Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 DOI 10.1007/s00247-014-2920-5

ABSTRACTS

The Society for Pediatric Radiology introduced its new logo August 15, 2013. The logo communicates both the warmth of the Society community and the strength of the members’ commitment to excellent and thoughtful care of the pediatric patient.

The first official logo for the SPR was designed by Tamar Kahane Oestreich of Cincinnati, Ohio in 1985. Thank you, Mrs. Oestreich.

Founded in 1959 The Society for Pediatric Radiology 57th Annual Meeting & Postgraduate Course Presented by The Society for Pediatric Radiology JW Marriott Hotel Washington DC Washington, D.C. Postgraduate Course May 13–14, 2014 Annual Meeting May 14–17, 2014 Jointly sponsored by the American College of Radiology

This supplement was not sponsored by outside commercial interests; it was funded entirely by the Society’s own resources.

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The Society for Pediatric Radiology - Washington, D.C. May 13-17, 2014

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TABLE OF CONTENTS Welcome from SPR President, Richard A. Barth, MD ..................................................................................................................................................... S5 SPR 2014 Organization ...................................................................................................................................................................................................... S6 Continuing Medical Education .......................................................................................................................................................................................... S7 Maintenance of Certification .............................................................................................................................................................................................. S8 Objectives ........................................................................................................................................................................................................................... S8 Disclosure ........................................................................................................................................................................................................................... S9 Acknowledgements .......................................................................................................................................................................................................... S12 Program Schedule ............................................................................................................................................................................................................ S13 Catalog of Scientific Exhibits/Posters ............................................................................................................................................................................. S27 General Information Mission Statement ...................................................................................................................................................................................................... S33 Sites of Previous Meetings ......................................................................................................................................................................................... S33 Future Meetings .......................................................................................................................................................................................................... S33 Officers, Directors and Committees ........................................................................................................................................................................... S33 Gold Medalists ............................................................................................................................................................................................................ S40 Pioneer Honorees ........................................................................................................................................................................................................ S41 Presidential Recognition Award ................................................................................................................................................................................. S41 Honorary Members ..................................................................................................................................................................................................... S42 Past Presidents ............................................................................................................................................................................................................ S43 Singleton-Taybi Award ............................................................................................................................................................................................... S44 John A. Kirkpatrick Young Investigator Award ........................................................................................................................................................ S44 Walter E. Berdon and Thomas L. Slovis Awards ...................................................................................................................................................... S45 The SPR Research and Education Foundation Awards ............................................................................................................................................ S46 Social Events .................................................................................................................................................................................................................... S47 SPR 2014 Gold Medalist ................................................................................................................................................................................................. S48 SPR 2014 Pioneer Honoree ............................................................................................................................................................................................. S50 SPR 2014 Presidential Recognition Award ..................................................................................................................................................................... S51 SPR 2014 Honorary Member .......................................................................................................................................................................................... S52 SPR 2014 Singleton-Taybi Award ................................................................................................................................................................................... S53 John Caffey Awards ......................................................................................................................................................................................................... S54 Edward B. Neuhauser Lecturers ...................................................................................................................................................................................... S57 Postgraduate Course Abstracts ......................................................................................................................................................................................... S59 Scientific Papers ............................................................................................................................................................................................................... S68 Scientific Exhibits/Posters .............................................................................................................................................................................................. S148 Author Index by Abstract .............................................................................................................................................................................................. S235 Keyword Index by Abstract ........................................................................................................................................................................................... S245

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WELCOME ADDRESS Dear Colleagues, I look forward to greeting you in Washington, D.C., for what promises to be a very exciting 57th Annual Meeting of The Society for Pediatric Radiology. We are at a critical crossroads in radiology with many new imaging innovations on the horizon, but also a rapidly changing environment related to healthcare reform and diminished research funding. Our nation’s capital is an excellent venue for engaging in conversation on healthcare reform, which is the featured topic for the Neuhauser Lecture. The meeting program is designed to stimulate conversation on a range of topics important to our mission for advancing the care of children via imaging. The 2014, Edward B. Neuhauser Lecturer is Dr. Robert Pearl, Executive Director and CEO of The Permanente Medical Group, the largest medical group in the nation. At the time of our meeting the U.S. affordable healthcare act core components will have been enacted for several months and we will be in the early stages of understanding the impact of this legislation on the practice of medicine. Apropos to the times, the Neuhauser Lecture topic is: “The Future of American Medicine—The Impact of Health Care Reform”. Dr. Pearl is a respected thought leader on the topic of healthcare reform and the coming changes in the practice of medicine. The 2014 meeting theme will be “The Pediatric Radiologist Consultant: Bridging Patient Care and Innovation to Improve Child Health”. The program will emphasize the role of the pediatric radiologist as a consulting physician and the importance of close collaboration and communication with our clinician colleagues to assure optimal care of our pediatric patients. The meeting will build on the successful model from prior years with rich use of clinician speakers. It is imperative that we bridge our knowledge and exciting innovations in imaging with the needs of the clinician to answer their critical questions and work collaboratively to improve pediatric care via diagnostic imaging, image-guided therapy, and imaging research. The Postgraduate Course and workshop speakers will embrace the theme of the consulting role of the radiologist and will emphasize “what is the question to be answered” when performing an imaging study. The Meeting Curriculum Committee has put forth an extraordinary effort to assure an outstanding program on a broad range of pediatric imaging topics. The Postgraduate Course Directors, Drs. Peter Strouse and Shreyas Vasanawala have put together a program comprised of highly pertinent topics for the practicing pediatric radiologist. The Postgraduate Course will also showcase innovations in the educational method. The Course will incorporate the Khan Academy (www.khanacademy.org) approach to education with focused 10-min presentations and dynamic interaction with attendees to assure that all are highly engaged in the educational experience. In Sal Khan’s words “I teach the way I wish I was taught”. In addition to the Khan Academy approach, the Course will provide an opportunity for SAM credits to be obtained through interactive sessions. I am excited to announce that the interactive sessions will showcase RSNA Diagnosis Live™ software enabling delivery of content and audience-response questions to your mobile device. Dr. Alex Towbin serves as the meeting’s Information Technology Medical Director and will oversee the innovative, interactive technology to assure a highly stimulating experience throughout the meeting. Drs. Sarah Milla, Ashok Panigrahy, and Mary Wyers are the Course Directors for the Annual Meeting’s workshops and special sessions. They have assembled an outstanding array of courses on a wide range of topics. New for this year’s meeting will be a challenging case session, which features a distinguished panel of SPR and international pediatric radiologists, who will discuss their approach to the diagnosis and management of challenging radiology cases. This will be the inaugural SPR meeting to support live streaming for offsite attendees, which will provide access and connect us to our WFPI colleagues located throughout the world. The Annual Meeting will also feature an ultrasound educational course organized by Dr. Brian Coley. The course will provide hands-on ultrasound training in basic and advanced ultrasound imaging techniques. Ultrasound is rapidly evolving as a point of service application and it is critical for pediatric radiologists to remain at the cutting edge of this technology to assure excellent care of our pediatric patients. Don’t miss the Reception and Annual Banquet, which will feature a special performance by the highly entertaining political satire group, “The Capitol Steps”. Back by popular demand is the SPR Research and Education Foundation Fun Run. Dr. Scott Dorfman has graciously agreed to organize this event. If you do not want to run, no problem—walkers are welcome! If you are not able to physically participate, you can support our onsite runners and walkers through sponsorship. Washington, D.C. is a great meeting venue within walking distance to the White House and Washington Mall. The meeting presents a great opportunity for you to spend time with your family, friends, or significant others and enjoy the numerous attractions, upscale nightlife, and excellent food venues. There will be ample opportunity for celebration and socialization. Please join us for SPR 2014 and embrace the Theme—Collaboration, Consultation, and of course, Celebration! Sincerely,

Richard A. Barth, MD President, The Society for Pediatric Radiology

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SPR 2014 ORGANIZATION 2014 MEETING CURRICULUM COMMITTEE Richard A. Barth, MD, Chair Dianna M.E. Bardo, MD (3D Sessions) Jane E. Benson, MD (Education Session) Dorothy I. Bulas, MD (Education Session) Michael J. Callahan, MD (CT Protocol Session) Brian D. Coley, MD (Hands-on US and US Protocol Sessions) John J. Crowley, MD (Interventional Session) Laura Z. Fenton, MD (US Protocol Session) Marilyn J. Goske, MD (Education Session) Jeffrey C. Hellinger, MD (3D Sessions) Nadja Kadom, MD (Education Session) Rajesh Krishnamurthy, MD (MR Protocol Session) Edward Y. Lee, MD, MPH (Thoracic Imaging Session) Lisa H. Lowe, MD, FAAP (Education Session) Sarah S. Milla, MD (Sunrise Sessions) Beverley Newman, MBBCh, FACR (Thoracic Imaging Session) Ashok Panigrahy, MD (Sunrise Sessions) Marguerite T. Parisi, MD, MS Ed (Nuclear Medicine Session) John M. Racadio, MD (Interventional Session) Susan E. Sharp, MD (Nuclear Medicine Session) Dennis W. Shaw, MD (Neuroradiology Session) Lisa J. States, MD (Nuclear Medicine Session) Peter J. Strouse, MD, FACR (Postgraduate Course) Alexander J. Towbin, MD (Meeting Technology) Shreyas S. Vasanawala, MD, PhD (Postgraduate Course and MR Protocol Session) Sjirk J. Westra, MD (CT Protocol Session) Mary Wyers, MD (Sunrise Sessions) ABSTRACT REVIEW COMMITTEE - PAPERS Richard A. Barth, MD, Chair Dianna M.E. Bardo, MD Dorothy I. Bulas, MD Christopher I. Cassady, MD Teresa Chapman, MD, MA Taylor Chung, MD Brian D. Coley, MD Jonathan Dillman, MD James Donaldson, MD Lynn A. Fordham, MD Marilyn J. Goske, MD Mark Hogan, MD Diego Jaramillo, MD, MPH Nadja Kadom, MD Bernadette L. Koch, MD Rajesh Krishnamurthy, MD David B. Larson, MD, MBA M. Beth McCarville, MD Ashok Panigrahy, MD Marguerite T. Parisi, MD, MS Ed John M. Racadio, MD Anil Rao, MD Cynthia K. Rigsby, MD Keith J. Strauss, MSc Peter J. Strouse, MD, FACR Alexander J. Towbin, MD Andrew T. Trout, MD Teresa Victoria, MD, PhD Stephan D. Voss, MD, PhD

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ABSTRACT REVIEW COMMITTEE - SCIENTIFIC EXHIBITS/POSTERS M. Beth McCarville, MD, Chair Nadja Kadom, MD, Vice Chair Madhan Bosemani, MBBS Michael J. Callahan, MD Maria A. Calvo-Garcia, MD Michael P. D’Alessandro, MD Kassa Darge, MD, PhD Steven Don, MD R. Paul Guillerman, MD Fredric A. Hoffer, MD Thierry A.G.M. Huisman, MD Douglas H. Jamieson, MD J. Herman Kan, MD Geetika Khanna, MD Neha Kwatra, MD Maria F. Ladino-Torres, MD Jonathan M. Loewen, MD Craig S. Mitchell, DO, MA Helen R. Nadel, MD, FRCPC Daniel J. Podberesky, MD Janet R. Reid, MD Douglas C. Rivard, DO Ashley J. Robinson, MBChB Susan E. Sharp, MD Manrita K. Sidhu, MD Stephen F. Simoneaux, MD Aylin Tekes-Brady, MD Alexander J. Towbin, MD Kristen Yeom, MD

CASE OF THE DAY Debra L. Pennington, MD, Chair, Community Hospital Based Pediatric Radiologists Committee

jSPR Sheryl Tulin-Silver, MD and Matthew Winfeld, MD

CONTINUING MEDICAL EDUCATION 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 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 Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation Statement (Postgraduate Course) The American College of Radiology designates this live activity for a maximum of 10.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Designation Statement (Annual Meeting) The American College of Radiology designates this live activity for a maximum of 23.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Technologists The American College of Radiology is approved by the American Registry of Radiologic Technologists (ARRT) as a Recognized Continuing Education Evaluation Mechanism (RCEEM) to sponsor and/or review Continuing Medical Educational programs for Radiologic Technologists and Radiation Therapists. The American College of Radiology designates this educational activity as meeting the criteria for up to 34.5 Category A credit hours of the ARRT.

MAINTENANCE OF CERTIFICATION Qualified on December 10, 2014, the Postgraduate Course as well as the Saturday Education, Interventional, Neuroradiology, Nuclear Medicine and Thoracic Imaging sessions meet the ABR’s criteria for a self-assessment (SAM) activity in the ABR Maintenance of Certification (MOC) Program.

OBJECTIVES The Society for Pediatric Radiology Annual Meeting and Postgraduate Course will provide pediatric and general radiologists with an opportunity to do the following: 1. 2. 3. 4. 5. 6.

Summarize the most current information on state of the art pediatric imaging and the practice of pediatric radiology. Describe and apply new technologies for pediatric imaging. Describe and apply basic principles for implementing quality and safety programs in pediatric radiology. Discuss trends in research concerning the care and imaging of pediatric patients. Identify common challenges facing pediatric radiologists, and possible solutions. Evaluate and apply means of minimizing radiation exposure during diagnostic imaging and image guided therapy.

At the conclusion of the experience, participants should have an improved understanding of the technologies discussed, increasing awareness of the costs and benefits of diagnostic imaging in children and of ways to minimize risks, and an improved general knowledge of pediatric radiology, especially as it interfaces with clinical decision making.

(2012) 44 42 (Suppl 1):S1–S253 1):S142–S149 Pediatr Radiol (2014)

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DISCLOSURE In compliance with ACCME requirements and guidelines, the ACR has developed a policy for review and disclosure of potential conflicts of interest, and a method of resolution if a conflict does exist. The ACR maintains a tradition of scientific integrity and objectivity in its educational activities. In order to preserve this integrity and objectivity, all individuals participating as planners, presenters, moderators and evaluators in an ACR educational activity or an activity jointly sponsored by the ACR must appropriately disclose any financial relationship with a commercial organization that may have an interest in the content of the educational activity. The following planners, presenters, and evaluators have disclosed no financial interests, arrangements or affiliations in the context of this activity: Presenters Alyssa M. Abo, MD N. Scott Adzick, MD, MMM Evelyn Y. Anthony, MD Sudha A. Anupindi, MD George S. Bisset, MD Sarah D. Bixby, MD M. Ines Boechat, MD, FACR Debra Boyer, MD Stephen D. Brown, MD Patricia E. Burrows, MD Timothy M. Cain, MBBS Michael J. Callahan, MD Christopher I. Cassady, MD Nancy A. Chauvin, MD Govind B. Chavhan, MD, DNB, DABR Ellen M. Chung, MD Robert H. Cleveland, MD Harris L. Cohen, MD Laurie S. Conklin, MD Jesse Courtier, MD Heike E. Daldrup-Link, MD, PhD Alan Daneman, MBBCh, FRCPC Kassa Darge, MD, PhD Gabrielle deVeber, MD Jonathan R. Dillman, MD Michael A. DiPietro, MD James Donaldson, MD Lane F. Donnelly, MD Mary T. Donofrio, MD, FAAP, FASE, FACC John P. Dormans, MD, FACS Kirsten Ecklund, MD Georges El Fakhri, PhD Monica Epelman, MD Hedieh K. Eslamy, MD Judy A. Estroff, MD Kate A. Feinstein, MD Laura Z. Fenton, MD

S10 Lynn A. Fordham, MD Stéphanie Franchi-Abella, MD Donald P. Frush, MD, FACR Laurent Garel, MD Brian S. Garra, MD Michael S. Gee, MD, PhD Michael J. Gelfand, MD Maryam Ghadimi Mahani, MD Damien Grattan-Smith, MBBS S. Bruce Greenberg, MD R. Paul Guillerman, MD H. Theodore Harcke, MD, FACR, FAIUM Dianne M. Hater Shilpa V. Hegde, MBBS Marta Hernanz-Schulman, MD, FAAP, FACR Mark J. Hogan, MD Franz Wolfgang Hirsch, MD Danny R. Hughes, PhD Thierry A. G. M. Huisman, MD Allison M. Jackson, MD, MPH, FAAP Hollie A. Jackson, MD Diego Jaramillo, MD, MPH Neil D. Johnson, MBBS Nadja Kadom, MD Amy Kao, MD S. Pinar Karakas, MD Sue C. Kaste, DO Geetika Khanna, MD, MS Bernadette L. Koch, MD Anastassios C. Koumbourlis, MD, MPH Gary E. Hartman, MD, MBA Shailee V. Lala, MD Tal Laor, MD Bernard F. Laya, DO Lisa H. Lowe, MD, FAAP Jeffrey Lukish, MD John D. MacKenzie, MD Massoud Majd, MD Gerald A. Mandell, MD Prakash Masand, MD An N. Massaro, MD Martha M. Munden, MD Jonathan G. Murnick, MD, PhD Jaishree Naidoo, FCRad (Diagn) (SA), Dip Paed Rad (UCT) Dilp S. Nath, MD Rutger A. J. Nievelstein, MD, PhD Mary C. Ottolini, MD, MPH Catherine M. Owens, MRCP, FRCR Robert Pearl, MD Jeannette M. Perez-Rossello, MD Andrada R. Popescu, MD Sumit Pruthi, MD Anil Rao, MD Janet R. Reid, MD Cynthia K. Rigsby, MD Hans G. Ringertz, MD, PhD Derek J. Roebuck, FRANZCR Nabile M. Safdar, MD, MPH

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Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Pallavi Sagar, MD Charles P. Samenow, MD, MPH Guy H. Sebag, MD Victor Seghers, MD, PhD Sabah Servaes, MD Jeff Sestokas, MAEd Susan E. Sharp, MD William E. Shiels, II, DO Richard M. Shore, MD Billie L. Short, MD Manohar Shroff, MD, FRCPC Ethan A. Smith, MD Stephanie E. Spottswood, MD, MSPH A. Luana Stanescu, MD Lisa J. States, MD Keith J. Strauss, MSc, FAAPM, FACR Raymond Sze, MD George A. Taylor, MD, FACR Paul Thacker, MD Richard B. Towbin, MD Donald A. Tracy, MD S. Ted Treves, MD Andrew T. Trout, MD Andy Tsai, MD, PhD Gilbert Vézina, MD Teresa Victoria, MD, PhD Stephan D. Voss, MD, PhD Daniel B. Wallihan, MD Michele M. Walters, MD Sjirk J. Westra, MD Andrew M. Zbojniewicz, MD Planning Committee/Presenter Teresa Chapman, MD (Content reviewer) Brian D. Coley, MD John J. Crowley, MD Marilyn J. Goske, MD Edward Y. Lee, MD, MPH Sarah S. Milla, MD Ashok Panigrahy, MD Beverley Newman, MBBCh, FACR Marguerite T. Parisi, MD, MS Ed John M. Racadio, MD Dennis W. Shaw, MD Peter J. Strouse, MD, FACR Shreyas S. Vasanawala, MD, PhD

Planning Committee Richard A. Barth, MD Angela R. Davis, CAE Mary Wyers, MD

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The presenters and content reviewer listed below have disclosed the following relevant financial relationships. All potential conflicts have been resolved. Name Dorothy I. Bulas, MD Taylor Chung, MD Rajesh Krishnamurthy, MD David B. Larson, MD, MBA Helen R. Nadel, MD Alexander J. Towbin, MD

Disclosure GE and Philips, Paid Consultant Philips, Honoraria and Speaker’s Bureau Philips Electronics, Research Support Radimetrics/Bayer, Intellectual Rights, Consulting IAEA, Consultant for Pediatric Nuclear Medicine Amirsys, Royalties and Merge, Shareholder

The scientific presenters at the 2014 Annual Meeting have indicated their applicable disclosures at the end of their abstracts. No statement indicates the authors have nothing to disclose.

ACKNOWLEDGEMENTS The Society for Pediatric Radiology gratefully acknowledges the support of the following companies in presenting the 57th Annual Meeting and Postgraduate Course: Platinum GE Healthcare Philips Healthcare Siemens Healthcare Toshiba America Medical Systems Exhibitors Agfa HealthCare Elsevier EOS imaging Guerbet LLC Hitachi Aloka Medical Imorgon Medical, LLC Kubtec Digital X-ray LMT Lammers Medical Technology GmbH Merge Healthcare PACSGEAR Pediatric Radiology of America (A Division of Aris Teleradiology) As of March 14, 2014

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PROGRAM SCHEDULE The Society for Pediatric Radiology Postgraduate Course 2014

Peter J. Strouse, MD, FACR and Shreyas S. Vasanawala, MD, PhD, Course Directors The Pediatric Radiologist Consultant: Bridging Patient Care and Innovation to Improve Child Health Supported in part by an educational grant from Bayer HealthCare Pharmaceuticals, Inc. Tuesday, May 13, 2014 7:00–8:00 a.m. 7:00 a.m.–5:00 p.m. 7:45–7:50 a.m. 7:50–8:00 a.m. 8:00–9:50 a.m. 8:00–8:10 a.m. 8:10–8:20 a.m. 8:20–8:30 a.m. 8:30–8:40 a.m. 8:40–8:50 a.m 8:50–9:00 a.m. 9:00–9:10 a.m. 9:10–9:20 a.m. 9:20–9:50 a.m. 9:50–10:10 a.m. 10:10 a.m.–12:00 p.m. 10:10–10:20 a.m. 10:20–10:30 a.m. 10:30–10:40 a.m. 10:40–10:50 a.m. 10:50–11:00 a.m. 11:00–11:10 a.m. 11:10–11:20 a.m. 11:20–11:30 a.m. 11:30 a.m.–12:00 p.m.

Continental Breakfast Registration Welcome and Introduction Richard A. Barth, MD Course Overview Peter J. Strouse, MD, FACR and Shreyas S. Vasanawala, MD, PhD BODY IMAGING TECHNIQUES: PRACTICAL ADVICE FOR CLINICALWORK Taylor Chung, MD and Shreyas S. Vasanawala, MD, PhD, Moderators How Should Image Quality be Evaluated in CT? David B. Larson, MD, MBA How to Perform a Contrast Enhanced PET/CT? Stephan D. Voss, MD, PhD How to Get the Lowest Dose in Abdominal CTA? Beverley Newman, MBBCh, FACR How Do I Get the Highest Resolution MRA? Taylor Chung, MD What is a b Value and How Should I Choose It? Govind B. Chavhan, MD, DNB, DABR Can 3 T Be Used for Fetal MRI? Teresa Victoria, MD, PhD When Should Eovist and Ablavar Be Used? Shreyas S. Vasanawala, MD, PhD How Do I Optimize Doppler Ultrasound Images and Waveforms? Marta Hernanz-Schulman, MD, FAAP, FACR Q&A with RSNA Diagnosis Live™ Break THORACIC IMAGING: FOCUS ON THE LUNGS Robert H. Cleveland, MD and Edward Y. Lee, MD, MPH, Moderators Cystic Fibrosis Update & Scoring: What Does the Pulmonologist Want to Know? Robert H. Cleveland, MD Children’s Interstitial Lung Disease (ChILD) 2014 Catherine M. Owens, MRCP, FRCR How Do I Perform a Dynamic Airway CT in Infants and Children? S. Bruce Greenberg, MD Update on Pulmonary Embolus in Children: What Does the Radiologist Need to Know? Pallavi Sagar, MD Pediatric Lung Neoplasms: Understanding Underlying Genetic Causes R. Paul Guillerman, MD Using SSDE to Manage Thoracic CT Radiation Dose in Children Keith J. Strauss, MSc, FAAPM, FACR HRCT in Pediatric Patients: When & How? Shilpa V. Hegde, MBBS MRI of the Lungs and Airways: Current Practical Imaging Approach Edward Y. Lee, MD, MPH Q&A with RSNA Diagnosis Live™

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S14 12:00–1:15 p.m. 1:15–3:05 p.m.

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4:45–5:15 p.m. 5:15 p.m.

Lunch GASTROINTESTINAL IMAGING: FOCUS ON THE PANCREAS & BOWEL Kassa Darge, MD, PhD and Jonathan R. Dillman, MD, Moderators How to Perform & Interpret a Secretin MRCP? Andrew T. Trout, MD Which Pancreatic Ductal Variants Predispose to Pancreatitis? Sudha A. Anupindi, MD What are the Imaging Signs of Pancreatic Ductal Trauma? Michael J. Callahan, MD How to Distinguish Acute Inflammation from Chronic Fibrosis in Crohn’s Disease? Ethan A. Smith, MD How to Image and Classify Perianal Fistulae? Jonathan R. Dillman, MD How to Interpret a Pelvic MRI After Rectal Pullthrough? Alexander J. Towbin, MD What is the Role of Ultrasound in Intestinal Malrotation? Alan Daneman, MBBCh, FRCPC What is Known About Radiation Issues in Imaging of IBD? Kassa Darge, MD, PhD Q&A with RSNA Diagnosis Live™ Break GENITOURINARY IMAGING: FOCUS ON GONADAL RADIOLOGY Lane F. Donnelly, MD and S. Pinar Karakas, MD, Moderators What is the Role of Imaging in Testicular Trauma and its Follow-up? Laura Z. Fenton, MD Torsion of the Testis: What is the Role of Doppler and What are Concerning Flow Patterns? Lynn A. Fordham, MD How and When Should a Radiologist Reduce Testicular Torsion? Laurent Garel, MD When and How to Find the Undescended Testicle: To Search or Not to Search? Kate A. Feinstein, MD Intersex States/Gonadal Dysgenesis: What is the Role of Gonadal Imaging? Ellen M. Chung, MD What is the Best Imaging Modality for Torsion of the Ovary/Fallopian Tube? S. Pinar Karakas, MD Pediatric Adnexal Masses: If, When, and What Constitutes Appropriate Follow-Up? Evelyn Y. Anthony, MD What is the Imaging Contribution to the Diagnosis of PCOS? Dorothy I. Bulas, MD Q&A with RSNA Diagnosis Live™ Adjourn

Wednesday, May 14, 2014 6:00 a.m.

SPR Research and Education Foundation Fun Run—Underwritten by Texas Children’s Hospital

1:15–1:25 p.m. 1:25–1:35 p.m. 1:35–1:45 p.m. 1:45–1:55 p.m. 1:55–2:05 p.m. 2:05–2:15 p.m. 2:15–2:25 p.m. 2:25–2:35 p.m. 2:35–3:05 p.m. 3:05–3:25 p.m. 3:25–5:15 p.m. 3:25–3:35 p.m. 3:35–3:45 p.m. 3:45–3:55 p.m. 3:55–4:05 p.m. 4:05–4:15 p.m. 4:15–4:25 p.m. 4:25–4:35 p.m. 4:35–4:45 p.m.

7:00–8:00 a.m. 7:00 a.m.–5:00 p.m. 7:50–8:00 a.m. 8:00–9:50 a.m. 8:00–8:10 a.m. 8:10–8:20 a.m. 8:20–8:30 a.m.

(Entrance fee is $25 and includes a T-shirt) Continental Breakfast Registration Welcome and Announcements Peter J. Strouse, MD, FACR and Shreyas S. Vasanawala, MD, PhD MUSCULOSKELETAL IMAGING: FOCUS ON ONCOLOGY Diego Jaramillo, MD, MPH and John D. MacKenzie, MD, Moderators Radiographic and CT Characterization of Aggressive Bone Lesions Tal Laor, MD MRI Characterization of Bone Lesions Diego Jaramillo, MD, MPH Staging and Assessment of Treatment Response in Osteosarcoma and Ewing Sarcoma Kirsten Ecklund, MD

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 8:30–8:40 a.m. 8:40–8:50 a.m. 8:50–9:00 a.m. 9:00–9:10 a.m. 9:10–9:20 a.m. 9:20–9:50 a.m. 9:50–10:10 a.m. 10:10 a.m.–12:00 p.m. 10:10–10:20 a.m. 10:20–10:30 a.m. 10:30–10:40 a.m. 10:40–10:50 a.m. 10:50–11:00 a.m. 11:00–11:10 a.m. 11:10–11:20 a.m. 11:20–11:30 a.m. 11:30 a.m.–12:00 p.m. 12:00 p.m.

MRI of Bone Marrow Nancy A. Chauvin, MD Whole Body MRI with DWI for Tumor Staging and Surveillance Jesse Courtier, MD Strategies to Image Around Hardware After Limb Salvage Surgery John D. MacKenzie, MD Osteonecrosis in BMT & Oncology Patients Sue C. Kaste, DO MSK Tumor Imaging—What the Pediatric Orthopedic Surgeon Wants to Know John P. Dormans, MD, FACS Q&A with RSNA Diagnosis Live™ Break & Exhibits CHILD ABUSE & NOT CHILD ABUSE: FOCUS ON RADIOGRAPHY Jeannette M. Perez-Rossello, MD and Peter J. Strouse, MD, FACR, Moderators Classic Metaphyseal Lesion-Micro-CT/Histopathologic Correlation Andy Tsai, MD, PhD Differential Diagnosis of Metaphyseal Fractures Sabah Servaes, MD Rickets Richard M. Shore, MD Rib Fractures: Location and Mechanisms Paul K. Kleinman, MD Imaging of the Skull: Is that a Fracture? Peter J. Strouse, MD, FACR Dating of Fractures Michele M. Walters, MD What is the Role for Follow-up Skeletal Surveys? Jeannette M. Perez-Rossello, MD What Does the Child Abuse Physician Need to Know & How to Tell Us Allison M. Jackson, MD, MPH, FAAP Q&A with RSNA Diagnosis Live™ Adjourn Postgraduate Course

The Society for Pediatric Radiology Annual Meeting Program 2014

Richard A. Barth, MD, Program Director Sarah S. Milla, MD, Ashok Panigrahy, MD and Mary Wyers, MD, Workshop Directors The Pediatric Radiologist Consultant: Bridging Patient Care and Innovation to Improve Child Health

Wednesday, May 14, 2014 12:05–1:15 p.m. 12:05–1:15 p.m.

12:05–1:15 p.m.

1:20 p.m.

Lunch 3D Read with the Experts Lunch (advance registration required; attendance is limited) Dianna M.E. Bardo, MD and Jeffrey C. Hellinger, MD, Moderators Supported by GE Healthcare, Philips Healthcare, Siemens Healthcare, Vital MR Protocol Lunch Session (advance registration required; attendance is limited) Shreyas S. Vasanawala, MD, PhD and Rajesh Krishnamurthy, MD, Moderators Supported by GE Healthcare, Philips Healthcare, Siemens Healthcare, Toshiba America Medical Systems Session Topics: Diffusion for Oncologic Applications, MR Angiography and Volumetric Spin Echo Welcome Richard A. Barth, MD

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S16 1:30–2:30 p.m.

2:30–3:30 p.m.

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6:15–7:30 p.m.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Edward B. Neuhauser Lecture The Future of American Medicine—The Impact of Health Care Reform Robert Pearl, MD Executive Director and CEO The Permanente Medical Group, Kaiser Permanente Oakland, California M&M Cases: Stump the Experts George A. Taylor, MD, FACR, Moderator Panelists: Donald P. Frush, MD, Marta Hernanz-Schulman, MD, FAAP, FACR, Neil D. Johnson, MBBS, Catherine M. Owens, MRCP, FRCR, Hans G. Ringertz, MD, PhD and Guy H. Sebag, MD Breaks & Exhibits Scientific Session I-A: Oncology & Nuclear Medicine (concurrent) Stephan D. Voss, MD, PhD and Rutger A.J. Nievelstein, MD, PhD, Moderators Whole Body Staging of the Pediatric Oncology Patient Heike E. Daldrup-Link, MD, PhD Scientific Papers—Oncology & Nuclear Medicine 4:10 Lin Does Surveillance Imaging of Childhood Rhabdomyosarcoma Improve Patient Survival? 4:20 Lyons Prognostic Value of Image-Defined Risk Factors in High-Risk Neuroblastoma 4:30 Guillerman The DICER1 Pleuropulmonary Blastoma Family Tumor and Dysplasia Syndrome (PPB-FTDS): Role of the Pediatric Radiologist in Diagnosis and Screening 4:40 Nguyen MR imaging patterns of leukemia and lymphoma 4:50 McCarten Retrospective review of bone changes in Hodgkin Lymphoma utilizing CT, 18F FDG-PET, 99m Tc-MDP bone scan and MRI from Children’s Oncology Group intermediate stage protocol AHOD0031. 5:00 Mhlanga Does contrast-enhanced CT (CECT) provide additional information to low dose CT/PET in pediatric Hodgkin Lymphoma? Scientific Session I-B: Gastrointestinal (concurrent) Alan Daneman, MBBCh, FRCPC and Ethan A. Smith, MD, Moderators Some Updated Clinical and Biological Perspectives of Neuroblastoma Anthony Sandler, MD Scientific Papers—Gastrointestinal 4:10 Serai Assessment of Hepatic Fibrosis in Pediatric Chronic Liver Disease with MR Elastography 4:20 Smith Ultrasound-Derived Shear Wave Speed Correlates with Liver Fibrosis in Children 4:30 Munden Acoustic Structural Quantification as a Potential Biomarker of Steatosis and Fibrosis in Pediatric Liver Disease 4:40 Gwal Reference Values of MRI measurements of the normal bile ducts and pancreatic duct in children 4:50 Brown Pediatric MRCP: Evaluation of the Pancreatic Duct 5:00 Fernandes Prussian Blue Nanoprobes for MRI-based Imaging of Eosinophilic Esophagitis Adjourn Awards Ceremony • Gold Medalist • Pioneer Honoree • Presidential Recognition Award • Honorary Member • Singleton-Taybi Award • Heidi Patriquin Award • Jack O. Haller Award Welcome Reception

Thursday, May 15, 2014 6:45–8:00 a.m. 6:30 a.m.–5:00 p.m. 7:00–8:20 a.m.

7:00–7:10 a.m.

Continental Breakfast Registration Sunrise Sessions (concurrent) IMPACT OF MRI AND CT IMAGING ON MANAGEMENT OF CHD Rajesh Krishnamurthy, MD, Moderator Newborn with Congenital Heart Disease Prakash Masand, MD

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 7:10–7:20 a.m. 7:20–7:30 a.m. 7:30–7:40 a.m. 7:40–7:50 a.m. 7:50–8:15 a.m. 8:15–8:20 a.m.

7:00–7:20 a.m. 7:20–7:40 a.m. 7:40–8:00 a.m. 8:00–8:20 a.m.

7:00–7:20 a.m. 7:20–7:40 a.m. 7:40–8:00 a.m. 8:00–8:20 a.m.

7:00–7:15 a.m. 7:15–7:45 a.m. 7:45–7:55 a.m. 7:55–8:05 a.m. 8:05–8:20 a.m. 7:00–8:20 a.m.

8:30–10:40 a.m. 8:30–8:50 a.m. 8:50–10:40 a.m. PA-013 PA-014 PA-015 PA-016 PA-017 PA-018 PA-019 PA-020 PA-021

Pre Glenn Evaluation in Single Ventricle Andrada R. Popescu, MD Repaired Tetralogy of Fallot S. Bruce Greenberg, MD s/p Arterial Switch Procedure for d-TGA Taylor Chung, MD Anomalous Aortic Origin of the Coronary Arteries Rajesh Krishnamurthy, MD MRI and CT for Surgical Decision Making in CHD: Where Do They REALLY Make a Difference? Dilip S. Nath, MD Question and Answer IMPROVING COMMUNICATION AND QUALITY David B. Larson, MD, MBA, Moderator Diagnostic Errors Lane F. Donnelly, MD Communicating with Parents About Radiation Risk: Doctor, Is a CT Scan Safe for My Child? Marilyn J. Goske, MD Establishing a Radiology Department Quality Improvement Program David B. Larson, MD, MBA Question and Answer FRIENDLY DEBATES: PEDIATRICIANS AND RADIOLOGISTS UNITE James Donaldson, MD, Moderator Point of Care Ultrasound—Who Should be Doing Ultrasound? William E. Shiels, II, DO vs. Alyssa M. Abo, MD Pediatric Lumps and Bumps: Ultrasound or MRI? Harris L. Cohen, MD vs. Thierry A. G. M. Huisman, MD Renal Artery Stenosis-MRA, CTA, US or IR? James Donaldson, MD vs. Ethan A. Smith, MD Question and Answer REVIEWING FOR PEDIATRIC RADIOLOGY Peter J. Strouse, MD, FACR, Moderator Introduction: Overview of the Review Process Peter J. Strouse, MD, FACR Evaluation of a Manuscript, Section by Section Brian D. Coley, MD, Cynthia K. Rigsby, MD and Geetika Khanna, MD, MS From a Reviewer’s Perspective: How I Approach a Review Alexander J. Towbin, MD What Happens After Review: How to Make Your Reviews Most Helpful to the Editors Peter J. Strouse, MD, FACR Question and Answer CT PROTOCOL SESSION (advance registration required; attendance limited) Michael J. Callahan, MD and Sjirk J. Westra, MD, Moderators Supported by GE Healthcare, Philips Healthcare, Siemens Healthcare and Toshiba America Medical Systems Session Topics: General Dose Considerations, Chest, Abdomen Scientific Session II-A: Neuroradiology (concurrent) Sarah S. Milla, MD and Dennis W. Shaw, MD, Moderators Neuroimaging During and After Therapeutic Hypothermia for Hypoxic Ischemic Encephalopathy An N. Massaro, MD Scientific Papers—Neuroradiology 8:50 Verhey Rate of agreement for manual and automated techniques for determination of new T2 lesions in children with multiple sclerosis and acute demyelination 9:00 Verhey MRI Features Distinguish Monophasic ADEM from MS: Findings from a Canadian Cohort of Children with Incident CNS Demyelination 9:10 Nagaraj Improved cerebral perfusion following open heart surgery in newborns with complex congenital heart disease 9:20 Jerdee Faster Pediatric MRI 9:30 Hercher Reduced field-of-view EPI diffusion tensor imaging of the spine for CNS tumors 9:40 Bireley The Spectrum of Neuroimaging and Clinical Findings in Children with Optic Nerve Hypoplasia: Should SOD Be DNR? 9:50 Hayes Altered Neural Activation in Children with Sports-Related Concussion Revealed with fMRI 10:00 Klobuka Diffusion and Perfusion Correlates of Heterogeneous Treatment Response in Peptide-Based Pediatric Glioma Immunotherapy 10:10 Januzis Radiation Dose to the Lens of the Eye for Neuroradiology CT Protocols in Pediatric Patients

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PA-023 8:30–10:40 a.m. 8:30–8:50 a.m. 8:50–10:40 a.m. PA-024

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10:20

Tekes

Does near infrared spectroscopy (NIRS) as marker of brain autoregulation correlate with apparent diffusion coefficient scalars in neonates who were treated with brain cooling for perinatal hypoxic ischemic injury (HII)? 10:30 Josephs Neonatal retropharyngeal cysts: Imaging, surgical and pathologic considerations. Scientific Session II-B: Cardiovascular (concurrent) Lorna P. Browne, MD and Cynthia K. Rigsby, Moderators What’s New in Fetal Cardiac Diagnosis and Treatment Mary T. Donofrio, MD, FAAP, FASE, FACC Scientific Papers—Cardiovascular 8:50 Hsiao Simultaneous 4D phase-contrast velocity and signal dispersion rendering may improve qualitative and quantitative evaluation of tricuspid and pulmonary regurgitation in repaired Tetralogy of Fallot 9:00 Popescu A Comparison of Standard MRA using Extracellular Contrast with Respiratory and ECG triggered Gradient Echo MRA Imaging using Blood Pool Contrast 9:10 Rigsby Safety of a Blood Pool Contrast Agent in Children and Young Adults 9:20 Krishnamurthy Biomechanical Differences between Functional Single Left and Right Ventricles in Pediatric Population: A MRI based Comparison of Myocardial Strain and Torsion in an Asymptomatic Cohort 9:30 Atweh Comparison of Two Single Breath-held 3D Cine Steady-State Free Precession with 2D Breath-held acquisition (BH-SSFP) in unsedated patients with single ventricles 9:40 Krishnamurthy Unsupervised free-breathing 3-dimensional imaging of morphology, function and flow in congenital heart disease (CHD) under 30min: pilot study 9:50 Malone Clinical evaluation of a novel MR angiographic protocol in congenital heart disease (CHD) using time resolved imaging and free-breathing steady state imaging following administration of blood pool contrast agent (BPCA) 10:00 Krishnamurthy Inter -Observer Variability in Manual Measurement of Aortic Root Dimensions in Pediatric Patients: Benefits of using a Semi-Automated Tool 10:10 Biko High-Resolution Sub-mm Coronary MRA for the evaluation of patients with Anomalous Coronary Artery—Visualization of the Intramural Segment 10:20 Krishnamurthy Biomodeling and Fitting Studies for Total Artificial Heart Implantation in Children 10:30 Luhar Magnetic Resonance Venography in Pediatric Patients with Chronic Kidney Disease: Initial Experience with Ferumoxytol. Scientific Session II-C: ALARA (concurrent) Timothy M. Cain, MBBS and Marilyn J. Goske, MD, Moderators Recent Trends in CT Dose and Image Quality Optimization: What the Practicing Radiologist Needs to Know David B. Larson, MD, MBA Scientific Papers—ALARA 8:50 Goske Quality Improvement Registry in CT Scans in Children (QuIRCC) Pediatric Diagnostic Reference Levels (DRL) compared to Adult-focused Facilities in the American College of Radiology (ACR) Dose Index Registry(DIR) 9:00 Goske Quality Improvement Registry in CT Scans in Children (QuIRCC): Diagnostic Reference Levels for Pediatric Chest CT 9:10 Brinkley Effects of Automatic Tube Potential Selection on Radiation Dose, Image Quality and Lesion Detectability in Pediatric Abdominopelvic CT and CTA: A Phantom Study. 9:20 Zhu Dual energy compared to single energy CT scans in pediatric patients: dose neutral or not? 9:30 Samei Comprehensive Image Quality Phantom for Pediatric and Adult CT Imaging 9:40 Derderian Increased Organ Dose in Overlapped Upper Abdomen CT Scans of Chest and Abdomen/Pelvis 9:50 Thomas Parental Perception of Potential Risk associated with Ionizing Radiation Exposure from Computed Tomography 10:00 Zucker Impact of California CT Dose Reporting Requirements: Survey of Radiologists

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10:30 Jung Break & Exhibits Scientific Session III-A: Public Policy, Healthcare, Education, Technology (concurrent) Neil D. Johnson, MBBS and Janet R. Reid, MD, Moderators How Physicians Can Become More Effective Teachers Mary C. Ottolini, MD, MPH Scientific Papers—Public Policy, Healthcare, Education, Technology 11:20 Yaniv A Cost Effective High Fidelity Fluoroscopy Simulator 11:30 Benya Evaluation of Simulation Education to Improve Performance of Fluoroscopic Upper Gastrointestinal Exams in Infants with Bilious Emesis 11:40 Shekhar Integration of high-speed single- and multi-modality deformable image registration with clinical PACS 11:50 Donnelly Reliable and Efficient Supply Chain Management in Pediatric Radiology—Implementation of a 2-Bin Demand Flow System Scientific Session III-B: Genitourinary (concurrent) Damien Grattan-Smith, MBBS and Donald A. Tracy, MD, Moderators How Does Functional MR Urography Help Pediatric Urologists? Stephen A. Zderic, MD Scientific Papers—Genitourinary 111:20 Cerrolaza Hydronephrosis Severity Diagnosis From Ultrasound Imaging Biomarkers 111:30 Grattan-Smith Evaluation of Works-In-Progress package for MR urography post-processing 111:40 Pugmire Automated assessment of 3-compartment renal function using Factor Analysis of Dynamic Sequences (FADS) in MR Urography (MRU) 111:50 Hammer Pediatric UPJ Obstruction—Can MR Urography Identify Crossing Vessels and Do They Matter? Lunch jSPR and AAWR Joint Luncheon (advanced registration required) A Panel Discussion—Research: How We Do It Moderator: Sarah S. Milla, MD Panelists: Heike E. Daldrup-Link, MD, PhD, Marilyn J. Goske, MD, Tal Laor, MD and Susan E. Sharp, MD Ultrasound Protocol Session (advance registration required; attendance limited) Brian D. Coley, MD and Laura Z. Fenton, MD, Moderators Supported by GE Healthcare, Philips Healthcare, Siemens Healthcare and Toshiba America Medical Systems Session Topics: Contrast Applications, Elastography, Musculoskeletal Community Based Pediatric Radiologists Lunch (advance registration required) Scientific Session IV-A : Gastrointestinal (concurrent) Kate A. Feinstein, MD and Michael S. Gee, MD, PhD, Moderators Update on Pediatric Inflammatory Bowel Disease: Questions to be Answered by Imaging Laurie S. Conklin, MD Scientific Papers—Gastrointestinal 1:50 Kulkarni Should Routine UGIs Include Screening for Swallowing Dysfunction? 2:00 Gaffney Title: Diagnostic yield of the upper gastrointestinal (UGI) series in the pediatric outpatient setting: Low enough to say no? 2:10 Serai Retrospective Comparison of GRE T2* and SE T2 Analysis Methods for Estimating Liver Iron Content 2:20 Ruangwattanapaisarn Faster Pediatric 3T Abdominal Single Shot MRI: Comparison between Conventional and Flip Angle Modulated Single Shot Fast Spin Echo sequences 2:30 Potnick Fast Pediatric 3D Free Breathing Abdominal Dynamic Contrast Enhanced MRI with High Spatiotemporal Resolution 2:40 Koning Contrast Enhanced Magnetic Resonance Evaluation of Acute Appendicitis in the Pediatric Population: Efficacy of a Novel Imaging Protocol 2:50 Didier Accuracy of Diagnosing Pediatric Acute Appendicitis with ReducedCTDIvol CT Using Iterative Reconstruction: A Comparison with Traditional Weight-Based FBP

11:00–11:20 a.m. 11:20 a.m.–12:00 p.m. PA-046 PA-047

PA-048 PA-049 11:00 a.m.–12:00 p.m. 11:00–11:20 a.m. 11:20 a.m.–12:00 p.m. PA-050 PA-051 PA-052 PA-053 12:00–1:30 p.m. 12:00–1:30 p.m.

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Monitoring Radiation Exposures from Pediatric CT in Child Visits to Pediatric and Adult-focused Emergency Departments Development of a comprehensive risk assessment methodology for pediatric patients undergoing all types of imaging examinations using ionizing radiation The recent trend of pediatric CT dose in Korea

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

S20 PA-061 PA-062 PA-063 PA-064 1:30–3:40 p.m. 1:30–1:50 p.m. 1:50–3:40 p.m. PA-065 PA-066 PA-067 PA-068 PA-069 PA-070 PA-071 PA-072 PA-073 PA-074 PA-075

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3:00

Sharatz

Determination of CT enterographic and MR enterographic imaging biomarkers of active Crohn disease in pediatric patients 3:10 Cerrolaza Quantitative Imaging Biomarkers of Chron’s Disease 3:20 Greer Can MRE screen for perianal disease in pediatric IBD? 3:30 Ayyala Comparison of hand versus mechanical administration of intravenous contrast: Quality of Abdominal CTA in pediatric patients. Scientific Session IV-B: Chest (concurrent) Beverley Newman, MBBCh, FACR and R. Paul Guillerman, MD, Moderators Update on ECMO: A Clinician’s Perspective Billie L. Short, MD Scientific Papers—Chest 1:50 White Postnatal Chest CT Findings after Left Congenital Diaphragmatic Hernia (CDH) Repair. 2:00 Compton Main Pulmonary Artery:Aorta Diameter Ratio in Normal Children on MDCT 2:10 Nevrekar Pulmonary Hypertension in Children: CMR with Phase Contrast Imaging to Identify Prognostic Indicators 2:20 Halula Establishing accuracy of airway measurements via CT in pediatrics 2:30 Martelius Correlation of lung ultrasound artefacts to chest CT in children 2:40 Dunnavant Chest Radiographic Features of Human Metapnueumovirus Infection in Pediatric Patients 2:50 Zhao Going Beyond the Haller Index: Model-based Costal Cartilage Estimation for Surgical Planning of Pectus Excavatum 3:00 Breen Clinical Significance of Incidental Pulmonary Nodules Detected on Abdominal CT in Pediatric Patients 3:10 Zucker Radiologist Compliance with California CT Dose Reporting Requirements: Review of Pediatric Chest CT 3:20 Kino Minimum CTA Radiation Dose and the Impact of Iterative Reconstruction in Children: a Prospective Randomized Trial 3:30 Schooler Evaluation of contrast administration site effectiveness when performing hand administration of intravenous contrast for thoracic CT angiography in pediatric patients Break & Exhibits Scientific Session V-A: Neuroradiology (concurrent) Ashok Panigrahy, MD and Bernadette L. Koch, MD, Moderators Update on Low Grade Pediatric Glioma Eugene Hwang, MD Scientific Papers—Neuroradiology 4:20 Palasis Neuroimaging Evaluation in Children Under Two Years of Age with Suspected Non Accidental Trauma: Impact of Early Brain and Cervical Spine MRI 4:30 Flom Optimizing A FAST-MR Protocol for Abusive Head Trauma Screening 4:40 Altinok Evaluation of Ruptured thrombosed bridging veins by Susceptibility Weighted Imaging in Non Accidental Trauma 4:50 Beavers MR Detection of Retinal Hemorrhages: Correlation with Graded Ophthalmologic Exam 5:00 Bosemani Diffusion tensor imaging of the brainstem in children with achondroplasia 5:10 Olson Are those dots important? Focal susceptibility on Gradient Echo imaging: incidence and potential significance in pediatric brain tumor patients following whole brain radiation 5:20 Sharma Diffusion Weighted MR Imaging in Retinoblastoma Scientific Session V-B: Genitourinary (concurrent) Kassa Darge, MD, PhD and Anil G. Rao, DMRD, DNB, Moderators Voiding Function and Dysfunction - What Can Pediatric Radiologists Tell Us? Stephen A. Zderic, MD Scientific Papers – Genitourinary 4:20 Darge Forty-five extravesical ectopic ureters: morphological and functional MR urography (fMRU) findings 4:30 Johnson Nationwide emergency department imaging practices for pediatric urolithiasis patients: room for improvement 4:40 Orth Renal ultrasound for infants under 2months of age with a first febrile urinary tract infection 4:50 Back In-vitro Optimization of a New US Contrast Agent for Intravesical Administration in Children 5:00 Darge Intra- and interobserver variability of functional MR urography (fMRU) analysis results

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Adjourn

S21 Clinical and Imaging Features of Tuberous Sclerosis Complex/Autosomal Dominant Polycystic Kidney Disease: A Unique Genetic Disorder Outcome’s Predictors of Children With Primary Non Refluxing Megaureter Prenatally Detected

Friday, May 16, 2014 6:45–8:00 a.m. Continental Breakfast 6:30 a.m.–5:00 p.m. Registration 7:00–8:20 a.m. Sunrise Sessions (concurrent)

7:00–7:20 a.m. 7:20–7:40 a.m. 7:40–8:00 a.m. 8:00–8:20 a.m.

7:00–7:20 a.m. 7:20–7:40 a.m. 7:40–8:00 a.m. 8:00–8:20 a.m. 7:00–8:20 a.m.

7:00–7:40 a.m. 7:40–8:20 a.m.

7:00–7:20 a.m. 7:20–7:40 a.m. 7:40–8:00 a.m. 8:00–8:20 a.m.

7:00–7:20 a.m. 7:20–7:40 a.m. 7:40–8:00 a.m.

ADVANCED BODY MRI Damien Grattan-Smith, MBBS, Moderator MR Urography-Current Technique and Practice Damien Grattan-Smith, MBBS MR Enterography—Technique, Pearls and Pitfalls Shailee V. Lala, MD MR Elastography: How and When to Do It Daniel B. Wallihan, MD Question and Answer THE WORLD FEDERATION OF PEDIATRIC IMAGING (WFPI) M. Ines Boechat, MD, FACR, Moderator Volume Sweep Imaging and Worldwide Opportunities for Rural Outreach Brian S. Garra, MD Worldwide TB: What the Radiologist Needs to Know Bernard F. Laya, DO Chest Ultrasound for Pediatric TB Jaishree Naidoo, FCRad (Diagn) (SA), Dip Paed Rad (UCT) Question and Answer EDUCATION & COMMUNICATION: THE ART AND PRACTICE OF COMMUNICATION IN PEDIATRIC RADIOLOGY: AVIDEO-BASED, INTERACTIVE APPROACH Stephen D. Brown, MD, Moderator Bernadette L. Koch, MD and Dianne M. Hater, Co-Moderators Communicating Bad News Medical Error Disclosure FETAL Christopher I. Cassady, MD, Moderator Fetal Brain Imaging Hollie A. Jackson, MD 3T Fetal Imaging & Safety Teresa Victoria, MD, PhD Fetal Brain MRI-Perspective of a Fetal Neurologist Adré J. du Plessis, MBChB Question and Answer MUSCULOSKELETAL Tal Laor, MD, Moderator Adolescent Hip Pain Jeffrey L. Hanway, MD Radiology of the Adolescent Hip Sarah D. Bixby, MD MRI of the Adolescent Hip: Advanced Techniques Nabile M. Safdar, MD, MPH

S22 8:00–8:20 a.m. 8:30–10:50 a.m.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

Question and Answer Scientific Session VI-A: Interventional (concurrent) James Donaldson, MD and John M. Racadio, MD, Moderators 8:30–8:50 a.m. What’s New in the Management of Pediatric Appendicitis Gary E. Hartman, MD, MBA 8:50–10:50 a.m. Scientific Papers—Interventional PA-090 8:50 Patel Contrast induced nephropathy following high contrast dose angiographic procedures PA-091 9:00 Metwalli Orbital Lymphatic malformations: Does treatment with percutaneous bleomycin have promise? PA-092 9:10 Kukreja Venous thrombolysis in children under 24months PA-093 9:20 Chiramel Impact of endovascular treatment for extensive veno-occlusive deep vein thrombosis in the pediatric population. PA-094 9:30 Sharma Endovascular Management of Extensive Venous Thrombosis in Adolescent Patients-A Single Center Experience PA-095 9:40 Zahra IVC Filter Retrieval in Children: Experience in a Tertiary Pediatric Center PA-096 9:50 Kurzendorfer 3D Fusion of preprocedural MRI with intraprocedural C-arm CT for confirmation of bone biopsy location in pediatric interventional radiology PA-097 10:00 Hwang First Experience with iGuide Navigational Software Application for Bone Biopsies in Pediatric Interventional Radiology PA-098 10:10 Jawahar Clinical and surgical correlation of Hip MR Arthrographic findings in adolescents PA-099 10:20 Nguyen Clinical impact of diagnostic image guided hip steroid injections in CP patients with neuromuscular hip subluxation PA-100 10:30 Cornejo Utility of intra-arterial Verapamil injection in patients with posttraumatic vasospasm monitored by transcranial Doppler. PA-101 10:40 Davis The Management Challenges of Intra-Oral Sclerotherapy 8:30–10:50 a.m. Scientific Session VI-B: Musculoskeletal (concurrent) Tal Laor, MD and Rebecca Stein-Wexler, MD, Moderators 8:30–8:50 a.m. Pediatric Sports Injuries: What the Orthopedic Surgeon Needs from Radiology John F. Lovejoy, III, MD 8:50–10:50 a.m. Scientific Papers—Musculoskeletal PA-102 8:50 Ho-Fung MRI diagnosis of discoid lateral meniscus in children—Usefulness of morphometric values with arthroscopic and normal control group correlation. PA-103 9:00 Ntoulia Diffusion tensor imaging in evaluation of Anterior Cruciate Ligament microstructure. Preliminary data in children with normal ACL and children with ACL tears. PA-104 9:10 Githu 3D Isotropic Resolution Fast Spin-Echo Knee MR imaging—Diagnostic Performance Compared to Conventional MR Imaging at 1.5T. PA-105 9:20 Akyol Expected Knee MRI Findings in Symptomatic Children with Achondroplasia PA-106 9:30 Stewart Pediatric Traumatic Posterior Hip Dislocation: Emerging Role of MRI PA-107 9:40 Hill Prevalence and prognosis of osteonecrosis of the hips in children with Trichothiodystrophy with osteosclerosis. PA-108 9:50 Eghbal Indirect Shoulder Magnetic Resonance Arthrography: A Novel Technique for Identifying Labral Pathology in Young Patients PA-109 10:00 Ma Temporomandibular joint involvement in Juvenile Idiopathic Arthritis (JIA): Are there thresholds that distinguish normal from mild TMJ involvement? PA-110 10:10 Kim Quantitative Skeletal Muscle MR Imaging: MR spectroscopy (MRS) as a noninvasive biomarker to determine pathologic fatty infiltration: Comparison between boys with Duchenne muscular dystrophy (DMD) and healthy boys PA-111 10:20 Massey Does double reading skeletal surveys improve sensitivity of diagnosing nonaccidental trauma? PA-112 10:30 Chang Radiologist and CPT physician preferences for inclusion of computerized tabulations of multiple fractures in skeletal survey reports. PA-113 10:40 Wang Longitudinal Assessment of Bone Loss Using Quantitative Ultrasound in a Blood-Induced Arthritis Rabbit Model 10:50–11:10 a.m. Break & Exhibits 11:10 a.m.–12:30 p.m. Scientific Session VII-A: Public Policy, Healthcare, Education, Technology (concurrent) George S. Bisset, MD and Keith S. White, MD, Moderators 11:10–11:30 a.m. Payment for Value: The Practice of Radiology in a post-ACA World Danny R. Hughes, PhD 11:30 a.m.–12:30 p.m. Scientific Papers—Public Policy, Healthcare, Education, Technology PA-114 11:30 Heller Incorporating a radiology resident consultant into daily pediatric rounds: What is the value? PA-115 11:40 Zucker Added Value of Radiologist Consultation for Pediatric Ultrasound: Implementation and Survey Assessment PA-116 11:50 Hyatt No longer a holiday: Improving the pediatric radiology elective for medical students and pediatric housestaff PA-117 12:00 Back 5min Ultrasound: Validation of Point-of-Care Milestone learning in small aliquots PA-118 12:10 Back How and How Well Do Pediatric Radiology Fellows Learn Ultrasound? A National Survey. PA-119 12:20 Towbin Evaluating the transcription accuracy of a clinical speech recognition system

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11:10 a.m.–12:30 p.m. Scientific Session VII-B: Fetal (concurrent) Christopher I. Cassady, MD and Teresa Chapman, MD, MA, Moderators 11:10–11:30 a.m. Fetal Surgery for Lung Lesions N. Scott Adzick, MD, MMM 11:30 a.m.–12:30 p.m. Scientific Papers—Fetal PA-120 11:30 Estroff A normative spatiotemporal MRI template of human fetal brain growth in-utero PA-121 11:40 Estroff Volumetric reconstruction of fetal brain MRI on 3T versus 1.5T scanners PA-122 11:50 Evangelou Retrospective motion correction and signal recovery in MR Spectroscopy of the fetal brain PA-123 12:00 Mehollin-Ray Pre- and post-operative fetal MRI appearance of the brains and spines of patients with open neural tube defects who underwent in utero repair. PA-124 12:10 Rosines Correlation between spleen and stomach position by MR with the presence of a hernia sac in fetuses with left-sided congenital diaphragmatic hernia. PA-125 12:20 Afacan Preliminary results on measuring fetal lung maturation using diffusion weighted MRI at 3T 12:30–1:45 p.m. SPR Members’ Business Meeting & Lunch 1:45–3:55 p.m. Scientific Session VIII-A: Fetal (concurrent) Judy A. Estroff, MD and Teresa Victoria, MD, PhD, Moderators 1:45–2:05 p.m. Fetal Surgery for Myelomeningocele N. Scott Adzick, MD, MMM 2:05–3:55 p.m. Scientific Papers—Fetal PA-126 2:05 Otero Real-time Cine Magnetic Resonance Imaging of Swallowing Abnormalities in the Fetus with Head and Neck Pathology: Frequency and Patterns PA-127 2:15 Jennings Disorders of Sex Differentiation (DSD): The Radiologist’s Role in Prenatal Diagnosis PA-128 2:25 Ayyala Prenatal Observation of Echogenic Kidneys: What Have We Learned? PA-129 2:35 Seed MRI Shows Limited Mixing Between Systemic and Pulmonary Circulations in Fetal Transposition of the Great Arteries—A Potential Cause of In Utero Pulmonary Vascular Disease PA-130 2:45 Jadhav Novel approach for cardiovascular CT in neonates and infants using indication-based, first-pass contrast enhanced, ‘target-mode’ prospective EKG-gated volumetric imaging PA-131 2:55 Sammet An imaging strategy for lower dose cardiac CTA in infants PA-132 3:05 White Impact of Intravenous Radiographic Contrast Administration on Serum Creatinine in Neonates. PA-133 3:15 Patil Neonatal Necrotizing Enterocolitis: Quality of Reporting of Diagnostic Accuracy of Abdominal Ultrasound—A Systematic Review PA-134 3:25 Otero MR Imaging evaluation of liver lesions in children: Added Value of Hepatobiliary Contrast PA-135 3:35 Tun Cerebral ultrasound findings in neonates undergoing whole body hypothermia for hypoxic ischemic encephalopathy PA-136 3:45 Harcke Can Swaddling be done safely in Infants with and without DDH? 1:45–3:55 p.m. Scientific Session VIII-B: Oncology & Nuclear Medicine (concurrent) Geetika Khanna, MD, MS and Andrew T. Trout, MD, Moderators 1:45–2:05 p.m. PET/MR in Children: Early Successes and Challenges Franz Wolfgang Hirsch, MD 2:05–3:55 p.m. Scientific Papers—Oncology & Nuclear Medicine PA-137 2:05 Khanna Renal cell carcinoma in children and adolescents: a summary of imaging findings from the Children’s Oncology Group PA-138 2:15 Atweh MR Image Acquisition during the FDG Uptake Phase is Associated with an Increased Rate of False Positive Brain PET Examinations Performed on an Integrated PET-MR Scanner PA-139 2:25 Martinez-Rios Comparison of quantitation of tracer uptake and radiation dosage between PET/MRI and PET/CT in a pediatric population. PA-140 2:35 Lyons Comparison of standardarized uptake values (SUV) in normal structures between PET/CT and PET/MRI in a pediatric patient population PA-141 2:45 Lyons Qualitative [18F]-FDG PET image assessment using automatic three-segment MR attenuation correction versus CT attenuation correction in a pediatric population. PA-142 2:55 Krishnamurthy Quantitative Comparison of Attenuation Corrected FDG-PET Images Acquired on Integrated PET/MR and PET/CT Systems: Validation of an MR-based Attenuation Correction Algorithm PA-143 3:05 Robertson Pediatric PET-MR Registration for the Rest of Us! Validation of a Novel Software Based Solution for PET/MR Coregistration. PA-144 3:15 Towbin Fractures in Newly Diagnosed Hepatoblastoma Patients: Incidence and Imaging Features PA-145 3:25 Lee Patient Size-Specific k-factors for Pediatric and adult CT examinations PA-146 3:35 Goske Improving Patient Safety: Development of a Web-based Curriculum with Assessment to Promote Competency in “Child-sizing” Radiation Dose for Medical Professionals PA-147 3:45 Umstead Age based characterization of pediatric soft tissue masses of the hand, and value of added MRI following ultrasound. Break & Exhibits 3:55–4:15 p.m. 4:15–5:25 p.m. Scientific Session IX-A:Musculoskeletal (concurrent) Sarah D. Bixby, MD and Diego Jaramillo, MD, MPH, Moderators 4:15–4:35 p.m. Dx and Management of Legg Calve-Perthes What the Radiologist Needs to Know John F. Lovejoy, III, MD

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S24 4:35–5:25 p.m. PA-148 PA-149 PA-150 PA-151 PA-152 4:15–5:25 p.m. 4:15–4:35 p.m. 4:35–5:25 p.m. PA-153 PA-154 PA-155 PA-156 PA-157 5:25 p.m. 6:30–11:00 p.m.

Scientific Papers—Musculoskeletal 4:35 Fadell CT Outperfoms Radiographs at a Comparable Radiation Dose in the Assesment for Spondylolysis 4:45 Duan Clinical Value of Adipose Volume Measurements Obtained from Routine Body CT:Associations with Body Mass Index and Clinical Observations 4:55 Deng Characterization of Brown Adipose Tissues using MRI in the Pediatric Population—a Pilot Study 5:05 Chauvin Ultrasound of the Joints and Entheses in the Healthy Child 5:15 Bedoya Quantification of bone marrow involvement in Gaucher disease with proton MR Spectroscopy: correlation with bone marrow score, and clinical status Scientific Session IX-B: Interventional (concurrent) John J. Crowley, MD and Mark J. Hogan, MD, Moderators Innovative Techniques of Minimally Invasive Surgery Jeffrey R. Lukish, MD, FACS Scientific Papers—Interventional 4:35 Hawkins Pediatric liver transplant portal vein anastomotic stenosis: correlation between transabdominal ultrasound and percutaneous transhepatic portal venography. 4:45 Zahra Trans—Jugular Liver Biopsy (TJLB) in Children: A Single Institutional Experience 4:55 King Fluoroscopic maintenance of pediatric gastro-jejunostomy tubes: What is the radiation dose to the patient and the fluoroscopic operator’s hands? 5:05 Bisset Image-guided prediction of pseudocyst formation following traumatic pancreatic injury in children 5:15 Golriz MR imaging characteristics of focal nodular hyperplasia (FNH) of the liver in children. Adjourn Reception & Annual Banquet—Special Performance by Capitol Steps

Saturday, May 17, 2014 7:00–8:00 a.m. Continental Breakfast 7:00 a.m.–12:00 p.m. Registration 8:00 a.m.–12:00 p.m. NEURORADIOLOGY SESSION Neuro Session Part I Jason N. Nixon, MD and Gilbert Vézina, MD, Moderators 8:00–8:30 a.m. Epilepsy in Childhood Amy Kao, MD 8:30–9:00 a.m. MR Imaging in Pediatric Epilepsy Gilbert Vézina, MD 9:00–9:30 a.m. Challenging Cases in Epilepsy Jonathan G. Murnick, MD, PhD 9:30–9:45 a.m. Discussion 9:45–10:00 a.m. Break Neuro Session Part II Dennis W. Shaw, MD and Manohar Shroff, MD, FRCPC, Moderators 10:00–10:30 a.m.

Childhood Stroke Gabrielle deVeber, MD 10:30–11:00 a.m. Stroke Imaging in Childhood Manohar Shroff, MD, FRCPC 11:00–11:45 a.m. Case Presentations Sumit Pruthi, MD 11:45 a.m.–12:00 p.m. Discussion 8:00 a.m.–12:00 p.m. 7TH ANNUAL SPR EDUCATION SUMMIT Dorothy I. Bulas, MD and Marilyn J. Goske, MD, Moderators 8:00–8:05 a.m. Introduction Dorothy I. Bulas, MD 8:05–8:15 a.m. ABR Updates Lane F. Donnelly, MD 8:15–8:25 a.m. Milestone Updates Dorothy I. Bulas, MD

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 8:25–8:30 a.m. 8:30–9:15 a.m.

9:15–9:20 a.m. 9:20–10:00 a.m. 10:00–10:05 a.m. 10:05–10:35 a.m. 10:35–10:55 a.m. 10:35–10:40 a.m. 10:40–10:55 a.m.

10:55–11:10 a.m. 11:10–11:25 a.m. 11:25–11:45 a.m. 11:45–11:50 a.m. 11:50 a.m.–12:00 p.m. 8:00 a.m.–12:00 p.m. 8:00–8:30 a.m. 8:30–9:00 a.m. 9:00–9:30 a.m. 9:30–9:50 a.m. 9:50–10:20 a.m. 10:20–10:50 a.m. 10:50 a.m.–12:00 p.m. 8:00 a.m.–12:00 p.m. 8:00–8:30 a.m. 8:30–9:00 a.m. 9:00–9:30 a.m. 9:30–9:45 a.m. 9:45–10:15 a.m. 10:15–10:45 a.m. 10:45–11:15 a.m. 11:15 a.m.–12:00 p.m. 8:00 a.m.–12:00 p.m.

8:00–8:05 a.m. 8:05–8:20 a.m. 8:20–8:40 a.m.

Question and Answer The Expert Clinician: Transformative Online Education to Accelerate the Professional Development of Today’s Medical Professionals Jeff Sestokas, MAEd Question and Answer Physician Wellness: It’s More Than A Yoga Group! Charles P. Samenow, MD, MPH Question and Answer Break Patient Care: Critical Conversations RADPED: Teaching Communication Skills to Radiology Trainees Marilyn J. Goske, MD Sharing Difficult News with Patients and Families in the Radiology Department—A Program for Improving Communication Bernadette L. Koch, MD Systems-based Practice-(P)QI for trainees AND faculty! Nadja Kadom, MD Communication and Reporting Skills: What Clinicians Want Lisa H. Lowe, MD, FAAP Healthcare MBA (Minimal Business Acumen) for Radiology Fellows Raymond Sze, MD Question and Answer Closing Marilyn J. Goske, MD INTERVENTIONAL SESSION John J. Crowley, MD and John M. Racadio, MD, Moderators Management of Benign Biliary Strictures Stéphanie Franchi-Abella, MD New Developments in Renovascular Hypertension Derek J. Roebuck, MD Venous Malformations: How to Stay Out of Trouble and Not Undertreat Patricia E. Burrows, MD Break Management of Low Flow Vascular Lesions: Optimum Choice of Agents William E. Shiels, II, DO New Horizons Richard B. Towbin, MD Interventional Case Club John M. Racadio, MD THORACIC IMAGING SESSION Edward Y. Lee, MD, MPH and Beverley Newman, MBBCh, FACR, Moderators Thoracic Manifestations of Systemic Disease in Children: Imaging Clues to Diagnosis Anastassios C. Koumbourlis, MD, MPH and Beverley Newman, MBBCh, FACR Imaging Evaluation of Pediatric Airway and Lung Neoplasms: What Does the Clinician Need to Know? Paul Thacker, MD Pediatric Mediastinum: Clinical Correlation and Practical Imaging Assessment Maryam Ghadimi Mahani, MD Break Pediatric Thoracic Vascular Imaging: How I Do It Monica Epelman, MD Pediatric Lung Transplantation: Clinical Perspectives & Imaging Assessment Debra Boyer, MD and Edward Y. Lee, MD, MPH Risks and Benefits of Pediatric Thoracic CT: Updated Information for Clinicians Sjirk J. Westra, MD Question and Answer NUCLEAR MEDICINE SESSION Marguerite T. Parisi, MD, MS Ed, Moderator Susan E. Sharp, MD and Lisa J. States, MD, Co-Moderators Pediatric Dose Harmonization Project: An Update S. Ted Treves, MD Communicating with Parents and Referring Clinicians S. Ted Treves, MD Bone Scintigraphy-State of the Art Helen R. Nadel, MD

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S26 8:40–9:00 a.m.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

Pediatric Diuresis Renography Massoud Majd, MD 9:00–9:20 a.m. Pediatric Gastrointestinal Scintigraphy Stephanie E. Spottswood, MD, MSPH Uncommonly Performed Pediatric Nuclear Medicine Procedures 9:20–9:50 a.m. 9:20–9:30 a.m. Ventilation/Perfusion Scans Lisa J. States, MD 9:30–9:40 a.m. NM Evaluation of CSF Shunts Hedieh K. Eslamy, MD 9:40–9:50 a.m. Lymphoscintigraphy Gerald A. Mandell, MD 9:50–10:00 a.m. Break 10:00–10:40 a.m. Oncologic Imaging Michael J. Gelfand, MD and Susan E. Sharp, MD 10:40–11:00 a.m. NM Infection Imaging in Children Marguerite T. Parisi, MD, MS Ed 11:00–11:20 a.m. FDG PET: Neurologic Applications A. Luana Stanescu, MD 11:20–11:40 a.m. PET-MR: Equipment, Technical and Imaging Considerations Georges El Fakhri, PhD, DABR 11:50 a.m.–12:00 p.m. PET/MR: Implementing a Clinical Program Victor Seghers, MD, PhD 8:00 a.m.–12:00 p.m. HANDS-ON ULTRASOUND SESSION (advanced registration required; attendance is limited) Brian D. Coley, MD, Moderator 8:00–9:15 a.m. Hip Dysplasia: DDH H. Theodore Harcke, MD, FACR, FAIUM and Michael A. DiPietro, MD 9:15–10:30 a.m. Musculoskeletal: Sports Medicine and Rheumatology Andrew M. Zbojniewicz, MD and Michael A. DiPietro, MD 10:30–10:45 a.m. Break 10:45 a.m.–12:00 p.m. Appendicitis: Complications and Mimicks Martha M. Munden, MD and Andrew T. Trout, MD 12:00 p.m. All Saturday Sessions Adjourn

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

CATALOG OF SCIENTIFIC EXHIBITS/POSTERS The top 12 candidates for a Caffey Scientific Exhibit Award will present their work during one of the scheduled breaks at the Annual Meeting. Case Reports CR-001 Bandarkar CR-002 CR-003 CR-004 CR-005 CR-006

Loke Ratino Withdrawn Davis Farmakis

CR-007 CR-008 CR-009 CR-010 CR-011 CR-012 CR-013

Compton Cusack Alaref Withdrawn Lu Gupta Kovanlikaya

CR-014 Paltiel CR-015 Davignon CR-016 Natera CR-017 CR-018 CR-019 CR-020

Hayes Scrugham Zandieh Johnsen

CR-021 Herskovits CR-022 Jindal CR-023 CR-024 CR-025 CR-026

Qin Artunduaga Withdrawn Eslamy

Transcutaneous Sonography of Tonsils in the Pediatric Patient: a novel imaging technique to detect peritonsillar abscess. Software Segmentation and Rapid Prototyping of Congenital Heart Defects with Cardiac MRI images Multimodality Imaging Findings of Arterial Tortuosity Syndrome, a Case Series Cross My Heart: Case Series of Criss-Cross Congenital Heart Disease Neurofibromatosis Type 1 Arterial Vasculopathy Manifesting as a Superficial Peripheral Arterial Aneurysm in an Adolescent Sonographic: Pathologic Correlation of Pulmonary Lymphangectasia Ovarian torsion in the fetus—prenatal and postpartum imaging and management Infected cephalohematoma Torsion of an accessory hepatic lobe: Two cases in children Burkitts lymphoma of bowel mimicking Crohns disease on initial presentation Quantitative ADC measures as an imaging biomarker for fibrosis in pediatric Crohn’s disease: Preliminary experience Contrast-enhanced Ultrasound of Pediatric Abdominal Visceral Trauma: Initial Data Herniation of Meckel’s Diverticulum into a Ventriculoperitoneal Shunt Tract: An Unusual Shunt Complication Duodenal-pancreatic-duodenal intussusception in the setting of malrotation with a duodenal duplication cyst. Empty TPN: A Cautionary Case of Copper Deficiency Congenital portosystemic shunt: an important and overlooked cause of neonatal cholestasis—a case report Complications of Pediatric Liver Transplantation: Case Series and Pictorial Review. Radiologic, pathologic, and surgical correlation in unusual large and small bowel lead point intussusceptions: a case series A Case Series: Rare Extraosseous Manifestations of Langerhans Cell Histiocytosis Congenital Intrahepatic porto-systemic shunts; a case-based illustration of clinical manifestations, imaging findings and endovascular management Mesenteric Venolymphatic Malformation causing Small Bowel Obstruction in a Child Biliary rhabdomyosarcoma: Review of three cases

MR Enterography Technical Note: Slow Intravenous Infusion of Glucagon Diluted in D5W with an MR-Compatible Infusion Pump CR-027 Bittman The effective use of blueberry juice, pineapple juice and acai juice as negative contrast agents for MRCP in children at a large tertiary pediatric medical center. CR-028 Thomas You got to be KIDNEYing me?! A Pediatric Case Series of Rare Non-Wilms Tumors CR-029 Goldfisher Multi-modality Imaging Evaluation of Peritoneal Inclusion Cysts in the Pediatric Age Group CR-030 Aria The Changing Character of Urinary Infection in Children: Influence of No Circumcision CR-031 Vatsky Case Series: Endovascular Radiofrequency Ablation in the treatment of long segment lower extremity venous malformations in pediatric patients. CR-032 Shenoy-Bhangle Novel image guided treatment for local control of a recurrent plexiform schwannoma in a 3 year-old male. CR-033 Gaballah Mechanical embolectomy using the Solitaire FR revascularization device for acute arterial ischemic stroke in a pediatric ventricular assist device patient: A Case Report CR-034 McCarron Look, ma, no hands! Introducing the MIRA (MRI Interventional Robotic Assistant): a proof of concept for an MRI compatible, patient mounted robot for radiation-free arthrography and other percutaneous procedures CR-035 Bedford Additional value of C-arm CT in imaging patent ductus venosus (PDV) and its intra-procedural role in guiding endovascular occlusion.

S27

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

S28 CR-036 Pimpalwar CR-037 Bedford CR-038 Bao CR-039 Josephs CR-040 Green CR-041 Jindal CR-042 CR-043 CR-044 CR-045 CR-046 CR-047 CR-048

Zahra Barnes Thomas Yadav Ilivitzki Patel Dunnavant

CR-049 CR-050 CR-051 CR-052 CR-053 CR-054 CR-055 CR-056 CR-057

Adeyiga Emerson Jamieson Khan Hayes Dizor Averill Whitehead Horst

CR-058 Saigal CR-059 CR-060 CR-061 CR-062 CR-063 CR-064 CR-065

Palasis Rogers Guimaraes Leake Cyriac Palasis Han Suyin

CR-066 Hegde CR-067 Singh CR-068 Eslamy CR-069 Eslamy CR-070 Lee CR-071 CR-072 CR-073 CR-074 CR-075 CR-076 CR-077 CR-078 CR-079 CR-080

Yadav Milks Adeyiga Zahiri Hoare Emerson Eklund Emerson Addicott Ghadimi Mahani CR-081 Rosenbaum CR-082 Withdrawn

Denver shunt malfunction: can replacement be avoided with minimally invasive innovative techniques? Role of doppler ultrasound imaging guidance in the treatment of angiographically occult traumatic arteriovenous fistula in a child. Novel technique using MRI/X-ray overlay to guide sclerotherapy for treatment of low-flow vascular malformations in children Congenital segmental ectasia of central venous structures: intervene or observe? Ultrasound guided muscle biopsy using a Vacuum Assisted Biopsy System (Vacora®) Endovascular management of a congenital intrahepatic porto systemic shunt using Amplatzer occlusion device in a 2months old infant Wire trapping and unwrapping; a rare complication of Trerotola device. M-Dixon: Fat Suppression Has Never Looked So Good CT Angiography changes practice: the surgical management of pediatric digital syndactyly Idiopathic chondrolysis of hip: MR Imaging spectrum with emphasis on early MRI features STERNAL PSEUDOTUMOR OF CHILDHOOD—DON’T TOUCH LESION When evaluating a joint, WATS not to like Intraoperative Ultrasound Use in Children with Brachial Plexus Birth Injury and Glenohumeral Instability: A Case Series Pelvic Fractures in Non-Accidental Trauma Comparison of CT and MRI for Evaluation of Glenoid Bone Loss in Pediatric Patients Prenatal Cortical Hyperostosis—Caffey Dysplasia Scurvy in an autistic child; early disease on MRI and Bone Scintigraphy can mimic an infiltrative process. Readout-Segmented EPI for Diffusion Imaging of the Pediatric Spine: an Illustrative Case Review Minimally Invasive MRI-guided Stereotactic Laser Thermal Ablation—A Step-by-Step Tutorial Fetal brain MRI findings of congenital cytomegalovirus infection with post-natal MRI correlation CNS Imaging Manifestations of Cornelia de Lange Syndrome Isolated Cranial Nerve and Cervical Nerve Root Enhancement in an Infant with Polymerase Gamma Mutation Mitochondrial Disease Utility of Susceptibility Weighted (SWI) and Constructive Interference in Steady State (CISS) Sequences in the Evaluation of Hydrocephalus in the Newborn Current T2* Based MRI Techniques and their Applications in Pediatric Neuroimaging Smoothing things over: Model based CT image iterative reconstruction approaches MR image quality Differentiating Prominent Subarachnoid Spaces from Isodense Subdural Collections seen on CT in Infants Melanotic Neuroectodermal Tumor of Infancy: A Case Report Childhood Primary Angiitis of the Central Nervous System presenting with bilateral panuveitis and anisocoria MR Imaging Manifestations of Epstein Barr Virus (EBV) Encephalitis in Children Traumatic Pseudoaneurysm causing Intracerebral Haemorrhage in a Child: The importance of CT angiography in blunt head trauma. Pediatric Crossed Cerebellar Diaschisis: A case report and review of the pathophysiology Non visualization of dural sinuses in the setting of posterior fossa epidural collection- Are the sinuses compressed or thrombosed? Imaging Dietl’s crisis (intermittent ureteropelvic junction obstruction) with renal ultrasound and nuclear medicine renogram Novel use of a disposable pressure transducer for intracranial pressure measurement for nuclear medicine CSF shunt studies The use of 18F-Fluoro-Deoxy-Glucose Fused Positron Emission Tomography CT in Detecting Recurrent Hepatoblastoma at a large tertiary Children’s Hospital Inflammatory Myofibroblastic Tumor: ‘Pseudo’ tumor Or ‘Real’ Tumor? Unique Imaging Characteristics of Primary Pediatric Lymphoma of Bone: A Case Series Extranodal Rosai-Dorfman Disease of the Pediatric Female External Genitalia Primary mature teratoma presenting as an adrenal tumor in an Infant. Anaplastic Lymphoma—an unusual presentation and a diagnostic dilemma. An Introduction to PPB: A Case Report of Pleuropulmonary Blastoma MRI abdomen/pelvis in pediatrics: Is DWI part of your routine protocol? The Great Imitator: A Case Report of Congenital Syphilis Traumatic Handle Bar Injury with Aortic Disruption Imaging of Hepatopulmonary syndome, a case report Pulmonary artery sling with type IIa tracheobronchial anomaly and imperforate anus

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

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Educational Exhibits EDU-001

Khawaja

EDU-002 EDU-003 EDU-004 EDU-005 EDU-006 EDU-007 EDU-008

Agarwal Kunam Ayyala Aamir Farmakis Withdrawn Constantino

EDU-009 EDU-010 EDU-011 EDU-012 EDU-013

Hoare Blask Deaver Nagaraj Chan

EDU-014

Chan

EDU-015 EDU-016 EDU-017 EDU-018 EDU-019 EDU-020 EDU-021 EDU-022 EDU-023 EDU-024 EDU-025 EDU-026

Tenenbaum Withdrawn Ngo Aamir Liang Brown Decter Peterson Gowdy Yoo Gowdy McGraw

EDU-027

Davila-Acosta

EDU-028

Davila-Acosta

How low can we go? Iterative Reconstruction Techniques to achieve pediatric CT radiation dose less than 1 mSv. Auto mAs and Auto kVp: Improving Child Size Parameters for Dose Reduction Radioisotope Imaging: Strategies to Decrease Radiation Exposure in Pediatric Patients Multi-modality Imaging of Vascular Anomalies in Alagille Syndrome in Children: A Pictorial Review Pediatric cardiac devices: Review of imaging features and complications Perspectives in state-of-the-art vascular MR imaging with blood pool contrast agent Cardiac CT with 3D Segmentation of Congenital Aortic Arch Anomalies: A Pictorial Review with Surgical Correlation Congenital Brain Tumours—Antenatal and Postnatal Imaging Features Prenatal Imaging of the Gastrointestinal Tract with Postnatal Imaging Correlation Imaging the Prenatal Spine: Dysraphism and Beyond The Dandy-Walker Spectrum: Fetal MR findings with postnatal correlation Common Genitourinary Fetal MRI Diagnoses with Postnatal Imaging Correlation: What Clinicians Need to Know Common Thoracic Fetal MRI Diagnoses with Postnatal Imaging Correlation: What Clinicians Need to Know 3 T Fetal MRI: Review of Safety and Benefits Pictorial Review of Proper and Improper Enteric Tube Placement Imaging pediatric peritoneal pathology: Beyond the misty mesentery Appendicitis or Not Appendicitis: Imaging Acute Right Lower Quadrant Pain in Children Pictorial Review of Pancreatic Duct Anomalies seen on Pediatric MRCP Imaging of Complications of Enteric Tubes in Children More than Appendicitis: An Ultrasound Pictorial Review Pictorial Review of Acquired Abnormalities of the Biliary Tree MR Enterography of Pediatric Inflammatory Bowel Disease and its Complications- A Pictorial review. Pictorial Review of Congenital Bile Duct Abnormalities with Clinical and Pathological Correlation Pediatric Liver Masses: A Pictorial Review with Emphasis on Ultrasound, Computed Tomographic and Magnetic Resonance Appearance MR Enterography: Differences Between Active Chron’s Disease and Ulcerative Colitis in Pediatric Population MR Enterography: How to Recognize Post Treatment Changes in Chron Disease in Pediatic Population? Pediatric Liver Masses—Multimodality Evaluation with Pathologic Correlation

EDU-029

Machnitz

EDU-030 EDU-031 EDU-032

Shaikh Breen Kocaoglu

EDU-033 EDU-034

Phewplung Thompson

EDU-035 EDU-036 EDU-037 EDU-038 EDU-039

Kricun Rubio Yoo Deshmukh Hancock

Pictorial Essay in Performing Barium Enemas The Role of Imaging in Pediatric Bladder Augmentation Split-Bolus MR urography: Synchronous visualization of obstructing vessels and collecting system in children. The Why, When and How of Magnetic Resonance Urography Radiographic Features of Uncommon Benign and Malignant Bladder Abnormalities that Present with Hematuria Imaging of the Genitourinary Tract during VCUG in the Pediatric Population: A Pictorial Review Beyond Torsion: Common and Uncommon Entities Encountered in Acute Pediatric Scrotal Evaluation Evaluation of Renal/Urinary Anomalies with MR Urography. Pediatric Cystic Renal Disease: Review of pathology, imaging features, mimics and differential diagnosis. The Pediatric Renal Lesion—A logical approach to a not uncommon diagnostic finding.

EDU-040 EDU-041 EDU-042

Shruti Nguyen Krishnamurthy

Pictorial Review of Disease seen on MR Urogram Bubbly Badness in the Pediatric Genitourinary System. Capsular, Conceptual and Continuing Education in Pediatric Cardiovascular Imaging

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

S30 EDU-043

Sura

EDU-044 EDU-045 EDU-046 EDU-047 EDU-048 EDU-049 EDU-050

Sze Reid Chiramel Sharma Sharma Griggs Jadhav

EDU-051 EDU-052 EDU-053 EDU-054 EDU-055 EDU-056 EDU-057 EDU-058 EDU-059

Johnsen Blumer Hull Aquino Soliman Vatsky McMahan Silva Sharafinski

EDU-060 EDU-061 EDU-062 EDU-063 EDU-064 EDU-065 EDU-066 EDU-067 EDU-068 EDU-069 EDU-070 EDU-071 EDU-072 EDU-073 EDU-074 EDU-075 EDU-076 EDU-077 EDU-078 EDU-079 EDU-080 EDU-081 EDU-082 EDU-083

Yam Withdrawn Grissom Alaref Liang Bartlett Joshi Winfeld Drake Bosemani Hayes Hendi Muthusami Nguyen Withdrawn Kelly Le Bailey Ledford Vorona Holwerda Whitehead Kricun Maki

EDU-084

Gross

EDU-085 EDU-086 EDU-087 EDU-088 EDU-089 EDU-090 EDU-091 EDU-092 EDU-093 EDU-094 EDU-095

Kricun Reddy Kricun Gill Ledford Hurteau-Miller Gadde Withdrawn Shaikh Zahra Yoo

EDU-096 EDU-097 EDU-098 EDU-099 EDU-100

Moy Otero Withdrawn Alazraki Shah

EDU-101

Burns

Teaching to the New Diagnostic Radiology Core Exam: An Innovative Audience Response Based-Approach via the Resident’s Cellphone or Tablet An efficient and cost-effective way to create videos for Radiology education Micro-learning: Pediatric Radiology skills and knowledge transfer in 5min or less through “You Tube®” Using Redcap (Research Electronic Data Capture) as a tool to perform research studies MR-HIFU: Applications in Pediatric Oncology and Surgery MR-HIFU: A Primer for Pediatric Radiologists Complications of Vascular Interventional Procedures in Children: A Radiographic Review Multi-compartmental steroid joint injections of the wrist and ankles in juvenile idiopathic arthritis: Rationale and comprehensive review A pictorial review of Lisfranc injury in pediatric patients Using Low Dose Digital Slot-Scanning for Orthopedic Imaging in Children: How we do it Impact of a Novel Upright Low-dose Slot Scanner Biplanar X-ray System (EOS) in Pediatric Orthopedics Whole Body MRI of Juvenile Spondyloarthritis: Protocol and Characteristic Patterns Imaging of Systemic Vasculitis in Childhood: A “Geographic” Pictorial Essay Fluoroscopic arthrography, a forgotten tool in evaluating shoulder pathology in the pediatric patient. Lytic acetabular tumors in the pediatric population Cartilage Injuries of the Pediatric Knee Transient patellar dislocation in pediatric patients: Evaluation of the preoperative, normal postoperative, and complicated postoperative states. Imaging of the pediatric sacrum and sacroiliac joints: sometimes a pain in the butt! Maturation of the Triradiate Cartilage on CT in Healthy Children MR Arthrogram of the Shoulder in Children: A Correlation between Radiologic and surgical Findings. “You Are My Density”: Sclerotic Bone Lesions in Children Palpable Masses of the Pediatric Foot and Ankle: Imaging Evaluation Vertebral lesions in children: A pictorial review Imaging of Non-Traumatic Pediatric Foot Deformities: A Clinical Perspective Ultrasound of “Lumps and Bumps”: A Pictorial Essay Susceptibility-weighted imaging: a powerful diagnostic tool in pediatric neuroimaging Acute Toxic Brain Injuries in Children: a Simple Approach to Rapid Radiological Diagnosis Zebras in the Pediatric Brainstem Pictorial review of pediatric syndromic CNS vascular disorders Pre- and Post-operative MRI Imaging of Endoscopic Third Ventriculostomy MRI Bone Marrow Patterns in the Normal Developing Head and Spine Not Just Another Lymph Node: Unusual Causes of Neck Masses in Infants and Children A Case Based Approach to Pediatric Pontine Lesions MR Imaging of Pediatric Bone Marrow Disease States Diffusion Tensor Imaging (DTI) in Pediatric Neuroradiology: An Overview From the Everyday to the Exotic: A Cased Based Review of Pediatric Head and Neck Tumors. The Imaging Workup of Childhood Ptosis A Multimodality Review of Nasal Masses in the Pediatric Population: Sniffing Out the Diagnosis The Phakomatoses: A Focus on Imaging of Neurofibromatosis Types I & II, Von Hippel-Lindau, Tuberous Sclerosis and Sturge-Weber Syndrome Taking a “Bite” out of the Mandible: A Wide Spectrum of Mandibular Lesions in the Pediatric Population MR Imaging in Children with Sellar Pathology Spectrum of Imaging Findings in Cerebellar Malformations The Skull Base Revisited: Anatomy of the skull base on CT Cervical Spine Radiographs: Normal or Not? Demystifying Premature Sutural Closure Sinonasal imaging in children The Chiari malformations, revisited: a pictorial essay Neonatal Jaundice Made Easy—The Nuclear Way Tc99M-MAG3 Diuretic Renography in Pediatrics: A Pictorial Review Hepatobiliary Scans and Supplemental Modalities (US & MRCP) in the Diagnosis of Biliary Atresia- an institutional review. The spectrum of imaging findings in renal lymphoma in the pediatric population Multimodality Imaging of Pediatric Head and Neck Neoplasms utilizing CT, MRI and 18FDG PET Pediatric Thyroid Ultrasound: To biopsy or not? Hair Apparent: Clinical and Radiological Features of Hairy Diseases and Their Mimickers in the Pediatric Population The Pediatric Breast: What to do with Lumps and Bumps

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 EDU-102 EDU-103 EDU-104 EDU-105

Sharatz Braithwaite Serai Baines

EDU-106 EDU-107

Inarejos Clemente Baez

EDU-108 EDU-109

Baad Otrakji

EDU-110 EDU-111

Horsley Shah

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Abnormal Calcifications in Infants and Young Children—A Pictorial Review Pictorial Review: Complications of implanted surgical devices in pediatric patients Early experience with gadoterate meglumine (Dotarem) at a large tertiary care, U.S. Children’s Hospital Understanding the potential for sedation-related complications associated with diagnostic imaging exams: An educational tool for parents Thyroglossal duct cysts in children: sonographic and histopathologic correlation—what matters? A Practical Approach to Pediatric Chest MRI: Bridging the Gap between Inherent Challenges and Clinical Practice Pediatric Upper Airway Emergencies Dual Energy CT in young children: a new low dose technique for characterizing focal lesions without general anesthesia Mass-like Lung Opacity in the Pediatric Population: Multimodality Pictorial Review How to approach Unilateral Hyperlucent Hemithorax in Children?

Scientific Exhibits SCI-001

Gupta

SCI-002 SCI-003 SCI-004

Springer Ramirez-Giraldo Bernbeck

SCI-005

Thomas

SCI-006

Gaballah

SCI-007

Ballah

SCI-008

Mourtos

SCI-009 SCI-010

Deng Ekram

SCI-011

Tani

SCI-012 SCI-013

Sanghvi Fagen

SCI-014

Cassia

SCI-015 SCI-016

Kuo-Bonde Kitami

SCI-017 SCI-018

Abdullah Sheybani

SCI-019 SCI-020 SCI-021 SCI-022

Loewen Kassis Almotairi Eslamy

SCI-023

Aquino

SCI-024

Al-Aswad

SCI-025

Nielsen

Tool for rapid comparison of current exam dose to dose index registry values at the time of image acquisition and interpretation Effective Dose Estimates for Four Types of Fluoroscopy Examinations Performed at a Pediatric Hospital Radiation Dose and Image Quality in Pediatric Dual Energy CT: Phantom Study Pediatric Chest Radiography Dose Monitoring by S Values: An Efficient Way to Indirectly Monitor Exposure Indices at the PACS Station Radiation Exposure From Imaging Procedures In Pediatric Emergency Medicine—A Survey of Physician Knowledge and Risk Disclosure Practice Radiation dose and image quality in the use of low-dose C-arm CT in the treatment of head and neck vascular malformations Radiation dose and image quality in the use of low-dose C-arm CT in the treatment of temporomandibular joint arthritis in patients with juvenile idiopathic arthritis Coronary CT angiography in pediatric patients of different ages, using a second generation dual-source CT scanner Optimization of NATIVE TrueFISP protocol for non-contrast renal MRA Risk Factors for Compromised Venous Assess in Pediatric Patients with Congenital Heart Disease before Heart Transplant Towards radiation dose reduction in MDCT with iterative reconstruction for the prenatal diagnosis of skeletal dysplasia: the minimum radiation dose required to evaluate the normal fetal bones? A Novel Near-Infrared Imaging Approach to Visualizing Peripherally Inserted Central Catheters MRI in the Male Fetus with Megacystis: Imaging Features and Contributions to Diagnosis and Management Cerebral Perfusion Measurements using dynamic Color Doppler Sonography in Normal Neonates and Neonates with Mild Hypoxic Ischemic Encephalopathy MRA characterization of supraclavicular brown fat in infants Evaluation of fetal cystic lung lesions—“Hump sign” suggesting congenital pulmonary airway malformation type 1. Incidental Maternal Findings on Fetal MRI Studies Incidental Extra-intestinal Findings on Magnetic Resonance Enterography in Children with Inflammatory Bowel Disease Magnetic Resonance Enterography Identifies Silent Crohns Disease Imaging of extraintestinal manifestations of IBD in children and young adults Utility of MRI in pediatric multiple liver lesions. Effect of Slow Intravenous Infusion of Glucagon on Small Bowel Peristalsis in Magnetic Resonance Enterography Assessment of the value of upper gastrointestinal series for evaluation of malrotation and volvulus in patients with a distal obstructive bowel gas pattern on abdominal radiograph. Recognizing Causes of Inaccurate Ultrasound Diagnoses in Pediatric Appendicitis by Direct Imaging-Histology Correlation of Equivocal Cases Appendicoliths on Ultrasound are Highly Specific for Appendicitis in Patients with Abdominal Pain

SCI-026

Bedoya

Assessment of upper gastrointestinal studies (UGI) in children with 22q11.2 deletion syndrome.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

S32 SCI-027 SCI-028 SCI-029 SCI-030 SCI-031 SCI-032 SCI-033

Patrick Swischuk Marine Cardenas Blask Blask Tse

SCI-034

Warade

SCI-035 SCI-036 SCI-037 SCI-038 SCI-039

Lungren Chand Vatsky Shah Kammen

SCI-040 SCI-041 SCI-042 SCI-043 SCI-044 SCI-045 SCI-046 SCI-047 SCI-048

McKinney AlRayahi Batmanabane Mubarak Kim Thompson Pluto Kucera Galassi

SCI-049 SCI-050 SCI-051 SCI-052

AlRayahi Vali Tsai Farley

SCI-053 SCI-054 SCI-055 SCI-056 SCI-057 SCI-058

Pugmire Li Chang Baez Tan Swerdlow

SCI-059 SCI-060

Tkach Tkach

Appendicitis in the Young Child—Pictorial Review Non-Fecalith Induced Appendicitis: Is There Another Etiology? Acute Abdominal Pain in Pediatric Patients with Chronic Colonic Dysmotiliy: Be aware of colonic volvulus. Medullary nephrocalcinosis: an overused diagnosis in pediatric patients? The sonographic diagnosis of testicular torsion in the pediatric patient: “Knot” that easy! Neonatal Testicular Torsion: Update on Sonographic Imaging and Management Diagnostic efficacy of novel vesicoureteric reflux imaging technique Voiding Urosonography (VUS): A systematic review Radiology Report Quality and Automated Speech Recognition Software Utilization: Errors and error rates—A 5year Assessment. Endovasular management of upper extremity deep venous thrombosis in children The Use of Totally Implantable Venous Access Devices for Chronic Apheresis in Children. Outpatient ultrasound guided renal biopsy: is it safe? Suprapubic Catheterizations in Pediatric Patients Rapid Two-Point DIXON Turbo Spin Echo (TSE) MR Imaging provides robust fat suppression for pediatric musculoskeletal imaging on 3T Assessing the Accuracy of MRI Sequences for Measurements of Pediatric Cartilage: A Phantom Study Skeletal dysplasia: Review and Approach A multimodal approach to imaging the visual pathway in pediatric syndromes with ocular involvement Brain MRI Findings in Patients with Developmental Delay With Correlation With Clinical Presentation Effect of Extracorporeal Membrane Oxygenation therapy on ventricular size. Cerebral Deep Venous Thrombosis in Children: Spectrum of Imaging Findings based on Structural Anatomy Pediatric Meningioma—Atypical and Typical Anatomic variants on neonatal spine ultrasound: frequency and clinical significance Role of magnetic resonance in the management of pediatric patient with Guillan-Barrè Syndrome in acute and chronic phase Correlation of Clinical Presentation and Brain MRI Findings in Children with Seizure Disorders The usefulness of FDG-PET/CT scan imaging at initial diagnosis of post-transplant lymphoproliferative disease. Normal FDG uptake in the pediatric thymus on PET imaging Misty Mesentery in Patients with Pheochromocytoma Corresponds to Activated Brown Adipose Tissue on F18-FDG PET-CT Early validation of combined 18F-FDG PET/MRI in pediatric cancer patients Single acquisition 3D versus multi-plane 2D pelvic imaging: Can a single sequence replace many? Analysis of thyroid masses detected on thyroid sonography in children Incidental Thyroid Nodules Detected on Thoracic Contrast Enhanced CT: Prevalence and Outcomes Congenital cystic lung lesions: computed tomography characteristics Fluoroscopic imaging, compared to endoscopic visualization, improves detection of esophageal stricture in children with Eosinophilic Esophagitis T2*-MRI Relaxometry Assessment of Liver Iron Concentration in Neonates: A Feasibility Study Cine MRI Evaluation of Intestinal Motility in Preterm Infants: A Feasibility Study

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GENERAL INFORMATION MISSION STATEMENT

The Society for Pediatric Radiology is dedicated to fostering excellence in pediatric health care through imaging and image-guided care. SITES OF PREVIOUS MEETINGS 1991 & IPR‘91 1992 1993

Stockholm, Sweden Orlando, Florida Seattle, Washington

1994 1995 1996& IPR‘96 1997 1998 1999 2000 2001 & IPR‘01 2002 2003 2004 2005 2006 & IPR‘06 2007 2008 2009 2010 2011 & IPR‘11

Colorado Springs, Colorado Washington, D.C. Boston, Massachusetts St. Louis, Missouri Tucson, Arizona Vancouver, British Columbia, Canada Naples, Florida Paris, France Philadelphia, Pennsylvania San Francisco, California Savannah, Georgia New Orleans, Louisiana Montreal, Quebec, Canada Miami, Florida Scottsdale, Arizona Carlsbad, California Boston, Massachusetts London, England

2012 2013

San Francisco, California San Antonio, Texas

FUTURE MEETINGS 2015 2016 & IPR‘16 2017

April 27-May 1, 2015 May 16–20, 2016 May 16–20, 2017

OFFICERS, DIRECTORS AND COMMITTEES 2013–2014

Board of Directors Sue C. Kaste, DO, Chair Richard A. Barth, MD, President Brian D. Coley, MD, President-Elect James Donaldson, MD, 1st Vice President Diego Jaramillo, MD, MPH, 2nd Vice President Christopher I. Cassady, MD, Secretary Molly E. Dempsey, MD, Treasurer George S. Bisset, MD Edward Y. Lee, MD, MPH Lisa H. Lowe, MD, FAAP Beverley Newman, MBBCh, FACR Cynthia K. Rigsby, MD Rafael Rivera, MD Neil D. Johnson, MBBS, Past President Dorothy I. Bulas, MD, Past President

Seattle, Washington Chicago, Illinois Vancouver, British Columbia, Canada

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Donald P. Frush, MD, FACR, Past President M. Ines Boechat, MD, FACR, WFPI Liaison Marilyn J. Goske, MD, Image Gently Alliance Liaison Marta Hernanz-Schulman, MD, FACR, ACR Commission LiaisonPeter J. Strouse, MD, FACR, Editor Benjamin H. Taragin, MD, Web Editor Robert C. McKinstry, MD, PhD, SOCRCH President Maria-Gisela Mercado-Deane, MD, AAP Radiology Section Head Adbominal Imaging Committee Daniel J. Podberesky, MD, Chair Karen Blumberg, MD, FACR Jonathan R. Dillman, MD Edward Y. Lee, MD, MPH Arthur Meyers, MD Martha M. Munden, MD Ethan A. Smith, MD Andrew T. Trout, MD Bylaws Sue C. Kaste, MD, Chair Lisa H. Lowe, MD, FAAP Rafael Rivera, MD Cardiac Imaging Committee Dianna M. E. Bardo, MD, Chair Molly E. Dempsey, MD Sadaf T. Bhutta, MD, MBBS Lorna P. Browne, MB BS Harris L. Cohen, MD, FCR Maryam Ghadimi-Mahani, MD S. Bruce Greenberg, MD Shilpa Hedge, MD Jeffrey C. Hellinger, MD Joshua Q. Knowlton, MD Prakash M. Masand, MD Mike Seed, MBBS Cynthia K. Rigsby, MD, FACR Laureen M. Sena, MD Suraj Serai, PhD Shreyas S. Vasanawala, MD, PhD Sjirk J. Westra, MD Child Abuse Committee Jeannette M. Perez-Rossello, MD, Chair Leslie A. Bord, MD Stephen D. Brown, MD Jerry R.l. Dwek, MD Lynn A. Fordham, MD P. Ellen Grant, MD, MSc Laura L. Hayes, MD Thaddeus W. Herliczek, MD, MS Lisa H. Lowe, MD, FAAP Bradley A. Maxfield, MD Daniel M. Schwartz, MD Sabah Servaes, MD Andy Tsai, MD Consultants: Ingrid Holm, MD Carole Jenny, MD Paul K. Kleinman, MD Ms. Joelle Moreno

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Clinical Practices Steering Committee Christopher I. Cassady, MD, Co-Chair James Donaldson, MD, Co-Chair Dianna M. E. Bardo, MD Jerry R. I. Dwek, MD Judy A. Estroff, MD G. Peter Feola, MD Lynn A. Fordham, MD Geetika Khanna, MD Beth M. Kline-Fath, MD Beverley Newman, MBBCh, FACR Marguerite T. Parisi, MD, MS Jeannette M. Perez-Rossello, MD Daniel J. Podberesky, MD Tina Young Poussaint, MD Dennis W. Shaw, MD Shreyas S. Vasanawala, MD, PhD Sjirk J. Westra, MD Community Hospital-based Pediatric Radiologists Debra J. Pennington, MD, Chair Maria-Gisela Mercado-Deane, MD Contrast-Enhanced Ultrasound Task Force Kassa Darge, MD, PhD, Chair Dorothy I. Bulas, MD Brian D. Coley, MD Jonathan R. Dillman, MD Lynn A. Fordham, MD M. Beth McCarville, MD Sara M. O’Hara, MD Harriet J. Paltiel, MD Frank M. Volberg, MD CT Committee Sjirk J. Westra, MD, Chair Sheila C. Berlin, MD Steven L. Blumer, MD Michael J. Callahan, MD Jonathan R. Dillman, MD R. Paul Guillerman, MD Thaddeus W. Herliczek, MD, MS Edward Y. Lee, MD, MPH John D. MacKenzie, MD Grace S. Phillips, MD Anil G. Rao, DMRD, DNB Pallavi Sagar, MD Sabah Servaes, MD Alexander J. Towbin, MD Education – Curriculum Diego Jaramillo, MD, MPH, Chair Brian D. Coley, MD Molly E. Dempsey, MD Donald P. Frush, MD, FACR Sue C. Kaste, DO Arnold Merrow, MD Sarah S. Milla, MD Peter J. Strouse, MD, FACR Fellowship Program Directors Jane E. Benson, MD, Chair

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Fetal Imaging Beth M. Kline-Fath, MD, Chair Leslie A. Bord, MD Dorothy I. Bulas, MD Maria A. Calvo-Garcia, MD Lucia Carpineta, MD, CM Kimberly A. Dannull, MD Monica Epelman, MD Judy A. Estroff, MD Shilpa Hegde, MD Hollie A. Jackson, MD Mariana L. Meyers, MD Cynthia K. Rigsby, MD Ashley J. Robinson, MBChB Erika Rubesova, MD Chetan C. Shah, MD Teresa Victoria, MD, PhD Finance Stephen F. Simoneaux, MD, Chair Brent H. Adler, MD Richard A. Barth, MD Brian D. Coley, MD Molly E. Dempsey, MD Diego Jaramillo, MD, MPH Matthew Schmitz, MD Randheer Shailam, MD History Alan Schlesinger, MD, Historian N. Thorne Griscom, MD, Consultant Honors Neil D. Johnson, MBBS, Chair Dorothy I. Bulas, MD Donald P. Frush, MD, FACR Informatics Alexander J. Towbin, MD, Chair R. Paul Guillerman, MD James D. Ingram, MD Neil D. Johnson, MBBS David B. Larson, MD, MBA Edward Y. Lee, MD, MPH Peter A. Marcovici, MD Janet R. Reid, MD Mahesh M. Thapa, MD, BS Keith S. White, MD Innovation Donald P. Frush, MD, FACR, Chair George S. Bisset, MD Brian D. Coley, MD Neil D. Johnson, MBBS Sue C. Kaste, DO Peter J. Strouse, MD, FACR Alexander J. Towbin, MD Jennifer K. Boylan, MA Angela R. Davis, CAE Corporate Colleagues: Cheri Gotke Cindee Guy Eugene Mensah, PhD, MBA Craig Peterson Chrisine Ziemba-Landon

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Interventional G. Peter Feola, MD, Chair Mark A. Bittles, MD John J. Crowley, MD Els Nijs, MD Rafael Rivera, MD Ashley J. Robinson, MBChB Andrew T. Trout, MD Judiciary Richard B. Gunderman, MD, FACR, Chair Stephen D. Brown, MD Neil D. Johnson, MBBS Charles D. Williams, MD MR Committee Shreyas S. Vasanawala, MD, PhD, Chair Adina L. Alazraki, MD Kiery A. Braithwaite, MD Govind B. Chavhan, MD DNB Taylor Chung, MD Jesse Courtier, MD Michael S. Gee, MD, PhD Ramesh S. Iyer, MD Arzu Kovanlikaya, MD Jeannie K. Kwon, MD Edward Y. Lee, MD, MPH Michael M. Moore, MD Anil G. Rao, DMRD, DNB Mahesh M. Thapa, MD, BS MSK Committee Jerry R. I. Dwek, MD, Chair Lynn A. Fordham, MD Tal Laor, MD Arthur Meyers, MD Beverley Newman, MBBCh, FACR Shawn E. Parnell, MD Neuroradiology Tina Young Poussaint, MD, Chair S. Srinivas Ganapathy, MD Marta Hernanz-Schulman, MD, FACR Paritosh C. Khanna, MD, DMRE Arzu Kovanlikaya, MD Sarah S. Milla, MD Sumit Pruthi, MD Raghu H. Ramakrishnaiah, MD Dennis W. Shaw, MD Cicero T. Silva, MD Aylin Tekes-Boyd, MD Lynn M. Trautwein, MD Newborn Judy A. Estroff, MD, Chair John B. Amodio, MD Leslie A. Bord, MD Christopher I. Cassady, MD Ellen Chung, MD Monica Epelman, MD Neil D. Johnson, MBBS Maria F. Ladino-Torres, MD Kathleen M. McCarten, MD, FACR Harriet J. Paltiel, MD Valerie L. Ward, MD Consultant: Richard Parad, MD

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Nominating Sue C. Kaste, DO, Chair Ronald A. Cohen, MD Kassa Darge, MD, PhD Beth M. Kline-Fath, MD Edward Y. Lee, MD, MPH Lisa J. States, MD Raymond W. Sze, MD Nuclear Medicine Marguerite T. Parisi, MD, MS, Chair Lisa J. States, MD, Vice Chair Deepa R. Biyyam, MB BS Hedieh Eslamy, MD Marilyn J. Goske, MD Elizabeth A. Hingsbergen, MD Gerald A. Mandell, MD, FACR Lena Naffaa, MD Sara M. O’Hara, MD Victor J. Seghers, MD, PhD Sabah Servaes, MD Susan E. Sharp, MD S. Ted Treves, MD John B. Wyly, MD Oncology Committee Geetika Khann, MD, Chair M. Ines Boechat, MD, FACR Heike E. Daldrup-Link, MD, PhD Michael S. Gee, MD, PhD Michael J. Gelfand, MD Sue C. Kaste, MD Shailee Lala, MD M. Beth McCarville, MD Marguerite T. Parisi, MD, MS Sabah Servaes, MD Susan E Sharp, MD Marilyn J. Siegel, MD, FACR Thomas L. Slovis, MD Alexander J. Towbin, MD Shreyas S. Vasanawala, MD, PhD Stephan D. Voss, MD, PhD Consultants: Peter C. Adamson, MD Greg Reamon, MD Physician Resources Committee Rebecca L. Hulett-Bowling, MD, Chair Ramesh S. Iyer, MD Brooke S. Lampl, DO Jason B. Mitchell, MD Avrum N. Pollock, MD, FRCPC Mitchell L. Simon, MD Paul Thacker, MD Public Policy Richard M. Benator, MD, FACR, Chair Richard A. Barth, MD Kate A. Feinstein, MD, FACR Donald P. Frush, MD, FACR Matthew Schmitz, MD

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Publications Ashok Panigrahy, MD, Chair Dorothy I. Bulas, MD, FACR Edward Y. Lee, MD, MPH Ethan A. Smith, MD Christopher I. Cassady, MD, ex officio Sue C. Kaste, DO, ex officio Editors: Peter J. Strouse, MD, FACR Brian D. Coley, MD Geetika Khanna, MD Cynthia K. Rigsby, MD, FACR Research and Education Foundation Board Brian D. Coley, MD, President Richard A. Barth, MD, Vice President Christopher I. Cassady, MD, Secretary Molly E. Dempsey, MD, Treasurer Johan G. Blickman, MD, PhD, FACR Kassa Darge, MD, PhD Jonathan R. Dillman, MD Rajesh Krishnamurthy, MD Lisa H. Lowe, MD William H. McAlister, MD, FACR Richard L. Robertson, MD Stuart A. Royal, MS, MD, FACR Safety Dennis W. Shaw, MD, Chair George S. Bisset, MD Einat Blumfield, MD Lynn A. Fordham, MD Thomas R. Goodman, MBBCh Ramesh S. Iyer, MD David B. Larson, MD, MBA Michael M. Moore, MD Grace S. Phillips, MD Pallavi Sagar, MD Ramon Sanchez, MD Thomas L. Slovis, MD Dayna M. Weinert, MD Thoracic Imaging Beverley Newman, MBBCh, FACR, Chair Alan S. Brody, MD Maryam Ghadimi-Mahani, MD Shilpa Hedge, MD Ramesh S. Iyer, MD Edward Y. Lee, MD, MPH Daniel J. Podberesky, MD Peter J. Strouse, MD Paul Thacker, MD Sjirk J. Westra, MD Ultrasound Lynn A. Fordham, MD, Chair Ellen M. Chung, MD Harris L. Cohen, MD, FACR Monica Epelman, MD Ramesh S. Iyer, MD Shailee Lala, MD Martha M. Munden, MD Sara M. O’Hara, MD Cicero T. Silva, MD Andrew T. Trout, MD Dayna M. Weinert, MD

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Website Editorial Committee Benjamin H. Taragin, MD, Chair and Web Editor Amy R. Mehollin-Ray, MD, Assistant Web Editor Peter A. Marcovici, MD Representatives Richard M. Benator, MD, FACR, ACR Alternate Councilor Dorothy I. Bulas, MD, Academy of Radiology Research Brian D. Coley, MD, AIUM Kate A. Feinstein, MD, FACR, ACR Councilor Donald P. Frush, MD, FACR, ABR Trustee C. Matthew Hawkins, MD, ACR Council Steering Committeee Susan D. John, MD, FACR, ASER Maria–Gisela Mercado-Deane, MD, AAP Richard L. Robertson, MD, ASPNR Susan E. Sharp, MD, SNMMI Dennis W. Shaw, MD, ASPNR Member GOLD MEDALISTS 1988 1989 1990 1991 1991 1992 1993 1994

Frederic N. Silverman, MD John L. Gwinn, MD John F. Holt, MD John A. Kirkpatrick, Jr., MD Bernard J. Reilly, MB, FRCP Edward B. Singleton, MD Hooshang Taybi, MD Walter E. Berdon, MD

1994 1995 1995 1996 1996 1997 1997 1998 1999 2000 2001 2002 2003 2003 2004 2004 2005 2005

J. Scott Dunbar, MD Guido Currarino, MD Derek C. Harwood-Nash, MD, DSc Andrew K. Poznanski, MD Beverly P. Wood, MD N. Thorne Griscom, MD John F. O’Connor, MD William H. McAlister, MD E. Anthony Franken, MD Eric L. Effmann, MD Giulio J. D’Angio, MD David H. Baker, MD Brinton B. Gay, Jr., MD William H. Northway, Jr., MD Diane S. Babcock, MD Virgil R. Condon, MD Jerald P. Kuhn, MD Thomas L. Slovis, MD

2006 2006 2007 2008 2009 2010 2011

Robert L. Lebowitz, MD John C. Leonidas, MD Leonard E. Swischuk, MD Barry D. Fletcher, MD Charles A. Gooding, MD Janet L. Strife, MD Carol M. Rumack, MD

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 2012 2013 2014

Marilyn J. Goske, MD Stuart A. Royal, MS, MD David C. Kushner, MD, FACR

PIONEER HONOREES 1990 1991 1992 1993 1994 1995 1996 1996

John Caffey, MD M.H. Wittenborg, MD Edward B. Singleton, MD Frederic N. Silverman, MD John P. Dorst, MD E.B.D. Neuhauser, MD Edmund A. Franken, MD Kazimierz Kozlowski, MD

1996 1997 1998 1998 2000 2001 2001 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

M. Arnold Lassrich, MD Arnold Shkolnik, MD Heidi B. Patriquin, MD William H. Northway, Jr., MD Jerald P. Kuhn, MD Diane S. Babcock Fred E. Avni, MD, PhD Walter E. Berdon, MD G.B. Clifton Harris, MD Rita L. Teele, MD Robert L. Lebowitz, MD Carol M. Rumack, MD Paul S. Babyn, MD Kenneth E. Fellows, MD David K. Yousefzadeh, MD Massoud Majd, MD George S. Bisset, III, MD Barry D. Fletcher, MD

2014

Diego Jaramillo, MD, MPH

PRESIDENTIAL RECOGNITION AWARDS 1999 2000 2001 2001 2002 2002 2003 2003 2004 2005 2005 2005 2006 2007

David C. Kushner, MD Paul K. Kleinman, MD Neil D. Johnson, MBBS Christopher Johnson Jennifer K. Boylan Thomas L. Slovis, MD Danielle K.B. Boal, MD Marta Hernanz-Schulman, MD Kenneth L. Mendelson, MD Taylor Chung, MD J. A. Gordon Culham, MD Shi-Joon Yoo, MD L. Christopher Foley, MD Donald P. Frush, MD

2008 2008 2008

Mary K. Martel, PhD Connie L. Mitchell, MA, RT(R)(CT) Harvey L. Neiman, MD

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S42 2009 2010 2011 2011 2012 2012 2013 2014

Karen S. Schmitt Richard A. Barth, MD Kimberly E. Applegate, MD, MS, FACR Keith Strauss, MS, FACR David C. Kushner, MD, FACR Stuart A. Royal, MS, MD Alan E. Schlesinger, MD Richard M. Benator, MD, FACR

HONORARY MEMBERS 1985 1987 1987 1987

Jacques Sauvegrain, MD Bryan J. Cremin, MD Ole A. Eklof, MD Clement C. Faure, MD

1987 1987 1987 1987 1998 1989 1990 1990 1991 1991 1991 1991 1991 1991 1991 1992 1992 1992

Andres Giedion, MD Denis Lallemand, MD Arnold Lassrich, MD Ulf G. Rudhe, MD Frederic N. Silverman, MD John L. Gwinn, MD John F. Holt, MD Richard G. Lester, MD Gabriel L. Kalifa, MD Javier Lucaya, MD John P. Masel, MD Noemi Perlmutter-Cremer, MD Hans G. Ringertz, MD John A. Kirkpatrick, Jr., MD Bernard J. Reilly, MB, FRCP(C) Edward B. Singleton, MD Donald R. Kirks, MD Beverly P. Wood, MD

1993 1992/94 1994 1994 1994 1994 1994 1994 1995 1992/95 1995 1995 1996 1996 1996 1997 1996 1998 1998

Hooshang Taybi, MD Walter E. Berdon, MD Marie A. Capitanio, MD Edmund A. Franken, Jr., MD John C. Leonidas, MD William H. McAlister, MD Andrew K. Poznanski, MD J. Scott Dunbar, MD David H. Baker, MD Derek C. Harwood-Nash, MD, DSc N. Thorne Griscom, MD Guido Currarino, MD Francis O. Brunelle, MD Lloyd L. Morris, MD Heidi B. Patriquin, MD John F. O’Connor, MD Theodore E. Keats, MD Rita L. Teele, MD H. Ted Harcke, MD

1999 2000

J. Bruce Beckwith, MD Joseph Volpe, MD

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 2001 2001 2001 2002 2002 2003 2004 2005 2006 2007 2008 2009 2009 2009 2009 2010 2011 2011 2012 2013 2014

Ulrich V. Willi, MD Henrique M. Lederman, MD Mutsuhisa Fujioka, MD Eric J. Hall, DSc, FACR, FRCR Walter Huda, PhD Michael R. Harrison, MD Lee F. Rogers, MD Carden Johnston, MD, FAAP, FRCP Alan B. Retik, MD Robert R. Hattery, MD Professor Hassen A. Gharbi Dolores Bustelo, MD Pedro A. Daltro, MD Cristian Garcia, MD Antônio Soares de Souza, MD Stephen Chapman, MD Catherine M. Owens, MBBS Madan M. Rehani, PhD Harvey L. Neiman, MD, FACR Savvas Andronikou, MBBCh, FCRad, FRCR, PhD Timothy M. Cain, MBBS

PAST PRESIDENTS 1958–59 1959–60 1960–61 1961–62 1962–63 1963–64 1964–65 1965–66 1966–67 1967–68 1968–69

Edward B. Neuhauser, MD* Frederic N. Silverman, MD* John F. Holt, MD* Arthur S. Tucker, MD* John W. Hope, MD* R. Parker Allen, MD Edward B. Singleton, MD J. Scott Dunbar, MD* Harvey White, MD* M.H. Wittenborg, MD* David H. Baker, MD

1969–70 1970–71 1971–72 1972–73 1973–74 1974–75 1975–76 1976–77 1977–78 1978–79 1979–80 1980–81 1981–82 1982–83 1983–84 1984–85 1985–86 1986–87

John A. Kirkpatrick, Jr., MD* Norman M. Glazer, MD* Bertram R. Girdany, MD* Donald H. Altman, MD Hooshang Taybi, MD* John L. Gwinn, MD* Lawrence A. Davis, MD* Marie A. Capitanio, MD John P. Dorst, MD* Bernard J. Reilly, MB, FRCP (C) Walter E. Berdon, MD Andrew K. Poznanski, MD N. Thorne Griscom, MD Virgil R. Condon, MD Jerald P. Kuhn, MD Lionel W. Young, MD John C. Leonidas, MD* Derek C. Harwood-Nash, MD, DSc*

IPR ‘87 1987–88 1988–89

Denis Lallemand, MD (ESPR) Beverly P. Wood, MD John F. O’Connor, MD*

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S44 1989–90 1990–91 IPR ‘91 1991–92 1992–93 1993–94 1994–95 1995–96 IPR ‘96 1996–97 1997–98 1998–99 1999–00 2000–01 IPR‘01 2001–02 2002–03 2003–04 2004–05 2005–06 IPR‘06 2006–07 2007–08 2008–09 2009–10 2010–11 IPR‘11 2011–12 2012–13 *Deceased

E.A. Franken, Jr., MD Donald R. Kirks, MD Hans G. Ringertz, MD, PhD (ESPR) William H. McAlister, MD M. B. Ozonoff, MD Joanna J. Seibert, MD Eric L. Effmann, MD Kenneth E. Fellows, MD Paul S. Thomas, MD (ESPR) Diane S. Babcock, MD Charles A. Gooding, MD Robert L. Lebowitz, MD Thomas L. Slovis, MD Janet L. Strife, MD Francis Brunelle, MD (ESPR) Bruce R. Parker, MD Richard B. Towbin, MD David C. Kushner, MD Stuart A. Royal, MS, MD George A. Taylor, MD Richard Fotter, MD (ESPR) Marilyn J. Goske, MD Marta Hernanz-Schulman, MD M. Ines Boechat, MD Neil D. Johnson, MBBS Dorothy I. Bulas, MD Catherine M. Owens, MD Donald P. Frush, MD Sue C. Kaste, DO

SINGLETON-TAYBI AWARD 2006 2007 2007 2008 2009 2010 2011

Corning Benton, Jr., MD Michael P. D’Alessandro, MD Janet R. Reid, MD Dorothy I. Bulas, MD Lane F. Donnelly, MD Wilbur L. Smith, Jr., MD Ralph S. Lachman, MD, FACR

2012 2013 2014

Alan Daneman, MD Lisa H. Lowe, MD, FAAP Robert H. Cleveland, MD

JOHN A. KIRKPATRICK YOUNG INVESTIGATOR AWARD

This award is given to the author of the best paper presented by a Resident or Fellow at the SPR meeting. Beginning in 1995, the award became known as the John A. Kirkpatrick Young Investigator Award. 1993 1993 1994 1995 1996 1997

Philipp K. Lang, MD Stephanie P. Ryan, MD Sara O’Hara, MD Philipp K. Lang, MD Fergus V. Coakley, MB, FRCR Ronald A. Alberico, MD

1998 1999 1999 2000 2001

Laura J. Varich, MD A. E. Ensley, BS R.W. Sze, MD S. H. Schneider, MD Valerie L. Ward, MD

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Ricardo Faingold, MD Andrea Doria, MD Nina M. Menezes, PhD Lena Naffaa, MD Courtney A. Coursey, MD Ashley J. Robinson, MBChB Hee Kyung Kim, MD Conor Bogue, MD Albert Hsiao, MD, PhD Ethan A. Smith, MD Saivivek Bogale, MD Emma Raver, BA

WALTER E. BERDON AND THOMAS L. SLOVIS AWARDS—2012

Best Clinical Research Paper Swanson JO, Vavilala MS, Wang J, et al. Association of initial CT findings with quality-of-life outcomes for traumatic brain injury in children. Best Basic Science Paper Tkach JA, Hillman NH, Jobe AH. An MRI system for imaging neonates in the NICU: initial feasibility study. 2013 recipients will be announced at the meeting. For a list of prior recipients, please visit the SPR website.

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S46 THE SPR RESEARCH AND EDUCATION FOUNDATION AWARDS

The SPR Research and Education Foundation is dedicated to promoting research and scholarship in pediatric radiology. The SPR Board of Directors has supported research through grants since 1990. The Foundation was established in 1994 with an initial donation from the Society’s reserves. The Jack O. Haller Award for Excellence in Teaching 2005 2006 2007 2008 2009 2010 2011

Alan Daneman, MD William R. Cranley, MD and John F. O’Connor, MD Cindy R. Miller, MD Sara J. Abramson-Squire, MD Michael A. DiPietro, MD George A. Taylor, MD Paul K. Kleinman, MD

2012 2013 2014 2014

Richard I. Markowitz, MD Gary L. Hedlund, DO Tal Laor, MD Carrie B. Ruzal-Shapiro, MD

The Heidi Patriquin International Fellowship 2005 2006 2006 2006 2007 2008 2009 2010 2011 2012

Luy Lyda, MD, Angkor Hospital for Children, Siem Reap, Cambodia Hakima Al-Hashimi, MD Salmaniya Medical Complex, Manama, Bahrain Pannee Visrutaratna, MD, Chiang Mai University, Chiang Mai, Thailand Juana Maria Vallejo, MD, Clinica del Country, Bogota, Colombia Nathan David P. Concepcion, MD, St. Luke’s Medical Center, Quezon City, Philippines Rolando Reyna Lopez, MD, Hospital Santo Tomas, Panama City, Panama Ahmed Mussa Jusabani, MD, Kilimanjaro Christian Medical Centre, Moshi Town, Tanzania Omolola Mojisola Atalabi, MD, College of Medicine, University of Ibadan, Nigeria Kushaljit Singh Sodhi, MD, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India) Wambani Sidika Jeska, MBchB, Kenyatta National Hospital, Nairobi, Kenya

2012 2013 2013 2014 2014

Yocabel Gorfu, MD, Addis Ababa University, Addis Ababa, Ethiopia Regina Nava, MD, St. Luke’s Medical Center, Quezon City, Philippines Olubukola Abeni Omidiji, MBBS, University of Lagos, Lagos, Nigeria Nneka I. Iloanusi, MBBS, University of Nigeria Teaching Hospital, Enugu, Nigeria Beatrice Mulama, MBChB, M. Med, Kenyatta National Hospital, Nairobi, Kenya

Pilot Award

Ashok Panigrahy, MD, Innovative Molecular and MR Neuroimaging Biomarkers of Pediatric Brain Tumors, Children’s Hospital of Pittsburgh of UPMC Seed Grants

Daniel B. Wallihan, MD, Liver Elastography as a marker for progressive hepatic disease and failing Fontan physiology, Cincinnati Children’s Hospital Medical Center Katharine L. Hopkins, MD, Pilot study of rapid multiparametric abdominal MRI in the diagnosis of pediatric appendicitis, Oregon Health and Sciences University Nancy Chauvin, MD, Early Knee Cartilage Changes in the Obese Child “Early Knee Cartilage Changes in the Obese Child, The Children’s Hospital of Philadelphia” Fellow Award

Aisling Snow, MB BCh BAO, Assessment of the diagnostic quality and clinical value of pediatric imaging studies performed at non-specialist imaging centers and imported to the radiology PACS system at a pediatric teaching hospital, Boston Children’s Hospital 2014 recipients will be announced at the meeting. For a list of prior grant recipients, please visit the SPR website.

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SOCIAL EVENTS SPR Research and Education Foundation Fun Run Underwritten by Texas Children’s Hospital Wednesday, May 14 6:00 a.m. (Meet in the lobby of the JW Marriott) Benefiting the Research and Education Foundation Join us for this 3-mile run on the National Mall and get your day off to a great start! Runners and walkers are all welcome. Entrance fee is $25 and includes a T-shirt. Welcome Reception Wednesday, May 14 6:15–7:30 p.m. JW Marriott Hotel Hors d’oeuvres and Refreshments Casual Attire Reception and Annual Banquet Friday, May 16 6:30–11:00 p.m. JW Marriott Reception, Dinner and Performance by Capitol Steps Business Casual Activities The JW Marriott Hotel employs a full-service concierge staff who are happy to share their detailed knowledge of Washington, D.C. and the surround area. The concierge desk is located on the lobby level of the Hotel. Additioanl information is included on the SPR website.

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SPR 2014 Gold Medalist The Gold Medal of The Society for Pediatric Radiology is our most distinguished honor. The SPR Medal is awarded to pediatric radiologists who have contributed greatly to the SPR and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader.

David C. Kushner, MD, FACR “Because Children Enhance Your Life” Edward Neuhauser Scientist, Teacher, Leader, Mentor—David C. Kushner is all these to so many people. His career has been characterized by outstanding leadership and great achievements while exuding an effortless efficiency, perennial smile, and twinkle in his eye. His astute guidance in business as well as medicine have uniquely helped the SPR, ACR, and the medical centers he has helped lead. David Kushner is a man of great vision who was lucky to have encountered many unique leaders throughout his career while wise enough to learn from them. Likely the only pediatric radiology gold medalist to be born in Fargo North Dakota, even as a young boy, he knew he wanted to be a doctor. Early in his life in Minnesota, he needed to earn money and went to a medical center at age 12 to find work. There he met Sewell Gordon, a pediatric radiologist when there were no pediatric radiologists. This encounter gave DCK the vision for his life’s work. He never looked back. With his goal of becoming a pediatric radiologist, Dr. Kushner first studied child development at the University of Minnesota. He went on to medical school at the University of Pennsylvania where he had the “best time of his life”. He met numerous giants in pediatrics (Lewis Barness, Frank Oski), pediatric surgery (C. Everett Koop, Judah Folkman.), taking over 1 ½years of pediatric electives during his Philadelphia years. Dr. Kushner spent 2 years at NIH completing a 2 years fellowship in embryology and teratology. Pursuing his life’s vision then led DCK to Boston where he completed a radiology residency at Massachusetts General and Boston Children’s Hospital. He met many radiology giants during that era including Juan Tavaras, Murray Janower, John Kirkpatrick, Clif Harris, Thorne Griscom, Edward Neuhauser, Bob Lebowitz, Roy Strand, Ken Fellows, Bob Wilkinson, Rita Teele, Ted Treves and Jack O’Connor. He become fondly known as “Mad Dog”, and was quickly appointed section chief of pediatric radiology at Massachusetts General in 1979. While there, he developed his superb administrative skills under the tutelage of the great Juan Tavaras. When an opening for Director of Pediatric Radiology became available at Children’s National Medical Center in 1988, he was up to the challenge of building a pediatric radiology in the nation’s capital. Over the next 15 years, he built the department, trained numerous fellows, and survived challenges from health care threats and competing initiatives. He loved the international culture of the city, the fine arts and music opportunities, taking guitar lessons and learning to love the blues. DCK thrived during these years and became an important national leader on the behalf of pediatric radiology. His pivotal work for the Society for Pediatric Radiology included being SPR Treasurer and President of the Research and Education Foundation helping launch the fundraising “Campaign for Children”. He served as SPR President from 2003 to 2004 running a successful Savannah meeting. As Chair of the Board of Directors he led a strategic planning process which resulted in more focused divisions and clearly defined board responsibilities. Dr. Kushner also became an important leader in the American College of Radiology advocating tirelessly for children’s health while serving on the Council Steering Committee, then Council Vice Speaker and Speaker. He helped establish a pediatric radiology caucus at the annual ACR meeting. He brokered the SPR partnership with the ACR re society management and helped establish the first pediatric commission of the ACR while on the Board of Chancellors. He tirelessly contributed to the pediatric component of the ACR practice guidelines. When the opportunity came to move to Norfolk in 2005, DCK took up the challenge. He has thrived at King’s Daughters where he now works with great partners and staff. With his wife Peggy, DCK now lives on the waters of the Chesapeake where his love of sailing and fishing can be fulfilled. With five children and six grandchildren, his life remains full.

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David C. Kushner’s official title on his business card says much about this creative visionary. 1. 2. 3. 4. 5. 6.

Grandfather Unemployed musician Fly fisherman Sailor Italian cook Professor of Radiology and Pediatrics

DCK states “Everything that I can be said to have accomplished has come to me through the grace, charity and mentoring of others; and from plain dumb luck.” The Society for Pediatric radiology is lucky to have this tour de force as an advocate, mentor, and educator for children’s health. Dorothy I. Bulas, MD

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SPR 2014 Pioneer Honoree Pioneer Honorees were first acknowledged in 1990 as a means to honor certain physicians who made special contributions to the early development of our specialty.

Diego Jaramillo, MD, MPH Dr. Diego Jaramillo is the recipient of the 2014 SPR Pioneer Award in recognition of his numerous significant scientific and educational endeavors to advance the mission of the SPR and improve the healthcare of children. Throughout his career, Dr. Jaramillo has embodied the spirit of a pioneer by trailblazing new areas of research in pediatric musculoskeletal imaging. Diego was born in Cali, Columbia. His father was a gastroenterologist, who performed barium studies as part of his practice. Diego has early memories of red goggles and developing radiographs with images of upper GI’s and enemas. From his mother he remembers above all her kindness and intelligence, and a beautiful combination of discipline and reverence. He received his MD degree with Valedictorian recognition in 1981, from the Pontificia Universidad Javeriana in Bogota, Colombia, followed by a diagnostic radiology residency at the University of Texas in Houston. Subsequently, he trained as a pediatric radiology fellow at the Boston Children’s Hospital in 1987, where he was highly influenced by Dr. John A Kirkpatrick. Diego credits Dr. Kirkpatrick as a great mentor, who led by example and taught him about radiology, life, and the pediatric skeleton. Dr. Jaramillo was appointed to the faculty of Harvard Medical School from 1990 to 2004, serving as an attending radiologist at Boston Children’s Hospital and subsequently as division chief of pediatric radiology at the Massachusetts General Hospital. Diego also earned a Masters degree at the Harvard School of Public Health in 2002. In 2004, Dr. Jaramillo was appointed Radiologist-in-Chief and the Van Alen Chair of Radiology at the Children’s Hospital of Philadelphia and Professor of Radiology at the University of Pennsylvania School of Medicine. Diego has developed a renowned Department of Radiology at CHOP emphasizing excellence in pediatric radiology, pediatric care, expansion of knowledge, and the creation of a collegial environment. Under his leadership the department has expanded from 13 to 32 radiologists. Dr. Jaramillo’s greatest expertise and scientific contributions are in the areas of imaging of musculoskeletal disorders of childhood and pediatric magnetic resonance imaging. Diego has advanced the fundamental understanding of normal and abnormal development of epiphyseal cartilage and the growth plate and evaluation of physeal injuries via magnetic resonance imaging. He has published 124 peer-reviewed research papers and in 1995 received the prestigious John Caffey Award from the SPR for his seminal work on perfusion of the normal and ischemic cartilaginous epiphysis via gadolinium enhanced MRI. Frederic Shapiro, an orthopedic surgeon with a deep understanding of growth disorders and bone histology, and Tal Laor, a pediatric radiologist, friend, and a source of many great ideas have been his main research partners. Throughout his professional career, Dr. Jaramillo has worked tirelessly to advance the mission of the Society for Pediatric Radiology. He has served on the Research and Education Foundation Board, the Board of Directors, and on numerous committees including the Research and Technology Assessment Committee and SPR’s National Radiation Safety Initiative. He currently serves on the Board of Directors as Second Vice President in line to become President in 2017. Diego also serves on the editorial boards of Radiology and Pediatric Radiology. Diego has been widely recognized for his excellence in teaching and research with numerous awards from prestigious organizations including the International Society for Magnetic Resonance Imaging in Medicine, the Radiological Society of North America, and the Massachusetts General Hospital. He has mentored and collaborated with numerous trainees in pediatric radiology, many of whom have gone on to illustrious academic careers. Dr Tal Laor, one of Diego’s early trainees and collaborators, captures the essence of Diego perfectly: “Diego has been seminal in the development of “modern” pediatric musculoskeletal imaging. His research has advanced immeasurably our understanding about normal bone growth and abnormal development. Moreover, his passion has inspired countless colleagues and trainees to pursue similar areas of investigation. In one way or another, like “six degrees of separation”, the majority of pediatric musculoskeletal radiologists and their research endeavors are somehow connected to Diego! His enthusiasm is infectious, his fund of knowledge is extensive, and his wisdom is only matched by his salsa dancing skills!” Diego is the proud father of two children, Livia and Ricardo Jaramillo. Livia is currently a college student at Brown University and Ricardo is completing high school in Philadelphia. Diego is grateful to his children and Erika Rubesova, also a pediatric radiologist, for their inspiration and joie de vivre. The SPR and pediatric patients are highly fortunate to have benefitted from Diego’s outstanding contributions and dedication to the care of children. The Society for Pediatric Radiology is very proud to bestow the 2014 Pioneer Award on Dr. Diego Jaramillo. Richard A. Barth, MD

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SPR 2014 Presidential Recognition Award The Society bestows Presidential Recognition Awards on members orother individuals whose energy and creativity have made a significant impact on the work of the Society and its service to its members.

Richard M. Benator, MD, FACR Some accolades are stretch to find; some speak for themselves. Those of Richard Benator shout, if only we listen with the right ear. And the right ear is to recognize the care and quality of this care we deliver as pediatric radiologists. This starts, with Richard, with a tradition of business, of hard work, and of green smocks…which I will return to. For those of you who don’t know Dr. Benator, essentially a career pediatric radiologist at All Children’s in St. Petersburg Florida, his undergraduate training was at Tulane in biomedical engineering, with a subsequent MD from Medical College of Georgia, Radiology residency at University of Tennessee (Memphis), Pediatric Radiology fellowship at LeBonhner Hospital and St Jude’s Cancer and Research hospital, a couple of years at the Medical College of Virginia (Currently VCU) in Richmond as an assistant Professor in Radiology, and finally his home at All Children’s Hospital with a faculty appointment in the Radiology Department at the University of South Florida. Leadership positions include Florida Radiology Society (Program and Education Committee, Chair; Pediatric Radiology Committee, Chair; Education Foundation, President; Society Secretary, Treasurer, Vice-president, President), Florida West Coast Radiological Society (Secretary-Treasurer, Vice President and President), SPR Public Policy Chair, and the American College of Radiology (Alternate Counselor, and Counselor Florida; Alternate and Counselor for SPR; Committee on Government Relations for the Commission on General & Pediatric Radiology, and ACR Pediatric Radiology Commission member). We are getting to the green smocks. Most recently, he has been instrumental in establishing an ACR Medicaid Network, which by default emphasizes our Pediatric Radiology concerns as Pediatric imagers service a disproportionate large percentage of Medicaid patients. This is an accomplishment for our subspecialty, as previously; the emphasis of the ACR had been primarily focused on Medicare. He advocates for the missions of the Society for Pediatric Radiology and the American College of Radiology through promoting the value of diagnostic imaging and image-guided care for children. He has been a consistent presence in College activities for many years, and the first role as chair of the Pediatric Economics Committee under the newly formed (finally) Pediatric Commission, with membership on the Commission on Economics. Bibb Allen, M.D. past Economics Commission Chair and current ACR vice chairman recently commented, “Richard’s work on behalf of children’s radiology while on the Commission on Economics was invaluable. Richard led the effort to develop a grass-roots ACR Medicaid Network similar to the Medicare Contractor Advisory Committee Network for Medicare. That network tracked Medicaid coverage policies from state to state and helped promote fair coverage and payment. This was a big undertaking and occurred in addition to keeping up with other reimbursement issues affecting pediatric radiologists. Congrats to Richard!”. Richard has continued to advocate for our subspecialty emphasizing quality and expertise in pediatric imaging care. These focused efforts are with a backdrop of his widely recognized representation for Pediatric Radiology in the College. David Kushner, himself a pioneering voice for the SPR in the College commented, “Richard certainly deserves the award…he has been instrumental in carrying on the very important Pediatric Caucus at the ACR. We started the caucus perhaps 10 years ago, to organize the voice of advocacy for children in the many actions of the ACR Council….Richard has been part of the action from the very beginning…. The Caucus has been effective in getting advocacy for children in front of Council during the debates on every ACR Policy, Technical Standard and Guideline. Before the Caucus, pediatrics had no organized voice and pediatric issues were frequently glossed over. The Caucus was instrumental in persuading the ACR to invite the SPR to serve as joint sponsor of all appropriate documents. Finally, the Caucus has served as the advocate for children to encourage ACR Leadership to incorporate ‘pediatric issues’ in all new programs including the Learning Center and [the] Image Gently Campaign. Richard has played a very important role in all of these things. He has become a resource for pediatric radiologists who are new to Council and serves to coordinate the annual review of all ACR documents that will come before Council for consideration. None of this is glamorous. All of this is tedious and thankless. All of this is Democracy in Action on behalf of our pediatric patients. Rich has been a stalwart team member and leader. I am pleased that he is getting the award”. I have had the pleasure and privilege of working with Dr. Benator who has been enthusiastic and focused in his undertakings. He is currently recognized and will certainly be long acknowledged for his successes in the College on behalf of the SPR. I have to say he continues this while in full time practice. He meets challenges, always with a smile and a positive approach. The SPR is fortunate to have our prospects better for his efforts. Richard, you relayed that a “green smock” was the uniform (and emblematic) of your parents and preceding generations, and their tireless efforts in retail business. You have noted, “One of the lessons [we learned], is that one needs conviction and sometimes, without an immediate expectation of reward, you just need do to

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some things that’s for the greater good, because it is what you believe needs to done. In receiving the 2014 SPR Presidential Recognition Award, thank you for doing what needs to be done, for keeping that concern for the business of what we do in focus, and for wearing the green smock for the Society for Pediatric Radiology and the kids we serve. Donald P. Frush, MD, FACR

SPR 2014 Honorary Member The Society extends Honorary Membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children.

Timothy M. Cain, MBBS Dr. Tim Cain is the Directory of Medical Imaging at the Royal Children’s Hospital in Melbourne, Australia, the largest free standing children’s hospital in the Southern Hemisphere. Tim decided that he wanted to be a doctor while a foreign exchange student at Winneconne High School. It is in the small town near Oshkosh, Wisconsin that he realised how much he enjoyed being with people and that any vocation had to include personal interactions as well as intellectual stimulation. His plans changed slightly when he met the woman of his dreams during his studies at the University of Adelaide in South Australia. Married before completing his Medical degree and a father four times before completing his specialist training, children and family were destined to influence his career choice and love of paediatric imaging. During his radiology training in South Australia Tim rotated through the Adelaide Women’s and Children’s Hospital (WCH) where he was first exposed to dedicated paediatric radiologists including Drs. Lloyd Morris and Gary Lequesne who are well known to many senior SPR members. He followed his diagnostic radiology training with 2 years additional experience in Nuclear Medicine thus acquiring dual specialist qualifications. Tim’s radiology career started as a private practice radiologist with a sessional appointment as a Nuclear Radiologist at Flinders Medical Centre in Adelaide. While still a partner of the Radiology practice, he started working as a Nuclear Medicine Specialist at the WCH in 1997. This turned into an unconventional form of paediatric fellowship and marked a change in his career path that had him leave the private practice for a full time role in a teaching hospital. This role soon became the head of Paediatric and Women’s imaging at the WCH. At that time he realised that there was more to leadership than ‘standing up the front’ and this was his incentive to complete a Masters of Business Administration. This stimulating academic activity also provided Tim with tools to assist with the challenges of heading a recently merged Paediatric and Women’s imaging department. However, the opportunity to concentrate on paediatric imaging presented itself in 2005 when he became head of department at the Royal Children’s Hospital Melbourne (RCH). The prospect of being the 7th Director of Medical Imaging at the RCH in an 8 years period was a challenge he has successfully risen to, and he has now completed more than 8 years in the role. One of his first tasks as new Director was to assist in the design of the Medical Imaging Department for the new RCH which opened in December 2011. Among other achievements he ensured that there was provision for MR PET which has been a focus of much of his energy for the last few years. Even during his 10 years in private practice (he refers to this as his ‘previous life’), when having a large young family brought its own demands, Tim has always actively served on professional bodies. He sat on the South Australian branch of the Royal Australian and New Zealand College of Radiologists (RANZCR) executive committee for 10 years, including 6 years as Honorary Secretary. His interest in radiation safety was recognised by his Ministerial appointment as a member of the Radiation Protection Committee of the South Australian Government, Environment Protection Authority - Radiation Protection Division. He is currently the Chairman of the RCH Radiation Safety Committee. He has been a member of various other hospital Committees including Medical Appointment, Credentialing, Patient Safety, Quality and Safety, and Ethics technical review panel, and he currently represents the RCH Medical Staff Association as a Councillor for the Victorian Branch of the Australian Medical Association. Tim served as Secretary of the Australian and New Zealand Society for Paediatric Radiology (ANZSPR, formerly Australasian Society for Paediatric Imaging) for 5 years up to 2011 and was briefly the treasurer in 2012. He has become active with the World Federation of Pediatric Imaging (WFPI) where he is an Asian and Oceanic Society for Paediatric Radiology (AOSPR) representative and serves as the Membership Secretary and Vice Treasurer. He has recently been elected to the position of Vice President of the AOSPR. His desire to share knowledge with international colleagues has been stimulated by the many overseas trained radiologists who train in paediatric medical imaging at the RCH in one of the six available paediatric imaging fellowship positions he has helped establish.

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Actively involved in medical education, Tim was the convenor of the 53rd RANZCR Annual Scientific Meeting in Adelaide 2002, and the paediatric section convenor of the Asian and Oceanic Congress of Radiology in Sydney, 2012. With colleagues at the Royal Children’s Hospital in Melbourne, he was co-convenor of the Australian and New Zealand Society for Paediatric Radiology Annual meeting in Melbourne 2007. He is involved in undergraduate and postgraduate radiology education via the University of Melbourne and presents regularly at local, national and international radiology meetings. He also attends management courses to help maintain skills acquired during his MBA. He has published over 20 scientific articles in peer reviewed journals. Above all other aspects of his medical career, Tim enjoys the contact with patients and their families and carers. He practices an interesting blend of paediatric imaging, mixing Nuclear Medicine with some interventional radiology and body imaging. The patient contact keeps his focus and counters the demands of management and modern bureaucracy. He is supportive of his colleagues’ professional development and is a strong advocate for quality paediatric imaging locally and nationally. Tim is fortunate to have a supportive and healthy family. Tina, his wife of more than 30 years, has adapted to the challenges of being the partner of an overcommitted medical professional, although she refers to the RCH as the ‘other women with whom she competes for Tim’s attention’. Their four children have chosen diverse careers (Medicine, commerce, electronic media and advertising) and are proudly independent. Two grandchildren bring delight and a reminder of the challenges of raising young children. Paediatric radiology and involvement in AOSPR and WFPI allow Tim to combine his professional interests with his desire to meet like minded people and travel. He derives pleasure from interacting with his international colleagues by sharing knowledge and is always keen to discuss issues common to paediatric imaging departments around the world. The collegiality and professionalism of his RCH, national and international colleagues have been a driver for his continued involvement in his chosen career. His nomination for Honorary Member of the SPR is a tribute to his role in increasing the world wide profile of paediatric imaging in Australia, New Zealand and the Asian Oceanic Region through his roles in the ANZSPR, AOSPR and more recently the WFPI. Michelle Fink, MRCP (UK), FRCR (UK), FRANZCR

SPR 2014 Singleton-Taybi Award The Singleton-Taybi Award is given in honor of Edward Singleton and Hooshang Taybi, in recognition of their personal commitment to the educational goals of the SPR. Initiated in 2006, the Award is presented annually to a senior member of the SPR whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology.

