetrical bone lesions in a rare case of chronic osteomyelitis in a child with acute lymphoblastic leukemia (ALL). Material and methods. A 4-year-old boy with ALL who developed Proteus sp. sepsis after first chemotherapy treatment. The infection was treated based on blood culture results and continued until cultures returned negative
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
results. Afterwards, a significant inflammatory syndrome developed with negative blood, stool, urine and CSF cultures. Standard radiographs and CT examinations were performed. Results. Humeral, symmetrical, nonspecific bone lesions were incidentally found on chest radiograph. CT scan findings indicated were other bone lesions. Bone biopsy confirmed these were lesions of chronic osteomyelitis. In order to exclude lymphomatous infiltrates, immunohistochemistry was performed. Particularities of the case were: multifocal and symmetrical bone lesions, absence of bone pain, bilateral femoral and humeral lesions. Discussion and conclusions. Conventional radiographs of non-specific bone lesions suggested a differential diagnosis between lymphomatous infiltration and chronic osteomyelitis. CT scan suggested a diagnosis of chronic inflammatory lesions. The bone biopsy confirmed the diagnosis of chronic osteomyelitis and the immunohistochemical examination was negative for lymphomatous infiltrate.
229 Withdrawn
230 Chronic lumbar pain among children and adolescents: retrospective results from CT scans Themistoklis N. Spyridopoulos Ioannis Papadopoulos, Ioannis Christogiannis, Athanasia Stratigopoulou, Mariana Petra, Ioannis Hager, Nikolaos Evlogias Penteli’s Children Hospital, Athens (Greece) Purpose - Objective. To study the pediatric patients referred to the Computed Tomography (CT) Department for further imaging due to chronic low back pain Material and methods. Data of pediatric patients referred for CT by orthopedics were retrospectively collected and evaluated, during the last year. Descriptive analysis was performed. CTs were performed to the minimum diagnostic scan range with implementing patient size-dependent techniques. Results. During the study period 17 lumbar CTs were performed (8 boys and 9 girls, mean age011.8). In the majority of cases (14/17) spondylolysis of L5 vertebrae was found, (3 unilaterally and 11 bilaterally). In 1/3 of cases with bilateral pars defects, spondylolisthesis was also noticed. We also found a patient with a lytic lesion of the right iliac bone with mixed, relatively non sclerotic margins; another patient with L3 hemivertebrae, whereas the scan was negative in 1 patient.
S553
Discussion and conclusions. Chronic low back pain is not frequent among children and adolescents; however, if clinical symptoms persist, it should be further evaluated in order to reach diagnosis and provide proper therapy. CT, using approriate individualizing techniques is a useful imaging tool for this pathology.
231 Osteoid osteoma with a double nidi Cecilia Lanza, Vittoria Galeazzi, Lucia Amici, Enrico Paci, Valeria Bolli Ospedali Riuniti Ancona-Salesi Hospital (Italy), Purpose - Objective. Osteoid osteoma (OO) is a common benign lesion that occurs in children and young adults. Fewer than 30 cases of multicentric OO in a single bone have been reported in the world literature. We present the case of a 9-year-old boy with OO in the right femur, containing double nidi. Material and methods. A 9-year-old boy, admitted to our clinic with a 5-month history of right leg pain relieved by salicylates, underwent X-ray, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Results. A radiolucent area surrounded by sclerosis and cortical thickening was revealed on X-ray of the femoral neck. CT and MRI showed circumscribed annular pattern extending about 2.5 cm, indicating OO with a double nidi. Bone scintigraphy demonstrated increased activity in the right femoral neck region. The diagnosis of OO was confirmed after histological examination. The lesion was treated by CT-guided thermo-ablation with radiofrequency under general anaesthesia. Discussion and conclusions. The size of the OO (the nidus) usually varies from 0.5 to 2 cm. When CT imaging showed a nidus extending 2.5 cm it suggests the multifocal nature of the lesion. CT scan is the gold standard for diagnosis. It precisely shows the nidus. MRI disclosed edema of the bone marrow, edema of the soft tissues and synovitis with joint effusion. Radiofrequency ablation (RFA) is a safe, fast and reliable method of treating OO.
232 Disseminated rhabdomyosarcoma with spinal metastases Nasreen Mahomed University of Witwatersrand, Johannesburg (South Africa) Purpose - Objective. Rhabdomyosarcoma (RMS) is the most common pediatric soft tissue sarcoma, representing 5–10 % of malignant solid tumors. On histology RMS in
S554
childhood is classified into 2 main subtypes: embryonal RMS and alveolar RMS. Alveolar has an unfavorable prognosis. Approximately 20 % of patients with RMS have disseminated disease at the time of diagnosis. Lungs, lymph nodes and bone marrow are frequently involved. However epidural extension of a RMS is rare and not often included in the differential diagnoses of epidural tumors. RMS with leptomenengeal spinal metastases is very rare with isolated case reports described in the literature. The objective of this poster is to present a case of disseminated alveolar RMS with spinal epidural extension and leptomenengeal and intramedullary spinal metastases. Material and methods. Case report with MRI and multidetector C.T imaging Results. Histopathology demonstrated a high grade malignant neoplasm consisting of rhabdomyoblasts and small round tumor cells inkeeping with alveolar rhabdomyosarcoma. Discussion and conclusions. Primary neoplasms arising within the spinal epidural space are lymphomas, meningiomas, nerve sheath tumors and haemangiomas. This presentation of disseminated alveolar RMS with spinal epidural, leptomengeal and intramedullary extension is very rare. RMS should always be considered as a differential diagnosis in a paediatric patient presenting with atypical disseminated disease as RMS is a heterogeneous disease that may arise in virtually any organ or tissue except bone.
233 MRI and histopathologic outcome after preoperative chemotherapy in children with extremity osteosarcoma Christiana Hadjigeorgi 1 , Chris Zambakides 2 , George Pitsoulakis 1 , Ioannis Nikas 1 , Maria Hasiotou 1 , Maria Gavra1, Kaliopi Stefanaki1 1 “Agia Sophia” Children’s Hospital, Athens (Greece); 2 “P & A Kyriakou” Children’s Hospital, Athens (Greece) Purpose - Objective. To evaluate MRI prognostic factors in children with extremity osteosarcoma after preoperative chemotherapy. Material and methods. Preoperative MRI examinations were performed in 37 children with extremity osteosarcoma. Images were evaluated for eight prognostic factors at diagnosis and eight factors after preoperative chemotherapy. These factors were correlated with histopathologic and clinical outcome. Results. Metastases at presentation, a soft-tissue mass longer than 20 cm in diameter, tumor invasion of intracapsularintrasynovial joint space and neurovascular involvement were predictive of a poor outcome. Decrease in volume of the tumor, tumor necrosis in more than 80 %, absence of
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
joint and neurovascular invasion and metastases were predictive of a good response. Discussion and conclusions. MRI is sensitive for detecting joint invasion of ostesarcoma. However, false-positive diagnosis may lead to overstaging of osteosarcoma.
234 Comparative analysis between presenting symptoms in children with osteosarcoma and Ewing sarcoma until radiological diagnosis Christiana Hadjigeorgi, George Pitsoulakis, Georgia Panagi, Ioannis Nikas, Maria Gavra, Maria Hasiotou “Agia Sophia” Children’s Hospital, Athens (Greece) Purpose - Objective. Purposeof this study was to establish the presenting symptoms before the radiological diagnosis of osteosarcoma and Ewing sarcoma from the records of the first medical visit and to identify early characteristics of the diseases to shorten the delay in diagnosis. Material and methods. During a 20-year period, records from the first medical visit withpresenting symptoms and radiological examinations were obtained in 147 children, 82 with osteosarcoma and 65 with Ewing sarcoma, aged 17 months to 15 years. Results. Constant pain, pain related to strain, pain at night, minor trauma and palpablee mass were the main symptoms. Tendinitis, osteomyelitis and fractures were the most common reasons of misdiagnosis. Duration of symptoms until the radiological diagnosis was 10 days to 6 months. Discussion and conclusions. 1) The time between the initial symptoms of osteosarcoma and Ewing sarcoma in children and the correct final diagnosis is long, 2) the most important clinical feature was a palpate mass and 3) bone sarcomas must be included in the differential diagnosis in cases of fractures in minor trauma.
235 The target sign in infantile myofibromatosis Ian Robinson, Mike Watson Starship Children’s Hospital, Auckland (New Zealand) Purpose - Objective. To describe a characteristic target sign on MRI in infantile myofibromatosis and provide pathologic correlation. Material and methods. We present the multimodality imaging findings in a case of biopsy proven multicentric infantile myofibromatosis in a 3 month old girl, that demonstrates a striking target appearance on MRI, and provides correlation with the pathologic findings.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Results. Radiographic, ultrasound and MRI features are presented. MRI demonstrated multiple osseous and soft tissue lesions within the left calf with a striking target appearance, characterized by central T1 and T2 hypointensity and surrounding T1 intermediate signal, T2 hyperintensity and enhancement. Biopsy of a lesion confirmed the diagnosis of myofibromatosis and the presence of central necrosis and calcification. Discussion and conclusions. Infantile myofibromatosis is rare in daily practice, although it is the most common fibroblastic-myofibroblastic soft tissue tumour of childhood and adolescents. Whilst imaging can be variable, a number of authors have described a target appearance on MRI, which has been assumed to be secondary to central necrosis with calcification. This case illustrates this target appearance, and provides pathologic correlation. The presence of a characteristic target appearance on MRI of multiple soft tissue nodules in an infant, within the appropriate clinical setting, is highly suggestive of myofibromatosis.
236 Merosin-deficient congenital muscular dystrophy (MDCMD): a case report with MRI, MRS and DTI findings Peter Hui, Janice Ip, Wendy Lam Queen Mary Hospital, HKSAR, Hong Kong Purpose - Objective. Congenital muscular dystrophy (CMD) comprises a heterogeneous group of disorders that present at birth with muscle weakness, hypotonia, and contractures. A dystrophic pattern is present on muscle biopsies. They have a variety of neuropathologic abnormalities that include white matter changes on MR images. The pathogenesis of these changes remains uncertain. Material and methods. Poster Results. We outline the MRI findings, with abnormalities in MRS and DTI studies, seen in our patient, with documented merosin-deficient CMD and suggest the causes. Discussion and conclusions. It has been postulated that in CMD the lack of laminin alpha 2 may lead to abnormality in blood brain barrier causing increase in water content and resulting in abnormal white matter signal intensity. MRI Brain of our 3-year-old patient showed diffuse and symmetrical abnormal T2 prolongation in cerebral white matter, without involvement of corpus callosum, internal capsule, brain stem and cerebellum or other structural abnormalities. MRS showed that white matter metabolites, including NAA, choline (Cho) and creatine (Cr), were reduced, with increased Cho/Cr ratio. No abnormal lactate peak was seen. DTI also showed reduced fractional anisotrophy (FA) in affected white matter. There was no evidence of restricted diffusion in DWI scan. ADC mapping
S555
revealed abnormally high free-water concentrations in periventricular white matter, especially at bilateral occipital regions.
237 Congenital fibrosis of extraocular muscles (CFEOM): a case report and MRI findings of this rare entity Janice Ip, Peter Hui, Wendy Lam Queen Mary Hospital, HKSAR, (Hong Kong) Purpose - Objective. Congenital fibrosis of extraocular muscles (CFEOM) is a congenital, nonprogressive strabismus syndrome, characterized by diffusely infiltrative orbital lesions with secondary involvement of extraocular muscles, resulting in variable restrictive external ophthalmoplegia due to the cicatricial process. It can be unilateral or bilateral, affecting one, two or all the muscles and the degree of fibrosis of a muscle can be total or partial. Material and methods. Poster Results. We would like to present a case of this rare entity, with its clinical features, MRI imaging findings and correlation with intra-operative and histopathological findings. Discussion and conclusions. An 11-month girl was found to have right estropia and ptosis since she was 3 months old. MRI examination showed medial deviation of the right eye. Abnormal ill-defined thickening of right medial rectus was present, mainly involving the muscle belly, with insignificant contrast enhancement. Perilesional fat stranding was present. Incisional muscle biopsies of right medial rectus muscle and its tendon capsule were performed. The muscle was found to be tight, with an abnormal fibrous band at post-equatorial region. Histopathological examination showed only acellular fibrotic tissue and muscle fibers surrounded by acellular fibrofatty tissue. There was no evidence of malignancy or granuloma. Thorax
238 Withdrawn
239 MRI lung volumetry of children with left-sided congenital diaphragmatic hernia Alexandra Lohnegger, Erich Sorantin Medical University Graz, Graz (Austria) Purpose - Objective. Lung function cannot be assessed seperately by Spirometry or Bodyplethysmography, which
S556
is necessary for follow-up of patients with one-sided disturbance of respiration such as congenital diphragmatic hernia (CDH). The aim of the study was to evaluate MRI lung volumetry and perfusion compared to spirometry. Material and methods. Ten healthy participants (control group) and seven children with CDH were examined. Spirometry was performed to determine VC (vital capacity) of the entire lung. MRI of the lung was performed, where VIBE-sequences in maximum in- and exspiration were aquired to obtain the VC of each lung. Lungs were segmentated semi-automatically to obtain the side-related VC. VENC imaging was also used for assessement side-related assessment of pulmonary perfusion. For normalization, all values were expressed as proportions of body surface area. Results. For the control group, a significant correlation between the total VC of the spirometry and the total VC (p<0.05) of MRI was found, whereas a similar trend within the patient group was found without reaching statistical significance. In CDH,patients, there was a trend of increased perfusion of the non-operated lung. Discussion and conclusions. MRI allows side-related assessment of lung vital capacity. In CDH patients, there seems to be a ventilation/perfusion mismatch of the diseased lung. Since the investigated group was small, further studies for confirmation are necessary.
