Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 DOI 10.1007/s00247-015-3297-9

ABSTRACTS

SPR 2015 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 58th Annual Meeting & Postgraduate Course Presented by The Society for Pediatric Radiology Hyatt Regency Hotel Bellevue, Washington Postgraduate Course April 27-28, 2015 Annual Meeting April 28-May 1, 2015 Jointly provided 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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TABLE OF CONTENTS Welcome from SPR President, Brian D. Coley, MD, FACR ............................................................................................................................................ S5 SPR 2015 Organization ....................................................................................................................................................................................................... S6 Continuing Medical Education ........................................................................................................................................................................................... S7 Maintenance of Certification .............................................................................................................................................................................................. S8 Objectives ............................................................................................................................................................................................................................ S8 Disclosure ............................................................................................................................................................................................................................ S9 Acknowledgements ........................................................................................................................................................................................................... S11 Program Schedule ............................................................................................................................................................................................................. S12 Listing of Scientific Exhibits/Posters ............................................................................................................................................................................... S26 General Information .......................................................................................................................................................................................................... S32 Mission Statement ......................................................................................................................................................................................................... S32 Sites of Previous Meetings ........................................................................................................................................................................................... S32 Future Meetings ............................................................................................................................................................................................................ S32 Officers, Directors and Committees ............................................................................................................................................................................. S32 Gold Medalists .............................................................................................................................................................................................................. S39 Pioneer Honorees .......................................................................................................................................................................................................... S40 Presidential Recognition Awards .................................................................................................................................................................................. S40 Honorary Members ....................................................................................................................................................................................................... S40 Past Presidents ............................................................................................................................................................................................................... S42 Singleton-Taybi Award ................................................................................................................................................................................................. S43 John A. Kirkpatrick Young Investigator Award ........................................................................................................................................................... S43 Walter E. Berdon Awards .............................................................................................................................................................................................. S43 The SPR Research and Education Foundation Awards ................................................................................................................................................... S44 Social Events ..................................................................................................................................................................................................................... S45 SPR 2015 Gold Medalist ................................................................................................................................................................................................... S46 SPR 2015 Pioneer Honoree ............................................................................................................................................................................................... S48 SPR 2015 Presidential Recognition Award ...................................................................................................................................................................... S50 SPR 2015 Honorary Members .......................................................................................................................................................................................... S51 SPR 2015 Singleton-Taybi Award .................................................................................................................................................................................... S54 John Caffey Awards ........................................................................................................................................................................................................... S55 Edward B. Neuhauser Lecturers ........................................................................................................................................................................................ S58 Postgraduate Course Abstracts .......................................................................................................................................................................................... S60 Scientific Papers ................................................................................................................................................................................................................ S68 Scientific Exhibits/Posters ............................................................................................................................................................................................... S149 Author Index by Abstract ................................................................................................................................................................................................ S237 Keyword Index by Abstract ........................................................................................................................................................................................... S242

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WELCOME ADDRESS Dear Colleagues, Medicine is changing in response to new science and discovery, better knowledge about healthcare delivery and outcomes, changing government and payor regulations, and patient preferences and demands. Imaging is subject to these same influences and pressures, and our practices will not look the same in the coming years as they have in past decades. This has caused many radiologists to bemoan the demise of medicine and to become dissatisfied and discontent with the practice of radiology. I think that is an unfortunate and overly pessimistic view of the situation. While many of the forces of change are beyond our control, many are not, and we as a specialty have the ability (and even a responsibility) to work to shape our own destiny. This may not be easy or comfortable, but it is necessary and has the potential to place radiology as an even more important and relevant part of medicine than it is today. The theme of this year’s meeting is “Visualize the Future,” because that is what we need to do before making our future happen. To help us with that visualization, Dr. Robert Gillies from the Moffitt Cancer Center will deliver the Neuhauser Lecture and speak to us about radiogenomics, the integration of genetic and imaging data. The postgraduate course organized by Drs. Alex Towbin and Ethan Smith, the educational sessions put together by Drs. Paul Guillerman and Tess Chapman, and the presented academic work by our talented colleagues should also provide inspiration about where we can go, and what we can do to provide the pediatric imaging care of the future. Inspiration can also come during discussion with colleagues, during a good party, and with quiet contemplation. Bellevue and Seattle are in a beautiful setting that deserves to be explored. So at some point get out of the hotel for a walk or run and see the area. Take the time to get together with friends at any one of the many terrific restaurants and entertainment venues in the area. If that isn’t sufficient, then perhaps a pint of local pale ale, glass of fine Washington wine, or other beverage of your choice will lead to insight and inspiration, and maybe the next “big idea.” I hope that you find value in the meeting content and in the interaction with your friends and colleagues, and that you have some fun. Think about what pediatric radiology can be, where we can do more for our patients, and truly change the outcomes in their care. Take what you learn and discuss back home with you and put it to use, and together we can create a bright future for our specialty. Sincerely,

Brian D. Coley, MD, FACR President, The Society for Pediatric Radiology

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SPR 2015 ORGANIZATION 2015 MEETING CURRICULUM COMMITTEE Brian D. Coley, MD, FACR, Chair Dianna M.E. Bardo, MD (3D Sessions) Shelia Berlin, MD (CT Protocol Session) Teresa Chapman, MD, MA (Workshop Director & Potpourri Session) Michael J. Callahan, MD (CT Protocol Session) Nancy A. Chauvin, MD (US Protocol Session) Bairbre L. Connolly, MD (Interventional Radiology Session) Jesse Courtier, MD (MR Protocol Session) Laura Z. Fenton, MD (Hands-On US & US Protocol Session) G. Peter Feola, MD (Interventional Radiology Session) R. Paul Guillerman, MD (Workshop Director & Potpourri Session) Jeffrey C. Hellinger, MD, MBA (3D Sessions) Rajesh Krishnamurthy, MD (MR Protocol Session) Arnold Carl Merrow, MD (Education Session) Jenny McBroom, RT, RDMS (Hands-On US, Consultant) Marguerite T. Parisi, MD, MS (Nuclear Medicine Session) Richard L. Robertson, MD (Neuroradiology Session) Susan E. Sharp, MD (Nuclear Medicine Session) Dennis W. Shaw, MD (Neuroradiology Session) Ethan A. Smith, MD (Postgraduate Course Director) Keith J. Strauss, MSc, FAAPM, FACR (CT Protocol Session) Mahesh M. Thapa, MD (Education Session) Alexander J. Towbin, MD (Postgraduate Course Director) ABSTRACT REVIEW COMMITTEE – PAPERS Brian D. Coley, MD, FACR, Chair Dianna M. E. Bardo, MD Dorothy I. Bulas, MD, FACR Christopher I. Cassady, MD, FAAP Teresa Chapman, MD, MA Taylor Chung, MD Jonathan Dillman, MD James Donaldson, MD, FACR Lynn Fordham, MD, FACR Mark J. Hogan, MD, FSIR Diego Jaramillo, MD, MPH Nadja Kadom, MD Rajesh Krishnamurthy, MD Bernadette Koch, MD Neha Kwatra, MD David B. Larson, MD, MBA M. Beth McCarville, MD Robert Orth, MD, PhD Marguerite T. Parisi, MD, MS John M. Racadio, MD Anil Rao, DMRD, DNB Cynthia K. Rigsby, MD, FACR Maura Ryan, MD Keith J. Strauss, MSc, FAAPM, FACR 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 Nadja Kadom, MD, Chair Susan E. Sharp, MD, Vice Chair Anjum Bandarkar, MD Madhan Bosemani, MBBS Michael J. Callahan, MD Maria Calvo-Garcia, MD Michael D’Alessandro, MD Kassa Darge, MD, PhD Steven Don, MD R. Paul Guillerman, MD Fredric Hoffer, MD Thierry A. G. M. Huisman, MD Douglas Jamieson, MD J. Herman Kan, MD Geetika Khanna, MD, MS Neha Kwatra, MD Maria Ladino-Torres, MD Jonathan Loewen, MD M. Beth McCarville, MD Craig Mitchell, DO, MA Jonathan Murnick, MD, PhD Helen R. Nadel, MD, FRCPC Srikala Narayanan, MD Daniel Podberesky, MD Janet Reid, MD Douglas Rivard, DO Ashley Robinson, MBChB Manrita Sidhu, MD Stephen F. Simoneaux, MD AylinTekes-Brady, MD Alexander J. Towbin, MD Jason Tsai, MD Kristen Yeom, MD 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 providership 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 10.75 AMA PRA Category 1 Credits™. 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 Credits™. 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 35 Category A credit hours of the ARRT. MAINTENANCE OF CERTIFICATION Qualified on February 4, 2015, the Postgraduate Course as well as the Saturday Interventional, Neuroradiology and Nuclear Medicine 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. Summarize the most current information on state of the art pediatric imaging and the practice of pediatric radiology. 2. Describe and apply new technologies for pediatric imaging. 3. Describe and apply basic principles for implementing quality and safety programs in pediatric radiology. 4. Discuss trends in research concerning the care and imaging of pediatric patients. 5. Identify common challenges facing pediatric radiologists, and possible solutions. 6. 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.

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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 Catherine Amlie-Lefond, MD Paul Babyn, MD Hank Baskin, MD Gregory Bates, MD Richard Benator, MD, FACR Ellen Benya, MD George S. Bisset, III, MD Sarah Bixby, MD Susan Blaser, MD, FRCPC Leah Braswell, MD Alan Brody, MD Stephen Brown, MD Brandon Brown, MD, MA Dorothy I. Bulas, MD, FACR Michael J. Callahan, MD Maria Calvo-Garcia, MD Christopher I. Cassady, MD, FAAP Gulraiz Chaudry, MBChB, MRCP, FRCR Jonathan M. Chen, MD Edith Y. Cheng, MD, MS Jeanne S. Chow, MD Matthew Cooper, MD James E. Crowe, MD Michael Cunningham, MD Heike E. Daldrup-Link, MD, PhD Kassa Darge, MD, PhD Michael DiPietro, MD William B. Dobyns, MD Stephen Done, MD, FAAP Lane F. Donnelly, MD Jerry R. Dwek, MD Monica Epelman, MD Hedieh Eslamy, MD Ken Feldman, MD, FAAP Laura Fenton, MD G. Peter Feola, MD Mark Ferguson, MD Donald Frush, MD, FACR Michael Gelfand, MD Robert Gillies, PhD Adam Goldin, MD, MPH Damien Grattan-Smith, MBBS S. Bruce Greenberg, MD C. Matthew Hawkins, MD Shilpa Hegde, MBBS Richard Heller, MD Marta Hernanz-Schulman, MD, FACR, FAAP Anastasia L. Hryhorczuk, MD Mark J. Hogan, MD, FSIR Richard Hopper, MD David Horn, MD, MS Giselle Ishak, MD Ramesh Iyer, MD Siddharth Jadhav, MD Diego Jaramillo, MD, MPH Geetika Khanna, MD, MS

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Paul Kleinman, MD, FAAP Rajesh Krishnamurthy, MD Kamlesh Kukreja, MD Neha Kwatra, MBBS, MD Edward Lee, MD, MPH Matthew Lungren, MD Prakash Masand, MD Jenny McBroom, RT, RDMS M. Beth McCarville, MD Amy Mehollin-Ray, MD, FAAP Mariana Meyers, MD Arthur Meyers, MD David Mirsky, MD Joelle Moreno, JD Beverley Newman, BSc, MBBCH, FACR Jason Nixon, MD Robert Orth, MD, PhD Hansel Otero, MD Jeffrey Otjen, MD Randolph Otto, MD Siddharth Padia, MD Angelisa Paladin, MD Susan Palasis, MD Harriet Paltiel, MD, CM Ephraim Parent, MD, PhD Marguerite T. Parisi, MD, MS Shawn Parnell, MD Manish Patel, DO Grace Phillips, MD Andrada Popescu, MD John Racadio, MD Cynthia Rigsby, MD, FACR Richard Robertson, MD Eva Rubio, MD Maura Ryan, MD Carrie Schaefer, MD Victor Seghers, MD, PhD Susan Sharp, MD Dennis Shaw, MD Giri Shivaram, MD Manrita Sidhu, MD Akosua Sintim-Damoa, MD Jennifer Soares, MD Arta-Luana Stanescu, MD Lisa States, MD Peter J. Strouse, MD, FACR Jonathan Swanson, MD Paul Thacker, MD Mahesh Thapa, MD Kristen Thomas, MD S. Ted Treves, MD Shreyas Vasanawala, MD, PhD Stephan Voss, MD, PhD Ghassan Wahbeh, MD Daniel Wallihan, MD Edward Weinberger, MD Jason Weinman, MD Sjirk Westra, MD Klane White, MD, MSc Matthew Whitehead, MD Shi-Joon Yoo, MD

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Planning Committee/Presenter Teresa Chapman, MD, MA R. Paul Guillerman, MD Ethan A. Smith, MD Staff Angela R. Davis, CAE The presenters and content reviewer listed below have disclosed the following relevant financial relationships. Potential conflicts have been resolved. Name Disclosure Adam Alessio, PhD GE Healthcare, Research Grants Dianna M.E. Bardo, MD Koninklijke Philips NV, Consultant & Honoraria and Thieme Publishing, Royalties Brian D. Coley, MD, FACR Elsevier, Royalties Jonathan Dillman, MD Siemens Medical Solutions USA, Research Grants and Bracco Imaging, Research Grants Steven Don, MD Carestream, Inc., Research Grants and FUJIFILM Medical Systems, Research Grants Matthew Goette, PhD Philips Healthcare, Salary David B. Larson, MD, MBA Cincinnati Children’s Hospital, Intellectual Property Arnold Carl Merrow, MD Amirsys/Elsevier, Consultant and Royalties Helen Nadel, MD, FRCPC International Atomic Energy Agency, Consultant Michael Riccabona, MD GE, Honoraria and Siemens, Honoraria Mike Richardson, MD Barbones Books, Owenrship Erika Rubesova, MD Siemens, Honoraria Keith J. Strauss, MSc, FAAPM, FACR Philips Medical, Inc., Consultant Alexander J. Towbin, MD Amirsys, Inc, Royalties, Merge Healthcare, Ownership/partnership and Guerbet, Other Andrew T. Trout, MD Philips Healthcare, Honoraria Edward Yang, MD, PhD Corticometrics LLC, Consultant The scientific presenters at the 2015 Annual Meeting have indicated their applicable disclosures at the beginning of their abstracts. ACKNOWLEDGEMENTS The Society for Pediatric Radiology gratefully acknowledges the support of the following companies in presenting the 58th Annual Meeting and Postgraduate Course: Agfa HealthCare Bayer HealthCare Elsevier EOS imaging GE Healthcare Guerbet LLC Imorgon Medical, LLC lifeIMAGE National Decision Support Company Philips Healthcare ScanMed of Resonance Innovations LLC Siemens Healthcare Toshiba America Medical Systems ZONARE Medical Systems As of January 29, 2015

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PROGRAM SCHEDULE The Society for Pediatric Radiology Postgraduate Course 2015 Ethan A. Smith, MD and Alexander J. Towbin, MD, Course Directors Visualize the Future Monday, April 27, 2015 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. 12:00 – 1:15 p.m. 12:00 – 1:15 p.m. 1:15 – 3:05 p.m. 1:15 – 1:25 p.m. 1:25 – 1:35 p.m. 1:35 – 1:45 p.m.

Continental Breakfast Registration Welcome and Introduction Brian D. Coley, MD, FACR Course Overview Ethan A. Smith, MD and Alexander J. Towbin, MD FETAL IMAGING Eva I. Rubio, MD and Mariana L. Meyers, MD, Moderators Cortical Dysplasias and Implications in Postnatal Life David M. Mirsky, MD Sorting Out Posterior Fossa Fluid Collections Matthew T. Whitehead, MD Fetal Orbits and Ears Maria A. Calvo-Garcia, MD Spinal Dysraphism Imaging and Postnatal Correlation: Where Are We Now? Dorothy I. Bulas, MD, FACR CDH: What’s on the Horizon? Amy R. Mehollin-Ray, MD Prenatal Diagnosis of Congenital Chest Anomalies Akosua Sintim-Damoa, MD Fetal Intestinal Obstruction: Prenatal/Postnatal Correlation Eva I. Rubio, MD Prenatal Urinary Tract Dilatation: What to Tell the Pediatricians? Mariana L. Meyers, MD Q&A with RSNA Diagnosis Live™ Break MUSCULOSKELETAL IMAGING Robert Orth, MD, PhD and Mahesh M. Thapa, MD, Moderators Hip Dysplasia: What the Orthopedist Wants to Know Klane K. White, MD Infection Imaging Robert Orth, MD, PhD Ultrasound of Shoulder Dysplasia Mahesh M. Thapa, MD Pediatric Temporomandibular Joint Imaging Arthur Meyers, MD US Guided Joint Injections Jeffrey P. Otjen, MD Skeletal Dysplasia Shawn E. Parnell, MD Posterolateral Corner Injuries Siddharth P. Jadhav, MD Vascular Malformation Intervention Giridhar M. Shivaram, MD Q&A with RSNA Diagnosis Live™ Lunch On Your Own AAWR Lunch Women in Radiology Including Challenges & Climbing the Ladder to Success Jeanne Hill, MD, Meryle Eklund, MD and Melissa Hilmes, MD CARDIAC IMAGING S. Bruce Greenberg, MD and Prakash M. Masand, MD, Moderators Aortopathy Associated with Congenital Heart Disease Prakash M. Masand, MD Cardiopulmonary Disease Shilpa V. Hegde, MD Abdominal complications associated with congenital heart disease Shi-Joon Yoo, MD

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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. 4:45 – 5:15 p.m. 5:15 p.m. Tuesday, April 28, 2015 6:00 a.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. 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.

The Brain: Prenatal and Postnatal Effects of Congenital Heart Disease Dianna M. E. Bardo, MD Cardiomyopathy in Muscular Dystrophy Daniel Wallihan, MD Pregnancy and Congenital Heart Disease Siddharth P. Jadhav, MD Acquired Heart Disease in Adults with Congenital Heart Disease Andrada R. Popescu, MD Prognostic Imaging in Congenital Heart Disease S. Bruce Greenberg, MD Q&A with RSNA Diagnosis Live™ Break CHEST IMAGING Alan S. Brody, MD and Ramesh S. Iyer, MD, Moderators How to Image and Describe Congenital Lung Malformations Paul Thacker, MD How to Image Pulmonary Hypertension Alan S. Brody, MD How to Evaluate and Interpret BPD in Neonates Matthew L. Cooper, MD How to Dynamically Image the Lungs and Airways in Children Edward Y. Lee, MD, MPH Pediatric Chest Wall Masses Ramesh S. Iyer, MD I Found a Lung Nodule on CT – What is the Chance It Could Be Cancer? Sjirk J. Westra, MD Functional Vascular Imaging with Focus on Ablavar Mark R. Ferguson, MD The Radiologic Work Up of a Child with Suspected Diffuse Lung Disease Jennifer J. Soares, MD Q&A with RSNA Diagnosis Live™ Adjourn SPR Research and Education Foundation Fun Run – Underwritten by Texas Children’s Hospital (Entrance fee is $25 and includes a T-shirt) Continental Breakfast Registration Welcome and Announcements Ethan A. Smith, MD and Alexander J. Towbin, MD ONCOLOGICAL IMAGING I Paul S. Babyn, MD and Andrew T. Trout, MD, Moderators FDG-PET: Techniques, Pediatric Variants Andrew T. Trout, MD Whole Body MR: Techniques and Staging in Oncology Monica Epelman, MD Whole Body MR vs. PET/CT for Staging of Children with Cancer Heike E. Daldrup-Link, MD, PhD Whole Body MRI of Vascular Malformations Arnold Carl Merrow, MD PET-MR: Technique and Clinical Cases Victor J. Seghers, MD, PhD Cancer Predisposition Syndromes Paul S. Babyn, MD NF and MPNST: Evaluation with PET and MR Helen R. Nadel, MD, FRCPC Screening for and Assessment of Osteonecrosis in Oncology Patients Sue C. Kaste, DO Q&A with RSNA Diagnosis Live™ Break & Exhibits ONCOLOGICAL IMAGING II Stephan D. Voss, MD, PhD and Ethan A. Smith, MD, Moderators Abdominal MRI Protocols in Pediatric Oncology Jonathan R. Dillman, MD Update on RECIST and Staging of “Common” Pediatric Tumors Ethan A. Smith, MD

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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.

Pediatric Renal Tumors – Update from COG Geetika Khanna, MD, MS Pediatric Lymphoma – Update from COG Stephan D. Voss, MD, PhD Quantitative Nuclear Medicine Imaging in Oncology Susan E. Sharp, MD Diffusion and Perfusion MR in Pediatric Oncology Shreyas S. Vasanawala, MD, PhD Contrast Enhanced Ultrasound in Pediatric Oncology M. Beth McCarville, MD Nuclear Medicine Therapy in Pediatric Oncology Neha S. Kwatra, MD Q&A with RSNA Diagnosis Live™ Adjourn Postgraduate Course

The Society for Pediatric Radiology Annual Meeting Program 2015 Brian D. Coley, MD, FACR, Program Director Teresa Chapman, MD, MA and R. Paul Guillerman, MD, Workshop Directors Visualize the Future Wednesday, May 14, 2014 12:05 – 1:15 p.m. 12:05 – 1:15 p.m. 3D 12:05 – 1:15 p.m.

1:20 p.m. 1:30 – 2:30 p.m.

2:30 – 3:00 p.m. 3:00 – 3:30 p.m. 3:50 – 4:10 p.m. 3:50 – 4:10 p.m. 3:50 – 4:10 p.m. 3:50 – 4:10 p.m. 3:30 – 3:50 p.m. 3:50 – 5:10 p.m. 3:50 – 4:10 p.m. 4:10 – 5:10 p.m.

Lunch Read with the Experts Lunch (attendance is limited; first come-first serve basis) Dianna M.E. Bardo, MD and Jeffrey C. Hellinger, MD, Moderators Supported by, Philips Healthcare, Siemens Healthcare, Vital MR Protocol Lunch Session (attendance is limited; first come-first serve basis) Jesse Courtier, MD and Rajesh Krishnamurthy, MD, Moderators Supported by, Philips Healthcare, Siemens Healthcare, Toshiba America Medical Systems Welcome Brian D. Coley, MD, FACR Edward B. Neuhauser Lecture Radiomics and Radiogenomics Robert J. Gillies, PhD Chair, Department of Cancer Imaging and Metabolism H. Lee Moffitt Cancer Center Tampa, Florida Pediatric Ultrasound: An International Perspective Michael Riccabona, MD WFPI Sharing Resources Dorothy I. Bulas, MD, FACR, Moderator WFPI - Diverse Resources, Shared Restraints Dorothy I. Bulas, MD, FACR WFPI - Educational Collaboration Kassa Darge, MD, PhD Radiology Outreach Strategies Hansel Otero, MD Closing Comments Dorothy I. Bulas, MD, FACR Breaks & Exhibits Scientific Session I-A: Oncology & Nuclear Medicine (concurrent) Robert Orth, MD, PhD and Marguerite T. Parisi, MD, MS, Moderators PET/MR – Current State and Future Directions Victor J. Seghers, MD, PhD Scientific Papers - Oncology & Nuclear Medicine

Paper #: 001

4:10

Yang

Paper #: 002

4:20

Sher

Paper #: 003

4:30

Sher

Clinical Equivalence of PET/MRI- and PET/CT-Acquired Brain Exams in Children with Epilepsy. Performance of PET/MR in the Assessment of Pediatric Histiocytoses: A prospective study Comparison of Lesion Detection and Staging in Pediatric Lymphoma between PET/CT and PET/MR in a Tertiary Pediatric Hospital: A Prospective Study

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 Paper #: 004

4:40

Sher

Paper #: 005

4:50

Tijerin Bueno

Paper #: 006

5:00

Kaste

3:50 – 5:10 p.m.

S15 Comparison of Standardized Uptake Values between PET/CT and PET/MR in Pediatric Lymphoma: A Prospective Study Whole Body MRI in children with Cancer Predisposition Syndromes The Role of Chest Computed Tomography (CT) as a Surveillance Tool in Children with Neuroblastoma

Scientific Session I-B: Gastrointestinal (concurrent) Michael J. Callahan, MD and Kristen Thomas, MD, Moderators Appendicitis: Trends in Diagnosis and Treatment from a Surgeon’s Perspective Daniel J. Ledbetter, MD Scientific Papers – Gastrointestinal

3:50 – 4:10 p.m. 4:10 – 5:10 p.m. Paper #: 007

4:10

Parekh

Paper #: 008 Paper #: 009

4:20 4:30

Dao Leschied

Paper #: 010

4:40

Bailey

4D-flow Imaging of the Portal Venous System in Children and Young Adults – A Feasibility Study Ultrasound as a definitive imaging predictor of midgut volvulus Inter-Radiologist Agreement for CT Scoring of Pediatric Splenic Injuries and Effect on an Established Clinical Practice Guideline Ultrasound Elastography for Diagnosis of Liver Disease in Obese Children

Paper #: 011 Paper #: 012

4:50 5:00

Orth Orth

Diagnostic performance and predictive findings of ultrasound for perforated pediatric appendicitis Searching for certainty: Findings predictive of appendicitis in equivocal ultrasound exams

5:10 p.m. 5:15 – 6:15 p.m. 6:15 – 7:30 p.m. Wednesday, April 29, 2015 6:45 – 8:00 a.m. 6:30 a.m. – 5:00 p.m. 7:00 – 8:20 a.m. 7:00 – 7:05 a.m. 7:05 – 7:20 a.m. 7:20 – 7:40 a.m. 7:40 – 8:00 a.m. 8:00 – 8:20 a.m.

7:00 – 7:05 a.m. 7:05 – 7:15 a.m. 7:15 – 7:20 a.m. 7:20 – 7:35 a.m. 7:35 – 7:50 a.m. 7:50 – 8:05 a.m. 8:05 – 8:20 a.m. 7:00 – 7:20 a.m.

Adjourn Awards Ceremony Gold Medalist, Pioneer Honoree, Presidential Recognition Award, Honorary Member Award, Singleton-Taybi Award, Heidi Patriquin Awards and Jack O. Haller Award Welcome Reception

Continental Breakfast Registration Sunrise Sessions (concurrent) TOOLS FOR PROCESS IMPROVEMENT: LEARNING THE ABCs Eva I. Rubio, MD, Moderator Introduction Introduction to QA/PI Terminology and Approaches Hedieh K. Eslamy, MD Concepts of High Reliability David B. Larson, MD, MBA Tools in QA/PI: What Works and What Doesn’t Eva I. Rubio, MD The Role of Leadership in QA/PI Lane F. Donnelly, MD CHILD ABUSE: IN THE COURTROOM Paul K. Kleinman, MD, FAAP, Moderator Introduction Child Abuse in the Courtroom: An Introduction to the Law Joelle Moreno, JD Child Abuse Pediatricians in Court Ken Feldman, MD, FAAP Course Case Vignettes Paul K. Kleinman, MD, FAAP Expert Witness in the Courtroom Stephen L. Done, MD Osteogenesis Imperfecta and Other Diseases Both True and Untrue Jerry R. Dwek, MD Discussion, Question and Answer CONTRAST-ENHANCED ULTRASOUND Kassa Darge, MD, PhD Safety of US Contrast Agents Kassa Darge, MD, PhD

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S16

7:20 – 7:40 a.m.

Contrast Enhanced Ultrasound in Pediatric Oncology M. Beth McCarville, MD Application of CEUS in Blunt Abdominal Trauma Harriet J. Paltiel, MD, CM Application of CEUS for Pediatric Inflammatory Bowel Disease Jonathan R. Dillman, MD Question and Answer

7:40 – 8:00 a.m. 8:00 – 8:15 a.m. 8:15 – 8:20 a.m.

IMAGE GENTLY: UPDATE ON RADIATION DOSE RECORDING, REPORTING AND MONITORING: MEANINGFUL USE OR USELESS MEANING? Donald P. Frush, MD, FACR, Moderator Update on Radiation Dose Analytics: Meaningful Use or Useless Meaning? Introduction Donald P. Frush, MD, FACR General Dose Metrics Keith J. Strauss, MSc, FAAPM, FACR Modality Dose Estimation Metrics CT Keith J. Strauss, MSc, FAAPM, FACR New Digital Radiography Exposure Indicators and ACR Dose Index Registry for Digital Radiography Steven Don, MD Fluoroscopy Marta Hernanz-Schulman, MD, FACR, FAAP Interventional Radiology Bairbre Connolly, MD Radiation exposures in Pediatric Nuclear Medicine and Molecular Imaging Updates - S. Ted Treves, MD Risk Benefit Communication R. Paul Guillerman, MD Question and Answer PEDIATRIC THORACIC IMAGING Edward Y. Lee, MD, MPH and Beverley Newman, MBBCH, FACR, Moderators How to Deal with Breathing Motion Artefact and Atelectasis in Pediatric Chest CT Beverley Newman, MBBCH, FACR How to Do and Interpret CT for Interstitial Lung Disease in Childhood Alan S. Brody, MD How to Address the Incidental Pulmonary Nodule in a Child Sjirk J. Westra, MD When and How to Do Non-Cardiovascular Chest MRI in Children Edward Y. Lee, MD, MPH How and When to Use Chest Ultrasound in Children Monica Epelman, MD Question and Answer Scientific Session II-A: Fetal/Neonatal (concurrent) Erika Rubesova, MD and Eva I. Rubio, MD, Moderators Evidenced Based Value of Fetal MRI Edith Y. Cheng, MD, MS Scientific Papers – Fetal/Neonatal

7:00 – 7:10 a.m. 7:10 – 7:15 a.m. 7:15 – 7:23 a.m. 7:23 – 7:31 a.m. 7:31 – 7:39 a.m. 7:39 – 7:47 a.m. 7:47 – 7:55 a.m. 7:55 – 8:10 a.m. 8:10 – 8:20 a.m. 7:00 – 8:20 a.m. 7:00 – 7:12 a.m. 7:12 – 7:24 a.m. 7:24 – 7:36 a.m. 7:36 – 7:48 a.m. 7:48 – 8:00 a.m. 8:00 – 8:20 a.m. 8:30 – 10:40 a.m. 8:30 – 8:50 a.m. 8:50 – 10:40 a.m. Paper #: 013

8:50

Basta

Paper #: 014 Paper #: 015 Paper #: 016

9:00 9:10 9:20

Estroff Estroff Starr

Paper #: 017 Paper #: 018

9:30 9:40

Hughes Ponrartana

Paper #: 019 Paper #: 020 Paper #: 021 Paper #: 022

9:50 10:00 10:10 10:20

Rubesova Garel Barnewolt Saul

Paper #: 023

10:30

Neelavalli

Fetal stomach position predicts neonatal outcomes in isolated left-sided congenital diaphragmatic hernia Normative biometrics for fetal ocular growth using volumetric MRI reconstruction Correlation of fetal cerebellar measurements on US and MRI Placenta Accreta: Critical Diagnosis for the Pregnant Patient and Challenging Diagnosis for the Pediatric Radiologist Morbidly Adherent Placenta: An Imaging Score to Improve Antenatal Diagnostic Accuracy Sex-related Differences in the Fetal Programming of the Axial Skeleton Fetal Skeletal Development using Ultrasound Imaging Fetal bronchocele: imaging features and significance Choledochal Cyst in the Fetus: Can we make and accurate diagnosis and what does it mean? Hypoplastic Left Heart Syndrome and the Nutmeg Lung Pattern in Utero: Cause and Effect Relationship or Prognostic Indicator? In vivo Magnetic Resonance Angiography of fetal vasculature

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

8:30 – 10:40 a.m.

Scientific Session II-B: Cardiovascular (concurrent) Rajesh Krishnamurthy, MD and Daniel Wallihan, MD, Moderators Cardiac Imaging and Decision Making: A Surgeon’s Perspective Jonathan M. Chen, MD Scientific Papers – Cardiovascular

8:30 – 8:50 a.m. 8:50 – 10:40 a.m. Paper #: 024 Paper #: 025

S17

8:50 9:00

Paper #: 026 9:10

Golriz Bahouth

Appiawiah

Paper #: 027

9:20

Noel

Paper #: 028

9:30

Krishnamurthy

Paper #: 029

9:40

Krishnamurthy

Paper #: 030 Paper #: 031

9:50 10:00

Vasanawala Lyons

Paper #: 032

10:10

Bardo

Paper #: 033

10:20

Botelho

Paper #: 034

10:30

Ali

8:30 – 10:40 a.m.

Left main-stem bronchus compression after aortic arch Reconstruction Use of CT and MR in Neonatal and Infantile Congenital Heart Disease: Change in Practice Patterns with Advent of New Generation CT Scanner. The role of stress perfusion cardiac MRI in the evaluation of pediatric patients with suspected coronary arterial abnormalities Regadenoson as a Pharmacologic Stressor in Cardiac Magnetic Resonance Imaging in Congenital and Acquired Pediatric Heart Disease: Initial Experience Accurate Quantification of Cardiac Biomechanics in Pediatric population: Respiratory Triggered High Temporal Resolution (RT-HTR) Myocardial Tagging in Cardiac MRI Prospective Evaluation of Circumferential and Longitudinal Strain in Asymptomatic Children with Dual Ventricles who underwent Single Ventricle repair: comparison to Single LV, Single RV and Normal Hearts Freebreathing Cardiovascular MRI with Ferumoxytol Comparison of Respiratory-Triggered (RT) 3D Cine Steady-State Free Precession Cardiac MRI with Standard 2D Cine Imaging and Magnetic Resonance Angiography in Congenital Heart Disease (CHD) Pseudo ECG-gating: a new technique to achieve axial scan mode for dose reduction in cardiac CT Accelerated segmented and real-time aortic flow sequences compared with standard 2D phase contrast MR in children The pitfall of gadofosveset trisodium associated paradoxical negative enhancement on MR steady-state imaging in an animal model

Scientific Session II-C: ALARA (concurrent) Steven Don, MD and Keith J. Strauss, MSc, FAAPM, FACR, Moderators Image Gently: Where We’ve Benn and Where We’re Going Donald P. Frush, MD, FACR Scientific Papers – ALARA

8:30 – 8:50 a.m. 8:50 – 10:40 a.m. Paper #: 035

8:50

Rao

Paper #: 036

9:00

Creeden

Paper #: 037 Paper #: 038 Paper #: 039

9:10 9:20 9:30

Kaplan Goerner Baad

Paper #: 040 Paper #: 041

9:40 9:50

Parikh Phelps

Paper #: 042

10:00

Infante

Paper #: 043

10:10

Martinez-Rios

Paper #: 044

10:20

Parikh

Snapshot of radiation exposure contribution of scout abdomen radiograph in common pediatric fluoroscopic procedures. Pre-procedural scout radiographs may be unnecessary for routine pediatric fluoroscopic examinations. Lead Gonad Shields: Good or Bad for Patient Radiation Exposure? Table top Fluoroscopy: To Shield or Not to Shield Effect of comfort pads and incubator design on radiation dose and image quality of chest radiographs in neonates. Radiation Dose Reduction by Indication Directed Focused z-Direction Coverage for Neck CTs Pediatric Chest CT at Chest Radiograph Doses: When is the ultralow-dose chest CT clinically appropriate? Image quality in sinogram affirmed iterative reconstruction (SAFIRE) at low doses – is there a point of diminishing returns? Diagnostic Accuracy of Computed Tomography (CT) using Knowledge-based Iterative Reconstruction (KIR) versus Hybrid Iterative Reconstruction (HIR) in Combination with Reduced Tube Voltage (kV) for the Diagnosis of Acute Appendicitis in Children. Academic Pediatric versus Community General Radiologist Preference and Performance using Reduced Tube Voltage and Hybrid Iterative Reconstruction Protocols in Pediatric Abdominal CT for Appendicitis

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S18 Paper #: 035

8:50

Rao

Paper #: 045

10:30

Buchmann

10:40 – 11:00 a.m. 11:00 a.m. -12:00 p.m.

Snapshot of radiation exposure contribution of scout abdomen radiograph in common pediatric fluoroscopic procedures. Image gently lessons for community hospitals performing pediatric abdomen and pelvis computed tomography

11:20 a.m. – 12:00 p.m.

Break & Exhibits Scientific Session III-A: Public Policy, Healthcare, Education, Technology (concurrent) Richard E. Heller, III, MD, MBA and David B. Larson, MD, MBA, Moderators Adult Learning Mahesh M. Thapa, MD Scientific Papers - Public Policy, Healthcare, Education, Technology

Paper #: 046 Paper #: 047

11:20 11:30

Fefferman Reid

Paper #: 048

11:40

Nicholas

Paper #: 049

11:50

Zewdneh

11:00 – 11:20 a.m.

11:00 a.m. -12:00 p.m.

Virtual radiology rounds: Adding value in the digital era Learning, Technology and Intellectual Property: A Survey of the Philosophies and Practice of our Trainees and Peers Flipping the Classroom: Preparing Radiology Residents for Independent Pediatric Radiology Call Using the iPad Ultrasound Tutorials in Under 10: The Addis Ababa Experience

11:20 a.m. – 12:00 p.m.

Scientific Session III-B: Genitourinary (concurrent) Michael Riccabona, MD and Damien Grattan-Smith, MBBS, Moderators Is There a Role for MR Urography Without Quantitative Functional Analysis? Damien Grattan-Smith, MBBS Scientific Papers – Genitourinary

Paper #: 050 Paper #: 051

11:20 11:30

Chu Grattan-Smith

Paper #: 052 Paper #: 053

11:40 11:50

Bedoya Bedoya

11:00 – 11:20 a.m.

12:00 – 1:30 p.m. 12:00 – 1:30 p.m. 12:00 – 1:30 p.m.

Renal iron deposition in pediatric anemia: comparison of sickle and non-sickle groups MR Urography and the Mean Transit Time in the evaluation of hydronephrosis in children Renal Diffusion Weighted MR Imaging in Children with Pelvicalyceal Dilation Can we reproduce the age dependency of the ADC values in patients with various urological abnormalities undergoing functional MR urography?

Lunch On Your Own jSPR Luncheon (advanced registration required) CT Protocol Session (attendance is limited; first come-first serve basis) Michael J. Callahan, MD, Sheila Berlin, MD and Keith J. Strauss, MSc, FAAPM, FACR, Moderators Supported by GE Healthcare, Philips Healthcare, Siemens Healthcare and Toshiba America Medical Systems Scientific Session IV-A : Gastrointestinal (concurrent) Gregory Bates, MD and Ethan A. Smith, MD, Moderators Current Issues and Inflammatory Bowel Disease Ghassan Wahbeh, MD Scientific Papers – Gastrointestinal

1:30 – 3:40 p.m. 1:30 – 1:50 p.m. 1:50 – 3:40 p.m. Paper #: 054 Paper #: 055 Paper #: 056

1:50 2:00 2:10

Orscheln Swenson Trout

Paper #: 057

2:20

Dillman

Paper #: 058

2:30

Bernbeck

Paper #: 059

2:40

Shin

Paper #: 060

2:50

Phelps

Paper #: 061 Paper #: 062

3:00 3:10

Starr Mollard

Appendiceal diameter: Are CT and sonographic measurements interchangeable? MRI Findings of the Normal Appendix in Children: New Reference Standard MR as a rapid secondary assessment for suspected appendicitis following equivocal sonography: Feasibility and patient preference assessment Implementation of a Rapid Noncontrast MRI Protocol for Use in Children with Equivocal Appendicitis: a Clinical Effectiveness Study Diffusion and Post Contrast MRI for Evaluation of Acute Appendicitis: The Stanford Experience Comparison of Shear Wave Velocities on Ultrasound Elastography between Different Machines and Acquisition Depths ; A Phantom Study Quantitative Ultrasound Elastography for Pediatric Liver Disease: Can shear wave speed be reliably estimated from a single image? Shear wave Elastography (SWE) of the normal and fibrotic pediatric liver MR Enterography (MRE) Under the Age of 10 Years

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 Paper #: 054 Paper #: 063

1:50 3:20

Orscheln Ehman

Paper #: 064

3:30

Schweiger

1:30 – 3:40 p.m.

S19 Appendiceal diameter: Are CT and sonographic measurements interchangeable? Fused Color Map Diffusion Weighted and T2 Images versus Contrast Enhanced Imaging for the Detection of Path-Proven Bowel Inflammation in Pediatric MR Enterography MR colonography with diffusion weighted imaging (DWI) in children and adolescents with inflammatory bowel disease (IBD): Do we really need intravenous contrast?

Scientific Session IV-B: Chest (concurrent) Jason Weinman, MD and Edward Y. Lee, MD, MPH, Moderators Update on ChILD R. Paul Guillerman, MD Scientific Papers – Chest

1:30 – 1:50 p.m. 1:50 – 3:40 p.m. Paper #: 065 Paper #: 066

1:50 2:00

Crowe Choi

Paper #: 067

2:10

Martinez-Rios

Paper #: 068 Paper #: 069 Paper #: 070

2:20 2:30 2:40

Stein Singh Yu

Paper #: 071

2:50

Manning

Paper #: 072

3:00

Chan

Paper #: 073 Paper #: 074

3:10 3:20

Dodd Lyons

Paper #: 075

3:30

Clarke

3:40 – 4:00 p.m. 4:00 – 5:30 p.m.

The Elusive Right Aortic Arch Comparison of Image Quality and Radiation Dose between High-Pitch and Low-Pitch Spiral Chest CT in Young Children Knowledge-based Iterative Reconstruction versus Hybrid Iterative Reconstruction: Effect on Image Quality and Diagnostic Confidence in Reduced kV Pediatric Oncologic Chest CT. CT characterization of normal pediatric lung parenchymal density Hyperinflation of the left anterior basal segment: a new sign of pectus excavatum severity A Retrospective Review of Pulmonary Hemorrhage in Neonatal Respiratory Distress Syndrome - imaging, course, complications, and long term outcomes High Resolution Computed Tomography of Follicular Bronchiolitis in the Pediatric Population, a 5 Year Review of Imaging Findings with Pathologic Correlation Pediatric Aspirated Foreign Body: Adding digital tomosynthesis improves sensitivity compared to conventional radiographs Dynamic Volume CTA of the Airway and Vasculature in Children: Technical Report Low-dose free breathing dynamic volume CT Angiography in the evaluation of innominate artery compression of the trachea. Safe Performance of MRI in Children with Active Cardiac Devices

Break & Exhibits Scientific Session V-A: Musculoskeletal (concurrent) Sarah D. Bixby, MD and Peter J. Strouse, MD, FACR, Moderators Future Directions in Hip Imaging Sarah D. Bixby, MD Scientific Papers – Musculoskeletal

4:00 – 4:20 p.m. 4:20 – 5:30 p.m. Paper #: 076

4:20

Breen

Bone Age Assessment Practices Among SPR Members: Infants Are Not Just Little Children.

Paper #: 077

4:30

Bulman

Paper #: 078 Paper #: 079

4:40 4:50

Jaremko Jaremko

Paper #: 080 Paper #: 081 Paper #: 082

5:00 5:10 5:20

Breen Bixby Chauvin

Pilomatricoma: A Common Clinical and Pathological Entity, yet a Rare Radiological Diagnosis Beyond the central slice: spectrum of 3D ultrasound appearances in normal and dysplastic hips. Inter-scan fidelity of 3D acetabular surface models generated from 3D ultrasound for infant hip dysplasia. Imaging Findings and Clinical Outcomes in Traumatic Hip Dislocation in Pediatric Patients. Osteoid Osteoma of the Hip in Pediatric Patients Detection of Inflammatory Sacroiliitis in Children: Is MR contrast necessary?

4:00 – 5:30 p.m.

Scientific Session V-B: Genitourinary (concurrent) Jonathan R. Dillman, MD and Jeanne S. Chow, MD, Moderators Current Imaging Management of UTI and Future Trends Randolph K. Otto, MD Scientific Papers – Genitourinary

4:00 – 4:20 p.m. 4:20 – 5:30 p.m. Paper #: 083

4:20

Parad

Normal Sonographic Renal Length and Growth in Children without Vesicoureteral Reflux (VUR)

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S20 Paper #: 083 Paper #: 084

4:20 4:30

Parad O’Hara

Paper #: 085

4:40

Darge

Paper #: 086

4:50

Thacker

Paper #: 087

5:00

Towbin

Paper #: 088 Paper #: 089

5:10 5:20

Phewplung Bruno

5:30 p.m. Thursday, April 30, 2015 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. 7:10 – 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. 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 – 7:20 a.m. 7:20 – 7:40 a.m. 7:40 – 8:00 a.m. 8:00 – 8:20 a.m. 8:30 – 10:50 a.m.

Normal Sonographic Renal Length and Growth in Children without Vesicoureteral Reflux (VUR) Feasibility of superb microvascular imaging (SMI), an advanced noninvasive US technique to detect vesicoureteral reflux in pediatric patients without bladder catheterization or contrast use. Contrast Enhanced Voiding Urosonography With Intravesical Administration of Ultrasound Contrast Agent (Optison®) for Vesicoureteral Reflux Detection in Children: regulatory processes, procedural optimization and preliminary safety results Distress during voiding cystourethrograms: objective assessment using the brief behavioral distress scale Does internal complexity predict malignancy in cyctic adnexal lesions in pediatric and adolescent females? Clinical significance of incidentally discovered renal cysts in pediatric patients ARFI Evaluation of the Kidneys in Ex Premature Infants: A Preliminary Study

Adjourn Continental Breakfast Registration Sunrise Sessions (concurrent) WORKSHOP FOR PROCESS IMPROVEMENT Eva I. Rubio, MD, Moderator David B. Larson, MD, MBA and Hedieh K. Eslamy, MD, Speakers Introduction and Explanation of the Workshop A theoretical problem with a department of radiology will be provided. The moderator-led discussion will allow the audience to define/frame the problem, the goal for improvement, the factors to measure and appropriate tools for metric assessment and for achieving goals. REVIEWING FOR PEDIATRIC RADIOLOGY Peter J. Strouse, MD, FACR, Moderator Introduction: Overview of the Review Process Peter J. Strouse, MD, FACR Reviewing for Pediatric Radiology - Evaluation of a Manuscript Geetika Khanna, MD, MS and Cynthia K. Rigsby, MD, FACR From a Reviewer’s Perspective: How I Approach a Review Ethan A. Smith, MD What Happens After Review: How to Make Your Reviews Most Helpful to the Editors Peter J. Strouse, MD, FACR Question and Answer PROFESSIONALISM IN PEDIATRIC RADIOLOGY Stephen D. Brown, MD, Moderator Professionalism in Modern Healthcare Anastasia L. Hryhorczuk, MD Error Disclosure in Radiology: Background, Rationale, and Process Considerations Stephen D. Brown, MD Developing Professionalism in Radiology Training Brandon P. Brown, MD, MA Question and Answer FETAL IMAGING: TRICKS OF THE TRADE Erika Rubesova, MD, Moderator Fetal Lung Volume Measurements - Why, When & How? Amy R. Mehollin-Ray, MD Fetal Echogeniticies - Ultrasound and MRI Mariana L. Meyers, MD Congenital Diaphragmatic Hernia Christopher I. Cassady, MD, FAAP Question and Answer INITIATIVES OF THE ACR COMMISSION AND THE ABR ACR Initiatives Marta Hernanz-Schulman, MD, FACR, FAAP ABR Initiatives Lane F. Donnelly, MD New Horizons in Pediatric Imagin Heike E. Daldrup-Link, MD, PhD Question and Answer Scientific Session VI-A: Interventional Radiology/Gastrointestinal (concurrent) Leah Braswell, MD and Mark J. Hogan, MD, FSIR Moderators

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

8:30 – 8:50 a.m.

S21

Interventional Oncology Siddharth Padia, MD Scientific Papers – Interventional Radiology/Gastrointestinal

8:50 – 10:50 a.m. Paper #: 090 Paper #: 091 Paper #: 092 Paper #: 093

8:50 9:00 9:10 9:20

Yang Mahboubi Simmons Patel

Paper #: 094

9:30

Teplisky

Paper #: 095 Paper #: 096

9:40 9:50

Keller Shellikeri

Paper #: 097

10:00

Moudgil

Paper #: 098 Paper #: 099

10:10 10:20

Patel Pugmire

Paper #: 100 Paper #: 101

10:30 10:40

Connolly Shellikeri

8:30 – 10:50 a.m.

Intussusceptions occurring less than 6 months of age: An observational study. Failed intussusception reduction in children: Radiologic, surgical and pathologic correlation A Double Balloon Catheter for the Treatment of Intussusception Quality and Readability of Online Patient Information Regarding Sclerotherapy for Venous Malformations Ultrasound, clinical and cholangiographic findings correlation of biliary complications in pediatric liver transplant recipients Plastic Bronchitis Imaging and Intervention: Early Experience Embolization of intracranial arteriovenous malformations is associated with faster rate of perfusion in the peri-nidal region on color-coded quantitative digital subtraction angiography. Diagnostic Utility of Ultrasound-guided Fine Needle Aspiration Biopsy in the Evaluation of Pediatric Thyroid Nodules Experience with Stuck Implantable Venous Port Catheters in Children Percutaneous abscess drainage in young patients with Crohn’s Disease: its role and predictors of treatment success. Pediatric percutaneous nephrostomy – a Multi-Center Experience. Quantification and comparison of renal perfusion in percutaneous renal angioplasty patients with Renal Artery Stenosis and control group using syngo iFlow at a single Pediatric Institution.

Scientific Session VI-B: Musculoskeletal (concurrent) Arthur Meyers, MD and Jerry R. Dwek, MD, Moderators Future Impact of Adolescent Sports Injuries and How Pediatric Radiologists Can Help Mitigate Long Term Effect of Sports Activity When Skeletally Immature Jerry R. Dwek, MD Scientific Papers – Musculoskeletal

8:30 – 8:50 a.m. 8:50 – 10:50 a.m. Paper #: 102

8:50

Winfeld

Paper #: 103

9:00

Kassis

Paper #: 104

9:10

Chauvin

Paper #: 105

9:20

Radhakrishnan

Paper #: 106 Paper #: 107

9:30 9:40

Eutsler Winfeld

Paper #: 108

9:50

Bao

Paper #: 109

10:00

Swenson

Paper #: 110

10:10

Bedoya

Paper #: 111

10:20

Kim

Paper #: 112 Paper #: 113

10:30 10:40

Francavilla Delgado

10:50 – 11:10 a.m. 11:10 a.m. -12:30 p.m.

Differentiating os acromiale from normal developing acromial ossification center using magnetic resonance imaging Evaluation of Pediatric Long Bone Tumors with a single 3D T2-Weighted Fat-Water Separated Sequence Articular Cartilage Changes within the Medial Femoral Condyle in Obese Children As Compared to Normal Weight Children Characteristic MR imaging findings in patients with cold exposure – making a case for phalangeal microgeodic disease Localized Scleroderma in Children: Musculoskeletal MRI Findings Utilization of chemical shift MRI in the diagnosis of disorders affecting pediatric bone marrow Can bone marrow edema serve as a predictive biomarker for bone collapse in patients with corticosteroid-induced epiphyseal osteonecrosis? Chronic Avulsive Changes of the Inferior Patella in Children with Spastic Diplegia: Frequency and Imaging Appearance. Diffusion-Tensor Imaging and Tractography of the Knee in Children Reveals Changes in Physeal and Metaphyseal Architecture due to Age, Gender, and Height Patellofemoral instability (PFI) in children Part I: T2 relaxation time of the patellar cartilage in PFI, compare with patients without PFI and correlate with morphological grading of cartilage damage Diffusion tensor imaging of vastus muscle injury in children: preliminary data DTI of the femoral and tibial physes and metaphyses. Can it be done at 1.5T?

Break & Exhibits Scientific Session VII-A: Public Policy, Healthcare, Education, Technology (concurrent) Richard M. Benator, MD, FACR and C. Matthew Hawkins, MD, Moderators

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S22

11:10 – 11:30 a.m. 11:30 a.m. – 12:30 p.m.

A Pediatric Radiology Perspective on The Affordable Care Act Jonathan O. Swanson, MD Scientific Papers – Public Policy, Healthcare, Education, Technology

Paper #: 114

11:30

Pierce

Paper #: 115

11:40

Sharafinski

Paper #: 116

11:50

Goldfisher

Paper #: 117

12:00

Dasgupta

Paper #: 118 Paper #: 119

12:10 12:20

Greer Snow

11:10 a.m. -12:30 p.m.

Pre-authorization Processes Have No Effect on Outcomes in Pediatric Patients Undergoing Knee MRI Ordered by Pediatric Orthopedic Physicians. Pediatric Gastrojejunostomy Tube Replacement: Can Improved Communication Reduce Image Guided Procedures After Hours? Prospective Randomized Study of Utilizing Music Therapy For Reducing Patient Anxiety During Pediatric Ultrasound Utilization of Exposure Index for Dose Optimization in Pediatric Chest and Abdominal Radiography ED/Outpatient X-ray Request Form Audit (How to Make a Good Situation Better!) Assessing the quality of outside institution abdominal CTs performed for pediatric patients presenting to the emergency department of an academic children’s hospital.

11:30 a.m. – 12:30 p.m.

Scientific Session VII-B: Fetal/Neonatal (concurrent) Shawn E. Parnell, MD and Christopher I. Cassady, MD, FAAP, Moderators Fetal Neck Masses Christopher I. Cassady, MD, FAAP Scientific Papers – Fetal/Neonatal

Paper #: 120

11:30

Jones

Paper #: 121

11:40

Saul

Paper #: 122

11:50

Krishnamurthy

Paper #: 123

12:00

Meyers

Paper #: 124

12:10

Victoria

Paper #: 125

12:20

Jones

11:10 – 11:30 a.m.

12:30 – 1:45 p.m. 12:30 – 1:45 p.m. 1:45 – 3:55 p.m.

The inferior cavoatrial junction is located at the T8-T9 disc space level on CT: implications for umbilical venous catheter placement. Ultrasound for Central Vascular Catheter and Endotracheal Tube Position in the NICU A Pilot Study Macrocyclic gadobutrol – Pharmacokinetics, safety and efficacy evaluation of a body weighted standard dose in newborns, infants and toddlers <2 years of age in comparison to older populations. Effects of maternal Valium administration on fetal MRI motion artifact. A comparison study at high altitude. Comparison between 1.5T and 3T fetal imaging: Is there an advantage in imaging at higher field strength? Fetal imaging at 3T: whole fetal body EPI survey is a useful adjunct sequence

SPR Members’ Business Meeting & Lunch Lunch On Your Own Scientific Session VIII-A: Neuroradiology (concurrent) Susan Palasis, MD and Edward Weinberger, MD, Moderators Pediatric Stroke Catherine Amlie-Lefond, MD Scientific Papers – Neuroradiology

1:45 – 2:05 p.m. 2:05 – 3:55 p.m. Paper #: 126

2:05

Starosolski

Paper #: 127 Paper #: 128 Paper #: 129 Paper #: 130 Paper #: 131 Paper #: 132

2:15 2:25 2:35 2:45 2:55 3:05

Loomis Ruess Lindsay Ruess Speidel Stein

Paper #: 133

3:15

Tafti

Paper #: 134

3:25

Ahmed

Paper #: 135 Paper #: 136

3:35 3:45

Fenton Altinok

Cerebrovascular abnormalities in Acta2 knockout mice: a model for pediatric cerebrovascular disease associated with ACTA2 mutations ASL perfusion patterns reflects chronological rather than gestational age MRI Staging of Superficial Venous Thrombosis and Infarction in Children Cavernous Sinus Thrombosis in Children: Imaging Characteristics and Clinical Outcome Vein of Labbé Thrombosis and Infarction in Children MR of Infant Subdural Hemorrhage: Incidence, Etiology, and Imaging Differentiation Optimization of MR Enterography protocol: one or two doses of antiperistaltic agent? Magnetic Resonance Spectroscopy (MRS) in Infants with Non-accidental Mild Traumatic Brain Injury Sensitivity and specificity of lipid /lactate peaks on MR spectroscopy for prediction of grade in pediatric gliomas. MR Imaging Findings Associated with Poorer Outcome in Intracranial Ganglioglioma Utility of Diffusion Tensor Imaging for Language Lateralization prior to epilepsy surgery

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

1:45 – 3:55 p.m.