Robert Harris Cleveland, MD, FACR Robert Harris Cleveland is an extraordinary person. It is my great pleasure to introduce him and to write on his behalf. Bob Cleveland was born in 1945 in Dallas, Texas. He received his education at the University of Texas, the University of Texas Medical Branch and Harvard University. He received his hospital training at Rhode Island Hospital in Providence, Charity Hospital in New Orleans, State University of New York in Syracuse, and Children’s Hospital in Boston. He has progressed in his academic appointments from Instructor to Professor of Radiology at Harvard Medical School. He has worked professionally at Massachusetts General Hospital where he progressed to Director of the Division of Pediatric Radiology and Children’s Hospital in Boston where he progressed to Chief of the Division of General Radiology and Director of Quality Improvement for the Department of Radiology. He has received multiple honors including Fellowship in the American Academy of Pediatrics, Fellowship in the American College of Radiology, Best Scientific Exhibitor at the European Society of Pediatric Radiology, the Lawrence L. Robbins Teaching Award of the Massachusetts General Hospital and Distinguished Service and Lifetime Service Awards from the American Board of Radiology and the New England Roentgen Ray Society. His hospital committee work spans four pages of single spaced small font listings. He is and has been a member of 13 medical societies and a participant in numerous society committees. He has served as Examiner for the American Board of Radiology. Bob Cleveland has been active as a scholar and investigator. His research interests have covered radiation reduction, evaluation of infant swallowing, the manifestations of HIV infection in children, and many areas of pediatric pulmonary disease. He has participated in more than 150 publications, case reports, reviews, chapters, abstracts, presentations and posters. Seventy five publications have been peer-reviewed original publications. Bob has also published a successful book: “Imaging in Pediatric Pulmonology”.

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Robert Cleveland has been extraordinarily active as a teacher, speaking literally at hundreds of sessions. The listings run seven pages in his CV. These activities have included presentations to medical students, radiology residents, pediatric residents, surgical residents, fellows in all specialties, lectures at postgraduate courses, invited lectureships and many Visiting Professorships in the United States and Europe,. Bob’s true focus has been “the basics”. He has championed the excellence of radiography in a time with most people were more fascinated with so called “advanced imaging”. His forte has been teaching about the standard radiographic chest examination and the wealth of information that can be gleaned from this ancient technology. He has observed that younger radiologists and trainees are less prepared to properly diagnose from a standard chest x-ray or other basic radiograph than more modern techniques. In this effort, Bob has developed a superb and effective teaching style that is disarming, charming and effective. I have known and admired Bob Cleveland for almost 40 years. He is an extraordinary person and clearly follows in the footsteps of Ed Singleton and Hoosh Taybi—both of whom have served as my mentors and whom I have known and admired for my entire career. Both Ed and Hoosh would be pleased and proud that Bob Cleveland will be receiving an honor in their name. Congratulations Dr. Cleveland! David C. Kushner, MD, FACR John Caffey, MD 1895–1978

Dr. Caffey was regarded throughout the world as the father of pediatric radiology. His classic textbook, “Pediatric X-Ray Diagnosis”, which was first published in 1945, has become the recognized bible and authority in its field. The seventh edition of this book was completed several months before his death in 1978. It has been among the most successful books of its kind in the medical field. Dr. Caffey was born in Castle Gate, Utah on March 30, 1895. It is interesting that he was born in the same year that Roentgen discovered the x-ray. Dr. Caffey was graduated from University of Michigan Medical School in 1919, following which he served an internship in internal medicine at Barnes Hospital in St. Louis. He spent 3 years in Eastern Europe with the American Red Cross and the American Relief Administration, and returned to the United States for additional training in medicine and in pediatrics at the Universities of Michigan and Columbia, respectively. While in the private practice of pediatrics in New York City at the old Babies Hospital of Columbia University College of Physicians and Surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in 1929. He frequently expressed appreciation and admiration for the late Ross Golden, Chairman of Radiology at Columbia Presbyterian Hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. Dr. Caffey’s keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in 1945. Dr. Caffey received many awards in recognition of his achievements. Outstanding among these were the Mackenzie Davidson Medical of the British Institute of Radiology in 1956, the Distinguished Service Award of the Columbia Presbyterian Medical Center in 1962, the Outstanding Achievement Award of the University of Michigan in 1965, the Howland Award of the American Pediatric Society in 1967, the Jacobi Award of the American Medical Association in 1972, and the Gold Medal Award of the American College of Radiology in 1975. He had been a member of the American Journal of Roentgenology. He was a counselor of The Society for Pediatric Radiology and was an honorary member of the European Society of Pediatric Radiology. Dr. Caffey’s contributions to the pediatric radiologic literature were many. He was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. Infantile cortical hyperostosis was described by him and is called “Caffey’s Disease”. Dr. Caffey in 1946 first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. It was Dr. Caffey who first recognized and descried the characteristic bony changes in vitamin A poisoning. He recognized and described the findings associated with prenatal bowing of the skeleton.

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In 1963, 3 years after his retirement from Babies Hospital, he joined the staff of the Children’s Hospital of Pittsburgh as associate radiologist and as Visiting Professor of Radiology and Pediatrics at the University of Pittsburgh School of Medicine. Although Dr. Caffey came to Children’s Hospital and the University of Pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. In Pittsburgh, he made four major new contributions to the medical literature. He described the entity, “idiopathic familial hyperphosphatasemia”. He recognized and described the earliest radiological changes in Perthes’ Disease. He called attention to the potentially serious effects of shaking children, and used this as a subject of his Jacobi Award lecture. He described, with the late Dr. Kenny, a hitherto unrecognized form of dwarfism which is now known as the Caffey-Kenny dwarf. The John Caffey Society, which includes as its members pediatric radiologists who have been intimately associated with Dr. Caffey, or who have been trained by his students, was established in 1961. This society is now among the most prestigious in the field of radiology. His book and the society named in his honor will live on as important memorials to this great man. His greatness was obvious to all who worked with him. He was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. His dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. He was concerned with the written and spoken word and was a skilled semanticist. His book and his articles are masterpieces of language and construction. He stimulated and was stimulated and loved by all who had the privilege of working with him. Radiology and Pediatrics have lost a great man, but they shall ever have been enriched by his presence. Bertram R. Girdany, MD Caffey Award for Best Basic Science Research Paper 2005 2006 2007 2008 2009 2010 2010 2010 2010 2011 2012 2013

Quantitative Measurement of Microbubble Ultrasound Contrast Agent Flow to Assess the Efficacy of Angiogenesis Inhibitors In Vivo. McCarville B, Streck C, Li CS, Davidoff A 64 Cu-Immuno-PET Imaging of Neuroblastoma with Bioengineered Anti-GD2 Antibodies. Voss SD, Smith SV, DiBartolo NM, McIntosh LJ, Cyr EM, Bonab AA, et al. MR Imaging of Adenocarcinomas with Folate-Receptor Targeted Contrast Agents. Daldrup-Link HE, Wang ZJ, Meier R, Corot C Evaluation of Quality Assurance Quality Control Phantom for Digital Neonatal Chest Projection Imaging. Don S. Faster Pediatric MRI Via Compressed Sensing. Vasanawala S, Alley M, Barth R, Hargreaves B, Pauly J, Lustig M Clinical Evaluation of Readout-Segmented-EPI for Diffusion-Weighted Imaging. Bammer R, Holdsworth S, Skare S, Yeom K, Barnes P High-Resolution Motion-Corrected Diffusion-Tensor Imaging (DTI) in Infants. Skare S, Holdsworth S; Yeom K; Barnes P, Bammer R 3D SAP-EPI in Motion-Corrected Fast Susceptibility Weighted Imaging (SWI). Bammer R, Holdsworth S, Skare S, Yeom K, Barnes P T1-Weighted 3D SAP-EPI for Use in Pediatric Imaging. Bammer R, Holdsworth S, Skare S, Yeom K, Barnes P An MR System for Imaging Neonates in the NICU. Tkach J, Giaquinto R, Loew W, Pratt R, Daniels B, Jones B, Donnelly L, Dumoulin C Advantages of a Nanoparticle Blood Pool Contrast Agent Over Conventional Intravascular Glomerular-Filtered Contrast Agents for Pulmonary Vascular Imaging. Annapragada A, Guillerman RP, Hoffman E, Kaczka D, Ghaghada K, Badea C Psychometric Function: A Novel Statistical Analysis Approach to Optimize CT Dose: Steven Don, MD, Mallinckrodt Institute of Radiology, St. Louis, MO, Bruce Whiting, David Politte, Parinaz Massoumzadeh, Charles Hildebolt

Caffey Award for Best Clinical Research or Education Paper 2005

Evaluation of High Resolution Cervical Spine CT in 529 Cases of Pediatric Trauma: Value Versus Radiation Exposure. Shiran D, Jimenez R, Altman D, DuBose M, Lorenzo R

2006

Alterations in Regional O2 Saturation (StO2) and Capillary Blood Volume (HbT) with Brain Injuries and ECMO. Grant PE, Themelis G, Arvin K, Thaker S, Krishnamoorthy KK, Franceschini MA Evaluation of Single Functioning Kidneys Using MR Urography. Grattan-Smith D, Jones R, Little S, Kirsch A, Alazraki A Evaluating the Effects of Childhood Lead Exposure with Proton MR Spectroscopy & Diffusion Tensor Imaging Neuroradiology. Cecil KM Improving Patient Safety: Effects of a Safety Program on Performance and Culture in a Department of Radiology at a Children’s Hospital. Donnelly L, Dickerson J, Goodfriend M, Muething S

2007 2008 2009 2010 2011 2012 2013

Juvenile Osteochondritis Dissecans (JOCD): Is It a Growth Disturbance of the Secondary Physis of the Epiphysis? Laor T, Wall E; Zbojniewicz A Quantitative Assessment of Blood Flow with 4D Phase-Contrast MRI and Autocalibrating Parallel Imaging Compressed Sensing. Hsiao A, Lustig M, Alley M, Murphy M, Vasanawala S Multidetector CT Pulmonary Angiography in Children with Suspected Pulmonary Embolism: Thromboembolic Risk Factors and Implications for Appropriate Use. Lee EY, Tse SK, Zurakowski D, Johnson VM, Donald TA, Boiselle PM Prospective Comparison of MRI and Ultrasound for the Diagnosis of Pediatric Appendicitis Robert Orth, MD, PhD, Texas Children’s Hospital,Houston, TX, R. Paul Guillerman, Prakash Masand, MD, Wei Zhang, George Bisset

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CAFFEYAWARD FOR POSTERS 2005 2006 2006 2007 2008 2009

3D MRI and CT in the Evaluation of Congenital Anomalies of the Aortic Arch. Dehkharghani S, Olson K, Richardson R Diffusion Weighted Imaging in Pediatric Neuroradiology: A Primer. Sagar P, Grant PE Imaging of Suprarenal Fossa in Children: Radiological Approach and Clinico-Pathological Correlation. Kukreja K, Restrepo R, D’Almeida M Neuroimaging of Nonaccidental Trauma: Pitfalls and Controversies. Lowe L, Obaldo RE, Fickenscher KA, Walsh I, Estimation of Cumulative Effective Doses from Diagnostic and Interventional Radiological Examinations in Pediatric Oncology Patients. Thomas KE, Ahmed BA, Shroff P, Connolly B, Chong AL, Gordon C Case Report : Multi-Modality Imaging Manifestations of the Meckel’s Diverticulum in Pediatric Patients. Kotecha MK, Bellah RD, Pena AH, Mattei P

2009 2009

Educational: MR Urography: Functional Analysis—Made Simple! Khrichenko D, Darge K Scientific: MRI Findings in the Term Infant with Neonatal Seizures. An Etiologic Approach. Rebollo Polo M, Hurteau-Miller J, Laffan E, Tabban H, Naser H, Koujok K 2010 Scientific: Dual Phase Intravenous Contrast Injection in Pediatric Body CT. Mann E, Alzahrani A, Padfield N, Farrell L, BenDavid G, Thomas K 2010 Educational: Hemangiomas Revisited: The Useful, the Unusual and the New. Restrepo R, Palani R, Matapathi U, Altman N, Cervantes L, Duarte AM, Amjad I 2010 Case Report: MRI of Congenital Urethroperineal Fistula. Mahani M, Dillman J, Pai D, Park J, DiPietro M, Ladino Torres M 2011 Scientific: Updated Estimated Radiation Dose for Pediatric Nuclear Medicine Studies. Grant F, Drubach L, Treves ST, Fahey F 2011 Educational: Button Battery Ingestion in Children: What the Radiologist Must Know. Kappil M, Rigsby C, Saker M, Boylan E 2011 Case Report: MR Imaging Features of Fetal Mediastinal and Intrapericardial Teratomas. Rubio E, Kline-Fath B, Calvo-Garcia M, Guimaraes C 2012 Case Report: Neuroimaging in Hemiplegic Migraine: Cases and Review of the Literature. Stence NV, Kedia S, Maloney JA, Armstrong-Wells J, Bernard T 2012 Educational: Primary and Secondary Amenorrhea in Pediatric Patients: From the Beginning to the End. Cortes C, Ramos Y, Restrepo R, Diaz A, Sequeira L, Lee EY 2012 Scientific: Prenatal Evaluation of Limb Body Wall Complex with Emphasis on MRI. Aguirre-Pascual E, Victoria T, Johnson A, Chauvin N, Coleman B, Epelman M 2013 Scientific Exhibit: TIE Phantom Iterative Reconstruction Technique (PIRT)-a quantitative ALARA method to test iterative reconstructions effect on image quality and dose in the pediatric population Anne McLellan, Medical, Radiology, Phoenix Children’s Hospital, Phoenix, AZ; James Owen, John Egelhoff, John Curran, Jeffrey Miller, MD, Padmaja Naidu Morbidity associated with delayed treatment of cholelithiasis in pediatric patients with sickle cell disease Heather Imsande, MD, Boston Medical Center, Boston, MA The top four candidates from each category (Educational, Case Report/Case Series/Technical Development and Scientific) for a Caffey Scientific Exhibit Award will present their work during one of the scheduled breaks at the Annual Meeting.

For a list of Caffey Award papers and posters prior to 2005, please visit the SPR website.

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2014 Edward B. Neuhauser Lecture

The Future of American Medicine—The Impact of Health Care Reform

Robert Pearl, MD Executive Director and CEO The Permanente Medical Group President and CEO Mid-Atlantic Permanente Medical Group Dr. Robert Pearl is Executive Director and CEO of The Permanente Medical Group and President and CEO of the Mid-Atlantic Permanente Medical Group. Together these organizations are comprised of over 9,000 physicians and 34,000 staff members. Dr. Pearl is responsible for the health care that is delivered to approximately four million Kaiser Permanente members in the states of California, Virginia, Maryland and the District of Columbia. Board certified in Plastic and Reconstructive Surgery, Dr. Pearl received his Medical Degree from Yale University School of Medicine. He completed his residency in Plastic and Reconstructive Surgery at Stanford University and currently serves on the faculty as a Clinical Professor of Plastic Surgery. He is also on the faculty of the Stanford Graduate School of Business where he teaches courses on strategy and leadership, as well as lectures on the subject of health care technology. Selected by Modern Healthcare as one of the most powerful physician leaders in the nation, Dr. Pearl has published more than 100 articles in various medical journals and has been a contributor to many books. He has made over 100 presentations at national meetings in the areas of both clinical medicine and medical economics. In the past several years, he has been a visiting professor at the Johns Hopkins School of Medicine, Haas School of Business and Harvard School of Public Health. Recently, Dr. Pearl was a featured speaker at both the Commonwealth Club and the Institute for Healthcare Improvement’s National Quality Forum event. In addition, he participated in the Bipartisan Congressional Task Force on Delivery System Reform and Health IT. Most recently, he became the Chairman of the National Council of Accountable Physician Practices (which includes the largest medical groups from across the country such as the Mayo Clinic, Geisenger and Intermountain Healthcare). Dr. Pearl is a frequent lecturer on the opportunities to use 21st Century tools and technology to improve both the quality and cost of health care, while simultaneously making care more convenient and personalized. As a regular contributor to Forbes.com, Dr. Pearl publishes a weekly blog on the nexus of health care and business and provides frequent updates through Twitter. He is an advocate for the power of integrated, prepaid and technologically enabled health care delivery systems. He is also a strong believer that organizations like Kaiser Permanente in which physicians collaborate rather than compete, and in which a multi-specialty medical group works in partnership with a not-for-profit health plan and hospital system, are able to provide superior quality of care over fragmented insurance-based systems. Previous Neuhauser Lectures 1997 1998 1999 2000 2001 2002

S. Steven Potter, PhD, Cincinnati, Ohio “Homeobox Genes and Pattern Formation (Master Genes)” Roy A. Filly, MD, San Francisco, California “Fetal Thoracic Surgery” Harold A Richman, PhD “Child Abuse: From a Radiologist’s Discovery to a Major Issue of Public Policy. What Have We Wrought?” William D. Lyman, PhD, Detroit, Michigan “Prenatal Molecular Diagnosis and Fetal Therapy” Jerry R. Dwek, MD, Columbus, Ohio “Médecins Sans Frontiéres/The Doctors Without Borders Experience—Afghanistan” Eric J. Hall, DSc, FACR, FRCR, New York, New York

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2003 2004 2005 2006 2007 2008 2009

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 “Lessons We Have Learned From Our Children: Cancer Risks From Diagnostic Radiology” Jeffrey A. Towbin, MD, Houston, Texas “Molecular Cardiology: Laboratory to Bedside” Bruce R. Rosen, MD, PhD, Boston, Massachusetts “New Advances in MRI: A Guide for the Practicing Pediatric Radiologist” Bruce R. Korf, MD, PhD, Birmingham, Alabama “Pathobiology and Management of NF1 in the ‘Genomic Era’” Richard M.J. Bohmer, MD, MPH “Evolution, Innovation and the Changing Nature of Healthcare Delivery” Nogah Haramati, MD “21st Century Radiology: Growth and Development of Our Workflows and Processes” Emanuel Kanal, MD, FACR, FISMRM, AANG MR Technology: Where Are We, Where Are We Going?

Roberta G. Williams, MD “Cardiology and Radiology: Partners in Producing Healthy Adults with Congenital Heart Disease” 2010 Regina E. Herzlinger, PhD “The Economic Basis of Change in Healthcare” 2011 Sanjiv Gambhir, MD, PhD “Molecular Imaging” 2012 William R. Hendee, PhD “Past and Future Patient Benefits of Radiologist/Physicist Collaboration” 2013 James R. Downing, MD The Pediatric Cancer Genome Project—Implications for Clinical Medicine For a list of Neuhauser Lecturers prior to 1997, please visit the SPR website.

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POSTGRADUATE COURSE ABSTRACTS

S59 How to Get the Lowest Dose in Abdominal CTA? Beverley Newman, MBBCh, FACR

Tuesday, May 13, 2014

BODY IMAGING TECHNIQUES: PRACTICAL ADVICE FOR CLINICALWORK How Should Image Quality be Evaluated in CT? David B. Larson, MD, MBA

The goal of ALARA in CT is to use the minimum amount of radiation necessary while preserving diagnostic image quality. To do this, radiologists must have a means of estimating image quality. Historically, image noise has been the most commonly-used metric. Specific challenges with image noise include the facts that 1) image noise is highly susceptible to post-acquisition image processing, 2) there is currently no satisfactory means of measuring image noise directly on the image, and 3) the target image noise varies depending on patient size and diagnostic task. Until direct image quality measures can be established, indirect image noise estimation is a reasonable means of evaluating CT image quality for the purpose of minimizing radiation dose. For CT abdomen and pelvis, the size-specific dose estimate (SSDE) can be used as a surrogate for image quality measurement. Like target image noise, the target SSDE changes as a function of patient size. While the target SSDE also changes depending on the indication for the examination, only a few image quality target settings will suffice for a large number of indications. CT dose optimization is achieved by measuring SSDE on representative studies, determining an SSDE target curve as a function of patient size by evaluating perceived diagnostic image quality, coordinating with the manufacturer to adjust the protocols to consistently meet those targets, and monitoring SSDE for all studies. To be practical in the clinical setting, this requires the use of a CT monitoring application, preferably one that incorporates patient size.

How to Perform a Contrast Enhanced PET/CT? Stephan D. Voss, MD, PhD

Computed tomographic angiography (CTA) is a highly effective tool for imaging diseases of the blood vessels. Current multi-detector row CT scanner can scan a 1-m body length in 1 s at a resolution less than one millimeter. Performance improvements in successive generations of scanner help reduce the volume of contrast agent, the need of sedation, and the radiation dose. Special properties of CTA may be exploited to further reduce the last. For example, imaging different vascular beds normally require multiple scan passes. A properly shaped contrast injection profile can opacify multiple vascular beds at once that can be scanned in a single pass. A CTA generates an image composed of two dichotomous spaces: a contrast filled vascular space and everything else. Since the attenuation of the iodinated contrast increases with a lower tubevoltage, CTA works well with low voltage techniques that also reduce radiation dose. Excepting bones and metals, the attenuation difference between the first-pass contrast-enhanced vascular space and the nonvascular space is usually large. A reader of CTA may tolerate a greater level of noise compared to non-vascular CT studies. This permits a lower tube-current setting and a reduction in radiation dose. Finally, image- and model-based iterative reconstruction algorithms, now clinically available, help suppress image noise while preserving definition at the vascular margins. Today, high quality CTA of the abdomen for children can be routinely achieved at a radiation dose less than 3 mSv per study. How Do I Get the Highest Resolution MRA? Taylor Chung, MD

In this short 10-min discussion, emphasis will be place on reviewing the trade off between temporal and spatial resolution in contrast-enhanced MRA for body imaging, various acceleration schemes to increase the speed of acquisition, scan parameter manipulations related to acceleration schemes, and generic clinical protocols. The goal of this short discussion is to provide a generic understanding of how to achieve a robust contrastenhanced MRA in your clinical practice. What is a b Value and How Should I Choose It? Govind B. Chavhan, MD, DNB, DABR

PET/CT scanners use a multi-detector PET system coupled to multidetector row helical CT scanner. Standard PET/CT protocols include both a PET scan and a low dose attenuation correction CT (CT/Ac). The CT/ Ac is an essential component of the PET/CT examination. In additional to allowing anatomic co-localization of PET abnormalities, attenuation correction of PET data is necessary for accurate qualitative and quantitative measurements of metabolic activity. While it is suitable for colocalization and image fusion, the standard low dose CT/Ac does not utilize intravenous contract agents and is not considered adequate for diagnostic purposes. As such, patients often undergo a second diagnostic CT scan, using IV and oral contrast and conventional diagnostic CT imaging parameters, adding to the patients’ overall radiation burden. As a first step toward optimizing PET/CT protocols to reduce unnecessary duplicate CT imaging, the purpose of this presentation is to discuss the use of intravenous and/or oral contrast agents during PET/CT imaging. We will discuss potential for artifacts produced by contrast agents on the PET emission data, and consider basic imaging protocols in which: (1) low dose CT/ Ac imaging is performed with IV contrast, (2) diagnostic contrastenhanced CT images are used for attenuation correction, and (3) hybrid techniques that allow both low dose CT/Ac and diagnostic CT techniques to be combined in a single helical acquisition. In summary, the use of contrast-enhanced CT for attenuation correction can contribute significantly to reducing patient dose and enhancing the quality of the PET/CT examination.

The b-value indicates magnitude of diffusion weighting provided by diffusion gradients. The b-value depends on and increases with the amplitude, duration of application of the two diffusion gradient pulses and temporal separation of these pulses. The b-value is measured in s/mm2 unit. As the bvalue increases, sensitivity of the sequence to the diffusion increases and signal from water molecules reduces. At high b-value, tissues with either restricted water molecule mobility or very long T2 relaxation time will have high signal. The b-value needs to be chosen based on T2-relaxation time of the tissue in question. In body imaging, to counteract the low SNR from short T2 relaxation time of solid organs like the liver, lower ‘high bvalues’ than those typically found in neuroimaging are used. High b-values of 500–600 s/mm2 for liver and 800–1000 s/mm2 for kidneys are suitable in abdominal diffusion imaging. High b-values of around 800 are usually suitable for bowel and MSK imaging. Low b-values in the range of 50–100 are useful for detection of lesions especially in the liver. Can 3 Testa Be Used for Fetal MRI? Teresa Victoria, MD, PhD

Three testa MR imaging aims at improved image quality by increasing signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) when compared to 1.5 T. The search for better anatomic delineation and evaluation

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of the fetus warrants evaluation of the feasibility of imaging at 3 T. Another reason to consider fetal imaging at 3 T is that some imaging centers may only have one magnet available for all of their imaging needs, that magnet being a 3 T system. In the past, fetal imaging at 3 T has been done with often disappointing results with numerous artifacts impeding image analysis. Better magnets and coils and improved technology now allow imaging of the fetus at greater magnetic strength, while still encountering some hurdles in the shape of imaging artifacts. The goal of this talk is to review our experience of imaging the fetus at 3 T, with emphasis in technical parameters, artifact, and safety concerns. When Should Eovist and Ablavar Be Used? Shreyas S. Vasanawala, MD, PhD

Various MRI contrast agents with unique properties are now available, requiring careful assessment of the clinical goals of each MRI exam to ensure optimal contrast agent selection. Although most abdominal and pelvic applications are best served by standard extracellular agents, gadoxetate (Eovist/Primovist), and gadofosveset (Ablavar) are valuable in certain indications. Gadoxetate helps with biliary leaks, follow-up evaluation of known hepatic metastases, and evaluation of suspected focal nodular hyperplasia may be aided by gadoxetate. Conversely, evaluation of venous pathology may be facilitated with gadofosveset. How Do I Optimize Doppler Ultrasound Images and Waveforms? Marta Hernanz-Schulman, MD, FAAP, FACR

In the imaging of children, the physical principles governing ultrasound coalesce with patient body size to allow a comprehensive window into pediatric anatomy and physiology. This short session will review some of the fundamental principles which affect the pediatric examination. The reflected sound undergoes a frequency shift, caused by motion of the interrogated object, which falls within the range of the human ear and can be partially analyzed aurally. These frequency shifts are based on a flow vector directed towards (0°) or away (180°) from the transducer. The magnitude of the frequency shift (fD) is governed by the Doppler equation: fD =(2f0vcosθ)/c, where f0 =insonating frequency, v=velocity, and θ=the angle of interrogation from the 0° to 180° axis. Thus one can see at a glance that the Doppler shift will be increased with use of a higher frequency transducer and at angles of insonation as close to 0° and 180° degrees as possible (cos θ=1), while flow at 90° to the transducer (cos θ= 0) will be undetected or depicted ambiguously due to spectral broadening and poor convergence of the ultrasound beams from the main beam axis. In color Doppler, there is no angle correction; therefore the color depicted in the intravascular voxels is dependent on the angle of insonation across each portion of the vessel. Pulse Repetition Frequency (PRF) needs to be set appropriately: too high a setting will lead to loss of flow information, whereas too low a setting below the Nyquist frequency will lead to aliasing artifacts; in color Doppler imaging, such higher velocities will “wrap around” to the opposite direction color encoding, a misleading phenomenon which can be detected by comparison with the spectral waveform. Careful application of these and other principles augments gray-scale information, and allows an extremely useful window into pediatric vascular patency and hemodynamic phenomena. THORACIC IMAGING: FOCUS ON THE LUNGS Cystic Fibrosis Update & Scoring: What Does the Pulmonologist Want to Know? Robert H. Cleveland, MD

The clinical role of pulmonary imaging in CF is unchanged. Acutely, issues such as pneumonia, hemorrhage, atypical mycobacteria and ABPA

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dominate. Depending upon the question, either CXR or CT is appropriate. In the earliest phases when diffuse peribronchial thickening (PBT) is the only imaging finding, CXR is adequate. In the chronic phase, CT is preferred as it best detects progressive bronchiectasis and mucous plugging. However, high radiation exposure and financial costs of CT limit its use for routine serial imaging. Consequently CXR remains the common modality for longitudinal follow-up. This may be changing. CT doses approaching that of CXR are recently reported. As image acquisition times decrease and resolution increases, MRI may replace CT. MRI can reveal regional air trapping and hypoperfusion before PBT is evident. All three modalities have scoring systems to quantify disease severity. These are not to replace subjective assessment of acute issues or incremental change. Rather they are used in research to determine differences in rates of decline. They have shown effectiveness of treatment modalities, differences based on genotype and to predict future progression. In this setting, CXR data is as strong as CT data. With multiple serial CXR the standard of care, a large volume of images is readily available. With concerns surrounding dose and cost, neither CT nor MRI approach CXR in volume of studies. Two CXR scoring systems are most commonly in use, the Brasfield and Wisconsin. They perform almost identically compared to the gold standard (PFT) with high correlation to each other. Children’s Interstitial Lung Disease (ChILD) 2014 Catherine M. Owens, MRCP, FRCR

The term ‘interstitial lung disease’ sets to confuse, as the disease processes often also involve the alveoli, airway, blood vessels, lymphatics and pleura. Disease classification is based primarily on clinicopathological patterns and expert opinion, and pedantically should be described as ‘diffuse lung disease’ The ATS/ERS Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias was developed for the adult population so is inappropriate for chILD. Hence the chILD Research Cooperative based on presumed aetiology proposed a classification for diffuse lung disease in young children. According to this scheme, unique diseases more prevalent in infancy include the diffuse developmental disorders (lung growth abnormalities e.g. chronic neonatal lung disease, chromosomal disorders such as Downs’ syndrome), pulmonary interstitial glycogenosis (PIG), neuroendocrine cell hyperplasia of infancy (NEHI), and hereditary surfactant dysfunction disorders. Other categories include disorders of the normal host: constrictive (obliterative) bronchiolitis, aspiration, disorders of the immunocompromised host :(diffuse alveolar damage, opportunistic infection), disorders related to systemic disease: (collagen-vascular diseases, storage diseases), and ‘masqueraders’ such as pulmonary arterial hypertensive vasculopathy, pulmonary veno-occlusive disease (pVOD), and lymphatic disorders. Recent publications report diagnostic imaging findings for newer specific forms of chILD, which include mutations of the filamin A (FLNA) Xlinked gene (periventricular heterotopia, cardiovascular anomalies, skeletal dysplasia, Ehlers-Danlos variants, and a lung growth disorder characterized by alveolar oversimplification and pulmonary hypertensive changes. Other conditions such as pleuroparenchymal fibroelastosis (PPFE) will be introduced. Whatever the disorder, meticulous attention to imaging technique is required to enable evaluation of these complex disorders. This lecture will address imaging techniques, salient imaging findings in various forms of chILD, emphasizing more recently described disorders for the attendees. How Do I Perform a Dynamic Airway CT in Infants and Children? S. Bruce Greenberg, MD

Wide-detector computed tomography allows for simultaneous imaging of the airway and lungs in infants and small children. Continuous scanning during a single breath is used to create multiple dynamic phases which

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allow for creation of 3D or multiplanar cine-loop imaging of the airway and lungs. Intravenous contrast allows for cardiopulmonary evaluation and is particularly useful in the infant or small child following surgery for congenital heart disease. The gantry speed is adjusted to the patient respiratory rate to limit radiation exposure. Intubated infants typically are scanned with the respiratory rate set at 40 breathes per minute and imaged for a total of 1.4 s. Positive end expiratory pressure is turned off during the examination. Radiation exposure is typically < 1 mSv due to 80 kVp energy, low mA current and aggressive use of iterative reconstruction. mA is determined by the weight based formula: mA=[(kg× 1.5)+5]÷gantry speed in seconds. Tracheobronchomalacia is quantified using dynamic cross-sectional images. Lobar malacia is identified. Fixed stenosis is distinguished from malacia. Airtrapping, atelectasis and airspace disease can also be evaluated. The technique is a new standard for evaluating the relationship between vascular and airway abnormalities for children with congenital heart disease. Changes in medical or surgical management following dynamic airway computed tomography in children with congenital heart disease is common due to the identification tracheobronchomalacia or previously unidentified or poorly characterized vascular abnormalities. Update on Pulmonary Embolus in Children: What Does the Radiologist Need to Know? Pallavi Sagar, MD

Pulmonary embolism (PE) in children is an uncommon diagnosis that can be clinically silent and occasionally fatal. The clinical signs described in adults are less common in children. The overall incidence of PE in children is unknown but is expected to rise likely due to improved survival of children with chronic diseases and increased usage of central venous lines (CVL), the latter reported to be the most common predisposing factor. Other risk factors include immobility, prior PE, deep venous thrombosis, thrombophilia, congenital heart disease, nephrotic syndrome, estrogen usage and malignancy. Most of the recommendations regarding management of PE in children are extrapolated from adult studies. Unlike adults, where the clinical probability score and D- dimer estimation play a major role, they lack utility in children. CT pulmonary angiography (CTPA) the imaging modality of choice and the standard of care in evaluating PE. A chest radiograph should be obtained within the last 24 h to rule out other cardiopulmonary etiologies. Doppler study of the lower extremities is performed instead of CT venography to minimize radiation. In children with iodine allergy, ventilation-perfusion scan is the imaging modality of choice. In hemodynamically unstable patients with a high clinical suspicion of significant PE, echocardiography should be considered to evaluate for right ventricular dysfunction. Recently, dual energy CT has been studied in evaluating PE with some promising results by providing both anatomical and functional information. It not only detects emboli but also provides perfusion maps of the lungs, demonstrating perfusion defects in a setting of acute PE. However, it has to be further validated for its clinical utility and radiation exposure, with some reports suggesting that it is usually dose neutral. CTPA has a higher radiation dose and should be cautiously used in children only in the presence of compelling clinical signs and multiple risk factors. Pediatric Lung Neoplasms: Understanding Underlying Genetic Causes R. Paul Guillerman, MD

Pleuropulmonary blastoma (PPB), the most common pediatric primary lung malignancy, is also the most frequent tumor occurring in the recently recognized Pleuropulmonary Blastoma Family Tumor and Dysplasia Syndrome (PPB-FTDS). This genetic syndrome affects 30–40% of patients or families in which PPB is diagnosed and is characterized by autosomal dominant inheritance (~75% of cases are associated with

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heterozygous germline DICER1 gene mutations) and a distinctive constellation of mostly childhood tumors and dysplasias. The most characteristic manifestations of PPB-FTDS are PPB, cystic nephroma, multinodular goiter, differentiated thyroid cancer, Sertoli-Leydig cell tumor, cervical embryonal rhabdomyosarcoma, pituitary blastoma, pineoblastoma, nasal chondromesenchymal harmatoma, and ciliary body medulloepithelioma. Less common manifestations include hamartomatous polyps of the bowel and other tumors. Recognition of a characteristic manifestation of this syndrome should prompt genetic evaluation to identify and counsel carriers in affected kindreds. Most affected individuals have one or two manifestations, but there are no overt manifestations in 50% or more of DICER1 mutation carriers. Counseling and screening are complicated by the low penetrance, pleiotropy, lack of genotype-phenotype correlation, and generally non-lifethreatening nature of most of the manifestations, with exception of the blastomas. Screening for PPB in asymptomatic infant carriers should be considered due to the potential to detect PPB by chest imaging in the highly curable, cystic form in infancy before transformation into the less curable, solid form later in childhood. Using SSDE to Manage Thoracic CT Radiation Dose in Children Keith J. Strauss, MSc, FAAPM, FACR

The challenge is to carefully mange pediatric CT image quality and radiation dose during examinations of pediatric patients. One approach involves developing a detailed technique chart specific to each scanner within the department that lists scan parameters for each type of examination as a function of patient size (pediatric emphasis). The staffing required to achieve this may only be available in large, academic, tertiary care centers. Yet, the majority of pediatric CT scans in the US are performed in adult focused hospitals. A more direct approach develops patient specific scan parameters (based on patient size and type of exam) appropriate for use on any CT scanner in the department. This approach verifies the appropriate pediatric scan parameters just prior to the patient scan once the size of the patient, type of examination, and which CT scanner will be used becomes known. Essentially, the voltage and mAs used for the scan are adjusted to provide the patient dose that matches previously developed department Diagnostic Referecce Levels (DRLs). The method addresses manual vs modulated tube current, reduced voltage techniques for small body parts, and iterative reconstruction dose reductions for examinations of the head, thorax, and abdomen/pelvis. HRCT in Pediatric Patients: When & How? Shilpa V. Hegde, MBBS

Indications for high resolution CT (HRCT) in infants are persistent unexplained respiratory distress and an abnormal chest radiograph. Common indications in older children include evaluation of cystic fibrosis, chronic cough and abnormal lung function tests. Traditionally, chest HRCT is performed by obtaining thin, non- contiguous axial CT images. High spatial resolution algorithm images are viewed at a level of −500 HU and width of 1500 HU. Expiratory scans are sometimes contributory. Volume acquisitions using MDCT obtained in a single breath hold are replacing the older step and shoot technique. Thin non- contiguous slice reconstructions are created from the volume data. Sedation and anesthesia is less prevalent in small children due to shorter scan time. Scans can also be performed during quiet breathing if a child is unable to breath hold. The radiation settings (kvP and mA) are kept as low as possible to achieve a low dose technique. Abnormal findings are subgrouped as consolidation, ground glass changes, mosaic attenuation, septal thickening, and nodular opacities. HRCT findings are often non specific, but when correlated with the clinical

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findings, can narrow the differential diagnoses. HRCT is also helpful in guiding biopsy. MRI of the Lungs and Airways: Current Practical Imaging Approach Edward Y. Lee, MD, MPH

In recent years, magnetic resonance imaging (MRI) has been receiving a lot of attention particularly in pediatric patients mainly because pediatric patients have greater sensitivity to the potentially harmful effects of ionizing radiation associated with other imaging modalities. However, the physical properties of the lungs and airways present many challenges to obtaining diagnostic quality MR images, which have limited the clinical use. Fortunately, there have been several new MRI techniques that can be used to overcome these challenges. Therefore, the overarching goal of this presentation is to provide up-to-date information on these new MRI techniques, including pediatric patient preparation, imaging protocols, and imaging findings for the optimal management of pediatric patients with lung and airway disorders. Fast MR imaging sequence for evaluation of lung parenchyma and spirometer-controlled MR imaging of the large airways in pediatric patients are highlighted. GASTROINTESTINAL IMAGING: FOCUS ON THE PANCREAS & BOWEL How to Perform & Interpret a Secretin MRCP? Andrew T. Trout, MD

This lecture will address the basic elements of performing and interpreting magnetic resonance cholangiopancreatography in the pediatric patient. The three basic types of pancreaticobiliary MR exam (pancreatic parenchymal, standard MRCP, secretin-enhanced MRCP) will be reviewed with emphasis on when to use each. Basic elements of a routine MRCP exam will be covered including: sequence selection, sequence optimization, and key elements to assess on each imaging sequence. The use of intravenous contrast and secretin will be discussed, emphasizing when to use these adjuncts. The indications and contraindications to secretin will be reviewed and the basic structure of a post-secretin imaging sequence will be described. The two types of post-secretin imaging (dynamic and static) will be introduced with review of the role of each. Which Pancreatic Ductal Variants Predispose to Pancreatitis? Sudha A. Anupindi, MD

Although ultrasound is the first line of imaging to assess pancreatitis, in acute recurrent or chronic pancreatitis further evaluation with Magnetic Resonance Cholangiopancreatography (MRCP) is required to evaluate the ductal anatomy. MRCP has become the new gold standard for evaluating pancreaticobiliary abnormalities. The most common ductal variants that may lead to pancreatitis include: pancreas divisum (PDV), anomalous pancreaticobiliary junction (APBJ), choledochal cysts and annular pancreas. Pancreas divisum is the most common of the congenital anomalies resulting from failure of fusion of the ventral and dorsal anlage of the pancreas. In those with recurrent pancreatitis, 12–26% of patients have PDV. The main imaging feature of PDV on MR is that the main dorsal duct is in continuity with the duct of Santorini and drains into the major papilla and the ventral duct (not communicating with dorsal duct) joins the CBD and drains into the minor papilla. Due to obstruction at the minor papilla, there is often inadequate drainage of secretions resulting in pancreatitis. The clinical relevance of this entity is controversial, as most

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patients are asymptomatic. Anomalous PBJ is defined as premature union of the bile and pancreatic ducts outside of the duodenal wall which results in a long common channel. Pancreatitis occurs when there is a reflux of secretions into the pancreatic duct (PD) when bile duct pressure exceeds PD pressures. APBJ is often seen in conjunction with choledochal cysts. Large choledochal cysts without APBJ can also cause pancreatitis due to mass effect and back pressure on the PBJ. Finally, pancreatitis from annular pancreas is rare in children. Based on large published series, the majority of children present with a duodenal obstruction. Knowledge of pancreatic embyrology, ductal variants and their appearance on MRCP is essential in order to diagnose these disorders and help guide management. What are the Imaging Signs of Pancreatic Ductal Trauma? Michael J. Callahan, MD

Pancreatic injuries are relatively uncommon in children, particularly those involving the pancreatic duct. Most blunt pancreatic injuries are associated with additional hepatic, splenic and duodenal injuries, and the most common mechanism of injury in children is direct compression of the gland against the spine in the setting of a motor vehicle accident, sports injury, or bicycle handlebar injury. The primary imaging modalities used for the initial evaluation of suspected pancreatic injuries are ultrasound and computed tomography, and identification of potential signs of pancreatic ductal injury can directly impact initial patient management. Endoscopic retrograde cholangiopancreatography is the most reliable method to define continuity of the pancreatic duct, and can be used for therapeutic stent placement in the correct clinical setting. The goal of this presentation is to present the imaging findings of pancreatic ductal injury in children, and familiarize the audience with potential pitfalls in the diagnosis of pancreatic ductal injuries. How to Distinguish Acute Inflammation from Chronic Fibrosis in Crohn’s Disease? Ethan A. Smith, MD

Crohn disease is relatively common in children and the incidence is increasing. Active bowel wall inflammation in Crohn disease can lead to luminal narrowing and obstruction. Chronic inflammation leads to bowel wall fibrosis, which can also result in luminal narrowing and obstruction. In patients with known Crohn disease, determining the presence of bowel wall fibrosis is clinically important, as patients with luminal narrowing due to inflammation may respond to medical management, whereas those with fibrostenotic disease may require surgical resection to relieve obstructive symptoms. Several imaging features have been investigated in an attempt to distinguish fibrosis from active inflammation in patients with luminal narrowing and obstruction. These include evaluation of dynamic bowel wall enhancement at MR enterography and assessment of T2 weighted signal characteristics of the bowel wall. The evidence supporting these techniques, as well as their limitations, will be discussed. So far, the utility of these techniques has been limited to the observation that the segments of bowel with the most fibrosis are often also those with the most ongoing active inflammation. Novel imaging techniques undergoing investigation will also be described, including dynamic contrast enhanced ultrasound and acoustic radial force impulse elastography, which assesses bowel wall stiffness as a surrogate for fibrosis. Future directions will be briefly discussed, such as the use of novel biomarkers to determine fibrosis from superimposed active inflammation. How to Image and Classify Perianal Fistulae? Jonathan R. Dillman, MD

Perianal/perineal involvement by Crohn’s disease is common in the pediatric population. Manifestations include simple cutaneous

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inflammation, skin tags, fistulae, and abscesses, and they can take on a variety of appearances at magnetic resonance imaging (MRI) and physical examination. On occasion, such abnormalities may present prior to the recognition of intestinal inflammation. High-resolution, small fieldof-view, multi-parametric MRI at a field strength of 3 T permits comprehensive evaluation of perianal/perineal Crohn’s disease, including determination of the number and location of fistulae and abscesses (and their relationships to the internal and external anal sphincters) and assessment of inflammatory activity. MRI also helps guide surgical management of perianal/perineal Crohn’s disease and has been shown to improve outcomes in adults. My presentation will present an up-to-date review of perianal/perineal Crohn’s disease in children, including MRI technique, imaging features of fistulae and abscesses, and radiologic classification. In addition, the imaging appearances of medical conditions that can mimic perianal Crohn’s disease will be presented. How to Interpret a Pelvic MRI After Rectal Pullthrough? Alexander J. Towbin, MD

Increasingly, MRI is being used to identify post-operative complications in patients who have had prior corrective surgery for an anorectal malformation. When MRI is performed, the colorectal surgeon requires very specific information. After attending this lectures, radiologists should be able to describe the course of the rectum in relation to the levator sling/ sphincter complex; describe the appearance of the pelvic floor musculature; identify when the original rectum has been resected and the sigmoid colon has been pulled through; identify posterior urethral diverticula; identify previously missed masses or anomalies; and identify persistent rectourethral fistulas What is the Role of Ultrasound in Intestinal Malrotation? Alan Daneman, MBBCh, FRCPC

In the past two decades there has been an increasing use of ultrasound for the diagnosis of midgut malrotation. However, the exact role and relationship of ultrasound and fluoroscopically guided contrast examination of the upper gastrointestinal (UGI) tract for the diagnosis of anomalies of midgut rotation +/or fixation is yet to be addressed in a large series of children who have either normal rotation and fixation or those with an anomaly of midgut rotation +/or fixation. Several authors have advocated that ultrasound is the modality of choice for excluding such anomalies. Adequate depiction of the whirlpool sign of midgut volvulus on ultrasound obviates the necessity for an UGI series. The relationship of the superior mesenteric vessels as a sign on its own can be misleading. In more recent years attention has been focused on the position of the third part of the duodenum (D3) on ultrasound. It has been suggested that the normal position of D3 between the aorta and superior mesenteric artery excludes the risk of volvulus and obviates the need for an UGI series. This latter claim, however, has been challenged with both ultrasound and CT images with very small numbers of cases. The potential dire consequence of missing the diagnosis of an anomaly of midgut rotation demands that we be cautious of how we interpret the images from whatever modality we are using. Meticulous attention to technique is essential. One should never be reluctant to use a second modality if one is unsure of the diagnosis.

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focusing on this issue in various high-impact journals draw attention to the importance of this topic. The chronicity of the disease coupled with the need of repetitive diagnostic imaging raise the exposure of radiation to these patients. Such imaging modalities and the respective effective dose estimate are as follows: abdominal x-ray 0.7 mSv, upper gastrointestinal series 3.0 mSv, small bowel follow-through 5.0 mSv, Barium enema 7.0 mSv, abdominal/pelvic CT 10–15 mSv. The yearly exposure to radiation from medical imaging alone in patients with IBD is estimated to be 3–5 mSv. In about 6% of the IBD patients the cumulative effective dose (CED) is greater than 50 mSv, a level that has been associated with an increased risk of cancer development. In addition to all the known reasons for higher radiation risk in children, patients with IBD have inherently increased risk of cancer due to the disease itself and also related to some of the potent medications that are currently used in this condition. Consequently, reducing the radiation dose to “as low as reasonably achievable (ALARA)” is a diagnostic imaging necessity. Even better is avoiding imaging studies with radiation exposure and replacing them with those without. In this regard ultrasound and MR imaging play an important role. GENITOURINARY IMAGING: FOCUS ON GONADAL RADIOLOGY What is the Role of Imaging in Testicular Trauma and its Follow-up? Laura Z. Fenton, MD

Pediatric blunt scrotal trauma is most commonly due to sports-injury (>50%) followed by motor vehicle accidents (17%). Ultrasound (US) with color flow and Doppler imaging is the first-line imaging modality to guide therapy. Traumatic injuries diagnosed include hematoma, hydrocele, hematocele, testicular fracture and testicular rupture. As an accurate history is difficult to obtain from young children, US findings may be the first indication of trauma. In equivocal cases, MR imaging may aid in defining the injury. Timely diagnosis of testicular rupture, based on US finding of discontinuity of the echogenic tunica albuginea, is critical as surgery results in salvage of the testis in 80–90% if performed within 72 h The presence of heterogeneous testicular echotexture and loss of normal contour without direct discontinuity of the tunica albuginea have been reported as sufficient to diagnosis testicular rupture, with 100% sensitivity and 65–93% specificity. Controversy in the urology literature regarding management of testicular rupture after blunt trauma exists; historically operative approach has been advocated with a conservative approach akin to management of renal traumatic injuries recently suggested. Scrotal trauma may be associated with acute epididymitis, epididymo-orchitis and testicular torsion. Reportedly, 10–15% of testicular tumors are found incidentally at imaging following scrotal trauma. Following scrotal trauma, ultrasound imaging is performed for new or worsening symptoms. Scrotal tunica cyst and scrotal calculi following trauma have been reported. Torsion of the Testis: What is the Role of Doppler and What are Concerning Flow Patterns? Lynn A. Fordham, MD

What is Known About Radiation Issues in Imaging of IBD? Kassa Darge, MD, PhD

In patients with inflammatory bowel disease (IBD), exposure to radiation from imaging studies is a major concern. The many publications just

Go the operating room or discharge to home? In this presentation we will review normal and abnormal waveforms obtained during testicular ultrasound as well as discuss the secondary findings that counter or confirm a diagnosis of testicular torsion.

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Rationale Testis viability following intravaginal torsion ranges from 62 to 85% and depends on the duration of ischemia. Restoration of flow within 6 h is correlated with a 90 to 100% range of testis preservation, whereas a 6 to 12-h deprivation of flow results only in a 20 to 50% salvage rate. How

&

&

& &

Experimentally, a 540o twist of the spermatic cord completely occludes arterial flow. Accordingly, manual detorsion should be performed by 180–360° increments in cases of common torsion with completely absent arterial flow. Detorsion is lateral (“open the book” technique), caudal to cranial, under CDU monitoring, with or without sedation. Any resistance to initial lateral detorsion, should lead to medial direction of maneuver (10–30% of cases). Successful detorsion is indicated by the immediate relief of pain, the elongation of cord (testis mobility) and the restoration of flow (immediate or progressive). A known pitfall of manual detorsion is the partial reduction of 720° or greater twist, hence the importance of monitoring the restoration of flow by CDU.

When

& & &

Outside the neonatal period (extravaginal torsion). When the testis is still viable (preserved homogeneous echogenicity). When time delay (duration of torsion, access to OR) is significantly hampering testis recovery.

Clinical Relevance

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Manual detorsion is an old, effective and safe technique that results in 68 to 86% success rate. Manual detorsion is not a substitute for exploration and fixation: bilateral orchidopexy remains imperative.

When and How to Find the Undescended Testicle: To Search or Not to Search? Kate A. Feinstein, MD

The undescended testis is a common congenital abnormality, affecting up to 3% of term newborns. Most testes descend during the first few months of life, resulting in a prevalence of <1%. Treatment of undescended testes may improve fertility, reduce cancer risk, preserve testosterone production, and make the scrotum normal in appearance. Palpable undescended testes comprise 25% of undescended testes. Most palpable testes are below the inguinal ring and the rest are within the inguinal canal. Of the unilateral nonpalpable undescended testes, up to two-thirds are scrotal nubbins (probably as a result of in utero torsion). Of the viable one-third, half are in the abdomen and half are in the inguinal canal. In bilateral nonpalpable testes, half are located within the abdomen. Testicular loss is much less than in the unilateral population. What is the radiologist’s role: to identify the location of palpable undescended testis, find the nonpalpable testis, or do nothing at all? The goals of this presentation are to familiarize the radiologist with 1) the difference between retractile and undescended testes, 2) potential locations of undescended palpable

and nonpalpable testes, 3) the use of hormonal therapy in management, 4) surgical approaches to orchiopexy based on location, and 5) potential diagnostic imaging contributions to patient care. Intersex States/Gonadal Dysgenesis: What is the Role of Gonadal Imaging? Ellen M. Chung, MD

In intersex, or disorders of sexual development (DSD), there is discordance between the chromosomal, gonadal, and/or phenotypic sex. Many but not all patients with DSD present at birth with ambiguous genitalia. Timely evaluation by a multidisciplinary team of experts is important for prompt and appropriate sex assignment. Imaging plays an important role in the evaluation of the internal pelvic organs and the gonads which may be ectopic. Ultrasound is the primary modality for evaluation of such patients. Internal pelvic organs should be sought. The scrotum or labioscrotal folds and inguinal canals should be evaluated for the presence of gonads. Further, the kidneys and adrenal glands should be evaluated for associated abnormalities. Fluoroscopic evaluation of the urethra, vagina, and any fistulous tracts can determine the presence of a maleor female-type urethra or persistent urogenital sinus. MRI can be used in difficult cases to identify ectopic gonads, although dysgenetic or streak gonads are difficult to image with any modality. Streak gonads carry a risk of development of gonadoblastoma and germ cell tumors. What is the Best Imaging Modality for Torsion of the Ovary/Fallopian Tube? S. Pinar Karakas, MD

Adnexal torsion can be a challenging diagnosis in the absence of typical clinical and imaging presentation. Even if the clinical presentation suggests likelihood of adnexal torsion, without imaging confirmation, the diagnosis would be incomplete as many pathologic entities that originate in the pelvis can mimic ovarian torsion. Ultrasound (US) with Doppler analysis is the imaging modality of choice unless the clinical presentation is confusing enough to warrant initial imaging with computerized tomography (CT). US has high sensitivity and specificity but may be plagued with patient or operator related limitations. The imaging findings of ovarian torsion include unilaterally enlarged ovary with peripherally located cysts, increased central echogenicity, abnormal location of the ovary in the midline or superior to the anticipated location and tilting of the uterus towards the torsed ovary. In addition, with Doppler analysis decreased or dampened arterial flow, lack of venous flow, and twisted vascular pedicle creating a whirlpool sign may be documented. The whirlpool sign, which in itself is pathognomonic for torsion, is rarely seen by US. Complicating features which make the diagnosis of ovarian torsion by US more challenging include: incomplete or intermittent torsion, torsion with an ovarian mass resulting in an enlarged ovary and anatomic distortion, or an isolated torsion of the tubal structures. In such instances, the pathognomonic vascular pedicle twisting and additional confirmatory findings can be accurately demonstrated with cross sectional imaging, preferably with magnetic resonance imaging (MRI) to avoid radiation with CT. In conclusion, when US is inconclusive, MRI is a problem solving, fast and accurate technique. In selected cases, MRI can even be used as the initial imaging modality, especially if there is no need for sedation. Pediatric Adnexal Masses: If, When, and What Constitutes Appropriate Follow-Up Evelyn Y. Anthony, MD

Adnexal masses in pre- and postmenarchal pediatric females are not uncommon findings in patients imaged for abdominal pain or for

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unrelated indications. Fortunately, the vast majority of these lesions are benign, and many are self-limited. Nevertheless, the question of appropriate follow-up can be confusing. In this presentation, we will examine the range of pathologies and their imaging characteristics, attempting to create an algorithm for follow-up decisions based on the initial ultrasound examination. The algorithm will combine the clinical history, the risk profile of the lesion based on appearance and vascularity, and the needs of the referring physician—for rapid diagnosis, for identification of associated findings, and for surgical planning. When follow-up is required, ultrasound continues to serve as the workhorse modality for imaging of the female pelvis, which this presentation will highlight. Still, some lesions need the global assessment offered by MRI in either the presentation or follow-up phases to allow appropriate management decisions. What is the Imaging Contribution to the Diagnosis of PCOS? Dorothy I. Bulas, MD

PCOS is the most common endocrine abnormality in women. There are four key features: menstrual dysfunction; hyperandrogenism; polycystic ovaries; obesity, insulin resistance with risk of metabolic syndrome, cardiovascular disease, and endometrial carcinoma. No single etiologic factor has been identified. Increased androgen is responsible for anovulation and first presents in adolescence. Clinical features include hirsutism, ovarian abnormalities, obesity, insulin resistance and menstrual irregularity (60% of adolescents). Criteria are imperfect—US diagnosis is a moving target as technology improves. In adults one ovary > 10 mL or presence of >12 small follicles 2–9 mm should be present using TVUS—during follicular phase. In adolescents, ovaries should be > 10.8 mL (transabdominal) at any time if amenorrheic. Polycystic ovarian morphology (PCOM)—peripheral follicles, >6 (4–10 mm) follicles and/or dense stroma is not addressed in current criteria yet is common in puberty and can be confused with PCOS PCOS accounts for most cases of adolescent androgen excess but diagnosis is difficult. Oligo/anovulation may be physiologic, anovulation must be present for > 2 years (or primary ammenhorea at age 16) to meet criteria. PCOM can be present in 40% of normals or ovaries may not appear abnormal until 2 years after menarche. Only 30% of adolescents with PCOS have ovarian vol > 10 mL. Hyperandrogenism can be present in normal adolescents (75%) with acne. Differential includes physiologic cysts, endometrioma, benign and malignant neoplasms (serous/mucinous cystadenomas, teratoma, choriocarcinoma). While adults with PCOS have 85–100% PCOM, only 35–67% of adolescents with menstrual irregularities and hyperandrogenism have PCOM. Over diagnosis can also be a problem as PCOM can be present in normals. Caution is needed in over and under interpreting sonograms.

Wednesday, May 14, 2014 MUSCULOSKELETAL IMAGING: FOCUS ON ONCOLOGY Radiographic and CT Characterization of Aggressive Bone Lesions Tal Laor, MD

A child with a bone lesion may present with symptoms such as pain, a palpable mass, or a pathological fracture. However, some bone lesions are incidental findings when imaging is performed for another reason. The American College of Radiology Appropriateness Criteria state that the first imaging modality for a suspected bone lesion should be radiography. Radiographs offer clues from which to determine the aggressiveness of a

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lesion, to formulate a differential diagnosis, and to direct further investigation. Radiographic features that characterize an aggressive bone lesion include cortical disruption, a moth-eaten or permeative pattern of bone destruction, a wide zone of transition between lesion and surrounding bone, periosteal new bone formation in a sunburst or onion-skin pattern, a Codman triangle, and an associated soft tissue mass. These findings usually indicate malignancy, although benign etiologies, such as osteomyelitis may present with worrisome radiographic characteristics. Tumoral mineralization, such as osteoid production, may be a clue to etiology. Although aggressive lesions may be central, eccentric, cortical, or parosteal, anywhere along the length of a bone, most malignancies in children tend to be metaphyseal or metadiaphyseal. Patient age at presentation also should be used to formulate a differential diagnosis. CT imaging occasionally is obtained if MRI is not possible when further investigation is indicated. Features similar to those characteristic of aggressive bone lesions on radiography also can be seen with CT imaging. Occasionally, subtle mineralization, cortical breakthrough or pathologic fracture not identified on radiographs may be evident. However, the overall role of CT in the evaluation of aggressive bone lesions is considered limited. MRI Characterization of Bone Lesions Diego Jaramillo, MD, MPH

Analysis of MR characteristics of osseous lesions in children is key to differential diagnosis. A destructive lesion with a large soft tissue mass in a child under 5 years. is likely metastatic neuroblastoma, between 5 and 10 years., Ewing sarcoma and above 10 years., osteogenic sarcoma. Epiphyseal lesions suggest chondroblastoma or infection; metaphyseal lesions, infection, and osteogenic or chondrogenic tumors; and diaphyseal lesions, Ewing sarcoma or histiocystosis. Borders indicate perilesional edema and not malignancy. Inflammatory benign tumoral lesions (chondroblastoma, osteoid osteoma, osteoblastoma, histiocytosis) cause edema larger than the tumor extending circumferentially to the adjacent marrow and soft tissues. Traumatic lesions, if not associated with cortical break, produce marrow abnormality that extends along the shaft without substantially affecting adjacent soft tissues. Osteomyelitis resembles benign inflammatory tumors, but has nonenhancing areas in the marrow, subperiosteal space and soft tissues. Physeal transgression occurs with both inflammatory and malignant lesions, but in aggressive lesions the metaphyseal involvement is much larger than the physeal disruption. Chondroid lesions are of high T2 signal intensity and are nonenhancing unless highly malignant. Fibrous lesions and lesions with hemosiderin demonstrate low T2 signal intensity and enhance avidly.. Many aggressive lesions have well-circumscribed margins on T1-weighted images. Low T2 signal intensity within the marrow cavity indicates either osteoid formation or reactive bone formation. However, large areas of decreased signal intensity in the soft tissue component of the tumor strongly suggest osteoid tumor bone and thus osteogenic sarcoma. Staging and Assessment of Treatment Response in Osteosarcoma and Ewing Sarcoma Kirsten Ecklund, MD

The purpose of this brief talk is to review the imaging techniques currently utilized for staging, and subsequent monitoring of treatment response in patients with osteosarcoma and Ewing sarcoma. The goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. Standard morphologic as well as diffusion weighted (DW) and perfusion MR imaging techniques and PET/CT will be discussed.

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DWI can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. There is even greater potential for DWI in the assessment of tumor response to therapy. The apparent diffusion coefficient (ADC) maps are critical to accurate interpretation of diffusion sequences. ADC maps distinguish between restricted diffusion and T2 effect, both of which appear bright on DWI. Both qualitative and quantitative tissue assessments can be made with DWI. Challenges for DWI in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. Our current protocols and parameters for DWI will be presented. Perfusion imaging of MSK tumors is generally done with dynamic contrastenhanced (DCE) MR using one of a variety of vendor specific sequences. Qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. This technique is especially promising in those patients undergoing antiangiogenic therapy. MRI of Bone Marrow Nancy A. Chauvin, MD

strategies to greatly increase the conspicuity of normal anatomy and reveal previously hidden lesions. Proper MRI pulse sequence selection and modifications at 1.5 and 3-T will be covered. Optimization of CT scan parameters will also be covered including pre and post-scan modifications. Examples of these techniques will be presented in phantoms and patients. The goal of the presentation is to give the audience tools to confidently image around orthopedic hardware. Tips for MRI:—Use STIR over T2 fat sat

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Turn off fat sat for FSE imaging (e.g. acquire a pre T1 with post T1 contrast imaging, both without fat sat) Reduce the echo train length for FSE Doubling the readout BW at 3-T will cause susceptibility artifact similar to that at 1.5-T Decrease FOV and increase the matrix Avoid GRE imaging Tips for CT:—Expect a dose penalty

Magnetic Resonance (MR) imaging is the primary modality used to evaluate bone marrow. The MR appearance of bone marrow depends on the specific pulse sequence used and quantity of marrow water, fat, protein and cells. Alterations in chemical and cellular composition can be readily depicted using conventional imaging techniques such as spin-echo, fatsuppressed and short tau inversion recovery (STIR) sequences. In the growing skeleton, normal marrow transformation from hematopoietic to fatty marrow occurs in a predictable systematic pattern beginning in the appendicular skeleton and progressing to the axial skeleton. Within the long bones, transformation occurs first in the epiphyses, followed by the diaphyses, and ultimately the metaphyses, with adult marrow achieved by the middle of the third decade. Pathologic processes such as marrow hyperplasia, replacement disorders, depletion disorders and myelofibrosis can disrupt the marrow production and alter bone marrow signal intensity on MR imaging. In addition, treatment related effects due to irradiation or chemotherapy and marrow stimulating medications can cause local or generalized changes to bone marrow signal. Knowledge of the agerelated marrow signal changes is imperative in order to accurately differentiate normal cellular marrow from focal or diffuse neoplastic involvement as well as to recognize therapy related effects and tumor recurrence. Whole Body MRI with DWI for Tumor Staging and Surveillance Jesse Courtier, MD

Pediatric oncology patients will undergo a number of imaging studies over the course of their lifetimes. Awareness of this fact, coupled with the increased understanding of the need for judicious use of ionizing radiation exams has led to the investigation of non-radiation alternatives for the imaging evaluation of pediatric tumors. Whole body MRI with Diffusion-weighted imaging (WB-DWI) is an emerging technique that offers the potential of a non-radiation alternative to PET/CT for pediatric tumor staging and surveillance. Specifically, the application of this technique in the staging of lymphoma is of particular interest in the pediatric population. This presentation will discuss the technique, potential applications, and current challenges/controversies in whole body MRI with WB-DWI in pediatric oncologic imaging.

Increase kVp & mAs Decrease pitch Narrow collimation width

– – – –

Reconstruct with thick slices Use soft tissue recon algorithm and advanced IR Reconstruct in Sag/Cor rather than axial plane Orient hardware perpendicular to CT beam

Osteonecrosis in BMT & Oncology Patients Sue C. Kaste, DO

Osteonecrosis is a significant toxicity of disease and therapy in pediatric oncology that is of increasing importance due to the growing recognition of its prevalence, impact on the patient’s life, and lack of standardization of diagnosis and intervention guidelines. Children in whom osteonecrosis most frequently develops are those whose treatment includes exposure to glucocorticoids such as patients undergoing treatment for acute lymphoblastic leukemia and brain tumors and patients undergoing hematopoietic stem cell transplantation. MR is the most sensitive available modality for detecting osteonecrotic lesions and will serve as the primary modality discussed in this presentation. Lesion size is the best predictor of clinical joint outcome with. MR-determined lesions occupying more than 30% of the femoral head have a high likelihood of joint deterioration necessitating surgical intervention. As osteonecrosis is typically asymptomatic until late in the disease process, imaging necessary for its detection may be delayed even in high-risk patients. Thus, diagnostic imaging is critical for its detection and characterization and to follow its progression and effects of intervention. This presentation is designed to provide a brief review of the pathophysiology of osteonecrosis, describe the patient groups at risk for its development, patterns of involvement, imaging characteristics and techniques used for detection.

Strategies to Image Around Hardware After Limb Salvage Surgery John D. MacKenzie, MD

MSK Tumor Imaging—What the Pediatric Orthopedic Surgeon Wants to Know John P. Dormans, MD, FACS

Several simple strategies can drastically reduce the image artifact produced by metallic orthopedic hardware. We will review MRI and CT

Diagnosis and treatment of MSK tumors involves a close collaboration between the orthopedic surgeon and radiologist. Imaging will often

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dictate the course of action taken by the surgical team. Features identified by advanced imaging are integral to characterizing the malignancy of bone and soft tissue tumors. Beyond determining the potential for malignancy, imaging can define size, location, extent, relationship to other structures or anatomical compartments, and presence of skip metastases of suspected tumors. Though imaging is crucial in tumor detection and diagnosis, it also plays a role throughout patient treatment and posttreatment surveillance. Information provided by radiologists will ensure proper image guided or open biopsy and surgical resection of tumors. For pediatric tumors, radiation dose to the patient is also of increasing interest and scrutiny. Overall, advanced imaging of MSK tumors is vital to all phases of patient care, requiring continuous communication between the surgical team and radiologists. CHILD ABUSE & NOT CHILD ABUSE: FOCUS ON RADIOGRAPHY Classic Metaphyseal Lesion-Micro-CT/Histopathologic Correlation Andy Tsai, MD, PhD

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“rickets—nonaccidental trauma controversy” involves little scientific debate. The contention is that infants with multiple fractures who are thought to have been abused, may actually have insufficiency fractures from rickets, even without radiographically apparent rickets. There is no convincing evidence that such cases exist. Rather, infants with rickets and fractures usually have severe rickets and fractures other than those with a high specificity for NAT. With multiple fractures and significant rickets, evaluation includes the severity of bone disease, the types of fractures, and other clinical considerations. Rib Fractures: Location and Mechanisms Paul K. Kleinman, MD

Rib fractures are the most common high specificity injuries encountered in abused infants. This presentation explores the morphologic alterations, anatomic distributions, imaging patterns, and the mechanisms of these important injuries. Imaging of the Skull: Is that a Fracture? Peter J. Strouse, MD, FACR

The classic metaphyseal lesion (CML) is a common high specificity indicator of infant abuse. The injury patterns have been extensively studied radiographically, and the imaging features have been correlated histologically. Micro-CT with 3D modeling permits elucidation of the complex morphology and spatial relationships of the CML—a critical step in understanding the biomechanics of this distinctive injury. Differential Diagnosis of Metaphyseal Fractures Sabah Servaes, MD

Metaphyseal irregularities can be found in a variety of entities ranging from normal variants to fractures secondary to inflicted trauma. Distinguishing between these diagnoses is critical for the appropriate care and disposition of the patient and family. The appearances of the metaphyseal findings and additional imaging and clinical features can be helpful to the radiologist in making the distinction between these etiologies. The imaging features of these entities and a review of the scientific literature supporting our current understanding of the etiology of metaphyseal irregularities will be reviewed. Some of the more controversial purported etiologies and assessment of the evidence to date will be discussed. Rickets Richard M. Shore, MD

Vitamin D deficiency impairs intestinal absorption of calcium, leading to rickets and osteomalacia. Rickets entails deficient mineralization and endochondral ossification of the growth plates whereas osteomalacia is deficient mineralization of non-endochondral bone. The ossification defect results from failure of chondrocyte apoptosis. Hyperparathyroidism, caused by inadequate calcium absorption, plays a key role in the pathophysiology of rickets. Radiographic features reflect these disorders of mineralization and ossification with loss of mineralization of the zone of provisional calcification (ZPC) and excessive disorganized “rachitic cartilage” which has failed ossify. As the ZPC is lost, metaphyseal bone gradually fades into the lucent physis. Although the expanded rachitic cartilage is usually lucent, it may have variable cartilage calcification when the deficient ossification is more severe than deficient mineralization. The diaphyseal findings reflect the combined effects of osteomalacia and hyperparathyroidism. There is major scientific controversy regarding human vitamin D requirements, in part related to whether a multitude of proposed non-skeletal effects of vitamin D are sufficiently established. In contrast, the

Simple linear skull fractures are considered of low specificity for child abuse. Complex skull fractures are considered of moderate specificity for child abuse. Findings raising suspicion for child abuse include lack of a history of trauma, complex fractures occurring in the home, bilateral fractures, greater than one fracture line, fractures of the occipital bone, and fractures which are branching, stellate and/or diastatic. In order to properly identify fractures of the skull, knowledge of the normal sutural anatomy of the skull is paramount. Normal sutures such as the metopic, mendosal and squamous sutures may be mistaken for fracture. Widening of sutures should be recognized as indicative of an intracranial process. Extracranial soft tissue swelling is indicative of an impact injury. Variant fissures within the skull, most commonly occurring within the parietal and occipital bones, may be mistaken for fracture. Aids in differentiation of a fissure from a fracture include location and appearance and knowledge of normal anatomy. Small Wormian bones may be seen as a normal variant; however, significant Wormian bones are associated with osteogenesis imperfecta, Menkes syndome and other disorders, but are rare in normal children. In the evaluation of the skull, radiography and CT are considered complementary modalities. Proper technique and positioning for each modality aids interpretation. Thin CT source images allow for quality 2D (sagittal and coronal) and 3D (volume rendered) reformats. Dating of Fractures Michele M. Walters, MD

In this session the current literature on fracture dating in infants and young children will be reviewed. The relevance of available data to fractures of abuse will be discussed. A scientific system for dating fractures will be proposed, and several cases will be shown to highlight how such a system may be used clinically. What is the Role for Follow-up Skeletal Surveys? Jeannette M. Perez-Rossello, MD

The follow-up skeletal survey adds additional information in a significant number of suspected child abuse cases. It can identify new fractures, confirm suspected fractures and aid in dating. We will review recent studies that suggest decreasing the number of images performed in the follow-up studies.

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S68 What Does the Child Abuse Physician Need to Know & How to Tell Us Allison M. Jackson, MD, MPH, FAAP

Child maltreatment is a public health problem that impacts nearly 700,000 children each year with estimates of over four fatalities daily. Of these children, maltreatment is often repetitive resulting in multiple injuries, some of which are visible on physical exam, most of which are not. Radiologists play an integral role in the assessment of child physical abuse in particular. Diagnostic imaging can reveal acute and remote injuries resulting from abuse. Therefore, it is important for the radiologist to provide information in a manner that aids child abuse practitioners in the diagnosis and management of abuse-related injuries. These children do not always present with an injury complaint or concern for abuse, but instead often present with nonspecific signs and symptoms. Astute radiologists, therefore, have a unique opportunity to identify not only suspected injuries, but also unexpected injuries through diagnostic imaging. The radiographic evolution of acute and healing injuries helps to create a timeline that may assist in determining when a child was injured. Furthermore, radiologists can contribute to the differential diagnosis which may include medical conditions that may be mistaken for abuse. This presentation will give radiologists guidance on what information is most helpful to child abuse professionals in identifying and assessing musculoskeletal, head and visceral injuries associated with child abuse.

SCIENTIFIC PAPERS Authors are listed in the order provided. An author listed in bold identifies the presenting author.

extremity, and 6/10 for pelvis. Relapse occurred at the primary site in 24 (56%) and at a metastatic site in 19 (44%). There was no relation between relapse site (primary vs. metastatic) and survival after relapse (36% vs. 41%, p=0.7). Stage and Clinical Group at diagnosis were associated with survival after relapse, confirming previous reports. These results did not change when the analyses were performed only on patients who completed therapy (n=24). Conclusions: Our results suggest that routine imaging surveillance for relapsed disease in children with rhabdomyosarcoma is not associated with longer patient survival. Validation of these results in a larger study and more limited use of surveillance imaging could reduce medical costs and radiation exposure without compromising patient outcome. Paper #: PA-002 Prognostic Value of Image-Defined Risk Factors in High-Risk Neuroblastoma Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Baylor College of Medicine, Houston, TX, [email protected]; R. Paul Guillerman, MD, Yesenia Rojas, Chrystal Louis, Jed Nuchtern, Wei Zhang

Purpose or Case Report: Image-defined risk factors (IDRFs) were proposed in 2009 to facilitate consistent and uniform reporting of pediatric neuroblastoma (NB) according to the new International Neuroblastoma Risk Group Staging System (IINRGSS). Since these IDRFs have not previously been evaluated for prognostic value, we aimed to assess IDRFs for predicting outcome in NB. IDRF

Paper #: PA-001 Does Surveillance Imaging of Childhood Rhabdomyosarcoma Improve Patient Survival? Jody Lin, Baylor College of Medicine, Houston, TX, [email protected]; R. Paul Guillerman, MD, Heidi Russell, Philip Lupo, Mehmet Okcu

Purpose or Case Report: While routine imaging is often obtained for surveillance of disease relapse in children with rhabdomyosarcoma, there has been a lack of evaluations to determine if imaging surveillance improves patient outcome. We aimed to compare survival in patients in whom relapse was detected on the basis of clinical symptoms versus surveillance imaging. Methods & Materials: All children with relapsed rhabdomyosarcoma treated at Texas Children’s Hospital from 1993 to 2012 were identified, and their cross-sectional imaging studies were reviewed to define the anatomic sites of disease. Survival time after relapse was compared between two groups: (1) patients presenting with a symptom related to relapse; and (2) patients whose relapse was initially detected by imaging prior to symptoms. Differences in survival time were evaluated with Kaplan-Meier plots and log rank tests. Survival differences were also evaluated using Cox proportional hazards models to adjust for age, stage, Clinical Group, and histology at diagnosis. Results: Of the 43 children with relapsed rhabdomyosarcoma, 26 (60%) had metastatic disease at diagnosis and 19 (44%) had alveolar histology. With a median follow up time of 21 months in 17 survivors, overall survival was 38% (95%CI: 22%–54%) at 2 years. There was no difference in overall survival between patients in whom relapse was diagnosed based on imaging (n=13) versus clinical symptoms (n=30) (2-year survival 39% vs. 37%, p=0.28). The proportion of relapses that were initially detected by imaging prior to symptoms for each site were 1/7 for CNS, 2/11 for head/neck, 3/3 for lung, 1/8 for abdomen/trunk, 0/4 for

Lower mediastinal tumor infiltrating the costovertebral junction between T9 & T12 Tumor encasing the aorta, origin of the celiac artery or the origin of the SMA Tumor encasing the inferior vena cava

Timing of Study

Hazard Ratio (Increased Risk of Death) At diagnosis 1.874

0.1874

Pre-op 2.446 At diagnosis 1.74

0.0331 0.1982

Pre-op 1.488 At diagnosis 1.576

0.2819 0.2703

Pre-op Infiltration of porta hepatis, At diagnosis hepato-duodenal ligament or duodenopancreatic block Pre-op Tumor invading the SMA At diagnosis branches at root of the mesentery or infiltrating the mesentery Pre-op Tumor encasing At diagnosis iliac arteries Pre-op Invasion of more than one At diagnosis third of the spinal canal in the axial plane Pre-op

p value

1.529 2.362

0.2394 0.0169

1.889 1.201

0.146 0.6145

0.739 0.835

0.5058 0.6918

0.718 0.650

0.6527 0.5566

2.95

0.2932

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Pericardial infiltration Diaphragmatic infiltration Liver infiltration Imaging Findings not established as IDRFs Multifocal primary Pleural effusion (malignant or not) Ascites Other Risk Factors

MycN amplified status Abdominal (non-adrenal) tumor location vs thoracic location Adrenal tumor location vs thoracic location

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At diagnosis 1.181

0.7574

At diagnosis 1.658

0.2832

Pre-op 1.347 At diagnosis 2.273 Pre-op 2.566 Hazard Ratio (Increased Risk of Death) At diagnosis 1.357 Pre-op 1.439 At diagnosis 2.810

0.4700 0.0480 0.0411 p value

0.5345 0.5519 0.0058

Pre-op 1.452 At diagnosis 1.409 Pre-op 1.957 Hazard Ratio (Increased Risk of Death) At diagnosis 2.587 At diagnosis 1.929

0.4494 0.340 0.2170 p value

0.0291 0.5580

At diagnosis 1.598

0.6469

Methods & Materials: An institutional oncology database was queried for high-risk NB patients who underwent surgical resection between 01/01/2000 and 11/30/2012. Cross-sectional imaging studies obtained at diagnosis, pre-operatively after neoadjuvant chemotherapy, and post-operatively were reviewed and the status of IDRFs and 3D sizes of the primary tumors were recorded. Evidence of organ damage on post-operative studies was also noted. The patients’ medical charts were reviewed, and outcome measures including time to death or last follow-up and relapse were recorded. The independent prognostic power for all-cause mortality of each IDRF and groups of IDRFs was analyzed by univariate Cox’s regression. Fisher’s exact tests were conducted to study association between renal infiltration/hilar abutment and renal injury or nephrectomy. Pearson rank correlation coefficients were calculated and two-tailed paired t tests performed to compare changes in tumor maximal length and volume. Results: Sixty-one patients (30 M: 31 F) with mean age at diagnosis of 2.8 years (range 0.44–8.91) constituted the study cohort. Primary tumors were adrenal in 82%, extra-adrenal abdominal in 11.4%, and thoracic in 6.6%. At diagnosis, presence of a pleural effusion, infiltration of the liver or of the porta hepatis/hepatoduodenal ligament/duodenopancreatic block was significantly associated with mortality. Pre-operatively after chemotherapy, infiltration of the liver or invasion of the lower three costovertebral junctions was significantly associated with mortality. No significant association was found between renal infiltration/hilar abutment and renal injury (p 0.26), but the study was underpowered to test this association. A high correlation (r = 0.80, p < 0.0001) was found between change in tumor maximal length and volume. Conclusions: Certain IDRFs confer increased mortality from high-risk NB when present at diagnosis and pre-operatively, and special attention should be paid to their detection on imaging. The high correlation between changes in tumor maximal length and volume implies that unidimensional response criteria may provide adequate representation of tumor size.

Paper #: PA-003 The DICER1 Pleuropulmonary Blastoma Family Tumor and Dysplasia Syndrome (PPB-FTDS): Role of the Pediatric Radiologist in Diagnosis and Screening R. Paul Guillerman, MD, Department of Pediatric Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; M. John Hicks, Surya Rednam, John Priest

Purpose or Case Report: Pleuropulmonary Blastoma Family Tumor and Dysplasia Syndrome (PPB-FTDS) is a recently recognized syndrome affecting 30–40% of families in which PPB is diagnosed and is characterized by autosomal dominant inheritance (~75% of cases due to DICER1 gene mutations), low penetrance, highly variable expressivity and a distinctive constellation of mostly childhood tumors and dysplasias. To promote recognition by radiologists, we describe our institution’s experience with PPB-FTDS. Methods & Materials: A retrospective study was conducted entailing review of the medical charts and imaging exams of all patients with the distinctive conditions of PPB-FTDS at our children’s hospital from 1990 to 2013. Results: Six patients (3 M:3 F) had PPB-FTDS. The most common tumor was PPB: five cases (two Type I, two Type Ir, one Type II) with detection age from prenatal to 10 years. Three patients had cystic nephroma (CN) at age 0– 2 years, three patients had pineoblastoma (PinB) at age 2–10 years, one patient had a small bowel hamartomatous polyp at age 6 months, one patient had multiple thyroid nodules (age of presentation undefined due to incomplete medical records) and one patient had ovarian Sertoli-Leydig cell tumor (OSLCT) at age 16 years, cervical embryonal rhabdomyosarcoma (cERMS) at age 17 years, and brainstem ERMS (bERMS) at age 21 years. The proportion of FTDS cases among all cases of each tumor over the study period was 5/16 for PPB, 3/6 for CN, and 3/7 for PinB. In all 5 PPB patients, detection of PPB either preceded or coincided with the detection of the other tumors. Clinical presentations varied: incidental detection by imaging in Type I and Ir PPB and CN cases, neurologic signs/symptoms in PinB and bERMS cases, amenorrhea in the OSLCT case, vaginal bleeding in the cERMS case, and intussusception in the small bowel hamartoma case. The patient with Type II PPB died of disease; the others are either undergoing antitumor therapy or show no evidence of disease at post-treatment follow-up. Except for bERMS, the conditions encountered are typical of PPB-FTDS. Conclusions: DICER1 PPB-FTDS is a unique syndrome distinguished by a predisposition for certain tumors and dysplasias across a variety of organs over the first two decades of life, with PPB typically being the earliest and most frequent. Recognition of the imaging manifestations of this syndrome should prompt genetic evaluation to identify and counsel familial carriers, with imaging screening considered for those at risk.

Paper #: PA-004 MR imaging patterns of leukemia and lymphoma Jie Nguyen, M.D., M.S., Pediatric Radiology, CHOP, Philadelphia, PA, [email protected]; Diego Jaramillo

Purpose or Case Report: Leukemia and lymphoma (36% of pediatric malignancies) are often diagnosed incidentally. Due to variable presentation and increased use of MRI, they are sometimes detected because of abnormal marrow signal. We hypothesize that there are significant differences in the pattern of bone marrow involvement among acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML), and lymphoma. Methods & Materials: We retrospectively reviewed radiologic examinations, medical records and pathology reports in 377 leukemic and 492 lymphoma children who had undergone MRI between 1/1/1995 and 8/26/ 2013. We excluded patients with insufficient data, no MRI prior to treatment, or other associated bone marrow processes. Twenty three leukemic and 31 lymphoma patients with a total of 57 (22 ALL, 4 AML, 31 lymphoma) MR studies were included. A blinded pediatric musculoskeletal radiologist

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classified bone marrow infiltration patterns on T1-weighted images as diffuse, patchy, focal, or normal. Differences were analyzed using Chi-square test. Results: Of 19 children with ALL, marrow involvement was diffuse in 89% (17/19) and patchy in 11% (2/19). Of four children with AML, involvement was diffuse in 75% (3/4) and patchy in 25% (1/4). Of 31 children with lymphoma, involvement was diffuse in 23% (7/31), patchy in 26% (8/31), and focal in 19% (6/31), while the remainder had normal marrow. Overall, the pattern of marrow involvement was significantly different among the three malignancies (P=0.005). Specifically, diffuse bone marrow infiltration favored ALL (P<0.0001) and focal pattern was seen only with lymphoma. In the extremities, diffuse marrow involvement indicated ALL in 92% (12/13, p<0.0001). In the spine, a non-diffuse pattern was present only with lymphoma. Lymphoma was also more likely to have associated soft tissue mass (p=0.039). The miss rate for diagnosing abnormal bone marrow signal was independent of the pretest probability with 19% (4/21), 23% (5/22), and 14% (2/14) corresponding to no clinical suspicion, some clinical suspicion, and known malignancy, respectively. Overall, the miss rate is the highest for ALL at 32% (7/22), followed by AML at 25% (1/4) and lymphoma at 10% (3/31). Conclusions: Abnormal marrow pattern on T1-weighted images can suggest a specific hematologic malignancy. Focal marrow involvement or soft tissue mass favors lymphoma. Diffuse marrow involvement, which is the most common and specific presentation of ALL, is the pattern most commonly missed during routine image interpretation. MR bone marrow pattern distribution Diffuse

Patchy

Focal

Normal

Extremity

Spine Extremity Spine Extremity Spine Extremity Spine

ALL

12*

8*

2

0

0

0

0

AML

0

3

1

0

0

0

0

0

Lymphoma

1

6

5

3

3

3

6

4

0

*3 ALL patients had both extremity and spine MRIs interpreted by different radiologist as separate studies. Detection of appropriate bone marrow signal within the original dictation ALL AML Lymphoma Mis rates by Yes No Yes No Yes No Clinical No clinical 6 2 0 0 11 2 19% suspicion Some suspicion 4 4 0 0 13 1 23% Known 5 1 3 1 4 0 14% malignancy Miss rates by 32% 25% 10% malignancy

enrolled in Children’s Oncology Group(COG) AHOD0031 to establish an optimal imaging approach for assessing bone metastasis during interim and post treatment response assessment following multi-agent chemotherapy. Methods & Materials: Methods: COG AHOD0031 was conducted between 2002 and 2009 to evaluate response based treatment regimen in intermediate risk HL. Of 69 patients with bone disease, CT, FDG-PET, and 99mTc-MDP bone scans were obtained at diagnosis and after completion of multi-agent chemotherapy as part of required observation. MRI was not required but available in 13. Available scans of adequate quality were reviewed to assess response/resolution of healing of bone lesions over the course of therapy. Results: Results: CT scans were reviewed on 58 patients; 27 with a single lesion and 31 with multiple lesions. The foci most frequently involved were spine (N=36) and pelvis (N=31). Lesions were primarily lytic with sclerotic components in 34; 16 were sclerotic only. Associated soft tissue mass was seen in 23, 20 of which originated from bone, two from adjacent pleural masses, and one indeterminate. At chemotherapy completion there was some healing in 30/42 patients but none noted in 12. CT scans obtained on two patients 18 months and 3 years later showed residual CT abnormality without PET avidity. Bone lesions by CT were also reviewed by FDG-PET and 99mTc-MDP and adequate scans were both available in 23 patients. Bone scans remained positive after 2 cycles of chemotherapy in 15 patients and at end therapy in 12. In contrast only three patients had positive PET scans after 2 cycles of chemotherapy which remained positive in two at end therapy that were biopsied for residual disease. There were 31 patients with at least one PET(+) lesion at diagnosis without a CT correlate suggestive of bone marrow disease, all of which resolved by end of therapy. MRI was available in 11 patients at diagnosis and in two others at diagnosis and follow up. In the two with follow up to end therapy, MRI abnormalities persisted but were not associated with PET avidity. Conclusions: PET is a more specific measure of tumor response and is the modality of choice in HL patients with bone disease. In addition it may be a measure of bone marrow disease and its use may obviate the need for bone marrow biopsy. Bone changes detected by CT, bone scan and MRI after therapy with no FDG-PET avidity do not indicate residual disease.

Paper #: PA-006 Does contrast-enhanced CT (CECT) provide additional information to low dose CT/PET in pediatric Hodgkin Lymphoma? Joyce Mhlanga, M.D., Division of Nuclear Medicine, The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, [email protected]; Melissa Spevak, Richard Wahl, Steve Cho

Paper #: PA-005 Retrospective review of bone changes in Hodgkin Lymphoma utilizing CT, 18F FDG-PET, 99 m Tc-MDP bone scan and MRI from Children’s Oncology Group intermediate stage protocol AHOD0031

Kathleen McCarten, M.D., Diagnostic Imaging, Rhode Island Hospital, Providence, RI, [email protected]; Steve Cho, Peter Evangelista, Stephan Voss, Debra FRiedman, Cindy Schwartz

Purpose or Case Report: Purpose: A retrospective review was conducted of patients with Stage IVA Hodgkin Lymphoma(HL)and bone lesions

Purpose or Case Report: Staging and follow-up of Hodgkin lymphoma (HL) is often done with contrast enhanced CT (CECT) and usually performed for several years following therapy as most relapses occur in the first 5–10 years. Whole body PET-CT is integral in the diagnosis and staging of HLand has higher specificity in predicting relapse in abnormal residual anatomic disease. Interim and post-therapy PET results are highly predictive of treatment outcome. Whether PET-CT can guide treatment in favorable-prognosis HL continues to be evaluated as part of clinical trials. Many patients are studied with both conventional PETCT and CECT at our institution which contributes to a significant life time radiation dose exposure. It may be possible to eliminate the CECT and lower radiation dose (ALARA principal) without affecting diagnostic

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imaging evaluation. Our goal was to evaluate for discordance between the CT used for attenuation correction of the PET (CTAC) with PET and the CECT.

Methods & Materials: After IRB approval, we retrospectively reviewed pediatric lymphoma PET-CT studies of patients presenting for staging or restaging of HL performed between 2008 and 2012. Patients who had an accompanying CECT immediately following the PET-CTwere evaluated. We compared the CT portion of PET/CT used for attenuation correction (CTAC) with the diagnostic quality CECT. The clinical report including findings, final impression and dose length products of the CTs were evaluated. Results: Thirty-nine studies (in 21 patients) met study criteri. Most studies were for relapse evaluation in refractory HL. There were 26 male and 13 female patients with an average age of 16.5 years (range 10– 23 years). The average CTAC dose length product (DLP) was 593.1. The DLP was 1420.4 for the CECT which often included the neck, chest, abdomen and pelvis. The average injected FDG dose was 11.3 mCi (418.1Mbq). There was concordance between the CECT and CTAC with PET overall findings reporting progression versus non-progression. CECT did not provide additional information to the CTAC with PET in this cohort. Conclusions: The CTAC from PET/CT CT was concordant with the CECT in this cohort of HL pediatric patients. CECT did not provide additional information to the CTAC with PET in this cohort. If PET-CT is performed in the evaluation of recurrence and there is an equivocal finding such as mediastinal brown fat or indeterminate node, a limited CECT could be performed rather than a defacto whole body CECT, thus lowering the radiation burden to this group of patients.

Paper #: PA-007 Assessment of Hepatic Fibrosis in Pediatric Chronic Liver Disease with MR Elastography

Daniel Podberesky, MD, Suraj Serai, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Lili Miles, Eileen King, Rohit Kohli, Stavra Xanthakos

Purpose or Case Report: The diagnosis and management of chronic liver diseases in children, particularly non-alcoholic fatty liver disease (NAFLD), is hindered by the lack of validated non-invasive biomarkers of histological severity, often necessitating invasive and costly serial liver biopsies for

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staging and surveillance. The purpose of this investigation was to evaluate the accuracy of MR elastography (MRE) in non-invasively assessing hepatic fibrosis in pediatric patients with chronic liver disease.

Methods & Materials: Thirty-five children/adolescents (mean age 13.1, range 4–20 years) with chronic liver disease underwent liver MRE on a 1.5 T magnet with an active-passive driver system at 60Hz. Mean liver stiffness values (in kPa) were determined and compared to histopathologically determined fibrosis stage. A logistic regression was used to evaluate the ability of liver MRE stiffness value to predict significant fibrosis (stage ≥ 2) versus minor or no fibrosis (stage ≤ 1). Results: Higher MRE derived liver stiffness values were significantly associated with more severe liver fibrosis, with an area under the receiver operative curve (AUROC) of 0.92 (95% CI: 0.79, 1.00, p=0.02) (as shown in Figure 1). A liver stiffness cut-off of 2.71 kPa provided maximal sensitivity (88%) and specificity (85%) for detection of significant fibrosis. Conclusions: MRE shows great promise in the non-invasive assessment of liver fibrosis in children and may reduce, or even obviate, the need for liver biopsies in certain patients. Disclosure: Dr. Podberesky has indicated a relationship with GE Healthcare as a Speaker at MR User Group Meeting (Travel Reimbursement); Philips Healthcare as Speaker at MR User Group Meeting (Travel Reimbursement); Toshiba America Medical Systems, Speakers Bureau (Honoraria and Travel Reimbursement). Paper #: PA-008 Ultrasound-Derived Shear Wave Speed Correlates with Liver Fibrosis in Children

Jonathan Dillman, M.D., Department of Radiology, Section of Pediatric Radiology, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI, [email protected]; Ethan Smith, Amer Heider, Nahid Keshavarzi, Jacob Bilhartz, Jonathan Rubin

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Purpose or Case Report: To determine if increasing liver ultrasoundderived shear wave speed (SWS) measurements correlate with increasing parenchymal fibrosis in children.

9 L4 transducer; Siemens Medical Solutions USA, Inc.). Ten SWS measurements were acquired from each patient; five using each method. A fellowship-trained pediatric pathologist graded correlative histologic specimens for extent of liver fibrosis. Differences in mean SWS between liver biopsy specimens demonstrating low (Ishak 0–2) and high (Ishak 3–6) fibrosis scores were assessed using the student t-test. Spearman correlation (ρ) was used to assess the relationship between fibrosis score and SWS. Receiver operating characteristic (ROC) curve analyses were also performed. Results: Children with high liver fibrosis scores had significantly higher mean SWS measurements than children with low liver fibrosis scores (VTQ: 2.13±0.32 vs. 1.48±0.25 m/s; p<0.0001; VTIQ: 2.55±0.45 vs. 1.81±0.21 m/s; p=0.0005). Highly significant correlation was observed between fibrosis score (Ishak 0–6) and mean SWS using both the VTQ (ρ=0.65; p<0.0001) and VTIQ (ρ=0.69; p<0.0001) methods. ROC curve analyses demonstrated areas under the curve of 0.94 and 0.93 for VTQ and VTIQ, respectively. Nondiagnostic shear wave imaging occurred in five children using the VTQ method and in four children using the VTIQ method (all of these children were obese). Conclusions: Liver SWS measurements correlate with parenchymal fibrosis in children. Paper #: PA-009 Acoustic Structural Quantification as a Potential Biomarker of Steatosis and Fibrosis in Pediatric Liver Disease

Martha Munden, MD, Pediatric Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Stephanie Abrams, Daniel Leung, Wei Zhang, Lee Gerhart, Rajesh Krishnamurthy, MD

Methods & Materials: Following informed consent (and informed assent, as indicated), 35 children underwent both transcutaneous ultrasound shear wave elastography and same-day ultrasound-guided percutaneous liver biopsy. Shear wave imaging of the targeted biopsy site was performed in the operative (or interventional radiology) suite immediately prior to the liver biopsy procedure using two different methods (Virtual Touch Quantification [VTQ] and Virtual Touch IQ [VTIQ]; Acuson S3000 Ultrasound System/

Purpose or Case Report: Acoustic Structural Quantification (ASQ) represents a mathematical analysis of the differences between a theoretical echo amplitude distribution and the real measurement of echo distribution within tissue as a method to quantify the change of ultrasound texture (Toshiba Americal Medical Systems, Tustin, CA). The objective of the study is to determine if ASQ ultrasound analysis could serve as a reliable biomarker of steatosis and fibrosis in children with underlying diffuse or chronic liver disease. Methods & Materials: A prospective cohort of 26 children scheduled for liver biopsy, 15 with Non Alcoholic Fatty Liver Disease (NAFLD) and 11 with chronic hepatitis (B and C), underwent ASQ analysis of the liver immediately prior to ultrasound guided biopsy. There were five normal patients used in the analysis for a total of 31 patients. ASQ was perfomed by the same technician at the same location used for biopsy using the Aplio 500, Toshiba Medical Systems. Averaged ASQ values were correlated with histopathologic scores for severity of steatosis (NAS) and fibrosis (METAVIR). The ability of ASQ to predict the presence of significant fat, fibrosis, or both was assessed using histopathologic scores of greater than five for steatosis and fibrosis respectively being considered significant. The Kruskall-Wallis and Wilcoxon rank tests were used for statistical analysis. A p-value of less than 0.10 was considered significant. Results: Analysis was carried out based on results of five categories: + steatosis and + fibrosis (SF), + steatosis, and -fibrosis (SNF,),—steatosis and—fibrosis (NSNF), and—steatosis and + fibrosis (NSF) and normal (NO). Statistical analysis showed in the absence of fibrosis, the ASQ value showed a significant difference between those with and without

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steatosis (p value 0.096) but did not correlate with severity of steatosis. The presence of associated fibrosis lowered the accuracy of ASQ in detecting steatosis. In both the presence and absence of steatosis, ASQ failed to separate those with and without fibrosis. Conclusions: In this pilot study, ASQ ultrasound analysis shows promise as a biomarker for detection of steatosis without fibrosis, but did not serve as a marker of fibrosis in the setting of pediatric diffuse liver disease. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support.

Paper #: PA-010 Reference Values of MRI measurements of the normal bile ducts and pancreatic duct in children

Kriti Gwal, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Maria Bedoya, Neal Patel, Siri Rambhatla, Kassa Darge, MD, PhD, Sudha Anupindi, MD Purpose or Case Report: To determine reference MRI measurements of the bile ducts and pancreatic duct in normal children. Methods & Materials: With IRB approval, patients were selected from our MR urography (MRU) database, as sequences on MRU are common to our MRCP protocol. Exclusion criteria included: hepatobiliary or pancreatic disease, prior abdominal surgery, excessive motion on MRI or incomplete examinations. A total of 205 patients (ages 0–119 months): 107(52.2%) boys and 98(47%) girls were evaluated and stratified into five groups by age; see Table 1. Two radiologists retrospectively measured the common bile duct (CBD), the common, right and left hepatic ducts and the pancreatic duct (PD) on 2D axial, 3D coronal T2 and coronal T2 HASTE sequences. Weight and height at the time of the MRI were recorded. Statistical analysis including chi-square, linear regression and ANOVA were performed. Inter-reader variability was assessed using kappa statistics. Table 1. Age related measurements of the common bile duct (CBD), Common Hepatic Duct(SHD), right intrahepatic duct (RHD), left intrahepatic (LHD) in the coronal plane and Pancreatic duct (PD) in the axail plane. Measurements express in mm as: Mean ± standard deviation.

AGE GROUP <12 months n=67 12–23 months n=21 24–59 months n=55 60–95 months n=38 96–120 months n=22

CBD periamp 2.06±0.5 2.13±0.41 2.45±0.44 2.79±0.48 3.02±0.54

CHD 2.10±.62 2.16±0.42 2.38±0.58 2.83±0.59 3.07±0.61

RHD 1.54±0.42 1.62±0.44 1.84±0.46 2.06±0.47 2.27±0.67

AGE GROUP

LHD

PD head

PD body

PD tail

<12 months n=67

1.63±0.48

0.85±0.30

0.74±.24

0.73±0.19

12–23 months n=21

1.75±0.49

1.01±0.30

0.90±0.29

0.82±0.25

24–59 months n=55

1.88±0.48

1.15±0.33

1.13±0.32

1.09±0.29

60–95 months n=38

2.16±0.45

1.43±0.25

1.35±0.27

1.29±0.25

96–120 months n=22

2.29±0.63

1.32±0.38

1.34±.034

1.33±0.35

Results: The number of patients in each of the five age groups were the following: Group 1 n=67, Group 2 n=21, Group 3 n=55, Group 4 n=38, Group 5 n=22. The CBD was visible in all patients. The intrahepatic ducts were not visible in all patients, but visibility was not age dependent. The PD was significantly less visible in Group 1, not seen in 13/ 67(19.4%) (p=0.003). There was no correlation between visibility of ducts or size of ducts with gender. Height and weight relation was not significant in each group. Using a linear regression (Rs>0.60) and ANOVA (ps<0.001) analysis, all the duct measurements increased with age and the incremental differences between ages was significant (see Table 1). Both readers agree that the PD was better seen on axial plane and the CBD better depicted in coronal. Axial measurements of the PD were larger than the coronal, and for the CBD the coronal measurements were larger. These measurement variations between the axial and coronal planes were statistically significant (ps<0.001), however, these differences were small and may not be practically or clinically important. There was excellent agreement in measurements between readers (k=0.9). Conclusions: Our normative MRI data of duct measurements is a practical and useful reference for radiologists. Duct size increases with age. The CBD is the most visible duct across all age groups, and the PD is difficult to see in children less than 12 months.

Paper #: PA-011 Pediatric MRCP: Evaluation of the Pancreatic Duct

Brandon Brown, Radiology, Indiana University School of Medicine, Indianapolis, IN, [email protected]; Megan Marine, MD, Boaz Karmazyn, MD Purpose or Case Report: To retrospectively determine the accuracy of pancreatic duct evaluation in children by magnetic resonance cholangiopancreatography (MRCP), using endoscopic retrograde cholangiopancreatography (ERCP) as the reference standard. Methods & Materials: From the radiology archive, we retrospectively identified all children over a 10 year period (2003–2012) who underwent MRCP (performed with intravenous secretin to better visualize the pancreatic duct) at a tertiary care children’s hospital, and who later underwent ERCP without an intervening surgical procedure. Qualitative MRCP assessment of the pancreatic duct (as interpreted by the radiologist) was compared to the ERCP findings, any discrepancy was documented, and sensitivity and specificity of MRCP were calculated. Results: We identified 332 pediatric patients who underwent secretin-enhanced MRCP, 68 of whom (40 female, 28 male, mean age 14 years) later underwent ERCP. Sixteen of sixty-eight patients (24%) had pancreatic ductal abnormalities on MRCP, while 52 (76%) were normal. ERCP demonstrated pancreatic ductal abnormalities in 21 of 68 patients (31%); 19 had chronic pancreatitis, while two had pancreatic duct obstruction. Using ERCP as the reference standard, 1 of 16 positive MRCPs (6%) was a falsepositive, while 6 of 52 negative MRCPs (12%) were falsenegative. False-negative MRCPs had ERCP findings of minimal pancreatic ductal irregularity or dilation, or mild side-branch ectasia. The sensitivity and specificity of MRCP were found to be 71% and 98%, respectively. Conclusions: MRCP has very high specificity for pancreatic duct disease in children. While its sensitivity is lower, in false-negative cases the extent of disease noted by ERCP was minimal.

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Paper #: PA-013

Prussian Blue Nanoprobes for MRI-based Imaging of Eosinophilic Esophagitis

Rate of agreement for manual and automated techniques for determination of new T2 lesions in children with multiple sclerosis and acute demyelination

Matthieu Dumont, Laurie Conklin, Raymond Sze, Rohan Fernandes, PhD, Children’s National Medical Center, Washington, DC, [email protected]

Purpose or Case Report: Eosinophilic esophagitis (EoE) is an inflammatory disorder of the upper GI tract marked by the striking infiltration of eosinophils into the esophageal epithelium. A strong link exists between EoE and food/air allergens. EoE affects both children and adults and the presenting symptoms include difficulty eating, failure to thrive, chest or abdominal pain, dysphagia, and food impaction. Worldwide, the annual prevalence of EoE approaches 1:1000, and is rising. The current standard for diagnosis of EoE is upper endoscopy with biopsy with the primary histologic feature for EoE diagnosis being an eosinophil count of ≥15/hpf. This method of diagnosis by endoscopy/biopsy is invasive and causes patient discomfort. Due to the fragile nature of the esophagus in EoE, patients have a substantially increased risk of mucosal renting or perforation during endoscopy. Therefore there is an urgent need to develop non-invasive imaging techniques for EoE. Our overall goal is to develop Prussian blue nanoparticle-based “nanoprobes” that can be orally administered to patients for non-invasive, MRI-based imaging of EoE.

Methods & Materials: We have developed Prussian blue nanoprobes (PB-NPs) with a core-shell design. The core consists of an Iron (III) hexacyanoferrate (II) lattice containing trapped Gd-ions. The Gdions within the PB lattice enhance MRI signal. This MRI core of the PB-NPs is biofunctionalized with a shell consisting fluorophores and targeting ligands that molecularly target eosinophils or EoE-specific markers, and not normal squamous epithelial tissue. We harness fluorescence imaging using the fluorophores on the PB-NPs to calibrate our nanoprobe doses for selective targeting of eosinophils of EoE-specific markers. Synthesis of the core of PB-NPs is achieved in an aqueous suspension by mixing the constituent iron and Gd salts. For assembling the shell onto the core, we use electrostatic self-assembly and robust avidin-biotin interactions. Results: The PB-NPs have superior MRI contrast properties (10-fold higher measured r1 and r2 relaxivities) when compared equimolar amounts of the clinically used contrast Magnevist®. In preliminary studies in vitro, the PB-NPs can selectively target “diseased” eosinophilic cells (EoL-1) and not “normal” squamous epithelial cells (OE-21) using both fluorescence (figure panel A) and MRI (panel B). Conclusions: These results suggest the potential for our nanoprobes for MRI-based imaging of EoE in vivo. We are currently evaluating our PBNPs in a mouse model of EoE.

Leonard Verhey, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Colm Elliott, Helen Branson, Manohar Shroff, Brenda Banwell, Douglas Arnold Purpose or Case Report: Determination of new lesions on serial magnetic resonance imaging (MRI) is important in multiple sclerosis (MS) diagnosis, and new T2 lesions serve as a surrogate outcome for relapses in clinical trials. Absence of new lesions confirms a monophasic illness in children with an acute demyelinating syndrome (ADS). The objective of this study was to evaluate inter-rater variability in new T2 lesion determination based on a manual lesion identification method and an automated probabilistic segmentation technique. Methods & Materials: Scans were acquired according to a standard protocol at onset, 3, 6, and 12 months and annually as part of a national prospective study of children with ADS. New T2 lesions were manually identified independently by three experts (two pediatric neuroradiologists, one imaging scientist) using a standard scoring tool. PDw, T2w, and FLAIR sequences were used. Readers were blinded to clinical information. Automated new T2 lesion segmentation was performed on the same cohort using an optimized, computer-assisted method in which a voxelwise Bayesian and lesion-level random forest classification is performed on T1w pre- and post-contrast, T2w, PDw, and FLAIR sequences of reference, follow-up and difference images. Active scans were defined as having ≥1 new T2 lesion. New T2 lesion counts were categorized into 0, 1, 2 and ≥3 lesions. Rate of agreement was assessed for scan activity and new T2 lesion count. Results: From 19 children included (10 MS, 9 monophasic ADS), 130 scans were analyzed; 12 scans not meeting quality specifications were excluded. A mean of 101 new lesions were identified on all scans (expert readers: R1=87, R2=90, R3=106; automated method: A1=122). Mean rate of agreement on scan activity between the automated method and expert readers was 87% (R1-A1=91%, R2-A1=83%, R3-A1=88%), compared to 91% between readers. Mean agreement on lesion count of the automated method with expert readers was 82% (R1-A1=85%, R2A1=77%, R3-A1=84%) compared to 85% between readers; when zero counts were removed, the mean was 53% (R1-A1=61%, R2-A1=39%, R3-A1=59%), compared to 61% between readers. Conclusions: Agreement is high between manual and automated methods for new T2 lesion determination. Overall, the automated method is more sensitive than the manual readers and identifies a higher number of lesions. The automated method can feasibly aid in the determination of new T2 lesions for diagnosis and monitoring as well as in pediatric MS clinical trials. Paper #: PA-014 MRI Features Distinguish Monophasic ADEM from MS: Findings from a Canadian Cohort of Children with Incident CNS Demyelination

Leonard Verhey, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Manohar Shroff, Helen Branson, Douglas Arnold, Ruth Ann Marrie, Brenda Banwell Purpose or Case Report: The ability to distinguish monophasic demyelination from multiple sclerosis (MS) in children has implications for

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clinical care and prognosis. The objective of this study was to identify magnetic resonance imaging (MRI) features that differentiate monophasic ADEM from a first attack of MS. Methods & Materials: In a prospective incident cohort, T1-weighted preand post-contrast, PD-weighted, T2-weighted and FLAIR images were acquired at onset, 3, 6, and 12 months according to a standard protocol. ADEM and MS were diagnosed according to established criteria. Scans acquired at onset were evaluated using a standardized 16-parameter scoring tool to determine parameters that distinguish ADEM from MS; serial scans were assessed for new lesions meeting criteria for MS dissemination in time and to confirm absence of new lesions in monophasic ADEM. Multiple tetrachoric correlations were used to eliminate collinear parameters, permitting entry of five covariates into multivariable logistic regression models. Results: A total of 1139 MRI scans were evaluated in 284 children (mean observation from onset 4.7±1.5 years); 62 (22%) have been diagnosed with monophasic ADEM, 56 (20%) with MS, and 166 (58%) with nonADEM monophasic demyelination. Participants with ADEM were younger at onset (6.0±3.8 years) than children diagnosed with MS (12.8± 3.1 years; p<0.01). Compared to children with MS, T2-hyperintense gyral projections and lesions of the basal ganglia and thalamus were more frequent in children with ADEM (univariate; p<0.01). T2 periventricular, T1-hypointense and contrast-enhancing lesions were more frequent in children with MS compared to those with ADEM (univariate; p<0.01). In the multivariable model, deep grey matter lesions (odds ratio [OR] 9.9, 95% confidence interval [CI] 2.1–46.0) and absence of T1-hypointense (OR 45.5, 95% CI 9.7–214.5) and contrast-enhancing lesions (OR 4.2, 95% CI 1.0–17.7) predicted monophasic ADEM. Presence of two of these three parameters distinguished ADEM from MS: sensitivity 86%, specificity 93%, positive predictive value 93%, negative predictive value 87%. Conclusions: Specific MRI parameters present at onset can distinguish children with monophasic ADEM from those with MS. Early identification of children with monophasic illness is important in counseling families and also in planning treatment in children at risk for chronic relapsing disease. Disclosure: Dr. Marrie has indicated a relationship with Sanofi-Aventis as a Principal Investigator (Contracted Research). Paper #: PA-015 Improved cerebral perfusion following open heart surgery in newborns with complex congenital heart disease

Usha Nagaraj, MD, Children’s National Medical Center, Washington, DC, [email protected]; Iordanis Evangelou, DPhil, Mary Donofrio, Gilbert Vezina, Adre Duplessis, Catherine Limperopoulos Purpose or Case Report: To compare cerebral perfusion in neonates with complex congenital heart disease (CHD) before and after open heart surgery using quantitative analysis of arterial spin labeling (ASL) data. Methods & Materials: In the context of an ongoing prospective observational study, we recruited newborns with complex CHD prior to open heart surgery. All newborns underwent MRI on a 3 T scanner. A 3D FSE Pseudo-continuous ASL sequence was performed. All studies were reviewed by a board certified radiologist (UN). Post acquisition image processing was performed on a Linux workstation using FSL software. Calculated mean whole brain CBF was recorded in mL/100 g/min. CBF ASL images were linearly co-registered to the axial T2 weighted images for anatomic delineation and selection of regions of interest (ROIs). ROIs were selected (frontal white matter, occipital white matter, thalami and basal ganglia) in order to further evaluate regional blood flow using ITKSNAP software. Paired 2-tailed t-test was used to compare CBF between pre and post-op exams. Results: We performed both pre and post-operative MRIs with diagnostic ASL on a total of 14 neonates with complex CHD. Mean gestational age at birth was 37.6±2.5 weeks and mean birth weight was 3011.3±864.3 g. Preoperative MRI studies were performed at a mean age of 9±20.6 days and postoperative MRIs were repeated at a mean age of 32.7±22 days.

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Average age at operation was 12.6±19.8 days. CHD diagnostic groups included entities such as tetralogy of Fallot (n=3), hypoplastic left heart (n=4) and transposition of the great arteries (n=6). Types of surgeries varied and included corrective surgeries such as arterial switch procedure (n=6) and palliative surgeries such as Norwood stage I (n=5). There is a statistically significant increase in whole brain CBF post-op (p=0.03) compared to the preoperative scan, with 78.6% (11/14) of patients demonstrating increased whole brain CBF post-operatively. There is also a statistically significant increase in the post-operative regional CBF to the thalami (p=0.01) and basal ganglia (p=0.037). Conclusions: Quantitative analysis of ASL data reveals global and regional increases in cerebral perfusion in neonates with complex congenital heart disease post-operatively. ASL may be a valuable tool in assessing cerebral perfusion in neonates with complex CHD before and after open heart surgery. The extent to which cerebral perfusion relates to later neurodevelopmental disability has yet to be determined.

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Theodore Jerdee, MD, Department of Radiology, Stanford University, [email protected]; Stefan Skare, Kristen Yeom, Michael Moseley, Samantha Holdsworth, PhD Purpose or Case Report: MRI provides excellent contrast between the different soft tissues of the body, making it useful in imaging brain pathology. A disadvantage of MRI is that is lengthy, taking up to 1 h at our pediatric institution. Long protocols increase the risk of motion artifacts, thus GA is often used—at the expense of patient throughput and cost. With the goal of shortening the overall scan time in pediatric MRI, here we present preliminary data acquired using four in-house built MR methods that can be retrospectively corrected for patient motion: a T1-weighted 3D Short-Axis Propeller Echo Planar Imaging (SAP-EPI) sequence; a T2-weighted 3D SAP-EPI sequence, a novel Fluid Attenuated Inversion Recovery (FLAIR) Readout-Segmented (RS)-EPI sequence; and a dual-echo Diffusion-Weighted-Imaging (DWI) sequence. The first three of these methods are faster than their conventional counterparts; and the latter can also deliver R2 maps for free.

Methods & Materials: Ten pediatric patients ranging from 1 month to 18 years old were scanned on a 3 T GE system and an 8-channel head coil after informed parental consent was obtained. The scan parameters were: dual-echo DWI: FOV=22 cm, TR/TE1/TE2 =4000/48/115 ms, acquisition matrix=1922, in-plane acceleration factor (R)=3, signal averages (NEX)=3, slthck/gap=4/0 mm, 29 slices, 1 b=0, tetrahedral encoding with b=800 s/mm2, scan time=1:12 min. T1-w 3D SAP-EPI: matrix size=1922, R=NEX=3, TR/TE/FA=46 ms/9 ms/50°, 64 z-partitions, slthk=2 mm, seven blades of width 64, scan time=1:03 min. T2-w 3D SAP-EPI: matrix size=2522, R=NEX=3, TR/TE/FA=62 ms/22 ms/20°, 64 z-partitions, slthk=2 mm, nine blades of width 48, scan time= 1:42 min. FLAIR RS-EPI: matrix size=1922, R=NEX=2, TR/TE/TI= 10000/40/2250 ms, slthk/gap=4/0 mm, five blades of width 64, scan time=1:45 min. Results: Fig. 1 shows images acquired on a 4 year old male patient. Aside from reactive white matter signal abnormality from tumor treatment, no soft tissue or diffusion abnormality was seen to suggest residual/recurrent tumor. Conclusions: This work shows preliminary data acquired with four sequences that generate some of the leading contrast mechanisms in pediatric brain imaging. Together, the four sequences take

5:42 min - faster than the sum of their conventional alternatives scanned at our institution (totaling∼14 min). Future work will explore the sequences’ inherent motion-correction capability, and whether they have the diagnostic potential to replace the need for long scans in a pediatric setting.

Paper #: PA-017 Reduced field-of-view EPI diffusion tensor imaging of the spine for CNS tumors

Michelle Hercher, MD, Stanford University, Palo Alto, CA, [email protected]; Samantha Holdsworth, PhD, Kristen Yeom Purpose or Case Report: Spine MRI is routinely performed for pediatric CNS tumors. The application of diffusion imaging (DWI/DTI) is challenging in the spinal cord due to off-resonance induced artifacts, such as signal dropouts/pileups, geometric distortions and incomplete fat suppression. The zonal oblique multislice (ZOOM)-EPI technique reduces geometric distortion and image blurring by allowing one to reduce the field-of-view (FOV) without signal aliasing into the FOV. We hypothesized that ZOOM-EPI method of spine DTI improves diagnostic utility when combined with conventional spine MRI, and that the acquisition of this method in under 2 min is sufficient to extract diagnostic information.

Methods & Materials: Thirty-eight consecutive children (mean age of 9 years) who obtained ZOOM-EPI spine DTI for CNS tumor work-up were retrospectively identified. Conventional spine MRI and combined conventional and ZOOM-EPI DTI spine MRI were randomized and independently reviewed by two blinded-radiologists and scored for lesion conspicuity and diagnostic confidence, using a 5-point Likert scale. ADC measurements of various spinal tumors were obtained. Tractography was performed in three patients presenting with spinal cord ganglioglioma, pilocytic astrocytoma, and infiltrating glioma. Results: Sixteen patients demonstrated spinal lesions. The average scores calculated across the 38 patients are shown in Figure X. The readers were in moderate agreement (kappa=0.53, 82%CI). The following represent the mean scores for conventional MRI and combined conventional MRI and DTI, respectively: lesion conspicuity—3.0/4.0 (p=0.0039), and diagnostic confidence—2.8/3.9 (p<0.001). ZOOM-EPI DTI identified new lesions in three patients. In three patients, tractography showed characteristic fiber tract projections and were used for neurosurgical planning. The mean/minimum ADC of low and high-grade tumors was 1316/714 and 810/408, respectively.

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Conclusions: ZOOM-EPI method of DTI reduces distortion, improves lesion detection and characterization. With a total scan time of under 2 min, ZOOM-EPI DTI and subsequent tractography images may be promising tools for the clinical evaluation of spinal cord tumors.

Paper #: PA-018 The Spectrum of Neuroimaging and Clinical Findings in Children with Optic Nerve Hypoplasia: Should SOD Be DNR?

William Bireley, MD, Radiology, Children’s Hospital Colorado, Aurora, CO, [email protected]; Laura Fenton, MD, David Mirsky, Nick Stence, MD Purpose or Case Report: Considerable debate has surrounded the term septo-optic dysplasia (SOD) since first coined by de Morsier in 1956 and more fully described by Hoyt in 1970. Several authors suggest that absence of the septum pellucidum (SP) has no prognostic significance in children with optic nerve hypoplasia (ONH). Recently, abandoning the term SOD for “optic nerve hypoplasia syndrome” has been proposed as ONH alone highly correlates with endocrine and neurologic disorders, and SOD places too much emphasis on SP absence. We present the largest single center series of children with ONH and correlative neuroimaging. Our aim was to identify significant neuroimaging findings and clinical phenotypes associated with ONH. Methods & Materials: Following IRB approval, the electronic medical record at a tertiary care children’s hospital was searched for patients diagnosed with ONH between 2000 and 2013. All brain MRIs were independently reviewed by three pediatric neuroradiologists, discrepancies resolved by consensus. Degree of ONH, SP presence, brain malformations, and pituitary abnormalities were recorded. Medical charts were reviewed for endocrinopathy, epilepsy, and developmental delay. Spearman’s correlation and Fisher’s exact test were applied. Results: One hundred fifty-seven patients with ONH were included, 76 male, ranging in age from 0 days to 15 years. The SP was normal in 47.1% and absent in 52.9%. Cortical malformations were present in 56% (polymicrogyria 38%, schizencephaly 17%, heterotopic gray matter 6%, and miscellaneous 3%). The anterior pituitary was small in 23%, posterior pituitary ectopic in 17%, and posterior pituitary bright spot absent in 15%. Absence of the SP significantly correlated (p ≤ 0.0001) with polymicrogyria, schizencephaly, corpus callosum hypogenesis, and developmental delay, but not with pituitary abnormalities, endocrinopathy, or epilepsy. However, 29% of ONH patients with a normal SP had either cortical malformation, endocrinopathy, or developmental delay. Conclusions: In patients with ONH, an absent SP significantly correlates with the presence of cortical malformation and developmental delay. However, nearly one third of patients with ONH and a normal SP had significant imaging and clinical findings warranting further work-up. We agree with other authors that the term SOD places too much emphasis on an absent SP. Replacing the term SOD with Optic Nerve Hypoplasia Syndrome will emphasize the clinical finding of most relevance, which will aid physicians and patients dealing with this complex problem.

Paper #: PA-019 Altered Neural Activation in Children with Sports-Related Concussion Revealed with fMRI

Laura Hayes, M.D., Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Ana Arenivas, Binjian Sun, Richard Jones, Thomas Burns, Susan Palasis, MD

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Purpose or Case Report: As the pathophysiology of pediatric sportsrelated concussion (SRC) is not well understood, functional MRI (fMRI) was employed in an effort to identify alterations in brain activity in concussed children. Historically, fMRI studies have shown disrupted frontal activation patterns during working memory (WM) tasks with mixed results demonstrating either increased or decreased activation during WM tasks in patients vs. controls. Our study evaluated neural activation in high school boys with sports-related concussion (SRC) vs. controls using a multi-level (0,1,2,3,control) n-back fMRI paradigm on a 3 T MRI scanner. Methods & Materials: Functional MRI sequences were acquired within 2–7 days post-injury. Participants included 13 SRC (M=16.16 years, SD= 1.05) and 11 demographically matched controls, (M=15.89 years, SD= 1.07). All participants had a normal appearance of the brain on conventional images. All participants were right-handed males who were similar in race/ethnicity, education, and WASI IQ with no prior history of concussion. All subjects were evaluated with neuropsychological testing, and functional MRI analyses were completed in FSL v.5.0.2 (FEATv6.0.0 & FLAME) to examine WM (3 back) versus vigilance (0 back); threshold set at Z>1.9, cluster corrected p<.05. The fMRI session included three separate trials (runs), each with different randomization of the task ordering. Participants were excluded if there was excessive motion. One-way analyses of variance were carried out to determine group differences in percent change in BOLD responses. Because each participant has fMRI scan of three separate runs, the data was analyzed using a three level GLM. Results: Groups did not differ in accuracy or reaction time across n-back conditions, however the SRC group demonstrated significantly less activation in the right frontal lobe relative to controls on working memory tasks. Conclusions: Alterations in brain activation are present on fMRI scans of children who have sustained a single concussion 2–7 days after the injury compared to controls. Despite similar neurocognitive performances, differences in neural activation are observed, with significantly reduced activation in the right frontal lobe compared to controls. This is hypothesized to be related to deficits in attention in these recently concussed children. This correlates with WM literature suspecting frontal lobe dysfunction in patients with recent concussion. This study is currently ongoing in an attempt to identify the timeframe of recovery and clinical correlates of these altered activation patterns.

Paper #: PA-020 Diffusion and Perfusion Correlates of Heterogeneous Treatment Response in Peptide-Based Pediatric Glioma Immunotherapy

Andrew Klobuka, BS, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, [email protected]; Jack Schnur, Vincent Lee, Regina Jakacki, Ian Pollack, Ashok Panigrahy Purpose or Case Report: Diffusion and perfusion MR correlates of pediatric glioma peptide-based immunotherapy treatment response have not been well delineated. Apparent Diffusion Coefficient (ADC) is a measure of tumor cellularity using diffusion MR. Tumor vascularity can non-invasively be measured by arterial spin labeling (ASL) perfusion without use of contrast material. We tested the hypothesis that correlations between ADC (cellularity) and ASL (vascularity) would predict treatment response in pediatric gliomas treated with peptide-based immunotherapy. Methods & Materials: A total of 19 pediatric gliomas (brainstem and recurrent supratentorial gliomas [Grade II/IV]) were prospectively recruited as part of a single-site peptide-based immunotherapy imaging study. The ASL and ADC images from a total of 68 serial exams were registered to the corresponding DWI-B0 image using MIPAV software for measurements. Total tumor volume and necrosis were segmented in all glioma cases. For the supratentorial group, individual lesions were classified from serial radiographic evaluation through the course of therapy as (1) stable/responsive; (2) recurrent; (3) vasogenic edema.

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Results: The average number of necroses/patient was increased in the brainstem glioma cohort (3.9 foci of necrosis/patient) compared to the supratentorial glioma cohort (0.88 foci of necrosis/patient). Regression analysis demonstrated no significant correlation between ADC and ASL values in the brainstem glioma cohort (r=0.37, p value=0.231). There was a significant inverse correlation between ADC and ASL in the supratentorial glioma cohort (r=0.594, p value<0.0001). Within the supratentorial glioma cohort, recurrent lesions demonstrated a strong inverse correlation between ADC and ASL (r=0.72, p value<0.001). There was no significant correlation in stable/responsive lesions (r= 0.181; p=0.456) and vasogenic edema lesions (r=0.0391, p=0.894). Conclusions: A lack of correlation between cellularity and perfusion was noted in patients with newly diagnosed brainstem gliomas; (2) stable/ responsive supratentorial gliomas lesions throughout the course of immunotherapy. In contrast, recurrent supratentorial glioma lesions demonstrated a strong correlation between increased cellularity and vascularity. This finding suggests that ADC (cellularity) and ASL (vascularity) correlates of pediatric gliomas may differentially predict tumor response in pediatric gliomas treated with peptide-based immunotherapy and further validation in a larger dataset is warranted.

Paper #: PA-021 Radiation Dose to the Lens of the Eye for Neuroradiology CT Protocols in Pediatric Patients

Natalie Januzis, MS, Duke University Medical Center, Durham, NC, [email protected]; Giao Nguyen, Donald Frush, Jenny Hoang, Terry Yoshizumi.

Table 1. Manufacturer-specific scan parameter for neuroradiology protocols Protocol

Vendor

Brain

1 2 1 2 1 2 1 2 1 2 1 2

Sinuses Facial bones Orbits Temporal bones Craniofacial

120 120 120 120 120

77.5 46.0 70.0 28.0 87.5 59.0 87.5 41.0 175.0 40.0 24.5 22.0

Exposure Time (s) 3.00 7.52 2.50 5.17 3.50 7.22 2.00 5.09 0.50 11.80 7.41 9.65

Pitch

Brain

Axial

11.94

165.5

9.46±0.86

0.60

11.73

177.0

11.2±1.26

Sinuses Facial bones Orbits

Craniofacial

CTDIvol (mGy)

Tube Current (mA)

Protocol

Temporal bones

Purpose or Case Report: New lower thresholds for cataract formation (ICRP) justify the investigation of lens doses in patients, including children. The purpose of this study was two-fold: (1) to measure the radiation dose to the lens of the eye for pediatric neuroradiology protocols on CT scanners from two different vendors, and (2) to correlate lens doses to CTDIvol values.

Tube Voltage (kVp) 120

DLP (mGy-cm)

Lens Dose (mGy)

Axial

12.45

124.5

10.9±1.01

0.60

7.31

71.0

6.64±0.23

Axial

15.57

217.9

13.9±0.93

0.60

14.92

215.0

13.2±0.36

Axial

15.57

124.5

13.1±1.55

0.60

10.24

97.3

8.83±1.22

Axial

15.57

31.1

8.98±1.03

0.80

10.96

49.8

9.43±0.77

0.97

4.94

98.2

4.21±0.80

0.60

5.61

112.0

6.66±0.79

Results: For the six protocols, mean lens doses (mGy) for vendor one and vendor two were 9.46 and 11.18 (brain); 10.86 and 6.64 (sinuses); 13.92 and 13.20 (facial bones); 13.09 and 8.83 (orbits); 8.98 and 9.43 (temporal bones); and 4.21 and 6.66 (craniofacial), respectively. The greatest absolute variation between manufacturers was 4.25 mGy for the orbits protocol. Linear regression analysis of average lens dose and CTDIvol yielded a slope of 0.892 and a R2 value of 0.953.

Methods & Materials: Lens of the eye radiation dose was measured by scanning a 5-year-old anthropomorphic phantom (CIRS) with MOSFET detectors. The phantom was scanned with six current neuroradiology protocols that covered the orbit, which included CT brain, sinuses, facial bones, orbits, temporal bones, and craniofacial scans. All measurements were performed with 64-slice scanners from two different vendors (sizebased technical factors provided in presentation table). Linear regression analysis was used to determine the relationship of average lens dose and CTDIvol.

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Conclusions: The lens of the eye dose for pediatric neuroradiology CT protocols ranges from 4 to 14 mGy with variation between protocols and scanner vendors. There was excellent linear correlation between lens of the eye radiation dose and CTDIvol for CT scanners from two different vendors. This suggests an estimation of lens dose could be made from a reported dose index. This methodology provides opportunity for quality improvement and investigation of dose and image quality for identical examinations performed on diferrent vendor equipment.

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Purpose or Case Report: To evaluate the spectrum of pathologies found in neonates with retropharyngeal (RTP) cystic masses. Methods & Materials: A PACS search was performed using the Boolean combined terms of retropharyngeal AND cyst/cystic/fluid/branchial/ thymic/duplication/abscess/malformation. One thousand seven imaging results were obtained for children under 5 years of age. Inclusion criteria for analysis included age < 2 months, presence of cross sectional imaging and location centered in RTP space. Clinical presentation, surgical and pathology reports were obtained from the electronic medical record.

Paper #: PA-022 Does near infrared spectroscopy (NIRS) as marker of brain autoregulation correlate with apparent diffusion coefficient scalars in neonates who were treated with brain cooling for perinatal hypoxic ischemic injury (HII)?

Aylin Tekes, MD., Johns Hopkins Hospital, Baltimore, MD, [email protected]; Andrea Poretti, Jennifer Lee, Shang-En Chung, Frances Northington, Thierry Huisman Purpose or Case Report: Despite therapeutic hypothermia incidence of neurologic morbidity remains high in perinatal HII. Optimizing cerebrovascular autoregulation may reduce the risk for brain injury. NIRS allows to collect data about brain autoregulation bedside while DTI gives qualitative and quantitative information about the brain micro-architecture. Low apparent diffusion coefficient (ADC) values have been correlated with acute ischemic injury. We studied the correlation between NIRS and ADC values at various phases of brain cooling. Methods & Materials: Twenty-seven neonates with perinatal hypoxic ischemic injury were included in this institutional review board approved study. NIRS data were collected during therapeutic hypothermia, rewarming, and normothermia. The optimal mean arterial blood pressure (MAP) with most robust autoregulation was identified. MRI was done 1–2 weeks after completion of hypothermia. ADC values were measured bilaterally in the anterior and posterior centrum semiovale (ACO and PCO), basal ganglia, thalamus, PLIC, cerebellar white matter and pons. The lowest ADC measurements between right or left hemispheres were used as the representative value for that anatomic region. To account for pseudonormalization of ADC values, data were dichotomized into neonates who received MRI before and after day of life 10. Autoregulation and ADC measurements were analyzed with Spearman correlations. Results: Among neonates who had MRI after day 10 of life (n=9), low ADC scalars of the PCO correlated to spending more time with blood pressure below optimal mean arterial pressure (MAP) (r=−0.83; p=0.006) and greater blood pressure deviation below optimal MAP (indicating worse autoregulation; r=−0.71; p=0.03) during hypothermia. Greater blood pressure deviation below optimal MAP also correlated to low ADC scalars in the PLIC (r=−0.68; p=0.04). During rewarming, greater time and deviation of blood pressure below optimal MAP correlated to low ADC values in the basal ganglia (r=−0.71; p=0.05; n=8). No statistically significant relationships between blood pressure and ADC scalars were identified in neonates who had MRI done before day of life 10. Conclusions: Neonates with worse autoregulation had lower ADC values in the PCO and PLIC during hypothermia, and basal ganglia during rewarming. This finding was limited to neonates who had MRI done on day of life ≥10. Optimizing blood pressure autoregulation may decrease the risk of brain injury, and postponing MRI until after day 10 of life should be considered. Paper #: PA-023 Neonatal retropharyngeal cysts: Imaging, surgical and pathologic considerations

Shellie Josephs, MD, UT Southwestern Radiology, Dallas, TX, [email protected]; Eric Berg, Zi Jiang, Andrew Chang, Sandy Cope-Yokoyama, Timothy Booth

Results: A total of eight patients, (3 M, 5 F) were identified, age range 0– 24 days. Patient and lesion characteristics are presented in Table 1. Two lesions were diagnosed on prenatal ultrasound. All patients were symptomatic with inspiratory stridor or choking with feeds (4), increased work of breathing (2), grunting (1), oropharyngeal secretions (1) and cyanotic episode (1). All patients had left sided unilocular cysts with estimated volume from 11.24 to 77.2 cm3 (mean = 26.25 cm3) based on cross sectional measurements. An air fluid level was found on CT in patient 5. A sinus tract to the piriform sinus was found at direct laryngoscopy with pathology confirming third branchial pouch remnant. Patient 8, diagnosed with abscess, was the only patient presenting with fever. Six patients underwent surgical excision, one after drainage and two underwent drainage alone. All three patients who underwent drainage without excision had recurrent episodes of swelling or infection. Surgical complications include left true vocal cord paralysis in two patients and bilateral true vocal cord paralysis in one. Pathology revealed thymic cyst in 2, 3rd branchial pouch remnant in 2, branchial cleft remnant, thyroglossal duct cyst and isolated abscess. Column1 Table 1 Patient Age (days) Sex Side Presentation Fever Surgical Procedure Imaging Direct laryngoscopy Piriform sinus involvement Size (cm) Volume (cm3) Pathology

Column1 Table 1 Patient Age (days) Sex

Column2

Column3

1 24 M L stridor none excision CT bulge lateral no 1.9,3.6,3.9 13.96 Thymic cyst

2 11 F L stidor none excision CT effaced left edema 1.8,3.3,4.2 13.06 3rd Branchial

Column4

Column5

Column6

3 5 M

4 10 M

5 0 F

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L cyanosis

Fever Surgical Procedure Imaging Direct laryngoscopy Piriform sinus involvement Size (cm) Volume (cm3) Pathology

none excision MRI Fullness left no 3.2,6.4,7.2 77.2 Thymic cyst

Column1

L increased WOB none drainage MRI Fullness left fistula tract 2.0,2.9,3.7 11.24 None

L secretions

turbulent and complex flow using 4D-PC data, and use this to optimize flow quantification.

none excision MRI Fullness left no 3.4,4.4,3.9 30.55 Branchial remnant

Column7

Column8

Column9

Patient

6

7

8

Age (days)

28

19

28

Sex

F

F

F

Side

L

L

L

Presentation

choking with feeds

Increased WOB

Increased WOB yes

Table 1

Fever

none

none

Surgical Procedure

excision

excision

drainage

Imaging

CT

CT

CT

Direct laryngoscopy

prominence left medial deviation retropharyngeal left Piriform sinus involvement no no edema Size (cm)

3.3,2.3,3.0

3.5,4.3,3.6

Volume (cm3)

11.92

28.37

1.8,4.2,6.0 23.75

Pathology

Duplication cyst

Branchial remnant

Abscess

Conclusions: A wide range of RTP cystic masses present in neonates. Underlying developmental cysts are extremely common and simple abscesses are the exception. Imaging characteristics are very similar based on the common embryologic development of the piriform sinus and thymus, possibly related to the malformation of thymopharyngeal duct or 3rd branchial pouch. Surgical complication of vocal cord paralysis also can be linked to the embryology and proximity of the superior laryngeal nerve. Evaluation for a piriform sinus opening is warranted given the incidence of 3rd branchial pouch anomalies, but is not a common finding in our series.

Paper #: PA-024 Simultaneous 4D phase-contrast velocity and signal dispersion rendering may improve qualitative and quantitative evaluation of tricuspid and pulmonary regurgitation in repaired Tetralogy of Fallot

Albert Hsiao, MD, PhD, Radiology, Stanford University, Stanford, CA, [email protected]; Marcus Alley, Christopher Elkins, Shreyas Vasanawala Purpose or Case Report: Cardiac MRI is routinely performed for follow-up of patients with repaired Tetralogy of Fallot (ToF), but has some limitations. Turbulent and complex flow may compromise accuracy of phase-contrast pulmonary artery flow measurements. 4D phasecontrast (4D-PC) MRI has been proposed to improve and simplify congenital heart MRI. We hypothesized that it may be possible to localize

Methods & Materials: An algorithm for calculation and visualization of the signal dispersion (SD) field from tetrahedral-encoded 4D-PC was developed in Java, OpenGL and CUDA. The dispersion field was computed using the log-ratio of signal magnitude of sequential echoes. With HIPAA compliance and IRB approval, we retrospectively identified six patients who underwent accelerated whole chest 4D-PC MRI as part of their clinical 1.5 T MRI exam for repaired ToF between February 2012 to August 2013. Measurements of pulmonary blood flow were obtained at 12 positions along the pulmonary outflow without the benefit of SD visualization. Locations and temporal phases of increased SD were tabulated for each patient. With the hypothesis that main pulmonary artery (PA) and right ventricular outflow tract (RVOT) are differentially-impacted by signal dispersion, forward and regurgitant waveforms were compared between these locations (t-test, F-test).

Results: In all six patients, we observed increased SD in the PA during systole. Five had statistically different systolic waveforms between the PA and RVOT (p<0.05) and three had greater variance in the PA waveforms (p<0.05). In all five patients with at least mild-moderate pulmonary regurgitation, we found increased SD in the RVOT during diastole. All had statistically different diastolic waveforms in the RVOT than the PA (p<0.05) and two had greater variance in the RVOT waveforms (p<0.05). In addition, in all patients with tricuspid regurgitation, we found that SD augmented the visualization of the proximal tricuspid regurgitant jet, filling in gaps in phase-contrast flow data due to turbulent signal loss. Conclusions: Combined flow and SD rendering by 4D-PC MRI may help identify the optimal location for phase-contrast flow measurement and better characterize turbulent jets at the inlet and outlet valves. Among patients with pulmonary regurgitation, systolic flow quantification may be more consistent in the RVOT, while diastolic flow quantification may be more consistent in the PA. Disclosure: Dr. Hsiao has indicated a relationship with Morpheus Medical as a Company Founder and Consultant (Owernship Interest). Dr. Alley has indicated a relationship with GE Medical Systems

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(Research Support). Dr. Vasanawala has indicated a relationship with GE Healthcare as an Investigator (Research Collaboration); Morpheus Medical, Consultant.

Abbreviations Key: AoR-aortic root; AAo-ascending aorta; TxAtransverse arch; DAo- descending aorta; RBC-right brachiocephalic; LCCA-left pulmonary artery; LUPV-left upper pulmonary vein; LLPVleft lower pulmonary vein; RUPV-right upper pulmonary vein; RLPVright lower pulmonary vein

Paper #: PA-025 Paper #: PA-026 A Comparison of Standard MRA using Extracellular Contrast with Respiratory and ECG triggered Gradient Echo MRA Imaging using Blood Pool Contrast

Andrada Popescu, MD, Medical Imaging, Ann&Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Cynthia Rigsby, MD, Stanley Kim, R. Andrew deFreitas, Emma Boylan, Xiaoming Bi Purpose or Case Report: Gadofosveset trisodium (gadofosveset trisodium, ABLAVAR®, Lantheus Medical Imaging, Inc, North Billerica MA) is the first gadolinium based blood pool contrast agent (BPCA) approved in the US for imaging of aortoiliac MR angiography (MRA) in adults. Due to its long plasma half life, this BPCA provides long imaging time for MRA allowing for longer free-breathing imaging respiratory and ECG navigator triggered acquisitions relative to extracellular contrast agents (ECCA) which quickly diffuse into the interstitial space allowing for only relatively short imaging acquisition times. Standard MRA is performed during dynamic injection of ECCA (Magnevist, Bayer HealthCare Pharmaceuticals AG Leverkusen, Germany) and scanned with a standard high-resolution T1 fat suppressed gradient echo MRA sequence. We have revised our MRA scan technique to take advantage of the long plasma half-life of a BPCA, imaging following injection of BPCA using a respiratory and navigator triggered inversion recovery gradient echo (BPCAMRA) to potentially improve vessel visualization. Our purpose was to compare image quality of standard MRA to BPCA-MRA in our pediatric and young adult population. Methods & Materials: This retrospective study is IRB approved and HIPAA compliant. Informed consent was waived. A PACS search was undertaken to find patients who underwent BPCA-MRA from 8/2012 to 8/2013 who also had a prior standard MRA. The aortic root (AoR), ascending (AAo), transverse arch (TxA), descending (DAo), proximal great arteries, main (MPA), right (RPA), left (LPA) pulmonary arteries and pulmonary veins were scored for image quality on a Likert scale of 1– 5 by three independent reviewers. Image quality scores were compared using a standard t-test. Results: Eighty-four Chest MRA studies (42 standard MRA and 42 BPCA-MRA for each patient) in 42 patients (mean age 10.9 years) were found. Mean time interval between the two MRA studies was 2.2 years (range 8 months–3 years). Mean image quality score for all vessels combined was statistically significantly better with BPCA-MRA (4.84) than standard MRA (3.80) (p=0.00001). Mean vessel score was better for all vessels using MRA-BPCA (Table 1). Conclusions: BPCA-MRA offers superior image quality compared to standard MRA for visualizing all major thoracic vessels. Table1. Mean Score by Segment and Technique Abbreviations

BPCA-MRA Standard MRA

Average Mean Score 4.84 3.80

AoR

AAo

TxA

DAo

MPA

RPA

4.83 2.76

4.87 3.59

4.92 4.21

4.92 4.31

4.85 3.37

4.90 3.87

Cynthia Rigsby, MD, Lurie Children’s Hospital, Chicago, IL, [email protected]; Andrada Popescu, Emma Boylan, Samantha Schoeneman, R. Andrew deFreitas, R. Jason Orr

Purpose or Case Report: A single blood pool contrast agent (blood pool contrast) (gadofosveset trisodium, ABLAVAR®, Lantheus, N. Billerica, MA) is approved for use for MRA to evaluate for aortoiliac occlusive disease in adults. There are little data on administration of blood pool contrast to children. We have successfully utilized this blood pool contrast for MRI assessment of the heart and vascular structures in the chest and for assessment of abdominal and peripheral vasculature in our population of children and young adults. Our purpose is to review the safety of administration of blood pool contrast in our patient population. Methods & Materials: This retrospective review is IRB approved and HIPAA compliant. A review of our hospital information system was undertaken to locate all patients who received blood pool contrast between 10/2011 and 9/2013. An electronic chart review was performed to determine patient age, blood pool contrast dose, and any recorded complications related to the blood pool contrast. Screening for kidney function (e-GFR must be >60 mL/min/1.73 m2) and long QT syndrome (QTc must be < 480 ms) is performed prior to administration of blood pool contrast. Results: Four hundred thirty-seven patients (mean age 13.7 years; median age 14.3 years; range 0.13–41.2 years) received blood pool contrast. Of these, 409 patients (93.6%) received a single dose, 25 patients (5.7%) received two doses, and three patients (0.7%) received three doses of contrast over the 2 years time period. 430 (98.4%) patients received a standard blood pool contrast dose (0.03 mmol/kg); 7 (1.6%) patients received half of a standard blood pool contrast dose (0.015 mmol/kg). There were two adverse events (2/437 (0.46%) patients) that were both hypersensitivity reactions. This is greater than the hypersensitivity rate listed in the blood pool contrast package insert (2/1676 (0.12%) subjects). Both patients with reactions were immediately and successfully treated. There was no long-term adverse outcome from either hypersensitivity reaction. No other adverse events were recorded. Conclusions: Blood pool contrast can be safely administered in a population of children and young adults. Policies and equipment should be in place to treat hypersensitivity reactions in these patients. These data may be useful to other pediatric centers considering implementing administration of blood pool contrast. Paper #: PA-027

LPA RBC LCCA LSA LUPV LLPV RUPV RLPV BPCA-MRA

Safety of a Blood Pool Contrast Agent in Children and Young Adults

4.90 4.87

4.82

4.57

4.82

4.83

4.86

4.78

Standard MRA 3.90 4.26

4.28

4.25

3.59

3.50

3.64

3.60

Biomechanical Differences between Functional Single Left and Right Ventricles in Pediatric Population: A MRI based Comparison of Myocardial Strain and Torsion in an Asymptomatic Cohort

Ramkumar Krishnamurthy, Ph.D., Texas Children’s Hospital, Houston, TX, [email protected]; Cory Noel, Amol Pednekar, Rajesh Krishnamurthy, MD

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Purpose or Case Report: Ventricular dysfunction in patients with a single functional right or left ventricle (SRV, SLV) is a known risk factor for morbidity and mortality. Biomechanical differences in SRV and SLV function remain poorly understood1–6. Purpose: In normal subjects and in asymptomatic patients with SLV and SRV, after total cavopulmonary connection, to compare: 1) 2)

Global rotation (ROTglo), circumferential (εcc) and longitudinal (εL) strain. Regional rotation and strain in systole at free wall (ROTfree, εccfree, εL-free) and septal wall (ROT sept, εcc-sept, εL-sept) for each slice location.

Methods & Materials: Following IRB approval and informed consent, we performed a prospective analysis of 18 subjects. Seven subjects had normal cardiac anatomy (age 11.8 +/− 3), six subjects had a SVof right ventricular morphology (age: 11.4 +/− 2.3), and five had a SV of left ventricular morphology (age 12.7 +/− 4.2). Acquisition Protocol: On a 1.5 T Philips Acheiva MRI scanner, three short axis (SAX) slices at basal and apical locations were obtained in all subjects using CSPAMM7 and Fast SENC8 techniques. Data Analysis: Strain, rotation (in degrees), global torsion (τ) and normalized torsion (τNorm = τ/L) across all cardiac phases was calculated for all slices. The ventricular regions at each slice were assigned based upon the AHA 16 segment model. εcc-sept, εL-sept, εcc-free, and εLfree were also calculated for each slice and compared. Results: With respect to (wrt) normal data (Fig. 2): 1. 2. 3.

4. 5.

Global εcc reduced at mid and basal locations of both SLV and SRV patients (Fig 2). Global εL reduced in apical locations of SLV and SRV patients. SV groups exhibited significant reduction in εcc-sept, εLsept. This was significantly higher than the reduction in global strain. εcc-sept and εl-free significantly changed from apex of the ventricle to the base. Significant reduction in ROTglo, τ and τNorm in both SLVand SRV patients.

6.

SRV patients had more severely impaired rotation than SLV (significantly reduced global and septal clock-wise basal rotation).

Conclusions: Strain values and rotation of SLV and SRV demonstrate significant differences wrt normal subjects, with SRV patients more severely affected. εcc-sept is significantly reduced in single ventricle patients while εcc-free is normal. εcc of the SV progressively reduces from the apex to the base; basal rotation is more impaired compared to apical rotation, suggesting a deleterious effect of the hypoplastic chamber connected to the base.

Disclosure: Dr. Rajesh Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support. Dr. Pednekar has indicated a relationship with Philips as an Employee (Salary). Paper #: PA-028 Comparison of Two Single Breath-held 3D Cine Steady-State Free Precession with 2D Breath-held acquisition (BH-SSFP) in unsedated patients with single ventricles

Lamya Atweh, MD, Singleton Department of Pediatric Radiology, Texas Children’s Hospital, Houston, TX; Amol Pednekar, Rajesh Krishnamurthy, MD, Ramkumar Krishnamurthy, Zili David Chu, Cory Noel

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Purpose or Case Report: Breath-held 2D SSFP cine imaging (BHSSFP) is the method of choice for evaluating ventricular function due to its superior blood-to-myocardial contrast, edge definition, and high intrinsic SNR. In this paper, we compare ventricular volumes obtained by two fast cine 3D SSFP sequences performed in a single breath-hold (3D k-t BLAST SSFP and 3D multiple SENSE-SSFP (MS) against conventional 2D breath held SSFP in unsedated healthy volunteers and patients with single ventricle CHD.

caused by inconsistent amplitude of breathing. However, these sequences produce sub-optimal diagnostic images, which may be partly related to patient cooperation and faster heart rates in pediatric patients compared to adults. 3D-multiple SENSE SSFP produces better image quality in children than 3D k-t BAST SSFP. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support. Dr. Pednekar has indicated a relationship with Philips as an Employee (Salary). Paper #: PA-029 Unsupervised free-breathing 3-dimensional imaging of morphology, function and flow in congenital heart disease (CHD) under 30 min: pilot study

Methods & Materials: After obtaining IRB approval and informed consent, this prospective study was performed on 30 unsedated patients (9 healthy volunteers and 21 functional single ventricle patients), age 12.5 +/− 2.8 years. Imaging was done on a commercial 1.5 T MR scanner (Achieva, Philips Healthcare). BHSSFP, eight-fold accelerated 3D k-t BLAST, and MS-SSFP with parallel imaging factor of 2 ×2 were performed to evaluate ventricular volumes and mass in the short-axis (SA) orientation. Image quality scores (figure legend) and volumetric analysis was performed on the datasets by a blinded user. One-sided Wilcoxon signed rank test was performed to compare each of the 3D-k-t and MS clinical scores against BH-SSFP. BlandAltman (BA) analysis was performed on LV and single ventricle volumes. Results: The clinical scores were best for the BH-SSFP images. Between the two 3D sequences, MS performed better than 3D-k-t (Table 1). BA analysis (Table 2) for volumes indicates that variability was more between 3D-k-t and BH acquisitions than between MS and BH acquisitions. In the unsedated population, ISA scores were better for 3D-k-t and MS than BH. The BMC scores and EDef scores were better for BH than 3D-k-t and MS. Total score with equal weights to each clinical score category was best for BH-SSFP and better for MS than 3D-k-t. Scan duration was shorter for 3D acquisition sequences consisting of a single breath-hold, compared with multiple breath holds for the BH stack. Table 2: Bland Altman Analysis Results comparing 2D BH vs 3D MS vs 3D kt 3D-Multi SENSE vs. BH (n=30)

3D-Kt vs. BH (n=30)

EDV ml

ESV ml

SV ml

EF%

EDV ml

ESV ml

SV ml

Mean Bias

8.76

3.88

5.56

0.37

11.43

3.48

4.95

1.78

Limit of agreement (±2 SD)

28.98

13.12

16.8

6.48

37.34

17.82

38.72

5.96

Rajesh Krishnamurthy, MD, Texas Children’s Hospital, Houston, TX, [email protected]; Ramkumar Krishnamurthy, Ph.D., Elijah Bolin, LaDonna Malone, MD, Amol Pednekar, Myriam Almeida-Jones

EF%

Conclusions: 3D k-t BLAST and 3D-multiple SENSE for ventricular volumetry release the constraints of multiple breath-holds in pediatric patients and overcome problems related to inter-slice misalignment

Purpose or Case Report: Cardiac MRI for CHD is an operator dependent and time-intensive examination requiring real-time decision making regarding choice of sequences, planes, and acquisition parameters to adapt to unique morphological and functional variables in a given patient. This study evaluates technical feasibility, image quality and quantitative integrity of an unsupervised free-breathing (FB) protocol following administration of blood

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pool contrast agent, utilizing 3D imaging of morphology, function, and flow.