240 A new non-invasive method for evaluation of respiratory movements based on infrared trackers Alexandra Lohnegger, Erich Sorantin Medical University Graz (Austria) Purpose - Objective. Children with congenital diaphragmatic hernia (CDH) need long-term follow-up after surgical correction. The aim of the study was to evaluate a new, noninvasive method for semiqantitative estimation of respiratory movements based on infrared trackers Material and methods. Ten healthy students (control group) and 7 children with leftsided CDH were evaluated. Four infrared tracker were placed on the left and right side of chest and abdomen and their movements were recorded. Results were compared to diaphragmatic movements obtained by ultrafast MRI, where diagphragmatic movements were recorded for a whole respiratory cycle on midcoronal plane. Afterwards 5 equidistant points were selected on the diaphragm and their movements quantified. Both measurements were then correlated. Results. In the control group and in CDH patients, there was no significant difference between right and left diagphragmatic movements (p>0.05) although it could be shown that diaphragmatic movement in CDH patients was worse than
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
in healthy people. By comparing the diaphragmatic movements in MRI with respiratory movements obtained by the infrared trackers, significant correlation could be found for CDH patients. Discussion and conclusions. The new infrared method offers a new non-invasive method for monitoring respiration seperately for every bodyside. This novel method seems to be advantage for patients with one-sided diaphragmatic pathology, such as CDH patients, follow-up of phrenicus palsy or similar.
241 Unusual misplacement sites for central venous catheters in a pediatric population Cecilia Lanza, Giovanni Pieroni, Manuela De Vivo, Valeria Bolli Ospedali Riuniti Ancona-Salesi Hospital (Italy) Purpose - Objective. Central venous catheters play an integral role in the management of critically ill newborn. We describe eight such unusual sites of misplacement involving cannulation of central venous catheter (CVC). Material and methods. In two cases CVC were malpositioned in small tributaries of the left brachiocephalic vein (CVC placed through the left internal jugular vein, IJV), in one case,in the left ascending lumbar vein (after incannulation of inferior vena cava via left femoral vein), in three cases in the internal mammary vein (placed through the IJV), and in two cases in the azygos arch (placed through the left and right subclavin veins). Results. Malpositioning was suspected only in 3 cases when the central venous waveform could not be obtained despite all attempts, while in the other cases malpositioning was identified on postprocedural radiographic examination. Discussion and conclusions. Malposition of the catheter tip may occur at the time of insertion or later as a result of spontaneous migration due to anatomic positioning or pressure changes within the thoracic cavita. Successful aspiration of blood does not exclude the malpositioning of a central venous catheter. Correct positionning of the catheter must be verified using appropriate methods, including chest X-ray. It would be a good practice to have a lateral view to confirm the central neck line placement when the anteroposterior view does not look reassuring.
242 Radiology becomes more important to identify pulmonary and extrapulmonary tuberculosis (TBC) in childhood Vittoria Galeazzi, Lucia Amici, Cecilia Lanza, Manuela De Vivo, Giovanni Pieroni, Valeria Bolli Ospedali Riuniti Ancona-Salesi Hospital (Italy)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. description of RX, US, CT and MRI patterns in every localization of TBC as pediatric actual illness. Material and methods. Fifty-three pediatric patients were examined (period 2007–2010) with/or RX, US, CT and MRI for identify thoracic TBC (lymphonodal, pulmonary, pleural and pericardic localization) and extrathoracic (gastrointestinal, liver, spleen, bone, musculoskeletal, lymphonodal and cerebral involvment). 53 cases of TBC were examined (age between 2 and 12 years) for descriptive purposes, as radiology plays leading role in identifying and valuing the thc extension, evolution and complications. Results. In our experience 53 cases had an history of infection with exposure to TBC and a positive tuberculin skin test, but only 37 patients were symptomatic. The clinical and radiologic features made the definitive diagnosis in 49 cases. Biopsy was only required in 4 cases. Discussion and conclusions. All radiological methods are a great help for the clinicians in tuberculosis diagnosis, and are necessary tools to value the localization and extension of this disease. Tubercolosis is of pressing current concern, due to its resurgence in non-endemic populations in recent years. Radiographic TBC findings in childhood are also important for early clinical treatment and follow up, expecially in drug-resistant TB.
S557
244 Overview of plain film appearances in pathogenically confirmed paediatric pneumonia Alan Quigley, Samuel Stafrace Royal Aberdeen Children’s Hospital (United Kingdom) Purpose - Objective. In this poster we aim to demonstrate the spectrum of plain film appearances in paediatric patients from our institution admitted with a diagnosis of pneumonia and confirmed identified bacterial/viral pathogens. Material and methods. All admitted paediatric patients (less than 16 year) with a discharge diagnosis of pneumonia (205 cases) and with a confirmed pathogen on bacteriology/ virology testing (34 cases) over a 3 year period (2007–2010) had their plain film imaging reviewed retrospectively. Results. Pathogens identified included: streptococcus pneumoniae, streptococcus pyogenes, haemophilus influenzae, moraxella catarrhalis, staphylococcus aureus, mycoplasma pneumonia, respiratory syncitial virus, metapneumovirus, enterovirus and others. The radiological appearances on CXR are described. Discussion and conclusions. Appearances are often non specific with some typical features identified relating to the confirmed pathogens on bacteriology/virology. These radiological appearances are demonstrated to allow radiologists to build up confidence in suggesting a possible pathogen from the plain film appearances.
243 245 Breathtaking Africa Susan Lucas1, Savvas Andronikou1, Pierre Goussard,2 Robert Gie2 1 University of the Witwatersrand, Johannesburg; 2Stellenbosch University (South Africa) Purpose - Objective. Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children. Material and methods. This poster will represent a pictorial demonstration of the evolutionary changes of the parenchymal disease that starts as consolidation/collapse, progressing through drowned lung to necrosis and eventual cavitation with lung destruction. Results. This poster will highlight the complications of the entity of LBTB as well as benefits of either endoscopic or transthoracic airway decompression in preventing lung destruction. Discussion and conclusions. Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children.
The role of ultrasound (US) and computed tomography (CT) in the evaluation of complicated pneumonia in children Anna Charsoula, Dafni Katsiba, Ilias Torounidis, Petros Xatzipanagiotidis, Panagiotis Ziouras, Naoum Kotsidis, Dimitris Rafailidis General Hospital of Thessaloniki “G. Gennimatas” (Greece) Purpose - Objective. To illustrate the different but complementary roles of chest US and CT in the evaluation of complicated pneumonia in children. Material and methods. We retrospectively analyzed chest sonograms and CT scans of 21 children aged 2–5 years with pneumonia performed in our department during the last 4 years. Follow up US and CT scans were included. Clinical indications were the primary evaluation of parapneumonic effusions and persistent or progressive symptoms despite adequate therapy. Pleural effusions were basically evaluated on sonograms and specifically on their composition and location. Concomitant findings of parenchymal disease were described when possible. On CT scans complications of
S558
pneumonia involving pleura, lung parenchyma or pericardium were assessed. Results. Chest sonograms revealed pleural fluid in all children. Findings ranged from completely anechoic free effusions to loculated collections with low-level echoes or fibrin strands. Lung consolidation or atelectasis was occasionally identified. CT findings were variable: parapneumonic effusions (free, loculated or empyema), pericarditis, lung parenchymal disease (consolidation or alveolar infiltrates, atelectasis, decreased parenchymal enhancement, cavitary necrosis, bronchopleural fistula), malposition of chest tubes, pneumothorax and lymph nodes. Discussion and conclusions. US findings were adequate to evaluate parapneumonic fluid collections, but chest CT was superior in the depiction of parenchymal disease. In the event of positive US findings of loculated fluid or empyema, CT was usually performed, for better localization of the effusion to assist pediatric surgeons in appropriate therapy.
246 Ultrasound of the lung parenchyma and pleura in periatric patients with pneumonia Hippocratis Moschouris1, Eirini Papadaki2, Theodoros Harikopoulos, Marina Papadaki1 1 Tzanion General Hospital, Piraeus; 2Ag. Anargyroi Oncology Hospital, Kifissia (Greece) Purpose - Objective. Ultrasonography is a well-established technique for the characterization of pleural collections, and a study of lung parenchyma may add valuable information. We present the role of chest ultrasonography in children with pneumonia. Material and methods. The study includes 87 pts with pneumonia. We used 5–12 MHz transducers and a colourpower Doppler technique. Patients were examined in the supine, prone or lateral decubitus position and the appropriate window was selected. Results. Ultrasonography revealed the presence of minimal anechoic pleural effusion in 28/87pts. The underlying pneumonia presented as homogeneous and well-vascularized in all but 2 cases. The pPneumonia resolved within 3–7 days in all patients. In 46pts, effusions measured 1–2,5 cm in the lateral chest wall and contained septations, debris or had a honeycomb appearance. Consolidated parenchyma presented an air bronchogram in 31pts and vascularization was adequate in 41. Hypoechoic parenchymal lesions were revealed in 8pts. Recovery showed a significant delay in 7 cases. More voluminus, complicated effusions were detected in 18pts. Lung parenchyma was poorly vascularized in 14pts with hypoechoic lesions or areas of cavitation in 12. A thoracostomy tube was placed in 3pts and pleural decortication was decited in one case.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Discussion and conclusions. Ultrasound imaging of pleura and lung parenchyma in children with pneumonia provides valuable information that may influence treatment, especially in cases of poor therapeutic response. The consolidation’s appearance and vascularization correlates well to clinical outcome.
247 Chest CT manifestation and differentiation of pure Mycoplasma pneumoniae (MP) and Mycoplasma & Streptococcus pneumoniae in children Xinyu Yuan, Shuochun Wu Capital Institute of Pediatrics, Beijing (China) Purpose - Objective. To investigate the CT characteristics of pure mycoplasma pneumonia (PMP) and mycoplasma streptococcus Pneumoniae (MP SP) in children, and provide assistance with early differential diagnosis of PMP and MP SP. Material and methods. The CT images of 23 children with PMP and 23 children with MP SP proven by serology and hemoculture were reviewed retrospectively. The CT findings of each group were compared in terms of lesion distribution and density, ground-glass opacity (GGO), bronchovascular bundle thickening, bronchial wall thickening, pleural effusion, lymphadenopathy, and pulmonary emphysema. Results. The more common findings in the PMP group included ground-glass opacity (GGO), bronchovascular bundle thickening, and bronchial wall thickening (P < 0.05). The consolidation density, the amount of pleural effusion and size of lymphadenopathy were larger in the MP SP group (P<0.05). In terms of lesion distribution and density, the PMP commmonly appears as a thin sector shadow, from inside to outside (P<0.05), otherwise the MP SP appears frequently as consolidation without regular distribution (P<0.05). Discussion and conclusions. MP was mainly manifested as apparent changes of interstitial lung on the basis of a certain degree of changes in lung parenchyma. However, more severe pulmonary alveolitis was observed accompanied by a larger extent of inflammation-induced condensed shadow in a shape of flake and less infiltration of interstitial lung. MP SP was also manifestated as a large amount of pleural effusion and severe lymph node enlargement.