Scientific Session VIII-B: Oncology & Nuclear Medicine (concurrent) Susan E. Sharp, MD and Victor J. Seghers, MD, PhD, Moderators Quantitative Imaging in Assessing Tumor Treatment Response Adam M. Alessio, PhD Scientific Papers – Oncology & Nuclear Medicine

1:45 – 2:05 p.m. 2:05 – 3:55 p.m. Paper #: 137

2:05

Kaste

Paper #: 138

2:15

Martinez-Rios

Paper #: 139

2:25

Gelfand

Paper #: 140 Paper #: 141 Paper #: 142

2:35 2:45 2:55

Gupton Morani Mitchell

Paper #: 143 Paper #: 144 Paper #: 145

3:05 3:15 3:25

Plunk Plunk McCarville

Paper #: 146

3:35

Jones

Paper #: 147

3:45

Starosolski

3:55 – 4:15 p.m. 4:15 – 5:25 p.m.

Routine Imaging in Preparation for Bone Marrow Transplantation: Are abdominal CTs necessary? Knowledge-based Iterative Reconstruction vs Hybrid Iterative Reconstruction in Reduced kV Pediatric Body CT: Comparison of Image Quality and Reader Preference. Addition of SPECT/CT to Lymphoscintigraphy Facilitates Sentinel Node Localization in Pediatric Patients Is 18F-DOPA accurate in localizing insulinomas within the pancreas? Desmoplastic small round cell tumor: A comprehensive, single-institution study of 94 cases The Post-Radiation Quandary: Imaging Characteristics and Implications of Ewing Sarcoma treated only with Chemoradiation High frequency of hepatic vascular abnormalities in children with hepatoblastoma Do MRI imaging features predict tumor histology in hepatoblastoma? Contrast Enhanced Ultrasound in the Assessment of Pediatric Solid Tumor Response to Anti-Angiogenic Therapy Imaging Features of Neuroblastoma in Patients Presenting with Opsoclonus-Myoclonus Syndrome: a multi-institutional experience In Vivo Assessment of Nanotherapeutic Delivery to Neuroblastoma in Orthotopic Mouse Models

Break & Exhibits Scientific Session IX-A: Neuroradiology (concurrent) Dennis W. Shaw, MD and Maura Ryan, MD, Moderators Management of Congenital Inner Ear Anomalies David L. Horn, MD, MS Scientific Papers – Neuroradiology

4:15 – 4:35 p.m. 4:35 – 5:25 p.m. Paper #: 148

4:35

Tang

Paper #: 149 Paper #: 150 Paper #: 151

4:45 4:55 5:05

Grattan-Smith Wien Shin

Paper #: 152

5:15

Rozovsky

4:15 – 5:25 p.m.

Quantitative Analysis of Structural Abnormality of Semicircular Canals in Progressive and Non-progressive Adolescent Idiopathic Scoliosis using 3D Volumetric MRI Virtual Endoscopy of the Middle Ear The potential association among prematurity, cochlear hyperintensity, and hearing loss Brain Ultrasonographic Findings of Late-onset Circulatory Dysfunction Due to Adrenal Insufficiency in Preterm Infants with Gestational Age Less than 33 Weeks Can Ultrasound Replace X-Rays In The Evaluation Of Cranial Sutures?

Scientific Session IX-B: Interventional Radiology (concurrent) Matthew Lungren, MD and Manish Patel, DO, Moderators Treatment of Osteoid Osteomas Giridhar M. Shivaram, MD Scientific Papers – Interventional Radiology

4:15 – 4:35 p.m. 4:35 – 5:25 p.m. Paper #: 153

4:35

Pezeshkmehr

Paper #: 154

4:45

Rodriguez

Paper #: 155 Paper #: 156

4:55 5:05

Donegan Metz

Paper #: 157

5:15

Annam

5:25 p.m. 6:30 – 11:00 p.m.

S23

Adjourn Reception & Annual Banquet

Major joint arthrocentesis for suspected septic arthritis: validation of a multidisciplinary protocol. Utility of Image Guided Percutaneous Bone Biopsy in Diagnosis and Management of Osteomyelitis in Children Radiofrequency Ablation of Osteoid Osteomas in a Tertiary Pediatric Center Image-Guided Core Needle Biopsy of Soft Tissue Lesions in the Pediatric Population: Is it Adequate? Pediatric Interventional Radiology (PIR) Fellowship: The Need for Standardization and PIR Survey Implications for a Future Direction

S24

Friday, May 1, 2015 7:00 – 8:00 a.m. 7:00 a.m. – 12:00 p.m. 7:00 a.m. – 12:00 p.m.

8:00 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 – 9:45 a.m. 9:45 – 10:00 a.m. 10:00 – 10:30 a.m. 10:30 – 11:00 a.m. 11:00 – 11:30 a.m. 11:30 a.m.–12:00 p.m. 8:00 a.m. – 12:00 p.m. 8:00 – 8:10 a.m. 8:10 – 8:30 a.m. 8:30 – 8:50 a.m. 8:50 – 9:10 a.m. 9:10 – 9:30 a.m. 9:30 – 9:45 a.m. 9:45 – 11:00 a.m. 11:00 – 11:20 a.m. 11:20 – 11:35 a.m. 11:35 – 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 – 9:45 a.m. 9:45 – 10:00 a.m. 10:00 – 10:30 a.m. 10:30 – 11:00 a.m.

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

Continental Breakfast Registration US Protocol Session (attendance is limited; first come-first serve basis) Laura Z. Fenton, MD and Nancy A. Chauvin, MD, Moderators Supported by GE Healthcare, Philips Healthcare, Siemens Healthcare and Toshiba America Medical Systems SPECIAL CONCURRENT SESSIONS SPR POTPOURRI SESSION: CASE BASED LESSONS FROM THE EXPERTS (NON-SAM SESSION) R. Paul Guillerman, MD and Teresa Chapman, MD, MA, Moderators Thoracic Imaging R. Paul Guillerman, MD Thought-provoking Cases in Pediatric Thoracic Imagin Paul Thacker, MD Elusive Diagnoses in Pediatric Radiology James E. Crowe, MD Break Challenging Musculoskeletal Cases: The Good, the Bad and the Ugly Diego Jaramillo, MD, MPH Musculoskeletal Potpourri Sarah D. Bixby, MD Genitourinary Imaging Grace S. Phillips, MD Gastrointestinal Imaging Ellen Benya, MD 8TH ANNUAL SPR EDUCATION SUMMIT (NON-SAM SESSION) Arnold Carl Merrow, MD and Mahesh M. Thapa, MD, Moderators Introduction: What are you doing with those teaching files? Arnold Carl Merrow, MD Beyond Slideshows: Innovative Presentation Methods Mahesh M. Thapa, MD E-Publishing Mike L. Richardson, MD How to Create a Teaching Portfolio Angelisa Paladin, MD International Outreach in Pediatric Radiology Education Kassa Darge, MD, PhD Break Create Your Own iBook Workshop Hank Baskin, MD Educating from Peer Review Arta-Luana Stanescu, MD Coaching vs. Training David B. Larson, MD, MBA Deliberate Practic David B. Larson, MD, MBA Closing: A Call for Collaboration Arnold Carl Merrow, MD SPR NEURORADIOLOGY SESSION (SAM SESSION) Richard L. Robertson, MD and Dennis W. Shaw, MD, Moderators Neuro Session I BCH - Supratentorial Brain Malformations Edward C. Yang, MD, PhD Hindbrain Malformations Giselle E. Ishak, MD Inside Out: The Nature and Genetic Basis of Cortical and Subcortical Malformations William B. Dobyns, MD Discussion Break Neuro Session II Biology of Synostoses Michael L. Cunningham, MD Imaging of Craniosynostosis Susan Blaser, MD, FRCPC

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

11:00 a.m. – 11:45 a.m. 11:45 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 – 9:40 a.m. 9:40 – 9:55 a.m. 9:55 – 10:30 a.m. 10:30 – 11:00 a.m. 11:00 – 11:15 a.m. 11:15 – 11:30 a.m. 11:30 – 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 – 9:15 a.m. 9:15 – 10:30 a.m. 10:30 – 10:45 a.m. 10:45 a.m. – 12:00 p.m. 12:00 p.m.

S25

Surgical Considerations in Synostosis Richard A. Hopper, MD Discussion SPR NUCELAR MEDICINE SESSION (SAM SESSION) Marguerite T. Parisi, MD, MS and Susan E. Sharp, MD, Moderators Dose Reduction Strategies for SPECT/CT and PET/CT Adam M. Alessio, PhD SPECT/CT: Musculoskeletal Applications Andrew T. Trout, MD SPECT/CT: Oncologic Applications Susan E. Sharp, MD and Michael Gelfand, MD Break PET/CT in Oncology: Usual and Unusual Tumors Helen R. Nadel, MD PET in Epilepsy: The Added Value of MR Jason Nixon, MD PET/MR: Oncologic Applications MR Protocols Matthew J. Goette, PhD Feasibility of FDOPA-PET/MRI for Monitoring Response to Bevacizumab Therapy for Recurrent Pediatric Brain Tumors Ephraim E. Parent, MD, PhD PET/MR: Pediatric Solid Tumors Victor J. Seghers, MD, PhD Sequential Versus Simultaneous PET/MR Scanners: Advantages and Disadvantages; Managing Workflow Matthew J. Goette, PhD, Victor J. Seghers, MD, PhD and Ephraim E. Parent, MD, PhD Questions and Answers SPR INTERVENTIONAL RADIOLOGY SESSIONS (SAM SESSION) Manish Patel, DO, Moderator Block ‘Em: Hepatic, Splenic, and Gastrointestinal Embolization Carrie M. Schaefer, MD Embolization of Renal Angiomyolipoma John M. Racadio, MD Pulmonary Embolization Mark J. Hogan, MD, FSIR Break Embolization for Traumatic Injuries Gulraiz Chaudry, MBChB, MRCP, FRCR Liver Embolization, TACE/Y90 Kamlesh U. Kukreja, MD Interentional Case Club HANDS-ON ULTRASOUND SESSION (NON-SAM SESSION) (advanced registration required; attendance is limited) Laura Z. Fenton, MD and Jenny McBroom, RT, RDMS, Moderators Appendicitis US Mark R. Ferguson, MD and Jenny McBroom, RT, RDMS Hip US Pearls and Pitfalls Michael A. DiPietro, MD Break Ultrasound of the Pediatric Shoulder and Elbow Mahesh M. Thapa, MD All Friday Sessions Adjourn

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S26

SCIENTIFIC EXHIBITS/POSTERS Case Reports CR-001 CR-002 CR-003 CR-004 CR-005 CR-006 CR-007

Tun Medsinge Khanna Sreedher Donatelli Fagen Hull

CR-008 CR-009 CR-010 CR-011 CR-012 CR-013 CR-014 CR-015 CR-016

Dickson Cornejo Verdoorn Biyyam Dasari Jones Bacon Lim Ketwaroo

CR-017 CR-018 CR-019 CR-020

Zandieh Lay Sreedher Cornejo

CR-021

Thacker

CR-022

O’Dell

CR-023 CR-024 CR-025

Nguyen van Schuppen Ayyala

CR-026

Savage

CR-027 CR-028 CR-029 CR-030 CR-031 CR-032 CR-033 CR-034 CR-035

Sato Burton Eklund Yang Akyol Aria Withdrawn Mack Kousari

CR-036 CR-037

O’Dell O’Dell

CR-038 CR-039 CR-040

O’Dell Thomas Paddock

CR-041

Akyol

Testicular Torsion: A Case of Mistaken Identity MRI findings in an isolated non- apical congenital left ventricular diverticulum Paraneoplastic anti-NMDA recepector encephalitis associated with ovarian teratoma: A case report. Fetal sub cortical cysts during second trimester : a harbinger of cortical malformation? Glutaric Aciduria Type 1: A Rare Inherited Disorder - A case report in a 4 year-old female Achondroplasia in the Premature Infant: An Elusive Diagnosis in the Neonatal ICU 3D Printing of Anatomic Models for Pre-Operative Planning in Children with Scoliosis due to Vertebral Anomalies Be Wary of the Round Gastric Bubble in Children with Asplenia Malignant Ectomesenchymoma of the Scalp A Rare Case of Lupus Leukoencephalopathy: Review of MRI findings and Differential Diagnosis MRI appearance of Scurvy: Report of 4 cases Exploring the Void: Uncommon Findings on Voiding Cystourethrograms Imaging evaluation of acute iatrogenic intramural duodenal hematoma after endoscopic biopsy. Case Report: Complete Bladder Duplication and Lung Sequestration Supplied by Celiac Artery Barth Syndrome in the adolescent and adult Fetal Brain MRI in Thanatophoric Dysplasia Congenital Portocaval Shunt: A Rare Entity Spontaneous rupture of a Type I choledochal cyst in an infant. A rare complication with multimodality evaluation. Pulmonary Arterio Venous Fistulas in Pleuropulmonary Blastoma: A Report of Two Cases Periostitis Secondary to Prolonged Voriconazole Therapy in a Child with Lung Transplantation for Cystic Fibrosis. MRI-guided biopsy of a femoral cartilaginous epiphyseal lesion in a child Adrenal cortical hyperplasia with cytomegaly in Beckwith-Wiedemann syndrome: a multi-modality radiologicalpathological correlation. Splenogonadal Fusion Mimicking a Supernumerary Testis: Ultrasound and MR Features Piriform sinus fistula as cause for suppurative thyroiditis, “Not always left sided…” Imaging Findings of Calcineurin-Inhibitor Induced Pain Syndrome (CIPS) after Bone Marrow Transplant in a Child with Beta Thalassemia Major. A Case Of Bow Hunter Syndrome: Bilateral Rotational Extrinsic Compression-Related Vertebrobasilar Insufficiency Presenting As Recurrent Stroke In A Young Child. Evolution of an Unusual Shrinking T2-Dark Skull Lesion: Calvarial Desmoplastic Fibroma Primary Muscle Lymphoma: Imaging suggests a clinically unsuspected diagnosis Atypical accessory intraparietal sutures mimicking fractures A Unique Case of Ruptured Appendicitis with Fecalith Migration causing Lung Abscess. Syntelecephaly: Review of two cases in children with additional associated findings. Unique Positioning for CT Cisternography of Suspected CSF Leak: A Case Report Ancient Naval Disease Making a Comeback? A Case Report and Review of the Unique MRI Findings of Scurvy Twist and Shout! Imaging findings in isolated fallopian tube torsion, an unusual cause for severe abdominal pain in pediatric girls Aneurysmal Bone Cyst of Atlas Treated with Preoperative Embolization and Intraoperative MR Guided Excision Massive Torsed Hemorrhagic Ovarian Follicular Cyst Presenting as Palpable Abdominal Mass in an Anemic Neonate Neuroimaging Features of Haberland’s Syndrome TITLE: Pediatric case presentation of schwannomatosis, a rare but distinct form of neurofibromatosis. Traumatic celiac artery dissection in an adolescent diagnosed using a computed tomography split bolus “Afghan” technique. Intradiploic pseudomeningocele

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 CR-001 CR-042 CR-043 CR-044 CR-045

Tun Tu Hayes Wilson Saul

CR-046

Bourm

CR-047 CR-048 CR-049 CR-050 CR-051 CR-052 CR-053 CR-054 CR-055 CR-056 CR-057

Delumpa Bittman Wood Nakamura Nakamura Cornejo Ayyala Sheridan Bittman Bittman Medsinge

CR-058 CR-059 CR-060 CR-061 CR-062 CR-063

Weatherspoon Dhatt Al-Busaidi Sharma Martin Chand

CR-064 CR-065 CR-066 CR-067 CR-068 CR-069 CR-070

Acomb Williams Scrugham Gnesda Deraney Patel Noel

S27

Testicular Torsion: A Case of Mistaken Identity Duodenal intussusception secondary to web presenting as recurrent pancreatitis in a 7-year-old girl Indolent Malignant PEComa Two Recent Cases of Menkes Kinky Hair Disease Be Aware and Beware: Marked Respiratory Motion Resulting In Displacement of Voxels Mimicking Renal Obstruction on Functional MR Urography Investigation of suspected VP-shunt-related pseudocyst reveals rare complication of distal shunt erosion into the small bowel Encephalocraniocutaneous lipomatosis - a rare neurocutaneous syndrome Rhabdomyosarcoma of the Cervix and Type 1 Pleuropulmonary Blastoma: a DICER 1 gene mutation Bilateral Ovary-Containing Inguinal Hernias in a Premature Infant. Febrile Infection-related Epilepsy Syndrome (FIRES): A Rare But Very Severe Epileptic Encephalopathy Familial Hepatic Veno-occlusive Disease with Immunodeficiency: A Unique Mutation in Sp110 Olfactory Groove Schwannoma. Case Report A Case of Prenatal Diagnosis of Frontonasal Dysplasia Acute Synthetic Opioid Cerebellitis in an Abused Infant Choriocarcinoma in an ectopic pregnancy Plexiform gastric schwannoma Congenital thoraco-abdominal extralobar sequestration (broncho-pulmonary foregut malformation-hybrid lesion): A diagnostic dilemma 15-year-old male with early nonspecific abdominal symptoms causes a delay in diagnosis of intussusception. Trichobezoar Causing Small Bowel Obstruction: Case Report Fetal Lung Interstitial Tumour (FLIT) Challenging Pediatric Splenic Hilum Cystic Lesions: A Case Report and Review of Management MRI evaluation of uterine mass-like lesions in pregnancy Endovascular Rescue of Malfunctioning Surgical Shunts Used in Treatment of Children with Portal Hypertension: Case Report and Review of Portal Vein Thrombosis Management in Children. Extrapulmonary Intra-Abdominal Pulmonary Sequestration-CPAM-Hybrid Lesion Trick or Treat: Neoplasms Masquerading as Infection Subclavian Steal Syndrome Meckel-Gruber Syndrome on Prenatal MRI: A Case Report Extrarenal Malignant Rhabdoid Tumor Chondroblastic Osteosarcoma with tumor thrombus, a case report of two pediatric patients. Dobutamine Stress Cardiac MRI for Assessment of Myocardial Perfusion in Pediatric Patients with a Diagnosis of Intramyocardial Coronary Course.

Educational Exhibits EDU-001 EDU-002 EDU-003 EDU-004 EDU-005 EDU-006

Smith Harris Parikh Thomas Kaplan-List Ranade

EDU-007 EDU-008

Carey Vincent-Sheldon

EDU-009 EDU-010 EDU-011 EDU-012 EDU-013 EDU-014

Mayercik Mitchell West Yam Cherny Thomas

The Pediatric Clavicle. Intrathecal Baclofen Pump Access and Evaluation: How To For The Pediatric Radiologist. Imaging Review of Caudate Nucleus Lesions in Children Ultrasound of the Acute Pediatric Scrotum Systematic Radiographic Evaluation of Patients with Tibial Hemimelia relevant to the orthopedic surgeon. Imaging the epiphyses and epiphyseal equivalents: Review of epiphyseal normal developmental variants and pathologic processes that occur in the pediatric patients. MR imaging of Congenital Spinal Anomalies in the Pediatric Population: Normal versus Abnormal. Atlantoaxial Rotatory Subluxation, Dislocation, and Fixation in the Pediatric Population: An Educational Review. Colonic Atresia: Expanding the classic differential for low intestinal obstruction in the neonate. Gasp! Fetal Imaging of Congenital Airway Anomalies Radiology of Disorders of Sex Development: Taking the Ambiguity out of Intersex Imaging The Pediatric Neurogenic Bladder: What the Radiologist Should Know The Utility of MR Urography to Characterize Morphology and Function of Pediatric Urinary Tract Abnormalities. Get Wise about Cracks: Pictorial review of pediatric skull base fractures, their resultant complications, and normal variant lucencies of the pediatric skull base.

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S28 EDU-001 EDU-015 EDU-016

Smith Ro Talmadge

EDU-017

Gnerre

EDU-018

Parekh

EDU-019 EDU-020 EDU-021 EDU-022

Brinkley Thakrar Wilson Podhaizer

EDU-023

Ortiz-Neira

EDU-024 EDU-025 EDU-026 EDU-027 EDU-028

Zahra Fagen Shet Zandieh Sato

EDU-029 EDU-030

Withdrawn Kolbe

EDU-031 EDU-032

Kosik May

EDU-033 EDU-034 EDU-035 EDU-036 EDU-037

Rajderkar Leschied Daugherty Kaplan Wien

EDU-038 EDU-039 EDU-040 EDU-041 EDU-042 EDU-043 EDU-044

Scace Lai Kadom Martinez Ayyala Baskin Gale

EDU-045 EDU-046 EDU-047 EDU-048 EDU-049

Davis Loomis Udayasankar Hegde Escudero

EDU-050

Back

EDU-051 EDU-052

Ruby Christy

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

Gelfand Sturgill Griggs Sharma Beydoun Withdrawn Fujikawa

The Pediatric Clavicle. The utility of MR imaging for evaluating the spectrum of pars injuries in the pediatric population. The lateral chest radiograph: An underused problem-solving tool for identification of malpositioned endovascular catheters. A History Lesson for Physicians: The Importance of Providing Accurate Clinical History for Pediatric Imaging Interpretation T1 Mapping in Children and Young Adults - A Virtual Myocardial Biopsy The True Double Bubble…and its imposters. Evaluation and interventional radiology management of prehepatic portal hypertension in children. Whole-Body MRI & DWI in Adolescents With Lymphoma Improving the Static: Overview of Neurosonography of Premature Neonates using High Resolution Images Bowel Characterization with clinical relevance in patients with Cystic Fibrosis. Ultrasound and Magnetic Resonance Enterography findings. Ultrasound-guided peripheral intravenous cannula placement in children; a pictorial review Head-to-Toe Prenatal Evaluation of Skeletal Dysplasias-Clues to Diagnosis and Outcome MRI Findings in Sickle Cell Disease: From Head to Toe NICU Catheter Crash Course: A Guide to Neonatal Vascular Catheters and their Potential Complications All that twists is not midgut: Imaging of non-midgut, pediatric gastrointestinal volvulus. Pediatric Meckel Diverticulum: Retrospective Review and Pictorial Essay of a Major Pediatric Center’s Experience Demystifying Abnormal Myelination Rapid MRI for Pediatric Appendicitis: Challenges, Tips, Pitfalls, and Lessons Learned from Implementation at a Large Combined Adult and Pediatric Academic Tertiary Medical Center Common and uncommon causes of Ventriculoperitoneal shunt malfunction diagnosed on plain radiographs. Suspected Acute Appendicitis in Children: MRI Appearances, Alternative Diagnoses, and Lessons Learned Pediatric Posterior Fossa Abnormalities: A Pictorial Review Key Imaging Findings in Median Arcuate Ligament Syndrome Fetal MRI of the Holoprosencephaly Spectrum Multimodal Review of Pediatric Vascular Variants: Rings and Slings Patient- and Parent-Facing Radiology Reports for the Pediatric Personalized Health Record Pediatric Lucent Lesions Of The Squamous Skull Pediatric Spectral Doppler Waveforms Simplified Review of Imaging Findings in Pediatric Patients with Auxilary Partial Orthotopic Liver Transplant (APOLT) Gray matter matters: Ultrasonography of migrational and organizational brain abnormalities Surgical intervention for children and young adults with sickle cell disease and femoral head osteonecrosis; a pictorial essay. Trauma and Transducers - Ultrasonography in the Setting of Pediatric Musculoskeletal Injury Spectrum of radiologic findings in Gorlin-Goltz syndrome Diaphragmatic Hernia Beyond the Neonatal Period: Imaging Findings Juxtacortical Lesions of the Bone: Beyond Scratching the Surface Take the 1 to the 5, then head to the VI, VII and VIII. A review of the major cranial nerve highways and accidents to look for in the pediatric population. Pictorial Overview of the Multidisciplinary Consensus on the Prenatal and Postnatal Urinary Tract Dilation Classification System Twist and Shout: Common and Unusual Cases of Intestinal Volvulus The Menacing Meckel’s Diverticulum. Applications of SPECT/CT in Pediatric Oncology and Infection MRI Spectrum of Deep Medullary Vein Anatomy and Pathology in Infants at 1.5 T and 3 T Who Knows the Pediatric Nose? Circling the Globe: A Review of Pediatric Orbital Pathology Pediatric Vasculitis: The Role of the Radiologist Through Case Review Abdominal cocoon syndrome in pediatric oncology patients; Looking for the “invisible” sac

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S29

EDU-001 EDU-060

Smith Wood

The Pediatric Clavicle. Central nervous system imaging after bone marrow transplantation in children: a review of complications with an emphasis on history and engraftment status.

EDU-061 EDU-062 EDU-063

Withdrawn Lay Pfeifer

EDU-064

Henault

EDU-065 EDU-066

Sato Downey

EDU-067

Griggs

EDU-068 EDU-069 EDU-070 EDU-071

Sharma Loewen Senasi Escudero

EDU-072 EDU-073 EDU-074

Ellenbogen Horsley Reid

EDU-075 EDU-076 EDU-077 EDU-078 EDU-079 EDU-080 EDU-081 EDU-082 EDU-083 EDU-084 EDU-085 EDU-086 EDU-087

McCullough Ayyala Bittman Kazmi Machnitz Arneja Miller Nakamura Kazmi Mody Dasari Kazmi Basta

EDU-088 EDU-089 EDU-090 EDU-091 EDU-092

Valeur Opfer Sheridan O’Dell Savage

EDU-093 EDU-094 EDU-095

Fujikawa Rosenberg Goldfisher

EDU-096 EDU-097 EDU-098 EDU-099 EDU-100 EDU-101 EDU-102

Stein Tong Morani Tong Sharma Epelman Pillai

A stitch in time saves radiation exposure: Scoliosis Radiographs With Stitching Artifact Result in Distortion of Anatomy Necessitating Further Imaging Studies. A Quality Improvement Project. Imaging Review of Pediatric Segmental Multicystic Dysplastic Kidney Not your father’s Lincoln penny: Xray-guided triage and management of ingested foreign objects in the 21st century Flaccid Paralysis and the Pediatric Patient: Differentiating Polio-like Viral Myelitis from other Spinal Cord Pathology Potpourri of Pediatric Port Problems Problem Solving in MRI: Use of Alternative Contrast Agents Different Pathological Appearances of the Large Bowel on Ultrasound A - Z Imaging Atlas to Pediatric Seizures: A compilation of epileptogenic entities and what the radiologist needs to know. Neonatal Gastrointestinal Emergency Imaging Torticollis: A Pain in the Neck Ultrasound Tutorials in Under 10: Tour of a Comprehensive Curriculum with Assessment for Hands On Ultrasound Skills Implementation of Dual-Energy Computed Tomography in Pediatric Imaging Fetal MRI of Hemimegalencephaly; A Report of 4 Cases Unusual Cancers of Childhood: Rare abdominopelvic and thoracic tumors A Spectrum of Pediatric Orbital Imaging: A Real Eye Opener The many faces of neurofibromatosis type I A Radiographic Review of Pediatric Sellar and Parasellar Lesions Neuromuscular Disorders:; How Radiologists Have Enabled Neurologists to Go Beyond “Diagnose and Adios” Interpretation Pitfalls When Imaging a Child For Headaches Imaging of Pediatric Spinal Abnormalities: Solving the Puzzle Imaging of fetal brain at 3 Tesla: Our Experience Danger as Cute as a Button: Radiographic Findings of Ingested Button Batteries Volvulus in Infants and Children: Unraveling the Twist Spleen behind the heart complicates lung-to-head ratio measurement in left-sided congenital diaphragmatic hernia A Rare Opening: Cervicothoracic Spinal Cystic Dysraphism Imaging of the Ductus Arteriosus: Review of Normal Anatomy, Variants and Clinical Implications Imaging Marrow Involvement in Gaucher Disease: MRI, Fat Fraction, and Bone Marrow Burden A Multi-modality Review of Normal Abdominal Anatomy in Situs Anomalies Adrenocortical Carcinoma In Children: Imaging Of A Rare Adrenal Tumour And Experiences In The Role Of Fludeoxyglucose Positron Emission Tomography (FDG-PET CT) In Staging and Follow Up. Dynamic CT imaging for pediatric upper airway examination Pitfalls and Practical Challenges in Imaging of the Pediatric Scrotum BROWN BEAR, BROWN BEAR, WHAT DO YOU SEE? : ANIMAL INSPIRED SIGNS IN PEDIATRIC IMAGING Ryan Braun MD, Rachelle Goldfisher MD and John Amodio MD Do you remember Retrograde Ureteropyelogram? When Water Stops Flowing: Diffusion Weighted Imaging in Pediatric Tumors. Benign and Malignant Abnormalities of the Pediatric Peritoneal Cavity (including mesentery, and omentum) Unraveling Coronary Artery Anomalies: Investigation of Anatomy, Diagnosis, and Management. Imaging Atlas of Non-Accidental Trauma of the Neuro-Axis: What the Radiologist Needs to Know Vascular Rings for “D”ummies Foreign bodies, what are they doing here?

EDU-103

Damphousse

The lateral soft tissue neck X-ray in children : Much more than a prelude to CT

Don’t stumble on the metatarsal base of the pinky toe; recognize the variants and diagnose the fractures. The value of ultrasound evaluation of the right lower quadrant for acute appendicitis outside of the academic children’s hospital: Don’t let it become a throwaway exam.

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246

S30 EDU-001 EDU-104 EDU-105 EDU-106 EDU-107 EDU-108 EDU-109 EDU-110 EDU-111

Smith Schapiro Fleming Karakas Krishnarao Zahra Smith Fleming Artunduaga

EDU-112 EDU-113 EDU-114

Withdrawn Johnsen Ntoulia

EDU-115 EDU-116 EDU-117 EDU-118

Swenson Farley Otero Roach

The Pediatric Clavicle. Posterior sternoclavicular joint dislocation in the pediatric patient White Matter Matters Initial Clinical Experience of Fetal MRI on 3T with Multi-transmit Radiofrequency (TX) Technology Pearls and Pitfalls in Imaging of Pediatric and Adolescent Breast Masses Radionuclide Brain Imaging of Epilepsy in Children, A Pictorial Review. Imaging of Pediatric Portal Hypertension Pediatric Intramedullary Spinal Tumors and Tumor Mimics MR Imaging Features of Hepatobiliary Cystic Masses Arising in the Pediatric Age Group with RadiologicPathologic Correlation Pediatric Encephalitis: A Road Less Travelled Imaging findings of suspected retained surgical materials in postoperative pediatric patients. How can the radiologist become aware? Pediatric Radiology Economics and Politics in Jeopardy: A Primer. Chylothorax in Children: Bringing Clarity to an Opaque Topic Playing the hand you are dealt: Classification and structured differential diagnosis of hand congenital anomalies. Inflammatory Myofibroblastic Tumor: Imaging features and pathologic correlation.

Scientific Exhibits SCI-001

Goldfisher

SCI-002 SCI-003 SCI-004

Birmingham Sato Yang

SCI-005

Miyazaki

SCI-006 SCI-007 SCI-008

Zamiara Bojic Epelboym

SCI-009 SCI-010

Conley Wang

SCI-011 SCI-012 SCI-013 SCI-014 SCI-015 SCI-016 SCI-017 SCI-018 SCI-019 SCI-020 SCI-021 SCI-022 SCI-023 SCI-024

Appendicitis Ultrasound: Comparison Study of Performance of the On Call Junior Radiology Resident to the Technologist and Attending Four Cases of Congenital Bilateral PDA’s Diagnosed with Cardiac CT Angiography The uniqueness of right-sided congenital Bochdalek diaphragmatic hernias: A 10 year review Pathologic Arterial Sonographic Changes in Neurovascularly Intact Gartland III Supracondylar Humerus Fractures Model-based iterative reconstruction for fetal CT: Achieving ultra-low-dose CT for prenatal diagnosis of bone dysplasia – Pilot study Cumulative Radiation Dose in Esophageal Atresia patients: a 10 year cohort study Reducing the Need for MRI GA Using Melatonin Diagnosis of Fetal Hypospadias: Accuracy and Outcome

Performance Metrics for Tiered Reporting of Ultrasound for Acute Appendicitis Clinical Utility of Dual-Energy X-Ray Absorptiometry for Assessment of Fractures in Pediatric Osteoporosis: Evidence-Based Knowledge Synthesis Davis Hip Click and Developmental Hip Dysplasia: Correlation Between Physical Exam Findings and Hip Ultrasound. Thomas Impact of 4th generation Iterative Reconstruction on multi-detector pediatric head CT: effects on image quality and radiation exposure Toaff Transluminal Absorption of Doxycycline Following Catheter Sclerotherapy Treatment of Large Neonatal and Infant Lymphatic Malformations Aria The Efficacy of Propranolol Therapy on the Proliferative Phase of Infantile Hemangiomas Kim Clinician perception of radiology reports and communication in the pediatric/neonatal ICU setting. Pratt Imaging findings in acute and chronic bilirubin encephalopathy Sharma Reducing Radiation Dose in Neonatal Intensive Care Unit Imaging Podhaizer Residual Subependymal Germinal Matrix Tissue in Very Premature Neonates and its Association with Germinal Matrix Hemorrhage Fakharzadeh Long Segment Hirschsprung Disease: A Diagnostic Dilemma Fazeli Dehkordy Defining the Radiologic and Clinical Longitudinal Natural Histories of Newly Diagnosed Pediatric Small Bowel Crohn’s Disease Treated with Infliximab Mody Improved Fetal Magnetic Resonance Spectroscopy Using Selective Combination Dasgupta Comparison of the incidence of complications of techniques in placement of peripherally inserted central catheters in children GilbertsonDahdal Study of Concordance in Bone Age Estimation between Pediatric Endocrinologists vs. Pediatric Radiologists Tsai Infant Bone Age Estimation Based on Fibular Shaft Length: A Validation Study

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 SCI-001

Goldfisher

SCI-025 SCI-026

Davis Bezold

SCI-027 SCI-028

Mahieu Noga

SCI-029 SCI-030 SCI-031 SCI-032

Koc Hernandez Ahuja Downey

SCI-033

Ahuja

SCI-034

Krishnamurthy

SCI-035 SCI-036

Nguyen Bajno

SCI-037 SCI-038

Nguyen Ashmawy

SCI-039

Ligocki

SCI-040 SCI-041 SCI-042 SCI-043

Pluto Patil Withdrawn Stavrakis

SCI-044

Ghaghada

SCI-045

Patkar

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Appendicitis Ultrasound: Comparison Study of Performance of the On Call Junior Radiology Resident to the Technologist and Attending Liver Fibrosis in the Pediatric Population. Correlation of Elastography and Percutaneous Liver Biopsy. Sensitivity of Mastoid Approach Cranial Ultrasound for Detecting Posterior Fossa Abnormalities: Cine-Loop Acquisition versus Static Images Alone Pediatric AML Patients with Fungal Disease: Prevalence of Findings on Chest CT Normal Pediatric Left and Right Ventricular Functional Parameters Measured by Cardiac Magnetic Resonance Imaging Assessment of Motion Corrected T2-Weighted MRI for Abdominal Imaging of Non-Anesthetized Pediatric Patients Long term outcomes of hepatic arterial interventional procedures in children: single center experience. Computed tomographic detection of lung fissures in infants. When is it best to scan? Do plain radiographs of the skull distinguish vitamin D insufficiency/deficiency from vitamin D sufficiency in infants 6 months of age or younger? Comparison of relative pancreatic to splenic signal intensity for detection of acute pancreatitis on MRI in pediatric patients. Comparison of CT Angiography (CTA) with Surgery In Anomalous Aortic Origin Of The Coronary Arteries (AAOCA) In Children Using Monte Carlo Simulation to Understand Radiation Doses in Pediatric Image Guided Therapy Procedures The Effect of Radiology Residency Program Structure on Resident Interpretation of Pediatric Fractures: Canadian Experience Assessing Scattered Radiation to Operators during Interventional Radiology Procedures Retrospective review of neuroimaging findings in pediatrics ICU patients with Sustained Refractory Status Epilepticus A Systematic Review of Ultrasound Imaging as a Tool for Evaluating Hemophilic Arthropathy in Children Incidence of Cervical Spine Injury in Children with Abusive Head Trauma Computed tomography (CT) imaging parameters of the cranio-cervical junction in achondroplasia Non-Contrast CT Attenuation of Blood vs. Myocardium and Correlation with Hemoglobin and Hematocrit as a Sign of Anemia The Distribution of Neuroblastoma Cancer Stem Cells Within Solid Tumors SECURE Study: Prospective Observational Post-marketing Study on the Safety Profile of Gadoterate Meglumine Final Results in over 1,600 pediatric patients and patients with renal impairment

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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 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 2012 2013 2014

Stockholm, Sweden Orlando, Florida Seattle, Washington 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 San Francisco, California San Antonio, Texas Washington, D.C.

FUTURE MEETINGS 2016 & IPR ‘16 2017 2018

May 15-20, 2016 May 16-20, 2017 May 15-19, 2018

OFFICERS, DIRECTORS AND COMMITTEES 2014-2015 Board of Directors Richard A. Barth, MD, Chair Brian D. Coley, MD, FACR, President James S. Donaldson, MD, FACR President-Elect Diego Jaramillo, MD, MPH, 1st Vice President Peter J. Strouse, MD, FACR, 2nd VP and Editor Christopher I. Cassady, MD, FAAP, Secretary Molly E. Dempsey, MD, Treasurer George S. Bisset, III, MD, FACR Edward Y. Lee, MD, MPH Beverley Newman, MD, FACR Cynthia K. Rigsby, MD, FACR M. Beth McCarville, MD Daniel Podberesky, MD Dorothy I. Bulas, MD, FACR, Past President Donald P. Frush, MD, FACR, Past President Sue C. Kaste, DO, Past President Marta Hernanz-Schulman, MD, FACR, ACR Commission Liaision Marilyn J. Goske, MD, Image Gently Alliance Liaison Benjamin H. Taragin, MD, Web Editor Robert C. McKinstry, MD, PhD, SOCRCH President Maria-Gisela Mercado-Deane, MD, AAP Radiology Section Head M. Ines Boechat, MD, FACR, WFPI Liaison

Chicago, Illinois Vancouver, British Columbia, Canada Nashville, Tennessee

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Adbominal Imaging Committee Daniel J. Podberesky, MD, Chair Mark E. Bittman, MD Karen Blumberg, MD, FACR Lee K. Collins, MD Jonathan R. Dillman, MD Edward Y. Lee, MD, MPH Arthur B Meyers, MD Martha M. Munden, MD Lena N. Naffaa, MD Ethan A. Smith, MD Kristen B. Thomas, MD AndrewT. Trout, MD Bylaws Richard A. Barth, Chair George S. Simpson III, MD, FACR Beverly Newman, MD Cardiac Imaging Committee Dianna M. E. Bardo, MD, Chair Sadaf T. Bhutta, MD, MBBS Lorna P. Browne, MB BS Harris L. Cohen, MD, FACR Molly E. Dempsey, MD, Board Liaison S Bruce Greenberg, MD Shilpa V. Hegde, MD Jeffrey C. Hellinger, MD Eric Hoggard, MD Joshua Q. Knowlton, MD Prakash M Masand, MD Mike Seed, MBBS Cynthia K. Rigsby, MD, FACR Laureen M. Sena, MD Suraj D. Serai, PhD Shreyas S. Vasanawala, MD, PhD Esben S. Vogelius, MD Sjirk J. Westra, MD Child Abuse Committee Sabah Servaes, MD, Chair Lisa H. Lowe, MD Stephen D. Brown, MD Arabinda K. Choudhary, MBBS, MRCP, FRCR Stephen L. Done, MD Jerry R. Dwek, MD Lynn A. Fordham, MD, FACR Laura L. Hayes, MD Bradley A. Maxfield, MD Kenneth L. Mendelson, MD Ms. Joelle Moreno, Esq. Avrum N. Pollock, MD FRCPC Michael D. Rubin, MD Daniel M. Schwartz, MD Terry J. Vaccaro, MD Clinical Practices Steering Committee Christopher I. Cassady, MD, Chair James S. Donaldson, MD, FACR, Chair Taylor Chung, MD Jerry R. Dwek, MD Dianna M. E. Bardo, MD Monica Epelman, MD Judy A. Estroff, MD G Peter Feola, MD

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Geetika Khanna, MD, MS Beth M. Kline-Fath, MD Beverley Newman, MD, FACR Marguerite T. Parisi, MD, MS Daniel J. Podberesky, MD Tina Young Poussaint, MD Sabah Servaes, MD Dennis W. Shaw, MD Sjirk J. Westra, MD Contrast-Enhanced Ultrasound Task Force Kassa Darge, MD, PhD, Chair Dorothy I. Bulas, MD, FACR Brian D. Coley, MD, FACR Jonathan R. Dillman, MD Lynn A. Fordham, MD, FACR 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 Kara Gill, MD R. Paul Guillerman, MD Thaddeus W. Herliczek, MD, MS John D. MacKenzie, MD Anil G. Rao, DMRD, DNB Pallavi Sagar, MD Karuna V. Shekdar, MD Paul G. Thacker, MD Dayna M. Weinert, MD Jason P. Weinman, MD Education – Curriculum Diego Jaramillo, MD, MPH, Chair Brian D. Coley, MD, FACR Molly E. Dempsey, MD Ricardo Faingold, MD Donald P. Frush, MD, FACR Sue C. Kaste, DO Arnold Carl Merrow, MD Sarah S. Milla, MD Peter J. Strouse, MD, FACR Fellowship Program Directors Jane E. Benson, MD, Chair Fetal Imaging Beth M. Kline-Fath, MD, Chair Leslie A. Bord, MD Dorothy I. Bulas, MD, FACR Lucia Carpineta, MD, CM Kimberly A. Dannull, MD Nilesh Desai, MD Monica Epelman, MD Judy A. Estroff, MD Shilpa V. Hegde, MD

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Hollie A. Jackson, MD Mariana L. Meyers, MD Cynthia K. Rigsby, MD, FACR Erika Rubesova, MD Chetan C. Shah, MD Jacqueline Urbine, MD Laura J. Varich, MD Teresa Victoria, MD Finance Stephen F. Simoneaux, MD, Chair Richard A. Barth, MD Molly E. Dempsey, MD James Scott Donaldson, MD, FACR Diego Jaramillo, MD, MPH Avrum N. Pollock, MD, FRCPC Matthew D. Schmitz, MD Randheer Shailam, MD Peter J. Strouse, MD, FACR Dayna M. Weinert, MD History Alan Schlesinger, MD, Historian N. Thorne Griscom, MD, Consultant Honors Dorothy I. Bulas, MD, Chair Donald P. Frush, MD, FACR Sue C. Kaste, DO Informatics Alexander J. Towbin, MD, Chair Karen Blumberg, MD, FACR R. Paul Guillerman, MD Eric Hoggard, MD Neil D. Johnson, MBBS David B. Larson, MD, MBA Peter A. Marcovici, MD Narendra Shet, MD Keith S. White, MD Innovation Donald P. Frush, MD, FACR, Chair George S. Bisset, MD Brian D. Coley, MD, FACR Neil D. Johnson, MBBS Sue C. Kaste, DO Alexander J. Towbin, MD Jennifer K. Boylan, MA Angela R. Davis, CAE Corporate Colleagues: Eugene Mensah, PhD, MBA Craig Peterson Chrisine Ziemba-Landon Interventional G. Peter Feola, MD, Chair John J. Crowley, MD Kari L. Hayes, MD Shellie C. Josephs, MD Els Nijs, MD Manish N. Patel, DO Andrew T. Trout, MD

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Judiciary Richard B. Gunderman, MD, FACR, Chair Richard A. Barth, MD Stephen D. Brown, MD Neil D. Johnson, MBBS Charles D. Williams, MD MR Committee Taylor Chung, MD, Chair Govind B. Chavhan, MD, DNB Jesse Courtier, MD Robert J. Fleck, MD Michael S. Gee, MD, PhD Mai-Lan Ho Edward Y. Lee, MD, MPH Michael M. Moore, MD Anil G. Rao, DMRD, DNB Unni K. Udayasankar, MD Shreyas S. Vasanawala, MD, PhD MSK Committee Jerry R. Dwek, MD, Chair Murray J. Bartlett, MBBS Nancy A. Chauvin, MD Michael F. Fadell, MD Lynn A. Fordham, MD, FACR Munire Gundogan, MD Tal Laor, MD John D. MacKenzie, MD Arthur B. Meyers, MD Beverley Newman, MBBCh, FACR Kamaldine Oudjhane, MD, MSc Shawn E. Parnell, MD Neuroradiology Tina Young Poussaint, MD, Chair Timothy Nicholas Booth, MD S. Srinivas Ganapathy, MD Saurabh Guleria, MD Laura L. Hayes, MD Sarah S. Milla, MD Sumit Pruthi, MD Raghu H. Ramakrishnaiah, MD Diana P. Rodriguez, 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 Evelyn Y. Anthony, MD Karen Blumberg, MD, FACR Leslie A. Bord, MD John A. Cassese, MD Ellen M. Chung, MD Luis Goncalves, MD Emily M. Janitz, DO Thangamadhan Bosemani, MBBS David W. McDonald, MD Harriet J. Paltiel, MD Richard Parad, MD Kalyan C. Tatineny, MD R Nicholas Trane, MD

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Nominating Richard A. Barth, MD, Chair Ronald A. Cohen, MD Kassa Darge, MD, PhD Scott R. Dorfman, MD Beth M Kline-Fath, MD Edward Y. Lee, MD, MPH Janet R. Reid, MD Nuclear Medicine Marguerite T. Parisi, MD, MS, Chair Deepa R. Biyyam, MB BS Hedieh Eslamy, MD Gerald A. Mandell, MD, FACR Helen Nadel, MD Lena Naffaa, MD Sara M. O’Hara, MD Victor J. Seghers, MD PhD Sabah Servaes, MD Susan E. Sharp, MD Kalyan C Tatineny, MD S. Ted Treves, MD Esben S. Vogelius, MD Lisa J. States, MD Oncology Committee Kiery A Braithwaite, MD Michael S Gee, MD, Ph.D Kara Gill, MD Sue C. Kaste, DO M. Beth McCarville, MD Helen R. Nadel, MD, FRCPC Marguerite T. Parisi, MD, MS Edward Richer, MD Sabah Servaes, MD 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 Summer Kaplan, MD Brooke S. Lampl, DO Sosamma T. Methratta, MD Jason B. Mitchell, MD Debra J. Pennington, MD Avrum N. Pollock, MD FRCPC Mitchell L. Simon, MD Paul G. Thacker, MD Kristen B. Thomas, MD Public Policy Richard M. Benator, MD, FACR, Chair Evelyn Y. Anthony, MD Richard A. Barth, MD Steven L Blumer, MD Nilesh Desai, MD Aparna Annam, DO Kate A. Feinstein, MD, FACR Donald P. Frush, MD, FACR Marta Hernanz-Schulman, MD, FACR

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Summer Kaplan, MD Michael E. Katz, MD, FACR Megan B. Marine, MD Debra J. Pennington, MD Matthew D. Schmitz, MD Publications Ethan A Smith, MD, Chair Richard Allen Barth, MD Johan G. Blickman, MD, PHD, FACR Christopher I. Cassady, MD Matthew Hammer, MD Edward Y. Lee, MD, MPH Ashok Panigrahy, MD Andrew Trout, MD Editors: Peter J. Strouse, MD, FACR Brian D. Coley, MD, FACR Geetika Khanna, MD, MS Cynthia K. Rigsby, MD, FACR Research and Education Foundation Board Peter J. Strouse, MD, FACR, President Brian D. Coley, MD - Vice President Christopher I. Cassady, MD, FAAP Molly E. Dempsey, MD Johan G. Blickman, MD, PHD, FACR Jonathan R. Dillman, MD Geetika Khanna, MD, MS Rajesh Krishnamurthy, MD William H. McAlister, MD, FACR Richard L. Robertson, MD Stuart A. Royal, MS, MD, FACR Alexander J. Towbin, MD Safety Dennis W. Shaw, MD, Chair Einat Blumfield, MD Mary K. Drake, MD Thomas R. Goodman, MBBCh Ramesh S. Iyer, MD David B. Larson, MD Kristopher N. Lewis, MD Laura T. Meyer, MD Michael M. Moore, MD Pallavi Sagar, MD Christina L. Sammet, PhD Thomas L. Slovis, MD Dayna M. Weinert, MD Thoracic Imaging Beverley Newman, MD, FACR, Chair Alan S. Brody, MD Sarah Desoky, MD Monica Epelman, MD Robert J. Fleck, MD Maryam Ghadimi-Mahani, MD Shilpa V. Hegde, MD Ramesh S. Iyer, MD Edward Y. Lee, MD, MPH Daniel J. Podberesky, MD Mitchell L. Simon, MD Paul G. Thacker, MD Sjirk J. Westra, MD

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Ultrasound Monica Epelman, MD, Chair Richard D. Bellah, MD Harris L. Cohen, MD, FACR Ramesh S. Iyer, MD Shailee Lala, MD Harriet J. Paltiel, MD Andrew S. Phelps, MD Cicero T. Silva, MD Andrew T. Trout, MD Dayna M. Weinert, MD Website Editorial Committee Benjamin H. Taragin, MD, Chair and Web Editor Amy R. Mehollin-Ray, MD, Assistant Web Editor Peter A. Marcovici, MD Representatives Dorothy I. Bulas, MD, FACR, Academy of Radiology Research 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 GOLD MEDALISTS 1988 1989 1990 1991 1991 1992 1993 1994 1994 1995 1995 1996 1996 1997 1997 1998 1999 2000 2001 2002 2003 2003 2004 2004 2005 2005 2006 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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 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 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 Marilyn J. Goske, MD Stuart A. Royal, MS, MD David C. Kushner, MD, FACR George A. Taylor, MD, FACR, FAIUM, FSRU

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PIONEER HONOREES 1990 1991 1992 1993 1994 1995 1996 1996 1996 1997 1998 1998 2000 2001 2001 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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 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 Diego Jaramillo, MD, MPH William E. Shiels, II, DO

PRESIDENTIAL RECOGNITION AWARDS 1999 2000 2001 2001 2002 2002 2003 2003 2004 2005 2005 2005 2006 2007 2008 2008 2008 2009 2010 2011 2011 2012 2012 2013 2014 2015

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

HONORARY MEMBERS 1985 1987

Jacques Sauvegrain, MD Bryan J. Cremin, MD

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1987 1987 1987 1987 1987 1987 1998 1989 1990 1990 1991 1991 1991 1991 1991 1991 1992 1992 1992 1993 1992/94 1994 1994 1994 1994 1994 1994 1995 1992/95 1995 1995 1996 1996 1997 1998 1998 1999 2000 2001 2001 2001 2002 2002 2003 2004 2005 2006 2007 2008 2009 2009 2009 2009 2010 2011 2011 2012 2013 2014 2015 2015

Ole A. Eklof, MD Clement C. Faure, MD 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 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 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 J. Bruce Beckwith, MD Joseph Volpe, MD 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 In-One Kim, MD Professor Guy Sebag (posthumously)

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PAST PRESIDENTS 1958-59 1959-60 1960-61 1961-62 1962-63 1963-64 1964-65 1965-66 1966-67 1967-68 1968-69 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 IPR ‘87 1987-88 1988-89 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 2013–14 *Deceased

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 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* Denis Lallemand, MD (ESPR) Beverly P. Wood, MD John F. O’Connor, MD* 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, FACR Catherine M. Owens, MD Donald P. Frush, MD, Frush Sue C. Kaste, DO Richard A. Barth, MD

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SINGLETON-TAYBI AWARD 2006 2007 2007 2008 2009 2010 2011 2012 2013 2014 2015

Corning Benton, Jr., MD Michael P. D’Alessandro, MD Janet R. Reid, MD Dorothy I. Bulas, MD, FACR Lane F. Donnelly, MD Wilbur L. Smith, Jr., MD Ralph S. Lachman, MD, FACR Alan Daneman, MD Lisa H. Lowe, MD, FAAP Robert H. Cleveland, MD Stephen F. Simoneaux, 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 1998 1999 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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

WALTER E. BERDON AND THOMAS L. SLOVIS AWARDS - 2013 Best Clinical Research Paper Punwani S, Cheung KK, Skipper N, Bell N, Bainbridge A, Taylor SA, Groves AM, Hain SF, Ben-Haim S, Shankar A, Daw S, Halligan S, Humphries PD. Dynamic contrast enhanced MRI improves accuracy for detecting focal splenic involvement in children and adolescents with Hodgkin disease. Best Basic Science Paper Hanquinet S, Rougemont AL, Courvoisier D, Rubbia-Brandt L, McLin V, Tempia M, Anooshiravani M. Acoustic radiation force impulse (ARFI) elastography for the non-invasive diagnosis of liver fibrosis in children. 2014 recipients will be announced at the meeting. For a list of prior recipients, please visit the SPR website.

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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 2012 2013 2014 2014 2015

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

The Heidi Patriquin International Fellowship 2005 2006 2006 2006 2007 2008 2009 2010 2011 2012 2012 2013 2013 2014 2014 2015 2015

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 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 Nasreen Mahomed, MBBCh, University of the Wiwatersand, Johannesburg, Gauteng Waseem Akhtar Mirza, MBBS, The Aga Khan University, Karachi, Pakistan

Pilot Awards - 2014 Hee Kyung Kim, MD, Quantitative MR imaging of Cartilage in Juvenile Idiopathic Arthritis (JIA) , Cincinnati Children’s Hospital Medical Center Andrea Doria, MD, PhD, MSc, Molecular-Functional Imaging of Hypoxia in Childhood Sarcomas: Feasibility Steps Towards Personalized Medicine, Hospital for Sick Children Seed Grants - 2014 Michael F. Fadell, MD, A randomized controlled clinical and MRI trial of intra-articular injections with platelet rich plasma in patients with juvenile osteochondritis dissecans of the knee, University of Colorado Denver School of Medicine, Aurora Jesse Courtier, MD, Diffusion Tensor Imaging in Pediatric Renal Transplants: Testing A Potential Non-Invasive Alternative to Biopsy,University of California in San Francisco Fellow Award - 2014 Mai-Lan Ho, MD, Characterization of Cerebro-Cerebellar Functional Connectivity in Preterm Infants, University of California in San Francisco 2015 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 Tuesday, April 28, 2015 at 6:00 a.m. Join us for this 5-Mile run around Bellevue Downtown Park 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 Tuesday, April 28, 2015 6:15 – 7:30 p.m. Hyatt Regency Hotel Hors d’oeuvres and Refreshments Casual Attire Reception and Annual Banquet Thursday, April 30, 2015 6:30 – 11:00 p.m. Hyatt Regency Hotel Reception, Dinner and Dancing Business Casual Activities The Hyatt Regency Hotel employs a full-service concierge staff who are happy to share their detailed knowledge of Bellevue, Washington and the surrounding area. You may contact them by telephone at (425) 462-1234. Additional information is included on the SPR website under the Events menu.

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SPR 2015 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.