Clinical scores for 2D SSFP were better than 3D-SSFP, but 3D SSFP images were adequate for recognition of pathology in all cases (2D vs 3D: 1.5±0.5 vs 1.6±0.9) and had better inter-slice alignment (1.4±0.5 vs 1±0). See Table 3, Figure 2. Comparative flow analysis between 2D and 4D PC data revealed broad correlation (stroke volume: Fig 2, Table 3). The stroke volume, forward and backward flows through the aorta were not statistically different (p >0.35; paired Student’s t-test). Conclusions: We have demonstrated the feasibility of performing an observer independent comprehensive CMR in CHD utilizing FB 3D acquisitions for morphology, function and flow within 30 minutes using a 5-channel phased-array coil. Better acquisition hardware and dedicated post-processing options for functional 3D datasets will lead to superior image quality and faster adoption. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support. Dr. Pednekar has indicated a relationship with Philips as an Employee (Salary). Paper #: PA-030 Clinical evaluation of a novel MR angiographic protocol in congenital heart disease (CHD) using time resolved imaging and free-breathing steady state imaging following administration of blood pool contrast agent (BPCA)

LaDonna Malone, MD, Diagnostic Pediatric Radiology, Baylor College of Medicine, Houston, TX, [email protected]; Siddharth Jadhav, M.D., Prakash Masand, MD, Rajesh Krishnamurthy, MD Purpose or Case Report: Current angiographic protocols in CHD utilize either a time resolved first pass or a steady state technique. The objective of this study is to clinically evaluate a novel MRA protocol using BPCA that combines time resolved first-pass imaging (trMRA) and high resolution steady state imaging (ssMRA). Methods & Materials: Five patients (Table 2) with CHD were included in this pilot study (Table 2). The MR studies were performed with FB on a Philips Acheiva 1.5 T magnet.(see Table 1) 1. 2. 3. 4. 5.

Resp. synchronized (1), time-resolved MRA FB equilibrium phase MRA FB 3D cine SSFP FB 4D phase contrast (PC) flow imaging FB 3D whole-heart single phase SSFP (coronary)

Data was also obtained using 2D cine RT SSFP sequences (2) in the VLA, four chamber and short axis planes, and 2D PC imaging. Image quality assessment and quantitative volumetric and flow analysis were performed by three blinded, experienced users. MRA images were graded using a semi-quantitative scale from 1 to 5 for relevant imaging targets in CHD (1), with 1: excellent, no limitations, and 5: non-diagnostic. The clinical scoring system for 2D and 3D cine SSFP was based on blood-myocardial contrast, endocardial edge definition and inter-slice alignment (2). Results: All FB 3D sequences were technically feasible in all five patients. Average time for completion of 5 FB 3D sequences was 29 min. Average score for first-pass MRA was 1.9/5. Average score for equilibrium MRA was 1.3/5.

Image Quality Pulmonary Artery Pulmonary Vein Intercostal Artery Portal Vein Artifact Grade CNR Pulmonary Artery Pulmonary Vein Aorta Subclavian Vein Average Contrast Pulmonary Artery Pulmonary Vein Aorta Subclavian Vein Average variance

Dynamic 1.5+0.6 1.5+0.6 1.5+0.7 2.2+0.8 1.6+0.7 20.7+6.9 20.3+6.9 18.2+6.1 13.8+4.3 18.2+3.8 299+149 282+134 281+135

Steady State 1.3+0.6 1.4+0.6 1.1+0.4 1.9+1.1 1.7+0.7 14.6+5.6 15.1+5.4 13.6+3.1 16.0+5.7 14.8+3.7 297+142 316+146 293+122

196+96.9 277+122 264+120 296+130 55.4+32.4 28.3+15.5

p 0.19 0.54 0.063 0.24 0.9 0.0005 0.0016 0.0039 0.107 0.0012 0.937 0.16 0.619 0.0041 0.192

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Methods & Materials: Twenty-five patients with CHD were retrospectively included following IRB approval. The studies were performed on a Philips Acheiva 1.5 T magnet using a multielement phased array coil with 3D spoiled GRE sequences following injection of 0.03 mmol/kg of Gadofosveset, and injection rate 2–4 cc/s: 1.

2.

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significant inter-observer variability (IOV), especially if a followup study is performed in a different institution.

Free-breathing respiratory synchronized (15/25) or breath-held (10/ 25), trMRA with isotropic voxel size of 1.2–1.75 mm, 7–9 dynamics, CENTRA k-space filling, keyhole 20–25%, SENSE factor 1.5×1.5 to 2×2. Duration: <1 min. Free breathing ssMRA with isotropic voxel size of 0.8–1.3 mm, 1 dynamic, SENSE factor 1.3×1.3 to 1.9×1.9, 2–3 NEX. Duration: 2.5–4 min.

Dedicated 3D workstation was used for analysis (Vitrea, Toshiba Inc). Image quality, pathology detection and reader confidence for vascular targets in CHD were graded independently by two radiologists. Final diagnosis was based on consensus of both phases, and comparison to echo and catheterization, if available. Signal intensity in target vessels and muscle were used to calculate contrast to noise ratio (CNR) and homogeneity. Results: There was no difference in image quality or artifact grade between trMRA and ssMRA (Figure 1). CNR is higher on the peak phases in trMRA compared to ssMRA (p=0.0012), while ssMRA showed better homogeneity (p<0.0001). Vascular pathology was detected in 12 of 25 patients including stenosis or occlusion with collateral vessels. There was no difference for detection of vascular pathology or reader confidence, but grading of pathology severity was superior on trMRA due to visualization of transient phenomena such as systemic venous, systemicpulmonary venous or aortopulmonary collaterals, while demonstration of all venous structures and Fontan baffles was superior on ssMRA. Conclusions: This novel angiographic protocol using BPCA allows extraction of both temporal and high resolution static information from MRA datasets, increasing diagnostic yield in patients with CHD. TrMRA provides better separation of arterial and venous structures, and improved visualization of transient phenomena, while ssMRA allows for superior spatial resolution and improved visualization of structures with delayed filling. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support. Paper #: PA-031 Inter -Observer Variability in Manual Measurement of Aortic Root Dimensions in Pediatric Patients: Benefits of using a Semi-Automated Tool

Ramkumar Krishnamurthy, Ph.D., Texas Children’s Hospital, Houston, TX, [email protected]; Amol Pednekar, Shaine Morris, Rajesh Krishnamurthy, MD Purpose or Case Report: Accurate measurement of maximal aortic root dimensions is important for informed decision making on the timing/nature of aortic valve replacement surgeries in pediatric patients. Currently, the observer manually measures the 1) Cusp to Commisure (Cu-Co), and 2) Cusp to Cusp (Cu-Cu) lengths to quantify maximum aortic root dimensions: This introduces

Hypothesis: A simple post-processing tool that allows the observer to perform semiautomated measurements using reproducible landmarks will enable accurate quantification of maximal aortic root dimensions as well as decrease IOV, thereby leading to reproducibility of measurements. Methods & Materials: An image analysis tool was developed using MatlabTM that can automatically measure the Cu-Cu and Cu-Co lengths from easily reproducible landmarks namely: 1) location of the commissure, and 2) the external margin of the sinuses and aorta (Fig 1). The observer also performed manual measurements for comparison.

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Study Design: In this retrospective study, cine bSSFP CMR data (1.5*1.5*5 mm) of the aortic root of 11 patients with Tetrology of Fallot (Age: 16.6±7.5 years, LV EF: 59±5.5%) and 15 patients with Marfans’ Syndrome (Age: 12.8±8 years, LV EF: 59±6%) were analyzed by two experienced observers. Data Processing: Anonymized MR images of the aortic root in the shortaxis view were analyzed in early systole and Cu-Co, and Cu-Cu lengths were measured. IOV was computed using Pearson’s correlation coefficient (r) and Fisher’s z-transformation (z). Results: The manual measurements under-estimated aortic root dimensions (Figure 2). The r values (inter-observer agreement) were better for the semi-automated in both ToF and MFS patients. The p-values for ztransformation were a) 0.32 for Cu-Co; 0.045 for Cu-Cu measurements in ToF patients; and b) 0.27 for Cu-Co; 0.027 for Cu-Cu measurements for MFS patients. The p values for Cu-Cu measurements show a significant difference between the manual measurements and the semi-automated tool. Conclusions: Manual measurements under-estimate aortic root dimensions and have a significant higher IOV when compared to semiautomated measurements. We demonstrate that a simple semiautomated tool consistently captures the maximum dimension of the aortic root, and significantly improves IOV, and will be useful in detecting subtle interval change on serial studies conducted at varying imaging centers. Disclsoure: Dr. Pednekar has indicated a relationship with Philips as an Employee (Salary).

resolution (sub-mm in-plane) can accurate identify presence of intramural segment of anomalous coronary artery. Conclusions: This retrospective review suggest that high resolution (sub-mm in-plane resolution) coronary MRA may be able to identify intramural segment of anomalous coronary artery using the criteria of abnormally small ostium and a smaller calibre intramural segment compare to the normal epicardial segment of the anomalous coronary artery. Disclosure: Mr. Hitt has indicated a relationship with Philips Healthcare as an Employee in Clinical Development (Salary). Paper #: PA-033 Biomodeling and Fitting Studies for Total Artificial Heart Implantation in Children

Rajesh Krishnamurthy, MD, Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Sanjay Subramanian, Todd Pietila, Pascal Salazar, Iki Adachi Purpose or Case Report: The SynCardia TAH, used as a bridge to transplantation in adults, is increasingly considered for use in children with non-reversible bi-ventricular failure. Due to the large size of the currently available devices (70 ml pump) and the complexity of anatomy encountered in CHD, assessment of fit is a critical prerequisite prior to implantation in children. We describe our experience with 3D biomodeling and fitting studies for the TAH in four pediatric patients.

Paper #: PA-032 High-Resolution Sub-mm Coronary MRA for the evaluation of patients with Anomalous Coronary Artery - Visualization of the Intramural Segment

David Biko, Diagnostic Imaging, Children’s Hospital & Research Center Oakland, Oakland, CA, [email protected]; Claudia Chung, Dave Hitt, Gregory Kurio, Taylor Chung, M.D. Purpose or Case Report: This is a retrospective review of 5 years of clinical experience in our institution using high-resolution coronary MRA for evaluation of patient with suspected anomalous coronary artery to determine the ability of MRA to identify intramural segment of an anomalous coronary artery. We were motivated by an excellent poster presentation at the 2013 SPR meeting which concluded that coronary MRA cannot accurately identify the intramural segment. Methods & Materials: We retrospectively reviewed all coronary MRA performed from October 2008 to October 2013 for clinically suspected anomalous coronary artery with 1.5 T and 3 T MR scanners. Results: Twenty-seven coronary MRA examinations were performed associated with clinical indication of anomalous coronary artery. All cases except two were acquired with in-plane resolution ranging from 0.5× 0.5to 0.9×0.9 mm in-plane resolution using 3D-fast gradient echo sequence with respiratory navigator. The other two cases were performed with 1×1 mm in-plane resolution. Thickness was 2 mm reconstructed to 1 mm in all cases except for two cases where thickness was 1.5 mm and 3 mm. Twelve cases were performed on 3 T scanner (in-plane resolution 0.5×0.5 mm to 0.7 mm) and 15 cases were on 1.5 T scanner (in-plane resolution 0.7×0.7 to 1×1 mm). Seventeen were performed for preoperative evaluation and 12 cases have intra-operative correlation. Retrospective review using criteria of abnormal small ostium, smaller size of intramural segment compare to epicardial coronary artery shows that high

Methods & Materials: The indications for TAH included corrected TGA with biventricular failure, failed heart transplant, and dilated cardiomyopathy. Device fitting was initiated by a volumetric CT using a 320 detector scanner with retrospective gating in two patients, and ‘target mode’ prospective gating in two patients, with the TAH device placed on a foam pad on top of the chest. Image segmentation was performed on dedicated 3D software (Vitrea, Toshiba Inc, and Mimics Innovation Suite, Materialize), resulting in individual segments of the TAH device, ventricles, atria, extracardiac vasculature, thoracic cage, lungs and airway. In two patients, these segments were converted to.stl objects and imported to 3D-Tool, a 3D CAD program which allows movement and rotation of 3D objects. In two others, the TAH and cardiac segments were manipulated using 3-matic, a CAD tool within Mimics software. Virtual cardiectomy was performed, leaving a 1-cm rim of ventricular wall around the atrioventricular (AV) groove. The right- and left-sided components of the TAH were moved and rotated independently to fit within their respective AV inflow and semilunar outflow. The TAH was manipulated as a whole to determine orientation in the chest that would allow chest

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closure. The lungs and thoracic cage were then replaced to study the appearance of the final fit (1). Results: Based on the simulations, one patient with L-TGA had successful TAH implantation, and two patients were considered unsuitable for TAH due to inconsistent fit. The last patient was considered a viable candidate for TAH, but received a heart transplant due to availability at short notice. In one case of successful implantation, the orientation prediction from the virtual fitting study matched those determined at the time of open chest fitting as well as the postoperative CT. Conclusions: We have demonstrated two ways of performing 3D modeling and fitting studies in children, that will allow preoperative planning for TAH on a case-by-case basis and account for the anatomic variation encountered in CHD. Paper #: PA-034 Magnetic Resonance Venography in Pediatric Patients with Chronic Kidney Disease: Initial Experience with Ferumoxytol

Aarti Luhar, MD, University of California, Los Angeles-Department of Radiology, Los Angeles, CA, [email protected]; Sarah Khan, J. Paul Finn, Anjali Nayak, Joshua Zaritsky, Theodore Hall Purpose or Case Report: Several gadolinium based contrast agents (GBCA) are associated with risk of nephrogenic systemic fibrosis (NSF), a potentially debilitating disorder which occurs in patients with chronic kidney disease (CKD). Originally described in 2003, attention has recently refocused on ultrasmall, superparamagnetic iron oxide (USPIO) particles as potential alternatives to GBCAs in patients with CKD. Although not approved as an MR imaging agent, ferumoxytol is an FDA-approved parenteral treatment for iron deficiency anemia in adults with CKD, and is marketed in the U.S. as Feraheme (AMAG Pharmaceuticals, MA). Ferumoxytol has high T1 relaxivity and long intravascular residence time which are positive attributes for venographic imaging agents. We sought to evaluate Ferumoxytol as an alternative to GBCAs for patients with CKD. Methods & Materials: Eight pediatric patients with CKD who required detailed venographic imaging were referred for magnetic resonance venography (MRV) with Ferumoxytol. Parental consent was obtained in all cases. Imaging was performed on a 3.0 T scanner (TIM Trio, Siemens Medical Solutions) and high resolution images, encompassing the head, neck, thorax, abdomen and pelvis, were acquired during steady state distribution of ferumoxytol, 4 mg/kg. Image quality of the ferumoxytyl enhanced MRVs were subjectively assessed by a board certified pediatric radiologist at the time of study completion, Signal to noise ratios (SNR) and contrast to noise ratios (CNR) were measured in the inferior vena cava (IVC) and hepatic veins (HV) of MRVs for patients with CKD who received ferumoxytol, and were compared to SNRs and CNRs from MRVs for weight-matched patients without CKD who received gadopentetate dimeglumine (Magnevist, BayerSchering), 0.2 mmol/kg. Results: All eight patients successfully underwent MRV with Ferumoxytol without incident. Image quality was scored as diagnostic and subjectively comparable to gadolinium enhanced MRV. In the ferumoxytol enhanced MRVs, the mean SNRs in the IVC and HV respectively measured 73.75 (±29.77) and 74.68 (±30.84); the mean CNRs respectively measured 38.56 (±20.05) and 39.49 (±20.17). In the GBCA enhanced MRVs, the mean SNRs respectively measured 63.92 (±28.80) and 53.38 (±25.14); the mean CNRs respectively measured 29.82 (±19.24) and 19.24 (±12.70). Conclusions: Our initial experience suggests that ferumoxytol holds promise as a safe and practical alternative to GBCAs for high resolution MRV in pediatric patients

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Marilyn Goske, Radiolgy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Mythreyi Chatfield, Keith Strauss, MSc, Daniel Podberesky, MD, Jeffrey Prince Purpose or Case Report: Diagnostic Reference Levels (DRL) are thirdquartile values of mean radiation dose compared among imaging facilities meant to be used as a quality improvement tool. We compared the DRL for pediatric CT of the abdomen/pelvis (A/P) from a consortium of children’s hospitals (QUIRCC) to the DRL from adult-focused facilities for children of the same body width (BW). Methods & Materials: From January to June, 2013, five children’s hospitals within the QuIRCC consortium automatically uploaded data using DICOM SR or dose report on A/P CT with IV contrast on patients <19 years of age to the DIR. From the same period, data from “adult-focused” facilities (defined as sites with less than 75% of DIR patients < 19 years of age) uploaded the same scan type. Only data from scans that included the scout view were included so that SSDE (as well as CTDIvol32) could be calculated. SSDE was calculated by applying a correction factor to CTDIvol32 as a function of ED. CTDIvol32 and SSDE were compared as a function of ED between the two types of facilities. Results: There were 372 A/P CT scans with IV contrast for routine scan indications at the QuIRCC sites and 4326 at the adult facilities. For SSDE, the QuIRCC DRL (95%CI) in mGy were 6.6(3.7–6.6); 3.2(2.8–3.3); 6.4(4.8–7.0); 9.2(5.9–8.4); 16.4(8.2–13.7) for ED of 0– 15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. For SSDE, the adult focused facilities’ DRL (95%CI) were 30.4 (24.8–41.8); 10.4(8.7–10.9); 12.6(10.7–12.2); 16.1(13.7–15.9); 22.8(18.3–20.2) for ED of 0–15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. For CTDIvol32, the QuIRCC DRL (95%CI) in mGy were 2.4(1.4–2.3); 1.7(1.4–1.7); 3.9(2.9–4.3); 6.8(4.3–6.1); 15.5(7.2–13.3) for ED of 0– 15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. For CTDIvol32, the adult focused facilities’ DRL (95%CI) were 11.7(10.6– 17.6); 5.2(4.4–5.6); 7.7(6.6–7.5); 11.9(9.9–11.6); 21.3(17.1–18.9) for ED of 0–15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. Conclusions: There are few published reports that compare DRL for adult and pediatric facilities within the United States. Data from the first US national registry demonstrates SSDE for the smallest patient at an adultfocused facility is almost five times the estimated dose at a QuIRCC hospital and shows less variation the larger the child. This study highlights the difference in scan techniques and pediatric patient dose estimates between adult and pediatric facilities. Paper #: PA-036 Quality Improvement Registry in CT Scans in Children (QuIRCC): Diagnostic Reference Levels for Pediatric Chest CT

Marilyn Goske, Radiolgy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Keith Strauss, MSc, Mythreyi Chatfield, Alexander Towbin, MD, Michael Callahan, Kassa Darge, MD, PhD Purpose or Case Report: Information on radiation doses associated with pediatric chest CT is limited in the United States (US). Data from the QuIRCC consortium within the American College of Radiology’s (ACR)

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CT dose index registry (DIR) was used to establish baseline values for estimates of radiation dose production of the scanner for pediatric noncontrast chest CT. Size Specific Dose Estimates (SSDEs) were calculated for the purpose of establishing diagnostic reference levels (DRLs) for patient dose as a function of patient size. Methods & Materials: Five children’s hospitals participated in an 11 months review of non-contrast chest CT scans on patients < 19 years of age for routine clinical indications such as tumor metastases. This study was approved by the IRB from each participating institution. The DIR automatically records age, body size [effective diameter (ED)] based on the scout view, scanner identification, scan technique, FOV, CTDIvol and DLP. SSDE, a patient dose estimate which accounts for body size, was calculated for scans that included a de-identified scout view. CTDIvol and SSDE were compared as a function of ED. Results: Data from the DICOM SR or dose report and localizer images from 553 (53% male) routine non-contrast chest CT scans were automatically sent to the DIR between June 1, 2012 and June 30, 2013 Mean SSDE (95%CI) in mGy were 6.1(4.2–7.9); 3.7(3.3–4.1); 4.4(4.0–4.9); 5.6(5.0–6.2); 7.4(6.5–8.3) for ED of 0–15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. SSDE DRL in mGy were 7.0, 4.5, 5.3, 6.9 and 8.5 for ED of 0–15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. Mean CTDIvol32 (95%CI) in mGy were 2.3(1.6–2.9); 1.9(1.7–2.1); 2.7(2.5–3.0); 4.1(3.7–4.5); 6.6(5.6–7.5) for ED of 0–15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. CTDIvol32 DRL in mGy were 2.4, 2.3, 3.2, 5.1 and 7.6 for ED of 0–15 cm, 15–19 cm, 20–24 cm, 25–29 cm and 30+ cm respectively. For the three facilities with more than 100 non-contrast chest CT exams, mean SSDE varied from 4.1 to 6.2 mGy, a 150% (or 1.5 fold) variation. Conclusions: This QuIRCC data provides non-contrast chest DRL and provides a method for a facility to compare its radiation dose estimates with QuIRCC data for continuous quality improvement of its CT radiation dose.

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Methods & Materials: A proprietary phantom with inserts including iodine and polystyrene (soft tissue) consisting of a range of pediatric sized modules (12, 18.5, 23, and 30 cm) was scanned (Siemens Flash) independently and identically (including mA modulation; pitch 1.4) with and without ATPS: (1) standard weight-based abdominopelvic protocol with a fixed 120 kVp and 200 ref mAs and (2) ATPS (CARE kV where kVp and mAs are “optimized” automatically based on topogram, exam type, and operator desired study quality). CTDIvol 32 cm was compared between standard and ATPS exams. Quantitative measurements included contrast, noise, and CNR for iodine and soft tissue inserts, and a quantitative analysis of lesion detectability (detectability factor), d’, and figure of merit, d’2/CTDIvol, were calculated. Results: ATPS automatically reduced kVp from 120 to 80 or 100 in all scans. The reduction was accompanied by a decrease in CTDIvol in all ATPS scans, most pronounced in the CTA mode with a 52%, 51%, and 49% CTDIvol reduction in the 12, 18.5, and 23 cm modules, respectively. CTDIvol reductions were also observed in the contrast-enhanced mode (15–33% reduction) and the non-contrast mode (8–14%). CNR for the iodine and soft tissue inserts was either improved or maintained in all CARE kV scans. d’iodine was increased in 11/12 (92%) of the ATPS scans and d’soft tissue was increased in 9/12 (75%) CARE kV scans, while d’2/CTDIvol was increased in all ATPS scans compared to the standard protocol.

Paper #: PA-037 Effects of Automatic Tube Potential Selection on Radiation Dose, Image Quality and Lesion Detectability in Pediatric Abdominopelvic CTand CTA: A Phantom Study

Michael Brinkley, MD, Department of Radiology, Duke University Medical Center, Durham, NC, [email protected]; Juan RamirezGiraldo, Ehsan Samei, PhD, Daniel Frush, Carolyn Lowry, Donald Frush Purpose or Case Report: To assess automatic tube potential selection (ATPS) on radiation dose and study quality in pediatric abdominopelvic CT and CTA.

Conclusions: This is the first systematic study of ATPS (CARE kV) across a range of pediatric sizes and exam types, afforded by a proprietary versatile modular CT phantom. ATPS reduced radiation dose while maintaining or improving image quality across a range of age-related diameters. The phantom and CT image analysis program allowed for a more comprehensive assessment of study diagnostic quality, as both CNR and lesion detectability were maintained or improved with lower kVp, lower dose scans. Our results support prior studies demonstrating the greatest dose reductions with smaller patients in CTA; however, we also found substantial dose reductions with the larger phantom diameters and with the contrast-enhanced and non-contrast-enhanced ATPS scans, supporting applicability for a range of pediatric body sizes and clinical indications. Disclosure: Dr. Ramirez-Giraldo has indicated a relationship with Siemens Healthcare as an Employee (Salary). Dr. Samei has indicated a relationship with GE as Principal Investigator (Research Grant) and Siemens as Principal Investigator (Research Grant).

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Paper #: PA-038 Dual energy compared to single energy CTscans in pediatric patients: dose neutral or not?

Xiaowei Zhu, M.S., Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Patricia Mecca, Sabah Servaes, Kassa Darge, MD, PhD Purpose or Case Report: Dual energy CT scans (DE) improve the delineation of different structures that have similar linear attenuation coefficients providing additional diagnostic information. Manufacturers suggest that DE scans can be performed “dose neutral” in comparison with single energy CT scans (SE).The purpose of this study is to develop DE scan protocols based on optimized SE protocols and to compare the dose.

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Results: Head: The EffCTDI from SE & DE scans are within 10% in all three age groups. Chest: The DE EffCTDI are 153%,122% and 111% of SE, in 1, 5, 10y, respectively. Abdomen: The DE EffCTDI is 150% of SE in 1y; and are within 1% of SE in 5 &10y. Reducing RefCTDI did not effectively reduce resultant DE EffCTDI as expected in 1,5,& 10y chest scans and in 1y abdominal scans. CNR in 1y: Abdomen, no statistically significant CNR improvement in DE scan (mean CNRDE:78+/−2, CNRSE: 74+/−2, p-value=0.15); Chest, DE presented lower CNR than SE (mean CNRDE:37+/−1,CNRSE:44+/−2, p-value=0.013), despite a 53% Eff CTDI increase. Radiologists reported no clinically significant image quality difference by visual assessments. Conclusions: For the scanner in our study, if the original SE protocols are optimized to very low tube current (mA), it is not possible to go lower when doing DE due to limitations of the lowest tube mA of the scanner. Thus it is not possible to maintain dose neutrality with DE scans, especially in small phantoms. Our findings are important in making informed decisions when choosing SE and DE protocols based on dose and diagnostic benefits. CT Dual Energy Potential Applications Based on Dose Information Study Description Stones Stone and obstruction for virtual noncontrast CT cystography for virtual non-contrast Abdominal tumors with suspicion of calcifications for virtual non-contrast Remnant catheter in a vessel for virtual non-contrast Diagnosis of arterial calcinosis for virtual non-contrast

Age specification 5 year and older All ages All ages 5 years and older; and for younger if not seen on US All ages All ages

Paper #: PA-039

Methods & Materials: Three anthropomorphic phantoms of 1, 5, &10y olds were scanned with SE and DE protocols. DE were first performed with matching reference CTDIvol (RefCTDI) of our optimized SE clinical scan protocols for head, chest, & abdomen, utilizing mAs and kV modulations for SE, and mAs modulation for DE. A second DE was performed in each region with adjusted RefCTDI based upon the ratio of the resultant Effective CTDIVol (EffCTDI) of the two scans. Each phantom contains inserts with 1–6 mm contrast targets simulating blood in head, chest nodule and abdominal contrast for visual and contrast to noise ratio (CNR) assessments. EffCTDI from SE and DE were compared to quantify dose in each anatomical region and phantom size group. We estimated CNR for the chest and abdomen of the 1y phantom with the most significant differences in EffCTDI between SE& DE. Ten 3 mm slices with the contrast insert in each region were analyzed. Two radiologists provided visual assessments.

Comprehensive Image Quality Phantom for Pediatric and Adult CT Imaging

Ehsan Samei, PhD, Radiology, Duke University Medical Center, Durham, NC, [email protected] Purpose or Case Report: To design, fabricate, and test an innovative CT phantom for characterizing CT image quality as a function of patient size, noise, resolution, lesion contrast, and background heterogeneity.

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Methods & Materials: Current CT image quality phantoms reflect a single body habitus, background structure, and/or contrast level. To address these limitations, a new phantom (Mercury 3.0) was designed consisting of five cylindrical components (12–37 cm diameter) representing a wide range of patient sizes. Each component consisted of uniform sections with contrast inserts corresponding to bone, water, air, soft-tissue, and iodine (8.5 mg/cc) for resolution measurements. Additional sections represented lung texture, soft tissue texture, and contrast-detail with embedded low-contrast lesions to assess noise and its impact in varying background structures. With a definition of a targeted clinical lesion (in terms of morphology and tissue or iodine content), measurements could provide a detectability index (d’) quantifying the likelihood that the targeted lesion can be detectable in images with similar resolution and noise properties. The varying size of the phantom enabled quality characterization as a function of patient size, accounting for the influence of tube current and tube potential modulations. An image processing software was further developed to streamline the analysis of the images from the phantom. With a semi-automated process, the program enables rapid analysis of image quality across a large dataset for characterization and optimization studies. Size (cm)

Noise

Iodine contrast

12 18.5 23 30

2.0 3.2 4.6 7.3

325.1 311.4 283.4 276.5

Size (cm)

d’ soft tissue

12 18.5 23 30

4.0 3.4 1.9 1.1

Soft tissue contrast 84.7 90.9 81.4 82.3

d’^2 iodinated per CTDI 9.1 2.5 0.8 0.2

Purpose or Case Report: Optimizing radiation dose and image quality in body CT for surgical planning (3D post-processing) is changing in light of image processing advances which improve image quality and reduce need for separate exams. Overlapping scan areas in the upper abdomen may be disproportionately affected when separate exams are taken in the context of organ dose and body size. We estimated radiation dose exposure in separate same-day overlapping body CT exams (Chest and Abdomen/Pelvis: C+AP) and continuous exams (Chest, Abdomen and Pelvis: CAP). Patient-specific Size Specific Dose Estimation (SSDE), effective dose, and organ dose were calculated from C+AP and CAP exams and stratified by BMI (body mass index) for comparison.

d’ iodinated 7.0 3.9 2.2 1.3 d’^2 soft tissue per CTDI 4.4 1.9 0.6 0.2

Results: Prototypes of the phantom were fabricated at our institution, with texture and contrast-detail sections constructed with 3D printing with intermixing of different printing material. The initial trial of the phantom demonstrated achieving the desired imaging properties. The contrast of the inserts ranged from 2 to 7.3. The d’ could be readily extracted from the phantom images as a function of phantom size, target contrast, noise magnitude, and background heterogeneity. The mA values were similarly indicative of the mA modulation as a function of size. Conclusions: This is the first comprehensive phantom for quantifying image quality in CT in such a way that reflects differing sizes of pediatric and adult patients, lesions contrast, and anatomical texture. The phantom is portable and robust and when used with its adjunct analysis software can be readily used for a host of dose reduction and optimization studies within and between institutions. Disclosure: Dr. Samei has indicated a relationship with GE as Principal Investigator (Research Grant) and Siemens as Principal Investigator (Research Grant).

Paper #: PA-040 Increased Organ Dose in Overlapped Upper Abdomen CT Scans of Chest and Abdomen/Pelvis

Vana Derderian, BS, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, [email protected]; Choonsik Lee, Mohammad Soltanmohammadi, Michael Choi, Elizabeth Jones, Les Folio, DO, MPH

Methods & Materials: All patients (n=332 scans in 47 patients) with a same-session separate Chest and Abdomen/Pelvis (C+AP) CT from

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January to June 2013 and available dose page were included. Additional prior same-session C+AP or continuous CAP were included for these patients as available. Technical parameters (kVp, mAs, automatic exposure control use, scanner model) and radiation dose parameters (CTDIvol and DLP) were extracted from dose pages; demographics and BMI retrieved from patient records; and SSDE calculated from effective diameters generated on each exam by manual anteroposterior and lateral measurements at the middle scan slice. Two sets of SSDE, k-factorbased effective dose, and organ dose were calculated and each set compared. Computational whole body male and female phantoms and Monte Carlo simulation were adopted to calculate organ dose. Radiologists and ordering physicians subjectively assessed clinically relevant image quality reduction and repeat rate due to inadequate quality. Results: The separate C+AP exam on average produces higher estimated dose (k-factor effective dose: 0-30% more, p=0.02; SSDE: 50–100% more, p<0.0001) than routine continuous CAP. Organ dose assessments demonstrate higher doses in the overlapping exam (C+AP) for all organs, with the greatest increases in the liver (40%) and spleen (38%). Image quality was maintained in the CAP exam for use in 3D post-processing applications with no exams repeated. Conclusions: Utilizing routine continuous CAP instead of separate C+ AP exams can reduce effective dose and SSDE by as much as 50% and organ dose by as much as 40% while maintaining adequate image quality for 3D post-processing applications. Similar dose reduction is expected with preferred continuous CAP exam use in children. Paper #: PA-041 Parental Perception of Potential Risk associated with Ionizing Radiation Exposure from Computed Tomography

Karen Thomas, MD, Department of Diagnostic Imaging, Hospital for Sick Children, and University of Toronto, Toronto, ON, Canada, [email protected]; Kathy Boutis, William Cogollo, Jason Fischer, Stephen Freedman, Guila BenDavid Purpose or Case Report: Primary study objective was to determine the extent of parental awareness of the potential increase in excess lifetime malignancy risk associated with radiation exposure from CT of the head. Secondary objectives were to examine parental willingness to proceed with recommended Head CT once informed of the potential risks and benefits, and to assess expressed preference regarding provision of this information prior to imaging. Methods & Materials: A prospective cross-sectional survey of parents whose children presented to the Emergency Department of a tertiary pediatric hospital with an isolated head injury was performed. Survey questions included assessors of parental awareness of the use of ionizing radiation in imaging, the associated potential risks, sources of knowledge, and willingness to agree to Head CT examination before and following the provision of further dose and risk information. Results: Of 987 eligible parents, 742 (75.2%) were enrolled. Three hundred ninty parents (52.3%, 95% CI 48.7 to 55.9) believed that CT uses ionizing radiation and 357 (46.8%, 95% CI 43.2 to 50.4) were aware that there may be an increased lifetime malignancy risk after a Head CT. However, 467 (62.9%, 95% CI 59.4 to 66.4) underestimated the risk. Prior to provision of current risk estimates, the proportion of parents who were “very/willing” to proceed with physician recommended Head CT was 90.4%, while after risk disclosure, willingness decreased to 69.7% (p<0.0001). Despite increased concern, only 42 (5.6%) would refuse CT, the remainder preferring further discussion with a physician. Almost all parents (673, 90.3%) wished to be informed of the small potential risk. Conclusions: Approximately half of parents were aware of the potential increased lifetime malignancy risk associated with ionizing radiation. When provided with further information, concerns are moderately increased but the majority of parents are still willing to consider Head CT in the care of their child. Most would like to be informed of potential risks and have greater discussion prior to imaging.

S91 Paper #: PA-042 Impact of California CT Dose Reporting Requirements: Survey of Radiologists

Evan Zucker, M.D., Department of Radiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA, [email protected]; Richard Barth, MD Purpose or Case Report: In the wake of several widely reported incidents of radiation overexposure, California enacted mandatory CT dose reporting legislation (Senate Bill [SB] 1237) in 2012. We sought to determine the effects on the law on radiologist practice patterns and understanding of CT related radiation dose, which to our knowledge have not been previously reported. Methods & Materials: We conducted a survey of all radiologist members of the California Radiological Society (CRS) via a web-based SurveyMonkey tool. Questions were designed to assess radiologists’ understanding of and attitudes towards the law as well changes in practice following the legislation. Results: One hundred thirty-seven radiologists completed the survey. One hundred fifteen (84%) were in private practice and the rest in academics. One hundred thirty-two of 137 (96%) expressed familiarity with SB 1237. One hundred thirty of 135 (96%) understood that CT dose parameters must be included in the radiology report. One-hundred twenty-six and 115 of 135 responding (93% and 85%, respectively), correctly indicated that the CT dose index (CTDIvol) and dose-length product (DLP) must be reported; 24 (18%) chose erroneous answers such as absorbed dose and kVP. Sixty (45%) of 134 felt that the bill increased their awareness of appropriate dose ranges, and 29 of 133 (22%) indicated changing mAs or kVp parameters as a direct result of the law. Twentyeight of 134 (21%) had modified their CT protocols based on age or weight in response to SB 1237. Of 31 responding, 5 (16%) and 3 (10%) had modified protocols only in children or adults, respectively, and the remainder in all ages. Twenty-four of 129 (19%) had implemented automated dose reporting, while 48 (37%) and 57 (44%), used direct dictation/transcription and voice recognition templates, respectively. Forty of 134 (30%) responded that SB 1237 requirements caused delays in finalizing CT reports. Write-in comments expressed concern about the burden of additional reporting requirements but also suggested increased awareness of radiation dose as a result of the law, which spurred some radiologists to modify their protocols. Conclusions: California radiologists are largely aware of the SB 1237 dose reporting requirements. The CRS survey suggests increased awareness of dose issues as a result of SB 1237, and some practices attribute modification of CT protocols to SB 1237. Inefficiency in reporting was the primary cited concern regarding the legislation. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support. Paper #: PA-043 Monitoring Radiation Exposures from Pediatric CT in Child Visits to Pediatric and Adult-focused Emergency Departments

Saurabh Agarwal, MD, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, MO, [email protected]; Clint Jokerst, Marilyn Siegel, Charles Hildebolt Purpose or Case Report: To compare radiation doses and specific CT parameters in pediatric emergency CT scans performed at a Children’s hospital (CH) and adult-focused community hospitals (AFHs). Methods & Materials: Electronic records for emergency department visits were reviewed from January 2012 through December 2012 to identify patients with CT scans performed at our tertiary care, level I trauma center CH, and AFHs. Only CT scans ordered from the emergency

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radiographic, DEXA, and CT examinations. For CT, dose measurements were made using MOSFET dosimeters placed inside anthropomorphic phantoms representing 1, 5, 10 and 15 years old male and female patients. The phantom dose models were used to derive patient specific dose calculation equations that incorporated patient morphometric measurements and age and gender specific correction factors. The dose equations were used to perform a retrospective patient population dose and risk analysis. DEXA and radiography patient doses were assessed by calculating detector entrance Air KERMA that was corrected for known patient positioning and body habitus geometry and dose correction factors. Over 30 k x-ray and DEXA images were then analyzed for trends in detector exposure and correlated with the physical dose measurements to develop patient population risk assessment. Monte Carlo based internal dosimetry calculations (Olinda software, Vanderbilt University) were performed for nuclear medicine and PET/CT dose, and risk assessment. Patient phantom models provided by Olinda were used, and represented identical age populations measured for the other transmission examinations. Results: Patient organ dosimetry (CT, PET, and nuclear medicine) and entrance skin dosimetry (DEXA and radiography) were used to calculate both absolute patient population dose and patient population effective dose for risk assessment. These values were compiled into a single table and posted on an internal institutional IRB website. Conclusions: The patient absolute dose and risk assessment is used to develop comprehensive documentation for patient informed consent when enrolling patients in research studies. Additionally, the analysis of our institute’s complete patient dosimetry has provided a process allowing for a framework of ongoing patient quality assurance testing to maintain image quality standards as high as reasonably attainable (AHARA) with dose levels in conformance with ALARA standards.

department (ED) for acute clinical indications, including trauma, chest pain for suspected pulmonary embolus and abdominal pain for suspected appendicitis or renal stones, were included in the study. The medical records were reviewed for patient age and weight. CT dose index volume (CTDIvol) and size specific dose estimates (SSDE) were calculated for each patient. Tube kilovoltage (kVp), milliampere-second (mAs), and number of scan phases were analyzed. The Wilcoxon signed rank test and Fisher exact test were used to test differences. Results: There were 141 CT scans were performed at AFHs and 152 at a CH. Mean patient age was 11 years (8–15, 25th-75th percentile ranges) versus 13 (7–16), p=0.7635. For chest and abdomen/pelvis CT, mean CTDIvol was 7.2 mGy (6.4–7.9 mGy, 95% CI) for the Children’s hospital and 11.9 mGy (10.0–13.7 mGy, 95% CI) for the adult-focused hospital (p<0.0001). There were 58 females and 83 males in the outside cohort and 68 females and 84 males in the CH cohort. For all CT types, SSDE values were 11.1 mGy (10.6–11.7 mGy, 95% CI) at the CH and 18.1 mGy (15.8– 20.4 mGy, 95% CI) at the AFH (p=0.01). For abdomen/pelvis CT in isolation, SSDE was also significantly lower at the CH than AFHs (P= 0.005). The tube kVp and mAs were lower at the CH for all CT types. At the AFHs, 84% of all CTs used 120 kVp and 11% 100 kVp versus 60% and 36%, respectively at the CH (p<0.0001). Mean mAs were 134 and 124 for chest and abdomen/pelvis CTs at AFHs versus 83 and 118 at the CH (p= 0.04 and 0.140, respectively). Of note, only six of 141 AFHs CT scans were repeated at the CH. Multiphase studies were performed in five of 141 CT scans at the AFH compared to 0 of 152 CT scans performed at the CH. Conclusions: The radiation exposure to pediatric patients is significantly higher at adult-focused hospitals than at a Children’s hospital, which in large part is due technical factors for performing the examination. These data indicate the need for development of more educational programs for optimizing radiation dose at adult-focused hospitals. Disclosure: Dr. Siegel has indicated a relationship with Siemens Healthcare as a Speaker (Travel reimbursement).

Paper #: PA-045

Paper #: PA-044

The recent trend of pediatric CT dose in Korea

Development of a comprehensive risk assessment methodology for pediatric patients undergoing all types of imaging examinations using ionizing radiation

Ah Young Jung, Radiology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea, [email protected]; Kyung-Hyun Do, Jae-Yeon Hwang, Dong Hyun Yang, Young Ah Cho, Hye-Kyung Yoon

Samuel Brady, PhD, Radiological Sciences, St Jude Children’s Research Hospital, Memphis, TN, [email protected]; Bria Moore, Amy Mirro, Robert Kaufman Purpose or Case Report: To facilitate the process of investigational informed consent, methodologies were developed to measure pediatric patient population radiation dose and calculate relative risk from ionizing radiation for the most common patient examination types in CT, DEXA, radiography, nuclear medicine, and PET/CT. The results are published internally on our institutional IRB website.

Methods & Materials: The IRB waived informed consent for this quality assurance analysis. Physical dose measurements were performed for

Purpose or Case Report: With rapid technological advances in CT, the use of CT has been growing resulting in increased amount of radiation exposure to patients. This can be problematic, especially in children because they are more sensitive to radiation than adults. Although use of CT has been continuously rising, recently a slight decrease in CT utilization and dose reduction to pediatric population has been reported. The aim of this study was to assess the trend of CT practice and doses delivered to Korean pediatric population and compare it with published international survey data. Methods & Materials: Survey was conducted consisting of questionnaire addressed to the pediatric radiologist in South Korea. The use of shields, contrast media, automatic current modulation, kVp, mAs, number series, rotation time, reconstruction slice thickness, pitch, CTDI and DLP were analyzed. The pediatric population was categorized into four age groups (<1 years, 1–5 years, 6–10 years, 11–15 years). CT protocols, parameters and dose report of the children were collected. The indication for CT were acute abdominal pain and head trauma. To assess the trend of the CT dose, data from unpublished survey conducted on 2009 and data from this study were compared. At the end of the survey, a feedback form was sent to the participating hospitals Results: On 2012 survey data, most of the CTDI and DRL values decreased compared with the data from 2009. The values were comparable or lower than previous reports by Germany and UK. Unlike the data from 2009, most of the institutions used single phase for acute abdomen CT. No institutions used adult protocols on children but each had pediatric protocols.

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Four pediatric designated centers had lower CTDI and DLP values. Conclusions: As part of ‘the Image Gently Alliance’,the awareness on need for radiation protection has been raised among the pediatric radiologists in South Korea. As a result, the dose of pediatric CT as of 2012 has decreased since 2009 and practice of pediatric CT scanning has been changed positively to provide safer, high quality pediatric imaging.

S93 Paper #: PA-047 Evaluation of Simulation Education to Improve Performance of Fluoroscopic Upper Gastrointestinal Exams in Infants with Bilious Emesis

Ellen Benya, MD, Ann & Robert Lurie Children’s Hospital, Chicago, IL, [email protected]; Mary Wyers, MD, Ellen Hawkinson Paper #: PA-046 A Cost Effective High Fidelity Fluoroscopy Simulator

Ren Hui Gong, PhD, Brad Jenkins, Ziv Yaniv, Children’s National Med. Ctr., Washington, DC, [email protected]; Raymond Sze Purpose or Case Report: In clinical training of fluoroscopy procedures, such as voiding cystourethography (VCUG), trainees acquire their skills by observing procedures performed by experts and then practicing the procedures themselves on patients. This exposes both staff and patients to higher levels of ionizing radiation, and could potentially increase the cancer rate for pediatric patients. We propose a low cost, high fidelity fluoroscopy simulator which allows trainees to acquire the skills in a radiation free environment by simulating X-ray imaging of a virtual patient.

Methods & Materials: We developed a set of add-on components to an existing fluoroscopy device, Figure 1a, to support fluoroscopy training. A virtual patient is used in place of the patient, and simulated X-rays, or digitally reconstructed radiographs (DRRs), are computed from this virtual model. The virtual patient consists of processed temporal CTs that model respiratory and cardiac motion, and a printed marker that represents the patient in the physical world. A webcam is used to track the patient’s pose, and to establish the spatial relationship between the virtual patient and the X-ray imager such that DRRs can be generated using the fluoroscopy imaging parameters. The fluoroscopy imaging parameters are obtained using an X-ray calibration phantom. A workstation is used for virtual patient tracking, DRR generation, and simulation of machine specific functions such as collimation, zoom, image store, and color inversion. To achieve interactive performance in DRR generation, a discrete graphics processing unit is used to accelerate the computation. Finally, a numeric keypad whose key-mapping closely mimics the fluoroscopy control panel is used to provide the control of operations. Results: We used CT and X-ray images from a spine phantom to evaluate the proposed simulator. Simulated X-rays closely resembled the real Xrays as shown in Figure 1b, and interactive DRR generation rate of 17 frames per second were achieved. For tracking accuracy, an average static tracking error of 1.2 mm was reported, which is sufficient for training. Conclusions: Using a virtual patient with the clinical fluoroscopy device enables high fidelity simulation of fluoroscopy-based procedures in a radiation free environment. The use of webcam-based tracking is cost effective and meets the accuracy requirement for clinical training. This platform can be adapted to help trainees acquire and refine technical skills and to recognize abnormalities while performing the procedure.

Purpose or Case Report: During standard pediatric fluoroscopy training many diagnostic radiology (DR) residents do not get to see or become comfortable performing upper GI (UGI) exams on infants presenting emergently with bilious emesis. The purpose of this study was to determine if the addition of simulated UGI exams to the DR curriculum improves skill and accuracy in diagnosing or excluding volvulus in infants. Methods & Materials: Seven DR residents in training (RIT) and six recently graduated, traditionally trained residents (TTR) participated in our IRB approved project. All participants took a written test and then performed three randomly selected simulated UGIs from seven different clinical scenarios of neonates with bilious emesis. Studies were performed in the fluoro suite using a doll on an octagon board with an attached accelerometer which sensed the board in supine and lateral positions. The board was connected to the fluoro monitor via a laptop computer running a MATLAB program with sequential anonymized UGI images from neonates with normal anatomy, volvulus or duodenal web. Participants pressed the simulator fluoroscopy button to view sequential, still UGI images and were not exposed to ionizing radiation. Based on positional data from the accelerometer and time elapsed, the program displayed the appropriate image on the monitor. Two observers evaluated performance of the simulated UGI using a checklist assessing for appropriate interaction with the parent, proper technique and correct diagnosis. Afterward, the observers debriefed RIT and reviewed procedural technique and diagnoses. RIT also received a lecture on UGI technique and literature on malrotation and volvulus. After 6–8 weeks RIT retook the written test and performed three different randomized simulated UGIs with checklist evaluation. Final checklist and test results of the RIT were compared with the TTR using the Kruskal Wallis Test. Results: RIT performed significantly better than TTR on both the written test (p=0.0025) and checklist evaluation (p=0.0329). The mean score of the written test for TTR was 0.67±0.09 (range 0.55–0.79) and for RIT, 0.87±0.04 (range 0.83–0.93). The mean checklist score for TTR was 0.71±0.14 (range 0.50–0.92) and for RIT, 0.87±0.09 (range 0.75–1.00). Conclusions: A structured DR curriculum on malrotation and midgut volvulus which included simulated UGIs on infants with bilious emesis resulted in significantly higher scores on written test and checklist evaluation of simulated UGIs compared to traditional DR training. Paper #: PA-048 Integration of high-speed single- and multi-modality deformable image registration with clinical PACS

Wen Li, Matthew Robertson, William Plishker, George Zaki, Nabile Safdar, Raj Shekhar, Bioengineering, Children’s National Medical Center, Washington DC, DC, [email protected] Purpose or Case Report: Pediatric imagers use PACS (picture archiving and communication system) to transfer and store images. We present a useful implementation of integrating a high-speed image registration server with PACS at our institution and allowing radiologists to send registration requests effortlessly during reading. The registration of two volumetric images (CT, MRI, or PET), whether of the same or difference

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modalities, takes approximately 1 min on the server. Accounting for data transfer times, the results of registration are available to the requesting radiologists in few minutes. The tool may be helpful for fusing different modalities or to compare serial imaging studies.

Table 1 Case study and image alignment evaluation

REF FLT Age Gender Anatomy REF Imaging Protocol

Case 1 MR PET 13 Year M Pelvis T2; No contrast MR

FLT Imaging Protocol REF Voxel Size (mm3) FLT Voxel Size (mm3) Score (1–5) TRE (mm) Response Time (min)

FDG 0.6×0.6×8.0 3.6×3.6×3.3 5 3.5 3.3

REF FLT Age Gender Anatomy REF Imaging Protocol FLT Imaging Protocol REF Voxel Size (mm3) FLT Voxel Size (mm3) Score (1–5) TRE (mm) Response Time (min)

Case 3 MR CT 13 Year M Pelvis T2; No contrast No contrast; low dose 0.6×0.6×8.0 1.4×1.4×3.3 3 5.6 4.0

REF FLT Age Gender Anatomy REF Imaging Protocol FLT Imaging Protocol REF Voxel Size (mm3) FLT Voxel Size (mm3) Score (1–5) TRE (mm) Response Time (min)

Case 2 MR PET 14/16 Year F Abdomen FLEX; With & without contrast FDG 0.7×0.7×2.2 3.6×3.6×3.3 4 3.8 3.5 Case 4 MR CT 15/17 Year F Lower extremity T2; With contrast No contrast 0.6×0.6×4.0 0.8×0.8×2.5 4 5.1 1.8

Case 5 MR CT 16 Year F Pelvis T2; With & without contrast With contrast 0.7×0.7×6.0 0.6×0.6×5.0 5 3.3 2.3

Case 6 CT CT 11 Year F Lung No contrast No contrast 0.5×0.5×5.0 0.6×0.6×5.0 4 2.4 1.9

Methods & Materials: A high-speed single- and multi-modality deformable image registration server was developed and integrated with the PACS at our institution: Synapse by FUJIFILM Medical Systems USA, Stamford, CT. The option of sending registration requests to the server was implemented in the PACS image viewer. Six pediatric cases were chosen to test the integration in accordance with the approval of the Institutional Review Board. Each case consisted of two image series, one treated as the reference (REF) and the other as the floating (FLT). The floating image was deformed to register with the reference image. Cases were chosen to have a variety of modality combinations (see Table 1). A pediatric radiologist evaluated registration results both qualitatively and quantitatively. The qualitative evaluation was performed by giving a subjective score (1–5) in the order of poor to excellent registration for each case. The quantitative evaluation was performed in terms of target registration error based on anatomic landmarks. Response time was recorded as the time between the clinician initiated registration request from Synapse and receipt of the ready to be read registered image series by Synapse. Results: Our experimental results are shown in Table 1. In six cases, four had a registration error smaller than the reference image voxel size. The largest error was less than 6 mm. The mean qualitative score was 4.2 that indicated good-to-excellent registration quality. Conclusions: We have demonstrated the integration of a highspeed registration server with a pediatric radiology PACS. The quantitative and qualitative evaluations on clinical data showed both high accuracy and high speed in all cases. This easily accessible advanced image analysis tool may permit pediatric radiologists to perform serial comparison or multimodality fusion routinely. Disclosure: Dr. Plishker has indicated a relationship with IGI Technologies, Inc. as an Employee (Salary). Dr. Zaki has indicated a relationship with TGI Technologies as an Employee (Salary).

Paper #: PA-049 Reliable and Efficient Supply Chain Management in Pediatric Radiology—Implementation of a 2-Bin Demand Flow System

Lane Donnelly, MD, Radiology, Nemours Children’s Hospital, Orlando, FL, [email protected]; Lerry Forester, Dino Carbone, Angela Mariano, William Higginbotham Purpose or Case Report: Medical supplies typically account for approximately 20% of hospital costs, 2nd in expense only to labor. Typical hospital supply chain systems are often costly with large inventories and labor expense related to associates searching for needed items. We evaluate the reliability of a demand-flow supply chain system implemented in a new children’s hospital, as it pertains to pediatric radiology. Methods & Materials: A two-bin Kanban supply delivery system was implemented. This lean system removes end-users from the supply management business, allows clinical hours to be focused on patients, promotes efficient workflow, and optimizes supply availability. Two supply rooms (Nodes) were established for radiology—one in the main imaging department and one in interventional radiology (IR)—in the perioperative area. Each particular supply item has two bins, in racks in parallel, with predetermined PAR levels and bar coded labels. When associates consume the product from the front bin, they place the empty bin on the top shelf signaling the need for refill. The second rear bin is then pulled forward for continued use. The empty bins are brought to materials management, scanned, and ordered. Deliveries from the supplier are received to replenish empty bins daily. The refilled bins are then delivered back to the node and placed in the rear of the remaining bin, ensuring first-in-first-out usage. A stock out is defined as when both bins become empty and that particular supply is unavailable. System

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reliability was measured by the fill rate (= 100%−stock out rate). The number of supplies per node and fill rates were evaluated. Results: For Radiology, 696 total unique supply types are managed by the system (261 in Imaging, 435 in IR). The Fill Rate is 98.08% for the imaging node and 98.7% for IR. There is no central stored supply inventory for radiology. Conclusions: The 2-bin demand flow system offers a reliable and cost effective means of managing radiology supplies.

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avoided in a majority (75%) of non-critical cases. It has the potential to assess renal OS non-invasively, minimize the use of ionizing radiation tests on children with hydronephrosis, and reduce clinical cost.

Paper #: PA-050 Hydronephrosis Severity Diagnosis From Ultrasound Imaging Biomarkers

Juan Cerrolaza, PhD, Sheikh Zayed Institute for Pediatric Surgical Innovation—Children’s National Medical Center, Washington, DC, [email protected]; Craig Peters, Aaron Martin, Emmarie Myers, Nabile Safdar, Marius George Linguraru Purpose or Case Report: To create new ultrasound (US) based quantitative imaging biomarkers of pediatric hydronephrosis in order to limit the need for invasive and ionizing diuretic renograms in young patients. The underlying hypothesis of the study is that renal morphology can be quantitatively correlated with renal function. Methods & Materials: The data set in this study (IRB approved) consists of 50 hydronephrotic cases from 45 children from newborns to 14 years of age. For each case, concurrent renal 2D ultrasound imaging acquired with a GE Healthcare LOGIC E9 scanner, and diuretic renography (MAG-3) acquired with a Siemens E. Cam single head gamma camera scanner were available. The obstructive severity (OS) was described by means of the washout half time (t1/2). A 2DUS slice containing a longitudinal section of the kidney and its collecting system was selected and manually segmented in consensus by a radiologist and urologist. From these binary masks, a set of 131 features (including size, geometric, and curvature descriptors) were automatically extracted, using an optimal subset as potential predictive variables to evaluate the diagnostic performance of two different supervised classification models: logistic regression analysis (LOG), and support vector machine (SVM) with radial basis function kernel. Using t1/2 as a reference, thresholds of functional significance were defined to determine those patients that would benefit from invasive functional imaging (critical cases) and those where diuretic renography could be safely avoided (noncritical). A threshold of 40 min was considered in this study.

Results: The area under the receiver operating characteristic curve for LOG was 0.93, and 0.89 for SVM. After identifying the optimal operating points that provide 100% sensitivity to determine critical patients, while maximizing the specificity of the system (maximize number of identified non-critical patients) the false positive rate), the accuracy and specificity for SVM and LOG were 0.76 and 0.71, and 0.78 and 0.73, respectively. Conclusions: This study demonstrates the feasibility of developing reliable and objective imaging biomarkers to support the routine clinical evaluation of kidneys from non-invasive US. We identified 100% of the critical hydronephrotic cases and indicated that MAG-3 could likely be

Paper #: PA-051 Evaluation of Works-In-Progress package for MR urography post-processing

Damien Grattan-Smith, MBBS, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Stephen Little, Richard Jones, Peter Gall Purpose or Case Report: To evaluate the ease and reliability of a worksin-progress program used to post-process MR urography datasets for functional analysis. Methods & Materials: Imaging datasets from 30 children who underwent routine MR urography were used to evaluate a works-inprogress analysis program. Initial training was performed on five datasets. The MR urography datasets were then processed independently by two pediatric radiologists and one MR physicist, all with experience in MR urography. The results were then compared. The key steps in the analysis package included determination of the arterial input function, segmentation of each kidney and determination of begin and end points for Patlak slope calculation. The kidneys were selected using a semi-automated algorithm and renal volumes and time intensity curves were generated. The data was processed to derive values for the Patlak slope for each kidney, the asymmetry index, and time to peak enhancement as well as calculating volumetric and Patlak differential renal function. The functional analysis derived from the WIP was also compared to functional analysis generated by home-grown MR urography analysis program used for the last 10 years. The cases used for analysis included kidneys with a spectrum of abnormalities including normal, hydronephrotic, decompensated and uropathic kidneys. Results: Overall there was good agreement for the data analysis using the MR urography WIP for the three observers when compared to the functional analysis derived from routine analysis. Signal intensity curves and calculated values for differential renal function, asymmetry index and time to peak enhancement were similar for the three observers as well as when compared to routine analysis. Absolute renal volumes did demonstrate some variability between observers but this difference was minimized when considered as a differential renal function and was related to determination of baseline thresholding. The selection of the arterial input function was critical to successful post-processing. Once familiartily with the analysis program was established, routine postprocessing was performed in less than 10 min.

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Conclusions: The WIP post-processing package shows great promise in enabling rapid and reliable calculation of functional data to complement anatomic imaging of MR urography. Once commercially available, the analysis package should help widespread implementation of MR urography.

Paper #: PA-052 Automated assessment of 3-compartment renal function using Factor Analysis of Dynamic Sequences (FADS) in MR Urography (MRU)

Brian Pugmire, M.D., Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Xiaomeng Zhang, Arkadiusz Sitek, Georges El Fakhri, Michael Gee, Ruth Lim

Purpose or Case Report: MR Urography (MRU) is a powerful modality for the assessment of renal abnormalities. MRU can provide both anatomic and functional information, which can guide treatment decisions regarding surgical intervention for urinary tract obstruction. The aim of this study was to evaluate the ability of a novel GFADS software to 1) automatically extract three spatial compartments of renal tissue in 3D (cortex, medulla, collecting system) and 2) determine time-intensity curves for each compartment, using dynamic contrast-enhanced MRU datasets.

Methods & Materials: Five pediatric urology patients (ages 2 months to 7 years) underwent contrast-enhanced MRU using coronal VIBE fat saturation sequences for the evaluation of hydronephrosis. The dynamic acquisitions were analyzed using GFADS software, which automatically extracts from the MRI volume three tissue compartments based on differences in temporal behavior of enhancement. Images and timeintensity curves were reviewed. Time-to-peak (TTP) intensity of the cortex and medulla was calculated for all kidneys. Mean TTP measurements for obstructed vs. non-obstructed kidneys were analyzed with t-tests. Results: Ten kidneys in five children were analyzed. Five of the 10 kidneys demonstrated normal morphology and enhancement pattern with normal appearing time-intensity curves for all three factors. Of the five abnormal kidneys, two demonstrated at least partial urinary tract obstruction; one due to UPJ obstruction and one due to partial ureteral obstruction. One had renal pelvis dilatation without obstruction, one had primary megaureter, and one had a duplex kidney with a completely nonfunctioning upper pole moiety and normal lower pole moiety. The five abnormal kidneys demonstrated time-intensity curves consistent with the underlying obstructive versus non-obstructive pathologies. The mean TTP cortical intensity for the obstructed kidneys was 2.8 min. vs. 0.6 min. for all other non-obstructed kidneys (p<0.0001). The mean TTP medullary intensity for the obstructed kidneys was 10.2 min. vs. 3.88 min. for the non-obstructed kidneys (p=0.024). Conclusions: GFADS analysis of dynamic contrast-enhanced MRU images is a promising novel technique in the evaluation of pediatric hydronephrosis. It provides automated extraction of renal tissue compartments, and generates time enhancement curves for each renal compartment. Future work will incorporate compartment-based kinetic modeling to generate quantitative estimates of differential renal function and glomerular filtration rate. Paper #: PA-053 Pediatric UPJ Obstruction—Can MR Urography Identify Crossing Vessels and Do They Matter?

Matthew Hammer, MD, Radiology, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, [email protected]; Kushal Parikh, Ethan Smith, Kate Kraft, Vesna Ivancic, Jonathan Dillman, M.D. Purpose or Case Report: To determine if MR urography (MRU) can detect the presence of crossing vessels in the setting of pediatric ureteropelvic junction (UPJ) obstruction and to compare MRU findings with intraoperative findings to determine the clinical significance of these vessels. Methods & Materials: Following Institutional Review Board approval and in a HIPAA-compliant manner, we searched Department of Radiology electronic medical records to identify all pediatric (<18 years of age) MRU examinations with findings consistent with UPJ obstruction. Children that did not undergo subsequent pyeloplasty at our institution were excluded. Two board-certified fellowship-trained pediatric radiologists reviewed (blinded to intraoperative findings) relevant MRU examinations and documented pertinent findings, including the presence of crossing vessels at the level of the UPJ obstruction. Two board-certified fellowship-trained pediatric urologists separately reviewed (blinded to the MRU findings) the operative and medical records from these same children to verify the presence or absence of a crossing vessel and categorize the etiology of obstruction. MRU and intraoperative findings were correlated, and related clinical data were recorded. Results: Seventeen UPJ obstructions were identified in 16 children (one child had bilateral UPJ obstruction) that had undergone preoperative MRU and pyeloplasty at our institution. Six children were found to have one or more UPJ crossing vessels on MRU, all of which were confirmed intraoperatively. The crossing vessel was determined to be the only cause of obstruction in four of these six children, while two children with a crossing vessel also had an intrinsic UPJ abnormality. The average age of

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children with UPJ obstruction due to a crossing vessel only was 115 months (range, 98–143 months) vs. 70 months (range, 7–153 months) for children with an identified intrinsic UPJ abnormality. No crossing vessels observed intraoperatively were undetected by MRU preoperatively. Conclusions: MRU accurately detects crossing vessels in the setting of pediatric UPJ obstruction. Although our study is small, two-thirds of crossing vessels were the only cause of UPJ obstruction, while onethird were also associated with an intrinsic UPJ abnormality. Knowledge of the presence of a crossing vessel may aid in surgical planning. Paper #: PA-054 Should Routine UGIs Include Screening for Swallowing Dysfunction?

Kopal Kulkarni, M.D., Radiology, Johns Hopkins Medical Institution, Baltimore, MD, [email protected]; Renee Flax-Goldenberg, Bonnie Martin-Harris, Maureen Lefton-Greif Purpose or Case Report: Feeding/swallowing problems are common in healthy infants and those with specific diagnostic conditions (e.g., prematurity and neurologic disorders). Given that dysphagia may involve any or all phases of swallowing, the diagnostic process may include multiple procedures, including an upper gastrointestinal series (UGI) and/or Videofluoroscopic Swallow Study (VFSS). Our aim was to evaluate the utility of the UGI as a screening tool for detection of aspiration and laryngeal penetration. We hypothesized that routine swallowing screening would not impact radiation exposure during UGI. Methods & Materials: A retrospective review was performed of all bottlefed children who underwent both standardized VFSS at 30 frames per sec (fps) continuous fluoroscopy and UGI at three fps pulsed fluoroscopy between March 2012 and September 2013. Laryngeal penetration and aspiration on UGI and VFSS were coded according to the Rosenbek et al., 8-point scale. Cumulative radiation dose (CRD) and radiation dose area product (DAP) were also recorded for each UGI performed. Results: Of 49 patients undergoing both VFSS and UGI, 21 had documentation of swallow function on UGI. On UGI, 18 patients had no penetration or aspiration (score: 1) and three had aspiration (score: 8). On VFSS, five patients had no penetration or aspiration (score: 1), four had penetration (scores: 2–6), and 12 had aspiration (scores: 7–8). Using VFSS as the gold standard, the UGI sensitivity and specificity for aspiration were 25% and 100%, respectively. UGI sensitivity for penetration alone was 0%. UGIs for 28 patients with and 21 without swallow evaluation had comparable average CRDs (0.43 mGy and 0.49 mGy; p=0.91) and DAPs (5.08 μGy and 5.19 μGy; p=0.95). Conclusions: The UGI series is a specific but not sensitive marker for aspiration, suggesting that screening for swallow dysfunction should not be part of the routine UGI series; however, for patients at risk for dysphagia, UGI studies can be tailored to screen swallow function without increasing radiation exposure. Although aspiration on UGI series is highly predictive of swallowing dysfunction on VFSS, low sensitivity for aspiration and penetration events on UGI may be attributed to use of pulsed versus continuous fluoroscopy and other procedural differences.

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abnormality”. However, few studies have been conducted on the diagnostic performance of the UGI series in this setting. We aimed to determine the diagnostic yield of the UGI series in pediatric outpatients for previously undiagnosed significant anatomic abnormalities of the UGI tract. Methods & Materials: A cohort of 463 patients (age range: 1 month– 21 years) who underwent an UGI series at Texas Children’s Hospital between 1/1/13 and 8/25/13 was identified from a database search. Patients were excluded from further analysis based on status as an inpatient or emergency department patient, history of bilious vomiting, prior UGI tract surgery or known UGI tract structural abnormality. A retrospective review of the imaging studies and medical charts was conducted on the resulting study sample of 259 patients. Results: Out of 259 patients (139 males, 119 females, and 1 ambiguous genitalia; mean age 8.8 years) there was one false positive diagnosis of malrotation (95%CI=0–2.5%) and no true positive diagnosis of midgut malrotation, mass, web, stricture, or other previously undiagnosed significant anatomic abnormality of the upper GI tract (95%CI=0–1.8%). Using the upper CI limit, the exam charge/true positive yield for UGI is $40,000, an order of magnitude higher than similar estimates for abdominal CT. No cases of esophagitis, gastritis or duodenitis diagnosed by subsequent UGI endoscopy (N=12) were detected by UGI series. Findings demonstrated by UGI but medically managed or previously known from other diagnostic tests included 70 cases of uncomplicated gastroesophageal reflux, three cases of aberrant subclavian arteries, and one case of a vascular ring. The absence of true positive diagnoses precluded determination of clinical symptoms/signs predictive of previously undiagnosed significant anatomic abnormalities on UGI. Conclusions: UGI studies performed in the pediatric outpatient setting have a very low yield for detection of previously undiagnosed significant anatomic abnormalities. Given the associated costs and radiation exposure, efforts to identify better clinical predictors and decrease the number of UGI studies performed should be advocated.

Paper #: PA-056 Retrospective Comparison of GRE T2* and SE T2 Analysis Methods for Estimating Liver Iron Content

Suraj Serai, Ph.D, CCHMC, Cincinnati, OH, [email protected]; Robert Fleck, Daniel Podberesky, MD, Rhonda Strunk, Charles Quinn Purpose or Case Report: Iron deposition in the liver is associated with primary genetic disorders such as hemochromatosis, and secondary acquired disorders such as parenteral iron overload and iron loading anemias. The diagnosis of hepatic iron overload traditionally relies on core liver biopsy, which has limitations, due to invasiveness, cost, complications, sampling error and expense. Thus, non-invasive diagnostic methods such as MRI are highly attractive and gaining in popularity. We compared two MRI methods for liver iron quantification, namely - T2*methods with gradient recalled echo (GRE) images and T2 method with spin echo (SE) images.

LIC Category Paper #: PA-055 Title: Diagnostic yield of the upper gastrointestinal (UGI) series in the pediatric outpatient setting: Low enough to say no?

Christopher Gaffney, Baylor College of Medicine, Houston, TX, [email protected]; R. Paul Guillerman, MD, Robert Orth, M.D, Ph.D. Purpose or Case Report: Upper gastrointestinal (UGI) series are frequently requested in the pediatric outpatient setting to “rule-out anatomic

0 <= LIC < 5 5 <= LIC < 10 10 <= LIC < 20

Number Of Observations 13 11 14

Mean (Std Dev0

Min

Q1

0.47 (0.77) 0.06 (1.54) 1.13 (2.94)

−1.419 −2.991 −4.1

0.403 −0.785 −1.492

LIC Category

Medlan

Q3

Max

0 <= LIC < 5 5 <= LIC < 10 10 <= LIC < 20

0.61 −0.1 1.557

0.836 0.8 3.456

1.422 3.261 5.091

Signed Rank Statistic 29.0 0.5 21.0

P Value 0.0417 0.9854 0.1984

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Methods & Materials: Thirty-eight patients (age range: 4–21 years.) were examined by MRI at 1.5 T to evaluate the Liver Iron Concentration (LIC). For the T2* method, we used the GRE protocol published by Wood et al., and the analysis was done in-house. For the T2 method, examinations with SE were performed according to St. Pierre et al. and the images were analyzed by Ferriscan (Resonance Health, Australia) for a fee. LIC was determined as proposed in the corresponding publications, and results were compared. Correlation between T2* method and T2 method was determined. Bland Altman plots were generated for a twoway comparison with line of equality, limits of agreement and 95% confidence intervals on the limits of agreement. Results: Bland-Altman plots showed increased variability in the mean difference in LIC between methods as the mean of methods increase for the two types of measurements. As seen in the table and figure, the comparison has all points within the confidence limits of the limits of agreement. The strongest co-relation is observed with mean LIC < 5 mg/g dry tissue.

The purpose of this study is to compare the image quality and acquisition time of conventional and flip angle modulated SSFSE sequences. Methods & Materials: With IRB approval and informed consent/assent, 25 consecutive (13 males and 12 females) pediatric patients referred to our clinic for abdominal MRI were recruited. Mean age (+/− SD) was 6.2 years +/− 5.1 (range, 1 month–17 years). The MR imaging protocol consisted of standard institutional sequences, single-shot FSE (SSFSE) and flip angle modulated single-shot FSE (fmSSFSE). For fmSSFSE, the flip angle train was optimized to minimize SAR and blurring, while maintaining high flip angles near the center of k-space to minimize flow and motion related signal loss. Two readers independently scored the images in blinded, randomized order for noise, tissue contrast, sharpness, artifacts, and left lobe hepatic signal uniformity on a 4-point scale (1Poor, 2-Fair, 3-Good and 4-Excellent). The null hypothesis that there is no significant difference in image quality between SSFSE and fmSSFSE for each image quality feature was assessed with a Mann–Whitney U test. Scan times were also recorded.

Conclusions: With the availability of oral iron chelators, noninvasive determination of LIC is gaining greater importance in the surveillance and management of iron overload in pediatric patients. GRE T2* techniques are available on almost all commercial MR scanners whereas SE T2 based techniques are proprietary and require payment to an independent healthcare company for analysis. With the current protocol, agreement between the two methods is best when LIC is < 5 mg/dry tissue and becomes more variable when LIC is >5 mg/dry tissue. T2 based SE techniques may be used for patients with high LIC levels and when a more precise LIC is needed, as opposed to simply following LIC trends over time, in which case GRE T2* technique suffices.

Results: Mean acquisition time of SSFSE and fmSSFSE were 53.8 and 26.3 s, respectively. For both readers, the study showed no significant difference in image quality between SSFSE and fmSSFSE in terms of noise, tissue contrast, sharpness and artifacts with the p-values of 0.63, 0.63, 0.33 and 0.63 for reader 1 and 0.48, 0.40, 0.83 and 0.56 for reader 2, respectively. On the contrary, the SSFSE images had significantly better left lobe hepatic signal uniformity compared to fmSSFSE with the p-values of 0.005 for reader 1 and 0.00004 for reader 2. Conclusions: fmSSFSE is twice as fast as conventional SSFSE and largely provides equivalent image quality. However, left hepatic lobe signal uniformity is somewhat compromised on fmSSFSE, which requires further investigation. Disclosure: Dr. Saranathan has indicated a relationship with GE Healthcare for Research Funding. Dr. Vasanawala has indicated a relationship with GE Healthcare as an Investigator (Research Collaboration).

Paper #: PA-057 Faster Pediatric 3 T Abdominal Single Shot MRI: Comparison between Conventional and Flip Angle Modulated Single Shot Fast Spin Echo sequences

Nichanan Ruangwattanapaisarn, MD, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, [email protected]; Andreas Loening, Manoj Saranathan, Daniel Litwiller, Shreyas Vasanawala Purpose or Case Report: Pediatric abdominal MRI at 3.0 T is increasingly preferred over 1.5 T due to higher SNR. Single-shot FSE (SSFSE) is particularly appealing in pediatric patients as it has little motion artifacts on individual images. However, the significantly increased SAR at 3.0 T forces a higher per-slice TR leading to longer scans and breath-hold times. One potential way of addressing this issue is using modulation of the refocusing flip angle train. Theoretically, controlled modulation can reduce SAR while also better preserving signal levels (leading to sharper images).

Paper #: PA-058 Fast Pediatric 3D Free Breathing Abdominal Dynamic Contrast Enhanced MRI with High Spatiotemporal Resolution

Aaron Potnick, M.D., Stanford University, Palo Alto, CA, [email protected]; Tao Zhang, Joseph Cheng, Marcus Alley, Richard Barth, MD, Shreyas Vasanawala Purpose or Case Report: We aim to develop and evaluate in a clinical setting a method for pediatric abdominal 3D dynamic contrast enhanced (DCE) MRI that (i) has high spatial resolution, (ii) affords high temporal resolution, and (iii) is acquired on a freely breathing patient. Methods & Materials: With IRB approval and informed consent/assent, 23 pediatric patients were recruited. A 3D SPGR pulse sequence at 3 T

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was modified to enable (i) spatial compressed sensing, (ii) temporal acceleration, and (iii) self navigation. Image reconstruction (FB-LR) incorporated (i) parallel imaging, (ii) locally low rank spatiotemporal compressed sensing, and (iii) soft respiratory self-navigation. Freebreathing DCE MRI with approximately 1 mm^3 spatial resolution and 6.5 s frame rate was obtained. For comparison, data were also reconstructed with just spatial compressed sensing (FB-CS). Also, as a spatial resolution gold-standard, a slower respiratory-triggered acquisition (RTCS) was obtained on each subject. Quantitative evaluation of contrast dynamics was performed as a marker for temporal resolution. The reconstructed images were evaluated independently by two radiologists for overall image quality, structural delineation and motion artifacts. Wilcoxon tests were performed to test the hypothesis that there was no significant difference between different reconstructions. Table 4: Mean scores of image assessments and the results of paired Wilcoxon test (when reconstructed images were assessed individually)

Overall image quality Degree of non-cardiac motion ghosts Hepatic Artery Hepatic Vein Sharpness of Diaphragm Adrenal Gland

Overall image quality Degree of non-cardiac motion ghosts Hepatic Artery Hepatic Vein Sharpness of Diaphragm Adrenal Gland

Mean scores (reader1/reader2) FB-CS FB-LR RT-CS 3.0/2.8 4.0/4.0 4.2/4.1 3.8/3.2 4.1/4.0 4.1/4.1

2.5/2.8 1.5/2.1 1.4/1.3 3.6/3.4

3.9/4.1 3.5/3.6 2.5/2.1 4.3/4.3

N/A 3.9/3.9 2.3/3.0 4.4/4.2

P values of the Wilconxon test (reader1/reader2) FB-CS vs. FB-CS vs. FB-LR vs. FB-LR RT-CS RT-CS <0.05/<0.05 <0.05/<0.05 0.36/0.13 <0.05/<0.05

<0.05/<0.05

1.0/0.77

<0.05/<0.05 <0.05/<0.05 <0.05/<0.05

N/A <0.05/<0.05 <0.05/<0.05

N/A 0.15/0.17 0.50/<0.05

<0.05/<0.05

<0.05/<0.05

0.70/0.39

*P<0.05 was considered as a statistically significant level (shown in bold)

Results: The mean overall image quality of FB-LR was 4.0 on a 5-point scale, significantly better (p<0.05) than FB-CS reconstruction (mean score 2.9), and similar to RT-CS (mean score 4.1). Degree of non-cardiac motion ghosts was significantly better (p<0.05) for FB-LR (mean score 3.5) than FB-CS (mean score 4.05) and similar to RT-CS (mean score 4.1). Structure delineation of the FB-LR was significantly better (p<0.05) than FB-CS reconstruction for the hepatic arteries (mean scores 4.0 vs. 2.65) hepatic veins (mean scores of 1.55 vs. 4.05), the sharpness of the diaphragm (mean scores of 1.35 vs. 3.55) and the adrenal gland (mean scores of 3.5 vs. 4.3). FB-LR structure delineation was similar (p>0.05) to RT-CS for the hepatic veins (3.55 vs. 3.9), adrenal gland (4.3 vs. 4.3) and diaphragm for reader 1 (2.5 vs. 2.3). The hepatic artery was of higher signal than the hepatic vein on multiple phases for the FB-CS and FB-LR reconstructions. Conclusions: Pediatric 3D free-breathing abdominal DCE MRI with high spatiotemporal resolution provides diagnostic image quality similar to a slow respiratory-triggered scan, but captures temporal dynamics. Disclosure: Dr. Alley has indicated a relationship with GE Medical Systems (Research Support). Dr. Cheng as indicated a relationship with

GE Healthcare as an Investigator (Research Support). Dr. Vasanawala has indicated a relationship with GE Healthcare as an Investigator (Research Collaboration). Dr. Zhang has indicated a relationship with GE Healthcare as an Investigator (Research Support). Paper #: PA-059 Contrast Enhanced Magnetic Resonance Evaluation of Acute Appendicitis in the Pediatric Population: Efficacy of a Novel Imaging Protocol

Jeffrey Koning, M.D., Radiology, University of California San Diego, San Diego, CA, [email protected]; John Naheedy, Peter Kruk, John Hauschildt Purpose or Case Report: Non-enhanced magnetic resonance (MR) has recently emerged as an effective imaging technique for diagnosing pediatric acute appendicitis. Adding intravenous contrast to MR protocols has the potential to increase accuracy for diagnosing appendicitis and alternative pathologies causing acute abdominal pain. The purpose of this study is to examine the efficacy of contrast enhanced MR for diagnosing acute appendicitis and alternative entities in the pediatric population presenting to the emergency room with acute abdominal pain. Methods & Materials: A retrospective review was conducted of 254 consecutive pediatric patients undergoing contrast enhanced MR for the evaluation of possible appendicitis at a single institution between November 2012 and June 2013. The imaging protocol included axial and coronal T2-weighted and FIESTA sequences, axial diffusion weighted images, and axial and coronal post-contrast LAVA-FLEX sequences. Imaging reports were compared with clinical data and pathology results to determine the diagnostic accuracy of the imaging protocol for appendicitis among other causes of acute abdominal pain. Results: There were 88 cases of pathologically confirmed appendicitis out of 254 pediatric patients (34.7%). Overall specificity and sensitivity of the imaging protocol were 95.2% (CI 90.5%–97.8%) and 95.5% (CI 88.1%–98.5%), respectively. Positive predictive value and negative predictive value were 91.3% (CI 83.1%–95.9%) and 97.6% (CI 93.5%– 99.2%), respectively. The appendix was not visualized in 81 cases (31.9%). Imaging confirmed alternative diagnoses in 45 patients, including most commonly colitis, enteritis or terminal ileitis (n=16, 6.3%) and adnexal cysts (n=10, 3.9%). Of alternative diagnosis cases, 32% were admitted to the hospital and 18% required surgery, compared to 100% of appendicitis cases (n=11, p<0.01 and n=7, p<0.01 respectively). Conclusions: This is the first study assessing contrast enhanced MR in pediatric patients for the question of appendicitis, and it is the largest cohort of pediatric patients specifically assessed with any MR protocol for appendicitis. Contrast enhanced MR is capable of providing a safe and efficient diagnosis of acute appendicitis and alternative entities while avoiding the operator dependency of ultrasound and ionizing radiation of CT. Future large-scale prospective studies are needed to evaluate the efficacy of contrast enhanced MR versus non-enhanced MR for diagnosing acute appendicitis and its mimickers in the pediatric population. Paper #: PA-060 Accuracy of Diagnosing Pediatric Acute Appendicitis with Reduced-CTDIvol CT Using Iterative Reconstruction: A Comparison with Traditional Weight-Based FBP

Ryne Didier, Oregon Health & Science University, Portland, OR, [email protected]; Petra Vajtai, MD, Daniel Schwartz, Katharine Hopkins, MD Purpose or Case Report: We compared the accuracy of diagnosing acute appendicitis in pediatric patients with established weight-based CT protocols and traditional filtered back projection (FBP) reconstruction

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versus CTDIvol-reduced CT protocols incorporating iterative reconstruction technique (IRT). Methods & Materials: A retrospective review was performed of pediatric abdomen/pelvis CT examinations done at our institution between October 2009 and September 2012. Patients aged 1–18 years were included if they underwent a CT scan to evaluate abdominal pain for which appendicitis was included in the differential. Scans were performed with either established weight-based CT protocols and FBP reconstruction (n=202) or CTDIvolreduced CT protocols employing IRT (n=207). CT diagnosis was correlated with surgical pathology and/or clinical follow-up. CTIvol and diagnostic accuracy of both methods were calculated and compared.

in pediatric patients compared with histologic reference to determine which is the best biomarker of active disease on each modality. Methods & Materials: In this retrospective study, a database query identified patients <20 years old who underwent either CTE or MRE from 2005 to 2013. Records then identified patients with known CD who had colonoscopic biopsy within 28 days of imaging. All studies were reviewed by a radiologist blinded to the histologic results. For each study, the bowel was divided into seven segments (from terminal ileum to anus) and each was scored for the presence/absence of two intramural features of inflammation [wall thickening >3 mm (WT), mucosal hyperenhancement (MH)] and four extramural features (mesenteric edema, hypervascularity, and lymphadenopathy, and fibrofatty proliferation). Test performance characteristics of each imaging feature were calculated, and multivariate analysis was performed using logistic regression. Results: Three hundred sixty-two bowel segments (135 CTE, 317 MRE) were evaluated from 84 patients (mean age 15.6 years) with histologic reference. For MRE, intramural features (WT and MH) were the best biomarkers of active CD (WT 82% accuracy/82% sens/91% spec; MH 78%/53%/96%) and were confirmed by logistic regression to be the only significant predictors of active CD. In contrast, for CTE all six imaging features were shown to be significantly associated with active CD (p<0.05, Fisher exact test), with extramural features demonstrating consistently higher accuracy and sensitivity on CTE compared with MRE. Reasons for false negative extramural feature assessment on individual MRE cases included diminished spatial resolution compared to CTE, partial volume averaging with adjacent bowel loops, and motion artifacts. Conclusions: Intramural features of inflammation (WT, MH) are the two best MRE imaging biomarkers of active CD in pediatric patients, while intramural and extramural inflammatory features are all significantly associated with active CD on CTE. The decreased performance of extramural features on MRE appears to be related to less consistent image quality, which has implications on the choice of MRE vs. CTE in individual pediatric CD patients.

Paper #: PA-062

Results: There was no statistically significant difference in patient demographics between groups. There was a statistically significant decrease in estimated radiation dose between the two groups (mean 7.7 mGy versus 4.3 mGy with standard FBP versus IRT, respectively; p<0.0001). The absolute decrease in CTDIvol with incorporation of IRT was 57%. There was no statistically significant difference in accuracy between the two groups in the diagnosis of acute appendicitis (98% and 99% accuracy in the traditional FBP and IRT techniques, respectively). Conclusions: Acute appendicitis is a common pediatric surgical emergency, often diagnosed by CT. When scanning children and adolescents, it is important to decrease CT radiation dose to As Low As Is Reasonably Achievable (ALARA) yet still meet diagnostic standards. Our study showed that diagnostic accuracy was maintained using CTDIvolreduced protocols incorporating IRT when compared to our standard pediatric weight-based protocols with FBP alone.

Paper #: PA-061 Determination of CTenterographic and MR enterographic imaging biomarkers of active Crohn disease in pediatric patients

Steven Sharatz, MD, Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Taphey Mayureewan, William Bradley, Michael Gee, MD, PhD Purpose or Case Report: Diagnosis of active Crohn disease (CD) on CT enterography (CTE) and MR enterography (MRE) typically involves identification of characteristic imaging features, which often are not all present and may be variably visualized on each modality. We compare the performance of several imaging features of active CD on CTE and MRE

Quantitative Imaging Biomarkers of Crohn’s Disease

Juan Cerrolaza, PhD, Sheikh Zayed Institute for Pediatric Surgical Innovation—Children’s National Medical Center, Washington, DC, [email protected]; Nabile Safdar, Laurie Conklin, Emmarie Myers, Raymond Sze, Marius George Linguraru

Purpose or Case Report: To create novel multimodal magnetic resonance (MR) imaging biomarkers of Crohn’s disease (CD) by merging detailed anatomical information with quantitation of small bowel motility. Methods & Materials: The technology was evaluated in 13 patients: seven healthy controls, and six with CD. MR enterography images were obtained using a Discovery MR750 3.0 T GE scanner (512×512; 0.82 to 0.94 mm resolution). Fast Imaging Employing Steady-State Acquisition (FIESTA) sequences were acquired at 18 locations - 15 frames per location with 8 mm slice thickness. Thirty Single-Shot Fast Spin Echo (SSFSE) sequences were acquired with 6 mm slice thickness. The FIESTA sequence is relatively slow (>100 s.) and performed without controlled breathing in pediatric patients. Thus, we first isolated the peristaltic activity from the breathing motion with FIESTA. First order B-spline registration was used to eliminate respiratory effects. Small bowel peristalsis was then extracted from the set of FIESTA frames via optical flow analysis. The

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result was an intestinal peristaltic activity map of the patient that provided quantitative information of the abdominal motility in mm/s. Finally, the two nearest sets of FIESTA frames were projected onto the SSFSE slices using an image-based multimodal similarity measure, obtaining new fused image that provided structural and functional information of the patient simultaneously. Results: The new images were evaluated by an expert radiologist to assess their potential for the evaluation of CD. Small bowel areas with wall thickening, luminal narrowing, and reduced motility were successfully identified in all cases with CD. The terminal ileal peristalsis rate was low in all cases of terminal ileal Crohn’s, in which was 5/6 CD cases. One Crohn’s cases demonstrated decreased peristalsis in the proximal small bowel. We calculated that healthy small bowel motility can measure up to 3 mm/s, while in areas of reduced motility secondary to disease, the motion of the bowel was less than 0.6 mm/s. Conclusions: Using the new fused images radiologists can simultaneously study the anatomic structure of the bowel and the motility of the intestine. These quantitative imaging biomarkers of IBD have the potential to enhance diagnosis, assess response to treatment, and advance objective patient follow up.

Paper #: PA-063 Can MRE screen for perianal disease in pediatric IBD?

Mary-Louise Greer, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Zehour Alsabban, Ryan Lo, Rahim Moineddin, Peter Church, Thomas Walters Purpose or Case Report: Increasing use of magnetic resonance enterography (MRE) in imaging pediatric inflammatory bowel disease (IBD) offers opportunity to assess the perianal region, with small bowel and perianal disease (PAD) often concurrent. MRE and pelvic MRI (PMRI) are seldom performed as a single procedure in most pediatric centers due to study duration and compliance issues. Recognizing PMRI is the gold standard in imaging PAD, the objective of this study is to assess the role of MRE in screening for PAD in children already undergoing MRE. Comparing with PMRI, the aims of this study are: 1. 2.

to determine if MRE can detect or exclude perianal disease in children, and to determine if MRE can distinguish between perianal fistulae (PAF) and abscesses (PAA).

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Methods & Materials: Institutional ethics board approval was obtained to perform a retrospective review of children and adolescents with suspected or proven IBD at a tertiary pediatric hospital undergoing both PMRI and MRE in a 2 years period from February 2011 to February 2013. Using PACS and electronic patient chart review, PMRI and MRE studies were subsequently excluded if their technique was not standard, MRI intervals were > 6 months, or if surgery was performed between MRIs. Images were independently reviewed by a pediatric radiologist and a radiology fellow recording: the presence of PAD; number, length and location of PAF and abscesses; PAF type according to Park’s classification; and the optimum sequences for lesion detection. Results: Thirty-six patients with IBD, a majority with Crohn’s disease (28 males: 8 females, mean age at first MRI 14 years) had 55 PMRI and 47 MRE, with 10 PMRI and 11 MRE subsequently excluded. Thirty-six MRE were compared with 45 PMRI performed at different time intervals within 6 months. Diagnostic tests results for detection of PAD, PAA and PAF on MRE vs. PMRI are as follows: PAD - sensitivity 77%, specificity of 50%, positive predictive value (PPV) 97%, negative predictive value (NPV) 0.1% and accuracy 76%; PAA - sensitivity 36%, specificity 95%, PPV 60%, NPV 88% and accuracy 85%; and PAF - sensitivity 55%, specificity 92%, PPV 95%, NPV 40% and accuracy 64%. Conclusions: MRE has a very high PPV for detecting perianal disease and PAF in particular, with a high NPV for abscesses, but very low NPV for PAD. When performing routine MRE, perianal interrogation for concurrent perianal disease should be undertaken. While MRE is helpful in excluding abscesses, it is not a robust screening tool to replace pelvic MRI where PAD is clinically suspected. Paper #: PA-064 Comparison of hand versus mechanical administration of intravenous contrast: Quality of Abdominal CTA in pediatric patients

Rama Ayyala, M.D., Boston Childrens Hospital, Boston, MA, [email protected]; David Zurakowski, Edward Lee, MD, MPH Purpose or Case Report: Pediatric patients undergoing abdominal CT angiography (CTA) can have variable intravenous (IV) access, which may require either hand or mechanical administration of the IV contrast in conjunction with determination of start of CT scanning using monitoring scanning. The purpose of this study is to compare hand versus mechanical administration on the quality of abdominal CTA in the pediatric population. Methods & Materials: A retrospective review of the electronic medical records was performed to identify pediatric patients (≤18 years) who had an abdominal CTA performed between 8/2012 and 8/2013. Information regarding the methods of IV contrast administration, (hand (group 1) versus mechanical (group 2)) was obtained. All of the abdominal CTA studies were reviewed for quality, by measuring the contrast enhancement (Hounsfield units (HU)) of the abdominal aorta at the level of the celiac axis and the inferior mesenteric artery (IMA). Statistical analysis was performed using analysis of variance (ANOVA) to assess differences in contrast enhancement adjusting for patient age as a covariate. Paired ttests were used to compare enhancement between celiac axis and IMA for each injection method. Results: The study population included 46 pediatric patients (24 M and 22 F; mean age 7.3±5.5 years, range 5 weeks to 18 years). Six patients had hand administration and 30 patients had mechanical administration. All abdominal CTA studies from both groups showed diagnostic quality contrast enhancement (≥ 150 HU) at both the celiac axis and the inferior mesenteric artery levels. ANOVA confirmed that contrast enhancement of the abdominal aorta was not significantly different between the two

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contrast administration methods at the celiac axis (360±158 vs. 353±116, p=0.24) or the IMA (340±140 vs. 351±90, p=0.27) adjusting for age. There was no statistical difference in contrast enhancement at the celiac axis and the IMA in patients who received hand injection (p=0.49) or mechanical administration (p=0.82) of contrast. Conclusions: Abdominal CTA using hand or mechanical administration of IV contrast has similar study quality in pediatric patients. In clinical practice, pediatric patients have variable sizes, types and locations of IVaccess, which may necessitate hand administration of contrast. Our findings show that either administration method will provide a diagnostic study quality.

Paper #: PA-065 Postnatal Chest CT Findings after Left Congenital Diaphragmatic Hernia (CDH) Repair

Ammie White, MD, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Andrew Mong, Enrico Danzer, Sabah Servaes, N. Scott Adzick, Teresa Victoria Purpose or Case Report: Degree of lung hypoplasia in CDH is associated with clinical findings of postnatal chronic lung disease (CLD). Chest CT imaging features specific to CDH-related CLD have not been described. The goal of this study is to describe the spectrum of abnormalities on postnatal chest CT post CDH repair. Scoring of Postnatal Chest CT in Congenital Diaphragmatic Hernia* Category Hyperexpansion

Variable Hyperexpansion and/or air trapping Mosaic pattern of attenuation Intercostal bulging Number of bullae or blebs Size of bullae or blebs Triangular subpleural opacities and parenchymal bands Distotion and thickening of bronchovascular bundle Consolidation and atelectasis Hyperluncency and decreaced interstitial markings Left pulmonary vessels asymmetrically small

Emphysema Fibrous/Interstitial

Simplified Architecture Vessels

Score 0 Hyperexpansion None None None Emphysema None None Fibrous/Interstitial None None None Simplified Architecture None

Methods & Materials: Medical records and imaging studies of patients with left CDH born from 1998 to 2012 with pre- and postnatal care at our institution, receiving both fetal MRI and postnatal chest CT were analyzed. The ratio of observed to expected fetal lung volume (O/E FLV) was calculated on MR according to Rypens et al. CT findings were classified in one of five categories: hyperexpansion, emphysema, fibrous/interstitial, architectural simplification, or vascular asymmetry; using a modified CT scoring system (see table) based on one for bronchopulmonary dysplasia (BPD) by Ochiai, et al. Main pulmonary artery to ascending aorta ratio was calculated on CT. Descriptive statistics and Pearson correlation values are presented. Results: Thirteen patients met inclusion criteria (seven boys; mean gestational age at birth 37.6 weeks, SD±1.6; mean age at CT 2.6 years, SD± 3.6). Three patients had recurrent hernia on CT. Most common findings included architectural simplification (94%), fibrotic changes (94%), bronchovascular distortion (88%), asymmetrically smaller left pulmonary vessels (88%), air trapping (56%), and pulmonary artery to aorta ratio ≥1.2 (46%). Of a maximum of 21, with increasing number denoting increasing severity, average CT score was 6.2 (SD±2.8) for the left lung (LL) and 2.8 (SD± 3.1) for the right lung (RL): Pearson correlation comparing LL to RL CT scores showed r=0.79 (p=0.001). Pearson correlation comparing O/E FLV to CT scores showed r=−0.34 (p=0.25) for the LL and r=−0.26 (p=0.40) for the RL. Conclusions: Chest CT findings post CDH repair are similar to those described in BPD, including parenchymal abnormalities and findings of pulmonary hypertension. Additional findings seen with CDH include simplified parenchymal architecture and asymmetrically smaller size of the left pulmonary vessels. While more severe abnormalities were overall seen in the left lung, the severity of findings in the left and right lung in each patient were strongly correlated, supporting that lung disease is bilateral but asymmetric in CDH. Although we did see correlation between lower O/E FLV and more severe lung abnormalities, this was not statistically significant, possibly due to small sample size. Paper #: PA-066 Main Pulmonary Artery: Aorta Diameter Ratio in Normal Children on MDCT

Gregory Compton, MBBS, MMed, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Joshua Florence, Cathy MacDonald, Shi-Joon Yoo, Tilman Humpl, David Manson

Category

Vessels

1 Focal Unclear Unclear Single ≤5 mm 1–3 lobes Mild Subsegmental Focal

Not present Unclear

2 3 Diffuse Obvious Obvious Multiple >5 mm 4–6 lobes Moderate Severe Lobar Diffuse Obvious

CT score was calculated separetely for the right left lung in each patient, with a possible score from to 21 points per lung: a score of 0 corresponding to normal CT findings and 21 most severe abnormalities. *Modified from Ochiai, et al. Journal of Pediatrics, January 2008.

Purpose or Case Report: To define a set of normal measurement values of the major mediastinal vascular structures in a normal pediatric population. In doing so, we attempted to verify whether the established adult ratio of 1:1, for the main pulmonary artery: ascending aorta diameter is accurate in children. Methods & Materials: This is a retrospective study of consecutive enhanced MDCT examinations in 200 normal children, stratified into four age groups (0–2, 3–5, 6–12, and 12–18 years; mean age 7 years)performed between 2010 and 2013. Included in the study were children undergoing CT scans for indications unrelated to cardio-thoracic disease. Exclusion criteria included children that had cardiac disease of any kind, pulmonary parenchymal disease, previously undergone thoracic radiation, had greater than or equal to two cycles of any chemotherapy, had a large mediastinal mass compressing thoracic structures, or have had a bone marrow transplantation. Standardized measurements were taken of the transverse diameters of the ascending aorta (AA), descending aorta (DA), main pulmonary artery (MPA), right pulmonary artery (RPA), left pulmonary artery (LPA), and descending left pulmonary artery (DLPA).—Measurements were

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completed and recorded by a trained observer, pediatric radiology fellow and a consultant pediatric radiologist.. The measurements were performed on axial 5 mm slices using a standard soft-tissue window. Images were magnified in a 50–100% range to facilitate accurate measurement of the endpoints of each vessel. Occasionally in the 0–23 month age group, axial 2.5 mm slices on a lung algorithm were required to decrease volume averaging in the smaller child. Results: We found that younger children have a significantly larger MPA diameter than the established values for adults in current literature, resulting in an elevated Ascending Aorta: MPA diameter ratio. Overall, on average, the MPA is approximately 8% larger than the AA in normal children resulting in a normal MPA/AA ratio of 1.08. Conclusions: In this study we have shown that normal children have a higher AA/MPA ratio than normal adults. Therefore some of the defining CT characteristics of PAH used in adults should not be applied to the pediatric population. We expect the results of this study to redefine the definition of CT diagnosis of pulmonary hypertension in children.

S103 Paper #: PA-067 Pulmonary Hypertension in Children: CMR with Phase Contrast Imaging to Identify Prognostic Indicators

Dipti Nevrekar, Department of Radiology, University of Colorado, Aurora, CO, [email protected]; Brian Fonseca, Jane Gralla, Daniel Vargas, Dunbar Ivy, Lorna Browne Purpose or Case Report: Identification of prognostic Cardiac MRI (CMR) indices in pediatric pulmonary hypertension (PAH) and comparison to controls.

Methods & Materials: CMR provides a reliable, noninvasive manner of following adult patients with PAH, however its role in pediatric PAH is unassessed. Twenty-six patients met the inclusion criteria (age < 25 years, mean MPA pressure > 25 mmHg, previous CMR) and were compared to 13 age matched controls. The following CMR parameters were obtained: right ventricular enddiastolic volume (RVEDV), end systolic volume (RVESV) and ejection fraction (RVEF), min and max MPA area, peak and average MPA velocity, acceleration time (AT), ejection time (ET) and MPA strain. WHO grade and 6 min walk test were also recorded. Statistical tests included Spearman rank correlation coefficients (ρ) and Wilcoxon rank tests for (PAH versus controls), linear regression models (6 min walk test) and logistic regression analysis (WHO grade). Correlation coefficients were compared with a z-test. Results: There was a significant difference between PAH patients and controls in RVEF (median 48% vs. 54% p=0.02), peak velocity (median 123 vs. 93 cm/s, p=0.008), AT (median 106 ms vs. 128, p=0.003) and ET (median 299 vs. 366 ms, p=0.001). The PAH group had a tendency to lower strain values compared to controls (p=0.08) (Fig 1). There was no significant difference in AT/ET ratio (median 0.31 vs. 0.35, p=0.26), min MPA area (median 790 mm2 vs. 791, p=0.94) and max MPA area (median 1108 mm2 vs.1150, p=0.92. When analyzed separately, patients with PAH demonstrated a linear relationship between strain and RVEF (ρ=0.57) and mean velocity (ρ=0. 78), a relationship which was not seen among controls (Fig 1). Average velocity and strain were significantly correlated with walk test (ρ=0.47, p=0.02) and were also correlated with each other (ρ=0.78, p=<0.001). None of the CMR variables were significantly associated with a higher WHO score (grades 3 or 4), although this was limited by the small number of patients with higher WHO scores (n=6). Conclusions: Phase contrast parameters (peak velocity, AT, ET and MPA strain) successfully distinguish PAH patients from normal controls and correlate with walk times (average velocity and MPA strain). Unlike in adults, MPA size and AT/ET were not significantly increased in pediatric PAH. RVEF decreases linearly with decreasing pulmonary artery compliance (MPA strain) implicating ventricular arterial coupling as an important driver of RV systolic dysfunction in pediatric PAH.

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Paper #: PA-069

Establishing accuracy of airway measurements via CT in pediatrics

Correlation of lung ultrasound artefacts to chest CT in children

Sarah Halula, University of Cincinnati, Cincinnati, OH, [email protected]; Robert Fleck, M.D., Robert Thomen, Jason Woods

Laura Martelius, Children’s Hospital, Helsinki Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland, [email protected]

Purpose or Case Report: Experimentally evaluate the accuracy of CT airway measurements in the setting of modern low dose CT techniques and multiplanar visualization.

Methods & Materials: To experimentally evaluate the accuracy of manual CT measurements of the airway, we created a polycarbonate phantom consisting of 21 precision drilled holes ranging from 1 to 12 mm at 45° to the z-axis. The phantom was imaged using dose reduction technology which results in a constant noise regardless of patient size; Adaptive Iterative Dose Reconstruction 3D (AIDR 3D) was applied to simulate patient CT scanning. The reconstruction diameter was set at 180 mm resulting in a 0.351 mm pixel size; reconstructions were performed in lung kernel and soft tissue kernel. The anteriorposterior (AP), transverse (Tx) and cross-sectional area of holes were measured by four observers using commercially available software for multiplanar rendering using a lung window (1600/−550). Results: Using the lung window, the average absolute difference between measured and actual airway diameter for the lung kernel was 0.32 mm (SE=0.03) and for soft tissue kernel was 0.34 mm (SE=0.02); p=0.3450. Comparison of manually drawn regions of interest for cross-sectional airway area resulted in an average absolute difference of 2.9 mm2 (SE=0.31) for the lung kernel and 3.5 mm2 (SE=0.32) for the soft tissue kernel; p=0.1021. The percent error of measurement increased substantially (error greater than 10%) when hole size was less than 4 mm and is graphically presented in the Figure below. Conclusions: Manual airway measurements were statistically equivalent here between the lung kernel and soft tissue kernel algorithms, using the lung window (1600/−550). However, percent error increases as hole size decreases; the error becomes substantially greater than 10%, when measuring airway diameters less than 4 mm. Therefore, small airway measurement in a single patient should be reported as a range rather than an absolute measurement, with particular care for larger error in smaller airways.

Purpose or Case Report: Vertical artefacts called B-lines arising from lung surface in lung ultrasound have been shown to correlate with interlobular septal thickening (ILST) and ground glass opacity (GGO) in chest computed tomography (CT) in adults with pulmonary edema. Blines are reverberation artefacts assumed to originate from thickened liquid filled interlobular septae. Our aim was to study whether GGO and ILST on chest CT correlate with B-lines in lung ultrasound in children.

Methods & Materials: Twenty-eight patients (ages 1–17 years) who underwent chest CT for clinical reasons were studied with ultrasound at the time of the exam using a linear tranducer. Images were stored from each intercostal space on the anterolateral chest. The total amount of Blines on the ultrasound images was counted by an observer blinded to the CT findings. The CT images were scored for ILST and/or GGO on the anterolateral subpleural regions. Results: 6/28 patients had anterlateral subpleural GGO or ILST in chest CT and these patients had significantly higher B-line counts in ultrasound (p<0.01, Mann–Whitney U-test). All patients with GGO or ILST had Blines in lung ultrasound, the mean B-line count in these patients was 28. 11/22 patients without GGO or ILST had no B-lines, the mean B-line count in this group was 3. Conclusions: Lung ultrasound has a high sensitivity in detecting subpleural GGO or ILST. Though unpesific, it is a promising method for detecting pulmonary edema in children. Paper #: PA-070 Chest Radiographic Features of Human Metapnueumovirus Infection in Pediatric Patients

Floyd Dunnavant, M.D., Vanderbilt University, Nashville, TN, [email protected]; Wendy Ellis, Melissa Hilmes, MD, Sudha Singh, John Williams Purpose or Case Report: Since its identification in 2001, human metapneumovirus (HMPV) has been found to be a common cause of respiratory illness in young children, resulting in as many as 55 clinic

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visits, 13 emergency department visits, and one hospitalization annually per 1000 children. Like respiratory syncytial virus (RSV), rates of HMPV infection are especially high in the first year of life and among immunocompromised patients. Despite the relative frequency of HMPV infection, we are unaware of any previous systematic evaluations of the radiographic characteristics of lower respiratory tract infection caused by HMPV in pediatric patients. Methods & Materials: Sixty-eight children diagnosed with HMPV by reverse transcription-polymerase chain reaction (RT-PCR) at our tertiary care children’s hospital between December 2003 and May 2009 were retrospectively identified. Presenting chest radiographs for these patients were evaluated independently and then in consensus by two fellowship trained CAQ pediatric radiologists, and were coded for a number of radiographic features, including consolidation, parahilar opacities, peribronchial thickening, atelectasis, pleural effusion, and hyperinflation. Results: Parahilar opacities were the most commonly observed abnormality, occurring in 87% of patients with HMPV. Hyperinflation was also seen frequently (69%). Atelectasis (40%) and consolidation (18%) were observed less frequently. Peribronchial thickening, pleural effusion, and pneumothorax were not seen. Conclusions: HMPV is a common cause of respiratory illness in young children. Radiography is a frequent and important part of the evaluation in children with suspected lower respiratory infections. The clinical presentations of HMPV include bronchiolitis and croup, and these symptoms are often accompanied by abnormal chest radiographs. Parahilar opacities and hyperinflation are the dominant features. Since viral lower respiratory illnesses are typically treated supportively, recognizing the imaging patterns seen with common viral illnesses like RSV and HMPV, and distinguishing them from bacterial pneumonia can hasten diagnosis and limit unnecessary treatment in these young patients. Disclosure: Dr. Williams has indicated a relationship with Quidel, Inc. as a Consultant (Scientific Advisory Board). Paper #: PA-071 Going Beyond the Haller Index: Model-based Costal Cartilage Estimation for Surgical Planning of Pectus Excavatum

Qian Zhao, PhD, Sheikh Zayed Institue for Pediatric Surgical Innovation, Children’s National Medical Center, Washington DC, DC, [email protected]; Nabile Safdar, Emmarie Myers, Chunzhe Duan, Master of Health Science, Anthony Sandler, Marius George Linguraru Purpose or Case Report: To identify and segment the costal cartilages in noncontrast computed tomography (CT) images for developing an optimal surgical planning system for the surgical correction of pectus excavatum (PE). Methods & Materials: This retrospective study was IRB approved. A dataset of 12 thoracic CT scans was collected, including six PE patients and six healthy subjects. The ages of patients vary from 9 to 21 years. Each volumetric image consisted of axial images with resolution ranging from 0.59 to 0.82 mm and slice thickness of 0.62 mm. The cartilages were manually segmented from all CT scans by a board certified radiologists to provide ground truth. The ribs and sternum were then segmented by an interactive region growing method. The chest wall was similarly segmented to simulate the skin surface. To model the cartilages, the skeletons of the ribs and cartilages were extracted and statistical shape models were built to estimate the cartilages as 3D curves that connect the ribs and sternum. The cartilages one through eight were modeled on both sides of the thorax (left and right). Finally, the cartilages were identified by minimizing the difference between the reconstructed rib skeleton and the ground truth. The results were refined by the cartilage surface that was approximated by contracting the skin surface to the bones. Leaveone-out validation was performed and each cartilage was estimated between the end point of the rib and the joint with the sternum. The cartilage estimation method was evaluated through the average distance

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between the estimated cartilages and the ground truth. Statistical significance was assessed via the Wilcoxon test.

Results: The average distance between the estimated cartilages and the ground truth was 1.53+/−1.0 mm. The maximum error lied on the 7th pair of cartilages with 2.04+/−0.65 mm due to the large inter-patient shape variation reflected by the model. The minimum error was found on the 3rd pair of cartilages with 1.10+/−0.24 mm. There were no significant difference between the distance errors for PE and healthy cases, which were 1.61+/−0.58 mm and 1.46+/−0.51 mm, respectively (p=0.11). Conclusions: The technology allows for accurate identification and segmentation of the costal cartilages in noncontrast CT and has great potential toward an image-based surgical planning system for PE correction. The proposed clinical tool can indicate the severity of the deformation and facilitate non-invasive diagnosis and personalized surgical planning for minimally invasive operation. Paper #: PA-072 Clinical Significance of Incidental Pulmonary Nodules Detected on Abdominal CT in Pediatric Patients

Micheal Breen, MBBChBAO (Hons) BMedSc MRCPI FFRRCSI, Department of Radiology, Boston Children’s Hospital, Boston, MA, [email protected]; David Zurakowski, Edward Lee, MD, MPH Purpose or Case Report: The purpose of this study was to investigate the clinical significance of incidental pulmonary nodules detected on abdominal CT in pediatric patients. Methods & Materials: This was a retrospective study performed following institutional review board approval. Abdominal CT reports in patients under the age of 18 years from July 2004 to June 2011 were reviewed for the terms “nodule,” “nodular,” or “mass” in reference to the lung bases. Patients with concurrent chest CT examinations or nodules that had been previously identified on a prior CT were excluded; the study population included those patients in whom pulmonary nodules were initially detected on abdominal CT. Follow-up CTs and clinical records were reviewed for demographic information, history of underlying malignancies, interval nodule growth of and clinical outcomes. Using Fisher’s exact test, an underlying history of malignancy was compared with the incidence of malignancy of the incidentally detected pulmonary nodules on abdominal CT. Results: Seven thousand nine hundred twelve abdominal CTs were performed in this study period. Pulmonary nodules meeting inclusion criteria were detected in 62 patients (Mean age=11.2 years; range= 5 months−18 years). Fifty percent (n=31) of patients had follow-up CTs performed; 11 of these patients had a history of underlying malignancy. Two of these patients (6%) were subsequently found to have malignant pulmonary nodules; both of these patients had a history of malignancy. None of the 50% (n=31) of patients who did not have follow-up CT had a history of malignancy. Clinical follow-up information

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was available for 26 (84%) of these patients; none had evidence of malignant pulmonary nodule development based on clinical follow-up information. There was a statistically significant association between a history of malignancy and incidentally detected pulmonary nodules on abdominal CT subsequently found to be malignant (p=0.035). Conclusions: Incidental pulmonary nodules detected on abdominal CT are rarely malignant. These incidental pulmonary nodules have increased risk of becoming malignant in pediatric patients only in the setting of a history of malignancy. In pediatric patients without a history of malignancy, a strategy of clinical follow-up instead of additional CT seems appropriate for incidental pulmonary nodules detected on abdominal CT.

Paper #: PA-073 Radiologist Compliance with California CT Dose Reporting Requirements: Review of Pediatric Chest CT

Evan Zucker, M.D., Department of Radiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA, [email protected]; David Larson, Beverley Newman, Richard Barth, MD Purpose or Case Report: In response to sentinel cases of radiation overexposure, California enacted a law mandating that all radiology reports specify the CT dose index (CTDIvol) and dose-length product (DLP) if available from the scanner. Our goals were to document radiologist compliance with the law and areas for improvement; to our knowledge, no similar studies exist. Methods & Materials: We retrospectively reviewed all chest CTs (including combination exams) performed at our institution, an academic children’s hospital utilizing a dictation/transcription service, in the year following enactment of the law (effective 7/1/2012). Each radiology report was compared to the corresponding CT dose page on PACS for errors in CTDIvol, DLP, and phantom size (not a legally required parameter but standard at our institution and many others). Reports were considered compliant with the law if the CTDIvol and DLP (for at least the chest portion) were documented (when available) and numerically accurate when compared to the CT dose information page. Reports met our minimum institutional standards if phantom size was additionally accurately reported. We also logged cases that deviated from reporting dose in our standard format (phantom size, CTDIvol for each series, and total DLP). Results: Radiologists failed to document CTDIvol, DLP, or both in 9 (1%) of 673 exams reviewed and inaccurately reported one or more of these parameters in 57 (9%) of the remaining 664 exams. Radiologists omitted phantom size in 11 (2%) of 673 exams and inaccurately documented it in 17 (3%) of the remaining 662 reports. Using our definitions, of 673 reports, 607 (90%) met legal reporting requirements, and 590 (88%) met our institutional requirements. The most common variation in dose reporting was to use less decimal precision for the CTDIvol or DLP than available (71/664 cases [11%]). Other report disparities observed included summing of CTDIvols, variable reporting of dose information from the topogram or series from another exam performed concurrently, documenting CTDIvol but not DLP for a specific non-chest series, or vice versa, and providing only series-level (not total) DLP. Conclusions: Our current processes demonstrate low reliability, with only 88% and 90% of reports meeting minimum institutional and legal dose reporting requirements, respectively. Additionally, we observe much variation in dose reporting format. Better-defined standards and investment in high-reliability, automated systems may allow for more consistent dose reporting in the future. Disclosure: Dr. Larson has indicated a relationship with Radimetrics/ Bayer Healthcare for Intellectual Rights (Potential Royalties).

Paper #: PA-074 Minimum CTA Radiation Dose and the Impact of Iterative Reconstruction in Children: a Prospective Randomized Trial

Aya Kino, MD, Radiology—CV Imaging, Stanford University_LPCH, Stanford, CA, [email protected]; Beverley Newman, JIa Wang, Frandics Chan Purpose or Case Report: Cardiac CTA is an indispensable tool for the diagnosis of cardiovascular abnormalities, but it incurs some of the highest radiation dose of all CT protocols. We conducted a prospective randomized trial to examine the minimum achievable radiation dose in a group of pediatric patients clinical indicated for cardiovascular CTA, and the potential improvement with iterative reconstruction. Methods & Materials: With IRB approval, pediatric patients clinically referred for a cardiac CTA were randomized split dose protocol using a 128-slice dual-source MSCT scanner (Flash, Siemens). Based on patient’s size, tube voltage, and heart rate, the scanner predicts a clinical CTDI value for a typical study. By adjusting the tube current, a high- and lowdose scans were planned such that their total CTDI did not exceed the clinical CTDI value. The two scans were performed sequentially under a single breath-hold and contrast injection. Images were reconstructed at 0.6 mm section thickness with and without iterative reconstruction (SAFIRE level 0 to 5). Two experienced cardiac radiologists independently determined if a scan was diagnostic and at which SAFIRE level. For each scan, body size-adjusted CTDI, dose-length product (DLP), and equivalent dose (ED) values were calculated. Results: Twenty-five patients were recruited, with mean age of 8.2 years (range 2 months to 17 years) and weight 30.6 +/− 18.9 kg. Clinical indications included Fontan and Glenn shunts patency, aberrant coronary arteries, patency of the great arteries and veins, and intracardiac anatomy. 18/25 studies employed the FLASH mode while the rest used retrospective ECG gating. For the 50 scans, the ranges for CTDI, DLP, and ED were 0.11 to 19 mGy, 2 to 327 mGy-cm, and 0.02 to 5.45 mSv, respectively. For the two readers, 36/50 and 32/50 scans were deemed diagnostic, with good interobserver agreement (kappa=0.85). The average ED for diagnostic scans was 1.66 mSv and for non-diagnostic scans 0.73 mSv. Without iterative reconstruction, the two readers reported 7/30 and 4/30 nondiagnostic scans above ED=0.8 mSv, and 11/20 and 10/20 nondiagnostic scans below 0.8 mSv. With iterative reconstruction, nondiagnostic scans drops to 1/30 and 2/30 above 0.8 mSv, and 0/20 and 5/20 below 0.8 mSv. Conclusions: Modern MSCT scanner is capable of achieving 1 mSv diagnostic cardiac CTA scans in pediatric patients with cardiovascular diseases. Iterative reconstruction primarily helps reduce nondiagnostic studies at low dose level. Paper #: PA-075 Evaluation of contrast administration site effectiveness when performing hand administration of intravenous contrast for thoracic CTangiography in pediatric patients

Gary Schooler, MD, Boston Children’s Hospital, Boston, MA, [email protected]; Edward Lee, MD, MPH, David Zurakowski Purpose or Case Report: Thoracic CT angiography (CTA) is a frequent procedure in the pediatric population for various indications. In infants and young children with only small intravenous (IV) catheter access, hand administration of contrast is often required for thoracic CTA. The purpose of this study was to evaluate the effectiveness of various contrast administration sites based on hand administration of IV contrast for thoracic CTA in infants and young children.

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Methods & Materials: We utilized our hospital information system to retrospectively identify consecutive pediatric patients who underwent thoracic CTA with hand administration of contrast from August 2012 to July 2013. Study indication of thoracic CTA was to evaluate the thoracic systemic arterial vasculature and pulmonary venous vasculature. Hounsfield unit (HU) measurements were obtained with regions of interest placed at the level of the aortic arch and descending thoracic aorta at the level of the carina to evaluate the thoracic systemic arterial vasculature and at the central left atrium to evaluate the pulmonary venous vasculature. Eight injection sites were identified: 1) internal jugular vein, 2) external jugular vein, 3) head, 4) hand vein, 5) arm vein, 6) femoral vein, 7) leg vein, and 8) foot vein. Injection sites were categorized into three regional groups: 1) head/neck region (internal jugular, external jugular veins, and head vein), 2) upper extremities (hand and arm veins), 3) lower extremities (femoral, leg, foot veins). Comparisons of HU values between contrast injection sites were determined using the F-test in analysis of variance (ANOVA). Results: The study cohort included 51 patients (22 M, 29 F; median age 7 months, range 3 days to 7 years), who underwent a total of 51 thoracic CT angiography studies for evaluating the thoracic systemic arterial vasculature (n=39) and pulmonary venous vasculature (n=12). All 51 thoracic CTA studies were of diagnostic quality, with the threshold for a diagnostic exam defined as HU>150 in the vessels of interest (mean +/− SD for aortic arch: 380 +/− 150; aortic carina: 391 +/− 154; left atrium: 393 +/− 89) There were no significant differences in mean HU between injection sites (P>0.49) or different regional groups (P>0.67). Conclusions: Diagnostic quality thoracic CTA can be achieved with hand administration of IV contrast in infants and young children independent of IV access location. Paper #: PA-076 Neuroimaging Evaluation in Children Under Two Years of Age with Suspected Non Accidental Trauma: Impact of Early Brain and Cervical Spine MRI

Susan Palasis, MD, Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Stephen Messner, Laura Hayes, M.D., Damien Grattan-Smith Purpose or Case Report: To evaluate the impact of early MR imaging evaluation of the brain and cervical spine in infants with suspected non accidental trauma (NAT). Methods & Materials: A total of 236 children were consulted upon by Child Protective Services at our institution for suspected abuse from 2011 to 2013. Retrospective review of the imaging data was performed. Inclusion criteria for our study were that all children were 24 months or less in age and that they had undergone a nonenhanced head CT. Results: Our review revealed a total of 110 children under 2 years of age that had undergone a non-enhanced head CT. A total of 65 had CT studies that revealed non-suspicious findings (negative study, prominent extraaxial fluid spaces, small convexity SDH, linear fracture). Sixty-one MRI exams on this group of children were performed on average between 1 and 4 days from time of initial CT. The MR studies revealed suspicious findings for non-accidental head trauma (NAHT) such as mixed convexity, posterior fossa, and interhemispheric SDH in 12 cases looking only at T1 and T2 weighted sequences. When the findings from T2* susceptibility weighted imaging were taken into account, they were considered suspicious (hemorrhagic shear injury, hemorrhagic contusions, more extensive extraaxial hemorrhage) in 30 cases. Diffusion weighted imaging demonstrated findings suspicious for abusive injury in only several cases. A total of 40 children had a screening MRI study of the cervical spine performed with fat saturated T2 FSE or STIR sequences. Of these children, 19 demonstrated findings of paraspinous soft tissue edema indicating a whiplash mechanism of injury. Children with positive

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cervical spine imaging had more severe clinical outcomes (seizure disorders, cerebral palsy, paralysis, death). Out of the children that had positive cervical spine MRI, 10 of them had non-suspicious findings on CT and MRI examination. Conclusions: Children under 2 years of age are difficult to evaluate for symptoms indicating brain or cervical spine injury. Early MRI evaluation of the brain can reveal injury that is not apparent on the clinical exam or the non-enhanced CT evaluation, especially with susceptibility weighted MR imaging techniques. Our preliminary findings show that MR screening of the cervical spine can yield supportive forensic evidence that a whiplash mechanism of injury typically encountered in the abusive setting has occurred. This study is ongoing and data for 2013 is currently under review.

Paper #: PA-077 Optimizing A FAST-MR Protocol for Abusive Head Trauma Screening

Lynda Flom, MD, Radiology, Children’s Hospital of Pittsburgh, Pittsburgh, PA, [email protected]; Elizabeth Tyler-Kabara, Ashok Panigrahy, Janet Fromkin, Rachel Berger Purpose or Case Report: Computed tomography (CT) is the gold standard screen for Abusive Head Trauma (AHT), but there is increasing concern about radiation exposure. Magnetic resonance imaging (MRI) eliminates radiation exposure, but has sedation risks. Rapid-sequence MRI (RSMRI) would eliminate both these risks. RSMRI has been successful in evaluating children with shunted hydrocephalus. Typical RSMRI protocols include fast TSE-T2 and GRE sequences. No studies have evaluated the use of RSMRI to screen for AHT and it is unclear if additional optimized sequences (i.e. T1 weighted) are needed to identify intracranial abnormalities (ICA) in the setting of possible AHT. To determine whether a limited optimized set of standard MRI sequences could identify ICA in children being screened for AHT. Methods & Materials: A cohort of children less than 1 year of age who underwent both brain CT and MRI with abnormalities in both studies were used to identify which of seven sequences Coronal T2, Sagittal T1, Axial T1, Axial T2, Coronal MPIR, Axial DWI, Axial Proton Density and Axial Gradient Echo/SWAN were sensitive for ICA. MRIs sequence were assessed as either normal or abnormal by two readers. A second cohort of children was used to validate the selected sequences. Results: A total of 115 children were enrolled. Seventeen subjects with ICA were included in the initial cohort. At least one of three sequences Axial T2, GRE/SWAN and Coronal MPIR was abnormal in all 17 subjects; these three sequences were evaluated in the validation cohort. Of the 98 subjects in the validation, 57% had no ICA and 43% had ICA. Both readers agreed that the optimized set of MRI images were abnormal in 95% of subjects with ICA, including all 22 subjects with AHT. Other abnormalities were identified in children with ICA including intracranial hemorrhage not due to AHT. Both readers agreed that 80% of the optimized images in subjects without ICA were normal. Conclusions: Three MRI sequences identified ICA in all AHT cases in this cohort suggesting that RSMRI, with a fast T1 inversion recovery sequence, might be able to replace head CT as a screening tool for AHT. In addition,80% of infants who underwent both CT and MRI, both readers agreed that the limited sequence MRI was normal suggesting that both radiation exposure from head CT and sedation risk from MRI could have been avoided in these patients. We are now evaluating the prospective feasibility of completing this “revised” RSMRI without sedation in infants undergoing MRI as part of clinical care.

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S108 Paper #: PA-078 Evaluation of Ruptured thrombosed bridging veins by Susceptibility Weighted Imaging in Non Accidental Trauma

data and comparisons of categorical data was done using Fisher’s exact test. Exam grade data was compared between MR classification groups using the Wilcoxon Rank Sum test and when grade was categorized compared between the MR classification groups using Fisher’s exact test. P<0.05 was considered statistically significant.

Sheena Saleem, DNB, MBBS, Deniz Altinok, Childrens Hospital of Michigan, Detroit, MI, [email protected] Purpose or Case Report: Susceptibility-weighted imaging (SWI) is a 3D high-resolution MRI technique that is more sensitive than conventional imaging in detecting hemorrhagic lesions. We evaluated the use of SWI in Non Accidental Trauma (NAT) for detecting ruptured thrombosed bridging veins. Methods & Materials: We retrospectively reviewed the Brain MRI images of patients with a history of suspected Non Accidental Head Trauma between 2010 and 2013. We looked at the findings on Susceptibilty weighted imaging (SWAN). We looked for the presence of ruptured thrombosed bridging veins and their location. Results: Fifty-nine patients with Non Accidental Trauma were detected between January 2010 and September 2013. We detected ruptured thrombosed bridging veins in 20 patients. The ruptured veins were detected in the following locations: Frontal : 6 (with bilateral thrombosed veins in 2),Parietal : 3, Frontoparietal :11(with bilateral thrombosed veins in 4). Conclusions: Susceptibilty weighted imaging is very sensitive for detecting the presence of ruptured thrombosed bridging veins in patients with non accidental trauma.

Paper #: PA-079 MR Detection of Retinal Hemorrhages: Correlation with Graded Ophthalmologic Exam

Angela Beavers, Univ of Nebraska Medical Center Dept of Radiology, Omaha, NE, [email protected]; Anna Stagner, Sandra Allbery, MD, Elizabeth Lyden, Thomas Hejkal, Suzanne Haney Purpose or Case Report: Determine ability of standard brain protocol MR to detect retinal hemorrhage (RH) and determine if there is any correlation with MR detection of RH and the dilated fundoscopic exam (DFE) grade of the hemorrhage. Table 2a: Descriptive Statistics: Grade by MR Classification Grade of hemorrhage on exam Retinal hemorrhage visible on MR No

N Obs Mean Std Dev Median Minimum Maximum

23

5.83

Yes

28

10.29 2.12

4.78

5.00

0.00

12.00

11.00

4.00

12.00

P=0.0012 Methods & Materials: Retrospective chart review 51 patients < 2 years old who were seen for head trauma from 4–2007 to 7–2013 and had both brain MR and DFE were included in analysis. MRs reviewed by staff pediatric radiologist and radiology resident. DFE RH grading on a 12point scale (J AAPOS.2009 13(3):268–272) based on type, size, location, and extent performed by chief ophthalmology resident with 40 graded on review of retinal camera images and 11 graded on detailed reports by retinal specialists. Grade 0 indicated no RH and higher scores indicated increased severity of RH. Descriptive statistics included mean, standard deviation, median, minimum, and maximum for continuous data(i.e. exam grade). Counts and percentages were used to display categorical

Results: There was a statistically significant difference in the median grade of RH on exam between patients who had RH detected on MR relative to patients who did not have RH detected on MR (11.0 vs 5.0, p= 0.0012). When exam grade was categorized 0–4, 5–8, >8, there was a statistically significant association between exam grade and diagnosis based on MR (p=0.0003). Only 4% of patients with an exam grade of 0–4 were classified as having RH on MR compared to 79% who had an exam grade >8. DFE grade four was lowest grade detected by MR. Detection of RH using MR showed Sensitivity=(28/46)=61%, Specificity=5/5=100% ,PPV=28/28=100%, NPV=5/23=22%. RH was best seen on MR FFE and T2 sequences. Conclusions: There was a statistically significant association between RH exam grade and diagnosis based on MR (p=0.0003). Only 4% of patients with an exam grade 0–4 were classified as having RH on MR compared to 79% who had an exam grade >8. MR using routine Brain Protocol including FFE has a 61% sensitivity and 100% specificity in detecting RH. DFE can be difficult to obtain in infancy. MR is a useful modality for added documentation of infant RH and an alternative exam when ophthalmologic expertise or retinal camera images are unavailable.

Paper #: PA-080 Diffusion tensor imaging of the brainstem in children with achondroplasia

Thangamadhan Bosemani, Section of Pediatric Neuroradiology, Division of Pediatric Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, [email protected]; Gunes Orman, Kathryn Carson, Avner Meoded, Thierry Huisman, Andrea Poretti Purpose or Case Report: Achondroplasia is a skeletal dysplasia and the most common form of disproportionate short stature in children. One of the key anatomical features includes a diminished growth of the skull base leading to a narrowing of the cranio-cervical junction (CCJ) and foramen magnum. This may cause cervicomedullary compression. Diffusion tensor imaging (DTI) is an advanced magnetic resonance imaging technique that allows evaluation of the microstructure and integrity of white matter tracts in vivo. DTI is consequently a suitable technique to study possible white matter changes secondary to chronic cervicomedullary compression in achondroplasia. Methods & Materials: This study aimed to 1) assess the microstructural integrity of major brainstem white matter tracts using DTI in children with achondroplasia in comparison to age-matched controls and 2) correlate severity of CCJ narrowing and neurological findings with DTI scalars in children with achondroplasia. DTI data were acquired on a 1.5 T MR-scanner using a balanced pairs of diffusion gradients along 20 orthogonal directions. Measurements from regions of interest were

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sampled in each pontine corticospinal tract (CST), medial lemniscus (ML) and middle cerebellar peduncle (MCP) as well as in the lower brainstem for fractional anisotropy (FA), mean (MD), axial (AD) and radial (RD) diffusivity. Additionally, a severity score for achondroplasia was assessed by measuring the CCJ narrowing. Results: Eight children with achondroplasia and eight age-matched controls were included in this study. Compared to age-matched controls, decrease in FA and increase in MD and RD were found in the lower brainstem of patients. CST’s and MCP’s showed increase in MD, AD and RD. FA in the lower brainstem negatively correlated with the degree of CCJ narrowing. Conclusions: Reduction in FA and increase in diffusivities in the lower brainstem may reflect secondary encephalomalacic degeneration and cavitation of the affected white matter tracts as shown by histology. In children with achondroplasia, DTI may serve as a potential biomarker for brainstem white matter tract injury and aid in the management of these patients.

Paper #: PA-081 Are those dots important? Focal susceptibility on Gradient Echo imaging: incidence and potential significance in pediatric brain tumor patients following whole brain radiation

Andrew Olson, MD, University of Colorado, Aurora, CO, [email protected]; Laura Fenton, MD, Arthur Liu, Nick Stence, MD, Nicholas Foreman, Steven Plimpton Purpose or Case Report: In adults, the incidence of intracranial cavernous malformations following whole brain radiation therapy is~1%. The incidence is unknown in the pediatric population. We have identified new foci of intracranial susceptibility on Gradient Echo (GRE) images in children treated with whole brain radiation with increased frequency. While the underlying pathology remains unknown, potential differential considerations include cavernous malformations, calcification/ mineralization, and microhemorrhage. Our aim was to identify the incidence, mean time from radiation completion, MRI features, location, and complications of new foci of susceptibility on GRE in pediatric brain tumor patients following whole brain radiation therapy. Methods & Materials: Following IRB approval, we conducted a retrospective review of children with brain tumors who received craniospinal radiation from 1997 to 2013. Brain MRIs were reviewed with attention to GRE sequence for new foci of susceptibility and corresponding T1 and T2 abnormality. If no GRE sequence was available, the B0 EPI DWI sequence served as a surrogate. Lesions were excluded if present at diagnosis or first postoperative year, adjacent to the operative cavity, located along a shunt or biopsy tract, contiguous with a cortical vein, near skull base artifact, or at suspected bilateral basal ganglia mineralization. Results: One hundred sixty-seven patients (118 medulloblastoma, 49 non-germinomatous germ cell tumors) were reviewed. Thirty-nine out of 167 (23.4%) had new GRE susceptibility. Only 20.5% of the patients with new GRE findings had corresponding T1 and T2 abnormalities. Foci were solitary in 58.9% of patients and multiple in 41.1%. 79.5% had only supratentorial lesions, 12.8% had only infratentorial lesions, and 7.7% had both supra and infratentorial lesions. 10.3% of patients had lesions with evidence of significant hemorrhage. The average latency from radiation completion to detection was 54.3 months. The diagnosis of cavernous malformation was confirmed by pathology in one patient following resection for possible tumor recurrence. Conclusions: The incidence of new foci of susceptibility on GRE in pediatric brain tumor patients following whole brain radiation is 23.4% with 54.3 months average time from radiation. While the underlying pathology remains unclear, some cases may reflect new cavernous malformations. Therefore, we recommend surveillance MRIs for brain tumor follow-up include GRE sequences, and that GRE abnormalities be identified and followed.

S109 Paper #: PA-082 Diffusion Weighted MR Imaging in Retinoblastoma

Manish Sharma, Sanjay Sharma, MD, FRCR, Radiology Section, Dr R P Centre, AIIMS, New Delhi, India, [email protected]; Manisha Jana, Bhavna Chawla, Seema Kashyap, Seema Sen Purpose or Case Report: To correlate the diffusion weighted (DW) MRI with morphological features of retinoblastoma that determine its outcome and assess its clinical utility as an adjunct in the conventional MRI protocol. Table. Correlation of ADC versus characteristics of retinoblastoma

ADC of mass versus pathological grade of tumor (n=12), Gp-I Poorly defferentiated (n=0) Moderately differentiated (n=4) Poorly differentiated (n=8) ADC of mass versus tumor volume (n=22), Gp-I and II Small (<10 mm3) (n=4) Large (≥10 mm3) (n=18) ADC of mass versus post-laminar optic nerve involvement (n=12), Gp-I Normal (n=7) Involved (n=5) ADC of mass versus anterior chamber involvement (n=12), Gp-I Normal (n=7) Involved (n=5) ADC of mass versus choroid involvement (n=12), Gp-I Normal Focal (by tumor) Massive (by tumor) Inflammatory ADC of optic nerve Gp-I (n=12), Gp-I Normal Involved #ADC of optic nerve Gp-II (n=10) Normal Involved

EPI ADC*

HASTE ADC*

− 587 590

− 827 776

705 675

921 811

1467 1470

1428 1466

799 603

885 627

653 604 648 1063

750 857 727 1253

1437 1509

1344 1465

653 1416

878 1354

‘n’ represents number of eyes ‘-’ not applicable *ADC values (×103mm2/s) # In 10 eyes of Gp-II, the optic nerve invasion is basec on MRI alone

Methods & Materials: Twenty two eyes in 20 consecutive children with non-hereditary retinoblastoma [12 intra-(Gp-I), 10 extra-ocular (Gp-II)] underwent both EPI (GRE) and HASTE (SE) DWI, in addition to the standard MRI (T1, T2, post contrast) on 1.5 T system (Siemens, Avanto) under general anesthesia. The TR/TE/signal averages were 3400/100 (ms)/3 and 2000/105 (ms)/10 for EPI and HASTE DWI respectively.

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The b values used were 0, 500 and 1000 s/mm2. The ADC (×103mm2/s) represented the degree of diffusion restriction. Tumor ADC was the mean of three ROIs from its enhancing portion carefully excluding areas of calcification, hemorrhage and necrosis. The ADC was calculated both for normal and affected optic nerves from a single ROI, within a centimeter of the optic disc. The ADC values were correlated with pathological grade (well, moderate or poorly differentiated), tumor volume (small <10 mm3, large ≥ 10 mm3), high risk features (optic nerve involvement, massive choroidal invasion, anterior segment invasion) and extra-ocular spread. Children in Gp-I and Gp-II underwent upfront enucleation and neoadjuvant chemotherapy respectively. Mean interval between MRI and enucleation in Gp-I was 20.5 days. Pathologist was blinded to MRI results. Results: Diagnostic DW images were obtained in all eyes. The HASTE DWI took significantly longer (12.42 min.) to acquire than EPI DWI (1.19 min.). All masses showed a degree of restricted diffusion. The HASTE ADC values tended to be higher than EPI ADC values both for tumor and optic nerve (normal or abnormal) and appeared linearly related. EPI ADC at normal posterior segment was >2000. The correlation of ADC with various tumor characteristics is listed in the Table. Conclusions: DWI does not reliably predict the tumor grade or other high risk features in intra-ocular retinoblastoma including optic nerve invasion and hence should not be a part of routine MRI protocol. It appears to better predict the optic nerve invasion in the extra-ocular retinoblastoma. Higher restriction of diffusion in the mass is more likely to be related to inflammatory involvement of the choroid than by tumor. HASTE DWI considerably increases the imaging time and hence does not appear suitable. Studies with larger sample size are warranted.

Paper #: PA-083 Forty-five extravesical ectopic ureters: morphological and functional MR urography (fMRU) findings

Aikaterini Ntoulia, MD, Maria Bedoya, Jorge Delgado, Dmitry Khrichenko, Thomas Kolon, Kassa Darge, MD, PhD, Department of Radiology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, [email protected]

-Patlak (pDRF) -Volumetric Patlak (vpDRF)

37.5%±13.6% 44.7%±20.5%

30.6%±13.7% 20.1%±19.2%

<0.001 <0.001

CTT = time for contrast agent to reach the calyces RTT = time for contrast agent to reach the proximal ureter (at the level of the lower pole of the kidney) vDRF = split renal function based on the parenchymal volume pDRF = split renal function based on the Patlak number i.e. glomerular filtration (GFR) index vpDRF = split renal function based on both the parenchymal volume and Patlak number Methods & Materials: Thirty-seven children with 106 Pelvi-UreterUnits (PUUs), median age 5.8 months, range 15 days–17.2 years, with EEU who underwent fMRU, including functional analysis, were retrospectively reviewed. The indications for fMRU were prenatal hydronephrosis (n=13), urinary tract infection (n=10), urinary incontinence (n=8), cystic renal disease (n=3), cloacal anomaly (n=1) and abdominal pain/mass (n=2). Cystoscopic and/or surgical confirmation of the findings was available in all cases. Results: A total of 32 females (86.5%) with 93 PUUs and 5 males (13.5%) with 13 PUUs were included. 45/106 (42%) PUUs were drained by EEU; 38 PUUs in 32 girls and 7 PUUs in 5 boys. In 28/45 (62%) PUUs (18 girls, 2 boys) the ectopic ureter was associated with the upper moiety of a duplicated system and in 17/45 (38%) (14 girls, 3 boys) with a single system. The ureteral insertion sites included in girls the urethra (25/ 32), vagina (6/32) and Gartner’s cyst (1/32) and in boys the urethra (4/5) and the seminal vesicle (1/5). fMRU detected the correct ureteral insertion in 41/45 (91.1%) PUUs. VCUG was performed in 24/37children (68 PUUs). Vesicoureteral reflux (VUR) was found in 6/32 PUUs with ureteral ectopia and in 7/36 without. VUR grades among 6 PUUs with EEU were grade I = 1, grade II = 2, grade III = 1 and grade IV = 2. In 29/37 (78.3%), without clinical findings of EUU, diagnosis was made at a mean age of 4.5 months (range = 1–12 months). Mean Patlak differential renal function was significantly lower in PUUs with ectopic ureter (30.6 ±13.7) compared to those without (37.5±13.6) (p<0.001). Surgery was performed in 30/37 children: 13/37 ureter-ureterostomy, 10/37 vesicoureteral reimplantation, 7/37 nephro-ureterectomy. Conclusions: This is the largest series of pediatric patients with extravesical ectopic ureter examined with fMRU. fMRU allows exact morphological depiction and functional evaluation of the ectopic moiety. With fMRU, unlike in the past, the diagnosis of ureteral ectopia has shifted in the majority of patients to infancy, a period prior to development of clinical symptoms.

Purpose or Case Report: Morphological and functional MR urography (fMRU) combines in a single examination superb anatomic details of the urinary tract with renal function information without radiation exposure. The purpose of this study is to describe the fMRU morphological imaging findings in children with extravesical ectopic ureter (EEU) and evaluate the renal function of the associated kidney that may affect the clinical management.

Paper #: PA-084

Table 1: Functional anaysis results in kidneys/moieties drained by normally inserting ureter compared to those drained by extravesical ectopic ureter

Emilie Johnson, Boston Children’s Hospital Urology, Boston, MA, [email protected]; Caleb Nelson, Dionne Graham, Jeanne Chow, MD

Calyceal Transit Time (CTT) Renal Transit Time (RTT) Defferential Renal Function (DRF) -Volumetric (vDRF)

Kidney/moiety drained by normally inserting ureter mean ± SD 143.9 s±63.7 s

Kidney/moiety drained by extravesical ectopic ureter mean ± SD 166.7 s±63.1 s

P-values

180.4 s±92.5 s

400.0 s±512.9 s

<0.001

44.5%±20.6%

21.2%±17.4%

<0.001

0.06

Nationwide emergency department imaging practices for pediatric urolithiasis patients: room for improvement

Purpose or Case Report: Although computed tomography (CT) is the gold standard for evaluation of suspected urolithiasis (SU) in adults, it is less clear that this should be true for children. Studies conducted at pediatric hospitals have suggested that >75% of children with urolithiasis can be managed effectively without CT. However, >90% of pediatric emergency care is provided in non-pediatric emergency departments (EDs), where radiation safety in children may be less emphasized. The aims of our study were to (1) characterize the imaging practices for children presenting to the ED with SU and (2) determine patient, hospital and regional factors associated with the choice of imaging study.

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Methods & Materials: We used the 2006–10 Nationwide Emergency Department Sample (NEDS) to conduct a retrospective cohort study of patients aged 0–17 years who were evaluated for SU, based on having an ICD-9 code for urolithiasis and/or flank pain. We determined the imaging practices for visits in EDs where billing codes for CT and ultrasound were reliably reported. Weighted logistic regression was used to delineate patient- and hospital-level factors associated with the use of CT vs. ultrasound. Results: There were 18096 pediatric SU visits in the 1191 NEDS EDs with reliable imaging codes. Mean age was 14±3 years, 62% were female, and 97% were evaluated in an adult-focused ED. Of the 12185 patients with any imaging, only 12% had an ultrasound. Furthermore, of the 11215 patients receiving a CT alone, an ultrasound alone, or both, 9773 (87%) were imaged with CT alone. CT use appeared to peak in 2007, and then declined gradually thereafter. On multivariate analysis, the following factors were associated with the use of CT alone: lower proportion of pediatric patients treated in the ED (OR 1.5 [95% CI 1.3–1.8] for lowest vs. highest quartile), older age (OR 7.6 [4.4–13.1] for adolescents vs. young children), region (OR 2.6 [2.0–3.3] for Northeast vs. Midwest; OR 2.3 [1.7–2.3] for Northeast vs. South), and non-teaching hospital status (OR 2.0 [1.7–2.2]). Conclusions: 87% of children imaged for SU in the ED are evaluated by CT. The lowest CT use is seen in EDs that care for more children. Ultrasound is used very infrequently regardless of site. Paper #: PA-085 Renal ultrasound for infants under two months of age with a first febrile urinary tract infection

Robert Orth, M.D, Ph.D., Texas Children’s Hospital and Baylor College of Medicine, Houston, TX, [email protected]; Nadia Mahmood, Jennifer Williams, Sowdhamini Wallace Purpose or Case Report: The American Academy of Pediatrics guidelines for infants 2–24 months of age with a first febrile urinary tract infection (UTI) state that voiding cystourethrography (VCUG) should be performed only if a renal ultrasound (US) is abnormal. The purpose of this study was to determine the diagnostic yield and test performance measures of renal US in hospitalized infants <2 months of age with a first febrile UTI. Methods & Materials: Institutional Review Board approval was obtained for this retrospective study and informed consent was waived. All children with a positive urine culture from 1/1/2008 to 12/31/2011 were identified through our institutional microbiology database. Inclusion criteria were age <2 months, temperature ≥100.4, and culture proven UTI. Exclusion criteria were known pre- or post-natal genitourinary abnormality and VCUG not performed within 30 days of renal US. Renal US exams were independently reviewed by two pediatric radiologists blinded to VCUG results and deemed abnormal if any of the following were present—hydronephrosis (pelvic diameter ≥4 mm or pelviectasis), renal size discrepancy >10%, duplication, urothelial thickening, and ureteral or bladder abnormalities. VCUG exams were subsequently reviewed and vesicoureteral reflux (VUR) grade recorded. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and negative predictive (NPV) of renal US were calculated for all grades and for high-grade (4–5) VUR. Results: Two-hundred thirty-six patients met inclusion criteria, of whom 42 were excluded for a final study group of 194 patients (M:F = 126:68, mean age = 34 days+/−15.2). Twenty-six percent of patients had VUR (51/196), 7.7% high-grade (15/196). For all VUR grades, renal US Sn= 31.4% [19.1–45.9], Sp=69.8% [61.8–77.0], PPV=26.2 [15.8–39.1], and

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NPV=74.8 [66.8–81.8]. For high-grade VUR, renal US Sn=86.7 [59.5– 98.3], Sp=74.1 [67.1–80.2], PPV=21.3 [11.9–33.7], and NPV=98.6 [94.9–99.8]—(95% confidence intervals in brackets). Hydronephrosis and duplication had a statistically significant association with high-grade VUR, p=<0.0001 and p=0.015, respectively. No obstructive uropathies were diagnosed by VCUG in patients with a normal renal US. Conclusions: The high NPV of renal US for high-grade VUR and the lack of data supporting intervention in children with a first febrile UTI and low-grade VUR (grades 1–3) argue against routinely performing VCUGs in infants <2 months of age with a normal renal US. Paper #: PA-086 In-vitro Optimization of a New US Contrast Agent for Intravesical Administration in Children

Susan Back, MD, Department of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; J. Christopher Edgar, Kassa Darge, MD, PhD Purpose or Case Report: Pediatric contrast enhanced ultrasound (CEUS) is primarily performed outside of the United States where a track record for safety in both intravenous and intravesical applications has been established. Contrast enhanced voiding urosonography (ceVUS) has also been shown to have a much higher rate of vesicoureteral reflux detection compared to voiding cystourethrography. US contrast agents (UCA) available in the United States differ from those abroad. Optison® (GE Healthcare) is such an UCA. Intravenous use of Optison® in children has already been optimized. As the CEUS Task Force of the Society of Pediatric Radiology seeks to advance the use of pediatric CEUS, our objective was to optimize the intravesical use of Optison® in-vitro for ceVUS before its use in a comparative multi-center pediatric study. Methods & Materials: The experimental design simulated intravesical use. We scanned 20 ml syringes containing saline and/or urine with UCA, varying UCA concentration (0.25%, 0.5%, 1.0%), mechanical index (MI), and physical conditions (mode of administration, shelf life, refrigeration) using 9 and 12 MHz linear transducers (Philips iU22®). We evaluated MI settings and contrast duration, optimized the contrast dose, measured the effect of urine, different delivery systems (injection versus infusion) and the impact of length of shelf life and refrigeration. Results: One hudred fifty-six experiments were performed. The 0.5% contrast concentration was the most optimal with a mean time to visualize homogenous contrast and 50% of microbubble destruction of 2.0 and 7.8 min, respectively using the 9 MHz transducer. Consistent visualization was achieved at MI 0.06–0.17 and 0.11–0.48 for L9 and L12 MHz transducers (p<0.01), respectively. Thus it is necessary to increase the MI for better visualization of the microbubbles with a higher transducer frequency. The lowest MI for earliest visible microbubble destruction was 0.21 for the 9 MHz and 0.39 for the 12 MHz (p<0.01) transducers. Accounting for refrigeration and shelf life, UCA degraded faster in the presence of urine (0–20+ min) than in pure saline (2–40+ min). We observed no significant difference (p>0.05) between injecting or infusing contrast. Time from refrigeration and age of contrast did not affect contrast performance. Conclusions: 0.5% UCA volume to bladder filling may suffice for ceVUS. Transducer settings need to be optimized. Emptying the bladder prior to intravesical administration of the UCA may be important. Once opened, the UCA is useable throughout the day.