248 Inflammatory pseudotumors of the lung in children: imaging aspects Meryem Boubbou, Aziz Elmadi, Sarra Benmiloud, Siham Tizniti Centre Hospitalier Universitaire Hassan II (Morocco)
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Purpose - Objective. Because inflammatory pseudotumors may mimic malignant tumors, the radiologist should be aware of this entity and avoid aggressive treatment whenever possible. The authors report two cases of inflammatory pseudo-tumors and describe the imaging aspects. Material and methods. The two cases involve children aged 14 and three respectively, with pulmonary inflammatory pseudotumors. The diagnosis was placed on the histological analysis of surgical specimens. Both patients underwent imaging (CT). Results. The scans both showed very limited tumours, moderately enhanced after injection of contrast agent and the nature of which was difficult to characterize. Discussion and conclusions. The inflammatory pseudotumor is a specific pathologic entity, diagnosis is difficult before surgery. Imaging is not specific. It is considered a benign tumor, but the high risk of local recurrence and cancer surgery requires a careful monitoring. Conflict of interest. no
249 Chronic Granulomatous Disease—Two Cases with Completely Different Presentations Janice Ip, Peter Hui, Wendy WM Lam, Anita MC Tsang Queen Mary Hospital, HKSAR (Hong Kong) Purpose - Objective. Chronic Granulomatous Disease (CGD) is a rare inherited disorder in which antimicrobial activity of phagocytes is impaired due to the lack of reactive oxygen species, or oxidative burst, produced by NADPH oxidase. The hallmark of this genetic disorder (X-linked or AR) is the occurrence of purulent inflammation due to lowgrade micro-organism. Although many organs may be involved with infection, the most common sites are lung and skin, followed by generalized lymphadenopathy. Material and methods. We would like to report two cases of CGD and share our experience in the challenging diagnostic process and interesting imaging findings in different imaging modalities including CXR, CT and PET-CT, in different phases of the course of the illness, with histological pathological correlation as well. Results. Lung infections in CGD patients tend to follow a protracted course and may be complicated by granulomatous inflammation, persistent hilar or mediastinal lymphadenopathy, pulmonary fibrosis, and honeycomb lung. Pulmonary infection can involve previously scarred areas, which may delay radiographic detection. Affected individuals (X-linked) are also prone to infections caused by staphylococci, Salmonella, Candida, and Aspergillus. We also observed a high incidence of Mycobacterium tuberculosis infection in Chinese children with CGD.
S559
Discussion and conclusions. We believed the differences in presentations are related to the differences in their mode of inheritance of the genetic disorder.
250 Radiological diagnosis and differential of mediastinal lymphadenopathy in chindren Xinyu Yuan, Haining Yu, Yuchun Yan Capital Institute of Pediatric, Beijing (China) Purpose - Objective. To evaluate the radiologic findings and differentiations of mediastinal lymphadenopathy in children. Material and methods. Fifty-nine cases with mediastinal lymphadenopathy were involved in this study, and were divided into inflammation (n 029), tuberculosis (n 018) and tumor (included lymphoma, acute lymphocytic leukemia and neuroblastoma, n012) groups, depended on etiological or clinical examination. The CT images of the cases were reviewed and analyzed respectively. Results. The area (S) and minor axis (D) of the three groups were statistically significant (P<0.05). Lymph node was significantly larger in TB group than that in inflammation group. In contrast enhancement CT, lymph nodes were completly enhanced in the tumor group, while the annular enhancement and center low density were more common in TB group. More than three regions in mediastinum presenting abnormal enlarged lymph nodes implied a higher possibility of TB or tumor. Discussion and conclusions. The area, minor axis, density and distribution of enlarged lymph nodes are the helpful in identifying the causes of mediastinal lymphadenopathy in children.
251 Lung diseases in very preterm infants: radiologic-clinical correlation Jaroslaw Madzik, Hanna Bragoszewska, Maria Uliasz, Magdalena Rutkowska, Beata Iwanowska, Astra Cabaj Institute of Mother and Child, Warsaw (Poland) Purpose - Objective. To illustrate the lung diseases, complications during intensive care therapy and assess correlation between radiologic and clinical features Material and methods. A total of 136 small preterm infants (46 girls and 90 boys) with a median gestational age of 27 (range 22–30) weeks, median birthweights 800 g (range 400–1820 g). Chest X-ray and clinical status were observed during first 2 months of intensive care therapy.
S560
Results. Sixty-nine neonates (50,7 %) developed RDS (29 RDS I°, 19 - RDS II°, 11 - RDS III°, 10 - RDS IV°). 20 neonates (14,7 %) had congenital or secondary pneumonia. Complications were observed: BPD to 19 (14 %), pulmonary emphysema to 12 (8,8 %), atelectasis to 9 (6,6 %), others (i.e. NEC, intestinal perforation, IVH) to 25 (18,4 %). Six neonates died (4,4 %). Discussion and conclusions. Many premature newborns require treatment in a neonatal intensive care unit. Among many complications of prematurity, lung disease remains the most common cause of neonatal morbidity. Plain chest radiograph is still the basic imaging method used for assessment of lung disease and complications of respiratory tract occured during intensive care therapy of premature neonates. We observed good correlation between radiologic assessment and clinical status of neonate.
252 A pleuropulmonary blastoma pediatric case presented with dysphagia as main clinical manifestation Themistoklis N. Spyridopoulos, Athina Balaska, Eleftherios Valanidas, Anastasios Sakelaropoulos, Nikolaos Evlogias Penteli’s Children Hospital, Athens (Greece) Purpose - Objective. We present an interesting pediatric case that presented in our hospital with dysphagia as a main clinical manifestation, and that was finally diagnosed with pleuropulmonary blastoma (PPB). Material and methods. Clinical, laboratory and imaging findings are presented, along with a brief literature review on PPBs. Results. A 2 years old child presented to our hospital complaining of dysphagia, even after small snacks. Her general clinical condition was rather good. Blood tests showed leukocytosis with lymphocytosis. Chest x-Ray showed a complete opacification of the right hemithorax with contralateral mediastinal shift. Ultrasound revealed a relatively small complex nonseptated pleural effusion and the presence of mixed echogenic, non-aerated solid tissue, with increased vascular supply from pleural vessels. At diagnostic aspiration, the pleural fluid was blood stained; bacterial cultures were negative and no evidence of malignancy was detected at cytopathological examination. CT revealed a large solid, peripheral lesion with parenchymal infiltration and atelectasis, causing significant mediastinal shift and inversion of the hemidiaphragm. The lesion had variable contrast enhancement and internal necrotic areas. Histology was suggestive of PPB, and the child underwent surgery and chemotherapy. Discussion and conclusions. PPB consist of a rare aggressive group of primary lung neoplasms. They usually present with non-specific respiratory symptoms, whereas almost
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
half of them are found coincidentally on chest radiographs performed for other indications. 253 Langerhans cell histiocytosis with lung involvement in a 6-month-old boy: a case report and a literature review Eva Nordenskjöld Kvanta, Kerstin Johansson, Jan-Inge Henter Karolinska University Hospital, Stockholm (Sweden) Purpose - Objective. To present a case report and a literature review of Langerhans cell histiocytosis, (LHC), focusing on pulmonary involvement in children. Material and methods. Case report and literature review. Results. We present a six-month-old boy with pulmonary involvement at initial diagnosis of LCH. Computed tomography (CT) showed bilateral nodular opacities and multiple thin-walled cysts. Enlargement of the spleen was also present. The boy underwent chemotherapy and follow-up CT showed resolution of the nodular opacities. Discussion and conclusions. Langerhans cell histiocytosis, LCH, may involve several organ systems. Pulmonary involvement is rare in children with LCH. The prognosis depends on the presence or absence of involvement of risk-organs, (i.e., lungs, hematopoietic system, liver or spleen). LCH should be considered as a differential diagnosis in children with pulmonary cysts and/or nodules. LCH can present as a multisystem, life-threatening disorder. 254 Usefulness of CT image guided biopsy in the diagnosis of lung and mediastinum lesions in children Evanthia Botsa1, Ioannis Koutsogiannis2, Petros Fillipousis1, Elena Marinaki3, Loukas Thanos1 1 Sotiria General Hospital, Athens (Greece); 2Aglaia Kyriakou Childrens’ Hospital Athens (Greece); 3Addenbrooks Hospital, Cambridge (United Kingdom) Purpose - Objective. To detect the effectiveness and safety of fine or core needle biopsy as an accurate technique for the diagnosis of thoracic lesions. Material and methods. A total of 34 patients underwent an interventionnal procedure. The patients ranged in age from 2 to 18 years, with a mean age of 12 years. 8 patients presented with lung masses and 26 with mediastinum masses. All procedures were done under sedation. Fine needle and core needle biopsies were done with 18 G and 22 G needles. Results. Lung lesions were proved to be inflammatory, infectious processes (granulomatous inflammation, abscess, pneumonia), Langerhans cell histiocytosis, lipoblastoma, pleuropulmonary blastoma, metastatic lung tumors.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Lymphomas were the most common mediastinal tumors, located in the middle mediastinum, and represented 58.8 % of our patients (20/26). Lymphomas were Hodgkins disease in 38 % and non- Hodgkins lymphoma in the remaining 62 %. Neurogenic tumors, located in the posterior mediastinum, were the second most common mediastinal tumors. One lesion located to the anterior mediastinum referred to thymoma. There was a cystic lesion of the mediastinum, a cystic hygroma. Adequate diagnostic cytologic material was obtained in 96 % of our cases. No major complication occurred. Discussion and conclusions. CT image guided percutaneous biopsy is a diagnostically helpful, effective, secure, minimally invasive procedure that can be performed in children as part of the evaluation of a thoracic lesion.
255 Congenital left ventricular (LV) aneurysm in an 8-year old boy: a case report Dimitra Loggitsi, Georgia Papaioannou, Panagiotis Tagalakis, Nikolaos Kritikos Mitera Maternity and Children’s Hospital, Athens (Greece) Purpose - Objective. Congenital LV aneurysm is a rare malformation of unknown cause. Depending on its size and location, it complications can include rupture, endocarditis, heart failure, coronary compression, thromboembolism, and arrhythmias. Material and methods. We present the case of an 8-year old boy who was admitted to our hospital with 3 syncopal episodes and ventricular tachycardia recorded on a 24 h Holter monitor. An echocardiograph was carried out showing a large, almost akinetic LVaneurysm with submitral location. After an unsuccessful attempt for compete surgical excision of the aneurysmn our patient was finally treated with the implantation of a cardioverter defibrillator. As there was an absolute contraindication for MR imaging, Computed Tomography (CT) was requested, serving as a baseline postoperative study. CT was performed in a 64-slice CT scanner with prospective ECG triggering, during the intravenous injection of iodine contrast media (flow rate01,5 ml/s). Results. The obtained image data was used to create multiplanar reconstructed and 3D images. The study confirmed the presence of a residual submitral saccular LV aneurysm extending to the inferolateral free wall, measuring 5.8×3.6× 2.5 cm and having normal thickness. Discussion and conclusions. Congenital LV aneurysm is an infrequent entity in the pediatric population. The mode of treatment has to be individually tailored and depends on clinical presentation, accompanying abnormalities and possible complications. Detailed multimodality imaging is part of the clinical assessment.
S561
256 Aneurisms of left ventricle in children with noncompacted myocardium Irina Silnova, Igor Dvoryakovskiy, Elena Basargina, Anna Sugak, Malika Umarova Scientific Centre of Children Health, Moscow (Russia). Purpose - Objective. Noncompacted myocardium (NM) is a rare congenital cardiomyopathy. Aneurisms of the left ventricle are not universally recognized complications of NM. The aim is to evaluate the prevalence of the left ventricle aneurisms development in children with noncompacted myocardium. Material and methods. Forty-nine children with noncompacted myocardium (from 3 month to 17 years) were examined. Cardiac ultrasound investigation was undertaken on all patients using the standard methods, and magnetic resonance imaging (50 %) and computed tomography (26 %) were performed if indicated. Results. According to the data received, we could distinguish 3 types of NM: NM with well visualized trabecules with wide, deep lacunas to lacunar type; NM with numerous tiny lacunas and trabecules, separable from each other with difficulty to spongy type; NM combined signs of both these types to transitional type. During a 4 year follow-type, development of left ventricle aneurism in the cardiac apex and posterolateral cardiac wall was detected in 9 of 50 patients (18 %). Among them, 5 children had lacunar type of noncompacted myocardium. In 4 children,, transitional type of noncompacted myocardium was identified. In children with spongy type of NM, development of aneurisms was not found. In 2 children, development of thrombi in aneurisms lumen was detected as their condition worsened. Discussion and conclusions. Left ventricle aneurisms are common complication of NM in children. Predisposing factors of left ventricle aneurisms development are lacunar and transitional types of NM.