George A. Taylor, MD, FACR, FAIUM, FSRU Renaissance Man “a man who can do all things if he will” Leon Battista Alberti (1401–1472) George Taylor embodies the definition of Renaissance Humanism – embracing knowledge in many areas of accomplishment including science, research, education, photography, music, and the languages. Born in São Paulo, Brazil to an American father - J Denver Taylor and an El Salvadorian mother - Norma Maria Rivera, George Taylor grew up learning Portuguese, Spanish and English. He moved quite a bit during his early years through states as varied as Ohio and California and countries such as Puerto Rico and El Salvador. He completed his high school education in Mexico City on scholarship and was accepted to George Washington University initially planning to study international affairs. Lucky for us, he fell in love with biology and became a biology major. He met his wife Lydia during college and completed medical school at the George Washington University School of Medicine with distinction. Dr. Taylor was initially attracted to pediatrics, working in a migrant pediatric clinic during his college years. He moved to Baltimore, completing a residency in pediatrics at Johns Hopkins Medial Center. While still a medical student, he took an elective with Bill McSweeney at Children’s National Medical Center (CNMC). During his rotation he met John Kirkpatrick who had traveled to Washington DC as a visiting professor. This was to be a transformational encounter inspiring George to go into pediatric radiology. He began his radiology training at Johns Hopkins working with John Dorst, Sue Kramer and Stan Siegelman. He then moved to Boston to complete a pediatric radiology fellowship with Dr. Kirkpatrick at Boston Children’s. During his years at Boston he worked with many great mentors including Thorne Griscom, Ted Treves, Rita Teele and Robert Lebowitz. George Taylor’s first job after fellowship was at Children’s National Medical Center under the leadership of Bill McSweeney. When Bill retired, David Kushner became a great mentor as well. George enjoyed his years at CNMC working with Bruce Markle, Kathleen Eggli and Massoud Majd. His expertise as a researcher and educator flourished in this environment where he became renowned for his work in pediatric trauma, neurosonology and ECMO. His reputation as a wonderful teacher, accomplished researcher and brilliant clinician quickly grew. He moved to Johns Hopkins to become section head of pediatric radiology. There his research focused on US contrast agents, perfusion of solid organs as well as excitotoxic brain injury. During this time, Lydia and his children Kate and Sasha thrived, taking advantage of the great schools and activities Baltimore had to offer. When an opportunity opened up at Boston Children’s, George moved with his family, becoming the John A. Kirkpatrick Professor of Radiology. In 1999 he was appointed Radiologist in Chief of the Department of Radiology, Boston Children’s Hospital. During his leadership years at Boston, he grew the program, developing an animal imaging facility and research lab. Many societies have benefitted from Dr. Taylor’s talents, commitment to excellence and generosity of time. As a member of the RSNA, Dr. Taylor has served on the program committee, chaired the pediatric refresher courses, served on the pediatric radiology subcommittee, and was vice chair and chairman of the committee on international relations and education. For the American College of Radiology, he has volunteered on the committee of research and technology assessment, commission on ultrasound, and international outreach committee. For his important contributions to the ACR, he became a fellow in 2013. As member of the American Board of Radiology, he chaired the pediatric certification and maintenance of certification exams, was a member of the pediatric category steering committee and served as an examiner of the oral certification examination. His tireless work for the Society for Pediatric Radiology has been significant. He has served on the program committee, publication committee, Bylaws committee, and as chair of the research committee. He has been active on the board of directors of the research and education foundation. As president of the SPR, he led the successful IPR 2006 in Montreal and served as Chairman of the board of directors from 2005 to 2006.

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Dr. Taylor has been honored for his many accomplishments including Alpha Epsilon Delta, Alpha Omega Alpha, Jacobi Society award, and RSNA award for image interpretation. In addition to the groundbreaking research mentioned earlier, Dr. Taylor’s areas of research have included clinical predictors of abdominal injury in childhood following blunt trauma, abdominal CT imaging predictors of outcome, diagnostic errors, and development of physician performance metrics for radiologists. He has authored or coauthored over 150 peer reviewed manuscripts, 60 reviews, 24 chapters and 22 abstracts. His scientific works have been recognized by the Advances in Pediatric Forum, SPR (Caffey, Silver Award, Bronze Award), and RSNA. Numerous research projects have been funded from CNMC, Johns Hopkins, the SPR, and the Alliance Pharmaceutical Corporation. Dr. Taylor is a prolific manuscript reviewer for multiple journals including the AJR, Pediatric Radiology, Journal of Pediatrics and Pediatrics. He served as associate editor of Radiology and was the recipient of numerous editors recognitions awards with distinction from Radiology through the years. A master teacher, Dr. Taylor has been asked to speak at over 150 regional national and international lectures. He is the recipient of numerous teaching awards including the radiology resident award at Johns Hopkins, IPOKRaTES, Harvard University, the Jack O Haller Award for Excellence in Teaching (SPR), and John Kirkpatrick Award for Excellence in Teaching. He serves on the Board of Directors of Boston Children’s Hospital Academy of Educators. His skills as an educator are world renowned, with numerous invitations to participate in international visiting professorships by organizations such as RSNA and IPOKRaTES. Dr. Taylor continues to lecture throughout the world due to his thoughtful, probing, entertaining presentations. His interested in international outreach has lead him to far off lands throughout all the continents and he serves as an important educator for the World Federation of Pediatric Imaging. Sadly, Lydia, his wife of over 35 years, passed away in 2008 from acute myelogenous leukemia. Kate, their daughter, was able to complete her pediatric residency at Boston Children’s and Sasha remained in Boston during this time. The family was able to supporteach other during Lydia’s battle. With the loss of Lydia, George stepped down as chair of the department. Ever the renaissance man, George remains active not only in pediatric radiology as teacher, researcher and clinician, but in multiple other exciting areas. He is an accomplished photographer with a web site garnering numerous awards for his work. A new passion is filming, now working with drones flying over his beloved Cape Cod. He is an accomplished singer, musician, and adventurer. His love of travelling benefits not only those he teaches, but provides rich material for his photography and art. George’s “second chance” came in the form of Nancy, a medical school classmate he reconnected with when she moved to the Boston area. Nancy, a pediatric dermatologist, is a force as strong as George. Equally talented and passionate, the two married in Hawaii and have been able to share their families and adventurous spirits. Together, they have shared a number of medical missions abroad. Their combined families now include Kate a pediatric cardiologist, her husband Matt and Madeline, George’s granddaughter; Sasha, a medical student at the University of Vermont; Nancy’s daughters Kate, a digital director for a global fashion and lifestyle site; and Sara, a psychology professor. Dr. Taylor fulfills the Renaissance ideal. George is always questioning and learning excelling as a teacher, researcher, clinician, and humanist. Pediatric Radiology is lucky to have such a thoughtful, talented scholar in our profession! Dorothy I. Bulas, MD, FACR

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SPR 2015 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.

William E. Sheils, II, DO It is an honor to highlight the life and career of Dr. William E. Shiels, II, who is the 2015 Pioneer Award winner. He is the recipient of this award in recognition of a career marked by curiosity, discovery, innovation, and improvement in the imaging care of children. Born in Cincinnati, Ohio, by his own description Bill was not necessarily a model child or student, but perhaps that irreverence for convention and conformity was an indication of the attitudes that he has carried with him in his life and career. He attended college at Villanova, medical school at Philadelphia College of Osteopathic Medicine, residency at Tripler Army Medical Center, and then back to Cincinnati for his pediatric radiology fellowship. It was in Cincinnati that he met influential mentors Don Kirks, Diane Babcock, and Corning Benton. From residency and fellowship he learned, as he puts it, that we (and I quote) “…have the potential, through medical research and discovery, to improve the lives of patients in new ways and change the direction of medicine, in unique and discrete ways, for patients around the world.” And that “…medical teaching was about evoking (calling out of others) others’ potential and helping physicians discover their ability to provide care better (than they previously thought possible), and the joy in seeing them live this potential and succeed in remarkable ways in their careers.” (end quote) Following his fellowship he returned to the Army, serving as the Chief of Pediatric Radiology at Walter Reed and as the Radiology Consultant to the U.S. Army Surgeon General. These experiences uniquely prepared him for the rather unusual opportunity of starting an entirely new pediatric radiology group at Columbus Children’s Hospital (now Nationwide Children’s Hospital). Starting with only six faculty in 1995 (of which I was one) that was the first in the country to be in house 24 h a day. Today, the group has grown to over 20 diagnostic and interventional radiologists, what a remarkable achievement. Many people recognized for this award have great distinction in a narrow area of focus, but Bill is unique in having many areas of inquiry, which reflect a recurring career theme of the pursuit of unanswered questions, and a passion for finding solutions. It’s often not clear how our ideas and practices come about, and the contributions of the individuals involved often become obscure or completely lost over time. The changes that Bill has helped to develop seem like common knowledge today, but I think that a short review is warranted. Let me start with family, I realize that family is typically highlighted at the end of tributes like this, but instead I will put it first, just to be clear about Bill’s two proudest personal accomplishments: his daughters Courtney and Moira. They have always been and will always be his greatest delights and loves. Now, as far as his medical accomplishments: Musculoskeletal and soft tissue ultrasound: While this is very much in vogue now, and recognition of its value is increasing, Bill was an earlier pioneer in its use. His exploration of the use of US to detect soft tissue foreign bodies dates to the late 1980’s, along with the development of techniques for US-guided foreign body removal in 1990. These techniques, subsequently developed and refined, allow the minimally invasive removal of these foreign bodies with incisions of only a few millimeters and markedly reduced morbidity compared with standard surgical approaches. Most recently, this work has led to a $1 million grant from the Department of Defense to develop a program to train military physicians in these techniques to allow removal of shrapnel and other war related foreign bodies from wounded active duty fighters and veterans. Interventional ultrasound training: Another of Bill’s passions has been teaching. His work with foreign bodies led him to develop didactic and hands-on methods of teaching US-guided techniques. His use of real tissue phantoms and his creative development of realistic targets have become standard for many training programs. He has taught courses at the RSNA, SPR, SIR, and other breast and musculoskeletal courses nationally and internationally for over 25 years. Having participated in teaching the course at the last RSNA, I can attest that these programs are still full and well-attended, and that Bill hasn’t lost any of his enthusiasm for teaching practitioners methods to treat patients better.

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Intussusception: The use of air for intussusception reduction was invented by Bill, but it’s the dominant method of reduction in North America because of Bill’s work starting in fellowship. His investigations sought to answer if air was safer than liquid agents, is there a difference in efficacy, does Valsalva help, how much pressure can be applied, if perforations happen are there differences, if there is a perforation what is the risk to the child and how can this be promptly treated? Recognized by the 1991 Caffey Award, the answers to these questions have shaped our thoughts about and treatment of intussusception for the last 25 years. Lymphatic malformation treatment: The treatment of lymphatic malformations has historically been marked by trial and error, with little consideration of the biology of the process and thus what treatments have the greatest chance of success. Bill took the same approach as he took with intussusception, and developed techniques that now routinely have a 95% success rate. His development of an animal model of lymphatic malformations earned the 2004 SPR Caffey Award for Outstanding Basic Science Research, and trainees working with him won the 2013 SPR John Kirkpatrick Young Investigator Award for demonstrating the synergistic effect of detergent poration with ethanol ablation. From starting an entirely new group, to researching animal models of disease, to developing new interventional techniques, to teaching and mentoring, Dr. Bill Shiels has been a unique force in our specialty, and the Society for Pediatric Radiology is proud to present him with the 2015 Pioneer Award. Brian D. Coley, MD, FACR

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SPR 2015 Presidential Recognition Award The Society bestows Presidential Recognition Awards on members or other individuals whose energy and creativity have made a significant impact on the work of the Society and its service to its members.

Cynthia K. Rigsby, MD, FACR Dr. Cynthia K. Rigsby is the 2015 Presidential Award recipient in recognition of quiet and substantial service to the Society. Educated at Duke, and trained at Mallinckrodt and Cincinnati, Dr. Rigsby is a professor of Radiology and Pediatrics at the Northwestern University Feinberg School of Medicine and the vice-chair of the Department of Medical Imaging at Lurie Children’s Hospital in Chicago. Dr. Rigsby has been a member of the SPR Cardiac Committee since 2005, and has co-directed the ACR/SPR Pediatric and Adult Congenital Cardiovascular Imaging course since 2007. She has also been a teaching faculty member for the SPR Basic and Advanced Cardiac MRI course. She has been instrumental to SPR’s educational initiatives and meetings as an SPR Postgraduate Course co-director in 2010 and 2013, the Annual Meeting scientific sessions co-director in 2012, and a member of the Abstract Review (Poster) Committee for 2010 and 2011, as well as a member of the Abstract Review (Paper) Committee for 2014. Additional responsibilities have included work on the Publications and Nominating Committees, and recently she has become a member of the Board of Directors. Dr. Rigsby has been an assistant editor for Pediatric Radiology since 2011. Weekly I have the privilege of listening to her critiques and reviews of submitted manuscripts, and am always impressed by her knowledge and clarity of thought, as well as her thoughtful comments to authors as she attempts to guide them in making their manuscripts as strong as possible. This can be difficult work, and Cindy has the perfect combination of “head and heart” to handle it with skill and sensitivity. Other service to pediatric radiology includes work with the ACR on MR accreditation, being a member and chair of the core committee for the ABR, a member of the RSNA pediatric educational exhibits committee, and the section editor for the Cardiovascular section of Caffey’s Pediatric Diagnostic Imaging. If you want something done, if you want it done well, and if you want to do it with someone with a positive attitude, then you should ask Dr. Rigsby. The leaders of the SPR have known this for some time, and for all she has done for the SPR and its members I am happy to present her with the SPR 2015 Presidential Award. Brian D. Coley, MD, FACR

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SPR 2015 Honorary Members The Society extends Honorary Membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children.

In-One Kim, MD Dr. In-One Kim has been awarded the 2015 SPR honorary membership in recognition of his outstanding academic achievements and international leadership in pediatric radiology. In-One Kim was born in Incheon, Korea where he grew up and received his education until the end of high school. He attended medical school at Seoul National University in Seoul, Korea, where he received his MD degree in 1978. He then chose to specialize in radiology and trained in the Department of Radiology at Seoul National University Hospital from 1979 to 1983. During residency, Dr. In-One Kim was inspired by Professor Kyung Mo Yeon, the founder of pediatric radiology in Korea and decided to become a pediatric radiologist. After completing his resident training, he served Korean military service for 3 years as a captain in the Capital Armed Forces General Hospital. He graduated PhD from Seoul National University in 1986 and then, he started as a pediatric radiologist in Seoul National University Children’ Hospital which was established in 1985 as the first children’s hospital in Korea. From 1989 to 1990, he was a visiting fellow of radiology at the Children’s Memorial Hospital in Chicago, Illinois, in the United States. It was here that he learned and widened the scope of pediatric radiology, attended his first SPR meeting in Cincinnati (1990), and become friends with Jim Donalson and Arnie Shkolnik. He was appointed Professor of Radiology at Seoul National University College of Medicine in 1997. Recently he became an adjunct Professor of Pediatrics. From 1993 to 2006, Dr. In-One Kim has been the Radiologist-in-chief in the division of pediatric radiology at Seoul National University Hospital, and then, he served as the chairman of the Department of Radiology at Seoul National University Hospital from 2006 to 2008. He was the president of the Korean Society of Pediatric Radiology from 2006 to 2008. He also served as the president of the Korean Society of Ultrasound in Medicine from 2009 to 2010. Dr. In-One Kim has devoted himself to all aspects of pediatric radiology including patient care, teaching and research. Although his main area of interest has been in pediatric neuroimaging, his interests in pediatric radiology are extremely wide and this is reflected in the two books authored by him. The most recent book is entitled Radiology Illustrated: Pediatric Radiology, which covers a wide range of pediatric radiology. His previous book, published in 1999, co-authored with Professor Kyung Mo Yeon, is entitled Standard Bone Age in Korean Children. Dr. Kim has published over 120 articles in peer review journals as the primary author, corresponding author or co-author. His broad range of interests in pediatric radiology is also reflected in the wide range of topics he has published. Dr. Kim is also committed to teaching residents and fellows and many of his published articles are with trainees whom he has mentored. He has served as a member of the editorial board of many international radiology journals including Pediatric Radiology. Dr. In-One Kim visited many children’s hospital and has learned from many teachers such as Dr. Fujioka, Derek Harwood-Nash, Alan Daneman, Donald Kirks, Heidi Patriquin, Janet Strife and Lane Donnelly. In 2003, Dr. Kim joined the board of AOSPR (Asian and Oceanic Society for Pediatric Radiology) and he hosted AOSPR meeting in Seoul as a secretary general. Involvement in AOSPR allows Dr. Kim to share his experience with international colleagues and to discuss worldwide issues in pediatric radiology. He was the president of AOSPR from 2005–2009. He tried to make strong consolidation between AOSPR members and also to enhance the global cooperation with SPR, ESPR, and SLARP. He was titled an Honorary Member of AOSPR in 2013. Dr. Kim’s devoted wife, Soo Jeong, has been a constant inspiration and companion to him, along with their two children, JeongHye and Joon Hwan. Currently JeongHye and Chris, his son-in law, are studying clinical psychology in Chicago and Joon Hwan is a dentist at the Seoul National University Dental Hospital. Dr. Kim is cordially grateful to his family for their support. Beloved by his colleagues and respected by the international radiology community, Dr. Kim has dedicated his academic career to patient care, teaching, and research. His exceptional leadership and academic contributions to the field of pediatric radiology have been recognized by the SPR. The Society for Pediatric Radiology is very proud to bestow the 2015 Honorary Member on Dr. In-One Kim. Jung-Eun Cheon, MD

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Prof. Guy Sebag, MD (Posthumously) The Society for Pediatric Radiology is privileged to recognize Guy Sebag, MD with honorary membership. Guy was a great friend of the SPR and a true partner in furthering the care of children. His life and contributions are truly worthy of reflection and celebration. It is very sad and tragic that Guy is not here to share his honor for he passed away suddenly and unexpectedly on November 28th, 2014. He was just 55-years-old. Guy’s early years were spent in Egypt. Egypt was increasingly uncomfortable place for a Jewish family to live. As Guy would tell it, his family decided to emigrate and narrowed their future home down to two locations – Paris or Vermont. Undoubtedly, Paris was the right decision, for it is very hard to envision Guy as a New Englander. Guy attended medical school at the Faculté de Medecine – Pitié Salpétrière, University Paris VI. Guy completed an internship and residency at the Assistance Publique – Hôpitaux de Paris. After his residency, Guy completed two fellowships in pediatric radiology, one at Stanford University in Palo Alto, California and the other at Hôpital Necker-Enfants Malades in Paris. While at Stanford, Guy began lifelong fellowships and connections with the American pediatric radiology community. In 1989, after his fellowship, Guy joined the Pediatric Radiology Department at Hôpital Necker-Enfants in Paris. A few years later, he was recruited across the city to the Hôpital Robert Debré, where he spent the rest of his career. Guy became a university professor in 1997 (Paris Diderot University, University Paris VII). Since 1998, he served as head of the Research Unit on Developmental Imaging in the laboratory. Since 2003, he served as Chairman of the Pediatric Radiology Department at the Hôpital Robert Debré, and since 2006, he served as Director of the Physiology, Imaging and Computer Assisted Medical Information Departments and as member of the executive board at the Hôpital Robert Debré. Guy was the Director of the University Department of Radiological Sciences at Paris Diderot University (2007-2012) and the Chairman of the Board of the College or Radiologists of Paris University Hospitals (2012-2014). Guy was active in the French Society of Radiology, the Société Francophone d’Imagerie Pédaitrique et Prénatale (SFIPP), the European Society of Pediatric Radiology (ESPR) and the European Society of Radiology. He served as the General Secretary of the SFIPP (1996-2002) and Treasurer of the ESPR (2007-2009). He was a member of the European Institute of Biomedical Imaging Research (EIBIR, 2004-2007). Guy was a very strong supporter and contributor to the efforts of the World Federation of Pediatric Imaging. Guy was a gifted academic radiologist. He published 86 peer-reviewed papers and 23 book chapters and contributed to 190 scientific presentations. His CV shows a wide variety of interests but also focus in pediatric musculoskeletal and neuroimaging. In some of his best work, Guy used gadolinium based contrast to define the evolution of Perthes disease. Guy was an accomplished teacher. He delivered 104 lectures at national and international meetings, was an awarded educator in his institution, and excelled in day-to-day instruction of trainees in his place of work. Guy had a genuine gift for inspiring the work of others; he frequently sowed the seeds of ideas for others to grow as projects and papers. For the last decade of his life, Guy was instrumental to the success of the journal Pediatric Radiology. From 2003 to 2009, Guy served as an Assistant Editor. From 2009 until the time of his passing, Guy was the Editor-in-Chief of the European office of the journal. Guy was an excellent journal editor. He was highly skilled at working with colleagues from many nations and ethnicities, synthesizing their work and working with his American counterparts to create a consistent and cohesive journal. He was passionate and professional. He was compassionate and honest. Guy had great vision as an editor. His sight was always set on learning about new technologies, adapting journal paradigms to modern times, and learning about anything that would help us to better take care of children. The continued growth and success of Pediatric Radiology is in large part due to Guy’s teamwork in working with the American office and for this we are very grateful. This teamwork required a continual dialog of communication, sharing of tasks, and yearly meetings to review progress, look ahead and strategize. Guy was very skilled at negotiation, understanding the needs of others, politely championing the needs of his constituents, and reaching a mutual agreement which pleased all at the table. Guy was a true French gentleman and scholar. He had an immense fund of knowledge and a keen intellect. He was very observant. He was highly skilled at dissecting a manuscript submission and identifying how to make it better. Guy had a great sense of humor, which he used at key moments to liven a group. An occasional email montage from Guy received in the American editorial office would liven up even the dreariest day. Guy will be missed by the Society for Pediatric Radiology community, but much more so by his colleagues in France and his dear family. Guy was adored by his radiology colleagues who relished the opportunity to work with him. He was highly appreciated by his clinical colleagues. Guy was a wonderful husband and father. He is survived by his wife Christina Mouroutis, and his children, Alexandra, Paul and Angélique, of whom he was very proud. Their loss is profound.

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Dear Guy, adieu mon ami. Thank you for the friendship and support that you have given members of the SPR and to the society itself. Thank you for working with us to improve the healthcare of children throughout the world. We are so sorry that you are not here with us to share this award, but nonetheless, it is with heartfelt thanks and great respect that we bestow upon you Honorary Membership in the Society for Pediatric Radiology. Peter J. Strouse, MD, FACR

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SPR 2015 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.

Stephen F. Simoneaux, MD Steve Simoneaux is one of the nicest people I know. It is a great pleasure to be able to write this introduction as he receives the 2015 Singleton-Taybi Award. Steve was born on December 4, 1962 in Jackson, Mississippi, the son of two missionaries. At age 7, his parents’ work took the family to Japan where Steve lived until graduating from high school. While attending the local international school, Steve met his future wife, Irene, whose parents were also in Japan as missionaries. They became high school sweethearts, went to the prom together and after returning to the States were married in 1988. Luckily for his patients and those of us who have become his friends through the practice of medicine, Steve never considered following in his parents’ footsteps. Although he started college as an English major, he eventually realized medicine was more to his liking and finished out his college career taking the required freshman chemistry in his senior year. Steve graduated from the College of William and Mary in 1984 and the University of Miami School of Medicine in 1988. He completed his radiology residency at the University of Miami/Jackson Memorial Hospital in 1992. He then moved to Atlanta for his pediatric radiology fellowship at Emory, where he has remained ever since. He has been a rising star throughout his career at Emory. Sought out as a talented clinician he also has been recognized as a gifted teacher and superb administrator. For many years he has served as lecturer and coordinator for medical student teaching, also teaching radiology residents and fellows and directly supervising pediatric radiology fellows. He has lectured actively as an invited speaker for radiology and pediatrics both locally and abroad while publishing widely. He service as an able administrator has been sought out since his first day at Emory when he was appointed Program Director of the Pediatric Radiology Fellowship Program. Since then he has served in countless administrative roles rising to his current positions of Chief of Pediatric Radiology and Medical Director of the Department of Radiology at Children’s Healthcare of Atlanta at Egleston and Associate Professor of Radiology at Emory University School of Medicine. Steve has been very active with several national organizations. His work for the Society of Chairs of Radiology at Children’s Hospitals (SCORCH) is lengthy and continues as its President-elect. He has functioned in multiple capacities for the ACR and SPR. He has served a central role for the ABR as it transitioned from general to subspecialty certification and from an analogue to a digital image format. He has held positions as Chair of the Certificate of Added Qualification Committee, as a member of the Written Item Committee, the Oral Exam Committee and as Image Asset Coordinator for Pediatric Radiology. It has been an absolute pleasure to have worked with Steve on various of these committees for over two decades. Even in committee settings, it is clear that Steve is a brilliant teacher. But more than that, he is a superb, kind and yet humble human being. Congratulations Dr. Simoneaux on this richly deserved award. Bob Cleveland, MD

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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. 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

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Caffey Award for Best Basic Science Research Paper 2005 2006 2007 2008 2009 2010 2010 2010 2010 2011 2012 2013 2014

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 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, Cody Penrod, Sudha Singh, Jayne Seekins, DO, Amy Fleming, Melissa Hilmes, MD

Caffey Award for Best Clinical Research or Education Paper 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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 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 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 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, Ethan Smith, Amer Heider, Nahid Keshavarzi, Jacob Bilhartz, Jonathan Rubin

CAFFEY AWARD FOR POSTERS 2005 2006

2007 2008 2009 2009 2009 2010 2010 2010 2011 2011 2011 2012

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 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 Scientific: Dual Phase Intravenous Contrast Injection in Pediatric Body CT. Mann E, Alzahrani A, Padfield N, Farrell L, BenDavid G, Thomas K Educational: Hemangiomas Revisited: The Useful, the Unusual and the New. Restrepo R, Palani R, Matapathi U, Altman N, Cervantes L, Duarte AM, Amjad I Case Report: MRI of Congenital Urethroperineal Fistula. Mahani M, Dillman J, Pai D, Park J, DiPietro M, Ladino Torres M Scientific: Updated Estimated Radiation Dose for Pediatric Nuclear Medicine Studies. Grant F, Drubach L, Treves ST, Fahey F Educational: Button Battery Ingestion in Children: What the Radiologist Must Know. Kappil M, Rigsby C, Saker M, Boylan E Case Report: MR Imaging Features of Fetal Mediastinal and Intrapericardial Teratomas. Rubio E, Kline-Fath B, Calvo-Garcia M, Guimaraes C Case Report: Neuroimaging in Hemiplegic Migraine: Cases and Review of the Literature. Stence NV, Kedia S, Maloney JA, Armstrong-Wells J, Bernard T

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2012 2012

2014 2014 2014

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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 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, DO, Medical, Radiology, Phoenix Children’s Hospital, Phoenix, AZ; James Owen, MS, Robyn Augustyn, BSRT (R)(CT), John Egelhoff, DO, John Curran, MD, Jeffrey Miller, MD, Richard Southard, MD, William Pavlicek, PhD, Richard Towbin, MD Morbidity associated with delayed treatment of cholelithiasis in pediatric patients with sickle cell disease Heather Imsande, MD, Boston Medical Center, Boston, MA Case Report: 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 Educational Poster: The Pediatric Breast: What to do with Lumps and Bumps; Natalie Burns, University of Washington Medical Center, Seattle, WA, Habib Rahbar, Teresa Chapman Scientific Poster: 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, Yoshinori Funama, Chikako Fujioka, Kazuo Awai

The top 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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2015 Edward B. Neuhauser Lecture Radiomics and Radiogenomics

Robert J. Gillies, PhD Department Chair, Cancer Imaging and Metabolism H. Lee Moffitt Cancer Center Professor Gillies is Chairman of the Department of Cancer Imaging and Metabolism; Director of the Center of Excellence in Cancer Imaging and Technology; Vice-chair for research in the Department of Radiology and Scientific Director of the Small Animal Imaging Lab (SAIL) and Image Response Assessment Team (IRAT) shared services at the Moffitt Cancer Center. His research is focused on functional and molecular imaging of cancer, specifically with an emphasis on the use of imaging to inform evolutionary models of carcinogenesis and response to therapy. Prof. Gillies has received numerous local, national and international awards for his teaching and research, including Researcher of the Year 2012 (Moffitt Cancer Center), Furrow award for innovative teaching (U. Arizona), the Yuhas award for radiation oncology research (U. Penn) and the TEFAF professorship (U. Maastricht) a named Fellow of the International Society for Magnetic Resonance in Medicine and the distinguished Basic Scientist award from the Academy for Molecular Imaging. Dr. Gillies’ vision for the Moffitt imaging initiative includes development of new applications to diagnose, predict and monitor therapy response using noninvasive imaging. This work spans a breadth from molecular and chemical work, to animal studies and to human clinical trials and patient care. He has been involved in a number of clinical trials. Dr. Gillies also leads a post-doctoral/resident training program in cancer imaging. Previous Neuhauser Lectures 1997 1998 1999 2000 2001 2002 2003

2005 2006 2007 2008 2009 2010 2011

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 “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” Regina E. Herzlinger, PhD “The Economic Basis of Change in Healthcare” Sanjiv Gambhir, MD, PhD “Molecular Imaging”

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2012 2013 2014

William R. Hendee, PhD “Past and Future Patient Benefits of Radiologist/Physicist Collaboration” James R. Downing, MD “The Pediatric Cancer Genome Project – Implications for Clinical Medicine Robert Pearl, MD “The Future of American Medicine – The Impact of Health Care Reform”

For a list of Neuhauser Lecturers prior to 1997, please visit the SPR website.

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S60 POSTGRADUATE COURSE ABSTRACTS Monday, April 27, 2015

FETAL IMAGING Cortical Dysplasias and Implications in Postnatal Life David M. Mirsky, MD

Fetal MRI provides a window into brain development and allows for early diagnosis of congenital malformations for which evaluation by sonography may be limited. Additionally, it offers prognostic information that may affect perinatal care and facilitate the counseling of parents. This session will review various fetal CNS pathology with an emphasis on disorders of migration and cortical organization including heterotopia, polymicrogyria, schizencephaly, lissencephaly, and hypogenesis of the corpus callosum. Post-natal correlation will be provided. Additionally, the impact of fetal MRI on prognosis and perinatal therapy will be addressed.

Sorting Out Posterior Fossa Fluid Collections Matthew T. Whitehead, MD

Learning Objectives: 1. To review normal embryologic development of the cerebellum, meninges, and meningeal spaces to help improve understanding of posterior fossa fluid collections 2. To introduce a pattern approach for diagnosis of posterior fossa fluid collections Abstract: Posterior fossa fluid collections can be a diagnostic challenge in the developing fetus. Etiologies range from normal developmental variation to pathologic cystic, ventricular, and meningeal fluid space enlargement. Comprehension of basic regional embryology is necessary to achieve a true understanding of the various differential etiologies. Common imaging patterns of posterior fossa fluid collections including enlarged (“mega”) cisterna magna, Blake pouch cyst, arachnoid cyst, and Dandy-Walker continuum will be discussed within the framework of developmental posterior fossa anatomy. Fetal Orbits and Ears Maria A Calvo-Garcia, MD

Evaluation of the fetal face is always included in all standard fetal anatomic surveys. Facial malformations are obviously important and may also indicate and underlying problem, such as chromosome abnormalities, genetic syndromes or environmental insults. We will review essential steps for the anatomic assessment of the fetal face. Subsequently, we will focus on specific conditions affecting the orbits and ears. With this presentation we expect the audience to become familiar with characteristic scenarios and potential search patterns during US and fetal MRI evaluations. Imaging Pulmonary Hypertension Dorothy I. Bulas, MD, FACR

PHtn can be defined as mean pulmonary arterial pressure (PAP) >25 mmHg, or >50% systemic. Secondary PHtn is far more common than idiopathic, but idiopathic PHtn is often rapidly fatal. Most common secondary causes are cardiac disease; persistent pulmonary hypertension or neonatal lung disease; and lung disease or hypoxia. Pulmonary venooclusive disease and pulmonary capillary hemangiomatosis are rare causes that may be suggested by imaging, but require lung biopsy. Echocardiography is the usual screening method. Tricuspid regurgitant velocity >2.5 m/s is often used for further evaluation. RVH further supports the diagnosis. Echocardiography also identifies intracardiac causes of PHtn. Correlation for PAP is fair to good between echocardiographic and angiography which remains the gold standard. In addition to the most

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accurate measurement of PAP pulmonary vascular resistance can be measured and pulmonary venous anatomy assessed. CXRs may show increased MPA and pruned vessels. MRI can provide comprehensive evaluation. PAP accuracy on MR is similar to echocardiography. Cardiac MR requires highly expert interpreters. CT also provides a useful assessment. Three suggestions for the reading room: Although the CXR will rarely be the first indication of PHtn, the diagnosis should be suggested if the appearance is suggestive. PHtn requires different treatment from most other cardiac disease. On CT or MRI, the pulmonary artery should be about the same size as the ascending aorta. A ratio of clearly greater than 1:1 suggests possible PHtn. A CT scan that shows mosaic attenuation without air trapping on expiratory images should raise the possibility of PHtn. CDH: What’s on the Horizon? Amy R. Mehollin-Ray, MD

This 10-min presentation will review current prenatal imaging measures of disease severity in congenital diaphragmatic hernia, such as the ultrasound-based lung-head ratio (LHR) and the MRI-based observed-to-expected total fetal lung volume (O/E-TFLV). An overview of the recent literature on prenatal diagnosis of congenital diaphragmatic hernia will conclude the presentation, including prognostic markers in fetal tracheal occlusion (FETO) therapy, the prediction of pulmonary hypertension and the prospective identification of a hernia sac. As fetal tracheal occlusion is employed to improve survival in patients with severe CDH, fetal therapy centers are evaluating imaging findings for their ability to predict survival, including a recent study from four centers in Europe that assessed stomach position in fetuses with CDH with and without FETO. Recent studies have assessed imaging markers for the prediction of pulmonary hypertension both on power Doppler ultrasound (contralateral vascularity index – CVI) and on MRI (modified McGoon index). The presence of a hernia sac covering the herniated abdominal contents has been shown to predict better survival and less frequent ECMO and patch repair. There are prenatal imaging findings which can suggest the presence of a hernia sac, which can be added to the radiologist’s imaging checklist. Prenatal Diagnosis of Congenital Chest Anomalies Akosua Sintim-Damoa, MD

Prenatal diagnosis of fetal chest lesions is important in determining the severity of pulmonary hypoplasia. Early diagnosis enables parents to be adequately counseled and allows for potential avenues for fetal intervention. Several factors are critical in ensuring normal lung development. Adequate thoracic space, intrapulmonary fluid, fetal lung growth factors, amniotic fluid, and unimparied fetal breathing are all necessary for normal lung development. Fetal chest lesions can be subdivided into extrapulmonary and bronchopulmonary masses. Extrapulmonary lesions include congenital diaphragmatic hernia while bronchopulmonary masses can be further differentiated as parenchymal lesions or lesions secondary to tracheal or bronchial obstruction. Parenchymal lesions include congenital pulmonary airway malformation and bronchopulmonary sequestration. Lesions secondary to tracheal or bronchial obstruction include congenital lobar overinflation and congenital high airway obstruction. These intrathoracic lesions exert mass effect on adjacent structures and subsequently can lead to fetal hydrops and pulmonary hypoplasia. A systematic approach should be utilized when evaluating a fetal chest lesion. Although ultrasound is the first line modality in the assessment of fetal anomalies, MR can be helpful in providing additional details. If stomach, peristalsing bowel loops, or abdominal viscera can be discerned in the thoracic cavity, then congenital diaphragmatic hernia can be diagnosed. If discrete cysts are seen, then congenital pulmonary airway

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malformation should be considered. With Color Doppler, if pulmonary arterial supply can be demonstrated, then CPAM should be considered. With systemic arterial supply, bronchopulmonary sequestration is the primary differential consideration. If the sonographic findings are unclear, MR may be helpful for further evaluation. Fetal Intestinal Obstruction: Prenatal/Postnatal Correlation Eva I. Rubio, MD

Fetal intestinal obstruction presents in myriad ways and at varying times during prenatal life. There is also a great deal of variability in the sensitivity and specificity associated with prenatal diagnosis of intestinal obstructive processes. This presentation will take a top to bottom approach describing findings by US and MRI, the current medical literature and the imaging pitfalls in assessing the fetal patient with intestinal obstruction. Proximal intestinal obstruction, to include primarily esophageal, gastric and duodenal atresia, may be the most well-described and generally straightforward category in terms of confirming the presence and level of diagnosis, although concomitant diagnoses, such as Down syndrome are VACTERL and are a significant consideration. Rare entities such as pyloric atresia, pyloric membranes and colonic mimics will be reviewed, in addition to the occurrence of false positive and false negative diagnoses. Mid intestinal obstruction diagnosis and counseling may be more complex, owing to difficulties in correctly determining the level of obstruction. The cases are less commonly associated with syndrome or other anomalies. The use of MRI for improved soft issue resolution and assessment of meconium signal is often beneficial, but misdiagnoses still occur, and often it is most prudent to counsel the family about a range of potential outcomes. Distal intestinal obstruction etiologies, defined as occurring at the distal ileum and beyond, are primarily comprised of atresias, cysts and cloacas/ anorectal malformations. MRI T1 weighted imaging, pitfalls and the role of standard measurements of colorectal diameter will be reviewed. Prenatal Urinary Tract Dilatation: What to Tell the Pediatricians? Mariana L. Meyers, MD

Urinary tract dilatation is frequently seen in fetuses by ultrasound and may indicate a spectrum of pathology. Different grading systems for hydronephrosis have been developed by different specialties without unification. Recently, a urinary tract dilatation classification consensus was created to be applied prenatally and postnataly with the objective of universalizing the grading of hydronephrosis. Here we will review the highlights of the new consensus, its importance, and briefly outline the risk- based management of prenatally diagnosed hydronephrosis after birth. Additionally, we will illustrate how prenatal MRI can be useful in identifying additional renal and urinary tract pathology not seen by ultrasound that may alter the prognosis and perinatal management.

MUSCULOSKELETAL IMAGING Hip Dysplasia: What the Orthopedist Wants to Know Keith S. White, MD

The term developmental dysplasia of the hip (DDH) indicates a spectrum of pathologies from stable acetabular dysplasia to frankly dislocated hips. Congruent reduction and stability of the femoral head are necessary for normal growth and development of the hip joint. Failure to diagnose DDH and treat in infancy can result in significant long-term disability. Early diagnosis can often be accomplished through thorough physical examination of all newborns. While universal screening is advocated in many countries, in the United States selective screening by ultrasound is indicated for those children with risk factors for DDH (family history, breech presentation, and unstable hip examination at the initial newborn examina¬tion). Ultrasound screening for infants with risk factors for

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DDH is rec¬ommended at age 6 weeks. Pavlik harness treatment for children with unstable hips or significant dysplasia on ultrasound is continued until the hips stabilize and show concentric reduction on imaging. With time, diagnosis and treatment evolve to ac¬commodate the growing child. Infants who fail to respond to nonoperative manage-ment may require more extensive interventions. Post-operative imaging by CT or MRI is commonly employed to ensure adequate reduction of the hip. In the adolescent evaluation, better definition and localization of bony deficiency as well as evaluation of cartilage and labral integrity are critical to treatment strategies. Infection Imaging Robert Orth, MD, PhD

The clinical presentation of children with musculoskeletal infections is variable, especially in infants and young children. Imaging has an important role in confirming diagnosis, localizing abnormalities, and directing biopsy, aspiration, and debridement. The initial imaging study in children with suspected musculoskeletal infection is radiography, primarily to exclude other abnormalities, most commonly trauma. MRI is the most appropriate definitive imaging study. Ultrasound may be used to screen for joint effusions and to evaluate for fluid collections in cases where soft tissue infection is favored over osteomyelitis. Bone scintigraphy has a very limited role and is reserved for patients with contraindications to MRI. Because localization of involved sites is often difficult on clinical examination, MRI should start with a large field-of-view (FOV) STIR or other fluid-sensitive sequence. For small infants, the FOV can extend from the feet to the upper lumbar spine, which allows evaluation of the lower extremities, pelvis, and lower spine (which can be a source of referred pelvic and lower extremity pain). Once the site and extent of abnormality is localized from the large FOV images, more focused pre-contrast imaging with T1-weighted and fluid-sensitive sequences is performed. Gadolinium-enhanced imaging may be necessary to identify intraosseous, intra-articular, subperiosteal, and soft tissue collections that may benefit from intervention, as well as to identify growth cartilage infection of the unossified epiphyses and apophyses. Except for young infants (below 18–24 months of age) gadolinium-enhanced imaging is unnecessary if bone marrow signal is normal, unless extra-osseous fluid collections are suspected. Ultrasound of Shoulder Dysplasia Mahesh M. Thapa, MD

Cancer predisposition syndromes (CPS) encompass a variety of familial and hereditary cancers and a multitude of gene abnormalities with high risk of cancer. Advances in genetics have led to improved understanding and earlier detection of these syndromes and now offers the potential for preclinical diagnosis of associated tumors. Imaging has become an essential component of the clinical approach to management of many CPSs and the care of children with a confirmed diagnosis or suspected of having a CPS. Some common and uncommon CPSs in children will be reviewed including neurofibromatosis type 1, Beckwith-Wiedemann syndrome, multiple endocrine neoplasia, Li-Fraumeni syndrome, von Hippel– Lindau syndrome, and familial adenomatous polyposis. Radiologists should be familiar with these syndromes, their commonly associated tumors, and the imaging techniques often used, and the current screening and surveillance recommendations to optimize the assessment of affected children. Imaging the Temporomandibular Joint in Pediatric Patients Arthur Meyers, MD

Imaging of the temporomandibular joint (TMJ) in children is most commonly done in the setting of juvenile idiopathic arthritis (JIA). Approximately half of children with JIA have at least one sign or symptom attributable to their TMJs and many more have pathologic findings on

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MRI. The TMJ is a complex synovial joint with a fibro-cartilaginous disc between the mandibular condyle and the glenoid fossa of the temporal bone. As in other synovial joints JIA can cause inflammatory synovial hypertrophy with eventual cartilage loss and osseous erosions. Destructive changes at the TMJ may also cause limited motion and disc subluxation or dislocation. These changes lead to a variety of symptoms including decreased chewing ability, jaw and facial pain, headaches, and malocclusion. Additionally, children with JIA may also develop growth abnormalities at the mandibular condyle causing disfiguring facial deformities which limit jaw opening. MRI of the TMJ allows for detection of synovial hypertrophy, osseous erosions, disc subluxation/dislocation, and allows assessment of joint motion. Using MRI for early detection and monitoring of TMJ disease in children with JIA aids clinicians in the use of local and systemic treatments with the goal of preventing long-standing joint disease and craniofacial deformities. US Guided Joint Injections Jeffrey P. Otjen, MD

Cancer predisposition syndromes (CPS) encompass a variety of familial and hereditary cancers and a multitude of gene abnormalities with high risk of cancer. Advances in genetics have led to improved understanding and earlier detection of these syndromes and now offers the potential for preclinical diagnosis of associated tumors. Imaging has become an essential component of the clinical approach to management of many CPSs and the care of children with a confirmed diagnosis or suspected of having a CPS. Some common and uncommon CPSs in children will be reviewed including neurofibromatosis type 1, Beckwith-Wiedemann syndrome, multiple endocrine neoplasia, Li-Fraumeni syndrome, von Hippel–Lindau syndrome, and familial adenomatous polyposis. Radiologists should be familiar with these syndromes, their commonly associated tumors, and the imaging techniques often used, and the current screening and surveillance recommendations to optimize the assessment of affected children.

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needed for optimal long-term postoperative results and knee stability. The structures forming the posterolateral corner include lateral (fibular) collateral ligament, arcuate ligament, popliteus muscle and tendon, popliteofibular ligament, fabellofibular ligament and posterolateral capsule. Fibular collateral ligament, popliteus myotendinous complex and popliteofibular ligament are important stabilizers of the knee. Injuries to these and other structures will be discussed through case examples. Pitfalls of MRI will also be addressed. Conclusion: It is important to recognize posterolateral corner injuries accompanying other internal derangements of the knee so that they can be treated appropriately for optimal long-term surgical results and knee stability.

Vascular Malformation Intervention Giridhar Shivaram, MD

Pediatric vascular tumors (VTs) and vascular malformations (VMs) can be confusing entities both clinically and on imaging. These lesions are commonly misdiagnosed on diagnostic imaging studies, which can lead to inappropriate management, especially when there is additional uncertainty in the clinical diagnosis. However, by using a few simple clinical and imaging rules, the majority of VTs and VMs can be correctly classified and appropriate treatment can be selected. The purpose of this presentation is to present a simple and practical approach to the selection and interpretation of diagnostic imaging studies for VTs and VMs. Basic interventional radiology treatment options for their management will also be outlined.

CARDIAC IMAGING

Skeletal Dysplasias Shawn E. Parnell, MD

Aortopathy Associated with Congenital Heart Disease Prakash Masand, MD

The skeletal dysplasias are a large, complex group of disorders characterized by abnormal bone growth and short stature. The standard imaging modality for the diagnosis of skeletal dysplasias is the skeletal survey, and familiarity with its interpretation is important for the guidance of appropriate treatment and genetic testing. In this brief 10 min discussion, we will review the components of the skeletal survey, highlighting key imaging findings, appropriate nomenclature, and providing examples of several common dysplasias. The goal of this short discussion is to provide an organized approach for imaging interpretation of skeletal dysplasias.

INTRODUCTION: Bicuspid aortic valve is associated with coarctation and ascending aorta dilation. Abnormalities of the ascending aorta and aortic root are prevalent in other types of congenital heart disease such as single ventricle, truncus arteriosus, transposition of the great vessels, and tetralogy of Fallot amongst others. Connective tissue disorders like Marfans and Loeys-Dietz also predispose to aortic dilation and tortuosity which requires frequent follow-up imaging. The concept of aortic dilation related to these entities is rightly referred to as intrinsic aortopathy, rather than so called post-stenotic dilation. The ongoing dilation of the aortic root and ascending aorta may predispose to dissection and rupture . Further, if aortic insufficiency develops, it may lead to ventricular failure. DISCUSSION: Imaging of the aorta in the realm of CHD is usually performed using cross-sectional imaging techniques such as CT and MRI, with angiographic information provided after contrast administration. The recent developments in MR technology have ensured that aortic imaging can be performed using robust non-contrast sequences such as the spoiled gradient-recalled echo and the 3D SSFP (Steady state free precession) sequence , both commonly run with any basic cardiac MRI exam package. Advances in MR angiography allow beautiful images of the aorta to be acquired using free-breathing techniques, and the advent of blood-pool contrast has ensured superior contrast resolution. Whenever MRI cannot be performed, latest developments in scanner hardware allow CT angiography to be done at very low radiation doses. CONCLUSION: Aortic abnormalities are fairly common with underlying CHD and it is important to know the imaging techniques, parameters and criteria for a thorough evaluation of these patients. Further follow-up and surgical decision making is reliant upon the information provided by the Radiologist when intrinsic aortopathy is in question.

Posterolateral Corner Injuries Siddharth P. Jadhav, MD

Posterolateral corner injuries are being seen more commonly in pediatric patients with increased participation in competitive sports. Objectives: 1. To describe anatomy and normal variations of the posterolateral corner 2. To review imaging findings in posterolateral corner injuries through case examples 3. To discuss pitfalls of imaging Discussion: The anatomy of the posterolateral corner of the knee is complex. Normal variations and disagreement over attachments further complicate matters. Posterolateral corner injuries are being increasingly recognized in pediatric injuries with more involvement in competitive and contact sports as well as from increased use of MR imaging. They often accompany other internal derangements of the knee. Clinical evaluation of these at the time of injury may be limited due to significant joint effusion and swelling that results from associated injuries, usually anterior cruciate ligament tear. Repair of posterolateral corner injuries may be

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 Cardiopulmonary Disease Shilpa V. Hegde, MD

Congenital heart diseases are frequently associated with abnormalities of the airway and lungs. Extrinsic compression of the airway by vascular rings and slings are well known. However intrinsic airway abnormalities such as tracheal stenosis and tracheobronchomalcia are also often seen. Airway compression is also seen as a post-operative complication such as with placement of vascular stents. Lung abnormalities found with congenital heart disease are lung hypoplasia, lobar overinflation and horse shoe lung. Pulmonary artery and vein occlusion and pulmonary arterial hypertension are frequently associated with congenital heart disease. Pleural effusion secondary to abnormal lymphatic drainage is associated with congenital heart disease. Chest wall abnormalities such as scoliosis, pectus excavatum and diaphragmatic palsy effect respiratory function and increase the morbidity. Chest radiographs play an important role as a first line of investigation and demonstrate many of the abnormalities. Contrast enhanced CT and MRI are invaluable in the assessment of the mediastinal structures, pulmonary vasculature and parenchyma. Dynamic pulmonary CT is becomingly increasingly popular in diagnosing abnormalities of airway dynamics. This technique in particularly useful in the assessment of unstable patients and evaluation of severely stenotic airways where invasive procedures such as bronchoscopy is difficult or even impossible. Abdominal Complications Associated with Complex Congenital Heart Disease Shi-Joon Yoo, MD

Gastroenteric complications in patients with congenital heart disease increase morbidity and mortality. Some complications involve the abnormally developed organs, while others are associated with compromised circulation of otherwise normally developed organs. Necrotizing enterocolitis (NEC): NEC is associated with compromised abdominal circulation due to systemic-to-pulmonary arterial shunt, such as patent ductus arteriosus and Blalock-Taussig shunt, particularly in infants with a low birth weight. While abdominal radiographs provide the evidences of developed NEC, Doppler ultrasound or phase-contrast MR provides information regarding compromised abdominal circulation preceding NEC, Hepatic fibrosis: Right-side heart failure including Fontan operation results in hepatic congestion and fibrosis. As the liver function test is often normal despite severe hepatic damage, imaging assessment of the extent of hepatic damage is important. MR angiograms and phase-contrast imaging provide morphologic and hemodynamic changes of the liver. Protein losing enteropathy: Protein losing enteropathy is a catastrophic complication of Fontan operation. It is the result of cardiovascular compromise and lymphatic insufficiency. Phase-contrast MR or Doppler ultrasound may provide information regarding compromised intestinal blood flow, allowing detection of the disease in preclinical stage. Contrast-enhanced lymphangiography is an emerging technique for detection of leaking lymphatics. Midgut volvulus: Heterotaxy syndrome is associated with intestinal malrotation and at a high risk of midgut volvulus. Published data from large series suggest that imaging is required only for symptomatic patients and that prophylactic Ladd procedure is not required. Gastroesophageal reflux and vomiting: Approximately 15% of patients with right isomerism have hiatal hernia. Chest radiographs may prompt the diagnosis by showing the gas-filled gastric fundus in the thorax. When the patient presents with frequent respiratory infection, barium esophagography is recommended. The Brain: Prenatal and Postnatal Effects of Congenital Heart Disease Dianna M. E. Bardo, MD

Early growth and development of the brain begins with neurulation and cellular migration throughout fetal life and continues in stages, during which synapse connections are made, throughout infancy and early

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childhood. Synaptogenesis around the time of birth in the primary sensorimotor cortex is key for normal movement and sensation, at approximately 9 months successful connections in the parietotemporal association cortex are important in language and spatial attention, and those in prefrontal cortex between 2 and 3 years, are crucial in executive and integrative neurocognitive function. It is believed that the brain is most susceptible to injury during these times of peak growth. Growth and development of the brain in a fetus with congenital heart disease (CHD) may be altered perhaps due to inadequate perfusion via the placenta (two vessel umbilical cord), reduced cerebral perfusion limited by an obstructive lesion (HLHS, aortic arch hypoplasia or interruption), or perhaps increased cerebrovascular flow (large R to L shunts, PA atresia or TOF). Infants and young children with CHD may also suffer from poor brain growth and development secondary to a variety of factors including persistent hypoxia, multiple exposures to general anesthesia required for imaging, other diagnostic procedures, or surgical repair/palliation, or intraoperative cardiopulmonary bypass or peri operative ECMO. Insults which occur at crucial times in brain growth and development, from whatever cause, may lead to focal or global injury which may result in learning and mental disability, seizure activity, and behavior and learning problems, in children with CHD. Cardiomyopathy Associated with Muscular Dystrophies Daniel Wallihan, MD

Muscular dystrophy (MD) is a group of genetic disorders resulting in progressive weakness and dysfunction of the musculoskeletal system. Several of these conditions can also result in myocardial dysfunction. MD patients are now living longer due to improved treatment of associated pulmonary complications, historically the leading cause of death. This longer lifespan has resulted in cardiomyopathy becoming a leading cause of morbidity and mortality despite the limited demands placed on the heart due to relative immobility. Treatments exist which have been reported to delay the onset or slow the progression of cardiomyopathy in this population. However, many of the medications may result toxicity to other organs or have limited long term effects. The potential complications make early identification, grading the severity and monitoring progression of cardiac dysfunction of paramount importance. The cardiac pathology occurring in the muscular dystrophies is a dilated cardiomyopathy with pathogenesis depending on the type of cardiomyopathy. In the most common forms of MD, Duchenne and Becker MD, a defect in the synthesis of dystrophin leads to myocardial disease. The assessment of cardiac dysfunction is best performed with MRI. Decreasing left ventricular systolic function and increasing end-diastolic volume are the primary measures used to determine progression of cardiomyopathy. Many studies have suggested that following late gadolinium enhancement is also of great importance as it may be seen before the onset of measurable cardiac dysfunction and may predict a subgroup of patients who will have earlier onset or more rapid progression of cardiac disease. Many centers also use different forms of strain analysis to quantitate regional myocardial dysfunction. The imaging evaluation of cardiomyopathy associated with MD is of critical importance, often guiding care and leading to improved long term outcomes. Pregnancy and Congenital Heart Disease Siddharth P. Jadhav, MD

Background: Pregnant women with congenital heart disease are at increased risk for cardiac and neonatal complications Objectives: 1. To describe how pregnancy affects the cardiovascular system 2. To review congenital heart diseases that increase risk for a cardiac event in pregnancy 3. To discuss role of imaging Discussion: Congenital heart disease has become more prevalent in women of childbearing age. It represents about 75% of the heart disease seen in

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pregnancy in the developed world. During the course of pregnancy, hormonally mediated changes result in an increase in blood volume, red blood cell mass, and heart rate. Systolic subaortic ventricular function decreases near term and early postpartum. Different degrees of chamber enlargement have been observed. The risk of pregnancy depends on the underlying heart disease and factors such as ventricular and valvular function, functional class, and cyanosis. Acyanotic conditions, such as atrial and ventricular septal defects, usually cause no increased maternal or fetal risk. Similarly, surgically repaired cyanotic conditions such as tetralogy of Fallot usually cause no problems. The main problems arising from congenital heart disease are due to obstructive lesions, pulmonary hypertension or Eisenmenger’s syndrome. MRI (without gadolinium) should be considered if echocardiography is insufficient for diagnosis. Imaging is helpful for prognostication and also guides intrapartum and peripartum decision making. Conclusion: Hemodynamic changes during pregnancy can adversely affect maternal and fetal outcome in the setting of congenital heart disease. Imaging plays an important role in making management decisions in accordance with set guidelines. Acquired Heart Disease in Adults with Congenital Heart Disease: What to Image, How to Image, When to Image Andrada R Popescu, MD

Great achievements and major developments in pediatric cardiology, cardiac surgery and critical care have significantly decreased mortality in pediatric population with congenital heart disease. Mortality has shifted from childhood towards adulthood, with steady increase of age at death. Acquired coronary artery disease, arrhythmias, and heart failure are the leading causes of morbidity, hospitalization and mortality in adults with congenital heart diseases (ACHD). This is a review of main congenital heart disease associated acquired heart disease by cross sectional imaging including echocardiogram, computer tomography and cardiac MRI. Acquired heart disease in patients with tetralogy of Fallot, coarctation of aorta, transposition of great vessels, single ventricle physiology and pulmonary hypertension will be discussed. The role of cross sectional imaging with focus on computer tomography and magnetic resonance for detailed assessment and surgical planning will be discussed. Prognostic Imaging in Congenital Heart Disease S. Bruce Greenberg, MD

Surgical and medical management of children with congenital heart disease has resulted in an improved prognosis. Although mortality and morbidity is improved, both remain below that of the general public. Imaging can be used as a prognostic tool to predict increased morbidity and mortality. Ascending aorta size in patients with bicuspid aortic valve and collagen vascular disease guides the timing of future surgery. Children following surgery for coarctation of the aorta are susceptible to re-coarctation and aneurysm formation. CTA and MRA play an important role in detection of coarctation repair complications. Right ventricle progressive enlargement is the result of tetralogy of Fallot repair and pulmonary stenosis treated by valvotomy. Cardiac MRI guides the timing of valved pulmonary conduit placement in patients with chronic pulmonary regurgitation. Right ventricle size is prognostic for survival in patients with single ventricle physiology following Fontan palliation.