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S112 Paper #: PA-087 Intra- and interobserver variability of functional MR urography (fMRU) analysis results

Dmitry Khrichenko, Kassa Darge, MD, PhD, Dept. of Radiology, The C h i l d re n ’s H o s p i t a l o f P h i l a d e l p h i a , P h i l a d e l p h i a , PA , [email protected]; Melkamu Adeb, Camilo Jaimes, Khalil Betts, Stephanie Barron Purpose or Case Report: For appropriate interpretation of the results of fMRU and surgical decision making, it is essential to know the intra- and interobserver variability of the parameters. This will allow to better set the cut-off point between normal and abnormal function and correctly categorize pathologies. The differential renal function (DRF) based on volume (vDRF) and Patlak (pDRF) are the two most important measures of split renal functions chosen for evaluation of variability. Methods & Materials: Fifteen cases of fMRUs (10 = non- and 5 = unilateral duplications) with a total of 35 pelvi-ureteric-units were included. A group of six persons comprising of one pediatric radiologist, one pedatric radiology fellow, one radiology resident, one pediatric urologist and two MRI technologists performed the analysis after a standardized rigorous training using the “chopfmru” freeware. Each participant was provided with the T1dynamic series for analysis on an external computer. Each case was analyzed twice, at least 1 week apart. For the intraobserver variability the results of rounds one and two were compared. For the interobserver variability the results of both rounds were included. The difference in percentage between the right and left kidney was chosen for comparison instead the values of each kidney separately. Results: The interobserver variability expressed in average standard deviation in the difference of the right and left volumetric DRF was 5.8%. The corresponding value for the Patlak DRF was 4.0%. When this result is broken down in non-duplicated and duplicated ones the differences in volumetric DRF are 4.9% and 7.4% and in Patlak DRF 3.8% and 4.5%, respectively. When the volume of a duplicated kidney was measured as a whole and compared to the contralateral non-duplicated one the average standard deviation for the volumetric DRF was 4.9%. The separate analysis of the upper and lower moieties of a duplex kidney resulted in average standard deviation in the difference of the volumetric DRF of 13.6% and Patlak DRF of 6.3%. Thus delineation of each moiety of a duplex kidney is a difficult task. The intraobserver variability i.e. between rounds one and two of the analysis was for the difference in volumetric DRF 5.4% and for Patlak DRF 3.9%. Conclusions: There is a relatively low intra- and interobserver variability of the fMRU DRF analysis results, which is 4–5% and thus in a similar range as that derived from scintigraphic studies. The delineation of the upper and lower poles of a duplex kidney has relatively high variability.

Paper #: PA-088 Clinical and Imaging Features of Tuberous Sclerosis Complex/Autosomal Dominant Polycystic Kidney Disease: A Unique Genetic Disorder

Susan Back, MD, Department of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Savvas Andronikou, Tracy Kilborn, Bernard Kaplan, Kassa Darge, MD, PhD

Purpose or Case Report: Genes for Tuberous Sclerosis Complex (TSC) type 2 and Autosomal Dominant Polycystic Kidney Disease (ADPKD) type 1 are both encoded over a short segment of chromosome 16. Deletions involving both genes, known as the contiguous gene syndrome (CGS), exhibit variable phenotypes of TSC and ADPKD. Unlike renal cysts in TSC, cystic disease in CGS results in hypertension and renal failure. This syndrome has not been reviewed in the radiology literature. Because patients undergo abdominal imaging for a variety of indications, the radiologist may see polycystic kidney disease before the patient develops other stigmata of TSC. Conversely, in patients with known TSC, enlarged polycystic kidneys should signal the possibility of the CGS and not simply TSC. Distinguishing these diagnoses has implications in prognosis, treatment and genetic counseling. This study describes the clinical and renal imaging findings of TSC/PKD in seven patients and reviews the literature. Methods & Materials: Renal ultrasounds of patients with genetically proven or high clinical suspicion of the CGS were retrospectively reviewed. When available, abdominal and brain CT and/or MRI were also reviewed. Results: Patient ages ranged from birth to 21 years over the course of imaging. The mean follow-up period was 10y 5 m (4y 6 m to 18y 3 m). No patient progressed to end-stage renal disease in this period. Three patients were initially imaged due to stigmata of TSC, three due to abdominal distension and one due to elevated creatinine. All patients developed enlarged, polycystic kidneys. 50% or more of the parenchyma was ultimately replaced by >15 cysts resulting in significant cortical thinning. The largest cysts in each kidney ranged from 2.4 to 9.3 cm. Multiple echogenic lesions were present in each kidney, suspected angiomyolipomas (AML), ranging from 0.3 to 3.5 cm. Compared to the last imaging studies, the initial ones only demonstrated 50% of kidneys to be borderline or enlarged. The majority had 10 or more cysts and 0–5 echogenic foci in each kidney, measuring 0.8 cm maximally, which were possible AML’s. All kidneys demonstrated increased cortical echogenicity and decreased corticomedullary differentiation. Cortical thinning varied with size and number of cysts. Conclusions: The sonographic renal findings in CGS progress over time and appear to have a specific pattern different from typical TSC. As findings of TSC may not manifest in the young child, the radiologist can be the first to suggest this diagnosis with implications for prognosis and management. Paper #: PA-089 Outcome’s Predictors of Children With Primary Non Refluxing Megaureter Prenatally Detected

Maria Tombesi, Hospital Interzonal Dr. Jose Penna, Bahia Blanca, Argentina, [email protected]; Laura Alconcher Purpose or Case Report: Primary non refluxing megaureters (PMU) tend to resolve spontaneously, however predictor factors are not clear. Our objective was to assess possible clinical and radiological predictor’s factors of evolution Methods & Materials: The charts of 50 NB with PMU were reviewed. Sex, unilateralism or bilateralism, urinary tract infection incidence, treatment and outcome were determined. Based on the anteroposterior retrovesical ureteral diameter, PMU were classified into grades (G) I: <7 mm, II: 7–10 mm and III: >10 mm. In patients with PMU G III and in those in whom dilatation progressed, diuretic radiorrenogram was performed. The outcome of the ureteral and pelvic dilatation was assessed as resolution, stability or progression. Statistical analysis was performed

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(Kaplan-Meir resolution curves, Fisher and long -rank test); a p<0.05 was considered significant. Results: Forty four (88%) patients were males, 13 (26%) had bilateral PMU. Nine out of the 63 PMU were G I, 35 GII and 19 G III. Mean follow-up was 57 months (r: 12–132 m). Eleven patients (22%) had urinary tract infection, 5/32 patients (15%) with G I and G II PMU vs.6/18 (33%) with G III (p=0.13). Forty four (64%) PMU resolved spontaneously during the first year of life. In none of the G I and G II patients the ureteral dilatation progressed, in 9 of 19 G III (47%) progressions was observed and 8 PMU required surgery. Resolution median age was 12 months for PMU ≤ 10 mm vs. 43 months > 10 mm (long rank p =0,045). Neither bilateralism nor gender had any effect on the rate of resolution (p=0.53 years 0.23 respectively). There was a significant correlation between the initial anteroposterior ureteral and pelvic diameters and the outcome—resolution vs. progression (p<0.001 and 0.002). Conclusions: 64% of PMU resolved spontaneously during the first year of life; none GI-GII progressed, 14% required surgery. Neither gender, bilateralism nor urinary tract infection were predictors of outcome. A statistically significant correlation between anteroposterior ureteral diameter and median age at resolution was found. The most important predictor factors of outcome were the anteroposterior retrovesical ureteral and pelvic diameters in the first postnatal ultrasound.

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necessary part of life-saving angiographic procedures. There is currently little evidence to support a CM “dose limit” in these circumstances. Paper #: PA-091 Orbital Lymphatic malformations: Does treatment with percutaneous bleomycin have promise?

Zeyad Metwalli, MD, Sheena Pimpalwar, Interventional Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Chinnadurai Ponraj, Megha Agrawal, Doug Marx, Ashwin Pimpalwar Purpose or Case Report: Although lymphatic malformations (LM) occur most commonly in the face and neck, orbital LM’s are fortunately rare. Unlike other locations, intra-lesional hemorrhage may result in elevation of intraocular pressure and vision loss. These lesions are a management challenge for both surgeons and interventional radiologists due to their deep location. The interconnected morphology of lymphatic cysts may however allow treatment of the deeper cysts by sclerosant injection into the percutaneously accessible cysts. We report our results of percutaneous sclerotherapy with bleomycin in the treatment of forehead and orbital mixed macro-microcystic LM.

Paper #: PA-090 Contrast induced nephropathy following high contrast dose angiographic procedures

Premal Patel, BSc(Hons) MBBS MRCS FRCR, Interventional Radiology, Great Ormond Street Hospital For Children, London, United Kingdom; Jonathan Pass, Clare McLaren, Sam Stuart, Derek Roebuck Purpose or Case Report: Use of iodinated contrast media (CM) is purportedly associated with contrast-induced nephropathy (CIN), defined as an increase in creatinine (Cr) of 25% over baseline. There is limited data on CIN in children. Large doses of CM are sometimes required during interventional angiography. This study aims to determine the incidence of CIN in children when a high contrast dose is given intra-arterially. Methods & Materials: A database of pediatric angiographic procedures performed over an 8-year period was analyzed in conjunction with periprocedural serum Cr levels obtained by review of a pathology database. Results: CM dose was prospectively recorded in 1132 of 1654 angiographic procedures (68%). In 549 (48%) of these CM dose was >2 ml/kg iohexol 240 equivalent, with a median of 4.3 ml/kg (maximum 31.8 ml/ kg). Pre-procedure Cr (within 30 days) was available in 476/549 (87%). Post-procedure Cr (within first 4 days) was also available in 263 (48%). 55/263 (21%) had abnormally high pre-procedural Cr. Post-procedure Cr was high in 67 (25%). There was an increase in the Cr compared to the pre-procedural value in 151 (57%), implying stable or reduced Cr in the other 43%. Only 60 (23%) had a rise in Cr of 25% (the definition of CIN). If CM load were the cause of these changes in Cr we would expect to see a relationship between dose and effect. Comparing procedures with lower dose (2–4.3 ml/kg, n=132) to higher dose (4.3–31.8 ml/kg, n=131) showed no statically significant difference in pre-procedural Cr levels, proportion with high Cr, percentage increase in Cr from baseline, or the proportion who developed CIN. No patients with normal preoperative Cr developed chronic kidney disease. Conclusions: CIN (as defined above) does develop after high CM dose angiograms (>2 ml/kg of iohexol 240 or equivalent) but the causative relationship is unclear as higher CM load was not shown to cause an increased rate of CIN. Effect of potential risk factors (such as underlying diagnosis and nature of angiographic procedure) and long-term effects on renal function are still to be analysed. Large contrast doses are often a

Methods & Materials: Data of three children aged 1,6 and 12 years with LM of the forehead and orbit who underwent percutaneous sclerotherapy using bleomycin over a 1 year period was retrospectively reviewed. Clinical presentation included a combination of pain, swelling and recurrent intra-lesional hemorrhage. Baseline intraocular pressure, vision test and chest radiograph were performed in all children. Sclerotherapy was performed under general anesthesia using sterile corneal protector and following bleomycin precautions. The cysts smaller than or equal to 1 cm were cannulated using a 25G needle while larger cysts were cannulated using 20G angiocatheter or 5 F Yeuh pigtail followed by aspiration and injection of bleomycin opacified with iodinated contrast. Ultrasound and

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fluoroscopic guidance was used during injection and C-arm CT imaging was obtained at the conclusion of the injection. Patients were admitted overnight and intraocular pressure and vision were monitored until discharge from the hospital. Results: Only one treatment session was used per patient. All procedures were successfully completed with no complications. There was good dispersion of bleomycin from the site of injection into the deeper intraorbital cysts as demonstrated by C-arm CT imaging which also correlated with the location and extent of the LM seen on preoperative MRI. At a median follow-up of 1 year, all patients had resolution of clinical symptoms. Follow-up MRI demonstrated > 90% reduction in the LM. One patient underwent additional surgical resection of the hypertrophic subcutaneous fatty tissue after successful sclerotherapy of the LM. Conclusions: Percutaneous sclerotherapy using bleomycin has promising results in the management of mixed macro-microcystic LM of the forehead and orbit. Further evaluation with long term follow-up and larger number of patients would be helpful. Disclosure: Ponraj Chinnadurai has indicated a relationship with Siemens Medical Solutions USA Inc as an Employee (Salary). Paper #: PA-092 Venous thrombolysis in children under 24 months

Kamlesh Kukreja, MD, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, [email protected]; John Racadio, Chrsitopher Dandoy, Cristina Tarango, Manish Patel Purpose or Case Report: The prevalence of thromboembolic disease (deep venous thrombosis and pulmonary embolism) in hospitalized children is estimated to be 25%. Most of these are related to catheters in young children. We aimed to assess the technical feasibility and safety of endovascular thrombolysis in children less than 24 months of age. Methods & Materials: After IRB approval, we retrospectively reviewed patients younger than 2 years who underwent venous thrombolysis between 01/2010 and 06/2013. Medical and imaging data were reviewed for the indications for thrombolysis, technique, devices and medications used. Post procedure imaging was assessed for short term efficacy and complications related to the procedure. Results: Eleven children (eight males and three females) with mean age of 490 days (21 days to 717 days) underwent endovascular thrombolysis for deep venous thrombosis involving upper extremity (6) and lower extremity including IVC (5) with the most common indication of line associated thrombosis. All upper extremity thrombosis were on left side and six patients had complex cardiac disease. The equipment used were angiojet for mechanical thrombectomy in three with infusion catheter and angioplasty in all patients. No stents were placed. There was significant reduction in thrombus burden in eight patients with partial response in three patients with central lines at the site of thrombosis. There was one episode of suspected pulmonary embolism in an upper extremity thrombolysis managed with intravenous systemic tPA. There were no episodes of significant bleeding. Two patients had no evidence of post thrombotic syndrome at a mean follow up of 183 days. Conclusions: Endovascular thrombolysis is technically feasible and safe in children less than 24 months of age and has acceptable complication risk. Paper #: PA-093 Impact of endovascular treatment for extensive veno-occlusive deep vein thrombosis in the pediatric population

George Chiramel, MD, Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Joao Amaral, Mattia Rizzi, Michael Temple, Leonardo Brandão

Purpose or Case Report: To evaluate our experience and impact of using endovascular treatment (ET) strategies in a cohort of children with acute deep vein thrombosis (DVT) of a limb. Methods & Materials: This was a retrospective study of 29 patients referred for ET using pharmaco-mechanical strategies (thrombolysis, thrombectomy or a combination of the two) for management of acute DVT in a pediatric hospital over the last 7 years. Approval from the institutional research ethics board was obtained for this review. Data collected from the electronic medical records and PACS system included clinical presentation, medical treatment prior to ET, endovascular procedure performed, immediate post-procedural course, medical treatment provided after ET and radiological findings on follow up. The follow up visits included clinical evaluation findings and the results of doppler and MRI scans, if available. The efficacy of treatment, incidence of complications, radiological follow up and outcomes were evaluated using descriptive statistics. Results: Twenty-nine patients (16 girls and 13 boys) with a median age of 16 years (range 12–17) and a median weight of 66.1 kg (range 17.8 kg to 87 kg) underwent ET for acute DVT from 2006 to 2012. Of the 12 patients with upper limb involvement, 7 (58.3%) underwent angioplasty and none underwent stenting. Of the 17 patients with lower limb involvement, 7 (41%) underwent angioplasty of which two required stenting. Temporary IVC filters were placed in 16 of the 17 patients with lower limb DVT. Two patients developed transient bradycardia and hypertension during thrombectomy, which resolved spontaneously. These patients also developed hematuria which cleared after a day. Extravasation was seen in one patient while traversing an occlusion. In one patient, removal of the IVC filter was difficult. No patient had severe bleeding during the treatment period. The extent of recanalisation ranged from 60 to 96%. Imaging findings on follow up visits showed that 18 patients (62%) had complete resolution of deep venous thrombosis, six patients (20%) had residual thrombosis, and five patients (17.2%) had re-occluded veins. Conclusions: Endovascular treatment is a valuable option in children with extensive DVT enabling a favourable post-procedural recanalisation without major complication. Endovascular strategies should be considered in the treatment of children with acute limb DVT in addition to anticoagulation. Paper #: PA-094 Endovascular Management of Extensive Venous Thrombosis in Adolescent Patients-A Single Center Experience

Karun Sharma, MD, PhD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Bhupender Yadav, Michael Guerrera, Deepika Darbari, Christien Guelcher, Yaser Diab Purpose or Case Report: Symptomatic, occlusive, proximal-limb deep vein thrombosis (DVT) treated with anticoagulation alone is associated with prolonged morbidity and increased risk of post thrombotic syndrome. Pharmacomechanical catheter directed thrombolysis (CDT) represents a more effective strategy that could lead to improved outcomes. We report our center’s experience with endovascular interventions for the management of adolescent patients presenting with extensive proximal extremity DVT who did not have symptomatic improvement despite therapeutic systemic anticoagulation. Methods & Materials: Between December 2011 and October 2013, we treated seven patients [all females; median age 17 years (Table)] with occlusive proximal limb DVT with symptoms onset of ≤4 weeks and who had no bleeding risk factors with endovascular therapy according to a standard institutional protocol. All patients were initiated on therapeutic Enoxaparin as soon as diagnosis was confirmed. Due to lack of improvement or worsening symptoms within the following 48–72 h, these patients underwent percutaneous pharmacomechanical thrombolysis

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followed by catheter-directed thrombolytic infusion (Alteplase 0.5–1 mg/ h infused via multi-side-hole catheter) and regional low-dose heparin infusion (10 units/kg/h infused via catheter sheath). Systemic anticoagulation with Enoxaparin was continued without interruption during endovascular treatment. Additional adjunctive endovascular interventions (Balloon angioplasty with/without stent placement) were also performed in patients found to have compressive anatomic venous anomalies (May-Thurner syndrome). Patients were then maintained on anticoagulation (Enoxaparin/Warfarin) for a minimum of 3–6 months. Results: All patients reported rapid symptomatic relief after completion of treatment. Grade II (50–99%) or grade III (complete) clot lysis was achieved in all patients without major bleeding events. Complications included early locally recurrent DVT (presumed due to non-compliance with post procedure Enoxaparin) in one patient which was successfully re-treated and symptomatic non-massive pulmonary embolism which required no additional treatment in another patient. TABLE: Patient 1

Age (y) 18

Gender F

2

17

F

3

17

F

4

15

F

5

18

F

6

17

F

7

16

F

Affected Venous Segment Left iliofemoral and popliteal Left sigmoid sinus and left internal jugular, innominate subclavian, axillary, brachial and basilic Right subclavian, axillary, brachial and basilic Left subclavian, axillary, brachial, basilic and cephalic Infrarenal IVC, Left iliofemoral and popliteal Infrarenal IVC and Left iliofemoral Left iliofemoral, popliteal and posterior tibial

Patient Underlying venous Thrombophilia anomaly 1 Type 1 MT None

Type (Trigger) Provoked (Surgery) Unprovoked

Provoked (OCP, PSS) Provoked (OCP, PSS) Provoked (Surgery)

Unprovoked Provoked (OCP)

Endovascular interventions CDT and balloon angioplasty

2

None

3

Venous TOS

Heterozygous FVL, CDT High Lp(a) None CDT and balloon angioplasty

4

Venous TOS

Elevated FVIII

CDT and balloon angioplasty

5

None

AT deficiency

CDT

6

Type 3 MT

None

CDT, balloon angioplasty and stent deployment

7

Type 3 MT

None

CDT, balloon angioplasty and stent deployment

MT = May-Thurner; CDT = Catheter-Directed Thrombolysis; FVL = Factor V Leiden; Lp(a) = Lipoprotein a; OCP = Oral Contraceptive Pill; PSS = Paget- Schroetter Syndrome (Effort thrombosis); TOS = Thoracic Outlet Syndrome; FVIII = Factor VIII; AT = Antithrombin Conclusions: Our experience suggests that intensive catheter-based endovascular interventions in carefully selected adolescents with extensive proximal limb DVT are safe, effective and may lead to improved early outcomes. Long term follow-up is planned for all these patients.

Paper #: PA-095 IVC Filter Retrieval in Children: Experience in a Tertiary Pediatric Center

Mahmoud Zahra, MD, FRCR, Radiology, Children’s hospital of philadelphia, Philadelphia, PA, [email protected]; Ganesh Krishnamurthy, Marc Keller, Adeka McIntosh, Anne Marie Cahill Purpose or Case Report: The purpose of the study is to describe the technique including adjunctive maneuvers, technical success, and complications of IVC filter retrieval in children referred from within and outside our institution. Methods & Materials: A retrospective 10 years review was performed of 19 children (12 males, 7 females), mean age 15 years (range 12– 17 years) who underwent IVC filter retrieval. 10/19 filters were placed in our institute. Radiologic and medical records were reviewed to determine technique of IVC filter retrieval, implantation period, technical success and complications. Results: Technical success was 100%. Filter types included; G2 Recovery 9/19, Gunther Tulip 6/19, Celect 3/19 and OptEase 1/19. Indications for filter placement included: DVT and PE 8/19 patients (42.1%), IVC floating thrombus 6/19 (31.5%), trauma prophylaxis 7/19 (36.8%) and Klippel-Trenaunay prophylaxis 1/19 (5.3%). IVC filter placement was suprarenal in 2/19 patients. The mean implantation period was 9 weeks, (range 3–35 weeks). The standard retrieval technique was used in 16/19 patients (84%). Adjunctive techniques were performed in 3/19 patients (17%); double snare technique in 1 (Gunther Tulip), single snare with balloon technique in 1 (OptEase), endbronchial biopsy forceps in one patient (Gunther tulip). The implantation time of three patients who needed adjunctive techniques were 7, 9 and 20 weeks. Procedures were performed under IV sedation in 10/19 procedures and general anesthesia in 9/19 procedures. Mean procedure time was 86.7 min (45–240 min.). Mean fluoroscopy time for 11/19 procedures was 17.9 min (range 7–82 min). On pre-retrieval cavogram filter tilt was present in 5/19 patients, mean angle 16.6°, (range 8–40°) and no patient demonstrated IVC or filter clot. On CT imaging filter strut wall transmigration occurred in one patient and the filter cone was embedded in the IVC wall in one patient. Post retrieval venography was normal in 18/19 patients with IVC mural dissection noted in one patient. No immediate, early or late complications occurred. Conclusions: IVC filter retrieval in children can be performed safely but may be challenging especially in cases of filter tilt or embedment. Adjunctive techniques may increase filter retrieval rates. Paper #: PA-096 3D Fusion of preprocedural MRI with intraprocedural C-arm CT for confirmation of bone biopsy location in pediatric interventional radiology

Tanja Kurzendorfer, Siemens Corporate Technology, Princeton, NJ, [email protected]; Erin Girard, PhD, Ganesh Krishnamurthy, Anne Marie Cahill Purpose or Case Report: Bone lesions requiring biopsy are often identified using preprocedural magnetic resonance imaging (MRI), but the MRI is typically reviewed prior to the biopsy and not used for interventional guidance. MRI has the advantage of being able to visualize lesions with bone marrow abnormalities and with an intact cortex which cannot be readily seen with computed tomography (CT) or C-arm CT, the modalities commonly used for bone biopsies. Therefore we present a pilot study to evaluate the software application of syngo iGuide needle guidance and syngo 3D/3D Fusion (Siemens Healthcare AG, Forchheim, Germany)

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using preprocedural MRI and intraprocedural C-arm CT for bone biopsies in the pediatric population.

Methods & Materials: With the help of iGuide needle guidance software, a needle trajectory from the skin to the target was planned on an intraprocedural C-arm CT acquisition. The 3D path was then dynamically overlaid onto the live fluoroscopic images to guide the biopsy needle. A collimated C-arm CT was acquired when the target was reached and fused with preprocedural MRI using 3D/3D fusion to confirm the correct needle position within in the lesion. Seven iGuide bone biopsies (six lumbar, one extremity) in combination with 3D/3D fusion were reviewed in six males and one female, with a mean age of 10.5 years (range 3.3 - 14.9 years). Results: All seven bone biopsies achieved technical success at lesion localization and provided diagnostic samples using iGuide needle guidance and 3D/3D fusion. All lesions could be visualized on preprocedural MRI acquisitions (MR positive). However 4/7 lesions were not visible on C-arm CT (CT negative). In the CT negative cases, the 3D/3D fusion of the preprocedural MRI with the intraprocedural C-arm CT helped to confirm that the biopsy was lesional. Conclusions: Our pilot experience with iGuide and 3D/3D fusion of preprocedural MRI acquisitions in the interventional radiology suite yielded diagnostic specimens in all cases and provided added confirmation of target localization especially of CT negative lesions. Future studies will investigate initial fusion of the preprocedural MRI acquisitions with the C-arm CT to plan the needle trajectory. Disclosure: Ms. Kurzendorfer has indicated a relationship with Simens AG Healthcare as an Employee (Salary). Dr. Girard has indicated a relationship with Siemens Corporation, Corporate Technology as an Empolyee, Research Scientist (Salary).

Methods & Materials: Twelve iGuide bone biopsies (five lumbar, five pelvic, two extremity) were performed in nine males and three females (mean age 9.77 years) and compared to anatomically matched CT-guided bone biopsies performed from 2008 to 2012 (19 pelvic, 24 extremity, 7 lumbar). Parameters compared were radiation dose mean and procedure time mean using z-scores. Effective doses for iGuide biopsies were estimated using the PCXMC program (v2.0.1.3, STUK, Helsinki, Finland) with an age-appropriate model and study-specific techniques including kVp and dose-area product. Effective doses for CT-guided biopsies were calculated using doselength products and age-appropriate k-factors. Results: 11/12 (91.67%) iGuide procedures were diagnostic. Compared to the corresponding CT-guided cases, average iGuide procedure time was longer for pelvic cases but shorter for lumbar and extremity cases, all without statistical significance (p>0.05). 5/5 iGuide pelvic biopsies had lower radiation doses (0.5, 0.9, 1.5, 4.6, 4.8 mSv) than the CT-guided cases with a mean of 5.39 mSv (z=−1.00, −0.92, −0.87, −0.79, −0.16). 5/5 iGuide lumbar biopsies also had lower radiation doses (0.7, 0.8, 2.9, 1.8, 10.5 mSv) than the CT-guided mean of 15.6 mSv (z=−1.21, −1.20, −1.12, −1.03, −0.41). 2/2 iGuide extremity cases had lower radiation doses (0.03, 0.05 mSv) than the CT-guided mean of 0.47 mSv (z=−0.73, −.70). Conclusions: In our initial experience, iGuide technology in the IR suite provided high diagnostic accuracy, lower radiation dose, and no significant change to procedure time. Increased experience and optimized imaging protocols may further decrease procedure time and radiation dose. Disclosure: Ms. Hwang has indicated a relationship with Siemens Corporation, Corporate Technology as a Research Assistant (Salary). Dr. Girard has indicated a relationship with Siemens Corporation, Corporate Technology as an Empolyee, Research Scientist (Salary).

Paper #: PA-098 Clinical and surgical correlation of Hip MR Arthrographic findings in adolescents

Anugayathri Jawahar, DNB, Loyola University Medical Center, Maywood, IL, [email protected]; Aruna Vade, Laurie Lomasney, Douglas Evans Purpose or Case Report: Femoro-acetabular impingement and various hip pathologies in children can cause labral tears which if left undiagnosed and untreated may lead to early osteoarthritis. The purpose of this study was to analyze the utility of hip MR arthrogram (MRA) in children by comparing the MRA findings with surgical, arthroscopic and clinical outcome. Table 1: Indications for MRA of the hip

Paper #: PA-097

Indications for MRA of the hip

No. of patients

Suspected labral tear

6

First Experience with iGuide Navigational Software Application for Bone Biopsies in Pediatric Interventional Radiology

Suspected FAI

8

Snapping hip

2

Tiffany Hwang, Children’s Hospital of Philadelphia, Los Angeles, CA, [email protected]; Erin Girard, PhD, Tanja Kurzendorfer, Xiaowei Zhu, M.S., Anne Marie Cahill

Exostosis

1

SCFE

1

Hip dysplasia

1

Purpose or Case Report: syngo iGuide (Siemens Healthcare AG, Forchheim Germany) is a novel navigational software used for needle guidance whereby a path is defined on an intraprocedural C-arm computed tomography (CT) image and the 3D path is transposed onto fluoroscopic images to guide the biopsy. iGuide allows the procedure to be performed in interventional radiology (IR) rather than the conventional CT suite. The purpose of this study is to review the radiation dose and procedure time for our initial experience using iGuide in comparison to CT-guided biopsies.

Legg –Perthes

1

Trauma evaluation

1

Sports hernia

1

Trochanteric bursitis

1

Pain for evaluation

1

Coxa profunda

1

Total

26

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Table 2: Labral tears in all study groups Group

No. of patients

Labral tears on MRA

Follow up

I

11

9

True positive—8; False positive—1 True negative—1; not evaluated—1

II

8

8

Pain resolved—6 Persistent pain—2

III

7

6

Lost to follow-up

Total

26

23

Methods & Materials: This was an IRB-approved retrospective study of 26 consecutive adolescents (ages 13–18 years) who had a hip MRA in the last 9 years and presented with groin pain and/or a snapping or popping hip. Some form of recreational physical activity was present in 18 patients. Indications for MRA are listed in Table 1. Relevant clinical history, clinical examination and operative notes were documented from hospital medical records and correlated with MRA findings. Results: The patients were grouped as follows: Group I) patients who underwent surgical management (n=11); group II) patients managed conservatively (medication, intra-articular injection, physical therapy) (n=8); group III) patients lost to follow up after being advised to have surgery (n=7). Labral tear was diagnosed on MRA in 23 patients of which 16 were anterior or antero-superior, six posterior and one multifocal. MRA labral findings were confirmed at surgery in nine, whereas one labral tear seen on MRA was found to be intact at surgery. One intact labrum on MRA in a patient with slipped capital femoral epiphysis (SCFE) could not be confirmed as the joint space was not entered during intertrochanteric osteotomy surgery (Table 2). Coexistent bone abnormalities were seen in 12 patients in our study (Table 3), of which 10 were group I patients. After surgery, pain was resolved or reduced in 9/11, persisted in severity in one who eventually required a repeat femoral osteoplasty for SCFE and one patient was lost to follow up. In group II, pain was resolved or reduced in six and persisted in two patients. MRA findings in six patients of group III correlated with clinical examination findings consistent with a labral tear and surgery was recommended but were lost to follow up. Conclusions: Labral tears diagnosed by MRA of the hip correlated well with clinical examination and surgical findings. Conservative management of labral tears diagnosed on MRA frequently led to improvement of clinical symptoms. MRA of the hip is an important diagnostic tool in the evaluation of children with clinical suspicion of isolated labral tears or tears associated with bone abnormalities.

Slipped capital femoral epiphysis (SCFE)

+

SCFE Legg-Perthes disease (LCP) LCP

− +

LCP

−

Exostosis

+

Developmental hip dysplasia

+

Total

9

12

Bone abnormalities on MRA

Surgical hip dislocation with femoral neck osteotomy, acetabular osteoplasty, labral debridement and repair Intertrochanteric osteotomy Chondroplasty with femoral neck debridement with labral repair Femoral head osteoplasty with labral repair Periacetabular osteotomy with surgical dislocation and femoral head/neck osteoplasty Resection of femoral osteochondroma with surgical hip dislocation, femoral neck osteoplasty, varus intertrochanteric osteotomy with labral repair Periacetabular and intertrochanteric osteotomy, arthroscopic labral repair

+

Confirmed at surgery Bone abnormality

Labral tear

Femoro-acetabular impingement (FAI) - cam FAI - cam

+

+

+

+

FAI - cam

Lost to follow up

FAI - cam

Lost to follow up

FAI – cam and pincer

+

+

Slipped capital femoral epiphysis (SCFE) SCFE

+

+

+

Joint space not entered

Legg-Perthes disease (LCP) LCP

+

+

+

+

LCP

+

− (true negative)

Exostosis

+

+

Developmental hip dysplasia Total

+

+

10

8

Paper #: PA-099

Table 3: Bone abnormalities detected on MRA in all study groups Bone abnormalities on Associated labral MRA tears on MRA

Surgery

Femoro-acetabular impingement (FAI) - cam FAI - cam

+

FAI - cam FAI - cam FAI – cam and pincer

− + +

Surgical hip dislocation with femoral osteoplasty and labral repair Greater trochanteric osteotomy with capsulotomy, resection of acetabular rim, labral repair with femoral neck osteoplasty Advised femoral neck osteoplasty Advised arthroscopy Periacetabular osteotomy and femoral neck osteoplasty

+

Clinical impact of diagnostic image guided hip steroid injections in CP patients with neuromuscular hip subluxation

HaiThuy Nguyen, MD, Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, TX, [email protected]; J. Kan, MD, Scott Rosenfeld Purpose or Case Report: Neuromuscular hip subluxation in the cerebral palsy (CP) population is an acquired condition that can result in pain and limitation of function. Determining whether the pain is intra- or extra-articular is important particularly if surgical intervention is considered. The purpose of this paper is to assess the diagnostic value and review technical challenges of intraarticular hip steroid injections in cerebral palsy patients.

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Methods & Materials: A retrospective review of 67 CP patients who underwent fluoroscopically guided intra-articular hip steroid (Kenalog or Aristospan) injections between 2006 and 2013 was performed. Charts were reviewed for treatment indications and follow-up treatment. A total of 21 patients were excluded due to inadequate clinical follow-up. The final study population was 46 patients with a total of 57 successful hips injected. A total of 83 injections were performed on the 57 hips; 41 used Aristospan with an average dose of 43 mg (range 20–80 mg) and 42 used Kenalog with 40 mg as the standard dose. Response to steroid injection and subsequent treatment were documented.

Results: Forty-six patients (average age: 12.8 years, range: 4–28) underwent steroid treatment of 58 hips. 57 were technically successful. Of these, 91% (52/57) had a positive response (i.e. pain relief) and 9% (5/57) had no response to fluoroscopically guided steroid hip injections. For those who demonstrated relief, 21%(9/52) underwent subsequent proximal femoral osteotomy and 29% (15/52) underwent additional hip steroid injections. For the 9% (5/57) who had no response to steroid injections, subsequent therapy was directed to extra-articular causes of hip pain. Conclusions: Diagnostic image guided steroid injections in CP patients is a viable tool for identifying and treating intra-articular causes of pain in neuromuscular hip subluxation. A multidiscplinary approach involving radiology, physiatry, and orthopaedic surgery should be considered a routine part of care in CP patients with neuromuscular hip subluxation.

Paper #: PA-100 Utility of intra-arterial Verapamil injection in patients with posttraumatic vasospasm monitored by transcranial Doppler

Patricia Cornejo, M.D, Pediatric Radiology, Phoenix Childrens Hospital, Phoenix, AZ, [email protected]; David Aria, MD, John Condie, Ruth Bristol, John Curran, Richard Towbin Purpose or Case Report: The incidence of vasospasm in children after moderate to severe traumatic brain injury is reported between 18 and 46%. The clinical exam in these patients is often noncontributory due to induced coma for treatment of the brain injury. Additional parameters, such as intracranial pressure, or brain oxygenation may or may not change significantly during vasospasm. Transcranial Doppler ultrasound (TCD) can be performed at the bedside without need for sedation. CT, MR angiography and digital subtraction angiography (DS) are often used to confirm findings suspected from elevated TCDs. In contrast to post-aneurysmal subarachnoid hemorrhage in adults, there is no established intra-arterial therapy for vasospasm in children. The purpose of this study is to determine if intra-arterial verapamil, a vasodilator, as monitored by TCD, is effective in treating children with TBI. Methods & Materials: Four children with severe TBI and low Glasgow Coma Scale (GCS), underwent daily TCD to monitor intracranial blood flow. TCD demonstrated elevated velocities and elevated MCA/ICA ratios (indicating vasospasm). All patients underwent cerebral angiography and intra-arterial verapamil injection after vasospasm was documented. Angiography post injection and immediate post-procedural and follow up TCD studies were obtained. Results: Cerebral angiography and intra-procedural TCD prior to and immediately after Verapamil injection revealed improved vessel calibers, distal flow and TCD parameters in all patients. No areas of diffusion change occurred in the territories supplied by the treated vessels. No patient exhibited change in ICP or other clinical metric. There was no recurrence of spasm and all patients have recovered to a Glasgow outcome score of 5, with follow up at 2, 10, and 16 months. Conclusions: TCDs show high specificity in the detection of vasospasm in children after TBI. It can be done safely, without moving the patient, or need for sedation. Cerebral angiography with the potential for intra-arterial calcium channel blocker should be obtained in patients with abnormal vessel velocities, patterns of flow and MCA/ICA ratios. Intra-arterial Verapamil injection is an effective method to treat vasospasm in children after severe TBI. In our group of patients, the treated vessels demonstrate improved flow dynamics by increased vessel diameter, with greater amplitude and increased velocity of flow. Children treated with verapamil show improvement in their clinical symptoms and GCS.

Paper #: PA-101 The Management Challenges of Intra-Oral Sclerotherapy

David Aria, MD, Trevor Davis, DO, Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Seth Vatsky, DO, Robin Kaye, Carrie Schaefer, Richard Towbin Purpose or Case Report: To identify and discuss the management challenges unique to intra-oral sclerotherapy. Methods & Materials: From November 2010 to October 2013, 16 intraoral sclerotherapy procedures were performed by the interventional radiology department on seven patients (four male: three female) ranging in

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age from 10 months to 21 years (mean of 10.5 years). The indications for treatment included four lymphatic malformations, two venous malformations, and one venolymphatic malformation. Treatment locations included the tongue (11), floor of mouth (7), soft palate (3), uvula (1), and palatine tonsils (1). Four patients had more than one location treated during a single procedure. All procedures were guided by ultrasound and/or direct visualization. Peri-procedural oral/intravenous steroids were administered in 9 of 16 patients (56%). Sclerotherapy agents included doxycycline emulsion (11), bleomycin (3), sotradecol (1) and kenalog. Immediate procedural and both short and long-term complications were documented. Results: Technical success was achieved in all 16 procedures. Five of sixteen patients (31%) were discharged the day of the procedure with one procedure complicated by a return and admission to the hospital the following day. Twelve patients (75%) were admitted, eight to the floor (67%) and four to the intensive care unit (33%) as a precautionary measure for airway protection. Five of twelve (42%) inpatients required post-procedural intubation (1–2 days). Length of post-procedural hospital stay ranged from 1 to 33 days (mean 6 days). The single child who had a prolonged hospital stay of 33 days underwent tracheostomy placement due to prolonged intubation (10 days). All 12 inpatients received shortterm pain and anti-nausea management with 4 (25%) requiring consultation of the pain management service. Eight of twelve inpatients (67%) required the services of child life for emotional support. One patient with doxycycline therapy became neutropenic. All 16 patients had follow-up imaging demonstrating decreased size of their treated lesions. Fifteen of sixteen (94%) patients reported improved symptomatology with no long-term complications. One patient with bleomycin therapy reported alopecia post-procedurally. Conclusions: Sclerotherapy is a highly effective treatment for a variety of vascular malformations throughout the oral cavity. However, in contrast to treatment of low-flow vascular malformations in other areas of the body, intra-oral vascular malformations are more complex due to the proximity to the airway often requiring inpatient stay and multidisciplinary management. Paper #: PA-102 MRI diagnosis of discoid lateral meniscus in children—Usefulness of morphometric values with arthroscopic and normal control group correlation

Victor Ho-Fung, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Maria Bedoya, Nancy Chauvin, MD, Theodore Ganley, John Lawrence, Diego Jaramillo

Purpose or Case Report: Discoid lateral meniscus (DLM) is a congenital variant. DLM have a propensity to degeneration and tearing. MRI criteria for diagnosis of DLM in children are not well established. The purpose of this study is to establish MR diagnostic criteria for correct diagnosis using arthroscopically proven DLM and comparing them with a normal control group (NCG).

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Methods & Materials: This is a retrospective study with IRB approval. From 2000 to 2013, 257 knee-MRIs were reviewed by a pediatric musculoskeletal radiologist. We included patients without knee surgery and available knee MRI with subsequent arthroscopic confirmation of DLM (n=78; mean age 10.3 years, range 1.7–18.3 years; 40 F, 38 M). The NCG (n=186; 76 F, 110 M) with mean age of 8.9 years (range 0.3–17.8 years). The DLM group was subdivided as intact DLM (n=31) and DLM with tear (n=47) based on arthroscopic findings. Additional patients (n=26) with massive tears or severe displacement precluding adequate measurements were excluded. Multiple morphometric measurements were obtained in the DLM and NCG groups (Figure 1). Morphometric ratios were derived from these values. Statistical analysis: independent t-test comparing DLM and NCG groups, Mann–Whitney U test to identify differences between DLM with and without tear and linear regressions to evaluate the age-relation of the measures. Receiver operator curve (ROC) analysis was used to establish cut-off values, sensitivity and specificity. Results: Age-independent cut-off values with highest sensitivity and specificity for diagnosis of DLM are: Lateral Meniscus Coronal Width (LMCW)=13.25 mm (S=96.2%, SP=97.3%) and Lateral/Medial coronal width ratio (LMCW/MMCW)=1.6 (S=93.6%, SP=95.7%). Age-dependent cut-off values with highest sensitivity and specificity for diagnosis of DLM are: Coronal tibial coverage of the lateral meniscus (%) ((LMCW/TCW)x100) under the age of 8 years=24.36% (S=100%, SP= 98.8%) and over 8 years=18.8% (S=93.9%, SP=98.1%); Lateral Meniscus Mid-Condylar Height (LMMCH) under 8 years=1.9 mm (S=100%, SP=100%) and over 8 years=1.4 mm (S=85.7%, SP=100%). Parameters with high sensitivity and specificity for DLM (p<0.001) are summarized in Table 1. There was no significant difference between DLM with and without tear (p=0.55) (evaluated as single DLM group). Table 1 - Measurements and ratios wtih highest sensitivity and specificity for diagnosis of doscoid lateral menisci MRI Parameters Lateral Meniscus Coronal Width (LMCW) Lateral/Medial coronal width ratio (LMCW/MMCW) Coronal tibial coverage of the lateral meniscus (%) (LMCW/TCW)X100 Lateral Meniscus MidCondylar Height (LMMCH)

Age Age independent R2=0.087 Age independent R2=0.023 <8 years >8 years

Cut-off Value 13.25 mm

<8 years >8 years

1.9 mm 1.4 mm

MRI Parameters

p-value

Lateral Meniscus Coronal Width (LMCW) Lateral/Medial coronal width ratio (LMCW/MMCW) Coronal tibial coverage of the lateral meniscus (%) (LMCW/TCW)X100 Lateral Meniscus MidCondylar Height (LMMCH)

1.59 24.4% 18.8%

<0.001

Sensitivity (%) 96.2

Specificity (%) 97.3

<0.001

93.6

95.7

<0.001 <0.001

100 93.9

98.8 98.1

<0.001 <0.001

100 85.7

100 100

Conclusions: The most accurate diagnostic criteria for DLM in children of all ages are: Lateral meniscus coronal width > 13 mm and Lateral/ Medial coronal width ratio >1.6.

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S120 Paper #: PA-103 Diffusion tensor imaging in evaluation of Anterior Cruciate Ligament microstructure. Preliminary data in children with normal ACL and children with ACL tears

Aikaterini Ntoulia, MD, Department of Radiology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, [email protected]; Maria Bedoya, Bernard Dardzinski, Diego Jaramillo Purpose or Case Report: Diffusion-tensor imaging (DTI) is a useful way to analyze microstructure of organized tissues. In the brain, fractional anisotropy correlates with fiber density and alignment. Using DTI of the knee in children with normal ACL and children with ACL tears, apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were evaluated and compared. Methods & Materials: Twelve children with ACL tears, eight females– four males, median age 16.1 years (range 9.1–17.6 years) and 19 agematched normal controls were retrospectively analyzed. MRI examinations were performed at 3 T. Coronal echo-planar DTI was performed in 20 directions with b values of 0 and 600 s/mm2. ACL-tibial plateau angle was measured in sagittal and coronal planes. In DTI images, ACL was outlined and subdivided into three distinct segments: femoral origin, middle portion and tibial insertion segments. In normal controls, FA and ADC values were calculated for each ACL segment, compared between segments, and correlated with age and ACL-tibial plateau angles. In children with ACL tears, FA and ADC values were compared to the corresponding values of each matched control. Non-parametric and linear regression models were used.

Results: In normal controls, mean ± SD, FA and ADC values were 0.24± 0.073 and 0.0015±0.0003 mm2/s. Mean FA values were greater at the femoral origin (0.31±0.11), than the middle portion (0.25±0.10) and tibial insertion (0.20±0.07); and were significantly different when compared between each segment (p=0.001). No significant changes in mean ADC values were noted between femoral origin (0.0015 ± 0.0004 mm2/s), middle portion (0.0015±0.0004 mm2/s) and tibial insertion segments (0.0016±0.0003 mm2/s) (p=0.247). Mean FA values increased significantly with age (R2=0.761, p<0.001) and correlated with sagittal ACL-tibial plateau angle (R2=0.305, p=0.003). In children with ACL tears mean FA and ADC values were 0.14±0.02 and 0.0019 ± 0.0002 mm2/s, with mean FA values being smaller (p<0.001) and mean ADC values larger than in controls (p<0.001). Conclusions: DTI provides valuable quantitative information for evaluation of ACL microstructural changes in childhood. ACL FA

values increase with age and are higher closer to the femoral insertion, presumably indicating greater fiber organization. FA values are lower in children with ACL tears, reflecting disorganization in microstructure due to injury. Paper #: PA-104 3D Isotropic Resolution Fast Spin-Echo Knee MR imaging–Diagnostic Performance Compared to Conventional MR Imaging at 1.5 T

Tangayi Githu, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH, [email protected]; Kathleen Emery, Kerri Highmore, Christopher Anton, Bin Zhang, Andrew Zbojniewicz Purpose or Case Report: Prior work has shown the efficacy of 3D isotropic voxel imaging of the knee at 3 T. Our purposes were 1)

2)

to assess whether a proton density (PD) 3D isotropic resolution fast spin-echo sequence (FSE-CUBE) has similar diagnostic performance as a routine magnetic resonance (MR) imaging protocol for evaluating menisci and cruciate ligaments in pediatric knees at 1.5 T whether there was any difference in reader confidence for diagnosing tears on the CUBE sequence.

Methods & Materials: This retrospective, institutional review boardapproved study was performed after proton density FSE-CUBE (approximate 4 min sequence, 1–1.5 mm resolution) was added to the routine 1.5 T MR imaging protocol performed in 150 pediatric patient (age 5–18 year). All studies were independently reviewed by two MSK radiologists separately in a blinded fashion for identification and localization of meniscal and cruciate ligament pathology. The review of the combined conventional knee MR sequences and the sagittal CUBE sequence review (including at least coronal and axial reformatted images) were separated in time by at least 3 weeks to reduce any recall bias. Confidence level for diagnosis was recorded for each structure using a five point Likert scale (1 = definite tear to 5 = definite normal). Results: A total of 51 meniscus (32 medial, 19 lateral), 32 anterior cruciate, and 19 posterior cruciate ligament tears were diagnosed. CUBE had similar sensitivity and specificity when compared with the routine MR imaging protocol for detecting meniscal and cruciate ligament tears. There were no significant differences in the CUBE and conventional 2D readings within each reader, with the first reader having a concordance rate of 94% (p<0.0001) and the second reader 93% (p<0.0001). The average level of confidence in diagnosis of tears was higher for CUBE vs the conventional series (4 vs 3.5). Conclusions: 3D CUBE imaging at 1.5 T has similar diagnostic performance as a routine MR imaging protocol for detecting meniscal and cruciate ligament tears while potentially affording a higher level of diagnostic confidence. Paper #: PA-105 Expected Knee MRI Findings in Symptomatic Children with Achondroplasia

Yakup Akyol, Nemours/A I duPont Hospital for Children, Wilmington, DE; Lauren Averill, MD, Alfred Atanda, Heidi Kecskemethy, Michael Bober, William Mackenzie

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Purpose or Case Report: Achondroplasia is the most common form of skeletal dysplasia, characterized by short limbed dwarfism. In the knee, genu varum and patellar dislocation have been well described, usually evaluated with radiographs. The MRI features of the knee in achondroplasia have not previously been reported. The purpose of this study is to describe common MRI findings of menisci, ligaments and bony relationships in the knees of symptomatic children with achondroplasia as compared to normal children. Methods & Materials: This retrospective study was IRB approved. A total 10 knee MRIs in eight children with achondroplasia and knee pain were available in the PACS at a tertiary-care children’s hospital. Two radiologists evaluated the MRI images by consensus for the presence of discoid meniscus and meniscal tear. The following measurements were also made for each knee: modified Insall-Salvati index for presence of patella baja/alta, ACL-Blumensaat’s line angle, ACL-tibial angle, PCL angle, intercondylar width index, and intercondylar depth index. The femoral notch shape was categorized as ‘A’, ‘U’ or ‘W’. Findings were compared with an age/gender matched control group of 20 healthy children with knee pain and normal MRIs and correlated with arthroscopy results. Results: All of the knees of children with achondroplasia had discoid lateral meniscus (eight complete and two incomplete), with five meniscal tears identified; none were observed in controls. Half of the study group had patella baja while none in the control group showed low position of the patella. The ACL was more vertically oriented in relation to the femoral notch in children with achondroplasia, with an average ACL-Blumensaat’s line angle of 43° (versus 10° in the control group). The PCL was taut in the study group, with a higher average PCL angle (159° versus 127°). Children with achondroplasia had deeper femoral notches than seen in the control group, and the notch extended anteriorly with an ‘A’ shape. In all six knees with arthroscopic correlation, lateral discoid meniscus, vertically oriented ACL and anteriorly positioned femoral intercondylar notch were confirmed. Conclusions: Discoid lateral meniscus, often with tear, is a consistent feature seen in knee MRIs of symptomatic children with achondroplasia. In addition, the ACL is vertically oriented and the PCL is taut. The femoral notch is deep and extends anteriorly in an ‘A’ shape. These findings should be expected in knee MRIs of symptomatic children with achondroplasia, and subsequently at arthroscopy. Paper #: PA-106 Pediatric Traumatic Posterior Hip Dislocation: Emerging Role of MRI

Jaime Stewart, MD, Children’s Hospital Colorado, Aurora, CO, [email protected]; Michael Fadell, Eduardo Novais, Mary Hill Purpose or Case Report: Historically, pediatric patients with traumatic posterior hip dislocation have been evaluated with radiographs and computed tomography (CT). Magnetic resonance imaging (MRI) is superior in evaluation of intra- and extra-articular soft tissue injuries and nonossified posterior acetabulum in the skeletally immature patient. Our aim is to compare abnormalities identified by radiograph, CT, and MRI in pediatric patients following traumatic posterior hip dislocation to determine optimal imaging evaluation. Methods & Materials: With IRB approval, the orthopaedic database was searched from July 2010 to July 2013 for children with traumatic posterior hip dislocation who had radiographs, CT, and

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MRI within 3 months of the injury. Seven pediatric patients ranging in age from 10.1 to 14.6 years (median age of 12.7 years) were identified. Six were male. Radiographs, CT, and MRI were evaluated for joint space asymmetry post reduction, posterior acetabular wall or femoral head fracture, and intra-articular fragments/loose bodies. MRIs were further evaluated for intra- and extra-articular soft tissue injury including injury to the acetabular labrum, cartilage, hip capsule, and ligamentum teres. Results: Posterior acetabular wall fractures were identified on three radiographs, five CTs, and five MRIs. Femoral head fractures were identified on one radiograph, two CTs, and five MRIs. Joint space asymmetry post reduction was visualized on four plain radiographs, three CT scans, and six MRIs. Radiographs failed to show intra-articular fragments/loose bodies, visible on two CTs and three MRIs. Intra-articular fragments/loose bodies with osseous components were better visualized on CT; however MRI was able to identify fragments/loose bodies without osseous components. MRI demonstrated six labral tears, four chondral injuries, and six ligamentum teres tears, and additionally showed capsular and peri-articular muscle injury, present in all patients. Conclusions: Following traumatic posterior hip dislocation, MRI is superior to radiographs and CT in identification of femoral head fractures, joint space asymmetry, intra-articular injuries including non-osseous fragments/loose bodies, labral tears, chondral injuries, and ligamentum teres tears, as well as capsular and extraarticular soft tissue injury, with the benefit of no radiation exposure. Paper #: PA-107 Prevalence and prognosis of osteonecrosis of the hips in children with Trichothiodystrophy with osteosclerosis

Suvimol Hill, MD, NIH, Bethesda, MD, [email protected]; Andrew Dwyer, Alexandra Barsell, Deborah Tamura, Kenneth Kraemer, John Digiovanna Purpose or Case Report: To report the prevalence and nature of the skeletal abnormalities in patients with Trichothiodystrophy. Methods & Materials: We followed 32 patients (age: 9 months– 29 years) with trichothiodystrophy (TTD) in the Clinical Center at the National Institutes of Health as part of a natural history protocol. Radiographic bone surveys were performed on 31 patients and outside radiographs were sought to evaluate bone abnormalities. In patients with hip pain or difficulty walking, hip radiographs were also obtained. A candidate gene approach was applied to all patients to assess for mutations in the XPD gene. Results: Twenty patients had mutations in the XPD gene; 17 (85%) of them had central osteosclerosis, and 9 (45%) also had osteopenia of the distal appendicular skeleton. Sixteen patients had repeat skeletal surveys and in all of the eight patients who had osteosclerosis, it was shown to be acquired/progressive.. One patient had bilateral subluxation of the hips with contractures which were treated with osteotomies and adductor release surgery. Four other patients developed osteonecrosis of the hips. These differed from the osteonecrosis of Legg Calve Perthes disease in their bilateral hip involvement, progression to deterioration of the hips, and unfavorable surgical outcomes in three of the four. All five of these patients lost ability to ambulate and three of them died, two at age nine and one at age 15 years. The only favorable outcome was in the patient who developed osteonecrosis at age

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12 and had bilateral hip replacement at age 17 years that rendered him able to walk after surgery. Conclusions: Central osteosclerosis is a common manifestation of TTD. Osteonecrosis of the hips is seen in a subset of patients with osteosclerosis that can lead to permanent inability to ambulate and differs from Legg Calve Perthes disease in its bilateral involvement, progression to deterioration of the hips, and unfavorable outcome of surgical intervention.

Conclusions: Direct shoulder arthrography is currently as the gold standard imaging technique in the diagnosis of labral pathology. However, indirect shoulder arthrography is a less invasive alternative, which is extremely helpful in the young population. In this series, the sensitivity of I-MRI for detecting labral pathology was 94% (100% for the second reader) which is comparable to the historical range reported for D-MRI of 88-96%. It appears that IMRI may be a reasonable and less invasive alternative to D-MRI in young patients.

Paper #: PA-108 Paper #: PA-109 Indirect Shoulder Magnetic Resonance Arthrography: A Novel Technique for Identifying Labral Pathology in Young Patients

Azam Eghbal, Akron Children Hospital, Akron, OH, [email protected]; Kerwin Jones, Andrew Razzano, Melanie Morscher

Purpose or Case Report: The purpose of this study is to show the sensitivity of indirect magnetic resonance imaging arthrography (IMRI) for detecting shoulder labral pathology in patients less than 21 years of age and as the direct MR arthrography replacement. The significance of the study is that shoulder I-MRI may be a reasonable and less invasive alternative to direct magnetic resonance arthrography (D-MRI) in this population. Methods & Materials: A retrospective review identified 68 cases of indirect shoulder arthrography performed over a 2-year period at a single pediatric institution, 37 of which had subsequent shoulder arthroscopic findings available for review. The I-MRI reports were compared to the operative images for the presence or absence of labral pathology by an independent pediatric orthopedic surgeon. An independent pediatric radiologist on staff provided the MRI reports. Labral pathology was defined as a labral tear or fraying. All MRI images were also reviewed by a second pediatric radiologist for labral pathology without knowledge of surgical findings. Descriptive statistics were used to analyze data

I-MRI D-MRI 94–100% 88–96% Decreased Increased due to added fluoroscopy cost Physician time for joint injection None Physician dependent Radiation Exposure None Physician dependent Consent for procedure Not Required needed Risk of joint infection & soft None Minimal tissue damage Scheduling coordination Routine Difficult (MRI, fluoro, physician) Patient compliance Improved Patient dependent Sensitivity Cost

Results: Of the 37 cases included in the study, the I-MRI reports correctly identified the presence or absence of labral pathology found during surgery in 32 cases. Compared to arthroscopic findings, the sensitivity of I-MRI for detecting labral pathology in young patients was 94%, with a positive predictive value of 90% and a 6% false negative percentage. The sensitivity for the second pediatric radiologist was 100%, with a positive predictive value of 94%, and a 0% false negative percentage.

Temporomandibular joint involvement in Juvenile Idiopathic Arthritis (JIA): Are there thresholds that distinguish normal from mild TMJ involvement?

Grace Ma, The Ohio State University Wexner Medical Center, Columbus, OH, [email protected]; Afsaneh Amirabadi, Emilio Inarejos, Rahim Moineddin, Lynn Spiegel, Andrea Doria Purpose or Case Report: Currently there is no consensus agreement on the degree of enhancement in normal temporomandibular joints (TMJ) in children, which makes it difficult to distinguish between the presence/absence of mild synovitis. Decisions to institute/discontinue therapy depend on accurate diagnosis of synovitis. Quantitative measurements of synovial and condylar enhancement (CE) maybe useful additions to current qualitative methods on early MRI diagnosis and post-therapy follow-up of TMJ involvement. The purpose of this study is to establish thresholds/tendencies for quantitative signal-to-noise (SNR) measures that enable distinction between mild TMJ involvement and normal TMJ appearance based on degree of synovial enhancement in JIA patients and to scrutinize similar thresholds/tendencies for CE. Methods & Materials: We conducted a retrospective study of TMJ MRI examinations in 77 children with JIA (58[75%] female, mean/range age 12, 5–17) and in 16 non-rheumatologic (control) children (8 [50%] female, mean/range age 9, 2–17) who underwent MRI for neurologic/orbit indications at The Hospital for Sick Children between 2010–2013. Using Muller et al’s criteria for active synovitis, TMJs of JIA patients were categorized into normal, mild, moderate/severe findings subjectively by experienced staff radiologists. The signal intensity (SI) of the synovial/ perisynovial tissues around the condyle was measured. Enhancement ratios (ER = [SNRpost-SNRpre]/SNRpre) and relative SI changes (RSIC = [SIpost-SIpre]/SIpre) were calculated. SI measurements were repeated in six patients per category to determine the inter-/intra-reader reliability. Same categorization and measurements were used to assess CE. Results: Mean ER and RSIC values of synovial/perisynovial tissues were significantly different between normal, mild and moderate/ severe with highest values in the moderate/severe group (P<0.002). TMJs with mild synovitis had significantly higher RSIC and ER than normals and controls (P <0.0009; 95% confidence interval [CI] for mild vs normal TMJs, 0.7–1.3 vs 0.2–0.5 for RSIC and 0.9–1.4 vs 0.3–0.5 for ER). Similar findings were seen for CE, P<0.009; 95% CI for mild vs normal TMJs, 0.2–0.5 vs −0.2–0.03 for RSIC and 0.3–0.6 vs −0.06–0.2 for ER. Inter-/intra-reader correlation coefficients for the measured values were excellent (90% for RSIC, 93% for ER).

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S123 Paper #: PA-110 Quantitative Skeletal Muscle MR Imaging: MR spectroscopy (MRS) as a noninvasive biomarker to determine pathologic fatty infiltration: Comparison between boys with Duchenne muscular dystrophy (DMD) and healthy boys

Hee Kyung Kim, Radiology, CCHMC, Cincinnati, OH, Hee. [email protected]; Suraj Serai, Ph.D, Diana Lindquist, Paul Horn, Brenda Wong Purpose or Case Report: To validate MRS in measurement of muscular fat and to compare with T2 maps in segregation of boys with DMD from healthy boys. Methods & Materials: Forty-two DMD boys and 31 healthy boys were evaluated with 1H-MRS in conjunction with conventional MR and T2 maps. Grading of muscle fat (0–4) and edema (0–3) on conventional images and fat fractions (fat/fat + water) on MRS of the gluteus maximus (GM) and vastus lateralis (VL) muscles were obtained. Group comparisons were made. The upper limit of the 95% reference interval (95% RI) of fat fraction for the control was applied and compared to T2 map results.

Results: Minimal fatty infiltration (grade 1) was seen in 90.3% (GM) and 71.0% (VL) of healthy boys vs. 33.3% (GM) and 52.2% (VL) of DMD boys. Muscle edema was seen in none of healthy boys vs. 52.4% (GM) and 57.1% (VL) of DMD boys. Fat fractions were significantly higher in patients with DMD than in control (P<0001). The 95% RI for GM (38.7%) resulted in 61.9% sensitivity and 100% specificity for separating boys with DMD from controls, while the value for VL (17.8%) resulted in 76.2% sensitivity and 100% specificity; both had lower accuracy than T2 maps (100% sensitivity and specificity). There was positive correlation between T2 fat values and fat fractions (P<0.0001, r=0.873 for GM, 0.861 for VL). Conclusions: MRS can differentiate DMD from control better than fat grading on T1WI. In segregation of two groups, T2 maps were more accurate than MRS. Fat fractions can underestimate actual amount of fat due to coexisting muscle edema in DMD. Paper #: PA-111

Conclusions: Quantitative SI measurements of the degree of TMJ synovitis and CE generate thresholds/tendencies which maybe useful for differentiating mild synovitis from normal TMJs in JIA.

Does double reading skeletal surveys improve sensitivity of diagnosing nonaccidental trauma?

James Massey, Radiology, Indiana University School of Medicine, Indianapolis, IN; Megan Marine, MD, Boaz Karmazyn, MD

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Purpose or Case Report: The practice of double reading has been demonstrated to improve sensitivity of detecting some pathology (e.g., cancers with both CT colonoscopy and mammography). Complete detection of fractures is important to the proper clinical management of suspected non-accidental trauma. Here we investigate if second reads of the improve skeletal survey sensitivity that could positively impact clinical outcomes. Methods & Materials: Current standard of practice at our institution is for all skeletal surveys to be initially interpreted by a pediatric radiologist and then reviewed by a second non-blinded pediatric radiologist using a dedicated standardized review form. A retrospective analysis of all available skeletal surveys of children aged up to 2 years old acquired at Riley Children’s Hospital (Indianapolis, IN) between April and September 2013. The findings in these studies were categorized as negative (no fractures), positive (definite fractures) or equivocal (undetermined if representing a fracture or variation) by the first reader and by concordance by the second reader. Results: One hundred two patients were included aged up to 2 years old. 53/102 (52%) studies were interpreted as normal with a concordant review by the second reviewer. Similarly, there were 38 (37%) studies were initially interpreted positive findings and also concordant review by the second staff radiologist. Of the 38 with concordant positive findings, 34 (89%) were suspicious for nonaccidental trauma. The remaining had positive findings that were unrelated to abuse. There were a total of 6 (4%) equivocal cases as interpreted by the first reader with a concordant interpretation by the second reader of noncontributory findings. There were 5 (6%) total non-concordant interpretations. In four of these cases, the study was interpreted as either normal or equivocal by the first reviewer and had additional findings documented by the second reviewer that did not significantly add to or change the initial interpretation or management. There was single case where a fracture was noted by the first reader with additional fractures questioned by the second reader. Conclusions: These results demonstrate that in patients with negative initial skeletal surveys, no fractures or other findings effecting clinical management were made by the second reader. Additionally, double reads in skeletal surveys in positive studies can, though rarely, result in significant change in interpretation change the management of the patient suspected of nonaccidental trauma. Paper #: PA-112

improve report accuracy. 91.7% (11/12) of radiologists felt clinicians preferred reports with both tabulated data and narrative text over narrative alone when there were >3 fractures. When radiologist were queried about preferences regarding reports used for testifying in court, 58.3% (7/12) preferred a combined data tabulation and narrative text report over a narrative text only when >1 fractures were present, compared to 91.7% (11/12) when >10 fractures were present. 100% (4/4) of pediatricians felt the tool was helpful for SS reports with >1 fracture. All CPT physicians expressed a personal preference for a SS report that included a narrated portion as well as a tabulated list of fractures. 100% (4/4) of CPT physicians preferred a combined tabulated data and narrative report for testifying in court when >3 fractures were present. Conclusions: Both pediatric radiologists and CPT pediatricians expressed a preference for SS reports that included both a narrative component and a tabulated list of fractures when multiple fractures were present. Radiologist preferences for data tabulation increased with greater numbers of fractures. An electronic fracture reporting tool was felt to improve organization and accuracy of reports, and was considered helpful to both radiologists and CPT members for purposes of testifying in cases of alleged child abuse.

Paper #: PA-113 Longitudinal Assessment of Bone Loss Using Quantitative Ultrasound in a Blood-Induced Arthritis Rabbit Model

Kuan Chung Wang, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Kuan Chieh Wang, Afsaneh Amirabadi, Anguo Zhong, Rahim Moineddin, Andrea Doria Purpose or Case Report: Osteoporosis is a common comorbidity in hemophilic arthritis. Quantitative Ultrasound (QUS) could be a suitable alternative test to Dual-Energy X-ray Absortiometry (DEXA) for assessment of osteoporosis due to its lack of ionizing radiation, and easy accessibility. We investigated the intra- and inter-operator reliability of QUS, its responsiveness to bone growth, its ability to differentiate bone adjacent to blood-injected or control joints, and the effect of soft tissues on speed-of-sound (SOS) values in a juvenile white New Zealand rabbit model of blood-induced arthritis.

Radiologist and CPT physician preferences for inclusion of computerized tabulations of multiple fractures in skeletal survey reports

Patricia Chang, Boston Children’s Hospital, Boston, MA, [email protected]; Sarah Bixby, MD, Ignasi Barber, Paul Kleinman Purpose or Case Report: To assess radiologist and clinician attitudes toward skeletal survey (SS) reporting that includes computerized tabulations of abusive fractures vs. purely narrative reports. Methods & Materials: This study was exempt from IRB review. Twenty pediatric radiologists and four Child Protection Team (CPT) pediatricians completed an electronic survey assessing reporting preferences for SS’s using computerized entry and output tabulations of abusive fractures vs. purely narrative reports. Results: 100% (4/4) of CPT clinicians and 70% (14/20) of radiologists responded to the survey. 100% (11/11) of radiologists felt a tabulated reporting tool was helpful for a SS with >3 fractures, and 63.6% (7/11) felt it helpful when 1–3 fractures were present. Similarly, 100% (11/11) of radiologists felt tabulated fracture data from a prior SS was helpful when interpreting a follow-up SS with >3 fractures and 63.6% (7/11) felt the tabulation useful when 1–3 fractures were present. 76.9% (10/13) of radiologists felt an electronic reporting tool could improve the organization of their SS reports, and 61.5% (8/13) felt the technology would

Methods & Materials: Eight (50%) of 16 rabbits were injected with autologous blood (0.1 ml/kg) eight times over a 17-week period. The remaining 8 (50%) rabbits served as controls. SOS was measured at baseline, weeks 8 and 17 post-injection (timepoints), in vivo and after the bones were excised on week 17. Longitudinal scans were obtained by two operators at the midpoint from the bottom of the heel to the top of the knee on the medial side of the tibia (Figure) at each timepoint 2 days apart. Single-timepoint intra- and inter-operator reliability was analyzed

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using intraclass correlation coefficients (ICC) and coefficients of variation (CV). Assessment of variations of intra- and inter- operator reliability according to timepoints and groups were investigated by 95% confidence intervals (CI) of ICCs. ICC <0.40 indicate poor agreement, ≥0.40 and <0.60 moderate agreement, ≥0.60 and <0.80 good agreement, and ≥0.80 excellent agreement.

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knowledge of general pediatrics. The majority (91.67%) reported that the rotation increased their understanding of the clinician’s imaging needs. 100% responded that they were either satisfied (8.3%) or very satisfied (91.7%) with the rotation, and 100% responded they would do the rotation again if given the opportunity. When asked if they would like a similar rotation on another clinical service, 75% responded definitely and 25%, probably yes. RR felt that members of the pediatrics team became more knowledgeable about radiology studies and indications as a result of having a RR on rounds, with 83.3% responding definitely and 16.67% probably yes. Conclusions: RR who rotated with general pediatrics were highly satisfied with their experience. All felt it improved their core communication and consultation skills, as well as knowledge of general pediatrics. The rotation improved their understanding of the clinicians’ imaging needs, and the pediatric team members’ knowledge of imaging findings and indications. All would choose to repeat the same or a similar clinical rotation if possible.

Paper #: PA-115

Results: Intra- and inter-operator coefficients of variation were <5% at all timepoints, and 22/27 (81.5%) ICCs were >0.60. Interval increase of SOS values in bones adjacent to injected joints was significantly lower than in control bones (P<0.01). The level of interval increase in SOS values from baseline to week 17 was significantly different in all three groups (P<0.0001). In vivo measurements did not correlate with corresponding QUS measurements performed directly on the bone (r=0.291) Conclusions: QUS has a potential clinical role for in the assessment of childhood osteoporosis. It has an acceptable intra- and inter- operator reliability, and shows responsiveness to bone growth changes over time being able to differentiate SOS measurements obtained in tibiae adjacent to injected and in control knees. Nevertheless, due to the presence of soft tissues overlying bones, in vivo SOS measurements tend to be underestimated.

Paper #: PA-114 Incorporating a radiology resident consultant into daily pediatric rounds: What is the value?

Randall Heller, Munir Patel, University of Missouri - Kansas City School of Medicine, Kansas City, MO, [email protected]; Lisa Lowe Purpose or Case Report: In the past, clinical services rounded in radiology allowing residents to learn core competencies such as communication skills, patient care and system based practice. However, with the introduction of PACS, this interaction has become far less frequent. To bridge this gap, we developed a rotation incorporating upper level radiology residents (RR) into daily pediatric rounds. The purpose of this study is to determine RR satisfaction and perceived value of the rotation. Methods & Materials: Over 2 years, 12 RR (10 PGY-4 s and 2 PGY-3 s, with an average training level of PGY 4.2 years) each spent 4 weeks rounding daily on the floor with general pediatrics. The RR responsibilities included: 1) daily presentation of imaging studies, 2) assistance with decisions on future exams, 3) review of other imaging, 4) teaching imaging indications and interpretation. The RR were surveyed to assess their experience. Results: Response rate was 100% (n=12). All RR found the experience to be definitely (83.3%) or somewhat useful (16.7%) in improving core communication and consultation skills. 100% of RR felt that the rotation was definitely (75%) or somewhat useful (25%) to increase their

Added Value of Radiologist Consultation for Pediatric Ultrasound: Implementation and Survey Assessment

Evan Zucker, M.D., Department of Radiology, Lucile Packard C h i l d re n ’s H o s p i t a l , S t a n f o rd U n i ve r s i t y, S t a n f o rd , C A , [email protected]; Beverley Newman, David Larson, Erika Rubesova, Richard Barth, MD Purpose or Case Report: To determine whether radiologist-parent (guardian) consultation sessions for pediatric ultrasound, with immediate disclosure of exam results if desired, increases visit satisfaction and understanding of the radiologist’s role. Methods & Materials: Parents (guardians) of children undergoing outpatient ultrasounds for any indication were eligible. Subjects completed a survey prior to the exam assessing demographics and baseline anxiety and knowledge of the radiologist’s role. Participants then spoke with a pediatric radiologist on a randomized basis but could opt out and request the consultation. All subjects completed a post-ultrasound survey assessing change in responses and visit satisfaction. Ordinal anxiety and satisfaction ratings were mapped to integral 1–4 point scores (lowest to highest, respectively). Differences in anxiety and understanding of the radiologist’s role pre- and post-consultation were compared using the Wilcoxon signed ranks and McNemar tests, respectively. Multivariate linear regression was used to evaluate associations between demographics and responses. Results: Fifty-three subjects participated to date, 48 (91%) of whom spoke to a radiologist. As most subjects initially randomized to nonconsultation elected to speak with a radiologist, meaningful comparison between the two groups was not possible. Mean +/− standard deviation (SD) age of subjects was 35.5 +/− 7.7 years. Forty (75%) were women, and 13 men (25%). Twenty-four (46%) were white, 16 (31%) Hispanic, 11 (21%) Asian, and 1 (2%) other. In the consultation group, mean +/− SD scores for overall experience, consultation benefit, and radiologist interaction were 3.8 +/− 0.4, 3.8 +/− 0.5, and 3.7 +/− 0.6, respectively. Demographics did not predict satisfaction with statistical significance in a multivariate model. Thirty-four (74%) of 46 respondents correctly described the radiologist’s role pre-consultation, increasing to 39 (85%) post-consultation; the difference approached statistical significance (p= 0.06). There was a statistically significant decrease in mean +/− SD anxiety from 2.1 +/− 1.0 to 1.5 +/− 0.8 post-consultation (p<0.001). Forty-five (96%) of 47 respondents indicated they would prefer to speak with a radiologist on every visit and the remainder on request. Conclusions: Radiologist consultation is well-received among parents and associated with decreased anxiety and a trend toward increased

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understanding of the radiologist’s role. Our results support the value of routine radiologist-parent interaction. Disclosure: Dr. Larson has indicated a relationship with Radimetrics/ Bayer Healthcare for Intellectual Rights (Potential Royalties).

Paper #: PA-116

Paper #: PA-117 5 minute Ultrasound: Validation of Point-of-Care Milestone learning in small aliquots

Susan Back, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Laura Poznick, RDMS, AAS, Kassa Darge, MD, PhD, Janet Reid, MD, FRCPC

No longer a holiday: Improving the pediatric radiology elective for medical students and pediatric housestaff

Eddie Hyatt, Vanderbilt University, Department of Radiology and Radiological Sciences, Nashville, TN, [email protected]; Cody Penrod, Sudha Singh, Jayne Seekins, DO, Amy Fleming, Melissa Hilmes, MD Purpose or Case Report: To formalize education in the pediatric radiology elective for medical students and pediatric residents. To use objective assessment tools measuring the impact of implemented changes. To obtain real time written feedback at the end of the elective for continuous improvement. Methods & Materials: Previously, our pediatric radiology elective for medical students and pediatric residents consisted of a morning reading room teaching session mainly focused on radiography and fluoroscopy. Afternoon time was left for self-directed study. Beginning in July 2012, the structure of the elective was changed: 1. 2.

An introductory email and formal syllabus were sent to participants prior to the start date. It included required reading assignments. A rotating weekly schedule was expanded to include cross sectional imaging (US, CT, MR), neuroradiology and nuclear medicine. The schedule could accommodate specific goals of the pediatric resident/ medical student, as requested.

Beginning academic year 2013: 1. 2. 3. 4.

An online pre test and post test tools were added. Scores were reviewed and percent improvement noted. Taking the “Image Gently” pledge was required. A scavenger hunt tool was added. It included both hardware items in radiology as well as imaging findings. Online end of rotation survey, specific to the pediatric radiology elective, was developed. This survey was in addition to the general survey medical students or residents complete for other electives.

Pediatric Residents’ surveys of the elective from pre 2012 were compared to subsequent academic years to measure the effects of the implemented programming. Results: 1. Scores improved from pre test to post test, with the highest increase in medical students (average of 27% increase). Pediatric residents showed an average 20% improvement in scores. 2. Data from 2013 survey showed students and residents rated the elective experience with >90% satisfaction for all categories. 3. The pediatric residents’ surveys for the rotation suggest increase in perception of educational value of attending rounds, overall course educational value, and applicability to future plans compared to pre-2012 data (increases of 0.17 -0.2 on a 4.0 scale.) Conclusions: Organizational efforts, including an introductory email, weekly schedule, and introduction of learning objectives through a pretest/post-test tool and scavenger hunt tool improve radiology exposure and knowledge for clinicians. They also provide objective data to assess the impact of the changes made.

Purpose or Case Report: With workflow pressures and the advent of 24/7 technologists in many hospitals, residents and fellows may not be receiving adequate training in US scanning, despite ACGME milestones and curriculum requirements to attain competency. Five minutes US provides focused,

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brief US tutorials in an enduring MP4 format with a “You tube®” appeal and available at point of care and on any mobile device. Methods & Materials: A list of the top ten pediatric US scans was developed and tutorials constructed. Using FUZE® telepresence platform, US scans were performed on volunteer patients with informed consent and approval by the IRB. Dual screen capture was achieved through streaming the US feed on a laptop computer and the patient scan on a separate mobile recorder and merging the dual feeds to permit simultaneous display. The MP4s captured in FUZE® were then “layered” into a new FUZE® presentation and voice-over and text-over added and published as a second layer MP4. The tutorials were available in a secured password protected cloudbased locker in a FUZE® account. Ten pediatric radiology fellows underwent testing to evaluate the effectiveness of two tutorials, pylorus and intussusception including 1. Skills test- observation and grading of their US skills before tutorial viewing 2. Viewing of two tutorials (pylorus and intussusception). 3. Skiils test following the tutorials 4. Survey evaluating appeal, potential reach, and learning effectiveness. Results: Cumulative skills pretest scores were 54.8% for pylorus and 54.4% for intussusception. Posttest scores were 96.8% for both. Fellows’ scanning confidence for pylorus was 44% before and 73% after watching the tutorial for pylorus, and 49% and 80% respectively for intussusception. 87% felt the tutorials lasted an appropriate amount of time and 85% felt the level of difficulty was appropriate for fellows. 72% would review the tutorials for future reference and 80% found the format appealing as a learning tool. 80% felt the tutorials have a high learning impact and far reach with potential for use outside the parent institution. Conclusions: Pediatric radiologists must have top US skills and teaching must embrace the new paradigm of learning in small aliquots at point of care. Five minutes US showed a dramatic impact on fellows’ levels of skill and confidence in US scanning for two techniques. The “You tube®” model is appealing and effective and potentially scalable to other areas of pediatric radiology. Disclosure: Dr. Reid has indicated a relationship with Oxford University Press as an Author and Editor (Royalties, Chief Editor Textbook). Paper #: PA-118 How and How Well Do Pediatric Radiology Fellows Learn Ultrasound? A National Survey

Susan Back, MD, Department of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Michael Gurian, Janet Reid, MD, FRCPC, Kassa Darge, MD, PhD Purpose or Case Report: Ultrasound (US) comprises a significant portion of pediatric imaging. Technical as well as interpretive skills are consequently fundamental in training pediatric radiologists. Unfortunately, formalized technical US education in pediatric fellowships has lagged. We surveyed pediatric fellows and program directors regarding US scanning education to improve this experience moving forward. Methods & Materials: We conducted an online survey of all United States pediatric radiology body imaging fellows and fellowship program directors. Questions posed to fellows assessed their educational US experiences during their residencies and fellowships. Directors were asked to evaluate US educational opportunities in their programs. Results: 43.9% of fellows undertook on-call US scanning without a sonographer in residency and 23.3% in fellowship. 41.8% of fellows and 58.6% of program directors reported that their fellowship had a dedicated curriculum to facilitate independent US scanning. Both fellows and program directors cited the volume of cases requiring immediate dictation as an obstacle to scanning. Fewer program directors than fellows identified lack of sufficient staffing as an obstacle, but more identified fellow disinterest. Both program directors and fellows rated independent US scanning as highly important to pediatric radiologists’ future success. Conclusions: Both pediatric radiology fellowship directors and fellows agree that technical US skills are crucial to the practice of pediatric radiology.

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However, the groups identify different obstacles to training. As US instruction is developing in undergraduate medicine and subspecialists are acquiring point of care (POC) US skills, pediatric radiology education should address the obstacles to US training and formalize a curriculum at the fellowship level. Disclosure: Dr. Reid has indicated a relationship with Oxford University Press as an Author and Editor (Royalties, Chief Editor Textbook). Paper #: PA-119 Evaluating the transcription accuracy of a clinical speech recognition system

Alexander Towbin, MD, Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; C Matthew Hawkins, MD, Rose Martin, Bin Zhang Purpose or Case Report: A large percentage of final radiology reports contain errors. The purpose of this study was to determine the transcription accuracy of a modern speech recognition system in a clinical environment, identify variables that affect its accuracy, and evaluate the change in accuracy over time. Methods & Materials: A prospective study evaluating the performance of a modern speech recognition system was performed. Participating radiologists read 10 standard reports spanning seven subspecialties at two time points: between 1 and 3 weeks after installation of the dictation software (time 1) and between 4 and 5 months after the installation of the software (time 2). Radiologists were not permitted to edit their dictations. The transcribed dictations were copied into a text document and printed. Each dictation was recorded and the following data were measured at each time point: voice pitch (Hz), rate of reading (words/minute), presence of an accent, background volume (dB), and volume of dictation (dB). The printed dictations were compared to the audio recording and errors were classified. Multiple measurements of accuracy were obtained at each time point. Results: Thirty-seven radiologists (22 M:15 F) participated at time 1 and 33 radiologists participated at time 2 (19 M:14 F). The 10 standard reports contained 1693 words. The number of errors per radiologist ranged from 15 to 75 at time 1. The accuracy of transcription ranged from 95.6 to 99.1% with an overall mean of 98%. The number of dictated words per error ranged from 17.8 to 112.9 (mean = 56.3). A total of 92% of reports contained at least one error. There was no significant difference in the mean words/error rate between time 1 (56.3) and time 2 (49.0), although a trend towards a worsening error rate was observed at time 2 (p=0.124). Multivariate analysis revealed that presence of an accent (p=0.0053) or a lower-pitched voice (p=0.0475) resulted in a statistically significant increase in errors. The rate of dictation, volume of dictation, and background noise had no significant effect on the number of errors. Conclusions: Even though speech recognition software is accurate, transcription errors are common in the clinical setting, occurring in nearly every report. Paper #: PA-120 A normative spatiotemporal MRI template of human fetal brain growth in-utero

Judy Estroff, M.D., Boston Children’s Hospital and Harvard Medical School, Boston, MA, [email protected]; Catherine Limperopoulos, Cedric Clouchoux, Edward Yang, Ali Gholipour, PhD, Simon Warfield Purpose or Case Report: Recent advances in volumetric fetal brain MRI (Studholme, Ann Rev Biomed Eng 13, 2011; Gholipour et al. IEEE Trans Med Imag 29, 2010) hold the potential for in-vivo longitudinal analysis of early brain development. A primary step for this analysis is the development of a digital MRI template of normal fetal brain anatomy. The purpose of this study is the development of a spatiotemporal MRI template characterizing normal brain development in the third trimester.

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Methods & Materials: Fetal MRI was obtained in 40 healthy fetuses from 26.14 to 35.86 weeks gestation age (30.50±3.05). The criteria for choosing healthy fetuses involved excluding pregnant women with multiple gestations, congenital infection, or any maternal contraindication to MRI, and excluding fetuses with brain dysgenesis or other systemic anomalies by ultrasound, as well as those with chromosomal abnormalities by amniocentesis. Imaging was performed on a 1.5 T Philips scanner using a phased-array cardiac coil. Multi-planar single-shot turbo spin echo MRI was performed with TE/TR of 120 ms/12500 ms and 2-mm slice thickness. Volumetric brain MRI was reconstructed for all fetuses with isotropic resolution of 1 mm3 in 3D using motion-corrected super-resolution volume reconstruction (Gholipour et al. IEEE Trans Med Imag 29, 2010). A spatiotemporal MRI template was constructed via groupwise diffeomorphic deformable registration of subjects within 1 week of the target gestation age (GA). The template was constructed via weighted averaging of registered images. A Gaussian kernel centered on the target GA was used for weighted averaging.

Results: The procedure described here takes any number of fetal brain MRI images as input and generates an unbiased average template at any gestation age. Using fetal MRI of 40 normal fetuses we generated a spatiotemporal MRI template of normal fetal brain growth in the third trimester. Figure 1 shows coronal and axial slices of this template at five GA points. As compared to the average of all 40 images (on the left), which is blurred, the template shows sharp anatomic boundaries at any target age. Conclusions: The developed deformable spatiotemporal MRI template can be used as a reference for inter-subject registration, segmentation, shape analysis, and the analysis of cortical folding in normal vs. abnormal brains based on in-vivo fetal MRI. The developed algorithm is generic and templates with more details can be obtained by using higher number of individual fetal brain MRI volumes.

Siemens Skyra 3 T scanner. Twelve cases were analyzed on each scanner. The average gestation age was 27.7±5.7 weeks on the 3 T scanner and 28.3±5.3 weeks on the 1.5 T scanner. Clinical fetal MRI involved multiplanar HASTE with TR = 2500 ms, TE = 98 ms, 3 mm slice thickness on the 1.5 T scanner and 2 mm slice thickness on the 3 T scanner without maternal sedation or breathhold. The SNR was too low with 2 mm slice thickness on the 1.5 T scanner so 3 mm was used. A volumetric image was reconstructed using the motion-robust super-resolution volume reconstruction technique developed in (Gholipour et al. IEEE Trans Med Imag 29, 2010). The reconstructed images were evaluated in a blind fashion by two independent observers with a 5-scale image quality rating system (five was the highest image quality score and one was the lowest). Results: The average score of the reconstructed MR images was 3.7± 0.9 on the 3 T scanner and was 2.9±1.0 on the 1.5 T scanner. We used a two-tailed two sample t-test to test the null hypothesis that the difference in the mean of the two groups of reconstructed images was equal. The null hypothesis was rejected by a p value less than 0.05. This indicates that on average the quality score of the images were higher in 3 T than in 1.5 T. Conclusions: In our comparison study volumetric fetal brain MRI reconstruction received significantly higher scores when scans were performed on a Siemens 3 T scanner as compared to a Siemens 1.5 T scanner. The relatively higher SNR achieved with 3 T fetal MRI enables high quality 2D HASTE acquisitions with 2 mm slice thickness which in turn result in high-resolution volumetric reconstructions. Paper #: PA-122 Retrospective motion correction and signal recovery in MR Spectroscopy of the fetal brain

Iordanis Evangelou, DPhil, Diagnostic Imaging and Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Ralph Noeske, Adre Duplessis, Catherine Limperopoulos Table 1

TE = 144 ms Before After

S/N 4 7

FWHM ppm 0.096 0.096

GPC+Ch 2.755 2.715

GPC+PCh %SD 6 3

Paper #: PA-121 TE = 144 ms Volumetric reconstruction of fetal brain MRI on 3 Tesla versus 1.5 Tesla scanners

Ali Gholipour, PhD, Judy Estroff, M.D., Boston Children’s Hospital and Harvard Medical School, Boston, MA, [email protected]; Carol Barnewolt, Susan Connolly, Sanjay Prabhu, Simon Warfield Purpose or Case Report: Volumetric reconstruction of fetal brain MRI is now achievable through iterations of inter-slice motion correction and robust super-resolution volume reconstruction (Gholipour et al. IEEE Trans Med Imag 29, 2010). The efficacy of this technique, however, is dependent upon the type and amount of motion and the quality of the acquired 2D slices in terms of in-plane spatial resolution, slice thickness, signal-to-noise ratio (SNR), and image contrast. These characteristics vary based on the type of the scanner, coil, imaging protocol and parameters. The purpose of this study is to compare 3D volumetric reconstruction of fetal brain MRI from Half-Fourier Acquisition single shot turbo spin echo (HASTE) scans acquired on 3 T MRI versus 1.5 T MRI scanners. Methods & Materials: In a random design data experiment, we processed clinical fetal MRI scans acquired on a Siemens 1.5 T scanner and a

Before After

NAA+ NAAG 4.330 4.240

TE = 35 ms Before After

S/N 6 10

TE = 35 ms

NAA+ NAAG 2.615 2.625

Before After

NAA+ Cr+PCr Cr+PCr %SD NAAG %SD 9 4.039 11 6 4.262 6

FWHM ppm 0.076 0.067

GPC+PCh 1.951 1.823

GPC+PCh %SD 6 5

NAA+ Cr+PCr Cr+PCr %SD NAAG %SD 18 3.273 10 11 3.169 7

Purpose or Case Report: In vivo fetal MR imaging and spectroscopy remain challenging due to maternal breathing, fetal movement as well as low signal to noise. We developed a motion robust fetal brain MR

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spectroscopy acquisition and pre-processing methodology that improves metabolite quantification. Methods & Materials: Single voxel 1H MR Spectroscopy was acquired on a 1.5 T GE scanner using an 8-channel surface coil. No maternal or fetal sedation was used during the MRI and MRS exams. A customized PRESS sequence with water suppression was used with the following parameters: repetition time (TR) 1500 ms, echo time (TE) both 144 ms and 35 ms, 128 excitations, voxel size 27 mL and acquisition time of 3:48 mins. Anatomical scans in three orthogonal planes were first acquired to guide voxel placement. The voxel was placed in the midbrain to avoid contributions from scalp and extracranial tissue, which may cause contamination of the spectra with unwanted lipid signals. Auto-prescan and auto-shim procedures were performed followed by fine adjustment of the center frequency, transmitter and receiver gains. Raw spectra were transferred to an off-line Linux workstation for linear weighted coil element combination and for subsequent pre-processing. This included zero-filling, line-broadening and frequency correction, phasing, averaging and baseline correction. Resulting spectra were then fitted to basis spectra spectra of Ch, GPC, Cr, PCr, NAA and NAAG, using LCModel to calculate metabolite ratios in the chemical shift range of 4.0 ppm to 1.0 ppm using the un-suppressed water signal as internal reference.

Results: MRS was performed during the 2nd and 3rd trimester of pregnancy in 108 normal subjects with 90% success rate. Spectra were quantified with LCModel before and after pre-processing. Signal to noise ratio was improved in the pre-processed spectra and the Full Width Half Maximum (FWHM) was decreased allowing better resolution of adjacent peaks. Also the level of uncertainty calculated by the Cramer-Rao lower bounds (%SD) was also decreased. The improvements in the quantification of the concentrations for both acquisitions in a 34.5 week fetus are shown in Table 1. The improvement in the spectra quality is shown in Figure 1. Conclusions: The proposed methodology combines both acquisition and pre-processing steps and offers great promise in acquiring reliable and valid spectra during the 2nd and 3rd trimester of pregnancy realizing the fact that the fetus moves constantly during acquisition.

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Amy Mehollin-Ray, Texas Children’s Hospital, Houston, TX, [email protected]; Gregor Kasprian, Anil Shetty, Jennifer Williams, Christopher Cassady, MD Purpose or Case Report: Open fetal repair for myelomeningocele is now being performed at many centers across the United States, but there is little published information regarding imaging the fetal brain and spine after this procedure takes place. We report our experience with 12 cases of fetal repair, imaged pre- and post-operatively with fetal ultrasound and MRI.

Methods & Materials: The pre- and post-operative fetal ultrasound and MRI examinations of 12 patients who underwent in utero myelomeningocele repair were reviewed by two radiologists. The following anatomical features were evaluated: size of cerebral ventricles, amount of supratentorial subarachnoid space, level of tonsillar herniation and spinal defect site. Results: The average gestational age at the time of fetal repair was 24 3/7 weeks (range: 21–25 6/7 weeks). The average time between the first fetal MR and repair was 2 5/7 weeks (range: 1–4 3/7 weeks). The average time between repair and post-operative MR was 6 2/7 weeks (range: 4– 8 weeks). The pre-operative fetal examinations all showed open neural tube defects beginning between L2 and S1. All defects were myelomeningoceles except for one case of myeloschisis. All pre-operative examinations showed typical Chiari II malformation features. The average lateral ventricle diameter was 11.6 mm (range: 7–18 mm). The average subarachnoid fluid depth at the insular cistern was 3.9 mm (range: 0–6 mm) and at the occipital lobe, 0 mm. The average level of tonsillar herniation was C2 (range: C1-C3). Post-operatively, four of eight patients with adequate T1-weighted images showed a T1-hyperintense covering at the repair site suggesting primary skin closure. All patients showed an increase in the diameter of the lateral ventricles of 4 mm on average (range:1–7 mm; average post-operative lateral ventricle diameter, 15.1 mm {range: 8–23 mm}). All but two patients showed an increase in extra-axial space of 5.5 mm on average. All but one patient (myeloschisis) showed correction of tonsillar herniation.

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Conclusions: Besides correction of tonsillar displacement, increase in width of the subarachnoid space was the most prominent morphologic change after fetal myelomeningocele repair. The size of the cerebral ventricles was also found to increase.

Paper #: PA-124 Correlation between spleen and stomach position by MR with the presence of a hernia sac in fetuses with left-sided congenital diaphragmatic hernia

Lucila Rosines, Texas Children’s Hospital, Houston, TX, [email protected]; Amy Mehollin-Ray, Gregor Kasprian, Wei Zhang, Christopher Cassady, MD Purpose or Case Report: The presence of a hernia sac confers a better prognosis in fetuses found to have congenital diaphragmatic hernia (CDH). Accurate prediction of a hernia sac by fetal imaging would allow for more precise prenatal counseling. The purpose of this study was to determine if the position of the spleen or the stomach was related to the presence of a hernia sac and whether their position could predict the presence or absence of a hernia sac in patients with left-sided congenital diaphragmatic hernia.

sac (p=0.0005). When the spleen position was ≥3, the negative predictive value for the presence of a sac was 0.95, and when the spleen was in position 4, the negative predictive value was 1.00. There was a 3.6-fold increase in the likelihood of having a hernia sac for each one unit decrease in spleen position. Conclusions: The position of the spleen in fetuses with left-sided CDH is significantly related to the presence of a hernia sac. A spleen positioned in the midline or right thorax has a very high negative predictive value for the presence of a hernia sac. Improvements in the ability of fetal MR to detect or exclude a hernia sac in patients with congenital diaphragmatic hernia allow for more accurate prognostication and facilitate prenatal counseling. Table 1 - Logistic Regression for Spleen Position

Cutoff ≤1 ≤2 ≤3

Sensitivity (95% CI) 0.23 (0.08–0.45) 0.86 (0.65–0.97) 1.00 (0.85–1.00)

Specificity (95% CI) 0.9 (0.84–0.97) 0.64 (0.53–0.74) 0.23 (0.14–0.33)

NPV (95% CI) 0.83 (0.74–0.80 0.95 (0.86–0.99) 1.00 (0.83–1.00)

PPV (95% CI) 0.42 (0.15–0.72) 0.37 (0.24–0.52) 0.24 (0.16–0.34

Paper #: PA-125 Preliminary results on measuring fetal lung maturation using diffusion weighted MRI at 3 T

Onur Afacan, PhD, Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, [email protected]; Ali Gholipour, PhD, Judy Estroff, M.D., Carol Barnewolt, Susan Connolly, Simon Warfield Methods & Materials: A retrospective review of fetal MR exams for CDH obtained at Texas Children’s Hospital over a 12-year period was performed. The position of the stomach and spleen was noted for each fetus and was categorized using the following scale: 1, left upper abdominal quadrant; 2, left hemithorax; 3, midline thorax; 4, right hemithorax. The presence or absence of a hernia sac was confirmed at the time of surgery and by pathologic review of the specimen. Contingency tables and Fisher’s exact tests were produced to test the association between spleen and stomach positions and the presence of a hernia sac. Multivariate logistic regression was then applied with spleen and stomach positions as covariates. ROC analysis was applied to evaluate the predictive value of spleen position. Results: A total of 110 patients had fetal MR exams for left CDH. Twenty-two patients were found to have a hernia sac while 88 did not. The presence of sac was significantly related to spleen position (p < 0.0001). Stomach position was only significantly associated with hernia sac when the stomach position was ≥ 3 (p=0.0293). Logistic regression analysis revealed that only the spleen position had a predictive value for the presence of a hernia

Purpose or Case Report: The aim of the study is to establish the normal range of fetal lung diffusion values measured at a 3 T MRI scanner in fetuses with normal lung development. This study will help to determine whether diffusion coefficient can be used to assess fetal lung development.

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Methods & Materials: Multi-slice single shot Echo Planar Imaging (EPI) sequence was used to acquire diffusion weighted scans in 24 fetal MRI exams. All scanning was performed on Siemens 3 T Skyra scanner. In-plane resolution was 2.5 mm×2.5 mm and slice thickness was set at 3 mm. Each patient was scanned with six different B values (0, 50, 100, 200, 400, 600 s/mm^2) in multiple planes (axial, coronal) for better identification of the diffusion decay. After the image acquisition, cases with large maternal movements (nine cases) were identified and removed from the study. In this work results from 15 patients are reported. For each case a region of interest was manually drawn in each lung and the mean signal value was calculated for each B value. A single exponential was fit into the data and for each case a single apparent diffusion coefficient (ADC) value was calculated. Results: The ADC averaged over all 15 subjects with an average gestational age of 28 weeks, was found to have a mean of 2um^2/ms with a standard deviation of 0.4um^/ms. ADC values ranged from 1.2um^2/ms (21 weeks) to 2.8um^2/ms (36 weeks). In the supplementary figure ADC values from each patient was plotted against gestational age. ADC was found to be positively associated with gestational age, with a regression value of 0.061 and correlation coefficient of 0.8021. Conclusions: This work presents the first in vivo measurements of diffusion in the fetal lungs at a 3 T scanner. We have found a high correlation between ADC and gestational age in fetuses with normal lung development. This might be a reflection of an increase in pulmonary vasculature as reported in a 0.5 T study (Moore et al. MRM 2001). There has also been reports (Balassy et al. Eur Radiol 2008, Lee et al., Ultrasound Obstet Gynecol) that found no correlation between ADC and gestational age, but it should be noted that these studies only acquired two B values (B=0 & B=700) and therefore might be affected by the fast diffusion component resulting from perfusion.

Paper #: PA-126 Real-time Cine Magnetic Resonance Imaging of Swallowing Abnormalities in the Fetus with Head and Neck Pathology: Frequency and Patterns

Hansel Otero, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Lisa States, Maria Bedoya, Avrum Pollock, Tamara Feygin Purpose or Case Report: We retrospectively studied the patterns of abnormal swallowing in fetuses with head and neck pathology as depicted with real time cine MRI using a 2-dimensional fast imaging with steady state acquisition technique in the mid sagittal plane Methods & Materials: All fetuses with head and neck pathology referred for MRI in which cine sequences were obtained in 2012 were selected. The demographics, indications, and cine findings were reviewed and described. Cine MR Images were used to assess the degree of involvement, displacement, compression and function of the oral cavity, oropharynx, hypopharynx, and trachea by head and neck pathology Results: Four hundred twenty-nine MR studies evaluating the brain, head and neck, and spine of 454 fetuses were performed in 2012. Fifty seven cases with gestational ages ranging from 18 to 37 weeks, were referred for head and neck pathology. Cine MR sequences were obtained in 31 of these fetuses with the following indications: cleft lip (12/31–39%), craniosynostosis (4/31−13%), face mass (5/31–16%), neck mass (9/31–29%), and a skull lesion (1/31–3%). Fetal swallowing abnormalities were observed in 19/31 (61%) cases; while the swallowing mechanism was normal in the remaining 12/31 (39%) cases. The patterns of abnormal swallowing included velopalatine incompetence with or without glosoptosis and abnormal tongue contraction (10/19–53%), impaired swallowing due to mechanical obstruction (5/19–26%), isolated hypopharyngeal pooling of

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ammiotic fluid (3/19–17%), and isolated glosoptosis with abnormal tongue contraction and foreshortening (1/19–5%) Conclusions: Fetal cine-MR imaging allows the determination of different patterns of swallowing abnormalities, which complement the MRI evaluation of upper GI function and might impact treatment planning and prognosis Paper #: PA-127 Disorders of Sex Differentiation (DSD): The Radiologist’s Role in Prenatal Diagnosis

David Jennings, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Anna Blask, MD, Dorothy Bulas, MD, Margaret Menzel, Eva Rubio Purpose or Case Report: Disorders of Sex Differentiation (DSD), (ambiguous genitalia), are a rare spectrum of anomalies. The role of fetal US and MRI imaging in conjunction with a multi-disciplinary team is discussed.

Diagnosis

US Findings

MRI Findings

AIS (Partial) with hypospadias (XY)

“tulip sign”-micropenis between scrotal folds

Same-Small scrotum with micropenis

Gonadal Dysgenesis (XY) Phenotypic Female Hypospadias (XY)

20 Weeks: “tulip sign” N/A 29 Weeks: prominent labia “tulip sign”

N/A

Hypospadias (XY)

“tulip sign”

Same-Small scrotum with micropenis

True Hermaphrodite with hypospadias and bifid scrotum (XY) True Hermaphrodite (XY) UG sinus and prominent clitoris

“tulip sign”

N/A

Same -“tulip sign” with “tulip sign” with flattened flattened central central bump bilobed cystic bump structure in pelvis with bilobed cystic strucpossible internal gonads ture in pelvis with possible internal gonads

Normal Female (XX)

clitoral prominence

Superior-normal female genitalia

Normal Female (XX)

clitoral prominence on single image, normal female genitalia on all other images questionable micropenis

N/A

Normal Male (XY), DWM Diminutive phallus with epispadias (XY) OEIS

Superior- Normal male genitalia

two separated scrotal sacs with Same-two separated testes, no penis scrotal sacs with testes, no penis

Methods & Materials: A retrospective review was performed of potential prenatal DSD cases referred to our fetal center from 2007 to 2013. Prenatal US/MRI images were reviewed and correlated with gestation age, differential diagnosis, associated syndromes and work-up garnered by a multi-disciplinary team and correlated with postnatal follow up. Results: Fifteen cases with DSD diagnosed prenatally were identified. All 15 had a prenatal US, 10 also had a fetal MRI performed on the same day. GA 18–33 weeks. Follow up was available in 10. Of the remaining five; two terminated, two fetal demise (one OEIS, one Dandy Walker Malformation), and one lost to FU.

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Of the 10 cases with FU, eight were referred for suspected DSD, two for other abnormalities. Six had US and MRI; four US only. US/MRI findings most useful were penile size and configuration of the genitalia (see Table). Similar findings were noted on US and MRI in 4/6 and correctly correlated with postnatal exam. MRI was superior to US in 2/6 cases confirming normal genitalia that were not as clearly seen by US. Of four cases in which only US was performed, three correctly reflected postnatal diagnosis. In one case, the US questioned clitoral prominence but at delivery normal XX genitalia was noted. MRI was superior in delineating associated findings including Dandy Walker Malformation and OEIS. Postnatal diagnosis included four hypospadias (one AIS, one true hermaphrodite), one gonadal dysgenesis XY phenotypic female, two normal females, one normal male, one true hermaphrodite with UG sinus, and one OEIS with epispadias. In several cases, final sex assignment took months to establish using fluoroscopy, sonography, MRI, clinical, pathologic and laboratory results in consult with the interdisciplinary team: (geneticists, endocrinologists, urologists, gynecologists and radiologists). Conclusions: DSD is a complex group of disorders requiring an understanding of anatomical variations of genitalia. US is the screening tool to suggest DSD. MRI is a useful adjunct to help confirm the presence of normal or abnormal genitalia and delineate additional anomalies. Prenatal assessment is important in counseling and management, helping parents come to terms with the disorder prior to delivery. Disclosure: Dr. Bulas has indicated a relationship with GE as a Non-paid Consultant; Philips, Non-paid Consultant. Paper #: PA-128 Prenatal Observation of Echogenic Kidneys: What Have We Learned?

Rama Ayyala, M.D., Boston Childrens Hospital, Boston, MA, [email protected]; Judy Estroff, M.D., Richard Lee, Michael Somers, Susan Connolly, Carol Barnewolt Purpose or Case Report: Abnormally echogenic kidneys (EK) in the fetus present a counseling dilemma. Very little is known about the implication of this observation. The purpose of this study is to correlate the prenatal observation of EK with early postnatal outcomes. Methods & Materials: A retrospective study of patients diagnosed with EK on antenatal ultrasound between 2002 and 2011 was performed. Prenatal data collected included: gestational age at observation, laterality, renal size, presence of cysts, amniotic fluid (AF) volume, and associated anomalies. Postnatal data included: imaging, clinic notes, and renal function tests. Statistical analysis was performed using MATLAB (Mathworks Inc, Natick, MA). Results: Forty-two fetuses were identified with the prenatal diagnosis of EK. 11/42 were either interrupted, had an intrauterine demise, or the infant died moments after birth. Suspected diagnoses in this group include: bladder outlet obstruction (4/11; 37%), polycystic kidney disease (2/11; 18%), multiple anomalies (2/11; 18%), unspecified dysplasia (2/11; 18%), and twin-twin transfusion syndrome (1/11; 9%). 9/11 had low or absent AF. Of the remaining 31 who survived the newborn period, two were lost to follow up. Unilateral EK was identified in 10/31 (32%) and bilateral EK in 21/31 (68%). 15/31 (48%) had discernible renal cysts and 13/31 (42%) had hydronephrosis. 22/31 (71%) had normal AF and 7/31 (23%) had low AF. 7/31 (23%) had other non-renal anomalies identified on the antenatal ultrasound. Confirmed postnatal diagnoses include: resolution of EK (4/29; 14%), polycystic kidney disease (PKD) (3/29; 10%), unilateral multicystic dysplastic kidney (9/29; 31%), Prune Belly Syndrome (PBS) (2/29; 7%), urethral valves (3/29; 10%), reflux (2/29; 7%), ureterovesicle or ureteropelvic obstruction (2/29; 7%) and unspecified dysplasia (4/29; 14%). 6/29 (21%) to date had abnormal renal function tests with

diagnoses of valves (3), PBS (1), and PKD (2). 3/29 (10%) required dialysis with diagnoses of valves (2) or autosomal recessive PKD (1). Two who required dialysis have died. Conclusions: In this retrospective review, 79% of infants with prenatal EK, who survived day one of life, have done well in the first year of life. Those with low amniotic fluid, evidence for valves or with enlarged kidneys are at risk for early onset impaired renal function. Analysis is confounded by the non-surviving group with no confirmatory data, though the high percentage of low or absent AF may imply more severe renal dysfunction.

Paper #: PA-129 MRI Shows Limited Mixing Between Systemic and Pulmonary Circulations in Fetal Transposition of the Great Arteries—A Potential Cause of In Utero Pulmonary Vascular Disease

Prashob Porayette, Joshua van Amerom, Shi-Joon Yoo, Edgar Jaeggi, Christopher Macgowan, Mike Seed, Diagnostic Imaging, SickKids, Toronto, ON, Canada, [email protected] Table 1 – Flows in twelve fetuses with normal hearts and four fetuses with transposition of the great arteries. Flows were measured by phase contrast cardiovascular magnetic resonance with metric optimized gating and expressed as a percentage of the combined ventricular volume. MPA % cvo Normal† 60±4 TGA 1 31 2 37 3 38 4 40 t-test‡ p <0.001

AAo % cvo

SVC DA % cvo % cvo

DAo PBF UV FO % cvo % cvo % cvo % cvo

37±4

28±7

41±8

50±12 17±9

30±9

17±14

66 60 59 57

21 20 24 18

17 19 20 15

49 40 46 37

14 12 11 40

32 27 24 20

4 0 11 −1

0.818

0.331

0.014

<0.001 0.014

<0.001 0.126

TGA- transposition of the great arteries, CVO- combined ventricular output, MPA- main pulmonary artery, AAo- ascending aorta, SVCsuperior vena cava, DA- ductus arteriosus, DAo- descending aorta, PBF- pulmonary blood flow, UV- umbilical vein, FOforamen ovale. † values for normals (n=12) are expressed as sample mean ± standard deviation ‡ two-tailed independent t-test with unequal variance Purpose or Case Report: Objectives: To investigate the relationship between fetal hemodynamics and postnatal clinical presentation in patients with transposition of the great arteries using phase contrast cardiovascular magnetic resonance. Background: A severe and irreversible form of persistent pulmonary hypertension of the newborn occurs in up to 5% of patients with transposition and is now the leading cause of morbidity and mortality in these infants. Restriction at the foramen ovale and ductus arteriosus has been identified as a risk factor for the development of pulmonary hypertension, and this can now be studied with MRI using a new technique called metric optimized gating. Methods & Materials: Blood flow was measured in the major vessels of four fetuses with transposition with intact ventricular septum (gestational age range: 35–38 weeks) and compared with values from 12 normal fetuses (median gestational age: 37 weeks; range: 30–39 weeks). Results: We found significantly reduced flows in the ductus arteriosus (p<0.001) and foramen ovale (p=0.01) and increased ascending aortic

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(p<0.01) and aorto-pulmonary collateral (p<0.01) flows in fetuses with transposition compared with normals. The fetus with the lowest foramen ovale shunt and highest aorto-pulmonary collateral flow developed fatal pulmonary vascular disease. Conclusions: We found limited mixing between the systemic and pulmonary circulations in a small group of late gestation fetuses with transposition. We propose that the resulting hypoxia of the pulmonary circulation leads to increased aorto-pulmonary collateral flow and may contribute to the development of pulmonary vascular disease in some fetuses with transposition. Figure 1

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padding. Dose can be further reduced by tailoring scan parameters to the clinical indication and optimizing contrast injection for first-pass enhancement of target vasculature. This study evaluates our initial experience with the ‘target mode’ for cardiovascular studies in neonates and infants. Methods & Materials: After IRB approval, retrospective evaluation of ‘target mode’ CTA for cardiovascular indications was performed. Twenty-seven patients aged 0–6 months were included. All scans were on a 320-detector scanner at exposure time of 350 ms, half-scan reconstruction, 80 kV and 30–100 mA (indication based). Heart rate was used to determine the target phase and ImageExact was used to reconstruct a motionless phase of the cardiac cycle. A 3D image processing workstation was used for analysis. Image quality, pathology detection and reader confidence for vascular targets was graded independently by two radiologists on a four or five point scale. Quantitative ROI-based density measurements in vessels of interest and skeletal muscle were used to calculate CNR. Final diagnosis was based on consensus reading, and by comparison to catheterization and surgical reports if available. Results: Mean age was 34.3 days. Indications included status of branch pulmonary arteries and aorta in Tetralogy of Fallot, evaluation of major aortopulmonary collaterals or ductal dependent pulmonary flow in pulmonary atresia, anomalous pulmonary venous return, pulmonary vein stenosis, coarctation and heterotaxy. All studies were done free-breathing and were diagnostic for the clinical indication with high reader confidence. Mean scan length was 87.1 mm (range 59.75–119.75). Average DLP was 5.9 (2.2–10) with average effective dose of 0.46 mSv (0.18–0.82) using conversion tables from ICRP publication 103. Average DLP and effective doses were 5.3 and 0.44 mSv when the target was large vessels, 5.9 and 0.48 mSv in the setting of pulmonary atresia with MAPCAs and heterotaxy, and 7.0 and 0.58 mSv when the target was pulmonary veins respectively. Conclusions: Volumetric imaging with target mode of prospective EKG gating, in conjunction with indication-based scan parameters and a firstpass contrast enhancement protocol, provides diagnostic studies in freebreathing neonates and infants with adequate cardiac and respiratory motion compensation at low radiation dose. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support. Paper #: PA-131 An imaging strategy for lower dose cardiac CTA in infants

Christina Sammet, Ph.D., DABR, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Cynthia Rigsby, MD, Barbara Karl, Joshua Robinson, Andrada Popescu Purpose or Case Report: The goal of this study is to develop an imaging strategy to lower dose in infant cardiac computed tomography angiography (CTA). Our hypothesis is that dose may be reduced by lowering applied peak kilovoltage (kVp) and defining a CT dose index threshold without compromising diagnostic image quality.

Table 1 Paper #: PA-130 Novel approach for cardiovascular CT in neonates and infants using indication-based, first-pass contrast enhanced, ‘target-mode’ prospective EKG-gated volumetric imaging

Siddharth Jadhav, M.D., Texas Children’s Hospital, Houston, TX, [email protected]; Farahnaz Golriz, Lamya Atweh, MD, Prakash Masand, MD, Rajesh Krishnamurthy Purpose or Case Report: The ‘target mode’ of prospective EKG gating with volumetric 320-detector scanner provides cardiac pulsation-related motion compensation at a reduced radiation dose due to lack of temporal

70 kVp 80 kVp p-value Table 1 70 kVp 80 kVp p-value

Age (years) Mean StDev 0.59 0.29 0.79 0.22 0.013

Diameter (mm) Mean StDev 104.75 11.36 100.52 12.21 0.264

ICRP103 (mSv) Mean StDev 4.26 1.56 6.70 2.49 5.6E-07

CTDIvol (mGy) Mean StDev 0.71 0.21 1.18 0.62 1.4E-10 SSDE (mGy) Mean StDev 3.73 1.76 5.68 2.05 2.3E-11

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Methods & Materials: We retrospectively reviewed all infants who received a 70 kVp chest CTA on our SOMATOM Definition Flash (Siemens Healthcare, Erlangen, Germany) CT scanner from July 2012 to 2013. Medical condition was not an inclusion/exclusion criterion. Included were 20 infants (10 males; 0.59 +/− 0.29 years) scanned at 70 kVp using a fixed mAs technique adjusted to match a target CT dose index (CTDI) of 1.4 mGy (n=11) or 0.9 mGy (n=9). These studies were compared to 20 age-matched infants (13 males; 0.79 +/− 0.22 years) scanned at 80 kVp utilizing automatic dose modulation (CareDose) which was our previous standard-of-care protocol. The 70 and 80 kVp protocols utilized dual-source imaging (Flash), pitch=3.0 and 2.8, respectively, nominal slices=128×0.6 mm, reconstructed slice thickness = 2.0 mm, and field of view = 250 mm. Both protocols utilized iterative reconstruction (SAFIRE = 2) and the same soft-tissue reconstruction algorithm (140f medium). The analysis included a comparison of the CTDI, size specific dose estimate (SSDE), effective dose (per ICRP103), and evaluation of image quality. Comparisons were made with a twotailed two-sample student’s t-test assuming equal variance. Differences were considered significant if p<0.01. Results: Results of the dosimetry analysis are presented in the Table 1. Mean CTDI, effective dose, and SSDE were all significantly (p<0.001) lower in the 70 kVp cohort than the 80 kVp cohort. Group difference in age was nearly significant (p=0.013), however, patient size as evaluated by diameter was not (p=0.264). All CTA images were of excellent diagnostic quality and answered the clinical question. Images from the infants scanned at 70 kVp with a CTDI of 0.9 mGy and 1.4 mGy had comparable image quality. Conclusions: The results of this study indicate that dose may be reduced in infant chest CTA by reducing the kVp from 80 to 70 and implementing a CTDI threshold as low as 0.9 mGy. This strategy combined with iterative reconstruction and dual source imaging (Flash) can dramatically lower dose in infant cardiac CTA studies while preserving diagnostic image quality. Future studies will explore lowering this CTDI threshold even further.

Paper #: PA-132 Impact of Intravenous Radiographic Contrast Administration on Serum Creatinine in Neonates

Ammie White, MD, Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Maria Bedoya, J. Christopher Edgar, Madhura Pradhan, Elisabeth Raab, James Meyer Purpose or Case Report: To assess the impact of intravenous radiographic contrast media (IVRCM) administered in the neonatal period on renal function. Table 1: Mean and standard deviation creatinine levels (Cr) and p-values for the main effect of group at each pre- and post-scan period. No group differences were observed

Age at scan (days) Pre-scan Cr 1–2 days Post-scan Cr 3–5 days Post-scan Cr 6–9 days Post-scan Cr 10–45 days Post-scan Cr >45 days Post-scan Cr

Age at scan (days)

Control Group N Mean SD 73 10.04 7.23 72 0.49 0.17 43 0.49 0.20 45 0.45 0.19 32 0.38 0.12 42 0.28 0.07 35 0.22 0.06

Contrast MRI Group N Mean SD 27 10.00 8.76 27 0.45 0.17 17 0.45 0.12 17 0.38 0.11 15 0.36 0.09 15 0.25 0.06 11 0.23 0.06

Conrast CT Group N Mean SD

Group Difference p-value

20

0.75

8.40

9.47

Pre-scan Cr 1–2 days Post-scan Cr 3–5 days Post-scan Cr 6–9 days Post-scan Cr 10–45 days Post-scan Cr >45 days Post-scan Cr

20 17 13 9 7 9

0.55 0.52 0.42 0.40 0.24 0.20

0.20 0.22 0.13 0.16 0.08 0.07

0.24 0.24 0.12 0.49 0.16 0.44

Methods & Materials: The electronic medical records of all inpatient neonates (0–30 days of life) undergoing MR or CT at our institution from 10/9/12 to 4/26/13 were reviewed. Query of the radiology information system identified 178 neonates. Serum creatinine levels (Cr) were recorded and grouped into 6 time periods: 1) pre-scan, 2) 1–2 days post-scan (PS), 3) 3–5 days PS, 4) 6–9 days PS, 5)10–45 days PS and 6) >45 days PS. Change in Cr at each time period was compared to pre-scan value. Lab standard normal Cr for age is ≤0.4 mg/dl. Subjects were divided into three groups: MR contrast (MRC), CT contrast (CTC) and no contrast (NC). Inclusion in the study required: gestational age at birth and Cr obtained prior to imaging and at least one time after imaging. Statistical analysis was performed using SPSS, including hierarchical regressions, repeated measures ANOVAs, and chi-square analyses. Results: Fifty-eight patients were excluded, 54 due to incomplete data, three NC with extreme abnormal Cr and one who received both MR and CT contrast. One hundred twenty neonates met inclusion criteria: 27 MRC group (52% male, 89% term), 20 CTC (55% male, 65% term), and 73 NC (63% male, 73% term). Regression analysis showed no difference between groups (MRC, CCT, NC) at any of six time periods (r’s>0.48, p>0.16). A significant main effect of age was observed in the acute and sub-acute time periods (periods two, three and four), with significant decrease in Cr between time periods in all groups pre- to post-scan (p<0.01). Acute and sub-acute time period analyses showed no differences in Cr (p>0.42) or the proportion of subjects with abnormal Cr per standard between groups (p>0.31). There were no abnormal Cr levels in any group at 10–45 days PS. Conclusions: Neonates have decreased renal function. Serum creatinine levels at birth and in the immediate newborn period reflect maternal levels, making it difficult to get an accurate estimation of renal function to assess the safety of IVRCM administration. Nonetheless, there may be clinical situations requiring IVRCM. We found the expected decline in Cr in the first few postnatal weeks in all groups and no differences in Cr in acute, sub-acute or long term periods between neonates receiving MR or CT contrast and age matched controls. This indicates that neonates receiving standard inpatient care are not at increased risk for developing renal toxicity due to IVRCM. Paper #: PA-133 Neonatal Necrotizing Enterocolitis: Quality of Reporting of Diagnostic Accuracy of Abdominal Ultrasound—A Systematic Review

Kedar Patil, Medical Doctorate, Diagnostic Imaging, McGill University Health Centre, McGill University, Montreal, QC, Canada, [email protected]; Karl Muchantef, Ricardo Faingold Purpose or Case Report: The objective was to evaluate the diagnostic accuracy of abdominal ultrasound for evaluation of necrotizing enterocolitis (NEC) in neonates based on the level of evidence of relevant publications in order to make recommendations and identify gaps in the literature. Overarching questions included: Can the plain radiographic findings outlined in the Modified Bell’s Criteria for NEC, including intestinal dilatation or ileus/aperistalsis, pneumatosis intestinalis, portovenous gas, complex intra-abdominal ascites/collection, and pneumoperitoneum, be accurately identified by ultrasound?; Can ultrasonographic evaluation of bowel wall characteristics (wall thickness or echogenicity), bowel wall

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perfusion, and SMA velocity assist in the diagnosis of NEC?; Should the Modified Bell’s Criteria incorporate ultrasonographic findings? Methods & Materials: MEDLINE (1946-September 2013) and EMBASE (1947-September 2013) databases were searched using a systematic approach. Each selected study was given a semi-quantitative score out of 25 for quality of reporting of studies, based on the Standards for Reporting of Diagnostic Accuracy (STARD) tool. Each study was then rated as “Good” (0.80–1.00), “Fair” (0.50–0.79), or “Poor” (0.00– 0.49) and based on its level of evidence (I–IV). A summative grade of evidence was assigned to each overarching question according to the Canadian Task Force on Preventive Health Care guidelines. Results: The literature search retrieved 445 citations. Fifty articles were reviewed: 4/15 (27%) had a “Good” score, 6/15 (40%) had a “Fair” score, and 5/15 (33%) had a “Poor” score. A total of 507 neonates, with either suspected or definite NEC, were included. Validity was assessed in 14/15 articles (93%). None of the articles assessed inter-rater reliability. Conclusions: There is good (grade A) evidence that abdominal ultrasound is an accurate diagnostic method for evaluating multiple signs of NEC. Ultrasound is a useful tool for independent staging of NEC in neonates. There is insufficient data supporting the correlation between ultrasound evaluation of SMA velocities and NEC. Further research is needed evaluate to impact of ultrasound on management and outcomes in neonates with NEC, and the reliability and practicality of its use in the clinical setting. Paper #: PA-134 MR Imaging evaluation of liver lesions in children: Added Value of Hepatobiliary Contrast

Hansel Otero, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Asef Kwaja, Maria Bedoya, Nancy Chauvin, MD, Kassa Darge, MD, PhD, Sudha Anupindi Purpose or Case Report: To investigate the added value of Gadoxetate disodium (Gd-EOB-DTPA) enhanced MRI in the evaluation of liver lesions in children. Methods & Materials: Patients who underwent Gd-EOB-DTPA enhanced MRI for the evaluation of known or suspected liver masses over a 2-year period were included. Indications, MR images, reports, subsequent imaging, biopsies and plans for follow up were recorded. Additionally, hepatobiliary(HB) phase images were reviewed and stratified: 1) adding to diagnostic certainty (i.e.; if the final diagnosis was indistinguishable from others but for presence or absence of functioning hepatocytes), 2)questionable benefit (if there were highly characteristic findings in other sequences) 3) no benefit Results: Thirty-one patients (21 M:10 F; 10 months–19 years) were selected; 42% had a history of cancer, most commonly hepatoblastoma and neuroblastoma (13% each). Gd-EOB-DTPA was used for characterization of lesion(s) found in a different modality in 20/31 (65%) cases (ultrasound 10/20–50%; CT 8/20–40%; and MRI 2/20–10%). The MR interpretation described the lesions as: six focal nodular hyperplasias (FNH); two hemangiomas; two hepatoblastomas; three infection/abscess; two regenerative nodules; one fatty infiltration; two non-specific but benign and two as no lesion identified. Of these patients, 7 (35%) required no further work up and six (30%) returned to regular follow up. Four (20%) patients underwent short term follow up (two suspected FNH and two for infection) and 3 (15%) went on to biopsy (one hepatoblastoma; one abscess, and one biliary cirrhosis with acute cholangitis). In the remaining 11/31 (35%) cases MRI was used for surveillance in patients with suspected/increased risk of tumor. Of these, six were normal, two had FNHs, one showed a known hepatoblastoma and two had regenerative nodules in the setting of cirrhosis. However, none of these went on to further imaging or biopsy. HB phase images added diagnostic value in 12/31 (39%) cases (eight FNHs, two cirrhosis, one infection, and one benign lesion of unknown etiology). In 4/31 (13%) cases the added value was questionable (1 fatty

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infiltration, 2 FNHs, and 1 case of regenerative nodules) and in 15/31 (48%) cases, the HB images were not beneficial for diagnosis. Conclusions: Gd-EOB-DTPA-enhanced MRI in the evaluation of pediatric liver lesions plays a promising problem solving role by increasing diagnostic confidence in a significant number of cases. In turn, Gd-EOB-DTPA-enhanced MRI can potentially curtail additional imaging studies and biopsies Paper #: PA-135 Cerebral ultrasound findings in neonates undergoing whole body hypothermia for hypoxic ischemic encephalopathy

Moe Tun, Ph.D., D.O., University of Missouri-Kansas City, Kansas City, MO; Neil Thakur, Howard Kilbride, Roshan Babu, Lisa Lowe Purpose or Case Report: Hypothermia causes cerebral pathophysiologic changes leading to alterations of ultrasound findings in cooled infants with hypoxic ischemic encephalopathy (HIE) compared to normal control populations. The purpose of this study is to determine findings on initial cerebral ultrasound (CUS) in whole-body hypothermia treated neonates with HIE. Methods & Materials: A retrospective medical record review of 49 consecutive infants treated with whole body hypothermia for HIE was performed. Infants were selected for hypothermia by neonatologists using institutional criteria based on the National Institute of Child Health and Human Development (NICHD) Neonatal Research network protocol. Two infants were excluded leaving a cohort of 47. The first did not undergo CUS and the second infant had CUS on DOL-1 that was inadequate due to scalp edema and sutural override. All CUSs were done within 24 h of birth. Recorded data included demographics, findings on CUS and ages (in hours) at time CUS was performed. Resistive indices(RI) in infants undergoing hypothermia treatment were compared to normal published values using an unpaired t-test. The normal RI range of 0.59–0.83 (0.71+/−0.12) based on published values in term infants without HIE. An abnormal RI was defined as a middle cerebral artery (MCA) value outside of the normal range. Demographics and Clinical Findings Mean gestational age in weeks [range] Mean birth weight ingrams [range] Female: Male Mean APGAR score at 1 min [range] Mean APGAR score at 5 min [range] APGAR 10 min (mean [range] Mean cord pH ± std [range] Mean arterial pH within 1 h ±std [range] Mean age at CUS in hours [range]

Cerebral Ultrasound(n=47) Normal (n=16) 38.7 [36–41]

Abnormal (n=31) 39 [36–42]

3360 [1997–6020]

3442 [2500–4370]

9 F:7 M

11 F:20 M

1.63 [0–4]

1.47 [0–6] (n=30)*

4.00 [2–7]

2.73 [0–7] (n=30)*

5.69 [3–8]

3.64 [0–8] (n=28)*

6.97±0.26 [6.58− 7.32] (n=12)** 7.08±0.10 [6.89– 7.24] (n=15)**

6.97±0.20 [6.52– 7.29] (n=26)** 7.06±0.21 [6.48– 7.37] (n=25**)

16.05 [5.43–43.97]

16.52 [2.87–64.30]

Table 1: Infant demographics (gestational age, birth weight, sex), clinical findings (APGAR scores, cord and arterial pH) and age at time of normal or abnormal cerebral ultrasound n = number; * = APGARs available for indicated number of infants; **pH available for indicated number of infants Results: CUS demonstrated increased echogenicity and/or alteration of graywhite matter differentiation on gray scale imaging in 18 of 47(38%) infants.

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Screening Doppler interrogation revealed abnormal RI in 27 of 47(57%) infants, 19 of which had a low RI <0.59, and eight with a high RI>0.83. 15 of 47 (32%) infants had both abnormal grayscale and Doppler imaging. Four of 47(9%) infants had abnormal grayscale findings only, and 13 of 47(28%) had only abnormal RIs. The mean RI of infants undergoing hypothermia (0.65± 0.15, median 0.65, range 0.35–1.0) was significantly lower than reference values (0.71±0.12) from normal term infants (p=0.0349) without HIE. Overall, CUS less than 24 h of age demonstrated abnormalities in 31 of 47(66%) infants, and 16 of 47(34%) CUS were normal. Conclusions: CUS shows hyperechogenicity and/or low RI in 66% of infants with HIE undergoing therapeutic hypothermia. RIs in infants undergoing cooling therapy for HIE are significantly lower than those of normal infants without HIE. Paper #: PA-136 Can Swaddling be done safely in Infants with and without DDH?

H. Harcke, MD, Medical Imaging, Nemours/AI duPont Hospital for Children, Wilmington, DE, [email protected]; Susan Cummings, Richard Bowen Purpose or Case Report: Swaddling, now popular for an infant has been controversial with regard to effects on the hip. This study was designed to sonographically evaluate hip joint stability in infants who were swaddled by the traditional method, safe blanket techniques, and commercial devices. Methods & Materials: Dynamic sonography was used to evaluate 30 infants in both swaddled and unswaddled positions. Sixteen infants (32 hips) being treated in a Pavlik harness for DDH composed a “treatment group”. 14 infants (28 hips) that were untreated and had a free range of hip motion composed a “non-treatment group”. Sonographies were performed in all hips unswaddled at presentation, in selected hips in traditional and safe swaddled blanket techniques, and/or subsequently in two types of commercial product. Swaddlings by various techniques were progressively applied until the infant became impatient. Criteria for comparing results of sonographies between swaddled and unswaddled hip positions included femoral head position, instability, and range of motion restriction. Results: Traditional swaddling with a tight blanket was applied in 11 “nontreatment group” cases (20 hips) and limited flexion and abduction of the legs. One unstable left hip dislocated when placed in the tight swaddle and then returned to its original position after the swaddle was removed. Using a blanket technique described as safe in 12 cases (24 hips) showed no limitation of flexion and abduction of the legs and no change in stability by sonography, whether the hips were in the “non-treatment group” or in the “treatment group.” Commercial swaddling products appeared to mildly restrict leg motion in 14 hips, but there was no change in hip position in the “non-treatment group.” However, the commercial swaddling products changed the hip position of three cases being treated in a Pavlik harness. Conclusions: Swaddling techniques allowing a free range of leg motion did not appear to affect hip stability in normal hips or those with DDH under treatment in Pavlik harness. Swaddling with restricted leg motion increases the potential for hip instability. Caution is advised before advocating swaddling because our study swaddled only long enough to perform the hip sonography. However, tight swaddling dislocated one unstable hip, and commercial swaddling products, observed to apply only mild restriction of leg motion, negatively impacted three infants being treated for DDH with a Pavlik harness. Paper #: PA-137 Renal cell carcinoma in children and adolescents: a summary of imaging findings from the Children’s Oncology Group

G ee t i k a Kh a n n a , w a s h i n g t o n u n i v e r s i t y, C l a y t o n , M O , [email protected]; James Geller, Peter Ehrlich, Arlene Naranjo, Sabah Servaes, Jeffrey Dome

Purpose or Case Report: Renal cell carcinoma (RCC) accounts for 2–6% of pediatric renal tumors. Lymph node involvement, a common feature of pediatric RCC, has prognostic significance and therapeutic implications. To ascertain the sensitivity/specificity of imaging studies to detect lymph node metastases, imaging studies of patients with RCC enrolled on the Children’s Oncology Group (COG) AREN03B2 renal tumor biology and classification study were compared with histologic findings. Methods & Materials: AREN03B2 is a prospective study opened in 2006 that collects data on patients under the age of 30 with first occurrence of a renal tumor. Clinical, radiologic, surgical, and pathologic data are centrally reviewed. We reviewed imaging findings in cases with central pathologic confirmation of RCC. Cases were classified as N+ if retroperitoneal lymph nodes measured ≥1 cm in short axis at the renal hilum level. Sensitivity and specificity of imaging for detection of regional lymph node metastasis were calculated. Results: As of June 2012, 120/3250 (3.8%) patients had central pathologic confirmation of RCC. Median age at diagnosis was 12.9 years (range 1.9– 22.1 years) and 52.5% were female. Contrast enhanced CT or MRI abdomen was available for central review in 118/120 cases. The distribution of laterality of RCC was as follows: 59 right, 57 left, and 2 bilateral. The longest dimension of the renal mass ranged 0.8–19.7 cm (median 6.35 cm). Based on size criterion 32/118 (27.1%) cases were classified as N+ at imaging. The size of the primary renal tumor was <7 cm in 12/32 (37.5%) of the cases that were noted to have enlarged lymph nodes. Pathologic proof of lymph node status was available in 73 (60.8%) cases. In this cohort, imaging detected lymph node metastasis with a sensitivity of 57.1% [(20/35); 95% CI: 39.4%, 73.7%] and specificity of 94.6% [(35/37); 95% CI: 81.8%, 99.3%]. Metastatic disease was noted in 23 cases (19.5%) on imaging (lung 19, liver 5, mediastinal lymph nodes 5, supraclavicular lymph nodes 2, bone 2, and muscle 1) with multifocal metastasis in 9/23 at initial presentation. Conclusions: Using a size criterion of ≥1 cm, imaging has high specificity but relatively low sensitivity for detection of lymph node disease in pediatric RCC. Pathologically confirmed nodal disease is common at presentation and can be seen with small primary tumors. This emphasizes importance of lymph node sampling. The majority of pediatric RCC patients present at an advanced stage. Paper #: PA-138 MR Image Acquisition during the FDG Uptake Phase is Associated with an Increased Rate of False Positive Brain PET Examinations Performed on an Integrated PET-MR Scanner

Lamya Atweh, MD, Singleton Department of Pediatric Radiology, Texas Children’s Hospital, Houston, TX; Michael Paldino, M.D., Jeremy Jones, Jennifer Williams, Nadia Mahmood, Ramkumar Krishnamurthy Purpose or Case Report: The duration of integrated PET/MR examinations, which includes an uptake period prior to imaging, remains a significant barrier to the accessibility of this technology, especially in children. Acquisition of MR images during uptake has been implemented at our institution for FDG-PET imaging of the body. However, scanner noise could in theory alter the pattern of FDG uptake in the brain, particularly in auditory pathways. The goal of this study is to evaluate this new, efficient workflow with respect to its impact on the diagnostic performance of FDG-PET imaging of the brain. Methods & Materials: All patients referred for clinical whole body FDGPET/CT exams with an indication of lymphoma were prospectively recruited to undergo an additional research FDG-PET acquisition (including brain imaging) on an integrated PET/MR system (Philips Ingenuity). Patients were imaged according to two workflows: 1. Standard: uptake phase in a quiet room, followed by image acquisition; 2: New: acquisition of diagnostic MR sequences immediately after radiotracer injection, followed by PET imaging. Four experienced observers blinded to both the workflow

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and the actual clinical indication reviewed the brain FDG-PET exams for abnormal tracer accumulation. An indication of “focal seizures” was provided. Since these brain exams were all negative, true positive brain exams were added to the list of studies for review to simulate clinical experience. All “positive” interpretations were reviewed at the conclusion of the study and discrepancies were settled by consensus. Fisher exact test was used to compare the rate of false positive results for the two workflows. Results: The final study population comprised forty-seven patients (mean age: 11 years; range: 0–20 years). Seventeen patients were imaged according to the standard workflow; 30 with the new workflow. Exam duration decreased significantly with the new workflow (p<0.05). The standard workflow yielded no false positive interpretations; brain exams acquired according to the new workflow had a 6% rate of false positive interpretation. This difference was statistically significant (p<0.05). Conclusions: Although misinterpretation occurred at a very low rate, we found significantly more false positives when MR sequences were performed during the FDG uptake phase. These results suggest that, for neurologic indications, alternative workflows in PET/MR must be evaluated carefully prior to widespread implementation. Paper #: PA-139

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was 63±5 min and 94±6 min respectively. PET images from PET/CT and from PET/MRI were analyzed for SUV quantitation using volumes of interest drawn in blood pool, lungs, myocardium, muscle, bone, liver and fat. Age-adjusted effective radiation doses (ED) per patient between PET/ CT, PET/MRI and CT exams acquired on the hospital visit were calculated. For PET, radiation doses were calculated based on the ED per FDG dose. For CT age adjusted ED was calculated from the dose length product (DLP) from low dose CT and diagnostic CT scans. Table 1. Age-adjusted radiation dose for pediatric patients.

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Average

PET/CT+CT Dose (mSv) 30.1 13.3 16.8 19.5 8.4 11.1 19 13.6 16.5

PET/MR Dose (mSv) 9.7 5 10.4 14.7 4.4 6.3 8 5.6 8

Dose Reduction 68% 62.00% 38.00% 25.00% 47.00% 44.00% 57.00% 59.00% 50.00%

Comparison of quantitation of tracer uptake and radiation dosage between PET/MRI and PET/CT in a pediatric population

Claudia Martinez-Rios, M.D., University Hospitals Case Medical Center. Case Western Reserve University, Cleveland, OH, [email protected]; Andrew Sher, Lingzhi Hu, Karin Herrmann, Peter Faulhaber, Barbara Bangert Purpose or Case Report: A potential for improved patient care may be achieved with PET/MRI taking advantage of both imaging modalities. One such opportunity is in pediatric patients, for whom reducing radiation, without sacrificing consistent, accurate diagnostic interpretation, is paramount. The aim of this study was to compare the reproducibility of the PET quantitation from a whole-body PET/CT to that of a subsequently obtained whole-body PET/MRI.

Results: SUV (max) and SUV (mean) in specified anatomic regions are summarized in Fig. 1. Both SUV (max) and SUV (mean) show no significant difference between PET/CT and PET/MRI through paired t testing at the significance level of p=0.05. For SUV (max), there is significant correlation between PET/CT and PET/MRI within bone, fat and myocardium, as evidenced by Pearson correlation factor (r)=0.91, 0.80 and 1.00, respectively. For SUV (mean), such correlation is significant in fat and myocardium with r=0.83 and 1.00, respectively. The radiation dose comparison is summarized in Table 1. Compared to the combination of a PET/CT and diagnostic CT, the average radiation dose reduction of PET/MRI is 50%. Conclusions: PET/MRI demonstrated good performance and quantitation accuracy in pediatric imaging with significant reduction of radiation dose. SUV value of normal tissue does not exhibit significant difference between PET/CT and PET/MRI. Disclosure: Dr. Martinez-Rios has indicated a relationship with Philips Healthcare North America as a Research Fellow at Case Western Reserve University (Research Contract—Salary sponsored by Philips). Dr. Faulhaber has indicated a relationship with MIM Software as a Consultant (Honoraria) and Philips Medical as an Advisor and Spaker (Consulting, Grant). Dr. Sher has indicated a relationship with Philips Healthcare as a Research Fellow (Research Grant, Salary). Paper #: PA-140

Methods & Materials: This HIPAA-compliant prospective study was approved by the Internal Review Board. All study participants provided assent/consent and parental permission. A total of eight pediatric patients (mean age 14±3; 4 female, 4 male) underwent a whole-body Philips PET/ CT scan after injection of [F-18]Fluorodeoxyglucose (FDG) (140uci/kg), followed by a subsequent Philips PET/MRI scan. Whole-body 3D T1weighted spoiled gradient echo and a whole body 3D mDixon volumetric examination were acquired for attenuation correction and anatomical localization. Time difference after FDG injection between both studies

Comparison of standardarized uptake values (SUV) in normal structures between PET/CTand PET/MRI in a pediatric patient population

Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Baylor College of Medicine, Houston, TX, [email protected]; Victor Seghers, Wei Zhang, Shireen Hayatghaibi, Rajesh Krishnamurthy, Eric Rohren Purpose or Case Report: To compare standardarized uptake values (SUV) of normal organ tissues derived from [18F] fluorodeoxyglucose (FDG) positron emission tomography (PET)/magnetic resonance

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attenuation correction(MRAC) using a three-segment model, with those derived from PET/computed tomography(CT) attenuation correction(CTAC) in a pediatric population.

Paper #: PA-141 Qualitative [18F]-FDG PET image assessment using automatic three-segment MR attenuation correction versus CTattenuation correction in a pediatric population

Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Baylor College of Medicine, Houston, TX, [email protected]; Victor Seghers, Jennifer Williams, Wei Zhang, Rajesh Krishnamurthy, Eric Rohren Purpose or Case Report: To qualitatively evaluate attenuation-corrected PET image quality using magnetic resonance attenuation correction (MRAC) versus CT attenuation correction (CTAC) in a cohort of pediatric patients.

Methods & Materials: This prospective study was approved by our IRB. All subjects gave written informed consent prior to inclusion. Twenty-six patients, (61.5% male) referred for 32 clinically indicated PET/CT scans underwent a research PET/MRI at the same visit. The indication was lymphoma in 69% and Langerhan’s cell histiocytosis in 22%. Mean age was 14.2 years (range 0.64– 20.78). Patients were divided into two groups based on workflow. In the first group (12/32), PET/CT was performed first, and in the second group (20/32), PET/MRI was performed first. Regions of interest were drawn over nine normal structures to obtain SUV minimum, mean and maximum values. Spearman rank correlation coefficients were calculated and two-tailed paired t tests performed to compare SUVs obtained from CTAC with those from MRAC. Results: For the first group, mean time after FDG injection was 69.4± 11.1 min for PET/CT and 114.4±16.8 min for PET/MRI. For the second group, mean time after injection was 108±16.1 min for PET/CT and 58.2 ±4.9 min for PET/MRI. SUV using MRAC in the first group was not significantly different than the SUV from CTAC, except for in the psoas major muscle. MRAC SUV values in almost all tissues in the second workgroup were significantly lower than the CTAC (mean difference −28.9±31.1%, p<0.05). The mean difference exceeded 20% in the SUVmax values for brain, myocardium, bone marrow, fat, liver, lung, iliacus and psoas major muscles (Fig. 1). Very high/high correlation between CTAC and MRAC SUVmax was found in the first group in bone marrow, myocardium and brain, fat, liver, MBP and psoas muscle, and in the second group in brain, myocardium, bone marrow and psoas muscle (p<0.001). Intermediate or weak correlations with non-significant p values were found between CTAC and MRAC SUVmax values in all other tissues. Conclusions: Our study showed a high correlation between SUV values derived from MRAC compared to CTAC. Differences observed between MRAC and CTAC SUV in the second group is likely due to differences in interval from injection to imaging. Further research is required to assess intra-patient consistency of MRAC SUV measurement in normal structures over sequential studies. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support.

Methods & Materials: This prospective study was approved by our Institutional Review Board and all subjects gave written informed consent prior to their inclusion. Thirty-four patients, (18 male, 16 female) who were referred for 38 clinically indicated PET/CT scans also underwent a research PET/MRI. The indication was staging of lymphoma in 22/38 (57.9%), seizure disorder in 9/38 (23.7%) and Langerhan’s cell histiocytosis in 7/38 (18.4%). The mean age at the time of study was 13.75±5.56. MRAC was performed using an automatic three-segment model. Two experienced nuclear radiologists scored image quality of PET studies generated by MRAC and CTAC methods using a Likert five-point scale (1: extremely poor, major artifacts, not clinically useful, 2:poor, major artifacts, clinical use not advised, 3: average, of borderline clinical use, 4: good, with minor artifacts not affecting clinical use and 5: excellent, no artifacts). Reviewers were blinded to the correction method used. A Wilcoxin rank test was performed to compare the grades between MRI and CT, and a Fisher’s exact test conducted to study the association between the two grades. Results: The mean image quality difference using the Likert scale for each reviewer is shown on Figure 1. There was no statistical difference between CTAC and MRAC using the five-point scale (p=0.1484, 0.0918) for either of the reviewers. The mean image quality difference using the Likert scale for each reviewer is shown on Figure 1. There was a significant association between the CTAC and MRAC grading for both of the reviewers (p=0.0267, 0.0388). Conclusions: Our data does not show a clinically or statistically significant difference in quality between PET images generated from PET/MRI to those generated from PET/CT, demonstrating that the three segment model produces diagnostic image quality in a pediatric population with significant savings of radiation dose. Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support.

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Paper #: PA-142

Paper #: PA-143

Quantitative Comparison of Attenuation Corrected FDG-PET Images Acquired on Integrated PET/MR and PET/CT Systems: Validation of an MR-based Attenuation Correction Algorithm

Pediatric PET-MR Registration for the Rest of Us! Validation of a Novel Software Based Solution for PET/MR Coregistration

Michael Paldino, M.D., Ramkumar Krishnamurthy, Ph.D., Radiology, Texas Children’s Hospital, Houston, TX, [email protected] Purpose or Case Report: Integrated PET/MR scanners offer the potential to acquire diverse image contrasts—including structural, functional, and metabolic—in a single examination session. To reach its full potential, this technology will require robust attenuation correction algorithms that are based on MR images. The goal of this study is to quantify the relationship between FDG-PET images obtained using MR- and CTbased attenuation algorithms in a cohort of pediatric epilepsy patients.

Methods & Materials: IRB approval and informed consent were obtained for this HIPAA-compliant study. All patients referred for clinical FDGPET/CT exams of the brain at our institution were prospectively recruited to undergo an additional FDG-PET acquisition on an integrated PET/MR system (Philips Ingenuity). All PET/MR examinations were performed immediately after completion of the PET/CT. Raw FDG-PET images were processed according to standard, vendor-provided attenuation correction algorithms based on either MRI or CT images. Attenuation-corrected images acquired at PET/MR (MRAC) and PET/CT (CTAC) were aligned using a normalized mutual information registration algorithm. First, a pixel-by-pixel comparison between the two image volumes was performed. A paired t-test was used to assess any potential difference between MRAC and CTAC tracer accumulation at each pixel location. The relationship between the two image sets was then quantified using linear regression and coefficient of determination (R2) analyses. Finally, a region-of-interest (ROI) comparison was performed. Tracer accumulation was compared within user-defined regions-of-interest within the thalamus, putamen, centrum semiovale, and frontal lobe cortex using a paired t-test. Results: The study population comprised 13 patients (mean age: 11 years; range: 2–18 years), all referred with a diagnosis of epilepsy. Despite being performed at slightly different times, regression and R2 analysis demonstrated a highly consistent relationship between pixel values in the two image sets for all patients (Figure 1; population r=0.95; p<0.0001; population R2 =0.91). Similarly, user-defined ROIs demonstrated no significant difference in tracer accumulation between MRAC and CTAC images (p value range: 0.83–0.99). Conclusions: These findings demonstrate a strong relationship between FDG-PET images generated by vendor-provided MR- and CT-based attenuation correction algorithms. These results further support the use of integrated PET/MR systems in clinical practice.

Matthew Robertson, MD, Children’s National Medical Center, Washington, DC, [email protected]; Wen Li, Pranav Vyas, MD, Nabile Safdar, Raj Shekhar Purpose or Case Report: PET imaging is widely used to accurately monitor pediatric oncology patient disease activity. Hybrid PET/CT scanners are currently the hardware of choice for this evaluation. Newly available commercial hybrid PET/MR scanners allow for reduction of CT radiation dose, in accordance with ALARA principles, but require significant capital investment limiting early adoption. Current software options, utilizing independently acquired data from stand alone MRI and PET/CT scanners, permit existing hardware to be employed, but at the cost of possible image set mismatches. In this study, we demonstrate a novel, fully-automated software-based solution utilizing deformable coregistration to create a composite PET/ MR data set from independently acquired PET/CT and MRI data. Methods & Materials: Patients at Children’s National Medical Center who underwent MRI of the abdomen within 4 weeks of PET/CT imaging were identified. The coregistration algorithm was applied to create coregistered PET data sets for MRI fusion. Maximum standardized uptake values (SUVmax) were measured for volumetric regions of interest in lung, liver, kidney, bone, and muscle on PET/CT and PET/MR. Landmarks were selected on CT and MRI images and degree of spatial offset after the coregistration process was measured. Results: A total of nine patient data sets consisting of five VOI (n=45) and four landmark points (n=36) were analyzed. For each VOI, absolute (range, mean) and relative [range, mean] SUV differences are as follows: lung (0–0.2, 0.07)[0–25%, 8.9%], liver (0–0.2, 0.07)[0–11.8%, 3.7%], kidney (0.1–2.2, 0.8)[3.9–16.9%, 8.4%], bone(0–0.5, 0.1)[0–9.1%, 8.4%], and muscle (0–0.2, 0.07)[0–28.6%, 8.5%]. The overall average absolute and relative SUV differences were 0.24 and 6.6% respectively. The largest absolute SUV differences arose in locations of high FDG localization. High relative differences, as a result of minimal changes in absolute SUV, were noted in tissues with low FDG uptake. In the clinical setting, these differences are unlikely to limit accuracy of interpretation. Spatial offset ranged from 3.3 to 7.1 mm with an average of 6.0 mm. Conclusions: In this study, we demonstrate a novel software based solution utilizing a deformable coregistration process to create composite PET/MR data sets from independently acquired PET/ CT and MRI series. The resultant data sets had highly accurate SUV values and limited spatial offset allowing for diagnostic quality interpretation in pediatric oncology cases. Paper #: PA-144 Fractures in Newly Diagnosed Hepatoblastoma Patients: Incidence and Imaging Features

Fernanda Braojos, MD, Daniel Podberesky, MD, James Geller, Joel Sorger, Greg Tiao, Alexander Towbin, MD, Radiology, Faculdade de Medicina de Sao Jose do Rio Preto, Sao Jose do Rio Preto, Brazil, [email protected] Purpose or Case Report: Hepatoblastoma is the most common primary hepatic malignancy in children. Recently, we have noticed an increased incidence of unsuspected fractures in these patients at presentation. While this association has been suggested in the past, the pathophysiology behind this association, and the incidence, is uncertain. The purpose of this investigation was to

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define the incidence and imaging features of fractures in children with newly diagnosed hepatoblastoma.