257 Second generation dual source CT in the diagnosis of congenital heart disease in neonates and children Marika Lidegran, Lena Gordon, Christin Ekestubbe, Gloria Broberg, Henrik Andersson Karolinska University Hospital, Stockholm (Sweden) Purpose - Objective. To describe our experience with cardiovascular CT in neonates and children using a second generation dual source CT scanner and suggest techniques for high quality, dose-optimized scanning. Material and methods. During a 10 month period, 45 pediatric and neonatal cardiovascular CT examinations were
S562
performed using a second generation dual source CT scanner. Mean age was 2,6 years (1 day–18 years) with body weights ranging from 800 g to 82 kg. Indication for scanning, sedation, method of intravenous contrast injection, CT techniques and scan parameters were noted. Effective dose values were calculated and image quality assessed. Results. In 32 of the 45 examinations, a high-pitch dual source spiral CT protocol was used for evaluation of extracardiac great vessels, in six patients prospective ECGtriggered sequential scanning was chosen for assessment of coronary arteries and in seven patients on ECMO, a conventional spiral protocol was used for safety reasons. Most patients were examined without sedation. Mean effective dose was 1,2 mSv (0,3–2,9 mSv, lower values for younger patients). Mean image quality was four on a five grade scale. Five examinations were graded 2 (poor but diagnostic) due to suboptimal contrast timing and/or high image noise. No examination was non-diagnostic. Discussion and conclusions. Second generation dual source CT scanners can provide high quality, low-dose ECG-gated and non-ECG-gated examinations in the evaluation of neonates and children with congenital heart disease.
258 Aortic arch malformations and their embryological basis Jon Loo, Tara Holm University of Minnesota, Minneapolis (United States) Purpose - Objective. Development of the aortic arch system, specific aortic malformations and their imaging evaluation are discussed. Material and methods. Anomalies to be reviewed include the left arch with aberrant right subclavian artery, right arch with mirror-image branching, right arch with aberrant left subclavian artery, double aortic arch, and interrupted aortic arch. Patients with these malformations were identified at our institution via imaging reports. Results. Two-dimensional and three-dimensional CTA and MRA images and conventional angiographic and fluoroscopic images were chosen to illustrate key concepts of the above-mentioned malformations. The embryological basis of these malformations was described using Edwards’ hypothetical double aortic arch. Discussion and conclusions. Congenital anomalies of the aortic arch and great vessels are often encountered in pediatric radiological practice. Many of these are discovered incidentally on imaging though some present with significant symptoms requiring therapy. It is thus important to be familiar with the appearance and associated complications of these malformations. This poster presents several of these aortic arch anomalies utilizing a variety of imaging
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
modalities. Focus is placed on the embryological development of these malformations to aid in their understanding and classification.
259 Congenital malformations of the aortic arch in paediatric patients demonstrated by high field ppen (HFO) 1.0Tesla MRI scanner Dimitra Loggitsi, Georgia Papaioannou, Ioannis Zampelis, Nikolaos Kritikos, Aphrodite Tzifa Mitera Maternity and Children’s Hospital, Athens (Greece) Purpose - Objective. Anomalies of the aortic arch are relatively uncommon malformations, often associated with congenital heart disease. The purpose of this review is to illustrate radiologic findings of vascular rings, interrupted and hypoplastic aortic arch in children using a HFO 1.0Tesla MRI scanner. In each case embryology will be described. Material and methods. All studies were performed in a 1.0Tesla open MRI scanner (Panorama, Philips) and included children aging from 1-day to 16-years old. Black-blood and 3D MR images were chosen to illustrate each form of aortic malformation and key concepts of each malformation. In the cases treated surgically, post-surgical images will be presented. Results. Aortic arch malformations to be illustrated include: left aortic arch with aberrant right subclavian artery, double aortic arch (complete with right arch dominant and double with atretic left arch), right aortic arch with aberrant left subclavian artery, right circumflex retroesophageal aortic arch with aberrant left subclavian artery, right aortic arch with mirror imaging branching, interrupted arch (types B, C), hypoplastic arch with coarctation of aorta. The anatomic relationship to the trachea and the esophagus is commented on Black-blood images. Discussion and conclusions. The exact anatomy of an aortic arch malformation and its relationship to adjacent structures is essential for their accurate diagnosis, classification, management and risk stratification. HFO 1.0Tesla MRI provides excellent image quality, comparable to 1.5Tesla conventional MRI scanners.
260 Normal abdominal aortic diameter in pediatric MRI Mohammed Algathradi, Nishard Abdeen Childrens Hospital of East Ontario, Ottawa (Canada) Purpose - Objective. To establish normal age-related aortic diameters in pediatric MRI Material and methods. Aortic diameter was assessed by MRI in 86 children varying in age from 4 months to 12 years
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
with no history of aortic pathology. Aortic diameter was measured on T1 weighted gradient echo images at four levels: immediately above the celiac origin, between the celiac origin and superior mesenteric artery origin, below the renal arteries and immediately above the bifurcation. AP and transverse diameters were measured with electronic calipers and an effective diameter (square root of the product of AP and transverse diameter) was calculated. Results. Regression analysis of diameters in relation to age demonstrated a linear relationship between the effective diameter and age. Normative effective diameters in mm related to age in years were: 0.56(age)+6.2 above the celiac origin, 0.51(age)+6.0 between the celiac and superior mesenteric origins, 0.49(age)+4.6 cm below the renal arteries and 0.48(age)+4.4 above the bifurcation Discussion and conclusions. Normative values for abdominal aortic effective diameter on MRI as a function of age are presented. These are expected to be of value in the detection and treatment of aortic pathology in pediatric patients.
261 Doppler-echocardiography of the left ventricular diastolic function in children Iryna Andrushchenko Scientific and Practical Center of Radiology NAMS (Ukraine) Purpose - Objective. To evaluate the left ventricular diastolic function in children with combined cardiac rhythm disturbance: shortened P-Q syndrome, WPW syndrome, sick sinus syndrome (SSS) and long QT syndrome (LQTS). Material and methods. Left ventricular diastolic function was evaluated with Doppler-echocardiography in a regime of constant wave Doppler using the E/A ratio, transmitral blood flow acceleration and expulsion time, isovolumic relaxation time (IVRT) in 105 children. Additionally, the M-mode mitral valve motion pattern was evaluated: mitral valve anterior cusp opening velocity and early mitral valve diastolic covering velocity were measured. Results. Patients with WPW syndrome demonstrate diagnostically valuable mitral valve opening velocity reduction and significant (p<0.05) reduction of early mitral valve diastolic covering velocity, which can be explained by the special of mitral valve movement at given syndrome. The significant (p<0.05) lengthening of IVRT was detected in children with SSS and LQTS. The E/A ratio studied did not differ from control group. Discussion and conclusions. During the last 10 years the morbidity of children with cardiovascular diseases increased from 14.4 to 20.0‰. Combined cardiac rhythm disturbances and long QT syndrome are especially important, as they may lead to sudden cardiac death. Children with SSS and LQTS
S563
demonstrate initial manifestations of impaired left ventricular diastolic function (isovolumic relaxation time 0,07 ±0,007 msec and 0,06 ±0,004 msec, respectively). Urogenital
262 Pre-and postnatal imaging of urogenital sinus anomalies Cecilia Lanza, Giovanni Pieroni, Lucia Amici, Valeria Bolli Ospedali Riuniti Ancona-Salesi Hospital (Italy) Purpose - Objective. Cloacal malformation and urogenital sinus include a spectrum of complex, congenital malformations with different constellations and degrees of persisting fusion of parts of the urinary, genital and intestinal tracts. We describe eight cases of urogenital sinus malformations. Material and methods. We reviewed imaging of 8 patients with urogenital sinus malformations (including two complex cloacal malformations), diagnosed prenatally with ultrasonography (US), and in two cases with fetal MRI and confirmed on postnatal US and MRI. Results. Prenatal US revealed an enlarging cystic abdominal mass. Fetal MRI, performed in two cases, revealed a fluid-filled retrovescical cyst and a second, smaller cyst, communicated with a larger cyst. Based on US and MRI imaging, diagnoses of urogeital malformations with urometrocolpos was considered. Postnatal MRI showed better gross hydrocolpos communicating with the uterine cavity in six cases. In two cases vaginal atresia was present, in two others, bicornuate uterus with septa vagina, and in four others, septa vagina. One fetus with cloacal malformation died in the 30th week of gestation. The last one underwent MRI that confirmed the hypotesis of cloacal malformation. Discussion and conclusions. Hydrocolpos may be associated with urinary and intestinal tract defects through a wide spectrum of more complex malformations, from persistent urogenital sinus to cloacal dysgenesis. MRI provides the surgeon with precise anatomical information to facilitate accurate surgical planning.
263 Imaging findings of Mullerian duct anomalies Ji Young Kim1,2, Yun-Jung Lim3 1 Seoul National University Bundang Hospital, Seong Nam; 2 CHA-Bundang Medical Center, Seongnam; 3Haeundae Paik Hospital, Busan (Republic of Korea) Purpose - Objective. The purpose of this exhibit is to review the embryology, classification and imaging findings of MDA for the accurate diagnosis and categorization of each anomaly.
S564
Material and methods. Mullerian duct anomalies (MDA) are congenital entities that result from various embryological abnormalities in the development and resorprtion of mullerian duct. In most cases, these anomalies can be surgically treated. The role of imaging is to help diagnose and surgically distinguish correctable forms of MDA from inoperable types. The purpose of this exhibit is to review the embryology, classification and imaging findings of MDA for the accurate diagnosis and categorization of each anomaly. Various classes of MDA will be presented using hysterosalpingography, ultrasound and MRI. Key differential diagnostic points for categorization will be discussed in the discussion of each case. The embryological phases for mullerian duct development will be also described. Results. The list of cases includes: uterovaginal hypoplasia, unicornuated uterus, uterus didelphys. bicornuate uterus. septate uterus, arcuate uterus, vaginal agenesis and cervix agenesis Discussion and conclusions. In conclusion, this exhibit could be helpful for establishing the correct diagnosis of various MDA and the appropriate treatment for each anomaly.
264 Two similar clinical histories, two different but related diagnoses on ultrasound examination Shyam Mohan, Nigel Broderick Nottingham University Hospitals NHS Trust (United Kingdom) Purpose - Objective. To describe radiological findings in two neonates who presented with umbilical discharge in the first week of life. Although similar in clinical presentation, ultrasound and fluoroscopic examinations revealed two different diagnoses, both of which were related to embryological umbilical remnants. Material and methods. Initial high frequency ultrasound examination and subsequent fluoroscopic contrast study were performed in two patients with umbilical discharge. Results. Initial ultrasound examination in the first patient revealed a ‘beak like’ extension of the bladder dome to the umbilical region. Subsequent sinogram performed through the umbilical opening demonstrated urinary bladder filling, confirming the diagnosis of a urachal remnant. In the second patient, also referred for ultrasound examination with a discharging umbilicus, a definite connection to the bladder was not demonstrated on ultrasound examination. Sinogram performed through the umbilical defect showed opacification of the small bowel, confirming the diagnosis of a persistent Vitello-intestinal duct. Discussion and conclusions. Non-infectious umbilical discharge in a neonate is an important condition to recognise and can be due to persistent umbilical remnants. Clinical history
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
and examination generally aid in identifying the nature of discharge, ie urinary or bowel contents, consitent with a urachal remnant or persistent vitellointestinal duct respectively. The underlying cause can usually be demonstrated by ultrasound examination and confirmed by fluoroscopic contrast studies.
265 Anterior urethral valve and diverticulum: an uncommon cause of obstructive uropathy in children Mairoula Arvaniti, Anna Charsoula, Aggeliki Papadimitriou, Charikleia Mavridou, Styliani Kakani, Petros Xatzipanagiotidis, Dafni Katsiba General Hospital of Thessaloniki “G. Gennimatas” (Greece) Purpose - Objective. To discuss the US findings of anterior urethral valves (AUV), emphasizing the importance of early diagnosis. Material and methods. We retrospectively studied the sonographic findings of AUV in five children aged between 11 months and 16 years. Fluoroscopic findings, were possible, were also evaluated. Results. In two cases, a diverticulum of the anterior urethra was depicted by longitudinal transpenile US and voiding cystourethrography. Severe accompanying obstructive uropathy was also revealed on imaging and laboratory examinations. In the other three cases, a valve tissue was depicted by longitudinal transpenile US of the anterior urethra, identical to that of the posterior urethral valve. Discussion and conclusions. AUV is an uncommon, but severe cause of urinary tract obstruction in childhood. Early diagnosis is crucial, as delayed management may lead to renal damage.