CHEST IMAGING How to Image and Describe Congenital Lung Malformations Paul Thacker, MD

Congenital lung anomalies represent a broad spectrum of developmental malformations of the lung parenchyma, venous drainage, and arterial supply. These lesions can present across a wide age range extending from

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the prenatal period into adulthood. Thus, it is crucial for the pediatric radiologist to be aware of the most up-to-date imaging evaluation and descriptive terminology to ensure accurate and timely diagnosis, aiding in patient outcome optimization. This presentation aims to demonstrate the spectrum of these lesions which may be encountered in clinical practice. We will first discuss a simple algorithm for imaging as well as the strengths and weaknesses of each modality, emphasizing the latest advanced techniques in multidetector computed tomography and magnetic resonance imaging. We will then discuss each malformation in brief, stressing accurate description of each malformation as well as key findings that should be reported in order to aid treatment planning. Through this discussion, audience members will gain increased knowledge of the nuances of describing and imaging these relatively uncommon congenital anomalies. Imaging Pulmonary Hypertension Alan S. Brody, MD

PHtn can be defined as mean pulmonary arterial pressure (PAP) >25 mmHg, or >50% systemic. Secondary PHtn is far more common than idiopathic, but idiopathic PHtn is often rapidly fatal. Most common secondary causes are cardiac disease; persistent pulmonary hypertension or neonatal lung disease; and lung disease or hypoxia. Pulmonary venooclusive disease and pulmonary capillary hemangiomatosis are rare causes that may be suggested by imaging, but require lung biopsy. Echocardiography is the usual screening method. Tricuspid regurgitant velocity >2.5 m/s is often used for further evaluation. RVH further supports the diagnosis. Echocardiography also identifies intracardiac causes of PHtn. Correlation for PAP is fair to good between echocardiographic and angiography which remains the gold standard. In addition to the most accurate measurement of PAP pulmonary vascular resistance can be measured and pulmonary venous anatomy assessed. CXRs may show increased MPA and pruned vessels. MRI can provide comprehensive evaluation. PAP accuracy on MR is similar to echocardiography. Cardiac MR requires highly expert interpreters. CT also provides a useful assessment. Three suggestions for the reading room: Although the CXR will rarely be the first indication of PHtn, the diagnosis should be suggested if the appearance is suggestive. PHtn requires different treatment from most other cardiac disease. On CT or MRI, the pulmonary artery should be about the same size as the ascending aorta. A ratio of clearly greater than 1:1 suggests possible PHtn. A CT scan that shows mosaic attenuation without air trapping on expiratory images should raise the possibility of PHtn. Bronchopulmonary Dysplasia: How to evaluate and interpret BPD in neonates Matthew L. Cooper, MD

BPD, also known as chronic lung disease of infancy, is a disorder of lung injury and repair originally ascribed to positive pressure ventilation and oxygen toxicity. Since the introduction of surfactant replacement therapy for RDS, antenatal glucocorticoid treatment, and refinements in assisted ventilation, BPD is now uncommon in larger and more mature infants with gestational age exceeding 30 weeks or weighing more than 1200 g at birth, and survival has improved for the extremely low birth weight infants (<1000 g). In 1999, the term “new BPD” was coined to distinguish the type of chronic lung injury in very immature infants in the post surfactant era from the condition originally described in 1967. “New BPD” is fundamentally an inhibition of acinar and vascular growth during the vulnerable saccular stage of lung development and has a different radiographic appearance than old BPD. The updated clinical definition of BPD should be kept in mind when interpreting radiographic studies. In the clinical setting of an acute decompensation, the referring clinician wants to know about support apparatus placement, atelectasis, inflation status and interstitial edema. CT scans accurately depict the underlying gross pathological lung parenchymal changes and can help assess disease

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severity and evaluate for complications. Neither radiographic studies nor other biomarkers yet developed can accurately predict patients’ long term clinical outcome and risk of chronic respiratory morbidity. How to Dynamically Image the Lungs and Airways in Children Edward Y. Lee, MD, MPH

Recent advances in multidetector computed tomography (MDC) and magnetic resonance imaging (MRI) have revolutionized imaging evaluation of lungs and airways in the pediatric population. Paired inspiratory-expiratory MDCT imaging and cine MDCT imaging can be used to assess dynamic disease processes such as tracheobronchomalacia in pediatric patients. With the latest widedetector MDCT scanners (256 – 320 detectors), real-time and dynamic four-dimensional (4D) MDCT imaging is possible even in infants and young children without sedation and intubation with controlled ventilation. MRI, which is a powerful imaging modality that combines anatomic and functional data without the use of ionizing radiation exposure, can now be used for dynamically imaging the lungs and airways in older children utilizing fast imaging sequences. In addition, with the recent development of MRI compatible spirometer, MRI can be now used in infants and young children who cannot follow breathing instruction. With these many recent technical advances in dynamically imaging the lungs and airways in children, the main challenge is to continuously and sufficiently gain necessary technical knowledge. Therefore, the overarching goal of this presentation is to review the upto-date MDCT and MRI techniques in dynamically imaging the lungs and airways in the pediatric population. A clear understanding of the up-to-date knowledge of clinical utilization of MDCT and MRI for dynamically imaging the lungs and airways has great potential to lead to optimal pediatric patient care. Pediatric Chest Wall Masses Ramesh S. Iyer, MD

Disorders of the pediatric chest wall comprise a wide array of pathology. They may be evaluated by several imaging modalities including radiography, ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). The most common chest wall disorders include congenital deformities, infection, and benign and malignant tumors of soft tissue and bone. The purpose of this talk is to equip the learner with important entities within each of these categories of chest wall pathology. Among congenital disorders, pectus deformities will be highlighted. Bacterial and tuberculosis infections will be discussed. Benign vascular lesions of the chest wall include hemangioma and venolymphatic malformations. Review of benign bone tumors will incorporate fibrous dysplasia and osteochondroma. Finally, malignancies of the chest wall will be discussed, with focus on Ewing family sarcomas, osteosarcoma and rhabdomyosarcoma. The primary imaging modalities for each of these disease categories will be reviewed. I Found a Lung Nodule on CT – What is the Chance it Could be Cancer? Sjirk J. Westra, MD

In order to answer this question, I will present a short review of the literature on pediatric lung cancer. Metastatic disease in the setting of a known extrapulmonary malignancy is much more likely to be a cause of a malignant nodule (typically solid or lobular with sharp borders), than is a primary lung tumor. Pleuropulmonary blastoma, the most common primary lung malignancy of childhood, usually presents before the age of 6 years, and has a varied appearance ranging from cystic to solid, but is typically a larger mass when solid. The cystic form of

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pleuropulmonary blastoma can be small, but should not be confused with a solid pulmonary nodule. Neoplasms associated with the central airways (carcinoids, mucoepidermoid carcinomas, etc.) are nearly always symptomatic at the time of diagnosis and usually present as an endobronchial mass with post-obstructive atelectasis or pneumonitis. Primary bronchogenic carcinoma is extremely rare in childhood, and reported cases of squamous cell carcinoma presented with a large tumor with a secondary respiratory infection, or were secondary to recurrent respiratory papillomatosis. Smooth muscle cell tumors have presented as pulmonary nodules on CT in HIV-infected children and in those with other immune deficiencies. Bronchioalveolar carcinoma has been described in children treated for extrathoracic malignancy, and is associated with chronic infections and congenital pulmonary airway malformations. Unlike in adults, the presence of ground-glass characteristics within a nodule or mass does not signify a potential malignancy. The work-up of a solid pulmonary nodule that is truly incidentally detected should individualized. Functional Vascular Imaging of the Chest Mark Ferguson, MD

The dynamics of vascular blood flow can be assessed by several imaging modalities including ultrasound, magnetic resonance imaging (MRI), and catheter based angiography. To evaluate vasculature within the chest in a non-invasive fashion, MRI stands out as a superior option. Time-resolved MR angiography (MRA) allows for visualization of vascular structures in a physiological sequential manner. The contrast bolus can be followed as it passes through the pulmonary and systemic circulations. Furthermore, when utilizing this technique with a blood-pool contrast agent, both the dynamic assessment as well as high-resolution equilibrium imaging can be obtained of the same structures. This combination can be helpful in confidently establishing a diagnosis. Phase contrast imaging is another powerful MRI tool for functional blood flow assessment. This technique can be performed without intravenous contrast agents, and allows for the evaluation of blood flow velocities and volumes in a quantified manner as well as the visualization of pulse waveforms. Such metrics are critical when assessing for stenoses, collateral flow, or shunts. This brief talk is intended to describe the application of these MRI techniques to the evaluation of vasculature within the chest. Childhood Interstitial Lung Disease Jennifer Soares, MD

Childhood Interstitial Lung Disease (chILD) is a term used to describe a broad range of diverse and rare conditions in children. Individually these disorders are rare but as a group of rare diffuse lung diseases, there are many patients. ChILD is defined as a syndrome consisting of signs and symptoms of chronic lung disease such as crackles, retractions, hypoxemia, and diffuse lung disease on imaging, in the absence of a known cardiopulmonary disorder. Once a child presents with a chILD syndrome a more extensive search for an underlying etiology or histopathologic diagnosis must be sought. This search and discovery is complicated by invasive testing, an actively evolving pediatric classification system for these disorders, poorly understood treatment options, and significant morbidity and mortality. In the last decade, developments in genetic sequencing and recognition of specific imaging patterns has allowed for the diagnosis of some forms of ChILD without need for invasive studies such as lung biopsy. This short talk will concentrate on the current evaluation of interstitial lung disease in children and the need for a standard organized method of imaging for the patient.

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Tuesday, April 28, 2015

ONCOLOGICAL IMAGING I FDG-PET: Techniques, Pediatric Variants Andrew T. Trout, MD

FDG-PET is the workhorse of metabolic imaging in oncology. FDG-PET is widely applied in adult malignancies with demonstrable benefit in the identification, staging and follow up of many types of tumors. FDG-PET is not as widely applied in pediatric patients but adds value in the assessment of many pediatric and young adult neoplasms as well as in some non-neoplastic conditions. FDG-PET also provides a means to survey the whole body for neoplastic or inflammatory abnormalities. While FDG-PET imaging of the pediatric and young adult patient has many similarities to FDG-PET imaging of adult patients, there are important differences in patient preparation, radiotracer dosing and scanning parameters. Additionally, there are normal findings that are unique to pediatric patients that need to be recognized. The purpose of this talk is threefold: 1. To provide a review of the basics of FDG-PET (and FDG-PET/CT) imaging technique for pediatric and young adult patients 2. To review some normal findings on FDG-PET imaging that are unique to young patients 3. To briefly survey applications of FDG-PET in pediatric and young adult patients After this talk, the participant should be able to recognize the role FDGPET imaging plays in the management of pediatric and young adult malignancies and should have an understanding of the basics of imaging young patients with this modality. Whole Body MR: Techniques and Staging in Oncology ‐ How To Monica Epelman, MD

Whole-body magnetic resonance imaging (WB-MRI) is an evolving technique that allows imaging of the entire body in a reasonable time. Its wide availability and lack of radiation exposure makes this method appealing for the evaluation of the pediatric patient. WB-MRI assists in the evaluation of metastatic spread and in monitoring treatment, which are important for prognostication. WB-MRI is highly sensitive for the detection of pathologic lesions, but it is not specific for malignancy; therefore, it cannot be used to differentiate benign conditions from malignant entities. Bone marrow lesions manifest as high signal intensity lesions and are usually more easily detected on STIR images than on scintigraphy. Focal parenchymal lesions could potentially be differentiated by their slightly different signal intensity; however, pathologic lymph nodes cannot be discretely distinguished from normal nodes on the basis of signal intensity. Although WB-MRI allows evaluation of the entire body with a single examination, more experience and data are needed to standardize indications in each type of cancer and at every stage of it and to evaluate its utility in the evaluation of other multifocal processes in children. Whole Body MR versus PET/CT for Staging of Children with Cancer Heike E. Daldrup-Link, MD, PhD

The increase in clinical radiation exposure during the last decade has led to growing concerns throughout the medical community. Several human population studies have shown that exposure to ionizing radiation above doses of 50-100 mSv increases the risk for development of secondary cancers later in life. This is especially concerning for young patients because they are more susceptible to the effects of radiation than older patients and they live long enough to encounter secondary cancers later in live. In pediatric oncology patients, imaging exams at diagnosis are essential for tumor staging, yet should not cause additional harm later in life.

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In a recent study, we demonstrated sensitive tumor staging of children with lymphomas and sarcomas with a radiation free imaging MR imaging test, composed of integrated color-encoded whole body diffusion weighted MR images and ferumoxytol-enhanced T1-weighted gradient echo scans for anatomical orientation. This MR imaging test detected 158 of 174 malignant tumors while FDG-PET/CT detected 163 of 174 malignant tumors. Resultant sensitivities, specificities, and diagnostic accuracies were excellent, with values above 90%, and were not significantly different between the two imaging modalities. Tumor staging results also showed very good agreement between both imaging modalities with a κ of 0.93. At the same time, the associated radiation exposure could be reduced from 12.5 mSv for the PET/CT scans to zero for the MRI scans. Both exams required roughly the same time between tracer injection and end of scan. Therefore, this MR imaging test could serve as a potential alternative to PET/CT scans for cancer staging. Whole Body MRI of Vascular Malformations Arnold Carl Merrow, MD

Whole body MRI has been used increasingly over the last decade in oncologic, traumatic, and infectious imaging investigations that demand high-sensitivity screening for bone, soft tissue, and visceral abnormalities. While MRI has long been used for detailed evaluation of focal soft tissue disorders, evolving imaging methods, including rapid sequence acquisition and preservation of blood pool contrast, are advancing the utility of whole body MRI in the interrogation of vascular anomalies. This complex group of diseases, ranging from neoplastic to developmental, benign to malignant, and focal to diffuse processes, requires a variety of MRI methods for detection and characterization. This session will review the indications for whole body MRI in patients with vascular malformations and discuss optimization of relevant MRI techniques. PET/MR: Technique and Clinical Cases Victor J. Seghers, MD, PhD

PET/MR is a relatively new invention that promises lower radiation relative to PET/CT, improved functional and diagnostic imaging by leveraging the strengths of MRI relative to CT, and greater convenience to patients by combining two modalities onto one machine. However, the technology is so new that devising scheduling, staffing, and imaging protocol PET/MR workflows is challenging. The lack of a PET/MR CPT code raises not only questions regarding billing, but also the definition of a PET/MR exam. Is it a PET + MR-Attenuation Correction Sequence? PET + streamlined MR? PET plus full diagnostic MR? This definition will affect the overall value of PET/MR relative to PET/CT. The culture and workflows of Nuclear Medicine and MRI are different, and introducing a new technology into a non-research, clinical environment can be difficult. This talk will discuss our 2 year experience with PET/MR at Texas Children’s Hospital, and how we have tried to overcome these challenges. Cancer Predisposition Syndromes Paul S. Babyn, MD

Cancer predisposition syndromes (CPS) encompass a variety of familial and hereditary cancers and a multitude of gene abnormalities with high risk of cancer. Advances in genetics have led to improved understanding and earlier detection of these syndromes and now offers the potential for preclinical diagnosis of associated tumors. Imaging has become an essential component of the clinical approach to management of many CPSs and the care of children with a confirmed diagnosis or suspected of having a CPS. Some common and uncommon CPSs in children will be reviewed including neurofibromatosis type 1, Beckwith-Wiedemann syndrome, multiple endocrine neoplasia, Li-Fraumeni syndrome, von Hippel– Lindau syndrome, and familial adenomatous polyposis. Radiologists should be familiar with these syndromes, their commonly associated

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tumors, and the imaging techniques often used, and the current screening and surveillance recommendations to optimize the assessment of affected children. NF and MPNST: Evaluation with PET and MR Helen R. Nadel, MD, FRCPC

Neurofibromatosis type 1 (NF1) are considered RAS opathies and are part of neurocutaneous syndromes or phakomatoses. In NF1 the nerve tissue grows tumors (neurofibromas) that may be benign but cause serious damage by compressing nerves and other tissues. A sarcoma arising from a neurofibroma or peripheral nerve sheath is called a malignant peripheral nerve sheath tumor (MPNST). At least one of three criteria need to be met to define a MPNST: 1.arises from a peripheral nerve; 2. arises from a preexisting benign nerve sheath tumor (neurofibroma); 3.demonstrates Schwann cell differentiation on histologic examination. Up to 50% of MPNST occur in NF1 patients. There is a 1-2% prevelance of MPNST in NF1. Most occur in adulthood between 20 and 50 years of age but 10-20 % MPNST occur in first 2 decades of life but can occur even in young infants. MPNST occur as enlarging palpable masses and need to be assessed in this clinical context in patients with NF1. MRI is the main tool for evaluation. Wholebody MRI with STIR sequences has been recommended for yearly evaluation. MPNST however have similar characteristics to benign neurofibromas. Some worrisome findings include: Large tumors (> 5 cm), invasion of fat planes, heterogeneity, ill-defined margins, and edema surrounding the lesion are more suggestive of MPNSTs. FDG PET CT with dual time point imaging and SUV cut off of greater than 3.5 has been suggested to provide diagnostic and prognostic information in detecting malignant potential and lesions recommended for biopsy. Screening for and Assessment of Osteonecrosis in Oncology Patients Sue C. Kaste, DO

Survivors of childhood cancer are at increased risk for developing chronic conditions as a result of their disease and therapy. Osteonecrosis is a significant toxicity in pediatric oncology with growing recognition of its prevalence, impact on the patient’s life, and lack of standardization of diagnosis and intervention guidelines. Children treated with high dose and/or prolonged glucocorticoids as well as those aged older than 10 years at the time of therapy are the patient populations in whom osteonecrosis most frequently develops. As the glucocorticoid exposure is systemic, multi-joint involvement is typical. Though easily obtained and relatively inexpensive, radiographs are insensitive for identifying osteonecrosis in its earliest stages when interventions may be most effective in ameliorating the process. MR is the most sensitive available modality for detecting osteonecrotic lesions and will be the primary modality discussed in this presentation. Extensive lesions may be present and remain asymptomatic. Thus, recognizing the ‘at risk’ patient populations is necessary to develop screening protocols to identify these lesions early in their development in order to preserve joint function. MR-determined lesions occupying more than 30% of the femoral head frequently progress to collapse, even in young patients. Thus, diagnostic imaging is critical for its detection, characterization, follow-up for progression or healing and to assess the effects of intervention. This presentation is designed to provide a brief review of the pathophysiology of osteonecrosis, describe the ‘at risk’ patient groups, patterns of involvement, imaging characteristics and techniques used for detection.

ONCOLOGICAL IMAGING II Abdominal MRI Protocols in Pediatric Oncology Jonathan R. Dillman, MD

Magnetic resonance imaging (MRI) is increasingly used to evaluate benign and malignant abdominal tumors in children. This increased

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utilization likely relates to multiple factors, including recent increased emphasis on the potential harms of ionizing radiation, superior soft tissue contrast resolution compared to CT, and improving image quality. Roles of MRI in the assessment of pediatric abdominal masses include: initial characterization at the time of diagnosis, assessment of response to therapy, and surveillance for recurrent disease after the completion of treatment. The purpose of this talk is to present stateof-the-art clinical MRI techniques and protocols for the evaluation of pediatric abdominal masses, with an emphasis on liver and renal imaging. Coil selection, pulse sequence choices, artifact reduction, and selection of gadolinium-based contrast agent will be discussed. The roles of certain advanced MRI techniques (such as chemical shift and diffusion-weighted imaging) in assessing pediatric abdominal tumors will be presented as well.

Update on RECIST and Staging of “Common” Pediatric Tumors Ethan A. Smith, MD

Imaging plays a critical role in the care of pediatric oncology patients, especially those with solid tumors. Initial diagnosis and staging of tumors, often based primarily on imaging, assists oncologists and surgeons in establishing a treatment plan and allows for discussions with patient families regarding prognosis. Imaging also plays a vital role in following treatment response in patients undergoing chemotherapy and/or radiation therapy, as well as assessing for tumor recurrence after therapy. As such, staging systems have been developed for several pediatric solid tumors, and specific criteria for objectively measuring treatment response have also been established and revised. The objectives of this session will be to describe specific methods for measuring treatment response, including RECIST (Response Evaluation Criteria In Solid Tumors) and its newer iterations, as well as the World Health Organization (WHO) criteria. Additionally, specific staging systems for certain relatively common pediatric tumors will be presented, including Wilms tumor, neuroblastoma and hepatoblastoma.

Pediatric Renal Tumors - Update from COG Geetika Khanna, MD, MS

Renal tumors are the second most common abdominal malignancy in children. Though Wilms tumor is widely recognized as the most common renal malignancy in children, it is less well known that renal cell carcinoma (RCC) is the second most common renal tumor in children. This is followed by rhabdoid tumors, clear cell sarcomas, mesoblastic nephroma, and cystic nephroma. The presentation will provide a summary of the Children’s Oncology Group imaging experience with pediatric renal tumors. When a renal mass is discovered at sonography, the vasculature should be carefully evaluated for tumor thrombus. However, routine Doppler sonography for tumor thrombus evaluation after CT/MR evaluation is no longer recommended. CT and MR have comparable diagnostic accuracy for local staging of renal tumors, but MR is the preferred modality for children with multifocal, bilateral masses. Ascites beyond cul-de-sac and retroperitoneal hemorrhage have high specificity for tumor rupture, which implies stage III disease. Detection of lymph node metastasis remains limited by imaging. While nephrogenic rests show homogeneous enhancement and Wilms tumors tend to be more heterogeneous, imaging differentiation of the two remains challenging. Translocation morphology RCC is the most common subtype of RCC in children. Lymphatic/hematogenous spread is common at initial presentation of pediatric RCC, even in patients with local T1 disease. The current evidence on implications of pulmonary metastasis in this patient population will be summarized.

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S68 Pediatric Lymphoma – Update from COG Stephan D. Voss, MD, PhD

Contrast Enhanced Ultrasound in Pediatric Oncology M. Beth McCarville, MD

Hodgkin lymphoma has served as a paradigm for the use of functional imaging to guide clinical management. Over the past decade, imaging in Hodgkin lymphoma has evolved from simply providing anatomic measurements to offering comprehensive functional imaging and metabolic characterization of sites of disease. This increasing use of functional imaging to guide clinical management necessitates a change in the current definition of response. This presentation will provide an overview of the current response criteria utilized in Hodgkin lymphoma, with emphasis on 18F-FDG PET/CT. In so doing, we will compare response criteria used by cooperative trials groups in Europe and the US. We will also discuss the increasing use of PET/MRI in place of PET/CT, and explore strategies to accomplish CT dose reduction during the multiple PET/CT and CT examinations performed on these patients. At the end of the session, the participant should have an improved understanding of the role functional imaging plays in Hodgkin lymphoma management, the strategies to harmonize response criteria between European and US cooperative groups, and the evolving use of other advanced hybrid imaging techniques to improve our management of these patients.

As cancer therapies become more targeted toward specific tumor markers there is a growing need for imaging modalities that go beyond an assessment of tumor morphology to monitor tumor response. Modalities that provide functional and quantitative information are gaining an increasingly important role in cancer imaging. The conversion of normal tissue to cancer depends on a complex interaction between altered metabolism, hypoxia, angiogenesis, proliferation, apoptosis and metastasis. There are numerous modalities that are available to image these various aspects of tumor biology including FDG PET imaging of tumor glucose metabolism, BOLD MRI of tumor hypoxia and diffusion MRI of tumor proliferation. Tumor angiogenesis can be measured by dynamic contrast enhanced MRI, dynamic contrast enhanced CT or dynamic contrast enhanced ultrasound (CEUS). In the pediatric population the most attractive of these angiogenesis imaging biomarkers is contrast enhanced ultrasound because it avoids exposure to ionizing radiation and the need for sedation. In this talk I will discuss the potential role of CEUS in measuring tumor blood flow in pediatric solid malignancies.

Quantitative Nuclear Medicine Imaging in Oncology Susan E. Sharp, MD

The review aims to provide up-to-date information on nuclear medicine therapy in pediatric cancers focusing on pediatric thyroid cancer and neuroblastoma. Neuroblastoma is the most common malignancy in infancy constituting approximately 30% infantile cancers. The high metaiodobenzylguanidine (MIBG) avidity and known radiosensitivity of neuroblastoma makes 131I-MIBG a potential therapeutic agent. There is objective response to 131I-MIBG therapy in ~30% patients and disease stabilization in another 30-40% of patients. Logistic and radiation safety considerations of MIBG therapy program as well as advances in dosimetry will be discussed. Thyroid cancer is a rare malignancy of childhood and accounts for 0.7% of all pediatric cancers, the vast majority of which are differentiated thyroid cancer. Even though only a few small studies of children treated with radioiodine are available, adult studies have demonstrated reduced risk of recurrence and mortality in patients with differentiated thyroid cancer with postsurgical residual disease. Dosage administration considerations and other practical aspects of radioiodine therapy in children will be outlined. Peptide receptor radionuclide therapy using labeled somatostatin analogues for neuroendocrine tumors and other miscellaneous radionuclide therapies will also be briefly discussed. Radiation risks related to radionuclide therapies, both to the treated children and the bystander risks will be outlined.

Nuclear medicine plays an important role in the evaluation of cancer patients, from initial diagnosis and staging to assessment of treatment response and follow-up after therapy. Standardized approaches for interpreting and reporting nuclear medicine studies are being developed to improve concordance between readers and better quantify treatment response. In FDG PET imaging of lymphoma, Deauville scoring has been shown to be an accurate and reproducible way to report interim scans performed after two cycles of chemotherapy, allowing identification of a cohort of Hodgkin Lymphoma patients with significantly better failure free survival rates. In I-123-MIBG imaging of neuroblastoma, Curie and SIOPEN scoring have been shown to have good interobserver concordance, allowing reproducible assessment of disease extent and response with good correlation to patient outcomes. An important advantage of PET over other imaging modalities is its ability to measure absolute regional radiopharmaceutical concentrations. Quantitative assessments of FDG PET scans (including measurements of SUVmax, percent change in SUVmax, metabolic tumor volume, and/ or tumor-to-non-tumor uptake ratios) have been studied to determine their ability to predict tumor necrosis and patient outcomes. These measurements have been variably shown to provide prognostic information in sarcoma patients.

Nuclear Medicine Therapy in Pediatric Oncology Neha Kwatra, MD

SCIENTIFIC PAPERS Diffusion and Perfusion MR in Pediatric Oncology Shreyas S. Vasanawala, MD, PhD

Qualitative and quantitative assessment of tumors beyond size measurements can be performed with MRI. The two most common techniques are diffusion imaging and perfusion imaging. A synopsis of core concepts of data acquisition and processing for both diffusion and perfusion imaging will be reviewed. For diffusion, impact of echo planar imaging and minimization of resulting artifacts will be covered along with processing of data with multiple diffusion sensitivities. For perfusion imaging, multiphasic data acquisition and the concept of a pharmacokinetic model will be reviewed. Then the most influential recent developments for each method will then be covered. For diffusion, inner volume imaging will be addressed. For perfusion, radial acquisition will be covered.

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

Paper #: 001 Clinical Equivalence of PET/MRI- and PET/CT-Acquired Brain Exams in Children with Epilepsy

Erica Yang, MD, Texas Children’s Hospital, Houston, TX, [email protected]; Ramkumar Krishnamurthy, PhD, Nadia Mahmood, Victor Seghers, Andrew Sher, MD, Michael Paldino, MD.

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Disclosures: Victor Seghers indicated a relationship with Philips Healthcare as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Integrated PET/MR scanners offer the potential to acquire diverse image contrasts - structural, functional, and metabolic - in a single examination. To reach its full potential, this technology will require robust attenuation correction (AC) algorithms based on MR images. The goal of this study was to compare the diagnostic accuracy of FDG-PET images of the brain processed according to an MR-based attenuation algorithm with that of images obtained using traditional CT-based AC. Methods & Materials: IRB approval and informed consent were obtained for this HIPAA-compliant, prospective study. All patients referred for clinical FDG-PET/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). A bootstrap power calculation was performed to determine the number of patients required to detect a 10% difference in diagnostic accuracy (power: 0.8). Raw FDGPET images were processed according to standard, vendor-provided AC algorithms based on either MRI or CT images. Attenuation-corrected images acquired at PET/MR (MRAC) and PET/CT (CTAC) were interpreted by five expert readers. Readers were blinded to the method of attenuation correction as well as all other clinical and imaging data. Consensus between the readers at unblinded re-review of all imaging and clinical data was considered the gold standard. Any potential difference in the accuracy of MRAC compared to CTAC images was assessed using McNemar’s test. Cohen’s kappa was calculated to measure agreement between each reader’s interpretation of MRAC a nd CTAC. Results: The study population comprised 35 patients referred for a diagnosis of epilepsy (mean age: 11 years; range: 2–18 years), each with a paired PET/CT and PET/MR exam. Test characteristics of the blinded interpretation of the PET/MR- and PET/CT acquired AC images compared to gold standard are provided in Table 1. The accuracy of images processed according to an MRAC algorithm did not differ significantly from those obtained using CT-based AC (p>0.3). Overall, there was good intra-reader agreement between the interpretation of MRAC and CTAC (kappa range: 0.55–0.78). Conclusions: The accuracy of FDG-PET images generated by a vendorprovided MR-based AC algorithm was comparable to that of FDG-PET images processed by traditional CT-based AC. These results further support the use of integrated PET/MR systems in clinical practice. Table 1. Diagnostic performance of PET/MR and PET/CT for detection of seizure focus

Sensitivity (%) Specificity (%) Accuracy (%)

PET/MR 71.6 74.7 74.7

PET/CT 70.2 85.1 76.6

Paper #: 002 Performance of PET/MR in the Assessment of Pediatric Histiocytoses: A Prospective Study

Andrew Sher, MD, Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Victor Seghers, MD, PhD, Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Matthew Goette, PhD, Ramkumar Krishnamurthy, PhD, Rajesh Krishnamurthy, et al. Disclosures: Victor Seghers indicated a relationship with Philips Healthcare as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Analyze the performance of 18F-FDG PET/ MR compared to 18F-FDG PET/CT in Langerhans Cell Histiocytosis (LCH) and Rosai Dorfman Disease (RDD) . Methods & Materials: This prospective study had IRB approval and was HIPAA compliant. Following written informed consent 17 18FFDG PET/CT and 18F-FDG PET/MR examinations were performed on nine patients (six male, three female, mean age six; range: 7 months to 16 years) following a single-injection dual-imaging protocol. The indication was LCH in 10/17 exams and RDD in 7/17 exams. A freebreathing, 3D T1-weighted spoiled gradient echo sequence was used for MR attenuation correction and anatomic localization on PET/MR. Two readers blinded to clinical history assessed the anonymized data for metabolically active disease by consensus read. Lesions, defined as non-physiologic FDG uptake above surrounding normal tissue were classified as either disease or benign by the readers. Lesion detection rates and classification agreement between modalities were analyzed via Cohen’s Kappa statistic. Comparison between the two modalities and the reference standard (all available examinations and clinical history) were analyzed with the exact McNemar’s test. Results: 94 lesions were identified on PET/MR compared to 100 on PET/ CT. Of the 94 lesions identified on both exams there was concordant classification in 93 (99%), representing excellent agreement, κ = 0.97 (p <.001), 95% CI (0.94–1.0). Of the six lesions identified on PET/CT but not PET/MR, three were foci of active disease, one was an inflammatory lymph node, while two were artifactual or physiologic. Per the standard of reference, 101 metabolically active lesions were available for analysis (80 were active disease while 21 were benign). There was no statistically significant difference in active disease lesion detection between PET/MR and PET/CT (76/80 (95%) vs. 79/80 (99%), respectively; p=.25) or classification (74/80 (93%) vs. 77/80 (98%); p=.25). The etiology of the misclassified metabolically active disease from each modality is shown in Table 1. The overall accuracies of PET/MR and PET/CT were comparable, measuring 94 and 96% respectively. Conclusions: PET/MR demonstrates clinically equivalent performance to PET/CT for lesion detection and classification in patients with LCH or RDD. PET/MR imaging is a promising lower-radiation alternative to PET/CT for this patient population; further work is warranted to explore monitoring of treatment response in these patients.

Table 1: Etiology of misclassified metabolically active disease on PET/ MR and/or PET/CT Region

Type

Location

Pelvis Chest Chest Abdomen Neck Neck

Bone Lymph node Lymph Node Lymph Node Lymph node Lymph node

Left acetabulum Subcarinal Subcarinal Aortocaval Cervical Cervical

Region Pelvis Chest Chest Abdomen Neck Neck

Dignosis on: PET/MR Benign Benign Benign Benign Benign Benign

PET/CT Benign Disease Disease Disease Benign Benign

Detected on: PET/MR PET/CT No No No Yes No Yes No Yes Yes Yes Yes Yes Reference Standard Diagnosis Disease Disease Disease Disease Disease Disease

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Paper #: 003 Comparison of Lesion Detection and Staging in Pediatric Lymphoma between PET/CT and PET/MR in a Tertiary Pediatric Hospital: A Prospective Study

Andrew Sher, MD, Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Victor Seghers, MD, PhD, Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Ramkumar Krishnamurthy, PhD, Rajesh Krishnamurthy, Eric Rohren, et al. Disclosures: Victor Seghers indicated a relationship with Philips Healthcare as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Analyze the performance of 18F-FDG PET/ MR and 18F-FDG PET/CT in a pediatric lymphoma population by comparing lesion detection, classification and clinical staging between the two modalities. Methods & Materials: This HIPAA compliant prospective study had IRB approval. Following written informed consent 40 18F-FDG PET/CT and 18 F-FDG PET/MR examinations were performed on 25 patients (15 male, 10 female, age 14.7 +/− 3.6). Patients underwent a single-injection dualPET-imaging protocol. A free-breathing, 3D T1-weighted spoiled gradient echo sequence was used for MR attenuation correction and anatomic localization. Two readers blinded to clinical history and previous exams assessed the anonymized data, evaluating for lesion detection, lesion classification (benign or malignant) and Ann Arbor stage. Discrepencies were resolved by consensus. Statistical analyses of lesion detection, classification and Ann Arbor staging were performed via Cohen’s Kappa statistic. Overall accuracy was compared, differences between sensitivity and specificity between each exam and the reference standard (all available examinations and clinical history) were analyzed with the exact McNemar’s test. Results: PET/MR identified 54/55 (98%) of the lesions seen on PET/CT. Of these lesions 49/55 (89%) showed concordant classification representing a substantial agreement, κ=0.681 (p<.001), 95% CI (0.450.92). Ann Arbor staging between modalities demonstrated 85% concordance (34/40 studies), representing a substantial agreement, κ=0.660 (p <.001), 95% CI (0.44-0.88). The etiology of 3/6 discordant exams was a difference in perceived anatomic localization of FDG uptake. Two discordant stagings were due to differences in the interpretation of FDG uptake (i.e. inflammatory vs. malignant lymphadenopathy). The final discordant read was due to non-visualization of a lesion on PET/MR (Table 1). PET/CT and PET/MR did not detect a malignant femoral condyle lesion. Relative to the reference standard, overall accuracy was 82% for both modalities. There was no significant difference between PET/ MR and PET/CT for sensitivity (92 vs. 95%, p>.05) or specificity (61 vs. 56%, p>.05) compared to the reference standard. Conclusions: In patients with pediatric lymphoma, PET/MR demonstrates statistically equivalent performance to PET/CT. Given the reduced radiation exposure, PET/MR imaging is a promising alternative to PET/ CT for pediatric lymphoma patients with improvements likely as advances in whole-body MR sequences are further implemented.

Table 1: Discordant lesions with focal uptake on PET/MR and PET/CT Region

Type

Location

Abdomen Metastasis Right lower quadrant Chest Lymph Prevascular node

Detected on

Diagnosis on: PET/MR

PET/ PET/ MR CT Yes Yes Malignant Yes

Yes

Malignant

Axilla Chest

Chest

Lymph Bilateral Level II node Lymph Right axilla node Metastasis Mediastinum w/ pulmonary involvement Lymph Left hilum Node

Region

Yes

Yes

Benign

Yes

Yes

Benign

Yes

Yes

Malignant

No

Yes

Benign

Diagnosis on: PET/CT Abdomen Benign Chest Benign Neck Malignant Axilla Malignant Chest Malignant

Ann Arbor Staging PET/MR PET/CT 2 1 1 0 0 2 0 1 2 2E

Chest

1

Malignant

2E

Reference Standard: Benign bowel uptake Malignant Malignant Malignant Malignant, mediastinum only Malignant

Paper #: 004 Comparison of Standardized Uptake Values between PET/CT and PET/MR in Pediatric Lymphoma: A Prospective Study

Andrew Sher, MD, Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Victor Seghers, MD, PhD, Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Matthew Goette, PhD, Ramkumar Krishnamurthy, PhD, Rajesh Krishnamurthy, et al. Disclosures: Victor Seghers indicated a relationship with Philips Healthcare as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Compare lesion-based SUV measurements from 18 F-FDG PET/MR with those derived from 18 F-FDG PET/CT in a pediatric lymphoma patient population. Methods & Materials: This prospective, HIPAA compliant study had IRB approval. Following written informed consent 40 18 F-FDG PET/CT and 18 F-FDG PET/MR examinations were performed on 25 lymphoma patients (15 male, 10 female). Patients underwent a single-injection dual-imaging protocol. Mean age was 14.7 (range 5-20). Two different workflows were evaluated. The first cohort (8/40 scans) had PET/CT performed first with an average time of 37.5 ± 7.4 min between PET-CT and PET-MR. The second cohort (32/40 scans) had PET/MR performed first with an average time of 60.4 ± 14.6 min between the PET studies. For analysis the PET/CT and PET/MR were viewed simultaneously and volumes of interest (VOI) were drawn over lesions visualized on PET/MR and PET/CT. Lesions were defined as non-physiologic uptake above background. SUV maximum and mean values were recorded for each lesion and compared between the two modalities in both workflows. For statistical analysis, Spearman correlation coefficients and Wilcoxon signed-rank tests were utilized as appropriate.

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Results: In the PET/CT followed by PET/MR workflow, 25 lesions were identified on seven exams. For the second workflow, PET/MR followed by PET/CT, 30 lesions were identified on 12 exams. In the ‘PET/CT first’ workflow, there was no significant difference in the absolute mean and maximum SUV measurements, with PET/MR SUVMax and SUVMean averaging 7% (p=0.3) and 5.8% (p=0.9) higher, respectively, compared to PET/CT (Table 1). In the ‘PET/MR first’ workflow, the absolute SUVMax and SUVMean values were both significantly lower than those for PET/CT, with an average difference of 33.8% for SUVMax and 31.5% for SUVMean (p< 0.001 for both). SUVMax and SUVMean demonstrated strong correlations between the two modalities in both the first workflow (ρ=0.94 and 0.92 for SUVMax and SUVMean, respectively, p<.01) and second workflow (ρ= 0.86 and 0.82 for SUVMax and SUVMean, respectively, p<.01). Conclusions: Our study demonstrates a high correlation for SUVMax and SUVMean measurements between PET/MR and PET/CT in pediatric lymphoma, implying dependable SUV quantification with PET/MR in this population. Absolute differences in SUV values observed between the two workflows can be partly explained by continued radiotracer uptake over time, but also raises the possibility of systematic under-measurement of absolute SUV by PET-MR

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reviewed, only 20 (17.7%) WBMRI studies had no findings. Of the 93 (82.3%) positive WBMRI, 153 findings were reported, of which 92 were new. WBMRI was performed at 1.5T in 68% and 3T in 32% of patients. Imaging findings were divided into skeletal (63%) or extra-skeletal (37%). Skeletal sites included the skull, spine, ribs/sternum, pelvis, arms or legs. The extra-skeletal findings involved the lungs, liver, lymph nodes, kidneys, adrenal glands, pancreas and other. Findings were classified depending on their specificity and association with CPS, defined as related or unrelated pathology. Most reported skeletal findings consisted of non-specific bone marrow hyperintensities. In all, 10.5% (16/153) of reported abnormalities were tumors related to CPS, 5.9% were benign lesions and 4.6% malignant. Conclusions: WBMRI is very useful in children with CPS to screen for tumors without ionising radiation and to direct other investigations. In addition to detecting related malignancies, of low incidence, it enables close monitoring of non-specific abnormalities that may be of less concern in the general population, but in children with CPS have greater potential to evolve. WBMRI can be performed satisfactorilly at both 1.5 and 3T.

Table 1: Comparison of Quantitative Values between PET/MR and PET/CT

Paper #: 005 Whole Body MRI in Children with Cancer Predisposition Syndromes

Marta Tijerin Bueno, Fellow, Sickkids Hospital for Sick Children/ University of Toronto, Toronto, ON, Canada, [email protected]; Mary-Louise Greer, MBBS, David Malkin, Anita Villani, Rahim Moineddin. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To review Whole Body MRI (WBMRI) performed anually in the surveillance of children with Cancer Predisposition Syndromes (CPS) to evaluate the incidence and spectrum of abnormalities and WBMRI technique. Methods & Materials: A retrospective review of imaging and clinical findings in WBMRI at a tertiary pediatric institution from January 1, 2006 to August 31, 2014 was performed with PACS and electronic patient chart review. The inclusion criteria were children 0-18 years who underwent WBMRI for clinically suspected or genetically confirmed CPS. We also included WBMRI requested for tumors with histology related to Li Fraumeni, Von Hippel Lindau, Hereditary Paraganglioma, Gorlin and Dicer I Syndromes. When WBMRI were positive, derived imaging studies were reviewed, as well as derived clinical examinations, histology from biopsy or surgery and the outcome. Details of WBMRI protocols and techniques were also captured. Data was analyzed with descriptive statistics. These are preliminary results of the study. Results: Our population consisted of 41 patients (15 males and 26 females), with a mean age of 10.8 years at baseline WBMRI. CPS patients identified were Li Fraumeni Syndrome (21), Von Hippel Lindau Syndrome (5) and Hereditary Paraganglioma Syndrome (15). Of 113 WBMRIs

Paper #: 006 The Role of Chest Computed Tomography (CT) as a Surveillance Tool in Children with Neuroblastoma

Sara Federico, Samuel Brady, Alberto Pappo, Jianrong Wu, Robert Kaufman, Sue Kaste, DO, St. Jude Children’s Research Hospital, Memphis, TN, [email protected], et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The amount and frequency of imaging in children with neuroblastoma varies among institutions. This study examines the value of chest CT in a cohort of pediatric patients with high-risk neuroblastoma. Methods & Materials: With IRB approval, we retrospectively reviewed medical records and imaging of 88 patients with high-risk neuroblastoma (NB) diagnosed from January 2002 through December 2009; surveillance imaging conducted through 2013. We excluded 10 patients with chest disease at diagnosis. Using the Kaplan and Meier method, we estimated event free survival (EFS) and overall survival (OS). We used size specific dose estimates for CT scans of the chest, abdomen, pelvis to estimate organ doses to 23 organs. Organ dosimetry was used to calculate cohort effect dose. Results: Median age at diagnosis was 2.7 years (range, 4 months to 12.7 years). 64% were male; 74% were white. 89.7% had stage four

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and 10.3% had stage three disease. Dosimetry was analyzed for 67 of the 78 patients. Sixty-seven patients underwent 1978 CT scans (671 chest, 681 abdomen, 626 pelvis). 5-year OS and EFS were 51.9±6.5% and 42.6 ±6.5%, respectively. Forty-six patients (58.9%) progressed/recurred; 41 (52.6%) died of idsease. 11 (14%) developed thoracic disease/progression found by chest CT (one paraspinal mass, one pulmonary nodules, and nine nodal); MIBG found chest disease in 6. Three of five patients with MIBG-normal studies were symptomatic. The two asymptomatic patients had MIBG-avid bone disease. Estimated radiation dose savings from gender neutral CT surveillance without chest imaging was calculated at 42% (3.2±2.1 mSv, 3.0±2.5 mSv, 1.5+0.8 mSv, chest, abdomen, pelvis, respectively) for CTs performed 2006-2013; 34% for CTs performed 2011-2013 using more modern acquisition parameters. Conclusions: Intrathoracic NB progression/recurrence is rare but often presents with symptoms or is found using standard non-CT surveillance modalities. For patients with high-risk NB without intrathoracic disease at diagnosis, omission of on-therapy/surveillance chest CTs can save 3442% radiation burden without compromising disease detection.

Conclusions: 4D flow is feasible and holds promise for comprehensive 3D visualization and quantification of flow dynamics of the native and post surgical portal venous system in children and young adults.

Paper #: 007 4D-flow Imaging of the Portal Venous System in Children and Young Adults – A Feasibility Study

Keyur Parekh, MD, Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Michael Markl, Michael Rose, Andrada Popescu, Cynthia Rigsby, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine the feasibility of 4D flow MRI for visualization and quantification of portal venous hemodynamics in children and young adults. Methods & Materials: Twenty patients were included (mean age, 11.4± 5.7 years) with 13 patients having a surgical shunt [meso-Rex (n=9), meso-caval (n=3), spleno-renal (n=1)]. ECG gated 4D flow was used to acquire in-vivo time-resolved 3D blood flow velocities in an oblique axial plane through the upper abdomen using respiratory navigator gating. Imaging parameters were: 1.5T MR system, voxel size, 2.1×2.1× 2.5 mm; TR/TE=5/3 ms; temporal resolution 40 ms; flip angle=15°; and Venc=60 cm/s. Data analysis include the calculation of 3D phase contrast angiogram and time-resolved 3D pathlines. Assessment of 3D pathlines for vessel image quality and presence of a surgical shunt was scored by two independent readers using a 5-point Likert scale (1 = poor, nondiagnostic; 2 = fair, diagnostic; 3 = good, pixilation present; 4 = very good; 5 = excellent, intrahepatic portal vessels visualized). Portal venous net flow and peak velocity obtained from 4D flow were compared with standard 2D phase contrast (PC) MRI at the same location in 13 patients with a surgical shunt. Wilcoxon rank sum test was used to compare image quality between readers and for quantitative analyses. Image quality between patients > 10 years and < 10 years was compared using Mann– Whitney test. Intraclass correlation coefficient (ICC) was used to measure reliability of qualitative readings. p<0.05 was considered significant. Results: 3D flow visualization: Mean vessel image quality score was 4.0 ±0.9. Image quality was very good or excellent in 14/20 patients (70%) and poor in none. Image quality scores were similar between the two readers (p=0.25) with excellent correlation (ICC, 0.808). Image quality in patients <10 years was significantly less compared to patients >10 years (3.7±0.72 vs. 4.3±1.2, p=0.04). Surgical portal shunts were correctly identified in all 13 patients. Quantitative: Mean peak velocity (4D flow: 23.7±13.5 cm/s and 2D PC MRI: 25.1±11.2 cm/s, p=0.19) and net flow (4D flow: 9.5±7.9 mL/sec and 2D PC MRI: 10.1±7.4 mL/s, p=0.51) through the portal vein/shunt obtained from 4D flow and 2D PC MRI were similar.

Paper #: 008 Ultrasound as a Definitive Imaging Predictor of Midgut Volvulus

Tuan Dao, MD, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Tammam Beydoun, Mostafa Youssfi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To assess the predictive value of targeted abdominal ultrasound in the diagnosis of midgut volvulus. Methods & Materials: Retrospective review of ultrasound reports in the hospital database over a 14-year period was performed using the keywords: “volvulus”, “whirlpool” or “swirling”. Ultrasound was considered positive when, on cine clips, there was swirling of the bowel and mesenteric vessels around the superior mesenteric artery (SMA) and/or abrupt cutoff of the SMA. The location of the superior mesenteric vein in relation to the superior mesenteric artery and Doppler images were not necessary for diagnosis. The results were correlated to surgical reports, Upper GI examinations (UGI) and/or clinical follow up. Results: 245 ultrasound studies of 226 patients were identified. The age of the children ranged between 1 day and 16 years. There were 15 positive ultrasounds confirmed surgically. There were 230 negative ultrasounds. No surgery was performed in any of the negative ultrasounds. However, 78 patients with negative ultrasound also had negative UGI exams. The sensitivity, specificity, positive predictive value, and negative predictive value are all 100%. Conclusions: Ultrasound is a definitive predictor of midgut volvulus. It should be considered as a screening tool when midgut volvulus is suspected.

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Paper #: 009 Inter-Radiologist Agreement for CT Scoring of Pediatric Splenic Injuries and Effect on an Established Clinical Practice Guideline

Jessica Leschied, MD, Division of Pediatric Radiology, C.S. Mott Hospital, University of Michigan Health System, Ann Arbor, MI, [email protected]; Jonathan Dillman, MD, Michael Mazza, Matt Davenport, Suzanne Chong, Ethan Smith, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Clinical Practice Guidelines (CPGs) incorporating CT injury grade are being used to standardize the non-operative management of children with splenic injuries. The purpose of this study is to establish and determine the potential effect of radiologist agreement for CT scoring of splenic injuries in children with blunt abdominal trauma. Methods & Materials: Blunt splenic injuries occurring in children from January 2007 to January 2012 at a single level I trauma center were reviewed (n=90, mean age: 11.3 years, range: 1-17 years) in this HIPAA-compliant, IRB-approved, retrospective analysis. Contrast-enhanced abdominal CT exams performed at clinical presentation were reviewed independently by four radiologists (two boardcertified pediatric radiologists and two board-certified emergency radiologists) who documented the following: a) splenic injury grade (American Association for the Surgery of Trauma [AAST] system), b) splenic artery active extravasation, and c) splenic artery pseudoaneurysm. Overall inter-rater agreement for AAST injury grade was assessed using multi-rater Fleiss’ Kappa and Kendall’s coefficient of concordance. Inter-rater agreement was assessed using weighted (AAST injury grade) or prevalence-adjusted bias-adjusted (binary measures) Kappa statistics. 95% confidence intervals were calculated. The hypothetical effect of radiologist disagreement on an established American Pediatric Surgical Association (APSA) CPG was evaluated. Results: Overall inter-rater agreement was good for absolute AAST injury grade (Kappa: 0.64 [0.59-0.69]) and excellent for relative AAST injury grade (Kendall’s w: 0.90). Agreement between radiologist pairs was good for AAST injury grade (Kappa: 0.70-0.77), good for active extravasation (Kappa: 0.62-0.76), and good-to-excellent for pseudoaneurysm (Kappa: 0.73-1.00). All four radiologists agreed on the AAST grade in only 52% of cases (47/90). Based on an established CPG, radiologist disagreement could have changed the decision for ICU management in 11% (10/90 children), changed the length of hospital stay in 44% (40/90 children), and changed the time to return of normal activity in 44% (40/90 children). Conclusions: Radiologist agreement when assigning splenic AAST injury grades is less than perfect, and disagreements have the potential to change management in a substantial number of pediatric patients.

Paper #: 010 Ultrasound Elastography for Diagnosis of Liver Disease in Obese Children

Smita Bailey, MD, Trevor Davis, DO, Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Mostafa Youssfi, Mittun Patel, MD, Houchan Hu, Richard Towbin. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: The purpose of this study is to determine whether shear wave elastography (SWE) is a reliable method for predicting liver disease in obese children. Methods & Materials: IRB approved prospective study of sheer wave elastography (SWE) of the liver was conducted on 216 children: 112 obese (>95% BMI, 62M, 50F, mean age-12 years, range-6 months to18 years); and 104 non-obese (<95% BMI, 38M, 66F, mean age-9 years, range-25 days to18 years). Children with underlying liver disease (other than hepatic steatosis in the obese group) were excluded from the study. A total of 15 SWE measurements were obtained (10-Right lobe and 5-Left Lobe) in each child at various depths throughout the liver using Philips IU-22 Elast PQ system. In addition, qualitative gray-scale assessment (normal vs. abnormal echogenicity) of the liver was performed by two experienced pediatric radiologists. Qualitative assessment was performed prior to review of quantitative SWE data to avoid reader bias. Statistical analysis was done using STATA®13 software using t-test, ANOVA and linear regression to compare SWE values as a function of BMI, age, gender and left/right lobe liver measurements. Results: 1. Mean SWE velocity (liver stiffness) was 1.55 +/− 0.25 (obese group) and 1.08 +/− 0.16 (non-obese group) which is statistically significant (p<0.01). 2. Obese children showed increasing SWE velocities with increasing BMI (Fig. 1) and age (Fig. 2) which was found to be statistically significant (p<0.05) compared to the non-obese group. 3. There was no statistically significant difference in SWE values with respect to gender or left/ right lobe in both non-obese and obese children. We were able to obtain valid left lobe measurements in 93% of children. 4. Qualitative assessment for abnormal liver echogenicity in the obese group has a sensitivity of 86% and specificity of 75% and negative predictive value of 69% (using the SWE velocity of 1.24 m/s as the threshold, which is +1SD from the mean of the non-obese group). Conclusions: 1. SWE offers a valuable non-invasive method for detecting and quantifying liver disease in obese children. Obese children showed increasing liver stiffness with increasing BMI, likely related to fibrosis from NAFLD. 2. SWE offers a quantitative measure of the liver elasticity which is superior to qualitative assessment for diagnosis of liver disease in obese children.

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predictive value (NPV)=97.8%. For perforated appendicitis (5b), US performance was: sensitivity=39.7%, specificity=98.7%, PPV=72.2%, and NPV=95.1%. Statistically significant associations with perforated appendicitis were found for duration of symptoms (odds ratio (OR)= 1.43, p<0.0001), increased maximum diameter (OR=1.26, p<0.0001), increased simple fluid (OR=2.00, p=0.002), increased complex fluid (OR=12.4, p<0.0001) and appendicolith (OR=1.72, p=0.013). Conclusions: Ultrasound is highly specific but insensitive for perforated pediatric appendicitis. Several US findings are significantly associated with perforation, especially complex fluid. Particular attention should be paid to these findings when interpreting US exams for pediatric appendicitis.

Figure 2 3.0 Non-Obese Group

Velocity (m/s)

2.5 2.0 1.5 1.0 0.5 0.0

Velocity (m/s)

3.0

Obese Group

2.5 2.0

Paper #: 012

1.5

Searching for certainty: Findings predictive of Appendicitis in Equivocal Ultrasound Exams

1.0 0.5 0.0 <1y

1-6y

7-12y

13-18y

Morgan Telesmanich, Robert Orth, MD, PhD, Texas Children’s Hospital, Houston, TX, [email protected]; Wei Zhang, Nadia Mahmood, Siddarth Jadhav, Robert Guillerman, et al.