Methods & Materials: We searched the oncology database and the radiology picture archiving and communication system of our large, tertiary care children’s hospital, between January, 2000 and August, 2013 for all patients who presented to our institution with newly diagnosed hepatoblastoma. All available imaging exams (radiographs, CT scans, MRIs, and nuclear medicine studies) and clinical records were reviewed to identify those patients who had radiologically apparent fractures on exams within 1 month of the date of hepatoblastoma diagnosis. Results: Seventy one patients were diagnosed with hepatoblastoma during the investigation’s time frame. Of these, 24 were diagnosed and referred from an outside institution and did not have complete imaging and clinical records available for review. They were therefore excluded from this analysis. Of the remaining 47 patients, eight (17.0%) had unsuspected fractures. Five patients had rib fractures (one seen on a chest radiograph and the others chest CT), and three of these five also had thoracolumbar vertebral body compression fractures (one seen on radiograph and four on CT). The remaining three patients had fractures of the lower extremity (all seen on radiographs); one with a spiral fracture of the distal tibia, one with a fracture of the femur, and one with fractures of the distal aspect of the second and third metatarsals. Fractures in four of the eight patients (50%) were not identified at the time of initial image interpretation. Conclusions: Unsuspected fractures were relatively common in patients newly diagnosed with hepatoblastoma (17.0% in this series). The fractures were not identified at the time of imaging in 50% of patients underscoring the need to educate pediatric radiologists of this association and to be vigilant when reviewing the osseous structures on imaging exams in these patients. In addition, increased awareness and diagnosis of underlying fractures might improve the assessment and management of pain, not uncommon in infants and children with hepatoblastoma undergoing therapy.

Paper #: PA-145 Patient Size-Specific k-factors for Pediatric and adult CT examinations

Choonsik Lee, National Cancer Institution, Rockville, MD, [email protected]; Vana Derderian, BS, Stephanie Lamart, Mohammad Soltanmohammadi, Michael Choi, Les Folio, DO, MPH Purpose or Case Report: Actual patient body size may deviate significantly from standard size and discrete age stylized computational phantoms used to generate traditional k-factor (AAPM Report 96) for CT effective dose estimation. To improve the accuracy of dose estimation, we propose size-specific k-factors for a spectrum of patient sizes and ages generated by hybrid computational whole body phantoms and Monte Carlo simulation of CT x-ray.

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Methods & Materials: We used hybrid computational human phantoms (12 pediatric and adult males and females) coupled with Monte Carlo transport simulations of the CT exposure to generate k-factors for chest, abdomen/pelvis (A/P), and chest, abdomen and pelvis (CAP) scans as effective dose per unit dose-length-product (DLP) (mGy mGy-1 cm-1). We derived exponential fitting curve for size-specific k-factor as a function of the effective diameter generated from anteroposterior (AP) and lateral (LAT) dimensions of the phantoms at the middle scan slice in each exam. To illustrate the use of the size-specific k-factor, we assessed two sets of effective dose for 103 adult patients (age 20–80 years) given a CT Chest exam using traditional k-factor (0.014 mGy mGy-1 cm-1 for adult chest scan) and size-specific k-factor, and compared the results. Effective diameters were derived from each patient; DLP was extracted from dose pages. Size-specific k-factor was calculated for each patient using the regression curve for chest scan and effective diameter. Results: We provide size-specific k-factors for chest, A/P, and CAP scans as a function of the effective diameter from newborn to adult. Traditional k-factor calculations showed overall overestimation in effective dose up to 2.5 times higher than size-specific effective dose. The effective diameter measured in real patients was overall greater than the stylized phantom used to generate traditional k-factors. Conclusions: Our method provides size-dependent k-factor compared to age-dependent traditional k-factors. We also calculated the size-specific k-factor for CAP scan which is not covered by the traditional k-factor. The new k-factor will be tested for pediatric patients by using patient size instead of age and will be extended for a variety of anatomic sites.

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The parameter A and B for the regression curve of phantom-based kfactors vs. effective diameter (cm). k-factors (mSv mGy−1 cm−1) for different effective diameter (cm) for chest, AP, and CAP CT scans with body filter and 32–cm CTDI phantom are listed for look-up–table. Regression parameters A B Effective Diameter (cm) 10 11 12 13

Chest AP CAP 0.0924 0.1437 0.1190 −0.0730 −0.0109 −0.0950 Effective dose per DLP (mSv mGy−1 cm−1) 0.0445 0.1289 0.0460 0.0414 0.1275 0.0419 0.0385 0.1261 0.0381 0.0358 0.1247 0.0346

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

0.0333 0.0309 0.0287 0.0267 0.0248 0.0231 0.0215 0.0199 0.0185 0.0172 0.0160 0.0149 0.0138 0.0129 0.0120 0.0111 0.0103 0.0096

0.1234 0.1220 0.1207 0.1194 0.1181 0.1168 0.1156 0.1143 0.1131 0.1118 0.1106 0.1094 0.1082 0.1071 0.1059 0.1048 0.1036 0.1025

0.0315 0.0286 0.0260 0.0237 0.0215 0.0196 0.0178 0.0162 0.0147 0.0134 0.0122 0.0111 0.0101 0.0092 0.0083 0.0076 0.0069 0.0063

32 33 34 35 36 37 38 39 40

0.0089 0.0083 0.0077 0.0072 0.0067 0.0062 0.0058 0.0054 0.0050

0.1014 0.1003 0.0992 0.0981 0.0971 0.0960 0.0950 0.0939 0.0929

0.0057 0.0052 0.0047 0.0043 0.0039 0.0035 0.0032 0.0029 0.0027

Paper #: PA-146 Improving Patient Safety: Development of a Web-based Curriculum with Assessment to Promote Competency in “Child-sizing” Radiation Dose for Medical Professionals

Marilyn Goske, Radiolgy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Keith Strauss, MSc, Judy Racadio, Christopher Alsip, Ronny Salmeron, Elizabeth Yarboro Purpose or Case Report: Despite the fact that CT scans have been in clinical use since 1974, computed tomography (CT) was

not a part of the radiologic technologists’ (RT) basic 2 years curriculum until 2007. Many CT RT performing pediatric CT may not have had formal training in pediatric CT scanning. To fill this practice gap and address potential safety issues, we developed an online CT educational module for RT to be used by facilities that participate in the American College of Radiology (ACR) Dose Index Registry (DIR™). Methods & Materials: A multidisciplinary team developed the “Child-sizing CT” curriculum, which was subsequently used to create a highly interactive online and mobile-enabled e-learning course. Built using Articulate Storyline authoring software, the course includes optional audio narration and features such as embedded questions with expert feedback - Knowledge Checks—and a postassessment to help identify knowledge gaps, benchmark against best practice standards, and to reinforce immediate learning and retention. The course resides within the ACR learning management system providing continuing education credits for radiologists, radiologic technologists and medical physicists. Results: A 1 h module was created and is free to CT RT and other imaging professionals at ACR DIR facilities. Ten pre-and post assessment questions were created and may be used to assess competency in the use of appropriate scan techniques. The module promotes “best practice” in radiation dose saving strategies, assessment of patient dose, and comparison of a site’s results to national data contained within the ACR DIR. A basic practice quality tool is also presented along with a clinical example. Conclusions: This online learning tool may help facilities in improving safety training in pediatric CT scan techniques and protocols. The presented tool designed to promote and document practice quality improvement in pediatric CT, targeted at radiologic technologists, should help departments improve many aspects of their CT practice.

Paper #: PA-147 Age based characterization of pediatric soft tissue masses of the hand, and value of added MRI following ultrasound

Eric Umstead, Diagnostic Imaging, Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Mary Wyers, MD, Jackson Norman Purpose or Case Report: Due to the paucity of literature on soft tissue hand masses in children and the wide variety of potential lesions, we sought to characterize the differential diagnosis of pediatric hand masses through an age-based approach. We also wanted to assess whether the addition of MRI in children who already had an ultrasound for a hand mass led to improved diagnostic accuracy or reader confidence.

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Methods & Materials: Following IRB approval, we searched our EMR and PACS retrospectively for patients with a soft tissue hand mass who were also imaged in our department with ultrasound, MRI, or both. Eighty-four patients were identified between 2005 and 2013. Eighteen patients received only ultrasound, 54 received only MRI, and 12 received both. The lesions were categorized according to age group, diagnosis, and method of diagnosis. Four age groups were evaluated: age <5, 6–10, 11– 15, and 16 and over. Final diagnosis was classified into the following groups: cyst, inflammatory, vascular anomaly, posttraumatic, benign tumor, or malignant tumor. Method of diagnosis included pathology, classic imaging findings, or clinical followup. The 12 patients who had both ultrasound and MRI were then reviewed by three radiologists blinded to patient history and diagnosis. Ultrasounds were first reviewed alone, followed by review with corresponding MRIs. Each reader assigned the exam to one of the above diagnostic categories and ranked his confidence on a scale of 1–5. Statistical analysis was performed to assess the readers’ diagnostic accuracy and confidence. Results: Most common diagnoses (Fig 1) were as follows: age 0– 5, vascular anomalies (33%); age 6–11, vascular anomalies and inflammatory (25% each); age 12–15, vascular anomalies and benign tumor (33% each); age 16 and over, inflammatory (55%). Addition of MRI following ultrasound did not significantly improve reader accuracy(56% vs 36%),but mean confidence levels for two of the readers were significantly higher with correct diagnoses compared with missed diagnoses (p<.05). Successful prediction rates were not significantly different among the three readers. Age of the patient did not significantly affect accuracy using either diagnostic method. Conclusions: The most common hand masses imaged were vascular anomalies and inflammatory lesions, with minor differences among the age groups, most notably in the older patients. Addition of MRI following ultrasound did not significantly improve diagnostic accuracy, but did improve confidence when making a correct diagnosis.

Those assessed by radiography received five radiographic views. Both radiographic and CT examinations were assessed anonymously in random order for the presence or absence of spondylolyisis by six raters. Negative was coded as one and positive as five with two, three, and four being various grades of equivocal. Radiographic assessment was by two views (frontal and lateral), three views (frontal, lateral and magnified view at the lumbrosacral junction) and four views (frontal, lateral and bilateral obliques). Agreement was assessed between raters using a Fleiss Kappa statistic for multiple raters on an ordinal scale, and lack of confidence compared using chi-squared tests. Results: CT provided a higher level of agreement than radiographs. The overall Kappa for rater agreement with radiographs was 0.24, 0.34, and 0.40 (Figure 1a) for two, three, or four views respectively and 0.80 with CT (Figure 1b). With CT all raters agreed 78% and with radiographs all raters agreed in 13% (two views), 32% (three views), and 43% (four views). Lack of confidence, defined as being scored as either a two or 4, was significantly lower with CT at 6% than with radiography at 30% (two views), 23% (three views) and 18% (four views). Conclusions: Inter observer agreement is significantly greater using limited field of view CT when compared with radiographs. Radiologist confidence improved significantly with CT compared to radiographs regardless of the number of views.

TABLE 1a. Effective Dose Estimated of Lumbar Spine Radiographs in Multiple Views for Three Differenct Ages with a Standard Source to Image Receptor Distance (SID) Age (Years) 5

Paper #: PA-148 10 CT Outperfoms Radiographs at a Comparable Radiation Dose in the Assesment for Spondylolysis

Michael Fadell, M.D., Radiology, Children’s Hospital Colorado, Aurora, CO, [email protected]; Jason Weinman, Jane Gralla, Jaime Stewart, MD, Angie Miller, John Strain, MD Purpose or Case Report: Lumbar spondylolysis, a unilateral or bilateral fracture at pars interarticularis, is a common cause of low back pain (LBP) in pediatric patients. The initial imaging study in the diagnosis of lumbar spondylolysis has historically been lumbar spine radiographs; however, radiographs can be equivocal or false negative. Definitive diagnosis can be achieved with computed tomography (CT), but its use has been limited due to the dose of ionizing radiation to the patient. At our institution, we have began utilizing limited field of view CT altering the technique such that the dose to the patient is comparable or lower than radiographic work-up (Tables 1a & 1b). As there is no gold standard for the diagnosis of spondylolysis, with the exception of surgery, we have chosen to compare inter-observer agreement and degree of confidence to determine which modality is preferably. Methods & Materials: Between 2011 and 2013 56 patients with low back pain aged 5–18 years were assessed for the presence of spondylolyis. Forty-seven patients were evaluated by radiography and nine patients were evaluated by limited field of view CT.

15

SID (″) 40

View AP Oblique Lateral Spot AP Oblique Lateral Spot AP Oblique Lateral Spot

kVp 70 70 75 75 75 75 80 80 80 80 85 85

mAs 10 12.5 18 20 16 20 20 32 20 25 32 40

Effective Dose (mSv) 0.107 0.139 0.122 0.100 0.256 0.270 0.216 0.126 0.307 0.288 0.337 0.250

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Paper #: PA-149 Clinical Value of Adipose Volume Measurements Obtained from Routine Body CT: Associations with Body Mass Index and Clinical Observations

Chunzhe Duan, Master of Health Science, Children’s National Medical Center, Washington, DC, DC, [email protected]; Nabile Safdar, Evan Nadler, Jiamin Liu, Ronald Summers, Marius George Linguraru Purpose or Case Report: Investigate the associations between adipose volumes obtained automatically from routine body CTs, body mass index (BMI), and clinical phenotype in pediatric patients.

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significantly correlated with all the adipose variables and BMI (p < 0.05); mean BP was significantly correlated with relative VAT (p = 0.048) and relative TAT (p = 0.038). In the logistic regressions, hyperglycemia was significantly associated with maximum relative SAT (p = 0.029) and TAT (p = 0.040); while insulin resistance was significantly associated with total SAT (p = 0.017), total TAT (p = 0.030) and maximum relative SAT (p =0.033). Conclusions: Adipose volumes obtained from CT examinations and BMI are highly correlated; however, measures of adipose volumes from abdominal CT are better indicators of clinical phenotype related to hypertension, hyperglycemia, diabetes, and insulin resistance in pediatric patients than BMI. Adding adipose volumes obtained automatically from CT may add value to reports to pediatricians concerned about clinical conditions associated with obesity. Paper #: PA-150 Characterization of Brown Adipose Tissues using MRI in the Pediatric Population—a Pilot Study

Jie Deng, PhD, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Jami Josefson, Soyang Kwon, Helen Binns, Samantha Schoeneman, Cynthia Rigsby, MD

Methods & Materials: We collected axial contrast-enhanced CT images of 183 patients ages 13 to 21 years. Thirty-nine cases were underweight (BMI < 18.5), 49 had normal weight (18.5 ≤ BMI < 25.0), 41 were overweight (25.0 ≤ BMI < 30.0), 37 were obese(30.0 ≤ BMI < 40.0) and 17 were morbidly obese (BMI ≥ 40.0). Abdominal CT images were acquired by GE Discovery 690 or Philips Brilliance 64 scanners with slice thickness ranging from 2.5 to 5.0 mm. Adipose tissue volume were obtained automatically using previously validated software. We assessed the volume of visceral fat (VAT), subcutaneous fat (SAT), total fat (TAT), and body volume in the region of vertebrae T10 to S1. Relative total adipose (total adipose/body volume) and maximum relative adipose (maximum of relative adipose in each slice among all the slices) volumes were also calculated. Spearman’s rank correlation was used to investigate the relationship between the adipose volume and BMI, and both these measurements and clinical phenotype. Generalized linear models of logistic regression were created to measure the association between adipose volume and BMI, and the clinical phenotype, correcting for age, sex and race; the significance level is α=0.05. Results: All adipose volumes and BMI were significantly correlated (p< 0.0001). Hyperglycemia was significantly correlated with maximum relative SAT (p =0.037) and maximum relative TAT (p=0.036). Insulin resistance was correlated with maximum relative SAT (p = 0.046). Systolic Blood Pressure (BP) was

Purpose or Case Report: To exploit chemical-shift and intravoxel incoherent motion diffusion-weighted (DW) MRI methods to characterize brown adipose tissues (BAT) and compare the tissue composition between normal-weight and obese pediatric groups. Methods & Materials: Twenty healthy children (9–15 years) were enrolled in four groups: lean/prepubertal(G1), obese/ prepubertal(G2), lean/pubertal(G3) and obese/pubertal(G4). MRI was performed on a 3.0 T scanner (Siemens Trio). A 3D T1W 2-point Dixon VIBE sequence was acquired for neck fat scout, followed by a 2D six-echo SPGR sequence with consecutive in-phase (IP) and out-of-phase (OP) echo time (TE) for fat fraction (FF) and T2* measurements. DW-BLADE images were acquired to measure microscopic tissue water mobility. A stack of scout FF maps throughout the neck area were generated from the 2-point Dixon VIBE images for BAT localization (Fig.1A). Regions of interest (ROIs) were drawn in the presumed BAT areas on the 2D SPGR images (Fig.1B), and the signal oscillations (Fig.1C) were fitted to calculate FF and T2* based on a multi-point, multi-fat-peak model (Fig. 2). In DW-BLADE images, the signal decay within each ROI was fitted to calculate the apparent diffusion coefficient (ADC) and pseudo-perfusion parameter fast diffusion volume (Vperf) as well. FF, T2*, ADC and Vperf of BAT tissues were compared between the four groups using multilevel linear regression analyses (α = 0.05). Results: Obese groups showed significantly higher FF than lean groups, whereas FF was not affected by pubertal stages. The prepubertal lean group had significantly lower T2* compared to the other three groups. Higher T2* values in older and obese groups indicated less mitochondria content in BAT tissues. Over all BAT pixels, the joint plot of FF and T2* showed that BAT in the obese groups tended to have higher FF and T2* than the lean groups (Fig. 3). The ADC of BAT was not significantly different between any two groups. Prepubertal, both lean and obese groups had significantly higher Vperf than the pubertal obese group. Interestingly, the pubertal lean group had lower Vperf than the prepubertal obese group.

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Conclusions: Overall, the results suggested that the adipose tissues at BAT sites may contain a mixture of brown and white adipocytes. BAT in obese and pubertal subjects showed more ‘white adipose tissue (WAT)-like’ properties with increased FF and T2*. The increased capillary perfusion volume (Vperf) in prepubertal groups indicated greater microvasculature compared to pubertal groups.

Paper #: PA-151 Ultrasound of the Joints and Entheses in the Healthy Child

Nancy Chauvin, MD, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Pamela Weiss, J. Christopher Edgar, Klink Andrew, Diego Jaramillo Purpose or Case Report: Knowledge of the age dependent normal US appearance of joints and entheses in children is crucial in order to evaluate for pathology such as acute trauma, overuse injuries or arthritis. We describe the typical age-related grayscale and Power Doppler (PD) ultrasound features of the elbows, knees and feet, providing a reference for the appearance of the tendon insertions in healthy children ages 4–18 years. Methods & Materials: We conducted a prospective cross-sectional study of 30 healthy children. Subjects were grouped according to age; group #1 (4–9 years, n=11), group #2 (10–13 years, n=9), and group #3 (14– 18 years, n=10). Patients completed questionnaires measuring function and pain. For each subject, both elbows, knees and feet were imaged with grayscale in the longitudinal and transverse planes to assess the appearance and thickness of the common extensor, common flexor, quadriceps, patellar and Achilles tendons and plantar fascia at the insertion. PD was used to assess vascularity within the tendon as well as peritendinous vascularity. The anterior elbow, suprapatellar, and retrocalcaneal bursae were evaluated for fluid. In skeletally immature children, the apophyseal cartilage thickness at the enthesis was measured. Correlation analyses examined associations between age and tendon thickness. Repeated measures ANOVA with location as a repeated measure examined examining gender differences in cartilage thickness.

Mean Tendon Thickness in mm (95% CI) Insertion Site Common Extensor Tendon Common Flexor Tendon Quadriceps Tendon Patellar Tendon Achilles Tendon Plantar Fascia

Group 1 N=22 3.4 (3.2, 3.5)

Group 2 N=18 3.8 (3.6, 4.0)

Group 3 N=20 4.5 (4.3, 4.7)

2.3 (2.2, 2.4)

2.8 (2.7, 3.0)

3.1 (3.0, 3.2)

4.1 (3.9, 4.3) 2.9 (2.8, 3.0) 3.4 (3.3, 3.5) 2.9 (2.8, 3.0)

5.2 (5.1, 5.3) 3.8 (3.6, 4.0) 4.1 (4.0. 4.3) 3.4 (3.2, 3.5)

5.7 (5.3, 6.0) 4.0 (3.8, 4.2) 4.5 (4.2, 4.7) 3.7 (3.5, 3.9)

Table 1. Mean Tendon Thickness with 95% Confidence Intervals

Results: Subjects had a median age (IQR): 12.1 years (7, 15) and 55% were boys. All 360 entheses appeared normal on grayscale. There was a linear relationship between tendon thickness and age

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(Table 1, Figure 1). Tendon vascularity was only present in group #1, in 7/22 (32%) quadriceps tendons. Peritendinous PD signal was seen at seven sites; two patellar, four quadriceps and one common flexor tendon and all subjects were in group #2. Suprapatellar bursal fluid <3 mm was detected in 9/60 (15%) knees. No retrocalcaneal or anterior elbow bursal fluid was present. Cartilage measures were available only for the youngest group and analyses were restricted to group #1. Boys had statistically significant thicker apophyseal cartilage compared with girls at the medial epicondyle, patellar poles and os calcis (p<0.05). Conclusions: Tendon thickness has a linear relationship with age. Tendon vascularity may be a normal finding in young children. Peritendinous vascularity is not uncommon in children 10–13 years. At certain sites, cartilage thickness varies with gender.

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Median age of onset of symptoms was 4.0 years (range 0.3– 9.0 years); median age of enzyme replacement initiation was 4.8 years (range 1.1–15.1 years); median treatment duration was 10.3 years (range 0.8–14.2 years). Hb, platelet count and liver volume at MR imaging were normal. Mean pre-treatment spleen volume (14.8 times above normal) decreased to 3.1 times at the time of MRI (p=0.008). Conclusions: Femoral spectroscopy showed lower fat fraction values in Gaucher patients than controls, and increasing fat fraction with age in both groups. MR spectroscopy detected FF differences that are undetectable with MRI. Since fat fraction increases with age, adult cut-off values of less than 0.23 are invalid to predict bone complications in children. Disclosure: Dr. Jaramillo has indicated a relationship with Genzyme as a Principal Investigator and Research Support. Dr. Kaplan has indicated a relationship with Genzyme Corporation as an Investigator and Member of Advisory Board Gaucher Registry.

Paper #: PA-152 Quantification of bone marrow involvement in Gaucher disease with proton MR Spectroscopy: correlation with bone marrow score, and clinical status

Maria Bedoya, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Jorge Delgado, Camilo Jaimes, Dah-Jyuu Wang, Paige Kaplan, Diego Jaramillo Purpose or Case Report: In children treated for type 1 Gaucher disease, 1) to use proton MR spectroscopy to quantitatively evaluate bone marrow infiltration measuring fat fraction (FF); and 2) to compare the FF with qualitative scores on bone marrow MRI and clinical status. In adults, low FF (<0.23) measured by Dixon method increases osteonecrosis risk.

Methods & Materials: During 3 years we prospectively evaluated 10 Gaucher patients (6 M, 4 F, median age 15.3 years (5.5–21.3)) and 10 age-matched controls (5 M, 5 F, median age 15.1 years (5.4–20.7)) using 3.0 T MR spectroscopy (Single-voxel STEAM) in the L5 vertebral body and femoral neck. Water and lipid areas under the curve (AUC) were measured to calculate FF: lipid AUC/(lipid AUC + water AUC). T1weighted and water sensitive sequences were acquired. A blinded pediatric musculoskeletal radiologist qualitatively analyzed MR images for marrow involvement using the bone marrow burden score and S-MRI score. We assessed symptoms, changes in spleen and liver volumes, platelets, hemoglobin (Hb), and bone complications. We assessed age and group differences using hierarchical regressions of age, group, and ageXgroup interaction. Results: In the femur, fat fraction was higher in controls (0.69) than Gaucher patients (0.55) (p=0.02). In L5, higher FF in controls (0.36) than Gaucher patients (0.32) was not significant (p=0.16). In both groups and regions, FF increased with age (p<0.02). The interaction term showed fat fraction similarly decreased with age in both groups ((p>0.21), Figure 1). Qualitative scores showed no significant differences between control and Gaucher groups (p>0.22) and subjectively controls and Gaucher patients were indistinguishable. 8/10 patients were asymptomatic, two had chronic bone pain.

Paper #: PA-153 Pediatric liver transplant portal vein anastomotic stenosis: correlation between transabdominal ultrasound and percutaneous transhepatic portal venography

C Matthew Hawkins, MD, University of Washington School of Medicine/Seattle Children’s Hospital—Radiology, Seattle, WA, [email protected]; Dennis Shaw, Patrick Healey, Simon Horslen, Andre Dick, Giri Shivaram Purpose or Case Report: To determine which transabdominal grayscale and Doppler ultrasound (DUS) parameters are predictive of hemodynamically significant portal venous (PV) anastomotic stenosis (PVS) in pediatric liver transplants as determined by percutaneous transhepatic portal venography (PTPV). Methods & Materials: An IRB approved retrospective search was done for PTPVs performed for suspected post-transplant PVS over a 14 years period at a single pediatric hospital. Findings from PTPV were compared to DUS obtained immediately before PTPV. Recorded parameters were: patient age, transplant indication, whole or segmental transplant, peak systolic velocity (PSV) at the PV anastomosis on DUS, change in systolic velocity across the anastomosis (dSV) on DUS, % stenosis on US and PTPV, and details of venoplasty or stent placement when performed. Using PTPV as the reference standard, patients were stratified on the presence or absence of hemodynamically significant PVS, defined as >50% (Group 1) or ≤50% (Group 2). DUS findings from these patients were compared to age-matched controls with normal post-transplant DUS followed for 0.4 to 78 months (mean 47). Parametric and non-parametric analyses were done with SPSS 19 (IBM, Chicago IL).

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Results: Twenty-one PTPVs were performed on 12 patients. Average age at transplant; 32 months: at PTPV; 61 months. Technical success was 100%, with intervention performed in 18 cases (16 venoplasty, 2 stent). 14/21 (67%) PTPVs demonstrated hemodynamically significant (>50%) PVS. Mean PSV in Group 1 was 253.6 +92 cm/s; Group 2 169.7 + 45 cm/s; Control group 49 + 19 cm/s. Mean dSV in Group 1 was 80.3+62 cm/s; Group 2 65.9+32 cm/s; Control group −2+17 cm/s. PSV on DUS correlated with PVS measurement on PTPV (R= 0.672, p=0.002). (Graph 1) No correlation was seen between PVS measured by US (R=0.19) or dSV (R=0.13) with PVS measured by PTPV. To evaluate the ability of PSV measured by DUS to predict the presence or absence of hemodynamically significant PVS, an ROC curve was generated. (Figure 1) Area under curve = 0.75; trend significance = 0.076. Conclusions: In pediatric liver transplants, PSV at the portal vein anastomosis was the only US measurement that correlated with the degree of anastomotic PVS measured by PTPV. PSV can predict the presence or absence of hemodynamically significant anastomotic PVS in patients with PSV > 260 cm/s (85% sp) and <180 cm/s (83% sn), respectively. For patients with 180
Paper #: PA-154 Trans—Jugular Liver Biopsy (TJLB) in Children: A Single Institutional Experience

Mahmoud Zahra, MD, FRCR, Radiology, Children’s hospital of philadelphia, Philadelphia, PA, [email protected]; Ganesh Krishnamurthy, Marc Keller, Adeka McIntosh, Anne Marie Cahill Purpose or Case Report: To describe the technical success, diagnostic accuracy and outcomes of trans-jugular liver biopsy in children Methods & Materials: A 10 years retrospective review was performed of 22 children (17 males, 5 females) who underwent transjugular liver biopsy, mean age 11.8 years, (0.16–19 years), range mean weight53.8 kgs (range 5.8–112.4kgs). Radiologic and medical records were reviewed for technical success, sample adequacy and complications. TJLB was the method of choice due to thrombocytopenia 11/22 patients, ascites 9/22 patients and hepatic wedge pressure requirement 2/22 patients. Technical success was defined as the ability to obtain gross tissue specimen. Results: Technical success was 100%. Three patients were post liver transplantation. Diagnostic specimens were obtained in 21/ 22 patients (95.5%) There was 1 inadequate specimen (4.5%). Biopsy was performed with an automated 19 g needle set in 19/ 22 patients and an automated 18 g needle set in 3/22 patients under general anesthesia in 13/22 and IV sedation in 9/22

patients. The right hepatic vein was accessed in 17/22 and the middle hepatic vein in 5/22 patients. The mean number of passes was 2.5 (range 1–4). Hepatic wedge measurement was performed in 5/22 patients with an elevated pressure of 19 mmHg noted in only 1 patient. US assistance was used in 8/22 procedures. There were 2 intra-procedural self - limiting complications, mild subcapsular extravasation on post biopsy venogram (9%). No early or late complications were encountered. Mean procedure time was 67.6 (range 60–90 min). Fluoroscopy time was more recently documented as a standard and available in 8/22 patients, ranging from 3.3 to 18 min. 8/22 patients were deceased from their primary disease at the time of the completion of this study. Conclusions: Trans—jugular liver biopsy is a safe and technically feasible procedure in infants and children. Trans-abdominal US assistance may increase operator confidence of needle localization.

Paper #: PA-155 Fluoroscopic maintenance of pediatric gastro-jejunostomy tubes: What is the radiation dose to the patient and the fluoroscopic operator’s hands?

Justin King, Keith Strauss, MSc, Radiology, Cincinnati Childrens Hospital, Cincinnati, OH, [email protected]; Neil Johnson, MB.BS, Marilyn Goske, Jason Lee, Steven Kraus Purpose or Case Report: Placement of gastro-jejunostomy (GJ) tubes for pediatric patients requiring post pyloric nutrition is an increasingly common procedure. These tubes generally require regular exchange or unscheduled maintenance, usually performed under fluoroscopic guidance by a radiologist or assistant. Our study was designed to estimate the entrance skin dose (ESD) to the hands of the fluoroscopist and the ESD to the patient as a function of patient size. Table 1: Operator’s Hand vs Patient’s Dose Range of Patient Size (cm) 11–12 13–14 15 16–18 20–25 Averages

Number of Patients in Size Range 7 6 6 6 5

Range of Patient Size (cm) 11–12 13–14 15 16–18 20–25 Averages

Ave Patient Skin Dose (mGy) 0.8 0.9 1.1 1.3 3.2 1.5

Patient Ave Fluoroscopic Time Thkness (cm) Average (min) 11.6 13.5 15 17 21.4 15.7

1.8 2.5 2.1 1.7 3.4 2.3

Higher hand Skin Hand/Patient Dose (μGy) Dose (μGy/mGy) 12 18 19 9 28 17

9 14 16 5 6 10

Methods & Materials: This prospective IRB approved study of 30 unselected patients analyzed each recorded (Perkins system) fluoroscopic video frame for the presence of any bony part of the operator’s hand indicating exposure to primary radiation. Patient skin dose in Table 1 was estimated from the calibrated air KERMA displayed by the fluoroscopes

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injuries. Using the AAST scale, pseudocyst development occurred in 2/23 (9%) of patients with grade I or II injuries, 7/11 (64%) of patients with grade III injuries and 1/7 patients with grade IVor V injuries. Notably, 12 patients (23%) could not be classified per the AAST scale because of inability to clearly determine ductal injury on imaging. Positive and negative predictive values (PPV and NPV), sensitivity and specificity for pseudocyst formation were all higher using the Wong scale (AAST: PPV 42%, NPV 91%, sensitivity 80%, specificity 65% vs. Wong: PPV 50%, NPV 94%, sensitivity 82%, specificity 77%). Conclusions: The Wong CT grading scale may be superior to the AAST scale for early risk stratification for pseudocyst development following non-operative management of pediatric pancreatic trauma patients, which can lead to a prolonged and complicated treatment course. Children with Wong grades BII or CII may benefit from early intervention. Prospective studies are needed to confirm these findings.

specifically configured for pediatric patients.. The doses to the operator’s hands were measured with calibrated Al2O3:C microdot dosimeters taped to the dorsal skin of the middle finger of each hand of the operator. Results: A part of the operator’s hands was observed in 40% of the recorded fluoroscopic frames. Average fluoroscopy time was 2.4 +/− 2.2 min, (range 0.4–8.5 min). Average patient skin dose was 1.5 +/− 1.8 mGy (range 0.3–8.1 mGy), which was proportional to the patient size. The skin dose to the operator’s hand receiving the higher dose ranged from 9 to 28 μGy. The ratio of the operator’s hand to patient’s skin dose averaged 10 with a range of 5–16 (μGy/mGy). This ratio allows an estimate of the dose to the operator’s hands if the entrance dose to the patient is known. Conclusions: The operator’s hands received a skin dose of 1% of the skin dose received by the patient averaged over all patient sizes. Due to pediatric specific settings of our fluoroscopes an operator at our institution can perform about 3,000 procedures annually before the published ALARA Maximum Permissible Dose hand dose is reached.

Paper #: PA-157

Paper #: PA-156

MR imaging characteristics of focal nodular hyperplasia (FNH) of the liver in children

Image-guided prediction of pseudocyst formation following traumatic pancreatic injury in children

George Bisset, M.D., Texas Children’s Hospital, Houston, TX, [email protected]; Fariha Sheikh, Sara Fallon, Daniel Podberesky, MD, Jicui Zheng, Richard Falcone Purpose or Case Report: Grading of pancreatic trauma by computed tomography (CT) is widely based on the American Association for the Surgery of Trauma (AAST) scale, which has limitations as it involves subjective interpretation of ductal injury. We hypothesized that the Wong grading scale, which is based on the size and depth of the laceration, is more predictive of complications following non-operative management of traumatic pancreatic injury in children. Table 1 Comparison of AAST and Wong scales for CT grading of pancreatic injury AAST Scale

Wong Scale

Grade

Injury

Grade

Injury

I

Minor contusion/superficial laceration without duct injury

A

Pancreatitis or superficial laceration

II

Major contusion/laceration without duct BI injury or tissue loss

Deep laceration involving tail of pancreas

III

Distal transection or parenchymal injury CI with duct injury

Deep laceration involving head of pancreas

IV

Proximal transection or parenchymal injury BII involving ampulla

Complete transection involving tail of pancreas

V

Massive disruption of pancreatic head

Complete transection of head of pancreas

CII

Methods & Materials: A retrospective review of children admitted to two large level I pediatric trauma centers for traumatic pancreatic injuries between 2000 and 2012 was conducted. Initial CT scan was reviewed by a radiologist blinded to the clinical outcome and an injury grade was assigned based on both the Wong and AAST scales (Table 1). The primary outcome was pseudocyst formation. Positive and negative predictive values for pseudocyst formation based on injury grade were compared. Results: Fifty-three patients (ages 7 months to 17 years) were included, all of whom were initially managed non-operatively. Per the Wong scale, pseudocyst development occurred in 0/20 (0%) of patients with grade A injuries, 2/15 (13%) of patients with BI or CI injuries and 9/18 (50%) of patients with BII or CII

Farahnaz Golriz, Texas Children’s Hospital, Department of Pediatric Radiology, Houston, TX, [email protected]; Sanjeev Vasudevan, Patrick Thompson, Milton Finegold, Rajesh Krishnamurthy, Prakash Masand, MD Purpose or Case Report: FNH is increasingly diagnosed in children and it is well established in the literature that dynamic contrast enhanced MRI with a hepatocyte specific contrast agent (Gadoxetate Disodium) is helpful for the diagnosis of FNH. The purpose of this paper is to determine if prospective diagnosis of FNH can be made on MR imaging features. Methods & Materials: We retrospectively reviewed abdominal MR examinations performed on 30 pediatric patients between 2006 and 2013, diagnosed with FNH on contrast enhanced MR scans performed with Gadoxetate disodium contrast and confirmed by biopsy (n=7) or stability on follow up exams (n=23). The range of follow up was 4– 48 months, with an average follow up of 14.3 months. Indications for MR imaging included incidentally detected lesions on ultrasound or CT, prior history of chemotherapy, congenital portocaval shunt, chronic portal vein thrombosis and palpable mass lesions. A blinded reader with more than 5 years’ experience looked at T1/T2 including in and out of phase sequence signal characteristics, and dynamic contrast enhanced appearance on the arterial, portal, hepatic venous, and 20 min delayed phase images after administration of Gadoxetate disodium. Results: Of the 30 patients diagnosed with FNH, 25 patients were female (83%). The average age at diagnosis was 12.4 years (range, 14 months– 18 years). Ten patients had more than 1 FNH (33%). Total number of lesions reviewed were 53 (n=53). Pathologic confirmation was obtained in seven patients,where the dominant lesion was biopsied. There were 20 incidentally detected lesions, five in patients who received chemotherapy, two with underlying portocaval shunts, one with chronic portal vein thrombosis and two presenting as palpable masses. FNH was isointense to surrounding liver parenchyma on T1 and T2 weighted sequences in 33 lesions (63%), and showed mild T2 hyperintense/T1 hypointense signal in 20 lesions (37%). After injection of Gadoxetate disodium, all lesions had avid arterial phase enhancement, became isointense to surrounding liver on the portal and hepatic venous phases, and showed retention of contrast on 20 min hepatocyte specific phase. A central scar was noted in 40 lesions (75%), more apparent on the 20 min delayed sequence. Conclusions: Focal lesions in the pediatric liver which demonstrate contrast retention at 20 mins after the administration of hepatocyte specific contrast,when detected incidentally or in the setting of prior chemotherapy,can be safely followed,obviating the need for tissue sampling in most instances.

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Disclosure: Dr. Krishnamurthy has indicated a relationship with Philips Electonics as a Principal Investagtor and Research Scientist Support.

ALTERNATE PAPERS Whole Body MRI (WBMRI) evaluation in children with cancer predisposition syndromes

Sudha Anupindi, MD, Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Kim Nichols, Maria Bedoya, Robert Lindell, Siri Rambhatla, Nancy Chauvin, MD Purpose or Case Report: To determine the diagnostic performance of WBMRI in tumor surveillance for children with genetically-confirmed cancer predisposition syndromes. Methods & Materials: Screening non-contrast targeted WBMRI scans of children with cancer predisposition syndrome were retrospectively and independently reviewed by two radiologists who were blinded to the medical records. The WBMRI scans were assessed for quality (very good, satisfactory, inadequate); imaging sequences; osseous, soft tissue, or solid organ abnormalities; and incidental findings. Positive findings of possible malignancy were stratified by risk: low (<20%), moderate (20-80%), or high (>80%). Discordant findings were resolved in consensus. Findings were correlated with the medical record, biopsy results, or additional follow-up imaging; with biopsy or follow-up considered gold standard. Results: Forty-seven WBMRI studies in 23 children(mean age 11.2 years) with cancer predisposition syndromes: paraganglioma-pheochromocytoma syndrome (n=13) and Li-Fraumeni syndrome (n=10). All patients were asymptomatic at the time of screening. 7/23 (30%) had a personal history of malignancy and 15/23 (65.2%) had a family history of malignancy. 45/47 (95.7%) WBMRI scans were very good quality. WBMRI sequences included whole body Coronal STIR (100%) and T1 (98%), and focused axial fluid sensitive sequences. Abnormal marrow signal was noted in seven patients and classified as high risk (n=1), moderate risk (n=1) and low risk (n=5). The high and moderate risk lesions were false positives; one resolved on follow-up imaging and one was a biopsy proven benign bone cyst. Among the five with low risk abnormalities; two were attributed to stress related changes in the pubic ramus; a biopsy confirmed bone cyst; a possible paraganglioma,diagnosed as a lymph node on follow up dedicated contrast enhanced neck MRI; multifocal marrow signal changes related to prior treatment confirmed by prior MIBG study. In our false negative follow-up dedicated contrast enhanced brain MRI revealed cortical dysplasia vs low grade glioma, not seen on WBMRI(technically limited for brain parenchymal detail). Common incidental findings which had no clinical impact included atelectasis, adnexal cysts, sinusitis, and fibrous cortical defects. Overall, WBMRI demonstrated a negative predictive value (NPV) of 98%. Conclusions: Focused non-contrast WBMRI produces high-quality diagnostic imaging, and its high NPV makes it a valuable screening tool in these high-risk children.

applied to neonates. Our objective was to determine the feasibility of cine MRI to assess intestinal motility in neonates. Methods & Materials: We performed an IRB approved, prospective observational study. Subjects included neonates with no history of abdominal pathology (normal) and infants with gastroschisis (GS), a congenital anomaly known to adversely affect intestinal motility. MRI was performed without sedation on a small footprint 1.5 T MR system located within the neonatal intensive care unit. Infants were scanned supine and, if not NPO for clinical reasons, fed 30 to 60 min prior to the exam. Coronal balanced steady state images were acquired at a temporal resolution of approximately 0.5 s/image over 16–52 s from 3 to 5 locations in the abdomen. 1–3 segments of well-distended bowel were selected in each data set. Manual measurements of the cross-sectional diameter (orthogonal to the long axis of the small bowel) of each segment were recorded for each time point. Motility patterns were evaluated qualitatively (paralytic, quivering, uncoordinated or sinusoidal) and quantitatively (contraction frequency, amplitude and ratio) and their relationship to concurrent clinical data was explored. Results: Motility data was obtained in seven normal and five GS infants. Two GS infants were imaged at two time points, while three were imaged at three distinct time points as bowel function improved. Two of the seven normal motility data sets were eliminated due to inadequate distension, excessive bowel gas, or out of plane motion. Motility plots of normal infants exhibited a sinusoidal pattern (Fig. 1a) with mean frequency of 11.1±1.7 [range 9.3–12.9] contractions per minute. These findings are consistent with adult measures. Intestinal motility in GS infants included paralytic, quivering, uncoordinated (Fig 1b) and sinusoidal patterns. The observed pattern related to the concurrent degree of abnormal bowel distension and/or clinical status (e.g. volume of enteral feeds).

Conclusions: Cine MRI is a viable method to assess intestinal function/ motility in neonates. Further studies to evaluate its efficacy in the diagnosis of intestinal dysfunction and abdominal pathology associated with prematurity are warranted.

Poster #: SCI-060 Cine MRI Evaluation of Intestinal Motility in Preterm Infants: A Feasibility Study

Jean Tkach, Ph.D., Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Mantosh Rattan, Andrew South Purpose or Case Report: Preterm and term neonates are at high risk of intestinal motility disorders. In older children and adults, cine MRI has proven useful in diagnosis and management of intestinal motility disorders. However, standard technique includes breath holding and oral bowel preparation—techniques that cannot safely or practically be

SCIENTIFIC EXHIBITS/POSTERS Authors are listed in the order provided. An author listed in bold identifies the presenting author. Poster #: CR-001 Transcutaneous Sonography of Tonsils in the Pediatric Patient: a novel imaging technique to detect peritonsillar abscess

Anjum Bandarkar, MD, Diagnostic Imaging and Radiology, Childrens National Medical Center, Washington, DC, [email protected]; Brian Reilly, Nabile Safdar

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Purpose or Case Report: Peritonsillar abscess (PTA) is a common deep neck infection characterized by collection of purulent fluid between the palatine tonsil capsule medially and the fascia of the superior constrictor muscle laterally. It is typically more common in adolescents. Due to the similar presentation, differentiation of PTA from peritonsillar cellulitis (PTC) can be very challenging based on clinical exam alone but is critical in its management because PTA needs needle drainage of pus or tonsillectomy and PTC can be treated with antibiotics. Contrast-enhanced CT scan is currently used to confirm the diagnosis however it is far from ideal due to its relatively higher cost and ionizing radiation exposure. Needle aspiration is considered the gold standard for diagnosis and treatment but can be painful and extremely difficult in children. There are a few recent reports of use of intraoral ultrasonography to assess PTA in adult emergency medicine but the procedure may not be well tolerated in children due to the size of the intracavitory probe and trismus. Hence we would like to introduce a promising novel technique using transcutaneous ultrasound in the pediatric patients. The purpose of this presentation is to demonstrate the technique of performing transcutaneous sonography of the tonsils to detect PTA by placing a high frequency linear transducer over the submandibular gland beneath the mandible and scanning the tonsillar fossa. Transcutaneous sonography is an easy and safe imaging method to differentiate peritonsillar abscess from cellulitis. Poster #: CR-002 Software Segmentation and Rapid Prototyping of Congenital Heart Defects with Cardiac MRI images

Yue-Hin Loke, Children’s National Medical Center, Washington DC, DC, [email protected]; Laura Olivieri, Peter Kim, Axel Krieger Purpose or Case Report: Visualizing the 3D anatomy of congenital heart disease (CHD) via 2D images is often difficult for clinicians who are inexperienced in the reconstructive visualization process. The use of physical 3D models may be useful in improving the understanding and visualization of CHDs. We describe an efficient technique to fabricate physical models of heart defects using software segmentation and 3D rapid-prototyping.

Methods & Materials: The cardiac MRI axial images of an adult patient with repaired Tetralogy of Fallot was obtained. An axial stack of steady state free precession images, 1.1 mm slices, isotropic voxels, were uploaded into a 3D segmentation software Mimics (Materialise, Leuven, Belgium). Both the cardiac features and the intracardiac blood pool were segmented to appropriately reflect internal anatomy. The segmentation process involved use of a simple threshold, use of region growing tools, and manual segmentation techniques to preserve the intracardiac anatomy and distinguish cardiac features from MRI artifact. Using design modification software (3-Matic), the 3D model was further partitioned into two separate “Lego” pieces to expose relevant anatomy (see Figure 1). The finalized digital 3D file was then printed with an Object500 Connex (Stratasys, Rehovot, Israel) Poly-jet 3D Printer to obtain a physical 3D model.

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Results: We present the technical aspects of fabricating a physical CHD model, with emphasis on segmentation techniques, “Lego” style partitioning for accurate display of the intracardiac defect to showcase clinically-relevant anatomy, and materials useful for printing out the 3D model. Combining segmentations of myocardium and blood pool was an efficient way of preserving intracardiac anatomy without drastically increasing the time required for manual segmentation. Conclusions: Physical CHD models can be readily fabricated from cardiac MRI data. These 3D models may be used for enhancing the education experiences of medical trainees, for operative planning, or for consultations with family members regarding a patient’s diagnosis of CHD. Segmentation software and rapidprototyping can further be utilized in other imaging modalities such as 3D echocardiography. Poster #: CR-003 Multimodality Imaging Findings of Arterial Tortuosity Syndrome, a Case Series

Julie Ratino, MD, Children’s Mercy Hospital, Kansas City, MO, [email protected]; Joshua Knowlton, MD, MPH, Mark Gelatt, Sanket Shah, Karina Carlson Purpose or Case Report: Arterial tortuosity syndrome is an autosomal recessive connective tissue disorder characterized by elongation, tortuosity, stenosis and aneurysmal dilatation of large and middle-sized arteries. The purpose of this presentation is to educate the radiologist regarding this unusual syndrome with striking imaging findings. We present two sets of siblings with arterial tortuosity sundrome. Key imaging features are demonstrated by magnetic resonance angiography (MRA), computed tomography angiography (CTA), catheter angiography and ultrasound. We discuss the role of vascular imaging studies for diagnosis and screening of affected individuals. Mediumterm outcomes and follow-up imaging guidelines over the years are suggested. Descriptions of the clinical manifestations, histologic findings and genetic analysis are also included. Poster #: CR-004

Withdrawn Poster #: CR-005 Cross My Heart: Case Series of Criss-Cross Congenital Heart Disease

Leah Davis, DO, Henry Ford Health System/Michigan State University, Wyandotte, MI, [email protected]; Aparna Joshi, Luis Goncalves, Nancy Cutler

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which was confirmed at surgery and on histology. This appears to be the only reported case of aneurysmal involvement of the superficial peripheral arterial branches in an adolescent with NF1 in the literature. We present the MRI findings in correlation with surgical and pathologic images. We hope this illustrative case will increase recognition of the variable clinical manifestations of NF-1 vasculopathy amongst pediatric radiologists.

Poster #: CR-007 Sonographic: Pathologic Correlation of Pulmonary Lymphangectasia

Gregory Compton, MBBS, MMed, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Tanmay Bhamare, Mike Seed

Purpose or Case Report: Criss-Cross heart is a rare congenital anomaly seen in fewer than 0.1% of congenital heart defects. It is characterized by apparent “twisting” of the developing heart resulting in crossing vascular tracts at the level of the atrioventricular valves. Although juxtaposition of the atria may occur, in most patients, there is situs solitus of the atria so the atrioventricular tracts may be concordant, as often occurs with righthanded ventricles, or discordant, as often occurs with left-handed ventricles. There is a strong association with other cardiac anomalies such as pulmonary stenosis, ventricular outlet anomalies, and right ventricular and tricuspid valve hypoplasia. Imaging with cardiac MRI, fetal sonography/echocardiography, or angiography is critical for accurate diagnosis and for evaluation of extent of disease. Preferably diagnosis is made prenatally with sonography and color doppler mapping of the vascular tracts, as affected patients usually present with other severe cardiac anomalies, cyanosis and systolic murmur in infancy. Poster #: CR-006 Neurof ibromatosis Type 1 Arterial Vasculopathy Manifesting as a Superf icial Peripheral Arterial Aneurysm in an Adolescent

Shannon Farmakis, MD, MIR, Washington University School of Medicine, St. Louis, MO, [email protected]; Geetika Khanna Purpose or Case Report: Arterial vasculopathy is a well-recognized but uncommon manifestation of Neurofibromatosis Type 1 (NF-1). It can manifest as stenoses, aneurysms, or arteriovenous malformations. NF-1 vasculopathy typically involves the aorta, visceral arteries, or carotidvertebral circulation. Aortic and visceral vasculopathy typically presents as stenotic lesions, while aneurysms have been reported primarily in the subclavian and vertebral arteries. Aneurysms of the peripheral/extremity arteries are an extremely rare complication of NF-1 which may present as a mass or spontaneous rupture. While peripheral vasculitis has been previously described in children with NF1, to the best of our knowledge, there is only one prior reported case in the English literature of a child with peripheral aneurysms in NF-1, and it involved the larger arteries of the lower extremities. Our case is a 15 year old male with known NF-1 who presented with a growing right arm mass which was clinically concerning for a malignant peripheral nerve sheath tumor. MRI findings were consistent with a peripheral artery aneurysm,

Purpose or Case Report: A healthy patient with no significant medical history was referred to our institution in her first pregnancy for further assessment of an abnormal fetal ultrasound suspicious for congenital heart disease in the fetus. Fetal echocardiography confirmed pulmonary venous obstruction due to cor triatriatum. Fetal MRI showed low pulmonary blood flow and demonstrated lung changes typical for pulmonary lymphangectasia(PL). In utero stenting of the obstructive left atrial membrane was performed which resulted in normalization of the pulmonary venous Doppler and an increase in pulmonary blood flow on MRI, indicating likely resolution of the pulmonary venous obstruction. Neonatal cardiac surgery was performed soon after birth, at which time a lung biopsy was obtained. The specimen showed marked dilatation of the interlobular lymphatics as well as dilatation of the pleural lymphatic channels, in keeping with pulmonary lymphangectasia. An ultrasound performed at 1 week demonstrated an irregular pleural surface, and there were multiple small echolucent areas in the subpleural space with posterior acoustic enhancement in keeping with cystic lesions.

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The cysts on ultrasound and dilated lymphatics in the biopsy were similar in size. At 5 months of age the patient was discharged. At 2 year follow-up he was making progress, however he died of upper airway obstruction as a complication of tracheostomy soon after. We have identified other patients at our institution with primary and secondary PL. All of these patients have a similar abnormal pleural/ subpleural appearance on ultrasound. Half of these patients have biopsy results consistent with PL. As far as we are aware, this report represents the first description of the use of ultrasound to diagnose PL. The abnormal ultrasound appearances are easily detectable using a high frequency linear probe in an intercostal scanning approach. These findings correlate well with the histopathologic description of PL. This simple bedside test could represent a new technique to achieve increased diagnostic accuracy using a non-invasive imaging test, and obviating the need to move critically ill patients and to expose them to ionizing radiation. Patient 1 2 3 4 5 6

PL Cause Obstructed TAPVR Idiopathic Obstructed TAPVR Idiopathic Idiopathic Obstructed TAPVR

Ultrasound Positive Positive Positive Positive Positive Positive

Biopsy Positive N/A Positive Positive N/A N/A

Poster #: CR-008 Ovarian torsion in the fetus—prenatal and postpartum imaging and management

Johanna Schubert, Katherine Cusack, B.S., Creighton University School of Medicine, Omaha, NE; Caroline Cusack, Megan Hora Purpose or Case Report: Approximately 30% of neonates have ovarian cysts prenatally, most of which regress spontaneously. Non-resolving pelvic cystic masses need immediate postnatal imaging evaluation to guide further management. The follicular ring sign can be key in differentiating antenatal ovarian torsion from other etiologies to avoid unnecessary surgical interventions. We highlight two cases of fetal ovarian torsion which presented as a large cystic abdominal mass detected on routine prenatal ultrasound. The pathophysiology of fetal ovarian torsion, the key prenatal and postpartum findings on ultrasound and MRI, differential diagnosis and suggested management will be reviewed. Poster #: CR-009

few case reports of infected cephalohematoma. We describe the radiologic and pathologic features of this rare entity, and highlight the importance of its recognition. Poster #: CR-010

Withdrawn Poster #: CR-011 Torsion of an accessory hepatic lobe: Two cases in children

L u c y L u , P h D , Va n d e r b i l t U n i v e r s i t y, N a s h v i l l e , T N , [email protected]; Marta Schulman, MD, Sumit Pruthi, Melissa Hilmes, Matthew Day, M.D. Purpose or Case Report: Torsion of an accessory hepatic lobe is a rare cause of abdominal pain. Unlike information currently in the literature, imaging findings can be sufficiently characteristic to allow preoperative diagnosis. We report two cases presenting at our institution over the last 25 years. Patient 1: 12y/o girl with acute onset epigastric pain, mild leukocytosis and normal LFTs. CT revealed a hypoenhancing 5×3cm ovoid structure abutting the undersurface of the left hepatic lobe, with surrounding inflammation. On ultrasound the lesion was hypoechoic with respect to the adjacent liver but otherwise of similar appearance. There was peripherally increased echogenicity denoting inflammation, but no internal Doppler flow. At laparotomy, the torsed accessory lobe arose from the left lobe. Patient 2: 13y/o boy also with acute onset epigastric pain, mild leukocytosis and normal LFTs. CT revealed a hypoenhancing 3×3cm structure abutting the undersurface of the left hepatic lobe, with peripheral fatstranding. On ultrasound the lesion was hypoechoic with respect to liver, with otherwise similar echo characteristics, no internal Doppler flow, and peripherally increased echogenicity. Torsion of an accessory hepatic lobe was diagnosed based on the imaging findings, and confirmed by laparoscopy. Although accessory hepatic lobes occur in approximately 1% of the population, they are rarely symptomatic, with less than 30 cases of torsion reported, only nine in pediatric patients, none diagnosed preoperatively. Sonographic findings, available in seven pediatric cases, show a hypoechoic, or mixed echogenicity structure adjacent to the liver with similar echotexture. Depending on the degree of vascular compromise, the torsed lobe may or may not show flow. Conclusion: Our patients had similar imaging findings, consisting of an exophytic hypoenhancing mass, inseparable from and subjacent to the undersurface of the liver. On ultrasound, the diagnosis is most apparent: there is a striking similarity to the hepatic parenchyma, although the lesion is slightly hypoechoic. Torsion of the lobe is denoted by the peripheral inflammation, in conjunction with the absence of Doppler signal. We believe that, in the appropriate clinical context, these finding may allow preoperative diagnosis. It is possible that, if preoperatively recognized, in a manner analogous to preoperatively diagnosed omental torsion, some of these patients might be managed nonsurgically.

Infected cephalohematoma Poster #: CR-012

Amer Alaref, MD, MCs, diagnostic imaging, Children hospital of eastern ontario, Ottawa, ON, Canada, [email protected]; Alireza Khatami, Elka Miller, Kristin Udjus, Michael Vassilyadi, Julie Hurteau-Miller Purpose or Case Report: Case report Cephalohematoma is normally a self limiting condition affecting 1–2% of live births. Although benign in most instances, this condition may be complicated by infection. We report a case of Infected cephalohematoma in a 31-day -old male who presented with left parietal painful swelling, fever and high CRP. Further investigation with ultrasound, CT scan and MRI outlined the involvement. A literature review demonstrates only a

Burkitts lymphoma of bowel mimicking Crohns disease on initial presentation

Supriya Gupta, MD, Radiology, Georgia Regents University, Augusta, GA, [email protected]; Matthew Lynn Purpose or Case Report: Burkitt’s lymphoma of bowel is reported to have many forms of clinical presentations especially in children. This rapidly growing tumor is highly malignant, aggressive, and may cause either indirect symptoms, due to pressure phenomena or direct involvement of the bowel lumen, leading to either intestinal obstruction or intussusception.

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We describe the case of a 14-year-old boy with intraabdominal abscess with fistula formation, initially diagnosed with Crohn’s disease and treated with steroids. He subsequently developed mesenteric lymphadenopathy and a diagnosis of high-grade mature B-cell Burkitt lymphoma was given.

Patient initially presented with weight loss, anemia and hepatomegaly discovered on exam and bloody diarrhea for 2 months. Abdominal CT showed a large central collection with apparent fistulous connection to the terminal ileum, distal ileum, and sigmoid colon containing a large amount of fecalized material. Additional abscesses were visualized in the rectovesical space along with wall thickening of sigmoid colon, cecum, and terminal ileum was noted. This constellation of findings, along with clinical history and age, led to an initial diagnosis of Crohn’s disease (see attached figure). After percutaneous drainage, repeat MRI demonstrated interval decrease in size of the dominant fistulous collection, but there were persistent, extensive inflammatory changes in the abdomen, worst in the right lower quadrant, again compatible with active Crohn’s disease. Patient was started on antibiotics and steroids, and colonoscopy at this time showed colitis without granulomata. He was discharged but came back nearly 1 month later with worsening abdominal pain and increased bloody diarrhea. Repeat MRI showed new massive retroperitoneal, mesenteric, deep pelvic and inguinal adenopathy. The degree of adenopathy was deemed to be beyond what would be expected solely on the basis of inflammatory bowel disease. Additionally, multiple bilateral renal cortical defects in enhancement were now present, new from the prior. At this point, additional diagnostic considerations were suggested, including lymphoma, and a tissue diagnosis was encouraged. Patient was taken for exploratory laparotomy with ileostomy and mesenteric node dissection and a final diagnosis of Burkitt’s lymphoma was established. The teaching point of this case is that bowel wall thickening and fistula formation, while typical of Crohn’s disease, can also be a rare feature of lymphoma.

Poster #: CR-013 Quantitative ADC measures as an imaging biomarker for fibrosis in pediatric Crohn’s disease: Preliminary experience

Arzu Kovanlikaya, M.D., Radiology, Weill Cornell Medical College, New York, NY, [email protected]; Debra Beneck, Pooja Renjen, MD, Paula Brill Purpose or Case Report: The modern concept of Crohns disease emphasizes progressive nature of disease from inflammation to fibrosis manifesting as disease complications such as stricture. It is widely accepted that stricture formation (given the transmural nature of the disease) affects all layers of the bowel wall. However, there is no histological scoring system available to grade fibrosis yet. Imaging biomarkers for strictures could allow understanding of fibrogenesis and patient stratification. Previous MRI studies in adults have reported ADC values for inflamed bowel ranging between 1.59–1.98×10–3 mm2/s and for normal bowel ranging between 2.56–3.11×10–3 mm2/s (1–2). The purpose of this study was to

measure ADC values in strictured bowel segments in pediatric patients with known Crohns disease who had surgical bowel resection. Materials and Methods: MRE images of 14 subjects with known Crohns disease who had surgical bowel resection were reviewed. 5(mean age 16.6 years) of 14 subjects had DWI (b=0,500,1000) sequences included in the MRE study. ADC measurements were made by placing three ROI’s (2–4 mm2) in the strictured bowel wall on the ADC map by two pediatric radiologists independently and an average of these measurements were calculated. Full thickness histologic analysis of resected strictures was done. Results: All five subjects who had surgery for strictures had transmural fibrosis and mild inflammation on histologic analysis. The mean ADC value with b=500 in the strictured segments of these five patients was 0.92×10–3 mm2/s (0.7–1.3×10–3 mm2/s min. and max. values). Conclusion: Quantitative ADC measures of transmural fibrosis are lower compared to the reported values of inflammation in Crohns disease. Our results are comparable to a recently published study(3) in adult Crohns patients showing a significant correlation between a decrease in ADC values and fibrosis. To our knowledge, this is the first pediatric pilot study to investigate the correlation of quantitative DWI with histology of surgical specimens in pediatric patients with Crohns disease. 1. Oto A et al. Active Crohn’s disease in the small bowel: evaluation by diffusion weighted imaging and quantitative dynamic contrast enhanced MR imaging. J Magn Reson Imaging. 2011 Mar; 33(3):615–24. 2. Kiryu S et al. Free-breathing diffusion-weighted imaging for the assessment of inflammatory activity in Crohn’s disease. J Magn Reson Imaging. 2009 Apr; 29(4):880–6 3. Tielbeck JA et al. Evaluation of conventional, dynamic contrast enhanced and diffusion weighted MRI for quantitative Crohn’s disease assessment with histopathology of surgical specimens. Eur Radiol. 2013 Sep 15. Epub Poster #: CR-014 Contrast-enhanced Ultrasound of Pediatric Abdominal Visceral Trauma: Initial Data

Beatrice Dionigi, Carol Barnewolt, Jill Zalieckas, David Mooney, Harriet Paltiel, MD, Department of Surgery, Boston Children’s Hospital, Boston, MA, [email protected] Purpose or Case Report: Contrast-enhanced CT is the “gold standard” imaging test for suspected abdominal injury although 60– 75% of these studies in children are normal. Children are at increased risk for cancer related to radiation exposure. Contrastenhanced US (CEUS) may improve the sensitivity and specificity of US in diagnosis of abdominal injury in children, thereby obviating the need for CT. We recently began enrolling patients in a study to compare the utility of CEUS with CT in the evaluation of children with suspected blunt abdominal trauma. Patients referred to the Trauma Service from outside institutions are considered for inclusion in the study. Projected enrollment is for 22 patients able to give assent who are hemodynamically stable, had outside CT performed, with ongoing clinical concern for blunt abdominal injury. CEUS with Optison™ is performed within 12 h of admission to hospital. Conventional US and CEUS are performed using Optison™ and interpreted by two pediatric radiologists blinded to the results of the CT scans. Each patient receives two injections of Optison™ spaced 10 min apart; 0.3 cc for children < 20 kg weight and 0.5 cc for children ≥ 20 kg. An assessment is made for presence of free fluid and injury to the liver, kidneys, pancreas and spleen. Image clips are stored and subsequently reviewed. Patients are continuously monitored by nursing staff during the CEUS study and for 30 min afterward. A patient questionnaire is also completed. CT scans are interpreted independently by pediatric radiologists not involved in the CEUS studies. Solid organ injury is graded

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according to American Association for the Surgery of Trauma (AAST) injury tables. US findings are then compared to results of the CT scan. Five children have been studied to date. There were four boys and one girl ranging from 10 to 17 years of age, mean 13.8 years. There were five splenic injuries, two grade II, one grade III and two grade III–IV. On gray scale imaging alone, 1/5 splenic injuries was not depicted; 3/5 were very subtle and one was obvious. All injuries were easily depicted by CEUS with no false positive diagnoses of hepatic, pancreatic or renal injury, all of which were normal by CT. Optison™ has been well-tolerated with no documented adverse events. In conclusion, our preliminary experience with CEUS has improved our ability to depict splenic injuries without associated adverse events. These results hold promise for future evaluation of children with blunt abdominal trauma. Poster #: CR-015 Herniation of Meckel’s Diverticulum into a Ventriculoperitoneal Shunt Tract: An Unusual Shunt Complication

Daniel Davignon, DO, Radiology, Children’s Mercy Hospital, Kansas City, MO, [email protected]; Hanna Alemayehn, Sohail Shah, Amy Dahl Purpose or Case Report: A 22 month old female with a history of hydrocephalus and ventriculoperitoneal (VP) shunt placement presented to the emergency department with fever for 4 days and tenderness around the subcutaneous portion of the shunt within the right anterior chest wall. The patient had an intact right frontal VP shunt and previously removed right posterior parietal VP shunt. A combination of head computed tomography (CT), chest ultrasound (US) and abdomen CT demonstrate a herniated loop of bowel within the subcutaneous tract of the previously removed VP shunt. The loop of bowel extends from the abdominal wall defect created by the shunt tract and terminates within the right supraclavicular fossa. A diagnostic laparoscopy was performed which found an incarcerated loop of small bowel within the abandoned subcutaneous tract from the previously removed VP shunt. An open incision of the chest wall was made along the shunt tract which clearly revealed a perforated Meckel’s diverticulum terminating in an abscess cavity. Poster #: CR-016 Duodenal-pancreatic-duodenal intussusception in the setting of malrotation with a duodenal duplication cyst

Alejandro Natera, M.D., Radiology, Children’s Mercy Hospital and Clinics, Kansas City, MO, [email protected]; Brenton Reading

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Purpose or Case Report: The duodenum is the least common location for enteric duplication cysts with prevalence under 1 per 100,000 live births. Duodenal duplication cysts clinical presentations include incidental discovery, pancreatitis, gastrointestinal bleed, obstructive jaundice, and proximal obstruction. The presence of bowel wall signature on ultrasound or direct communication with the duodenal lumen can be helpful imaging findings for its diagnosis. Entero-enteric intussusception is a common complication of distal enteric duplication cysts. However, the fixed retroperitoneal position of most of the duodenum normally precludes the duodenal duplication cyst from acting as a lead point for intussusception to occur. A 14 year-old female presented with a 3 weeks history of worsening nausea and vomiting. Abdominal physical examination was normal. Laboratory evaluation revealed elevated amylase and lipase with a hypokalemic/hypochloremic metabolic alkalosis. An abdominal ultrasound demonstrated a right mid abdominal intussusception with a cystic lesion at the leading edge of the intussusceptum. The cystic lesion measured 3.4×2.5×2.6 cm and had internal debris with bowel wall signature. Given the elevation of pancreatic enzymes further evaluation with computed tomography was pursued. The examination showed a midgut malrotation with a cystic structure serving as a lead point for a duodenal-duodenal intussusception. The intussusceptum contained a portion of the pancreatic head with resulting pancreatic edema and ductal dilatation. The cyst communicated with the duodenal lumen as evidenced by delayed filling with oral contrast. A diagnostic laparoscopy was performed. Midgut malrotation was confirmed and the intussusception was reduced. The cyst and its communication with duodenal lumen were exposed. The cyst was excised and Ladd’s procedure was performed (malrotation correction). Histopathological evaluation of the cyst demonstrated bowel wall stratification consistent with a duodenal duplication cyst. Conclusions: The presence of midgut malrotation and its innate increased duodenal mobility allowed for the duodenal duplication cyst to act as a lead point for a duodenal-duodenal intussusception. Even though this is an atypical presentation, the understanding of ultrasonographic and tomographic imaging characteristics and potential complications of duodenal duplication cysts were valuable in its correct diagnosis and treatment.

Poster #: CR-017 Empty TPN: A Cautionary Case of Copper Deficiency

Laura Hayes, M.D., Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Jay Hochman, David Blews, Susan Palasis, MD, Damien Grattan-Smith Purpose or Case Report: The purpose of this report is to bring attention to the current critical shortages of vital nutrients in total parenteral nutrition (TPN) by presenting a case of copper deficiency acquired by a

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TPN-dependent child. Other pathological states that may arise in TPNdependent children are also discussed. A 22 month-old girl presented with leg pain and refusal to walk. Prior history included full-term infant who underwent laparotomy for bilious emesis without a mechanical bowel obstruction identified. Necrotizing enterocolitis resulted in enteric strictures. Multiple bowel resections caused short bowel syndrome, severe bowel dysmotility, and feeding difficulties requiring a GJ tube and TPN. Plain radiographic appearance of the lower extremities demonstrated thick wavy periosteal reaction cloaking the long bones most prominent along posterior aspects of both femurs. Radionuclide bone scan demonstrated multifocal areas of abnormal radiotracer uptake including the long bones of both upper and lower extremities, multiple anterior ribs, mandible, and maxilla most likely indicating metabolic disease versus multifocal osteomyelitis, fractures, abuse, metastases, or infiltrative marrow process. Subsequently, severe copper deficiency was detected by serum analysis with an extremely low level of 10 mcg/dL (normal range 75–153 mcg/dL). Copper supplementation resulted in resolution of symptoms within weeks. Intermittent shortages of many TPN components (excepting dextrose) have occurred in recent years related to manufacturing and profitability challenges. Consequently, supplemental vitamin and mineral substitutions and rationing have changed the standard composition of TPN. Physicians are not always made aware of these alterations. Deficient or omitted nutrients can include zinc, phosphorus, copper, selenium, chromium and calcium. TPN nutrient deficiency precipitated pediatric conditions may also include rickets, osteomalacia, scurvy, Wernicke’s encephalopathy, zinc deficiency dermatitis, and steatosis. Premature and exclusively TPN dependent children are particularly at risk. Radiologists should be aware of the possible lack of vital nutrients in current TPN formulations. A higher index of suspicion for conditions related to nutritional deficiencies will aid in prompt diagnosis and supplementation for these treatable conditions. Early intervention is particularly important for TPN-dependent children who are often also fragile from their primary illness. Poster #: CR-018 Congenital portosystemic shunt: an important and overlooked cause of neonatal cholestasis – a case report

Jeffrey Scrugham, MD, Dept. of Radiology, LeBonheur Children’s Hospital, Memphis, TN Purpose or Case Report: Cholestatic jaundice (or cholestasis) is defined as jaundice that is the result of an elevation in conjugated bilirubin. Neonatal cholestasis is a nonspecific indicator of hepatobiliary dysfunction, and its differential considerations are broad. One must differentiate between causes that require surgical treatment and those requiring only medical treatment and supportive care. Congenital portosystemic shunts (CPSS) are abnormal vascular connections between the portal system and the systemic venous system, usually connecting the portal system to a hepatic vein or the inferior vena cava. The reported incidence of CPSS is increasing, perhaps due to improved detection related to advances in imaging technology and an increase in newborn surveillance. When present, a portion of the portal venous return bypasses the liver, resulting in high concentrations of unmetabolized nutrients, including galactose, within the systemic circulation. The resultant “hypergalactosemic” state can cause alterations in the metabolism of bilirubin and, subsequently, development of cholestasis. A full-term male presented with profound hypoglycemia and direct hyperbilirubinemia shortly after birth. The more common causes of neonatal cholestasis (i.e. - biliary atresia, common genetic/metabolic disorders) were excluded. Abdominal ultrasound and magnetic resonance imaging of the abdomen demonstrated a large, aberrant vessel connecting the left portal vein to an enlarged middle hepatic vein, representing a

CPSS. Imaging features of this entity and underlying metabolic consequences as well as differential considerations will be discussed. Poster #: CR-019 Complications of Pediatric Liver Transplantation: Case Series and Pictorial Review

Arash Zandieh, MD, Dept. of Radiology, MedStar Georgetown University Hospital, Washington, DC, [email protected]; EC Christabel Lee, Frank Volberg Purpose or Case Report: Liver transplantation remains the definitive treatment for end-stage liver disease in both adults and children. In the pediatric population, the donor pool includes reduced size cadaveric, split liver allografts, and segmental living-related donor options. Advances in surgical technique and improved preoperative and postoperative care have substantially improved patient outcomes and increased graft survival. Nevertheless, there continues to be a wide host of potential complications following pediatric liver transplantation, including vascular and biliary complications, parenchymal abnormalities such as hepatic infarction or localized collections, and immune-mediated complications such as organ rejection or post-transplant lymphoproliferative disorder. In this case series, we present a select group of children in whom postoperative complications occurred following liver transplantation. We review salient imaging features and discuss the role of imaging in a pictorial format with a focus on the imaging manifestations central to early detection of these various complications. Prompt recognition allows early intervention, which is essential for graft survival and leads to better patient outcome. Poster #: CR-020 Radiologic, pathologic, and surgical correlation in unusual large and small bowel lead point intussusceptions: a case series

Allison Johnsen, MD, Vanderbilt University, Department of Radiology and Radiological Sciences, Nashville, TN, [email protected]; Melissa Hilmes, MD, Sudha Singh, Wendy Ellis, Marta Schulman, MD Purpose or Case Report: Background: Idiopathic ileocolic intussusception is an entity very familiar to pediatric radiologists. Occasionally, there are lead points that need to be recognized. Small bowel intussusception has been recognized as a common entity, typically transient and inconsequential. However, in children with lead points, small bowel intussusception can be severe and result in bowel necrosis. Colocolic intussusception can also occur. As the management of colocolic, ileocolic, and small bowel intussusception differs, atypical lead points should be recognized preoperatively when possible. Illustrative cases: A case of ileocolic intussusception secondary to intussusception of the inflamed appendix in a three years old girl imaged with CT (outside institution), ultrasound, and air enema, and then proven pathologically. A case of appendiceal intussusception has not been reported since 1953, to our knowledge. Three cases of small bowel intussusception, all requiring bowel resection at surgery: 1) four years old girl with Henoch- Schonlein purpura; 2) three years old Amish boy with Ascaris lumbricoides, single worm acting as a lead point within the intussusceptum complex; 3) three years old boy with ileo-ileal intussusception, a large B cell lymphoma acting as the lead point. A case of colocolic intussusception secondary to a polyp in a two years old girl with juvenile retention polyps. Most of the lead points were confidently diagnosed preoperatively. All cases have surgical and pathological correlation. Discussion: It is important for pediatric radiologists to recognize unusual cases of intussusception. Differentiating these types of intussusception from the commonly encountered idiopathic ileocolic

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intussusceptions and the transient ones in the small bowel will affect subsequent management. Although a reduction enema may be undertaken in ileocolic intussusception despite the presence of a lead point, this is not the case in small bowel intussusception, which when recognized as complicated and significant, are managed operatively. In this case series, we illustrate the differences in the imaging findings in these unusual intussusceptions and in the evaluation of the lead points. Poster #: CR-021 A Case Series: Rare Extraosseous Manifestations of Langerhans Cell Histiocytosis

Pnina Herskovits, North Shore University Hospital/Long Island Jewish Medical Center, Manhasset/New Hyde Park, NY, [email protected]; Susie Chen, Mark Bittman Purpose or Case Report: Langerhans Cell Histiocytosis (LCH) is a rare idiopathic disease, usually affecting pediatric patients, characterized by focal or systemic proliferation of antigen-presenting Langerhans cells. Its manifestations are most commonly osseous, with abdominal pathology prevalent in a minority of patients. In this case series, we present three patients, between the ages of 3 months and 2 years, who presented to our institutions with unusual extraosseous manifestations of LCH. These children had multisystem involvement with unusual masses in the abdomen and pelvis which could mimic other diseases such as neuroblastoma and other metastatic neoplasms. The aim of our case series is threefold: (1) to highlight the unusual abdominopelvic masses in these three patients; (2) to demonstrate the multisystem involvement using multiple imaging modalities, with emphasis on the extraosseous imaging findings; and (3) to review the clinical and histopathologic correlation of these patients. We hope this case series will raise awareness of the extraskeletal manifestations of LCH which includes but is not limited to unusual abdominopelvic adenopathy. Poster #: CR-022 Congenital Intrahepatic porto-systemic shunts; a case-based illustration of clinical manifestations, imaging findings and endovascular management

Gaurav Jindal, MD, Radiology, Yale New Haven Hospital, New Haven, CT, [email protected]; Cicero Silva, Jeffrey Pollak Purpose or Case Report: To describe the varying clinical manifestations, imaging findings and endovascular management of congenital intra hepatic porto-systemic shunts. Congenital intra hepatic porto-systemic shunts are rare developmental vascular malformations present in about one in 30,000 children, resulting in an abnormal intrahepatic connection between the portal and hepatic veins. They are believed to arise from abnormal coalescence of the vitello-umbilical venous plexus during embryogenesis. These shunts are characterized anatomically into four different types according to classification system proposed by Park et al. Clinical manifestations are widely variable and do not correlate with the anatomic subtype of the shunt. These shunts can be easily detected on color Doppler ultrasonography and may be confirmed with an MRI/MRA. While asymptomatic shunts can be followed with imaging studies, symptomatic patients often require treatment of the vascular shunt. This can be successfully achieved with endovascular techniques utilizing microcoils or Amplatzer occlusion device. In this exhibit we will present five patients with congenital intrahepatic shunts. We will discuss their clinical course, imaging findings (on sonography, MRI and angiography), and management (expectant with

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spontaneous closure in one; expectant with stability in two; endovascular embolization in two) Poster #: CR-023 Mesenteric Venolymphatic Malformation causing Small Bowel Obstruction in a Child

Curtis Qin, Pediatric Radiology, UAMS, Little Rock, AR, [email protected]; Shilpa Hegde, Raghu Ramakrishnaiah, Jeffrey Burford, Sumit Singh Purpose or Case Report: Mesenteric venolymphatic malformations are rare, benign abdominal mass found in children. It is a combined type of slow flow vascular malformation. The presentation and imaging appearance of these tumors are variable depending on the predominant contribution of their lymphatic and venous components. There are few case reports in clinical journals of the mesenteric origin vascular malformations but to our best knowledge mesentric venolymphatic malformation has been not described in radiology literature. We report an unusual case of a 3 year-old child presenting to emergency room with symptoms of subacute bowel obstruction. This was secondary to a large mesenteric venolymphatic malformation encircling and compressing the distal ileum. Our goal is to illustrate CT imaging features, pathology and potential complications of mesenteric venolymphatic malformation. Conclusions: Mesenteric venolymphatic malformations are rare. It should be considered as a differential in an enhancing mesenteric based lesion in children along with more aggressive malignant mesenchymal origin tumors. The vascular malformations have a good prognosis although they have a high recurrence rate because they originate from the mesenchymal cells at an early stage of embryogenesis and retain the embryonic growth potential. Poster #: CR-024 Biliary rhabdomyosarcoma: Review of three cases

Maddy Artunduaga, M.D., Baylor College of Medicine, Houston, TX, [email protected]; Johanna Monsalve, Amy Mehollin-Ray, Prakash Masand, MD Purpose or Case Report: To share our experience regarding ultrasound and magnetic resonance (MR) imaging features in three pediatric patients who presented with signs and symptoms of obstructive jaundice and were diagnosed with biliary rhabdomyosarcoma (BRMS) by tissue sampling after initial radiologic investigation. Although BRMS is a rare tumor in children, the outcome after surgical and chemotherapeutic treatment is very good, especially in the absence of metastatic disease. Methods & Materials: Medical records and imaging studies of three patients diagnosed with BRMS were reviewed retrospectively. There were two male patients, ages 3 and 5 years, and one female patient, age 9 years at the time of presentation. All patients presented with jaundice, abdominal distention and conjugated hyperbilirubinemia. Ultrasound and MR scans including MR cholangiopancreatography (MRCP) were ordered in all patients as part of initial work-up. Subsequently two patients underwent initial surgery and concomitant tissue sampling for suspected biliary lesions and one underwent endoscopic retrograde cholangiopancreatography (ERCP) with biopsy. Results: In all patients, ultrasound imaging demonstrated significant dilation of the intra- and extrahepatic bile ducts, with echogenic content within the common hepatic and bile ducts. Duplex Doppler evaluation was not helpful due to relative lack of internal vascularity within the intraductal material. Choledochal cyst with internal sludge was initially suspected in two patients and a biliary-origin soft tissue mass was suspected in one patient. MR

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imaging was performed as a problem-solving measure, which showed a T1-hypointense, T2-iso/hyperintense mass with homogeneous enhancement within the extrahepatic bile duct in each case. Associated moderate to significant dilation of the biliary tree was seen in all cases. The three-dimensional MRCP sequence was a good adjunct to the traditional sequences for the delineation of the biliary system. All patients were proven to have BRMS on pathologic evaluation, and one patient had a diagnosis of BRMS arising within a choledochal cyst. Conclusions: Outcome in BRMS has improved, especially in cases with no metastatic spread; hence early diagnosis when the disease is localized is very important. BRMS can be overlooked especially since other biliary pathologies like choledochal cyst are more common. In our experience, contrast-enhanced MRI/MRCP does complement the information obtained from ultrasound when a diagnosis of BRMS is in question. Poster #: CR-025

Withdrawn

Poster #: CR-026

experience that despite the early termination of the infusion, Glucagon is still effective in decreasing small bowel peristalsis on the post-contrast sequences. We report the effect of Glucagon infused with this protocol on decreasing small bowel peristalsis in a separate abstract.

Poster #: CR-027 The effective use of blueberry juice, pineapple juice and acai juice as negative contrast agents for MRCP in children at a large tertiary pediatric medical center

Mark Bittman, Radiology, Long Island Jewish Medical Center, New Hyde Park, NY, [email protected]; Michael Callahan Purpose or Case Report: Magnetic resonance cholangiopancreatography (MRCP) is commonly performed in the evaluation of known or suspected pancreaticobiliary disease in children. The administration of a negative oral contrast agent can improve the quality of the examination, without significant additional cost. We describe our experience with certain brands of acai juice, blueberry juice and pineapple juice as negative oral contrast agents in pediatric patients. We believe these fruit juices are safe, palatable and can improve MRCP image quality.

MR Enterography Technical Note: Slow Intravenous Infusion of Glucagon Diluted in D5W with an MR-Compatible Infusion Pump

Poster #: CR-028

Hedieh Eslamy, MD, Seattle Children’s Hospital, Seattle, WA, [email protected]; Gisele Ishak, Luana Stanescu, Randolph Otto, Dennis Shaw

You got to be KIDNEYing me?! A Pediatric Case Series of Rare Non-Wilms Tumors

Purpose or Case Report: Magnetic resonance enterography (MRE) is used to assess active inflammation and complications in patients with Crohn’s disease. There is a wide variation in the MRE protocols utilized. We describe slow intravenous infusion of Glucagon, diluted in 5% dextrose in water (D5W), with an MRI-compatible infusion pump over 8 min prior to the acquisition of dynamic contrast-enhanced 3D T1-W GRE images. “Glucagon hydrochloride recombinant” is an antihypoglycemic agent and a gastrointestinal motility inhibitor. Glucagon is available for use intravenously, intramuscularly, or subcutaneously in a 1 mg vial that is reconstituted with 1 mL of sterile water for reconstitution. Reconstituted Glucagon should be used immediately. Adverse reactions include nausea and vomiting. Glucagon also has an inotropic effect and historically has been used in cardiac diseases. Cardiologists reconstituted it with water for injection and diluted it to the desired volume with D5W for IV infusion. The resultant solution was stable for several hours. In our institution the majority of patients experienced nausea and vomiting even with decreased doses and slow IV injection of Glucagon. We theorized that diluting Glucagon and infusing it at a steady rate would result in decreased incidence of side effects. Pharmacy reconstitutes all medications in our institution. Therefore, given the logistics, any infused medication should have a stability of several hours and a volume of several mL. One milligram of Glucagon reconstituted to 1 mL did not meet these criteria. In conjunction with our colleagues in pharmacy we reviewed the cardiology literature and concluded that Glucagon diluted in D5W should be stable for several hours. In addition, to decrease the likelihood of medication errors, and confusion with the 1 mg/mL solution used for other indications, pharmacy chose a concentration of 0.05 mg/mL for the Glucagon used in MRE. After several Plan-Do-Study-Act cycles, we adopted our current protocol which is injection of either 4 mL (0.2 mg) or 8 mL (0.4 mg) of Glucagon for patients weighing < or ≥ 40 kg respectively. If the patient experiences nausea during the infusion, the infusion is terminated. It has been our

Jennifer Thomas, MD, Radiology, NYMC-WMC, Valhalla, NY, [email protected]; Anupriya Barot, Adele Brudnicki, Lesli LeCompte Purpose or Case Report: Wilms tumor is the most common abdominal malignancy in pediatric patients, accounting for approximately 8% of all childhood malignancy tumors. The age at presentation of clinical symptoms can usually guide a differential, as Wilms tumor does not typically occur within infants or teenaged pediatric populations. Rather, malignancies such as rhabdoid and renal cell carcinoma are more likely. Utilizing clinical and imaging features, it is important to distinguish other potential renal malignancies, such as renal cell carcinoma, renal lymphoma and rhabdoid tumors, from a diagnosis of Wilms tumors particularly for preoperative and clinical planning. Although there are classic imaging findings seen in the setting of Wilms tumor, these findings unfortunately are not always definitive. In some instances, even the most appropriate and sophisticated imaging techniques can conceal a raging renal cell carcinoma or rhabdoid tumor where a preoperative diagnosis of Wilms tumor was proposed. In a pictorial review, we demonstrate a series of interesting cases where uncommon renal cell malignancies masked themselves in the disguise of a Wilms tumor. Only following surgical intervention and correlation with histopathology reports were we able to appreciate the vicarious nature of pediatric renal malignancies. Poster #: CR-029 Multi-modality Imaging Evaluation of Peritoneal Inclusion Cysts in the Pediatric Age Group

Rachelle Goldfisher, MD, Department of Radiology, SUNY Downstate Medical Center, Brooklyn, NY, [email protected]; Divya Awal, MD, John Amodio Purpose or Case Report: Peritoneal inclusion cysts (PIC), also known as “peritoneal mesothelial cysts,” “peritoneal pseudocysts,” and

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“inflammatory cysts of the pelvic peritoneum,” have been described in females of reproductive age. While there have been a few reports of this entity in the pediatric population, they have largely focused on the clinical and pathological features. Familiarity with the characteristic imaging findings and knowledge of the clinical associations of this benign lesion is useful to establish diagnosis, and may prevent aggressive intervention. Common causes for the development of peritoneal inclusion cysts include post-surgical adhesions, pelvic inflammatory disease, endometriosis, and trauma. Additionally, the co-existence of peritoneal inclusion cysts in patients with urogynecological malformations has been described. In this review, we present the characteristic multi-modality imaging findings of peritoneal inclusion cysts in two adolescent females with a history of prior surgery. Our first case discusses a 16 year old female with Mullerian Renal Cervical Somite (MURCS) syndrome. The patient was born with ambiguous genitalia, multiple vertebral body segmentation anomalies, and unilateral renal agenesis. She underwent a right renal transplant and 3 years later presented with a peritoneal inclusion cyst. Our second case discusses a 17 years old female, who presented with a peritoneal inclusion cyst, and a history of partial colectomy for necrotizing enterocolitis as a premature infant. This case series highlights the importance of entertaining the diagnosis of a peritoneal inclusion cyst in a pediatric patient of reproductive age, with a history of prior surgery. Furthermore, it emphasizes the co-existence of this entity in patients with urogynecological malformations. Characteristic multi-modality imaging findings of PIC are illustrated. Poster #: CR-030 The Changing Character of Urinary Infection in Children: Influence of No Circumcision

David Aria, MD, Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Kristin Constantino, M.D., Gerald Mandell, MD Purpose or Case Report: Introduction: The predominance of urinary tract infections (UTI) in female children compared to male children has been historically (1970s–80s) documented at a ratio of 4:6 to 1. Over the last decade and a half, many more male infants contribute to the pediatric population being hospitalized for UTIs. The change dates back to 1999 when the American Academy of Pediatrics (AAP) concluded via a policy statement that there were potential medical benefits to newborn male circumcision but not enough to be routinely recommended. Given this policy, insurance companies decided not to support routine circumcisions and directly, the number of male infants circumcised dropped dramatically. Purpose: To confirm the increased prevalence of UTIs in male infants resulting in increased performance of voiding cystourethrograms (VCUG) and hospitalizations and to demonstrate the possible cost effectiveness of performing routine circumcisions. Methods & Materials: A retrospective review of the medical records of children under 18 years of age with a history of UTI and performance of VCUG during an 8 month period in 2013 was undertaken. In a subgroup of patients less than 6 months of age, demographics of age and sex, VCUG results and circumcision status were recorded. Results: Eight hundred eighty-three patients (617 females (f) and 266 males (m), ratio 2.3:1) were discovered. Two hundred thirty-eight patients (84 f. 148 m), ratio 1:1.7) were less than 6 months of age. Eighty-nine of 148 males had clinical documentation of circumcision status (84 uncircumcised and 5 circumcised, ratio of 17:1). Fourteen males (14.5%) and 48 females (57%) had evidence of vesicoureteral reflux (VUR) or ureterocele. Conclusions: A 17-fold greater number of UTIs is seen in uncircumcised versus circumcised male infants. The reasons for increased infections include improper care by the caretaker and mucosa of the foreskin being more likely to bind pathogenic bacteria than keratinized skin on the circumcised penis. Comparison of costs of hospitalization was compared

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to prevention of infection with circumcision. One hundred thirty-three patients could be circumcised ($150 each for $19,950) for the cost of a single hospital stay ($20,000). Poster #: CR-031 Case Series: Endovascular Radiofrequency Ablation in the treatment of long segment lower extremity venous malformations in pediatric patients

Seth Vatsky, DO, Diagnostic Imaging, Phoenix Children’s Hospital, Scottsdale, AZ, [email protected]; Trevor Davis, DO, David Aria, MD, Carrie Schaefer, Robin Kaye, Richard Towbin Purpose or Case Report: Superficial venous malformations in the lower extremities can be a challenging entity, because of extended length and the presence large communicating channels with the deep venous system. Previous treatment strategies have included placement of embolization coils or vascular plugs, and the use of chemical sclerotherapy and tissue adhesives. More recently energy ablation treatments have become available including laser and RFA. We present a series of four children in whom endovascular RFA (ClosureFast) was utilized to ablate large, long segment type IV venous malformations in the lower extremity. The treatments have resulted in effective closure of the large venous components, a low risk of recanalization, and minimal post procedural swelling and tenderness. RFA treatment offers advantages over other embolization techniques. There is a rapid learning curve because of defined treatment. Continuous power output monitoring during endovenous RFA cycling provides the operator with the effectiveness of tissue heating. Energy ablation offers an advantage over mechanical embolization devices because of the lack of residual embolization material, which can be palpable and uncomfortable in superficial venous malformations. In blinded and unblinded comparison trials in adults between RFA and laser treatment, RFA has demonstrated superior long-term venous occlusion and less post procedural swelling and discomfort. Limitations of this treatment method include size restrictions based on catheter length and sheath diameter (7 Fr) relative to vessel length and diameter. The need for tumescent anesthesia requires an awareness of maximal lidocaine dose based on patient weight. In summary, endovascular radiofrequency ablation offers a new and effective tool in the treatment of venous malformation in children. Poster #: CR-032 Novel image guided treatment for local control of a recurrent plexiform schwannoma in a 3 year-old male

Anuradha Shenoy-Bhangle, MD, Massachusetts General Hospital, Boston, MA, [email protected]; Michael Gee, Florian Fintelmann, Raul Uppot

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Purpose or Case Report: A 3 year-old male was discovered to have a thoracic plexiform schwannoma when he underwent emergent spinal cord decompression from T3 to T5 in February 2012. He thereafter underwent multiple surgical resections for recurrent disease. As an attempt to achieve local control with intent to avoid further surgeries, we performed cryoablation of this recurrent tumor in the paraspinal soft tissues using ultrasound and CT as imaging guidance and general anesthesia. The tumor being in the subcutaneous plane, a different hydrodissection technique was adopted to prevent thermal injury to the overlying skin. Details of the procedure with clinical pictures and relevant imaging will be included in the final exhibit. There were no complications, the patient recovered well post procedure and was discharged on day 6. A 1 month imaging and clinical follow up has been set up and a 6 month follow up will be available at the time of presentation of this exhibit.

Poster #: CR-033

Poster #: CR-034 Look, ma, no hands! Introducing the MIRA (MRI Interventional Robotic Assistant): a proof of concept for an MRI compatible, patient mounted robot for radiation-free arthrography and other percutaneous procedures

Audrey McCarron, M.D., Radiology, Children’s National Medical Center, Washington, D.C., DC, [email protected]; Reza Monfaredi, Raymond Sze, Kevin Cleary, Nabile Safdar, Karun Sharma Purpose or Case Report: In Radiology, robotic systems have only been used in small-scale research efforts. This abstract introduces an MR compatible, patient mounted robot called MIRA (MRI Interventional Robotic Assistant), initially intended for arthrography. The current workflow for MR arthrography is a two-step process. Typically under fluoroscopy, a needle is guided into the joint space for injection of MR constrast material. The patient is then transferred to the MR suite for imaging.

Mechanical embolectomy using the Solitaire FR revascularization device for acute arterial ischemic stroke in a pediatric ventricular assist device patient: A Case Report

Marian Gaballah, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Eileen Rhee, Robert Hurst, Rebecca Ichord, Ganesh Krishnamurthy, Anne Marie Cahill Purpose or Case Report: To describe the first published report of the Solitaire FR revascularization device for mechanical embolectomy in a child with acute arterial ischemic stroke and contraindications to thrombolysis. Methods & Materials: Case History: A 9-year old male with a biventricular assist device for heart transplant rejection developed sudden decreased consciousness and weakness of the right face, arm, and leg. A CT head showed early hypoattenuation in the left MCA territory. A CTA showed proximal and distal left MCA branch filling defects. The child was not a candidate for thrombolysis so mechanical embolectomy was performed. Technique: A 4×20 mm Solitaire FR revascularization device was positioned across the occlusion from the proximal M1 segment to its bifurcation. The device was deployed for 10 min twice, recaptured, and withdrawn from the artery with continuous aspiration through the guiding sheath. A small amount of clot was retrieved with minimal improvement on angiogram. A 4×15 mm Solitaire device was then deployed for 20 min and withdrawn with large clot retrieval. Angiogram showed complete recanalization of the occluded segment and restoration of antegrade blood flow without distal embolization. Results: Complete revascularization was achieved within 7 h of symptom onset, without complications. One month later, the child developed a repeat acute arterial ischemic stroke following diaphragm plication. A CTA showed distal left MCA occlusion. The patient underwent repeat mechanical embolectomy with two deployments of the 4×20 mm Solitaire device and successful revascularization within 7 h of symptom onset. His neurologic exam improved significantly over the first 24 h, with residual mild right-sided weakness, improved mental status, and resolution of aphasia. The child underwent heart transplantation 10 days later. Two months post-transplant, he was ambulatory and communicating with mild diffuse weakness and mild language impairment. The child was discharged home after 1 month with continued outpatient rehabilitation. Conclusions: The Solitaire FR revascularization device can be successfully used for mechanical embolectomy in children with acute arterial ischemic stroke and contraindications to thrombolysis. Disclosure: Dr. Ichord has indicated a relationship with Berlin Heart as a Consultant (Clical Event Committee).

An MR compatible robot eliminates the preliminary fluoroscopy procedure. The potential benefits of MR robot-assisted arthrography include no radiation dose, theoretically streamlined workflow, decreased facility usage, reduced examination time, precise movement, improved dexterity, and minimization of operator dependence. Pediatric patients especially vulnerable to the risks of radiation stand to benefit from radiation sparing procedures. MIRA has 4° of freedom and is actuated by non-ferromagnetic piezomotors. Two degrees of freedom locate the needle tip at the point of interest on a cartesian plane. Using the other two degrees of freedom, the needle is aligned to the precise angle required. A torus design allows the robot to nest onto the patient and accommodates variable anatomy and size. The robot is not designed to automatically drive the needle for safety reasons, but instead orients a needle guide along the physician-selected trajectory; the physician then drives the needle by hand. To investigate the feasibility of the robotic mechanism to precisely orient a needle toward a target, a study was performed using a gelatin phantom with 2 cm embedded grapes as targets. A joystick was used to orient the robotic needle holder towards each of three targets in turn, followed by needle deployment by hand. The target was hit in 5/6 trials with average time of 25 ±7 s. To estimate accuracy, digital photographs were taken in two orthogonal planes with a ruler in view. The distance from needle center to target center was calculated, with result of 5.3±4.6 mm, showing the mechanism could precisely orient a needle. We also verified MRI compatibility of the piezomotors at the isocenter of the scanner using a body coil and four channel flexible coil. Future work will include registration of spatial data from MRI to robot, robot-targeted injection of contrast material into a phantom test subject, and demonstration of targeting accuracy from MR images.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Poster #: CR-035 Additional value of C-arm CT in imaging patent ductus venosus (PDV) and its intra-procedural role in guiding endovascular occlusion

Chris Bedford, MD, Radiology, Baylor College of Medicine, Houston, TX, [email protected]; Chinnadurai Ponraj, Prakash Masand, Ryan Himes, Alberto Hernandez, Sheena Pimpalwar Purpose or Case Report: Children with symptomatic PDV are selected for endovascular occlusion based on the size of intrahepatic portal veins and portal pressures after balloon test occlusion. Recently, C-arm angiography systems have the capability to acquire CT-like 3D images of vascular anatomy which could be applied in this scen

Our purpose is: 1. To illustrate the additional value of C-arm CT in imaging PDV and its intraprocedural role in guiding endovascular occlusion using vascular plug. 2. To illustrate the steps involved in endovascular PDV occlusion procedure and to report a complication of post-procedural portal vein thrombosis. A 4 years old girl with Trisomy 12 mosaicism presented with a 3 years history of recurrent episodes of altered mental status and hyperammonemia (49–136 micromol/L). MRV showed a 10 mm diameter PDV. Using a right jugular venous approach, C-arm CT superior mesenteric venography was performed pre and post balloon occlusion. Hemodynamic pressure measurements were obtained and the PDV was occluded using a 14 mm Amplatzer Vascular Plug II under C-arm CT guidance. C-arm CT (syngo DynaCT®, Siemens AG, Forchheim, Germany) imaging was performed using 8-s DR low dose body protocol. Forty milliliter4 iodinated contrast (320 mgI/ml) was injected through a 4Fr catheter at 4 ml/s, 500 psi with 2-s X-ray delay. Initial C-arm CT venography was helpful in demonstrating the complex 3D relationship between the PDV, left portal vein and IVC. C-arm CT imaging further helped with confirmation of device size and position in relationship to the portal vein and IVC prior to actual deployment. Serum ammonia levels normalized within 2 days post occlusion. Twelve hours post procedure ultrasound demonstrated an occlusive left portal vein thrombus which was treated with intravenous heparin and subsequently transitioned to lovenox. Three months follow-up ultrasound showed complete occlusion of the PDV and resolution of the portal venous thrombus. C-arm CT venography is a useful intra-procedural imaging tool for guiding endovascular closure of PDV. The hypoplastic portal venous system is at risk of thrombosis which can be managed with appropriate anticoagulation.

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Disclosure: Ponraj Chinnadurai has indicated a relationship with Siemens Medical Solutions USA Inc as an Employee (Salary). Poster #: CR-036 Denver shunt malfunction: can replacement be avoided with minimally invasive innovative techniques?

Sheena Pimpalwar, Interventional Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Alberto Hernandez, Judith Margolin, Ashwin Pimpalwar Purpose or Case Report: Denver shunts are used for short term palliation of refractory malignant and chylous pleural and peritoneal effusions. Their primary patency is limited (87+/− 57 days) (1). Shunt occlusion is a frequent problem (25%)(1) and may require shunt replacement.

We describe a variety of innovative minimally invasive techniques for management of Denver shunt malfunction. A 13 years old girl with generalized lymphatic anomaly had placement of a denver (pleurovenous) shunt for refractory left chylous pleural effusion to allow home medical management of her systemic disease. During a 14 month follow-up period there were three episodes of shunt malfunction at 5, 9 and 12 months respectively secondary to occlusion of the shunt chamber, pleural catheter or venous catheter. The shunt chamber was recanalized using a variety of percutaneous ultrasound and fluoroscopy guided techniques. The mechanical techniques included saline irrigation and aspiration using double needle technique, maceration and aspiration of shunt debris using Amplatz guide wire, Atrieve snare device, Angio-jet thrombolysis device and bronchoscopic biopsy brushes. Pharmacological dissolution of shunt debris was performed using tissue plasminogen activator and hyaluronidase injections into the shunt chamber. The venous catheter was recanalized using fibrin sheath stripping and percutaneous microcatheter- guide wire recanalization. Pleural catheter and pleural space debridement was performed using thoracoscopic techniques. The denver shunt remains secondarily patent at 14 months followup allowing home medical management of the generalized lymphatic anomaly.

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Purpose or Case Report: Currently, 2-dimensional (2D) X-ray imaging is the standard imaging modality for guiding sclerotherapy as it provides real-time visualization of the sclerosing agent distribution. However, fluoroscopy does not provide soft-tissue lesion characterization. 3dimensional (3D) magnetic resonance imaging (MRI) details the extent of the lesion, but is traditionally viewed on a separate monitor. This abstract describes the novel technique of using syngo InSpace 3D/3D Fusion and syngo iPilot Dynamic software applications (Siemens Healthcare AG, Forchheim, Germany) to superimpose 3D MRI on live 2D fluoroscopy for real-time monitoring of the sclerosing agent distribution within the vascular malformation.

Minimally invasive innovative techniques can be used to prolong the life a denver shunt thus avoiding replacement. References: 1. White et al. Am Surg: 2011; Aug 77(8):1070–5 2. Rahman N et al. Journal of pediatric surgery 2011; 46: 315–319 Poster #: CR-037 Role of doppler ultrasound imaging guidance in the treatment of angiographically occult traumatic arteriovenous fistula in a child

Chris Bedford, MD, Radiology, Baylor College of Medicine, Houston, TX, [email protected]; Sean Raj, Michel Mawad, Sheena Pimpalwar Purpose or Case Report: Use of doppler ultrasound imaging plays an integral part in the treatment of vascular anomalies. Our purpose is to illustrate our experience with the use of this modality during treatment of an angiographically occult traumatic arteriovenous (AV) fistula in a child. A 5 years old girl with a remote history of trauma to the forehead presented with a bluish swelling above the left eyebrow that enlarged with Valsalva. MRI demonstrated a focal subcutaneous venous malformation, however, color doppler ultrasound showed an arterial jet within the venous sac suggestive of an AV fistula. After transarterial embolization of the anterior deep temporal branch of the left internal maxillary artery feeding the fistula, no further arterial feeders could be identified despite detailed high resolution four vessel angiography and 3D CT angiography. Color doppler ultrasound showed successful thrombosis of the lateral half of the venous sac with a persistent arterial jet within the medial half of the sac. This residual angiographically occult AV fistula was treated with an ultrasound guided percutaneous approach in two sessions using absolute alcohol and n-Butyl cyanoacrylate, respectively. Four weeks post embolization, the venous sac demonstrated complete thrombosis with resolution of the arterial jet on color doppler ultrasound. There was complete clinical resolution of the left forehead swelling even after provocation with Valsalva with no recurrence at 7 months follow-up. Color doppler ultrasound imaging is a useful adjunct to arteriography during interventional management of AV fistulae. It has a valuable role in monitoring the success of transarterial embolization and guiding percutaneous treatment of angiographically occult fistulae.

Methods & Materials: Initially, the pre-procedural 3D MRI dataset is segmented using the volume-of-interest punching and color rendering tools from syngo InSpace 3D to visualize the lesion. A 3D rotational Carm Computed Tomography (syngo DynaCT) dataset is acquired without radiation and merged with the MRI dataset using 3D/3D Fusion in order to register the MRI volume to the C-arm and patient table positions. Using iPilot Dynamic, the MRI volume is then registered to the anatomic region of the patient in two fluoroscopic planes, frontal and lateral (2D/3D registration). During the procedure, iPilot Dynamic overlays 3D MRI lesion on real-time fluoroscopic images. Results: Thirteen sclerotherapy procedures using 3D/3D Fusion and iPilot Dynamic were performed in 5 males and 8 females, with a mean age of 11.09 years. Locations of the lesion include head and neck (7/13), lower extremity (3/13), and upper extremity (3/13). A post-procedural physician questionnaire reported an increase in intra-procedural lesion treatment confidence in 10/13 procedures performed using this technique. Conclusions: MRI/X-ray overlay brings 3D lesion information directly to the interventional procedure, enabling physicians to monitor real-time sclerosing agent distribution within the lesion. Our preliminary results show that the added information acquired by this technique increases physician confidence of lesion therapy during the procedure. One limitation of the current technique is interval growth of lesion and patient, especially when there is a significant time lapse between the MR study and the interventional procedure. Disclosure: Dr. Joyce Bao has indicated a relationship with Siemens Healthcare as a Research Consultant (Salaried Employee). Dr. Girard has indicated a relationship with Siemens Corporation, Corporate Technology as an Empolyee, Research Scientist (Salary).

Poster #: CR-038

Poster #: CR-039

Novel technique using MRI/X-ray overlay to guide sclerotherapy for treatment of low-flow vascular malformations in children

Congenital segmental ectasia of central venous structures: intervene or observe?

Joyce Bao, Siemens Healthcare, Malvern, PA, [email protected]; Tanja Kurzendorfer, Erin Girard, PhD, Anne Marie Cahill

Shellie Josephs, MD, Pediatric Radiology, UT Southwestern, Dallas, TX, [email protected]; Nancy Rollins

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Purpose or Case Report: Congenital segmental ectasia of central veins varies with respect to severity of ectasia and length of vein involved. Case reports of natural history and non-surgical intervention are infrequent. We report a single site series that suggests more severe lesions may warrant intervention. Table 1

Column1

Column2

Column3

Column4

Patient

1

2

3

4

Age at presentation Imaging

14 weeks

prenatal US

22 month

20 years old

MRI, US

Right IJ

MRI, CT, Venogram, arteriogram right subclavian axillary

MRI, CTA

Venous Segment

MRI, CT, Venogram, arteriogram Left renal pedicle

3.5, 2.8, 4.4

4.1, 7.5, 6.5

12.7, 5.4, 12.6

none

none

none

none

thrombosis, thrombosis, PE arterialized thrombus Embolization and Stent graft placement resection

Maximum size (T 4.5, 4.2, 4.9 x AP x L) cm Other VLM abnormality Complications none

Outcome

Treatment of VLM, observation

Observation

Right axillary, subclavian, brachiocephalic

Methods & Materials: Four patients; age range 4 months to 21 years, were referred for sclerotherapy of presumed venous malformation (VM) or venolymphatic malformations (VLM) seen by MR, were found to have segmental venous ectasia rather than, or in addition to, an VLM. The MR diagnosis of VM/VLM was made on the basis of a slow-flow lesion showing intense enhancement with or without phleboliths and in the case of VLM; cysts of variable size with or without blood fluid levels. The presentation and management of these lesions, including complications, were reviewed and compared to the existing literature on venous ectasia. Results: Table I indicates patient demographics, presenting symptoms and vein(s) involved. One patient had involvement of the internal jugular vein (IJV) and one diffuse involvement of the left renal venous pedicle. Two patients had involvement of the subclavian vein, which was focal in one and involved the ipsilateral axillary and brachiocephalic vein in another. The patient with focal involvement had progressive aneurysmal dilatation of the subclavian vein complicated by thrombosis and arterialization of intraluminal thrombus. This patient underwent venous embolization followed by en bloc resection. The more extensive subclavian vein ectasia was complicated by clinically unsuspected recurrent pulmonary emboli resulting in severe pulmonary hypertension. Conclusions: Venous ectasia is a rare congenital abnormality, most commonly described in the internal jugular vein. The usual presentation is an asymptomatic neck mass that may vary in size, with exertion or crying. Surgical intervention is recommended primarily for cosmoses as complications of these dilated veins are reported to be very rare. We identified four of these lesions; two of which had serious complications of thrombotic disease, both involving the subclavian vein. More extensive disease may warrant consideration of anticoagulation therapy and/or more urgent intervention. To date, these are the first reported cases of thrombosis of segmental venous ectasia of the subclavian vein. Poster #: CR-040 Ultrasound guided muscle biopsy using a Vacuum Assisted Biopsy System (Vacora®)

Jared Green, MD, Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Joao Amaral, Dimitri Parra, Bairbre Connolly, Saadet Mahmutoglu, Saeed Nihayah

Purpose or Case Report: To describe a new minimally invasive ultrasound guided technique with the Vacora® 10 Gauge Vacuum Assisted Biopsy System (off label use) to obtain muscle tissue for morphologic and metabolic analysis in patients with Metabolic or Neuromuscular Disorders (MND). To assess the adequacy of samples obtained via the new minimally invasive ultrasound guided muscle biopsy technique as compared to muscle samples obtained via surgical biopsy. Methods & Materials: Procedures were performed under the Innovative Procedure Policy from the Department of Diagnostic Imaging. Informed consent was obtained from all patient’s parents after explaining the procedure, the off label use of the device and the potential need for a future surgical open biopsy. Technique: General anesthesia; sterile technique; mapping ultrasound with grayscale and color Doppler imaging; 5 mm skin incision; 10 Gauge Vacora® needle advanced into the right Vastus Lateralis muscle under ultrasound guidance, with the needle positioned parallel to muscle fibers; automated needle biopsy mechanism activated (needle notch opened, vacuum suction, outer needle closed over notch obtaining sample); needle removed and pressure applied; local anesthesia (Marcaine 0.25%) injected into the biopsy site muscle and subcutaneous tissues; skin incision closed with one stich of a 5–0 absorbable monofilament suture. Results: Five patients (female n=4, male n=1) with a mean age of 9 years and 9 months (range: 2 years and 10 months to 12 years and 7 months) underwent ultrasound guided muscle biopsy using a 10 Gauge Vacora® System. Indications included muscular dystrophy (n=2), congenital myopathy (n=1), neuromuscular disorder (n=1), and mitochondrial disease (n=1). Multiple biopsy passes were performed in all patients and each pass provided a satisfactory muscle sample (length: approximately 2.0 cm; mass: approximately 100 mg) for morphological and metabolic analysis. An average of four passes was performed in each patient. A 4 mm skin punch biopsy was performed prior to muscle biopsy in two patients. All patients tolerated the procedure well and were discharged home 4 h post procedure. No immediate complications were noted. Conclusions: Ultrasound guided muscle biopsy using the Vacora® system allows for adequate tissue sampling via a minimally invasive technique and is a viable alternative to surgical muscle biopsy for morphologic and metabolic analysis in patients with MND. Poster #: CR-041 Endovascular management of a congenital intrahepatic porto systemic shunt using Amplatzer occlusion device in a 2 month old infant

Gaurav Jindal, MD, Radiology, Yale New Haven Hospital, New Haven, CT, [email protected]; Cicero Silva, Jeffrey Pollak Purpose or Case Report: Congenital intrahepatic porto systemic shunts are anomalous venous connections between the portal and hepatic veins which divert the portal blood flow into the systemic circulation resulting in myriad clinical manifestations. These are very rare vascular anomalies but are being increasingly recognized with advances in imaging techniques. Endovascular management has largely superseded open surgical techniques for treating these shunts. While some of the shunts may spontaneously involute in infancy, closure of shunts in symptomatic patients has been shown to have a favorable clinical outcome. We describe a case of a 2 months old infant with persistent hyperbilirubinemia, hyperammonemia, episodes of respiratory distress and pulmonary edema who was found to have a large fistulous venous connection between the left portal and left hepatic vein on color Doppler sonography. Imaging findings were confirmed with an MRI/ MRA of the liver. Given the clinical findings of hepato pulmonary

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syndrome, it was decided to close this shunt. This was successfully achieved by deploying 2 Amplatzer vascular occlusion devices within the shunt. The patient made a steady clinical recovery and no flow was detected within the shunt on follow up colr Doppler study. The use of Amplatzer vascular occlusion device to treat congenital intrahepatic porto systemic in such a young patient has not been previously described.

In this case series we will compare the effectiveness M-Dixon water only images with that of STIR, T2 FSE with chemical shift fat saturation and T1 FSE with chemical shift fat saturation. All of the example will be of the pelvis, upper and lower extremities. After reviewing these cases it will be clear that the M-Dixon sequences compare favorably with other sequences more commonly used and may have potential as an adjunct or replacement of these sequences for musculoskeletal work.

Poster #: CR-042 Poster #: CR-044 Wire trapping and unwrapping; a rare complication of Trerotola device

Mahmoud Zahra, MD, FRCR, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Ganesh Krishnamurthy, Anne Marie Cahill Purpose or Case Report: The purpose of this case is to describe a rare complication of Trerotola device during decloting of AV graft. This would increase the awareness to the complication and helps to avoid its occurrence. Methods & Materials: We report a 12 years male with history of end stage renal disease and left arm AV graft which was created few months ago. The patient presented with incomplete dialysis due to poor flow through the graft. Doppler Us study was performed which demonstrated thrombosis of the graft with total absence of the flow. The patient was referred to interventional radiology department for graft decloting. Fistulogram demonstrated acute thrombosis in the graft and significant central stenosis involving the left brachicephalic vein. Graft decloting was performed using Trerotola device over 021 Nitrex wire. During the procedure the wire found to be migrated distally through the abdominal aorta with the tip of the wire was stuck in a posterior branch of the left internal iliac artery. Several attempts were performed to remove the wire but were unsuccessful. Finally the wire came out, but the tip of the wire got unraveled and a thin portion of the wire was seen extending from the left internal iliac artery all the way up to the graft. Additional maneuvers and several tools were utilized to the take the wire out. At the end the wire was removed and a small unwound filament fragment of the wire tip was left in a small branch of left internal iliac artery. Conclusions: In conclusion Trerotola device for graft decloting should be used either without wire or the wire should be clamped to prevent it from spinning and unintentional advancement.

Poster #: CR-043 M-Dixon: Fat Suppression Has Never Looked So Good

Craig Barnes, MD, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; David Aria, Mittun Patel, MD, Deepa Biyyam, MD, Amber Pokorney, Scott Jorgensen, MD Purpose or Case Report: Fat suppression is most frequently achieved by nulling of T1 signal, chemical shift with selective fat suppression or a combination of the above. We have begun looking at the feasibility of using the water only images generated by the two-point M-Dixon technique in musculoskeletal applications. This sequence can be done as a T1 or T2 weighted sequence. On T2 weighting it show fat suppression that rivals STIR while having better contrast between normal structures such as fat, muscles, tendons, bones and marrow space. The T1 weighted sequences are particularly useful for post contrast imaging in the extremities where failure of fat suppression is frequently a problem along the ends and margins of the extremity.

CT Angiography changes practice: the surgical management of pediatric digital syndactyly

Karen Thomas, MD, Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Sally Hynes, Isaac Harvey, Jocelyne Copeland, Gregory Borschel Purpose or Case Report: To illustrate the development and impact of a new CT angiography protocol on the surgical management of children with complex osseous and soft tissue syndactyly of the hands. Due to the risk of digital ischemia, especially if digital arterial supply is aberrant, traditional staged release surgery involves multiple operations over many months to years to achieve a 5-digit hand. CT angiography-guided single stage 5-digit release offers the potential to achieve this with a single surgery and recovery period. Methods & Materials: Seven hands in four infants (4–12 mths) with NonApert Syndactyly were scanned using a new peripheral CT angiography protocol (final parameters 32×0.0625 mm, 80 kVp, 60mAs, pitch 0.53, CTDI 7.24 mGy, DLP 72–109 mGycm), designed to delineate the arterial supply to each digit/web space for the purposes of pre-operative planning. Examinations were performed under sedation or general anesthetic. Intravenous contrast (2–3.5 ml/kg) was injected at 1.5mls/s, with use of either automated triggering or timing bolus methods for scan initiation. Multiplanar MIP series and 3D reconstructions were reviewed with the plastic surgery team and used to plan single stage surgical release procedures. Surgical outcomes were assessed with functional activity evaluation, range of motion measurements and a parental Visual Analog Scale. Results: The new CT Angiography technique provided high quality preoperative planning images in all patients, although one patient required a repeat study due to motion artifact. Challenges with patient positioning were overcome with ‘Velcro band’ extension of the arms above the head to avoid or minimise cranial exposure. Palmar and digital arterial anatomy varied with complexity of osseous and soft tissue syndactyly and was individual to each patient. All four patients underwent single stage surgical release with no cases of digital ischemia or loss. Functional outcomes are presented. Conclusions: This case series illustrates the development of a new CT technique designed to address a specific clinical challenge, with resultant direct impact on surgical planning and approach. Further experience and follow up will be necessary but for patients with complex digital syndactyly, CT angiography-guided single stage release offers potential to significantly reduce the number of surgeries and anesthetics necessary to achieve a functional 5-digit hand with completion of therapy at an earlier age.

Poster #: CR-045 Idiopathic chondrolysis of hip: MR Imaging spectrum with emphasis on early MRI features

Vikas Yadav, MD, Radiology, Christian Medical College, Vellore, India, [email protected]; Jyoti Sureka, Shyamkumar Keshava

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Purpose or Case Report: This poster presentation aims to provide various MR imaging features of idiopathic chondrolysis of hip with emphasis on early MR features. Idiopathic chondrolysis of hip is a rare, often under diagnosed disease affecting the preadolescent & adolescent age group characterized by progressive loss of cartilage around the hip joint. Typical clinical presentation includes pain & stiffness followed by restricted range of motion of the hip joint. Symptoms are often non-specific initially which makes early detection difficult. Identification of early MR features aid in planning the optimal conservative and surgical approach to avoid the further disease progression. MRI is helpful in detecting the early features and defining the extent of involvement thus can delineate the various stages of the chondrolysis of hip from early to the advanced stage. We present MR findings of 10 cases of biopsy proven idiopathic chondrolysis of hip on the basis of a retrospective review. In the early stage, we found the ligamentum teres thickening, non-specific mild joint effusion and synovitis and characteristic trapezoid shaped marrow edema centered in the proximal femoral epiphysis. The cartilage swelling & high signal without appreciable loss were also noted in early stage. In the advanced stage, variable loss of the cartilage, joint space narrowing, subchondral plate irregularity, cystic changes & marginal osteophytes were noted. Thus these MRI features can provide both radiologists and orthopedic surgeons with rapid and reproducible information for diagnosis and aid therapeutic planning.

S163 Poster #: CR-047 When evaluating a joint, WATS not to like

Mittun Patel, MD, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Seth Vatsky, DO, Deepa Biyyam, MD, Scott Jorgensen, MD, Craig Barnes, MD Purpose or Case Report: Originally intended to assess cartilage, we have found WATS imaging allows better visualization of osseous abnormalities. A subset of ProSet (PRinciple Of Selective ExCitation Technique), WATS stands for WATer Selection. A binominal pulse is applied that allows for the magnetization of fat and water to be separated. By selecting for water, fat is suppressed. Water selection was utilized in cartilage imaging as hyaline cartilage is high in fluid content. We added this sequence to our knee and shoulder protocols. Over time, it was appreciated that fat suppression properties of WATS was also very useful. By homogenously suppressing marrow signal, we observed better visualization of osseous abnormalities. In this case series, we will demonstrate examples where osseous abnormalities to include glenoid dysplasia, bony Bankart lesions, and intraarticular osteochondral bodies were either better or only seen on WATS images. Radiographs and CT remain complimentary to MRI; however, this sequence is a quick and easy way to assess for osseous abnormalities otherwise not readily seen on conventional MRI sequences.

Poster #: CR-048 Poster #: CR-046 STERNAL PSEUDOTUMOR OF CHILDHOOD—DON’T TOUCH LESION

Anat Ilivitzki, MD, Radiology, Rambam, Haifa, Israel, [email protected] Purpose or Case Report: The common approach to rapidly growing peristernal lesions in young infants is oncologic consultation, imaging and early tissue diagnosis. We represent five such cases, with unique sonographic findings, favoring a non aggressive lesion named SELSTOC*, in which a conservative approach of sonographic follow up was chosen. We review the typical sonographic images in this rather new and rare entity, separating it from the more aggressive group of lesions in this location and age group and suggest that the classic appearance should imply a weight and see approach, with sonographic follow-up studies, rather than invasive intervention.*SELSTOC—self limiting sternal tumor of childhood.

Intraoperative Ultrasound Use in Children with Brachial Plexus Birth Injury and Glenohumeral Instability: A Case Series

Floyd Dunnavant, M.D., Radiology, Vanderbilt University, Nashville, TN, [email protected]; Melissa Hilmes, MD, Christopher Stutz Purpose or Case Report: The use of ultrasound in the diagnosis of posterior shoulder dislocation in children with Erb’s palsy due to brachial plexus birth injury was first described in the literature in 1998. Since then, ultrasound screening in children with neonatal brachial plexus injury has been shown to be a fast and effective way of identifying glenohumeral subluxation or dislocation even when it is not clinically apparent. Screening at 3 and 6 months of age in these children has been recommended. At our institution, children with neonatal brachial plexus palsy and accompanying posterior glenohumeral subluxation/dislocation undergo surgical reduction of the joint. The surgical procedure most often includes lengthening of the internal rotators of the humerus, including the pectoralis major and subscapularis muscles. In addition, lengthening of the conjoined tendon of the biceps and coracobrachialis with concomitant neurolysis of the musculocutaneous nerve is often performed. In some cases, the release of the anterior deltoid from its humeral insertion is often required to accomplish acceptable positioning of the glenohumeral joint. The use of intraoperative ultrasound to demonstrate successful operative relocation of the humeral head has not previously been documented in the literature. We present at least two cases from our institution where intraoperative ultrasound was utilized to demonstrate relocation as well as optimal positioning at the shoulder joint prior to intraoperative casting. This technique offers a distinct advantage over traditional fluoroscopic techniques, in that no ionizing radiation is utilized. Performance of an arthrogram is unnecessary. This technique also eliminates the need for continued sedation for postoperative MRI, and is a dynamic procedure which allows for real-time optimization of glenohumeral positioning.

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The aim of this presentation is to review the findings of glenohumeral instability after brachial plexus injury, as well as the ultrasound techniques for evaluation of the glenohumeral joint. We will present preoperative and intraoperative images from cases at our institution where intraoperative ultrasound was utilized to aid our surgical colleagues in optimal positioning of the humeral head. Poster #: CR-049 Pelvic Fractures in Non-Accidental Trauma

Adebunmi Adeyiga, Division of Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Anna Blask, MD, Katherine Deye, Eglal Shalaby-Rana Purpose or Case Report: To determine the prevalence, describe the spectrum, and highlight the importance of pelvic fracture in the setting of non-accidental trauma. Methods & Materials: We reviewed our IRB approved data base of 1035 infants and children who had undergone a skeletal survey as part of the assessment for possible abuse or neglect over a 15 years period from 1997 to 2012. The patients with pelvic fractures were identified and their clinical histories and imaging studies were reviewed. Results: Four patients were identified with pelvic fracture, for a prevalence of 0.4% (4/1035). The ages of the patients ranged from 3 months through 7 years; gender distribution was two boys and two girls. All four patients had multiple stigmata of nonaccidental trauma, in addition to multiple other fractures. All pelvic fractures were healing. Two patients had a fracture of the superior pubic ramus, one of the inferior pubic ramus and one patient a fracture of the left iliac bone. Computed tomography added significant additional information in two of the cases by confirming a suspected pelvic fracture on the radiograph and indicating the phase of acuity (healing) in both cases. Three patients had findings suspicious for sexual abuse, with soft tissue injury consisting of scrotal swelling and ecchymosis in one boy, and genital (2/2), buttock (2/2) and anal injuries (1/2) in two girls. Conclusions: Although rare, pelvic fractures in the setting of nonaccidental trauma are important findings that should be recognized by the pediatric radiologist. One should also be aware of the suspected association with sexual abuse. Poster #: CR-050 Comparison of CTand MRI for Evaluation of Glenoid Bone Loss in Pediatric Patients

Jeannie Kwon, MD, Joseph Emerson, MD, UT Southswestern, Dallas, TX, [email protected]; Jerry Powell, Henry Ellis, Phillip Wilson Purpose or Case Report: In the clinical setting of recurrent anterior shoulder instability, MRI of the shoulder is used to evaluate for soft tissue injury involving the capsule, ligaments, and the labrum. Such injuries are amenable to arthroscopic repair. However, if there is significant deficiency of the bony glenoid surface, CT of the shoulder is performed, as it has been shown to reliably quantify bone loss. When significant, glenoid bone loss is an indication for open surgical repair, such as the Latarjet coracoid transfer. This study is designed to assess the accuracy and reproducibility of MRI in quantifying glenoid bone loss, as compared to established CT methods. If equivalent, MRI may be used as a single modality for pre-surgical evaluation. In the era of ALARA, being able to use MRI as a single modality helps to avoid

unnecessary radiation in these pediatric patients. Also, using a single modality may help reduce the overall cost of pre-surgical planning. Poster #: CR-051 Prenatal Cortical Hyperostosis—Caffey Dysplasia

Douglas Jamieson, MD, Radiology, BCCH, Vancouver, BC, Canada, [email protected]; Heather Bray Purpose or Case Report: Case Report: We report a cluster of three cases seen at our institution. Case 1: Stillborn at 29 weeks gestation Case 2: Premature delivery at 29 weeks gestation, discharged 3 months later with near normal radiographs Case 3: Premature delivery at 31 weeks gestation, died 38 days of life. Case 3 would have been Case 2’s younger sibling! Our imaging is postnatal but the disease process in all was clearly evolving prenatally. The findings of hyperostosis including mandible, ribs, and long bones will be illustrated. (Our cases did not show significant clavicle involvement.) Case 3 had significant limb shortening and bowing. We will discuss differing Caffey Dysplasia from Caffey Disease or Infantile Cortical Hyperostosis (Ref 1). A differential diagnosis will be discussed, which in our cases included ostegenesis imperfecta, osteopetrosis and ricketts. We have not seen a case of Caffey Disease in many years and this has been reported by others (Ref 2). Autosomal dominant inheritance with variable penetrance has long been noted (Ref 3). The interesting recent finding of heterozygous mutation in the alpha 1 collagen type 1 gene in some (but not all) cases is reviewed (Ref 4). Reference 1: Nemec SF, Rimoin DL, Lachman RS. (2011) Radiological aspects of prenatal onset cortical hyperostosis (Caffey Dysplasia). Eurpean Journal of Radiology 81:565–572 Reference 2: Maclachlan AK, Gerrard JW, Stuart Houston C, Ives EJ. (1984) Familial infantile cortical hyperostosis in a large Canadian family. Can Med Assoc J. 130:1172–1174 Clinical Dysmorphology 2:81–86 Reference 3: Turnpenny PD, Davidson R, Stockdale EJN, Tolmie JL, Sutton AM. (1993) Reference 4: Gensure RC, Makitie O, Barclay C et al. (2005) A novel COL1A1 mutation in infantile cortical hyperostosis(Caffey Disease) expands the spectrum of collagen—related disorders. J Clin Invest 115:1250–1257 Poster #: CR-052 Scurvy in an autistic child; early disease on MRI and Bone Scintigraphy can mimic an infiltrative process

Nadir Khan, Radiology, Arkansas Children’s Hospital, Little Rock, AR, [email protected]; Robert Buchmann, D.O. Purpose or Case Report: We report a case of scurvy in an 8 years old male with autism who presented with severe leg pain that prevented him from walking. Initial radiographs were normal, but bone scintigraphy demonstrated subtle band like uptake localized to the metaphyses of both legs. Subsequent magnetic resonance imaging (MRI) demonstrated intense marrow signal abnormality and enhancement confined to the metaphyseal regions of the long bones of both legs. Our initial differential included an infiltrative process such as leukemia, multifocal osteomyelitis or neuroblastoma metastases; trauma was felt to be unlikely due the multifocal nature of this lesion. A subsequent bone biopsy was normal and led to further investigation. It was later revealed that this patient had a very limited dietary intake restricted to cookies, brown sugar pop tarts,

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chocolate milk and doughnuts. Further laboratory assessment of this patient’s nutritional status demonstrated a vitamin C level of 0.1 mg/dL (normal 0.4–2.0 mg/dL). A presumptive diagnosis of severe vitamin C deficiency and scurvy was made and the patient was placed of supplemental vitamin C therapy. A follow-up MRI of both legs 8 months later demonstrated complete normalization of previously described MRI findings. Vitamin C deficiency resulting in scurvy is rarely seen in well developed countries. It has been reported in the elderly population and alcoholics but is unusual in the pediatric population. A handful of case reports have been described in children with developmental and neuropsychiatric disorders due to unbalanced diets. Previously described imaging findings include extensive subperiosteal hemorrhages on plain films as well as metaphyseal signal abnormality on MRI. Band-like uptake localized to the metaphyses on bone scintigraphy has not previously been described in patients with scurvy. We conclude that band like abnormality confined to the metaphysis of long bones on bone scintigraphy and MRI may represent an early manifestation of scurvy and should be considered in patients with an unbalanced diet. Timely intervention with vitamin C therapy could help prevent further complications such as subperiosteal hemorrhages.

Poster #: CR-053 Readout-Segmented EPI for Diffusion Imaging of the Pediatric Spine: an Illustrative Case Review

Laura Hayes, M.D., Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Susan Palasis, MD, Richard Jones, Damien Grattan-Smith Purpose or Case Report: To demonstrate how readout-segmented echo planar imaging ((RS) EPI) is a powerful method of diffusion-weighted MR imaging of the pediatric spine in the evaluation of various pathological states. Methods & Materials: Readout-segmented diffusion tensor imaging was performed on a 1.5 T Avanto and a 3 T Trio scanner with seven segments, a parallel imaging factor of two, a b factor of 500 s/mm2 and an in-plane resolution of 1.25 mm2. A sagittal slice orientation was chosen, as it allows an entire section of the spine to be assessed with a single acquisition. Gating was used for the C-spine, with a single slice acquired on every third heartbeat and a delay for the peripheral trigger of approximately one third of the cardiac cycle. Gating was not needed for the T or L spine. This sequence was added to standard protocols for imaging pediatric spines in various pathological conditions, including drop metastases, infarction, infection, demyelination, vertebral and paravertebral tumors, and epidermoid cysts. Results: (RS) EPI produced excellent image quality, nearly free from the artifacts degrading other types of diffusion imaging of the spine. Usual artifacts from bone and CSF flow, breathing, and arterial pulsations were strikingly reduced, providing good spatial resolution and strong signal, thereby allowing identification of drop metastases from hypercellular brain tumors, some of which were not apparent on conventional images. Diffusion imaging was also helpful in diagnosing spinal cord infarction, allowing differentiation from bland cord edema. Diffusion imaging helped define the extent of epidural abscesses and distinguish them from other collections. This sequence aided in diagnosing and evaluating vertebral and paravertebral tumors such as Ewing’s sarcoma and neuroblastoma. Furthermore, restricted diffusion within a solitary intradural cyst was essentially pathognomonic for an epidermoid. Conclusions: Readout-segmented echo planar imaging is a powerful tool in the evaluation of pediatric spine disease. It is a diffusion technique that is nearly free from artifacts that typically affect spine diffusion imaging. The cases presented in this exhibit demonstrate how exquisitely helpful this technique is in the work-up of numerous pathological conditions of the pediatric spine, including tumor, infection, and infarction.

S165 Poster #: CR-054 Minimally Invasive MRI-guided Stereotactic Laser Thermal Ablation—A Step-by-Step Tutorial

Robert Dizor, MD, Radiology, Miami Children’s Hospital, Miami, FL, [email protected]; Santiago Medina, Mona Yasrebi Purpose or Case Report: Open surgical resection of cortical abnormalities associated with lesional refractory epilepsy utilizing intraoperative electrocortical mapping is the standard treatment. At Miami Children’s Hospital, we have had experience with over 15 procedures treating lesional epilepsy by minimally invasive stereotactic laser thermal ablation under MRI guidance. For this educational exhibit, we review our thermal ablation cases and provide a step-by-step tutorial of the laser thermal ablation process we employ at our institution. This tutorial is helpful as more institutions embark on this minimally invasive procedure. In step 1: Pre-procedure MRI, fMRI, PET and SPECT are done to identify lesion and seizure focus. Images are fused and reviewed to determine if patient is a candidate for thermal ablation. In step 2: Stereotactic frame is placed and scanned with CT. Prior imaging of step 1 is fused with CT in Brain lab for guidance. Laser fiber is placed with Brain Lab and Stereotactic frame guidance. In step 3: Patient is placed in a 1.5 T scanner. Fast single shot T1 and T2 weighted sequences are done to identify the long axis and tip of the fiber. These sequences are also done to exclude hemorrhage from the procedure. Conventional T2 weighted sequence is done for pre-treatment documentation. In step 4: A test thermal sequence is performed with a temperature setting of less than 45C documenting the laser fiber tip position within the lesion. Subsequently treatment of the lesion is done with temperature between 50-70C for 1–2 min. Safety temperature probes are placed to protect critical structures from reaching more than 45C. Prediction thermal ablation map is generated real time to monitor treatment. In step 5: Treatment effect is documented immediately with diffusion weighted images which show restricted diffusion around the lesion. T1 and T2 weighted sequences are done to document central area of high T1 and low T2 signal which represent protein denaturalization from thermal ablation. This exhibit will provide the reader with a very clear understanding of the steps and imaging findings of this novel approach of minimally invasive thermal ablation in seizure disorders. Poster #: CR-055 Fetal brain MRI findings of congenital cytomegalovirus infection with post-natal MRI correlation

Lauren Averill, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, [email protected]; Vinay Kandula, Monica Epelman Purpose or Case Report: Congenital cytomegalovirus (CMV) infection is the leading cause of intrauterine infection, affecting approximately 1% of all live births. The vast majority of infected fetuses are asymptomatic at birth, but 10% show neurological impairment in the neonatal period and another 10–15% will develop persistent neurological problems including seizures, hypotonia, mental retardation, autism, cerebral palsy, sensorineural hearing loss and learning disabilities. Magnetic resonance imaging (MRI) of the fetal brain is complimentary to fetal ultrasound evaluation, and may be pursued in cases of suspected CMV infection, and also in fetuses demonstrating ventriculomegaly on second trimester ultrasound without other features to raise concern for congenital infection. In addition, infants and young children with static encephalopathy and/or sensorineural hearing loss without an underlying cause identified may be

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referred for brain MRI. As congenital CMV infection may not be suspected, radiologists evaluating fetal and post-natal brain MRI studies need to have a high level of suspicion for this diagnosis. We present a series of five cases of congenital CMV infection evaluated with second or third trimester MRI of the fetal brain with post-natal MRI correlation. Infection was confirmed with neonatal urine polymerase chain reaction. The clinical indications for fetal MRI varied, including ventriculomegaly, intracranial cyst, and suspected CMV infection. Features seen on fetal MRI included: dilated atria, temporal horns and occipital horns of the lateral ventricles; intraventricular septations; cystlike foci in the anterior temporal lobes; polymicrogyria; dysplastic cerebellum; porencephalic cyst and calcifications. Pre-natal features were confirmed on post-natal MRI, with better delineation of the extent of polymicrogyria, enhanced detection of intraventricular septations, and clearer demonstration of abnormal white matter T2 hyperintensity.

Poster #: CR-056

Results: All patients had congenital skull base dysplasia, most with an unusual sagittal or parasagittal cleft in the basiocciput (4/5). All brain MR exams showed microcephaly, white matter hypoplasia, gyral simplification, and brainstem hypoplasia (4/4). Three patients had small globe anterior segments, optic pathway hypoplasia, and absent massa intermedia. Distal basilar artery “fenestration” was present in two patients. The inner ear vestibules were dysplastic in one patient. One patient had pachymeningeal thickening. Spinal anomalies incuded scoliosis, segmentation anomalies, endplate irregularities, basilar invagination, foramen magnum stenosis, and tethered spinal cord. Conclusions: Typical imaging manifestations of Cornelia de Lange syndrome include skull base dysplasia, parenchymal hypoplasia, and gyral simplification. Membranous labyrinth dysplasia, anterior segment and optic pathway hypoplasia, basilar artery fenestration, absent massa intermedia, and spinal anomalies may also be present.

CNS Imaging Manifestations of Cornelia de Lange Syndrome

Poster #: CR-057

Matthew Whitehead, MD, Neuroradiology, Children’s National Medical Center, Washington, DC, [email protected]; Usha Nagaraj, MD, Phillip Pearl

Isolated Cranial Nerve and Cervical Nerve Root Enhancement in an Infant with Polymerase Gamma Mutation Mitochondrial Disease

Purpose or Case Report: Cornelia de Lange Syndrome (CdLS) is rare genetic disease characterized by a distinctive facial dysmorphia and dwarfism. Multiple organ system involvement is typical. Various central nervous system aberrations have been described in the pathology literature. However, the spectrum of CNS MR imaging manifestations is less well documented. We present MR imaging findings in the brain and spine from a series of five patients carrying the diagnosis of CdLS. Methods & Materials: The diagnostic imaging report database at a single academic children’s hospital was retrospectively searched for the terms “Cornelia de Lange”, “de Lange”, and “Brachmann de Lange” after filtering by modality (MR). The search yielded 10 exams, all from different patients. Two non CNS exams were excluded (chest and lower extremity MRIs). The remaining three exams were excluded as images were not available for direct review. All images were evaluated by a board certified radiologist with neuroradiology CAQ. Electronic medical records of all patients were reviewed for symptomatology, past medical history, and confounding variables that could cause secondary CNS pathology such as congenital heart disease.

Deanna Horst, Nationwide Children’s Hospital, Columbus, OH; Lynne Ruess, MD, Jerome Rusin, Dennis Bartholomew Purpose or Case Report: We present an infant with Myocerebrohepatopathy Spectrum (MCHS) disease caused by heterozygous POLG mutations who had abnormal gadolinium enhancement of multiple cranial nerves and cervical nerve roots and an otherwise normal brain MRI. Nuclear polymerase gamma (POLG) mutations are the most common cause of mitochondrial disease. Mutations indirectly interfere with the mitochondria’s ability to manufacture ATP by incorrectly transcribing the mitochondrial DNA (mtDNA) and reducing the mtDNA copy number. POLG mutation diseases have a broad spectrum of clinical manifestations; the lethal infantile form is MCHS. A 4-month-old male infant was referred for poor feeding, emesis, failure to thrive, and hypotonia. Initial laboratory tests: elevated direct bilirubin 2.8 mg/dL (nl <0.6 mg/dL), indirect bilirubin 1.3 mg/dL (nl 0.1– 1.0 mg/dL), AST 448 U/L (nl 5–105 U/L), ALT 167 U/L (nl 7–110 U/L), and LDH 2221 U/L (nl 600–1400 U/L). Plasma lactate level peaked at 12.3 mmol/L (nl 0.5–2.2 mmol/L). CSF protein level was 1113 mg/dL (nl 15–45 mg/dL). A brain MRI with and without contrast demonstrated bilateral enhancement of CN III, CNs V-X, and the upper and mid cervical nerve roots. Galactocerebroside betagalactosidase and arylsulfatase A activities were normal. Testing for spinal muscular atrophy, tyrosinemia type 1, galactosemia, mitochondrial genome mutations, pyruvate disorders, Niemann-Pick disease and perioxisomal defects were negative or normal. Three weeks after admission, the child’s clinical picture worsened. He developed hypoxia, ascites, tachycardia, intermittent fevers and sepsis. Liver biopsy showed findings of early cirrhosis, steatosis, and focal necrosis. Muscle biopsy did not demonstrate any specific abnormality of mitochondrial morphology or number. Electron transport chain (ETC) analysis of both liver and muscle demonstrated deficiencies. Because of suspicion for a mitochondrial depletion disorder, testing was performed for mitochondrial abnormalities including analysis of the POLG gene which revealed two pathogenic mutations, c.1399G>A (p.A467T) and c.3285C>G (p.S1095R). Similar patterns of enhancement have been reported in Krabbe’s disease and infantile metachromatic leukodystrophy. This case of MCHS expands the differential diagnosis of isolated cranial nerve/cervical nerve root enhancement. We recommend brain MRI protocols include

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gadolinium enhanced T1 weighted sequences for infants with suspected neurometabolic disease. Poster #: CR-058 Utility of Susceptibility Weighted (SWI) and Constructive Interference in Steady State (CISS) Sequences in the Evaluation of Hydrocephalus in the Newborn

Gaurav Saigal, Univerisity of Miami Miller School of Medicine, Miami, FL, [email protected]; Susan Williams Purpose or Case Report: Susceptibility weighted imaging (SWI) is a magnetic resonance imaging (MRI) technique that is highly sensitive for blood, iron, and calcium deposition in the brain. In certain neonatal neurological disorders such as traumatic brain injury, coagulation disorders, vascular malformations, cerebral infarction, neoplasms, and neurodegenerative disorders, SWI has an established role. In the evaluation of hydrocephalus in the newborn, SWI is traditionally not performed. However, in unexplained neonatal hydrocephalus, SWI can play an important role by demonstrating blood products in the ventricles and sub-arachnoid spaces. Constructive Interference in Steady State (CISS) is a gradient-echo MRI sequence with increased sensitivity for differentiating cerebrospinal fluid (CSF) intensity from pathological structures. CISS provides superior topographic information that helps to delineate the exact location of various cranial pathologies, and is useful in evaluating aqueductal stenosis. The purpose of this exhibit is to demonstrate the utility of SWI and CISS sequences in the evaluation of hydrocephalus in newborns by helping to differentiate congenital aqueductal stenosis from acquired aqueductal stenosis. Methods & Materials: Eight patients underwent conventional MR imaging which demonstrated enlargement of the lateral and third ventricles without enlargement of the fourth ventricle, indicating obstructive hydrocephalus. Etiology of the obstructive hydrocephalus was not determined on standard imaging. Addition of SWI and CISS sequences helped to differentiate acquired aqueductal stenosis from congenital aqueductal stenosis. Results: In five cases, SWI demonstrated hemorrhage along the ventricles and cerebral aqueduct suggesting an acquired cause for the obstructive hydrocephalus. In the remaining three cases, CISS sequence demonstrated a clear narrowing of the cerebral aqueduct to indicate congenital aqueductal stenosis. Conclusions: SWI and CISS are useful sequences in the evaluation of neonatal hydrocephalus at the level of the cerebral aqueduct. SWI increased the diagnostic sensitivity and specificity of MRI for evaluation of hemorrhage that was not evident on standard sequences. CISS imaging increased the diagnostic sensitivity for determining congenital aqueductal stenosis in cases where SWI was negative. Therefore, inclusion of SWI and CISS sequences in the standard neonatal brain MRI protocol when evaluating for hydrocephalus should be considered. Poster #: CR-059 Current T2* Based MRI Techniques and their Applications in Pediatric Neuroimaging

Susan Palasis, MD, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Laura Hayes, M.D., Stephen Little, Damien Grattan-Smith, Binjian Sun, Richard Jones Purpose or Case Report: T2* based imaging is a technique that accentuates the paramagnetic properties of blood products such as deoxyhemoglobin, intracellular methemoglobin, and hemosiderin. It is particularly useful for detecting intravascular venous deoxygenated blood

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as well as extravascular blood products. It is also sensitive in detecting and quantifying the presence of iron. We have used this technique over the past several years to study a wide variety of pediatric neurologic disorders. T2* relaxation imaging has the ability to reveal pathologic and physiologic conditions of the brain that alter regional susceptibility and reveal abnormalities that are unapparent on conventional MR sequences. We are presenting select case histories to demonstrate their clinical usefulness in pediatric neuroimaging. A brief discussion of the various susceptibility techniques of GRE, SWI, QSM, and BOLD will be included. 1. Chavhan GB, Babyn PS, Thomas B, Shroff MM, Haacke EM. Principles, techniques, and applications of T2*-based MR imaging and its special applications. Radiographics. 2009 Sep-Oct;29(5):1433–49. 2. Tong KA, Ashwal S, Obenaus A, Nickerson JP, Kido D, Haacke EM. Susceptibility-weighted MR imaging: a review of clinical applications in children. AJNR 2008 Jan;29(1):9–17. 3. Bing Wu, Wei Li, Arnaud Guidon, Chunlei Liu. Whole Brain Susceptibility Mapping Using Compressed Sensing Magn Reson Med. 2012 January; 67(1): 137–147. Poster #: CR-060 Smoothing things over: Model based CT image iterative reconstruction approaches MR image quality

Sarah Rogers, Diagnostic Radiology, Oregon Health & Science University, Portland, OR; Dianna Bardo, MD Purpose or Case Report: The purpose of this exhibit is to educate the reader about new model-based iterative image reconstruction techniques for pediatric brain CT. We compare image quality of model based (IMR) and first generation anatomic based iterative reconstruction (iDose4) brain CT to standard filtered back projection (FBP) and correlate imaging findings to brain MR. Methods & Materials: IRB approval was obtained. A database of patients in whom brain CT was performed during beta testing of a model-based iterative image reconstruction (IMR) (Philips Healthcare, Cleveland, OH) was reviewed to identify pediatric patients with contemporaneous brain CT and MR. CT images were reconstructed using FBP, iDose4, (Philips, Cleveland, OH), and IMR (Philips, Cleveland, OH) and reviewed by two reviewers for image quality and correlative anatomy and pathology. Image noise measurements were made in normal grey matter and white matter. Definition of grey-white junction and definition of deep grey nuclei in normal brain were visually assessed and compared. Image post-processing, including image contrast inversion, and comparison to MR findings was performed on a PACS workstation to optimize image appearance comparison.

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Results: Three pediatric patients were identified with correlative brain CT and MR performed within days of each other. CT images reconstructed with IMR show 42–54% decrease noise in white matter and 36–50% decrease noise in grey matter. Cortical grey-white junction definition and conspicuity of deep grey nuclei was rated higher in images reconstructed with IMR than with FBP and iDose4. The degree of noise reduction in IMR images results in smooth textural appearance of brain tissue, similar to that seen in brain MR images. By adjusting MR image windows by inverting T2 or T2* it is possible to make direct comparison of regional pathology such as contusion, stroke, hemorrhage and edema. Conclusions: IMR provides low noise brain CT images which results in increased conspicuity of grey-white junction and definition of deep grey matter nuclei. IMR appears to be a valuable tool for increasing conspicuity of normal brain anatomy and pathology. Comparison of IMR brain CT images with brain MR findings provides an interesting area for further study. Disclosure: Dr. Bardo has indicated a relationship with Philips Healthcare as a Consultant and Speaker (Honoraria); Thieme Publishing, Author (Royalties).

The presence of displaced “parallel vessels” running adjacent to the brain parenchyma may prove to be a more reliable finding, suggestive of subdural location. In cases where prominent extraaxial spaces are more than expected for age on CT and displaced “parallel vessels” are seen or there is a high level of clinical suspicion, MRI is a very important tool. MRI proved useful in identifying the subdural collections, especially when using b-FFE sequence, and other findings of abuse.