266 Imaging evaluation of a neonate with ambiguous genitalia Georgios Velonakis, Argyro Mazioti, Vasiliki Bizimi, Ekaterini Shtukkert, Aristodimos Maratsos, Natali Sideri, George Stathis, Efthymia Alexopoulou Attikon University Hospital, Athens (Greece) Purpose - Objective. To report the imaging findings in a newborn with ambiguous genitalia and to discuss the role of pediatric radiology in timely gender assignment. Material and methods. Clinical examination revealed a penis with hypospadias, a palpable testis and a vagina. US examination confirmed the existence of a sole testis and of a penis, as well as the presence of a normal uterus. No ovary was
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
identified. No abnormalities were detected from the adrenals, liver, kidneys, and spleen. Micturating Cystourethrogram (MCU) demonstrated the presence of a male type urethra and hypospadias. Retrograde filling of the vagina was also noted. Results. The karyotype test revealed a genotype of 46XY. Our case was consistent with persistent mullerian duct syndrome. Discussion and conclusions. Disorders of sex development, are very distressing for families and a diagnostic challenge for clinicians. Management requires a coordinated effort by a multidisciplinary medical team that includes pediatric radiologists and other pediatric experts, in order to make a proper gender diagnosis early in life. Imaging can demonstrate the urogenital anatomy and contribute in gender assignment. US is the primary modality for evaluating ambiguous genitalia as it demonstrates the internal organs, whereas MCU (or genitography) is useful in evaluating the urethral type, the vagina, possible fistulous communications or complex tracts. MR-scan can be used for further evaluation.
267
Withdrawn
268 US presentation and evaluation of the undescended testis in children Bojan Vucinic, Goran Djuricic, Marija Mandic University Children’s Hospital, Belgrade (Serbia) Purpose - Objective. Our aim was to show US presentation of the rare pathology of undescended testis in the ingvinal canal position. Material and methods. Our US team performed US examination on around 300 patients with undescended testis in a period of 6 years with 10 MHz high frequency linear probe, using CD. In eleven children, painful swelling were presented and in five, swelling was painless. Results. Painless swelling testis in five patients were presented as highly heterogeneous, round or oval shaped masses, with bizarre hypervascularisation- testicular neoplasm, surgically confirmed. Painful swelling testis in eleven patients were presented as enlarged homogeneous, hypogeneous mass, with complete absence of blood flowtesticular torsion, surgically confirmed.
S565
Discussion and conclusions. Ultrasonografy is proven as the first line method of undescended testicular pathology diagnostic evaluation.
269 US findings of testicular and paratesticular cystic lesions in infants and children. Mairoula Arvaniti, Anna Charsoula, Aggeliki Papadimitriou, Chrysi Nalmpantidou, Styliani Kakani, Aikaterini Sdrolia, Dafni Katsiba General Hospital of Thessaloniki “G. Gennimatas” (Greece) Purpose - Objective. To present the aspect of cystic lesions of the testis revealed on US examination. Material and methods. We retrospectively reviewed US scrotal examinations of infants and children (age range 11 months–16 years) that were performed in our department during the years 2003–2011 for cystic testicular lesions. Results. Cystic lesions were observed in 13 patients: testicular cyst (n02), cystic teratoma (n02), cyst of tunica albuginea (n03), torsed cyst of tunica vaginalis (n01), cystic dysplasia (n01), cystic lympagioma (n01) and abscess (n03). Discussion and conclusions. The main difficulty was in differentiating testicular cysts from cystic teratoma. Accurate and definite diagnosis in all the remaining cases was made sonographically.
270 Early ovaric torsion or disfunctional disease? The diagnostic value of an ultrashort MRI protocol for atypical cases Manuela De Vivo, Cecilia Lanza, Valeria Bolli, Giovanni Pieroni, Vittoria Galeazzi, Lucia Amici Ospedali Riuniti Ancona-Salesi Hospital (Italy) Purpose - Objective. The aim of this work is to assess the possible clinical value of an ultrahort MRI examination in the diagnosis of ovarian troubles in order to avoid laparoscopy or surgical treatment. Material and methods. During 2010 and 2011, twelve young girls -mean age 11- with pelvic trouble were examined with US at first instance; then an ultrashort MRI protocol with contrast medium injection was performed. The following parameters were considered: the presence and degree of ovarian enlargement, gland location, the presence of masses or cysts, wall thickness, contrast enhancement and fluid collections.
S566
Results. All these patients had ovarian disease features without “plum cake” signs at US examination and the hypothesis of a close menarche could be advanced for most of them. An ultrashort MRI protocol in a 0.3 T. open unit was performed, finding one small teratoma, six haemorrhagic corpus luteum and five unbroken follicles. In ten girls, surgery was avoided with success, in two cases laparoscopy was required. Discussion and conclusions. Ovarian torsion without any gland lesions is common in childhood until puberty, especially in right side, because of ligament and tube hypermobility, but in 9–12 year-old girls we can find some disfunctional diseases simulating or, as sometimes happens, preparing a gland torsion. In these cases, MRI can guide the diagnosis and a quick examination can be helpful for patient management.
271 Ovarian torsion in a pre-menarcheal girl: MR imaging features with pathological correlation George Hadjidekov, Ivan Plachkov University Hospital Lozenetz (Bulgaria) Purpose - Objective. MRI and US findings in ovarian torsion in a pre-menarcheal girl are described. Adnexal torsion is an uncommon cause of severe lower abdominal pain in young women (mean age is 10–11), and in 50 % of cases such symptoms are observed in pre-menarchal females. However, adnexal torsion should be considered in all pre-menarcheal girls admitted with acute abdominal pain and evidence of an ovarian mass. Material and methods. Due to the inconclusive US findings in this young patient with subacute symptoms and a suspected adnexal mass, magnetic resonance imaging have been performed. Results. A pelvic ovoid mass was visualized on ultrasound, performed in an emergency setting band as an initial examination, suggesting several hypotheses—cystic mass, ovarian torsion, dermoid. MRI demonstrated edematous ovary enlargement and the presence of multiple follicules at the periphery due to congestion from the twisted vascular pedicule. Smooth wall thickening of the partially necrotic twisted ovary was observed in the sub acute phase, which was confirmed during laparoscopy. Discussion and conclusions. Accurate imaging is crucial after the onset of early clinical symptoms to confirm the diagnosis and to preserve the viability of the affected ovary. MRI is suitable as additional diagnostic method in premenarcheal girls with subacute right fossa pain. CT should be avoided whenever possible in young patients due to ionizing radiation.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
272 Hemorrhagic ovarian cyst in an adolescent girl with acute pelvic pain: the role of sonography Marina Vakaki1, Despina Grigoraki1, Katerina Terzaki1, Magdalini Smarda1, George Pitsoulakis2, Chris Koumanidou1 1 “P & A. Kyriakou” Children’s Hospital, Athens (Greece); 2 “Agia Sofia” Children’s Hospital, Athens (Greece) Purpose - Objective. A young adolescent girl with a pelvic pain is always a diagnostic challenge, both for the clinician and the pediatric radiologist. Sonography can be invaluable in this situation. A hemorrhagic ovarian cyst alone, or as lead point for adnexal torsion, may be the cause of the pain and the pediatric radiologist has to provide essential information about the necessity of surgical intervention. The purpose of this study is to present the multiple sonographic appearances of hemorrhagic ovarian cyst and to emphasize the role of sonography in the differentiation of hemorrhagic cyst from adnexal torsion associated with a hemorrhagic cyst. Material and methods. The pelvic sonograms of 123 girls, 11–15 years old, examined in a 10-year period were reviewed. Results. The whole spectrum of sonographic patterns of hemorrhagic ovarian cyst are presented, from the solidappearing to the purely cystic mass. The key findings for the distinction of hemorrhagic cyst from ovarian tumor are highlighted. The importance of surrounding ovarian parenchyma evaluation is emphasized for recognition of ovarian torsion. The evolution of findings, when sonographic follow-up is decided, is presented, allowing high confidence in the diagnosis of hemorrhagic cyst. The role of further imaging work-up is discussed. Discussion and conclusions. The sonographic patterns of hemorrhagic ovarian cyst are variable. However, the detailed sonographic examination provides essential information and answers important clinical questions, avoiding unnecessary or leading to emergency surgery.
273 Documented progressive to complete kidney atrophy following renal artery injury due to blunt abdominal trauma Živa Zupancic, Senja Mali Brajovic University Medical Centre, Ljubljana (Slovenia) Purpose - Objective. Pediatric injuries of renal arteries from blunt abdominal trauma are rare. Imaging data on
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
changes of the kidney following traumatic renal artery occlusion are limited. We report a renal artery injury due to blunt trauma, initial CT findings, treatment decisions and 3month follow-up kidney changes due to ischemia as assessed by US, Doppler flow and scintigraphy, and US follow-up after 1 year. Material and methods. A 9-year-old boy suffered blunt abdominal trauma. Contrast CT revealed liver rupture and occlusion of the right renal artery. At surgery, exploration of the right kidney revealed no major changes and no additional measures were taken by the vascular surgeon as the ischemic time was considered too long to save the kidney. In the following 3-month period, we evaluated morphologic changes of the kidney by US, vascular perfusion by US Doppler, and function by scintigraphy. We evaluated the kidney by US after 1 year. Results. Minimal vascular flow appeared on day two post surgery, sustained for 3 weeks, then decreased. Kidney size decreased minimally in 3 weeks, later more. At 3 months, it measured 4 cm; scintigraphy revealed a total loss of function. US evaluation after 1 year demonstrated no kidney whatsoever. Discussion and conclusions. Consequences of renal artery injuries with occlusion are severe. This case clearly demonstrates complete function loss, progressive renal atrophy, and complete disappearance of the kidney after 1 year.
274 Infant with renal calyx rupture and urinoma secondary to posterior urethral valve: sonographic diagnosis. Hakan Gençhellaç, Veli Ermis, Mehmet Yadigar Kirici, Osman Temizöz Trakya University, Edirne (Turkey) Purpose - Objective. The literature reports only rare cases of urinoma, usually secondary to rupture of the bladder and not to renal calyx rupture. The present report describes an uncommon case of posterior urethral valve in an infant with urinoma caused by the rupture of a renal calyx that, to our knowledge, was diagnosed for the second time by ultrasonography. Material and methods. A male infant was born by caesarean, weighing 2,890 g. On the first day of his life, the infant was admitted to intensive care unit due to progressive abdominal distention and anuri. Ultrasonographic examination showed bilateral hydronephrosis (grade 3), bladder wall thickening, urinoma and calyx rupture in the lower pole of right kidney. These findings were suggestive of obstructive complications of posterior urethral valves. Our ultrasonographic images demonstrated calyceal rupture in the lower group of the right kidney.
S567
Results. Cystoscopy and vesicostomy were performed. The patient was discharged in good general conditions. Discussion and conclusions. Treatment of this disease is surgical. Early diagnose and treatment are significant for prognoses. The urinary extravasation resulting from PUV in the presense of peritoneal or retroperitoneal fluid during early childhood shall be considered different diagnosis. Bladder wall thickness is especially premonitory with the other symptoms.
275 Multilocular cystic nephroma with herniation into the renal pelvis and ureter—case report Korcan Aysun Gonen, Zeynep Yazici, Hasan Serkan Dogan, Berna Aytac Uludag University, Bursa (Turkey) Purpose - Objective. We report an unusual case of multilocular cystic nephroma (MLCN). Material and methods. A 16-month-old girl presented with an increased abdominal girth. Abdominal ultrasonography (US) and magnetic resonance (MR) imaging were performed to reveal the cause of abdominal distension. Results. At physical examination, a large, non-tender mass was felt on the right abdomen. Urinalysis revealed haematuria, proteinuria and leukocyturia. Abdominal US demonstrated a large, multiloculated cystic mass on the right kidney measuring 10 cm in diameter, with moderate pelvicaliceal dilatation. On contrastenhanced MR imaging, the mass had enhancing capsule and internal septa with no solid or nodular elements and extended into the renal pelvis and proximal ureter. The radiological findings were consistent with multilocular cystic renal tumor. The patient underwent radical nephrectomy of the right kidney. Histopathological examination revealed the diagnosis of MLCN. Discussion and conclusions. MLCN is a rare benign, nonhereditary neoplasm. It is indistinguishable from cystic partially differentiated nephroblastoma on the basis of radiographic findings alone. However, imaging may be helpful in differentiating MLCN from other cystic renal masses such as cystic Wilms tumor, clear cell sarcoma, cystic renal cell carcinoma and, segmental form of multicystic dysplastic kidney. MLCN is a purely cystic mass that may herniate into the renal pelvis and ureter.