Age (Years)

Paper #: 011 Diagnostic Performance and Predictive Findings of Ultrasound for Perforated Pediatric Appendicitis

Jennifer Carpenter, MD, Robert Orth, MD, PhD, Texas Children’s Hospital, Houston, TX, [email protected]; Wei Zhang, Monica Lopez, Kate Louise Mangona, MD, Robert Guillerman. Disclosures: Robert Orth has indicated a relationship with General Electric as a fellow. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Differentiating perforated from non-perforated appendicitis is important for surgical planning and for counseling families about post-operative management and in-hospital length of stay. We evaluated the diagnostic performance of ultrasound (US) for differentiating perforated from non-perforated appendicitis and investigated the association between specific US findings and perforation. Methods & Materials: All limited abdominal US exams performed at our institution from 7/1/13-7/9/14 (n=7773) were retrospectively identified. US exams for suspected appendicitis (n=3590) were reported using a structured template and risk-stratified grading system (1 = normal appendix; 2 = incompletely visualized normal appendix; 3 = non-visualized appendix; 4 = equivocal; 5a = non-perforated appendicitis; 5b = perforated appendicitis). Diagnostic performance measures of US for all appendicitis (5a and 5b) and perforated appendicitis (5b) were calculated. The following US findings for patients diagnosed with appendicitis (5a and 5b) were recorded from structured templates and correlated with perforation by multivariate analysis via logistic regression: maximum appendiceal diameter, wall thickness, wall hyperemia, loss of mural stratification, periappendiceal fat-inflammation, increased periappendiceal fluid (simple or complex), and appendicolith. Patient charts were reviewed for the number of symptomatic days prior to presentation. Operative diagnosis and clinical follow-up served as the reference standards. Results: 662 patients were diagnosed with appendicitis during the study period (5a=459, 5b=203). US test performance for appendicitis (5a and 5b) with equivocal exams considered positive was: sensitivity=93.5%, specificity=93.0%, positive predictive value (PPV)=81.2%, and negative

Disclosures: Robert Orth has indicated a relationship with General Electric as a fellow. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Ultrasound (US) is the preferred imaging modality for evaluating suspected pediatric appendicitis. However, interpretation can be confounded in the setting of borderline appendiceal enlargement or questionable inflammatory changes, leading to equivocal US exams. The purpose of this study was to determine which findings on equivocal US exams are predictive of appendicitis. Methods & Materials: 3590 consecutive limited right lower quadrant US exams performed for suspected appendicitis from 7/1/13-7/9/14 were retrospectively identified. Exams were interpreted using a risk-stratified scoring system (Appy-Score 1 = normal appendix; 2 = incompletely visualized normal appendix; 3 = non-visualized appendix; 4 = equivocal; 5a = non-perforated appendicitis and 5b = perforated appendicitis). Two blinded pediatric radiologists independently reviewed equivocal exams (Appy-Score = 4) and recorded the following findings: increased wall thickness (>2 mm), loss of mural stratification, periappendiceal fat inflammation, periappendiceal fluid (simple or complex), presence of an appendicolith, and maximum appendiceal diameter. A third pediatric radiologist resolved discrepant interpretations. US features were correlated with the surgical or clinical diagnosis by multivariate analysis via logistic regression. Mean appendiceal diameter for patients with and without appendicitis was compared by the Wilcoxon rank test. Results: 162/3590 (4.5%, age=9.4+/−3.8 years) patients were diagnosed as equivocal for appendicitis (Appy-Score=4) during the study period. Four outpatients were lost to follow-up and one patient was transferred to another hospital. 48/157 (29.8%) patients had an operative diagnosis of appendicitis. Findings with statistically significant associations for appendicitis included loss of mural stratification (odds ratio (OR)=6.69, p=0.035), periappendiceal fat inflammation (OR = 10.0, p < 0.0001), and an appendicolith (OR = 15.751, p = 0.025). Mean maximum appendiceal diameter was larger (p = 0.0006) for patients with appendicitis (7.4+/−1.4 mm) compared to patients without appendicitis (6.7+/−0.9 mm). Conclusions: Loss of mural stratification, periappendiceal fat inflammation, and an appendicolith are significant predictors of appendicitis in patients with equivocal US exams. While maximum appendiceal diameter is larger in patients with appendicitis, a mean appendiceal diameter of 6.7 mm in those without appendicitis suggests that the customary upper normal value of 6 mm may be too sensitive.

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Paper #: 013

Paper #: 014

Fetal stomach Position Predicts Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia

Normative Biometrics for Fetal Ocular Growth Using Volumetric MRI Reconstruction

Amaya Basta, MD, Oregon Health & Science University, Portland, OR, [email protected]; Leslie Lusk, Roberta Keller, Roy Filly.

Clemente Velasco-Annis, Ali Gholipour, Onur Afacan, Judy Estroff, MD, Radiology, Boston Children’s Hospital, Newtonville, MA; Sanjay Prabhu, Simon Warfield

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine the relationship between degree of stomach herniation by antenatal sonography and neonatal outcomes in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH). Methods & Materials: We retrospectively reviewed neonatal medical records and antenatal sonography of fetuses with isolated left CDH cared for at a single institution (2000–2012). Fetal stomach position was classified on sonography based on extent of abnormal stomach position, as follows: intra-abdominal, anterior left chest, mid-to-posterior left chest, or retrocardiac (right chest). Results: Ninety fetuses were included, with 70% survival to neonatal discharge. Stomach position was intra-abdominal in 14% (n=13), anterior left chest in 19% (n=17), mid-to-posterior left chest in 41% (n = 37), and retrocardiac in 26% (n = 23). More abnormal stomach position was associated with worsening clinical outcomes in both bivariate and multivariate analyses. After adjusting for birth era, gestational age, and fetal tracheal balloon occlusion, more abnormal stomach position was linearly associated (odds ratio, 95% confidence interval) with an increased odds of death (OR 4.8, 95%CI 2.1-10.9), extracorporeal membrane oxygenation (ECMO) (OR 5.6, 95%CI 1.9-16.7), non-primary diaphragmatic repair (OR 2.7, 95%CI 1.4-5.5), prolonged mechanical ventilation (>14 days of age, OR 5.9, 95%CI 2.3-15.6), and prolonged respiratory support (≥56 days of age, or discharge on oxygen supplementation at <56 days, OR 4.0, 95%CI 1.6-9.9). All fetuses with intra-abdominal stomach position survived without substantial respiratory morbidity or need for ECMO. Conclusions: Fetal stomach position is strongly associated with neonatal outcomes in isolated left CDH. This objective prognostic tool may allow for accurate prognostication in a variety of clinical settings.

Table 1 – Data summary. Mean and standard deviation (SD) per gestational age (GA) week for normative binocular distance (BOD), interocular distance (IOD), ocular diameter* (OD) and volume*, as well as the number of fetuses imaged at each GA are displayed.

Fetal stomach position as a predictor of neonatal outcomes: Bivariate analysis Stomach Position Neonatal Outcomes

Abdomen

Death Extracorporeal membrane oxygenation (ECMO) Non-primary diaphragm repair† Prolonged mechanical ventilation (>14 days)‡ Prolonged respiratory support (≥56 days)§

Mid-to-posterior left chest

Retrocardiac (right chest)

n (%)

Anterior left chest n (%)

n (%)

n (%)

P-value*

0/13 (0%)

1/17 (6%)

12/37 (32%)

14/23 (61%)

<0.001

0/13 (0%)

0/17 (0%)

5/37 (14%)

8/23 (35%)

0.005

5/13 (38%) 0/13 (0%)

9/17 (53%)

25/33 (76%)

17/17 (100%)

<0.001

0/13 (0%)

6/17 (35%)

3/16 (19%)

21/34 (62%)

13/28 (46%)

15/16 (94%)

6/9 (67%)

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The aim of this research was to establish normative values for fetal ocular biometrics as well as characterize the pattern of ocular development between 19 and 38 weeks gestational age (GA) using volumetric MRI reconstruction. Methods & Materials: 3D images of 114 healthy fetuses between 19 and 38 weeks GA were created using super-resolution volume reconstruction from MRI T2-slice acquisitions. The orbits in these 3D images were semi-automatically segmented in ITK-SNAP. Biometric measurements for binocular distance (BOD), interocular distance (IOD), ocular diameter (OD) and orbit volume were computed by an automated algorithm. Results: We report mean data at each week of GA between 19 and 38 weeks GA. All biometrics correlated with gestational age (Volume, R2 =0.965, BOD, R2 =0.955, OD, R2 =0.945, and IOD, R2 =0.843) and were comparable to data reported in similar studies. Regression analysis showed BOD (BOD=- 0.04161*GA2 +3.722*GA - 26.99), IOD (IOD=0.01023*GA2 +0.987*GA - 2.191) and OD (OD=- 0.01543*GA2 + 1.35*GA - 11.13) to best fit quadratic models (P<.001), and volume (Volume=0.1101*GA - 1.915) to best fit a linear model (P<.001) for 19–38 weeks GA. Conclusions: Volumetric reconstruction from MRI acquisitions is an accurate method for obtaining fetal ocular biometrics including volume. Volume has been only reported in an extremely limited number of studies, both of which utilized ultrasound images (Odeh et al., Prenat Diagn 2009, Bojikian et al., J AAPOS 2013). To our knowledge, this is the first MRI study to report fetal orbit volume as well as the first study to report fetal ocular biometrics based on the true 3D shape of the orbit. Orbit volume had the greatest correlation with GA, though BOD and OD also showed strong correlation. The normative data found in this study may be used for the estimation of GA and for the detection of congenital fetal anomalies.

<0.001

<0.001

*P-value refers to a Fisher’s exact test of association. † Excludes patients who died prior to surgical repair (n=80). ‡ Excludes patients who died prior 14 days of age (n=80) § Of these, seven patients were discharged home on oxygen prior to reaching 56 days of age. Age at discharge ranged from 29 to 43 days, mean of 37.9+/−4.8 days. Excludes patients who died prior to 56 days of age (n=66).

Gestational age (weeks)

n

BOD

IOD

19

1

mean SD (mm) 29.51 -

mean (mm) 13.00

20

2

31.34

1.77 13.02

0.03 9.76

0.64 0.34

0.06

21

5

32.28

1.33 13.84

1.28 10.17

0.38 0.39

0.05

22

3

35.77

1.88 14.03

0.98 11.56

0.48 0.56

0.06

23

5

36.08

1.39 15.43

0.84 11.72

0.92 0.54

0.08

24

4

37.52

0.65 16.00

1.15 12.18

0.53 0.67

0.07

25

1

42.88

-

-

-

-

26

7

42.08

1.09 16.60

0.77 13.81

0.52 0.98

0.10

27

8

42.97

1.40 17.13

0.83 13.79

0.68 1.02

0.16

28

16 45.27

1.36 17.73

0.63 14.77

0.63 1.20

0.09

29

11 46.19

1.48 17.69

0.96 15.07

0.50 1.36

0.19

30

7

46.65

1.12 17.58

0.54 15.40

0.62 1.38

0.10

31

9

47.37

1.46 18.44

1.56 15.76

0.96 1.38

0.09

17.22

OD SD -

mean (mm) 9.36

13.37

Volume SD -

mean (mL) 0.32

0.80

SD -

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5

48.31

2.95 18.80

2.18 15.58

0.46 1.47

0.09

33

8

50.75

2.32 18.84

2.03 17.05

0.67 1.78

0.12

34

3

51.54

2.26 20.10

0.18 16.64

0.81 1.80

0.12

35

6

53.61

1.95 20.33

1.02 17.37

0.70 2.07

0.23

36

4

53.17

1.14 20.50

1.29 17.18

0.39 2.05

0.07

37

7

52.80

1.28 19.61

1.23 17.66

0.45 2.12

0.14

38

2

55.47

0.18 21.51

0.69 18.22

1.00 2.15

0.23

*Average of left and right measurements.

highly correlated (average rho=0.85, p<0.0001). Median cerebellar diameter measured on MRI (averaged over four readers) was 26.5 mm (mean=28.1 mm, SD=9.7 mm). The four MRI-based sets of measurements were statistically similar (p > 0.5 for all pairwise comparisons) and highly correlated (average rho=0.86, p<0.0001). Finally, reader-averaged US- and MRI-based cerebellar diameters were statistically similar (p=0.4, confidence interval (CI): [−0.92, 2.25]) and highly correlated (rho=0.98, p<0.0001). Conclusions: US- and MRI-based fetal cerebellum measurements are highly reproducible, with comparable inter-observer variability. Cerebellar diameters estimated by the two modalities were found to be statistically similar and highly correlated. These results suggest that US and MR may be used interchangeably to measure the fetal cerebellum.

Figure 2 – Biometric data with 5%, 50% and 95% confidence intervals for ocular diameter (OD) and orbit volume between 19-38 weeks gestational age (GA). OD and volume are reported as the average of the left and right eye measurements.

Paper #: 015 Correlation of fetal cerebellar measurements on US and MRI

Catherine Stamoulis, Deborah Levine, Henry Feldman, Rebecca Parad, Judy Estroff, MD, Radiology, Boston Children’s Hospital, Newtonville, MA, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Gestational age-based nomograms for various fetal structures have typically been generated by sonography (US). More recently, magnetic resonance imaging (MR) has been utilized as a complementary modality, especially for fetal brain imaging. To date, the interchangeability of US and MRbased measurements has not been shown. This study assessed (1) inter-observer variability of cerebellar diameter measurements by experienced radiologists on US and MR , and (2) the interchangeability of US and MR measurements. Methods & Materials: Four hundred twenty-five pregnant women with 433 fetuses, referred for ventriculomegaly, were imaged with US and MR between July 2003 and May 2009. Gestational age at imaging was 15.7-39.4 weeks. More than 95% of patients had same-day sonography and MRI. A total of 382 fetuses with at least two US and two MR measurements were included in the study. Four to seven radiologists independently reviewed sonographic and MR images and recorded cerebellar diameters. One hundred sixty nine fetuses had complete data (three US and four MR measurements), 225 fetuses had three US and 0.9 for all pairwise comparisons) and

Paper #: 016 Placenta Accreta: Critical Diagnosis for the Pregnant Patient and Challenging Diagnosis for the Pediatric Radiologist

Vanessa Starr, MD, Pediatric Radiology, Lucile Packard Children’s Hospital Stanford, Redwood City, CA, [email protected]; Richard Barth, Barbara Mrazek-Pugh, Erika Rubesova, MD. Disclosures: Richard Barth, Siemens Medical Systems, Salary Support. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: With increased number of patients with previous C-section, pediatric radiologists interpreting fetal ultrasound (US) and MRI should be familiar with placenta accreta (PA) as a primary or incidental finding. Recognition is important given high morbidity and mortality of PA. Development of MRI and US has improved spatial resolution of the interface between placenta and myometrium. In spite of this progress, neither ultrasound nor MRI is able to make the diagnosis with confidence. The aim of our study was to determine the sensitivity (Se), specificity (Sp) and confidence of diagnosis of MRI compared to US. We evaluated imaging criteria and performance characteristics of US and MRI for diagnosis of PA. Methods & Materials: 24 patients referred for evaluation of PA that underwent US and MRI (1.5 T GE) were retrospectively reviewed. Two radiologists blinded to surgical pathology results independently interpreted MRI and US with 1 week interval. US and MRI criteria for placenta accreta included placental lakes, nodular borders, crossing vessels. Loss of a fat plane between the placenta and bladder on T1-LAVA fat sequences was a criteria on MRI. Increased vascularity on Doppler was a

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criteria on US. Presence or absence of PA, confidence level (1-5, 5 highest) for each modality were determined. Presence of PA was determined by surgical pathology. Patients with no PA on pathology or a normal operative note were grouped into the non-accreta category for statistical analysis. Results: 15/24 patients had path-proven PA and 9/24 had no PA. US was more Se but less Sp for diagnosis of PA (87% Se; 44% Sp) as compared to MRI (80% Se; 78% Sp). PPVof MR was greater than that of US (85% vs 72%). Common criteria for PA on US and MR were placental lakes, crossing vessels and nodular borders. US was more Se but less Sp than MR on all of these criteria: US placental lake Se/Sp 73/67% vs MR placental lake Se/Sp 40/89%; US crossing vessels Se/Sp 87/44% vs MR crossing vessel 47/89%.; US nodular border Se/Sp 87/56% vs MR nodular border 73/89%. Unique MR criteria for PA was the loss of fat band, with Se 87% and Sp 78%. Increased vascularity by Doppler was seen in patients with and without PA. Mean confidence for MRI was 4 and 3.8 for US. Cohen’s kappa determined good inter-observer variability, slightly better with US (0.5) than MRI (0.4). Conclusions: Pediatric radiologists should be aware of the imaging signs of placenta accreta on fetal MRI. MRI and US are complementary for the diagnosis of PA.

N=24; 15 with acreta by path, 9 with no acreta on path or normal op note

Accreta

Placental Lakes

Crossing vessel

Nodular Border

Band of fat Lost

Sensitivity MR

80%

40%

47%

73%

87%

Specificity MR

78%

89%

89%

89%

78%

PPV MR

85%

86%

88%

92%

87%

NPV MR

70%

47%

50%

66%

78%

Sensitivity US

87%

73%

87%

87%

n/a

Specificity US

44%

67%

44%

56%

n/a

PPV US

72%

79%

72%

76%

n/a

NPV US

67%

60%

67%

71%

n/a

created for each reviewer (Fig 1.) A numeric imaging score for each modality and a combined score (MRI+US) were generated and receiver operator curves (ROC) of scores using the multi-reader, multi-case method were generated and compared (Fig 2). Results: Substantial intra-observer variability exists among experienced readers. Sensitivity, specificity, PPV and NPV were calculated for each reviewer and are listed in the table. ROCs indicate improved diagnostic accuracy with use of a combined imaging score over the use of either imaging modality in isolation. Conclusions: The use of a subjective impression including terms such as “low-risk” leaves the potential for misinterpretation, as our data indicate that MAP exists in a substantial number of cases interpreted as “low-risk.” Use of a combined MRI+US score improves diagnostic accuracy and communicates levels of risk more objectively.

Paper #: 017 Morbidly Adherent Placenta: An Imaging Score to Improve Antenatal Diagnostic Accuracy

Katrina Hughes, MD, Texas Children’s Hospital, Dept Pediatric Radiology, Houston, TX, [email protected]; Christopher Cassady, MD, Amy Mehollin-Ray, MD, Jimmy Espinoza, Edwina Popek, Karin Fox. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To 1) identify the diagnostic accuracy of US and MRI for MAP within our center, and 2) improve diagnostic accuracy by developing an objective diagnostic score, based upon the correlation of imaging findings with surgical/pathologic diagnosis. Methods & Materials: Seventy-two patients were referred to a single tertiary referral center for suspected MAP and underwent US and MRI during a 2-year period. Of these, eight were excluded due to incomplete pathology or imaging. Two experienced radiologists independently reviewed each MRI for seven accepted imaging characteristics of MAP. Two experienced Maternal-Fetal Medicine specialists independently reviewed each US for six imaging characteristics of MAP. Reviewers were blinded to clinical history, imaging reports and pathologic diagnosis. Both groups were also asked to give an overall subjective impression (No MAP, Low-risk, Accreta, Percreta/Increta). Contingency tables were

Table 1:

Reviewer1 (MRI) Reviewer2 (MRI) Reviewer3 (US) Reviewer4 (US)

Sensitivity (%) [95% Specificity (%) [95% PPV (%) [95% CI] CI] CI]

NPV (%) [95% CI]

60 [45-74]

90.9 [58-99.8]

90 [74-97.9]

30 [14-51]

62.8 [46-77]

90.0 [58.7-99.8]

96 [81-99]

38 [29-59]

64 [47-78]

100 [54-100]

100 [86-100]

30 [11-54]

50 [33-66]

87.5 [44-99]

95 [77-99.9]

26.9 [11.548]

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MALES (n=15) 38.3±1.24

FEMALES

p-value

(n=15) Gestational Age (wk)

39.1±1.37

0.094

Age (d) Weight (kg) Length (cm) Head Circumference (cm) Waist Circumference (cm) Subcutaneous Fat CSA (cm2) Paraspinous musculature (cm2) Vertebral Height (cm) Vertebral CSA (cm2)

2.87±1.25 3.35±0.50 50.6±3.04 33.6±1.21 30.5±1.83 10.46±1.06 3.29±0.67 0.73±0.07 1.79±0.22

3.27±1.79 3.49±0.26 49.7±2.98 33.7±1.13 31.5±2.73 11.14±2.45 3.30±0.57 0.73±0.05 1.58±0.21

0.484 0.491 0.419 0.712 0.255 0.336 0.971 0.974 0.012

Paper #: 018 Sex-Related Differences in the Fetal Programming of the Axial Skeleton

Skorn Ponrartana, MD, MPH, Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; patricia Aggabao, Naga Dharmavaram, Vicente Gilsanz, MD, PhD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The female vertebral cross-sectional area, a major determinant of its strength, is smaller than that of males throughout childhood, adolescence, and at the timing of peak bone mass. In this study, we examined for sex-related differences in the fetal development of the axial skeleton. Methods & Materials: Detailed measurements of the lumbar vertebrae, paraspinous musculature, and subcutaneous adiposity were obtained using magnetic resonance imaging (MRI) in a random sample of 60 singleton healthy full-term infants (30 male and 30 female; aged two to 7 days). Data were analyzed with unpaired Student t test and multiple regression analysis. Results: Compared to newborn boys, girls had significantly smaller vertebral cross-sectional dimensions (1.479 ± 0.10 vs. 1.303± 0.13 cm2; P<0.0001) - a disparity that persisted even after accounting for weight, body length (or vertebral height), and paraspinous musculature. On average, newborn girls had 11.9% smaller vertebral cross-sectional area than boys (see Figure). In contrast, sexes were monomorphic with regard to vertebral height and paraspinous musculature. There were also no sex-related differences in birth weight, body length, waist circumference, or MRI measures of adiposity (see Table). Conclusions: Factors related to sex have an important role in the fetal programming of the axial skeleton. The smaller vertebral cross-sectional area of newborn females imparts a mechanical disadvantage that increases the stress within the vertebrae and, if persists, the susceptibility for fragility fractures later in life.

Paper #: 019 Fetal Skeletal Development using Ultrasound Imaging

Erika Rubesova, MD, Radiology, Lucile Packard Children’s Hospital, Stanford, CA, [email protected]; Diego Jaramillo, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Diagnosing fetal skeletal pathology requires understanding of normal development. Ultrasound remains the main modality for screening of fetal skeletal abnormalities. With advances in Ultrasound (US) technology over the last decade, our ability to visualize subtle changes in bone and cartilage development has significantly improved. Histologically, advancing gestational age (GA) induces definition of metaphyseal border, and development of ossification centers. Perichondral structures are more prominent prenatally. We evaluated whether prenatal Ultrasound can depict these changes. Methods & Materials: We retrospectively reviewed the knees of fetuses (12-39 weeks) without skeletal abnormalities in 64 patients scanned in our prenatal diagnostic center in 2014. Distribution of GA: under 18 weeks, n=10; 18-24 weeks, n=31; 19-32 weeks, n=14; over 32 weeks, n=9. We graded metaphyseal border as round or straight, and as brushy or smooth. We assessed presence of patella, perichondral bone bark and groove, and femoral ossification center. We classified the shape of epiphysis as rounded, with shallow or deep notch. We observed echogenicity of the femoral intercondylar notch as a feature of knee development, and classified it as absent or present.

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Results: Round metaphyseal border was seen only before 18 weeks (7/10) and straight in all other fetuses. A brushy metaphyseal border was seen in 4/10 fetuses before 18 weeks and 49/54 after 18 weeks. Perichondral bone bark was seen in 5/10 fetuses before 18 weeks and in 53/54 after 18 weeks (figure). A perichondral grove was seen only in 18/64 fetuses, a patella in 51/64, and an ossification center in 11/64. The epiphysis had a shallow notch in 28/64 and a deep notch in 24/64 fetuses; superficial notching was seen in only one fetus before 18 weeks and deep notching in all but one after 28 weeks. Echogenic intercondylar notch was seen in 43/64 fetuses; one before 18 weeks, and in 42/ 54 after 19 weeks. With the exception of the perichondral grove, all bone maturation characteristics correlated with GA (p<0.001, Chi-Square tests). Four fetuses with various bone dysplasia served as comparison to show lack of normal metaphyseal and epiphyseal development characteristics. Conclusions: We describe the normal sonographic pattern of fetal skeletal development, which is useful for the pediatric radiologist in order to detect abnormal development and diagnose bony dysplasia.

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sonographically as a linear, branching or non-branching, fluid-filled, nonvascular structure, centrally located within the CLL. Also recorded: location of CLL, echostructure (echogenicity, cysts), systemic arterial feeder and venous return. Final diagnoses based upon pathology or postnatal CT angiography in non-operated cases. Results: Fetal bronchoceles were seen in 27 patients, including 14 intralobar pulmonary sequestrations (ILPS), one extralobar pulmonary sequestration (ELPS), and 12 cases of non-sequestrated bronchial atresia (BA). Two additional bronchocele with ILPS were noted during ongoing pregnancies at time of submission. Careful color Doppler ultrasound (CDU) allows for the recognition of systemic arterial feeder and the distinction between systemic (ELPS) and pulmonary (ILPS) venous return. Among the 14 ILPS with bronchocele, associated congenital pulmonary airways malformation (CPAM) type two was seen in seven cases. Ten ILPS underwent surgery, one embolization and three conservative management. Most BA without PS occurred in the upper lobes. Still two cases of BA had a bilobar involvement. Conversely, all ILPS were located in the lower lobes. Conclusions: Fetal bronchocele can be displayed on mid-2nd trimester imaging and are mostly associated with ILPS and non-sequestrated BA. Interestingly, our series confirms the common occurrence of congenital ILPS (14 cases with bronchocele, five cases without bronchocele) within CLL.

TABLE I - CLASSIFICATION OF CONGENITAL LUNG LESIONS*

Figure: Coronal image of the distal femur in a 29 week-old fetus shows the perichondral bone bark (arrow), straight metaphyseal border and notched epiphysis

Paper #: 020 Fetal Bronchocele: Imaging Features and Significance

Juliette Garel, CHU Sainte-Justine, Montreal, QC, Canada, [email protected]; Laurent Garel, Françoise Rypens, Chantale Lapierre, Andrée Grignon, Josée Dubois. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Congenital lung lesions (CLL) are best approached according to Langston classification (cf. Table). Routine mid-2nd trimester ultrasound allows for the detection of most CLL by showing various features of cysts, hyperechoic parenchyma, systemic arterial feeder, systemic or pulmonary venous return. The conspicuity of bronchocele may furthermore characterize the subtypes of CLL. Methods & Materials: Retrospective review of a single institution data bank of 130 CLL seen in utero. Pre- and postnatal imaging performed by the same radiologists in the same department. Fetal bronchocele appears

BRONCHOPULMONARY MALFORMATIONS Pulmonary sequestration (extalobar, intralobar) CPAM 1 et 2 (isolated, associated with PS) Bronchial atresia (isolated, associated with IPLS) Bronchogenic cyst PULMONARY HYPERPLASIA AND RELATED LESIONS Laryngeal atresia Solid type CPAM (Stocker type 3) Polyalveolar lobe CONGENITAL LOBAR OVERINFLATION OTHER CYSTIC LESIONS Lymphatic, enteric, mesothelial, simple cysts Low-grade cystic pleuropulmonary blastoma (Stocker type 4)

*According to Claire Langston

Paper #: 021 Choledochal Cyst in the Fetus: Can We Make and Accurate Diagnosis and What Does it Mean?

Carol Barnewolt, MD, Children’s Hospital Boston, Boston, MA, [email protected]; Judy Estroff, MD, Susan Connolly, Heung Kim. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The observation of a fetal abdominal cyst is relatively common, including such structures as: duplication cysts,

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mesenteric cysts, ovarian cysts, meconium pseudocysts and choledochal cysts. The first three tend to require little or no intervention, while the latter two may have significant consequences. We sought to determine how accurately our Children’s Hospital based fetal program made the diagnosis of choledochal cyst in the fetus and how many such cysts were associated with biliary atresia. Methods & Materials: A review of our data base was performed, covering a period of 10 years, searching for fetuses with diagnoses of abdominal cysts after on-site sonography and/or magnetic resonance imaging (MRI). When possible, the records of the resulting infants were reviewed, including imaging studies, clinical and surgical notes, and bilirubin levels, to determine the actual postnatal diagnosis. Results: A total of 85 fetuses with abdominal cysts were identified, but 20 of this cohort were lost to follow-up, resulted in IUFD or termination. Of the remaining 65, leading prenatal diagnoses were as follows: 56 ovarian cysts or duplication cysts, four meconium pseudocysts, and five choledochal cysts. The observations of unusually large gallbladders (2) and a single fetus with gallbladder duplication were also noted prenatally and found to be accurate on postnatal sonography. After birth one of the presumed meconium pseudocysts proved to actually be ileal ectasia and one of the presumed choledochal cysts proved to be a simple hepatic cyst. The remaining diagnoses were found to be accurate in the operating room or presumed to be accurate based on imaging and clinical follow-up. Of the four true choledochal cysts, two had a correctable form of biliary atresia and are doing well to date. Conclusions: Choledochal cysts are sometimes associated with biliary atresia and, at least if unrecognized, are thought to be associated with an increased risk of malignancy later in life. In our experience, an accurate diagnosis was made in 4/5 thought to have choledochal cysts out of a cohort of 65 fetuses with abdominal cysts. Half (2) of these had a correctable form of biliary atresia and half did not have biliary atresia. This information may provide guidance for families when presented with a suspected choledochal cyst on prenatal imaging.

Results: 44 fetal MR studies met inclusion criteria. Average fetal GA: 31.5 weeks (range 22-38), average maternal age: 30.2 years (range 2042). 4/44 cases (9%) had the NML pattern, and three of these had restrictive lesions postnatally (two restrictive atrial septum, one stenotic total anomalous pulmonary venous return). Mortality in this group was 4/4 (100%) by 5 months of age, with no survival to stage two repair. Of the 40 patients without NML, 5/40 had restriction on echo, of whom three died/had OHT before 5 months of age (60% of patients with restriction or 7.5% of the overall non-NML population). Of the 40 patients without NML, overall mortality/OHT was 14/40 (35%). There was a significantly higher incidence of restrictive lesions (OR 4.13; 95% CI 1.77-9.60, p= 0.02) and mortality/OHT (OR 2.86; 95% CI 1.87-4.36; p=0.02) in NML patients compared to non-NML. Conclusions: NML in fetuses with HLHS appears to be associated with increased mortality and likelihood of a restrictive cardiac lesion, with 100% mortality in the first 5 months of life in our four cases (compared to 35% mortality/OHT if HLHS alone). Not all patients with restrictive lesions develop NML, and outcome is not as poor when restriction is present in isolation. Dedicated evaluation for NML pattern on fetal MRI studies may be useful to guide prognostication and aid clinicians in counseling parents of fetuses with HLHS.

Paper #: 022 Hypoplastic Left Heart Syndrome and the Nutmeg Lung Pattern in Utero: Cause and Effect Relationship or Prognostic Indicator?

David Saul, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Karl Degenhardt, Suzanne Iyoob, Ann Johnson, Jack Rychik, Teresa Victoria, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Hypoplastic left heart syndrome (HLHS) is the most common congenital cardiac cause of death in the 1st year of life. Secondary pulmonary lymphangiectasia has been recognized in association with HLHS, an appearance termed on fetal MRI as “nutmeg lung” (NML). The purpose of this study is to investigate the association of fetal NML with HLHS survival. Methods & Materials: Following IRB approval, a retrospective search of the radiology fetal MRI database for the words “HLHS” or “hypoplastic left heart” (1/1/2002 to 2/3/2014) was performed, yielding 59 cases. Exclusion criteria: no followup (n=6), wrong diagnosis (n=5), other abnormalities resulting in hypoplastic lung (n=4). NML on fetal MR was defined as T2 heterogeneous pulmonary parenchyma signal with tubular structures radiating peripherally from the hila. Postnatal echocardiograms/charts were reviewed for mortality or cardiac equivalent, orthotopic heart transplant (OHT).

Paper #: 023 In Vivo Magnetic Resonance Angiography of Fetal Vasculature

Jaladhar Neelavalli, PhD, Wayne State University, Detroit, MI, [email protected]; Uday Krishnamurthy, Pavan Jella, Swati Mody, MD, Ewart Haacke, Roberto Romero. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To evaluate the feasibility of acquiring three dimensional magnetic resonance angiographic (MRA) data in the human fetus for visualizing major vessels in the brain, the heart and the abdominal vessels. The work was motivated by the fact that angiographic data could be useful in evaluating developmental vasculature of the human fetus non-invasively and in contrast to ultrasound, MRA is operator independent, has larger field of view and is unaffected by the position of the fetus and presence of bone. Methods & Materials: All MRI scans were performed on 3.0T Siemens Verio system. The standard 2D and 3D time of flight (TOF) MRA

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sequences used for imaging the vasculature in the adults were adapted to fetal imaging. The resultant 2D sequence acquired a single slice of MRA data in approximately 4 seconds with a reconstructed voxel size of 0.40.7 mm in-plane and 2 mm through plane. The 3D MRA sequence acquired a 16 slice volume in 28-40 s with a voxel size of 0.7 mm in-plane and 1.2 mm in through plane direction. Fetal vessels were visualized by creating maximum intensity projections (MIPs) and/or 3D reconstructions. Results: The MRA data from six subjects (third trimester) with uncomplicated singleton pregnancies is presented. Vessels comprising the Circle of Willis were visualized in the fetal brain. The superior sagittal sinus, the transverse sinus, the basilar artery, the carotid arteries and the jugular veins were also visualized. Fetal heart, the inferior venacava, the aortic arch, the descending aorta, the ductus arteriosus, the ductus venousus and the subclavian artery were also clearly discernible. Further processing of the raw images allowed for 3D reconstructions of these vessels. The SAR of the implemented 2D and 3D MRA sequences was < 0.6 Watt/Kg. Conclusions: In the third trimester fetuses, visualization of the major fetal cerebral arteries and dural venous sinuses, and the great vessels from the heart in three dimensions is possible using magnetic resonance angiographic imaging at 3.0T.

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one patient for whom LMB obstruction was recognized 19 months after surgery. The reason was longstanding redistribution of blood flow away from the left lung. Conclusions: Children who undergo aortic arch reconstruction are at risk of LMB compression. Awareness and early recognition of this problem is important as delayed intervention may decrease the chance of resolution.

Paper #: 024 Left Main-Stem Bronchus Compression after Aortic Arch Reconstruction

Farahnaz Golriz, MD, Radioloogy, Texas Children’s Hospital, Houston, TX, [email protected]; Rajesh Krishnamurthy. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We are describing a newly recognized complication, extrinsic vascular-mediated compression of the left main stem bronchus (LMB), which can occur after aortic arch reconstruction in the setting of congenital heart disease (CHD). We discuss diagnosis, possible mechanism, management and outcome of this entity. Methods & Materials: We retrospectively reviewed the medical records and imaging of patients who underwent aortic arch reconstruction for interruption or diffuse hypoplasia of the aortic arch at a tertiary center for CHD during the first month of life. LMB compression was found in six patients. Imaging techniques included CXR and CT angiography with dynamic imaging to differentiate between intrinsic versus extrinsic airway compromise and to screen for bronchomalacia. Post processing techniques included multiplanar reformation, maximum intensity projections, and 3D volume rendering, including virtual bronchoscopy. Results: The intervals between arch reconstruction and diagnosis of LMB obstruction varied between 1 to 19 months. Two asymptomatic patients were recognized on postoperative follow-up CXR and four patients presented with respiratory distress. In all six patients, LMB obstruction was suspected at CXR and confirmed with chest CT angiography. The main findings in CXR were hyperinflation and decreased vascularity of the left lung. CT showed extrinsic stenosis of the LMB, with minimal or no improvement in caliber on expiration, and associated air trapping. Vascular redistribution to the right lung and subsequent increase in right pulmonary artery caliber was seen in four patients. Narrowed interaortic space, due to low-lying aortic arch and anterior and posterior displacement of descending and ascending aorta respectively, were the main underlying mechanisms. In one patient, left atrium enlargement due to residual mitral regurgitation had further compromised the narrowed interaortic space. LMB compression in two asymptomatic patients improved with age. In three symptomatic patients, clinical and imaging findings improved following aortopexy (N=2) or mitral valve replacement (N=1). Aortopexy was unsuccessful in improving the symptoms in

Paper #: 025 Use of CT and MR in Neonatal and Infantile Congenital Heart Disease: Change in Practice Patterns with Advent of New Generation CT Scanner

Sara Bahouth, MD, Pediatric Radiology, Texas Children’s Hosp i t a l , H o u s t o n , T X , s m b a h o u t @ t e x a s c h i l d re n s . o rg ; Wei Zhang, Prakash Masand, Siddharth Jadhav, MD, Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Rajesh Krishnamurthy. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Magnetic Resonance Imaging (MRI) and Computed Tomography scans (CT) play an essential complementary role to echocardiography in the diagnosis and management of neonatal and infantile congenital heart disease (CHD). The choice between these two modalities involves weighing the risk of sedation with MRI against the risk of radiation exposure with CT, and the comprehensive evaluation of morphology, function and flow with MRI against the higher resolution of CT. With an increase in

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awareness of the long-term side effects of sedation, and the advent of new generation CT scanners, which freeze respiratory and cardiac motion, and decrease radiation exposure by 70-80% in neonates and infants, there has been a trend towards the use of CT over MRI for common cardiovascular indications. The aim of this study is to compare the use of CT and MRI for common cardiovascular indications in neonates and infants before and after the advent of new generation CT scanners in a single major center for CHD. Methods & Materials: The use of CT versus MR for cardiovascular imaging in seventy-eight consecutive infants less than 6 months of age (40:38 female: male, age: 2.6 ± 1.83 months) with CHD at a single institution was retrospectively studied. Data was collected from Oct 2010-Sep 2012 and from Oct 2012-Sep 2014 which represented 24-month periods before and after installation of a 320-detector volumetric CT (Toshiba Aquilion) respectively. Data collected included age of subject, type of underlying CHD, indication for the study, use of CT vs. MRI, and use of sedation. Indications were classified based on the major imaging target for the study like aorta, pulmonary artery etc. A z-test was performed to assess differences in utilization percentage of CT vs. MRI between the two periods for each indication group. A p-value of less than 0.05 indicated a significant difference. Results: Please refer to table 1. There is an overall 22.5% increase in the use of CT (p<0.001) after the advent of volumetric CT. For two of the eight major indications, there was a statistically significant increase in the use of CT compared to MR. The evaluation of AP collaterals has always depended on CT, and experienced no change in utilization. Conclusions: The advent of new generation volumetric CT has been associated with a significant shift in practice pattern favoring CT over MR for major indications in the setting of CHD in neonates and infants.

Paper #: 026 The Role of Stress Perfusion Cardiac MRI in the Evaluation of Pediatric Patients with Suspected Coronary Arterial Abnormalities

Nana Appiawiah, Children’s Colorado, Aurora, CO; Lorna Browne, Brian Fonseca, Pei Ni Jone, Uyen Truong, Michael DiMaria Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Stress perfusion CMRI (stress CMRI) has a high diagnostic and prognostic value in identifying regions of reversible myocardial ischemia in adults. Little has been published about it’s value in children, where there are unique challenges including elevated heart rate, increased sedation requirement and impact of dark ring artifacts on the small fields of view. This review will assess the role of stress CMRI in the evaluation of pediatric patients with suspected coronary arterial abnormalities. Methods & Materials: A retrospective review of pediatric patients (<25 years) who underwent a stress CMRI from 2005–2014. The following findings were recorded: Clinical: Age, indication, diagnosis, prior imaging, adverse cardiac events. Stress CMRI: Function, wall motion abnormality (WMA), perfusion defect/s, myocardial delayed enhancement (MDE) and coronary arterial abnormalities. Technical parameters: Exam duration, sedation, degree of vasodilatory response, and presence of dark ring artifact. Results: Forty-three stress CMRIs were performed in 34 patients (mean age 9.8 years; range 2-21). Indications were Kawasaki disease (n = 20), prior coronary artery re-implantation/s (n = 6), anomalous coronary artery (n=3), exertional chest pain/syncope (n=4) and rheumatic heart disease (n=1). The Kawasaki patients were subdivided according to their risk level into levels I and II (n=1), level III (n=9) or level IV and V (n=10). Stress perfusion defects were present in 3/34 (8%) in whom the indications were Kawasaki disease IV/V (n=2) and prior coronary reimplantation (n=1). All three patients had significant coronary arterial stricture (>50%) on CMRI. Function was normal in all, one patient had WMA and 0 had MDE. No patient with negative stress CMRI went on to have an adverse cardiac event (mean follow up 2.75 years). Of the 43 stress CMRI exams, 20 required general anesthesia (mean age: 5.05 years, range: 2-12) and 23 were not sedated (mean age 14.0 year, range: 9-21). Mean exam duration was 105 min (range: 66-157). Maximum vasodilatory response was achieved in 43/43 patients. Severe dark ring artifact severely limited evaluation in 2/43 exams. Conclusions: Stress CMRI proved to be useful in pediatric patients with a high risk of coronary artery abnormalities, (Kawasaki grade IV/Vor prior coronary artery reimplantation), identifying those requiring coronary artery intervention. Patients with lesser risk factors (Kawasaki I/II, exertional chest pain/syncope) did not benefit from the addition of stress perfusion imaging to their evaluation.

Paper #: 027 Regadenoson as a Pharmacologic Stressor in Cardiac Magnetic Resonance Imaging in Congenital and Acquired Pediatric Heart Disease: Initial Experience

Cory Noel, MD, Texas Children’s Hospital, Houston, TX, [email protected]; Ramkumar Krishnamurthy, PhD, Brady Moffett, Rajesh Krishnamurthy.

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Adenosine has traditionally been utilized for coronary hyperemia during myocardial perfusion assessment in adults, however regadenoson has recently become more popular1. With improved survival of congenital heart disease (CHD), and increased diagnosis of acquired heart disease (AHD), there’s an increasing need for assessment of myocardial perfusion in pediatrics2. Regadenoson has a more favorable side-effect profile and less stimulation of receptors associated with bronchospasm, and decreased chronotropy1. It is administered as an IV bolus and thus only a single IV is required. Peak onset is at 60-90 s, with hyperemia lasting up to 6 min allowing additional wall motion assessment3. Purpose: To observe the safety, feasibility and effectiveness of regadenoson as a pharmacologic stressor for perfusion CMR in a pilot cohort of CHD and pediatric AHD patients, as part of an ongoing clinical study Methods & Materials: We reviewed our initial experience with regadenoson stress CMR in nine subjects (aged 16.6 +/− 1.6 years) with CHD and pediatric AHD. All patients underwent stress CMR due to clinical symptoms and/or signs suggestive of ischemia. Cohort included six patients with D-TGA, two with coronary aneurysm, and one with coarctation Acquisition Protocol: See table for full details. Heart rate and blood pressure were monitored during CMR. Pharmacologic stress obtained by injecting 400 mcg of regadenoson 60 s prior to stress perfusion assessment. Rest and stress myocardial perfusion were assessed. Ventricular wall motion was assessed with cine SSFP imaging. Myocardial viability imaging was performed. Patients were monitored for 2 h after the study. Data Analysis: Myocardial perfusion and viability images were jointly assessed by a pediatric cardiologist and radiologist. MR images were assessed for WMA. Results: All stress CMR examinations were completed uneventfully. There were no serious adverse events. Resting heart rate was 63 +/− 12 beats per minute (bpm) and rose to a peak of 132 +/− 22 bpm. One patient with D-TGA had an irreversible perfusion defect (fig 1), and one patient with D-TGA had reversible subendocardial perfusion defect. Conclusions: Regadenoson may be a safe, feasible and effective pharmacologic stress agent for use in CMR of CHD and pediatric AHD. The use of a single IV bolus, and the advantage of a prolonged hyperemia makes it appealing in pediatrics. References: 1.) J. CMR 15:85 2.) J. CMR 11:51 3.) Int. J Cardio Imag 30:949

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Paper #: 028 Accurate Quantif ication of Cardiac Biomechanics in Pediatric Population: Respiratory Triggered High Temporal Resolution (RT-HTR) Myocardial Tagging in Cardiac MRI

Ramkumar Krishnamurthy, PhD, Texas Children’s Hospital, Houston, TX, [email protected]; Cory Noel, MD, Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Shiraz Maskatia, Rajesh Krishnamurthy;

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Myocardial tagging have been performed in pediatric patients for studying LV cardiac biomechanics [1-2]. However, the conventional tagging sequence suffers from poor temporal resolution (~40-50 ms), in part because they are designed as breath-held acquisitions. This makes a free breathing high temporal resolution (HTR) (10-20 ms) tagging sequence desirable [3]. This could provide more accurate metrics to analyze cardiac biomechanics in free breathing children. To determine feasibility of a respiratory triggered (RT) high temporal resolution (RT-HTR) tagging sequence in free-breathing children, and compare biomechanical indices from HTR tagging to conventional tagging. Methods & Materials: In this pilot study, we perform a comparison of global and regional circumferential strain (εcc) in seven pediatric patients (four males, age 8±3.6 years), undergoing cardiac MRI. The underlying conditions included HOCM, coarctation of aorta etc. three of these patients were sedated. Acquisition Protocol: After the initial scout sequences, RT-HTR tagged images (1020 ms per cardiac phase) in the basal short axis plane were acquired in a 1.5T MRI scanner (Philips Acheiva) using Spatial Modulation of Magnetization (SPAMM) (figure 1) [1-2] . Scan time: 70-100 s. Acquisition metrics: Voxel size: 1.5 * 1.5 *5 mm3; Tag spacing: 5-7 mm. Data Analysis: The HTR data was sub-sampled at the conventional temporal resolution (CTR) (~40-50 ms) to generate a CTR dataset. Diagnosoft™ was used for analysis of circumferential strain (εcc) across all cardiac phases (figure 2). Peak systolic strain, time to peak systolic strain (TPS) and time to peak diastolic strain rate (TPDSR) were calculated for both HTR and CTR and compared using Student’s paired t-test. Results: Compared to HTR, CTR had a 1. Statistically significant reduction in global (7.9±2.3%), septal (6.9± 1.7%), and freewall (9.4±3.1%) peak εcc (figure 3) (all p< 0.05). 2. Significant and consistent reduction of peak diastolic strain rate (6.8± 2.3%) 3. Significant variation also found in a) TPS, and b) TPDSR (all p<0.03). Conclusions: The RT-HTR tagging sequence a) yields significantly better study of biomechanical metrics like εcc, primarily due to its higher sampling rate, b) produces a larger number of images, thereby increasing the SNR for data analysis, c) offers the ability to image sedated and free-breathing patients.

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Ref: 1) Circ. 98:330 2) JASE 25:11, 1222 3) JMRI:Volume 31, Issue 4, 872-880.

Paper #: 029 Prospective Evaluation of Circumferential and Longitudinal Strain in Asymptomatic Children with Dual Ventricles who Underwent Single Ventricle Repair: Comparison to Single LV, Single RV and Normal Hearts

Ramkumar Krishnamurthy, PhD, Texas Children’s Hospital, Houston, TX, [email protected]; Cory Noel, MD, Amol Pednekar, Ricardo Pignatelli, Jeffrey Jacot, Rajesh Krishnamurthy, et al. Disclosures: Amol Pednekar has indicated a relationship with Philips Healthcare as an employee. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Rarely, patients with normally sized RV and LV (DV) will undergo total cavopulmonary connection (TCPC) due to the complexity of their intra-cardiac anatomy. The ventricular function in this unique physiology compared to SRV, SLV and normal hearts remains poorly understood, with few studies performed1-3. In this study, we perform a comprehensive comparison of global and regional strain in both the circumferential (εcc) and longitudinal (εL) dimensions to conventional SV hearts and normal hearts. Purpose: In normal subjects and asymptomatic patients with DV (LV and RV calculated independently), SLV and SRV after TCPC, to compare: 1) Global εcc and εL strain, 2) Regional circumferential and longitudinal strains at free wall (εcc-free, εL-free) and septum (εcc-sept, εL-sept), 3) εcc and εL across the ventricle from apex to base. Methods & Materials: We performed a prospective analysis of 23 subjects (seven normals age in years: 11.8 +/− 3.1, 5 DV age: 12.4 +/− 2.7, 6 SRV age: 11.4 +/− 2.3, 5 SLV age: 12.6 +/− 4.2). Acquisition Protocol: Strain information was acquired at three short axis slices at basal, mid-cavity, and apical locations in all 123 subjects in a 1.5 T MRI scanner (Philips Acheiva) using: a)

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Complementary Spatial Modulation of Magnetization (CSPAMM) images: Used for generating εcc; and b) Fast-Strain Encoded (fSENC) images: Used for generating εL. Data Analysis: εcc and εL were calculated from SAX slices using DiagnosoftTM. The ventricular regions at each slice were assigned based upon the AHA 16 segment model (fig. 1). εcc-sept, εL-sept , εcc-free, and εL-free were also calculated for each slice and compared. Results: Compared to normals, 1.) Significant reduction in global εcc at all ventricular levels of DV patients (fig 2). 2.) Significant reduction in global εL in mid-ventricular and apical locations of DV patients. 3.) The εcc of the LVof DV patients consistently lower than SLV for global and regional calculations. 4.) In the same DV patient at the basal location, the εcc was higher in the RV, with the εL being higher in the LV. 5.) Global εL progressed from base to apex. Conclusions: Strain values of the RV and LV in DV patients demonstrate significant differences compared to normal subjects. The LV of DV patients had lower strain values than the SLV. The shared workload of the LVand RV for a single cardiac output may contribute to their lower strain values. References: 1.) Circ. 98:330 2.) JASE 25:11, 1222 3.) Con.HD 7:16

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Paper #: 030 Freebreathing Cardiovascular MRI with Ferumoxytol

Shreyas Vasanawala, MD,PhD, Radiology, Stanford University, Stanford, CA, [email protected]; Nichanan Ruangwattanapaisarn, Albert Hsiao.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Ferumoxytol is an ultrasmall superparamagnetic iron oxide (USPIO) nanoparticle agent used to treat iron deficiency anemia in adults with chronic kidney disease. We aim to determine the feasibility of using of ferumoxytol for clinical pediatric cardiac and vascular imaging. Methods & Materials: We retrospectively identified 23 consecutive children who underwent MRI with ferumoxytol (11 males; mean age: 7.4 years, range: 3 days-18 years), yielding 12 abdominal MR angiography and 15 cardiac MRI studies. Medical records were reviewed for the clinical indication, ferumoxytol dose, injection rate, sedation and any complication. A two-reader consensus scored the images on a 5-point scale for overall image quality and delineation of various anatomical structures. Signal-to-background ratios for abdominal aorta and inferior vena cava for abdominal cases and blood pool-myocardium contrast ratios for cardiac cases were calculated. The confidence intervals for obtaining a score of three or above for each image parameter were calculated by using adjusted Wald method. Results: For abdominal MR angiography, average scores for overall image quality, as well as delineation of the hepatic artery, superior mesenteric artery, renal artery, and veins were 4.5, 4.3, 4.3, 3.7 and 4.7, respectively. For cardiac exams, the average scores for overall image quality, systemic arteries, pulmonary arteries, pulmonary veins, valves and ventricles were 4.4, 4.6, 4.1, 4.8, 4.1 and 4.7, respectively. For all parameters, lower bound for proportion of cases to have a score of three or above was 65%. Signal-to-background ratios for aorta and abdominal veins averaged 86 +/− 74 and 86 +/− 77 for full-dose images, and 23 and 18 for half-dose images, respectively. Mean blood pool to myocardium contrast ratio was 3:3. Conclusions: Ferumoxytol can provide excellent image quality for pediatric body MR angiography/MR venography at a dose of 1.5 or 3 mg Fe/kg. Further investigation should be directed towardunderstanding the lowest dose that can be administered.

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Paper #: 031 Comparison of Respiratory-Triggered (RT) 3D Cine Steady-State Free Precession Cardiac MRI with Standard 2D Cine Imaging and Magnetic Resonance Angiography in Congenital Heart Disease (CHD)

Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Diagnostic Imaging, Texas Children’s Hospital, Houston, TX, [email protected]; Lamya Atweh, Amol Pednekar, Ramkumar Krishnamurthy, Rajesh Krishnamurthy. Disclosures: Amol Pednekar has indicated a relationship with Philips Healthcare as an employee. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Conventional assessment of cardiac morphology and function in CHD comprises multi-planar 2D cine SSFP (short axis (SA), 4-chamber, long axis, aortic root, PA and outflow tract geometries) and gadolinium enhanced 3D MRA (3D Gd-MRA). This is a pilot study to evaluate the performance of whole-heart RT-3D cine SSFP as a single solution for assessment of morphology and function in CHD by comparing it to conventional CMR. Methods & Materials: Fifteen patients with CHD (8M, mean age 11.7 years, 80% sedated), referred for CMR had an additional RT 3D SSFP sequence (Table 1) on a Philips Achieva 1.5T MRI, using a 5-channel phased array cardiac coil,. The maximum parallel imaging factor was 2 on 2D, and 3 on 3D SSFP. Imaging targets are listed on Table 1. LV volumetry was performed on 3D and 2D SA datasets by one reader on CMR42 software. VD measurements, image quality analysis, and pathologic findings were assessed on 3D, 2D SSFP and MRA datasets using Vitrea™ by another reader. Pearson and Spearman correlation coefficients and paired t tests were calculated for statistical analysis. Results: Excellent correlation between LV volumetry from 3D and 2D SSFP (r=0.91-0.99, p<.0001), between aortic root measurements on 3D and 2D SSFP, and on 3D SSFP and MRA (r=0.98, 0.96, p<0.0001), and between VD on 3D SSFP and MRA (r=0.96-0.99, p<0.001). Moderate performance for intra-cardiac morphology and pathology (Figure 1); aortic and tricuspid valve scores were lower on 3D SSFP (mean diff -29%, -21%, p=0.003, 0.005). Interslice alignment was better on 3D SSFP (mean diff 8.9%, p=0.04). Aortic and PA scores were overall not significantly different; but 3D scores were lower for 1st and 2nd order branches, and for AV separation (mean diff -23%, -53%, -27%, p=0.03, <0.0001, 0.01). 3D scores were also lower for veins (mean diff -25%, 29% p=0.03, 0.01). Overall diagnosis was different (p=0.02) on 3D SSFP in 5/15 cases (nine missed findings). 5/9 reflected valve pathology, two 1st order vessels, one aorta, and one atrial septum. Four of the missed findings were related to suppression of turbulence by gadofosveset. Mean duration of 3D SSFP was 5.1±0.5 vs. 23±6.7 min for multiplanar 2D SSFP. Conclusions: RT 3D cine SSFP can replace conventional MR sequences for LV volumetry, function, aortic root and vessel diamter. Improved hardware and software, and spatial resolution are needed before it can replace current sequences for evaluation of intracardiac morphology and extracardiac vesseles.