Poster #: CR-062 Melanotic Neuroectodermal Tumor of Infancy: A Case Report

David Leake, MD, Radiology, Dell Children’s Medical Center of Central Texas, Austin, TX; Bhairav Patel

Poster #: CR-061 Differentiating Prominent Subarachnoid Spaces from Isodense Subdural Collections seen on CT in Infants

Carolina Guimaraes, Radiology, Nemours Children’s Hospital, Orlando, FL, [email protected]; Lane Donnelly, MD Purpose or Case Report: In infants with prominent extra-axial spaces identified on head CT, the idenification of cortical veins traversing the subarachnoid space is a finding often used to confirm that the prominent fluid represents prominent subarachnoid spaces, as opposed to more clinically signifcant subdural collections. This cases series describes three cases in which infants with prominent extra-axial spaces with traversing vein seen on CT were shown on MRI to actually represent subdural collections with visualization of bridging veins. Methods & Materials: Three infants (4 months, 2 months, and 3 months of age) underwent CT which demonstrated varying prominence of the extra-axial spaces, isodense to CSF. In each case, traversing veins were identified within the prominent extraaxial spaces - suggesting the prominent fluid was subarachnoid in nature. However, in addition, displaced veins running parallel and immediately adjacent to the brain parenchyma were also identified. Because of clinical concerns, the size of the extra-axial spaces, and/or presence of displaced parallel veins, MRI including balanced steady state free procession imaging (b-FFE) was performed. Results: In all three cases, MRI with b-FFE demonstrated that the collections were subdural in location. Associated hemosiderin staining in each case, either extra-axial or parenchymal, raised the suspicious for child abuse. Other findings suggestive of abuse were also identified. In each case, the presence of traversing veins was a false positive predictor for subarachnoid location of the promient extra-axial spaces. Conclusions: The finding of traversing extra-axial veins is not a reliable differentiator for separating benign prominent subarachnoid spaces seen commonly in infancy from subdural collections, as can be seen in more ominous condition such as child abuse.

Purpose or Case Report: Eighty-two days old infant presented to her pediatrician with a mass of the left upper gum line growing rapidly over a 7 days period. The consulting Craniofacial Surgeon requested preoperative imaging. CT craniofacial exam revealed a well circumscribed expansile bony lesion of the left medial maxilla displacing adjacent teeth. MRI facial exam revealed a localized mass of the left medial maxilla. It demonstrated isointense signal on T1-weighted images and predominately isointense signal on T2-weighted images. There was inhomogeneous contrast enhancement. The pathology report described a 2.9 cm mass with neuroectodermal cells with abundant melanin compatible with Melanotic Neuroectodermal Tumor of Infancy (MNTI). This tumor is a rare benign osteolytic pigmented neoplasm that primarily affects the maxilla of infants less than one year of age. There are few reports in the Radiological literature. Knowledge of the clinical, pathologic, and radiologic pattern of this rare tumor would help Radiologists in identifying this tumor preoperatively.

Poster #: CR-063 Childhood Primary Angiitis of the Central Nervous System presenting with bilateral panuveitis and anisocoria

Megan Saettele, George Cyriac, Saint Luke’s Hospital, Kansas City, MO, [email protected]; Anatoly Loskutov, Matthew Sigley, Lisa Lowe, MD, David Nielsen, MD

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S169 Poster #: CR-065 Traumatic Pseudoaneurysm causing Intracerebral Haemorrhage in a Child: The importance of CTangiography in blunt head trauma

Kathleen Han Suyin, LRCP & SI MB BCh NUI, Childrens University Hospital, Dublin, Ireland; Deirdre Devaney, Michael Farrell, John Caird, Darragh Crimmins, Eoghan Laffan

Purpose or Case Report: Childhood primary angiitis of the central nervous system (cPACNS) is a rare immune-mediated vasculitis that preferentially affects blood vessels of the central nervous system (CNS). We describe a biopsy-confirmed case of cPACNS in a 9-year-old female presenting with panuveitis and anisocoria. The presentation of cPACNS is highly variable, which can make an accurate clinical diagnosis challenging. We emphasize typical MRI features such as perivascular space inflammation and enhancement that should prompt the radiologist to suggest this diagnosis. Methods & Materials: This is a case report. Conclusions: cPACNS is an immune-mediated vasculitis with devastating consequences if left untreated. MRI and cerebral angiography can be useful for evaluating patients with suspected CNS vasculitis. Recognizing typical findings suggestive of cPACNS allows a radiologist to specifically suggest this rare diagnosis.

Poster #: CR-064 MR Imaging Manifestations of Epstein Barr Virus (EBV) Encephalitis in Children

Susan Palasis, MD, Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Laura Hayes, M.D., Sumit Verma, Matthew Schniederjan, Damien Grattan-Smith Purpose or Case Report: Encephalitis is uncommon in the context of typical infectious mononucleosis syndrome in the majority of pediatric cases, occurring in less than 10% of children affected. Imaging studies are normal in the vast majority of children with neurologic symptoms, however, an array of imaging findings ranging in severity up to fatal fulminant encephalitis can be encountered. Increasing awareness around the various imaging appearances of EBV encephalitis is important. Given the widespread prevalence of human EBV infection, the incidence of EBV associated encephalitis with neurological sequelae has probably been underestimated. We present a series of cases from our institution demonstrating imaging findings that can be encountered with EBV encephalitis. Included is a fatal case of primary EBV infection involving the brain and spinal cord which has not been reported previously in the literature. The diagnosis of EBV encephalitis should be considered in the differential diagnosis in children with imaging findings of encephalomyelitis who present with an acute neurological illness of uncertain etiology. Tien R, Felsberg G, Osumi A. Herpesvirus infections of the CNS: MR findings. AJR 161: 167–176; 1992 Biebl A, Webersinke K, Traxler B, Povysil B, Furthner D, Schmitt K, Weis S. Fatal Epstein Barr Encephalitis in a 12 years old child: an underappreciated neurological complication? Nature Clinical Practice Neurology 5: 171–174; 2009

Purpose or Case Report: We present a case of a ruptured traumatic pseudoaneurysm of a branch of the middle meningeal artery in a child causing massive intracerebral haemorrhage. Our purpose is to highlight the critical role of CT angiography in traumatic head injuries, especially in delayed rehaemorrhage. Methods & Materials: A 7 year-old boy was admitted following blunt trauma to the left temporal region. Initial non-contrast CT showed a complex, comminuted fracture of the left frontotemporal and parietal bones. There was acute subarachnoid haemorrhage, a small subdural haemorrhage and several small areas of intracranial haemorrhagic contusion. The patient proceeded to neurosurgical evacuation of haemorrhage, fracture repair and ICP monitoring. Day 8 following surgery, the patient developed seizures. Non-contrast CT showed a new left parietal intraparenchymal haematoma, with associated midline shift and compression of the basal cisterns. The patient underwent an emergency decompressive craniectomy involving most of both frontal bones and some parietal bone bilaterally. On Day 6 post-craniectomy, the patient acutely deteriorated and a CT angiogram was performed. Results: CTangiography revealed a further increase in the acute parenchymal haematoma. There was new intraventricular blood and diffuse cerebral oedema. In addition, there was a 1 cm diameter high attenuation, enhancing focus noted peripherally, lateral to the left frontal lobe and adjacent to the parenchymal haematoma. This was diagnosed as a traumatic pseudoaneurysm of the left middle meningeal artery. Unfortunately, the patient died shortly after. Autopsy confirmed the presence of a pseudoaneurysm. Conclusions: This case highlights the critical role of CT angiography in children with blunt head injury, where there is a delayed recurrence of acute intracranial haemorrhage. Delayed diagnosis may result in acute rupture of the pseudoaneurysm and even death. Poster #: CR-066 Pediatric Crossed Cerebellar Diaschisis: A case report and review of the pathophysiology

Ashwin Hegde, M.D., UNMC, Omaha, NE, [email protected]; Sandra Allbery, MD

Purpose or Case Report: A 21 month old female with a history of trichorhinophalangeal syndrome and an absent corpus callosum presented with prolonged seizure activity. The seizures resolved with diazepam,

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although she had persistent right-sided hemiparesis. MR imaging demonstrated cerebral edema and swelling in the left cerebral hemisphere, which clinically was suspected to be a result of viral encephalitis. Serial MRIs up to 9 years of age demonstrate progressive atrophy in the left cerebral hemisphere and right cerebellum. Disruption of the corticopontocerebellar tract by a supratentorial insult can result in hypometabolism and atrophy in the contralateral cerebellar hemisphere. This exhibit will review the imaging characteristics and pathophysiology of crossed cerebellar diaschisis, which is uncommon in pediatric patients. The anatomy of the corticopontocerebellar tract, extending from the cortex to the contralateral cerebellum via the pontine nuclei, will be displayed. Poster #: CR-067 Non visualization of dural sinuses in the setting of posterior fossa epidural collection- Are the sinuses compressed or thrombosed?

Sumit Singh, Pediatric Radiology, UAMS, Little Rock, AR, [email protected]; Shilpa Hegde, Raghu Ramakrishnaiah, Nadir Khan, Charles Glasier Purpose or Case Report: We report four cases of initial non visualization of transverse and sigmoid sinuses in posterior fossa epidural collection mimicking dural sinus thrombosis. There was subsequent reappearance of sinuses after surgical extraction of epidural collection. We suggest that initial non visualization of sinuses in posterior fossa epidural collectioncould be due to detachment and compression of transverse and/or sigmoid sinuses rather than venous sinus thrombosis. To our knowledge this has not been described in literature before. Methods & Materials: Four cases were obtained after retrospective review of our institutional Neuroradiology data base at a tertiary care pediatric hospital. These include three cases of epidural hematoma and one case of epidural abscess. Routine CT head was obtained on Toshiba volume scanner and helical CTscanner. MRI and MRAwas performed on Philips and GE scanners. Results: Posterior fossa epidural collections are mostly traumatic in origin although other non-traumatic causes like thrombolytic therapy or epidural abscess have been described. Epidural hematoma generally develops by separation of the periosteal dura from the calvarium and rupture of the interposed vessels after trauma. The hemorrhage in posterior fossa is most commonly venous in origin related to trauma to the transverse or sigmoid sinuses versus supratentorial predominant arterial origin collection. The non visualization of the transverse and sigmoid sinuses in patients with traumatic or nontraumatic epidural collection has been erroneously ascribed to dural venous thrombosis. This leads to a different clinical management, serial CT venograms and follow up CT scans adding to radiation dose burden on the patient and also leading to increased cost of treatment. A case of epidural abscess with non visualization of posterior fossa dural sinuses was interpreted as sinus thrombosis and led to thrombolytic therapy which was complicated by intracranial hemorrhage. Conclusions: Transverse and Sigmoid sinuses like other intracranial venous sinuses are intradural structures contained in a dural sheath which may be peeled off the calvaria in cases of extradural collection (hemorrhage or abscess). Although the dural sinuses are commonly injured and are most common source of epidural blood in posterior fossa, their non visualization in pediatric population is mostly secondary to compression of the detached dural sinuses. Poster #: CR-068 Imaging Dietl’s crisis (intermittent ureteropelvic junction obstruction) with renal ultrasound and nuclear medicine renogram

Hedieh Eslamy, MD, Radiology, Seattle Childrens Hospital, Seattle, WA, [email protected]; Marguerite Parisi, MD; MS

Purpose or Case Report: Dietl’s crisis or intermittent ureteropelvic junction obstruction (UPJ) is well described in the urologic but not the radiologic literature. First reported by Josef Dietl in 1864, Dietl’s crisis encompasses a spectrum of episodic crampy upper abdominal pain, nausea, and vomiting associated with intermittent renal obstruction at the ureteropelvic junction. Lack of awareness of this entity leads to delay in diagnosis, particularly in this era where most cases of UPJ obstruction are identified on prenatal ultrasound. We report the imaging findings of a 13-year-old boy who presented to the emergency department with acute onset of right lower quadrant/flank pain. Previous similar episodes had been attributed to constipation. Ultrasound (US) performed for suspected appendicitis was normal except for the incidental discovery of moderate right hydronephrosis without parenchymal thinning, abnormal parenchymal echogenicity, stone, or hydroureter. The consulting urologist’s diagnosis was UPJ obstruction due to Dietl’s crisis. Surgery was scheduled for 3 days later. Repeat US on the morning of surgery was identical to the initial study except for the development of abnormally increased parenchymal echogenicity. Nuclear medicine diuretic renogram with Tc-99 m mertiatide demonstrated markedly decreased renal perfusion, prolonged renal cortical retention of radiotracer and absent excretion into the renal collecting system on the right. Differential renal function was 73% on the left and 27% on the right. At surgery, a high grade right UPJ obstruction due to a crossing vascular arcade to the lower pole was confirmed. The patient underwent a roboticassisted laparoscopic pyeloplasty and has been asymptomatic since. We surmise that the increased renal cortical echogenicity seen on the second ultrasound reflects a combination of renal edema and tubular injury secondary to the ongoing but acute high-grade UPJ obstruction. Dietl’s crisis is an uncommon presentation of UPJ obstruction. Awareness of this entity will facilitate prompt diagnosis and treatment, preventing potential sequelae of renal parenchymal damage which, as demonstrated by this case, can occur very quickly. Poster #: CR-069 Novel use of a disposable pressure transducer for intracranial pressure measurement for nuclear medicine CSF shunt studies

Hedieh Eslamy, MD, Seattle Children’s Hospital, Seattle, WA, [email protected]; Mariann Abrahamson, Lisa Aldape, Marguerite Parisi, MD; MS Purpose or Case Report: We describe the novel use of a disposable pressure transducer for intracranial pressure (ICP) measurement during NM CSF shunt studies. The Compass Lumbar Puncture (Mirador Biomedical, Seattle WA) is a single-use pressure transducer with digital display designed for pressure measurement during lumbar puncture. It received FDA clearance in 2010. Other alternatives for measurement of ICP, liquid column manometry and pressure transduction probes that connect via tubing to external monitors, are fraught with shortcomings. Supplies in “shunt cart” a. COMPASS lumbar puncture b. Screw top, sterile, leak-proof tube (for CSF sample) c. Clippers/blade d. Povidone-iodine (Betadine) swabs (three) e. Sterile gloves f. Sterile fenestrated drape g. Surgical mask h. Sterile gauze i. 25 gauge needle j. Surgical marking pen

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Procedure: 1. Review prior imaging to locate shunt reservoir. 2. Patient lies supine on imaging Table. 3. Identify location of shunt reservoir by palpation and correlation with imaging. 4. If hair overlies reservoir, part hair away from reservoir and clip area. 5. Mark site for puncture with a surgical pen (optional). 6. Position head so that reservoir lies perpendicular to surface of table. In this position dome of reservoir can be entered with needle parallel to Table. 7. Put on surgical mask and sterile gloves. 8. Clean skin with Betadine swabs (×3). Circle outward from entry site. 9. Let Betadine dry; excess Betadine may be swabbed with gauze. 10. Place a sterile plastic drape on head with fenestration centered on reservoir. 11. Remove COMPASS from its sterile package and detach cover of rear port. 12. Activate COMPASS and calibrate it to atmospheric pressure by pressing power button until display reads “00”. 13. Reattach cover of rear COMPASS port. 14. Insert needle perpendicular to skin into reservoir. Puncture site should be at center of reservoir and needle should be held parallel to table. Once entered, a drop in resistance is felt. Advance slowly until bevel of needle is fully inside reservoir. If flow is poor, slightly adjust angle of needle or alter depth. 15. Once reservoir has been successfully accessed CSF will start flowing out needle hub. However, poor flow is strongly correlated with proximal shunt obstruction. 16. Wait for a drop of CSF to appear at needle hub. Then attach COMPASS lumbar puncture to needle and obtain CSF opening pressure. 17. Detach COMPASS lumbar puncture and collect several drops of CSF in screw top, sterile, leakproof tube. 18. Attach slip-tip syringe containing radiotracer to needle and gently instill the radiotracer in reservoir. 19. Withdraw syringe and needle ensemble and place into lead pig. 20. Gently cover puncture site with a gauze pad. 21. Advance patient under gamma camera and initiate imaging immediately.

Poster #: CR-070 The use of 18F-Fluoro-Deoxy-Glucose Fused Positron Emission Tomography CT in Detecting Recurrent Hepatoblastoma at a large tertiary Children’s Hospital

Vincent Lee, MD, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, [email protected]; Kimberly Dao, Rakesh Sindhi, Sameh Tadros Purpose or Case Report: Although primary liver malignancies in children are rare, recent studies suggest that the incidence of the most common malignant pediatric liver tumor hepatoblastoma is increasing. Between 1975 and 2007, the incidence of hepatoblastoma has nearly quadrupled in the United States. The reasons underlying the increased incidence remain unclear, but the malignancy is curable with surgical resection. In cases where the tumor is not resectable, liver transplantation is the best option for cure. Post-resection or transplant, the recurrence rate of hepatoblastoma in the United States is 15.9%. Recurrence may occur in the liver, and may commonly metastasize to lung, brain, bone, and peritoneal sites. In the setting of a rising level of the biomarker alpha-fetoprotein (AFP), fused positron emission tomography CT (PET-CT) using 18F-fluoro-deoxy-glucose (18F-FDG) may be a better modality than conventional imaging methods to detect sites of hepatoblastoma recurrence. Methods & Materials: We performed a retrospective review of the patients with hepatoblastoma at a large tertiary Children’s Hospital from 1987 to 2013 and found four cases with recurrent hepatoblastoma who received imaging using 18F-FDG-PET-CT.

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Results: We found that, in all of these cases, 18F-FDG-PET-CT was positive when CT alone was negative, or was more accurate than CT alone. Our review further demonstrated that all four patients’ biopsies were later positive for hepatoblastoma, showing that 18F-FDG-PET-CT is highly accurate (100%) in predicting hepatoblastoma recurrence. Additionally, we found that 18F-FDG-PET-CT was likely to be positive when AFP was greater than 1900 ng/mL, and when recurrence occurred in the liver. Interestingly, the pathology of these tumors when 18F-FDG-PET-CT was positive tended towards the teratoid type (n=2 patients) or the mixed fetal, embryonal, and small cell type (n=2 patients). Conclusions: In all of our patients, the positive findings from 18F-FDGPET-CT imaging led to additional treatment, including salvage chemotherapy, surgical resection, or liver transplant. From our case series, we conclude that 18F-FDG-PET-CT is highly accurate in predicting hepatoblastoma recurrence and can significantly influence management after recurrence. We hope that 18F-FDG-PET-CT will be increasingly utilized in future cases of recurrent hepatoblastoma after considering the success of the modality in our case series. Poster #: CR-071 Inflammatory Myofibroblastic Tumor: ‘Pseudo’ tumor Or ‘Real’ Tumor?

Vikas Yadav, MD, Radiology, Christian Medical College, Vellore, India, [email protected]; Aparna Irodi, Ashok Mithra, Shyamkumar Keshava Purpose or Case Report: Inflammatory myofibroblastic tumor (IMT), also known as inflammatory pseudotumor, plasma cell granuloma and inflammatory fibrosarcoma, is a soft tissue lesion consisting of inflammatory cells and myofibroblastic spindle cells. IMTs have a predilection for the lung, abdomen, and pelvis of children and young adults. They usually behave like benign pathology; however, rarely metastatic disease has also been described. Case report: A 3 year old girl presented with history of the vomiting for a week and a left adrenal mass was found on imaging which was completely excised. Five months later, she presented with fever for a week associated with loss of appetite & abdominal pain. Chest radiograph showed multiple nodular opacities scattered throughout both lung fields. Contrast enhanced CT showed recurrence of the adrenal lesion with metastasis in lung, liver & retroperitoneum. PET-CT showed that the metastatic lesions were FDG avid with SUV ranging from 11 to 18.5 We reviewed the literature of the metastatic cases & found that metastases are more common in children as compared to adults, either at presentation or subsequently. Twenty-one cases of metastatic IMTs are reported in English literature. The most common sites of metastasis are lung and brain, followed by liver and bone. Although initially called as pseudotumor, IMT can rarely develop metastases making them ‘true’ tumors. When there is widespread metastatic disease, the prognosis is bad with limited treatment options including chemotherapy. Metastatic disease can involve various different sites and as seen in the index case and reported in literature, these lesions are FDG avid. Therefore PET-CT may serve as an important tool in follow up of these patients and also in assessing response to treatment.

Poster #: CR-072 Unique Imaging Characteristics of Primary Pediatric Lymphoma of Bone: A Case Series

Kathryn Milks, MD, Radiology, Wake Forest Baptist Medical Center, Winston Salem, NC, [email protected]; Lauren Golding, MD, Thomas McLean, Evelyn Anthony, MD

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Purpose or Case Report: Primary pediatric lymphoma of bone is exceedingly rare, and literature on the imaging characteristics of this disease is similarly sparse. At our institution between 2004 and 2013, six cases of pathology-proven, primary pediatric lymphoma of bone presented—four with diffuse large B-cell lymphoma and two with lymphoblastic lymphoma. Our experience with these cases revealed several imaging characteristics, which we believe unique to bone lymphoma in the pediatric population. In this presentation, we will review multimodality imaging (plain film, CT, MRI, and PET) of the patients in our series, highlighting features that may serve as distinguishers from other pediatric primary bone neoplasms, including Ewing sarcoma and osteosarcoma. Since various bone neoplasms have some overlapping features by pathology, correlation with imaging is an important diagnostic tool. Moreover, our experience may corroborate the pathologic literature that pediatric primary bone lymphoma may be a less aggressive form or a different entity altogether from the adult form. We hope to extend this series to a more extensive evaluation, as identification of imaging features that suggest a less aggressive neoplasm would have implications for treatment and imaging follow up. Poster #: CR-073 Extranodal Rosai-Dorfman Disease of the Pediatric Female External Genitalia

Adebunmi Adeyiga, Division of Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Anjum Bandarkar, MD Purpose or Case Report: Rosai-Dorfman disease (RDD) also referred to as sinus histiocytosis with massive lymphadenopathy (SHML), is a rare proliferative disorder of phagocytic histiocytes of unknown etiology. Systemic and cutaneous forms of the disease have been described, the systemic form occurring more commonly in the pediatric population and with a slight male predominance. Systemic RDD most typically presents as painless cervical lymphadenopathy with constitutional symptoms, including fever, night sweats, weight loss and anemia. Extranodal involvement by RDD has previously been reported in nearly half of all cases, including skin, head/neck and upper respiratory tract. Genitourinary involvement has rarely been described. We report a case of a 6 year old Spanish-speaking girl with a history of Trisomy 21 who presented with a large firm vulvar mass with greenish discoloration of the overlying skin. The mass had been slowly enlarging since the age of 1, and appeared to extend along the lower abdominal wall and inner thighs as well. Partial surgical excision was performed at the request of the patient’s parents, and biopsy results were consistent with extranodal RDD.

Poster #: CR-074 Primary mature teratoma presenting as an adrenal tumor in an Infant

Homeira Zahiri, MD, Creighton University, Omaha, NE, [email protected]; Johanna Scubert, Gopi Sirineni, Lisa Wheelock Purpose or Case Report: The aim of this study is to report a case of a rare and uncommon mature adrenal teratoma in an infant, mimicking a primary adrenal tumor. Extragondal teratoma is a rare entity. Diagnosis of adrenal teratomas relies on the findings from radiologic examinations. Early diagnosis and surgical resection are important for effective treatment. The success of the treatment determines the need for postoperative chemotherapy. Because the prognosis is currently difficult to predict, close, lifelong follow-up is recommended. The present study discusses the character of mature teratomas of the adrenal gland. We report one case of a primary mature

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teratoma presenting as an adrenal tumor in an infant and review the published data. A 14-day old female presented with jaundice. Abdominal ultrasound revealed a cystic mass in region of the right adrenal gland, which was interpreted as adrenal hemorrhage. Follow up abdominal ultrasound in 6 months showed interval enlargement of the mass and a new liver lesion, interpreted as neuroblastoma with liver metastasis. An abdominal MRI showed an adrenal mass with areas of hyperintense T1 signal and hyopintese T2 signal. It also showed contrast enhancement in solid components of the mass. Liver lesion showed hypointense T1 signal and hyperintense T2 signal and contrast enhancement. To better characterize liver lesion repeat abdominal MRI with contrast, using dynamic vascular imaging sequences was performed. The findings were suggestive of liver hemangioma. The infant underwent an adrenalectomy with total resection of the tumor, which proved on histologic examination to be a mature teratoma. The patient had an uneventful postoperative course and is free of recurrence after 11 months of follow-up.

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Methods & Materials: The presenting manifestations, radiographic characteristics providing pertinent ultrasound and MRI images, gross and microscopic pathologic images and review published data. Conclusions: Infantile detected suprarenal masses are likely to be neuroblastoma or adrenal hemorrhage, but may be rare benign lesions such as extralobar pulmonary sequestration, bronchogenic cyst, or renal dysplasia. Teratoma in the adrenal region is extremely rare. However, it needs to be included in the clinical and radiologic differential diagnosis of prenatally or infantile detected suprarenal masses. Poster #: CR-075 Anaplastic Lymphoma—an unusual presentation and a diagnostic dilemma

Siobhan Hoare, MB BCh BAO, Radiology, Childrens University Hospital, Dublin, Ireland, [email protected]; Gabrielle Colleran, Roisin Hayes, Eilish Twomey, John Gillick, Eoghan Laffan Purpose or Case Report: A 15 years old female presented with a 1 month history of right leg swelling and 1 week history of shortness of breath. She had no significant past medical or surgical history, was taking the oral contraceptive pill and had recently acquired a tattoo. Doppler Ultrasound of the right lower limb did not demonstrate a DVT. An abdomino-pelvic ultrasound demonstrated inflammation in the right iliac fossa and right hydronephrosis but the appendix was not seen. There was a broad differential diagnosis including acute appendicitis, inflammatory bowel disease, pelvic inflammatory disease, TB or lymphoma. Atypical mycobacteria, such as M.chelonae, was also considered because of the tattoo. MRI and CT imaging of the abdomen and pelvis also suggested an inflammatory process in the right iliac fossa involving the right iliopsoas muscle and pelvic sidewall lymph nodes. Mild hydronephrosis and hydroureter as far as the right iliac fossa were also seen. The appendix, terminal ileum and right colon were normal. The bones were normal. Gynaecological consult excluded pelvic inflammatory disease. Oncology and Infectious Diseases consults were also obtained. She was initially managed conservatively with oral antibiotics which were modified to cover for mycobacteria. Subsequent imaging failed to show any significant improvement and laparoscopic biopsy only showed inflammation. The girl presented again with worsening right iliac fossa pain. A repeat CT showed progression of the inflammation into the right psoas and worsening right hydronephrosis. The right ureter was stented. Repeat MRI and a barium follow-through were performed showing thickening of the cecal wall. Colonoscopic biopsy diagnosed anaplastic lymphoma. Anaplastic lymphoma is a rare lymphoma with non-specific, often inflammatory features. Diagnosis can be difficult and requires histopathological confirmation. This case demonstrates the diagnostic dilemma it presented, even though lymphoma was included in the differential diagnosis. Its presentation in the right iliac fossa and the history of a tattoo confounded factors. Radiologists should be alert to its diagnosis in any atypical and ongoing inflammatory process. Poster #: CR-076 An Introduction to PPB: A Case Report of Pleuropulmonary Blastoma

Miriam Emerson, M.D., University of Arizona College of Medicine-Department of Medical Imaging, Tucson, AZ, [email protected]; Gregory Woodhead, Dorothy Gilbertson, Sarah Desoky Purpose or Case Report: Pleuropulmonary blastoma (PPB) is an uncommon embryonic mesenchymal malignancy of the lung and pleura that

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typically presents in early childhood. There are three subtypes which include: type 1, being purely cystic, type 2, composed of cystic and solid tissues, and type 3, which is primarily solid. PPB can be clinically and radiographically mistaken for alternative entities such as other neoplasms, congenital anomalies, as well as complex pleural effusions. Here we present a case of PPB and discuss the clinical, radiologic, and pathologic findings. A 28 month-old girl with a history of empyema status-post video assisted thoracic surgery presented with worsening respiratory distress, fatigue, and cough. Family history was significant for a brother and a cousin who died at young ages from lung and brain cancers respectively. Physical exam revealed diminished left sided breath sounds, with clinical concern for recurring empyema. An initial chest radiograph demonstrated opacification of the left lung and suggestion of a mediastinal mass. Subsequent CT examination of the chest, abdomen, and pelvis confirmed a large heterogeneous, predominantly soft tissue density mass arising from the inferior left lung with possible cystic components including at least one punctate calcification. This mass resulted in superior displacement of the left lung, rightward shift of the mediastinum, and inferior displacement of the left diaphragm. Additionally, the mass was observed to abut, rather than invade the mediastinal structures. The patient was taken to surgery where the tumor was discovered to occupy the entire left pleural cavity. Nearly 5 h were required to resect the mass from the chest wall and diaphragm. Pathologic examination established the diagnosis of PPB, type 2. The patient did well clinically following surgery. She has since completed multiple cycles of chemotherapy and continues to be followed with serial imaging. Several similarities exist between our patient and those described in the literature. For instance, PPB is often diagnosed in those with a strong family history of childhood cancers. Additionally, PPB can present radiographically as an opacified hemithorax with mediastinal shift, as in our patient. Although rare, this case highlights the importance of timely diagnosis. Early identification through imaging is warranted due to PPB’s malignant nature, the need for wide surgical excision, and post-excisional monitoring.

Poster #: CR-077 MRI abdomen/pelvis in pediatrics: Is DWI part of your routine protocol?

Meryle Eklund, MD, Children’s Healthcare of Atlanta/Emory University, Atlanta, GA, [email protected]; Adina Alazraki, Stephen Simoneaux Purpose or Case Report: The use of MRI of the abdomen and pelvis has steadily increased in the pediatric patient population in recent years. This imaging modality offers exquisite soft tissue contrast without exposure to ionizing radiation and with useful applications in evaluation and diagnosis of a wide variety of pathology. We aimed to evaluate the utility of incorporating diffusion weighted imaging (DWI) into routine MRI abdomen and pelvis protocols with respect to accuracy in detection and diagnosis of pathologic conditions as well as to efficiency in scan time. Methods & Materials: After IRB approval was obtained, we performed a restrospective analysis of all MRI examinations of the abdomen and pelvis performed at our institution between 2006 and 2013 using a database query for “restricted diffusion” and “abnormal diffusion.” Study reports were cross-checked with clinical data and pathologic results to evaluate for accuracy in diagnosis. Results: In 37 cases, findings of abnormal diffusion were helpful to arrive at the correct diagnosis in a wide array of pathologic conditions. Scan times for the diffusion sequences averaged 2 to 3 min each for the abdomen and pelvis. Illustrative examples include diagnoses of Bartonella hepatic microabscesses, transplant kidney pyelonephritis, acute pancreatitis, Crohn’s disease, peritoneal and perineal abscesses,

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hepatoblastoma metastasis, metastatic paraganglioma, desmoid tumor, neuroblastoma, and gastrointestinal stromal tumor recurrence. Conclusions: We present a case series of interesting examples which illustrate the utility of DWI in the identification and diagnosis of a variety of infectious, inflammatory, and neoplastic conditions common to the pediatric population. Based on our experience, we would recommend the addition of these relatively short sequences to the routine body MRI protocol in order to add a level of confidence in evaluation of these conditions. Poster #: CR-078 The Great Imitator: A Case Report of Congenital Syphilis

Miriam Emerson, M.D., University of Arizona College of MedicineDepartment of Medical Imaging, Tucson, AZ, [email protected]; Dorothy Gilbertson, Sarah Desoky Purpose or Case Report: Congenital syphilis presents a challenging diagnostic dilemma owing to involvement of multiple organ systems and a clinical presentation that often overlaps with multiple diagnoses including osteomyelitis, leukemia, and child abuse, among others. We present a case of congential syphilis diagnosed at our institution. A 54-day-old, Hispanic, otherwise healthy male, native to Arizona, presented to the emergency department for evaluation for multiple complaints including increased fussiness, recurrent emesis, and loss of spontaneous movement. The initial clinical suspicion and subsequent workup was for nonaccidental trauma. Physical examination revealed a papular rash on the palmar aspects of the bilateral hands and feet with decreased upper extremity tone. A bone survey revealed multiple metaphyseal abnormalities including demineralization and periostitis of bilateral upper and lower extremities with imaging findings suspicious for congenital syphilis. Further imaging was pursued including bilateral upper and lower extremity MRIs which revealed inflammation of the bone marrow, musculature, and soft tissues with distal humeral and distal femoral metaphyseal enhancement. Serologic workup revealed that the patient was anemic which required packed red blood cells transfusion. Transaminases were elevated, although a hepatitis panel was negative. CSF fluid from a lumbar puncture was also found to be VDRL positive, which subsequently corresponded to a positive fluorescent treponemal antibody with a titer of 1:512. The combination of clinical and radiologic findings together allowed for a diagnosis of congenital syphilis. Treatment with Penicillin G was initiated and the patient clinically improved during his hospitalization and was discharged to follow up with Infectious Disease. Despite medical advances, congenital syphilis continues to plaque our society. According to the most recent data from 2011 from Center for Disease Control and Prevention (CDC), 360 cases per 100,000 population were reported, stemming from Treponema pallidum infection in pregnant women with transplacental transmission to the fetus. Unfortunately, a disproportionate number of affected patients originate from Southern states, as was in this case. Radiologists play a valuable and even an initial role in the detection of congenital syphilis. Awareness of its prevalence, associated risk factors, as well as familiarity with key associated radiographic findings will aid diagnosis.

Poster #: CR-079 Traumatic Handle Bar Injury with Aortic Disruption

Benjamin Addicott, MS MD, Diagnostic Radiology, Oregon Health & Science University, Portland, OR, [email protected]; Kelli Schmitz

Purpose or Case Report: Blunt trauma from bicycle handlebar is not an uncommon complaint in pediatric emergency rooms. The well described mechanism of injury and knowledge of the more common complications provides for an appropriately high index of suspicion for pancreatic, liver, spleen and bowel injuries. Injuries to the great vessels, however, are considerably less common, demonstrated by a paucity of case reports in the literature. We present a rare case along with clinical, radiologic and intraoperative correlations of a 12 year old boy who suffered a contained perforation of the abdominal aorta secondary to a handlebar injury. Our patient is an otherwise healthy 12 year old male who presented to the Pediatric Emergency Department approximately 2 h after sustaining a blunt handlebar injury to the umbilicus while attempting a jump on his bike. Physical exam was significant for an umbilical abrasion without laceration or hematoma and mild tenderness. Vital signs were stable and within normal limits. The patient only complained of abdominal/pelvic tenderness when ambulating. Contrast enhanced CT was remarkable for a pseudoaneurysm of the abdominal aorta at the level of the bifurcation and an associated retroperitoneal hematoma. No active contrast extravasation was seen. The patient was taken urgently to the operating room by vascular surgery. Intraoperatively, a contained rupture of posterior wall of the aorta with dissection into the proximal right common iliac artery with associated retroperitoneal hematoma were noted. These were primarily repaired and the patient experienced an uncomplicated post operative course with discharge the following day. Great vessel disruption as a result of traumatic blunt abdominal injury, specifically handlebar injuries in the pediatric population represents a rare, but potentially life threatening complication. This type of injury should be kept in mind in the appropriate setting and a high degree of clinical suspicion warrants diagnostic workup as contained aortic rupture may not be appreciated by initial physical exam and laboratory tests. Poster #: CR-080 Imaging of Hepatopulmonary syndome, a case report

Soudabeh Fazeli Dehkordy, Maryam Ghadimi Mahani, M.D., C.S. Mott Children’s Hospital, Department of Radiology, Ann Arbor, MI, [email protected]; Jimmy Lu, Frank DiPaola, Morgan Govindan, Thomas Shanely Purpose or Case Report: The purpose of this case report is to review the imaging features of the hepatopuolmonary syndrome and relevant literature. An 8-month-old boy with a past medical history of heterotaxy, biliary atresia status post Kasai operation, dextrocardia, and malrotation status post Ladd’s surgery presented with fever and hypoxia. He was seen for a schedule clinic visit where he was reported to be febrile, tachypnic and cyanotic in his hands and feet so he was sent to emergency department for further evaluation. Due to respiratory distress he was admitted to the general pediatric ward and because of progressive hypoxia was subsequently admitted to the intensive care unit. He was evaluated by pediatric pulmonary and cardiology services and the reason of his hypoxia remained unclear. He had continuing severe hypoxia requiring supplemental oxygen. Radiology department was consulted for further imaging work up plan. A computed tomography (CT) angiogram with added high resolution reconstruction of the lung parenchyma was suggested for further evaluation of the pulmonary vasculature and lung parenchyma. The CT images revealed diffuse dilation of the peripheral pulmonary vasculatures bilaterally. Lung parenchyma was unremarkable except for a small area of atelectasis. Hepatopulmonary syndrome was suggested among the differential diagnoses. Patient underwent agitated saline transthoracic contrast echocardiography which revealed late filling of the right-sided atrium through pulmonary veins consistent with substantial pulmonary arterio-venous malformations. Diagnosis of the hepatopulmonary syndrome was confirmed in the setting of biliary atresia and liver disease, though his

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synthetic function and portal venous pressures were assessed to be within normative values. Patient was listed as a liver transplant candidate for treatment of his disease. Conclusions: Hepatopulmonary syndrome is one of the thoracic manifestations of advanced liver disease with or without portal hypertension. Familiarity with the imaging feature of this abnormality will help radiologists to diagnose this abnormality and facilitate management of the patient.

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Purpose or Case Report: 1. Assess the role of iterative reconstruction techniques (IRTs) for dose reduction in sub-milli Sievert pediatric CT examinations. 2. Evaluate and illustrate the effect of different IRT from same vendor with different generations, and across different scan manufacturers.

Poster #: CR-081 Pulmonary artery sling with type IIa tracheobronchial anomaly and imperforate anus

Daniel Rosenbaum, Radiology, NewYork-Presbyterian Hospital, New York, NY, [email protected]; Paula Brill, Pooja Renjen, MD, Arzu Kovanlikaya, M.D. Purpose or Case Report: A 33 week-old premature boy with an imperforate anus underwent echocardiography as part of a workup for VACTERL association. On echocardiography, the left pulmonary artery was not seen and the possibility of a left pulmonary artery sling (LPAS) was raised. The patient did not have any respiratory distress or stridor. A contrast-enhanced CT scan of the chest was obtained to evaluate for LPAS. CT with volumerendered reconstruction of the airways showed LPAS with associated tracheobronchial abnormalities. Specifically, the right upper lobe bronchus was arising from the trachea at the level of T2 and a left intermediate bronchus continued inferiorly within the mediastinum to the level of T6, giving off a bridging bronchus to the right lower lobe, as well as left upper and lower lobe bronchi (pseudocarina). No tracheobronchial stenosis was present. A left pulmonary artery arising from the right and passing posterior to the left intermediate bronchus, superior to the bridging bronchus, and anterior to the esophagus was present. These findings were consistent with LPAS type IIa according to the Wells classification. The patient also had bilateral Grade III vesicoureteral reflux and an imperforate anus with a rectourethral fistula. LPAS with tracheobronchial abnormalities is rare and CT with threedimensional volume rendering plays an important role in evaluating complex tracheobronchial anatomy. The case presented here is atypical when compared to previous reported cases of LPAS type IIa for several features. Typically, LPAS type IIa demonstrates a carina at or below the level of T4-5, short or long segment tracheobronchial stenosis, and clinical presentation with dyspnea or stridor. In contrast, our patient demonstrated a high right upper lobe bronchus arising at the level of T2, no evidence of tracheobronchial stenosis, and absence of respiratory symptoms. LPAS is also rarely associated with imperforate anus, having been previously reported in approximately 14% of type II cases. Given the rarity of LPAS, radiologists should be aware of its association with tracheobronchial abnormalities in order to facilitate prompt diagnosis on CT and assist with potential operative planning. Poster #: CR-082

Withdrawn Poster #: EDU-001 How low can we go? Iterative Reconstruction Techniques to achieve pediatric CT radiation dose less than 1 mSv

Ranish Khawaja, MD, Massachusetts General Hospital, Boston, MA, [email protected]; Michael Gee, Ruth Lim, Sjirk Westra, Mannudeep K Kalra, Sarabjeet Singh

Methods & Materials: 1. Basic fundamentals of various types of iterative reconstruction algorithms. 2. Review currently published pediatric data on dose reduction with IR 3. Illustrate clinical examples with several IRTs showing image noise reduction and dose reduction potential including, — Adaptive Statistical Iterative Reconstruction (ASiR), and ModelBased Iterative Reconstruction (MBIR, VEO) — Iterative Reconstruction in Image Space (IRIS), Sinogram-Affirmed Iterative Reconstruction (SAFIRE), and IRIDIUM — iDose and knowledge-based Iterative Iodel Reconstruction (IMR), — Adaptive Iterative Reconstruction (AIDR 3D) — Image based vendor neutral IR algorithm (SafeCT). 4. Practical tips and guidelines on selecting dose levels with scan parameters and various settings of IRTs. 5. Applications and limitations of IRTs with examples of head, chest, and abdominal CT examinations. Conclusions: Although various IRTs are currently in use for pediatric CT, the image quality, noise and dose reduction potential varies across techniques, and scanners from different vendors. This exhibit will help learn the audience about pediatric IR techniques with their limitations across different vendors with examples at sub-milli Sievert radiation dose.

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S176 Poster #: EDU-002 Auto mAs and Auto kVp: Improving Child Size Parameters for Dose Reduction

Saurabh Agarwal, MD, Mallinckrodt Institute of Radiology, Washington University, Saint Louis, MO, [email protected]; Marilyn Siegel, MD, Juan Carlos Ramirez-Giraldo, David Bradley Purpose or Case Report: Given the widespread use of CT, dose reduction efforts require knowledge of CT scanning parameters and their impact on radiation dose and image quality. We review the effects of automated tube current modulation and automated tube potential selection on radiation dose and image quality in pediatric CT. Methods & Materials: Because of large size variations in children, it is important to stratify technical settings for pediatric body CT. Although approaches for optimizing tube current are available based on weight and diameter, automated technologies have the potential to enhance further radiation dose reduction. This poster will address automated technologies to achieve dose reduction and maintain image quality. The following areas will be addressed: Discuss basic principles of dose reduction. Discuss technical details and principles underlying tube current modulation and automated tube potential selection. Discuss dose reduction expected from each technology alone and maximum radiation dose savings expected in combination. Results: Tube current modulation is one of the most common methods for dose reduction and lowers dose by adapting milliamperage (mAs) to the area of interest. Recently, an automated kilovoltage (kVp) selection technology that reduces radiation exposure while optimizing the contrast-to-noise ratio has become available. This tool selects a single kVp based on the patient’s attenuation on the scout radiograph and diagnostic task and simultaneously optimizes mAs. Automated kVp technology also allows 70 kVp imaging. Neither technology needs to take into account patient size. Studies have shown tube current modulation can reduce dose by approximately 30–50% with acceptable levels of image noise. The addition of automated tube potential can reduce dose additionally by up to 60%. Conclusions: Understanding primary scanning factors, particularly tube current and tube potential, can allow radiologists to obtain necessary diagnostic information while reducing radiation doses to as low as reasonably achievable. Tube current modulation and tube potential selection in conjunction can further reduce radiation dose in pediatric CT. Disclosure: Dr. Ramirez-Giraldo has indicated a relationship with Siemens Healthcare as an Employee (Salary). Dr. Siegel has indicated a relationship with Siemens Healthcare as a Speaker (Travel reimbursement). Poster #: EDU-003 Radioisotope Imaging: Strategies to Decrease Radiation Exposure in Pediatric Patients

Brian Magee, DO, Vamsi Kunam, Radiology, SUNY Downstate Medical Center, Brooklyn, NY, [email protected]; John Amodio, Rachelle Goldfisher, MD Purpose or Case Report: Radioisotope imaging in infants and children can provide useful diagnostic information which often is not possible with conventional anatomical imaging studies alone. The administration of radiopharmaceuticals, however, does expose patients to potentially harmful radiation. In order to minimize risk, the as low as reasonably

achievable (ALARA) concept should be employed when administering radiopharmaceuticals. Pediatric patients require special consideration when conducting nuclear studies. Given the smaller size and weight of children, standard adult doses of radiotracer most often are greater than necessary. Reduction of administered dose will decrease exposure, however, care must be taken to ensure high quality images.In 2010, the North American consensus guidelines for pediatric radiopharmaceutical administration were released. These guidelines provide guidance for the calculation of pediatric patient dose. Our purpose is to review these guidelines and imaging strategies which may be undertaken when performing pediatric nuclear examinations to decrease radiation exposure while maintaining high image quality. Methods & Materials: The 2010 North American consensus guidelines for pediatric radiopharmaceutical administration will be reviewed. Recommended minimum and maximum doses of commonly utilized tracers will be presented. In addition, equipment and software considerations which may used to decrease required minimum dose will be addressed. The format of this presentation will be an educational exhibit. Results: Pediatric patient radiation exposure can be decreased through the use of current weight-based radioisotope recommendations and other readily employable imaging strategies in an effort to prevent later radiation induced carcinogenesis. Conclusions: Adoption of recommended radionuclide doses can aid in limiting radiation exposure in children. Additional measures performed during image acquisition, display and analysis as well as optimization of imaging equipment can be implemented to achieve ALARA radiation exposure.

Poster #: EDU-004 Multi-modality Imaging of Vascular Anomalies in Alagille Syndrome in Children: A Pictorial Review

Rama Ayyala, M.D., Boston Children’s Hospital, Boston, MA, [email protected]; Sanjay Prabhu, Laureen Sena Purpose or Case Report: Alagille Syndrome is a genetic disorder associated with microdeletion of the JAG1 gene, which affects multiple organs such as the liver, heart and kidneys and the cerebral and cardiovascular system. The purpose of this exhibit is to depict the imaging findings of vascular anomalies in pediatric patients with Alagille syndrome. Methods & Materials: A retrospective review of imaging studies performed in 17 patients with diagnosis of Alagille Syndrome (age range 9 months—25 years) was conducted. Multimodality imaging approach involving computed tomography (CT), magnetic resonance imaging (MRI), and angiography was implemented to characterize the imaging features of the various vascular anomalies associated with Alagille Syndrome Results: Various vascular anomalies of the cerebral and cardiovascular system, and imaging characteristics are described. Cerebral vascular anomalies include Moya-Moya and intracranial cerebral aneurysms. Cardiovascular anomalies include pulmonary artery stenosis, stenosis of the abdominal aorta and visceral branches, renal artery stenosis, as well as a case of early atherosclerotic calcification and stenosis of the infrarenal aorta. Conclusions: Vascular anomalies in Alagille syndrome can be serious and potentially fatal. This review provides key imaging findings of the typical associated vascular anomalies using a multimodality approach. Evaluation and early diagnosis of these anomalies on imaging studies performed in these patients is critical for prevention of potential complications.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Poster #: EDU-005 Pediatric cardiac devices: Review of imaging features and complications

Asmaa Aamir, Pediatric Radiology, Oregon Health Science University, Portland, OR, [email protected]; Yama Kharoti, Laurie Armsby, Kelli Schmitz, Petra Vajtai, MD, Dianna Bardo, MD

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5. Imaging of both arterial and venous anatomy after a single contrast bolus 6. Can perform multiposition exams without administration of a second contrast bolus 7. Exquisite opacification of veins to evaluate venous malformations, venous thrombosis, and normal venous anatomy for surgical planning. Conclusions: MR angiography with blood pool contrast agents has opened new horizons in non-invasive vascular imaging.

Purpose or Case Report: The aim of this exhibit is to familiarize the radiologist with the radiographic appearance of various devices used in the treatment of congenital heart disease and with the support equipment used in heart failure and arrhythmias. Chest radiograph is often the first line imaging modality in the postoperative period and recognizing appropriate placement of these devices, as well as potential complications, is imperative for accurate interpretation. Methods & Materials: We reviewed chest radiographs of children in the NICU and PICU at our tertiary care center and selected images of the common devices seen after cardiac interventional procedures and cardiac surgery. Correlative CT and MR images were also reviewed and selected for the presentation. Results: We will describe the radiologic appearance and expected correct positioning of devices used in patients with heart failure (extracorporeal membrane oxygenation system and ventricular assist devices); abnormal heart rhythm (pacemakers and implantable cardioverter defibrillator); transcatheter procedures for congenital heart disease (including devices for ASD, VSD and PDA occlusion, embolization coils, endovascular stents, Medtronic Melody Pulmonary Valve); and cardiac surgery (prosthetic valves and annuloplasty rings). Conclusions: After viewing this presentation, the reviewer should be familiar with the expected position of common cardiac devices seen in the pediatric ICU setting after cardiac interventional or surgical procedures. This knowledge would aid in early detection and better management of complications. Disclosure: Dr. Bardo has indicated a relationship with Philips Healthcare as a Consultant and Speaker (Honoraria); Thieme Publishing, Author (Royalties

Poster #: EDU-007

Poster #: EDU-006

Poster #: EDU-009

Perspectives in state-of-the-art vascular MR imaging with blood pool contrast agent

Congenital Brain Tumours—Antenatal and Postnatal Imaging Features

Shannon Farmakis, MD, Mallinckrodt Institute of Radiology at Washington University School of Medicine, St. Louis, MO, [email protected]; Constantine Raptis, Geetika Khanna

Siobhan Hoare, MB BCh BAO, Temple Street Childrens University Hospital, Dublin, Ireland, [email protected]; Stephanie Ryan, Eilish Twomey, Eoghan Laffan, Ian Robinson, Veronica Donoghue

Purpose or Case Report: 1. Pictorial review of indications where blood pool contrast agent enhanced MRI will improve evaluation of anatomy and pathology in children 2. Facilitate understanding of the kinetics and safety profile of Gadofosveset trisodium 3. Review changes in MR angiographic techniques using Gadofosveset trisodium as compared to MR angiography with extracellular agents Methods & Materials: We present a pictorial essay of MR angiographic exams to illustrate techniques and advantages of MRA using a blood pool contrast agent. A spectrum of pediatric vascular pathology will be used to illustrate arterial and venous applications. Results: Prolonged intravascular phase markedly increases the acquisition window resulting in the following advantages: 1. Potential for the acquisition of high spatial resolution images 2. Allows for the acquisition of navigated sequences with free breathing 3. Repeat imaging if patient moves, without need for second contrast bolus 4. Time resolved angiography for vascular malformations

Purpose or Case Report: To illustrate the MR imaging characteristics of the six major types of congenital brain tumours seen in the paediatric population and where available demonstrate their features on antenatal MR. Methods & Materials: Congenital brain tumors, defined as those presenting within the first 60 days of life, are rare, representing only about 0.5%–1.9% of all childhood brain tumors. In addition to relative frequency there are other striking differences between fetal and pediatric CNS tumors. These include histologic characteristics, anatomic location and prognosis. Teratoma is the most common fetal brain tumor, accounting for almost half of all reported cases. They are followed in frequency by astrocytomas, lipomas, choroid plexus papillomas, craniopharyngiomas and primitive neuroectodermal tumors. The majority of fetal CNS tumors are supratentorial, compared with pediatric tumors which are more commonly infratentorial. The prognosis for those with congenital brain tumors is significantly worse than for children who present with brain tumors presenting later in life, the exception being lipomas and choroid plexus papillomas.

Withdrawn Poster #: EDU-008 Cardiac CT with 3D Segmentation of Congenital Aortic Arch Anomalies: A Pictorial Review with Surgical Correlation

Kristin Constantino, M.D., Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Patricia Cornejo, M.D, Mittun Patel, MD, Scott Jorgensen, MD, Richard Southard, M.D. Purpose or Case Report: To demonstrate the utility of cardiac CT with 3D segmentation in the delineation of congenital aortic arch anomalies and relationships with surrounding structures. Methods & Materials: Representative pediatric cases of different subtypes of aortic arch anomalies demonstrated by CT and confirmed at surgery were selected. 3D segmentation using specialized software was applied in each case. Results: Cardiac CT with 3D segmentation aids in the delineation of congenital aortic arch anomalies and their relationship with surrounding structures, such as the airway. 3D segmentation facilitates the understanding of complex anatomy and clinical implications. Conclusions: Anomalies of the aortic arch are not uncommon in the pediatric population. Cardiac CT with 3D segmentation can further define the complex anatomy and serve as an additional aid in the understanding of aortic arch anomalies.

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Results: The imaging features of congenital brain tumors overlap considerably. Differentiation of individual tumor types is often not possible with imaging. The presence of a large intracranial mass frequently causes hydrocephalus, disrupts normal neural development and indicates a grave outcome, regardless of histological subtype. If a fetal brain tumor remains undiagnosed before the onset of labor there are risks to the mother and fetus. Thus the value of antenatal MR diagnosing these lesions is to allow appropriate planning of both prenatal and postnatal care. Conclusions: This presentation will aim to create awareness of the major congenital brain tumors, demonstrate certain imaging features that can aid the radiologist and neurosurgeon to narrow the differential diagnosis and illustrate how these tumors may appear on antenatal imaging. Poster #: EDU-010 Prenatal Imaging of the Gastrointestinal Tract with Postnatal Imaging Correlation

Anna Blask, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Kimberly Fagen, MD Purpose or Case Report: Prenatal detection of a wide variety of anomalies and masses of the gastrointestinal tract is now possible. Prenatal imaging with ultrasonography and in selected cases MRI provides invaluable information to the referring obstetrician, the maternal fetal medicine specialist, the neonatologist and pediatrician who will care for the child after birth, the surgeons and pediatric specialists that will repair or manage a prenatally detected anomaly and of course to the parents, allowing them to prepare psychologically and financially for the specific interventions that may be needed for their child. Additional screening for associated anomalies can take place, route of delivery decided and arrangements for delivery in an appropriate setting can be made. Prenatal detection also allows for consideration for pregnancy termination. This poster will give a broad overview of anomalies of the gastrointestinal tract that can be detected prenatally and their imaging appearance postnatally. Methods & Materials: The normal fetal gastrointestinal tract and the complete gamut of anomalies of the pre and postnatal gastrointestinal tract will be demonstrated on US and MRI with images and descriptions provided. Each prenatal image will include a postnatal image of the same infant. The topics that will be demonstrated include upper and lower bowel obstruction, malrotation, cystic fibrosis, liver mass, abdominal cystic masses, and abdominal wall defects. Results: Esophageal, duodenal, and jejunal atresia, meconium peritonitis and pseudocyst, imperforate anus and malrotation are demonstrated. Liver lesions including hemangioma, mesenchmal hamartoma and hepatoblastoma are highlighted. Enteric duplication cyst, mesenteric and omental cysts are among the cystic abdominal masses. Imaging features of omphalocele and gastroschisis and postnatal complilcations are described. Conclusions: Prenatal US and MRI contribute to the detection and management of pathology of the gastrointestinal system in the fetus, facilitating prompt treatment postnatally and adding to our understanding of these diseases in the neonate. Poster #: EDU-011 Imaging the Prenatal Spine: Dysraphism and Beyond

Pamela Deaver, MD, Brigham & Women’s Hospital/Harvard Medical School/Boston Children’s Hospital, Boston, MA, [email protected]; Judy Estroff, M.D.

Purpose or Case Report: Prenatal evaluation of the fetal spine supplements screening blood tests in the evaluation of neural tube defects. While some anomalies along the spina bifida spectrum result in open neural tube defects and therefore may be detected with elevated maternal serum alpha fetoprotein, other skin-covered spinal anomalies may only be detected prenatally by the imaging team. Our purpose is to review examples demonstrating the prenatal imaging findings of a spectrum of spinal anomalies as well as their postnatal appearance, surgical treatment, and prognosis. Methods & Materials: Approximately 5 years of cases of spinal anomalies from Boston Children’s Hospital Advanced Fetal Care Center were reviewed. Representative examples with prenatal ultrasound and/or MRI were selected to illustrate the spectrum of prenatal findings in patients with open and closed neural tube defects. Post-natal imaging was available for some patients, which provided confirmation of the suspected prenatal findings in most cases. Results: Spinal anomalies, including both open and closed neural tube defects, are increasingly important to diagnose prenatally, as the therapeutic options for these patients have expanded in the recent past. Recognizing the radiological appearance of these defects, particularly in cases with normal maternal serum alpha fetoprotein, is critical for providing important diagnostic, therapeutic, and prognostic information for expectant families and clinical colleagues. Conclusions: Understanding the spectrum of spinal anomalies, especially those which may be detected only by prenatal imaging, affords fetal imagers the opportunity play a crucial role in the multidisciplinary fetal diagnosis team and positively impact the postnatal treatment plan.

Poster #: EDU-012 The Dandy-Walker Spectrum: Fetal MR findings with postnatal correlation

Usha Nagaraj, MD, Children’s National Medical Center, Washington, DC, [email protected]; Matthew Whitehead, MD, Gilbert Vezina, Dorothy Bulas, MD Purpose or Case Report: The Dandy-Walker Spectrum comprises a group of disorders of the posterior cranial fossa that have generated considerable confusion and controversy. One theory suggests that Dandy-Walker malformation, Blake’s pouch cyst, and mega cisterna magna are a single spectrum of developmental abnormalities of the roof of the rhombencephalic vesicle. We aim to describe the imaging characteristics of the disorders comprising the Dandy-Walker spectrum. Corresponding embryologic development as well as correlation with fetal and postnatal imaging is also reviewed. Methods & Materials: We present a variety of cases of Dandy-Walker malformation, vermian hypoplasia, Blake’s pouch cyst, and mega cisterna magna that we have encountered at a large children’s hospital, including postnatal CT and MR correlation (when available), and use these cases to illustrate the imaging findings seen in the Dandy-Walker disease spectrum. Differential considerations, including arachnoid cyst, are also reviewed. Results: In most cases, a careful review of the anatomical features of the posterior fossa allows for proper characterization and naming of the anomaly. Imaging findings can be correlated with corresponding abnormalities in embryologic development. Conclusions: Dandy-Walker malformation, vermian hypoplasia, Blake’s pouch cyst and mega cisterna magna can be viewed as a single spectrum of developmental abnormalities. While these entities have well-described characteristics on post-natal imaging, most of the characteristics can also be demonstrated on fetal MRI as well. Disclosure: Dr. Bulas has indicated a relationship with GE as a Non-paid Consultant; Philips, Non-paid Consultant.

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from 2008 to 2013. Cases of congenital genitourinary anomalies were selected, based on incidence of the diagnosis at our institution and on the availability of postnatal imaging. Postnatal outcome and postnatal imaging were obtained by accessing the electronic medical record and PACS system. Results: The most common genitourinary anomalies in our database were renal agenesis, renal duplication, renal ectopia, hydronephrosis, ureteropelvic obstruction, and multicystic dysplastic kidney. Review of postnatal imaging findings for the selected diagnoses demonstrated strong correlation with the fetal MRI findings. A pictorial review of the diagnoses will be illustrated with fetal MR images and postnatal images. The characteristic MR imaging features and what the clinicians need to know will be reviewed. Conclusions: Fetal MRI is an invaluable adjunct imaging modality in diagnostic dilemmas when US examination is inconclusive. Excellent correlation with postnatal imaging findings supports the accuracy and utility of fetal MRI in prenatal diagnosis of congenital genitourinary anomalies. A thorough understanding of the common diagnoses encountered at fetal MRI will assist clinicians in optimizing patient counseling, management of the pregnancy and delivery, and postnatal treatment planning.

Poster #: EDU-014 Common Thoracic Fetal MRI Diagnoses with Postnatal Imaging Correlation: What Clinicians Need to Know

Danielle Chan, MD, Department of Radiology, Indiana University School of Medicine, Indianapolis, IN; Nucharin Supakul, Lisa Delaney

Poster #: EDU-013 Common Genitourinary Fetal MRI Diagnoses with Postnatal Imaging Correlation: What Clinicians Need to Know

Danielle Chan, MD, Department of Radiology, Indiana University School of Medicine, Indianapolis, IN; Nucharin Supakul, Lisa Delaney Purpose or Case Report: Fetal magnetic resonance imaging (MRI) is a useful imaging technique for diagnosing fetal abnormalities when ultrasound (US) examination is limited or equivocal. This pictorial review will illustrate and discuss several common genitourinary abnormalities encountered at fetal MRI. Key imaging findings will be documented, emphasizing what clinicians need to know. Correlation with postnatal imaging will be provided. Methods & Materials: Using our institution’s radiology database, we performed a retrospective review of all 2nd and 3rd trimester fetal MRIs

Purpose or Case Report: Fetal magnetic resonance imaging (MRI) is a useful imaging technique for diagnosing fetal abnormalities when ultrasound (US) examination is limited or equivocal. This pictorial review will illustrate and discuss several of the most common thoracic abnormalities encountered at fetal MRI. Key imaging findings will be documented, emphasizing what clinicians need to know. Correlation with postnatal imaging will be provided. Methods & Materials: Using our institution’s radiology database, we performed a retrospective review of all 2nd and 3rd trimester fetal MRIs from 2008 to 2013. Cases of congenital thoracic anomalies were selected, based on incidence of the diagnosis at our institution and on the availability of postnatal imaging. Postnatal outcome and postnatal imaging were obtained by accessing the electronic medical record and PACS system. Results: The most common congenital thoracic anomalies in our database were congenital diaphragmatic hernia, congenital pulmonary airway malformation, pulmonary sequestration, bronchogenic cyst, pulmonary hypoplasia, and esophageal atresia with tracheoesophageal fistula. Review of postnatal imaging findings for the selected diagnoses demonstrated strong correlation with the fetal MRI findings. A pictorial review of the diagnoses will be illustrated with fetal MR images and postnatal images. The characteristic MR imaging features and what the clinicians need to know will be reviewed. Conclusions: Fetal MRI is an invaluable adjunct imaging modality in diagnostic dilemmas when US examination is inconclusive. Excellent correlation with postnatal imaging findings supports the accuracy and utility of fetal MRI in prenatal diagnosis of congenital thoracic anomalies. A thorough understanding of the common diagnoses encountered at fetal MRI will assist clinicians in optimizing patient counseling, management of the pregnancy and delivery, and postnatal treatment planning.

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S180 Poster #: EDU-015 3 T Fetal MRI: Review of Safety and Benefits

Poster #: EDU-016

Withdrawn

Mary Tenenbaum, Boston Children’s Hospital, Boston, MA, [email protected]; Borjan Gagoski, Edward Yang, Carol Barnewolt, Ellen Grant, Judy Estroff, M.D.

Poster #: EDU-017

Purpose or Case Report: Fetal MRI has become prevalent both for further evaluation of anomalies detected by ultrasound as well as for screening fetuses at risk for brain abnormalities due to family history. Post-natally, imaging at 3 T has become preferable due to improved signal to noise ratio compared to 1.5 T. Despite the fact that these benefits also hold for fetal imaging, safety concerns have impeded routine use of fetal MRI at 3 T. Methods & Materials: Although no specific FDA safety criteria for fetal imaging exist, there are FDA guidelines for determining MRI risks. Factors addressed are main static magnetic field (MSMF), specific absorption rate (SAR), gradient fields rate of change (GF), and sound pressure level (SPL). ACR guidelines for use of MRI in fetal imaging recognize the safety of 1.5 T imaging. Risk in each of these four areas is assessed through review of the literature.

Anh-vu Ngo, MD, Seattle Children’s Hospital, Seattle, WA, [email protected]; Arta-Luana Stanescu, Stephen Done

Results: MSMF: There is no verification of adverse effects on biologic systems due to magnetic fields at clinically used field strengths. FDA guidelines classify devices as a non-significant risk at 4 T or less. SAR: Sequence parameters can be adjusted such that there is no difference in SAR at 1.5 T and 3 T. Experimental models and electromagnetic simulations on virtual models of pregnant women with fetuses at different gestational age have shown no evidence of risks to the fetus or the mother as long as the FDA approved global body SAR limit of 2 W/kg is not exceeded. GF: FDA guidelines classify any GF sufficient to produce severe discomfort or peripheral nerve stimulation (PNS) as a safety risk. The safety software of the MRI scanner is able to detect and prohibit sequence parameters likely to induce PNS. Further, PNS effects are minimal at the isocenter of the gradient fields, where fetal imaging takes place. Thus, PNS adverse effects are unlikely. SPL: Studies on fetuses exposed to MRI at 0.5 T-1.5 T have shown no increased risk for adverse noise-related outcomes. As parameters related to current switching influence noise more than field strength, it is reasonable to extrapolate these results to 3 T. Similar precautions can be used to reduce noise at both 1.5 T and 3 T. Example 1.5 T and 3 T images will be shown to demonstrate differences in image quality. Conclusions: There is no evidence that 3 T fetal imaging poses significant increase in risk relative to imaging at 1.5 T if standard safety precautions are strictly followed. 3 T offers benefits in improved image quality with the potential to improve diagnostic accuracy in the prenatal period.

Pictorial Review of Proper and Improper Enteric Tube Placement

Purpose or Case Report: 1. Review the proximal GI tract anatomy in relation to the surrounding organs. 2. Review the common indications, various methods of placement and position confirmation of enteric tubes. 3. Review the common proper and improper locations of various enteric tubes. 4. Introduce a new concept of the triangle tube sign for recognition of a kinked enteric tube. 5. Describe other common diagnostic pitfalls in evaluating enteric tubes. Methods & Materials: CONTENT ORGANIZATION —Pertinent proximal GI tract organ anatomy. — Common indications and approaches for nasogastric, nasoduodenal, percutaneous gastric, and percutaneous gastrojejunal tubes. — Various confirmation techniques. Briefly discuss single frontal view versus multiple views. — Expected proper positions of the various tubes on radiographs. Common improper positions. — The triangle tube sign of a kinked enteric tube. — Common pitfalls in inaccurate descriptions of tube positioning. — Sample cases Conclusions: Major teaching points of this exhibit are: 1. Review of anatomy of the proximal GI tract. 2. Describe the proper and improper positions of the various enteric tubes, including common pitfalls in inaccurate descriptions of enteric tube positions. 3. Introduce the triangle tube sign as a reliable way to recognize a kinked enteric tube. Poster #: EDU-018 Imaging pediatric peritoneal pathology: Beyond the misty mesentery

Asmaa Aamir, Oregon Health Science University, Portland, OR, [email protected]; Kathryn Snyder, Kelli Schmitz, Atiya Mansoor, Katharine Hopkins, MD, Petra Vajtai, MD Purpose or Case Report: Peritoneum and its folds, the mesentery and omentum, are complex anatomic structures that may become involved by a variety of diseases. We present a comprehensive review of rare and common conditions, both primary and secondary, involving the pediatric peritoneal cavity, mesentery and omentum. Readers of this educational exhibit will gain familiarity with the protean conditions that involve these spaces as well as a greater understanding of complex peritoneal anatomy. Methods & Materials: We collected representative cases of peritoneal, mesenteric and omental pathology from the imaging database at our university children’s hospital. Imaging modalities include plain radiography, sonography, CT and MRI. Clinical data, operative reports and pathology reports are correlated. Results: A targeted discussion of peritoneal pathology is provided with illustrative imaging. Cases include congenital abnormalities (malrotation, lymhangiectasia, and congenital cystic lesions); infectious, inflammatory, traumatic and vascular processes (tuberculous and bacterial peritonitis, abscess, panniculitis, laceration, epiploic appendagitis, and omental infarct); rare primary tumors of peritoneal cavity (mesothelioma, desmoplastic round cell tumor, and myofibromatosis); and secondary neoplastic processes

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(lymphoma, leukemia, and metastases from local and remote solid tumor sites). Emphasis is on distinguishing characteristics that define location, narrow the differential, and steer both diagnosis and treatment. Conclusions: Knowledge of disease patterns in the peritoneum, greater and lesser omenta and mesentery can aid the radiologist in localizing the pathology to the peritoneal cavity, a challenge in infants and children due to a relative paucity of omental and mesenteric fat. Familiarity with the characteristic imaging features of different peritoneal pathologies is important in formulating an appropriate differential diagnosis and in guiding therapy. Poster #: EDU-019 Appendicitis or Not Appendicitis: Imaging Acute Right Lower Quadrant Pain in Children

Teresa Liang, MD, University of British Columbia, Vancouver, BC, Canada, [email protected]; Lila Yewchuk Purpose or Case Report: Children often present with right lower quadrant (RLQ) pain. However, not everything that localizes to this location is appendicitis. Learning how to differentiate between the many causes of RLQ pain will allow early and accurate diagnosis and management. Thus, in this pictorial review, we will review common causes of acute right lower quadrant pain in the pediatric population and their characteristic imaging findings, and provide imaging examples of each. Methods & Materials: A retrospective review of multiple radiographic examinations in patients who presented to BC Children’s Hospital with RLQ pain was conducted. Multiple examples of classic imaging findings of each disease process potentially resulting in RLQ pain were compiled and placed into a pictorial review. Results: This poster reviews the pathophysiology and clinical presentation of common causes of acute RLQ pain in the pediatric age group. Imaging modalities available for assessment including radiographs, ultrasound, CT, and MRI, and their utility and clinical limitations are discussed. Characteristic findings and imaging examples of various causes of RLQ pain including appendicitis (the most common cause), ovarian torsion, inflammatory bowel disease, inguinal hernia, Meckel’s diverticulum, ileocolic intussusception, Henoch Schonlein Purpura and mesenteric adenitis are demonstrated. Examples of unusual presentations of RLQ pain such as hemolytic uremic syndrome and malrotation are also discussed and demonstrated. Conclusions: While acute appendicitis is the leading cause of acute RLQ pain in children, not everything that localizes to this location is appendicitis. Kids often present with non-specific symptoms and when the diagnosis is not certain, other diagnostic possibilities must be considered. Learning how to distinguish between these disease processes will facilitate accurate and timely diagnosis in this challenging population. Poster #: EDU-020 Pictorial Review of Pancreatic Duct Anomalies seen on Pediatric MRCP

Brandon Brown, Radiology, Indiana University School of Medicine, Indianapolis, IN, [email protected]; Megan Marine, MD, Boaz Karmazyn, MD Purpose or Case Report: Magnetic resonance cholangiopancreatography (MRCP) has emerged as a noninvasive and useful imaging technique for evaluating the pancreatic duct in children. There is a wide spectrum of congenital pancreatic duct anomalies that are encountered in the pediatric population, some of which can predispose to disorders such as pancreatitis, while others may only simulate pathologic conditions. Awareness of the appearance of these ductal variations can help to prevent confusion. We present here the MRCP appearance of several of the most common pancreatic duct anomalies.

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Methods & Materials: From our radiology archive, we retrospectively identified all children over a 3 years period (2010–2012) who underwent MRCP at a tertiary care children’s hospital. These studies were then assessed for the presence of pancreatic duct anomalies, and optimal MRCP images of these anomalies were selected to demonstrate the variable appearance of the pancreatic duct seen in the pediatric population. All of the MRCP studies were performed with intravenous Secretin, to assist in visualization of the pancreatic duct. Results: Our review identified 127 patients (81 female, 46 male, mean age 13 years) who underwent secretin-enhanced MRCP, of which there were 30 cases with congenital anatomic anomalies of the pancreatic duct. These included 15 cases (12%) of pancreas divisum (including both partial and complete divisum), eight cases (6%) of “ansa pancreatica” looping of the duct, five cases (4%) of a high insertion of the pancreatic duct into the common bile duct forming a common channel, and two other variants. Conclusions: Congenital anomalies of the pancreatic duct in children represent a complex set of anatomic variations. MRCP imaging is a valuable tool in recognizing and reviewing this spectrum, and can help the radiologist to recognize those patients who may be predisposed to pancreatic pathology, and also avoid any confusion of normal variant with true disease.

Poster #: EDU-021 Imaging of Complications of Enteric Tubes in Children

Irina Decter, Montefiore Medical Center/Albert Einstein College of Medicine of Yeshiva University, New York, NY, [email protected]; Nicole Pattamanuch, Anita Mehta, Terry Levin, Benjamin Taragin Purpose or Case Report: Percutaneous enteric tubes are widely used to provide nutrition to children with neurologic impairment, feeding dysfunction or failure to thrive. While enteric tube placement and usage is ubiquitous, potential complications may arise. We present the imaging findings of common and uncommon complications associated with enteric tubes in children. Methods & Materials: An IRB approved search of our hospital system database from 2005 to 2013 was performed and imaging and clinical findings in children with complications of enteric tube placement or use were reviewed. Results: Patients were identified with complications arising from the placement or presence of percutaneous enteric tubes. Complications included extraluminal position of a jejunostomy balloon, gastric outlet obstruction due to balloon malposition, gastrostomy balloon migration into the distal duodenum, partial obstruction of the transverse colon secondary to extrinsic compression by the intraperitoneal portion of the gastrostomy tube, gastrocolic fistula, colonic perforations complicating gastrostomy tube placement, migration and erosion of a gastrostomy tube into the right kidney, acute bowel obstruction secondary to internal hernia and volvulus around an existing gastrostomy tube and malposition of the gastrostomy stabilizing bumper. Conclusions: After reviewing this exhibit, the viewer will have an improved understanding of range of complications associated with percutaneous enteric tube placement and use, and their imaging characteristics.

Poster #: EDU-022 More than Appendicitis: An Ultrasound Pictorial Review

Michael Peterson, M.D., St Josephs Hospital and Medical Center, Phoenix, AZ, [email protected]; Smita Bailey, Craig Barnes, MD

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Purpose or Case Report: An ultrasound of the right lower quadrant is a commonly ordered test from the emergency department for the evaluation of pediatric right lower quadrant pain and in particular to look for signs suggestive of acute appendicitis. While sonographic findings commonly do suggest appendicitis, numerous other entities have also been the cause of right lower quadrant pain at our institution. The purpose of this review will be to review the sonographic findings of the many potential causes which have clinically mimicked appendicitis in our patient population. Methods & Materials: Right lower quadrant ultrasound findings of numerous patients obtained at our large free standing children’s hospital were reviewed. While we did find a large number of cases of either uncomplicated or complicated acute appendicitis, we also found numerous other causes to account for the children’s pain. All of our cases were reviewed by at least one sonographer, one radiology resident, and at least one attending pediatric radiologist. Results: Sonographic findings from our patient population showed pathology involving the small and large bowel, the pelvic organs, the right kidney, and even the biliary tract. Findings were congenital, inflammatory, infectious, vascular, and neoplastic. Diagnoses, among others included cholelithiasis, ovarian cysts, urachal sinus remnant, intussusception, ovarian teratoma, colitis, hydronephrosis, omental infarct, enteritis, Meckel’s diverticulum, and even psoas muscle hematoma. Conclusions: The causes of right lower quadrant pain in children are diverse, and while acute appendicitis is often the suspected source, there are many mimickers which can be detected by ultrasound. It is critical that the sonographer and interpreting radiologist consider and recognize these entities in order to properly treat the patient, look for associated complications and even to avoid unnecessary follow-up tests. Our review will show and describe a vast array of pathology to promote properly detecting the etiology of right lower quadrant pain in children. Poster #: EDU-023 Pictorial Review of Acquired Abnormalities of the Biliary Tree

Susan Gowdy, BMBS, Radiology, BC Childrens Hospital, Vancouver, BC, Canada, [email protected]; Gianluca Valsenti, Heather Bray, Douglas Jamieson, MD Purpose or Case Report: Aims/Purpose: 1. To review the spectrum of acquired intrinsic abnormalities of the biliary tree in children. 2. To discuss how clinical findings and biochemical parameters may guide imaging investigation. 3. To illustrate the imaging findings of acquired biliary tree abnormalities and the role of interventional radiology in treatment. Methods & Materials: Content Organisation: A case based review of the spectrum of acquired abnormalities of the biliary tree in the paediatric population is presented. Illustrative cases include inflammatory/autoimmune, infectious, neoplastic, metabolic, and traumatic etiologies. Findings on various imaging modalities including plain film, ultrasound, ERCP, CT, MRI, and MRCP are presented. Relevant patient history, clinical findings and biochemical parameters are discussed as a guide to imaging investigation. The discussion includes risk factors and associated abnormalities relevant to the paediatric population. The role of interventional radiology in treatment of acquired biliary tree disorders is also illustrated. Conclusions: Summary: Acquired intrinsic abnormalities of the biliary tree are uncommon in children and may easily be overlooked. The clinical presentation is often nonspecific and may include jaundice, nausea and

vomiting, and recurrent abdominal pain. The patient’s history, associated medical conditions and biochemical parameters may guide the imaging investigation. It is important that the paediatric radiologist have a working knowledge of the spectrum of acquired abnormalities of the biliary tree in order to facilitate appropriate imaging, diagnosis and intervention. Poster #: EDU-024 MR Enterography of Pediatric Inflammatory Bowel Disease and its Complications- A Pictorial review

Raphael Yoo, MD, Hahnemann University Hospital, Havertown, PA, [email protected]; Bret Kricun, Archana Malik, Erica Poletto, Eric Faerber, Jacqueline Urbine Purpose or Case Report: Inflammatory Bowel Disease consists of a group of chronic inflammatory disorders affecting the gastrointestinal tract in children and young adults. The incidence of IBD in the pediatric population has doubled in the last decade. Unlike small bowel follow through or CT enterography, MR Enterography does not utilize ionizing radiation, making it an ideal imaging modality in pediatric patients. The purpose of this presentation is to review characteristic imaging findings of inflammatory bowel disease and its various complications demonstrated by MR Enterography. Methods & Materials: We retrospectively reviewed MR Enterography studies performed at St. Christopher’s Hospital for Children between Jan, 2010 and Oct, 2013. A group of cases comprised of inflammatory bowel disease (both Crohn’s Disease and Ulcerative Colitis), as well as complications arising from IBD, were collected. The imaging findings were then analyzed and correlated with the patient’s medical record, as well as surgical and pathologic reports when applicable. Results: A collection of MR Enterography cases is presented highlighting the classic findings of IBD in both Crohn’s disease and Ulcerative colitis, such as terminal ileal thickening, skip lesions, and smooth featureless colon, along with complications, such as strictures, abscesses, and fistulae. Post-operative changes related to surgery for IBD are discussed briefly as well as IBD mimics. Conclusions: With its lack of ionizing radiation and superior soft tissue detail, MR Enterography provides the ideal modality for initial diagnosis of the disease and monitoring progression, making familiarity with this modality and the various findings related to IBD in the pediatric patient of utmost importance to the practicing radiologist. Poster #: EDU-025 Pictorial Review of Congenital Bile Duct Abnormalities with Clinical and Pathological Correlation

Susan Gowdy, BMBS, Radiology, BC Childrens Hospital, Vancouver, BC, Canada, [email protected]; Gianluca Valsenti, Heather Bray, Douglas Jamieson, MD Purpose or Case Report: Aims/Purpose: 1. To demonstrate the imaging findings in congenital bile duct abnormalities such as biliary atresia including the cystic variant of biliary atresia, Alagille’s syndrome, choledochal cyst and Caroli’s disease. 2. To correlate the clinical and pathologic findings of the various described congenital biliary duct abnormalities with imaging findings. 3. To review current theories on the pathogenesis of congenital biliary tract abnormalities. Methods & Materials: Content Organisation: The imaging findings of congenital bile duct abnormalities are demonstrated using plain film, ultrasound, intra-operative cholangiogram, MRI and MRCP. Pathologic correlation is illustrated with histological examples and medical photography of specimens. The clinical presentation of

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each disease entity is described using individual cases with relevant examination findings and biochemical parameters provided. Conclusions: Summary: Congenital bile duct abnormalities present frequently to the pediatric radiology department. Biliary atresia and cystic variant, choledochal cyst and Alagilles syndrome must be excluded in children presenting with neonatal jaundice. Early recognition and treatment of biliary atresia is key to preventing early onset hepatic fibrosis. Cystic variant biliary atresia should be considered in any child with an antenatal diagnosis of choledochal cyst.

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The main differences will be based on the evaluation of the pattern of enhancing, bowel wall thickening pattern, restricted diffusion and the presence or absence of fistulas in MRE. Conclusions: MRE has a high correlation with the pathological characteristics of CD and UC, reason why MRE has a very high predictive value differentiating active CD and UC. MRE is an important adjuvant tool that complements the initial clinical assessment of patients with IBD and should be part of the initial routine diagnostic work up. Poster #: EDU-028

Poster #: EDU-026 Pediatric Liver Masses: A Pictorial Review with Emphasis on Ultrasound, Computed Tomographic and Magnetic Resonance Appearance

Elizabeth McGraw, M.D., Nemours Children’s Clinic, Jacksonville, FL, [email protected]; Ana Gaca, MD Purpose or Case Report: To review the spectrum of benign and malignant pediatric liver masses with an emphasis on their appearance on ultrasound, computed tomographic (CT) and magnetic resonance imaging (MRI). Correlation with relevant clincial,laboratory and pathologic data will also be performed when applicable. Methods & Materials: After obtaining IRB approval, cases of pediatric liver masses were collected from clinical workflow encounters and from the medical records database. Imaging studies were correlated with clincial histories and available laboratory and pathologic findings. Results: Benign lesions included in this presentation are mesenchymal hamartoma, biloma, adenoma, abscess, infantile hemangioendothelioma and focal nodular hyperplasia. Malignant lesions included in this presentation include hepatoblastoma, hepatocellular carcinoma (HCC), fibrolamellar HCC, embryonal sarcoma and metastatic lesions from neuroblastoma. Conclusions: Pediatric liver masses are freqently divided into benign and malignant categories and demonstrate a varied but somewhat predictable imaging appearance on ultrasound, CT and MRI. Knowledge of their typical imaging appearance on ultrasound, CT and MRI, combined with the clinical presentation and pertinent laboratory data, allows the radiologist to generate a relevant differential diagnosis necessary for the timely and efficient management of these lesions. Poster #: EDU-027 MR Enterography: Differences Between Active Crohn’s Disease and Ulcerative Colitis in Pediatric Population

Jorge Davila-Acosta, MD, Diagnostic Imaging, Children Hospital of eastern Ontario, Ottawa, ON, Canada, [email protected]; Claudia Lazarte, Radiologist, Amer AlAref Purpose or Case Report: Inflammatory bowel disease (IBD) is a spectrum that includes Crohn’s disease (CD), ulcerative colitis (UC) and nonclassified IBD. Ulcerative colitis is a form of IBD that is characterized by the presence of superficial ulcers or open sores and involves predominantly the mucosa of the bowel. CD is characterized by transmural involvement of the bowel wall including the presence of deep ulcers, granulomas, fistulas, abscess and bowel wall thickening. All forms of IBD are medically incurable with complications arising from the chronic and recurrent inflammation. Therapeutic approach and management of UC and CD are different, reason why it is imperative to try to make a proper diagnosis of the disease at the beginning. Actually, MR Enterography (MRE) has become a routine diagnostic tool in the diagnosis, management and follows up of IBD. The purpose of this medical education is to illustrate and describe the characteristic MRE findings to differentiate active CD from active UC.

MR Enterography: How to Recognize Post Treatment Changes in Chrohn Disease in Pediatric Population?

Jorge Davila-Acosta, MD, Children’s Hospital of eastern Ontario, Ottawa, ON, Canada, [email protected]; Claudia Lazarte, Radiologist, Pablo Caro Purpose or Case Report: Crohn’s Disease (CD) is an inflammatory bowel disease which is characterized by segmental transmural involvement of the bowel and can compromise the tissues surrounding the bowel. Although capsule endoscopy and upper and lower gastrointestinal endoscopies have been used to follow these patients after treatment, its used is limited by the use of sedation for the endoscopy and the need of imaging to exclude strictures before using capsule endoscopy. In the other hand the clinical markers show poor correlation with the clinical activity of the disease. Lately, MR Enterography (MRE) has become a main tool to assess the response to treatment in patients with CD allowing not only the evaluation of the large bowel but also the small bowel and its extraluminal findings. The small bowel is the most common site of CD. Severe stenosis can occur as chronic changes of CD that explains the poor accessibility to video capsule endoscopy in some cases. As well, neither endoscopy nor video capsule endoscopies are able to evaluate the extra intestinal changes. That’s why the purpose of this presentation is introducing MRE as the first-choice imaging modality in the evaluation of post treatment changes of small-bowel CD. We purpose a pictorial review of the main post treatment changes of CD, differentiating fibrosis, active disease and non-active post treatment changes including abnormal peristalsis and limited bowel distension. Conclusions: MRE is further suggested as none invasive exam in the assessment of post treatment CD activity. Loss of proper bowel distension, abnormal peristalsis and hypertrophic mesenteric fat are the most frequent non active CD post treatment changes which could account for post treatment symptomatology in patients with controlled CD. Poster #: EDU-029 Pediatric Liver Masses—Multimodality Evaluation with Pathologic Correlation

Judit Machnitz, Hahnemann University Hospital, Philadelphia, PA; Archana Malik, Jacqueline Urbine, Erica Poletto, Bret Kricun, Erin Horsley Purpose or Case Report: A wide variety of hepatic masses can be seen in the pediatric population. Differentiating between these masses may be challenging. Although ultrasound is the main modality of choice for the initial evaluation, CT and MRI are often subsequently obtained for further lesion characterization. MRI has the benefit of obviating the use of radiation. The purpose of this presentation is to review the imaging findings of several hepatic masses.

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Methods & Materials: We conducted a retrospective review of abdominal ultrasound, CT and MRI studies performed at St. Christopher’s Hospital for Children between 2009 and 2013. We collected a series of cases which demonstrated hepatic masses, and we correlated the imaging findings with pathology reports when appropriate. Results: We collected multiple ultrasound, CT, and MRI examinations in children with a variety of hepatic masses. We will present these cases and discuss the distinguishing imaging features of these masses. The masses which will be discussed include choledochal cyst, abscess, hematoma, cyst, hemangioma, focal nodular hyperplasia, adenoma, hemangioendothelioma, hepatoblastoma, multifocal hepatoblastoma, hepatocellular carcinoma, undifferentiated embryonal sarcoma, and metastatic disease. Conclusions: There are numerous congenital, benign, malignant, infectious, and traumatic hepatic masses imaged on ultrasound, CT, and MRI. Understanding the characteristic imaging findings of pediatric hepatic masses, both symptomatic and incidentally found, can improve patient care by guiding the next appropriate step in management. Poster #: EDU-030 Pictorial Essay in Performing Barium Enemas

Abdullah Shaikh, Baystate Medical Center/Tufts University, Springfield, MA; Dustin Nguyen, D.O., Tara Catanzano Purpose or Case Report: 1. Performing a barium enema can be a daunting task early in one’s career. This is an educational poster designed to teach trainees the various anatomical positions with a mannequin side by side with the corresponding fluoroscopic image. 2. The aim of this poster would be to create a resource that residents can refer back for a quick review especially when many months have gone by without doing the procedure. Methods & Materials: The poster will have the following headings with an image rich review: — Anatomy: Review of colonic anatomy. — Indications and Contrainidcations — Preparation: Must knows prior to any enema procedure including various rectal tubes and tips. — Various fluoroscopic stages with the mannequin Conclusions: By visiting this exhibit, a trainee should be able to have a systematic approach to performing a pediatric enema. Knowing the maneuvers to perform during the procedure will ensure that all views are obtained to delineate all of the anatomy. Poster #: EDU-031 The Role of Imaging in Pediatric Bladder Augmentation

Micheal Breen, MBBChBAO (Hons) BMedSc MRCPI FFRRCSI, Department of Radiology, Boston Children’s Hospital, Boston, MA, [email protected]; Carlos Estrada, Jeanne Chow Purpose or Case Report: The purpose of this exhibit is to review the indications for bladder augmentation in the pediatric population, surgical techniques employed, normal post-operative appearances on imaging studies and the role of imaging complications of bladder augmentation including suspected perforation. Methods & Materials: We present a pictorial essay of our experience with bladder augmentation in a quaternary pediatric referral center. Results: Bladder augmentation is indicated when non-surgical measures fail in children with markedly reduced bladder capacity or compliance. The most common pediatric indications for bladder

augmentation include spina bifida/myelomeningocele, bladder exstrophy and cloacal exstrophy. Imagin g studies including renal ultrasound an d voiding cystourethrography, in combination with urodymanic studies, play an important role in determining which patients are likely to benefit from augmentation. The most common surgical techniques utilize enteric segments for augmentation such as ileocystoplasty, ileocecocystoplasty and sigmoid cystoplasty. Gastrocystoplasty, ureterocystoplasty, autologous augmentation and autoaugmentation are less commonly used techniques. The various types of bladder augmentation have different imaging findings on ultrasound, fluoroscopic cystography, CT, CT cystography and MRI. The appearance of the augmented bladder is different in the early and late post-operative period. Complications of bladder augmentation that can be identified on imaging studies include bladder calculi, bladder malignancy, spontaneous bladder perforation and small bowel obstruction. Perforation can be seen in both the early and late post-operative period. Conclusions: Bladder augmentation is an excellent method of improving bladder capacity in pediatric patients with severe bladder dysfunction. Imaging has an important role in their diagnostic work-up and in the postoperative period. The most common augmentation procedures utilize enteric segments to augment the bladder. The various types of bladder augmentation have characteristic appearances on different imaging modalities. These are important to recognize; not just on dedicated genitourinary studies but also on cross-sectional imaging of the abdomen and pelvis performed for other indications. Spontaneous bladder perforation is a complication that is seen in both the early and late post-operative period. Poster #: EDU-032 Split-Bolus MR urography: Synchronous visualization of obstructing vessels and collecting system in children

Murat Kocaoglu, MD, Radiology, Gulhane Military Medical School, Ankara, Turkey, [email protected]; Selami Ince, Veysel Akgun, Faysal Gok, Mustafa Tasar Purpose or Case Report: MR urography can provide both morphologic and functional information including split renal function. Current MR urography protocols use administration of single bolus of intravenous contrast material followed by multiphasic scanning including the arterial, venous and excretory phases. By using single bolus technique, vessels and collecting systems cannot be demonstrated simultaneously. The aims of this exhibit are: 1. Describe the split-bolus MR urography technique in children. 2. List the coexisting congenital collecting system and vascular abnormalities. 3. Exhibit the splitbolus MR urographic appearances of concurrent collecting system and vascular abnormalities by using split-bolus MR urography technique. Methods & Materials: Patients with renal collecting system dilatations underwent MR urography with conventional MR urography sequences. Contrast enhanced scans were obtained with split contrast bolus method during arterial and excretory phases to demonstrate the arteries and the collecting system concurrently. Axial sections and maximum intensity projections were evaluated to document concurrent vascular and collecting system abnormalities. Results: Split-bolus MR urography can show several vascular abnormalities such as crossing accessory renal arteries, retroiliac ureters, retrocaval ureters and ovarian vein syndrome that responsible for the renal collecting system obstruction. Conclusions: It is essential to carefully select the correct imaging technique to evaluate a specific clinical indication. Split-bolus MR urography can demonstrate the urinary tract and vessels

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simultaneously and allows the preoperative radiologic diagnosis of obstructing vessels.

Poster #: EDU-033 The Why, When and How of Magnetic Resonance Urography

Teerasak Phewplung, M.D., Dept. of Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Brian Pugmire, M.D., Michael Gee, Ruth Lim Purpose or Case Report: Goals of this educational exhibit are to 1) review magnetic resonance urography (MRU) technique including patient preparation and image acquisition, 2) demonstrate urinary tract abnormalities that can be imaged by MRU, 3) describe advantages and disadvantages of MRU compared to conventional imaging modalities (ultrasound and diuretic renal scintigraphy), and 4) summarize clinical indications for MRU. Background: MRU is a functional modality that has many advantages for imaging the pediatric urinary tract. It consists of static pre-contrast and dynamic post-contrast sequences. The static sequences provide anatomical details and tissue characterization, and the dynamic post-contrast sequences provide information on renal function. Because of superior soft tissue characterization, high spatial resolution and no ionizing radiation, MRU is well-suited for children. The most common indication for MRU in children is hydronephrosis; it can also evaluate for pyelonephritis and renal scarring. By providing both anatomic and functional information, MRU is advantageous over US in determining which hydronephrotic patients should be considered for corrective surgery, and assists in surgical planning. Dynamic contrast-enhanced MRU evaluates both extrarenal causes of obstruction (e.g. crossing vessels) as well as renal excretory function. At this time, there is no final consensus or standardization for quantitative renal functional evaluation by MRU.

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weighted fat suppression sequences acquired before, during and after intravenous administration of gadolinium contrast agent. Intravenous hydration and furosemide are administered prior to the static MRU. In this pictorial review we present common abnormalities seen on MRU, including ureteropelvic junction obstruction (both idiopathic and secondary to crossing vessels), primary megaureter, ectopic ureteric insertion, fetal folds, mid ureteric stricture, and duplicated collecting system. Conclusions: In today’s era of high-field MRI scanners, faster sequences, more sophisticated post-processing analysis, and better access to pediatric anesthesia expertise, MRU has become a feasible imaging modality for more widespread use in the evaluation of pediatric urinary tract abnormalities. MRU should be considered as the modality of choice for presurgical decision-making in the abnormal pediatric urinary tract. Poster #: EDU-034 Radiographic Features of Uncommon Benign and Malignant Bladder Abnormalities that Present with Hematuria

Benjamin Thompson, DO, Nationwide Children’s Hospital, Columbus, OH, [email protected]; Brent Adler, D. Bates, Cody Young, Bonita Fung, Seth Alpert Purpose or Case Report: Hematuria is one of the most common clinical presentations of pediatric patients who undergo genitourinary imaging. Our goal is to highlight the radiographic findings observed in patients with uncommon benign and malignant bladder conditions that presented with hematuria. Methods & Materials: We performed a retrospective review at a large children’s hospital of pediatric patients with hematuria over the last 8 years. We reviewed the imaging with a focus on MRI, multidetector row nonenhanced and enhanced CT, plain film, flouroscopy and ultrasound. Four independent readers reviewed the imaging findings related to each patient. We excluded cases that did not have pathologic correlation. Three pathologists and four radiologists came to a group consensus to determine the most interesting cases seen at our institution. Results: Ten uncommon causes of hematuria were selected: Infected urachal remnant, embryonal rhabdomyosarcoma of the bladder, ruptured appendicitis, xanthogranulomatous cystitis, fibroepithelial polyp, schistosomal cystitis, interstitial cystitis, transitional cell polyp, nephrogenic adenoma and eosinophilic cystitis. Conclusions: The radiographic features observed in this group of uncommon causes of hematuria were not specific enough to distinguish benign from malignant diagnoses and tissue samples were needed to further guide therapy. Poster #: EDU-035 Imaging of the Genitourinary Tract during VCUG in the Pediatric Population: A Pictorial Review

Bret Kricun, St. Christopher’s Hospital for Children, Philadelphia, PA; Archana Malik, Raphael Yoo, MD, Jacqueline Urbine, Erica Poletto, Eric Faerber

Contents: Static MRU images include T1- and T2-weighted multi-planar sequences. Dynamic contrast-enhanced MRU sequences are coronal T1-

Purpose or Case Report: Voiding cystourethrography (VCUG) is a valuable, relatively non-invasive imaging modality used to evaluate the urinary tract. Urinary tract infection, vesicoureteral reflux, dysfunctional voiding, and ambiguous genitalia are just some of the reasons that pediatric patients are referred for VCUG. During the examination, the urinary bladder can be evaluated for shape, size, and presence of filling defects, and the presence of vesicoureteral reflux can be determined. Additionally, during voiding, a detailed dynamic evaluation of the ureters, urinary bladder, and urethra makes it possible to readily diagnose many urinary abnormalities. The purpose of this presentation is to

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present several cases of urinary tract abnormalities, specifically those involving the distal ureters, urinary bladder, and urethra, and to review their characteristic imaging findings during VCUG examination. Methods & Materials: We retrospectively reviewed VCUGs performed at St. Christopher’s Hospital for Children between 2009 and 2013. We collected a group of cases with both common and uncommon abnormalities of the distal ureters, urinary bladder, and urethra. The imaging findings were then compared to the patient’s clinical history and surgical and pathological reports when available. Results: We compiled a group of VCUG examinations which demonstrate abnormalities involving the distal ureter, urinary bladder, and urethra, and we grouped these abnormalities by anatomic location. The imaging features of many common and uncommon congenital and acquired abnormalities of the genitourinary tract will be presented. Conclusions: There are many urinary tract abnormalities in the pediatric population that can be identified during VCUG examinations. Familiarity with the imaging characteristics of these processes is essential for the radiologist in diagnosis.

complementary, it would be useful to find an imaging modality which could provide both sets of information in a single exam. The purpose of this presentation is to review the utility of MR Urography in the diagnosis of renal anomalies as well as its ability to analyze renal function. Methods & Materials: We retrospectively reviewed MR Urography studies performed at St. Christopher’s Hospital for Children between Jan, 2010 and Oct, 2013. A group of cases comprising various renal anomalies, as well as functional analyses, was collected and the imaging findings were then analyzed and correlated with the patient’s medical record and findings on other supplemental imaging modalities if available. Results: Presented are a collection of MR Urography cases highlighting several renal anomalies such as: UPJ obstruction, partial and complete duplicated renal collecting systems, ectopic ureter insertion, malrotation, and renal agenesis. Also presented are the functional analyses of these anomalous renal systems. Conclusions: With its lack of ionizing radiation and excellent soft tissue detail coupled with the ability to obtain renal functional analysis, MR Urography provides an ideal modality with which to evaluate renal anomalies in the pediatric population.

Poster #: EDU-036

Poster #: EDU-038

Beyond Torsion: Common and Uncommon Entities Encountered in Acute Pediatric Scrotal Evaluation

Pediatric Cystic Renal Disease: Review of pathology, imaging features, mimics and differential diagnosis

Eva Rubio, MD, CNMC, Washington, DC, [email protected]; Anna Blask, MD, Anjum Bandarkar, MD

Tejaswini Deshmukh, M.D, Children’s Hospital of Wisconsin, Milwaukee, WI, [email protected]; Christine Menias

Purpose or Case Report: The purpose of this educational exhibit is to provide a comprehensive review of the many entities other than testicular torsion that may be encountered in evaluation of the pediatric scrotum in the acute setting. Methods & Materials: A retrospective review of scrotal ultrasound studies performed over the preceeding 7 years at a medium size freestanding pediatric hospital was conducted. Excluded from this review were cases of acute or chronic testicular or spermatic cord torsion, as well as cases lacking clinical, surgical or pathologic confirmation. Results: A total of 30 cases comprise this presentation, organized into the following categories: Structural abnormalities; Congenital/genetic/chromosomal entites; Trauma; Inflammatory/Infectious conditions; Neoplasms; and Vascular abnormalities. Patient ages range from 0 to 20 years. Clinical, surgical and/or pathologic correlation was obtained in all cases. Conclusions: Pediatric scrotal ultrasound evaluation is a common study performed in any radiology department. Because the provided clinical history may be vague, incomplete or misleading, familiarity with the broad spectrum of potential abnormalities in this population is key to providing optimal guidance and recommendations for the subsequent clinical workup.

Purpose or Case Report: 1. To describe the imaging features of pediatric cystic renal disease including ultrasound, CT, MRI and renal scintigraphy when relevant. 2. To review the pathology, associated congenital genitourinary anomalies, mimics, differential diagnosis and management in brief. Methods & Materials: 1. A succinct review of the EMBRYOLOGYof the kidneys. 2. HYDRONEPHROSIS 3. CONGENITAL CYSTIC RENAL DISEASE (a) Multicystic dysplastic kidney (MCDK) (b) Autosomal recessive polycystic kidney disease (ARPKD) (c) Autosomal dominant polycystic kidney disease (ADPKD) 4. CYSTIC RENAL MASSES: (a) Multilocular cystic nephroma (b) Cystic Wilms tumor (c) Nephroblastomatosis (d) Mesoblastic nephroma with necrosis/cystic degeneration (e) Rhabdoid tumor (f) Clear cell sarcoma (g) Cystic metastases (from neuroblastoma, sarcoma) 5. INFECTION: Abscess Conclusions: The major teaching points of this exhibit are: 1. Typical imaging features of congenital cystic renal disease and cystic renal masses. Identify lesions which mimic cystic renal disease. 2. To provide a reasonable differential diagnosis for a cystic renal lesion in a child. 3. Distinguish between surgical and non-surgical entities.

Poster #: EDU-037 Evaluation of Renal/Urinary Anomalies with MR Urography

Raphael Yoo, MD, Hahnemann University Hospital, Havertown, PA, [email protected]; Cristian Coroian, Erica Poletto, Archana Malik, Eric Faerber, Jacqueline Urbine Purpose or Case Report: Renal anomalies are commonplace in the pediatric population with several modalities available for evaluating them. Ultrasound provides exquisite anatomic detail, while nuclear medicine renal scans provide essential information regarding renal perfusion and function. While these methods are

Poster #: EDU-039 The Pediatric Renal Lesion—A logical approach to a not uncommon diagnostic finding

Matthew Wedman, MD, S. Hancock, MD, Radiological Sciences, University of Oklahoma, Oklahoma City, OK, [email protected]; Mahmoud Elkaissi, Sandeep Prabhu

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Purpose or Case Report: The purpose of this exhibit is to engage participants in common and relatively uncommon renal lesion cases in attempts to review and consolidate differentiating characteristics that aide in the most accurate diagnosis. Methods & Materials: Richly illustrated cases from our institutional database will be presented with focus placed on key differences such as age related incidence, tumor spread and tumor specific organs of involvment. Emphasis will be placed on relevant anatomy and specific imaging utilization to assist in diagnosis. Results: Cases included are as follows: Angiomyolipoma, cystic nephroma, mesoblastic nephroma, renal cell carcinoma, wilms tumor, neuroblastoma involving kidney, nephroblastomatosis, malignant rhabdoid tumor, renal PNET and leukemia/lymphoma. A diagnostic algorithm chart will be provided to consolidate concepts. Tumor specific areas of involvement relevant to treatment planning for the referring physician will also be discussed. Conclusions: Knowledgeable evaluation of diagnostic imaging in the patient with a pediatric renal mass plays a crucial role in appropriate management and has a direct effect on timely treatment, and in some cases, prognosis. A working understanding of the key differentiating features of specific pediatric tumors is an essential first step when evaluating this patient population and recommending further imaging or interventions.

Poster #: EDU-040 Pictorial Review of Disease seen on MR Urogram

Aditi Shruti, Radiology, Geisinger Medical Center, Danville, PA, [email protected]; Satre Stuelke, Joel Sumfest, George Wu, MD Purpose or Case Report: In the past few years, MR urogram (MRU) has become a hot topic in pediatric imaging. The purpose of this exhibit is to illustrate the common and uncommon diseases of the urology tract as seen on MR urogram. MR urogram is composed of both a functional and anatomical evaluation. This review will focus on the anatomical evaluation of disease. As MRU is a recent modality, many pediatric radiologists may not be as familiar with pediatric urological disease seen on MRU as compared to more conventional modalities such as VCUG or US. Methods & Materials: From our PACs database, we identified all patients examined by MRU for a urological condition. We then reviewed the accompanying medical records, clinical outcomes, and pathology reports when available. Results: We will show cases of duplicated collecting systems with ectopic insertion and ureteropelvic junction obstruction. The above two conditions are common indications for MRU. We will show some of the pearls and pitfalls when evaluating those two conditions. We will then shows cases of uncommon conditions, such as a case of infundibulopelvic stenosis and mesonephric duct cyst with a rudimentary ureteral bud Conclusions: This exhibit will provide an excellent pictorial review of disease seen on MR Urogram.

Poster #: EDU-041 Bubbly Badness in the Pediatric Genitourinary System

Dustin Nguyen, D.O., Baystate Medical Center/Tufts University, Springfield, MA; Abdullah Shaikh, Tara Catanzano

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Purpose or Case Report: Cystic lesions in the pediatric patient are common, particularly in the genitourinary system. The goal of this educational exhibit is to: 1. Review the anatomy and embryology of the genitourinary system. 2. Review various cystic lesions (malignant and benign, i.e. MCDK, UPJ obstruction, adrenal hemorrhage, neuroblastoma, etc.) involving the genitourinary system. 3. Provide a differential diagnosis and outline features and methods that separate the various cystic lesions from each other (hydronephrosis versus MCDK versus UPJ obstruction). 4. Demonstrate the lesions on different modalities (ultrasound, MRI, nuclear medicine, etc.) reinforcing the reader’s knowledge. Poster #: EDU-042 Capsular, Conceptual and Continuing Education in Pediatric Cardiovascular Imaging

Madhumita Parmar, Sushain Cherivirala, Sneha Balachandar, Amrita Murali, Rohan Manickam, Rajesh Krishnamurthy, MD, University of Miami, Coral Gables, FL, [email protected] Purpose or Case Report: There is a renewed focus on engagement with audiences for the intermediate to long term, rather than lecturing to them on a one-off basis. We explore a novel approach to pediatric cardiovascular education that introduces critical concepts and techniques using experts (conceptual and procedural education), keeps it focused wit hin the attention span of average interested listeners (educational capsules of 10 min or less), uses the concepts as building blocks to create a big picture, and provides resources for continuing education online. The objective of this study is to assess the effectiveness of such an approach. Methods & Materials: A 4-h focused session on pediatric cardiovascular imaging was organized at the SPR in San Antonio in May, 2013 using a capsule-based approach, with 21 talks, each lasting 8 min, with 2 min for discussion(1). The topics were focused, fundamental, and conceptual. The speakers were invited to summarize their topic in 3–4 critical concepts and present their opinion as an expert. The talks were recorded on video, and the speakers’ permission was obtained to upload selected presentations on the web. A separate curriculum entitled ‘Practical Pediatric Cardiovascular Imaging (PePCI)’ was created to reinforce the educational material in the session with online talks by experts, and utilized a similar capsular and conceptual format of teaching. The opinions of the attendees was catalogued using an online survey, which studied the effectiveness of the content from the cardiac session, and pros and cons of the capsule based lecture format versus the conventional format used in previous years. Results: This is a study in progress. The presentations from the focused SPR session, the PePCI talks, and survey are hosted on a new website developed for this purpose entitled ‘www.ImageCHD. com’, to be inaugurated on 11/01/2013. Unique content for PePCI that has been developed so far includes one module with four lectures on ‘The Segmental Approach to CHD’. Survey results will be catalogued until March 2014, and then analyzed and presented at the 2014 SPR meeting. Conclusions: The conceptual, capsular and continuing approach to pediatric cardiovascular education ensures that the educational process continues long after the conference sessions have ended and will lead to new entrants to the field on a regular basis. By providing readily available resources online that the users can tap into at their convenience, it places the onus of learning on the user rather than the provider. SPR 2013 Focused Cardiac Session

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Pediatric Cardiac MRI: The What, How, Why and Why Nots Rajesh Krishnamurthy, MD, Moderator

What is It? 8:00–8:10 a.m. 8:10–8:20 a.m. 8:20–8:30 a.m. 8:30–8:40 a.m.

Poster #: EDU-043 Teaching to the New Diagnostic Radiology Core Exam: An Innovative Audience Response Based-Approach via the Resident’s Cellphone or Tablet

Black Blood Imaging Taylor Chung, MD Dynamic Bright Blood Imaging Amol Pednekar, PhD Flow Velocity Mapping Mike Seed, MD 3D SSFP Raja Muthupillai, PhD

Amit Sura, MD/MBA, Diagnostic Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Esha Gupta, Fariba Goodarzian

How Do I Do It? 8:40–8:50 a.m.

Assess Segmental Cardiac Anatomy Shi Joon Yoo, MD 8:50–9:00 a.m. Assess Ventricular Systolic and Diastolic Function Robert J. Fleck, MD 9:00–9:10 a.m. Evaluate Valvular Stenosis and Regurgitation Sadaf T. Bhutta, MD, MBBS 9:10–9:20 a.m. Perform Qp:Qs Randolph K. Otto, MD 9:20–9:30 a.m. Set Up a Contrast-Enhanced MRA Dianna M.E. Bardo, MD 9:30–9:40 a.m. Question and answer 9:40–10:00 a.m. Break 10:00–10:10 Evaluate the Systemic and Pulmonary Veins a.m. Prakash M. Masand, MD 10:10–10:20 Evaluate Pulmonary Blood Flow a.m. J. A. Gordon Culham, MD 10:20–10:30 Evaluate LV Outflow Tract and Aortic Arch a.m. Obstruction Shreyas S. Vasanawala, MD, PhD 10:30–10:40 Evaluate the Neonate with Heterotaxy a.m. Rajesh Krishnamurthy, MD Why Do I Do It? 10:40–10:50 s/p TOF repair a.m. Shiraz A. Maskatia, MD 10:50–11:00 a.m. 11:00–11:10 a.m. 11:10 a.m.– 11:20 11:20–11:30 a.m. 11:30–11:40 a.m. 11:40–11:50 a.m. 11:50–12:00 a.m.

Purpose or Case Report: 2013 marked the first year in which the new diagnostic radiology core exam was administered. Residents and program directors have searched for learning tools to incorporate an approach that helps residents make pertinent imaging findings, synthesize and communicate findings to clinicians to propose the next plan of action, and finally select an answer to a question amongst a range of multiple choices similar to the current exam format in place. A unique, innovative teaching tool utilized at Children’s Hospital in Los Angeles (CHLA) to prepare radiology residents for the objectives listed above is an accessible free online application, Poll Everywhere. Poll Everywhere serves a range of functions. First, the application is accessible from any mobile device, tablet, laptop, or desktop. The presenter creates an account and begins formulating “polls” on the application. The polls consist of true or false, multiple choice, or image enriched questions and answers. Once the presenter has finished typing their questions into the application, the presenter then has the option of creating each question into a PowerPoint slide to use in their existing presentation. They also have the choice of running Poll Everywhere simultaneously during their presentation rather than placing each question into their PowerPoint.

s/p Arterial Switch Operation for d-TGA Marc S. Keller, MD s/p Atrial Switch for d-TGA Jeffrey C. Hellinger, MD Cardiac Tumors Maryam Ghadimi-Mahani, MD Post-Fontan Cynthia K. Rigsby, MD Anomalous Coronaries Lorna P. Browne, MBBS Vascular rings and slings Prachi P. Agarwal, MD Pre-Glenn and Pre-Fontan Shaine A. Morris, MD

For example, in the context of an image-rich presentation to residents rotating at CHLA, presenters create or use an existing PowerPoint or Keynote presentation with multiple cases previously acquired. The presenter then inserts the questions created on Poll Everywhere after each

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case’s images. Once the questions are placed into the presentation, after a particular case, the resident will have the opportunity to answer the question using his or her cell phone or tablet by simply sending a text message that represents the right answer. The answers are then polled based on the responses submitted and instantaneous graphs are created showing how the audience performed, i.e. those in the audience who selected the right answer. It also allows a comparison to what others thought was the right answer such that a discussion can occur to elucidate any misconceptions the participating members may have about the case. The purpose of the presentation is achieved: residents can take cases, synthesize findings, and select the correct answer amongst multiple choices. Below is a schematic using the program Poll Everywhere.

S189 Poster #: EDU-045 Micro-learning: Pediatric Radiology skills and knowledge transfer in 5 minutes or less through “You Tube®”

Janet Reid, MD, FRCPC, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Laura Poznick, RDMS, AAS, Kassa Darge, MD, PhD, Susan Back, MD Purpose or Case Report: Micro-learning encapsulates the new adult learning style- where small aliquots given on-the-fly often while multitasking are better retained than 1 h lectures or continuing medical education tasks. The fast pace of our current workflow allows only small injections of new knowledge during the day, often most effectively retained when introduced alongside a clinically relevant case. This electronic poster showcases 10 video-tutorials for pediatric ultrasound techniques including: Brain, Hips, Spine, Renal & Bladder, Intussusception, Appendix, RUQ, Female pelvis, Scrotum, Pylorus. These are designed to give specific facts in 5 min or less in an accessible MP4 format incorporating synchronous dual display of the patient scan and ultrasound feed for each of the ten body parts/indications.

Poster #: EDU-044 An efficient and cost-effective way to create videos for Radiology education

Annie Xu, Raymond Sze, Walter Johnson High School, Bethesda, MD, [email protected] Purpose or Case Report: Instructional on line videos, popularized by the Khan Academy, enable “flipped classrooms,” where students watch lectures at home, then do homework in class while interacting with the teacher. This educational exhibit provides step by step instructions for creating Khan Academy style videos to facilitate the creation of “flipped classrooms” for Radiology education. Methods & Materials: The instructional content is organized into a storyboard. SmoothDraw 3 is used to illustrate imaging findings on representative imaging studies and the video and audio are captured using the FrontCam program. Final audio and video editing is performed using Final Cut Pro. We demonstrate the process with a three part introduction to chest radiograph interpretation. Our initial target audience was high school students interested in careers in medicine, but the content and complexity can be easily adapted to residents and fellows in radiology. Results: The first video focused on generation of X rays and the four major densities visible with radiography. The second video applied this knowledge to identifying the four major densities in a normal chest radiograph. The third video introduced basic findings in pneumonia, including consolidation and effusions, then provided a patient-based scenario with challenges to the trainee to identify the abnormalities. The story lines and the animations in the video create a more vivid experience, can be viewed after hours over the web, and set the stage for more interactive and individually targeted learning experiences for times designated for education during the work day. Conclusions: On line videos enable “flipped classroom” approaches to more interactive and engaging radiology education. We present the basic software and steps to create Khan Academy style radiology instructional videos.

Disclosure: Dr. Reid has indicated a relationship with Oxford University Press as an Author and Editor (Royalties, Chief Editor Textbook).

Poster #: EDU-046 Using Redcap (Research Electronic Data Capture) as a tool to perform research studies

George Chiramel, MD, Division of Image Guided Therapy, Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada, [email protected] Purpose or Case Report: This poster provides an introduction to Redcap (Research Electronic Data Capture), and discusses its advantages and perceived disadvantages. Methods & Materials: This educational poster is based on the author’s experience in using this software to conduct two research studies. One study was performed within the institution while the other was between different institutions. The reference materials used to prepare the poster include various official websites and documents related to Redcap and the information provided from the support services provided within the institution. Results: The readers will gain a good understanding of what Redcap is and whether it could be used to carry out their own research studies, either large or small. The poster also provides information on how this could be introduced within an institution, the sources of support that is available and how different teams could work together using this online tool.

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Conclusions: Redcap is a useful online tool that could be utilised to carry out research studies and surveys within and between institutions. It provides a high level of security and stability to create data collection forms, collect the research data. It also allows easy export of data to various formats in order to analyse the results. Poster #: EDU-047 MR-HIFU: Applications in Pediatric Oncology and Surgery

Karun Sharma, MD, PhD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Pavel Yarmolenko, Haydar Celik, Matthew Oetgen, AeRang Kim, Peter Kim Purpose or Case Report: Magnetic resonance-guided high intensity focused ultrasound (MR-HIFU) provides precise and controlled tissue heating by delivering focused ultrasound energy noninvasively (external transducer) or minimally invasively (intracavitary or laparoscopic transducer), without the need for large incisions and traditional surgery. This technology has been used to successfully ablate primary tumors of brain, breast, liver, prostate and uterus and to treat epilepsy and movement disorders. Although experience in children is limited, lack of ionizing radiation and noninvasive nature of MR-HIFU make it attractive for clinical investigation and application in the pediatric population. Methods & Materials: Our goal is to replace more traditional and invasive surgical approaches with minimally invasive or noninvasive techniques which may be more precise and reduce pain and morbidity. Towards this goal, we chose to pursue pediatric applications where MRHIFU is well-positioned to impact therapy. Results: We are evaluating safety and feasibility of MR-HIFU for ablation of relapsed and refractory pediatric solid tumors. While some patients may benefit from ablation, retrospective analysis of imaging indicates that a sizeable fraction of these patients may derive more benefit from a combination of MR-HIFU-mediated mild hyperthermia and local drug delivery in addition to ablation. This is especially true in cases where critical structures such as nerves could be spared through this combination. Another MR-HIFU application is in treatment of pediatric musculoskeletal disorders. Uneven limb growth occurs in approximately 40% of children and may require surgery in up to 8%, for which morbidity is high. MR-HIFU offers the possibility of noninvasive focal heating to ablate the growth plate without the need for open surgery and curettage. Preliminary data indicate that MR-HIFUmediated ablation of the physis in an ex-vivo model is feasible. The technology allows for precise targeting of the physis and its preferential heating compared to surrounding soft tissues and we are exploring feasibility and safety of this application in a swine model. Conclusions: MR-HIFU applications discussed above are promising. Pediatric patients may benefit from this research direction and development of other exciting possibilities in the central and peripheral nervous systems. Poster #: EDU-048 MR-HIFU: A Primer for Pediatric Radiologists

Karun Sharma, MD, PhD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Pavel Yarmolenko, Haydar Celik, Brad Wood, Raymond Sze, Peter Kim Purpose or Case Report: High intensity focused ultrasound (HIFU) has been used for decades to ablate tissue via focal ultrasound energy deposition which causes thermal and mechanical effects leading to

coagulative necrosis. However, translation into clinical practice was slow due to lack of an imaging modality that could guide and control HIFU treatment. These limitations have now been overcome with newer magnetic resonance-guided high intensity focused ultrasound (MR-HIFU) systems which allow for precise image guidance coupled with real-time feedback and control during treatment. Successful treatment of uterine fibroids, painful bone metastases and prostate cancer with MR-HIFU has been reported in adults. However, given the lack of ionizing radiation and noninvasive nature of this therapy, MR-HIFU may be even better suited for pediatric applications. Methods & Materials: This exhibit provides an overview of current MR-HIFU technology including transducer design with mechanical and electronic steering, MR integration and how real-time MR thermometry feedback can control and shape fairly large ablation zones. Current systems can precisely target and ablate lesions (often in difficult to reach locations in the body) through focal heat deposition without the need for surgical incisions. MR-HIFU mediated hyperthermia, ie. heating to temperatures lower than needed for tissue ablation, can also be used to enhance local tissue drug delivery. We will review ongoing preclinical work and clinical applications in pediatric oncology and surgery at our institution. Clinical applications for pediatric oncology include palliative treatment of recurrent/refractory soft tissue sarcomas and painful bone metastases through ablation and enhancement of local chemotherapy delivery with mild hyperthermia. Clinical applications for benign pediatric disease include noninvasive physeal disruption for limb length discrepancy and angular deformity as well as nerve ablation to treat chronic pain. Conclusions: MR-HIFU combines two technologies familiar to most radiologists (Ultrasound and MRI) to guide and perform noninvasive therapeutic interventions without ionizing radiation. Further development and wider adoption of this technology will likely require close collaboration between radiologists and members of several different clinical subspecialties. Pediatric radiologists, given their formal training in ultrasound and MRI should embrace this exciting new technology and become active members of such multidisciplinary teams. Poster #: EDU-049 Complications of Vascular Interventional Procedures in Children: A Radiographic Review

Lydia Kuo-Bonde, MD, PhD, Rachel Griggs, Radiology, UCLA, Los Angeles, CA, [email protected]; Ines Boechat Purpose or Case Report: To review various post-procedural imaging findings, including expected findings and those associated with complications, as seen on radiographs following image guided procedures. Methods & Materials: Evolving technology in the field of vascular interventional radiology has expanded treatment options available to certain subgroups of pediatric patients. Disease processes previously treated with surgery are now being treated adjunctively with or replaced by less invasive image-guided vascular procedures. As pediatric radiologists, it is important that we become familiar with expected postprocedural radiographic appearances. It is equally as important that we become familiar with potential procedural complications and their appearance on post-procedural imaging. Here we present a series of radiographic findings associated with common vascular interventional procedural complications. Being able to readily identify them will lead to quicker, more efficient management of this particular group of patients. Results: We present radiographic cases demonstrating complications of common interventional procedures, as well as a brief description of the appropriate therapeutic response. Cases include:

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– Both normal and persistent nephrograms, after vascular/cardiac catheterization – Embolization of a hepatic arteriovenous malformation with migration of onyx material into the pulmonary arterial system – Embolization of a vein of Galen malformation with migration of Nbutyl cyanoacrylate into the pulmonary arterial system – PDA closure device migration to the aorta – Ventricular septal closure device migration to the pulmonary artery Conclusions: As vascular interventional procedures are becoming more commonplace in the treatment of pediatric conditions, it is important that we have a good understanding of both expected post-procedural radiographic appearances and those appearances associated with procedural complication. Being able to readily radiographically identify these complications will lead to faster, more efficient patient management. Poster #: EDU-050 Multi-compartmental steroid joint injections of the wrist and ankles in juvenile idiopathic arthritis: Rationale and comprehensive review

Siddharth Jadhav, M.D., Texas Children’s Hospital, Houston, TX, [email protected]; J. Kan, MD Purpose or Case Report: Juvenile idiopathic arthritis (JIA) presents in children before 16 years of age and can be rapidly progressive and lead to significant disability if left unteated. Radiology plays an important role in localizing active disease as well as providing image guided local control with steroids when systemic therapy fails to control synovitis. The multiple joints and tendons about the ankle and wrist are very close together, and oftentimes it is challenging to localize based on clinical exam which joint is inflamed and requires targeted local control in children. The objective of this exhibit is to describe our approach and rationale for multi-compartmental (wrist and ankle) local control in patients with JIA. Methods & Materials: We will illustrate through case examples our approach of routinely using MRI initially to map which specific joints are inflamed followed by multi-compartmental fluoroscopic or sonographic guided steroid injections of the wrist and ankle. Results: The patients referred for fluoroscopically guided multicompartment steroid joint injections have an established diagnosis of JIA. Fluoroscopic guidance allows for precise intra-articular injections as opposed to blind injections. Sonographic guidance can be used for tendon sheath injections when needed. These patients are scheduled for a pre-injection MRI to localize the sites of active inflammation that will be targets for the steroid injection. We will discuss the use of combined preinjection wrist and ankle MRI protocol and steroid joint injections. We will also review the use of sedation, pre-procedure consent and corticosteroid dosage. The injection procedure will be reviewed for each of the joints with the focus on our technique. Post-procedure instructions and follow-up will be discussed. Finally we will review the complications that the radiologist needs to be aware of and the tips to minimize these complications. Conclusions: Fluoroscopically guided multi-compartmental steroid joint injections play an important role in management of refractory JIA by providing local control of inflammation to minimize cartilage damage. The effective management of JIA requires a multidisciplinary approach with both radiologist and rheumatologists working together in the care of these patients. Poster #: EDU-051 A pictorial review of Lisfranc injury in pediatric patients

Allison Johnsen, MD, Radiology, Vanderbilt University, Nashville, TN; Yu Luo

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Purpose or Case Report: Lisfranc injuries are rare in pediatric patients. Mechanisms of injury include forced forefoot plantar flexion, crush injury, axial loading on the heel with toes extended, and forced plantar flexion caused by falling onto the toes from a height (i.e., bunk bed fracture in pediatrics). Knowledge of normal ligamentous and articular anatomy of the tarsometatarsal (TMT) joints is critical to understanding the mechanism of Lisfranc injuries. Briefly, no transverse ligament is present between the first and second metatarsal bases as is present connecting the remaining metatarsal bases. The second metatarsal is positioned in a mortise formed by the medial and lateral cuneiforms and acts as a keystone in the arch of the foot. “Lisfranc’s ligament,” an oblique ligament extending from the medial cuneiform to the second metatarsal base, is implicated in TMT fracture-dislocations. This ligament may remain intact, resulting in an avulsion fracture of the lateral margin of the medial cuneiform or the second metatarsal base (“fleck sign”). Alternatively, this ligament may rupture, resulting in subtle widening of TMT joint spaces. Therefore, up to 20% of injuries are missed on initial radiographs. Significant morbidity is associated with unrecognized injuries, resulting in post-traumatic arthritis and ultimately requiring arthrodesis of the involved joint(s). This exhibit’s purpose is to discuss Lisfranc injuries in pediatric patients using a multi-modality case-based approach in order to help pediatric radiologists recognize this important entity. Methods & Materials: Cases of Lisfranc injury in adolescents from a busy tertiary children’s hospital are presented with a multimodality approach to illustrate the scope of findings in TMT fracture-dislocation. Results: We will present normal midfoot anatomy; the spectrum of Lisfranc injury patterns, from subtle to complex, in pediatric patients demonstrated by plain films, CT, and MRI; as well as current therapeutic approach. Conclusions: Review of normal midfoot anatomy and illustrative examples of the spectrum of findings in Lisfranc injury will assist the pediatric radiologist in recognizing this important diagnosis. Although rare in pediatric patients, a high index of suspicion must be maintained for TMT fracture-dislocations due to their often subtle appearance on plain films and high morbidity if untreated. Weight bearing films as well as advanced imaging with CT and MRI are often critical in detecting and/or fully characterizing the injury. Poster #: EDU-052 Using Low Dose Digital Slot-Scanning for Orthopedic Imaging in Children: How we do it

Steven Blumer, M.D., Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, [email protected]; Leslie Grissom Purpose or Case Report: The EOS system makes use of slot-scanning technology which allows pediatric radiologists to perform orthopedic imaging in children while utilizing lower doses than more conventional radiologic techniques. In this presentation, we review the EOS slot-scanning low dose imaging system and demonstrate how we use this system to image orthopedic abnormalities in children. We also review common artifacts seen on images obtained using this system and how to potentially correct them so that misdiagnoses as well as unnecessary future exams and intervention can be avoided. Methods & Materials: The relevant literature on slot-scanning technology will be reviewed. In addition, we will describe the technique used at our institution and also show relevant cases of orthopedic abnormalities imaged on the EOS system at our institution. Results: Many types of orthopedic abnormalities including scoliosis, limb deformities and skeletal dysplasia can be imaged using the EOS system and can be imaged using lower doses than conventional radiologic

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techniques. When reviewing these images, we also noted several common artifacts on these images and found solutions to correct some of them. Conclusions: The use of EOS slot-scanning technology has proven to be a helpful imaging modality to image orthopedic abnormalities reviewed in this presentation using the techniques described. Imaging can be performed at a lower dose than more conventional radiologic techniques. It is possible that the use of EOS imaging may prove to be helpful for other abnormalities as FDA approval has recently been granted for its use in diagnostic imaging in conditions other than orthopedic abnormalities. When using EOS, several characteristic artifacts may be encountered which are important to recognize to avoid misdiagnoses and other unnecessary exams and interventions. A better understanding of proper imaging techniques will allow correction or minimization of these artifacts. Poster #: EDU-053 Impact of a Novel Upright Low-dose Slot Scanner Biplanar X-ray System (EOS) in Pediatric Orthopedics

Nathan Hull, M.D., Mayo Clinic, Department of Radiology, Rochester, MN, [email protected]; Larry Binkovitz, Noelle Larson, Amy Kolbe, Kristen Thomas, Catherine Marks Purpose or Case Report: BACKGROUND: Pediatric skeletal disorders such as leg-length discrepancy, limb deformity and scoliosis typically require serial evaluation with x-ray studies for diagnosis, follow up and surgical planning. Similarly, 3D imaging of the skeleton for preoperative planning requires CT, which is high dose and typically obtained supine. A new, upright biplanar slot scanning X-ray system (EOS, EOS Imaging, Paris, France) offers a promising alternative low-dose imaging method for these patients. PURPOSE: To demonstrate the impact of EOS imaging on our orthopedic surgical practice in its first 6 months of use, we reviewed the EOS images of our first 450 pediatric cases since installation in March 2013. Our poster will review the basic technical aspects of low dose biplanar upright imaging, discuss its applications, limitations, and estimated radiation dosing from our unit. Strengths of the EOS include clarity of the lateral imaging, ease of use for radiology techs, and the ability to construct 3D models. Limitations include motion artifact and a labor-intensive 3D morphing/modeling process. We will provide examples of its impact on the surgical planning for pediatric spinal and limb deformity torsion with numerous case examples. Poster #: EDU-054 Whole Body MRI of Juvenile Spondyloarthritis: Protocol and Characteristic Patterns

Michael Aquino, MD, Radiology, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Shirley Tse, Jennifer Stimec Purpose or Case Report: Background: Spondyloarthritis refers to a group of immune-mediated inflammatory arthritides with overlapping features. Juvenile spondyloarthritis differs from adult spondyloarthritis in that it often manifests as peripheral arthritis and enthesisitis and rarely involves the axial skeleton at presentation. The juvenile spondyloarthritides are largely encompassed by the International League of Associations for Rheumatology classification under the enthesitis-related arthritis, psoriatic arthritis and undifferentiated arthritis subgroups. Whole body MRI is an important tool for identifying characteristic patterns of involvement to aid in early diagnosis and proper

classification. Early recognition of juvenile spondyloarthritis is critical to ensure early therapeutic intervention. The purpose of this exhibit is to 1) describe the whole body MRI imaging protocol, and 2) depict the characteristic patterns of involvement in juvenile spondyloarthritis on whole body MRI. Methods & Materials: Whole body MRI studies of patients with known juvenile spondyloarthitis were reviewed. Images depicting characteristic areas and patterns of involvement will be presented with corresponding clinical histories. Results: Asymmetric lower limb oligoarthritis (hips, knees, ankles) is most common in juvenile spondyloarthritis at presentation. Tarsitis is noted in upto a third of patients at presentation. The shoulder can be involved, though infrequently. Spine and sacroiliac joint involvement at presentation is less common than in adults but can develop within 5– 10 years from disease onset. Common sites of enthesitis include the inferior pole of the patella, plantar fascial insertion into the calcaneus or metatarsal head and Achilles tendon insertion into the calcaneus. Multiple sites on the pelvis are also frequently involved. Conclusions: Whole body MRI allows identification of characteristic patterns of involvement that aid in diagnosis and classification of juvenile spondyloarthitides. Poster #: EDU-055 Imaging of Systemic Vasculitis in Childhood: A “Geographic” Pictorial Essay

Magdy Soliman, consultant, The Hospital for Sick Kids, Department of Diagnostic Imaging, Toronto, ON, Canada, [email protected]; Ronald Lanxer, David Manson, Andrea Doria Purpose or Case Report: Background: The term “vasculitis” encompasses a diverse set of diseases linked by the presence of blood-vessel inflammation which are often associated with life-threatening or critical complications. This set of diseases is uncommon in childhood and frequently subjected to a delayed diagnosis. Awareness of the manifestations of childhood vasculitis is important to start early management, thus avoiding long term disabling morbidity and fatal complications of the disease process. Purposes: (1) to describe the imaging findings (x-ray, ultrasonography, computed tomography [CT], MRI and nuclear medicine) of the different systemic vasculitides in the pediatric population according to a “geographic” algorithm of distribution of vessel involvement[Chapel Hill Consensus Conference (2012)]. (2) to report the most frequent imaging findings of systemic vasculitis of childhood. (3) to develop a differential diagnosis of vasculitis and vasculitis-mimic conditions. Methods & Materials: Retrospective data collection for a pictorial essay. Results: We illustrate imaging findings of common vasculitides in childhood according to the Chapel Hill classification algorithm, which broadly categorizes systemic vasculitis into small-vessel (IgA vasculitis, Henoch-Schonlein, ANCA-associated small vessel vasculitis, granulomatosis with polyangiitis; GPA, microscopic polyangiitis, Churg-Strauss vasculitis), medium-vessel (polyarteritis nodosa, Kawasaki disease) and large-vessel (Takayasu arteritis) disease. Whenever a close differential diagnosis exists, its imaging is demonstrated and discussed. The relevant demographic, clinical and laboratory data as well as reference to the classification algorithm matching the described diseases are mentioned to deliver a comprehensive knowledge to radiologists and clinicians. This information can help them reach an early diagnosis aiming at better patient management.

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Conclusions: Multimodality imaging assessment of childhood vasculitis according to an algorithm of distribution of vessel involvement may provide clinicians with additional information for evaluating tissue/ organ damage, monitoring disease progression and guiding therapeutic decisions. Poster #: EDU-056 Fluoroscopic arthrography, a forgotten tool in evaluating shoulder pathology in the pediatric patient

Seth Vatsky, DO, Diagnostic Imaging, Phoenix Children’s Hospital, Scottsdale, AZ, [email protected]; Scott Jorgensen, MD, Mittun Patel, MD, Deepa Biyyam, MD, Smita Bailey, Craig Barnes, MD Purpose or Case Report: Early descriptions of shoulder arthrography technique were by Oberholzer and Samilson in the 1930’s. The technique was infrequently performed because of limited therapeutic options available at the time. By the 1980’s development of arthroscopic technological tools were available to help repair rotator cuff and labrum injuries. These developments spurred shoulder imaging to evaluate for internal derangement. By this time, MRI had supplanted fluoroscopic imaging as the method of choice to evaluate the shoulder, resulting in limited experience and expertise in fluoroscopic arthrography for the majority of radiologists. The process of fluoroscopic shoulder joint arthroscopy is, in essence, always preformed with MRI arthrograms, as the radiologist injects the joint under fluoroscopy. By obtaining a few additional images while the patient is in the fluoroscopy suite, a traditional fluoroscopic arthroscopy is obtained. We retrospectively reviewed 120 pediatric shoulder MRI and the corresponding fluoroscopic arthrograms performed over a 5-year period from 2008 to 2013. We found fluoroscopy interpreted in conjunction with the MRI evaluation often aided in demonstrating or confirming a diagnosis. This review provided an excellent opportunity to reevaluate the lost art of shoulder arthrography. In this exhibit we will describe our protocol for shoulder arthrography, provide a systematic method of evaluation, and provide examples of common pathology with corresponding MRI images. In summary, imaging for internal derangement of the shoulder is best performed utilizing both fluoroscopic and MRI techniques. Poster #: EDU-057 Lytic acetabular tumors in the pediatric population

Brian McMahan, M.D., Radiology, Indiana University School of Medicine, Indianapolis, IN, [email protected]; Rong Fan, Boaz Karmazyn, MD Purpose or Case Report: Primary lytic acetabular tumors are rare in children, and have been described only in a few case reports or small series. Our purpose is to correlate imaging and pathologic findings in children with lytic acetabular tumors in order to improve imaging diagnosis and thereby guide treatment. Methods & Materials: We identified all patients at our tertiary care children’s hospital from January 2003 to December 2012 who had both imaging and pathologic evidence of a lytic acetabular tumor. We then reviewed their medical records and excluded all patients with known malignancy. Presentation, lesion size and location, pathologic findings, and pertinent follow-up information were documented. Results: Ten children (six female) with primary lytic acetabular tumors were identified. Their mean age was 12.9 years (range 4.3 to 17.7 years). All presented with hip pain. Mean tumor size was 3.0 cm (range 0.6 to 8.5 cm). Seven of 10 tumors were localized to the posterior column of the acetabulum. Osteoblastic tumors were the most common (n=5) and included osteoid osteoma (n=3) and osteoblastoma (n=2). The remaining

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tumors included aneurysmal bone cyst (ABC, n=2), Langerhans cell histiocytosis (LCH, n=1), benign fibrous histiocytoma (n=1), and bone cyst (n=1). The lytic lesion was missed on radiography in three patients (two with osteoid osteoma and one with ABC). Two patients had recurrence after surgery; the child with LCH developed systemic disease 2 years after initial diagnosis and was treated with chemotherapy, while one child with ABC developed recurrence 6 months after curettage. Conclusions: All of our pediatric patients with lytic acetabular tumors presented with hip pain. Radiography may be negative and if this diagnosis is clinically suspected, CT or MR should be performed. Osteoblastic tumors (osteoid osteoma and osteoblastoma) were the most common lytic tumors identified. Poster #: EDU-058 Cartilage Injuries of the Pediatric Knee

Naomi Silva, MD, Radiology, Miami Children’s Hospital, Miami, FL, [email protected]; Mona Yasrebi, Anjeza Chukus, Ricardo Restrepo, Rachel Pevsner, DO Purpose or Case Report: To describe basic histology, pathophysiology, and mechanism of injury affecting the articular cartilage as well as different pathologies and normal variants that can affect the articular cartilage of the pediatric knee. Methods & Materials: We will discuss the following subjects in this order: Normal epiphyseal development throughout skeletal maturation and the MR appearance. Histology and composition of the normal articular cartilage stressing the osteochondral unit concept and its normal development. Old and new MR sequences to evaluate articular cartilage and protocols for different clinical scenarios. Normal variants encountered around the knee. Pathophysiology of articular cartilage injury based on the concept of osteochondral unit, including the different mechanisms of injury. Different pathology that can affect the articular cartilage, their etiology and radiographic and MR appearance: spectrum of injury after acute trauma from bone marrow contusions to osteochondral fractures, osteochondritis dissecans, chondromalacia patella, arthritides and infection. Results: New MR sequences and protocols for evaluating the articular cartilage of the pediatric knee are beneficial to the radiologist and ordering physicians in determining the cause and etiology of many common pediatric knee clinical scenarios. These new sequences and protocols further enable accurate diagnosis of acute versus chronic injuries to the osteochondral unit of the pediatric knee and subsequent proper treatment. Conclusions: Knowing the histology and composition of the articular cartilage as well as the pathophysiology and mechanism of injury is important in understanding the different entities (including normal variants) affecting the articular cartilage of the knee in children and their appearance on MRI. Poster #: EDU-059 Transient patellar dislocation in pediatric patients: Evaluation of the preoperative, normal postoperative, and complicated postoperative states

Mark Sharafinski, MD, Medical College of Wisconsin, Department of Radiology, Milwaukee, WI, [email protected]; Arthur Meyers, MD, Tal Laor Purpose or Case Report: Transient patellar dislocation (TPD) is a common entity in pediatric patients, characterized by lateral dislocation of the patella with spontaneous reduction. Predisposing conditions

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include trochlear dysplasia, lateral patellar tilt and subluxation, patella alta, and lateralization of the tibial tuberosity. Imaging findings include bone contusions of the medial patella and lateral femoral condyle, cartilage injuries of the patella and lateral femoral condyle, intraarticular bodies, injury of the medial patellofemoral ligament (MPFL), and tears of the vastus medialis obliquus muscle. A variety of surgical procedures have been developed to treat patients with TPD including: lateral retinacular release, MPFL reconstruction, and tibial tubercle repositioning. Often a combination of these procedures may be performed. The purpose of this educational exhibit is to review the MRI findings of TPD and to demonstrate the expected appearance and complications of operative management. Methods & Materials: We reviewed knee radiographs and Magnetic Resonance (MR) examinations performed at two large pediatric medical centers for patients with suspected or known TPD. Representative images were selected to demonstrate the typical post-injury findings, the normal post-operative appearances, and post-surgical complications. Results: Radiographs of pediatric patients with TPD may show joint effusions, lateral patellar tilt or subluxation and osteochondral injuries. MRI examinations reveal a variety of abnormalities, including: bone contusions of the medial patella and the lateral femoral condyle, cartilage injuries throughout the articular surface of the patella and of the lateral femoral condyle, intra-articular condral and osteocohondral bodies, injuries of the MPFL at its patellar and femoral insertion sites, and tears of the vastus medialis obliquus muscle. Post-operative images demonstrated procedure-specific findings and patterns of failure. Conclusions: TPD is a common cause of anterior knee pain in pediatric patients. Radiologists interpreting imaging in these patients should be familiar with the radiographic and MR imaging appearance of the injury patterns encountered in TPD, the surgical procedures performed to prevent TPD and the complications of those procedures. Poster #: EDU-060 Imaging of the pediatric sacrum and sacroiliac joints: sometimes a pain in the butt!

Benjamin Yam, MD, Hospital of the University of Pennsylvania, Philadelphia, PA, [email protected]; Sudha Anupindi, Reza Daugherty, Monica Epelman, Asef Kwaja, Nancy Chauvin, MD Purpose or Case Report: The sacrum and sacroiliac joints can exhibit a diverse range of pathology in the pediatric population. Sacral abnormalities maybe related to a localized disease process or represent involvement as part of a wider systemic disorder. Furthermore, findings can be either symmetric or asymmetric in either case. As a consequence the differential diagnosis for sacral abnormalities is vast and organization by etiologic mechanism can be helpful. Classification into congenital, traumatic, infectious, inflammatory, and neoplastic etiologies is one way to do so. This exhibit will review the spectrum of sacral and sacroiliac radiologic findings and the roles of various imaging modalities commonly used. Epidemiology, pathogenesis, clinical findings, and treatment will be reviewed. Methods & Materials: We plan to present the multimodality imaging spectrum of sacral and sacroiliac findings in the pediatric population with particular attention to normal development, variant anatomy, pathology, and pitfalls in diagnosis. We will do so by organizing abnormalities according to differential diagnoses. Our discussion will include traumatic processes: acute trauma and repetitive stress injury; congenital lesions: sacral agenesis, sacrococcygeal teratoma and anterior meningocele; nonaggressive neoplasms: osteoid osteoma and aneurysmal bone cyst; aggressive neoplasms: chordoma, plasmacytoma, and metastases; infections: pyogenic septic arthritis, tuberculous sacroiliitis; and inflammatory disorders: chronic noninfectious osteomyelitis, juvenile idiopathic arthritis, inflammatory bowel disease-related sacroiliitis, and pigmented villonodular synovitis.

Results: An organized approach should be used to evaluate each sacral lesion encountered in practice with particular attention to location, appearance, and differential diagnosis. Multiple imaging modalities are useful for diagnosing these lesions and therefore awareness of the strengths and limitations of each modality is necessary. Conclusions: Familiarity with the multimodality imaging spectrum and differential diagnoses of normal and abnormal pediatric sacral and sacroiliac joint processes allows for accurate characterization and diagnosis of a wide range of disease entities. Poster #: EDU-061

Withdrawn Poster #: EDU-062 Maturation of the Triradiate Cartilage on CT in Healthy Children

Leslie Grissom, Nemours/AI duPont Hospital for Children, Wilmington, DE, [email protected]; Grace Guo, Mary Harty Purpose or Case Report: To describe the normal appearance of the triradiate cartilage on CT scans in boys and girls of various ages in order to differentiate normal development from pathology. Methods & Materials: We retrospectively reviewed 300 CT scans of healthy children ranging in age from 5 to 15 years, using axial images and coronal/sagittal 2-D reconstructions in bone algorithm to evaluate the triradiate cartilage. We examined abdomen/pelvis CT scans of patients seen in our tertiary care children’s hospital, excluding any cases involving patients with bone disease, pelvic bone trauma and other conditions that would affect bone development. The appearance of the triradiate cartilage for each scan was classified based on 1) open triradiate cartilage with no ossification; 2) multiple small secondary ossification centers; 3) large secondary ossification centers; 4) fused triradiate cartilage in order to determine at what age by gender the triradiate cartilage ossifies and fuses and how it appears on CT. The irregularity of the acetabular roof was graded by the degree of fragmentation on axial images. Results: Small ossification centers begin to appear by age 7, progressing to larger ossification centers around age 10. Fusion begins during the 13th year of life. There are gender differences in age of appearance of ossification centers. During the ossification process, on axial images the acetabular roof is very irregular with various sized bone fragments normally seen. Images document the stages of ossification of the triradiate cartilage and acetabular roof. Conclusions: The triradiate cartilage ossifies in fragments starting in the latter half of the first decade of life and concluding in the early second decade of life. During the ossification process there is marked irregularity of the acetabular roof and fragmented ossification of the triradiate cartilage on CT which can be mistaken for pathology. It is important to be familar with the normal development and appearance of the triradiate cartilage. Poster #: EDU-063 MR Arthrogram of the Shoulder in Children: A Correlation between Radiologic and surgical Findings

Amer Alaref, MD, MCs, Diagnostic Imaging, Children Hospital of Eastern Ontario, Ottawa, ON, Canada, [email protected]; Nazih Shenouda, Nishard Abdeen, Adnan Shiekh, Khaldoun Koujok Purpose or Case Report: To describe and illustrate the imaging spectrum of shoulder abnormalities identified by MR arthrography in pediatric

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patients, correlated to surgical results. The pathology in pediatric age group is different from adults due to immature skeleton and open growth plates. Methods & Materials: We will present a review of MR arthrogram studies performed at the children’s hospital of eastern Ontario (CHEO), Ottawa. In our educational exhibit, we will discuss the technique, anatomy, and normal variants such as Buford complex. Then we will describe different types of labral tears seen in this age group, especially those seen after shoulder dislocation. Other pathologies such as Hill-Sachs, Bankart lesion, as well as paralabral cyst will also be discussed. Most shoulder arthrogram cases are performed after recurrent dislocations. Then we will correlate our results to the post operative surgical or arthroscopic report Results: MR arthrogram is particularly helpful in diagnosing tears of the glenoid labrum, which can be critical when evaluating the anterior labrum in the setting of traumatic anterior shoulder dislocation. Posterior shoulder dislocation is much less common than anterior dislocation. The objective of this presentation is to present an educational exhibit of shoulder arthrogram technique, anatomy, and normal variants, and present classical imaging findings of various types of shoulder pathology in children. Conclusions: This pictorial review illustrates that MR arthrogram of the shoulder is the modality of choice for evaluation of shoulder joint pathology and can be particularly useful for evaluation of labral abnormalities. The advantages of MR arthrogram are particularly evident when evaluating acute pathology in younger active patients. It continues to prove its superiority to conventional MR imaging for a growing number of indications. Poster #: EDU-064 “You Are My Density”: Sclerotic Bone Lesions in Children

Teresa Liang, MD, University of British Columbia, Vancouver, BC, Canada, [email protected]; Lila Yewchuk Purpose or Case Report: Sclerotic bone lesions are not uncommon in the pediatric population. However, these lesions can look similar and yet be attributed to various causes, some of which require urgent attention. Therefore, it is important to have an organized approach, recognizing the characteristics of each cause for efficient and effective management. Thus, the purpose of this pictorial review is to review a comprehensive and logical approach to sclerotic bone lesions in the pediatric population through a variety of sample cases. Methods & Materials: A retrospective review of multiple radiographic examinations in patients with sclerotic bone lesions was performed at BC Children’s Hospital. Multiple examples of classic imaging findings of each of these lesions were compiled and placed into a pictorial review. Results: This poster will review a systematic approach to sclerotic bone lesions in children. After briefly discussing the most common such lesions in adults, we will review the epidemiology, pathophysiology, clinical presentation, and characteristic imaging findings of pediatric sclerotic bone lesions, such as: enostosis, osteoma, osteochondroma, enchondroma, stress fracture, osteoid osteoma, osteoblastoma, chronic osteomyelitis, ossified non-ossifying fibroma and osteosarcoma in focal cases, and osteopoikilosis, chronic non-bacterial osteomyelitis (CNO), and bone infarcts in multifocal cases. Exceptional cases where usually lucent lesions can, on occasion, be sclerotic—like langerhans cell histiocytosis and fibrous dysplasia—will also be discussed. Emphasis is on plain film evaluation, and in certain circumstances, multimodal imaging with CT and/or MRI. Conclusions: Sclerotic bony lesions are not an uncommon finding in the pediatric population, however, their common etiologies differ from adults. Having an organized, systematic approach and knowledge of their

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characteristic findings will aid early and accurate diagnosis and management.

Poster #: EDU-065 Palpable Masses of the Pediatric Foot and Ankle: Imaging Evaluation

Murray Bartlett, MBBS FRANZCR, Diagnostic Imaging, Royal Childrens Hospital Melbourne, Parkville, VIC, Australia, [email protected] Purpose or Case Report: The purpose of this study is to present a review of palpable lesions of ankle and foot in the pediatric population with an emphasis on typical imaging features. Both non-specific and pathognomonic imaging features of the common and rare pathological entities of the pediatric ankle and foot are discussed. Methods & Materials: A review of all palpable masses in the pediatric foot were obtained via the institution PACS/RIS and pathologic confirmation obtained. Results: The lesions are broadly classified as neoplastic and nonneoplastic. Non-neoplastic lesions include a heterogeneous group of entities, comprising ganglion cysts, vascular malformations, infections, Morton neuroma, etc. The neoplastic lesions include benign masses e.g., hemangioma, lipoma, fibroma, bone cyst and giant cell tumor and the malignant lesions include sarcomas of various types and malignant peripheral nerve sheath tumor. Conclusions: A wide spectrum of neoplastic and non-neoplastic lesions present as palpable mass of the foot and ankle region in children. Imaging plays a pivotal role in characterization, diagnosis and differentiation of these pathological lesions. Certain lesions have a characteristic imaging appearance leading to prompt diagnosis, while some lesions have a non-specific appearance and differentiation between benignity and malignancy may not be possible at imaging alone.

Poster #: EDU-066 Vertebral lesions in children: A pictorial review

Madalsa Joshi, MD, BC Children’s Hospital, Vancouver, BC, Canada, [email protected]; Heather Bray, Lila Yewchuk Purpose or Case Report: To review common vertebral lesions in the pediatric population and become familiar with their radiographic appearance. To emphasize the importance of plain film evaluation of the pediatric spine and provide guidance when adjunct imaging (CT, MRI, nuclear medicine, PET/CT) is required to further evaluate these lesions. Discuss the epidemiology and clinical presentation of vertebral lesions in children. Review the imaging characteristics that help differentiate aggressive from non-aggressive bony lesions. Provide relevant representative cases using site specific differential diagnosis including congenital, traumatic, infection, inflammation (chronic recurrent multifocal osteomyelitis), benign tumors (aneurysmal bone cyst, osteoid osteoma), malignant tumors (osteoblastoma, Langerhans cell histiocystosis, metastatic disease) and vascular. Multimodality imaging of each lesion will be reviewed with important pearls to aid diagnosis. Conclusions: Vertebral lesions in the pediatric age group may not be commonly encountered by the general radiologist. Becoming familiar with the site specific differential diagnosis and characteristic imaging findings will help aid diagnosis and direct patient management in a timely fashion; the goal, to avoid unnecessary patient morbidity.