276 Pilot study of syngo iFlow in evaluating renal artery angioplasty digital subtraction angiography images at a pediatric institution Deddeh Ballah1, Erin Girard2, Heike Theessen2, Anne
S568
Marie Cahill1 The Children’s Hospital of Philadelphia (CHOP); 2Siemens (United States)
1
Purpose - Objective. syngo iFlow(Siemens Healthcare AG, Forchheim, Germany) is a color coded imaging adjunct that displays time to peak (TTP) opacification in time series digital subtraction angiography (DSA). This study investigates the ability of iFlow to evaluate flow changes patients undergoing angioplasty for renal artery stenosis (RAS). Material and methods. Images were retrospectively reviewed by two-reader, non-blinded consensus. From 2008 to 2011, 20 patients (12F, 8M), mean age 11.1 years, (range 1.8 to 18 years) underwent 26 percutaneous angioplasty procedures for RAS. 16/26 were non-cutting balloon angioplasty only and 10/26 were both cutting and noncutting balloon angioplasty. Pre- and post-angioplasty DSA images were viewed using iFlow. For each stenotic lesion, a pre- and post-stenotic location was chosen and the TTP of maximum contrast opacification was recorded. These values were subtracted to calculate the difference in TTP opacification (dTTP) and used as a surrogate for rate of flow. The pre- and post-angioplasty dTTP were compared using the Wilcoxon signed-rank test (p<0.05 significant). Results. Pre- and post-angioplasty iFlow images had a statistically significant (p00.002) difference in measured dTTP. 18/26 cases demonstrated a decrease in dTTP postangioplasty; 5/26 demonstrated no change dTTP; 3/26 demonstrated increased dTTP correlating with two mural dissections and one intraluminal thrombus. Discussion and conclusions. dTTP across stenotic vessels are quantitatively different in post-angioplasty iFlow images compared with pre-angioplasty images. iFlow may be an adjunctive technique to better predict post-angioplasty intraluminal flow. Conflict of interest. E.G., H.T. are Siemens employees.
277 Intraoperative voiding urosonography (VUS) during endoscopic injection of Deflux Magdalena Wozniak, Pawel Osemlak Medical University of Lublin (Poland) Purpose - Objective. Endoscopic injection of Deflux is one of the methods of treatment of vesicouretheral reflux (VUR). A recent meta-analysis by Elder et al. demonstrates that, after one treatment, the resolution rate of reflux per ureter for grades I and II was 78.5 %; grade III, 72 %; grade IV, 63 %; and grade V, 51 %. Thus it would be important to
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
find a method increasing the effectiveness of treatment and decreasing the number of re-injections. Material and methods. Intraoperative voiding urosonography (VUS) was performed during 15 procedures of endoscopic injection of Deflux. All patients suffered from unilateral VUR. VUS was performed before and after injection of the bulking material. In cases when the VUR was persisting after the first injection, the operator performed a second injection of Deflux, followed by VUS. Results. During 15 procedures of endoscopic injection of Deflux, in 11 (73.3 %) cases a single injection of Deflux resulted in effective treatment. In 4 (26,7 %) children, VUS performed after the first injection showed the presence of VUR, following which a second injection was performed. After the second injection, no VUR was visualized in all 4 cases. Discussion and conclusions. Intraoperative voiding urosonography (VUS) during endoscopic injection of Deflux enables immediate monitoring of the effect of treatment and allows for re-injection of Deflux during the same procedure. 278 Radiation and urological investigation—often as bad as CT Mark Page1, Michael Ditchfield2, Cosmin Florescu1 1 Southern Health, Melbourne; 2Southern Health, Monash Children’s and Monash University, Melbourne (Australia) Purpose - Objective. To compare the frequency and radiation exposure of the most common CT scans performed in our department with common fluoroscopic and nuclear medicine examinations used in urological assessment. Material and methods. A retrospective audit from July 2009–Dec 2011 of the most common CT scans, micturating cystourethrogram (MCU), DTPA, DMSA and MAG3 scans used for urological assessment performed in children <16 years in a tertiary paediatric centre. Radiation doses of these procedures was obtained from the literature. Results. A total of 3851 patients had a CT with a total dose of all exams 9,589 mSv and an average of 2.4 mSv/exam. A total of 828 patients had nuclear medicine examinations with a total dose of 819 mSv and an average of 1.0 mSv/ exam. A total of 118 patients had a MCU with a total dose of 59 mSv and an average of 0.5 mSv/exam. Discussion and conclusions. Urological assessment with MCU and nuclear medicine are commonly used in the assessment of the urinary tract, frequently used in tandem and frequently repeated. The radiation dose of investigation of the urinary tract often overlaps with CT. This is important in determining the risk/benefit ratio for investigating conditions such as antenatal hydronephrosis or urinary infection.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
List Of Authors, Ordered By Name, With The Position Of Their Submission & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Shadi Abdar Esfahani: 42 Nishard Abdeen: 260 Maya Abu Gazala: 73 Orthodoxos Achilleos: 203 Christelle Ackermann: 88 Gerhard Adam: 25 Judit Adam: 65 Melkamu Adeb: 17, 18 Joan Adiotomre: 79 Amit Agarwal: 71, 189 Leonor Alamo: 200 Afshin Alavi: 55, 60, 78, 201 Marco Albertario: 98 Jean Siador-Alcober: 171 Djordje Alempijevic: 222 George Alexiou: 156, 172 Efthymia Alexopoulou: 5, 36, 132, 266 Mohammed Algathradi: 260 Marianne Alison: 77, 197 Naved Alizai: 40 Abeer Almehdar: 120 Gisele Almeida: 81 Ahmad Alomari: 30 Lucia Amici: 123, 177, 231, 242, 262, 270 Evaggelia Anagnostaki: 138, 205 Henrik Andersson: 257 Alexandros Andreou: 156 Maria Andreou: 74, 211 Savvas Andronikou: 7, 26, 88, 150, 243 Styliani Andronikou: 84, 86, 159 Mehrak Anooshiravani: 38, 117 Christina Antal: 77 Milan Apostolovic: 222 Nira Arad: 73 Ioannis Arapakis: 5 Xristos Argiris: 80, 140, 145 Maria I Argyropoulou: 84, 86, 153, 159 Marc Arkovitz: 73 Owen Arthurs: 197 Mairoula Arvaniti: 112, 128, 130, 265, 269 Carmen Asavoaie: 99 Loukas Astrakas: 86, 159 Jeffrey Atkinson: 92 Achilleas Attilakos: 132 Thomas Angell Augdal: 102 Stein Magnus Aukland: 158 Daniela Avila-Smirnow: 56 Berna Aytac : 275 Brigitte Bader-Meunier: 52, 54 Fengsen Bai: 72
S569
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Manish Bajaj: 14, 64, 100, 155, 163, 164, 180, 188, 193, 207 Shalini Bajaj: 64, 163, 188 Lene Bak: 106 Kenneth Baker: 8 Athina Balaska : 252 Deddeh Ballah: 276 N. Bannink: 179 Eleni Barbagianni: 161 Ignasi Barber: 65 Maria Barbieri: 45, 223 Elena Barbu: 228 Natalia Barmpaliou: 134 Nikolaos Barmpas: 148 Christine Barnerias: 54 Dhiraj Baruah: 181 Elena Basargina: 256 Bilal Battal: 119, 141, 169 Luisa Battigelli: 196 Catherine Baud: 27 Nina Brauer: 173 Michele Bava: 215 Erik Beek: 65 Meinrad Beer: 48 Nadia Belarbi: 197 Miriam Ben Arush: 73 Ayelet Ben Barak: 73 Sarra Benmiloud: 248 Bruno Bernardi: 185 Laureline Berteloot: 54 Pierre Bessou: 61 Marc Bierings: 65 Pietro Biondetti: 191 Gianni Bisogno: 68, 69 Maria Bitsori: 23 Vasiliki Bizimi: 266, 99 Carla Bizzarri: 29 Eléonore Blondiaux: 77 Peter Boavida: 51 Srikanth Boddu: 31 Christine Bodemer: 54 Julie Bolivar Perrin: 27 Valeria Bolli: 123, 177, 231, 241, 242, 262, 270 Nicola Bonelli: 191 Philip Borg: 175 Norbert Bornfeld: 93 Irene Borzani: 191 Evanthia Botsa: 126, 209, 210, 254 Meryem Boubbou: 248 Catherine Bourget: 54 Maria Boviatsi: 156, 170, 172 Corinne Boyer: 98 Yalcin Bozkurt: 119, 141, 169
S570
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Hanna Bragoszewska: 251 Marie Brasseur-Daudruy: 77 Sylvain Breton: 52, 54 James Brian: 107 Paula Brill: 46 Penny Broadley: 62 Gloria Broberg: 257 Nigel Broderick: 31, 264 Muriel Brun: 61 Francis Brunelle: 52, 54 Costanza Bruno: 24 Livia Bruno: 47 Bojan Bukva: 222 Astra Cabaj: 251 Silvia Cacaci: 10 Bekir Cagli: 125 Anne Marie Cahill: 276 Alistair Calder: 218, 219 Giuliana Caliari: 24 Gilles Cambonie: 213 Hayley Danielle Cameron: 2 Mauro Campoleoni: 191 Teresa Cañas: 122 Vittorio Cannatà: 75, 108, 185 Marco Cappa: 29 Mary Card: 8 Pierre Carlier: 56 Robert-Yves Carlier: 56 Pablo Caro: 85, 224 Anna Caruso: 47 Pasquale Casale: 17, 18 Armando Casalino: 215 Marie Cassart: 77 Guilherme Cassia: 92 Jérome Caudron: 20 Jong Hee Chae: 157 Dimitra Chaini: 161, 204 Gcf Chan: 96 Tushar Chandra: 14, 64, 100, 155, 163, 164, 180, 181, 188, 207 Yun-Woo Chang: 142 Areti Charisiadi: 84, 86 Anna Charsoula: 112, 130, 245, 265, 269 Jean-François Chateil: 61 Athanasios Chatzimichael: 33 Dr Haseeb Chaudhary: 176 Govind Chavhan: 120 Huizhong Chen: 6 Lei Chen: 8 Paraschiva Chereches Panta: 99 Pt Cheung: 96 Bety Chisman: 81, 118 Tae-Joon Cho: 157
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Young Ah Cho: 124 Kling Chong: 158 Nucharee Chotipanvittayakul: 95 Arabinda Choudhary: 107 Iraklis Chrisatzas: 152 Apostolia Christakaki: 74, 211 Ioannis Christogiannis: 226, 230 Antonio Ciccarone: 50, 76, 87, 212 Marco Cirillo: 75, 108, 185, 223 Gregory Clement: 30 Robert Cleveland: 3 Malena Cohen-Cymberknoh: 4 Caterina Colantoni: 32, 97 Andrew Colin: 3 Mariana Coman: 228 Paul Connolly: 224 Teresa Corneli: 75 Lucie Corno: 35 Sara Costanzo: 22 Mark Cotton: 88 Alain Couture: 213 Sebastian Cristaldi: 223 Laura Cursi: 45 Giuseppina D’ottavio: 196 Jean-Nicolas Dacher: 20 Katerina Dailiani: 23 Beatrice Damasio: 22, 51, 53 Joanna Danin: 55, 60, 78, 201 Kassa Darge: 17, 18 Suzanne Davison: 40 Francesco De Cobelli: 32 Bart De Keizer: 65 Jacqueline De La Garanderie: 110 Gianluca De Salvo: 68, 69 Lien De Somer: 52 Manuela De Vivo: 123,177, 241, 242, 270 Savas Deftereos: 33, 202 Alessandro Del Maschio: 32, 97 Dimitrios Demenagas: 74, 211 Vassiliki Dermetzoglou: 114 Ioannis Dermitzakis: 152, 161, 204 Amira Dhouib: 117 Marianna Di Frenna: 97 Marco Di Maurizio: 50, 76, 198, 199 Elena Di Rosa: 32, 97 Vasiliki Diakatou: 74, 211 Abou Diallo: 61 Ioannis Diamantis: 21 Alessandra Dilascio: 32 Chrystalla Dimitriou: 112, 184 Michael Ditchfield: 278 Goran Djuricic: 133, 222, 268 Els Dobbels: 88