Table 1: Respiratory Triggered 3-D Cine SSFP Technique and Grading Methodology Duration Hardware

4.5-7 minutes Phillips Achieva 1.5T magnet; 5-channel

Duration

4.5-7 minutes phased array coil; Max. parallel acceleration: 2 (2D); 2×1.5 (3D); Acquisition Axial or sagittal Parameters acquisition; respiratory t riggered, retrospective EKG gated, TR/TE/ α=3/1.5/60; voxel size 1.5-2.5; SENSE 2.6-3.6; mean temporal resolution=35 ms; Imaging 3D RT-SSFP Conventional Targets CMR 3D RT-SSFP Short axis (SA) 2D cine SSFP 3D RT-SSFP Multiplanar 2D cine SSFP 3D RT-SSFP Cine 2D SSFP and Gd-3D MRA 3D RT-SSFP Gd-3D MRA 3D RT-SSFP

3D RT-SSFP

Target LV volumetry and function1 Intracardiac morphology2 Aortic root size3 Vessel diameter (VD)4 Morphology of extracardiac vasculature5

Multiplanar Cine 2D SSFP and Gd-3D MRA Multiplanar Overall Cine 2D diagnosis SSFP and Gd-3D MRA

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Paper #: 033 Accelerated Segmented and Real-Time Aortic Flow Sequences Compared with Standard 2D Phase Contrast MR in Children

Marcos Botelho, MD, Radiology, Lurie Children’s Hospital, Chicago, IL, [email protected]; Jie Deng, Ryan Kuhn, Ning Jin, Krishna Bandi, Cynthia Rigsby, MD

Paper #: 032 Pseudo ECG-Gating: A New Technique to Achieve Axial Scan Mode for Dose Reduction in Cardiac CT

Dianna Bardo, MD, Radiology, Swedish Cherry Hill Medical Center, Portland, OR, [email protected]; Robert Hill Disclosures: Dianna Bardo, MD, Koninklijke Philips Electronics Speaker & Consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To achieve lower radiation dose with excellent image quality for cardiac CT. Methods & Materials: Thirty-seven infants underwent clinically indicated chest CT for investigation of congenital heart disease. Intravenous contrast (23 mL/kg) was delivered by hand injection via umbilical venous catheter or peripheral IV. Scans were performed using kV (80-100), mAs (25-70) with 64-256 MDCT (Philips, Cleveland, OH). An electronic ECG simulator device, (commonly referred to as a ‘chicken heart’) attached to scanner ECG leads generated an ECG signal trigger for prospective (Step and Shoot) scan mode for cardiac CT with a pseudo ECG-gating technique (n=25). Dose (CTDIvol) and image quality (ability to identify coronary origins and definition of the intraventricular blood pool / myocardium margin & graded 1, well defined or 0, blurred margins) were tabulated. Dose and image quality were compared to exams acquired with non-ECG-gated helical (n=10) and patient generated prospective, ECG-gated (n=2) protocols in age matched patients. Results: Pseudo ECG-gated exams: Scan length range (6-14 cm, 1-4 axial steps). CTDIvol range (0.7-0.9)39 of 50 (78%) of coronary artery origins identified, 17 (68%) blood pool / myocardium well defined. Helical, non-ECG-gated exams: Scan length range (10-14 cm) CTDIvol range (1.0-2.0)13 of 20 (65%) of coronary artery origins identified, 5 (50%) blood pool / myocardium well defined. Prospective ECG-gated exams: Scan length range (8-14 cm, 2-4 axial steps). CTDIvol range (0.9-1.4)4 of 6 (67%) of coronary artery origins identified, (50%) blood pool / myocardium well defined. Conclusions: Pseudo ECG-gated axial (Step and Shoot) mode CTDIvol is decreased by up to 45% compared to helical nonECG-gated and by up to 50% for prospective ECG-gated exams, without decrease in image quality.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Standard two-dimensional (2D) phase contrast (PC) MR is an established method for flow assessment. 2D PC is an ECG synchronized gradient echo sequence performed with k-space segmentation, generally during free breathing with 2-3 signal averages leading to 1.5-3 min of imaging time per vessel. Accelerated flow sequences utilizing segmented echo planar imaging (EPI) readouts and temporal parallel acquisition have been developed to improve spatial and temporal resolution, with resultant diminished sensitivity to motion, acquired in under 30 s. Real-time (RT) EPI with shared velocity encoding has also been introduced as an alternative for faster flow assessment (<10 s) and no ECG synchronization. The accuracy of these methods for flow assessment in children is not known. Our purpose is to compare aortic flow in children obtained using segmented EPI and RT EPI with standard 2D PC. Methods & Materials: This prospective study is IRB approved. Informed consent was obtained. 32 patients (mean age 12±7 years) undergoing standard aortic 2D PC also had segmented EPI and RT EPI sequences obtained at the same location. Flow analysis was performed by placing aortic contours in the same location on each of the images for each sequence over the entire cardiac cycle. Cardiac output (CO) and peak systolic velocity (PSV) 2D PC values were compared to segmented EPI and RT EPI values using Wilcoxon Signed Rank test and Bland-Altman plots. Spearman correlation was calculated to evaluate for association between heart rate and flow values. Results: CO and PSV were not significantly different (p>0.05) between standard 2D PC and segmented EPI. CO was not significantly different (p>0.05) between 2D PC and RT EPI. PSV was significantly different between 2D PC and RT EPI (p<0.01). Bland-Altman analysis demonstrated better accuracy and precision of the segmented technique for CO, however, accuracy and precision were comparable for PSV assessment using either accelerated technique. There was a significant association between heart rate and RT EPI values (r=0.82 for CO and r=0.39 for PSV). Conclusions: Using standard 2D PC as the reference, segmented EPI generates more accurate and precise CO than RT EPI. Aortic PSV are of comparable accuracy and precision using either segmented or RT EPI. Heart rate may influence RT EPI values. These accelerated sequences have the potential to reduce scan time for pediatric CMR studies.

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Paper #: 034 The Pitfall of Gadofosveset Trisodium Associated Paradoxical Negative Enhancement on MR Steady-State Imaging in an Animal Model

Sumera Ali, Radiology, University of Arkansas for Medical Sciences, Little rock, AR, [email protected]; Robert Buchmann, DO, S Bruce Greenberg, William Reyenga. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Hypointense signal following gadofosveset trisodium injection was noted in a patient with venous malformation during steady-state imaging. Based on this observation, we derived a hypothesis that the vascular anomalies that concentrate a large amount of gadofosveset trisodium will have a paradoxical decrease in signal intensity. Our purpose was to test this hypothesis in an animal model. Methods & Materials: Gadofosveset trisodium (Ablavar 0.25 mmol/mL) was diluted using saline into the following solution concentrations: 50, 10, 1, 0.1 and 0.01%. One ml aliquot of each solution was then injected into a boneless, skinless chicken breast. The chicken breast was scanned using a 1.5T MRI unit using a T1-weighted steady state sequence (TR 400/TE 10/Flip angle 90). A region of interest (ROI) in the chicken breast without contrast was used as the control for signal intensity. Relative signal intensities (RSI) were then measured for each aliquot. The resulting scan revealed an abrupt change in signal between concentrations 1 and 10% and the experiment was repeated using the following solution concentrations: 4, 2 and 1.3%. Results: The RSI for the chicken breast without contrast measured 412. For the gadofosveset trisodium solutions tested, RSI was inversely related to concentration. The RSI decreased from 1497 to 60 as gadofosveset trisodium solution concentration increased from 0.01 to 50% (graph). Gadofosveset trisodium solution concentrations of 4% or less were associated with expected positive contrast enhancement, but negative contrast resulted from concentrations greater than 4%. Conclusions: High concentrations of gadofosveset trisodium results in the paradox of negative contrast enhancement. This potential pitfall should be recognized when using gadofosveset trisodium. The presence of negative contrast may be helpful in the evaluation of vascular malformations.

Paper #: 035 Snapshot of Radiation Exposure Contribution of Scout Abdomen Radiograph in Common Pediatric Fluoroscopic Procedures

Anil Rao, MBBS, DMRD, DNB, Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, [email protected]; Paul Thacker, MD, Cephus Simmons, MRS, RRA. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To assess the radiation exposure contribution of scout radiographs in common pediatric fluoroscopic studies. Methods & Materials: After IRB approval, we performed a retrospective review of all fluoroscopic procedures performed over a fourth month period by our pediatric radiology department. We evaluated each procedure in terms of patient age, sex, scout abdominal radiograph technique (AXR), and radiation dose area product (DAP) and skin entrance dose (SED) for the scout abdomen radiograph, and the total procedural DAP and SED. All studies were performed on a single digital fluoroscopy machine with a pulse rate of four frames per second and last image save technique for image archiving. We calculated the mean, median and range of the DAP and SED values for the scout radiograph and the total procedure for our most common fluoroscopic procedures, e.g. voiding cystourethrography (VCUG), fluoroscopic enema (BE), and upper gastrointestinal studies (UGI). Additionally, we determined the radiation associated with AXR as a percentage of the total radiation DAP and SED of each procedure (Table). Results: A total of 149 studies (23 BE, 64 VCUG and 62 UGI) were evaluated, 81 females and 12 males (ages from birth to 16 years). For scout AXR, DAP values (Gycm2) are 0.16 (mean); 0.05 (median); 0.004-2.635 (range). SED values (mGy) are 0.33 (mean); 0.15 (median); 0.06-4.72 (range). For total procedure, DAP values are 0.35 (mean); 0.096 (median); 0.014-6.114 (range). SED values are 1.46 (mean); 0.55 (median); 0.23-26.07 (range). The fractional radiation exposure contribution of scout AXR to total procedure for DAP are 50.4% (mean), 48.9% (median), 4.2-98.4% (range). SED are 29% (mean), 26.4% (median), 5.45-97.4% (range). 31 of 34 patients aged 6 years or older had scout radiograph performed with a grid. 112 out of the 115 patients less than 6 years of age had scout radiograph done without a grid. Conclusions: The fractional contribution of radiation exposure of the scout abdomen radiograph to the total procedure varies widely. However,

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radiation exposure from the scout abdomen radiograph can be a significant portion of the total procedure radiation exposure, found to be up to 50% (median value). Thus, the added value of scout radiographs likely should be reassessed in the setting of heightened awareness of the radiation exposure in our pediatric population.

Enema studies

UGI

Dose Area Skin entrance Product dose (Gy.cm2) (mGY) Mean Median Range Scout AXR 0.11 0.06 0.0041.08 Total 0.51 0.14 0.02procedure 3.4 Fraction (%) of 35.9% 36.5% 4.2scout to total 72% procedure Scout AXR 0.2 0.04 0.012.63 0.46 0.11 0.02-6.11 1.88

Total procedure Fraction (%) of 46.9% scout to total procedure VCUG Scout AXR Total 0.19 procedure Fraction (%) of 59% scout to total procedure

43.4%

12-98.4%

28.4%

0.11

0.05

0.09

0.01-2.47

0.010.83 0.9

58.8%

21.2-90%

31.7%

Enema studies

UGI Total procedure Fraction (%) of scout to total procedure VCUG Total procedure Fraction (%) of scout to total procedure

Median 0.16 0.79 22.2% 0.15 0.23-26.07 6.5-97.4% 0.15 0.23-10.40 5.4-72.6%

Range 0.06-2.06 0.25-10.06 5.8-50% 0.01-4.72

0.06-1.51

Table showing mean, median and range of values of radiation dose area product (in Gy.cm2) and skin entrance dose (in mGy) for scout abdomen radiograph only, total procedure (scout and fluoroscopy component) and fraction (in percentage) of scout AXR to total procedure radiation exposure for pediatric enema studies, UGI and VCUG respectively.

Paper #: 036 Pre-Procedural Scout Radiographs May be Unnecessary for Routine Pediatric Fluoroscopic Examinations

Sean Creeden, MD, Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, [email protected]; Paul

Thacker, MD, Anil Rao, MBBS, DMRD, DNB, Meryle Eklund, Jeanne Hill. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Traditionally, scout radiographs have been considered an integral part of pediatric fluoroscopy with the logic resting on their ability to detect unsuspected findings which may preclude exam performance or alter normal anatomy, e.g. unexpected abdominal masses. However, no study to date has assessed the incidence of such findings on pre-procedural scout radiographs. The objective of this study is to assess the incidence of unexpected findings and, by extension, the utility of routine scout radiographs in pediatric fluoroscopy. Methods & Materials: We performed a retrospective review of 1000 routine fluoroscopic examinations performed at our pediatric radiology department. Each examination was assessed for the presence of a scout radiograph, were any abnormalities detected on the scout radiograph, were the detected abnormalities previously unknown, and would these abnormalities change either examination or alter management. Results: Of the 1000 procedures, 991 (99.1%) received a pre-procedural scout radiograph. Study population age ranged from 1 day of life through 19 years of age with 528 male and 463 female patients. Thirty-three scout radiographs were read as positive (3.3%) with only four total studies (0.4%) demonstrating previously unknown or unsuspected findings (two umbilical hernias, one inguinal hernia, and one bilateral hip dysplasia. The inguinal hernia and one of the umbilical hernias was present on prior radiographs but not commented on. The hip dysplasia had no previous imaging but was in a patient with cerebral palsy. The second umbilical hernia had no prior imaging demonstrating the abnormality, but the patient also had no clinical follow-up since discharge. Thus, after a consensus conference between four pediatric radiologists, it was deemed that these four cases were not significant. Notably, there were no cases of unsuspected masses, pneumoperitoneum, retained radiographic contrast, or renal calculi. Conclusions: Our data suggests that scout radiographs prior to routine pediatric fluoroscopic procedures may be unnecessary as only 3.3% of cases were positive, none of which were clinically significant. However, this conclusion is not to say that scout radiographs are not useful in all scenarios and should be obtained at the pediatric radiologist’s discretion. In the setting of VCUG, we advocated fluoroscopic spot image obtainment prior to catheterization, rather than a true scout radiograph.

Paper #: 037 Lead Gonad Shields: Good or Bad for Patient Radiation Exposure?

Summer Kaplan, MD, Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, [email protected]; Dennise Magill, Marc Felice, Sayed Ali, Xiaowei Zhu. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Use of a lead shield to protect the gonads during radiography has been common practice for many decades, in spite of low accuracy in shield placement. The gonads were once thought to be extremely radiation-sensitive, but we now understand that they are among the least radiation-sensitive organs in the abdomen. Mean wh ile,

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radiographic techniques have evolved, and use of automatic exposure control (AEC) is now standard for most examinations. AEC surveys the exposure of the image detector and turns off the x-ray beam when a threshold exposure has been reached, contributing to lower patient exposures. However, a potential problem arises when these two radiation-sparing techniques are used together. A lead shield in the field of the AEC may cause the AEC to increase tube output, causing a paradoxical increase in radiation to unshielded areas. Methods & Materials: Using a 5-year old CIRS phantom, we implanted calibrated Gafchromic film at four sites in the phantom to simulate anatomy: (1) midline ovary; (2) right lateral ovary; (3) deep bowel at the right iliac crest; (4) greater curvature of stomach. The phantom was exposed with an AP pelvis technique using AEC with and without a gonad shield (Figure 1). In both conditions the AEC was set to terminate the exposure at 1.79 μGy. Serial exposures were made to ensure 98% accuracy. The organ dose per exposure was calculated and normalized to the average dose in each organ for the unshielded condition. Results: The AEC set exposure to 1.3 mAs without a shield and increased exposure throughout the field to 1.9 mAs in the presence of a shield. During shielding, there was a 20% increase in radiation to the lateral ovary, 14% increase to deep bowel at the iliac crest, and 18% increase at the stomach (Figure 2). A 50% reduction in radiation was seen at the shielded midline ovary dosimeter, but the radiation at this site was not negligible (Figure 3). Conclusions: Use of a gonad shield with AEC for female pelvic radiographs increases radiation to more sensitive bowel and stomach while sparing radiation to the less sensitive gonads. However, the ovaries are accurately shielded as little as 9% of the time, so shielding has the paradoxical effect of increasing radiation to the ovaries in up to 91% of cases. The likelihood of poor ovarian shielding, increased radiation throughout the abdomen, and the possibility of obscuring relevant anatomy argue against the use of gonad shields for female pelvis radiographs when AEC is employed.

Paper #: 038 Table top Fluoroscopy: To Shield or Not to Shield

Frank Goerner, PhD, Pediatric Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Cristina Dodge, Robert Orth, MD, PhD Disclosures: Robert Orth has indicated a relationship with General Electric as a fellow. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Young children often require gentle restraint during fluoroscopic imaging procedures. This can lead to additional radiation exposure to the patient, parent, and staff. The purpose of this study was to determine whether placing lead shields on the table above and below the anatomic area of interest decreases this radiation exposure.

Methods & Materials: A cylindrical, acrylic phantom set consisting of a head (Hd) and abdomen (Ab) phantom was used to simulate the patient. Both Hd and Ab measured 15 cm in the anterior-posterior dimension, with diameters of 32 cm for Ab and 16 cm for Hd. An upper GI protocol was selected on a Philips EasyDiagnost fluoroscope, which was operated in normal automatic mode and centered over the Ab portion of the phantom with Hd outside of the field-of-view. Scatter was measured with a Fluke Biomedical model 451P survey meter and read out in mili-Roentgen/hr with a manufacturer-specified error of 10%. To evaluate exposure to the individual restraining (RI) the patient’s arms or legs, scatter was measured at the head and foot of the table to approximate clinical conditions. As shown in Figure 1, measurements were taken at six positions: 1) head side, RI eye level; 2) head side, adjacent to Hd; 3) head side, 6″ above the table top adjacent to Hd; 4) foot side, RI eye level; 5) foot side, adjacent to Ab; 6) foot side, 6″ above the table top adjacent to Ab. Scatter measurements were taken with lead (W) and without lead (WO) present on the table top and percent difference (%Diff) was calculated as (W-

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WO)/W. An additional scatter measurement was taken at position 1) with lead partially covering the fluoroscopic field-of-view. Results: Scatter exposure rates and %Diff between measurements with and without lead are presented in Table 1. The average difference in scatter was 6%, greater with lead shielding in place. Additionally, when lead partially obstructed the field-of-view, the measurement at position 1) increased three fold from 13.3 to 44 mR/hr. Conclusions: All scatter measurements, except 1, were higher with lead on the table. Average %Diff between measurements with and without lead was below the specified error of the equipment, indicating there is no advantage to having table top lead shielding in place during fluoroscopic procedures. In cases with excessively non-compliant patients where the operator may be forced to perform the procedure with lead partially in the field-of-view, the increase in scatter to both the patient and operator is substantial.

beneath the phantom. The support tray alone resulted in reductions in EI, detector entrance exposure and CNR of 9-47, 9-52 and 6-34% respectively. The worse performing unit resulted in reductions of EI, detector entrance exposure and CNR of 52, 58 and 42% with the comfort pad and support tray compared to 20, 23 and 18% in the better performing unit. Additional reductions in EI and detector entrance exposure caused by the pad, compared to the support tray alone was 10-14 and 14-18% respectively. Conclusions: Comfort pads and tray support devices can have a considerable effect on radiation dose and image quality, with large variations between incubator and radiant warmer manufacturers. Simply removing the pad will result in decreased attenuation. However, the support tray itself also significantly reduces detector entrance exposure and image quality. The detector should be placed directly under the patient when clinically feasible and exposure parameters adjusted to minimize radiation dose.

Table 1: Scatter measurements during Fluoroscopy

Position 1 Position 2 Position 3 Position 4 Position 5 Position 6 Average

With Lead 14.4 mR/hr 110 mR/hr 5.1 mR/hr 31 mR/hr 320 mR/hr 63 mR/hr 91 mR/hr

W/O Lead 13.3 mR/hr 73 mR/hr 6.1 mR/hr 29 mR/hr 300 mR/hr 62 mR/hr 81 mR/hr

% Diff 8% 34% -20% 6% 6% 2% 6%

Paper #: 039 Effect of Comfort Pads and Incubator Design on Radiation Dose and Image Quality of Chest Radiographs in Neonates

Michael Baad, MD, University of Chicago, Chicago, IL, [email protected]; Xia Jiang, Ingrid Reiser, Zheng Feng Lu, Kate Feinstein. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Radiation dose remains a continuing concern in pediatrics. A recent study showed significant (12-72%) attenuation due to comfort pads interposed between neonate and detector during radiography using exposure index (EI) as a proxy for exposure to the detector. This ultimately leads to higher patient dose, as exposure factors must be increased to achieve the same image quality. Our study examines the effects of comfort pads and support devices unique to incubators as well as the validity of the prior study by direct measurements of detector entrance exposure and image quality. Methods & Materials: Incubators and radiant warmers from three manufacturers were examined in the range of 55-65 kVp on two digital radiography systems (GE and Shimadzu). Using a 5 cm thick acrylic phantom to simulate a neonate, detector entrance exposure was measured with an ionization chamber at detector level and EI was also recorded using the following detector configurations: 1) beneath the phantom; 2) beneath the support tray and phantom; 3) beneath the support tray, comfort pad and phantom. The same configurations were then used to measure contrast-to-noise ratio (CNR) using a 5 cm thick contrast detail phantom. Results: The support tray and comfort pad resulted in reductions in EI, detector entrance exposure and mean CNR of 20-54, 22-59 and 18-42% respectively when compared to direct placement

Paper #: 040 Radiation Dose Reduction by Indication Directed Focused z-Direction Coverage for Neck CTs

Ashish Parikh, MD, Radiology, Mayo Clinic, Jacksonville, FL, [email protected]; Chetan Shah. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: ACR-ASNR-SPR practice parameter for the performance of CT of the extracranial head and neck suggests coverage should be through the area of interest, specifically from the floor of the sella to the top of the aortic arch. It also recommends using CT scans judiciously to achieve the clinical objective. Our purpose is to analyze the potential dose reduction by decreasing the z-axis length of neck CTs and to assess for any clinically significant information that might be missed from this alternative targeted approach. Methods & Materials: The retrospective study included 126 children (60 girls and 66 boys) under the age of 18 years who had a neck CT performed on a 64-slice scanner at a tertiary care children’s hospital between 1st August 2013 and 30th September 2014. Children who had combined neck, chest, abdomen and pelvis CT for oncological diagnosis were excluded. Two children for whom dose information wasn’t available were excluded. Modification of the z-axis length for the alternative targeted CT was suggested on the topographic (scout) image based upon the indication of the study, while blinded from the CT slices and the CT report. Dose-length product (DLP) for the alternative targeted CT was extrapolated from the DLP for the original untargeted study by factoring

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for z-axis length. Effective dose was calculated from the DLP for the original untargeted study and for the alternative targeted study by using the conversion factors for various age groups provided in the AAPM report no. 96 (2008). The Mann–Whitney U-Test was used for statistical analysis. Results: Decreasing the longitudinal scan length along the z-direction resulted in an average estimated dose reduction of 49% (range 15-93%). Median effective dose of the potential alternative targeted CT (0.42 mSv) decreased significantly (p<0.0001) from the median effective dose of the original untargeted CT (0.78 mSv). Further, the change in scan length did not result in any significant missed findings/pathologies that changed management (Table 1). Out of the 27 abscesses seen in this study, none extended to the mediastinum. Conclusions: Decreasing the z-axis length of a neck CT targeted to the clinical indication provides a significant savings in radiation dose while not altering diagnostic ability or management. Using standard protocols regardless of indication on neck CTs subjects children to substantially more radiation exposure than necessary.

Case Indication

1

2

3

4

5

6

7

8

Missed Findings From Targeted CR Approach Right soft palate 3 mm thyroid cyst lesion

Clinical Significance

Not relevant for the current indication Left neck mass Adenoid and tonsillar Not relevant for the enlargement current indication Prevertebral Left middle cranial fossa Not relevant for the soft tissue arachnoid cyst current swelling indication Spine deformity Tracheo-cutaneous Not relevant for the fistula, partial fusion current left 3-5th indication, ribs, PDA ligation clip clinicians already had this information Lymphadenitis Direct origin of left Incidental normal vertbral artery from variant aorta Tonsils/adenoid Multiple vascular Not relevant for the hypertrophy anomalies, mastoid current opacification indication Enlarged lymph Left posterior arch of C1, Not relevant for the nodes unfused anterior arch current of indication C1, fusion of left C2C3 pillar Headaches, Direct origin of left Incidental normal acute vertebral artery from variant pharyngitis aorta

Paper #: 041 Pediatric Chest CT at Chest Radiograph Doses: When is the Ultralow-Dose Chest CT Clinically Appropriate?

Javier Villanueva-Meyer, MD, David Naeger, Jesse Courtier, MD, Michael Hope, John MacKenzie, Andrew Phelps, MD, Radiology

and Biomedical Imaging, University of California - San Francisco, San Francisco, CA, [email protected] Disclosures: John MacKenzie has indicated a relationship with with General Electric as a Principal Investigator. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Our institution uses an ultralow-dose chest CT protocol for evaluating pectus excavatum. The estimated effective dose is 0.04 mSv, a 94% reduction, compared to 0.7 mSv for our standard chest CT protocol. The primary purpose of our study was to subjectively evaluate whether ultralow-dose chest CT would be diagnostically adequate for other diagnoses. The secondary purpose of our study was to determine whether model-based iterative reconstruction (MBIR) could improve the diagnostic adequacy compared to adaptive statistical iterative reconstruction (ASIR) at ultralow doses. Methods & Materials: We retrospectively reviewed 20 pediatric (mean 13.7 years) chest CTs, 10 of which were standard-dose and 10 of which were ultralow-dose. Ultralow-dose CT was reconstructed with MBIR or ASIR. Standard-dose CT was only reconstructed with ASIR. Objective measures of radiation dose and image noise were obtained. All images were subjectively assessed by four radiologists for their adequacy to exclude five hypothetical diagnoses: foreign body, fracture, infection, interstitial lung disease, and metastasis. Additionally, pairwise comparison for subjective image quality was used to compare ultralow-dose chest CT with ASIR and MBIR. Data were analyzed with descriptive statistics, t-test, and analysis of variance. Results: For the exclusion of an airway foreign body, the adequacy of ultralow-dose CT was comparable to standard-dose (98% for MBIR and ASIR ultralow-dose versus 100% for standarddose, p=0.6). For the remaining diagnoses, the diagnostic adequacy of ultralow-dose CT was inferior to standard-dose CT (60-82% versus 92-100%, p=0.03-<0.001). MBIR partially recovered the adequacy of the ultralow-dose chest CT to exclude infection (85% for MBIR versus 68% for ASIR, p = 0.017), but there was no significant difference for the other four diagnoses. For the ultralow-dose CT, objective image noise was significantly lower with MBIR compared to ASIR (p<0.001), although subjective evaluation showed only a slight advantage of MBIR (58% versus 42%). Conclusions: Ultralow-dose chest CT may be adequate for the exclusion of an airway foreign body, but not for parenchymal lung disease. Although MBIR improves objective and subjective image quality, it does not completely rescue the diagnostic adequacy of ultralow-dose CT when compared to standard-dose CT. The next step is a prospective study for patients suspected to have airway foreign body, evaluating the diagnostic ability of ultralowdose CT, standard-dose CT, and bronchoscopy.

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Paper #: 042 Image Quality in Sinogram Affirmed Iterative Reconstruction (SAFIRE) at Low Doses – is There a Point of Diminishing Returns?

Juan Infante, MD, Medical Imaging, Ann & H. Robert Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Cynthia Rigsby, MD, Yu Liu. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine if the image quality advantage of iterative reconstruction (SAFIRE, Siemens AG Healthcare Sector, Germany) is constant across clinically utilized CT doses including the lower dose range used in pediatric imaging. Methods & Materials: An ACR quality phantom was scanned both in incremental kV steps from 70 to 120 kVand effective tube current steps of approximately 25 mAs/rot from 26 mAs/rot to the maximum possible setting for a given kV at interval while maintaining maximum allowable pitch of 0.32 (Table 1). Each scan was reconstructed with filtered back projection (FBP) and SAFIRE at strengths of one, three and five. Image quality measures including SNR calculation with a pixel by pixel comparison to a reference (ideal) image, mean Hounsfield unit (HU) and standard deviation (SD) within a region of interest (ROI), and contrast to noise ratio (CNR) were calculated with MATLAB (Mathworks, Natick, MA). High contrast resolution (HCR) was scored manually. Regression analysis was performed to assess the relationship between CTDI and SNR for each reconstruction method. ANOVA was used to determine if the percent improvement with SAFIRE was constant across the included CTDI range. Results: A linear relationship between CTDI and SNR was shown for all reconstruction methods with R2 values 0.95, 0.98, 0.99, and 0.99 for FBP and SAFIRE strengths of 1, 3, and 5, respectively. SNR estimated from HUs and SDs within ROIs qualitatively resembled these results in a logarithmic scale. There was a significant difference in the SAFIRE-to-FBP SNR and CNR improvement (p<0.001) across the explored dose range. The SNR advantage of SAFIRE peaked at a CTDI of 0.86 mGy with 171% improvement over FBP for SAFIRE strength 5 (Figure 1). SAFIRE SNR performance plateaued at greater doses with approximately 14, 43, and 74% improvement over FBP for strengths of 1, 3, and 5, respectively. There was no significant difference in HCR between the reconstruction methods. However, qualitatively, line pairs were more difficult to identify with all SAFIRE strengths compared to FBP. Conclusions: There is a dose threshold below which the relative image quality benefit of SAFIRE quantitatively suffers. Further studies of image quality aided by reference images may help confirm the reproducibility of these results across varying subject sizes. Given the qualitative trend towards decreased HCR, SAFIRE may be less desirable, particularly at low doses, when evaluating multiple line-pair structures (i.e. lung parenchyma detail, bones, etc.). Table 1. Study protocol showing the CT parameters kVp, effective mAs, and pitch factor. kVp 70

80

Eff. mAs 26 50

CTDI 0.25 0.48

Pitch 0.32 0.32

76 26 50

0.73 0.41 0.78

0.32 0.32 0.32

100

120

76 100 26 50 76 100 26 50 76 100 126

1.18 1.56 0.86 1.65 2.49 3.28 1.42 2.75 4.17 5.49 6.90

0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32

Paper #: 043 Diagnostic Accuracy of Computed Tomography (CT) Using Knowledge-Based Iterative Reconstruction (KIR) Versus Hybrid Iterative Reconstruction (HIR) in Combination with Reduced Tube Voltage (kV) for the Diagnosis of Acute Appendicitis in Children

Claudia Martinez-Rios, MD, University Hospitals Case Medical Center, Case Western Reserve University,Department of Radiology, Cleveland, OH, [email protected]; Sara Texteira, Dayna Weinert, Rahim Moineddin, David Jordan, Sheila Berlin; Disclosures: Claudia Martinez-Rios, MD, Research agreement between Case Western Reserve University and Philips Healthcare, Research Fellow. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare two different iterative reconstruction techniques, knowledge-based (KIR) and hybrid (HIR) at reduced kV CT to assess the diagnostic accuracy of acute appendicitis. Methods & Materials: Ninety five consecutive patients [mean 15.6 years (yrs); min 1.8 -max 21.8 years] who underwent enhanced abdominal CT for right lower quadrant abdominal pain were included in this study. CT protocols were based on body width (BW): 80 kV for BW≤18 cm, 100 kV for BW 19-30 cm, and 120 kV for BW>30 cm. CT data was reconstructed with KIR and HIR at a fixed preselected level and imaging algorithm. Two blinded readers with 26 and 2 years of experience in

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Pediatric Radiology, independently reviewed 180 multiplanar CT images in a randomized fashion. CT dose metrics were recorded, and Size Specific Dose Estimates (SSDE) and Effective Dose (ED) were calculated. CT Images were designated as positive or negative for acute appendicitis and the diagnostic confidence was assessed. Accuracy (Accu), Sensitivity (Sen), Specificity (Spec), Positive Predicitive Value (PPV) and Negative Predictive Values (NPV) for each technique were calculated and compared. Results: Twenty-four (25.26%) patients had pathologically proved acute appendicitis, and 9 (37.5%) of those were perforated. When comparing senior versus junior reader diagnostic performance for acute appendicitis using HIR and a 95% confidence interval (CI): Accu was 96 and 91% (CI: 90-99%; and 83-96%). P<0.0027. Diagnostic confidence was P <0.03. Sen for diagnosis of appendicitis was 92 and 100% (CI: 73-99%; and 86-100%). Spec was 97 and 88% (CI: 90-100%; and 76-95%). PPV 92 and 75% (CI: 73-99%; and 60-88%). NPV 97 and 100% (CI: 90-100%; and 94-100%) and with KIR, Accu was 93 and 82% (CI: 86-97%; and 72-87%). P = 0.001. Diagnostic confidence P=0.0008. Sen was 87 and 100% (CI: 67-97%; and 86-100%). Spec was 96 and 75% (CI: 87-99%; and 70-85%). PPV was 86 and 60% (CI: 68-97%; and 50-74%). NPV 95 and 100% (CI: 87-99%; and 93-100%), respectively. Agreement among readers was moderate to high for the diagnosis of appendicitis. Mean CT dose metrics were: CTDIvol: 6.1±4.9 mGy. SSDE: 5.4±5.11 mGy; and ED: 3.38± 2.7 mSv. Conclusions: Knowledge-based Iterative Reconstruction at low Kv enhanced abdominal CT demonstrates high diagnostic performance similar to that of Hybrid Iterative Reconstruction for suspected pediatric appendicitis, providing potential to further investigate decrease in CT dose at an equivalent diagnostic accuracy.

Results: The mean dose metrics were: CTDIvol 4.2 +/− 1.6 mGy, SSDE 6.3 +/− 2.0 mGy, and ED 3.2 +/−1.4 mSv. 16/55 cases were pathology-proven appendicitis. The two readers had a 90% agreement with the pathology report of appendicitis. There was good inter-reader agreement on whether the diagnosis was appendicitis (κ: 0.62, p <0.05). Both readers shared a 95% confidence in the determination of appendicitis, with no statistical difference. In the subjective evaluation of image quality there was fair to poor agreement between readers for questions on subjective image noise, presence of artifacts, low contrast detectability and visibility of small structures. Average overall image quality was rated 3.52 (R1: 3.18, R2: 3.87) on a Likert scale of 1–5. This score indicated that images were: “Good: few artifacts, low noise.” Conclusions: While the subjective interpretation of image quality varies between academic pediatric and community general readers, their ability to diagnosis appendicitis using HIR-enabled reduced kV protocols was 90% with good inter-reader agreement.

Paper #: 044 Academic Pediatric versus Community General Radiologist Preference and Performance using Reduced Tube Voltage and Hybrid Iterative Reconstruction Protocols in Pediatric Abdominal CT for Appendicitis

Roshni Parikh, MD, Radiology, University Hospitals Case Medical Center, Cleveland, OH, [email protected]; Sheila Berlin, Philip Yen, Stephanie Soriano, Hannah Barnard, Carlos Sivit. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare the preference and performance of an academic pediatric and community general radiologist interpreting hybrid iterative reconstruction (HIR)enabled low tube voltage (kV) protocols for enhanced abdomi n a l c o m p u t e d t o m o g r ap h y ( C T ) f o r th e e v a l u a t i o n o f appendicitis. Methods & Materials: Fifty-five patients (median age: 12.3 years, median weight: 50 kg) underwent enhanced abdominal CT for acute right lower quadrant abdominal pain. Patients were scanned using dimension-based protocols: 80 kV for body width (BW)≤ 18 cm, 100 kV for 19–30 cm BW and 120 kV for > 30 cm BW. An academic pediatric and community general radiologist independently reviewed axial, sagittal and coronal images reconstructed with HIR. CT dose index (CTDIvol), size-specific dose estimate (SSDE), and effective dose (ED) were calculated. Percentage agreement and kappa statistics were used to estimate inter-observer variability for each of the lesion assessment parameters. Wilcoxon signed rank test was used to compare the readers’ diagnostic confidence.

Paper #: 045 Image Gently Lessons for Community Hospitals Performing Pediatric Abdomen and Pelvis Computed Tomography

Robert Buchmann, DO, Radiology, Arkansas Children’s Hospital, Little Rock, AR, [email protected]; Shilpa Hegde, Leann Linam, MD, S Bruce Greenberg. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Our purpose was to compare radiation exposure of children who underwent abdomen and pelvis computed tomography (CT) at regional community hospitals with a tertiary care pediatric hospital. A secondary purpose was to analyze technique differences that can result in specific recommendations to reduce radiation exposure in community hospitals. Methods & Materials: The study included all 178 abdomen and pelvis CT examinations performed at community hospitals and later referred to a tertiary care pediatric hospital during the first 6 months of 2013. Inclusion criteria included age less than 19 years and a dose page that included phantom size, CTDI volume, and dose length product (DLP). The control group included 111 CT examinations performed at a tertiary care pediatric hospital between April and June, 2013. Patient age, number of imaging phases, kVp, CTDI volume and DLP were recorded for each

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examination. The size-specific dose estimate (SSDE) and effective dose were calculated. T tests compared differences in patient group ages, kVp, effective dose and SSDE. Fischer’s exact test was used to assess the frequency of single and multiphase studies in the two groups. Results: The community hospital (CH) group mean age (10.0 years) and was not significantly different from the control group (10.7 years, p= 0.25). The CH group mean SSDE (26.2 mGy) was 272% of the control group and the difference was extremely significant (p=0.0007). The CH group mean effective dose (13 mSv) was 197% of the control group and the difference was extremely significant (p<0.0001). The CH group used 120 kVp energy or greater in 83% of cases and the control group used 100 kVp or lower in 85% of cases. The CH group kVp was significantly greater (p<0.0001). Multiphase imaging was performed in 25% of CH studies and only 4.5% of the control group. The difference was significant (p<0.001). Conclusions: Radiation exposure of children undergoing computed tomography in community hospitals was significantly higher than at a tertiary care pediatric hospital. Higher kVp energy and the greater use of multiphase imaging accounted for the increased exposure - both of which can be improved regardless of the existing equipment available in any community hospital. Sharing this information with community hospitals should prompt a revision of pediatric CT imaging protocols and reduce radiation exposure to children undergoing computed tomography in community hospitals.

Patient age (years) Effective Dose (mSv) SSDE (mGy) kVp Number of exams

Tertiary care pediatric hospital (mean and SD) 10.7 (SD 5.1) 6.6 (SD 5.9)

Community hospitals (mean and SD) 10.0 (SD 4.8) 13.0 (12.4)

9.7 (SD 6.9) 101.5 (11.1) 111

26.4 (51.3) 116 (9.8) 178

Significance (p value) 0.2533 <0.0001 0.0007 <0.0007

Paper #: 046 Virtual Radiology Rounds: Adding Value in the Digital Era

Nancy Fefferman, MD, NYU School of Medicine, New York, NY; Naomi Strubel, Michael Recht, Sujata Chakravarti, Martha Caprio, Chandan Prithiani, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The increasing demands on our clinical colleagues in pediatrics challenge the longstanding tradition of reviewing inpatient imaging studies with the pediatric radiologist, classically referred to as “radiology rounds.” With the advent of PACS and readily available image viewing, referring clinicians are less likely to meet with pediatric radiologists to review imaging studies. Our pediatric radiology division at a large university hospital introduced an innovative initiative enabling clinicians to remotely review imaging studies with the pediatric radiologist, closely simulating the traditional radiology rounds. We describe our initial experience with virtual radiology rounds (VRR) and referrer impressions of this technology. Methods & Materials: VRR is a web-based conference between the referring pediatric unit and pediatric radiologist with remote sharing of radiology workstation screens; pediatricians view a 25×16 in. high resolution monitor located in the pediatric unit. Participants discuss the imaging studies by speakerphone. VRR were piloted with the Neonatal Intensive Care Unit (NICU) and the Congenital Cardiovascular Care Unit (CCVCU) teams. Prior

to the introduction of VRR, the NICU team routinely rounded in the radiology department. The CCVCU team had never previously rounded with radiology. Unit team providers including five attending physicians, five pediatric critical care fellows, three nurse practitioners, and three physician’s assistants completed a survey assessing the perceived impact and overall value of VRR with respect to patient care using a 10 point scale to report responses. Results: Clinical teams “virtually” round 4-5 times per week, reviewing approximately 13 cases/day. Clinicians rate confidence in their own image interpretation as 7.5 (10 = most confident). Although clinicians report uncommon disagreement between their own and radiologist interpretation (2.6, 10 = no agreement) they unanimously believe that VRR add value with improved workflow (9.2, 10 = most) and patient management (9.2, 10 = most). Clinicians feel virtual rounds are easy to participate in (8.5, 10 = easiest) and unanimously prefer them to traditional rounds in the radiology department. The CCVCU staff unanimously noted greater familiarity with the pediatric radiology staff after instituting VRR. Conclusions: Virtual radiology rounds are a viable alternative to traditional radiology rounds, maintaining the added value of radiologist involvement in patient care, and are preferred by busy critical care clinicians.

Paper #: 047 Learning, Technology and Intellectual Property: A Survey of the Philosophies and Practice of our Trainees and Peers

Janet Reid, MD, FRCPC, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, [email protected]; Kassa Darge, MD, PhD, Mary Scanlon, MD, Susan Back, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Education describes the adult learner as the “digital native”, a “multitasker” digesting information in small aliquots, easily navigating the Internet without much regard for intellectual property. The purpose of this survey was to establish an understanding of the learning preferences of our colleagues and trainees in pediatric radiology to serve as a foundation for the creation of future educational innovations. Methods & Materials: A 3-part survey consisting of 22 multiple choice, rating, ranking and scenario-type questions was electronically sent to the membership of the Society for Pediatric Radiology and all residents and fellows training at our institution between 2011 and 2014. Questions focused on learning and teaching preferences, technology interest, and intellectual property. This study was granted an IRB exemption. Results: Two thousand one hundred ten surveys were received by 100 trainees and 2010 staff radiologists; 356 were completed and returned (16.8%). Ages of responders is given in (Fig. 1); 47.4% were female, and 52.6% male. 79% spent 30 min or less for independent learning, with fewer than 20% spending 1 h or more per day. 52% required only 5-10 min to absorb a new concept, 38% required at least 30 min and the minority needed more time. Only 3.8% fell into the “tech-savvy” or “early adopter” group when given scenarios that tested interest in new gadgets, however by self-reporting, 62.7% considered themselves part of this cutting edge group. 66% were enthusiastic about recording lectures, while the rest demonstrated some skepticism, with 5.4% claiming this was an infringement on their intellectual property rights. 93% agreed with the statement “The dissemination of information is the core of education” however 14.4% agreed that “Institutions can only maintain individuality and greatness if they retain their teaching materials and avoid dissemination”. Conclusions: The learning practices of our members and trainees follow the newer trends in adult learning reported by our Education colleagues, favoring smaller time periods and point-of-care access with the minority setting aside an hour or more per day for continuing education. While the majority consider themselves “tech-savvy” most fall into the “late

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majority” in response to scenarios around technology interest. This valuable information serves as a guide in building new educational programs, with a caution that some technologic innovations may be slow to catch on in pediatric radiology.

a case-based curriculum emphasizing independent study and structured practice was delivered to radiology residents via the iPad for a year before they took independent pediatric radiology call at our children’s hospital. Methods & Materials: Each month, a learning module that included articles, didactic materials, and a series of relevant cases (including normal studies) was delivered to the residents via their iPads. The residents were asked to read the educational materials, view the cases independently, and generate reports. Although they had already taken call at our hospital, upper-level residents participated in the iPad curriculum as well. All residents convened monthly and the cases were reviewed with emphasis on effective and efficient search patterns, identification of pertinent positive and negative findings, report structure, and negotiating our medical imaging department and hospital. Before the curriculum started, residents were given subjective and objective pretests. When the residents rotated at our children’s hospital as second-year residents, the same subjective test and similar, but distinct, objective tests were given. The results of the residents’ tests were compared to residents from other programs in the city who rotate at our children’s hospital, but who did not participate in the iPad curriculum. Results: Initial analysis of the data indicates that residents who participated in the iPad curriculum (n=9) were more confident when they arrived at the children’s hospital to take independent overnight call when compared to the control group. The average level of overall confidence for taking independent overnight call was 4.1 (on a 5-point Likert scale) for the residents who had completed the iPad curriculum as compared to 2.8 for the residents at the same level of training who did not participate in the iPad curriculum (n=9). Residents who were further along in their training, but who did not participate in the iPad curriculum (n=12), reported a confidence level of 3.4. Conclusions: Independent study and structured practice facilitated via tablet technology seem to be an effective strategy for preparing radiology residents to take independent pediatric radiology call.

Paper #: 049 Ultrasound Tutorials in Under 10: The Addis Ababa Experience

Susan Back, M.D., Kassa Darge, MD, PhD, Maria Bedoya, MD, Yocabel Gorfu, Daniel Zewdneh, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Janet Reid, MD, FRCPC

Paper #: 048 Flipping the Classroom: Preparing Radiology Residents for Independent Pediatric Radiology Call Using the iPad

Jennifer Nicholas, MD, MHA, Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Wilmette, IL; Maura Ryan, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Preparing radiology residents for independent call is a daunting task, particularly as factors such as resident work hour restrictions and rotations at off-sites result in variability in conference attendance. In an attempt to fortify and better standardize resident call preparation,

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The practice of radiology in Addis Ababa, Ethiopia, relies heavily on Ultrasound (US). This is particularly important for the pediatric radiologist in a country where half of the population is under the age of 20 years. Hands-on skills are taught through an apprenticeship model without a formalized curriculum. This study evaluates the value of a standardized curriculum in pediatric US. Methods & Materials: Version 2.0: Ultrasound Tutorials in Under 10, includes 10 learning modules in renal, right upper quadrant (RUQ), thyroid, hips, pylorus, intussusception, head, abdomen, pelvis, scrotum. Each module consists of tutorials with three video feeds during a standard US examination to include: US console and buttons, US images, and transducer positioning. Rolling text is also accessible through a separate stream to highlight study indications, patient preparation and draping, positioning, transducer selection, scanning planes, image acquisition and image quality optimization. Trainees completed one module with an intake inquiry for demographics, pretest and post-test skills assessment and a questionnaire to evaluate learning effectiveness, reach and appeal. A single examiner, trained on site by one of the co-investigators, conducted all of the skills tests. Results: Eight residents completed the RUQ module and viewed it one time on average over 6-8 min. Residents had prior experience in performing a median of 400 US (150-1200) and overall pretest

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confidence was high at 13.5/15 increasing 7.4% to 14.5/15 after completing the module (p=0.039). Skills test scores increased 4% from 38/40 to 40/40 (p=0.041). There was no correlation between confidence (subjective) and competence (objective) either before or after viewing the module. The mean subjective scores for learning effectiveness, appeal and reach were 4/5, 4/5 and 5/5. Conclusions: A video-based curriculum developed in USA can be seamlessly applied to a radiology curriculum in Ethiopia without technical difficulty. Despite a high level of experience and competence at baseline, residents showed significant improvement in skills and knowledge and found the program enjoyable, simple to use, and scalable.

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transfusion burden. The strong correlation with hemolytic biomarkers in combination with absence of correlation with LIC suggests that differences in baseline inflammation between SC and NonSC groups influence the loading of iron in different tissues. Renal cortical R2* was significantly higher than medullary R2* in SC patients. No correlation was present between renal iron and common markers of renal, cardiac or hepatic dysfunction in either group. In the pooled group, there was negative correlation between renal cortical R2 and renal ADC at b-value of 800 s/mm2 (suggesting hemolytic process might trigger diffusion restriction events such as ischemia and acute microinfarction), and a moderate correlation between renal eGFR and renal ADC at b-value of 50 s/mm2 (reflecting changes to microcirculation like perfusion and glomerular filtration). Conclusions: Quantitative MR biomarkers may help to distinguish critical pathologic processes leading to renal dysfunction in the setting of hemolytic versus non-hemolytic anemia requiring chronic transfusion in children.

Paper #: 050 Renal Iron Deposition in Pediatric Anemia: Comparison of Sickle and Non-Sickle Groups

Zili Chu, PhD, Texas Children’s Hospital, Houston, TX, [email protected]; Poyyapakkam Srivaths, Braun Michael, Airewele Gladstone, Rajesh Krishnamurthy. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In pediatric patients with chronic transfusion burden related to sickle cell (SC) anemia versus other type anemia (nonSC), to: 1) Study differences in renal iron content as measured by MRI 2) Evaluate relative iron distribution in the cortex and medulla. 3) Correlate renal iron content with hepatic and cardiac iron content, and with parameters of renal, liver or cardiac dysfunction. Methods & Materials: Twenty-two pediatric patients (mean age 9.9 years, range 0.2 - 18 years) with anemia receiving chronic transfusions were evaluated by MRI. 11 had SC diseases and 11 had non-SC anemia (seven with Beta thalassemia major and four with miscellaneous rare anemias). Imaging of the kidneys included anatomic and R2* sequences, and DWIs with three sets of b-values (0,25,50; 0,200,400; 0,400, 800). Cardiac and liver R2*, and liver iron content (derived from R2) were calculated. The renal R2* of cortical and medullary regions were measured separately. Results: The statistical significant findings were highlighted in table 1 and table 2. There was an expected significant elevation of reticulocyte percentage (intravascular-hemolytic biomarker) and hemoglobin S in the SC group. There was no significant difference of eGFRs between the two groups (164.4 vs. 143.9 ml/min/1.73 m2, p=0.27), with both showing glomerular hyperfiltration (eGFR>140 ml/min/ 1.73 m2). Renal cortical R2* was significantly increased in pediatric patients with SC compared to non-SC anemia with similar

Paper #: 051 MR Urography and the Mean Transit Time in the Evaluation of Hydronephrosis in Children

Damien Grattan-Smith, MBBS, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected], et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: As opposed to two compartment models, three compartment models of renal function assess parameters of renal function beyond glomerular filtration. The purpose of this study was to evaluate the mean transit time (MTT) in the evaluation of hydronephrosis in children. Methods & Materials: The mean transit time was calculated in all patients studied with MR urography in the last twelve months. All patients were hydrated intravenously and given lasix 15 min prior to contrast adminstration. The MTT was calcuated using a three compartment model of renal function based on the work of Annet et al. which allows the

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evaluation of renal excretion of contrast medium after glomerular filtration until excretion into the collecting system. The MTT is a more precise numerical representation of the calyceal excretion of contrast medium. The study population included 43 children with normal MR urography as well as children with unilateral hydronephrosis, bilateral hydronephrosis and chidren with single functioning kidneys. Results: In 43 children without hydronephrosis the MTT was calculated at 52 s with a standard deviation of 11 s. In children with physiologically significant obstruction as indicated by a delayed and dense nephrogram the MTT was typically greater than 100 s. In children with physiologically significant UPJ obstruction, the MTT returned to the normal range after successful pyeloplasty. In children with hydronephrosis but without significant obstruction the MTT was within the normal range. Conclusions: The MTT is a powerful new tool in the evaluation of hydronephrosis. It identifies and quantitates physiologically significant obstruction and is particularly useful in children with bilateral hydronephrosis and children with single functioning kidneys.

Conclusions: Unlike in adults, renal DWI does not seem to reveal parenchymal alterations in children with pelvicalyceal dilation in relation to morphological and functional results of fMRU.

Paper #: 052 Renal Diffusion Weighted MR Imaging in Children with Pelvicalyceal Dilation

Maria Bedoya, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA; Dmitry Khrichenko, Robert Carson, Jeffrey Berman, Ann Johnson, Kassa Darge, MD, PhD. Disclosures: Jeffrey Berman indicated a relationship with McGowan Associates as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The use of renal diffusion weighted MR imaging (DWI) has increased in the last years. In adults, it has been demonstrated that there is a positive linear correlation between glomerular filtration rate (GFR) and apparent diffusion coefficient (ADC) in kidneys with pelvicalyceal dilation (PCD). The aim of this study was to evaluate the relationship between renal ADC and kidney morphology and function determined by functional MR urography (fMRU) in children with PCD. Methods & Materials: We retrospectively analyzed fMRUs with DWIs of the kidney, performed in 23 subjects (16 males, median age 7.1 years (range 5 months-22 years)) with 46 kidneys (27 with PCD and ureteropelvic junction obstruction configuration, and 19 with normal function and no PCD). Inclusion criteria were: PCD as indication for fMRU, absence of duplex kidneys and no ureteric dilation. DWI was performed on 1.5 T scanners in three directions with b values of 0, 200, 500, 800, and 1000 s/mm2. The mean non-linear ADC values of each individual kidney was calculated from a region of interest (ROI) placed in the renal parenchyma being exactly the same ROI as used in the fMRU analysis. FMRU results i.e. CTT, RTT, TTP, vDRF, pDRF and Patlak were noted for each kidney. We analyzed the RTT in three groups: <240, 240-490 and >490 s. Grade of PCD, cortical thinning and corticomedullary differentiation were evaluated. The relationship between ADC values and the fMRU parameters was analyzed. The ADC values of 27 kidneys with PCD were compared with those of 19 kidneys without PCD. Results: There was a positive correlation between the age and ADC values (p=0.002, R2=0.20). There was no significant difference in ADC values between kidneys with and without PCD (p=0.476). The median ADC values were 3.7×10−3 mm2/s for kidneys without PCD and 3.9×10−3 mm2/s in kidneys with PCD. Linear hierarchical regressions controlling the age did not show a significant correlation between ADC values and CTT, TTP, vDRF, pDRF and Patlak in both groups (pvalues>0.09) (Fig. 1). No correlation was found between ADC and RTT groups, grade of PCD, cortical thinning, and corticomedullary differentiation (spearman p-values >0.10) in kidneys with PCD.

Paper #: 053 Can We Reproduce the Age Dependency of the ADC Values in Patients with Various Urological Abnormalities Undergoing Functional MR Urography?

Maria Bedoya, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA; Raul Ramirez, Dmitry Khrichenko, Robert Carson, Jeffrey Berman, Kassa Darge, MD, PhD Disclosures: Jeffrey Berman indicated a relationship with McGowan Associates as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In recent years, the use of diffusionweighted imaging (DWI) has increased in pediatric body MRI. It has been previously described, in a normal cohort of patients, that the apparent diffusion coefficient (ADC) increases with age. The aim of this study was to determine if the age dependency of the ADC measured by DWI holds true in a clinical cohort of children with various urological abnormalities. Methods & Materials: We retrospectively analyzed DWIs of the kidneys carried out on 1.5 T MR scanners in 53 subjects, 27 males and 26 females with a mean age of 8.5 years (range 3 months-22 years) who had undergone functional MR urography (fMRU). There were a total of 104 kidneys: 53 normal without pelvicalyceal dilatation (PCD), 32 PCD with ureteropelvic junction obstruction (UPJO) configuration, eight ureteral dilation, nine with simple cortical cysts, and two cystic dysplastic kidneys. The clinical indications for the fMRU were: PCD (n=26), evaluation of a cyst-like structure (n=8), incontinence (n=4), hematuria (n=3), ureteral dilation (n=5), UPJO surgical follow-up (n=5), renal mass (n=1) and dysplastic kidney (n=1). DWI was performed in three directions with b values of 0, 200, 500, 800, and 1000 s/mm2. The mean non-linear ADC values of each individual kidney were calculated from a region of interest placed in the renal parenchyma. On the ADC image it was not possible to differentiate between cortex and medulla, particularly in younger children. The age dependency of the ADC was analyzed.

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Results: Renal ADC values increase with age in the whole cohort (linear regression p=0.000, R2 =0.28). The positive correlation was found in kidneys with and without pelvicalyceal dilation (linear regression p-values>0.024); however, kidneys without pelvicalyceal dilation have a higher correlation (R2 =0.36) than kidneys with pelvicalyceal dilation (R2 =0.15) (Fig. 1). Conclusions: Renal ADC significantly increases with age in children. The age dependency of the renal ADC values is reproducible in a cohort of pediatric patient with various urological abnormalities, too. This is important for appropriate interpretation of ADC values in future renal imaging applications using DWI.

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deviations were used to describe differences in CT and US measurements for the population. Results: One hundred seventy patients (40% male, 60% female) with a mean age of 11.9±4.5 years formed the study population. Overall, appendiceal measurements were larger by CT than by US with a mean difference at any location along the appendix of 1.4 ±1.1 mm. Differences between CT and US measurements of the proximal, mid and distal appendix were 1.5 ± 1.3, 1.3 ± 1.1 and 1.3 mm±1.7 mm respectively. Conclusions: Measurements of appendiceal diameter by CT are, in general, nearly 1.5 mm larger than measurements by US. This likely reflects the effect of compression applied during the ultrasound exam. While this difference may be explainable, the finding suggests that cut-off diameters for the diagnosis of appendicitis by CT and ultrasound should not necessarily be the same.