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Poster #: EDU-069

Imaging of Non-Traumatic Pediatric Foot Deformities: A Clinical Perspective

Susceptibility-weighted imaging: a powerful diagnostic tool in pediatric neuroimaging

Matthew Winfeld, MD, Radiology, NYU, New York, NY, [email protected]; Brittany Winfeld

Thangamadhan Bosemani, Section of Pediatric Neuroradiology, Division of Pediatric Radiology,The Johns Hopkins School of Medicine, Baltimore, MD, [email protected]; Andrea Poretti, Thierry Huisman

Purpose or Case Report: The management of pediatric foot deformities is very complex. A variety of surgical and non-surgical management options exist for each condition, and imaging is an important element when assessing the progress of these patients. In this collaborative effort between radiologists and podiatrists, we demonstrate keys to the diagnosis of these disorders, management options and the biomechanical principles that govern these strategies, and clinical goals of treatment with an emphasis on expected imaging findings. Topics include disorders such as talipes equinovarus, congenital vertical talus, brachymetatarsia, tarsal coalition, pes planus, pes cavus, and polydactyly. Methods & Materials: Searches were performed via PACS and clinical case logs from the past 5 years at two institutions for cases of nontraumatic pediatric foot deformities in which intervention was performed and imaging follow-up was obtained. All radiographic and clinical images were de-identified prior to inclusion. Results: Representative radiographic studies and clinical images were selected that best exemplify the diagnosis and management of various non-traumatic pediatric foot deformities. Conclusions: This educational exhibit comprehensively explains the principles of diagnosis and clinical management of pediatric foot deformities. Radiologists will have a better understanding of the expected radiographic appearance of these foot abnormalities at various stages of management to improve communication with referrers. Emphasis is placed on the elements of a radiology report that will best aid the pediatric podiatrist or orthopedist.

Purpose or Case Report: Susceptibility-weighted imaging (SWI) is a high-spatial-resolution, 3D, fully velocity compensated, gradient-echo magnetic resonance imaging (MRI) technique which accentuates the magnetic properties of various substances such as blood, blood products, non-heme iron and calcification. SWI has rapidly become a key MR sequence in pediatric neuroimaging with its utilization significantly expanding recently. The strength of SWI lies not just in its ability to identify hemorrhage, calcium or non-heme iron by virtue of its susceptibility artifact, but also more importantly, the strength of the blood oxygen level dependent venography principle. The recognition, early diagnosis and even prognosis of various pediatric neurological diseases have been made possible. In this educational exhibit, we will review and discuss the utility of SWI in pediatric neuroimaging in establishing the diagnosis, differential diagnosis, and also understanding of the pathomechanism of various pediatric brain pathologies. After a short introduction explaining the principles of SWI, we will discuss the role of SWI in following pediatric neurology diseases: intracranial hemorrhage, traumatic brain injury, cerebral vascular malformations, acute arterial stroke, sinus venous thrombosis, hypoxic-ischemic injury, infections, tumors, neurodegenerative and metabolic disorders. Finally, we will discuss the potential pitfalls in the interpretation of SWI studies. The familiarity with the technique and its applications should enable clinicians to identify, interpret, classify, diagnose, treat and manage children with neurological diseases. Poster #: EDU-070

Poster #: EDU-068 Ultrasound of “Lumps and Bumps”: A Pictorial Essay

Mary Drake, MD, Children’s Hospital and Medical Center, Omaha, NE, [email protected]; Sandra Allbery, MD

Purpose or Case Report: Ultrasound imaging of pediatric lumps and bumps is a common procedure at our institution, with recent advances in the literature on the imaging findings beyond just characterizing the lesion as cystic versus solid. The advent of high-resolution linear probes has resulted in improved visualization of these lesions. Often soft tissue lesions will have characteristic features on ultrasound that allow for confident diagnosis based on imaging alone, while others have ultrasound features that can limit the differential and aid further management. Based on a review of 231 cases from 8–2010 to 8– 2013, we will present a pictorial review of ultrasound of 25 representative soft tissue lesions at our institution with pathologic correlation and corresponding cross-sectional imaging modalities when relevant. While an all-encompassing management schema may not be achievable for soft tissue masses, general management strategies and management of characteristic lesions will also be addressed.

Acute Toxic Brain Injuries in Children: a Simple Approach to Rapid Radiological Diagnosis

Laura Hayes, M.D., Radiology, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Susan Palasis, MD, Damien Grattan-Smith Purpose or Case Report: To aid in understanding and provide an easy approach to interpreting imaging studies of children with acute toxic brain injuries. Various neurotoxins have deleterious effects on the brain that yield uniquely identifiable imaging patterns. In an effort to facilitate improved image interpretation, often without a relevant history, a novel step-wise approach has been created to assist in rapid identification of the toxin. Prompt diagnosis is critical, as most injuries are reversible with timely treatment. Illustrative cases and a discussion of the underlying pathophysiology are provided in order to reinforce knowledge and enrich understanding of neurotoxic injuries in children. Methods & Materials: An in depth review of the literature of toxic brain injuries was performed. Neurotoxins of interest include: opiates, tolulene, methanol, carbon monoxide, ethylene glycol, cyanide, lead, methotrexate, cyclosporine, tacrolimus, and metronidazole. Cases from our institution were identified by a review of radiology reports with IRB consent. The patterns of injury on brain scans were analyzed, and the pathophysiology was reviewed. A step-wise method of image interpretation was created based on involvement of certain structures: cortex, white matter, and/or gray matter, and this was further broken down into subdivisions of white and gray matter. Results: Although there is overlap in the neuroimaging findings of acute toxic brain injury, a step-wise analysis of images can readily allow either a very narrow differential or absolute identification of the offending agent. In

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most instances, certain susceptible structures are injured by each toxin. Predominant white matter injury is caused by opiates, tolulene, and methotrexate. Predominant gray matter injury is caused by carbon monoxide (globus pallidus), methanol (putamen), lead (caudate and putamen), and cyanide (caudate, putamen, and globus pallidus). The dentate nuclei are invariably injured by metronidazole. Cyclosporine and tacrolimus produce the posterior reversible encephalopathy syndrome (PRES) pattern. Conclusions: The cases demonstrated in this exhibit and the discussion of the pathophysiology should solidify a firm understanding of toxic brain injuries in children. A step-wise approach to image interpretation is helpful, especially when the images are confusing and time is of the essence. As the incidence of toxic brain injuries increases, the ability to diagnose these insults accurately and efficiently will aid in improved outcomes for these children. Poster #: EDU-071 Zebras in the Pediatric Brainstem

Aditi Hendi, M.D., Radiology, Thomas Jefferson University Hospital, Philadelphia, PA, [email protected]; Vinay Kandula

Methods & Materials: Of the lesions in the brain, 11% are present in the brainstem and in order to differentiate between them, judicious use of DWI, gradient, contrast and FLAIR sequences is necessary. By correlating signal characteristics, distribution of signal, location of lesion, enhancement pattern, restricted diffusion pattern along with associated findings in the remaining brain, one can narrow the differential. Synthesis of all available data enables specific diagnoses and recommendations are contributed to the clinical discussion. Results: Decreased gradient signal corresponding with calcifications and masses within the globes support a diagnosis of Coats Plus Syndrome. Similarly, restricted diffusion, hypointensity on gradient sequence representing hemorrhage and very minimal peripheral lesion enhancement in association with multicompartment involvement in an immunocompromised patient supports a diagnosis of Aspergillosis. In addition to these example cases, unique imaging characteristics of Alexander disease, Histiocytosis and MERRF will be described. Conclusions: Uncommon lesions in the brain stem beget markedly different treatments. Knowledge of their distinguishing clinical and imaging characteristics enable the radiologist in guiding the clinicians towards best standard of care. Poster #: EDU-072

Purpose or Case Report: Definitive MRI characterization of pediatric brainstem lesions remains a challenge because of overlapping presentations and their near-identical appearance on standard sequences. Because pediatric patients are rarely hospitalized unless very ill, uncommon disease processes must be considered within the differential. However, as most of these lesions are difficult to access for biopsy, imaging plays a unique role in this patient population in directing the course of care. Using T2/FLAIR, gradient, DWI and contrast, pediatric brainstem “zebras” are differentiated and explained both by imaging characteristics and supporting clinical information. This systematic approach to evaluating the pediatric brainstem will improve accuracy and add value to the care of the patient. The goal of this educational exhibit is to familiarize radiologists of all backgrounds with pediatric brainstem pathology. Emphasis will be placed on clinical correlation and identifying specific morphologic features which are characteristic for each type of lesion. Specific disease processes include: MERRF, Coats Plus Syndrome, Alexander disease, Histiocytosis and Aspergilloma. Disease Process

Contrast Enhancing

DWI

Acute Infarct Cavernoma Coats Plus Syndrome Aspergillosis Histiocytosis Alexander disease MERRF

No No Mild linear Minimal Peripheral Yes Yes No

Restricted Variable n/a Restricted Restricted n/a Restricted

Pictorial review of pediatric syndromic CNS vascular disorders

Prakash Muthusami, Department of Medical Imaging, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Helen Branson, Mike Seed, Timothy Bradley, Sarah Bowdin, Susan Blaser Purpose or Case Report: Background: Syndromic CNS vascular disorders are being increasingly recognized. Imaging is performed for screening if the disorder has been recognized in family members or may be obtained only after a catastrophic complication in a child not previously identified as syndromic. The pattern of vascular abnormality may be specific. CNS and systemic clues are useful in suggesting a diagnosis when it is not. Purpose: To illustrate the CNS and non-CNS vascular and non-vascular imaging manifestations of these disorders. Methods & Materials: Patients were identified via an IRB/REB approved retrospective radiology text search (ISYS tm). Arterial MIP reconstructions were evaluated for specific patterns. Additional clues t2o the diagnosis were sought on brain, spine and abdominal imaging studies.

Gradient Echo Dark No Yes Yes Yes No n/a No

Disease Process

T2/FLAIR Bright

Location/Distribution/Pattern/ Other

Acute Infarct

Yes

Pons, medulla

Cavernoma

Peripheral Rim

Mulberry-like cluster of thin, dilated capillaries

Coats Plus Syndrome

Yes

Orbital hamartomas

Aspergillosis Histiocytosis

No; hypointense Multicompartment rim Mild Multicompartment; diabetes insipidus

Alexander disease

Yes

Frontal, brainstem

MERRF

Yes

Brainstem, cerebellar

Results: There are characteristic vascular appearances that define certain conditions. CNS vascular changes such as arterial tortuosity (Loeys-Dietz syndrome, Arterial Tortuosity Syndrome and Menkes disease), straightening (ACTA-2 mutation), aneurysms (polycystic kidney disease, microcephalic osteodysplastic primordial dwarfism type II), arteriovenous malformations (hereditary hemorrhagic telangiectasia), steno-occlusive lesions (Hutchinson-Gilford progeria) or moyamoya patterns

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(Neurofibromatosis-1) may be seen. Non-CNS vascular clues include medial deviation of pharyngeal carotid arteries (22q11 deletion), aortic ectasia (Loeys-Dietz syndrome, arterial tortuosity syndrome) or stenosis (Takayasu disease). Non-vascular clues may further aid in identifying the disorder. CNS clues include FASI (Neurofibromatosis-1), posterior fossa abnormalities (PHACES association) and leukoencephalopathy (ACTA2 mutation syndrome). Colobomas in association with congenital or progressive vascular occlusions may be present (Morning Glory Syndrome). Spinal clues include C1-2 anomalies (22q11deletion Syndrome) amongst others. Musculoskeletal clues such as hyperlax joints (EhlersDanlos) or arthritis (SLE) may be present. Conclusions: CNS vascular abnormalities may be specific like the arterial straightening in children with ACTA-2 mutation. Less specific vascular patterns such as tortuosity or moyamoya appearance may be seen in several disorders. Additional CNS and non-CNS imaging clues may aid the radiologist and geneticist in suggesting and planning an appropriate diagnostic approach.

Poster #: EDU-073 Pre- and Post-operative MRI Imaging of Endoscopic Third Ventriculostomy

Ho Nguyen, MD, Radiology, Seattle Children’s Hospital, Seattle, WA, [email protected]; Gisele Ishak, Hedieh Eslamy, MD Purpose or Case Report: Hydrocephalus is a common but complex disorder with different etiologies that include: a. Disturbance of CSF flow or absorption - intraventricular or extraventricular obstructive hydrocephalus. b. Loss of thecal compliance (Greitz model of CSF hydrodynamics). c. CSF overproduction - choroid plexus papilloma or diffuse villous hyperplasia of the choroid plexus. Endoscopic third ventriculostomy (ETV), with or without choroid plexus cauterization, is an alternative to extracranial shunting in patients with intraventricular obstructive hydrocephalus. MRI is optimal for preoperative evaluation of ETV candidates and postoperative evaluation of technical success and complications. We discuss our protocol for imaging and interpretation and present cases.

Table 1. MRI Sequences and Interpretive Criteria for Endoscopic Third Ventriculostomy A Pre- and post-operative brain MRI sequences: 1 Standard sequences: non-contrast - sagittal T1 Ultrafast Gradient Echo 3D (with axial and coronal reformats), axial and coronal SE T2, axial FLAIR, axial Diffusion-Weighted Imaging. Optional: axial Susceptibility-Weighted Imaging or Gradient Echo.

2 Specific sequences: sagittal SE T2 (2mm thick, contiguous), sagittal T2 True FISP/Dual Excitation (with axial and coronal reformats), sagittal phase contrast perpendicular to the floor of the third ventricle (venc of 5cm/s). 3 Optional sequences: sagittal T2 3D TSE with Variable Flip Angle, axial phase contrast parallel to the floor of the third ventricle placed at the level of the interpeduncular cistern and/or prepontine cistern (venc of 5cm/s) B Pre-operative MRI to determine whether the patient is a candidate for ETV. Assess: 1 Presence of intraventricular obstructive hydrocephalus 2 Potential etiologies for obstructive hydrocephalus 3 Presence/absence of spontaneous third ventricular stoma formation. 4 Presence/absence of interpeduncular and/or prepontine cistern arachnoid membranes and Lilliequist membrane (is Lilliequist membrane partial or complete?). 5 Potential trajectory for the endoscope and size of foramen of Monroe. C Postoperative MRI to evaluate procedural technical success and complications. Assess: 1 Change in ventricular size. 2 Presence of defect in third ventricular floor. Anteroposterior dimension of defect and change in dimension over time (comparison to prior studies). 3 Presence and characteristic of flow through third ventricular floor defect. 4 Presence/absence of interpeduncular or prepontine arachnoid membranes and Lilliequist membrane. 5 Procedural complications. 6 Coexistent pathology (e.g. tectal glioma, intraventricular arachnoid cyst, posterior fossa mass).

Methods & Materials: Pre-operative MRI assesses: type of hydrocephalus and the underlying etiology; presence of spontaneous third ventricular stoma formation; presence of arachnoid membranes in basal cisterns; and planned endoscopic trajectory. Intraoperative complications of ETV include bleeding from subependymal veins or the ETV stoma. Early postoperative complications (<1 month) include CSF leak, ventriculitis, restenosis, and subdural fluid collections. Late postoperative (>1 month) complications are secondary to restenosis of the ETV stoma. Main causes of ETV failure in infants are: closure/narrowing of the third ventricular floor stoma, or development of arachnoid membranes in the basal cisterns. Post-operative MRI assesses technical success and complications of ETV. Technical success is determined by: presence and size of defect in the floor of the third ventricle; size of the ventricles (decrease in size of ventricles is slower compared to extracranial shunting); presence of arachnoid membranes in the basal cisterns. Coexistent pathology (such as tectal glioma and posterior fossa tumors) is also evaluated. Results: The sagittal T2 True FISP/Dual Excitation sequence provides optimal evaluation for the presence and size of the ETV defect, as well as the presence of arachnoid membranes in the basal cisterns. Compared with conventional MRI sequences, this sequence provides highresolution and high contrast visualization of the floor of the third ventricle, the ventriculostomy defect, and presence of extraneous arachnoid membranes in the basal cisterns. The sagittal phase contrast sequence assesses flow dynamics through the ETV defect. Conclusions: We describe our ETV imaging protocol, interpretive criteria, pitfalls, and present representative cases.

Poster #: EDU-074

Withdrawn

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causes of neck masses in children, including some less familiar causes that are apt to confuse and bewilder.

MRI Bone Marrow Patterns in the Normal Developing Head and Spine

Poster #: EDU-077

Samuel Frost, DO, Teresa Kelly, Children’s Hospital of Wisconsin, Wauwatosa, WI, [email protected]; Jamie Ledford, M.D.

A Case Based Approach to Pediatric Pontine Lesions

Purpose or Case Report: A focused systematic review of age related normal MR imaging signal characteristics of the developing axial skeleton is provided to facilitate accurate diagnosis of abnormal pediatric bone marrow pathology. Methods & Materials: MR imaging has long proven to be the mainstay of bone marrow evaluation because of its excellent tissue contrast differentiation. The normal MR signal characteristics and corresponding physiological changes of red and yellow bone marrow will be surveyed from the stage of the fetus through adolescence. Results: This educational exhibit will demonstrate the MR imaging patterns seen in the normal developing bone marrow which undergoes the most rapid change in size, composition and celluarity during the first 25 years of life. We will show that as the main site of hematopoiesis, pediatric spinal and calvarial bone marrow MR signal depends on the distribution of red and yellow bone marrow, which in turn depends on the child’s age, sex and marrow location within the body. Conclusions: This educational review can facilitate an accurate diagnosis of head and spine bone marrow pathology by providing a fundamental knowledge of the normal MR imaging pattern seen during various stages of development. Poster #: EDU-076 Not Just Another Lymph Node: Unusual Causes of Neck Masses in Infants and Children

Jenna Le, MD, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, [email protected]; Anita Mehta, Irene Sher, Benjamin Taragin

Kenny Rentas, Zachary Bailey, DO, University of Missouri - Kansas City, Kansas City, MO, [email protected]; Arun Reghunathan, BS, Lisa Lowe, MD Purpose or Case Report: The radiologist plays a critical role in evaluating pontine lesions in children. As CT findings are often nonspecific, MR imaging is the initial study of choice to classify pediatric pontine lesions into focal versus diffuse categories. Further evaluation, however, requires differentiating key imaging findings and correlation with clinical presentation. The ability to make this supplemental assessment enables the radiologist to consider a narrower range of pathophysiologic differential diagnoses. Methods & Materials: Using an image rich, case based format, this educational exhibit will demonstrate the imaging approach to pontine lesions by highlighting characteristic clinical findings and key imaging features of pediatric pontine lesions. Pertinent pathologies to be examined included brain stem neoplasms, ischemic infarcts, various inflammatory disorders (multiple sclerosis, acute disseminating encephalomyelitis, and abscess), traumatic brain injury, posterior reversible encephalopathy syndrome, central pontine myelinolysis and hemolytic uremic syndrome. Results: After completion of this educational exhibit, the viewer will be able to: (1) Recall multiple pathologies that affect the pediatric pons, (2) Explain the radiologic findings of these lesions, and (3) Create a differential diagnosis by characterizing the lesion as focal or diffuse. Conclusions: This case based exhibit seeks to guide learners through the imaging approach, physical findings, and key MR imaging features of common and uncommon pediatric pontine lesions. Viewers will, thus, gain the ability to reach a narrow differential that can aid clinical decision making. Poster #: EDU-078

Purpose or Case Report: The purpose of this educational exhibit is to expand our differential diagnosis of pediatric neck masses with a discussion of rare etiologies in infants and children. The imaging findings, management, and surgical findings are presented. Methods & Materials: The imaging findings of unusual neck masses in pediatric patients are retrospectively reviewed. The plain film, ultrasound, CT, MRI, and fetal MRI of seven cases will be discussed. The cases include: (1) esophageal duplication cyst, (2) ectopic thyroid, (3) ectopic thymus, (4) lymphatic malformation, (5) jugular vein ectasia, (6) teratoma, and (7) neuroblastoma. The surgical findings and gross pathology pictures are displayed where available. Results: There is a broad differential diagnosis for neck masses in infants and children which includes congenital, vascular, inflammatory, infectious, and neoplastic etiologies. Taken together with clinical history and physical examination findings, imaging is critical in characterizing the mass and guiding management. The relationship of the mass with the airway, esophagus, and vascular structures is a critical part of the imaging findings. Knowledge of a wide spectrum of disease processes and their characteristic imaging findings allows the radiologist to formulate an appropriate differential diagnosis especially when presented with a challenging case. Cross-sectional imaging also serves as a road map for surgical planning where indicated. Conclusions: The various etiologies of neck masses in the pediatric population can present a diagnostic challenge. After reviewing this exhibit, the reader will have an increased understanding of the various

MR Imaging of Pediatric Bone Marrow Disease States

Jamie Ledford, M.D., Pediatric Radiology, Children’s Hospital of Wisconsin, Wauwatosa, WI; Teresa Kelly, Samuel Frost, DO Purpose or Case Report: To provide a systematic method for evaluating magnetic resonance imaging (MRI) characteristics of various disease processes that can lead to the bone marrow signal abnormalities in the developing calvarium and spine. Methods & Materials: MRI has proven to be a highly effective means for evaluating the pediatric bone marrow. Throughout the skeletal maturation period, normal changes in the MR signal appearance of the developing bone marrow signal must be taken into consideration when evaluating for pathology. In this educational exhibit, examples of diseases that can affect the bone marrow will be compared to the expected MR changes seen in the developing normal bone marrow according to age. Results: This exhibit will categorize MRI patterns seen in a range of disease processes that involve the calvarium and spine as follows: (1) neoplastic (2) inflammatory/infectious (3) autoimmune (4) hematologic/ vascular or (5) traumatic/iatrogenic. Conclusions: This comprehensive review, comparing abnormal to normal bone marrow MRI signal alterations, can serve as a useful framework for distinguishing pediatric bone marrow pathology from the normal MRI changes that occur during development.

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S200 Poster #: EDU-079 Diffusion Tensor Imaging (DTI) in Pediatric Neuroradiology: An Overview

Gregory Vorona, MD, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Jeffrey Berman, Karuna Shekdar Purpose or Case Report: 1. To review the basic physics of DTI. 2. To review the major tracts most commonly analyzed for clinical DTI tractography in pediatric neuroimaging (i.e. corticospinal tract, optic pathway, arcuate fasiculus, etc.), including their respective seed point placements. 3. To demonstrate examples using tractography of common and uncommon pediatric neurological disorders. Methods & Materials: As part of our institutional protocol, MRI examinations of the brain performed at 3 T include a 30 directional DTI study, with fractional anisotropy maps and color maps sent to our PACS system for review. Tractography will be performed using DTIStudio. Results: Cases of both normal and abnormal anatomy of collected pediatric brain cases will be analyzed, and tractography will be performed on representative white matter tracts for demonstration. Pathologic conditions we intend to include are corpus callosal agenesis, Joubert’s syndrome, hemi-megalencephaly, and pontine tegmental cap dysplasia. Conclusions: DTI is a powerful tool that can provide clinical utility in routine pediatric neuroimaging. It is important for radiologists involved in pediatric neuroimaging to have familiarity with the major white matter tracts of clinical importance, as well as to have the ability to perform basic tractography when the capability to perform DTI is available. Disclosure: Dr. Berman has indicated a relationship with McGowan Associates as a Consultant (Consulting Fee).

was independently reviewed by residents and staff for accuracy and significant findings. Results: Representative images for each of the common and uncommon pediatric head and neck tumors were obtained and important imaging findings were illustrated. Conclusions: This exhibit will provide a high-yield review of common and rare pediatric head and neck tumors—including their MRI and CT appearances—to facilitate characterization and diagnosis by the practicing radiologist and, thus, prompt timely and appropriate therapy.

Poster #: EDU-081 The Imaging Workup of Childhood Ptosis

Matthew Whitehead, MD, Neuroradiology, Children’s National Medical Center, Washington, DC, [email protected] Purpose or Case Report: Blepharptosis is characterized by an involuntary upper eyelid droop. Childhood ptosis can be broadly divided into congenital and acquired forms. Congenital ptosis is more common and may be secondary to any underlying structural or functional abnormality of eyelid nerves, muscles, or aponeurosis. Horner syndrome is an additional cause of ptosis caused by central, preganglionic, or postganglionic oculosympathetic lesions. The purpose of this study is to review the basic imaging strategies employed in the workup of childhood ptosis with special focus on anatomic lesional localization.

Poster #: EDU-080 From the Everyday to the Exotic: A Cased Based Review of Pediatric Head and Neck Tumors

Ross Holwerda, MD, Radiology, University of Missouri Kansas City, Kansas City, MO; Stephane Desouches, David Nielsen, MD, Allen Heeger, B.S. Purpose or Case Report: Although relatively uncommon, pediatric head and neck malignant tumors comprise approximately 12% of all childhood malignancies. Fundamental knowledge of malignant and benign pediatric head and neck tumors—including their MRI and CT appearances—will facilitate tumor characterization, narrowing of the differential diagnosis, and timely intervention. This exhibit will provide a high-yield review of epidemiology, clinical manifestations, pathology, and image findings for several common malignant and benign pediatric head and neck tumors. It will also display a similar pictorial review of less commonly encountered tumors. The result will be a comprehensive review of the differential diagnoses for pediatric head and neck oncology cases. The exhibit will include frequently seen tumors, such as non-Hodgkin’s lymphoma, rhabdomyosarcoma, and neurofibroma; other rare head and neck malignancies will also displayed, including juvenile angiofibroma, esthesioneuroblastoma, and hemangiopericytoma. Each case will include MRI and CT imaging features and tumor location, with specific reference to anatomical landmarks and spaces within the head and neck. Pathology and other matters of clinical significance, such as hereditary syndromes, will also be explained. Methods & Materials: Images were obtained from the PACS of Children’s Mercy Hospital of Kansas City Radiology Department for each of the discussed pediatric head and neck tumors. Each imaging sequence

Methods & Materials: The imaging database at a single academic pediatric children’s hospital was retrospectively searched for the term “ptosis”. MR and CT images of the orbits, brain, neck, and cervical spine from selected pediatric patients with a history of ptosis were reviewed and selected to depict normal anatomy and associated pathology. Results: Normal imaging anatomy of the orbits and oculosympathetic pathway is reviewed. Pathologic entities associated with childhood ptosis are depicted including orbital plexiform neurofibroma, cervical lymphadenopathy, preseptal cellulitis/ abscess, cavernous sinus inflammation, demyelination, and neoplastic disease. Conclusions: Ptosis is a relatively common ocular disease in pediatric patients. A detailed knowledge of the related anatomic pathways and associated diseases can help guide the radiologist in determining the required location and extent of imaging, the best imaging modality, and the appropriate protocol prescription.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Poster #: EDU-082 A Multimodality Review of Nasal Masses in the Pediatric Population: Sniffing Out the Diagnosis

Bret Kricun, St. Christopher’s Hospital for Children, Philadelphia, PA; Eric Faerber, Judit Machnitz, Erica Poletto, Jacqueline Urbine, Archana Malik Purpose or Case Report: Patients with abnormalities of the nasal region often present with obstruction or epistaxis. MRI and CT are often complimentary in the imaging evaluation of nasal pathology. However, it may be challenging to differentiate among the various abnormalities of the nasal region. The purpose of this presentation is to review the CT and MRI imaging findings of the multiple pathologic processes that occur in the nasal region. Methods & Materials: We retrospectively reviewed CT and MRI examinations performed at St. Christopher’s Hospital for Children. We collected a series of cases which identified pathology in the nasal region. We reviewed medical records and radiologic studies, and where pertinent, correlated with clinical history and surgical and pathologic reports. Results: We collected a series of CT and MRI examinations which demonstrated abnormalities in the nasal region. These were grouped into congenital, traumatic, inflammatory, neoplastic, vascular, and metabolic categories. The imaging features of nasal pyriform aperture stenosis, dermoid, hematoma, foreign body, nasofrontal meningocele, choanal atresia, abscess, osteoblastoma, rhabdomyosaroma, esthesioneuroblastoma, lymphoma, and juvenile nasopharyngeal angiofibroma will be presented. Conclusions: There are multiple pathologic processes that can occur in the nasal region resulting from a number of etiologies. Knowledge of the imaging characteristics of these processes is important for the radiologist in diagnosis.

Poster #: EDU-083 The Phakomatoses: A Focus on Imaging of Neurofibromatosis Types I & II, Von Hippel-Lindau, Tuberous Sclerosis and Sturge-Weber Syndrome

Benjamin Addicott, MS MD, Zsoka Vajtai, Erik Maki, Diagnostic Radiology, Oregon Health & Science University, Portland, OR, [email protected]; Petra Vajtai, MD Purpose or Case Report: This educational exhibit describes the specific imaging characteristics along with a clinico-pathological correlation of the inhomogeneous cohort of neurocutaneous syndromes comprising the phakomatoses. Methods & Materials: We present a pictorial review of the specific neuroradiological and clinical characteristics of each of the primary neurocutaneous syndromes. Extracranial features as well as epidemiology, screening, treatment and prognosis are discussed. Radiologic features with emphasis on neurologic findings are examined. Clinical and pathologic correlations are described as they relate to specific imaging findings. Important extracranial imaging characteristics of specific syndromes are described. Results: The phakomatoses define a diverse group of primarily neurologic syndromes of neuroectodermal origin with extracranial and cutaneous manifestations. Each of these syndromes has characteristic imaging findings which can help to suggest a specific diagnosis as well as to describe the degree of expression. A comprehensive review of these syndromes in light of continuing advances in imaging capabilities demonstrates the specific constellation of clinical-radiologic findings which distinguish each of these syndromes as a unique clinical entity. Specifically, the defining characteristics of Type I and II Neurofibromatosis, Von

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Hippel-Lindau, Sturge-Weber and Tuberous Sclerosis are examined with emphasis on the unique aspects of the intracranial manifestations. Conclusions: Recognition of and differentiation amongst the phakomatoses is important in guiding clinical treatment as well as in predicting a prognosis. Familiarity of the specific imaging characteristics of each of these syndromes facilitates a prompt diagnosis. As the clinical manifestations, treatment and prognosis varies across each of these syndromes, accurate identification is important. This pictorial essay provides a concise analysis of the specific imaging characteristics of each syndrome as well as clinical and pathologic correlations as they relate to the radiologic findings. Poster #: EDU-084 Taking a “Bite” out of the Mandible: AWide Spectrum of Mandibular Lesions in the Pediatric Population

Jordan Gross, MD, Radiology, Einstein Medical Center, Philadelphia, PA, [email protected]; David Saul, Eric Faerber Purpose or Case Report: Review different lesions and pathologic conditions that involve the mandible in the pediatric population. Various imaging features will be demonstrated in an effort to aid in the diagnosis of these lesions, with an emphasis on CT and MRI. Methods & Materials: A retrospective, pictorial review of the wide spectrum of lesions involving the mandible at our institution will be presented. The review will be divided into different classifications of mandibular and soft tissue lesions including infectious, congenital, traumatic and neoplastic etiologies. Examples will include the more common entities, such as dentigerous cysts and ameloblastoma, as well as rare disease entities, such as mandibular involvement in Caffey’s disease. This will be a multimodality review with emphasis on the CT and MRI appearances of these lesions. Treatment and further management will also be described. Results: This is a pictorial, educational review of mandibular lesions in the pediatric population. In our review of these lesions, we found that the most important characteristics for lesion differentiation include: association with a tooth, internal characteristics of the lesion, aggressive features (i.e., spiculated or perpindicular periosteal reaction), and center of location of the lesion. Conclusions: Lesions of the mandible and the surrounding soft tissue are rare, particularly in the pediatric population. Jaw swelling and/or pain may be the most common presentation for many of these conditions, which is non-specific. Therefore, imaging is crucial to the diagnosis. The radiologist plays a key role in establishing the diagnosis as many of these lesions have different treatment and management implications. Poster #: EDU-085 MR Imaging in Children with Sellar Pathology

Bret Kricun, St. Christopher’s Hospital for Children, Philadelphia, PA; Erica Poletto, Archana Malik, Jacqueline Urbine, Eric Faerber Purpose or Case Report: Many pathologic processes occur in the pituitary gland and sellar region. It may be challenging for the radiologist to differentiate among these processes as well as to distinguish them from normal findings in children of varying ages. The purpose of this presentation is to review the MRI and clinical findings seen in several pathologic processes involving the pituitary gland and the sellar region. Methods & Materials: We retrospectively reviewed MRI examinations of the pituitary gland which were performed at St. Christopher’s Hospital for Children between 2006 and 2013. We collected a series of cases which demonstrated abnormal findings, and we correlated those findings with the medical records and pathology reports.

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Results: We collected MRI examinations in children with a variety of pituitary and sellar abnormalities. The distinguishing features of these abnormalities will be presented, including absence of normal posterior pituitary bright spot, hypoplastic pituitary gland, ectopic posterior pituitary, empty sella, partially empty sella with pseudotumor cerebri, Rathke cleft cyst, pituitary abscess, lymphocytic hypophysitis, pituitary microadenoma, pituitary macroadenoma, and metastatic disease involving the sella. These findings are contrasted with the normal appearance of the pituitary gland at birth, in childhood, and during adolescence. Conclusions: A variety of pathologic processes may affect the pituitary gland and sella in children. Knowledge of the distinguishing imaging characteristics of these pathologies and the normal appearance of the pituitary will help the radiologist in diagnosis.

Poster #: EDU-086 Spectrum of Imaging Findings in Cerebellar Malformations

Mahati Reddy, MD, University of Cincinnati, Cincinnati, OH, [email protected]; Marguerite M. Care, Lily Wang Purpose or Case Report: The purpose of the educational exhibit is to outline the common patterns of cerebellar malformations observed in pediatric patients. Basic anatomy of the cerebellum will be reviewed to understand associated clinical manifestations of cerebellar abnormalities. Basic anatomy of the Cerebellum Embryology of the Cerebellum Dandy Walker Syndromes spectrum Generalized cerebellar dysplasia Focal cerebellar cortical dysplasia Molar Tooth Malformations Rhombencephalosynapsis

Poster #: EDU-088 Cervical Spine Radiographs: Normal or Not?

Anne Gill, Radiology, Emory University/Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Kiery Braithwaite, MD, Adina Alazraki, MD, Chad Holder, Nilesh Desai Purpose or Case Report: With increased awareness of radiation risks, pediatric emergency medicine physicians are encouraged to practice judicious use of CT when evaluating cervical spine injuries in the setting of trauma. The pediatric radiologist is frequently consulted to triage patients who require additional cross sectional imaging. Because of the unique anatomy of children, traumatic cervical spine injuries are often ligamentous, which can be radiographically subtle and often occult. While MRI and CT of the spine are more definitive in the diagnosis of acute cervical spine injury, plain radiographs remain the initial screening study in the majority of cases. It is critical to have a methodical approach and a trained eye for correct interpretation of these films. Methods & Materials: Introductory review of the important plain film findings of cervical spine injury in children is presented. Review slides are followed by a collection of interesting cervical spine radiographs from a level I pediatric trauma center. Included cases have subsequent crosssectional imaging displayed alongside the radiograph to confirm suspected findings. Results: Case examples of ligamentous injuries, perched facets, dens fractures, SCIWORA, epidural hematoma and flexion and distraction type fractures/fracture-dislocations. Case review presented in a self-test format allows the viewer to maximize their learning opportunity. All selected cases have plain film radiographs displayed on the test slide followed by confirmatory CT or MRI follow up displayed on the subsequent slide with the diagnosis. Conclusions: Cervical spine trauma is a frequent presenting complaint to the pediatric emergency department. The radiologist is often called to assist in the decision to image further. This case review offers the opportunity to test one’s clinical acumen to benefit patient care.

Poster #: EDU-087 The Skull Base Revisited: Anatomy of the skull base on CT

Bret Kricun, St. Christopher’s Hospital for Children, Philadelphia, PA; Eric Faerber, Raphael Yoo, MD, Jacqueline Urbine, Erica Poletto, Archana Malik Purpose or Case Report: The anatomy of the skull base is complex, composed of numerous bones, sinuses, foramina, sutures, and other anatomical landmarks. It is important for the radiologist to be familiar with this intricate anatomy in order to differentiate normal from abnormal findings. It is also important for the radiologist to know what structures abut or travel through the portions of the skull base in order to formulate a meaningful differential diagnosis when pathology is present. The purpose of this presentation is to review the normal anatomy and normal anatomic variants of the skull base using axial images from CT scans. Methods & Materials: We retrospectively reviewed CT scans with imaging through the skull base that were performed at St. Christopher’s Hospital for Children. We collected studies which demonstrate normal anatomy of the skull base and a series of examinations which demonstrate anatomical variants. Results: We will present the normal anatomy and anatomical variants of the skull base as seen on CT. We will also review the normal structures which abut and course through various portions of the skull base. Conclusions: Skull base anatomy is complex. Knowledge of the normal anatomy and anatomical variants is important for the radiologist to accurately identify normal structures and to readily appreciate pathology.

Poster #: EDU-089 Demystifying Premature Sutural Closure

Jamie Ledford, M.D., Pediatric Radiology, Children’s Hospital of Wisconsin, Wauwatosa, WI Purpose or Case Report: To provide a logical algorithm for evaluating premature sutural closure that can sometimes be difficult for some who rarely see these entities. Also we will discuss various disease processes that are associated with craniosynostosis. Methods & Materials: Osseous congenital cranial abnormalities, those words can strike fear in clinicians and radiologists alike who do not see these on a regular basis. Many just lump all the sutural closure types into a basket term such as early sutural closure or findings consistent with craniosynostosis. There are many combinations of premature suture closures. Some of these are associated with a laundry list of other abnormalities and knowing the specific name of the craniosynostosis can facilitate the reader in determining what other process is involved. Results: This exhibit will formulate an easy to follow algorithm to evaluate the calvarial sutures and make the naming of the appropriate type an easier task. Computed tomography images of each type will be shown and described. A brief overview of the different associated disease processes will also accompany the different craniosynostosis. Conclusions: Hopefully at the end of this presentation, the observer will be able to approach a cranial suture abnormality in a logical and succinct manner to come up with the appropriate nomenclature.

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253 Poster #: EDU-090 Sinonasal imaging in children

Alireza Khatami, Radiologist, Elka Miller, Matthew Bromwich, Michael Vassilyadi, Amer AlAref, Julie Hurteau-Miller, Diagnostic Imaging, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada, [email protected] Purpose or Case Report: The purpose of this review is to describe the normal anatomy and development of the pediatric sinonasal cavities, the imaging characteristics of sinonasal inflammatory processes and their complications, congenital sinonasal anomalies and acquired benign and aggressive sinonasal lesions. Sinonasal symptoms are among the most common complains in pediatric population. What is the appropriate imaging and imaging technique? What are the differentiating characteristics between these pathologies? What information is particularly important for the consultant and ENT specialist? Methods & Materials: A retrospective search on PACS was performed at the Children’s Hospital of Eastern Ontario from January 2009 to September 2013. Cases were selected from different categories such as normal sinonasal anatomic variations, congenital anomalies, inflammatory processes and polyposis, benign and malignant sinonasal lesions. CT, MRI and radiography of any relevant cases were selected, de-identified and exported. Results: Different types of normal anatomical variation and about 14 different sinonasal pathologies will be discussed. Recognizing signs of sub-perisoteal abscess, osteomyelitis, pyomyositis, intra-cranial abscess, cavernous sinus thrombosis and optic neuritis can immediately change patient management. Conclusions: Differentiating sinonasal anatomical variant and pathology may be difficult unless one has good knowledge of the normal anatomy and sinonasal development in children. Many congenital, benign and aggressive sinonasal lesions may also present a diagnositic challenge. In the context of sinusitis complications, we emphasis that appropriate imaging, imaging technique and interpretation may be lifesaving. Poster #: EDU-091 The Chiari malformations, revisited: a pictorial essay

Judith Gadde, DO, MBA, Radiology, Christiana Care Health System, Newark, DE, [email protected]; Gregory Vorona, MD, Karuna Shekdar, M.D., Brian N. Harding, DPhil, BMBCh, FRCPath Purpose or Case Report: 1. To review the different types of Chiari malformations. 2. To illustrate MR imaging features of the different Chiari malformations, with emphasis on newer imaging techniques of phase contrast CSF flow study in Chiari I malformations and prenatal MR imaging in Chiari II malformations. 3. To demonstrate posttreatment MR imaging appearance of Chiari I and Chiari II malformations. Methods & Materials: All illustrations of this educational exhibit are from review of MR imaging studies of patients with Chiari group of malformations. These include MRI brain and spine studies performed at our institution using our institutional protocol on either 1.5 or 3.0 T MR scanners. Prenatal imaging illustrations are from fetal brain and spine MR imaging performed on 1.5 T scanners. Results: Anatomic MR imaging and functional CSF flow study findings of pretreatment and posttreatment Chiari I malformations will be illustrated. Cases of both prenatal and postnatal MR imaging of Chiari II malformations will be demonstrated. MR imaging findings of the extremely rare Chiari III and Chiari IV malformations will be reviewed.

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Conclusions: The Chiari malformations are a diverse group of defects associated with congenital caudal displacement of the cerebellum and brainstem with or without associated abnormalities of the spine and varying degree of cerebellar hypogenesis. All pediatric radiologists must be familiar with both the conventional MR imaging appearance and also with findings on the newer functional imaging technique of phase contrast MR CSF flow study. It is important for pediatric radiologists to be aware of the strides in prenatal imaging of Chiari II malformations and its impact on recent advances in management and outcome. Poster #: EDU-092

Withdrawn Poster #: EDU-093 Neonatal Jaundice Made Easy—The Nuclear Way

Abdullah Shaikh, Baystate Medical Center/Tufts University, Springfield, MA; Dustin Nguyen, D.O., Alena Kreychman, Steve Allen Purpose or Case Report: 1. This is an educational posters aimed to teach residents the clinical presentation of neonatal jaundice and recognize causes of this common disorder. 2. To review all necessary details that one must have with referring clinicians and parents regarding nuclear scans. Methods & Materials: The poster will have the following headings with an image rich review: – Anatomy: Review of hepatobiliary anatomy. – Epidemiology and pathophysiology – Review of radionuclide agents used in Hepatobiliary scintigraphy. – Patient preparation: Knowing indications and contraindications. What needs to be done prior to sending the patient to the nuclear department and understand phenobarbital. Also a review of what to discuss with the parents or caregivers. – Image rich review of various expected findings and differentiating hepatitis from biliary atresia and other less common causes. Ultrasound correlates given when appropriate. – Pitfalls in imaging. Conclusions: – By visiting this exhibit, a trainee should be able to understand how to differentiate the various causes of neonatal jaundice. – Trainees will be able to discuss the various pharmaceutical have a systematic understanding of what the collected data means. – Be able to know what points to discuss with parents and referring clinicians. Poster #: EDU-094 Tc99M-MAG3 Diuretic Renography in Pediatrics: A Pictorial Review

Mahmoud Zahra, MD, FRCR, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Feraas Jabi Purpose or Case Report: 1. Review normal renal physiology as delineated by a technetium99m-mercaptoacetyl triglycine (Tc99m-MAG3) renogram. 2. Present traditional protocol for performing a Tc99m-MAG3 diuretic renogram at our institution. 3. Review qualitative and quantitative scintigraphic findings of obstructive uropathy on Tc99m-MAG3 renogram before and after diuretic challenge. 4. Review the pertinent findings to be included in a Tc99m-MAG3 diuretic renogram report.

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5. Present sample cases of pediatric Tc99m-MAG3 diuretic renograms with sonographic correlations. Methods & Materials: N/A Results: N/A Conclusions: The vast majority of nuclear medicine imaging studies in the pediatric age group are interpreted by the pediatric radiologist. As such, a thorough knowledge of the underlying instrumentation and technique of nuclear imaging as well as normal renal physiology is essential in the identification of any functional abnormalities on Tc-MAG3 renograms. By the conclusion of this presentation, the reviewer will gain an appreciation of normal renal physiology and pathologic processes demonstrated on Tc99m-MAG3 renogram. It is also the hope of the authors that this review could serve as a supplement for the pediatric radiologist in formulating a concise yet informative Tc99m-MAG3 renogram report that will assist the referring urologist in determining the next best step in managing a child with suspected obstructive uropathy, thereby optimizing patient care

Poster #: EDU-095 Hepatobiliary Scans and Supplemental Modalities (US & MRCP) in the Diagnosis of Biliary Atresia- an institutional review

Raphael Yoo, MD, Hahnemann University Hospital, Philadelphia, PA, [email protected]; Cristian Coroian, Bret Kricun, Evan Geller, Polly Kochan, Jacqueline Urbine Purpose or Case Report: Neonatal jaundice is an important clinical indicator of several disorders, including neonatal hepatitis, TPN-induced cholestasis, and biliary atresia. Of these pathologic entities, biliary atresia requires urgent surgical intervention to reduce further morbidity and mortality. Several imaging modalities are available for the imaging of biliary atresia. The primary modality is nuclear medicine hepatobiliary imaging. In this presentation, we will evaluate the need for supplemental imaging, including ultrasound (US) & magnetic resonance cholangiopancreatography (MRCP), in further discerning the cause of neonatal jaundice after an abnormal hepatobiliary scan. Methods & Materials: Our study involves a retrospective analysis of 13 nuclear medicine hepatobiliary scans performed at St. Christopher’s Hospital for Children from January 2009 to October 2013 reported as being either concerning for biliary atresia or equivocal for biliary atresia or neonatal hepatitis. Of the 13 scans, 11 patients underwent surgery and a pathologic diagnosis for these patients was available for comparison. Results of the hepatobiliary scan were analyzed and correlated with the final diagnosis as well as additional imaging studies across different modalities, if available. Results: Of the 11 patients who underwent surgery, five patients were determined to have a pathologic diagnosis of biliary atresia. Two patients were diagnosed with TPN-induced cholestasis. Two patients were diagnosed with neonatal hepatitis. One patient was diagnosed with intrahepatic atresia, felt to be syndromic such as Alagille syndrome. One patient’s pathologic findings were nondiagnostic with the presence of immature bile ductules and canalicular cholestasis. Supplemental cross-sectional imaging of the five patients diagnosed with biliary atresia demonstrated absence of the extrahepatic common bile duct or a normal gallbladder. In the remaining non-biliary atresia cases, the other imaging modalities were able to identify both a common bile duct and a normal gallbladder. Conclusions: In addition to nuclear medicine hepatobiliary imaging, utilizing cross-sectional imaging modalities like US and MRCP to demonstrate the presence of absence of the extrahepatic common bile duct and a normal gallbladder can lead to an increase in accuracy in the diagnosis

of biliary atresia from mimics like neonatal hepatitis and TPN-induced cholestasis. Poster #: EDU-096 The spectrum of imaging findings in renal lymphoma in the pediatric population

Matthew Moy, M.D., Massachusetts General Hospital, Department of Radiology, Boston, MA, [email protected]; Michael Gee, MD, PhD, Howard Weinstein Purpose or Case Report: Hodgkin’s and non-Hodgkin’s lymphoma in children can affect the kidneys, almost always as part of systemic or extrarenal disease (secondary renal lymphoma). Identification of secondary renal involvement is particularly important as it may influence therapeutic decisions. The purpose of this educational exhibit is to show the imaging features and complications of renal lymphoma in the pediatric population across multiple modalities including plain radiographs, sonography, computed tomography (CT), positron emission tomography (PET), and magnetic resonance (MR) imaging. Methods & Materials: Using a searchable radiology information system database in this IRB-approved HIPAA compliant retrospective review, abdominal imaging examinations representative of common and unusual appearances of lymphomatous involvement of the urinary tract in patients aged 0 to 18 years were identified. The electronic medical record was reviewed to confirm the pathologic diagnosis. Results: The range of imaging appearances of renal lymphoma on different modalities will be shown, including a solitary renal mass, multiple renal masses, diffuse infiltration and enlargement of the kidney, and perinephric soft tissue mass. In addition, we will review complications of locally invasive renal lymphoma requiring urgent intervention, such as encasement of the renal vasculature, ureteral invasion and obstruction,as well ashydronephrosis without a visualized obstructing mass. Conclusions: After reviewing this educational exhibit, the reader will become familiarized with various renal/perinephric imaging appearances of pediatric lymphoma and complications across multiple modalities. Poster #: EDU-097 Multimodality Imaging of Pediatric Head and Neck Neoplasms utilizing CT, MRI and 18FDG PET

Hansel Otero, The Children’s Hospital of Philadelphia, Radiology Department, Philadelphia, PA, [email protected]; Karuna Shekdar, M.D., Lisa States, MD Purpose or Case Report: 1. Review the differential diagnosis of pediatric head and neck tumors. 2. Illustrate the utility of CT, MRI and 18FDG PET/CT in the diagnostic evaluation, treatment planning, and detection of residual or recurrent disease. 3. Highlight the cases that would benefit from evaluation with PET/MR co-registration. Methods & Materials: All illustrations of this education exhibit are from review of CT, MR and 18FDGPET/CT studies of patients with various head and neck neoplasms. These include contrast enhanced, multi-slice CT studies of the face and neck with optimized pediatric radiation dose reduction protocols, and MRI face and neck studies performed at our institute using our institutional protocol on either 1.5 or 3 T MR scanners. 18FDGPET/CT studies were performed on 16 slice PET/CT scanner. These studies

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were performed at diagnosis and usually following 6 weeks of treatment. Further follow up imaging was tailored for each case. For specific cases PET/MR co-registration was employed. Results: Most common neoplasm of the extra cranial head and neck are lymphomas, followed by rhabdomyosarcoma. The CT, MR and 18FDGPET/CT findings in lymphoma and rhabdomyosarcoma will be demonstrated. Other neoplasms illustrated will include nasopharyngeal carcinomas, thyroid malignancies, other sarcomas, salivary gland malignancies and neuroblastoma metastases, among others. Cases emphasizing the benefit of multi-modality imaging in diagnosis, evaluation of treatment response and detection of recurrent and/or residual disease will be demonstrated. Conclusions: CT and MR imaging with high spatial resolution are used in differentiating common pediatric benign lumps and masses of nonneoplastic etiology from malignancies and for improved characterization. 18FDGPET/CT is essential for appropriate staging of these neoplasms and monitoring treatment response. Multimodality imaging improves the diagnosis and management of children affected by head and neck malignancies.

Poster #: EDU-098

Withdrawn

Poster #: EDU-099 Pediatric Thyroid Ultrasound: To biopsy or not?

Adina Alazraki, MD, Radiology, Emory University/Children’s Healthcare of Atlanta, Atlanta, GA, [email protected]; Kiery Braithwaite, MD, Paula Dickson, M.D. Purpose or Case Report: Thyroid abnormalities on ultrasound have been thoroughly described and categorized in the adult radiology literature, although can still be a diagnostic challenge. But can we apply the same algorithm to pediatric thyroid ultrasound? A broad spectrum of the sonographic appearance of thyroid disease, both benign and malignant is encountered. The purpose of this educational presentation is to enhance the interpreter’s confidence in the diagnosis and management of pediatric thyroid lesions by ultrasound, including when to recommend excision, fine needle biopsy, or when to leave alone. Methods & Materials: A brief review of sonographic features of thyroid abnormalities previously categorized in the adult literature in a pattern recognition format using examples from our patient population followed by a series of unknown cases. The viewer will be challenged to assess their interpretive skills. Cases will include examples of thyroid malignancy, benign thyroid nodules, and thyroiditis. All cases include clinical history and relevant laboratory results when available, with subsequent pathology report when provided. Results: Selected cases of representative unknown thyroid ultrasounds are presented for the viewer to test themselves. All cases are ultrasound based, however some may have additional imaging including thyroid scintigraphy or MRI. Cases were confirmed pathologically. “Leave alone” cases without pathologic confirmation were followed clinically and/or with ultrasound for growth/change in the lesion. Conclusions: Thyroid abnormalities in children are uncommon, but when encountered, often present a diagnostic dilemma. Recognition of patterns of benignity and malignancy is important for the pediatric radiologist. After reviewing the tutorial and these cases, the interpreter will be better able to recognize distinct patterns in thyroid ultrasound imaging and make recommendations for next steps.

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Mansi Shah, MD, Montefiore Medical Center, Bronx, NY, [email protected]; Benjamin Taragin, Terry Levin, Jessica Kurian Purpose or Case Report: At birth, the human body is covered by approximately five million hair follicles. Derived from the ectodermal embryonic germ layer, hair is integral to several important biologic functions. It provides protection from the natural elements, disperses pheromones from sweat glands, and has an undeniable psychosocial role. In this case series, we will begin by brushing through the embryology and structure of the hair follicle. We will aim to shed light on several of the essential pediatric pathologic entities containing hair follicles. Diseases involving the proliferation of hair in abnormal locations will also be explored. We also will tease through several pseudo-pathologic processes that involve hair related entities and their associated diagnostic dilemmas. Through an image-rich demonstration of true pathology and pseudopathology relating to hair, we hope to improve overall diagnostic accuracy. With a multimodality approach utilizing MR, CT, XR, and US imaging, we will demonstrate common and uncommon presentations of pathologic entities involving hair such as: dermoids, epidermal inclusion cysts, bezoars, pilonidal cysts, and spinal dysraphism. Additionally, we will illustrate hair related radiologic signs. We will also dissect through the diagnostic dilemmas associated with hair related products, such as hair braids, hair crimps, and pony tails. There is a wide spectrum of pediatric disease entities involving hair follicles. Awareness of hair related pathology and pseudo-pathology is important for guiding appropriate imaging and treatment in the pediatric population. Poster #: EDU-101 The Pediatric Breast: What to do with Lumps and Bumps

Natalie Burns, University of Washington Medical Center, Seattle, WA, [email protected]; Habib Rahbar, Teresa Chapman Purpose or Case Report: Breast masses in the pediatric population can present a diagnostic challenge to radiologists, as they are infrequently encountered and can cause great consternation to patients and their families. Pediatric breast masses generally encompass a wide differential ranging from normal breast development to breast disease. However, primary breast cancers are decidedly rare in children, and most malignant breast masses are metastases from non-breast primary neoplasms. Although the vast majority of presentations are benign, many radiologists lack familiarity with the characteristic imaging features of pediatric breast masses that often can guide diagnosis and management, leading to increased anxiety for both radiologists and their patients. Methods & Materials: A literature review was performed and salient cases were collected. The information provided in this educational exhibit will allow the reader to do the following: 1. List the stages of normal breast development. 2. Provide an appropriate imaging protocol for evaluating a breast mass in the pediatric patient, including appropriate and judicious indications for biopsy. 3. Recognize the sonographic appearance of the normal breast at various developmental stages, including the appearance of a normal breast bud and other common sonographic mimics of pathology. 4. Identify the sonographic appearance, and when appropriate, the mammographic and magnetic resonance imaging findings of a spectrum of diseases, including benign (e.g. fibroadenoma, juvenile fibroadenoma,

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juvenile papillomatosis, pseudoangiomatous stromal hyperplasia [PASH], gynecomastia, galactocele, abscess and fat necrosis), malignant(e.g. breast carcinoma and metastases), and those with variable malignant potential (e.g. phyllodes tumor). 5. Correlate imaging findings with relevant clinical and histologic findings. Results: The approach to breast masses in the pediatric patient differs from adults in many ways, including diagnostic imaging algorithm, differential diagnosis considerations and appropriateness of biopsy as a means to further characterize lesions. Conclusions: Given the high prevalence of benign pathology and inherent risk of damage to the developing breast from biopsy, radiologists must be familiar and comfortable with the imaging appearance of common entities. Fortunately, imaging findings are often characteristic, allowing a confident distinction between benign and malignant etiology. Poster #: EDU-102 Abnormal Calcifications in Infants and Young Children - A Pictorial Review

Steven Sharatz, MD, Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Katherine Nimkin Purpose or Case Report: To exhibit cases of abnormal calcifications on imaging studies of infants and young children which provide clues to underlying pathology. Methods & Materials: A review of medical records and teaching file cases was performed searching for calcifications on imaging studies of young children. Imaging studies included radiographs, ultrasound, and CT. Results: The location and appearance of calcifications on imaging studies provide critical clues to diagnosis. Our cases include the following: In infants, cranial sonography demonstrates thalamostriate vasculopathy, and in another case calcified subependymal nodules in the setting of tuberous sclerosis. Abdominopelvic calcifications in young children include meconium peritonitis, enteroliths secondary to enterourinary fistula, hepatoblastoma, neuroblastoma, adrenal calcification, teratoma and appendicolith. In the chest, a calcified coronary artery aneurysm is seen with Kawasaki's disease and calcified lung masses represent necrotizing fungal pneumonia in the setting of chronic granulomatous disease. In the extremities, soft tissue calcifications are seen in myositis ossificans progressiva, burn injury and venous malformation with phleboliths. Conclusions: Calcifications in the pediatric patient occur for a number of reasons and are important clues pointing to unique and varied pathologic entities. The pattern and location of calcification is often typical for each disease entity.

radiologist is often asked to evaluate these devices, or may be the first to recognize an important complication in a routine film performed for another indication. Familiarity with these devices and their potential complications, allows for prompt treatment to avoid adverse outcome. Methods & Materials: We present a variety of cases that we have encountered at a large children’s hospital. Included in this educational exhibit are the normal and abnormal radiographic appearances of these devices. Results: Complications of implanted surgical devices in pediatric patients are reviewed in a pictorial format with relevant discussion. Devices include baclofen pumps, cardiac conduction devices, CSF shunt devices, enterostomy tubes, laparoscopic adjustable gastric bands, pectus bars, vascular occlusion devices, vascular ports, and vascular stents. Conclusions: This educational exhibit better familiarizes the radiologist with commonly encountered surgical devices seen in pediatric patients by presenting numerous examples of malpositioned or broken devices. Familiarity with the normal and abnormal appearance of these devices allows for prompt diagnosis and appropriate intervention.

Poster #: EDU-104 Early experience with gadoterate meglumine (Dotarem) at a large tertiary care, U.S. Children’s Hospital

Suraj Serai, Ph.D, CCHMC, Cincinnati, OH, [email protected]; Daniel Podberesky, MD, Alexander Towbin, MD Purpose or Case Report: Gadolinium-based contrast agents (GBCA) are widely used to enhance image contrast in pediatric magnetic resonance imaging (MRI) procedures. In recent years, there has been a renewed interest in more stable macrocyclic gadolinium chelates used as contrast agents for MRI procedures, as it has been suggested that dechelation of these molecules could be involved in the mechanism of nephrogenic systemic fibrosis (NSF) development. Pediatric patients with borderline or questionable renal function often do not receive GBCA because of the fear of a perceived adverse event, and hence potentially do not receive an optimal imaging evaluation. Gadoterate meglumine (Dotarem, Guerbet, Roissy CdG Cedex, France), an ionic, macrocyclic GBCA with a long history of safe use outside of the United States was recently approved for pediatric use by the U.S. Food and Drug Administration (FDA). The objective of this study is to review the physicochemical properties of gadoterate meglumine and to describe our early experience with its use in children with borderline/questionable renal function undergoing MRI.

Poster #: EDU-103 Pictorial Review: Complications of implanted surgical devices in pediatric patients

Kiery Braithwaite, MD, Emory University & Children’s Healthcare of Atlanta, Egleston Campus, Atlanta, GA, [email protected]; Adina Alazraki, Jonathan Loewen, MD Purpose or Case Report: Implanted surgical devices are commonly observed in pediatric patients by conventional radiography. These devices are routinely encountered in the care of pediatric patients. Complications are sometimes suspected clinically, while others may be discovered incidentally. While some complications are more subtle, they can have profound clinical impact. The

Methods & Materials: We will review the physicochemical properties, indications, dosage, side effects, and contraindications of gadoterate meglumine, and compare these properties with those of other widely used GBCA. We will review the available literature on the safety profile of gadoterate meglumine in both adults and children with normal and abnormal renal function.

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Results: Based on the recent FDA approval of gadoterate meglumine, and its excellent safety profile, we began using the agent in children with borderline (GFR 30–90 ml/min/1.73 m^2) or questionable renal function undergoing contrast-enhanced MRI in July 2013. There have been no reported adverse events with its use since we initiated this protocol. We will present clinical examples of its use in this population at our institution. Conclusions: Gadoterate meglumine, an ionic, macrocyclic GBCA recently approved by the FDA for pediatric use shows great promise in children undergoing contrast-enhanced MRIs who may otherwise have not received a GBCA due to concerns of adverse events related to borderline/questionable renal function. Poster #: EDU-105 Understanding the potential for sedation-related complications associated with diagnostic imaging exams: An educational tool for parents

Courtney Baines, Children’s National Medical Center, Silver Spring, MD, [email protected]; Domiciano Santos, Raymond Sze, Amy Rice, PhD Purpose or Case Report: Although extremely safe, pediatric sedation is not entirely risk-free. Whether or not school-age children or adolescents should/need to be sedated during a diagnostic imaging exam is often unclear. We aim to create a family-friendly discussion tool that will help medical staff talk to parents about the risk of sedation-related complications that might occur when children of any age have a diagnostic imaging exam under sedation. Methods & Materials: We conducted a literature review to identify materials which quantified the type, severity, frequency, duration and timing of sedation-related complications among children (0–18 years of age) undergoing a sedated diagnostic imaging exam. We focused on propofol and chloral hydrate since those are the most commonly used sedatives in our children’s hospital. The PubMed search was conducted with no restrictions on the language or year of publication. The titles/ abstracts of all retrieved articles were reviewed. Full copies of the most relevant articles were read and key data points extracted. Results: We reviewed over 100 articles and identified a core set of ~30. Those were used to develop a matrix summarizing the occurrence of sedation-related complications, based on developmental age, type of sedative and time since procedure. We plan to transform the distilled information into a more family-friendly discussion tool. Most of the studies which quantified adverse events dealt with the medically-related complications that occurred either during the procedure itself or soon (within 24–48 h) afterwards. Few studies tracked any events after that time frame. The only studies of longer-term risk assessed the link between sedating young children (<3 years of age) and the development of neurocognitive deficits a decade later. Although anecdotal reports suggest several other conditions (missing school due to delayed recovery, developing a fear of future medical procedures, etc.) that parents might more broadly consider to be ‘complications’, none of those have been systematically investigated. Conclusions: The risk of short-term, sedation-related complications has been well-described, even if the risk of longer-term complications has not. Talking to parents about this situation will help them make informed decisions about how to protect their children, either by choosing a non-sedate option (if appropriate) or knowing what type of complications might occur. Poster #: EDU-106 Thyroglossal duct cysts in children: sonographic and histopathologic correlation - what matters?

Emilio Inarejos Clemente, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Modupe Oyewumi, Bo-Yee Ngan, Evan Propst, Mary-Louise Greer

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Purpose or Case Report: 1. To highlight sonographic features with high positive predictive value for thyroglossal duct cyst (TGDC) diagnosis. 2. To discuss the embryogenesis and demonstrate the pathology corresponding with the ultrasound appearance. Methods & Materials: Research previously undertaken by our group correlated preoperative US images and pathology reports from surgically proven specimens of midline neck cysts in children (53 TGDC and 38 dermoid cysts) between 2005 and 2012. This identified very high and high positive predictive values (PPV), between 81 and 100%, and corresponding negative predictive values (NPV), for sonographic features consistent with TGDC. The features with a 100% PPV that when present confidently support the diagnosis of TGDC were: presence of fistulae (PPV 100%, NPV 48.7%), irregular wall (PPV 100%, NPV 62%), ill-defined margins (PPV 100%, NPV 56%) and internal septae (PPV 100%, NPV 46%). Intralesional flow (PPV 90.9%, NPV 46.35) and solid components (PPV 81.3%, NPV 46.7%) also had a high PPV. Depth, location as midline or off midline, and cyst size, heterogeneity and posterior enhancement were not discriminatory features for TGDC diagnosis. Ultrasound images and pathology specimen slides from each of the 53 surgically and pathologically proven cases of TGDC were reassessed to identify and directly correlate the very high and high PPV features described above. Results: For each of these 6 key ultrasound criteria identified as having very high or high PPV for TGDC, a series of ultrasound images are presented illustrating these features, with corresponding histopathology. The pathogenesis of these features is also described with reference to embryology. Conclusions: Identifying sonographic features that strongly correlate with TGDC in midline neck cysts in children will facilitate more accurate preoperative ultrasound diagnosis, guiding surgical planning and patient care. Poster #: EDU-107 A Practical Approach to Pediatric Chest MRI: Bridging the Gap between Inherent Challenges and Clinical Practice

Juan Baez, M.D., Radiology, Boston Children’s Hospital, Brookline, MA, [email protected]; Simon Warfield, Robert Mulkern, Edward Lee, MD, MPH Purpose or Case Report: In recent years, concerns about the harmful effects of radiation and the desire to minimize radiation exposure have substantially increased interest in magnetic resonance imaging (MRI) as an adjunct or replacement to other thoracic imaging modalities that utilize ionizing radiation. MRI provides improved tissue contrast and functional information when compared to cross-sectional imaging studies such as CT. However, there has been continuous sentiment that chest MRI is underutilized due to various obstacles in performing and obtaining optimal image quality, particularly in pediatric patients. The purpose of this presentation is to overcome inherent challenges of chest MR imaging in children by discussing the nuts and bolts of chest MRI, sharing our experience in developing pediatric patient specific chest MRI protocols, and providing a practical “how-to” manual for its optimal performance. Methods & Materials: The current literature is reviewed. Up-todate MRI techniques for the pediatric population including sedation strategies and pediatric patient specific chest MRI protocols, both for screening and problem solving purposes, are discussed. Selected examples of chest MRI for evaluation of the lung parenchyma, airways, vasculature, and mediastinum in the pediatric population are provided. Results: Strategies for successful pediatric chest MRI include appropriate patient selection, the use of safe and effective sedation when necessary and protocol optimization to minimize scan times and maximize diagnostic information. Techniques to manage respiratory motion

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and patient uncooperativeness as well as pediatric patient specific sequences tailored to common and rare pediatric chest disorders are discussed and illustrated. Conclusions: Motion and signal paucity are the two main obstacles to successful chest MRI, problems which are particularly compounded in an uncooperative pediatric population. Nevertheless, MRI can often provide beneficial anatomic and functional information unavailable from other radiologic modalities and without ionizing radiation exposure. These features have motivated an expanded use of MRI for various thoracic disorders in pediatric patients. With a clear understanding of up-to-date and practical MR protocols and characteristic MRI findings, the optimal contribution of chest MRI to clinical practice can be realized in the pediatric population. Poster #: EDU-108 Pediatric Upper Airway Emergencies

Michael Baad, M.D., Radiology, University of Chicago, Chicago, IL, [email protected]; Kate Feinstein Purpose or Case Report: 1. Discuss upper airway anatomy and factors which predispose the pediatric population to upper airway compromise. 2. Review proper imaging techniques and pitfalls to diagnosis. 3. Provide a location based differential diagnosis using an interactive approach with examples including inflammatory, neoplastic, congenital and traumatic etiologies. 4. Reinforce learning objectives through a self assessment module. Methods & Materials: Acute upper airway compromise is a potentially lethal problem in the pediatric population, accounting for up to 10% of emergency visits. While not all of these patients require imaging, it is important for the radiologist to have a thorough understanding of the diagnostic possibilities and potential pitfalls in these challenging situations. An interactive presentation is provided to review the differential diagnoses by location, offer representative examples, and reinforce learning objectives through self assessment. Results: Acute pediatric upper airway compromise is a potentially life threatening and common problem, owing to anatomic differences which make children more susceptible to obstruction. These differences in anatomy as well as proper imaging technique and potential pitfalls to diagnosis will be reviewed. A wide differential to upper airway compromise exists, although a majority of entities are well known and defined. It is important for the radiologist be familiar with both common and less common etiologies. Starting with radiography as the initial imaging technique, a multimodality approach to these differential diagnoses will be explored using CT and barium studies. The differential can be approached by location: nasopharyngeal, oropharyngeal, supraglottic, glottic/subglottic and retropharyngeal. Examples of inflammatory, neoplastic, congenital and traumatic etiologies will be discussed with an emphasis on key imaging features and indications for further evaluation. Conclusions: Acute pediatric upper airway compromise is a commonly encountered situation for which radiology plays a key role. With a thorough understanding of pediatric upper airway anatomy, proper imaging technique, differential diagnostic possibilities and indications for further evaluation, the radiologist can narrow the differential and often arrive at a specific diagnosis. This interactive educational exhibit is designed to aid the radiologist in the evaluation of emergent pediatric upper airway compromise and reinforce learning objectives though a self assessment module. Poster #: EDU-109 Dual Energy CT in young children: a new low dose technique for characterizing focal lesions without general anesthesia

Alexi Otrakji, Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Sarabjeet Singh, Pallavi Sagar, Sjirk Westra, Mannudeep K Kalra, Michael Gee

Purpose or Case Report: 1. To review basic fundamentals of dual energy CT. 2. To review the current literature for clinical studies in pediatric dual energy CT 3. To assess and illustrate the radiation dose neutrality with dual energy CT. 4. To assess the role of dual energy CT in the characterization of chest and abdominal lesions in children. Methods & Materials: 1. Review basic principles and different approaches of available techniques for dual energy CT 2. Review and illustrate various post processing techniques of dual energy CT datasets 3. Scan protocols with dual energy CT in pediatric chest and abdomen that are radiation dose neutral compared to single energy CT. 4. Suitable clinical examples for application of dual energy CT in chest and abdominal indications in children. 5. Advantages and limitations of dual energy CT in pediatric CT. 6. The potential of dual energy CT to be the preferred modality (over MRI) for characterizing chest/abdominal lesions in young children, because of the ability to get high quality multiphase images with low radiation dose and without the need for suspended respiration/anesthesia Conclusions: Dual energy CT can provide additional information without additional radiation dose to the children in specific clinical situations. This exhibit will help teach the audience about basics, applications as well as limitations of dual energy CT in children. Poster #: EDU-110 Mass-like Lung Opacity in the Pediatric Population: Multimodality Pictorial Review

Erin Horsley, Hahnemann University Hospital, Philadelphia, PA; Archana Malik, Bret Kricun, Jacqueline Urbine, Erica Poletto, Eric Faerber Purpose or Case Report: Mass-like lung opacities are often seen on chest radiography in the pediatric population. Although some etiologies have pathognomonic imaging findings, others can be more challenging to diagnose. The purpose of this study is to provide a multimodality pictorial review of mass-like lung opacities in children, with surgical and pathological correlation when available. Methods & Materials: We retrospectively identified pediatric patients at St. Christopher’s Hospital for Children who presented between 2009 and 2013 with mass-like lung opacity on chest radiography. Subsequent cross-sectional imaging examinations performed on those patients were reviewed. Radiological studies were correlated with clinical history and surgical and pathological reports when available. Results: We collected a group of patients with a mass-like lung opacity seen on chest radiography that had subsequent cross sectional imaging. After correlating with clinical, surgical, and pathological results, we grouped these abnormalities into congenital, infectious, vascular, and neoplastic categories. The imaging features of cystic pulmonary airway malformation, congenital lobar emphysema, congenital diaphragmatic hernia, intralobar and extralobar bronchopulmonary sequestrations, necrotizing pneumonia, lung abscess, arteriovenous malformation, and pleuropulmonary blastoma will be presented. Conclusions: Mass-like lung opacity in the pediatric population can be from common and uncommon causes. Accurate diagnosis on imaging examinations is essential for appropriate management. Poster #: EDU-111 How to approach Unilateral Hyperlucent Hemithorax in Children?

Jignesh Shah, MD, Pediatric Radiology, LeBonheur Children Hospital, Memphis, TN, [email protected]; Anand Majmudar, Harris Cohen

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Purpose or Case Report: 1. To discuss etiologies of unilateral hyperlucent hemithorax in children. 2. To discuss radiographic and cross sectional imaging features of various conditions leading to unilateral hyperlucent hemithorax. Methods & Materials: Etiologies of unilateral hyperlucent hemithorax vary. Discussion of the Radiographic and cross sectional imaging findings of the various conditions leading to unilateral hyperlucency in the lungs including but not limited to Chest wall conditions (such as scoliosis and Poland syndrome), Vascular conditions (such as pulmonary agenesis, pulmonary hypoplasia, scimitar syndrome, unilateral massive central pulmonary embolism), Pulmonary parenchymal abnormalities (such as atelectasis, pulmonary emphysema, postpneumonectomy, Swyer-James syndrome); Airway abnormalities (such as foreign body aspiration, bronchial atresia, congenital lobar emphysema, endobronchial mass and extrinsic bronchial compression); Mediastinal and Pleural space abnormalities such as mediastinal masses, pneumothorax, foregut malformations, diaphragmatic hernias; and Technical factors such as lateral decentering and rotation. Conclusions: A variety of abnormalities of the chest wall, pulmonary vessels, lung parenchyma, central airways, and mediastinum can result in unilateral hyperlucent hemithorax in children. Understanding the spectrum of these conditions and their characteristic imaging findings can permit early and accurate diagnosis, which in turn can result in optimal patient management.

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25th, 50th and 75th percentile, we assumed a linear correlation for CTDIvol values falling between these percentiles for developing the gauge. The CTDIvol values for these quartiles as well as the exam CTDIvol provided by the scanner would be provided beside the gauges. The gauges are small to preserve screen real estate (12 and 24 pixel high versions are demonstrated in Figure 1) and could be placed beside the exam performed text displayed in the PACS system. Results: The color coded gauge would indicate where the current exam or scan stands in relation to the regional average radiation dose for that particular age group and body region in an easy to visualize format. This can alert the operating technologist and the radiologist to the radiation dose which the patient receives immediately upon completion of the examination so that causes for abnormal doses can be rapidly assessed while the personnel and scan information are still available. Following installation of the gauge, the dose which the patient received could also be compared to the existing institutional mean doses. As soon as DIR data is available for computed and digital radiography, this tool could be easily adapted for use in plain film examinations. Conclusions: Radiation dose comparison at the time of completion and interpretation of CT scans in pediatric population can be a useful tool to improve consciousness of radiation doses to patients at the time of each exam without a significant time investment. Poster #: SCI-002

Poster #: SCI-001

Effective Dose Estimates for Four Types of Fluoroscopy Examinations Performed at a Pediatric Hospital

Tool for rapid comparison of current exam dose to dose index registry values at the time of image acquisition and interpretation

Adam Springer, MS, National Physics Consultants, Ltd., Brecksville, OH, [email protected]; Cheryl Miller, Robert Kobistek, Godfrey Gaisie, Michael Rubin

Kristopher Lewis, MD, Supriya Gupta, MD, Radiology, Georgia Regents University, Augusta, GA, [email protected] Purpose or Case Report: Creating a color-coded gauge for comparing radiation dose to standards at the time of scanning for the technologists and interpretation for the radiologists can be a useful tool for raising awareness of radiation dose while performing CT scan in a child.

Methods & Materials: The data from Dose Index Registry (DIR) is used to create an age-based color-coded gauge for dose corresponding to different quartiles as represented in the DIR. For development of this tool, DIR data is used specific to the local geographic region and the type of exam performed. For each exam, the total CTDIvol is estimated at the end of study (provided by the scanner) and plotted on the color coded gauge. The green category on the gauge corresponds to CTDIvol between below the 50th percentile of the DIR data, the orange category corresponds to the CTDIvol for that exam between the 50th and 75th percentile and the red category corresponds to the exams with total CTDIvol greater than 75th percentile in the DIR. Since the DIR data is represented only for

Purpose or Case Report: Effective doses were estimated for 909 patients who underwent one of four types of fluoroscopy exams at a pediatric hospital over a 6 month period. Methods & Materials: Exam types included were: upper gastrointestinal (UGI), UGI with small bowel follow-through (UGIsb), voiding cystourethrograms (VCUG), and swallowing function (SF). Radiation safety principles were employed to maintain doses ALARA. Medical physicists used patient information (e.g. weight and thickness) along with dose-area products (DAP) from each exam, average kVp and equipment half-value layers to calculate the effective doses. The results for each exam type were plotted versus age as well as weight and evaluated for trends. Data were binned by age and compared to published data.

Results: The median DAPs for the fluoro portion of each exam type were: 0.4 Gy cm^2 [range = 0.04 to 5.7] for UGI; 1.8 Gy cm^2 [0.1– 23.5] for UGIsb; 0.6 Gy cm^2 [0.004–5.5] for SF; 0.5 Gy cm^2 [0.1– 4.7] for VCUG. The median effective doses for each exam type were: 0.5 mSv [0.1–5.9] for UGI; 2.3 mSv [0.4–11.8] for UGIsb (fluoro only); 2.6 mSv [0.5–11.9] for UGIsb (fluoro and overheads); 0.7 mSv [0.003–

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4.6] for SF; and 0.5 mSv [0.2–2.5] for VCUG. DAPs generally increased with age, weight and thickness for UGI, UGIsb and VCUG exams (R^2 from >0.4). Effective doses did not appear to increase with age, weight or thickness for any exam types (R^2<0.05). The measured DAPs were up to 90% less than published reference levels; however, the DAPs and effective doses were up to 10 times higher than other published data. Although diligently following radiation safety practices ensured patient doses were well below published reference levels, it is apparent that much lower doses are achievable. Investigation is underway to further reduce dose through physical and software modifications to existing equipment, such as additional tube filtration and pediatric-specific automatic brightness control algorithms. Conclusions: Practicing best radiation safety practices is not sufficient to ensure pediatric fluoroscopy doses are ALARA. Institutions that examine pediatric patients under fluoroscopy should work with their medical physicists and equipment manufacturers to ensure the hardware and software on their fluoroscopy equipment is optimized for pediatric examinations. Disclosure: Dr. Springer has indicated a relationship with Toshiba Medical Systems (Grant Funds).

Poster #: SCI-003 Radiation Dose and Image Quality in Pediatric Dual Energy CT: Phantom Study

Marilyn Siegel, Charles Hildebolt, David Bradley, Bernhard Schmidt, Juan Carlos Ramirez-Giraldo, PhD, Mallinckrodt Institute of Radiology, University of Washington, St. Louis, MO, [email protected] Purpose or Case Report: To evaluate radiation dose and image quality in phantoms simulating pediatric patients undergoing conventional single energy CT (SECT) and dual energy CT (DECT). Methods & Materials: Tissue-equivalent oval torso phantoms (N=3, small S, medium M, large L) and anthropomorphic phantoms (N=2, simulating 1 and 5 year olds) underwent contrast-enhanced abdomen examinations using SECT at 80, 100 and 120 kVp and DECT at 80/140 kVp on a dual-source CT system. Tube-current-time product was adjusted such that volume CT dose index (CTDIvol) was matched for all kVp combinations for each size phantom. The oval phantoms were used to compare CTDIvol, size specific dose estimate (SSDE), and contrast to noise ratio (CNR). Anthropomorphic phantoms were used to asses organ dose and effective doses at 80 kVp and 80/140 kVp.

All Data All ER All Inpatient All Neonate All Infant All Toddler All Preadolescent All Adolescent All Teenagers

All Data All ER All Inpatient All Neonate All Infant All Toddler All Preadolescent All Adolescent All Teenagers

Mean S value, m1 282.8 186.9 559.0 586.1 227.8 158.6 217.4 287.6 330.4 Mean S value, m1 282.8 186.9 559.0 586.1 227.8 158.6 217.4 287.6 330.4

All Data All ER All Inpatient All Neonate All Infant All Toddler All Preadolescent All Adolescent

Mean S value, m2 314.8 228.4 389.2 457.1 305.0 267.3 230.7 217.8 231.1 Mean S value, m3 320.76 334.85 283.90 317.17 314.28 312.93 249.66 325.00 394.41

average deviation below 300, m2 74.32 89.51 55.54 23.51 82.82 95.91 103.14 86.23

p value 0.087240 0.001450 0.000008 0.008170 0.076490 0.000260 0.592130 0.170040 0.007550 p value 0.021244 <0.0000001 <0.0000001 0.0000009 0.0124109 <0.0000001 0.17894801 0.39494874 0.01981051

percent < 100, m1 16.9 22.9 1.2 4.0 29.6 26.4 18.8 0.0

average deviation below 300, m1 143.31 148.30 81.38 169.20 167.93 163.93 126.65 81.20 80.62 average deviation below 300, m1 143.31 148.30 81.38 169.20 167.93 163.93 126.65 81.20 80.62

percent < 100, m2 12.1 17.0 7.8 0.0 15.7 9.3 18.5 23.1

mGy] for DECT and SECT at 80 kVp [P>0.05] or effective doses (1.0 mSv, 1 year-old, and 3.0 mSv, 5 year-old). Conclusions: At matched scanner output for each size phantom, DECT image quality, measured by CNR, is comparable to that achievable at 80 kVp and superior to that at 100 and 120 kVp. DECT organ and effective doses are comparable to those of conventional SECT at appropriately adjusted tube potential (80 to 120 kVp). DECT has the potential to be implemented clinically without additional radiation dose penalty while maintaining high image quality. Disclosure: Dr. Ramirez-Giraldo has indicated a relationship with Siemens Healthcare as an Employee (Salary). Mr. Schmidt has indicated a relationship with Siemens Healthcare as an Employee (Salary). Dr. Siegel has indicated a relationship with Siemens Healthcare as a Speaker (Travel reimbursement).

Poster #: SCI-004 Pediatric Chest Radiography Dose Monitoring by S Values: An Efficient Way to Indirectly Monitor Exposure Indices at the PACS Station

Matthew Bernbeck, MD, William Beaumont Hospital, Royal Oak, MI, [email protected]; Rachel VanHulle, Michael Hall, Scott Emerson

Results: For the S, M, L phantoms, CTDIvol values were 0.63, 2.70 and 3.30 mGy with SSDE values of 1.64, 5.97, and 5.45 mGy, respectively. Image noise values were similar across all kVp combinations for each phantom size (Figure a). CNR values of DECT and SECT were similar at 80 kVp (17 vs 17, 14 vs 11, 9 vs 9, respectively [P>0.05]) while the values were higher for DECT than for SECT at 100 and 120 kVp [P<0.05] (Figure b). There was no significant difference in organ doses [in

Purpose or Case Report: The hazards of ionizing radiation, and the increased susceptibility of pediatric populations to them are well established. Although radiography accounts for the bulk of the imaging performed on pediatric patients, they are not as aggressively monitored as fluoroscopy or CT. Since DR radiography, there has been a tendency towards dose creep. The S value is reported by Konica X-ray machines, recorded on PACS, and is negatively correlated with radiation dose, and is a measure we proposed to use to control radiation dosing in our institution.

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All Data All ER All Inpatient All Neonate All Infant All Toddler All Preadolescent All Adolescent All Teenagers

104.10 average deviation below 300, m3 56.85 50.19 73.54 55.40 52.42 43.85 81.12 53.87 20.59

percent < 300, m1

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2.7 percent < 100, m1 16.9 22.9 1.2 4.0 29.6 26.4 18.8 0.0 2.7

25.0 percent < 100, m3 5.9 3.6 11.1 7.3 5.3 1.7 8 7.7 5.4

percent < 300, m2

percent technologist compliance, m2

All Data

66.8

59.2

9.4

All ER

84.0

74.1

19.3

All Inpatient

16.0

46.0

2.0

All Neonate

10.0

24.0

3.5

All Infant

78.9

68.6

11.8

All Toddler

93.1

74.4

20.5

All Preadolescent

81.3

78.5

12.1

All Adolescent

78.1

76.9

0.0

All Teenagers

36.1

59.4

0.0

percent < 300, m1

percent < 300, m3

percent technolgist compliance, m3

All Data

66.8

47.3

25.7

All ER

84.0

45.6

28.1

All Inpatient

16.0

51.2

19.8

All Neonate

10.0

43.9

19.5

All Infant

78.9

52

32

All Toddler

93.1

45

25

All Preadolescent

81.3

70

28

All Adolescent

78.1

46.2

28

All Teenagers

36.1

16.2

21.6

Methods & Materials: First, x-ray phantoms of different thicknesses were constructed to establish if S value correlated with patient dosing, Fig. 1. Then, all two view chest x-rays and NICU chest x-rays obtained at our institution obtained in 1 month were analyzed for age, location, patient AP thickness and S value of the frontal x-ray. Subsequently, the technologists were trained to use and record new AP thickness based protocols, and a second month of data was collected. The 2 months were compared. After final discussions with x-ray technologists regarding how to improve compliance with the new protocols, a final month of data was collected and compared to the first month.

Results: The first phase showed a correlation between S value and x ray exposure given a certain patient thickness. The second phase showed that although most of the S values were within the manufacture suggested range (100–600), a substantially smaller number of data points were found in our target range (300–600), Table 1. Between the first 2 months, there was an increased mean S value as well as decrease in deviation below our minimum S value in the majority of the subcategories, but only statistically significant in a few subcategories. With improved technologist compliance during the third month of the study, there was a statistically significant increase in average S value in the majority of the subcategories as well as the overall data set, as well as decreased deviation in data points below our target S value in all subcategories. Conclusions: S value, or its counterparts with other x-ray vendors, has proven to be a useful tool in x-ray dose monitoring. Its association with xray dose given a patient thickness makes it a useful parameter to guide xray dosing technique. A good working relationship with a program’s technologists, with emphasis of the mutual goal of improving patient care, and other active reminders helped reduce radiation exposure at our institution. Poster #: SCI-005 Radiation Exposure From Imaging Procedures In Pediatric Emergency Medicine - A Survey of Physician Knowledge and Risk Disclosure Practice

Karen Thomas, MD, Department of Diagnostic Imaging, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada, [email protected]; Kathy Boutis, Jason Fischer, Stephen Freedman Purpose or Case Report: The balanced disclosure of potential future malignancy risks from imaging procedures that expose children to ionizing radiation is a challenge currently facing many physicians. Pediatric emergency medicine (PEM) physicians are at the forefront of this, in an environment of increasing parental awareness and concerns. Our aim was to determine the proportion of PEM physicians who are aware of current malignancy risk estimates associated with head computed tomography (CT), to examine risk disclosure practice patterns, the specific strategies employed when discussing risks with families and patients, and the potential barriers to initiation of risk-benefit discussions. Methods & Materials: We conducted an on-line survey of members of a national Canadian PEM physician association using a modified Dillman’s technique. The survey addressed the following domains: demographics, knowledge of potential risks associated with ionizing radiation in imaging; risk disclosure practice; frequency of parental questioning and perception of public awareness. Results: Of 156 eligible participants, 126 (80.8%) responded to the survey. Of the 126 respondents, 124 (98.4%; 95% CI 96.2, 100) reported that there is a potential malignancy risk associated with head CT, and 46 (36.5%; 95% CI 28.1, 44.9) correctly identified the best current estimate of this risk. The majority, 68.8% (95% CI 60.7, 76.9), reported disclosing possible risks “most of the time/almost always.” Although many physicians reported varying their disclosure strategy according to the clinical scenario, comparison with everyday risks was most frequently selected (33.3%) as most helpful to parents. Frequently cited barriers to informed risk-benefit discussions were concerns that parents will worry excessively about cancer (27.8%), during the treatment of a critically ill child (23.8%), and a concern that parents may not want the imaging procedure (15.9%). Conclusions: Our survey suggests that the knowledge base among referring physicians is improving. Almost all pediatric emergency physicians were aware of the potential malignancy risk from a head CT, and approximately one-third were able to identify the best

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available estimate of this risk. Although there are some barriers, many PEM physicians report regularly participating in risk disclosure with patients’ families. Poster #: SCI-006 Radiation dose and image quality in the use of low-dose C-arm CT in the treatment of head and neck vascular malformations

Marian Gaballah, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Deddeh Ballah, Xiaowei Zhu, M.S., Sphoorti Shellikeri, Anne Marie Cahill Purpose or Case Report: C-arm CT has been increasingly utilized as an adjunct in interventional radiology procedures. There is little published data available regarding patient radiation exposure from C-arm CT imaging. Our institution has devised a low-dose protocol that utilizes copper filtration with decreased radiation receptor dose and number of projections compared to the default manufacturer’s setting reducing radiation exposure by 96%. The purpose of this study is to review radiation dose and image quality from sclerotherapy procedures that used low-dose Carm CT as an imaging modality. Methods & Materials: From June 2010 to May 2013, 48 head and neck sclerotherapy procedures were performed with low-dose C-arm CT as an adjunctive imaging technique (28 M, 20 F, mean age 8.8 years). Images were reviewed by two-reader consensus and rated as non-diagnostic, noise/artifact present but airway is visible, or minimal noise/artifact present. Radiation doses for each exposure were recorded. Results: Of the 48 sclerotherapy procedures, 28/48 (58.3%) procedural images demonstrated minimal noise/artifact with a median radiation dose of 6.35 mGy (range 0.7–158.2 mGy). 20/48 (41.7%) procedures demonstrated noise/artifact with a visible airway and a median radiation dose of 5.45 mGy (range 0.8–109.1 mGy). The difference in radiation dose between the two groups was not statistically significant (p=0.13). Conclusions: Adjunctive low dose C-arm CT provides imaging that is diagnostically useful for assessing airway proximity in head and neck sclerotherapy. The inherent contrast acquired with image components such as contrast medium and air in the airway facilitates less tissue detail requirements. Furthermore, radiation dose is not a statistical predictor of diagnostic quality. Poster #: SCI-007 Radiation dose and image quality in the use of low-dose C-arm CT in the treatment of temporomandibular joint arthritis in patients with juvenile idiopathic arthritis

Deddeh Ballah, Department of Radiology & Biomedical Imaging, UCSF, San Francisco, CA, [email protected]; Marian Gaballah, Xiaowei Zhu, M.S., Anne Marie Cahill Purpose or Case Report: C-arm CT has been increasingly utilized as an adjunct in interventional radiology procedures. There is little published data available regarding patient radiation exposure from C-arm CT imaging. Our institution has devised a low-dose protocol that utilizes copper filtration with decreased radiation receptor dose and number of projections compared to the default manufacturer’s setting reducing radiation exposure by 96%. The purpose of this study is to review radiation dose and image quality from temporomandibular joint steroid injections that utilized low-dose C-arm CT as an imaging modality. Methods & Materials: From November 2007 to December 2011, C-arm CT imaging was utilized in 133 cases (112 females, 21 males; mean age 14.1 years, range 2–21 years) to confirm needles location. Images were reviewed by two-reader consensus and rated needle conspicuity as

excellent, good, or inadequate. Radiation doses for each exposure were recorded. Results: Of the 133 cases, 67/133 were for bilateral needle visualization and 66/133 were for unilateral needle visualization. Needle conspicuity was excellent in 200/200 (100%) cases. Radiation dose per exposure was a median of 3.2 mGy (0.1 mGy–11.1 mGy). Conclusions: Adjunctive low dose C-arm CT provides images with excellent needle conspicuity during temporomandibular joint injections. The inherent contrast acquired with image components such as bone and metal facilitates less tissue detail requirements. Poster #: SCI-008 Coronary CTangiography in pediatric patients of different ages, using a second generation dual-source CTscanner

Evangelos Mourtos, Dept of Pediatric Radiology, Astrid Lindgren Children’s Hospital,Karolinska University Hospital, Stockholm, Sweden, [email protected]; Marika Lidegran, Lena Gordon Murkes, Gloria Broberg Purpose or Case Report: To describe our experience with prospective ECG-gated coronary CT angiography in infants and children using a second generation dual-source CT scanner and different low-dose scan protocols according to the child’s age and heart rate. Methods & Materials: During a 29 month period coronary CT angiography was performed in 30 children with mean age 12,9 years (14 days–19 years) and body weights ranging from 4 to 113 kg. Three different prospective ECG-triggered scan protocols were used depending on the child’s age and pulse frequency. A high-pitch spiral scan protocol was used for older children with heart rates 60 or less, a narrow-window sequential scan protocol with data acquisition in the diastolic phase was used for heart rates 60–80 and a sequential scan protocol with fixed end-systolic data acquisition for heart rates 80 or greater. Indications for scanning, sedation and administration of βblockers were noted. Effective dose values were calculated and image quality assessed. Results: Among the 30 examinations, 16 were follow-up of patients with transposition of the great arteries after arterial switch operation, ten were clinically suspected coronary artery anomalies and two had coronary artery aneurysms after Kawasaki disease. Most patients were examined without any sedation. Oral β-blockers were used in 10 of the older children. Mean image quality was graded 4 on a scale from 1 to 5. No scan was non-diagnostic. Mean effective age-adjusted radiation dose for the entire group was 0,89 mSv. Sequential scanning with data acquisition in the diastolic phase and systolic phase had a mean dose of 1,2 mSv and 0,71 mSv respectively. High-pitch spiral scans had a mean dose of 0,67 mSv. Conclusions: High quality coronary CT angiography can be performed in pediatric patients of all ages, using different low-dose, prospective, ECG-triggered scan protocols adapted to the child’s age and heart rate. Poster #: SCI-009 Optimization of NATIVE TrueFISP protocol for non-contrast renal MRA

Jie Deng, PhD, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Cynthia Rigsby, MD, Marci Messina, Sheila Bero, Gary McNeal Purpose or Case Report: To improve the image quality of non-contrast enhanced MRA of renal arteries by optimizing the acquisition protocol of

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the 3D steady-state precession sequence with slab-selective inversion prepulse (NATIVE TrueFISP).

Methods & Materials: In patients with renal transplant or renal dysfunction, contrast-enhanced MRA cannot be performed due to the risk of nephrogenic systemic fibrosis. Alternatively, a newly developed noncontrast MRA technique NATIVE TrueFISP (Siemens Medical Solution) utilizes a slab of selective inversion prepulse with an inversion time (TI) to suppress signals from static tissues within the imaging volume, while enhance arterial inflow. The inversion slab is asymmetric with reference to the imaging volume to reduce inflowing venous signal. To reduce the respiratory motion, a cross-pair navigator is placed at the diaphragm, which may cause signal void in the region of interest and manipulating it away leads to inefficient gating. In addition, the position of inversion slab relative to imaging slab is critical to achieve optimal renal artery enhancement with minimal background and venous contamination. In order to improve the image quality and accelerate the workflow, we modified the protocol: 1) Use respiratory bellow triggered acquisition with the following parameters: cycle TR/acquisition window = 2200 ms, threshold = 35%, trigger delay = 0, respiratory phase = expiration. Longer effective TR allows longer TI that can improve the background suppression. Bellow triggering is also easier to set up without needing to adjust the navigator position. 2) Center the imaging FOV on the renal arteries and use a second inferior inversion slab to further mitigate downstream venous inflow. 3) For axial acquisition, the first inversion slab (thickness = 150 mm, TI = 1350 ms) is placed with top aligning with the imaging volume; for coronal acquisition, the top of the first inversion slab matches the top of the kidneys. The second inversion slab (thickness = 100 mm and TI = 800 ms) is just inferior to the first slab. 4) Use ‘couple graphics’ to link imaging volume and both inversion slabs for fast setup. Results: Seven patient images (age 5 months–19 years) acquired with this protocol are shown in Fig. 1. All images delineated abdominal aorta and renal arteries with good vessel-background contrast and minimal respiratory motion and venous contamination. Conclusions: We modified the NATIVE TrueFISP protocol that is easily performed and provides robust image quality of non-contrast renal MRA in pediatric patients. Poster #: SCI-010 Risk Factors for Compromised Venous Assess in Pediatric Patients with Congenital Heart Disease before Heart Transplant

Tashfeen Ekram, MD, Stanford, Stanford, CA, [email protected]; Beverley Newman, Seth Hollander, David Rosenthal, Frandics Chan Purpose or Case Report: Children with complex congenital cardiac abnormalities after undergoing surgical interventions as palliation may

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eventually require heart transplant. Adequate venous access is crucial during and after transplant for resuscitations. Risk factors associated with venous compromise is unknown. We hypothesize that the age at first surgery, the number of surgeries, and the native cardiac abnormalities affect venous compromise. Methods & Materials: After IRB approval, we retrospectively identified all patients in 2012 to 2013 who underwent CT angiography as part of their pre-heart transplantation workup. The CT protocol was a thin section scan from base of the neck to the hips after a 80-90s delay from the administration of intravenous contrast agent. Each case was reviewed by at last two cardiovascular radiologists for the patency of 14 central veins: internal jugular, subclavian, innominate, SVC, IVC, common iliac, external iliac, and common femoral veins. A score of one was given to a patent vein and zero otherwise, for a total possible score of 14 per patient. The patency scores were compared between different ages at first surgery, numbers of surgery, and cardiac abnormalities for statistical significance using the Student t-test. Results: Twenty-two patients (age range 14 months to 20 years) were identified which comprised 10 cases of hypoplastic left heart with remaining 12 including atrioventricular canal defect, tricuspid atresia, double outlet right ventricle, and tetralogy of Fallot. Hypoplastic patients had statistically significant more occluded or stenotic veins (mean of 11.4) compared to the remaining cohort (13.2; p=0.01). Patients undergoing surgical intervention within 60 days of life on average have statistically significant more venous occlusion or stenosis (11.5 versus 13.6; p=0.01). Venous compromise is not significantly related to the number of surgery (p>0.05). Conclusions: Children who have hypoplastic left heart syndrome and first surgery at less than 60 days of age have increased number of central venous occlusions or stenoses. CT angiographic assessment for central venous access before heart transplant is especially important in these groups of patients.

Poster #: SCI-011 Towards radiation dose reduction in MDCT with iterative reconstruction for the prenatal diagnosis of skeletal dysplasia: the minimum radiation dose required to evaluate the normal fetal bones?

Chihiro Tani, Hiroshima University Hospital, Hiroshima, Japan, [email protected]; Yoshinori Funama, Chikako Fujioka, Kazuo Awai Purpose or Case Report: Decide to the sufficient minimum radiation dose for the prenatal diagnosis by multi-detector CT (MDCT) of skeletal dysplasia is our ultimate goal. As a preliminary step, it is investigated using fetal specimens the minimum radiation dose for obtaining the CT image that can evaluate the normal fetal bones in this study.

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Methods & Materials: We used 15 fetal specimens. As fetal CT tends to be performed at around 30 weeks of gestation, we selected specimens with a gestational age of 24 to 36 weeks. We wrapped each fetus in towels to avoid damage and placed it in a cylindrical, 30-cm and 35-cm diameter plastic container (circumference 94-cm and 110-cm) containing a solution of 5% formalin. The size of the container mimicked the abdomen of the pregnant woman at 30 weeks of gestation. We used 64-detector CT scanner (VCT, GE Healthcare). The scan parameters were tube voltage, 100 kVp; tube current, 600−, 300−, 150−, 100−, and 50 mA. Images were subjected to adaptive statistical iterative reconstruction (ASiR®). The fetal dose was measured using a glass dosimeter. Image quality was evaluated on maximum intensity projectionand volume rendering images of fetal skeletons. Two radiologists recorded the visualization of a metatarsal, metacarpal, the 12th ribs, fibula, and femoral metaphysis using a score where 3 = clear, 2 = unclear, 1 = not visible. Images acquired at 600 mAwere considered to be standard images.

Results: The absorption dose of the fetal specimens was 10.15 mGy, 10.01 mGy (30-cm, 35-cm diameter plastic container) at a tube current of 600 mA, 5.21−, 4.74− at 300−, 2.54−, 2.36− at 150−, 1.76−, 1.70− at 100−, and 0.90 mGy, 0.79 mGy at 50 mA. Visual evaluation showed that without ASiR there was a statistically significant difference between images acquired at 600 mA and those obtained at 50 mA (30 cm; p < 0.01, 35 cm; p < 0.01) and 100 mA (30 cm; p = 0.02, 35 cm; p<0.01) but not at 150- and 300 mA. With ASiR there was a statistically significant difference between 50−and 600 mA images (30 cm; p<0.01, 35 cm; p<0.01) but not between the standard images (600 mA) and those acquired at 100−, 150−, and 300 mA. Conclusions: In CT for the purpose of evaluation of fetal bone, using the ASiR, the fetal radiation dose can be reduced to 1.70 mGy without affecting the diagnostic performance in pregnant women abdominal circumference less than110cm.

Poster #: SCI-012 A Novel Near-Infrared Imaging Approach to Visualizing Peripherally Inserted Central Catheters

Neel Sanghvi, Children’s National Medical Center, College Park, MD, [email protected]; Karun Sharma, An Massaro, Raj Shekhar Purpose or Case Report: Peripherally inserted central catheter (PICC) placement for long-term, stable central venous access is common in pediatric patients. Frequent verification of catheter tip location is necessary because malpositioned PICCs may cause serious complications. Currently, repeat X-ray imaging is used to monitor and confirm tip

location. However, use of ionizing radiation and associated costs prevent frequent inspection; making early detection of catheter tip migration or malfunction difficult. We hypothesized that near-infrared (NIR) fluorescence dyes incorporated in PICCs could be detected with fluorescence imaging. Because appropriately positioned PICCs in small children are <5 cm from the skin surface, a few centimeter penetration of NIR light into the human tissue could enable visualization of the catheter with this technique. Methods & Materials: We conducted a proof-of-concept study, using different fluorescent dyes imaged under tissue phantoms. Fluorescent dyes, which operate near or in the NIR range (700 nm–1000 nm range where light has maximum penetration in tissue), were selected. Three dyes (Alexa Fluor 680, ICG, and IRDye 800CW) were chosen based on cost, dye properties, and availability of imaging resources. Small plastic tubes (2 mm; 6 Fr diameter) were filled with the dyes and placed under tissue phantoms. The tubes were scanned using an IVIS 200 Optical Imaging System (PerkinElmer, Waltham, MA). Results: Figure 1 shows images acquired with the system. The maximum imaging depths were 0.4 cm for ICG, 1.3 cm for IRDye 800CW, and 2.2 cm for Alexa Fluor 680. Conclusions: Differences in imaging depth are due to properties specific to each dye and the imaging system used. IRDye 800CW has very similar properties to ICG, but is three times brighter. Both are NIR dyes that fluoresce in the optical window, achieving maximum depth when properly excited. Meanwhile, Alexa Fluor 680 does not fluoresce in the optical window; however, it has a similar brightness to that of IRDye 800CW. Finally, the imaging system used is optimal for Alex Fluor 680, leading it to have a higher penetration depth than the NIR dyes. It is possible that higher imaging depths can be achieved with optimized imaging techniques. Ongoing work involves more intensive characterization of the dyes and in-vivo testing. Although our immediate focus is the visualization of PICCs, this concept is suitable for and adaptable to other catheters and implants situated at shallow depths from the skin. Disclosure: Dr. Sanghvi has indicated a relationship with Children’s National Medical Center as an Employee (Salary). Poster #: SCI-013 MRI in the Male Fetus with Megacystis: Imaging Features and Contributions to Diagnosis and Management

Kimberly Fagen, MD, Radiology, Walter Reed National Military Medical Center, Bethesda, MD, [email protected]; Anna Blask, MD, Eva Rubio, Lindsay Pesacreta, Dorothy Bulas, MD Purpose or Case Report: Prenatal US has been the mainstay for the diagnosis of megacystis and lower urinary tract obstruction. The role of MRI in the evaluation of megacystis will be reviewed to determine imaging features and additional information useful to diagnose these disorders. Methods & Materials: Retrospective review from 2000 to 2013 identified 10 cases with imaging concerning for possible bladder outlet obstruction with both US and MRI performed. US and MRI imaging features of the genitourinary system were evaluated. Assessment of the lungs was included. Final diagnoses/outcomes were compared to prenatal diagnosis. Results: Ten cases were imaged at 19–34 weeks gestational age. The presumed diagnoses were posterior urethral valves or prune belly syndrome. Oligohydramnios or anhydramnios was found in 8, polyhydramnios in 1, and normal AFI in 3.

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MRI and US equally detected renal dysplasia in four cases and was superior to US in three cases. Urinoma and urinary ascites were also detected. Hydronephrosis was present in almost all cases, equally seen in both modalities. Ureteral dilatation was better seen on MRI in five cases; similar to US in three cases. No hydronephrosis or ureteral distension was present in two cases. Bladder distention was equally well visualized in all cases except one, in which MRI was superior. The dilated proximal urethra was equally seen in both modalities in six cases, but MRI was superior to US in two cases. Dilated urethra was not seen in two cases. Bladder wall thickening was detected in seven cases with both modalities, but MRI was superior in three cases. Additional genitourinary anomalies included patent urachus and umbilical cord cyst, both better characterized on MRI. Knowledge of the gender is important, but was not seen in three cases. MR was superior in two cases and the same as US in five cases. An important consequence of obstructed bladder is the secondary effect on lung development. MRI was superior to US in detecting small lungs and abnormal appearance in six cases. MRI showed small lungs, but normal appearance in one case. In three cases, both demonstrated normal lungs. Outcome was as follows: fetal death in utero-two cases, pregnancy terminated-one case, and postnatally-two cases of prune belly, one Grade IV vesicoureteral reflux, and two deaths. Final outcome was unknown in two cases. Conclusions: MR is a useful in the evaluation of fetal megacystis. Lung size and appearance are more reliably assessed by MRI. Improved delineation allow for improved counseling and planning of prenatal and postnatal management. Disclosure: Dr. Bulas has indicated a relationship with GE as a Non-paid Consultant; Philips, Non-paid Consultant.

Poster #: SCI-014 Cerebral Perfusion Measurements using dynamic Color Doppler Sonography in Normal Neonates and Neonates with Mild Hypoxic Ischemic Encephalopathy

Guilherme Cassia, McGill University Health Center: Diagnostic Radiology, Montreal, QC, Canada, [email protected]; Ricardo Faingold, MD, Flavia Menegotto, Chatchay Prempunpong, Anne Roy, Guilherme Sant’Anna Purpose or Case Report: To establish normative data for the cerebral perfusion intensity (CPI) of the basal ganglia (BG) and Thalami (Th) using dynamic color Doppler sonography (CDS) and to evaluate for differences between normal infants and infants with mild HIE.

Gestational age (weeks) Birth weight (grams) Male Apgar at 5 min Apgar at 10 min Cord pH BE Sarnat at admission Age of HUS (hrs) Temperature at study (°C)

Normal 39.1±1.4 3339±432 8 (47%) 9 [8–9] 9 [9–9] 7.28±0.05 (16) −1.7±1.5 − 27.8±2.8 36.9±0.2

Mild HIE 39.3±1.6 3379±699 11 (65%) 5 [4–6]* 7 [5.25–7.75] 6.99±0.16* −12.4±5.2* 1 27.9±4.3 36.7±0.29

Results are presented as mean ± SD, median [IQ], (%) or (n) of patients for that specific variable. *p<0.05 Table 2. Differences in BG and Th perfusion between Normal and Mild HIE infants. Methods & Materials: Healthy term babies and infants classified as mild

Basal Ganglia (cm/s) Minimal value Maximum value Difference CPI > 0.4 cm/s Thalami (cm/s) Minimal value Maximum value Difference CPI > 0.3 cm/s

Normal

Mild HIE

0.053 0.410 0.357 1

0.073 1.062 0.989 5

0.063 0.631 0.568 1

0.034 1.068 1.034 5

HIE at admission (Sarnat 1) were prospectively studied during a 2 years period (2011 to 2013). The study was IRB approved and informed consent was obtained. Head ultrasound (HUS) was performed between 24 and 36 h of life using a 11LW4 MHz linear transducer to obtain DICOM color Doppler videos of the blood flow in the BG and Th. Pulsed Doppler (Resistive index) of pericalosal artery was performed. Three videos of 3 s each were obtained for the region of interest (ROI), in the coronal plane, and used to calculate the CPI by using the Pixelflux Chameleon® software. The software allows automatic quantification of color Doppler data from a ROI by dynamically assessing color pixels and flow velocity during the heart cycle. CPI is expressed in cm/s. Clinical and radiological data were collected. Results: A total of 34 term neonates were included in this study (17 normal and 17 mild HIE). Infants with mild HIE had lower 5 min Apgar scores 5 [4– 6] vs 9 [8–9] when compared to normal. HUS was performed at a median age of 28 h for both groups. CPI (normal vs mild HIE) of the BG and Th areas were 0.2211±0.107 cm/s vs 0.3018±0.2682 cm/s (p=0.189), and 0.1960± 0.1288 cm/s vs 0.2733±0.2504 cm/s (p=0.211). However, mild HIE infants had a wider range of perfusion values for both BG [0.053 to 0.410 cm/s vs 0.073 to 1.062 cm/s] and Th [0.063 to 0.631 cm/s vs 0.034 to 1.068 cm/s] when compared to normal. High values of BG (>0.4 cm/s) and Th perfusion (>0.3 cm/s) were detected in 5 (29%) mild HIE infants compared to only 1 (6%) normal. Resistive indices in pericalosal arteries were similar in both groups 0.661±0.071 vs 0.638±0.049 (p=0.237).

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Conclusions: Normative data on perfusion of the BG and Th areas was obtained using CDS. There were no statistical differences between the mean values of perfusion between normal and mild HIE infants. A wider variation was noted in the later group, which may reflect differences on the degree of brain perfusion/reperfusion within this population. Dynamic CDS may be a useful bedside tool to assess brain tissue perfusion and to guide management. Poster #: SCI-015 MRA characterization of supraclavicular brown fat in infants

Lydia Kuo-Bonde, MD, PhD, Radiology, UCLA, Los Angeles, CA, [email protected]; J. Paul Finn, Ines Boechat, Skorn Ponrartana, Vicente Gilsanz Purpose or Case Report: Brown fat, a key regulator of body temperature in infants, is a densely vascular and metabolically active tissue. We recently observed highly vascular adipose tissue in the supraclavicular area of one infant with transposition of the great vessels. Motivated by this observation, we retrospectively examined infants between 2 and 18 days of life with congenital heart defects to determine the prevalence and vascular characteristics of brown fat. Methods & Materials: The study subjects, 13 males and 18 females, ranged in age from 2 to 18 days old and were treated for heart disease (four tetralogy of Fallot, eight hypoplastic left heart, three total anomalous pulmonary venous return, two truncus arteriosus, four pulmonary atresia, two dextrocardia-heterotaxy, one atrio-ventricular canal and two rhabdomyomas) between 12/17/2007 and 1/16/2013 in the Division of Pediatric Cardiology at the Mattel Children’s Hospital. The birth weights ranged from 1600 g to 3880 g; nine were born premature and 22 were full-term. Results: In 11 pediatric cardiac patients, MRA images depicted increased blood supply from branches of the subclavian arteries and a “blush” in the supraclavicular area, comparable to the enhancement seen within the thyroid gland. Vascular blush in the supraclavicular area was present in 45% of the full-term infants, but only in 11% of premature infants; however this difference did not reach statistical significance (P=0.069). There was no gender difference in the prevalence of vascular brown fat on MRA and no association between birth weight and the depiction of brown fat. Conclusions: Our findings conform to known anatomical sites of deposition of brown fat and corroborate previous CT studies showing brown fat in the chest wall as an enhancing tissue in infants. Knowledge that brown fat can be repeatedly observed as vascular tissue in the supraclavicular areas of infants should avoid misinterpretation and unnecessary further examinations. Poster #: SCI-016 Evaluation of fetal cystic lung lesions—“Hump sign” suggesting congenital pulmonary airway malformation type 1

Masahiro Kitami, MD, PhD, Department of Diagnostic Radiology, National Center for Child Health and Development, Tokyo, Japan; Osamu Miyazaki, Haruhiko Sago, Kentaro Matsuoka, Toshihiko Watanabe, Shunsuke Nosaka Purpose or Case Report: Prenatal diagnosis of congenital cystic lung lesions is clinically important. However, it is often difficult to make apparent diagnosis. The purpose of this study is to evaluate additional fetal MR finding of “hump sign” as a

peripherally located, wedge shaped low intensity directed towards the center of cyst. We hypothesized that it may differentiate CPAM type 1 (CPAM-1) from Non-CPAM1 lesions. Methods & Materials: The study comprised a retrospective analysis of 26 fetal MRI whose congenital cystic lung lesion was confirmed by surgical pathology. Mean gestational age was 29 weeks (range 25–37 weeks) in CPAM-1 group (12 cases), and 27 weeks (range 22–31 weeks) in NonCPAM-1 group (14 cases). Non-CPAM-1 group comprises bronchial atresias (n=5), pulmonary sequestrations (n=5: intrapulmonary; n=4, extrapulmonary; n=1), CPAM-2 (n=2), bronchogenic cyst (n=1), and CPAM-3 (n=1). All examinations were carried out by 1.5 T MRI systems (Siemens Aera or Philips Intera). We evaluated the presence of “hump sign” on axial, coronal and sagittal images of single-shot turbo spin-echo sequence. Fisher’s exact test was applied to compare the frequencies of “hump sign” between CPAM-1 and non-CPAM-1 groups. Results: “Hump sign” was seen in four cases in CPAM-1 group. On the contrary, there were no cases with “hump sign” in non-CPAM-1 group. Difference of frequencies of the “hump sign” were statistically significant between two groups (p<0.05). Conclusions: Our results suggest that “Hump sign” was significantly more frequent in CPAM-1 group. It provides a distinctive radiological hallmark that makes it possible to differentiate the disorder from other congenital cystic lung disease.

Poster #: SCI-017 Incidental Maternal Findings on Fetal MRI Studies

Selwan Abdullah, BS, University of Minnesota - Medical School, Minneapolis, MN, [email protected]; Kelly Dietz, Jessica Kuehn-Hajder, Tara Holm Purpose or Case Report: Fetal magnetic resonance imaging (MRI) is frequently offered for obstetric patients with suspicious fetal findings on ultrasound. Incidental maternal abnormalities may be identified. Pediatric radiologists often interpret fetal MRI and these incidental maternal findings may be outside their area of expertise. The purpose of this study is to describe the rates and types of incidental maternal findings in fetal MRI scans. Methods & Materials: A chart review of patients who underwent fetal MRI at the University of Minnesota Medical Center from 2/2008 to 6/2013 was conducted. Follow up fetal MRI scans and patients receiving a scan for maternal indications were excluded. Extra-uterine abnormalities (EUAs), uterine abnormalities (UAs), and radiologist recommendations for follow-up of incidental findings were recorded.

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Results: Two hundred eighty-three patients were analyzed. 44/283 patients had at least one incidental finding. 31/283 patients had EUAs. There were 37 EUAs in total. Of the EUAs, 12 were renal cysts. Other EUAs included dilated maternal vasculature, cholelithiasis, vertebral body hemangiomas, and sacroiliac/acetabulofemoral abnormalities. Notable findings included autosomal dominant polycystic kidney disease and crossed fused renal ectopia. UAs were found in 17/283 patients. There were 18 UAs in total. Of the 18 UAs, 10 were uterine fibroids. Other UAs included bicornuate uterus, arcuate uterus, synechiae, and a septate uterus. The interpreting radiologist suggested follow-up for incidental maternal findings in nine patients. Ultrasound was recommended for eight patients; five with renal cysts, one with a scarred kidney, one with an adnexal cyst, and one with an arcuate uterus. MRI was suggested for the one patient with high signal intensity in her right sacroiliac joint. Conclusions: With rising healthcare costs and concern for overimaging, it is important to evaluate whether fetal MRI leads to incidental findings that cause unnecessary work-up. In our study, follow-up for maternal findings was suggested in only 3.2% of patients. The most common incidental findings were simple renal cysts and uterine fibroids, which do not generally require significant follow-up. These are also findings that pediatric radiologists engaged in fetal imaging would likely feel comfortable diagnosing. This study suggests that less than 5% of fetal MRIs result in incidental maternal findings that require further imaging. Further studies are necessary to quantify the health-care costs of these incidental maternal findings.

Methods & Materials: We retrospectively reviewed reports from 440 MRE examinations performed in 424 children at the Hospital for Sick Children during the year 2012. Reasons for referral included known IBD (n=279) or clinically suspected IBD (n= 161). All extra-intestinal findings not directly related to bowel inflammation were recorded. Those findings considered normal variants were excluded from further analysis. Available prior imaging reports were reviewed to identify those extra-intestinal findings that were previously unknown or significantly changed from prior. Subsequent imaging reports from these patients were reviewed to determine if the extra-intestinal finding resulted in further imaging or image-guided therapy. Results: The average age of all patients was 14.03±2.68 years (mean ± SD) with a range from 5.92 to 18.75 years. There were 221 reported extra-intestinal findings in 159 of 424 patients (38%). Fifty-seven percent (n=126) were previously unreported or significantly changed from prior imaging, 33% (n=73) were stable from prior imaging, and 10% (n=22) were descriptions of normal variants. Of these new or significantly changed findings, 22% (n=28) were further evaluated with subsequent imaging and/ or image-guided therapy. Overall, 24 MRE examinations (5%) had extra-intestinal findings that resulted in follow up imaging. The most common previously unknown extra-intestinal findings were renal cysts, enthesitis, and ovarian cystic lesions. Those most commonly resulting in further imaging included biliary ductal dilatation or irregularity, hip synovitis or effusion, ovarian cystic lesions, and thoracic or pulmonary masses, with biliary ductal dilatation or irregularity being the most frequent. Conclusions: While many extra-intestinal findings reported on MRE in children have been previously described on prior imaging, the majority of these findings are new or significantly changed from prior imaging and, of these, over 20% will undergo further imaging for characterization or treatment guidance.

Poster #: SCI-018

Poster #: SCI-019

Incidental Extra-intestinal Findings on Magnetic Resonance Enterography in Children with Inflammatory Bowel Disease

Magnetic Resonance Enterography Identifies Silent Crohns Disease

Elizabeth Sheybani, Diagnostic Radiology, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Mary-Louise Greer Purpose or Case Report: The goal of this study is to determine the occurrence and characteristics of extra-intestinal findings not secondary to bowel inflammation on magnetic resonance enterography (MRE) in children with known or suspected inflammatory bowel disease (IBD).

Jonathan Loewen, MD, Childrens Healthcare of Atlanta, Atlanta, GA, [email protected]; Cary Sauer, Kiery Braithwaite, MD Purpose or Case Report: Crohns disease is a chronic relapsing inflammatory disorder of the gastrointestinal tract commonly presenting in the pediatric population. The disorder results in significant morbidity in affected patients, as well as long term complications including growth failure in children. Imaging features of both active and chronic disease in pediatric patients by MR enterography (MRE) has been well-described in the literature,

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however with attention focused primarily on the symptomatic patient. The primary purpose of this study is to screen for ongoing active inflammatory changes diagnosed by MRE in pediatric Crohns patients defined to be in remission based on clinical parameters. Methods & Materials: Research MRE studies were performed prospectively. A pediatric radiologist blinded to the clinical information of the patients assessed the patients for evidence of both active and chronic changes of Crohns disease in the small and large bowel. Imaging results were subsequently compared to clinical remission scores using the Pediatric Crohns Disease Activity Index (PCDAI). Results: The number of patients who underwent research MRE that met clinical criteria for disease remission equaled 14, with patient ages ranging from 11 to 17. 10 patients were male and four were female. Assessment of clinical remission was defined by a PCDAI of less than or equal to 10. Of the 14 patients in clinical remission, seven had a PCDAI of 0. Of these seven patients, two had evidence of acute inflammation on MRE exams; one with isolated small bowel disease and one with both small and large bowel involvement. Of the 14 patients in clinical remission, seven had a PCDAI between 1 and 10. Of these seven patients, five had evidence of acute inflammation on MRE; four with isolated small bowel inflammation, and with isolated large bowel inflammation. Representative cases will demonstrate the wide spectrum of both severity and extent of active bowel inflammation. Conclusions: Although the sample size is small, 50% of pediatric patients who met clinical criteria for remission showed evidence of active inflammation on MRE. MRE therefore, may be useful in patients between symptomatic flares to screen for subclinical acute inflammation. The identification of this subset of patients may ultimately be useful, particularly if resultant management changes could avoid long term complications such as growth failure. More studies would be needed to assess whether this sub-clinical active inflammation has a direct relationship to future symptomatic flares.

Poster #: SCI-021

Poster #: SCI-020

Poster #: SCI-022

Imaging of extraintestinal manifestations of IBD in children and young adults

Effect of Slow Intravenous Infusion of Glucagon on Small Bowel Peristalsis in Magnetic Resonance Enterography

Christine Kassis, Massachusetts General Hospital, Boston, MA, [email protected]; Michael Gee, Katherine Nimkin

Hedieh Eslamy, MD, Radiology, Seattle Childrens Hospital, Seattle, WA, [email protected]; Luana Stanescu, Gisele Ishak, Randolph Otto, Dennis Shaw

Purpose or Case Report: Inflammatory bowel disease (IBD) is a multisystem disorder that can involve the lungs, eyes, skin, bones, joints, liver, urinary tract, vascular structures and central nervous system. Extraintestinal disease may be the first manifestation of IBD in young patients, may or may not correlate with bowel inflammation, and may also be related to drug therapy. Radiologists should be aware of these sometimes quite rare disease entities and their association with IBD. Methods & Materials: Medical records of children and young adults with IBD were analyzed and cases of extraintestinal IBD with imaging studies were selected. Results: We will show imaging studies of extraintestinal conditions in young IBD patients, including necrobiotic nodules in the lungs, chronic recurrent multifocal osteomyelitis (CRMO), arthropathy,venous thrombosis, sclerosing cholangitis and cholangiocarcinoma, pancreatitis, urinary calculi, white matter disease in the brain and pyoderma gangrenosum. Conclusions: Early recognition of these extraintestinal disorders in IBD may help diagnose bowel disease, guide treatment planning and reduce morbidity.

Utility of MRI in pediatric multiple liver lesions

Majed Almotairi, MBBS, Diagnostic Imaging,Sick Kids., Toronto, ON, Canada; Govind Chavhan, MD DABR, Kamaldine Oudjhane Purpose or Case Report: The purpose of this study was to review our experience with multiple liver lesions and describe the MRI features of multiple liver lesions. Methods & Materials: Retrospective review of the consecutive MRI exams performed for the evaluation of multiple liver lesions between January 01, 2007 - December 31, 2012 were reviewed to note number of lesions, size of the largest lesion, signal characteristics and background liver. Final diagnosis was assigned to each case bases on pathology in available cases, and based on combination of clinical features, imaging features and follow up in the remaining cases Results: A total of 47 children (21 boys, 26 girls; age between 3 and 216 months with average age 127 months) were included in the study. Total 50 lesion diagnoses were seen in 47 children that included 17 focal nodular hyperplasia (FNH), eight hemangioma, six metastases, five regenerative nodules, three adenomas, three abscesses, and one each angiomyolipoma, dysplastic nodule, epitheloid hemangioendothelioma, focal fatty infiltration, hepatocellular carcinoma, infarction, nodular regenerative hyperplasia and hepatic cyst. Background liver was normal in 32, cirrhotic in 10, fatty in three and siderotic in two children. Of 17 children with FNH, 10 had history of previous malignancy. Most FNH showed similar signal characteristics that included T1 iso-tohypointensity, slight hyperintensity on T2, prompt enhancement on arterial phase and iso intensity on the equilibrium phase. Most hemangiomas were hyperintense on T2-w and retained contrast on equilibrium phase. Conclusions: MRI can be used for evaluation of multiple liver lesions in children. It helps to arrive at reasonable differential diagnoses and guide further investigation and management.

Purpose or Case Report: As part of a group Performance Quality Improvement project we modified our Magnetic Resonance Enterography (MRE) protocol to incorporate IV infusion of Glucagon, diluted in D5W, over 8 min with an MR-compatible infusion pump before IV contrast. We describe the efficacy of this protocol in decreasing small bowel peristalsis. Table 1- Summary of the Results in the Study and Control Groups Gender Male Female Study Group 12 15 Control Group 21 6

Age (Years) Summed score Range Mean SD ≥8 <8 10–20 15.9 2.8 19 8 6–19 15.6 3.2 6 21

Methods & Materials: The study and the historical control groups were each composed of 27 consecutive patients with suspected small bowel Crohn’s disease referred for MRE.

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The study group received Glucagon infusion and the historical control group did not. The dose of Glucagon was 0.2 mg or 0.4 mg for patients weighing < or ≥ 40 kg respectively; the Glucagon dilution protocol is described in a separate technical note. Two radiologists independently reviewed the pre- & post-contrast (at three time points) coronal T1-W GRE sequences. The radiologists were blinded to the presence/absence of Glucagon. The conspicuity of the small bowel walls was rated on a 3-point scale (3 = mild to minimally blurred, 2 = moderately blurred, and 1 = markedly blurred) with disagreements resolved by consensus. The three scores for the post-contrast sequences in each case were summed to yield a total score ranging from 3 to 9. The studies were divided into two groups of “mild to minimally blurred SB wall” and “moderately to markedly blurred SB wall” corresponding to summed scores of ≥8 and <8 respectively. Fisher’s exact test (with a 2-tailed p value and a cutoff p value of 0.05) was used to compute p value.

Results: The study group was composed of 27 consecutive patients who had MRE between April and August 2013. Patients’ weight at the time of the MRE ranged from 26 to 88 kg; only two patients weighed less than 40 kg and received the 0.2 mg Glucagon dose. Nineteen cases had a summed score of ≥8. Of the eight cases with summed scores of <8, 2 weighed less than 40 kg, and the remainder ranged in weight from 42 to 88 kg (mean 59.3, SD 15.9). The control group was composed of 27 consecutive patients who had MRE without Glucagon administration between April and July 2012. Six cases had a summed score of ≥8. In addition to bowel peristalsis, respiratory motion and lack of adequate distention of the small bowel contributed to blurring and lack of conspicuity of the walls of the small bowel in both groups. Fisher’s exact test yielded a 2-tailed p value of 0.0009, which was highly significant. Conclusions: Glucagon administered as a slow IV infusion decreases bowel peristalsis and improves visualization of the walls of the small bowel.

Poster #: SCI-023 Assessment of the value of upper gastrointestinal series for evaluation of malrotation and volvulus in patients with a distal obstructive bowel gas pattern on abdominal radiograph

Michael Aquino, MD, Radiology, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Rahim Moineddin, Nigel Hall, Alan Daneman

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Purpose or Case Report: Background: Fluoroscopic studies of the upper gastrointestinal tract (UGI) are often requested in pediatric patients to evaluate for malrotation with volvulus, a pediatric abdominal emergency. Malrotation with volvulus is a proximal obstructive process. In rare, severe cases a distal obstructive gas pattern can be simulated on radiographs but these patients are typically unstable. Corresponding Abdominal Radiograph and UGI Fluoroscopy Results

Abdominal X-Ray Distal obstructive gas pattern No distal obstructive gas pattern

Malrotation on UGI + − 1 26 19 54

Objective: To determine the value of UGI series for suspected malrotation with volvulus in infants less than 6 months of age that present with a distal obstructive gas pattern on the preceding abdominal radiograph. Methods & Materials: In this retrospective study all fluoroscopic UGI studies performed on infants less than 6 months of age between January 1, 2012 and September 25, 2013 were reviewed. All UGI studies performed for evaluation of malrotation and volvulus with corresponding abdominal radiograph performed with 72 h prior were included in the study. If followup barium enema was performed, these studies were also reviewed. Abdomen radiographs were classified as having or not having a distal obstructive bowel gas pattern. Odds of having a distal obstructive bowel gas pattern on xray and having malrotation on fluoroscopy were compared to the odds of not having a distal gas pattern on xray and having malrotation on fluoroscopy. Results: A total of 206 UGI studies were performed for evaluation of malrotation and volvulus. Of these, 100 did not have a preceding radiograph in 48 h. Of the other 106 studies, 79 did not have a distal obstructive gas pattern on radiograph and 27 did have a distal obstructive gas pattern. The odds ratio for having a distal gas pattern on xray and having malrotation on fluoroscopy compared to not having a distal gas pattern on xray and having malrotation on fluoroscopy was 0.1 (Table 1). This indicates that having a distal gas pattern on xray is associated with lower odds of having malrotation and volvulus. Of those with a distal obstructive gas pattern, 17 had follow-up barium enemas suggestive of Hirschprung’s disease in nine cases, meconium plugs in two cases and negative in six cases. Conclusions: UGI fluoroscopy in patients with radiographs depicting a distal obstructive bowel gas pattern is of minimal diagnostic value and unnecessarily contributes to patient radiation dose. Poster #: SCI-024 Recognizing Causes of Inaccurate Ultrasound Diagnoses in Pediatric Appendicitis by Direct Imaging-Histology Correlation of Equivocal Cases

Nadine Al-Aswad, Bsc., The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Paola Bonasoni, Suzanne Schuh, Arun Mohanta, Carina Man, Andrea Doria Purpose or Case Report: The purposes of this study were to determine the proportion of inaccurate diagnoses of pediatric appendicitis due to an equivocal ultrasound (US) according to levels of visualization of the appendix on US and to demonstrate imaging-histologic correlative features. Methods & Materials: Three hundred two children (ages 4–17, 74 females) were enrolled from the emergency department of a tertiary care pediatric hospital with suspected appendicitis. Patients were managed according to an imaging pathway where those with an indeterminate

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clinical diagnosis (Pediatric Appendicitis Score, PAS 2–8/10 points) underwent one or two USs for diagnosis. Children with equivocal US were categorized as either having (1) a completely visualized appendix; (2) a partially visualized appendix, or (3) a non-visualized appendix, and in each category the number of false negatives (FN) and false positives (FP) was determined. FN’s were those with a diagnosis of “no appendicitis” but had histologic appendicitis within 1 month follow up. FP’s were those with a diagnosis of “appendicitis” but not on histology.

Results: Of the 302 enrolled patients, 132 (44%) were identified as having an equivocal US, with 6 FP/FN (4.5%) final diagnoses of appendicitis. In the category of completely visualized appendix (n=20, 15%), there was 1 FP and 1 FN diagnosis after the first US due to lymphoid hyperplasia (FP) and borderline measurement of appendix (FN),), and 2 FP and 0 FN after the second US (due to lymphoid hyperplasia and a normal appendix). The mean PAS in patients in this category was 4.55 (range 2–9). In the category of partially visualized appendix (n=26, 20%), there was 0 FP and 1 FN diagnoses after the first US (FN due to borderline measurement of appendix), and 0 FP or FN on the second US. The mean PAS in this category was 5.04 (range 2–9). In the category of non-visualized appendix (n=86, 65%), there was 1 FP (due to lymphoid hyperplasia) and 0 FN diagnoses on the first US, and 0 FPs or FNs on the second US. The average PAS in this category was 5.22 (range 2–10). Of 12 (9%) with wall hyperemia on US, eight had a final histological diagnosis of appendicitis, and of 13 (10%) with increased echogenicity of soft tissues on US, 11 had appendicitis confirmed histologically. Conclusions: Inaccurate final diagnoses of appendicitis in children with equivocal USs are uncommon. We found the lymphoid hyperplasia and a borderline appendix measurement as the main pathologic features in children with inaccurate diagnoses.

Poster #: SCI-025 Appendicoliths on Ultrasound are Highly Specific for Appendicitis in Patients with Abdominal Pain

Jason Nielsen, M.D., Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, [email protected]; Eric Lee, M.D., Laura Boomer, Brent Adler, D. Bates, Brian Kenney Purpose or Case Report: The diagnostic accuracy of ultrasound for appendicitis is improved by the inclusion of secondary sonographic signs particularly in patients where the appendix is incompletely visualized. As part of a quality improvement project to increase diagnostic accuracy, we developed a standard ultrasound report with required reporting of several features including the presence or absence of an appendicolith. This standard report allowed us to review the relative value of appendicoliths as a secondary sign of appendicitis and also any associated differences in clinical outcome. Methods & Materials: All ultrasounds performed for suspicion of appendicitis in the Emergency Department of our large pediatric hospital from June 2012 to July 2013 (n=1581) were reviewed. Information regarding visualization, presence of appendicolith, and final diagnosis was obtained and analyzed. The pathologic diagnosis was used as the standard for determination of sensitivity and specificity. Results: A total of 1581 ultrasounds were reviewed, of which 340 were diagnosed with appendicitis (21.5%). The appendix was not visualized or was only partially visualized in 721 out of 1581 (45.6%) ultrasounds. Appendicoliths were identified in 126 of 1581 (7.96%) patients. A total of 112 out of 126 (88.9%) patients with appendicoliths were diagnosed with appendicitis. Overall sensitivity and specificity of appendicoliths for appendicitis were 32.94% and 98.87% respectively. Positive and negative predictive values were 88.89% and 84.33%. Twenty five patients with appendicoliths only had partial visualization of the appendix, of which 22 of 25 were diagnosed with appendicitis. Sensitivity and specificity of appendicoliths were similar when the appendix was only partially visualized (27.85% and 99.53%). Sixty eight of 228 (29.82%) patients with appendicitis who did not have an appendicolith were diagnosed with ruptured or gangrenous appendicitis compared to 59 of 112 (52.68%, p=<.01) patients with an appendicolith. Conclusions: Appendicoliths on ultrasound are highly specific for appendicitis and have utility as a secondary sign to aid in diagnosis. Patients with appendicoliths are also more likely to present with ruptured or gangrenous appendicitis. Poster #: SCI-026 Assessment of upper gastrointestinal studies (UGI) in children with 22q11.2 deletion syndrome

Sudha Anupindi, Maria Bedoya, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Kesav Anupindi, Donna McDonald-McGinn, Elaine Zackai, Maria Mascarenhas Purpose or Case Report: 22q deletion syndrome has multi-organ involvement with variable gastrointestinal abnormalities. Our aim is to determine the UGI findings in children with 22q deletion syndrome Methods & Materials: One pediatric radiologist retrospectively reviewed in a blinded fashion 20 UGI series performed between 1997 and 2012 in children with 22q deletion syndrome. Seventeen subjects met our inclusion criteria: 5 girls and 12 boys. Mean age at UGI was 2.3 years (11 days-17.8 years) +/− 4.4 years. The most frequent indications for UGI were symptoms of reflux in 11 (65%), swallowing problems in 8 (47%), constipation in 8 (47%), and emesis in 7 (41%) patients. Documented

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UGI findings included: esophageal abnormalities; position, orientation and conformation of the stomach; and configuration and location of duodenum and duodenojejunal junction (DJJ). Also the location of jejunum and cecum were noted where possible. Studies were complete in 13/ 17 (76%); the esophagus was not evaluated in 4/17 studies and 6/17 studies (35%) had small bowel follow-through exams. Gastric emptying, esophageal motility and gastroesophageal reflux (GER) were documented from the UGI reports. Clinical and surgical histories were recorded.

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diarrhea. Their symptoms can mimic other disorders such as gastroenteritis, intussuception, urinary tract infection, hepatitis, and pneumonia. Associated illnesses such as otitis media, respiratory infection, and gastroenteritis can lead to a delay in diagnosis. Because of the nonspecificity of their symptoms, younger patients present with complicated appendicitis more often than older children. Imaging often plays a role in the work up. Radiographic, ultrasound, and CT images will be presented with findings in the younger child including small bowel obstruction, pneumoperitoneum, pelvic abscess, complicated multifocal abdominal and pelvic abscesses, subhepatic abscess, perinephric abscess, psoas abscess, and inflammatory process involving the abdominal wall. Conclusions: Appendicitis in young children can be difficult to diagnose leading to a delay in treatment and an increased incidence of perforation. Likewise, imaging for appendicitis in this age group may be confusing. It is important to be familiar with the spectrum of imaging appearances of appendicitis in the young child. Poster #: SCI-028 Non-Fecalith Induced Appendicitis: Is There Another Etiology?

Leonard Swischuk, MD, Radiology, University of Texas Medical Branch, Galveston, TX; Dai Chung, Hal Hawkins, Siddharth Jadhav

Results: Surgically confirmed intestinal malrotation was found in 4/17 (23.5%) patients; one had Ladd surgery before the UGI study. Two UGI cases that showed malrotation were surgically confirmed (true positives). One case initially considered to have malrotation at UGI was surgically confirmed to have normal intestinal rotation with a low ligament of Treitz (false positive). One case with normal UGI study was surgically confirmed with intestinal malrotation (false negative)(See Graph 1.). No study depicted midgut volvulus. By UGI report no patient showed delayed gastric emptying, 1/17 had severe GER and 4/17 (24%) showed moderate GER. Of note, in the esophageal exam two cases showed an aberrant right subclavian artery and two demonstrated evidence of a vascular ring. Conclusions: Common findings in patients with 22q deletion syndrome that undergo UGI studies are: intestinal malrotation, esophageal vascular anomalies and gastroesophageal reflux. Careful attention to the rotation of the bowel is essential when performing UGI studies in these children due to the presence of false findings. Evaluation of the esophagus must be included in all children with 22q deletion, otherwise thoracic vascular anomalies may go undetected.

Poster #: SCI-027 Appendicitis in the Young Child—Pictorial Review

Ellen Patrick, M.D., Children’s Healthcare of Atlanta, Egleston, Atlanta, GA, [email protected]; Paula Dickson, M.D. Purpose or Case Report: Appendicitis is the most common surgical cause for abdominal pain in the pediatric patient. In the young age group symptoms may be nonspecific, and making the diagnosis of appendicitis can be a clinical challenge. The goal of this report is to demonstrate imaging findings of appendicitis, often complicated, in the young child. Methods & Materials: Imaging examinations in patients with the diagnosis of appendicitis at Children’s Healthcare of Atlanta, Egleston under 5 years of age were reviewed. Examples of images with a variety of appearances are presented as a pictorial review. Studies include plain radiographs, ultrasound, and abdominal CT examinations. Results: Young children with appendicitis can present with a variety of symptoms including vomiting, fever, abdominal pain, anorexia, and

Purpose or Case Report: To investigate the etiology of non-fecalith induced appendicitis and determine what underlying etiology is present. Methods & Materials: We prospectively observed and documented the imaging and histologic findings in 40 cases of histologically proven purulent appendicitis seen over 2 years. Findings documented were: (1) presence of a fecalith (2) presence of lymphoid hyperplasia, (3) histopathology of the appendix. Results: There were a total of 40 patients, 28 males and 12 females. The age range was 2–18 years with a mean of 11.5 years. Twenty (22) patients demonstrated classic total appendiceal purulent appendicitis and twenty (20) had a fecalith. Eighteen (18) patients had purulent appendicitis confined to the tip of the appendix and all eighteen (18) patients demonstrated marked lymphoid hyperplasia. Only two (2) had a fecalith. Conclusions: Lymphoid hyperplasia appears to play a significant role in the development of non-fecal induced appendicitis, and especially vulnerable is the tip of the appendix. Poster #: SCI-029 Acute Abdominal Pain in Pediatric Patients with Chronic Colonic Dysmotiliy: Be aware of colonic volvulus

Megan Marine, MD, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, [email protected]; Boaz Karmazyn, Frederick Rescorla, Joseph Croffie Purpose or Case Report: Describe clinical and imaging findings of colonic volvulus in children with chronic colonic dysmotilty. Methods & Materials: This is an IRB approved, retrospective study (2002-April, 2013). We retrieved all patients admitted to our tertiary children’s hospital with surgically or endoscopically proven colonic volvulus. Only patients with medical history of chronic colonic dysmotility were included. We reviewed all available abdominal radiographs for baseline and change in bowel gas pattern. We also reviewed enema studies and CT exams when available. Results: There were 15 pediatric patients (6 females) with an average age of 14 years (range 8 to 19 years) with chronic colonic dysmotility who developed colonic volvulus. Acute abdominal pain and increased abdominal distension were the most common clinical presentations. Cecal volvulus was the most common type (n=10, 67%). Other types of volvulus included sigmoid (n=5, 33%) and transverse colonic volvulus (n=1, 7%). One of the patients with cecal volvulus had concominant

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midgut volvulus. The most common finding on abdominal radiograph was increased focal dilation of colonic loops. Other signs included absence of rectal gas. Enema studies (n=8) and CT exams (n=6) when available, aided in diagnosis but were not definitive in all patients. Conclusions: In children with colonic dysmotility who present with acute abdominal pain and/or increased abdominal distension, any change from baseline bowel gas pattern, especially presence of focal dilation of colonic loops, should raise the diagnosis of colonic volvulus. Enema and CT studies, while not always definitive, can aid in the diagnosis.

Purpose or Case Report: Intermittent, partial and early testicular torsion are difficult clinical and sonographic diagnoses because the testicular blood flow is maintained and symptoms may wax and wane. Torsion may be misdiagnosed as epididymitis. We reviewed our challenging cases of testicular torsion to determine imaging and clinical features which would assist in establishing the correct diagnosis.

Poster #: SCI-030 Medullary nephrocalcinosis: an overused diagnosis in pediatric patients?

Agustin Cardenas, Radiology, UCSF, San Francisco, CA, [email protected]; Andrew Phelps, Jesse Courtier, MD, John MacKenzie, MD, Peter Marcovici Purpose or Case Report: 1) To evaluate cases diagnosed by ultrasound as medullary nephrocalcinosis (MN), and determine if any of these cases were transient false positives. 2) To identify sonographic findings that could distinguish MN from other entities. 3) To identify clinical associations of MN that differ from false positives. Methods & Materials: With IRB approval, we retrospectively searched our radiology database over a 7-year period for renal ultrasounds in pediatric patients that contained the diagnostic term “medullary nephrocalcinosis”. Forty-two patients initially diagnosed with MN that had follow-up renal imaging beyond 6 months of life were randomly selected for re-review of imaging and clinical data, described in the results. Results: Of the 42 patients, 15 (37.71%) showed normal renal medullary parenchyma on follow up ultrasound and were considered false positives. The remaining 27 (62.29%) had persistent echogenic renal medullary parenchyma and were considered true positives. The average age of patients at the time of initial diagnosis was older in the true positives (70.88 months) than in the false positives (15.6 months) (p<0.001). There was no statistically significant difference between true and false positives when considering: the proportion of incidentally diagnosed MN (p 0.66), the presence of echogenic medullary tips (p 0.35), the presence of acoustic shadowing (p 0.49), history of prematurity (p 0.34), history of treatment with furosemide (p 0.63) or steroids (p 0.49), proportion of patients with hypercalciuria in the UA (p 0.25), or history of ventilation (p 0.27). Conclusions: The main difference between medullary nephrocalcinosis and other entities with no permanent medullary parenchymal calcification is the persistency over time of hyperechogenicity of the medullary pyramids. In our sample, the only variable which was significantly different between true and false positives was the age at the time of diagnosis. The ultrasound diagnosis of medullary nephrocalcinosis should therefore be made with caution in pediatric patients at the first ultrasound examination, particularly those younger than 1 year of age. The traditional US characteristics of hyperechogenicity of the renal medullary pyramids might be transient in children, and could for example represent Tamm-Horsfall proteinuria in neonates. We suggest that the diagnosis of medullary nephrocalcinosis be used carefully, and only in those patient with follow-up studies, confirming the finding is permanent.

Methods & Materials: Index cases were encountered by two pediatric radiologists and additional challenging cases were identified by retrospective review of radiology database over a 2 years period. Challenging cases were defined as those with preserved testicular flow, confusing appearance of paratesticular tissues or more than one sonogram for recurrent episodes of pain. Neonates were excluded. Images including cineloops, clinical and surgical history, and pathology results were analyzed. Results: Of the 310 cases of scrotal sonography for painful scrotum, 39 met our criteria and were divided into three groups Group A. 18—highly concerning for testicular torsion; 10/18 were surgically explored (nine true positives, one false positive). 8/18 did not undergo surgery due to discrepant clinical exam, resolution of symptoms or parents declined surgery. Of the 10 surgical cases, testicular flow was decreased in 6, symmetric in 3, first decreased then increased in 1 (consistent with detorsion). Globular testicular enlargement seen in all 10; abnormal lie in 9; homogeneous parenchyma in 4, heterogeneous in six cases. Redundant spermatic cord (bunched up paratesticular mass containing tortuous tubular vascular channels) present in all 10. Whirlpool sign (classic swirling of cord) noted in only 4/10. Flow was preserved in parts or all of the cord. Hydrocele in 10. Group B. 8—initially called epididymitis but diagnosed as torsion on repeat imaging; 6 surgically proven torsion. No surgery in two due to resolution of pain. Group C.13 were diagnosed with epididymitis (10), varicocele (2) or hydrocele (1), but imaging features showed some similarities to our proven cases of torsion. Conclusions: 1. Presence of intratesticular flow does not exclude torsion. 2. Presence of redundant spermatic cord within the scrotum is highly suspicious for torsion of the cord. 3. Astute analysis of the cord and size/shape of the testis may prevent overdiagnosis of epididymitis. 4. Red flag clinical features include nausea/vomiting, recurrent episodes of scrotal pain, abrupt onset or cessation of pain. The latter signs suggest intermittent testicular torsion.

Poster #: SCI-031 Poster #: SCI-032 The sonographic diagnosis of testicular torsion in the pediatric patient: “Knot” that easy!