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Michael Dodds: 224 Hasan Serkan Dogan: 275 Michael Dolores: 20 Maria Doniz: 43 Veronica Donoghue: 85 Stavros Doudounakis: 113 Konstantinos Douros: 5 Aikaterini Drougia: 84, 86, 159 Allison Dunning: 46 Igor Dvoryakovskiy: 256 Irina Dykan: 49, 149, 186 Felicitas Eckoldt: 21 Nikos Economopoulos: 36 Christin Ekestubbe: 257 Irene Elgen: 158 Caroline Elie: 54 Aziz Elmadi: 248 Monique Elmaleh-Berges: 197 Ahuva Engel: 44 Ingvild Engesaeter: 59 Lasse B Engesaeter: 59 Goya Enriquez: 65 Hong Eo: 187 Arne Erikson: 102 Veli Ermis : 125, 162, 274 Marco Esposito: 50, 87 Brigitte Estournet: 56 Carlos Estrada: 84 Nikolaos Evlogias: 138, 205, 226, 230, 252 Monique Fabre: 35 Jean-Pierre Farmer: 92 Edward Faustino: 8 Diana Feier: 99 Ursula Felderhoff-Mueser: 101 Patricia Fenton: 79 Andrea Ferme: 81, 115, 118 Konstantinos Filiopoulos: 226 Dimitrios Filippiadis: 132 Petros Fillipousis: 254 Michelle Fink: 267 Cosmin Florescu: 278 J. Florisson: 179 Claudio Fonda: 50, 76, 87, 91, 198, 199, 212 Teresa Fontanilla: 122 Stéphanie Franchi-Abella: 35 Martin Freesmeyer: 21 Otilia Fufezan: 99 Diana Gaitini: 73 Vittoria Galeazzi: 123, 177, 231, 242, 270 Stephanie Galler: 25 Catherine Garel: 77 Mukesh Garg: 14 Anastasia Garoufi: 80
S571
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Maria Gavra: 114, 233, 234 Antoinette Gelot: 77 Hakan Gençhellaç: 125, 162, 274 Elisabetta Genovese: 185 Anne Geoffray: 98 Eleni Georgiadou: 152 Vasiliki Georgopoulou: 148 Gianmarco Ghiggeri: 22 Panagiota Giamarelou: 203 Robert Gie: 7, 243 Jessica Giordano: 47 Erin Girard: 276 Luda Gluzman: 44 Sophia Goericke: 93 Gokhan Gokalp: 221 Korcan Aysun Gonen: 221, 275 Emmanuel Gonzales: 35 Marie Gonzales: 77 Matthew Goodier: 26, 225 Thomas Goodman: 8 Lena Gordon: 257 Pierre Goussard: 7, 243 Nishentha Govender: 26 Claudio Granata: 65, 103 Claire Grech: 98 Mary Louise Greer: 217 Massimo Gregori: 215 David Grevent: 54 Silja Griffiths: 158 Despina Grigoraki: 80, 140, 145, 272 Teresa C. Gross Kelly: 181 Violeta Groudeva: 19 Nasrin Guaenni: 125 Pierpaolo Guastalla: 196, 215 Myriam Guesmi: 98 Amit Gupta: 14, 64, 100, 155, 163, 164, 180, 188, 193, 207 Sy Ha: 96 Christian R. Habermann: 25 George Hadjidekov: 19, 271 Christiana Hadjigeorgi: 111, 113, 114, 170, 233, 234 Ioannis Hager: 230 Eustathios Hahamis: 146 Dietbert Hahn: 48 Katherine Halliday: 31 Shema Hameed: 55, 60, 78, 201 Sylviane Hanquinet: 38, 117 Grete Anita Hansen: 102 Theodoros Harikopoulos: 246 Maria Hasiotou: 170, 233, 234 Risha Hathi: 55, 201 Sokratis Hatzimichalis: 184 Knut Helmke: 25
S572
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Jan-Inge Henter: 253 Jochen Herrmann: 25 Michael Hess: 107 Nurith Hiller: 4 Markus Holdt: 93 Tara Holm: 258 Hyun Sook Hong: 142 Anastasia Hranioti: 111 Adrian Hrusca: 89, 104, 183 Tania Hrysopoulou: 148 Xihong Hu: 15, 16 Guoying Huang: 15, 16 Rongyan Huang: 6 Britta Huening: 101 Kenneth Hugdahl: 158 Peter Hui: 129, 154, 236, 237, 249 Michael Hulse: 107 Terry Humphrey: 40 Ellen Marie Husby: 102 Jae Yeon Hwang: 124 Kriengkrai Iemsawatdikul: 95 Ievgeniia Iershova: 9 Nikolaos Ifantis: 204 Anat Ilivitzki: 44, 73 Thomas Imschweiler: 173 Steve Innes: 88 Janice Ip: 96, 129, 154, 236, 237, 249 Beata Iwanowska: 251 Michael Jackson: 58 Lena Mari Dale Jakobsen: 102 Delma Jarrett: 227 Jose Jarrin: 217 Raj Jayarajasingam: 175 Sîan Jenkins: 206 Tae Yeon Jeon: 187 Kerstin Johansson: 253 Ulrike John: 21 Sylvie Kaiser: 134 Styliani Kakani: 130, 265, 269 Dr Musa Kaleem: 176 Neratzoula Kallia: 74, 211 Maria Kalmanti: 168 Peter Kalmar: 12 Kleanthi Kalogerakou: 80, 145, 190, 203 Ilias Kampas: 83 Parthena Kampouridou: 112 Aikaterini Kanavaki: 38, 117 George Kannas: 184 Fotini Karachaliou: 190 Maria Karagianni: 152, 161, 204 George Karapostolakis: 80, 136, 184, 190 Stauroula Karyda: 112 Marcus Katoh: 173
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Dafni Katsiba: 112, 128, 130, 245, 265, 269 Maria Katsikari: 127, 174, 192 Nikos Katzilakis: 168 Eirini Kazantzidou: 148 Markus Kemper: 25 Anton Kenig: 137 Eitan Kerem: 4 Sara Kernick: 267 Zarir Khademian: 165 Dmitry Khrichenko: 17, 18 Hyun Woo Kim: 220 Jee-Eun Kim: 147 Ji Hye Kim: 187 Ji Young Kim: 263 Myung-Joon Kim: 143, 167 Ok-Hwa Kim: 157, 220 Young-Jo Kim: 227 Steven King: 107 Mehmet Yadigar Kirici: 125, 162, 274 Eva Kis: 66 Paul Kleinman: 227 Damjana Ključevšek: 137 Dorthe Ulrik Knudsen: 106 Murat Kocaoglu: 119, 141, 169 Herbert Koestler: 48 Natalia Kokhanovsky: 135 Faidra Kokori: 161, 204 Oleksandr Kondrachuk: 9 Paraskevi Konstantopoulou: 126 Christina Kontopoulou: 36 Nadeeja Koralage : 78 Paraskevi Kosta: 86, 159 Naoum Kotsidis: 245 Sofia Koukouraki: 23 Chris Koumanidou: 80, 136, 140, 145, 184, 190, 203, 272 Ioannis Koutsogiannis: 126, 136, 145, 184, 203, 209, 210, 254 Georgios Koutsoumis: 130 Adam Kouvelis: 74, 211 Arzu Kovanlikaya: 46 Gerasimos Kremidas: 5 Nikolaos Kritikos: 83, 13, 255, 259 Neha Kwatra: 165 Thomas Kwee: 65 Dimitrios Kyriakou: 151 Thorsten Köhler: 102 Lynn La Pietra: 107 Lene B Laborie: 59 Eoghan Laffan: 224 Wendy Lam: 96, 129, 154, 236, 237, 249 Sarah Lambert: 17, 18 Karen Lambot: 51, 52, 54
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Niki Lamnatou: 128 Lawrance Cl Lan: 129 Isla Lang: 62 Cecilia Lanza: 123, 231, 241, 242, 262, 270 Christina Lappa: 74, 211 Anne Larroque: 77 Barbara Laughton: 88 Antonio Leal: 115 Leslie Lecompte: 17, 18 Christabel Lee: 165 Chuhee Lee: 63 Hee Jung Lee: 131 Jee Hun Lee: 187 Jin Seung Lee: 124 Ki Seok Lee: 220 Kwanseop Lee: 41 Mi Jung Lee: 143, 167 Mu Suk Lee: 143, 167 Richard Lee: 30 Trude G Lehmann: 59 Beatrice Leloutre: 98 Benedetta Leonardi: 10, 11 Fabrizio Leopardi: 212 Maarten Lequin: 94, 178, 179, 182 Carole Leroux: 98 Toulouse Leusin: 115 Simon Li: 8 Christina Liakou: 114 Agnès Liard: 20 Marika Lidegran: 257 Johannes Liese: 48 Gye Yeon Lim: 131 Yun-Jung Lim: 160, 263 Simon Ling: 120 Annemieke Littooij: 65 Claire Lloyd: 206 Antonio Lo Casto: 47 Dimitra Loggitsi: 13, 83, 255, 259 Alexandra Lohnegger: 239, 240 Roberta Lombardi: 28, 75, 108 Jon Loo: 258 Sebastian Loos: 25 Susan Lucas: 7, 243 Maria Chiara Lucchetti: 28 Bodil Lura: 102 Araceli Maciá: 122 Jaroslaw Madzik: 251 Andrea Magistrelli: 45, 75, 108, 109, 185, 223 Gian Michele Magnano: 22, 53 Mohit Maheshwari: 181, 207 Nasreen Mahomed: 150, 225, 232 Triantafillia Makri: 111 Clara Malattia: 51, 53
S573
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Saverio Malena: 108 Senja Mali Brajovic: 273 Uday Mandalia: 206 Marija Mandic: 133, 268 Alice Manna: 177 Evaggelia Manopoulou: 127, 174, 192 Aristodimos Maratsos: 266 Paola Marchese: 109 Paola Marchetti: 28, 45 Theodore Marentis: 208 Persefoni Margariti: 84 Stefano Marianeschi: 11 Elena Marinaki: 254 Alekos Marinos: 168 Thomas G Maris: 23 Robert Marterer: 183 Laurent Martille: 213 Claude Maschi: 98 Giulia Masini: 199 Travis Matheney: 227 Anup Mathew: 175 Irene Mathijssen: 94, 178, 179, 182 Domenica Matranga: 103 Marcia Matsuoka: 81 Girolamo Mattioli: 22 Chiara Mattiuz: 22, 53 Charikleia Mavridou: 128, 265 Argyro Mazioti: 5, 132, 266 Madhu Mazumdar: 46 Silvia Mazzocchi: 212 Valerie Mc Lin: 38 Patricia Mcclean: 40 Simon Mcgurk: 58 Kieran Mchugh: 68, 69 Maeve Mcphillips: 58 Josee Melancon: 92 Laura Menchini: 185 Hans-Joachim Mentzel: 21 Laura Merlini: 117 Sosamma Methratta: 107 Thomas Meyer: 48 Maria Michalakou: 127, 174, 192 Nikolaos Michalopoulos: 161 Salvatore Minniti: 24 María Miralles: 122 Ioannis Mitrakos: 210 Shyam Mohan: 31, 264 Suyash Mohan: 181 Rahim Moineddin: 120 Ahmad Monavari: 85 Dominique Monpoint: 56 Margarita Montero: 43 Jose-Luis Montes: 92
S574
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Aikaterini Monti: 128 Jung Won Moon: 187 Michael Moore: 107 Stefano Mora: 32 Anthoula Morihovitou: 148, 151 Marzia Mortilla: 87, 91, 198 Hippocratis Moschouris: 144, 146, 246 Athanasios Mourikis: 152 Verena Mueller: 48 Lyudmila Myronyak: 149, 186 Alicia Nachtigal: 135 Iliada Nakou: 153 Chrysi Nalmpantidou: 128, 269 Henning Neubauer: 48 Maria Nezi: 113 Rutger Jan Nievelstein: 65 Georgios Nikas: 146 Ioannis Nikas: 156, 233, 234 Vasilios Nikolaou: 161 Aggeliki Nikopoulou: 5 Katherine Nimkin: 90 Gen Nishimura: 157, 220 Luca Nocetti: 53 Eva Nordenskjöld Kvanta: 253 Maria Nordlander: 55, 60, 78, 201 Veronika Northrup: 8 Agisilaos Notidis: 151 Aikaterini Ntoulia: 84 Anna Nyitrai: 66 Morten Odberg: 158 Alan Oestreich: 34 Amaka Offiah: 62, 63 Jun Oh: 25 Luiz Antonio Oliveira: 118 Marco Olivieri: 177 Oystein Olsen: 1 Cinzia Orazi: 28, 29, 45, 223 Lil-Sofie Ording Muller: 51, 102 Daniela Origgi: 103 Manuel Ortiz: 43 Pawel Osemlak: 277 Claus Bjørn Outzen: 106 Catherine Owens: 1 Emrah Ozcan: 119, 169 Mier Pa: 15, 16 Preeyacha Pacharn: 95 Enrico Paci: 231 Pier Luigi Paesano: 32, 97 Mark Page: 278 Valentina Palazzetti: 177 Federica Palorini: 103 Harriet Paltiel: 30 Georgia Panagi: 234
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Dimitrios Panagopoulos: 172 Luciana Panizza: 115, 118 Eirini Papadaki: 144, 146, 246 Marina Papadaki: 144, 146, 246 Vassilios Papadakis: 170 Aggeliki Papadimitriou: 265, 269 Ioannis Papadopoulos: 138, 226, 230 Spyridon Papadopoulos: 151 Georgia Papaioannou: 13, 83, 255, 259 Asteroula Papathanasiou: 190 Panagiota Pardali: 148 Danièle Pariente: 35 Lucia Pasquini: 199 Carlo Passerotti: 30 Evrydiki Patriki: 74, 211 Polina Pavicevic: 139 Silvia Pederzoli: 53 Tiziana Pellegrini: 212 Zoi Pemma: 74, 211 Anna Perrone: 50, 91, 198, 199 Mariana Petra: 230 Agapios Petridis: 127 Theoni Petropoulou: 190 John Pettifor: 88 Odile Pidoux: 213 Giovanni Pieroni: 123, 241, 242, 262, 270 Ravishankar Pillenahalli Maheshwarappa: 155, 164, 180, 193 Matthew Pinto: 8 George Pitsoulakis: 113, 136, 140, 145, 184, 233, 234, 272 Ivan Plachkov: 271 Isabel Platzer: 48 Daniel Podberesky: 37, 121 Maja Podkrajšek: 137 Elena Polischuk: 49 Anastasia Polychronakou: 132 Giacomo Pongiglione: 10, 11 Sergey Postovsky: 73 Roberto Pozzi Mucelli: 24 Jean-Pierre Pracros: 110 Panos Prassopoulos: 33, 202 Helle Precht: 106 Konstantinos Priftis: 5, 132 Olivier Prodhomme: 27, 213 Katerina Prodromou: 130 Neofytos Prodromou: 172 Anastasios Protopapas: 144 Roberta Puccio: 109 Alan Quigley: 195, 244 Susana Quijano-Roy: 56 Andreea Rachisan: 89, 104, 183 Dimitris Rafailidis: 130, 245