Paper #: 055 MRI Findings of the Normal Appendix in Children: New Reference Standard

David Swenson, MD, Diagnostic Imaging, The Alpert Medical School of Brown University, Brooklyn, CT, [email protected]; Gary Schooler, Catherine Stamoulis.

Paper #: 054 Appendiceal diameter: Are CT and Sonographic Measurements Interchangeable?

Emily Orscheln, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Andrew Trout, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Appendiceal diameter is one criterion used to diagnose appendicitis. Cut-off values for appendiceal diameter for the diagnosis of appendicitis were largely developed for ultrasound (US) and subsequently extrapolated to computed tomography (CT). Despite this direct extrapolation, equivalence in appendiceal measurement between the two modalities has not been assessed. The purpose of this study was to compare measurements of appendiceal diameter on CT and ultrasound in patients who underwent both exams within a 24h period. Methods & Materials: In this IRB approved, HIPAA compliant study, CT and US examinations of the appendix performed within 24 h of one another between January 2010 and February 2014 were reviewed. Patients imaged at our institution were included regardless of age and ultimate diagnosis. The appendix was measured at three locations (proximal, mid, and distal) on both US and CT by a single reviewer with difficult cases reviewed by a second reviewer. Absolute differences in diameter for the proximal, mid, and distal appendix as well as the mean of these differences was calculated for each patient. Means and standard

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To investigate magnetic resonance imaging (MRI) findings of the normal appendix and establish a new reference standard in the pediatric population. Methods & Materials: This was a retrospective study performed following institutional review board approval. The study population included consecutive pediatric patients (<18 years of age) who underwent lumbar spine and/or pelvis MRI examinations between 1/1/2013 and 12/31/2013 for clinical indications other than acute abdominal pathologies related to appendicitis. Two boardcertified radiologists first reviewed each MRI examination for visualization of appendix independently. If the appendix was identified, the following MRI findings were evaluated: 1) appendix diameter; 2) presence of discrete appendiceal wall; 3) appendiceal wall thickness; 4) periappendiceal inflammation; and 5) free fluid. Cohen’s Kappa statistic was used to asses agreement regarding qualitative assessments (e.g. appendix visualization). In addition, Spearman’s and Pearson’s correlation coefficients were used to evaluate quantitative data (e.g. appendix diameter and wall thickness). Results: MRI examinations meeting inclusion criteria were 346 MRI studies. The appendix was visualized in 192/346 (55.5%) MRI examinations with strong agreement (kappa = 0.88, p < 0.0001). Mean appendix diameter was 5.5-5.7 mm (SD, 1.2 mm; range, 3.1-11.1 mm; r = 0.81, p < 0.0001). Discrete appendiceal wall visualization was seen by both readers in 117/ 192 (60.9%) cases where the appendix was identified. The mean wall thickness of the appendix was 1.4 mm (SD, 0.3 mm; range, 0.7-2.5 mm; rho=0.42, p<0.0001). Periappendiceal inflammation was visualized in 0/192 (0%), and free fluid in 6/192 (3.1%) of MRI examinations (kappa=1.0). Conclusions: The normal appendix was seen on MRI examinations in approximately half of pediatric patients. When visualized on MRI, the appendix has a mean diameter of 5.6 mm with a frequently seen discrete appendiceal wall measuring approximately 1.4 mm in thickness, without inflammatory changes and rarely surrounded by free fluid. Our findings can be used as a new

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reference standard for normal appendix on MRI in the pediatric population.

non-contrast MR. MR examinations that could not be initiated within 45 min (because of lack of scanner or technologist availability) were considered imaging failures. Following the MR, the patient underwent their clinically ordered CT and completed a survey concerning their preference for MR or CT. Results: Thirty-two patients were approached for enrollment with 17 patients (53.1%) consenting to participate. MR was successfully initiated within 45 min in 14 of 17 patients (82.4%). 8/14 (57.1%) imaged patients were female and median age was 15.4 years (range: 7.7-20.4 years). Survey results were available for 13 patients. Concerning their preference for MR versus CT, 62% (8/13) of participants responded that CT was the easier exam. When asked which exam they preferred, respondents were relatively evenly split between CT and MR (5 CT, 6 MR, 2 equal). When asked which exam they would want for a future similar episode of pain, respondents were similarly split (6 CT, 5 MR, 2 equal). Comments provided highlighted the duration and noise of the MR exam as negative factors. Conclusions: Urgent MR for appendicitis can be achieved expeditiously in the setting of a busy clinical MR practice at a large, tertiary care pediatric hospital. Patients are receptive to the use of MR despite feeling that CT was the easier exam. Prior to implementation of MR as a replacement for CT in the evaluation of suspected appendicitis, equivalent clinical performance needs to be demonstrated in pediatric patients, and individual institutions must ascertain whether their MR workflow can accommodate these urgent exams.

Paper #: 057 Implementation of a Rapid Noncontrast MRI Protocol for Use in Children with Equivocal Appendicitis: A Clinical Effectiveness Study

Jonathan Dillman, MD, Department of Radiology, Section of Pediatric Radiology, University of Michigan C.S. Mott Children, Ann Arbor, MI, [email protected]; Samir Gadapelli, Nicole Sroufe, Ethan Smith, Suzanne Chong, Michael Mazza

Paper #: 056 MR as a Rapid Secondary Assessment for Suspected Appendicitis following Equivocal Sonography: Feasibility and Patient Preference Assessment

Andrew Trout, MD, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Daniel Wallihan, MD, Alexander Towbin, Holly Depinet, Daniel von Allmen, Daniel Podberesky. Disclosures: Daniel Podberesky has indicated a relationship with Philips Healthcare – Honoraria and GE Healthcare – Honoraria. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: At our large, tertiary care pediatric institution, sonography is the primary diagnostic modality for suspected appendicitis with CT reserved for assessment of difficult cases. Some authors are advocating, however, that MR should replace CT. For this to occur MRI must be shown to be diagnostically equivalent to CT and equivalence in ease of access and patient tolerance/preference between the two modalities should be ascertained. The purpose of this study was to determine if MRI could be rapidly achieved amidst a busy clinical MR schedule. A secondary purpose was to compare patient preference for MR versus CT. Methods & Materials: In this IRB approved, HIPAA compliant prospective study, patients who had a CT ordered in the emergency department to evaluate for appendicitis were approached for enrollment. If consent was obtained, the department of radiology was allowed 45 min to initiate a

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine the clinical effectiveness of a rapid, noncontrast MRI protocol for use in children with ultrasound and/ or clinical findings equivocal for appendicitis. Methods & Materials: Pediatric patients (≤18 years-old) that underwent nonsedated, noncontrast MRI of the appendix within 24 h of appendiceal ultrasound between November 2013 and September 2014 were identified. Finalized MRI reports were reviewed and relevant findings were documented, including if the appendix was seen, if appendicitis was present, and if the appendix was perforated. Available operative and pathology reports were reviewed to confirm the diagnosis of appendicitis, and pertinent medical records from children with MRI exams negative for appendicitis also were reviewed over the 30-day period after imaging to identify any cases of delayed diagnosis. Results: Seventy-five children (mean age = 11.8 years; 41 girls) underwent noncontrast MRI after appendiceal ultrasound due to imaging and/or clinical findings equivocal for appendicitis. MRI was positive for 13/14 children (mean age=10.6 years; seven girls) with pathologicallyproved appendicitis. Diagnostic performance was as follows: sensitivity 93% [66-100%], specificity 100% [94-100%], positive predictive value 100% [75-100%], and negative predictive value 98% [91-100%]. MRI correctly predicted perforation status in 10/12 (83%) children (the final report was equivocal in a thirteenth child), and it revealed clinically important alternative diagnoses in 17/61 (28%) children without appendicitis. Appendicitis was present in 5/45 (11%) children with no right lower quadrant inflammation and a partially- or non-visualized appendix at ultrasound.

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Conclusions: Rapid, noncontrast MRI for assessment of pediatric appendicitis is effective in routine clinical practice.

Paper #: 058 Diffusion and Post Contrast MRI for Evaluation of Acute Appendicitis: The Stanford Experience

Matthew Bernbeck, MD, Radiology, Lucile Packard Children’s Hospital, Palo Alto, CA, [email protected]; Richard Barth, Alex Lewis, Bernard Dannenberg, Dan Imler, Shreyas Vasanawala Disclosures: Richard Barth indicated a relationship with Siemens Medical Systems - Research. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To evaluate the utility of DWI and intravenous contrast in MRI for pediatric appendicitis. Methods & Materials: With IRB approval, all pediatric appendicitis MRIs from 1/2014 to 9/2014 with diffusion and post contrast sequences at our institution were retrospectively identified and randomized into two groups (36 each). All studies were scored by three readers (one pediatric radiology fellow, one pediatric radiologist with > 20 years experience, and an MR fellow) blinded to the official interpretations and patient outcomes. The readers scored delineation of the appendix, confidence of assessment of acute appendicitis and perforation/abscess after each series reviewed within a study. For the first group of subjects, the order of series scored was single shot (SS, three planes with and without fat suppression), contrast-enhanced (CE, axial), and then diffusion weighted (DW, axial) sequences. For the second group of cases, the order was SS, DW, CE. Accuracy for diagnosis of appendicitis and perforation/abscess were calculated against a gold standard of histology and patient eventual outcome. Results: Appendicitis was present in 18/72 (25%) cases and complication in 6 (8%). An appendix or appendiceal candidate was identified in 36, 18 and 56% of cases for readers one, two and three respectively with SS, increasing to 89, 36 and 100% for SS+CE, and 53, 19 and 100% for SS+DW (Fig. 1). The sensitivity, specificity, positive predictive value, and negative predictive value (SN/SP/PPV/NPV) for appendicitis of reader one were 0.71/ 0.91/0.71/0.91 with SS, 1.0/0.93/0.75/1.0 with SS+CE and 0.89/1.0/1.0/ 0.96 with SS+DW. For reader two, they were 0.56/0.79/0.43/0.86 with SS; 1.0/0.82/0.62/1.0 with SS+CE and 0.63/0.79/0.45/0.88 with SS+DW. For reader three, they were 0.79/0.94/0.83/0.93 with SS, 1.0/1.0/1.0/1.0 with SS+CE and SS+DWI (Table 1A). For complicated appendicitis: SN/SP/PPV/NPV of reader one were 0.25/ 0.96/0.25/0.96 with SS, 0.50/0.94/0.33/0.97 with SS+CE, 1.0/0.91/0.40/ 0.97 with SS+DW and 0.80/0.94/0.50/0.98 with SS+DW+CE. For reader two, they were 0.0/0.98/0.0/0.92 with SS, 0.5/0.97/0.50/0.97 with SS+ CE, 0.25/0.97/0.50/0.91 with SS+DW and 0.67/0.98/0.80/0.97 with SS+ DW+CE. For reader three, they were 0.67/0.89/0.36/0.97 with SS, 0.0/ 1.0/0.0/0.94 with SS+CE, 1.0/0.97/0.80/1.0 SS+DW and 0.67/0.98/0.80/ 0.97 with SS+DW+CE (Table 1B). Conclusions: Either DWI or CE increase performance of MRI for diagnosis of appendicitis. The combination of SS, DWI, and CE provides improved performance for detection of complications of appendicitis. Table 1A. Diagnosis of Appendicitis Group 1 SS

CE

Group 2 DWI SS

DWI CE

Total Final Read Reader sensitivity 0.50 1.00 1.00 0.89 0.89 0.88 0.94 1 specificity 0.93 0.93 0.93 0.89 1.00 0.89 0.96

PPV NPV Reader sensitivity 2 specificity PPV NPV Reader sensitivity 3 specificity PPV NPV

0.67 0.87 0.38 0.79 0.33 0.81 0.88 0.93 0.78 0.96

0.75 1.00 1.00 0.82 0.62 1.00 1.00 1.00 1.00 1.00

0.78 1.00 1.00 0.82 0.62 1.00 1.00 1.00 1.00 1.00

0.73 0.96 0.75 0.79 0.50 0.92 0.73 0.96 0.89 0.89

1.00 0.96 0.63 0.79 0.45 0.88 1.00 1.00 1.00 1.00

0.70 0.96 1.00 0.88 0.75 1.00 1.00 1.00 1.00 1.00

0.88 0.98 1.00 0.85 0.68 1.00 1.00 1.00 1.00 1.00

Table 1B. Complications of Appedicitis Group 1 Reader 1

SS

CE

Group 2 Diffusion Sigle Diffusion CE Shot

Total Final Read

sensitivity 0.00 0.50 0.50

0.33

1.00

specificity 0.97 0.94 0.94

0.94

0.91

0.94 0.94

PPV

0.00 0.33 0.33

0.33

0.40

0.60 0.50

NPV

0.97 0.97 0.97

Reader SS CE DWI 2 sensitivity 0.00 0.50 0.50

0.67 0.80

0.94

0.97

1.00 0.98

SS

DWI

CE

0.00

0.25

0.75 0.67

specificity 1.00 0.97 0.97

0.97

0.97

1.00 0.98

PPV

0.00 0.50 0.50

0.00

0.50

1.00 0.97

NPV

0.94 0.97 0.97

0.89

0.91

0.97 0.97

SS

DWI

CE

Reader SS CE DWI 3 sensitivity 0.00 0.00 0.00

1.00

1.00

1.00 0.67

specificity 0.97 1.00 1.00

0.60

0.97

0.97 0.98

PPV

0.00 0.00 0.00

0.40

0.80

0.80 0.80

NPV

0.94 0.94 0.94

1.00

1.00

1.00 0.97

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Paper #: 059 Comparison of Shear Wave Velocities on Ultrasound Elastography between Different Machines and Acquisition Depths; A Phantom Study

Hyun Joo Shin, MD, Department of Radiology and Research Institute of Radiological Science, Severance Children’s Hospital, Seoul, Korea (the Republic of); Hyun Gi Kim, Myung-Joon Kim, Ha Yan Kim, Yun Ho Roh, Mi-Jung Lee Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To investigate whether variation exists between the shear wave velocities (SWVs) on ultrasound elastography using different machines and acquisition in different depths. Methods & Materials: SWVs were measured using elasticity phantom with 16.9 kPa stiffness, with low frequency convex and high frequency linear probes at different depths (2–5 cm), in recently introduced shear wave elastography of three different vendors (Aixplorer from SuperSonic, ACUSON S3000 from Siemens, and EPIQ 5 from Philips). The values were obtained fifteen times at each depth with available probes of each machine and mean values with coefficient of variation (CV) were obtained. Friedman test and Wilcoxon rank-sum test were used for the comparison of SWVs according to the depth and probes. Friedman test and Wilcoxon signed rank test were used for the vendor comparison of SWVs. Results: SWVs were not significantly different between convex and linear probes in 4 cm (all, 1.90±0 m/s) and 5 cm (1.98± 0.04, 1.99 ± 0.05 m/s) depths using Aixplorer (p > 0.999, 0.735, respectively). Other SWVs at different depths were significantly different in all the two probes and three machines (p<0.001). The CVs were slightly larger in EPIQ 5 than the others. In the vendor comparison, there was significant difference between SWVs in three machines together. In subgroup analysis using convex probes, there were no significant difference between ACUSON S3000 and EPIQ 5 in 3 and 4 cm depth (p=0.172, 0.064, respectively), and between Aixplorer and EPIQ 5 in 4 cm depth (p= 0.038). Conclusions: There are considerable differences in SWVs on ultrasound elastography depending on the acquisition depths, probes and machines using elasticity phantom.

Paper #: 060 Quantitative Ultrasound Elastography for Pediatric Liver Disease: Can shear wave speed be reliably estimated from a single image?

Andrew Phelps, MD, UCSF Benioff Children’s Hospital San Francisco, S a n F r a n c i s c o , C A , a n d r e w. p h e l p s @ u c s f . e d u ; Ra ga Ramachandran, Jesse Courtier, MD, Emily Perito, Philip Rosenthal, John MacKenzie. Disclosures: John MacKenzie has indicated a relationship with with General Electric as a Principal Investigator. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Quantitative ultrasound elastography is promising for the noninvasive measurement of pediatric liver fibrosis. Conventional technique requires up to 10 separate images to reliably measure shear wave speed (SWS). A newer technology, Virtual Touch IQ (VTIQ) allows for multiple SWS measurements from a single image. However, the reliability of VTIQ has yet to be tested.

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Methods & Materials: This was an IRB-approved prospective study of liver SWS in 29 children undergoing clinically-indicated liver biopsy (median age 12 years). SWS was measured by one of three pediatric radiologists using Siemens Acuson S3000 using two modes: Virtual Touch Quantification (VTQ) and Virtual Touch IQ (VTIQ). For each subject, 3 SWS averages were obtained. The first SWS was calculated by averaging 10 separate speeds from 10 separate VTQ acquisitions at the planned biopsy site. A second VTQ-measured SWS was similarly obtained from a separate liver segment. The third SWS was calculated from a single VTIQ acquisition by averaging the speeds from nine regions of interest (ROI) arranged in a contiguous 3 × 3 grid. The 3 SWS averages were analyzed with t - t e s t s , B l a n d - A l t m a n p l o t s , a n d P e a r s o n ’s c o r r e l a t i o n coefficient. Results: There was no significant difference in SWS measured by VTIQ versus VTQ (p = 0.43). The differences in SWS measurements using VTIQ versus VTQ were comparable to the differences in SWS measurements using VTQ in different liver segments in the same patient. For VTIQ versus VTQ, the mean difference in SWS (m/s) was -0.07, 95% confidence interval 1.0 to +0.89. For VTQ in different liver segments in the same patient, the mean difference in SWS (m/s) was +0.05, 95% confidence interval -0.83 to +0.94. For VTIQ versus VTQ, the SWS difference increased with higher body mass index (BMI, correlation coefficient +0.57). For VTIQ, the SWS decreased with deeper ROI placement (-0.07 m/s per 1 mm of increased depth, p = 0.0003). There was no horizontal dependency of ROI placement (p = 0.88). In 6 of the 29 subjects, VTIQ failed to produce valid shear wave speeds; these six patients tended to be older females with higher BMI, and five of six of these subjects were scanned by the radiologist with the least elastography experience. Conclusions: VTIQ is a rapid elastography technique that is most reliable in children with normal BMI. Individual measurement variability still needs to be placed into context with yet-to-be-defined SWS pathologic cutoff values.

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Paper #: 061

Paper #: 062

Shear Wave Elastography (SWE) of the Normal and Fibrotic Pediatric Liver

MR Enterography (MRE) Under the Age of 10 Years

Vanessa Starr, MD, Pediatric Radiology, Lucile Packard Children’s Hospital Stanford, Redwood City, CA, [email protected]; Evan Zucker, MD, Richard Sibley, MD, Erika Rubesova, MD, Alexis Rodriguez, MD, Richard Barth, et al. Disclosures: Richard Barth indicated a relationship with Siemens Medical Systems - Research. Purpose or Case Report: SWE is a promising non-invasive technique to quantify liver elasticity and risk stratify patients with hepatic fibrosis. Accurate assessment may replace more expensive and invasive procedures including liver biopsy. The purpose of this study was:1. To establish normative data for shear wave velocities (SWV) in the normal pediatric liver over a range of ages and 2. To assess the accuracy of SWV quantification for predicting liver fibrosis staging in children with pathologically proven hepatic fibrosis. Methods & Materials: A Siemens S-3000 ultrasound unit equipped with SWE was used to prospectively evaluate two groups. Group 1 consisted of children with no clinical evidence of hepatobiliary liver disease and group two consisted of patients with known liver disease undergoing liver biopsy. Data was collected on Couinaud segment VIII during free respiration with gentle pressure on the abdominal wall using C6 and 9L4 transducers. Two modes were utilized: VTQ, which is a quantification mode and VTIQ, which is a color and quantification mode. Using the C6 transducer in VTQ mode, five acquisitions at 4 cm depth were obtained. Using the L9-4 transducer, five acquisitions at 2 and 4 cm were obtained in VTQ and/or VTIQ. Average SWV was compiled for group one to establish normative values for children. Average SWV in group two were correlated with severity of histologic fibrosis using the Scheurer classification. Results: Group one consisted of 48 children (2 months to 18 years). Of these patients, 42 had C6 VTQ, 17 had 9LVTQ, and 22 had 9LVTIQ. C6 mean SWV was 1.36 cm/s, 9L4 VTQ mean SWV was 1.27 cm/s and 9L4 VTIQ color mean SWV was 1.57 cm/s. Group two consisted of 15 patients who underwent liver biopsy. Nine had pathologically proven hepatic fibrosis. Of these nine, nine had C6 VTQ, seven had 9L VTQ, and four had 9L VTIQ exams. Mean SWV in these nine was 1.87 and 1.78 cm/s for VTQ mode using the C6 and 9L transducers and 1.78 cm/s for the 9 L in VTIQ mode. There was a statistical difference in velocity (Table 1) between the two groups using the L9 probe (p<0.0001) and the C6 probe (p<0.0001). No velocity difference was detected using the VTIQ modality (p=0.31). Of the hepatic fibrosis patients, two had pericellular fibrosis, two had stage II fibrosis, one had stage II with focal III, two had stage II-III, 1had stage III and one had stage III-IV. Velocities did not correlate with pathology grading. Conclusions: Elevated SWV should raise suspicion for hepatic fibrosis. SWE in children may provide noninvasive screening for hepatic fibrosis in children.

n number 9L VTQ 17 6C 42 VTQ VTIQ#1 22

Controls sd vel (cm/s)

Fibrosis sd vel (cm/s)

n

1.27 1.36

0.19 1.78 0.19 1.87

0.24 7 0.26 9

T-test p value <0.001 <0.001

1.57

0.39 1.79

0.34 4

0.31

nunber

Brett Mollard, MD, Univeristy of Michigan, Ann Arbor, MI, [email protected]; Ethan Smith, Jonathan Dillman, MD, Manda Lai, Robert Christensen. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To present our institutional pediatric MR enterography (MRE) experience in children under the age of 10 years. Methods & Materials: Institutional review board approval was obtained for this HIPAA-compliant study. Department of Radiology records were searched to identify MRE exams performed in children under the age of 10 years between June 2009 to May 2013. Electronic medical records (including Departments of Radiology and Anesthesia) were reviewed to document the following: patient demographic data, clinical indications for exams, MRE diagnoses, lengths of MRE exams (in minutes), quality of MRE exams, distance of oral contrast progression, use of general anesthesia (GA), and any GA-related side effects/adverse events. Results: One-hundred-six children under the age of 10 years underwent a total of 119 MRE exams, including 47 girls (45%) and 59 boys (55%). Ages ranged from less than 1 month to 9 years, 11 months. Mean girl patient age was 6.3 +/− 2.7 years, and mean boy patient age was 6.3 +/− 2.4 years. Fifty children (42.0%) had known inflammatory bowel disease (IBD), 45 (37.8%) had suspected IBD, 5 (1.2%) had a family history of IBD, and 19 (16.0%) were imaged for various other known or suspected gastrointestinal tract conditions. MRE exams were abnormal in 82.0% of children with known IBD, while 28.9% of exams were abnormal in children with suspected IBD. Mean MRE exam time was 68 +/− 22 min for awake children and 52 +/− 13 min for children under GA. One-hundred-ten (92.4%) MRE exams were performed under GA and 9 (7.6%) MRE exams were performed awake. The mean time spent under GA was 160 +/− 32 min (n=108) with a range of 59-246 min. All MRE exams were of diagnostic quality. Oral contrast material progressed to the proximal ileum in 21.2%, mid ileum in 11.0%, distal ileum in 7.6%, and terminal ileum in 31.4% of cases. Side effects/adverse events associated with MRE under GA were uncommon and minor including: transient nausea in 13 patients (11%) and emesis in nine patients (8%). No child had a documented major GA-related side effect/adverse event or required hospitalization for an MRE with GA-related complication. Conclusions: MRE can be successfully performed in young children and can be used to diagnose suspected IBD, follow-up known IBD, and identify a variety of other gastrointestinal tract conditions. The majority of exams in this population were performed safely under GA, with GArelated side effects/adverse events being uncommon and minor.

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Paper #: 063

Paper #: 064

Fused Color Map Diffusion Weighted and T2 Images Versus Contrast Enhanced Imaging for the Detection of Path-Proven Bowel Inflammation in Pediatric MR Enterography

MR Colonography with Diffusion Weighted Imaging (DWI) in Children and Adolescents with Inflammatory Bowel Disease (IBD): Do we really need intravenous contrast?

Eric Ehman, MD, Radiology, UCSF, San Francisco, CA, [email protected]; Andrew Phelps, MD, Michael Ohliger, Sue Rhee, John MacKenzie, Jesse Courtier, MD.

Bernd Schweiger, Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany, [email protected]; Michael Forsting, Maria Hahnemann, Thomas Lauenstein, Selma Sirin, Sonja Kinner

Disclosures: John MacKenzie has indicated a relationship with with General Electric as a Principal Investigator. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare colorized diffusion weighted images (DWI) fused with anatomic T2 images to biopsy results, as an alternative to GRE gadolinium enhanced imaging for the detection of bowel inflammation in children. Methods & Materials: 20 MR Enterography (MRE) studies were retrospectively reviewed for the presence or absence of inflammation on colorized fused DWI/T2 images and dynamic contrast enhanced GRE images. Cases were included if they had both DWI and GRE contrast enhanced images in addition to histology results from colonoscopy performed within 2 months of imaging with mean time from imaging to biopsy = 15.3 days (SD=12.7, range 1-46). Fused 50%-blend, colorized DWI/T2 images were created for each case using a GE Advantage Workstation. Two pediatric radiologists recorded the presence or absence of inflammation in the following regions: distal small bowel, right colon, transverse colon, left colon, and sigmoid colon + rectum for each case using either the fusion DWI images or the post-gadolinium GRE images. Results were compared to the gold standard of colonscopy with biopsy to calculate sensitivity, specificity and positive and negative predictive value. Results: Demographics: mean age = 14.5 years (SD=3.4, range 6-21), 11 males, nine females. One hundred regions were reviewed (5 regions×20 patients). 38/100 regions showed inflammation on histology. Eight patients had no inflammation at biopsy. Two patients had distal small bowel and pan-colonic inflammation. Overall sensitivity and specificity for colorized fusion DWI images was 68 and 90% versus 46 and 87% for routine contrast enhanced images. PPV and NPV were 81 and 82% for colorized fusion DWI images and 68 and 73% for contrast enhanced images. Conclusions: Results show colorized fused DWI/T2 imaging has comparable test characteristics to conventional dynamic contrast enhanced GRE imaging in the detection of inflammation within the distal small bowel and colon. In patients who are unable to receive gadolinium contrast, fusion DWI images may be an alternative method for assessing inflammation. When contrast administration is possible, the high specificity of fusion DWI images for inflammation may be helpful in conjunction with traditional contrast enhanced images to provide greater accuracy or confidence in the diagnosis.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: MR colonography (MRC) is a well-accepted, non-invasive imaging modality for the depiction of IBD. Diffusion weighted Imaging (DWI) has been shown to show lesions in abdominal MRI as good as contrast-enhanced imaging and can also be used for bowel MRI. Aim of this study therefore was to assess if contrast enhancement is really needed to depict inflammatory lesions if DWI is available. Methods & Materials: Thirty-seven patients (23 girls, 14 boys, mean age 14.6 years) underwent MRC on a 1.5T (Magnetom Avanto, Siemens). In addition to T2-weighted and contrast-enhanced T1-weighted (ce-T1-w) data, DWI sequences in axial and coronal plane (b=50, 500, 1000) were acquired and ADC maps calculated. Two reviewers evaluated i) DWI, ii) ce-T1-w-MRC and iii) DWI and ce-T1-w-MRC concerning lesions (1 = none, 2 = one/continuous lesion(s), 3 = multiple, discontinuous lesions). Furthermore, the preferred b-value (0, 500, 1000) were assessed and correlated. Colonoscopy and biopsies served as reference standards. Results: Depiction of inflammatory lesions significantly increased with DWI compared to ce-T1-w-MRC (sensitivity/specificity 78.4/ 100% vs. 95.2/100%, respectively, compared histopathology, p< 0.001). In six patients each, inflammatory lesions were only detected by DWI or additional lesions found by DWI. Kappa values were excellent (k=0.92-0.96). A combination of the two higher bvalues (b=500 and 1000) was preferred. Conclusions: DWI of the bowel shows inflammatory lesions with high accuracy and proved to show lesions not seen with ce-T1-w-MRC. Therefore, DWI seems to be able to replace, in any case complement ce-T1-wMRC. This could be used for short examinations for therapy response assessments and has to be evaluated in future trials.

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Paper #: 065 The Elusive Right Aortic Arch

James Crowe, Pediatric Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; George Bisset, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In our experience the presence of a right aortic arch (RAA) is a frequently missed diagnosis on chest radiography. Most patients with a RAA have congenital heart disease with mirror-image branching and the diagnosis is usually made on echocardiography, CT or MRI. However, patients with a vascular ring usually do not have congenital heart disease and may present with severe airway obstruction that is mistaken for asthma. Failure to diagnose the RAA and vascular ring can have serious consequences. Methods & Materials: We searched our entire patient database for all patients with a diagnosis of RAA, confirmed by CT, MRI or ultrasonograpy since 2000. One hundred forty patients (ages < 16 years) were identified. We then retrospectively reviewed all of the chest radiographs and medical records. Four patients with dextrocardia and one patient with no chest radiographs were excluded. Two senior pediatric radiologists evaluated all patients’ initial radiographs for signs of a RAA (right aortic knob, deviation of the trachea to the left on a nonrotated radiograph, right-sided descending aorta, and right-sided umbilical artery position) and then reviewed medical records to determine if the diagnosis was suggested on the initial dictated radiology report. Patients were categorized in our retrospective review into two groups: Group 1 - Cases with unequivocal chest radiographs for RAA, Group 2 - Cases with suspicious or indeterminate radiographs for side of arch. Results: Of the 135 children included in the evaluation, 47 (35%) were in Group 1. Of these, 27 (57%) reports had no mention of the possibility of RAA and 20 (43%) were dictated as suspicious or indeterminate for side of the arch. Sixty-six patients (49%) were in Group 2. Of these, classic findings of a RAA were missed in 43 (65%), findings were correctly classified in 29 (32%), and the finding of a RAA was questioned in 9 (10%). A third group of patients included 23 in whom the diagnosis was not suspected initially or on retrospective review. Conclusions: A right aortic arch is missed by experienced pediatric radiologists more than half the time when typical findings are present on the chest radiograph. In cases where there are suggestive findings, the diagnosis is not suspected 65% of the time. Delayed diagnosis in these patients may result in significant morbidity as a result of chronic treatment for reactive airways disease. We are unable to discern a definite cause for this high miss rate, but will offer speculation as to why these findings go undetected.

Paper #: 066 Comparison of Image Quality and Radiation Dose between High-Pitch and Low-Pitch Spiral Chest CT in Young Children

YoungHun Choi, Radiology, Seoul National University Hospital, Seoul, Korea (the Republic of), [email protected]; Jung-Eun Cheon, Woo Sun Kim, In-One Kim, So Mi Lee, Hyun-Hae Cho. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare the image quality and radiation dose between high-pitch mode (HPM, FLASH spiral mode) and lowpitch mode (LPM, X-CARE organ-based dose modulation mode) chest CT in young children who are incapable of holding the breath.

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Methods & Materials: Between March 2014 to August 2014, 49 chest CT examinations were conducted with a 128-channel dual source CT using HPM (n=26) or LPM (n=23) in 47 young children who could not hold their breath. For radiation dose measurement, dose length product (DLP) and z-overscanning were obtained from the dose reports. Organ doses and effective doses for both two modes were calculated using a 5-year-old anthropomorphic pediatric phantom. Four pediatric radiologists assessed overall image quality on a five-point scale (1, unacceptable; 2, poor; 3, average; 4, good; 5, excellent). Motion artifact was assessed on a four-point scale (0, no artifacts; 1, mild artifacts; 2, moderate artifacts; 3, severe artifacts) at the diaphragm, left heart border, upper lung parenchyma, middle lung parenchyma, and lower lung parenchyma, respectively. Finally, enrolled patients were divided into two subgroups based on the patients’ respiratory rate (RR): low RR group (RR <26, n=16) and high RR group (RR ≥26, n=33) for subgroup analyses. Results: The HPM showed the shorter mean scanning time (HPM vs. LPM, 0.64 vs. 2.62 s, P<.0001) and the longer z-overscanning (62.74 vs. 17.12 mm, P<.001). The mean DLP was also significantly higher in HPM (29.48 vs. 23.46 mGy*cm, P=.022). The phantom study revealed the 26% higher effective dose in HPM (1.82 vs. 1.44 mSv). The overall image quality score was better in HPM (4.00 vs. 3.46, P=.004), particularly in the high RR group (4.00 vs. 3.22, P=.001). The motion artifact score of HPM was lower than that of LPM in the high RR group regardless to the locations. However, there were no significant differences in the overall image quality and motion artifact scores between two modes in the low RR group. middle lung parenchyma, and lower lung parenchyma, respectively. Finally, enrolled patients were divided into two subgroups based on the patients’ respiratory rate (RR): low RR group (RR <26, n= 16) and high RR group (RR ≥26, n=33) for subgroup analyses. Conclusions: The HPM chest CT showed better image quality in small uncooperative children. However, The LPM chest CT can be considered for chest CT evaluation of stable children with low RR in favor of the radiation dose saving, while maintaining the image quality.

Paper #: 067 Knowledge-Based Iterative Reconstruction versus Hybrid Iterative Reconstruction: Effect on Image Quality and Diagnostic Confidence in Reduced kV Pediatric Oncologic Chest CT

Claudia Martinez-Rios, MD, University Hospitals Case Medical Center Case Western Reserve University, Department of Radiology, Cleveland, OH, [email protected]; Sara Texteira, Philip Yen, Leslie Ciancibello, Abdus Sattar, Sheila Berlin, et al. Disclosures: Claudia Martinez-Rios, MD, has indicated a relationship with Case Western Reserve University and Philips Healthcare as a Research Fellow. Leslie Ciancibello has indicated a relationship with Siemens - Honoraria and Philips – Research Grant. All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare image quality and diagnostic confidence in reduced tube voltage (kV) in pediatric oncologic chest computed tomography (CT) reconstructed with knowledge-based (KIR) and hybrid iterative reconstruction (HIR). Methods & Materials: Thirty-one pediatric oncology patients [mean age 9.7±5.7 years; median weight 31.2 kg (16, 51)] underwent chest CT. CT protocols were based on body width (BW): 80 kV for BW ≤18 cm, 100 kV for BW of 19-30 cm and 120 kV for BW >30 cm. CT dose index (CTDIvol) was recorded. Size-Specific Dose Estimates (SSDE) and Effective Dose (ED) were calculated. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured. Three blinded readers independently evaluated side-by-side CT data sets reconstructed with HIR and three levels of KIR. Subjective assessment included pathologic findings, anatomic landmarks,

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image quality, and diagnostic confidence. Statistical analysis included descriptive statistics, sign test and Kappa analysis. Results: Mean CT dose metrics were volumetric CT Dose Index 4.5± 3.3 mGy, Size Specific Dose Estimates 6.9±3.2 mGy, and Effective Dose 2.9 ±1.9 mSv. CNR and SNR were higher on KIR, though CNR on KIR Level one showed no significant difference compared to HIR (P=0.07). Overall KIR image quality and assessment of lung parenchyma, distal airways, and peripheral vascular structures were rated as superior or equivalent to HIR in more than 74.2% of the cases. For assessment of pathologic findings, 96.8% of cases were rated as superior or equivalent with substantial or almost perfect agreement among readers. KIR was considered as helpful in assessing chest pathologic findings in 35.4-38.4%. KIR Level one was the preferred algorithm (64.5%) for all readers followed by KIR Level 2 (41.9%) and KIR Level 3 (26.9%). Readers’ diagnostic confidence was not significantly different using KIR compared to HIR. Conclusions: Compared to Hybrid Iterative Reconstruction, Knowledgebased Iterative Reconstruction-enabled low kV protocols produce equivalent to superior image quality with comparable diagnostic confidence in pediatric oncologic chest CT.

decreasing exponential fit (HU=424*exp(-1.56*V) - 863.6, R2 = 0.68, with V in liters), with a 12-14% variation between subjects of the same age or lung volume. Conclusions: Normal lung parenchyma in infants and young children is considerably higher in attenuation than that of older children. As lung volume increases with age, CT attenuation decreases significantly during the first 2 years of life and then more slowly as age increases; this should be taken into consideration when evaluating lung disease in very young pediatric patients.

Paper #: 068 CT Characterization of Normal Pediatric Lung Parenchymal Density

Jill Stein, MD, Radiology, Cincinnati Children’s Hospital, Cincinnati, OH, [email protected]; Laura Walkup, Robert Fleck, Alan Brody, Jason Woods. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Imaging characteristics of adult and adolescent lung parenchyma have been quantified in normal and pathologic conditions, but there is currently a lack of data in young pediatric patients. The purpose of our study is to characterize the x-ray CT attenuation of pediatric lung parenchyma and to evaluate how that attenuation changes with age. Methods & Materials: Following IRB approval, our institution’s radiology database was retrospectively queried for normal CT examinations of the chest performed in children age 0-7 years from 2004-2014. Studies performed in patients with a history of underlying lung conditions and those with substantial atelectasis were excluded; studies with normal findings and contiguous axial CT image reconstructions via standard lung algorithm were included. The lungs were segmented from the chest to exclude major vasculature and sub-segmental atelectasis; lung volume, mean attenuation, and standard deviation were measured from the segmented lungs. Lung volume measurements were also obtained to include sub-segmental atelectasis; these total lung volumes were compared to mean attenuation and provide standardization for the variability in patient age-based breathing technique during CT acquisition. Results: A total of 43 CT examinations were included for analysis, performed in 40 children (17M/23F) with age range 3 days to 6 years 11 month. Twelve of the 43 (28%) CT examinations were performed in children 0-2 years, 9 (21%) in children 2-4 years, 17 (40%) in children 4-6 years, and 5 (12%) studies in children 6-7 years. Lung volume ranged from 0.10-1.63 L. Mean lung attenuation was much higher in children under the age of 12 months, with average values as high as -380 HU for neonates (0.10 L lung volume). Lung attenuation decreases to an approximate value of -730 HU by age 2 (lung volume 0.47 L), with subsequent slow decrease in lung attenuation as age and lung volume increase, toward a near-constant value of -860 HU. Lung volume and mean-lung attenuation were correlated via a

Paper #: 069 Hyperinflation of the Left Anterior Basal Segment: A New Sign of Pectus Excavatum Severity

Sumit Singh, MD, Pediatric Radiology, UAMS, Little Rock, AR, [email protected]; S Bruce Greenberg. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Insurance companies refuse reimbursement for pectus excavatum repair based on a lack of associated functional abnormalities. The aim of the study is to identify the frequency of left anterior basal segment hyperinflation in children with pectus excavatum. Methods & Materials: The study population included 49 patients who underwent computed tomography for pectus excavatum evaluation. Patient age ranged from 12 to 20 years (mean 14.8 years, sd 1.9 years). 37 patients were male. The Haller index, visual presence of left anterior basal segment hyperinflation (LABSH) and Hounsfield unit measurements in regions of interest in right and left lower lobe anterior basal segments were recorded. Fisher exact test compared the visual presence of LABSH with Haller index > 3.9. A 2-tailed t test compared differences in right and left anterior segment Hounsfield unit measurements in patients with or without visible LABSH. Results: Eleven (22%) patients had LABSH on visual inspection. The presence of the finding was significantly associated with Haller index of >3.9 (p=0.0146). The mean difference in left and right anterior basal segment Hounsfield units for the hyperinflation group was 98 HU (sd 40 HU) and for the non-hyperinflation group -4.3 HU (sd 36 HU). The difference was extremely significant (p<0.0001). Conclusions: LABSH is a new sign associated with severe pectus excavatum present in 22% of patients in the study group. The sign suggests bronchial compression caused the deformity resulting in air trapping - a functional justification for pectus excavatum repair.

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Paper #: 070 A Retrospective Review of Pulmonary Hemorrhage in Neonatal Respiratory Distress Syndrome - Imaging, Course, Complications, and Long Term Outcomes

Alvin Yu, MD, Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Randheer Shailam, Pallavi Sagar. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pulmonary hemorrhage (PH) is a known complication after surfactant treatment for respiratory distress syndrome (RDS) in premature neonates. Patent ductus arteriosus (PDA) is a known risk factor. In the modern era, many neonates are surviving PH and RDS and receive frequent chest radiography (CXR), enabling close radiography-clinical correlation during PH and at long-term follow-up. Methods & Materials: Premature neonates with RDS and PH were included. Clinical notes were reviewed for gestational age (GA), birth weight (BW), surfactant dose, PD duration, PDA, oxygen use at discharge, comorbidities, and mortality. CXRs were interpreted for laterality of new alveolar opacities before, during, and after the episode of PH, within 1 week of discharge, and at furthest follow-up. Results: Sixteen premature neonates born between 2005 and 2014 were included with mean GA 26.3 weeks and mean BW 838 g. 75% had antenatal steroid therapy. PH onset was 1.75 days of life and lasted 1.53 days. 88% had PDA and 56% developed ICH. All 3/16 (19%) who died from overwhelming PH had ICH and were born before 2010. At discharge, 50% required oxygen and 17% had tracheostomies. All were on room air at mean furthest follow-up of 18.4 months. One patient is still hospitalized. Immediately before PH, CXR showed findings of RDS in all 16 patients. At time of PH, CXR showed bilateral opacification in 44%, left lung opacities in 31%, right lung opacities in 13%, and no significant change in 13%. All three mortalities showed bilateral opacification at time of PH persisting until death. All survivors reverted to an RDS pattern after PH resolution, out of which 31% developed barotrauma (pulmonary interstitial emphysema or pneumothorax). Follow-up CXR showed fine diffuse hazy and reticular opacities suggesting CLD in 92% of patients, air-trapping in 43%, and normal CXR in 9%. No classic pattern of bronchopulmonary dysplasia was seen. Conclusions: PH is predominantly seen in extremely low birth weight premature neonates with a mortality of 19%. During PH, CXR shows bilateral opacification (44%) and left predominant unilateral opacification (31%), which generally resolves within 2 days. Interestingly, all mortalities had ICH and were born before 2010. Patients born after 2010 had no ICH, which may reflect changes in RDS management. All survivors were on room air with CXR showing CLD (92%) and air trapping (43%) at 18.4 months follow-up. None developed traditional patterns of cystic changes with architectural distortion as in BPD.

Paper #: 071 High Resolution Computed Tomography of Follicular Bronchiolitis in the Pediatric Population, a 5 Year Review of Imaging Findings with Pathologic Correlation

David Manning, MD, Pediatric Radiology, Children’s Hospital of Colorado, Aurora, CO, [email protected]; Jason Weinman, Lorna Browne, Amanda Krausert. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Follicular bronchiolitis (FB) is a rare form of interstitial lung disease (ILD) defined by the presence of peribronchial lymphoid follicles that exists within a spectrum of ILD known as diffuse pulmonary lymphoid hyperplasia. Associations include prodromal viral infection, autoimmune disease, and immunodeficiency. The typical presentation is respiratory distress in infancy followed by a prolonged course with gradual improvement over years. Despite improvement of symptoms, pulmonary function tests typically remain abnormal. While high-resolution CT (HRCT) findings of FB in adult patients have been described, no systematic review of HRCT findings of pediatric FB has been reported. The purpose of this review is to determine the HRCT findings of FB in children. Methods & Materials: Following IRB approval, a 5 year retrospective analysis of pediatric patients (age < 21 years) who underwent a HRCT and lung biopsy was performed. Inclusion criteria were HRCT within 6 months prior to lung biopsy and pathology-proven follicular bronchiolitis. HRCTs were reviewed by three observers and scored using the system described by Brody et al. Results: Six of the 206 patients reviewed met inclusion criteria (three male, three female). Patients ranged in age from 7 to 82 months at time of pre-biopsy HRCT. Pulmonary symptoms presented by 4 weeks (n=2), 4 months (n=2) and 4 years (n=1). One patient exhibited no pulmonary symptoms. Pulmonary nodules (n= 6) was the most common HRCT finding, followed by consolidation/ atelectasis (n=5), bronchiectasis (n=4) and lymphadenopathy (n= 3). Ground glass opacity, parenchymal cysts and air trapping were uncommon findings (n≤1). The most severe HRCT findings were bronchiectasis and pulmonary nodules, predominantly involving the lower lung zones bilaterally. Conclusions: The salient HRCT findings of pediatric follicular bronchiolitis are bilateral, lower lung zone predominant pulmonary nodules and bronchiectasis with infantile onset of symptoms. These characteristic HRCT findings enable differentiation of FB from other forms of infantile onset ILD including neuroendocrine cell hyperplasia of infancy, pulmonary interstitial glycogenosis and congenital abnormalities of surfactant function. Earlier recognition of these characteristic HRCT findings may lead to earlier diagnosis and treatment of follicular bronchiolitis and hopefully earlier control and improvement of pulmonary symptoms and greater preservation of pulmonary function.

Paper #: 072 Pediatric Aspirated Foreign Body: Adding Digital Tomosynthesis Improves Sensitivity Compared to Conventional Radiographs

Sherwin Chan, MD, PhD, Radiology, Children’s Mercy Hospital, Kansas City, MO, [email protected]; Daniel Hippe, Greg Kicska. Disclosures: Sherwin Chan, MD, PhD indicated a relationship p with GE Healthcare as a investigator. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Foreign body aspiration is a life threatening event that is difficult to diagnose in the pediatric population. Many aspirated foreign bodies contain low-density materials. Conventional radiographs are used in the diagnosis but have low sensitivity and specificity for radiolucent foreign bodies. The objective of this study was to quantify the sensitivity and specificity for diagnosing low density foreign airway bodies using digital tomosynthesis with conventional radiographs compared to conventional radiographs alone. Methods & Materials: Unenhanced chest computed tomography of normal pediatric patients was obtained retrospectively. Computed tomography of low density foreign bodies was obtained separately. The foreign body data was digitally inserted into the chest computed tomography data sets. These fused images were used

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to simulate digital tomosynthesis and conventional radiographs. An observer performance study was conducted with four radiologists who evaluated for the presence of an airway foreign body on digital tomosynthesis and conventional radiographs or conventional radiographs alone using a ten-point probability scale. The sensitivity, specificity, area under the curve and interobserver agreement for detection of airway foreign bodies was calculated. The optimal operating point on the ROC curve was determined by maximzing the Youden Index (sensitivity+specificity-1). Results: Digital tomosynthesis and conventional radiographs was significantly better than conventional radiographs alone on a per exam (AUC 0.82 vs 0.60, p=0.004; Figure 1) and a per location basis (AUC 0.78 vs 0.65, p=0.03). There was better interobserver agreement for digital tomosynthesis and conventional radiographs than for conventional radiographs (κ=0.86 vs κ=0.024, p<0.001). Using an optimal threshold for digital tomosynthesis and conventional radiogaphs, the per location sensitivity and specificity for detection of airway foreign bodies on digital tomosynthesis and conventional radiographs were 67 and 100% and on conventional radiographs alone were 15 and 94%. Conclusions: Adding digital tomosynthesis images to conventional radiographs significantly increases the sensitivity of foreign body detection and the interobserver agreement compared to conventional radiographs alone. These findings suggest that digital tomosynthesis may have added clinical value in the management of suspected foreign body aspiration.

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expiratory acquisitions for diagnosis of malacia. Dynamic volumetric CTA (DVCTA) offers an appealing alternative since morphology of the airways, their relationship to the vasculature, changes across the respiratory cycle and impact on the end-organ can be evaluated without sedation or respiratory control. This report describes the technical elements of a low dose, unsedated, free-breathing (FB) DVCTA protocol for the detection/ assessment of intrinsic and extrinsic airway compromise in children. Methods & Materials: All exams performed over the last 3 months using our institution’s low-dose FB DVCTA protocol were retrospectively reviewed. Per our protocol, respiratory rates (RR) determine acquisition mode; with continuous cine acquisition (rotation time 0.35-0.5 s) when RR >30/min, and intermittent acquisition every 1.4 s when RR <30/min (Fig. 1). Acquisition duration is 1.5-2 respiratory cycles, yielding 6-9 volumes. kVp is 80 in all patients and mAs is 20-50, depending on patient size. The z-axis is tailored to include the trachea, mainstem bronchi, and up to four generations of bronchioles. Power injection of i.v. contrast achieves 1st pass enhancement of rightand left-sided cardiovascular structures during acquisition. Postprocessing is on a Vitrea TM workstation, including virtual bronchoscopy and 3D reconstruction of the vasculature and airways. All studies were reviewed by a pediatric radiologist to assess for adequacy of respiratory sampling, image quality, vascular opacification, air trapping and atelectasis. Results: This is an ongoing study. To date, 11 children have been studied. Technical parameters and patient characteristics are listed in Tbl 1a. Sampling of respiration and central vascular opacification was adequate or excellent in all cases (Tbl 1b). Image quality was poor in 1 case (patient motion), adequate in three and excellent in 7/11. There was air trapping in seven and atelectasis in 6/11. 6/11 patients had recent bronchoscopy reports available with correlation results pending. Conclusions: Low-dose, FB DVCTA of the airways is a useful tool for comprehensive evaluation of the airways and central vasculature, does not require sedation, and yields good to excellent image quality at an effective dose of 0.8-2.5 mSv. Table 1a: Patient Characteristics and Technical Parameters Applied

Paper #: 073 Dynamic Volume CTA of the Airway and Vasculature in Children: Technical Report

Nicholas Dodd, BM, Diagnostic Imaging, Texas Children’s Hospital, Houston, TX, [email protected]; Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Prakash Masand, Siddharth Jadhav, MD, George Bisset, MD, Rajesh Krishnamurthy. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Conventional MDCT protocols require sedation with controlled apnea or endotracheal intubation in children unable to follow breath-holding commands. A pitfall of using CT for airway assessment is exposure to ionizing radiation, exacerbated by a need for separate inspiratory and

Table 1b: Image Quality and Presence of Air trapping and Atelectasis

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and %MAC (r=0.99). Excellent agreement between DVCTA and bronchoscopy for presence of TM and severity of airway narrowing. Airtrapping was seen on 41%, atelectasis on 35%. Conclusions: Unsedated free breathing DVCTA of the airways is a fast, low dose technique for evaluation of the pediatric airway in the setting of IAC. It has excellent agreement with bronchoscopy, excellent interobserver variability, does not require sedation or GA, and should be considered the first line investigation when the diagnosis is suspected.

Table 1a: Dynamic Volume CT Airway Tecnique and Grading Methodology Mean Range 80 none 36 20-50 7.5 5-11 2.06 1.36-3.31 Grading Methodology Tracheomalacia >50% change in cross-sectional area (CSA) at crossing of innominate artery between inspiration and expiration Severity of Airway Collapse Comparing maximal CSA of trachea below narrowing to minimal CSA at narrowing: None (0-49% change); Mild (50-74% change); Moderate (7589%); Severe (>90% change) kVP mAs Number of phases Effective Dose (mSv)

Paper #: 074 Low-Dose Free Breathing Dynamic Volume CT Angiography in the Evaluation of Innominate Artery Compression of the Trachea

Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Diagnostic Imaging, Texas Children’s Hospital, Houston, TX, [email protected]; Nicholas Dodd, BM, James Sorensen, Siddharth Jadhav, Rajesh Krishnamurthy, Prakash Masand Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Traditionally, bronchoscopy is deemed the gold standard for assessing the airway in the setting of innominate artery compression (IAC). Dynamic CT is an appealing alternative as airway morphology; their relationship to vascular structures, changes across the respiratory cycle and impact on the end-organ can be evaluated. Standard MDCT technique in small children requires GA, intubation and breath-hold technique for paired inspiratory and expiratory CT. The objective of this study is to determine the accuracy, image quality, and inter-observer variability of an unsedated freebreathing, low dose dynamic volume CT angiography (DVCTA) protocol for diagnosis of IAC, using bronchoscopy as the gold standard. Methods & Materials: All patients with IAC who had unsedated, free-breathing DVCTA at our institution from 2011-2014 were retrospectively identified. This included 17 children (65% M, mean age 3.6 years). Eleven had concomitant CHD. Acquisition was continuous if the respiratory rate (RR)>30/min, and intermittent (every 1.4 s) if RR<30 min. Technical factors are listed on Table 1a. Each CT study was reviewed by two pediatric radiologists in an independent and blinded fashion, followed by a consensus read. Parameters included image quality, severity of airway narrowing, presence of tracheomalacia (TM), and presence of air-trapping/ atelectasis. TM was defined as >50% reduction of tracheal cross-sectional area in expiration. Cohen’s kappa coefficients were calculated and paired t tests performed to compare CT findings to bronchoscopy. Paired ttests and Pearson correlation coefficients were used to evaluate interobserver agreement in assessing % expiratory collapse (EC) and % maximal airway collapse (MAC). Bronchoscopy reports performed within 90 days of CT were available in 14/17 cases. Results: Image quality for DVCTA was adequate or excellent in all cases (Table 1b). There was perfect interobserver agreement for TM and MAC. Excellent correlation between readers for estimation of %EC (r=0.95)

Table 1b: Results CT vs. Bronchoscopy

Presence of tracheomalacia

Severity of maximal airway narrowing Interobserver Agreement % Expiratory collapse % Maximal airway narrowing % Expiratory collapse % Maximal airway narrowing Presence of Air-trapping/ atelectasis Air-trrapping Atelectasis Image Quality Sampling of respiration Aortic opacification Pulmonary arterial (PA opacification) Overall image quality

Cohen’s Kappa Coefficient 1 Weighted Cohen’s Kappa Coefficient 0.82

p value

Pearson rank coefficient 0.95 0.99 Mean Difference 4.5% (95% CI 0.7-9%) 2.5% (95% CI 0.1-4.8% Yes; n (%)

p value 0.0001 0.0001 p value 0.025 0.039 No; n (%)

7 (41%) 6 (35%)f Poor; n (%) 1 (6%)

Adequate, n (%) 0

10 (69%) 11 (65%) Excellent, n (%) 16 (94%)

1 (6%) 1 (6%)

2 (12%) 4 (24%)

14 (82%) 12 (70%)

0

3 (18%)

14 (82%)

0.002 p value 0.0001

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Paper #: 075

Device Type

Type of Scan(s)

Safe Performance of MRI in Children with Active Cardiac Devices 3

Rebekah Clarke, MD, Radiology, Children’s Medical Center, Dallas, TX, Dallas, TX, [email protected]; Michael Morriss, William Scott. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Magnetic resonance imaging (MRI) is an important tool in pediatric radiology and is frequently the most appropriate imaging choice for making critical diagnoses. However, there are significant potential safety risks to MR in patients with active implanted cardiac devices related to radiofrequency irradiation and thermal injury, exposure to static magnetic fields with movement or torque of the device, as well as induction of electrical currents and interference with device function. Several institutions have recently developed MRI protocols to safely image patients with these devices. The majority of these studies involve adult patients and there is very little published data on MR imaging in pediatric patients with such devices. The purpose of this study is to document the outcomes of MRI in children with active implanted cardiac devices in a large tertiary care children’s hospital and describe the protocols which were followed to safely scan these devices. Methods & Materials: Seven patients with active implanted cardiac devices underwent a total of 10 MRI examinations over a 4 year period from 2010–2014. Screening and imaging protocols were developed based on recommendations from published studies and the ACR Guidance Document on MR Safe Practices: 2013. Patients were evaluated prior to imaging by a pediatric cardiologist specializing in electrophysiology. Pacemaker “dependent” patients (native heart rate less than 30 bpm) were excluded from MR imaging. The institutional MR Safety Officer was responsible for assessing the appropriateness of each examination, obtaining informed consent, and was present during all MRI examinations. All devices were interrogated including sensing and stimulation thresholds before and after imaging. Prior to entering the magnet, all ICDs were programmed so that a shock could not be delivered. Patients were monitored by telemetry and pulse oximetry for the duration of each examination. Results: No adverse events occurred as a result of MR imaging of seven patients with a total of nine different cardiac devices. Device types included five pacemakers, two loop recorders and two ICDs. No significant ECG changes occurred in any patient during the course of the MRI. One pacemaker required minor adjustments to chronic settings following an MR examination. Conclusions: With appropriate screening and patient selection, collaboration with cardiology and specific monitoring and imaging protocols, MRI may be safely performed in certain pediatric patients with pacemakers, loop recorders and ICDs.