Anjum Bandarkar, MD, Anna Blask, MD, Diagnostic Imaging and Radiology, Childrens National Medical Center, Washington, DC, [email protected]

Neonatal Testicular Torsion: Update on Sonographic Imaging and Management

Anna Blask, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Anjum Bandarkar, MD

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Purpose or Case Report: To analyze the sonographic imaging features of neonatal testicular torsion and the clinical presentation, management decisions and outcome. Methods & Materials: A radiology database was searched to identify all testicular sonograms performed in neonates less than 30 days of life for scrotal swelling, discoloration, palpable mass, or rule out testicular torsion from 2006 to 2013. Results: Nineteen cases with scrotal US. 8/19 (42%) were testicular torsion (unilateral 7, bilateral 1); 11/19 were hydrocele (6), hernia (3), hematoma (1), and incompletely descended testes (1). Age at clinical presentation: seven babies with abnormal scrotum at birth, one baby at 5 days Age at sonogram: 9 h–20 days (four babies on day one of life) Imaging Features in 9 symptomatic testis: Testicular enlargement with globular shape 8, testis small 1, lobular borders 3, heterogeneous echotexture 8, homogeneous echotexture 1, radiating lucent bands 8, egg shell hyperechoic rim 3, absent Doppler flow 7, decreased Doppler flow 2, normal Doppler flow 0 Extratesticular Findings: Clear hydrocele 2, complex hydrocele 6, classic whirlpool sign 0, redundant cord vs. epididymal enlargement 5, straight spermatic cord 1, band (s) of circumferential thickened soft tissue 9, hyperemic halo 7 Findings of contralateral asymptomatic testis: Normal 7, Hydrocele 6 Management: Orchiectomy with orchidopexy of contralateral side 3, no surgery 5 (parental refusal in 1, thoracic surgery for CPAM in 1) Outcome: Testicular salvage 0; Not salvaged 10 testes (includes 1 late atrophy of contralateral asymptomatic testis), extravaginal 3, intravaginal 0 Conclusions: Neonatal torsion is rare, but may be the cause of the “vanished” testis. Globular testicular enlargement, altered echotexture, radiating lucent bands, peritesticular circumferential bands of tissue thickening, and absent or decreased testicular Doppler flow are the imaging findings of neonatal torsion. Involuted testis with “eggshell” rim may be detected. “Whirlpool” sign is not typical, possibly since many of these cases are extravaginal torsion. Excess intrascrotal tissue may reflect epididymal enlargement, redundant cord or hemorrhagic clot. Testicular salvage did not occur in our series, but is reported in cases of postnatal torsion. Management, while controversial, is trending toward surgical exploration, especially to try to protect the contralateral testis. An abnormal testis in the neonate is due to torsion, not neoplasm. Poster #: SCI-033 Diagnostic efficacy of novel vesicoureteric reflux imaging technique Voiding Urosonography (VUS): A systematic review

Sunny KS Tse, MBBS, FRCR, MMed(DR), Department of Radiology and Imaging, Queen Elizabeth Hospital, Hong Kong, Hong Kong, [email protected]; Hin Yue Lau, Elaine WS Fok Purpose or Case Report: Fluoroscopic Voiding cystourethrography (VCUG), the standard examination of vesicoureteric reflux, has been challenged recently for its radiation exposure and diagnostic accuracy. Hence alternative method Voiding urosonography (VUS) is utilized, with favourable results in various primary studies and our local experience. To further evaluate the diagnostic accuracy of voiding urosonography, in particular with the use of newer generation of ultrasound contrast and ultrasound technique, we performed this systematic review to determine and summarize the diagnostic accuracy of voiding urosonography as compared to the traditional VCUG or radionuclide cystography (RNC) from various primary studies. Methods & Materials: Systematic literature search in the database Medline Ovid in the period between year January 1995 and July 2013, restricted to English-based literature, was performed. Additional studies were scrutinized from Embase, international conference abstracts and Google Scholar. All the primary diagnostic validation studies comparing

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the diagnostic accuracy of VUS with VCUG or RNC, in the diagnosis of vesicoureteric reflux in children, were recruited. Those studies on adult or other primary outcomes were excluded. Those studies exclusively on subjects known to have vesicoureteric reflux were also excluded. The search strategy and results will be further described. Results: There were 108 studies retrieved for abstract and full-text assessment. In total, 19 eligible primary studies, with total 2921 subjects, were included for analysis. Demographic and clinical data of the recruited subjects, description of index (VUS) and reference examinations (VCUG/RNC), study outcomes and definition of positive/negative results, and results of the included studies were extracted and analyzed with Review Manager (RevMan, Version 5.2). Their methodological quality was assessed based on the STARD (Standards for Reporting of Diagnostic Accuracy) statement 2003. Tking VCUG/RNC as reference, VUS had a sensitivity of 57–100%, which increased to 80–100% in 6 studies using second-generation contrast agent SonoVue. Graphical representation with Forest plots will be described. Other secondary outcomes, including technical aspects, examination duration and safety will also be elaborated. Conclusions: Voiding Urosonography (VUS) is a sensitive, safe, and radiation-free modality in diagnosing vesicoureteric reflux in children, and is a valid alternative examination modality to VCUG in the ALARA era. Poster #: SCI-034 Radiology Report Quality and Automated Speech Recognition Software Utilization: Errors and error rates—A 5 year Assessment

Monali Warade, The Hospital for Sick Children, Toronto, Toronto, ON, Canada, [email protected]; Manohar Shroff, Lisa Jong, Andre Pereira, Suhas Kotecha, Erika Mann Purpose or Case Report: The purpose of this study was to assess errors associated with implementation of automated Speech Recognition Software (SRS) on radiology reporting with a focus on types and frequency of error occurrence in finalized reports. Methods & Materials: Randomly selected reports (n=150) were reviewed before SRS (Talk Technology, Version 3, 2008) was introduced (t = X), after 1 month (t=0), and at four recurring intervals of approximately 1 year from 2009 (t=1) to 2012 (t=4) at a major pediatric academic center. Each data set consisted of 30 MRI, 99 US, 33 CT and 18 IGT reports. Patterns and rates of errors in the finalized reports were delineated and comparatively analysed. Errors were categorized into: minor errors (spelling, sentence structure, spacing, report organization) and errors which changed intent/interpretation. Amongst these, errors with a potential to affect patient management were classified as major errors. Effect of interventions to decrease errors including: directives and recommendations, seminars, case conference, discussions, hand-outs, and targeted personal advisement in 2009–10 were assessed. Error rates were compared across modalities and single versus double reader status. Results: Post SRS an initial substantial increase in the total error rates in 2008 (1.36 +/−1.62) and 2009 (1.48 +/− 1.65) is attributed to the learning curve associated with the use of new technology. Following interventions, increase in the error-free reports was observed. At the end of 4 years post SRS implementation, the error rates had decreased to 0.69 +/− 0.98 in 2012 and returned to the pre-SRS baseline of 0.67 +/− 1.25 (p=0.57). PreSRS major error containing reports were notably absent and did not exceed 1.1% for SRS generated reports. The error rates were maximal in MRI reports as compared to combined error rates of US, CT and IGT (p=0.007 in the pre-SRS, 0.053 before and 0.0006 after interventions to decrease errors); presumably because of longer reports. Comparison of single versus double reader study error rates was inconclusive. A marked and sustained decrease in the overall report turn-around-time was noted with the use of SRS technology. Conclusions: Initial implementation of SRS may lead to significant increase in errors in finalized reports. It is important to measure and monitor

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the impact of such technology and use interventions to decrease error rates associated with SRS. Special attention has to be paid in reporting relatively lengthy reports such as MRI to keep minimum possible error rates

Poster #: SCI-035 Endovasular management of upper extremity deep venous thrombosis in children

Matthew Lungren, Cincinnati Children’s Hospital, Cincinnati, OH, [email protected]; Kamlesh Kukreja, MD, Manish Patel, Neil Johnson, MB.BS, John Racadio Purpose or Case Report: The annual incidence of venous thromboembolism (VTE) in children is estimated at 0.07–0.49 per 10,000 children with the highest frequency of events occurring in the neonatal period. More than 90% of thrombotic events in children are a result of underlying risk factors or disease processes, the most common being central venous catheters. With advanced medical treatments, use of central venous catheters is expected to increase. Treatment of DVT is important to prevent post thrombotic syndrome and preservation of venous access. There is very little information in the medical literature regarding endovascular incidence and management of upper extremity DVT in children. The purpose of this project was to characterize the technical success, complication rate, and endovascular management of upper extremity deep venous thrombosis in a pediatric population at a large tertiary care center. Methods & Materials: Sixteen patients (11 males, 5 females), average age 9.6 years (range 21 days to 18 years) with upper extremity DVT treated with endovascular thrombolysis between July 2006 to July 2013 were identified. Catheter directed therapy by using infusion of tPA locally in the thrombus with/without mechanical and pharmacologic thrombolysis was used in all cases. Patient history, pathological and procedural records, and clinical follow-up documents were retrospectively reviewed. Results: A total of 32 endovascular procedures were performed in 16 patients with upper extremity DVT. TPA infusion alone was performed in 6 (37%) while TPA with mechanical thrombectomy was performed in 10 (63%). The most common reported etiologies were indwelling central venous catheter (12, 75%), mechanical compression/thoracic outlet compression (3, 19%), and thrombophilia disorder (3, 19%), and/or malignancy (3, 19%) with multiple factors in five patients. There was a 100% initial technical success rate. Two patients had Haemoglobin drop > 2 g/dl without active bleeding and received prophylactic blood transfusion. No other bleeding complications were identified. Mean clinical followup was 513 days (range 2–2,428 days). DVT recurrence was found in four patients (25%) occurring in a mean of 124 days (range 4–378 days). Conclusions: Endovascular management is technically feasible, safe and effective method for treating upper extremity DVT in children. Larger trials are needed to determine better understand the etiology, optimal management and follow up protocol for this population.

Poster #: SCI-036 The Use of Totally Implantable Venous Access Devices for Chronic Apheresis in Children

Rajat Chand, M.D., The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Madeleine Sertic, Keturah Tomlin, Rose Nemec, Bairbre Connolly Purpose or Case Report: Traditionally a large bore external tunnelled central venous line is required to achieve adequate flow rates in children for chronic apheresis. Subcutaneous implanted ports, capable of high flows, have recently been developed which allow patients to lead a more normal life style. The purpose is to report our experience of paediatric patients undergoing chronic apheresis through a port, emphasizing technique, efficacy, and quality of life. Methods & Materials: Retrospective review of clinical details (demographics, insertion procedure, treatments and outcomes) of patients

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undergoing chronic apheresis through a port. Prospective assessment of family perception of apheresis through their port. Results: Six patients (3 M, 3 F), mean age 11.7 years (range 4–14 years), mean weight of 44 kg (range 13 kg–50 kg) had seven ports placed for apheresis. All ports were in placed by interventional radiology in the internal jugular veins (right = 5; left = 2), double lumen in 6, single lumen in 1. Regimens included biweekly photopheresis on two consecutive days for GVHD (n=4 pts), monthly red cell exchanges for sickle cell disease (n= 1 pt) and initially biweekly lipopheresis increasing to weekly for familial hypercholesterolemia (n=1 pt). All ports were accessed under sterile conditions with topical anesthesia cream, using a 16 G straight needle for withdrawal and a 20 G Huber needle for return. Routine pre-procedure oral analgesia and anxiolytics were used in one patient. Total number of apheresis treatments was 192 (median 20 sessions/port). All 192 sessions were successfully completed; intermittent alarms occurred in 27 sessions, managed by reposition needle (12), tPA (4) and/or flushing (14); access difficulties occurred on eight occasions. The median port dwell time was 545 days (range 96–868 days/port). One major complication (repeated S. aureus infection) required port removal at 792 days; 2nd port inserted 2.5 weeks later. Minor complications included: oozing from access site post needle removal (n=5/192) and bruising at the access site (n=2/192). The two youngest patients experienced anxiety prior to each access. One patient with end stage GVHD died of multiorgan failure/progressive disease after six treatments. Ports were well tolerated by patients and staff. Conclusions: Implanted ports provided adequate venous access for chronic apheresis in all patients. Poster #: SCI-037 Outpatient ultrasound guided renal biopsy: is it safe?

Seth Vatsky, DO, Diagnostic Imaging, Phoenix Children’s Hospital, Scottsdale, AZ, [email protected]; David Aria, MD, Trevor Davis, DO, Robin Kaye, Carrie Schaefer, Richard Towbin Purpose or Case Report: Determine the safety of outpatient renal biopsy in children. Methods & Materials: We retrospectively evaluated renal biopsies performed from January through July 2013. Through retrospective chart review we identified all renal biopsies performed in IR. Biopsies were performed utilizing an 18 gauge, BioPince needle under general anesthesia. Patient age, gender, weight, renal transplant status, pre-procedure coagulation panel, pre- and post-procedure hemoglobin and hematocrit were recorded. The electronic medical record was reviewed for evidence of complication and diagnostic or treatment interventions. Children without an acute health issue requiring hospitalization were discharged with follow up instruction following 4 h of observation and a hemoglobin and hematocrit at 3 to 4 h post procedure. Results: Thirty-five biopsies were performed in 19 males and 16 females. Patients ranged in age from 1 to 19.2 years (average 11.7 years). 14 (40%) were performed as outpatients and 21(60%) were performed as inpatients. Among the subset of outpatient biopsies indications included hematuria/ proteinuria (5), transplant rejection (5), nephrotic syndrome (3), FSGS (1). Complications included asymptomatic perinephric hematomas in six patients. No major complications or unanticipated diagnostic tests or admissions occurred. Average pre and post biopsy hemoglobin and hematocrit were 13.05 g/dL, 38.18 and 12.2 g/dL, 35.97 respectively. Average hemoglobin and hematocrit post biopsy change was 0.88 g/dL +/− 0.56 and 2.40 +/− 1.69. All outpatients were discharged at 4 h post procedure (n=14), and none returned to the hospital because of delayed complication. Conclusions: Ultrasound guided renal biopsy in outpatients is a safe procedure in low risk patients. Outpatient management offers improved family satisfaction and substantially lowered healthcare costs without increased risk to the patient. Small changes in hemoglobin and hematocrit in the absence of clinical signs, symptoms or complications should not prevent discharge following 4 h of observation.

S225 Poster #: SCI-038 Suprapubic Catheterizations in Pediatric Patients

Summit Shah, MD, MPH, The Ohio State University, Columbus, OH, [email protected]; Meagan Bechel, Mark Hogan Purpose or Case Report: Suprapubic catheterizations are often performed when it is impossible or impractical for transurethral catheterization. While this has been well-described in the adult population, the size of the child as well as the conditions necessitating the procedure in children are different. We aim to describe our clinical experience with suprapubic catheterizations. To our knowledge, no other study has characterized this procedure in pediatric patients. Methods & Materials: A retrospective review of consecutive patients receiving suprapubic catheterizations was performed from September 1998 to July 2012 at our pediatric hospital. Patients with incomplete data were excluded. Paper charts and electronic medical records were searched for information regarding the patients’ demographics, procedural details, complications and outcomes. Results: Over nearly 10 years, our institution performed 40 suprapubic catheterizations on pediatric patients, of which 34 had complete data available. The mean age of patients was 5.4 years (range of 0 days–16 years). Thirty were males and four were females. The mean weight of patients was 24.5 kg (range of 0.8 kg-88.9 kg). Six procedures were performed as an outpatient and 28 as an inpatient. For sedation, 10 patients received general anesthesia, 15 received conscious sedation, six were given IV pain medications only and three were given local anesthesia only. All 34 procedures were eventually successful, and two required a second attempt. No procedure had an immediate complication. Regarding complications, five patients (14.7%) had infectious complications with positive urine cultures after placement, three patients (8.8%) had trouble with leakage at some point and one patient (2.9%) had an occluded tube, which had to be changed. Patients had the catheter for a mean of 27.8 days (range of 1–141 days). Regarding outcomes, 23 patients (67.6%) had the tube removed with successful voiding, four patients (11.8%) had tubes changed to a vesicostomy and two patients(5.9%) had tubes changed to a transurethral catheterization. Four patients (11.8%) expired, all less than a week old and with other comorbidities. Conclusions: This is the first study to examine suprapubic tube placement in the pediatric population. Our experience over nearly 10 years demonstrated relatively few complications with most patients being able to void successfully after removal. This should aid others in comparing their own efforts and anticipating typical complications and outcomes specific to children. Poster #: SCI-039 Rapid Two-Point DIXON Turbo Spin Echo (TSE) MR Imaging provides robust fat suppression for pediatric musculoskeletal imaging on 3 T

Bamidele Kammen, MD, Diagnostic Imaging, Chlldren’s Hospital and Research Center, Oakland, Oakland, CA, [email protected]; Pinar Karakas, Eric Padua, Kenneth Martin, Dave Hitt, Taylor Chung, M.D. Purpose or Case Report: Purpose: This e-poster presentation compares rapid two-point DIXON TSE with conventional TSE with and without fat suppression (FS) with proton-density (PD) and T2-weighted (T2W) sequences in musculoskeletal MRIs of pediatric patients. Introduction: Twopoint DIXON is based on previously described three-point DIXON imaging for water and fat separation allows for more rapid acquisition time. In a single DIXON acquisition, four image types are generated: water-only, fat-only, water-and-fat in-phase, water-and-fat opposed-phase. The water-only image contains no signal from fat protons thus equivalent to fat suppression. The water-and-fat-in-phase image is equivalent to no fat suppression. Methods & Materials: Methods and Materials: MRI examinations of the hip, knee, ankle, shoulder and wrist will be utilized to demonstrate the

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homogeneity of fat suppression and consistent detection of pathology on rapid two-point DIXON imaging compared with conventional TSE images with proton-density and T2-weighting. Results: Results: Rapid two-point DIXON TSE has acquisition time comparable to that of conventional TSE sequences. Identical voxel size was acquired in all sequences. Water-only image from DIXON sequences consistently showed homogeneous fat suppression in all studies reviewed while TSE FS sequences showed inconsistent fat suppression. Water-only image provides identical to improved lesion conspicuity compared with TSE FS images. As DIXON TSE is a single acquisition, there is no spatial misregistration of anatomy between image types compared with the conventional separate acquisitions of non-fat-suppressed and fat-suppressed sequences. Conclusions: Conclusion: Compared with standard fat suppression techniques, rapid two-point DIXON method applied to TSE PD and T2W sequences consistently provides homogeneous fat suppression in various anatomic locations with identical to improved lesion conspicuity. Disclosure: Mr. Hitt has indicated a relationship with Philips Healthcare as an Employee in Clinical Development (Salary).

Methods & Materials: Four rectangular tissue-mimicking phantoms composed of distilled water and 3% by mass agar served as the pediatric cartilage samples (Figure 1a). The phantoms’ top view edge dimensions ranged from 10.5 to 14.5 mm (length) and from 1.25 to 5.5 mm (width). Phantom edge dimensions were independently measured by two readers using a 6-in. calibrated steel rule. Coronal T1-weighted spin-echo (T1 SE), fast spoiled gradient-recalled-echo (FSPGR) [3 sequences with different parameters] and multi-planar gradient-recalled-echo (GRE MPGR) of the phantoms were obtained (Table 1) with them embedded in a saline-Magnevist® bath at a concentration of 469 mg/mL [0.5 mmol/ mL]) using an 8-channel knee coil on a 1.5 T scanner. MR images (Figure 1b-f) were independently measured on the GE Advantage Workstation by two readers.

Poster #: SCI-040 Assessing the Accuracy of MRI Sequences for Measurements of Pediatric Cartilage: A Phantom Study

Jennifer McKinney, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Tammy Rayner, Rahim Moineddin, Marshall Sussman, Afsaneh Amirabadi, Andrea Doria

Differences (P values) in mean measurements between direct phantoms’ and MRI measurements (mm)

Purpose or Case Report: Background: MRI is used to diagnose and track the progression of childhood arthritis and its response to treatment. Given the small dimensions of pediatric cartilage, an evaluation of the accuracy of MRI-derived measurements of this tissue should be conducted. Objective: To evaluate the accuracy of MRI-derived measurements of tissue-mimicking phantoms (simulating pediatric cartilage dimensions) and to determine the combination of MRI sequence parameters that optimize measurement accuracy while minimizing scan time.

Differences (P values) in mean measurements between direct phantoms’ and MRI measurements (mm)

Pulse Sequence Matrix Slice Thickness (mm) NEX Scan Time (min) TE (ms) TR (ms) Bandwidth (kHz) FOV (cm) Dimension Phantom 1 (Minimum diameter = 3.0 mm, mean direct edge mesurements = 9.94 mm) Phantom 2 (Minimum diameter = 2.5 mm, mean direct edge mesurements = 8.69 mm) Phantom 3 (Minimum diameter = 1.5 mm, mean direct edge mesurements = 6.38 mm) Phantom 4 (Minimum diameter = 0.5 mm, mean direct edge mesurements = 7.94 mm)

GRE MPGR 320×320 4 2 3:40 15 450 15.6 15 2D .035 (P=0.11)

T1 SE 320×320 1.5 2 6:11 12 568 31.2 15 2D 0.45 (P=0.049)

0.05 (P=0.47)

0.25 (P=0.22)

-0.017 (P=0.04)

0.042 (P=0.83)

0.11 (P=0.45)

0.20 (P=0.51)

FSPGR

FSPGR

FSPGR

512×512

512×512

1024×1024

1.5

0.5

1.5

1

1

1

3:36

3:38

10:33

Min full

Min full

Min full

N/A

N/A

N/A

31.2

31.2

31.3

16

16

16

3D

3D

3D

0.40 (P=0.048)

0.39 (P=0.097)

0.41 (P=0.051)

0.19 (P=0.35)

0.32 (P=0.14)

0.23 (P=0.12)

0.092 (P=0.74)

-0.050 (P=0.71)

0.067 (P=0.69)

0.16 (P=0.63)

0.41 (P=0.20)

0.26 (P=0.34)

Table 1. MRI sequence parameters and mean MRI/direct phantoms’ measurements; NEX, number of excitations; FOV, field of view; TE, echo time; TR, repetition time; Min full, minimum achievable TE with full echo acquisition; N/A, not applicable

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Results: There was a high inter-reader reliability; coefficients of variation (CV) ranged from 2.5 to 6.4% (average: 4.4%) for direct phantoms’ measurements and from 0.6 to 5.2% (average: 2.4%) for MRI measurements. Intra-reader reliability was also high, with CVs ranging from 0.0 to 2.4% (average: 1.3%) for MRI measurements. No differences between the direct phantoms’ measurements and the MRI measurements were noted for phantoms 2 (P values ranged from 0.12 to 0.47 for different MRI sequences), 3 (P=0.40–0.83), or 4 (P=0.20–0.63) (Table 1). Significant differences between the mean direct phantoms’ measurements and the mean MRI measurements were noted for phantom 1 for the following MRI sequences; T1 SE (320×320 pixels, 1.5 mm slice thickness, scan time 6:11 min): difference = 0.45 mm, P=0.049; and FSPGR (512×512 pixels, 1.5 mm slice thickness, scan time 3:36 min): difference = 0.40 mm, P=0.0048. Conclusions: T1 SE was marginally inappropriate for accurate measurements of one of the phantoms’ diameters. Selection of appropriate FSPGR parameters that require feasible scanning time is essential for measurement accuracy of thin structures such as articular cartilage. Poster #: SCI-041 Skeletal dysplasia: Review and Approach

Hazar Tabban, Michel Azouz, Jehan AlRayahi, Hamad Medical Corporation, Doha, Qatar, [email protected]; Walid Mubarak, MBBCH, Arab Board of Radiology, Nazih Shenouda, Khaled Salem Purpose or Case Report: Simplify the systematic approach of skeletal dysplasia, with pictorial essay of the joined cases from Hamed Medical Corporation and CHEO(Canada). Conclusions: Skeletal dysplasias constitute a very wide clinicopathological spectrum of disease of bone formation that begin during fetal life and progresses through life. Diagnosis of skeletal dysplasia have been a life-long challenge for both clinicians and radiologists with over 450 disorders and numerous classifications, under 32 radiologic subgroups. The final diagnosis is multi factorial workout, however not always possible. In our presentation we try to simplify the diagnosis of skeletal dysplasia through a systematic approach in interpretation of the initial diagnostic tool; skeletal survey that would help in attaining the maximum information needed to shed light on the necessary clinical and genetic work-up. In this poster we demonstrate this algorithmic approach via a number of cases that shows radiological findings found in various classification groups including common skeletal dysplasia. Poster #: SCI-042 A multimodal approach to imaging the visual pathway in pediatric syndromes with ocular involvement

Vaishnavi Batmanabane, MS (Ophthalmology), Department of Medical Imaging,The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Manohar Shroff, Prakash Muthusami, Elise Heon Purpose or Case Report: Background: Children with ocular involvement in congenital syndromic disorders require a detailed and multipronged approach that includes ocular and brain imaging to qualify the extent of involvement and aid in guiding further management including genetic testing. Purpose: To illustrate the classical ocular and intracranial manifestations of these syndromes using optical coherence tomography (OCT), ultrasonography (USG), CT, and MRI. Methods & Materials: Patients with congenital ocular syndromes were identified via a retrospective text search program using pertinent keywords. Additional clues to the diagnosis were sought from clinical records, ocular and fundus photographs, ocular and orbital USG, brain imaging studies and genetic testing.

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Results: OCT in Bardet-Biedl, Joubert, and Kearne Sayre syndromes reveal characteristic findings of absent or rarefied cone outer segment tips line, and vitreoretinal interface abnormalities. Defects or absence of all retinal layers are seen in morning glory syndrome (MGS), CHARGE (chorioretinal colobomata), and Aicardi syndrome (chorioretinal lacunae). Enlarged optic cups with nerve fibre layer thinning are characteristic of secondary glaucoma in Axenfeld Rieger and Sturge Weber syndrome (SWS). Retinal capillary hemangioblastomas in von Hippel Lindau (VHL) disease, diffuse choroidal hemangioma in SWS, and retinal hamartomas in tuberous sclerosis are noted on OCT, USG and CT/MRI. Characteristic CT and MRI findings are noted in trilateral retinoblastoma and optic pathway gliomas in neurofibromatosis 1, in addition to the molar-tooth sign in Joubert syndrome, hemangioblastomas in VHL, leptomeningeal angiomatosis in SWS, and trans-sphenoidal basal encephalocoele in MGS. Conclusions: Qualification of retinal thickening, excavations and enlargement of the optic cup are useful in determining current and future impact on vision. OCT complements USG, CT and MRI which provide an extended view into the orbit and cranium, offering diagnostic clues about non-ocular lesions in these syndromes. Such comprehensive imaging not only aids in planning the best approach to diagnosis and management but also serves to prognosticate these disorders.

Poster #: SCI-043 Brain MRI Findings in Patients with Developmental Delay With Correlation With Clinical Presentation

Walid Mubarak, MBBCH, Arab Board of Radiology, Radiology, Hamad Medical Corporation, Doha, Qatar, [email protected]; Jehan AlRayahi, Mohammad AlBerawi, Ahmed Elsotouhy, Hazar Tabban, Hussein Kamel Purpose or Case Report: Developmental delay is a frequent clinical complaint referred for MRI. Its is frequently of unknown etiology with usually limited options in terms of long term management. In this retrospective study, we sought to determine the efficiency of MRI of the brain in depicting abnormalities in patients with developmental delay. Furthermore, the results found in isolated developmental delay were also compared with those seen in patients who also presented with associated neurological abnormality. Methods & Materials: MRI studies of 219 pediatric patients, older than 1 year of age presenting with developmental delay, with or without neurological abnormalities, was performed. Findings were reported by an attending neuroradiologists. No health insurance restrictions present. Results: Out of 219 children (mean age, 3.8 years; range, 1.0–11.0 years) referred for investigation of developmental delay, 53 patients (24.2%) had isolated developmental delay and 166 patients (75.8%) had developmental delay with an associated neurological abnormality. Neurological abnormalities included 23 with seizures, 64 with hypotonia and 39 with microcephaly and or dysmorphic features. Normal MRI reported were noted in 45 out of 53 patients (85%) of patients with isolated developmental delay, and 46 out of 166 patients with associated neurological abnormalities (28%). Radiological abnormalities were noted in 8 out of 53 patients (15%) of patients with isolated developmental delay, and 120 out of 166 patients (72%) with an associated neurological abnormality. Out of the 120 patients with neurological abnormality (seizures, hypotonia and microcephaly/dysmorphic features), 7 out of 19 (36.8%), 29 out of 60 (48.3%) and 20 out of 35 (57%) patients were reported as having a radiological abnormality respectively. Six patients had one or more neurological abnormality, and six out of six (100%) were found to have radiological abnormalities.

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Conclusions: A large percentage (84%) of patients with isolated developmental delay had no abnormal radiological findings in their MRI examinations. In contrast, 72% of patients with an associated neurological abnormality were found to have abnormal radiological findings and 100% of patients with more than one type of neurological abnormality had abnormal radiological findings. We conclude that the presence of associated clinical neurological abnormalities is an indication for MRI examination of the brain. Patient’s with isolated developmental delay are less likely to benefit from MRI.

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Ultrasound measurement of the ventricular index (VI) and anterior horn width (AHW) of the bilateral later ventricles were measured in the coronal plane before and during the ECMO therapy (D1, 3, 5, and last day of therapy). Friedman Two Way Analysis of Variance by Ranks test was used to evaluate the sonographic dimension of ventricular size in neonate who underwent ECMO therapy for respiratory failure.

Poster #: SCI-044 Effect of Extracorporeal Membrane Oxygenation therapy on ventricular size

Paggie Kim, Loma Linda University Medical Center, Loma Linda, CA; Beverly Wood Purpose or Case Report: Extracorporeal membrane oxygenation (ECMO) therapy are often used in neonates with primary pulmonary hypertension of the newborn, congenital diaphragmatic hernia, and congenital heart disease. Head echogram is routinely performed to evaluate for possible intra-cranial hemorrhage. We propose to retrospective review the sonographic dimension of ventricular size in neonate who underwent ECMO therapy for respiratory failure. Methods & Materials: We retrospectively reviewed a cohort of 42 pediatric patients who underwent ECMO therapy at Loma Linda University Medical Center for respiratory failure after receiving permission from local Institutional Review Board. Inclusion criteria: Age: 0 to 29 days, gestation age > 37 weeks, ECMO therapy, respiratory failure, and head echogram. Exclusion criteria: congenital heart disease, congenital neurologic abnormality, intra-cranial hemorrhage and prolonged asphyxia.

Results: Twenty-four patients were male. Mean and median ages were 4.1 days and 1 day. Mean and median duration of ECMO therapy were 9.7 days and 7 days. Primary diagnoses were meconium aspiration (37), neonatal pneumonia (3) respiratory syncytial virus pneumonia (1), and Pertussis pneumonia (1). All patients survived expect two who have meconium aspiration. The Friedman Two Way Analysis of Variance by Ranks test showed significant differences of sonographic dimension of ventricular size before (D0) and during the ECMO therapy (D 1, 3, 5, and last day of therapy); p<0.05. The ventricular index and anterior horn width of the right and left lateral ventricles were all significantly larger when compared between D0 and last day of ECMO (p<0.05). Conclusions: Our study shows that ventricular index and anterior horn width of the lateral ventricles were all significantly larger when compared between D0 and last day of ECMO therapy. Although the exact mechanism of ventricular enlargement during ECMO therapy is unknown, diffuse cerebral atrophy is a primary consideration. The degree of progressive ventricular enlargement may be a useful marker of the effect of ECMO patients on neurological outcomes.

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Cerebral Deep Venous Thrombosis in Children: Spectrum of Imaging Findings based on Structural Anatomy

Conclusions: Pediatric meningiomas (in the absence of neurofibromatosis or prior radiation therapy) are infrequent but important to identify, as atypical imaging features were common in this series and may be more common in children than previously recognized.

Benjamin Thompson, Nationwide Children’s Hospital, Columbus, OH; Jerome Rusin, Lynne Ruess, MD

Poster #: SCI-047

Poster #: SCI-045

Purpose or Case Report: Deep cerebral venous thrombosis is an important and potentially challenging diagnosis of stroke in children. We present the spectrum of imaging findings of deep cerebral venous thrombosis and infarction based on structural anatomy. Methods & Materials: An institutional review board approved retrospective review of imaging records to identify all patients with cerebral venous thrombosis at a large children’s hospital over an 18 years period. The imaging findings in these patients were categorized based on a structural venous anatomy: primary, secondary, tertiary and quaternary vessels. Results: Fifty-seven patients had deep venous thrombosis. Most were neonates (44, 77%) and most had quaternary vessel thrombosis. We illustrate: primary vein thrombosis with preserved deep venous system, secondary vein thrombosis with hemorrhagic venous infarction (HVI) and tertiary vein thrombosis with HVI. We also illustrate the broad spectrum of neuroimaging findings involving the quaternary deep intramedullary veins from a) periventricular white matter (PWM) edema without thrombosis or infarction, or b) PWM edema with deep venous thrombosis, but no infarction to c) increasing degrees of PWM edema, thrombosis and HVI with the most severe infarction associated with white matter liquefaction or hematoma. One patient had venous brain death. Patients with diffuse subcortical and complete white matter infarction without hemorrhage were difficult to categorize. Conclusions: Cerebral deep venous thrombosis is more common in neonates than older children. The radiological presentation of cerebral deep venous thrombosis and/or infarction is broad and may be subtle. We illustrate the spectrum of imaging findings based on structural anatomy. Poster #: SCI-046 Pediatric Meningioma—Atypical and Typical

Charles Pluto, MD PhD, Nationwide Children’s Hospital, Columbus, OH; Jerome Rusin, Lynne Ruess, MD, Daniel Boue, Christopher Pierson Purpose or Case Report: Meningiomas are usually benign tumors with characteristic imaging features, and are considered to be rare before the age of 40 except in the setting of neurofibromatosis or prior radiation treatment. Our purpose was to characterize the neuroimaging features of meningiomas in a series of pediatric patients, and to correlate atypical radiological features with pathology. Methods & Materials: An institutional review board approved this retrospective review of imaging and pathology records to identify all patients with pathology proven meningioma at a children’s hospital over a 24 years period. Neuroimaging, pathology, and clinical records were reviewed. Results: Forty-six meningiomas have been biopsied or resected at our institution since 1989. Tumors associated with neurofibromatosis (6) and radiation therapy (16 adults and 6 children) were excluded, leaving 18 pathologically proven solitary meningiomas in pediatric patients (mean age 15, range 1–21). Eight (44%) had typical imaging features including extra-axial location, well-circumscribed margins, inherent calcifications, a dural tail, and homogeneous contrast enhancement. Ten (56%) had atypical imaging features including intraventricular (1), intraosseous (3), and intraparenchymal (5) locations, and malignant features (2).

Anatomic variants on neonatal spine ultrasound: frequency and clinical significance

Jennifer Kucera, MD, MS, Radiology Associates of Florida, University of South Florida, and Florida State University, Sarasota, FL, [email protected]; Brian Coley Purpose or Case Report: Although the incidence of filar cysts on lumbar spine ultrasounds has been well documented, other anatomic variants including ventricularis terminalis, pilonidal tracts, and combination lesions have not been as thoroughly studied. Our goal was to document their frequency, as well as to evaluate their association with surgically important lesions. Methods & Materials: The reports of all patients undergoing spine ultrasound during a 12 years period were obtained. Patients with medical conditions were excluded. The reports were reviewed to evaluate for the presence of anatomic variants including a filar cyst, ventricularis terminalis, pilonidal tract, or combination lesion. Additional spine abnormalities were documented, including a conus below L2-L3, decreased conus or nerve root motion, an abnormal filum terminale, an intraspinal mass, osseous dysraphism, or a subcutaneous tract leading to the thecal sac. Medical records of all patients with abnormal ultrasounds were reviewed for follow up imaging studies and neurosurgical intervention. Results: 277/2662 (11.6%) of healthy patients had anatomic variants on spine ultrasound. The most common variant was an isolated filar cyst in 139 (5.2%), followed by an isolated pilonidal tract in 88 (3.3%), and an isolated ventricularis terminalis in 34 (1.3%). More than one variant was present in 16 (0.6%) with the most common combination being a filar cyst and pilonidal tract in 10 (0.4%), followed by a filar cyst and ventricularis terminalis in 4 (0.2%), and ventricularis terminalis and pilonidal tract in 2 (0.1%). 15/277 (5.4%) had anatomic variants in association with other abnormal findings. Eight had an isolated low conus, two had an isolated fatty filum, two had both a low conus and a fatty filum, and two had decreased conus or nerve root motion. None of these patients had other signs of tethering, and none underwent surgery. One asymptomatic patient underwent surgical detethering for an enlarging ventricularis terminalis. Thus, the incidence of surgery in healthy patients with anatomic variants was 1/277 (0.36%). Conclusions: Anatomic spine variants are common incidental findings which have a low association with surgically important abnormalities. It is also important for radiologists to recognize that patients may have a combination of more than one normal variant, so unnecessary additional work up may be avoided. Poster #: SCI-048 Role of magnetic resonance in the management of pediatric patient with Guillan-Barrè Syndrome in acute and chronic phase

Stefania Galassi, Children’s Hospital “Bambino Gesu”,Department of Images, Neuroradiology Unit, Rome, Italy; Chiara Carducci, MD, Bruno Bernardi, Lorenzo Figà Talamanca, Francesco Randisi, Daniela Longo Purpose or Case Report: To evaluate the role of magnetic resonance imaging (MRI) with contrast medium in a sample of pediatric patients with Guillain Barré syndrome with the aim of developing a diagnostic tool for the clinician.

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Methods & Materials: We retrospectively evaluated 30 patients (between 11 months and 9 years, 25 males, 5 females) suffering from acute poliradicoloneuritis, one of which evolved chronically. The diagnosis was based on clinical and CSF criteria with the support of the electroneurographic examination. All patients were evaluated by electroneurography (ENG) and MRI of the brain and spinal cord with contrast medium. Four of these patients were selected and examined, displayed the clinical and radiological possible representations of the disease, according to our experience. Results: Patient n.1 (11 months, M) Diagnosis of Severe Combined Immunodeficiency (SCID) RAG-1. ENG examination was normal. MRI performed on the same day: root enhancement after intravenous administration of contrast medium. Neurophysiological and clinical evolution towards a chronic poliradicoloneuritis. Patient n.2: (4 years, M). Clinical diagnosis of Guillain Barre Syndrome. Five days after the onset of symptoms and diagnosis: ENG not diagnostic and RM impregnation root. Patient n.3: (9 years, M). Doubtful clinical diagnosis for the presence of tendon reflexes. ENG positive for AMAN (Acute Motor Axonal Neuropaty). MRI positive for breaking of the barrier performed at the onset. Patient n.4: (3 years F). Clinical diagnosis of Miller Fischer. Brain MRI with contrast enhancement of the meninges post impregnation without obvious enhancement root. ENG negative. The cases reported reflect the large diversity of the paintings of ENG and MRI in Guillain-Barré syndrome in children. The retrospective evaluation of MRI data showed that the ENG and MRI findings can be superimposed on the ENG data in the follow-up of these patients while MRI has greater utility in the early stages. In three of the Patients studied the MRI showed signs of the onset of poliradicolonevrite symptoms not supported by the electroneurography framework. Conclusions: The heterogeneity of the presentation of the clinical picture described may cause a delay in early diagnosis of poliradicoloneuritis if supported only by examining ENG. Therefore, it highlights the need to perform a RM/ENG study series with the aim of proposing a diagnostic flow-chart for poliradicolonevrite in childhood, in which according to our experience, a MRI should be performed early. Poster #: SCI-049 Correlation of Clinical Presentation and Brain MRI Findings in Children with Seizure Disorders

Jehan AlRayahi, Radiology, Hamad Medical Corporation, Doha, Qatar; Hazar Tabban, Walid Mubarak, MBBCH, Arab Board of Radiology, Hussein Kamel, Tahiya Alyafei, Vishwanatha Kini

All patients under the age of 16 years referred to MRI for seizure (both new-onset and epilepsy) during the years 2012–2013 were included in the study. Poster #: SCI-050 The usefulness of FDG-PET/CTscan imaging at initial diagnosis of post-transplant lymphoproliferative disease

Reza Vali, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Somayeh Al Siyabi, Amer Shammas Purpose or Case Report: Post-transplant lymphoproliferative disease (PTLD) is relatively a common malignancy after solid organ tansplantation ranging from abnormal lymphoid hyperplasia to a more aggressive form indistinguishable from lymphoma. In many studies, Fluorodeoxyglucose (FDG) positron emission tomography (PET) has been shown to be useful in the assessment of response to therapy, however, there is little information about the usefulness of PET at diagnosis. In this study, the usefulness of FDG PET at initial staging is prospectively evaluated. Moreover, the intensity of FDG uptake was correlated with the presence of Ebstein-Barr Virus (EBV). Methods & Materials: Sixteen patients with high suspicious of PTLD after solid organ transplantation (nine cardiac, three renal, two lung, one liver and one liver & bowel) were included. The number of lesions detected by FDG-PET and CT at initial diagnosis, and the intensity of FDG activity by using standardized Uptake Value (SUV) were recorded in retrospect. The site of biopsy was selected based on clinical findings, PET/CT results and accessibility of the lesions. The result of biopsy (positive versus negative) was correlated with the findings of PET and CT. Results: Fifteen patients were proved to have PTLD on histopathology (five early hyperplasia, five polymorphous, five monomorphous or aggressive type PTLD). Overall 64 lesions were identified by PET/CT. FDG-PET detected 59 lesions and CT identified 44 lesions. Thirty-nine lesions were identified by both modalities while 20 lesions were detected only by FDG-PET and five lesions were detected only by CT. FDG was superior to CT scan for diagnosis of bone/bone marrow metastasis and probably small sub-centimeter cervical lymph nodes, while CT detected more lesions in the bowel. In 11 out of 16 patients the most positive area on FDG-PET was positive on biopsy. In the other cases, biopsy have been done from other sites based on the clinical finding and accessibility of the lesions. There was no correlation between the SUV-max and the presence of EBV. Conclusions: Our results reveal that combined FDG-PET and CT scan can be used for initial staging of PTLD. FDG PET may show more lesions than CT scan especially in bone/bone marrow metastases and sub-centimeter small cervical lymph nodes. In pediatric patients with high suspicious of PTLD, FDG-PET/CT can be a non-invasive tool for guiding the biopsy site. Poster #: SCI-051

Purpose or Case Report: Seizure disorders are one of the most common indications for neuroradiological evaluation, representing a lifelong challenge for patients and neuroscience physicians. Advances in MRI sequences and techniques help in diagnosis of the eleptogenic focus, therefore, surgical resection and eventually epileptic free life for patients. In this retrospective study, we review the MRI findings in pediatric patients at our institute, with the main complaint of seizure and correlate them with other clinical presentation such as age of onset, age, perinatal history, EEG findings, associated neurological deficit and abnormal physical examination.

Normal FDG uptake in the pediatric thymus on PET imaging

Jason Tsai, CNMC, Washington, DC, DC, [email protected] Purpose or Case Report: The purpose of this study was to examine the level of FDG uptake in the normal pediatric thymus on PET imaging. Comparison of physiologic thymic uptake in older versus younger children was also made. Methods & Materials: PET scans performed at Children’s National Medical Center from 1/2011 to 9/2013 were retrospectively assessed.

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All cases were performed on the same PET/CT scanner using a standard protocol. Scans with known or potential FDG-avid disease in the mediastinum were excluded, including all patients with lymphoma, other malignancies with mediastinal involvement, or NF-1. Exams where other factors may have influenced thymic uptake, such as those in patients who have received prior chemotherapy, or scans showing tracer infiltration or extensive brown fat uptake, were also excluded. Remaining scans were divided into two groups by age: group 1 (13 years or younger) and group 2 (older than 13). CT imaging was reviewed to confirm normal findings in the mediastinum and lungs. Maximum standardized uptake value (SUV) was obtained for the thymus in each case. Lung uptake was measured on the slice of maximum thymic uptake, using a circular region of interest (ROI) with radius of 7.2 mm, placed over the center of each lung. SUVavg for each lung ROI was taken, and the two lung measurements were then averaged. Ratio between maximum thymus SUV and this average lung SUV (mT/aL) was calculated for each case. Results: Two hundred ninety whole body PET-CT scans were reviewed. After application of exclusion criteria, 38 scans remained, 28 in group 1 and 10 in group 2. Overall patient mean age ± SD was 9.5±5.7 years (range 5 months to 18 years). All were presumed to have normal thymuses. None had symptoms suggestive of thymus-related diseases. Mean thymus SUVmax ± SD was 2.45±0.70 (range 0.9 to 3.8). Group 1 mean thymus SUVmax ± SD was 2.39 ± 0.67. Group 2 mean thymus SUVmax ± SD was 2.63±0.78. No significant difference was seen in thymus SUVmax between the two age groups (p=0.35). Mean mT/aL ± SD was 6.08±2.10. Group 1 mean mT/aL ± SD was 6.17± 2.14. Group 2 mean mT/aL ± SD was 5.83±2.06. No significant difference was seen in mT/aL ratio between the two age groups (p=0.67). Conclusions: Our experience with FDG uptake in the normal pediatric thymus is presented. Physiologic uptake in the thymus can be seen with children of all ages. No significant difference in level of FDG uptake is seen between younger and older children. Poster #: SCI-052 Misty Mesentery in Patients with Pheochromocytoma Corresponds to Activated Brown Adipose Tissue on F18-FDG PET-CT

Sarah Farley, M.D., Radiology, University of Washington, Seattle, WA, [email protected]; Hedieh Eslamy, MD, Marguerite Parisi, MD; MS Purpose or Case Report: Pheochromocytomas and paragangliomas are catecholamine-producing tumors that, although rare, are the most common neuroendocrine neoplasms in the pediatric population. In children, these tumors are more frequently hereditary, extra-adrenal and multifocal compared to those in adults. Correctly distinguishing tumor deposits from uninvolved tissues is necessary to inform treatment planning. Several case reports have described activated brown adipose tissue (BAT) in the mesentery on F18-FDG PET in adult patients with pheochromocytomas and paragangliomas. However, there have been no reports correlating misty mesentery with activated mesenteric BAT on computed tomography (CT). The purpose of this study is to identify the relationship of F18-FDG PET localization in mesenteric activated BAT with “misty mesentery” on CT in pediatric patients with pheochromocytoma/paraganglioma. Methods & Materials: We retrospectively identified all pediatric patients with pheochromocytoma or paraganglioma who were imaged with I123MIBG, F18-FDG PET-CT, and a contrast-enhanced CT abdomen/pelvis at presentation or at initial recurrence between 01/01/2007 and 07/30/2013. Six cases were identified: three pheochromocytomas and two paragangliomas at presentation, and one pheochromocytoma with osseous recurrence. The appearance of the mesentery was compared across imaging modalities. SUVmax values were measured in the mesentery and primary

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tumor on PET. CT attenuation was measured in the mesenteric fat and in normal subcutaneous flank fat using region-of-interest pixel values. Correlation was made with serum and urine metanephrines when available. Results: Misty mesentery associated with increased FDG uptake was identified in 50% of cases. There was no associated mesenteric MIBG uptake, although the primary masses were MIBG-avid in two of the three cases with hypermetabolic mesentery. Mesenteric biopsy was performed in one case and demonstrated benign fibroadipose tissue. After resection of the primary tumor, serum catecholamines subsequently normalized in all subjects with mesenteric imaging abnormalities. Conclusions: Activated brown adipose tissue may result in misty hypermetabolic mesentery on CT and F18-FDG PET-CT in patients with pheochromocytoma. In the absence of MIBG uptake in the mesenteric tissue, the misty hypermetabolic mesentery should not be mistaken for neoplastic infiltration. Poster #: SCI-053 Early validation of combined 18F-FDG PET/MRI in pediatric cancer patients

Brian Pugmire, M.D., Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Alexander Guimaraes, Ruth Lim, Howard Weinstein, Ciprian Catana, Michael Gee Purpose or Case Report: Combined PET/MRI is a promising new imaging modality in children, particularly pediatric cancer patients. Data regarding pediatric PET/MRI are scarce. In this pilot study, we report initial experience with PET/MRI in young cancer patients compared with PET/CT. Methods & Materials: Patients ≤19 years of age with known malignancy and not requiring sedation were eligible for this study. After completion of a clinically indicated 18F-FDG PET/CT, whole body PET/MRI was performed on a Siemens mMR with no additional radiotracer. Attenuation correction for the PET/MRI was performed using Dixon in-/ opposed-phase images. PET/MRI SUVmax and DWI ADCmin values were calculated for lesions visualized on PET/CT using co-localized 2D ROIs; analysis of overall FDG-avid tumor volume and SUVmax was performed using 3D ROIs. Test performance characteristics of PET/MRI parameters for detecting malignant lesions were calculated using lesion PET/CT SUVmax > 2.5 as reference standard for malignancy. Statistical analyses of correlation between the imaging modalities were performed using linear regression. Results: Three patients were enrolled with a total of four paired PET/CT and PET/MRI exams. Mean delay from tracer injection to PET/CT and PET/MRI was 67.5 and 179.25 min, respectively, with an average PET/ MRI scan time of 35 min. Mean total effective dose of PET/CT was 12.54 mSv; including 8.48 mSv (68%) from CT. A total of four malignant and 19 benign lesions were included for analysis. There was statistically significant correlation between PET/CT and PET/MR SUVmax for all lesions (r2=0.924, p<0.00001), as well as between ADCmin and PET/ CT SUVmax (r2=0.201, p=0.036). The calculated 3D SUVmax for FDG-avid tumor was 7.03 on PET/CT and 9.99 on PET/MRI with a volume of 15.70 mL and 15.27 mL, respectively, using a 50% SUVmax threshold. The sensitivity, specificity, PPV, and NPV of PET/MRI for detection of malignant lesions were 100%. Using a threshold of <1.0×103 mm2/s, PET-MR DWI exhibited sensitivity and NPV of 100% with 94.7% sensitivity and PPV 80%. One indeterminate liver lesion on PETCT was diagnosed as a complex cyst on PET-MR. Conclusions: Our early experience suggests that PET/MRI derived SUVmax and ADC values are sensitive and specific for detection of malignant lesions compared with PET/CT reference. Substitution of PET/MRI for PET/CT would result in radiation dose reduction of at least

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68% and potentially help characterize more indeterminate lesions. Studies with more subjects are needed to confirm these findings. Disclosure: Dr. Guimaraes has indicated a relationship with Siemens Medical, Spekers Bureau; Rice, Dolan, Kershaw as an Expert Witness. Poster #: SCI-054 Single acquisition 3D versus multi-plane 2D pelvic imaging: Can a single sequence replace many?

Yi Li, MD, UCSF Benioff Children’s Hospital, Department of Radiology and Biomedical Imaging, San Francisco, CA, [email protected]; Peter Marcovici, Andrew Phelps, John MacKenzie, MD, Jesse Courtier, MD Purpose or Case Report: To demonstrate the potential of a singleacquisition volumetric T2-weighted sequence with multi-planar reformatted images as a superior alternative to standard axial, sagittal, and coronal 2D in-plane imaging. Methods & Materials: Twelve pediatric patients (age 1 day–15 years; gender 3 M, 9 F) underwent pelvic MRI at 3 T with a single acquisition volumetric/three-dimensional (3D) coronal T2 CUBE (subsequently reformatted to axial and sagittal planes) in addition to dedicated inplane axial, sagittal, and coronal 2D T2-weighted fast spin echo (FSE) imaging. Two pediatric radiologists independently compared performance of the sequences for the ability to detect/visualize (=2) or not visualize (=1) small anatomic structures (the proximal urethra and exiting nerve roots). Pelvic/inguinal lymph nodes were scored with a rating of one for nonvisualization, two for visualization, and three for ability to see lymph node internal architecture. 2D and 3D scan times were compared with student t-test and reader scores were compared using Wilcoxon matched pairs signed-rank test. Results: Shorter scan times was observed for 3D T2 CUBE vs. 2D FSE imaging (average scan time = 440 s. [range 297–661]) vs. 586 s [range 271–900], p<0.05). Average slice thickness/interslice gap = 1.38 mm/−0.65 mm for 3D T2 MRI vs. 4.45 mm/0.24 mm for single in plane. Average rating for proximal urethral visualization = 1.8 for reformatted 3D T2 MRI versus 1.7 for single in plane 2D T2 MRI. Average rating for terminal nerve root visualization = 1.9 for reformatted 3D versus 1.9 for single in plane 2D. Average rating for lymph node evaluation for reformatted 3D T2 MRI = 2.0 versus 2.0 for single in plane 2D T2 MRI. No statistically significant difference was found between assessment of standard in-plane 2-D images and reformatted 3D T2 MRI in the assessment of proximal urethera (p=0.34, 95% C.I. = −0.293 to 0.112), terminal nerve roots (p=0.34, 95% C.I. = −0.147 to 0.056), and lymph nodes (p=0.58, 95% C.I. = −0.122 to 0.205). Conclusions: In the pediatric pelvis, volumetric T2-weighted MRI provides superior resolution in the primary acquisition plane compared to standard in-plane 2D imaging. 3D imaging also provides comparable image quality in reformatted planes, which may be done obliquely, with an overall decreased total scan time. Poster #: SCI-055 Analysis of thyroid masses detected on thyroid sonography in children

Yun Woo Chang, Radiology, Soonchunhyang University Hospital, Seoul, Republic of Korea, [email protected]; Dong Hwan Lee, Dae Young Seo Purpose or Case Report: The purpose of this study is to determine the incidence and pattern of sonographic depicted thyroid mass, and to

suggest the management of sonographic detected thyroid mass in children. Methods & Materials: One thousand two hundred eighty-two consecutive pediatrics under 13 years old underwent thyroid sonographic examinations (<1 year (n=463), 1–5 years (n=585), ≥6 year (n=234)). Eightytwo lesions on 69 patients were depicted on thyroid sonography (6.6%, 69/1282). There were 37 boys and 32 girls with a mean age of 51 months (2 weeks–12.8 years). We retrospectively reviewed the sonograpghic features according to the mass pattern (simple cyst, colloid cyst, solid mass, or intrathyroid thymus), number, size, and location in the thyroid gland. We checked whether the follow up examination was performed and whether the pathologic diagnosis was confirmed. In follow-up examination cases, we evaluated the change of thyroid masses (disappeared; decreased; no change; increased). Statistical analysis was performed using SPSS 14.0. Results: The results were simple cyst (n=25, 30%), colloid cyst (n=23, 28%), solid mass (n=20, 24.4%) and intrathyroid thymus (n=14, 17.1%). The mean mass size was 0.64 cm±0.6 (0.3–3.3 cm). There were significant differences among the three age groups (p<0.001). Children less than 1 year old had simple cysts (n=10), intrathyroid thymus (n=9), solid masses (n=12), and no cases of colloid cysts. The children between 6 and 13 years old had simple cysts (n=2), solid masses (n=3), colloid cysts (n=11), and no cases of intrathyroid thymus. Among the followup examination of 35 cases, there were statistical differences between age groups (p=0.002). Children less than 1 year showed disappeared or decreased size of masses versus the children between 6 and 13 years old, who showed no change or increased size of masses. Pathological confirmation was performed in four patients with all benign results. Conclusions: There is a significant difference to the thyroid mass pattern and follow up mass change according to the age. If the patient is under 6 years old, intrathyroid thymus could be seen in the thyroid gland and small intrathryoid thymus could be mistaken for a solid mass in the thyroid gland. Thyroid mass detected in children under 1 year old had disappeared when follow-up examinations were performed. Colloid cys incidence was increased in children over age 6. When solid masses are detected in children over the 6 years old, a follow-up examination or fine needle aspiration could be considered. Poster #: SCI-056 Incidental Thyroid Nodules Detected on Thoracic Contrast Enhanced CT: Prevalence and Outcomes

Juan Baez, M.D., Radiology, Boston Children’s Hospital, Brookline, MA, [email protected]; David Zurakowski, Edward Lee, MD, MPH Purpose or Case Report: Incidental thyroid nodules can be detected on contrast enhanced thoracic computed tomography (CECT) in pediatric patients; however, management of these incidental thyroid nodules remains controversial with prior studies and current guidelines focusing on adult patients. The purpose of this study was to investigate the prevalence and outcomes of incidental thyroid nodules detected on thoracic CECT in the pediatric population. Methods & Materials: We used our hospital information system to retrospectively identify all consecutive pediatric patients (<21 years of age) with thyroid nodules reported on thoracic CECT performed between January 2006 and December 2012. Patients with previously known thyroid nodules were excluded; the study population included patients with newly detected thyroid nodules. The study population was categorized into two groups: Group 1 (with available follow-up imaging study)

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and Group 2 (without available follow-up imaging study). A pediatric radiologist systematically reviewed the CT studies, available follow-up imaging studies and outcomes of patients meeting inclusion criteria. For patients in both groups, the duration of clinical follow up was also documented. If a biopsy was performed, the pathologic diagnosis was correlated with the imaging findings. Results: The study population consisted of 35 thoracic CECT studies from 35 individual pediatric patients (18 females, 17 males, mean age 13±6.2 years) that met inclusion criteria. Prevalence of incidental thyroid nodules detected on thoracic CECT in our study population was 1.4% (35 patients/2,525 patients). Seventeen (49%) of 35 patients (Group 1) had follow-up thyroid ultrasound with six patients (17%) that ultimately underwent biopsy of their thyroid nodules for pathological diagnosis. One case (3%) of papillary thyroid cancer was diagnosed. Other pathological diagnoses include benign nodular hyperplasia (n=4, 11%) and one case of metastatic disease from the patient’s known Burkitt lymphoma (n=1; 3%). The remaining 18 (51%) of 35 patients (Group 2) had clinical follow-up information (mean 36±30 months) with no subsequent development of neoplasm from incidentally detected thyroid nodules at most recent follow-up. Conclusions: Thyroid nodules detected incidentally on thoracic CECT are rare in pediatric patients. However, when present, ultrasound (± biopsy) seems an appropriate strategy due to a rare but real possibility of underlying thyroid malignancy in the pediatric population. Poster #: SCI-057 Congenital cystic lung lesions: computed tomography characteristics

Cynthia Tan, UCSF, San Francisco, CA; Jesse Courtier, MD, Andrew Phelps, John MacKenzie, MD, Peter Marcovici Purpose or Case Report: To systematically characterize congenital cystic lung lesions by specific CT features and determine if these features can differentiate lesions when compared to final pathologic diagnosis. Methods & Materials: With IRB approval, a retrospective review of 65 patients with congenital cystic lung lesions characterized on both CT imaging and pathology was performed. The CT characteristics we evaluated included location, maximum lesion diameter, distance of the lesion to the carina, cyst size, and cyst contents. We also evaluated for mediastinal shift, inflammatory changes, impacted airway, systemic feeding artery, and systemic draining vein. The imaging and pathological diagnosis(es) were compared. Results: Lesions were found in all lung lobes with predominance in the lower lobes. Mean maximal lesion size was 5.3±2.2 cm and mean distance from the carina was 2.5±1.1 cm. The prospective CT diagnosis was concordant with pathology in 72% of cases. The majority of the lesions were congenital pulmonary airway malformations (CPAMs), characterized as a variety of cyst sizes and contents. 95% of CPAMs were accurately diagnosed by CT features. Bronchial atresia was not uncommon and characterized as a homogenous gas-filled small-cyst lesion. Sequestrations were diagnosed by identifying a systemic feeding artery. The prospective accuracy of CT scans for hybrid lesions, congenital lobar overinflation (CLO), foregut duplication cysts, and cystic bronchiectasis was poor, possibly attributed to the variable appearance of these lesions. Hybrid lesions were a spectrum among CPAMs, sequestrations, CLO and foregut duplication cysts. Our only patient with pleuropulmonary blastoma (PPB) had multilobar cystic lesions with predominantly intermediate-sized gas-filled cysts. See Table 1 for additional characterization by lesion subtype.

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CPAM Bronchial (47/65) atresia (9/65) Average Maximum 5.3 4.6 diameter (cm) Distance of nearest 2.3 2.6 lesion edge to carina (cm) Mediastinal shift? 9/47 No Inflammatory 6/47 1/9 changes? Adjacent impacted 1/47 No airway Systemic feeding No No artery? Systemic venous No No drainage? % Radiologically 95% 38% diagnosed: Duplication CLO cyst (4/65) (3/65) Average Maximum 6.7 5.0 diameter (cm) Distance of nearest 2.3 1.3 lesion edge to carina (cm) Mediastinal shift? 1/4 No Inflammatory 1/4 No changes? Adjacent impacted No No airway Systemic feeding No 1/3 artery? Systemic venous No No drainage? % Radiologically 67% 33% diagnosed:

Sequestration Hybrid (6/65) (6/65) 4.3 4.3 2.9

2.0

No No

No No

No

No

3/6

2/6

No

No

67%

0%

PPB (1/65) 5.8

Bronchiectasis (1/65) 8.8

3.2

3.7

No No

No No

No

No

No

No

No

No

No CT 0% report

Table 1: Features of congenital cystic lung lesions Conclusions: The CT imaging features of congenital cystic lung lesions have considerable imaging overlap. Using the set of imaging features described in this report, the radiologist is equipped to confidently describe these lesions, and when appropriate suggest a specific diagnosis. Poster #: SCI-058 Fluoroscopic imaging, compared to endoscopic visualization, improves detection of esophageal stricture in children with Eosinophilic Esophagitis

Mathew Swerdlow, Children’s Hospital Colorado Department of Radiology affiliated with the University of Colorado-Denver School of Medicine, Aurora, CO, [email protected]; Calies Menard-Katcher, Glenn Furuta, Shahan Fernando, Laura Fenton, MD Purpose or Case Report: Eosinophilic Esophagitis (EoE) is a chronic inflammatory disorder of the esophagus characterized by often subtle imaging findings including small caliber esophagus, mucosal abnormality and esophageal stricture. The role of fluoroscopic studies following diagnosis of EoE is uncertain. We observed that esophageal strictures were only identified by esophagram, and not at the time of follow up endoscopy,

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for symptomatic children with EoE. We hypothesize that esophagram is more sensitive for esophageal strictures in EoE than endoscopy. The aim of our study is to compare the fluoroscopic and endoscopic findings in a series of patients with EoE to clarify the role of fluoroscopy. Methods & Materials: Under local IRB approval, a retrospective review of all children with EoE who had upper endoscopy and esophagram performed within 6 months of each other from January 2007 to July 2013 at a pediatric tertiary care center specializing in eosinophilic esophageal disease was conducted. All imaging studies were independently reviewed by two radiologists for evidence of esophageal stricture, mucosal abnormality, gastroesophageal reflux, and abnormal pill transit. Fluoroscopic results were correlated with endoscopy. Initial imaging interpretations were reviewed and compared. Results: Fifty-four patients with EoE met criteria above, ranged in age from 1 to 20 years with median of 12 years. 38 (70%) were male. Of these, 30/54 (56%) had mild or moderate esophageal narrowing by fluoroscopy with 11 in the proximal esophagus, 14 distal and five diffusely. In 66% of these, esophageal narrowing was not apparent by endoscopy. There was subtle mucosal irregularity by imaging in 35/54 patients (65%) that correlated with ‘trachealization’ on endoscopy. Only 11/54 (20%) were given a dissolvable barium pill, but of those, 6 (55%) showed impaction or abnormal pill transit. Imaging interpretation at the time of esophagram only identified 55% of the subtle esophageal narrowing identified on this dedicated review. Conclusions: Fluoroscopy studies add value by detecting mild esophageal narrowing that is often inapparent at endoscopy and therefore useful in directing proper management of children with EoE before reaching more advanced stages of disease. Children presenting with dysphagia and multiple food impactions should be carefully evaluated for subtle persistent mucosal abnormality or mild esophageal narrowing. The dissolvable barium pill is a useful, albeit underused tool in evaluation of these patients.

Poster #: SCI-059 T2*-MRI Relaxometry Assessment of Liver Iron Concentration in Neonates: A Feasibility Study

Jean Tkach, Ph.D., Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Mantosh Rattan, Rhonda Strunk, Andrew South

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Purpose or Case Report: Neonatal hemochromatosis (NH) is a severe neonatal liver disease associated with iron overload and extrahepatic tissue siderosis. A noninvasive, non-ionizing technique to quantify liver iron would be beneficial to the diagnosis and long-term management of affected infants. Iron measurements by T2*-MRI relaxometry in the liver have shown good correlations with liver iron concentration in adults. The purpose of this study is to determine the feasibility of applying T2*-MRI relaxometry iron quantification in neonates. Methods & Materials: After institutional review board approval, a prospective study was performed. Neonates with no history of hematology disorders or liver pathology were recruited for the study and written informed consent was obtained from the parents prior to imaging. MR imaging was performed without sedation on a small footprint 1.5 T MR system installed within the Neonatal Intensive Care Unit of our institution. Axial images through the liver were acquired using an RF spoiled multi-echo gradient echo sequence. The average T2* value for the liver parenchyma (excluding blood vessels) was then calculated for each infant by fitting the multi echo data to a monoexponential decay curve (Medis, the Netherlands). Results: Three neonates (all female, GA at birth 35–36 weeks, mean DOL 20.4±11.4 days at MRI) were evaluated. Multiple T2* data sets were obtained for two of the infants during independent MR exams. One of the six data sets was excluded due to excessive infant motion. The averageT2* value for the liver was found to be 26.43± 3.33 ms (Range 23.3–30.12 ms). The average T2* values obtained from the repeated exams in the two infants were: 29. 95 ms, 24.2 ms, 30.12 ms, and 23.3 ms, 24.57 ms, respectively. The measured neonatal liver T2* values are comparable to the value of 28.1±7 ms and greater than the value of 19.76± 7.4 ms reported for normal adults and third trimester fetuses at 1.5 T respectively. Conclusions: The use of T2* MR relaxometery is a viable means to obtain quantitative data relating to liver iron concentrations in neonates with suspected disease states. Although this study was performed on the neonatal MRI system, the technique and results are applicable to any 1.5 T system. Further studies to establish normative liver T2* values and to characterize/determine/validate the relationship of T2* to liver iron concentration for the physiologic range of normal and elevated liver iron levels in this population are warranted.

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2014 AUTHOR INDEX Aamir, Asmaa Abdeen, Nishard Abdullah, Selwan Abrahamson, Mariann Abrams, Stephanie H. Adachi, Iki Addicott, Benjamin Adeb, Melkamu Adeyiga, Adebunmi O. Adler, Brent Adzick, N. Scott Afacan, Onur Agarwal, Saurabh Agrawal, Megha Akgun, Veysel Akyol, Yakup Al Siyabi, Somayeh Al-Aswad, Nadine Alaref, Amer AlAref, Amer Alaref, Amer AlAref, Amer Alazraki, Adina AlBerawi, Mohammad Alconcher, Laura F. Aldape, Lisa Alemayehn, Hanna Allbery, Sandra M. Allen, Steve Alley, Marcus T. Almeida-Jones, Myriam Almotairi, Majed a. Alpert, Seth AlRayahi, Jehan Alsabban, Zehour Alsip, Christopher Altinok, Deniz Alyafei, Tahiya Amaral, Joao G. Amirabadi, Afsaneh Amodio, John Andrew, Klink Andronikou, Savvas Anthony, Evelyn Y. Anton, Christopher Anupindi, Kesav Anupindi, Sudha A. Aquino, Michael R. Arenivas, Ana Aria, David Aria, David J. Armsby, Laurie Arnold, Douglas Artunduaga, Maddy Atanda, Alfred Atweh, Lamya A. Averill, Lauren Awai, Kazuo Awal, Divya Ayyala, Rama Azouz, Michel Baad, Michael Babu, Roshan

EDU-005, EDU-018 EDU-063 SCI-017 CR-069 PA-009 PA-033 CR-079, EDU-083 PA-087 CR-049, CR-073 EDU-034, SCI-025 PA-065 PA-125 EDU-002, PA-043 PA-091 EDU-032 PA-105 SCI-050 SCI-024 CR-009 EDU-027 EDU-063 EDU-090 CR-077, EDU-088, EDU-099, EDU-103 SCI-043 PA-089 CR-069 CR-015 CR-066, EDU-068, PA-079 EDU-093 PA-024, PA-058 PA-029 SCI-021 EDU-034 SCI-041, SCI-043, SCI-049 PA-063 PA-146 PA-078 SCI-049 CR-040, PA-093 SCI-040, PA-109, PA-113 CR-029, EDU-003 PA-151 PA-088 CR-072 PA-104 SCI-026 EDU-060, SCI-026, PA-010 EDU-054, SCI-023 PA-019 CR-043 CR-030, CR-031, SCI-037, PA-100, PA-101 EDU-005 PA-013, PA-014 CR-024 PA-105 PA-028, PA-130, PA-138 CR-055, PA-105 SCI-011 CR-029 EDU-004, PA-064, PA-128 SCI-041 EDU-108 PA-135

Back, Susan J. Baez, Juan C. Bailey, Smita Bailey, Zachary D. Baines, Courtney Balachandar, Sneha Ballah, Deddeh Bandarkar, Anjum Bangert, Barbara Banwell, Brenda Bao, Joyce Barber, Ignasi Bardo, Dianna M. Barnes, Craig E. Barnewolt, Carol E. Barot, Anupriya Barron, Stephanie Barsell, Alexandra Barth, Richard Bartholomew, Dennis W. Bartlett, Murray Bates, D. G. Batmanabane, Vaishnavi Beavers, Angela Bechel, Meagan Bedford, Chris Bedoya, Maria A. BenDavid, Guila Beneck, Debra Benya, Ellen C. Berg, Eric Berger, Rachel Berman, Jeffrey Bernardi, Bruno Bernbeck, Matthew Bero, Sheila Betts, Khalil N. Bhamare, Tanmay Bi, Xiaoming D. Biko, David Bilhartz, Jacob Binkovitz, Larry Binns, Helen J. Bireley, William R. Bisset, George S. Bittman, Mark Bixby, Sarah D. Biyyam, Deepa R. Blaser, Susan Blask, Anna R. Blews, David E. Blumer, Steven L. Bober, Michael B. Boechat, Ines Bolin, Elijah Bonasoni, Paola Boomer, Laura Booth, Timothy

EDU-045, PA-086, PA-088, PA-117, PA-118 EDU-107, SCI-056 EDU-022, EDU-056 EDU-077 EDU-105 EDU-042 SCI-006, SCI-007 CR-001, CR-073, EDU-036, SCI-031, SCI-032 PA-139 PA-013, PA-014 CR-038 PA-112 CR-060, EDU-005 CR-043, CR-047, EDU-022, EDU-056 CR-014, EDU-015, PA-121, PA-125, PA-128 CR-028 PA-087 PA-107 PA-042, PA-058, PA-073, PA-115 CR-057 EDU-065 EDU-034, SCI-025 SCI-042 PA-079 SCI-038 CR-035, CR-037 PA-083, PA-103, PA-132, SCI-026, PA-010, PA-102, PA-126, PA-152 PA-041 CR-013 PA-047 PA-023 PA-077 EDU-079 SCI-048 SCI-004 SCI-009 PA-087 CR-007 PA-025 PA-032 PA-008 EDU-053 PA-150 PA-018 PA-156 CR-021, CR-027 PA-112 CR-043, CR-047, EDU-056 EDU-072 CR-049, EDU-010, EDU-036, SCI-013, SCI-031, SCI-032, PA-127 CR-017 EDU-052 PA-105 EDU-049, SCI-015 PA-029 SCI-024 SCI-025 PA-023

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Borschel, Gregory Bosemani, Thangamadhan Boue, Daniel R. Boutis, Kathy Bowdin, Sarah Bowen, Richard Boylan, Emma Bradley, David Bradley, Timothy Bradley, William F. Brady, Samuel L. Braithwaite, Kiery Brandão, Leonardo R. Branson, Helen Braojos, Fernanda D. Bray, Heather J. Breen, Micheal A. Brill, Paula Brinkley, Michael F. Bristol, Ruth Broberg, Gloria Bromwich, Matthew Brown, Brandon P. Browne, Lorna Brudnicki, Adele Buchmann, Robert F. Bulas, Dorothy Burford, Jeffrey M. Burns, Natalie Burns, Thomas G. Cahill, Anne Marie

Caird, John Callahan, Michael Carbone, Dino Care, Marguerite M. Cardenas, Agustin Carducci, Chiara Carlson, Karina Caro, Pablo Carson, Kathryn A. Cassady, Christopher I. Cassia, Guilherme Catana, Ciprian Catanzano, Tara Celik, Haydar Cerrolaza, Juan J. Chan, Danielle Chan, Frandics Chand, Rajat Chang, Andrew Chang, Patricia Chang, Yun Woo Chapman, Teresa Chatfield, Mythreyi B. Chauvin, Nancy A. Chavhan, Govind B. Chawla, Bhavna Chen, Susie Cheng, Joseph Y. Cherivirala, Sushain Chiramel, George K. Cho, Steve

CR-044 EDU-069, PA-080 SCI-046 SCI-005, PA-041 EDU-072 PA-136 PA-025, PA-026 EDU-002, SCI-003 EDU-072 PA-061 PA-044 EDU-088, EDU-099, EDU-103, SCI-019 PA-093 EDU-072, PA-013, PA-014 PA-144 CR-051, EDU-023, EDU-025, EDU-066 EDU-031, PA-072 CR-013, CR-081 PA-037 PA-100 SCI-008 EDU-090 EDU-020, PA-011 PA-067 CR-028 CR-052 EDU-012, SCI-013, PA-127 CR-023 EDU-101 PA-019 CR-033, CR-038, CR-042, SCI-006, SCI-007, PA-095, PA-096, PA-097, PA-154 CR-065 CR-027, PA-036 PA-049 EDU-086 SCI-030 SCI-048 CR-003 EDU-028 PA-080 PA-123, PA-124 SCI-014 SCI-053 EDU-030, EDU-041 EDU-047, EDU-048 PA-050, PA-062 EDU-013, EDU-014 SCI-010, PA-074 SCI-036 PA-023 PA-112 SCI-055 EDU-101 PA-035, PA-036 EDU-060, PA-102, PA-151 SCI-021 PA-082 CR-021 PA-058 EDU-042 EDU-046, PA-093 PA-005, PA-006

Cho, Young Ah Choi, Michael Chow, Jeanne Chow, Jeanne S. Chu, Zili David Chung, Claudia Chung, Dai H. Chung, Shang-En Chung, Taylor Church, Peter Chukus, Anjeza Cleary, Kevin Clouchoux, Cedric Cogollo, William Cohen, Harris Coley, Brian Colleran, Gabrielle Compton, Gregory Condie, John Conklin, Laurie Connolly, Bairbre Connolly, Susan Constantino, Kristin Cope-Yokoyama, Sandy Copeland, Jocelyne Cornejo, Patricia Coroian, Cristian Courtier, Jesse Crimmins, Darragh Croffie, Joseph Cummings, Susan Curran, John Cusack, Caroline Cusack, Katherine A. Cutler, Nancy Cyriac, George Dahl, Amy Dandoy, Chrsitopher Daneman, Alan Danzer, Enrico Dao, Kimberly Darbari, Deepika Dardzinski, Bernard Darge, Kassa

PA-045 PA-040, PA-145 EDU-031 PA-084 PA-028 PA-032 SCI-028 PA-022 SCI-039, PA-032 PA-063 EDU-058 CR-034 PA-120 PA-041 EDU-111 SCI-047 CR-075 CR-007, PA-066 PA-100 PA-012, PA-062 CR-040, SCI-036 PA-121, PA-125, PA-128 CR-030, EDU-008 PA-023 CR-044 EDU-008, PA-100 EDU-037, EDU-095 SCI-030, SCI-054, SCI-057 CR-065 SCI-029 PA-136 PA-100 CR-008 CR-008 CR-005 CR-063 CR-015 PA-092 SCI-023 PA-065 CR-070 PA-094 PA-103 EDU-045, PA-010, PA-036, PA-038, PA-083, PA-086, PA-087, PA-088, PA-117, PA-118 Daugherty, Reza J. EDU-060 Davignon, Daniel A. CR-015 Davila-Acosta, Jorge H. EDU-027, EDU-028 Davis, Leah C. CR-005 Davis, Trevor Z. CR-031, SCI-037, PA-101 Day, Matthew A. CR-011 Deaver, Pamela EDU-011 Decter, Irina EDU-021 deFreitas, R. Andrew PA-025, PA-026 Delaney, Lisa R. EDU-013, EDU-014 Delgado, Jorge PA-083, PA-152 Deng, Jie SCI-009, PA-150 Derderian, Vana PA-040, PA-145 Desai, Nilesh K. EDU-088 Deshmukh, Tejaswini EDU-038 Desoky, Sarah CR-076, CR-078 Desouches, Stephane EDU-080 Devaney, Deirdre CR-065 Deye, Katherine CR-049 Diab, Yaser PA-094 Dick, Andre PA-153

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Dickson, Paula Didier, Ryne A. Dietz, Kelly Digiovanna, John Dillman, Jonathan R. Dionigi, Beatrice DiPaola, Frank Dizor, Robert Do, Kyung-Hyun Dome, Jeffrey S. Done, Stephen Donnelly, Lane F. Donofrio, Mary Donoghue, Veronica Doria, Andrea S. Drake, Mary K. Duan, Chunzhe Dumont, Matthieu Dunnavant, Floyd D. Duplessis, Adre Dwyer, Andrew Edgar, J. Christopher Eghbal, Azam Ehrlich, Peter F. Eklund, Meryle Ekram, Tashfeen El Fakhri, Georges Elkaissi, Mahmoud Elkins, Christopher J. Elliott, Colm Ellis, Henry Ellis, Wendy Elsotouhy, Ahmed Emerson, Joseph Emerson, Miriam G. Emerson, Scott Emery, Kathleen Epelman, Monica S. Eslamy, Hedieh Estrada, Carlos Estroff, Judy Evangelista, Peter Evangelou, Lordanis Evans, Douglas Fadell, Michael Fadell, Michael F. Faerber, Eric

Fagen, Kimberly Faingold, Ricardo Falcone, Richard Fallon, Sara Fan, Rong Farley, Sarah A. Farmakis, Shannon Farrell, Michael Faulhaber, Peter Fazeli Dehkordy, Soudabeh Feinstein, Kate A. Fenton, Laura Z. Fernandes, Rohan Fernando, Shahan

EDU-099, SCI-027 PA-060 SCI-017 PA-107 PA-008, PA-053 CR-014 CR-080 CR-054 PA-045 PA-137 EDU-017 CR-061, PA-049 PA-015 EDU-009 PA-113, EDU-055, SCI-024, SCI-040, PA-109 EDU-068 PA-071, PA-149 PA-012 CR-048, PA-070 PA-015, PA-122 PA-107 PA-086, PA-132, PA-151 PA-108 PA-137 CR-077 SCI-010 PA-052 EDU-039 PA-024 PA-013 CR-050 CR-020, PA-070 SCI-043 CR-050 CR-076, CR-078 SCI-004 PA-104 CR-055, EDU-060 CR-026, CR-068, CR-069, EDU-073, SCI-022, SCI-052 EDU-031 EDU-011, EDU-015, PA-120, PA-121, PA-125, PA-128 PA-005 PA-015, PA-122 PA-098 PA-148 PA-106 EDU-024, EDU-035, EDU-037, EDU-082, EDU-084, EDU-085, EDU-087, EDU-110 EDU-010, SCI-013 SCI-014, PA-133 PA-156 PA-156 EDU-057 SCI-052 CR-006, EDU-006 CR-065 PA-139 CR-080 EDU-108 SCI-058, PA-018, PA-081 PA-012 SCI-058

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Feygin, Tamara Figà Talamanca, Lorenzo Finegold, Milton J. Finn, J. Paul Fintelmann, Florian J. Fischer, Jason Flax-Goldenberg, Renee Fleck, Robert Fleck, Robert J. Fleming, Amy Flom, Lynda Florence, Joshua Fok, Elaine WS Folio, Les Fonseca, Brian Foreman, Nicholas K. Forester, Lerry T. Freedman, Stephen FRiedman, Debra Fromkin, Janet Frost, Samuel I. Frush, Daniel J. Frush, Donald P. Fujioka, Chikako Funama, Yoshinori Fung, Bonita Furuta, Glenn Gaballah, Marian Gaca, Ana M. Gadde, Judith A. Gaffney, Christopher Gagoski, Borjan Gaisie, Godfrey Galassi, Stefania Gall, Peter Ganley, Theodore Gee, Michael Gee, Michael S. Gelatt, Mark Geller, Evan Geller, James Gerhart, Lee A. Ghadimi Mahani, Maryam Gholipour, Ali Gilbertson, Dorothy Gill, Anne E. Gillick, John Gilsanz, Vicente Girard, Erin Githu, Tangayi Glasier, Charles Gok, Faysal Goldfisher, Rachelle Golding, Lauren P. Golriz, Farahnaz Goncalves, Luis F. Gong, Ren Hui Goodarzian, Fariba Gordon Murkes, Lena Goske, Marilyn J. Govindan, Morgan Gowdy, Susan C. Graham, Dionne Gralla, Jane Grant, Ellen

PA-126 SCI-048 PA-157 SCI-015, PA-034 CR-032 SCI-005, PA-041 PA-054 PA-056 PA-068 PA-116 PA-077 PA-066 SCI-033 PA-040, PA-145 PA-067 PA-081 PA-049 SCI-005, PA-041 PA-005 PA-077 EDU-075, EDU-078 PA-037 PA-021, PA-037 SCI-011 SCI-011 EDU-034 SCI-058 CR-033, SCI-006, SCI-007 EDU-026 EDU-091 PA-055 EDU-015 SCI-002 SCI-048 PA-051 PA-102 CR-032, EDU-001, EDU-033, EDU-109, SCI-020, SCI-053, PA-052 EDU-096, PA-061 CR-003 EDU-095 PA-137, PA-144 PA-009 CR-080 PA-120, PA-121, PA-125 CR-076, CR-078 EDU-088 CR-075 SCI-015 CR-038, PA-096, PA-097 PA-104 CR-067 EDU-032 CR-029, EDU-003 CR-072 PA-130, PA-157 CR-005 PA-046 EDU-043 SCI-008 PA-035, PA-036, PA-146, PA-155 CR-080 EDU-023, EDU-025 PA-084 PA-067, PA-148 EDU-015

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Grattan-Smith, Damien Green, Jared Greer, Mary-Louise Griggs, Rachel Grissom, Leslie E. Gross, Jordan Guelcher, Christien Guerrera, Michael Guillerman, R. Paul Guimaraes, Alexander S. Guimaraes, Carolina V. Guo, Grace Gupta, Esha Gupta, Supriya Gurian, Michael Gwal, Kriti Hall, Michael Hall, Nigel Hall, Theodore Halula, Sarah E. Hammer, Matthew R. Han Suyin, Kathleen Hancock, S. B. Haney, Suzanne Harcke, H. T. Harding, Brian N. Harty, Mary Harvey, Isaac Hauschildt, John Hawkins, C Matthew Hawkins, Hal K. Hawkinson, Ellen K. Hayatghaibi, Shireen Hayes, Laura L.

Hayes, Roisin Healey, Patrick Heeger, Allen P. Hegde, Ashwin Hegde, Shilpa Heider, Amer Hejkal, Thomas Heller, Randall Hendi, Aditi Heon, Elise Hercher, Michelle A. Hernandez, Alberto Herrmann, Karin Herskovits, Pnina Hicks, M. John Higginbotham, William W. Highmore, Kerri Hildebolt, Charles Hill, Mary K. Hill, Suvimol Hilmes, Melissa Himes, Ryan Hitt, Dave M. Ho-Fung, Victor Hoang, Jenny Hoare, Siobhan Hochman, Jay A. Hogan, Mark

CR-017, CR-053, CR-059, CR-064, EDU-070, PA-051, PA-076 CR-040 EDU-106, SCI-018, PA-063 EDU-049 EDU-052, EDU-062 EDU-084 PA-094 PA-094 PA-001, PA-002, PA-003, PA-055 SCI-053 CR-061 EDU-062 EDU-043 CR-012, SCI-001 PA-118 PA-010 SCI-004 SCI-023 PA-034 PA-068 PA-053 CR-065 EDU-039 PA-079 PA-136 EDU-091 EDU-062 CR-044 PA-059 PA-119, PA-153 SCI-028 PA-047 PA-140 CR-017, CR-053, CR-059, CR-064, EDU-070, PA-019, PA-076 CR-075 PA-153 EDU-080 CR-066 CR-023, CR-067 PA-008 PA-079 PA-114 EDU-071 SCI-042 PA-017 CR-035, CR-036 PA-139 CR-021 PA-003 PA-049 PA-104 SCI-003, PA-043 PA-106 PA-107 CR-011, CR-020, CR-048, PA-070, PA-116 CR-035 SCI-039, PA-032 PA-102 PA-021 CR-075, EDU-009 CR-017 SCI-038

Holder, Chad Holdsworth, Samantha J. Hollander, Seth Holm, Tara Holwerda, Ross Hopkins, Katharine Hora, Megan Horn, Paul Horslen, Simon Horsley, Erin Horst, Deanna M. Hsiao, Albert Hu, Lingzhi Huisman, Thierry Hull, Nathan Humpl, Tilman Hurst, Robert W. Hurteau-Miller, Julie Hwang, Jae-Yeon Hwang, Tiffany Hyatt, Eddie Hynes, Sally Ichord, Rebecca N. Ilivitzki, Anat Inarejos, Emilio Inarejos Clemente, Emilio Ince, Selami Irodi, Aparna Ishak, Gisele Ivancic, Vesna Ivy, Dunbar Jabi, Feraas Jadhav, Siddharth P. Jaeggi, Edgar Jaimes, Camilo Jakacki, Regina Jamieson, Douglas Jana, Manisha Januzis, Natalie Jaramillo, Diego Jawahar, Anugayathri Jenkins, Brad Jennings, David C. Jerdee, Theodore J. Jiang, Zi Jindal, Gaurav Johnsen, Allison Johnson, Emilie Johnson, Neil D. Jokerst, Clint Jones, Elizabeth Jones, Jeremy Jones, Kerwin Jones, Richard Jong, Lisa Jorgensen, Scott A. Josefson, Jami Josephs, Shellie C. Joshi, Aparna Joshi, Madalsa Jung, Ah Young Kalra, Mannudeep K Kamel, Hussein Kammen, Bamidele F. Kan, J. H.

EDU-088 PA-016, PA-017 SCI-010 SCI-017 EDU-080 EDU-018, PA-060 CR-008 PA-110 PA-153 EDU-029, EDU-110 CR-057 PA-024 PA-139 EDU-069, PA-022, PA-080 EDU-053 PA-066 CR-033 CR-009, EDU-090 PA-045 PA-097 PA-116 CR-044 CR-033 CR-046 PA-109 EDU-106 EDU-032 CR-071 CR-026, EDU-073, SCI-022 PA-053 PA-067 EDU-094 SCI-028, EDU-050, PA-030, PA-130 PA-129 PA-087, PA-152 PA-020 CR-051, EDU-023, EDU-025 PA-082 PA-021 PA-004, PA-102, PA-103, PA-151, PA-152 PA-098 PA-046 PA-127 PA-016 PA-023 CR-022, CR-041 CR-020, EDU-051 PA-084 SCI-035, PA-155 PA-043 PA-040 PA-138 PA-108 CR-053, CR-059, PA-019, PA-051 SCI-034 CR-043, CR-047, EDU-008, EDU-056 PA-150 CR-039, PA-023 CR-005 EDU-066 PA-045 EDU-001, EDU-109 SCI-043, SCI-049 SCI-039 EDU-050, PA-099

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

Kandula, Vinay Kaplan, Bernard Kaplan, Paige Karakas, Pinar Karl, Barbara Karmazyn, Boaz Kashyap, Seema Kasprian, Gregor Kassis, Christine Kaufman, Robert A. Kaye, Robin Kecskemethy, Heidi H. Keller, Marc S. Kelly, Teresa Kenney, Brian Keshava, Shyamkumar N. Keshavarzi, Nahid Khan, Nadir Khan, Sarah Khanna, Geetika Kharoti, Yama Khatami, Alireza Khawaja, Ranish D. Khrichenko, Dmitry Kilborn, Tracy Kilbride, Howard Kim, AeRang Kim, Hee Kyung Kim, Paggie Kim, Peter Kim, Stanley T. King, Eileen King, Justin R. Kini, Vishwanatha Kino, Aya Kitami, Masahiro Kleinman, Paul K. Klobuka, Andrew J. Knowlton, Joshua Q. Kobistek, Robert J. Kocaoglu, Murat Kochan, Polly Kohli, Rohit Kolbe, Amy Kolon, Thomas F. Koning, Jeffrey L. Kotecha, Suhas Koujok, Khaldoun Kovanlikaya, Arzu Kraemer, Kenneth Kraft, Kate H. Kraus, Steven J. Kreychman, Alena Kricun, Bret

Krieger, Axel Krishnamurthy, Ganesh Krishnamurthy, Rajesh Krishnamurthy, Rajesh X.

Krishnamurthy, Ramkumar

CR-055, EDU-071 PA-088 PA-152 SCI-039 PA-131 EDU-020, EDU-057, SCI-029, PA-011, PA-111 PA-082 PA-123, PA-124 SCI-020 PA-044 CR-031, SCI-037, PA-101 PA-105 PA-095, PA-154 EDU-075, EDU-078 SCI-025 CR-045, CR-071 PA-008 CR-052, CR-067 PA-034 CR-006, EDU-006, PA-137 EDU-005 CR-009, EDU-090 EDU-001 PA-083, PA-087 PA-088 PA-135 EDU-047 PA-110 SCI-044 EDU-047, EDU-048, CR-002 PA-025 PA-007 PA-155 SCI-049 PA-074 SCI-016 PA-112 PA-020 CR-003 SCI-002 EDU-032 EDU-095 PA-007 EDU-053 PA-083 PA-059 SCI-034 EDU-063 CR-013, CR-081 PA-107 PA-053 PA-155 EDU-093 EDU-024, EDU-029, EDU-035, EDU-082, EDU-085, EDU-087, EDU-095, EDU-110 CR-002 CR-033, CR-042, PA-095, PA-096, PA-154 PA-130, PA-140, PA-141, PA-157 EDU-042, PA-009, PA-027, PA-028, PA-029, PA-030, PA-031, PA-033 PA-027, PA-028, PA-029, PA-031, PA-138, PA-142

S239

Kruk, Peter Kucera, Jennifer Kuehn-Hajder, Jessica Kukreja, Kamlesh U. Kulkarni, Kopal S. Kunam, Vamsi Kuo-Bonde, Lydia E. Kurian, Jessica Kurio, Gregory Kurzendorfer, Tanja Kwaja, Asef B. Kwon, Jeannie Kwon, Soyang Laffan, Eoghan Lamart, Stephanie Lanxer, Ronald Laor, Tal Larson, David B. Larson, Noelle Lau, Hin Yue Lawrence, John T. Lazarte, Claudia I. Le, Jenna Leake, David R. LeCompte, Lesli Ledford, Jamie Lee, Choonsik Lee, Dong Hwan Lee, EC Christabel Lee, Edward Y. Lee, Eric Lee, Jason K. Lee, Jennifer K. Lee, Richard Lee, Vincent Lefton-Greif, Maureen A. Leung, Daniel H. Levin, Terry Lewis, Kristopher N. Li, Wen Li, Yi Liang, Teresa Lidegran, Marika Lim, Ruth Limperopoulos, Catherine Lin, Jody L. Lindquist, Diana Linguraru, Marius George Little, Stephen Litwiller, Daniel Liu, Arthur K. Liu, Jiamin Lo, Ryan Loening, Andreas M. Loewen, Jonathan M. Loke, Yue-Hin Lomasney, Laurie Longo, Daniela Loskutov, Anatoly Louis, Chrystal Lowe, Lisa Lowe, Lisa H. Lowry, Carolyn

PA-059 N. SCI-047 SCI-017 SCI-035, PA-092 PA-054 EDU-003 EDU-049, SCI-015 EDU-100 PA-032 CR-038, PA-096, PA-097 EDU-060 CR-050 PA-150 CR-065, CR-075, EDU-009 PA-145 EDU-055 EDU-059 PA-073, PA-115 EDU-053 SCI-033 PA-102 EDU-027, EDU-028 EDU-076 CR-062 CR-028 EDU-075, EDU-078, EDU-089 PA-040, PA-145 SCI-055 CR-019 EDU-107, SCI-056, PA-064, PA-072, PA-075 SCI-025 PA-155 PA-022 PA-128 CR-070, PA-020 PA-054 PA-009 EDU-021, EDU-100 SCI-001 PA-048, PA-143 SCI-054 EDU-019, EDU-064 SCI-008 EDU-001, EDU-033, SCI-053, PA-052 PA-015, PA-120, PA-122 PA-001 PA-110 PA-050, PA-062, PA-071, PA-149 CR-059, PA-051 PA-057 PA-081 PA-149 PA-063 PA-057 EDU-103, SCI-019 CR-002 PA-098 SCI-048 CR-063 PA-002 PA-114, PA-135 CR-063, EDU-077 PA-037

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S240

Lu, Jimmy C. Lu, Lucy X. Luhar, Aarti P. Lungren, Matthew Luo, Yu Lupo, Philip J. Lyden, Elizabeth Lynn, Matthew Lyons, Karen Ma, Grace M. MacDonald, Cathy Macgowan, Christopher Machnitz, Judit MacKenzie, John D. Mackenzie, William G. Magee, Brian Mahmood, Nadia Mahmutoglu, Saadet Majmudar, Anand Maki, Erik Malik, Archana

Malone, LaDonna J. Man, Carina Mandell, Gerald A. Manickam, Rohan Mann, Erika Manson, David Mansoor, Atiya Marcovici, Peter Margolin, Judith Mariano, Angela Marine, Megan B. Marks, Catherine Marrie, Ruth Ann Martelius, Laura Martin, Aaron D. Martin, Kenneth W. Martin, Rose Martin-Harris, Bonnie J. Martinez-Rios, Claudia Marx, Doug Masand, Prakash Masand, Prakash M. Mascarenhas, Maria Massaro, An N. Massey, James Matsuoka, Kentaro Mawad, Michel Mayureewan, Taphey McCarron, Audrey McCarten, Kathleen M. McDonald-McGinn, Donna m. McGraw, Elizabeth P. McIntosh, Adeka McKinney, Jennifer McLaren, Clare McLean, Thomas W. McMahan, Brian L. McNeal, Gary Mecca, Patricia Medina, Santiago Mehollin-Ray, Amy Mehta, Anita

CR-080 CR-011 PA-034 SCI-035 EDU-051 PA-001 PA-079 CR-012 PA-002, PA-140, PA-141 PA-109 PA-066 PA-129 EDU-029, EDU-082 SCI-030, SCI-054, SCI-057 PA-105 EDU-003 PA-085, PA-138 CR-040 EDU-111 EDU-083 EDU-024, EDU-029, EDU-035, EDU-037, EDU-082, EDU-085, EDU-087, EDU-110 PA-029, PA-030 SCI-024 CR-030 EDU-042 SCI-034 EDU-055, PA-066 EDU-018 SCI-030, SCI-054, SCI-057 CR-036 PA-049 EDU-020, SCI-029, PA-011, PA-111 EDU-053 PA-014 PA-069 PA-050 SCI-039 PA-119 PA-054 PA-139 PA-091 CR-035 CR-024, PA-030, PA-130, PA-157 SCI-026 SCI-012 PA-111 SCI-016 CR-037 PA-061 CR-034 PA-005 SCI-026 EDU-026 PA-095, PA-154 SCI-040 PA-090 CR-072 EDU-057 SCI-009 PA-038 CR-054 CR-024, PA-123, PA-124 EDU-021, EDU-076

Menard-Katcher, Calies Menegotto, Flavia Menias, Christine Menzel, Margaret Meoded, Avner Messina, Marci Messner, Stephen Meyer, James Meyers, Arthur B. Mhlanga, Joyce C. Miles, Lili Milks, Kathryn S. Miller, Angie Miller, Cheryl Miller, Elka Mirro, Amy E. Mirsky, David M. Mithra, Ashok Miyazaki, Osamu Mohanta, Arun Moineddin, Rahim Monfaredi, Reza Mong, Andrew Monsalve, Johanna Mooney, David Moore, Bria A. Morris, Shaine Morscher, Melanie Moseley, Michael E. Mourtos, Evangelos Moy, Matthew P. Mubarak, Walid M. Muchantef, Karl Mulkern, Robert Munden, Martha M. Murali, Amrita Muthusami, Prakash Myers, Emmarie Nadler, Evan P. Nagaraj, Usha Naheedy, John Naranjo, Arlene Natera, Alejandro Nayak, Anjali Nelson, Caleb Nemec, Rose Nevrekar, Dipti Newman, Beverley Ngan, Bo-Yee Ngo, Anh-vu Nguyen, Dustin Nguyen, Giao Nguyen, HaiThuy N. Nguyen, Ho Nguyen, Jie C. Nielsen, David B. Nielsen, Jason W. Nihayah, Saeed Nimkin, Katherine Noel, Cory Noeske, Ralph Norman, Jackson Northington, Frances

SCI-058 SCI-014 EDU-038 PA-127 PA-080 SCI-009 PA-076 PA-132 EDU-059 PA-006 PA-007 CR-072 PA-148 SCI-002 CR-009, EDU-090 PA-044 PA-018 CR-071 SCI-016 SCI-024 SCI-023, SCI-040, PA-063, PA-109, PA-113 CR-034 PA-065 CR-024 CR-014 PA-044 PA-031 PA-108 PA-016 SCI-008 EDU-096 SCI-041, SCI-043, SCI-049 PA-133 EDU-107 PA-009 EDU-042 EDU-072, SCI-042 PA-050, PA-062, PA-071 PA-149 CR-056, EDU-012, PA-015 PA-059 PA-137 CR-016 PA-034 PA-084 SCI-036 PA-067 SCI-010, PA-073, PA-074, PA-115 EDU-106 EDU-017 EDU-030, EDU-041, EDU-093 PA-021 PA-099 EDU-073 PA-004 CR-063, EDU-080 SCI-025 CR-040 EDU-102, SCI-020 PA-027, PA-028 PA-122 PA-147 PA-022

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

Nosaka, Shunsuke Novais, Eduardo N. Ntoulia, Aikaterini Nuchtern, Jed G. Oetgen, Matthew Okcu, Mehmet F. Olivieri, Laura Olson, Andrew C. Orman, Gunes Orr, R. Jason Orth, Robert C. Otero, Hansel J. Otrakji, Alexi Otto, Randolph Oudjhane, Kamaldine Oyewumi, Modupe Padua, Eric M. Palasis, Susan Paldino, Michael J. Paltiel, Harriet J. Panigrahy, Ashok Parikh, Kushal S. Parisi, Marguerite T. Parmar, Madhumita Parra, Dimitri Pass, Jonathan H. Patel, Bhairav Patel, Manish Patel, Mittun C. Patel, Munir Patel, Neal Patel, Premal A. Patil, Kedar Patrick, Ellen Pattamanuch, Nicole Pearl, Phillip Pednekar, Amol Penrod, Cody Pereira, Andre Pesacreta, Lindsay Peters, Craig A. Peterson, Michael Phelps, Andrew S. Phewplung, Teerasak Pierson, Christopher R. Pietila, Todd Pimpalwar, Ashwin Pimpalwar, Sheena Plimpton, Steven Plishker, William Pluto, Charles Podberesky, Daniel J. Pokorney, Amber Poletto, Erica

Pollack, Ian F. Pollak, Jeffrey Pollock, Avrum Ponraj, Chinnadurai Ponrartana, Skorn Popescu, Andrada

SCI-016 PA-106 PA-083, PA-103 PA-002 EDU-047 PA-001 CR-002 PA-081 PA-080 PA-026 PA-055, PA-085 EDU-097, PA-126, PA-134 EDU-109 CR-026, SCI-022 SCI-021 EDU-106 SCI-039 CR-017, CR-053, CR-059, CR-064, EDU-070, PA-019, PA-076 PA-138, PA-142 CR-014 PA-020, PA-077 PA-053 CR-068, CR-069, SCI-052 EDU-042 CR-040 PA-090 CR-062 SCI-035, PA-092 CR-043, CR-047, EDU-008, EDU-056 PA-114 PA-010 PA-090 PA-133 SCI-027 EDU-021 CR-056 PA-027, PA-028, PA-029, PA-031 PA-116 SCI-034 SCI-013 PA-050 EDU-022 SCI-030, SCI-054, SCI-057 EDU-033 SCI-046 PA-033 CR-036, PA-091 CR-035, CR-036, CR-037, PA-091 PA-081 PA-048 SCI-046 EDU-104, PA-007, PA-035, PA-056, PA-144, PA-156 CR-043 EDU-024, EDU-029, EDU-035, EDU-037, EDU-082, EDU-085, EDU-087, EDU-110 PA-020 CR-022, CR-041 PA-126 CR-035, PA-091 SCI-015 PA-026, PA-131

S241

Popescu, Andrada R. Porayette, Prashob Poretti, Andrea Potnick, Aaron Powell, Jerry A. Poznick, Laura Prabhu, Sandeep Prabhu, Sanjay Pradhan, Madhura Prempunpong, Chatchay Priest, John R. Prince, Jeffrey Propst, Evan Pruthi, Sumit Pugmire, Brian S. Qin, Curtis D. Quinn, Charles Raab, Elisabeth Racadio, John Racadio, Judy Rahbar, Habib Raj, Sean Ramakrishnaiah, Raghu Rambhatla, Siri J. Ramirez-Giraldo, Juan C. Ramirez-Giraldo, Juan Carlos Randisi, Francesco Raptis, Constantine Ratino, Julie A. Rattan, Mantosh S. Rayner, Tammy Razzano, Andrew Reading, Brenton D. Reddy, Mahati Rednam, Surya Reghunathan, Arun Reid, Janet R. Reilly, Brian Renjen, Pooja Rentas, Kenny Rescorla, Frederick Restrepo, Ricardo Rhee, Eileen Rice, Amy Rigsby, Cynthia K. Rizzi, Mattia Robertson, Matthew Robinson, Ian Robinson, Joshua Roebuck, Derek J. Rogers, Sarah Rohren, Eric M. Rojas, Yesenia Rollins, Nancy Rosenbaum, Daniel Rosenfeld, Scott B. Rosenthal, David Rosines, Lucila Roy, Anne Ruangwattanapaisarn, Nichanan Rubesova, Erika Rubin, Jonathan Rubin, Michael Rubio, Eva Rubio, Eva I.

PA-025 PA-129 EDU-069, PA-022, PA-080 PA-058 CR-050 EDU-045, PA-117 EDU-039 EDU-004, PA-121 PA-132 SCI-014 PA-003 PA-035 EDU-106 CR-011 EDU-033, SCI-053, PA-052 CR-023 PA-056 PA-132 SCI-035, PA-092 PA-146 EDU-101 CR-037 CR-023, CR-067 PA-010 PA-037 EDU-002, SCI-003 SCI-048 EDU-006 CR-003 SCI-059, SCI-060 SCI-040 PA-108 CR-016 EDU-086 PA-003 EDU-077 EDU-045, PA-117, PA-118 CR-001 CR-013, CR-081 EDU-077 SCI-029 EDU-058 CR-033 EDU-105 SCI-009, PA-025, PA-026, PA-131, PA-150 PA-093 PA-048, PA-143 EDU-009 PA-131 PA-090 CR-060 PA-140, PA-141 PA-002 CR-039 CR-081 PA-099 SCI-010 PA-124 SCI-014 PA-057 PA-115 PA-008 SCI-002 SCI-013, PA-127 EDU-036

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S242

Ruess, Lynne Rusin, Jerome A. Russell, Heidi V. Ryan, Stephanie Saettele, Megan Safdar, Nabile Safdar, Nabile M. Sagar, Pallavi Sago, Haruhiko Saigal, Gaurav Salazar, Pascal Saleem, Sheena Salem, Khaled Y. Salmeron, Ronny Samei, Ehsan Sammet, Christina L. Sandler, Anthony Sanghvi, Neel Sant’Anna, Guilherme Santos, Domiciano Saranathan, Manoj Sauer, Cary Saul, David Schaefer, Carrie Schmidt, Bernhard Schmitz, Kelli Schniederjan, Matthew Schnur, Jack Schoeneman, Samantha Schooler, Gary Schubert, Johanna Schuh, Suzanne Schulman, Marta Schwartz, Cindy L. Schwartz, Daniel Scrugham, Jeffrey A. Scubert, Johanna Seed, Mike Seekins, Jayne Seghers, Victor Sen, Seema Sena, Laureen Seo, Dae Young Serai, Suraj Serai, Suraj S. Sertic, Madeleine Servaes, Sabah Shah, Jignesh Shah, Mansi Shah, Sanket Shah, Sohail Shah, Summit Shaikh, Abdullah Shalaby-Rana, Eglal Shammas, Amer Shanely, Thomas Sharafinski, Mark E. Sharatz, Steven M. Sharma, Karun Sharma, Karun V. Sharma, Manish Sharma, Sanjay Shaw, Dennis Sheikh, Fariha Shekdar, Karuna

CR-057, SCI-045, SCI-046 CR-057, SCI-045, SCI-046 PA-001 EDU-009 CR-063 CR-001, CR-034, PA-048, PA-062, PA-071, PA-143, PA-149 PA-050 EDU-109 SCI-016 CR-058 PA-033 PA-078 SCI-041 PA-146 PA-037, PA-039 PA-131 PA-071 SCI-012 SCI-014 EDU-105 PA-057 SCI-019 EDU-084 CR-031, SCI-037, PA-101 SCI-003 CR-079, EDU-005, EDU-018 CR-064 PA-020 PA-026, PA-150 PA-075 CR-008 SCI-024 CR-011, CR-020 PA-005 PA-060 CR-018 CR-074 CR-007, EDU-072, PA-129 PA-116 PA-140, PA-141 PA-082 EDU-004 SCI-055 EDU-104, PA-056, PA-110 PA-007 SCI-036 PA-038, PA-065, PA-137 EDU-111 EDU-100 CR-003 CR-015 SCI-038 EDU-030, EDU-041, EDU-093 CR-049 SCI-050 CR-080 EDU-059 EDU-102, PA-061 CR-034, SCI-012 EDU-047, EDU-048, PA-094 PA-082 PA-082 CR-026, SCI-022, PA-153 PA-156 EDU-079

Shekdar, Karuna V. Shekhar, Raj Shenouda, Nazih Shenoy-Bhangle, Anuradha S. Sher, Andrew Sher, Irene Shetty, Anil N. Sheybani, Elizabeth Shiekh, Adnan Shivaram, Giri M. Shroff, Manohar Shruti, Aditi Siegel, Marilyn J. Sigley, Matthew Silva, Cicero T. Silva, Naomi Simoneaux, Stephen Sindhi, Rakesh Singh, Sarabjeet Singh, Sudha P. Singh, Sumit Sirineni, Gopi Sitek, Arkadiusz Skare, Stefan Smith, Ethan A. Snyder, Kathryn Soliman, Magdy Soltanmohammadi, Mohammad Somers, Michael Sorger, Joel I. South, Andrew P. Southard, Richard Spevak, Melissa Spiegel, Lynn Springer, Adam Stagner, Anna Stanescu, Arta-Luana Stanescu, Luana States, Lisa States, Lisa J. Stence, Nick Stewart, Jaime R. Stimec, Jennifer Strain, John D. Strauss, Keith J. Strunk, Rhonda Stuart, Sam Stuelke, Satre Stutz, Christopher M. Subramanian, Sanjay Sumfest, Joel Summers, Ronald M. Sun, Binjian Supakul, Nucharin Sura, Amit S. Sureka, Jyoti Sussman, Marshall Swerdlow, Mathew Swischuk, Leonard E. Sze, Raymond

Tabban, Hazar Tadros, Sameh

EDU-091, EDU-097 SCI-012, PA-048, PA-143 EDU-063, SCI-041 CR-032 PA-139 EDU-076 PA-123 SCI-018 EDU-063 PA-153 SCI-034, SCI-042, PA-013, PA-014 EDU-040 SCI-003, PA-043, EDU-002 CR-063 CR-022, CR-041 EDU-058 CR-077 CR-070 EDU-001, EDU-109 CR-020, PA-070, PA-116 CR-023, CR-067 CR-074 PA-052 PA-016 PA-008, PA-053 EDU-018 EDU-055 PA-040, PA-145 PA-128 PA-144 SCI-059, SCI-060 EDU-008 PA-006 PA-109 SCI-002 PA-079 EDU-017 CR-026, SCI-022 PA-126 EDU-097 PA-018, PA-081 PA-106, PA-148 EDU-054 PA-148 PA-035, PA-036, PA-146, PA-155 SCI-059, PA-056 PA-090 EDU-040 CR-048 PA-033 EDU-040 PA-149 CR-059, PA-019 EDU-013, EDU-014 EDU-043 CR-045 SCI-040 SCI-058 SCI-028 CR-034, EDU-044, EDU-048, EDU-105, PA-012, PA-046, PA-062 SCI-041, SCI-043, SCI-049 CR-070

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

Tamura, Deborah Tan, Cynthia Tani, Chihiro Taragin, Benjamin Tarango, Cristina Tasar, Mustafa Tekes, Aylin Temple, Michael J. Tenenbaum, Mary Thakur, Neil Thomas, Jennifer Thomas, Karen Thomas, Kristen Thomen, Robert Thompson, Benjamin P. Thompson, Patrick A. Tiao, Greg Tkach, Jean A. Tombesi, Maria M. Tomlin, Keturah Towbin, Alexander J. Towbin, Richard Tsai, Jason Tse, Shirley Tse, Sunny KS Tun, Moe Twomey, Eilish Tyler-Kabara, Elizabeth Udjus, Kristin Umstead, Eric Uppot, Raul N. Urbine, Jacqueline

Vade, Aruna Vajtai, Petra Vajtai, Zsoka Vali, Reza Valsenti, Gianluca van Amerom, Joshua VanHulle, Rachel Vargas, Daniel Vasanawala, Shreyas Vassilyadi, Michael Vasudevan, Sanjeev A. Vatsky, Seth Verhey, Leonard H.

PA-107 SCI-057 SCI-011 EDU-021, EDU-076, EDU-100 PA-092 EDU-032 PA-022 PA-093 EDU-015 PA-135 CR-028 CR-044, SCI-005, PA-041 EDU-053 PA-068 SCI-045, EDU-034 PA-157 PA-144 SCI-059, SCI-060 PA-089 SCI-036 EDU-104, PA-036, PA-119, PA-144 CR-031, SCI-037, PA-100, PA-101 SCI-051 EDU-054 SCI-033 PA-135 CR-075, EDU-009 PA-077 CR-009 PA-147 CR-032 EDU-024, EDU-029, EDU-035, EDU-037, EDU-082, EDU-085, EDU-087, EDU-095, EDU-110 PA-098 EDU-005, EDU-018, EDU-083, PA-060 EDU-083 SCI-050 EDU-023, EDU-025 PA-129 SCI-004 PA-067 PA-024, PA-057, PA-058 CR-009, EDU-090 PA-157 CR-031, CR-047, EDU-056, SCI-037, PA-101 PA-013, PA-014

S243

Verma, Sumit Vezina, Gilbert Victoria, Teresa Volberg, Frank M. Vorona, Gregory Voss, Stephan Vyas, Pranav K. Wahl, Richard Wallace, Sowdhamini Walters, Thomas Wang, Dah-Jyuu Wang, JIa Wang, Kuan Chieh Wang, Kuan Chung Wang, Lily Warade, Monali K. Warfield, Simon Watanabe, Toshihiko Wedman, Matthew Weinman, Jason Weinstein, Howard J. Weiss, Pamela F. Westra, Sjirk Wheelock, Lisa White, Ammie M. Whitehead, Matthew Williams, Jennifer L. Williams, John V. Williams, Susan Wilson, Phillip Winfeld, Brittany E. Winfeld, Matthew J. Wong, Brenda L. Wood, Beverly Wood, Brad Woodhead, Gregory Woods, Jason Wu, George S. Wyers, Mary Xanthakos, Stavra Xu, Annie Yadav, Bhupender Yadav, Vikas K. Yam, Benjamin L. Yang, Dong Hyun Yang, Edward

CR-064 EDU-012, PA-015 PA-065 CR-019 EDU-079, EDU-091 PA-005 PA-143 PA-006 PA-085 PA-063 PA-152 PA-074 PA-113 PA-113 EDU-086 SCI-034 EDU-107, PA-120, PA-121, PA-125 SCI-016 EDU-039 PA-148 EDU-096, SCI-053 PA-151 EDU-001, EDU-109 CR-074 PA-065, PA-132 CR-056, EDU-012, EDU-081 PA-085, PA-123, PA-138, PA-141 PA-070 CR-058 CR-050 EDU-067 EDU-067 PA-110 SCI-044 EDU-048 CR-076 PA-068 EDU-040 PA-047, PA-147 PA-007 EDU-044 PA-094 CR-045, CR-071 EDU-060 PA-045 EDU-015, PA-120

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

S244

Yaniv, Ziv Yarboro, Elizabeth Yarmolenko, Pavel Yasrebi, Mona Yeom, Kristen Yewchuk, Lila Yoo, Raphael J.

Yoo, Shi-Joon Yoon, Hye-Kyung Yoshizumi, Terry Young, Cody Zackai, Elaine Zahiri, Homeira Zahra, Mahmoud

PA-046 PA-146 EDU-047, EDU-048 CR-054, EDU-058 PA-016, PA-017 EDU-019, EDU-064, EDU-066 EDU-024, EDU-035, EDU-037, EDU-087, EDU-095 PA-066, PA-129 PA-045 PA-021 EDU-034 SCI-026 CR-074 CR-042, EDU-094, PA-095, PA-154

Zaki, George Zalieckas, Jill Zandieh, Arash R. Zaritsky, Joshua Zbojniewicz, Andrew Zhang, Bin Zhang, Tao Zhang, Wei Zhang, Wei x. Zhang, Xiaomeng Zhao, Qian Zheng, Jicui Zhong, Anguo Zhu, Xiaowei Zucker, Evan J. Zurakowski, David

PA-048 CR-014 CR-019 PA-034 PA-104 PA-104, PA-119 PA-058 PA-002, PA-140, PA-141 PA-009, PA-124 PA-052 PA-071 PA-156 PA-113 SCI-006, SCI-007, PA-038, PA-097 PA-042, PA-073, PA-115 SCI-056, PA-064, PA-072, PA-075

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

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KEYWORD INDEX

18FDGPET/CT 22Q11.2 deletion syndrome 3T 3-D 3-Matic 3D fusion 3D modeling 3D post-processing 3D Printer 3D/3D Fusion 3rd branchial cleft cyst Abdomen Abdomen x-ray Abdominal mass Abdominal MRI Abdominal pain Ablavar Abscess Abuse Abusive Head Trauma Acceleration time Accuracy Acetabular fracture Acetabular injury Acetabulum Achondroplasia ACL Acute Appendicitis Acute demyelinating syndromes Acute pelvic pain ADC Adipose tissue Adolescent female Adrenal Adrenal glands Advanced MR techniques Advanced visualization Adverse events Agitated saline contrast echocardiogram Airway Alagille Alagille’s syndrome ALARA

Allergic Ambiguous genitalia Amplatzer plug Anatomic measurements Anesthesia Angiography Angioplasty Ankle Ankylosing spondylitis Anomalies Ansa pancreatica Aortic pseudoaneurysm Aortic Root Apheresis appendicitis Appendix

EDU-097 SCI-026 PA-121 MRI SCI-054 CR-002 CR-038 PA-033 PA-040 CR-002 PA-096 PA-023 CR-077, PA-038 EDU-016 CR-023 PA-059, SCI-060 PA-059 PA-025 EDU-024, EDU-038 CR-049, PA-078 PA-077 PA-067 PA-119 PA-106 PA-106 EDU-057, EDU-062 PA-080 PA-103, PA-105 PA-060 PA-014 PA-059 CR-013 PA-149 CR-029 CR-071, CR-074 EDU-041 PA-019 PA-048 EDU-105 CR-080 EDU-108 EDU-004 EDU-025 CR-034, CR-050, EDU-002, EDU-003, SCI-003, SCI006, SCI-007, PA-006, PA060, PA-072, PA-131 SCI-058 PA-127 CR-041 PA-068 EDU-109 PA-131 PA-094 EDU-065 EDU-054 EDU-013, EDU-014, EDU-090 EDU-020 CR-079 PA-031 SCI-036 EDU-019, SCI-028 SCI-025, PA-059

Appropriateness criteria Arterial Arterial supply Arterial tortuosity Arteriovenous fistula Arthritides Arthritis Arthrogram Arthrography Arthropathy Arthroscopy Artificial heart ASL Aspiration Ataxia Atlas Atresia Atrioventricular tract anomalies Atrophy Attenuation Correction Audience participation Autoregulation B-lines Back pain Barium follow-through Bell’s Criteria Benign neoplasm Benign tumor Bezoar Bile ducts Bile leak Biliary Biliary atresia Biliary stricture Biliary tract Bilious emesis Billiary atresia Biomechanics Biopsy Blastoma Bepharptosis Blood pool contrast agent Blunt head trauma Body Body CT Body mass index (BMI) BOLD Bone Bone fragments Bone in Hodgkin Lymphoma Bone marrow Bone strength Bowel obstruction Bowel peristalsis BPCA- MR angiography Brachial plexus Brain Brain CT Brain development Brain MR Brain tumor

PA-114 CR-033 CR-082 EDU-072 CR-037 EDU-058 EDU-054, EDU-055, SCI-040 CR-034 EDU-056 SCI-020 PA-098 PA-033 PA-015 PA-054 EDU-086 PA-120 EDU-093 CR-005 CR-066 PA-140, PA-141, PA-142 EDU-043 PA-022 PA-069 PA-148 CR-075 PA-133 CR-062 PA-147 EDU-100 PA-010 CR-019 EDU-093 EDU-025 CR-019 EDU-023, EDU-025 SCI-023 CR-080 PA-027 CR-034, SCI-037, PA-096, PA-097, PA-154 PA-003 EDU-081 PA-030 CR-065 CR-077 PA-040 PA-149 CR-059 SCI-041 EDU-062 PA-005 EDU-078, PA-004, PA-152 PA-113 EDU-010 CR-026, SCI-022 PA-025 CR-048 SCI-014, PA-100 CR-060 PA-120 CR-060 SCI-046

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Brainstem Brainstem gliomas Bronchial atresia Bronchopulmonary sequestration Brown adipose tissue Brown fat Burkitts lymphoma C-arm Computed Tomography C-arm CT C-arm CT Imaging Caffey Calcification Calvarial Calvarium Cancer Capsular lectures Cardiac Cardiac anomalies Cardiac CT Cardiac CTA Cardiac diverticulum Cardiac magnetic resonance imaging Cardiac MRI Cardiac transplant Cardiovascular Cardiovascular MRI Cartilage identification Catheter Catheter directed thrombolysis Cavernoma CCAM CDS perfusion CDT Cerebellum Cerebral infarction Cerebral palsy Cerebral Perfusion Cerebral ultrasound Cerebral vasculature Cervical spine Chest Chest and abdomen Chest computed tomography Chest CT Chest radiography Child Child abuse Childhood vasculitis Children

Children; bowel Choledocholithiasis Cholestasis Chromosomal Chronic lung disease Chronic non-bacterial osteomyelitis Cine MRI Circulation Circumcision Cirrhosis Clinical protocol Closure Clubfoot

EDU-071, EDU-091, PA-080 PA-020 SCI-016, SCI-057 SCI-016 PA-150 SCI-015 CR-012 PA-096, PA-097 SCI-006, SCI-007 CR-035 CR-051 CR-055 EDU-089 EDU-078 CR-076, SCI-053, PA-144 EDU-042 PA-024, PA-029 CR-005 PA-033 PA-074 CR-004 PA-129 CR-005 SCI-010 CR-003, PA-024, PA-032 PA-026 PA-071 SCI-012 PA-094 PA-081 CR-082 SCI-014 PA-092 CR-066, EDU-091 SCI-045 PA-099 PA-015 PA-135 SCI-045 EDU-088, PA-076 EDU-014, PA-025, PA-038, PA-072, PA-131 EDU-109 PA-068 PA-066, PA-145 EDU-110 PA-002, PA-140, PA-141 CR-061, PA-076, PA-079, PA-112 EDU-055 EDU-004, EDU-069, EDU-090, SCI-021, PA-008, PA-010, PA-013, PA-014, PA-080, PA-087, PA-152 SCI-026 EDU-023 CR-018 EDU-036 PA-065 EDU-064 PA-126 PA-129 CR-030 PA-009 SCI-040, PA-038 EDU-089 EDU-067

CNR CNS Color doppler Commissure Competency Completely visualized appendix Complication Compressed sensing Computational phantom Computed tomography

Conceptual Condylar enhancement Congenital

Congenital anomalies Congenital brain malformation Congenital Diaphragmatic Hernia Congenital heart disease

Congenital lesions of the mandible Congenital lobar emphysema Congenital pulmonary airway malformation Connective tissue disorder Conservative management Constipation Continuous improvement Contrast Agent Contrast induced nephropathy Cooling Corkscrew Cornelia de Lange Cortical dysplasia Corticopontocerebellar tract Cost Craniosynostosis Criss-cross heart Crohn Crohn disease Crohn’s disease Crohns Crohns disease Cryoablation CSF pressure transducer CSF shunt malfunction CT

CT Angiography CT dose index (CTDIvol) CT protocol CT radiation dose CT scan CTA CTDI CTDI (CT Dose Index) CUBE CUBE/SPACE/VISTA

PA-038 EDU-009 CR-037 PA-031 PA-114 SCI-024 SCI-038 PA-058 PA-040 CR-079, EDU-001, SCI052, PA-042, PA-044, PA-064, PA-069, PA-084 EDU-042 PA-109 EDU-007, EDU-013, EDU-014, EDU-025, EDU-026, EDU-092 CR-081 PA-018 PA-124 CR-005, EDU-005, PA015, PA-030, PA-033, PA-130 EDU-084 EDU-111 SCI-016, SCI-057 CR-003 PA-089 EDU-030 PA-049 PA-034 PA-132 PA-022, PA-135 PA-055 CR-056 CR-054 CR-066 SCI-017, PA-049 EDU-089 CR-005 SCI-020 CR-010, PA-061 CR-026, EDU-024, EDU027, EDU-028, SCI-022 CR-013 CR-012 CR-032 CR-069 CR-069 CR-011, EDU-007, EDU-082, EDU-097, EDU-110, SCI-042, PA-006, PA-045, PA-061, PA-131, PA-137, PA-148, PA-156 CR-044, CR-065, EDU-055, PA-130 PA-073 PA-042 SCI-005, PA-043 SCI-050 PA-064 PA-038 PA-042 PA-104 SCI-054

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Cusp Cystic Cystic lung disease Cystic neck mass Cystic Wilms tumor Cystitis Cystogram Cystoplasty Cytotoxic edema Dandy-Walker DAP DCE DDH DECT Deep vein thrombosis Deformable registration Delayed enhancement Dermoid Developing Device Device fitting Diagnostic Algorithm Diagnostic Reference Levels Diagnostic reference ranges Dietary deficiency related treatable disease Dietl’s crisis Differential renal function Diffusion MR Diffusion tensor imaging Diffusion Weighted Sequence Diffusion-weighted imaging Digitally reconstructed radiograph (DRR) Discoid Meniscus Disease Divisum DIXON DOSE Dose length product (DLP) Dose reduction

Dose-Area Product Dotarem Double read DTI EDU-079, DTI/ADC Dual Energy CT Duchenne muscular dystrophy Duct dilation Ductus venosus Dumb-bell lesion Duplication cyst DVT PA-092, DWI CR-013, Dynamic contrast-enhanced MRI Dysplasia Dysraphism Early features ECG-gated prospective scan Echo Planar Imaging Echogenic Ectopic thymus Ectopic thyroid Education Educational methods

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PA-031 EDU-041 SCI-016 EDU-106 EDU-038 EDU-034 EDU-031 EDU-031 EDU-070 EDU-012 SCI-002 PA-058 PA-136 EDU-109 SCI-035, PA-093 PA-048 CR-004 EDU-100 EDU-078 CR-034 PA-033 EDU-039 SCI-002 PA-036 CR-017 CR-068 PA-087 PA-020 CR-053, EDU-079, PA-080 EDU-071 CR-010, CR-077, PA-016 PA-046 PA-102 EDU-090 EDU-020 SCI-039 PA-006, PA-045 PA-042, PA-073 EDU-002, EDU-003, SCI011, PA-037, PA-039, PA040, PA-043, PA-044 SCI-002 EDU-104 PA-111 PA-103 PA-022 SCI-003 PA-110 PA-011 CR-018 CR-046 PA-023 PA-094 CR-077 SCI-022 CR-051, PA-003 EDU-011 CR-045 SCI-008 PA-016 PA-128 EDU-076 EDU-076 EDU-043, EDU-045, PA114, PA-118, PA-146 EDU-042

Effective dose Ejection fraction Ejection time Elastography Electronic reporting tool Emergency Emergency imaging Emergency radiology Emergency Room Emoral osteotomy Encephalomyelitis Enchondroma End Stage Renal Disease Endovascular management Enema Enhancement ratio Enterography Enterourinary fistula Entheses Enthesitis EOS Eosinophilia Eosinophilic Eosinophilic esophagitis Epidermal inclusion cysts Epiphyseal development Epyphysealdysplasia Equivocal ultrasound for appendicitis ERA Erb’s palsy ERCP Error rates Error types Errors Esophageal duplication cyst Esophagitis Esophagram Esophagus Evidence-based Extravesical ectopic ureter Eye globe Facial swelling Familial Fast acquisition time Fast MRI Fat Fraction Fat suppression FDG PET FDG PT FDG-PET Feeding Tube Fellowship Ferriscan Fetal Fetal brain Fetal CT Fetal Imaging Fetal MRI Fetus Fibroadenoma Fibrosis Filar cyst FILTER Fistula

PA-145 CR-004 PA-067 PA-008 PA-112 EDU-108, SCI-023 EDU-016, EDU-070 EDU-016, SCI-005 PA-084 PA-099 CR-064 EDU-064 PA-034 CR-022, CR-041, PA-093 EDU-030, SCI-023 PA-109 PA-061 EDU-102 PA-151 EDU-054 EDU-052 SCI-058 EDU-034 PA-012 EDU-100 EDU-058 SCI-041 SCI-024 EDU-054 CR-048 PA-011 SCI-034 SCI-034 PA-119 EDU-076 SCI-058 SCI-058 SCI-026, PA-055 PA-133 PA-083 PA-082 CR-062 PA-003 PA-057 PA-016 PA-152 SCI-039 SCI-051, SCI-053, PA-138 SCI-050 PA-142 EDU-017 EDU-045, PA-118 PA-056 EDU-009, EDU-011, PA-122, PA-126, PA-128 PA-121 SCI-011 SCI-013 SCI-016, PA-065, PA-120, PA121, PA-124 PA-129 EDU-101 CR-013, PA-008 SCI-047 PA-095 CR-012, EDU-024

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Flip angle modulation Flipped classroom Fluorescence Imaging Fluoroscopic guided injections Fluoroscopy Fluoroscopy guided fMRU FNH Follicular ring sign Foot Foot fracture Foreign Body in bronchus Fractures Free Breathing Functional Functional analysis Functional magnetic resonance imaging functional MR Urography (fMRU) Gadofosveset trisodium Gadolinium Gadoterate meglumine Galactosemia Gastrointestinal disorders Gastrointestinal reflux Gastrojejunal tube Gastroschisis Gastrostomy Gastrostomy malposition Gastrostomy perforation Gaucher Disease Genetic Genitourinary GI GJ Tube Glenohumeral Glenoid Graded Graded Dilated Fundoscopic Exam GRE Ground glass opacity Growth GU Guillain Barrè Gynecomastia Handle bar injury Head and Neck Head and neck tumors Heart Hemaprhodite Hematologic malignancy Hemisphere Hemodynamics Hemophilia hemorrhage Hepatic Hepatic arterial thrombosis Hepatic artery stenosis Hepatitis Hepatobiliary Hepatoblastoma Hepatopulmonary syndrome Hernia Hernia Sac HIDA HIE

PA-057 EDU-044 SCI-012 PA-099 EDU-056, PA-155 EDU-050 PA-083 SCI-021 CR-008 EDU-065 EDU-051 EDU-111 PA-144 PA-029 PA-083 PA-051 EDU-091 PA-052 EDU-006 PA-132 EDU-104 CR-018 SCI-060 PA-055 PA-155 EDU-010 EDU-021 EDU-021 EDU-021 PA-152 EDU-036 CR-073, EDU-031, EDU041, SCI-032, PA-087 CR-027 EDU-017 CR-048 PA-108 DFE PA-079 PA-079 CR-059 PA-069 EDU-062 EDU-040 SCI-048 EDU-101 CR-079 EDU-071, SCI-006, SCI-007 EDU-097 EDU-007 PA-127 PA-004 CR-066 PA-024 PA-113 PA-081 CR-011, EDU-029, SCI-021 CR-019 CR-019 EDU-093 CR-027 EDU-102, PA-144 CR-041 CR-015 PA-124 EDU-093, EDU-095 SCI-014, PA-022

HIFU High-pitch scan Hip Hip fracture Hip injury Hip Ultrasound Hirschsprungs Histiocytes Hodgkin Lymphoma Horner HSP Human metapneumovirus Hybrid Hybrid imaging Hydrocephalus Hydrodissection Hydronephrosis Hyperbilirubinemia Hypercalciuria Hyperglycemia Hyperostosis Hypertension Hypometabolism Hypoplastic left heart hypospadias Hypotonia Hypoxic ischemic injury ICG IDRF Image guided Image quaility Image quality ImageGently Imaging Imaging modalities in bone disease in Hodgkin Lymp Imaging of Immune-mediated Immunotherapy Impingement In infants and children Infant Infarction Infected cephalohematoma Infection Infectious Inflammaory Inflammatory bowel disease Inflammatory pseudotumour Informatics Inherited Initial anteroposterior retrovesical diameter Injury Injury grading Innovation Insitu lines and tubes Instructional video Insulin Resistance Inter-rater agreement Interlobular septal thickening Intermittent testicular torsion Intermittent ureteropelvic junction obstruction

EDU-047 SCI-008 PA-106 PA-106 PA-106 PA-136 EDU-030 CR-073 PA-005 EDU-081 EDU-019 PA-070 SCI-057 PA-143 CR-069, EDU-073 CR-032 EDU-038 CR-018 SCI-030 PA-149 CR-051 PA-066, PA-149 CR-066 SCI-010 PA-127 SCI-043 EDU-070, PA-135 SCI-012 PA-002 CR-032 CR-060 EDU-015, PA-037, PA-039 PA-072 EDU-090 PA-005 SCI-028 CR-063 PA-020 PA-098 SCI-051 PA-085 CR-053 CR-009 CR-053, EDU-071 CR-064 CR-075 CR-026, SCI-019, SCI-022, PA-063 EDU-023 EDU-046, SCI-001, PA-119 CR-003 PA-089 CR-049, EDU-070, PA-100 PA-156 PA-114 EDU-017 EDU-044 PA-149 PA-013 PA-069 SCI-031 CR-068

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Intervention Interventional Interventional radiology Intestinal motility Intra-articular hip injection Intrahepatic porto systemic shunt Intrathoracic shunting Intraventricular septations Intussusception Iodinated contrast Isotropic voxel Iterative reconstruction Iterative Reconstruction Techniques IV access IVC Jaundice Jaw lesion Jejunostomy JIA Joint Joints Joubert Jugular Jugular vein ectasia k-factor Khan academy Kidney Kidney, MRU Kidneys Knee Knee joint Kneecap Korea kVp Labral tear Latarjet Lateral Menisci Lead point Lean Leg-length discrepancy Legg Calve Perthes Lesion counts Leukemia Likert Limb deformity Liver

Liver Iron Liver mass Liver transplant Long term effects Low Bowel Obstruction Low rank Low-dose Lumbar spine Lung lesions Lung ultrasound Lymphadenopathy Lymphangiomatosis

PA-101 SCI-038, PA-097, PA-100 CR-040, EDU-047, EDU-048, PA-094 SCI-060 PA-099 CR-022, CR-041 CR-080 CR-055 CR-020 PA-090, PA-132 PA-104 CR-060, SCI-011, PA-060, PA-074 EDU-001 PA-064 PA-095 CR-018, EDU-093 EDU-084 EDU-021 EDU-054 CR-034 PA-151 EDU-086 PA-154 EDU-076 PA-145 EDU-044 EDU-013, EDU-037, PA-128, PA-137 PA-052 EDU-041, SCI-030 CR-047, PA-103, PA-104 PA-102 EDU-059 PA-045 EDU-002, PA-043 PA-098, PA-108 CR-050 PA-102 CR-020 PA-049 EDU-053 PA-107 PA-013 PA-004 PA-141 EDU-053 CR-011, CR-027, CR-070, EDU-026, PA-008, PA-144, PA-154 SCI-059, PA-056 EDU-010 PA-153 EDU-105 EDU-030 PA-058 EDU-052 PA-148 CR-082 PA-069 CR-073 CR-036

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Lymphatic malformation Lymphoid hyperplasia Lymphoma Lytic lession MAG3 Magnetic Magnetic Resonanace Enterography Magnetic Resonance Magnetic Resonance Angiography Magnetic Resonance Enterography Magnetic resonance imaging

Magnevist Main pulmonary artery strain Major aortopulmonary collaterals Malignancy Malrotation Mandible anatomy Mass Masses Masticator space Maxilla Maximum Dimensions May Thurner MDCT Mechanical embolectomy Meckel’s diverticulum Meconium peritonitis Medical student education Medulloblastoma Melanin Mesenteric adenitis Mesentric lymphovenous malformation Mesothelioma Metabolite Metaphyseal abnormality Metaphysealdysplasia Metastatic METAVIR Micro-learning Microcephaly Micturating cystourethrography Midgut volvulus Milestones Mimics Minimally invasive Minimize SAR Molecular imaging Monte Carlo Morphological Mortality Motion correction MoyaMoya MR MR angiography MR Arthrogram MR arthrography MR contrast MR Contrast agent MR hip arthrogram MR imaging MR scan time MR spectroscopy MR urography MR-HIFU

EDU-076 SCI-028 EDU-096, PA-004, PA-006 EDU-057 EDU-094 EDU-033 EDU-027, EDU-028 PA-032 EDU-006 CR-010, PA-063 CR-026, SCI-039, PA-013, PA-014, PA-080, PA-096, PA-102 PA-025 PA-067 PA-130 CR-076, PA-072 SCI-026, PA-047, PA-055 EDU-084 EDU-068, EDU-092 EDU-026 EDU-084 CR-062 PA-031 PA-094 CR-044, PA-041 CR-033 CR-015, EDU-019 EDU-102 PA-116 PA-081 CR-062 EDU-019 CR-023 EDU-018 PA-122 CR-052 SCI-041 CR-071 PA-009 EDU-045 SCI-043 SCI-033 PA-047 SCI-043, PA-114, PA-117 CR-002 EDU-048 PA-057 PA-012 PA-145 PA-083 PA-002 PA-121 EDU-072 PA-061 EDU-055, EDU-072, PA-030 EDU-063 PA-098 EDU-104 PA-026 PA-098 PA-004 SCI-040 PA-110, PA-152 EDU-032, PA-051 EDU-047, EDU-048

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MRA MRAC MRCP MRCP/MRI MRI

MRI DTI spine MRI DWI spine MRI MRA MRI X-ray overlay MRS MRU Mucosal hyperenhancement Multi-modality imaging Multicystic dysplastic kidney (MCDK) Multihance Multilocular cystic nephroma Multimodality Multiplanar Multiple Multiple sclerosis MURCS Musculoskeletal Musculoskeletal Mycobacteria Myelomeningocele Myositis ossificans progressiva NAFLD Nanoprobe NASH NATIVE TrueFISP Near Infrared Spectroscopy Near-Infrared Neck Necrotising Enterocolitis Neglect Neonatal Neonatal Hemochromatosis Neonatal hepatitis Neonatal imaging Neonatal jaundice Neonatal mass Neonatal Neonate Neoplasm Nephrogenic Systemic Fibrosis Neural crest Neural tube Neurofibromatosis Neuroimaging Neurology Neuroradiology Newbon Non-accidental trauma

SCI-015, PA-026 PA-140, PA-141 CR-027 PA-010 CR-006, CR-043, CR-047, CR-074, CR-075, CR-077, EDU-009, EDU-020, EDU-029, EDU-056, EDU-059, EDU-078, EDU-082, EDU-085, EDU-097, EDU-109, EDU-110, SCI-042, SCI048, SCI-053, PA-011, PA012, PA-024, PA-076, PA079, PA-081, PA-087, PA103, PA-150 PA-017 PA-017 CR-022 CR-038 PA-122 EDU-040, PA-052, PA-053, PA-083 PA-061 EDU-097 EDU-038 SCI-021 EDU-038, EDU-039 PA-048 PA-068 SCI-021 PA-013, PA-014 CR-029 CR-043, CR-072, EDU-047, EDU-065, SCI-040 MRI SCI-039 CR-075 PA-123 EDU-102 PA-009 PA-012 PA-009 SCI-009 PA-022 SCI-012 EDU-092 PA-133 CR-049 CR-074, PA-133 SCI-059 EDU-095 SCI-015 EDU-025, EDU-095 EDU-010 MRI SCI-059, SCI-060 SCI-014, PA-015, PA-132 EDU-026, EDU-071 PA-034 CR-062 EDU-011 EDU-083 EDU-069, PA-078 CR-063 CR-054, EDU-075, EDU-079 SCI-032 PA-111

Non-contrast enhanced MRA Non-visualized appendix Noncompaction Noncontrast Normal Normal variant Notch Nuclear imaging Nuclear medicine Nuclear medicine renogram Obesity Obstetric Obstruction OCT Odontogenic Omentum Omphalocele Oncologic imaging Oncology Online education Open fetal repair Ophthalmic Optison Oral contrast Ossification Osteochondral fractures Osteochondral unit Osteochondritis dissecans Osteoid osteoma Osteopoikilosis Osteoporosis Osteosarcoma Outcome Ovarian torsion Pacemaker PACS integration Paediatric emergency Pancreas Pancreatic duct Pancreatic duct obstruction Pancreaticobiliary system Pancreatitis Papillomatosis Paraganglioma Parallel imaging paraneoplastic Parents Partially visualized appendix Patella baja Patent Ductus Venosus PCL Peak velocity Pectus excavatum Pediatric

Pediatric abdominal MRI Pediatric Appendicitis Score Pediatric brain MRI Pediatric brain tumor Pediatric cardiovascular abnormalities Pediatric CT Pediatric CT Dose

SCI-009 SCI-024 CR-004 CT PA-071 PA-010 EDU-020 PA-105 EDU-003 CR-017, EDU-003, PA-044 CR-068 PA-150 SCI-017 CR-016, EDU-033, EDU-108 SCI-042 EDU-084 EDU-018 EDU-010 PA-143 CR-072, EDU-048, EDU-098 EDU-042 PA-123 PA-082 CR-014 CR-027 EDU-062 EDU-058 EDU-058 EDU-058 EDU-064 EDU-064 PA-113 EDU-064 SCI-038 EDU-019 EDU-005 PA-048 EDU-016 EDU-020 PA-010 PA-011 PA-156 CR-016, PA-011 EDU-101 SCI-052 PA-058 PA-144 PA-041 SCI-024 PA-105 CR-035 PA-105 PA-067 PA-071 CR-032, CR-038, CR-064, EDU-004, EDU-026, EDU056, EDU-062, PA-025, PA-027, PA-045, PA-064, PA-082, PA-093, PA-096, PA-105 CR-010, PA-057 SCI-024 EDU-070, SCI-046, PA-019 PA-020 PA-074 EDU-001, SCI-003, PA-066 PA-037, PA-039

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Pediatric dynamic contrast enhanced abdominal Pediatric intervention Pediatric Pediatric neuroradiology Pediatric ocular syndromes Pediatric oncology Pediatric population Pediatric shoulder Pediatric stroke Pediatric syndrome Pediatric trauma Pediatric tumor Pediatric urinary tract infection Pediatric vascular pathology Pediatrics Pelvic MRI Pelvis Penetration Percent error Percutaneous perfusion MR Perianal abscess Perianal fistula Perinatal Peripheral angiography Peripheral nerve stimulation Peritoneal metastases Peritonsillar abscess Pes planus PET PET CT PET-CT PET/CT PET/MR PET/MRI Phakomatoses Phantom Phlebectasia Phyllodes tumor Physiologic thymus uptake PICC Pilonidal Pilonidal cysts Pink appendix Pituitary Pleuropulmonary Pleuropulmonary blastoma Pneumothorax Poliradiculoneuritis Polycystic Kidney Disease Polymicrogyria Pons Pontine lesions Port Portal vein Portal vein stenosis Portal venography Portosystemic shunt Positron emission tomography Post-processing Post-transplant lymphoproliferative disease Posterior Fossa Posterior fossa epidural collection Posterior Urethral Valves Postoperative

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MRI PA-058 CR-040 MRI PA-059, PA-109 EDU-077 SCI-042 PA-143 PA-139 PA-108 CR-033 EDU-072 CR-079 CR-046 SCI-033 CR-007, EDU-006 EDU-105, SCI-055, PA-026, PA-102 SCI-054, PA-063 EDU-057 PA-054 PA-068 EDU-021 PA-020 PA-063 PA-063 SCI-032 CR-044 EDU-015 EDU-018 CR-001 EDU-067 CR-070 CR-071 SCI-052, PA-006 PA-139 PA-142 SCI-053, PA-139 EDU-083 PA-068, PA-145 CR-039 EDU-101 SCI-051 SCI-012 SCI-047 EDU-100 SCI-028 EDU-085, PA-018 PA-003 SCI-057 EDU-111 SCI-048 PA-088 CR-055 EDU-077 EDU-077 SCI-036 PA-153 CR-019 PA-153 CR-035 SCI-052 PA-051 SCI-050 EDU-012 CR-067 SCI-013 EDU-067

Posttreatment Pre-operative Predictors Predictors of resolution Pregnant Prenatal Prenatal diagnosis Prenatal MRI Prenatal ultrasound Primary peritoneal tumor Propofol Prospective trial Prosthetic valves Prune Belly Syndrome Prussian blue Pseudoangiomatous stromal hyperplasia (PASH) Pulmonary Pulmonary artery Pulmonary hypoplasia Pulmonary Lymphangectasia Pulmonary vasculature QSM Qualitative Quantitative ultrasound Radiation Radiation dose Radiation Dose Reduction Radiation doses Radiation protection Radiation risk Radiation risk assessment Radiation safety Radiograph Radiographic patterns Radiology elective Radiology report quality Radiology-Pathology Correlation Radionuclide cystography Real Time 3D RECIST Recurrent shoulder instability Redcap Redundant spermatic cord Reflux Relapse Reliability REMOVAL Renal Renal artery Renal cell carcinoma Renal failure Renal function Renal pyramids Renal scan Renal Tumors Renal ultrasound Reproducibility Research Electronic Data Capture tool Research studies Resident education Resistive index PA-135

EDU-028, EDU-091 CR-050 PA-014 PA-089 SCI-017 SCI-017, SCI-032, PA-128 SCI-011 EDU-091 CR-008, PA-089 EDU-018 EDU-105 PA-074 EDU-005 SCI-013 PA-012 EDU-101 EDU-014 PA-066 PA-065 CR-007 PA-129 CR-059 PA-141 PA-113 EDU-002 SCI-001, SCI-003, PA-074, PA-155 EDU-001, EDU-003 PA-139 PA-035, PA-036, PA-146 PA-041 PA-044 SCI-005, PA-041 EDU-088, SCI-029 CR-017 PA-116 SCI-034 CR-007 SCI-033 PA-029 PA-002 CR-050 EDU-046 SCI-031 PA-086 PA-001 PA-049 PA-095 EDU-013, SCI-037, PA-088 SCI-009 CR-028, EDU-039, PA-137 PA-090 PA-090 SCI-030 EDU-037 EDU-039 CR-068, PA-085 PA-087 EDU-046 EDU-046 PA-116

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Resonance Respiration Respiratory syncytial virus RETREIVAL Rhabdoid tumor Rhabdomyosarcoma Rheumatology RIF Right ventricular outflow RSV SAR Sarcoma Scan overlap Schwannoma Sclerosing cholangitis Sclerotherapy Scoliosis Secondary Segmentation Seizures Sella SELSTOC Septo-optic dysplasia Septum pellucidum Sequestration Shear wave imaging Short term effects Shoulder Shoulder MRI Sigmoid sinus Signal intensity Signs Simulation Single modality Sinonasal Size Size specific dose estimate Skeletal dysplasia Skeletal Muscle Skeletal survey Skull SLAP Slot-scanning Soft tissue Soft tissue masses Sonography Spatiotemporal Spectroscopy Speech recognition Speech recognition software Speech recognition technology Speed of sound Spina bifida Spinal defect Spinal dysraphism Spinal neoplasm Spine Spine MRI Spleen position Split bolus technique Spondyloepiphyseal Spondylolysis Spondylometaphyseal Sports Sports injuries SSDE

EDU-033 EDU-109 PA-070 PA-095 CR-028 EDU-023, EDU-034, PA-001 EDU-050 CR-075 EDU-007 PA-070 EDU-015 EDU-047, EDU-048 PA-040 CR-032 EDU-023, SCI-020 CR-038, SCI-006, PA-101 EDU-052, EDU-053 SCI-025 PA-071 SCI-043 EDU-085 CR-046 PA-018 PA-018 SCI-057 PA-008 EDU-105 CR-047, CR-048, EDU-056, EDU-063 PA-108 CR-067 PA-109 SCI-025 PA-046, PA-047 CR-050 EDU-090 PA-002 PA-035, PA-036 SCI-011 PA-110 PA-111, PA-112 EDU-075 PA-108 EDU-052 EDU-068 EDU-068 CR-046, EDU-068 PA-120 PA-122 PA-119 SCI-034 SCI-034 PA-113 EDU-031 PA-123 EDU-100 PA-017 EDU-011, EDU-075, SCI-047 CR-053 PA-124 EDU-032 SCI-041 PA-148 SCI-041 EDU-059 PA-019 PA-043

SSFSE Staging Statistical shape model Stenosis Sternal mass Strain Stricture Strictures Stridor Sturge-Weber Syndrome Subarachnoid space Subclavian vein Subdural collection Subdural hematoma Subluxation Supply chain management Supraclavicular brown fat Suprapubic Caheterization Suprapubic Tube Surveillance Survey Survival Susceptibility Susceptibility weighted images Susceptibility-weighted imaging Suture Swaddling Swallowing SWI Swyer-james syndrome Syndrome Synovitis T1-weighted imaging T2 quantification T2* relaxometry T2-weighted imaging Tamm-Horsfall Target radiation dose levels Tarsal coalition Tarsometarsal fracture dislocation Technology Template Tendons Teratoma Testicular ultrasound Tethered cord Tetralogy of Fallot Thalamostriate vasculopathy Therapeutic Therapeutic injection Thoracic Thoracic imaging Thrombectomy Thrombolysis Thrombosis Thymic cyst Thyroglossal duct cyst Thyroid TMJ Tonsillar herniation Tool Torsion TPD Tractography Training Transcatheter procedure

PA-057 PA-082, PA-137 PA-071 PA-153 CR-046 PA-027 SCI-058 EDU-024 EDU-108 EDU-083 CR-061, PA-123 CR-039 CR-061 CR-061 EDU-059 PA-049 SCI-015 SCI-038 SCI-038 PA-001 EDU-042 PA-001 PA-081 PA-079 EDU-069 PA-139 PA-136 PA-126 CR-059 EDU-111 PA-127 PA-109 PA-016 PA-056 SCI-059 PA-016 SCI-030 PA-036 EDU-067 EDU-051 EDU-043 PA-120 PA-151 CR-074 SCI-032 SCI-047 CR-002, EDU-007 EDU-102 EDU-030 EDU-050 PA-131 CR-081, EDU-111 PA-093 SCI-035, PA-092, PA-093 CR-039, SCI-020 PA-023 EDU-106 EDU-099, SCI-055 SCI-007 PA-123 PA-031 CR-011, PA-027 EDU-059 EDU-079 PA-117, PA-118 EDU-005

Pediatr Radiol (2014) 44 (Suppl 1):S1–S253

Transcutaneous Sonography Transplant Transposition of the Great Arteries Tranverse sinus Trapezoid shaped marrow edema Trauma Traumatic Pseudoaneurysm Tube current Tuberous Sclerosis Tumor

Tumor ablation Tumors of bone Turbulence Tutorial Ulcerative colitis Ulceratve Colitis Ultrasonography Ultrasound

Ultrasound contrast Unbalanced diet Unsupervised UPJ UPJO Upper extremity Upper Gastrointestinal Series Urachus Ureter Ureteral dilatation Urethra Urinary Urinary bladder Urinary Tract Infection Urography Urogynecological malformations Urolithiasis US Utilization

CR-001 CR-070 PA-129 CR-067 CR-045 EDU-036, PA-100 CR-065 EDU-002, PA-043 EDU-083, PA-088 CR-053, CR-074, CR-076, EDU-036, EDU-039, EDU098, PA-003, PA-082, PA-137 CR-054 CR-072 PA-024 EDU-045, PA-117 CR-010, EDU-027, SCI-020 EDU-024 SCI-042, SCI-055 CR-007, CR-011, CR-048, EDU-045, EDU-099, EDU106, EDU-110, SCI-017, SCI-025, SCI-030, PA-088, PA-117, PA-118, PA-133, PA151, PA-153 CR-014, PA-086 CR-052 PA-029 EDU-037, PA-053 PA-053 SCI-035 SCI-026 EDU-034 EDU-035 PA-089 EDU-035 EDU-033 EDU-035 CR-030, PA-085 EDU-033 CR-029 PA-084 EDU-068, SCI-014 PA-084

S253

Validation Vascular Vascular anomalies Vascular malformation Vascular malformations Vascular Mapping Vasculitis Vasular malformations VCUG voiding cystourethography (VCUG) Venogram Venous aneurysm Ventricular arterial coupling Ventricular assist devices Ventricularis terminalis Ventriculomegaly Ventriculoperitoneal shunt Vermian Hypoplasia Vertebra Vertical talus Vesicoureteral reflux Vesicoureteric reflux Videofluoroscopic Swallow Study (VFSS) Viral Visualase Vitamin C deficiency Voiding cystourethography (VCUG) Voiding Cystourethrogram Voiding urosongraphy Voiding urosonography Volume reconstruction Volumetric Vomiting Von hippel-lindau Vulva Web application Whirlpool sign Whole body hypothermia Wilms tumor Workflow X-ray X-ray fluoroscopy Xanthogranulomatous XPD gene

PA-117 EDU-004, EDU-036 EDU-072, PA-147 CR-038 EDU-006, SCI-006 PA-034 CR-063 PA-101 PA-085 PA-034 CR-039 PA-067 EDU-005 SCI-047 CR-055 CR-015, CR-069 EDU-012 EDU-075 EDU-067 PA-085 SCI-033 PA-054 CR-064, SCI-028 CR-054 CR-052 EDU-035, PA-046 CR-030 PA-086 SCI-033 PA-121 MRI SCI-054 PA-055 EDU-083 CR-073 EDU-046 SCI-031 PA-135 CR-028 PA-138 PA-044 PA-046 EDU-034 PA-107