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Maria Raissaki: 23, 168, 194 Sanjay Rajwal: 40 William Ramsden: 40, 216 Poul Ravn: 106 Antonino Reale: 45 Mauro Rebuzzi: 75 Jean-Luc Réhel: 61 Nadir Reindorp: 135 John Rhodda: 150 Bianca Rijken: 94, 178, 182 Ashley Robinson: 82 Ian Robinson: 235 Natally Rocha: 81 Silvia Rocha: 81, 115, 118 Nadya Rokitska: 9 Eleftheria Roma: 36 Marzia Rosati: 177 Daniel Rosenbaum: 46 Thorsten Rosenbaum: 173 Karen Rosendahl: 51, 59 Francesco Rossi: 212 Caroline Rouleau: 213 Céline Rozel: 77 Eliseo Ruggeri: 191 Gianni Russo: 32 Magdalena Rutkowska: 251 Stephanie Ryan: 85 Siegfried Rödl: 89, 183 Pallavi Sagar: 90 Magali Saguintaah: 27 Christine Saint-Martin: 92 Anastasios Sakelaropoulos: 252 Rebecca Salter: 78 Sergio Salerno: 47, 103, 109 Claire Sanavi: 20 Agnes Sartor: 197 Sara Savelli: 50, 76, 91, 198, 199 Valentina Savoia: 223 Paolo Ms Schingo: 29, 45, 223 Marc Schlamann: 93 Michal Schneider-Kolsky: 116 Martin Scholz: 173 Bernd Schweiger: 101 Aikaterini Sdrolia: 269 May-ai Seah: 55, 60, 78, 201 Guy Sebag: 197 Aurelio Secinaro: 10, 11 Fabienne Seguret: 213 Suraj Serai: 121 George Sfakianos: 172 Georgios Sgourdos: 200 Furqan Shaikh: 67 Ekaterini Shtukkert: 266
S575
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Natali Sideri: 266 Maria Sidiropoulou: 148, 151 Irina Silnova: 256 Cicero Silva: 8 Massimiliano Silveri: 29 Natalia Simanovsky: 4 Osman Simsek: 162 Sumit Singh: 181 Madhu Kumar Singhal: 100, 193 Selma Sirin: 93, 101 Anna Skorokhoda: 149, 186 Dubhfeasa Slattery: 3 Magdalini Smarda: 136, 152, 161, 204, 272 Penelope Smirnaki: 194 John Somers: 31 Erich Sorantin: 12, 89, 104, 183, 239, 240 Kanella Sotirakou: 127, 174 Evaggelia Sotiropoulou: 126 Chrisostomos Soultanidis: 202 Ioannis Spandonis: 13 Philip Spinella: 8 Bruce Spottiswoode: 88 Themistoklis Spyridopoulos: 36, 138, 205, 226, 230, 252 Konstantina Spyrou: 36 Samuel Stafrace: 2, 195, 244 Diana Stanescu: 228 George Stathis: 266 Kalliopi Stefanaki: 172, 233 Martin Stenzel: 21 Michael Stevens: 68, 69 Werner Steyn: 150 Eftichia Stiakaki: 168 Dr Stavros Stivaros: 176 Petronella Stoltz: 8 Rodney Strahan: 116 Athanasia Stratigopoulou: 138, 205, 226, 230 Yingzi Su: 72 Chirawat Sudla: 95 Anna Sugak: 256 Lucy Summers: 62, 63 Andrea Superti-Furga: 157 Lisa Suzuki: 115, 118 Sophie Swinson: 218, 219 Maria Synodinou: 74, 211 Vasilis Syrgiamiotis: 111 Panagiotis Tagalakis: 255 Heba Takrouri: 67 Joana Tala: 8 Reghana Taliep: 88 Raad Tammo: 9 Uenis Tannuri: 115 Laura Tanturri: 51
S576
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Boris Tarasyuk: 49 Osman Temizöz: 125, 162, 274 Sylvain Terraz: 38 Katerina Terzaki: 140, 190, 272 Martin Thaler: 137 Loukas Thanos: 126, 209, 210, 254 Heike Theessen: 276 Basil Theodoropoulos: 114, 156, 170 Ioannis Tierris: 209 Bogdana Tilea: 197 Siham Tizniti: 248 Paolo Tomà: 10, 11, 28, 29, 45, 75, 108, 109, 185, 223 Mojca Tomažič: 137 Ilias Torounidis: 245 Maria Ladino Torres: 208 Alexander Towbin: 37, 121 Jeffrey Traubici: 67 Marc Treyvaud: 200 Panagiotis Trimis: 83 Ioanna Tritou: 194 Andrew Trout: 37 Aggelos Tsalkidis: 33 Anita Mc Tsang: 249 Konstantinos Tsilikas: 138 Nikolaos Tsirakis: 152 Sofia Tsismalidou: 151 Christina Tsompanlioti: 36 Nermin Tunçbilek: 125 Sedat Tuncel: 125 Loukia C Tzarouchi: 84, 86, 153, 159 Aphrodite Tzifa: 13, 259 Meropi Tzoufi: 153 Ayse Kalyoncu Ucar: 221 Maria Uliasz: 251 Malika Umarova: 256 Sheila Unger: 157 Norbert Utz: 173 Marina Vakaki: 80, 136, 140, 145, 184, 190, 203, 272 Eleftherios Valanidas: 252 Xanthippi Vallianatou: 204 Ronald Van Toorn: 88 M.L.C. Van Veelen: 179 Euaggelia Varchalama: 152, 204 Maria Varela: 156 Ildikó Várkonyi: 66 Jose Vazquez: 43 Georgios Velonakis: 5, 266 Malou Vermoolen: 65 Gilbert Vezina: 165 Kanupriya Vijay: 71
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
Pierre-Hugues Vivier: 20 Elpida Vlachopapadopoulou: 190 Eugenia Vranou: 33, 202 Bojan Vucinic: 133, 222, 268 Daniel Wallihan: 121 Mike Watson: 235 Giovanna Weber: 97 Sabine Weissensteiner: 104 Ulrich Wenzel: 25 Jacquelyn Whaley: 107 Barbara Wildhaber: 38, 117 Thuzar Win: 79, 175 Carine Wouters: 52 Magdalena Wozniak: 277 Shuochun Wu: 247 Victor Wycoco: 217 Petros Xatzipanagiotidis: 245, 265 Polis Xenophontos: 36 Jiangxi Xiao: 166 Cheng Xie: 1 Sheng Xie: 166 Tetyana Yalynska: 9 Yuchun Yan: 250 Lang Yang: 63 Qiong Yao: 16 Zeynep Yazici: 221, 275 Ercüment Ünlü: 125 So Young Yoo: 187 Chong Hyun Yoon: 124 Choon Sik Yoon: 143, 167 Hye-Kyung Yoon: 124 Carolyn Young: 105 David Yousefzadeh: 42 Haining Yu: 250 Xinyu Yuan: 6, 72, 166, 247, 250 Marianne Yvert: 61, 77 Theodora Zachari: 205 Efthymia Zafeiriadou: 148, 151 Maria Zarifi: 114 Chris Zambakides: 233 Ioannis Zampelis: 259 Giovanna Zatelli: 76, 212 Abdel-Rauf Zeina: 135 Floriana Zennaro: 196, 215 Anastasia Zikou: 84, 86, 153, 159 Panagiotis Ziouras : 245 Jizhen Zou: 6, 72 Jozsef Zsiros: 65 Ziva Zupancic: 273 David Zurakowski: 3
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
CONTINUING MEDICAL EDUCATION EUROPEAN ACCREDITATION The ESPR’s 49th Annual Meeting and 35th Postgraduate Course, Athens, Greece, May-June 2012, was granted 27 European CME credits (ECMEC) by the European Accreditation Council for Continuing Medical Education (EACCME). The EACCME is an institution of the European Union of Medical Specialists (UEMS), www.uems.net. Each medical specialist should claim only those hours of credit that he/she actually spent in the educational activity. The EACCME credit system is based on 1 ECMEC per hour with a maximum of 3 ECMECs for half a day and 6 ECMECs for a full-day event. AMERICAN ACCREDITATION
S577
&
&
& &
New in 2012—upon completion of a test, you will be required to respond to a short survey required by our CME provider in order to assist us in determining if these activities are meeting your needs. Once you respond to the survey, your test results will be forwarded to you by e-mail. Documentation of credits earned for CME tests will be available on the CME Gateway at www.CMEGate way.org. Results are not posted immediately. It may take up to 30 days for your credits to be reflected, so be sure to retain your e-mails as confirmation of your credit. Instructions on logging into the CMEGateway are posted on the Education page of the SPR website. CME certificates will not be mailed. Only examinations completed on-line will be valid for CME credit. Please do not mail or FAX in responses to the questions following the CME article.
Physician Needs Statement This Pediatric Radiology Continuing Medical Education (CME) activity is designed to provide educational information primarily related to technology, techniques, and applications of pediatric and fetal imaging for radiologists and those involved in allied sciences. This material includes information on imaging appearances of normal growth and development, as well as injury and illness that effect the pediatric population.
Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American College of Radiology and The Society for Pediatric Radiology. The American College of Radiology is accredited by the ACCME to provide continuing medical education for physicians.
Participation is a benefit of SPR membership.
Credit Designation Statement The American College of Radiology designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The American Medical Association has determined that physicians not licensed in the US who participate in this CME activity are eligible for AMA PRA Category 1 Credit™. Learning Objectives and Disclosure Please consult the individual articles for specific Learning Objectives and Disclosure information.
Instructions &
&
On-line access to the test will be available on the first of the month of the corresponding journal issue and will remain up for 3 years after publication. All paid subscribers to the journal who are also SPR members may access the article and corresponding test on-line. Completion of each test with a score of at least 80 % results in the awarding of 1 AMA PRA Category 1 Credit™. Participants will have the opportunity to take each test up to three times, if the first attempt does not result in a passing score. Participants will be provided immediate feedback through e-mail notification to assist in further study prior to taking the test again. If you do not receive an e-mail notice, please contact
[email protected] for assistance.
Eligibility All SPR members in good standing are eligible to participate in this CME activity. Should you wish to become a member of the SPR, please review our membership page.
S578
In memory of Clément Fauré
The ESPR Board and all the members of Hôpital Trousseau’s Radiology Department are deeply saddened to announce the death of Professor Clement Fauré at the age of 91. His wife, Micheline, and family are in our thoughts.
Pediatr Radiol (2012) 42 (Suppl 3):S403–S578
Professor Fauré completed his internship at the Hôpitaux de Paris in 1945 and was appointed electroradiologist at the Hôpitaux de Paris in 1954. Working alongside Professor Jacques Lefebvre from 1954 to 1963 at the Hôpital des Enfants Malades, Professor Fauré helped create the French School of Paediatric Radiology. He went on to become Head of the Electroradiology Department at the Hôpital Hérold from 1963 to 1970, before becoming Head of the Radiology Department at Hôpital Trousseau from 1970 to 1988. Professor Fauré was President of the European Society of Paediatric Radiologists in 1983, and channelled the Society’s endeavours to extend the sub-speciality’s reach. Through his tireless efforts, he created a wide circle of friends and students around the world. His clinical excellence and gift for teaching inspired many young doctors to follow his footsteps, propelling paediatric radiology into prominence on the radiology stage. A tribute will be paid to him during the ESPR’s next General Assembly meeting in Athens, 31st May, 2012. On behalf of all ESPR members, we would like to express our deepest sympathy to his family and friends. MA/CMO