Patient History

Device Type

Type of Scan(s)

1

malignant vasovagal syncope

dual chamber pacemaker

MRI Brain

2

autonomic dysregulation

pacemaker, single lead

MRI Cervical spine with anesthesia

Events During Scan none; mirror adjustments to chronic settings following MRI none

4

5

6 7

dilated Loop recorder 1. MRI cardiomyopathy Biventricular Brain pacemaker 2. MRI and ICD Brain 3. MRI Brain 4. MRA Brain complete AV dual chamber MRI Brain block pacemaker with anesthesia d-TGA, ASD, dual chamber MRI/MRA VSD, pacemaker Cardiac hypoplastic right heart, post Fontan cardiac arrest ICD MRI Left Forearm restrictive loop recorder MRI/MRA cardiomyopathy Brain

Events During Scan none

none

none

none none

Paper #: 076 Bone Age Assessment Practices Among SPR Members: Infants Are Not Just Little Children

Micheal Breen, MBBChBAO (Hons) BMedSc MRCPI FFRRCSI, Department of Radiology, Boston Children’s Hospital, Boston, MA, [email protected]; Andy Tsai, MD, PhD, Paul Kleinman, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare current practices and reader confidence in infant radiographic bone age assessments with the techniques employed in older children. Methods & Materials: SPR members were invited by email to complete an online survey following IRB approval. Background questions included years’ experience as a pediatric radiologist and frequency of bone age assessment. Respondents were asked about methods used and confidence in their technique of choice for the following age groups: <1 year, 13 years and 3-18 years. They were asked about determining bone age when it appeared (1) to be markedly delayed compared to chronological age, and (2) to fall between two different standards using an atlas/template method. Results: 441/937 members (47%) responded. 160 pediatric radiologists (37%) had >20 years’ experience. Frequency of bone age assessments were as follows: <1/week 8%, 1-10 times/week, 57%; 11-20 times/week, 25%; and >20 times/week, 10%. For children <1 year old, 70% of respondents used Greulich & Pyle, 27% used a hemiskeleton method (e.g. Sontag or Elgenmark) and 14.4% used the Pyle & Hoerr knee method. For these infant assessments, 34% were unconfident with their technique. For children 1-3 years old, 86% used Greulich and Pyle and 19% used a hemiskeleton method; 21% of respondents were unconfident with their technique. For patients 3-18 years old, 97% used Gruelich and Pyle, and only 6% of respondents were unconfident with their technique. Choice of techniques used in <1 year olds was not statistically different from those used in 1-3 year olds. However, remaining pairwise comparisons of the 3 age groups showed statistical difference (p<0.05) in technique used and reader confidence. When bone ages were markedly delayed compared to chronological age, 18% adopted a different technique. When unable to

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decide between two bone age standards while using an atlas/template method, 19% picked one standard, 27% reported a mid-point interpolation and 51% provided the range of reference standards. Conclusions: For children >3 years, the majority of pediatric radiologists are very confident in their use of Greulich and Pyle for bone age assessment, but chosen method varies and reader confidence falls significantly for children 1-3 years. There is even lower confidence and less consensus regarding the appropriate method for estimation of skeletal maturity in infants. These data should encourage the development of a more suitable tool to assess bone age during this critical period of rapid growth and development.

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lesions), internal reticulations (38/58 lesions) and a hypoechoic rim (48/58 lesions). CT characteristics included isoattenuation to skeletal muscle (6/11), calcification (7/11) and enhancement (5/ 11). On MRI, isointense T1 signal intensity compared to skeletal muscle (12/18), heterogeneous T2 signal pattern (16/21) with regions of increased and decreased signal relative to skeletal muscle (16/21), moderately heterogeneous enhancement (14/16) and restricted diffusion (6/6). Pilomatricoma was mentioned in the differential diagnosis in 15 of 56 studies with differential diagnoses. Conclusions: Although pilomatricoma is a common clinical and pathological diagnosis, these lesions are infrequently imaged, likely resulting in the relative lack of awareness among pediatric radiologists. Pilomatricoma is a consideration for any wellcircumscribed subcutaneous lesion with hypoechogenicity, peripheral vascularity, calcifications, internal reticulations and hypoechoic rim on US; isoattenuation to skeletal muscle, calcifications and enhancement on CT or T1 isointensity to skeletal muscle, heterogeneous T2 signal pattern, heterogeneous enhancement and restricted diffusion on MR.

Paper #: 078 Beyond the Central Slice: Spectrum of 3D Ultrasound Appearances in Normal and Dysplastic hips

Jacob Jaremko, MD, PhD, Radiology & Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, Canada, [email protected]; Myles Mabee, Yeli Pi, Edwin Cheng, Alana Heath, Richard Thompson.

Paper #: 077 Pilomatricoma: A Common Clinical and Pathological Entity, Yet a Rare Radiological Diagnosis

Julie Bulman, MD, University of Texas Southwestern Medical Center, Dallas, TX, [email protected]; Veena Rajaram, Seckin Ulualp, Korgun Koral. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: i) characterize imaging features of pilomatricomas, ii) evaluate frequency of consideration of pilomatricoma in radiology reports of proven cases, iii) increase awareness of pilomatricoma among pediatric imaging specialists. Methods & Materials: Query of the pathology using the terms “pilomatrixoma” and “pilomatricoma” between 1/2009 and 2/ 2014 yielded 623 surgical specimens. Review of medical records revealed that 74 patients (33 males) underwent imaging of 81 excised lesions (seven patients had two lesions each) with one or more modalities (US, CT or MR). Ninety imaging studies were available (58 US, 11 CT, 21 MRI) and 10 patients were imaged with two modalities (eight US and MR, two US and CT). The average age at pathology diagnosis was 8.9 years (0.8-16.8). Studies were reviewed by a pediatric radiologist with 14 years of post-fellowship experience for size, location and imaging characteristics on US, CT and MRI. The radiology reports were reviewed to determine whether pilomatricoma was included in the differential diagnosis list and what the first and second diagnostic considerations were. Results: <13% (74/596) of patients underwent imaging evaluation of their lesions. US features most consistent with pilomatricomas included heterogeneous echo texture compared to skeletal muscle (51/58 lesions), peripheral vascularity on color Doppler (24/57

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Developmental hip dysplasia (DDH) is traditionally assessed in infancy by 2D ultrasound, particularly the appearance of the mid-acetabulum in the Graf standard plane and dynamic assessment of stability. Sonographers are trained to focus on obtaining/saving a standard plane coronal image, but this is a simplified view of the complex 3D acetabular shape. To gain improved understanding of hip dysplasia, we have been routinely performing 3D ultrasound (3DUS) in DDH patients since 2012. Here, we present variants of acetabular shape, as revealed by 3DUS, which may be of diagnostic and prognostic relevance. Methods & Materials: With institutional ethics approval and parental informed consent, we added 3DUS scans in infants undergoing 2D ultrasound for possible DDH. A pediatric musculoskeletal radiologist and a biomedical engineering graduate student reviewed 3D hip ultrasound images from 345 infants aged 0-6 months scanned from Sep 2012-May 2014, identifying cases as containing no variant, a variant affecting the mid-acetabular Graf standard plane (i.e., visible on 2D ultrasound), or a variant not visible on the standard plane (i.e., could be missed on 2D ultrasound). Variants were categorized and recorded for viewing as cine clips. Cases were flagged for future review to assess long term outcomes. Results: Variants affecting the Graf standard plane image included acetabular rounding (especially in infants); the acetabular ridge (preventing acquisition of any image with a completely straight lateral acetabular roof line); and the undulating iliac wall. Variants typically not affecting the Graf standard plane image included anterior acetabular roof deficiency with a well developed posterior acetabulum, and an anterior acetabular notch. Dysplastic hips fell into two groups: those with a rounded anterior lateral acetabular margin and those with a sharp corner in this location.

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Conclusions: 3D ultrasound reveals multiple variants of acetabular morphology in normal and dysplastic hips. Some of these make acquisition of a traditional 2D ultrasound Graf standard plane image difficult, while others are not seen in the 2D ultrasound standard plane. The findings presented here illustrate the complex 3D shape of the normal acetabulum, and different types of dysplasia which may have different prognoses and different optimal treatments. As 3DUS is a new imaging modality, the diagnostic and prognostic significance of these variants is unknown and will require longer-term prospective study.

Paper #: 079 Inter-Scan Fidelity of 3D Acetabular Surface Models Generated from 3D Ultrasound for Infant hip Dysplasia

Jacob Jaremko, MD, PhD, Radiology & Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, Canada, [email protected]; Myles Mabee, Yeli Pi, Alana Heath, Janet Ronsky, Richard Thompson. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Imaging of the infant hip for developmental hip dysplasia (DDH) is challenging, with 2D ultrasound limited by poor reliability, and other modalities impractical or too low-resolution to examine the tiny joint. 3D ultrasound (3DUS) captures the shape of the entire acetabulum in a single capture. However, reliability of the acquired data is unknown. We tested to what level of precision 3D acetabular surface models generated from 3DUS are consistent between different scans of the same hip. Methods & Materials: Scanning: With institutional ethics approval and parental informed consent, we added 3DUS scans in infants aged 0-6 months undergoing 2D ultrasound for possible DDH. Two observers (a radiologist or medical sciences graduate student, and a sonographer) each performed two 3DUS scans of each hip at the same visit, using a Philips VL13-5 probe (voxel size 0.2×0.1×0.1 mm). The hip of greatest clinical concern for each patient was selected for analysis. Surface modeling: A custom semi-automated segmentation routine was developed in Matlab, in which users manually draw acetabular contours on 3-5 of the base slices forming the 3DUS data set. Surfaces are interpolated onto the intervening slices, and the user can then review all contours and make any final adjustments needed. This process, similar to ventricular modeling in cardiac MRI, took 1-2 min per hip. A 3D surface model was then generated in STL format. Model fusion: We generated surface models for two 3DUS scans (by two different observers) of 15 hips. For each hip, the relevant pair of surface models was loaded into Amira (v. 5, FEI Inc., Hillsboro, OR). The models were positioned to overlap each other as closely as possible without deforming them, by initial manual positioning followed by automated optimization using affine transformations. Distance between every point on each model and its closest corresponding point on the other model was measured and is reported as root mean square (RMS) distance. Results: Models showed visually excellent overlap (Figure 1 - red = scan 1, white = scan 2), confirmed numerically with RMS error of 0.4+/ −0.1 mm (range: 0.2-0.6 mm). Conclusions: A 3D acetabulum surface model can be quickly generated from 3DUS scan with high reliability. This encourages future use of 3DUS for visual and quantitative assessment of DDH. The fusion techniques employed here can also be adapted to evaluate changes in acetabular shape during normal development and DDH treatment.

Paper #: 080 Imaging Findings and Clinical Outcomes in Traumatic Hip Dislocation in Pediatric Patients

Micheal Breen, MBBChBAO (Hons) BMedSc MRCPI FFRRCSI, Department of Radiology, Boston Children’s Hospital, Boston, MA, [email protected]; Young-Jo Kim, Yi-Meng Yen, Evgeny Bulat, Michael Millis, Sarah Bixby, MD; Disclosures: Yi-Meng Yen has indicated a relationship with Smith and Nephew as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this study was to review imaging findings in pediatric patients with traumatic hip dislocation. A secondary goal was to review management approaches and patient outcomes. Methods & Materials: This was a retrospective study performed following IRB approval. Radiology, orthopedic and hospital databases were electronically searched for episodes of traumatic hip dislocation occurring in patients under 19 years of age between January 2000 and October 2014. Electronic medical records were reviewed with note of the following: patient demographics, mechanism of injury, clinical management, type of surgery, length of cinical follow-up and incidence of complications including avascular necrosis and arthrosis. Imaging studies were reviewed with documentation of specific osseous and soft tissue injury. Results: Forty-five patients (37 male, 8 female; mean age 13 years, range 2-19 years) with traumatic hip dislocations were identified. Football injuries accounted for 33.3% (15/45) of dislocations, motor vehicle accidents for 26.7% (12/45), and snow sports for 15.6% (7/45). CT was performed in 33/45 of patients (73.3%) and MRI in 27/45 (60%). Both MRI and CT were performed in 18/45 patients (40%). Review of CT images demonstrated posterior acetabular fracture in 19/33 patients (57.6%), femoral head fracture in 11/33 (33.3%) and intra-articular osseous fragments in 16/33 (48.5%). Review of MRI images demonstrated 19/27 patients (70.4%) with posterior labral tear, 18/27 (66.7%) with femoral head fracture/contusion, 12/27 (44.4%) with posterior acetabular fracture, and 8/27 patients (29.6%) with intraarticular labral entrapment. 21 patients (46.7%) underwent an open surgical procedure. Avascular necrosis developed in 3 patients (8.9%) a mean of 2.3 months post injury. Arthrosis developed in 4/45 patients (8.9%) with 1 patient requiring total hip arthroplasty 21 months following dislocation. Conclusions: Fractures of the femoral head and posterior acetabulum are relatively common injuries in patients with traumatic posterior hip dislocation, which were demonstrated on both MRI and CT. MRI also

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identified associated soft tissue injuries, such as labral tears and intraarticular labral entrapment. All patients with labral entrapment identifed on MRI in this series underwent surgical hip dislocation. This study highlights the importance of MRI in directing management of patients with traumatic hip dislocation, particularly when there is concern for entrapped soft tissue in the joint.

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in patients with hip pain, and specific history of night pain relieved by NSAIDS should be solicited.

Paper #: 082 Detection of Inflammatory Sacroiliitis in Children: Is MR Contrast Necessary?

Nancy Chauvin, MD, Department of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; David Biko, Diego Jaramillo, MD, Ann Johnson, Pamela Weiss.

Paper #: 081 Osteoid Osteoma of the Hip in Pediatric Patients

Sarah Bixby, MD, Boston Children’s Hospital, Boston, MA, [email protected]; Collin May, Megan Anderson, YiMeng Yen, Young-Jo Kim, Benton Heyworth, et al. Disclosures: Yi-Meng Yen has indicated a relationship with Smith and Nephew as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To assess plain film, CT, and MRI imaging features of osteoid osteoma about the hip in pediatric patients, and identify potential imaging pitfalls that lead to incorrect diagnosis. Methods & Materials: A database of orthopaedic patients was retrospectively reviewed for patients with osteoid osteoma from 2003-2014. Medical records were reviewed to identify lesions around the hip joint. Relevant clinical and demographic data were recorded; imaging studies were reviewed. Fifty patients (48% female, mean age 12.4 years) were included in the study. Imaging studies were reviewed by a pediatric radiologist with attention to specific imaging findings based on modality. Results: Lesion locations incuded femoral neck (19/50), subtrochanteric (15/ 50), pertrochanteric (9/50), and acetabulum (7/50). Hip pain was the presenting complaint in 60% (30/50). Night pain was present in 96% (48/50). Pain relief with NSAIDS was noted in 88% (44/50). Radiographs were obtained in 96% (48/50). Sclerosis and/or cortical thickening were visible on 60% (29/48); a lucent nidus was visible on 44% (21/48). MRI was performed in 54% (27/50). Intracapsular lesions were present in 63% (17/27). For intracapsular lesions, focal medial retinacular/synovial thickening was noted in 53% (9/17), and joint effusion was present in 76% (13/17). Neither was present in patients with extracapsular lesion. Focal peri-lesional edema was present in 100% (27/27) regardless of lesion location. A focal nidus was visible in 59% (16/27). CT was performed in 86% of patients (43/50); a lucent nidus was present in all. Initial diagnoses that did not lead to resolution of symptoms were recorded in 46% (23/50) of patients, including FAI/labral tear (6), trauma/stress fracture (6), and synovitis. Significant delay in diagnosis (>6 months) occurred in 40% (20/50). Operative procedures for “incorrect” diagnoses were performed in 4% (2/50), including periacetabular osteotomy and femoral head/neck osteochondroplasty. Conclusions: Delayed diagnosis is common in pediatric patients with osteoid osteoma of the hip. Varying presenting complaints and nonspecific MRI findings may be attributed to other absent or potentially confounding conditions such as FAI, or trauma/stress fracture. Nonspecific MRI imaging findings including focal synovitis, joint effusion, and perilesional edema should suggest possible diagnosis of osteoid osteoma

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In children with Juvenile Spondyloarthritis, early identification of sacroiliitis may be an opportunity to alter the disease course. In adults, gadolinium-enhancement does not add incremental value to fluid sensitive sequences as synovitis rarely occurs in the absence of bone marrow edema. The purpose of this study is to determine if MR contrast is necessary to assess for sacroiliitis in children. Methods & Materials: We conducted a retrospective study of 55 subjects with clinically suspected or diagnosed Juvenile Spondyloarthritis. All subjects underwent dedicated MRI imaging of the pelvis consisting of multiplanar fluid sensitive- and postgadolinium T1-weighted fat saturated sequences that included small field-of-view coronal oblique imaging of the sacrum. Three radiologists independently evaluated the non-contrast sequences, and at a later date, the complete study (including post-contrast imaging) in randomized order. Images were evaluated for the presence of bone marrow edema, capsulitis, effusion and synovitis (post-contrast sequences only). With post-contrast imaging as the reference standard; the sensitivity, specificity, positive and negative predictive values of fluid sensitive sequences for the depiction of sacroiliitis were calculated. Inter-reader reliability was determined using Fleiss’ kappa. Results: Subjects had a mean age of 15 years (interquartile range: 12, 16); 55% were boys. Twenty-four subjects were diagnosed with sacroiliitis based on post-contrast imaging and none had synovitis in the absence of bone marrow edema. All 24 subjects demonstrated bone marrow edema on both fluid sensitive- and post-gadolinium T1-weighted fat saturated sequences. Twenty-five percent of subjects with sacroiliitis had capsulitis, which was depicted on both non-contrast and post-contrast imaging. Two of six subjects with sacroiliac joint enthesitis were seen only after contrast; however, the detection of enthesitis does not change the diagnosis. Sensitivity, specificity, PPV and NPV of fluid-sensitive sequences for the detection of sacroiliitis using post-gadolinium imaging as the reference standard were near perfect (Table 1a). Inter-rater reliability was substantial for all parameters (Table 1b). Conclusions: MR contrast is not necessary for detecting inflammatory sacroiliitis in children. Table 1a. Sensitivity, specificity, PPV and NPV of fluid-sensitive sequences for the detection of Sacroiliitis using post-gadolinium imaging as the reference-standard. Sacroiliitis diagnosed on fluid sensitive sequences Sensitivity Specificity Positive predictive value Negative predictive value

Estimate (95% CI) 1.00 (0.86, 1.00) 0.99 (0.94, 1.00) 0.96 (0.80, 1.00) 1.00 (0.96, 1.00)

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Table 1b. Inter-rater reliability for the detection of bone marrow edema (BME), capsulitis, enthesitis and synovitis.

0 1

Fleiss’ kappa (95% CI) Fluid sensitive sequences BME Capsulitis/Enthesitis Post-contrast sequences BME Capsulitis/Enthesitis Synovitis

2 0.83 (0.72, 0.94) 0.68 (0.57, 0.79) 0.74 (0.63, 0.84) 0.67 (0.56, 0.77) 0.64 (0.53, 0.75)

Paper #: 083 Normal Sonographic Rene Length and Growth in Children withoutENGTH AND Vesicoureteral Reflux (VUR)

Richard Parad, MD, MPH, Brigham and Women’s Hospital, Boston, MA, [email protected]; David Zurakowski, Jane Share, Judy Estroff, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Vesicoureteral reflux (VUR) can lead to renal scarring, and thus impact renal growth. The purpose is to develop a model for the prediction of normal age, gender and laterality specific renal length and derive rates of normal renal growth from a large cohort of children free of VUR Methods & Materials: Renal lengths were measured on normal renal sonograms of 946 patients under age 13 who had either a normal voiding cystourethrogram or a normal radionuclide cystogram. Regression analysis was used to determine the best relationship between renal length and age, as modified by gender and laterality. Results: Renal length increased with age according to a quadratic relationship. The quadratic regression equations for predicting normal renal length are: MALE Right Renal Length=5.24+0.052 (Age) - 0.00018 (Age)2 Left Renal Length=5.31+0.055 (Age) - 0.00019 (Age)2 FEMALE Right Renal Length=5.50+0.042 (Age) - 0.00011 (Age)2 Left Renal Length=5.56+0.044 (Age) - 0.00012 (Age)2 Left renal length was greater than right at all ages in both sexes. The gender by age interaction revealed significant slope differences between males and females on both the left and right sides (P=0.001). Right renal length measurements in females exceeded those in males up to age 2 years. Beyond age 3, male renal lengths were slightly greater than females. Predicted difference between right and left kidney length, and rates of normal renal growth were derived (Table). Conclusions: Normal age and gender specific renal lengths were predicted using a quadratic model based on sonographic measurements of kidneys unaffected by VUR or structural abnormalities. Renal length outside of the normal range or abnormal renal growth may reflect underlying pathology and may be an early indicator which directs treatment. Table: Derived Renal Growth Rates by Age Age Years

Months

Growth Rate (cm/year) Male R. Kidney L. Kidney

Female R. Kidney

L. Kidney

3 4 5 6 7 8 9 10 11

0 6 0 6 0 6 0 0 0 0 0 0 0 0 0

0.63 0.61 0.58 0.055 0.53 0.50 0.48 0.42 0.37 0.32 0.26 0.21 0.16 0.10 0.05

0.66 0.63 0.61 0.58 0.55 0.52 0.49 0.44 0.38 0.32 0.26 0.21 0.15 0.09 0.04

0.50 0.49 0.47 0.46 0.44 0.42 0.41 0.38 0.34 0.31 0.28 0.25 0.22 0.18 0.15

0.53 0.51 0.50 0.48 0.46 0.44 0.42 0.39 0.35 0.31 0.27 0.24 0.20 0.16 0.13

Paper #: 084 Feasibility of Superb Microvascular Imaging (SMI), an Advanced Noninvasive US Technique to Detect Vesicoureteral Rreflux in Pediatric Patients without Bladder Catheterization or Contrast Use

Sara O’Hara, MD, Radiology, Cincinnati Children’s Hospital, Cincinnati, OH, [email protected]; Hee Kyung Kim, MD, Bokyung Je, Janet Adams, Steven Kraus, MD, MS. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this study is to compare renal and bladder ultrasound using a new FDA approved technology, superb microvascular imaging (SMI-US) and fluoroscopic voiding cystourethrography (VCUG) to validate the feasibility and evaluate the accuracy of SMI-US in detection of vesicoureteral reflux (VUR) in pediatric patients. Methods & Materials: We retrospectively reviewed consecutive SMIUS and VCUG done in 25 patients, age range from 2 weeks to 17 years, 10 male and 15 female. Two patients had solitary kidneys. SMI-US was performed for both kidneys, 48 kidney ureter units (KUU) at the distal ureter near the vesicoureteral junction and at each renal pelvis. Presence or absence of reversed jet or swirl sign was evaluated at the distal ureter and renal pelvis respectively. Presence of reversed jet sign and renal pelvic swirl sign was defined as reflux and compared to the results of VCUG done on the same date. Results: Among 48 KUUs, 2 were considered non-diagnostic due to excessive patient motion. Twenty-six did not show any sign of reversed jet or swirl signs and none of them showed VUR on VCUG. Ten showed sign of reversed jet sign or pelvic swirl sign and also showed reflux on VCUG (1 grade 1, 2 grade 2, 3 grade 3, 2 grade 4, 2 grade 5). Discordant results, negative SMI and positive VCUG, were seen in 8 of 46 units (4 grade 1, 3 grade 2, and 1 grade 3). There were two discordant cases of positive SMI and negative VCUG. In summary: 36/46 (78%) concordant results, 10/46 (22%) discordant results, 2/48 (4%) non-diagnostic. Conclusions: We validated SMI-US in 48 KUUs and found good agreement between the results of SMI-US and VCUG in detecting VUR. Discordant results were seen primarily in grade 1 reflux and in patients who only refluxed at maximal bladder capacity or during voiding. SMIUS was performed at random bladder fullness and no voiding images were obtained. Two cases considered discordant showed reflux on SMIUS, which was not appreciated on VCUG. We are actively refining this

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technique and adjusting our imaging protocol to potentially decrease invasive imaging studies requiring catheterization and radiation.

Paper #: 085 Contrast Enhanced Voiding Urosonography with Intravesical Administration of Ultrasound Contrast Agent (Optison®) for Vesicoureteral Reflux Detection in Children: Regulatory Processes, Procedural Optimization and Preliminary Safety Results

Aikaterini Ntoulia, MD, PhD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Susan Back, Richard Bellah, Janet Reid, MD, FRCPC, Diego Jaramillo, MD, Kassa Darge, MD, PhD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: CeVUS is a sensitive and safe method for VUR detection. However, the UCA widely used outside the U.S. is not commercially available here. The off-label use of the UCA Optison®, obtainable in the U.S, was initiated for ceVUS performance. We describe regulatory processes involved, demonstrate in-vivo procedural optimization and present preliminary safety results in children. Methods & Materials: A prospective comparative study between ceVUS and VCUG was initiated. The use of the UCA required an Investigational new drug (IND) application. Initially, procedural optimization steps were conducted. The dosage of the UCA infusion and the settings of the contrast specific US modality were optimized. Safety evaluation was conducted prior to ceVUS and after completion of ceVUS and VCUG, including physical examination, continuous vital signs monitoring and questionnaire-based telephone interview 48 h after the hospital visit. Results: The study with the off-label use of the UCA entailed the following regulatory processes: 1. IND approval by the U.S. FDA; 2. Institutional IND and IRB approvals; 3. Pharmacy formulary registration of the UCA. For the initial procedural optimization and safety evaluation four children, two females and two males, mean age 4.2 years (2-10 years) were enrolled. As extrapolated from a preceding in-vitro optimization study results, the starting dose of the UCA infusion was 0.5% suspension with normal saline. This produced marked acoustic shadowing half way through the bladder obscuring the retrovesical space. Reducing the dose to 0.25% in combination with early and rapid injection of 10 ml normal saline directly into the bladder resulted in swift homogenous distribution of the microbubbles, allowing visualization of the whole bladder contour and retrovesical space. The use of contrast specific low MI imaging was feasible. Transperineal scan of the urethra was limited due to the performance of both ceVUS and VCUG. There was no early or late adverse event detected or reported with the intravesical UCA administration. Conclusions: Several regulatory processes need to be completed prior to initiation of a prospective ceVUS study. In vivo procedural optimization showed that a 0.25% UCA-normal saline suspension in combination with rapid direct injection of small amount of normal saline delivers the optimal distribution of the UCA. The preliminary safety analysis confirms the previously reported high safety profile of intravesical UCAs. Table 1. Abbreviations: ceVUS – contrast enhanced Voiding UroSonography FDA – Food and Drug Administration IND – Investigational New Drug IRB – Institutional Review Board VCUG – Voiding CystoUrethroGraphy VUR – VesicoUreteral Reflux UCA – Ultrasound Contrast Agent

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Paper #: 086 Distress During Voiding Cystourethrograms: Objective Assessment Using the Brief Behavioral Distress Scale

Paul Thacker, MD, Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, [email protected]; Jeanne Hill. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The voiding cystourethrogram (VCUG) is a common and valuable diagnostic imaging test for pediatric urinary anomaly evaluation. Despite multiple decades of experience, there remains controversy over whether VCUGs should be performed under sedation as many authors feel they are invasive and painful while others argue that with pre-procedural preparation, the distress experienced is limited. However, no study to date has systematically evaluated the pain and distress experienced by children during VCUGs other than comparing sedated to unsedated exams. The objective of this study is to use a validated and reliable tool (the Brief Behavioral Distress Scale) to objectively evaluate the distress experienced during VCUGs. Methods & Materials: A prospective study of 26 children (ages 3-7 years old) was performed by the pediatric radiology department at a large urban academic medical center. Patients were evaluated for distress during 12 separate VCUG steps beginning with the patient entering the room and ending with the clothing being replaced at study completion. Results: Using a general linear model (repeated measures ANOVA), significant distress was identified during two phases of the examination, catheter insertion (p-values ranging <0.001-0.19) and the full bladder phase (p-values ranging 0.005-0.043). The mean distress score for catheter insertion (mean=1.38, SD=1.098) was nearly three times higher than the next most distressful step, i.e. bladder full (mean=0.65, SD=0.745). Additionally, entering the room was perceived as significantly more distressing than the catheter out (p=0.016) and clothing replacement phase (p=0.006). This finding occurred despite our standard pre-procedural protocol of sending a pamphlet prior to the procedure date and orally explaining the procedure to the patient and the parents. Conclusions: Despite patient and parental pre-procedural preparation, patients still experience significant distress during VCUGs. Thus, further consideration of routine sedation during VCUGs is warranted. However, the distress appears to be limited to certain phases of the VCUG indicating that sedating our children during the entire procedure through long and intermediate acting pharmacologic agents is likely unnecessary, and shorter acting medications such as nitrous oxide or propofol may be more suitable.

VCUG Steps Enter room (1) Placed into position (2) Adjusted clothing to expose site (3) Site cleaned (4) Catheter inserted (5) Contrast on (6) Bladder filling (7) Bladder full (8) Urination (9) Bladder empty (10) Catheter out (11) Clothing replaced (12)

Mean 0.50 0.58 0.38 0.73 1.38 0.23 0.27 0.65 0.12 0.12 0.08 0.04

Standard Deviation (SD) 0.510 0.945 0.752 1.002 1.098 0.652 0.667 0.745 0.326 0.431 0.272 0.196

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Paper #: 087

Paper #: 088

Does Internal Complexity Predict Malignancy in Cyctic Adnexal Lesions in Pediatric and Adolescent Females?

Clinical Significance of Incidentally Discovered Renal Cysts in Pediatric Patients

Andrew Trout, MD, Jennifer Kucera, MD, MS, Beth Schwartz, Lesley Breech, Alexander Towbin, MD, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]

Teerasak Phewplung, MD, King Chulalongkorn Memorial Hospital, Pathumwan, Thailand, [email protected]; Avram Traum, Ruth Lim, Michael Gee.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Cystic ovarian lesions are a common sonographic finding in post menarchal females. While there are guidelines for the management of these lesions, the data supporting these recommendations comes from adult patients. The purpose of this study was to determine if the complexity of ovarian lesions could be used to predict malignancy in pediatric and adolescent females. Methods & Materials: Finalized radiology reports for all ultrasound examinations of the pelvis performed at our institution between January 1, 2008 and December 31, 2009 were retrospectively reviewed for mention of cyst, mass, tumor, neoplasm or lesion. Images from cases in which these terms were mentioned were reviewed by three radiologists who each reviewed 2/3 of the studies. Reviewing radiologists classified each lesion, documenting lesion size, internal echogenicity, outer wall thickness, outer wall contour, the number of septations, septal thickness, and the presence of solid components, mural nodularity, calcifications, and/or internal blood flow. For lesions larger than 3 cm in greatest dimension, imaging characteristics were combined into a lesion complexity score. Imaging findings and the calculated complexity score were correlated with clinical and imaging follow-up including histology if surgery was performed. Results: A total of 1576 pelvic ultrasounds over the 2 year study period had the search terms mentioned in the final report. Of these, 209 patients (13.3%) had an adnexal lesion with a maximal diameter >3 cm. Based on clinical and histologic diagnoses, lesions could be separated into six classes: benign lesions that did not require surgery (n=153), benign functional lesions (i.e. hemorrhagic cysts, corpus luteal cysts, paratubal cysts; n=23), benign ovaries with reactive changes (i.e. inflammation; n=4), torsion (n=9), benign neoplasms (n=17), and malignancies (n=3). The mean complexity score for each grouping is shown in the figure. Overall, malignant ovarian lesions had the highest complexity score compared to the remaining lesions groups. Conclusions: The vast majority of adnexal masses >3 cm identified by sonography are benign lesions that resolve with clinical or imaging follow-up. Malignant lesions tend to be more complex than benign cystic lesions.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine the clinical significance of incidentally discovered renal cysts in pediatric patients and identify imaging predictors of polycystic kidney disease (PKD). Methods & Materials: An IRB-approved, HIPAA-compliant retrospective search of radiology reports from 1989–2013 was performed to identify patients < 18 years old with an imaging exam identifying at least one renal cyst as well as a follow up renal imaging exam for cyst evaluation and/or subsequent clinical evidence of PKD. Electronic medical records and imaging were reviewed. Cysts with clear solid mass components were excluded. Results: Eighty-four pediatric patients with renal cysts were identified (46 females and 38 males; mean age, 9.48 years), including 76 patients with incidentally discovered cysts and 8 patients with cysts identified from screening for family history of PKD. US (81%) was the most common imaging modality for initial cyst identification. Among the incidentally discovered cyst group, 7.9% (6/76) were found to have PKD compared with 100% (8/8) patients with cysts plus a positive family history of PKD. Multiple cysts or bilateral cysts were imaging features associated with a significantly higher (P<0.01, Fisher’s Exact Test) incidence of PKD, both for the entire study population (12/14 and 11/14, respectively) and the incidentally discovered cyst group (5/5 and 5/5, respectively). Renal cyst size or complexity was not significantly associated with PKD. Seventyfour patients had a followup renal imaging exam (mean time 36.8 months from initial exam), and an increase in cyst size on the followup study was associated with a higher incidence of PKD (3/5 vs 1/69; P<0.05). No malignancies were identified in the study population, although one case was found to be a multilocular cystic nephroma on follow up imaging and surgery. Conclusions: Incidentally discovered renal cysts in pediatric patients are associated with a small but nonzero risk of PKD. Among cyst characteristics, bilaterality, multiplicity, and increased size on followup imaging were associated with significant elevation in PKD risk.

Paper #: 089 ARFI Evaluation of the Kidney’s in Ex Premature Infants: A Preliminary Costanza Bruno, Radiology, Policlinico GB Rossi, Verona, Italy, [email protected]; Marco Zaffanello. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To establish whether, in the school-aged children, any relationship exists between prematurity and US and ARFI findings Methods & Materials: Twenty-four patients born preterm (gestational age: 28.5+/-3.3 W; age range: 8+/-1.1 years) were compared with 20 healthy controls. Length and volume were measured for each kidneys. A mean SWV was calculated for each kidney from nine measurements obtained at the upper, middle and lower third

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An overall SWV for the two kidneys was also calculated. The statistical significance of the difference found between the two groups was evaluated by means of the Mann–Whitney test. Results: Non statistically significant difference was found between the two groups when considering the length of the two kidneys and the volume as well. The mean SWV of the two kidneys of ex premature infants was statistically higher than the mean SWV of healthy controls (3.02+/-0.60 vs.2.56+/-0.37 m/s; p <0.01); the difference existing between the SWV of left kidneys between the two groups was statistically significant too (3.30+/-0.66 vs. 2.73+/-0.27 m/s; p < 0.01). No statistical significant difference was found between the SWV of the right kidneys of the two groups (2.70+/-0.65 m/s vs. 2.40+/-0.51). Conclusions: Prematurity is associated to a statistically significant difference in the overall SWV of the two kidneys probably reflecting an early damage due to the reduced number of nephrons present at birth.

Paper #: 090 Intussusceptions Occurring Less than 6 Months of Age: An Observational Study Erica Yang, MD, Texas Childrens Hospital, Houston, TX, [email protected]; Rajesh Krishnamurthy. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The classic teaching states that very young pediatric patients, less than 6 months of age, have a higher incidence of lead points as a cause of intussusception than the 6 month-4 year group, and thus the chances of successful reduction are lower in this group. Furthermore, these young patients tend to have more complications upon presentation such as bowel obstruction, and, free fluid, and are more prone to perforation. This retrospective study analyses the clinical presentation, rate of successful fluoroscopic reduction, rate of complication (perforation), incidence of lead points, and clinical and surgical outcome of intussusceptions occurring in children less than 6 months of age. Methods & Materials: We retrospectively reviewed medical records of confirmed intussusception cases in children under the age of 6 months, treated during 2002-2014 at a tertiary care pediatric hospital. Demographic, clinical, diagnostic and treatment practices data were obtained from hospital records. Specific end points included clinical presentation, mode of diagnosis, rate of successful reduction, rate of complication (perforation), and incidence of lead points. Results: This is a study in progress involving 280 patients. So far, 100 confirmed cases of intussusception in children < 6 months of age have been identified, of which 61% were males. Age distribution was 1 (0-2 months), 44 (2-4 months), and 55 (5-6 months). Ninety-eight percent were diagnosed by ultrasound. 77% were treated by fluoroscopic reduction using air, 12% using water soluble contrast, 8% using both air and water soluble contrast, while 17% were treated by primary surgery. Seventeen percent failed fluoroscopic reduction, (5/17 perforated during attempts at reduction, all using air), and were successfully treated surgically. Incidence of lead points was 3%, and was diagnosed by preoperative imaging in 2 cases. The 3 identified surgical lead points were 2 Meckel’s diverticulum and 1 ileal cyst. Conclusions: In the < 6 months age group, the incidence of a lead point is 3%, and the intusssusception reduction failure rate is 17%, which compares favorably to reduction rates reported in the literature

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in the 6 months-4 year population. We recommend that children <6 months of age with intussusception should be offered fluoroscopic reduction with an expectation of similar outcomes as the 6 months4 year old population.

Paper #: 091 Failed Intussusception Reduction in Children: Radiologic, Surgical and Pathologic Correlation Aikaterini Ntoulia, MD, PhD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Sasha Tharakan, Soroosh Mahboubi. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To identify underlying etiology in children with irreducible intussusception following contrast enema reduction and correlate imaging findings with surgical and histopathology results. Methods & Materials: Between 2005 and 2013, 4850 children were referred to our Radiology Department for diagnosis and treatment of clinically suspected intussusception. 543/4850 (11.2%) children, 365 males and 178 females, mean age 18 months (1 month-14.9 years), underwent pneumatic (n=270) or hydrostatic (n=224) enema reduction of intussusception. Results: Intussusception reduction failed in 74 children. Surgical and/or histopathologic confirmation was available in all cases. 36.1% of children with failed intussusception reduction underwent laparoscopy and 52.8% laparotomy. In 11.1% of cases conversion from laparoscopy to laparotomy was required. Surgical reduction of the intussusception was performed in 61.1% of cases, small bowel resection and ileo-cecectomy were required in 19.4 and 12.5% of the cases respectively. In five patients selfreduction of intussusception occurred at the time of surgery. Histopathology revealed the presence of a pathologic lead point in 25% of cases: lymphoid hyperplasia (n=7), Meckel’s diverticulum (n=3), Burkitt’s lymphoma (n=3), enteric duplication cyst (n=2), juvenile polyp (n=2), adenovirus appendicitis (n=1). Length of hospitalization was significant longer in children who underwent laparotomy compared to laparoscopy. There were two cases of intestinal perforation. Conclusions: Pneumatic or hydrostatic enemas can safely and equally successfully reduce intussusception in the majority of cases. The most common cause for failure reduction of intussusception is idiopathic. In children with failed enema reduction, laparoscopy can be a safe and effective approach that also decreases the length of hospitalization.

Paper #: 092 A Double Balloon Catheter for the Treatment of Intussusception Cephus Simmons, MRS, RRA, Medical University of South Carolina, Charleston, SC, [email protected]; Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To identify an innovative device that will create the airtight seal around the anus during an intussusception reduction procedure. Methods & Materials: After a provisional patent application was submitted, an animal laboratory study was conducted utilizing a small pig’s rectum and anus to evaluate the appropriate size and shape of the two

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balloons and the distance between them. Two balloon shapes and four different sizes were utilized in this research. A spherical balloon was used for the internal balloon and a conical shaped balloon for the external balloon. An internal and external balloon was inflated with each run. The internal balloon was evaluated with inflation ranging from 10 to 30 mL. The external balloon was evaluated with inflation ranging from 20 to 50 mL. The external balloon was evaluated in position of 180° rotation. Please see table 1 for detail. Results: Eight inflation runs were conducted, 8 with the spherical balloon and four runs each of the conical balloons. The results of those runs identify that 30 mL was maximal inflation needed for the internal balloon and 50 mL was needed for the external balloon with the balloon diverging from anus to the catheter tip. The proof of concept identified during this study will be utilized to manufacture the prototype. Conclusions: The study identified the shape and size of balloons that will achieve the required seal for intussusception reduction procedures. This innovative device is to create an airtight seal, which prevents leakage of air from around the rectum. Leakage of air increases the length of time needed to reduce the intussusceptum. Therefore, the innovative device will improve the process of intussusception reduction. Once FDA approves the product for use in human, a clinical trial will be conduct to use the product during intussusception reduction procedures.

and Flesch Reading Ease Score (FRES) calculated. A subjective assessment of breadth of information was made. Results: Ten of 30 websites were eligible for analysis. Average LIDA score was 54.3 out of 96 (range 22-63). The average FRES was 41.8 (range 9.1 70.2). Only one met all 4 JAMA quality criteria (average was 2.4). None of the websites had the HONcode seal (‘Health on the Net Code’) displayed. Eight websites indicated that sclerotherapy is carried out by Interventional Radiology and that it may take several sclerotherapy sessions for the VM to improve. Five websites indicated that the VM may look worse for a while after sclerotherapy. STS as a sclerosant agent was discussed on seven websites. Risk of skin damage was mentioned on six websites and nerve damage on five websites. Conclusions: None of the websites were in the 6th grade reading age range as recommended by the American Medical Association. This suggests online information regarding VM sclerotherapy may be too complex for comprehension by the majority of the targeted population. Although many of the websites were produced by hospitals performing sclerotherapy, the lack of compliance with JAMA core standards suggests that the quality of the websites is low. The lack of HONcode badging may lead readers to feel the information presented is unreliable. The clinical information provided on websites is heterogeneous but broad. The findings from this study are important for those developing or updating websites with information regarding venous malformation sclerotherapy.

Paper #: 094 Ultrasound, Clinical and Cholangiographic Findings Correlation of Biliary Complications in Pediatric Liver Transplant Recipients Dario Teplisky, Staff Member, Pediatric Interventional Radiology, Hospital de Pediatria “Juan P. Garrahan”, Buenos Aires, Argentina, [email protected]; Matias Garriga, Sergio Sierre.

Paper #: 093 Quality and Readability of Online Patient Information Regarding Sclerotherapy for Venous Malformations Amani Patel, Jonathan Pass, Sam Stuart, Alex Barnacle, Premal Patel, BSc(Hons) MBBS MRCS FRCR, University College London Medical School, London, United Kingdom, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Venous malformations (VMs) are rare. Many patients struggle to access facts about their condition. The internet is a commonly utilized information source. However the Internet is unregulated and there is wide variation in information quality. The aim of this study was to evaluate the accessibility, readability and quality of the most popular online, patient-targeted resources for information about sclerotherapy for VMs. Methods & Materials: The search term “venous malformation sclerotherapy” was entered into Google search engine and the first 30 webpages reviewed. Scientific articles, non-patient-focused webpages and those <30 sentences were excluded. Website accessibility, usability and reliability was assessed using the validated LIDA tool, quality was assessed using Journal of the American Medical Association (JAMA) standards

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To correlate the US, laboratory and cholangiography findings in pediatric patients liver transplant with biliary complications Methods & Materials: We retrospectively reviewed the results of ultrasonography exams in 39 consecutive patients (from 2011 to 2013) in whom biliary complications after liver transplantation were documented by percutaneous transhepatic cholangiography (PTC). According to biliary tract dilation in US exams, patients were classified as: mild (less than 2.5 mm), moderate (from 2.5 to 5 mm) and severe (more than 5 mm), and according to laboratory findings: normal or abnormal serum bilirubin, hepatic enzymes and level of serum gamma-glutamyl transpeptidase (GGT). Data was correlated with percutaneous cholangiography (PTC) findings that were divided in 3 groups: mild, moderate and severe bile duct stenosis (BDS). Results: Indications for PTC were cholangitis (8 patients) and cholestasis (31 patients). Twenty seven patients were classified as mild biliary tract dilatation on the US exam, 13 of them showed severe biliary duct stenosis on the PTC. Six patients presented moderate dilatation on US exam, and severe BDS on PTC was found in two of them. Six patients presented with severe dilatation of the biliary duct, none of them was classified as a severe stenosis on PTC. There was no significant statistical correlation between the US findings and the laboratory findings and between US findings with PTC. There was a significant statistical correlation between laboratory findings (GGT) and cholangiography findings. Conclusions: In our series, abnormal biliary US findings could not predict the grade of biliary stenosis on PTC and laboratory results was not able to predict the US findings either. GGT results demonstrated a significant statistical correlation with the severity of biliary stenosis found on PTC. These findings emphasize the role of GGT in the evaluation and decision of percutaneous biliary interventions in pediatric liver transplant recipients in order to optimize the results of these invasive cholangiographic procedures

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Paper #: 095 Plastic Bronchitis Imaging and Intervention: Early Experience Marc Keller, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Yoav Dori, Maxim Itkin. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To illustrate the imaging findings of plastic bronchitis in five children with Fontan physiology, describe the imaging guided approach we have developed for treating it, and relate the short term results. Methods & Materials: We retrospectively reviewed our first five cases of evaluation and treatment for plastic bronchitis from June 2013-June 2014. In an XMR suite, we imaged and intervened in five children (four boys, one girl) aged 3-6 years (mean 5.3 years) with functional single ventricles and Fontan operations who developed plastic bronchitis. All procedures were performed under general endotracheal anesthesia. Diagnostic MRI sequences included T2W 3D SPACE lymphatic mapping, bi-inguinal intranodal dynamic MR lymphangiography with Magnevist, and post contrast 3D IR FLASH. After MRI, the patients returned back into a biplane fluoro suite. Venoatrial collaterals were coil embolized, and Fontan fenestrations were temporarily balloon occluded to protect against right to left shunts. Treatment involved percutaneous transabdominal thoracic duct access and peribronchial lymphatic embolization with Lipiodol in all and in some with NBCA. Results: MRI correctly predicted anatomy and pathophysiology in every patient. All five children showed abnormal mediastinal and peribronchial lymphatic channels arising from the thoracic duct, either low in the chest or at the thoracic inlet. Innovative treatment approaches for embolization needed to be designed based upon individual anatomy. No strokes or other major complications occurred. All children stopped coughing casts after the procedure. Months later, one of the children had a bout of viral pneumonia, coughed a cast, and had no more after recovery. Conclusions: Initial experience suggests that plastic bronchitis in Fontan patients is associated with abnormal thoracic duct flow diverted toward the peribronchial tissues and that interruption of this flow immediately alters and improves the disease process.

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Methods & Materials: Nineteen pediatric patients, 9 males, 10 females, mean age: 12 years (range: 5-16.5 years), underwent embolization of intracranial AVMs between April 2008 and May 2014. Post processing software (syngo iFlow; Siemens) was used to analyze the digital subtraction angiography (DSA) images. Regions of interest (ROI) were selected: 3 on AP and lateral DSA views (mean distance: 5.16±2.26 mm) for peri-AVM region and 2 on AP and lateral views for brain parenchyma located distant from the AVM (mean distance: 36.19±3.62 mm). Overall, 228 ROI’s were defined in the peri-AVM region (114 each for pre and post-embolization). Time to peak (TTP) contrast enhancement value of ROI’s was measured. dTTP, that represents the perfusion, was defined as the TTP at the selected region of interest minus TTP at either the ipsilateral internal carotid or vertebral artery. Results: Nineteen AVM’s were analyzed, 15 supplied by anterior circulation, 4 by posterior circulation. In the peri-AVM region, mean dTTP was 2.52±0.42 seconds(s) pre-embolization, compared with 2.20s±0.48 post-embolization (p=0.014). In the peri-AVM region, there was slightly faster perfusion post-embolization when compared to pre-embolization by an average of 0.33 s±0.53, and by 0.03 s±0.19 in the parenchyma distant from the AVM (p=0.007). There was no correlation between the size of the AVM and change in peri-nidal parenchymal perfusion (r=0.136, p=0.579). Blood flow was slower post-embolization in the draining vein (19/19, mean difference of 2.01 s±1.31) and in the venous sinus outflow (17/19, mean difference of 1.74 s±2.04). One patient underwent more than one embolization. Conclusions: This study demonstrates faster perfusion in the peri-nidal region of brain AVMs immediately after embolization of the AVM. This may give support to the theory that increased perfusion in normal tissue surrounding the AVM after embolization may underlie some post-procedural complications.

Paper #: 096 Embolization of Intracranial Arteriovenous Malformations is Associated with Faster Rate of Perfusion in the Peri-Nidal Region on Color-Coded Quantitative Digital Subtraction Angiography Sphoorti Shellikeri, Master’s in Biomedical Engineering, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Harrison Bai, Randolph Setser, Anne Marie Cahill, Robert Hurst. Disclosures: Anna Marie Cahill has indicated a relationship with Siemens AX, Inc as an advisory Board Member. Purpose or Case Report: Postoperative hemodynamic alternations precipitated by sudden changes in AV shunting post embolization of intracranial arteriovenous malformations (AVMs) have been postulated to cause edema or hemorrhage in brain parenchyma adjacent to the lesion. The purpose of this study was to quantitate and compare cerebral perfusion changes in the peri-AVM territory before and after embolization using the difference in time to peak (dTTP) metric reported in syngo iFlow, an imaging tool that creates a single composite image color-coded by time to peak opacification.

Paper #: 097 Diagnostic Utility of Ultrasound-Guided Fine Needle Aspiration Biopsy in the Evaluation of Pediatric Thyroid Nodules Pranav Moudgil, Wayne State University School of Medicine, Detroit, MI, [email protected]; Jonathan Dillman, MD, Ranjith Vellody, Amer Heider, Jason Grove, Steven Bruch, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: To retrospectively assess the utility of ultrasound-guided fine needle aspiration biopsy (US-FNAB) in the evaluation of pediatric thyroid nodules and to determine if certain factors affect the adequacy/accuracy of diagnosis. Methods & Materials: Medical records were searched to identify pediatric patients that underwent US-FNAB of a thyroid nodule between 2005 and 2013. Ultrasound exams were reviewed and pertinent findings were documented. Cytology report findings, including number of needle passes and final cytologic diagnosis, were recorded. Cytologic diagnosis was compared to surgical pathology diagnosis for resected nodules. Demographic information, use of conscious sedation/general anesthesia, and presence of onsite cytopathology feedback were also recorded. The student’s t-test was used to compare means, while Fisher’s exact test was used to compare proportions. A p-value<0.05 was considered significant. Results: Seventy children (mean age=14.0 years) underwent US-FNAB; 56 (80%) were girls. Eighty-six separate nodules underwent US-FNAB. 78/86 (91%) of US-FNAB procedures were diagnostic, arriving at a final cytologic diagnosis. 69/78 (88%) nodules were benign; 9/78 (12%) were malignant. There was no difference in maximum size between benign and malignant nodules (mean=2.1 vs.2.1 cm; p=0.82) or between cytologic diagnostic and non-diagnostic nodules (mean=2.1 vs. 2.1 cm; p=0.87). Non-diagnostic nodules underwent more needle passes than diagnostic nodules (9.9 vs. 5.8 passes; p<0.0001). Diagnostic result was not affected by gender (p=0.19), use of conscious sedation/general anesthesia (p= 1.0), or onsite cytopathologic feedback (p=1.0). Nodules containing microcalcifications (OR=114 [95% CI: 5.4, 2398]; p<0.0001) and coarse calcifications (OR=19.4 [95% CI: 1.6, 242]; p=0.03) were more likely to be malignant. Twenty-nine nodules underwent both US-FNAB and surgical resection; all 29 (100%) were correctly identified as benign or malignant by cytology (κ=1.0, perfect agreement). The final diagnosis between US-FNAB cytology and surgical pathology was concordant in 27/ 29 (93.1%) nodules. No US-FNAB complication was documented. Conclusions: US-FNAB of pediatric thyroid nodules provides a definitive cytologic diagnosis more than 90% of the time, with the cytologic and surgical pathology diagnoses showing excellent agreement.

Paper #: 098 Experience with Stuck Implantable Venous Port Catheters in Children Premal Patel, BSc(Hons) MBBS MRCS FRCR, The Hospital for Sick Children (SickKids), Toronto, ON, Canada, [email protected]; Dimitri Parra, Bairbre Connolly. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Implantable venous port (IVP) devices are used in patients requiring prolonged intermittent intravenous access. When treatment is complete they are usually removed without difficulty through a minor open procedure. However the catheter portion can get ‘stuck’ and be problematic to remove. This study aims to review the experience of implantable venous port removal by interventional radiology at a tertiary pediatric radiology hospital to identify the incidence and potential risk factors. Methods & Materials: Research ethics board approval was obtained. A retrospective single-center review was conducted. Cases of IVP removal were identified and data collected from PACS and electronic patient charts. Simple removals were defined as those in which the catheter slid out with traction alone. Difficult removals were defined as those with increased resistance to traction of the catheter requiring additional maneuvers/techniques. Difficult removals were compared to simple removals. Results: One thousand three hundred six IVP removals were performed between 2003 and 2012. 58 cases were identified as stuck at attempted

removal (incidence 4.4%). Potential risk factors identified included primary diagnosis of acute lymphoblastic leukaemia (ALL) (77.6% of difficult removals vs 36.7% of simple removals, p<0.0001) and catheter dwell time (mean 1355 days in difficult removals vs 690 days in simple removals, p<0.0001). 98% of stuck ports were successfully removed. Strategies for removal are described according to level of difficulty. Conclusions: Prolonged catheter dwell time and a diagnosis of ALL are risk factors for difficult catheter removal. By screening and identifying patients with these risk factors it is possible to be better prepared and minimize risk of complications on attempted removal. This knowledge helps when obtaining informed consent from parents whose child has one of these potential disk factors and aids with preparation for the procedure.

Paper #: 099 Percutaneous Abscess Drainage in Young Patients with Crohn’s Disease: It’s Role and Predictors of Treatment Success Brian Pugmire, MD, Radiology, Massachusetts General Hospital, Boston, MA, [email protected]; Jess Kaplan, Michael Gee; Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Abdominal abscesses frequently occur in pediatric patients with Crohn’s disease (CD). Percutaneous abscess drainage (PAD) has been shown to be a safe and effective method for treatment of CD-related abscesses in adults, frequently obviating the need for surgical drainage or providing a bridge to elective bowel resection following abscess resolution. Few studies have evaluated this procedure in the pediatric population specifically. We present data from a retrospective review of 25 cases of young patients who underwent percutaneous drainage for CD-related abscesses. Methods & Materials: Twenty-five cases of young patients (age ≤ 20 years) with proven CD who underwent percutaneous drainage at our institution were reviewed. Technical success was defined as drainage catheter placement within the abscess with reduction in abscess size on post-treatment imaging. Clinical success was defined as (1) no surgery within 1 year of drainage or (2) surgical resection following drainage with no residual abscess at surgery or on preoperative imaging. Multiple parameters including patient gender and age, abscess volume, abscess location, site of primary bowel disease, number and size of drainage catheters used, resumption of IBD-related medical therapy, and need for repeat drainage were analyzed for association with treatment success or failure. Fisher exact tests and unpaired Student’s t-tests were used as appropriate to assess for statistical significance. Results: Using the criteria listed above, all cases were classified as technical successes. Nineteen cases were classified as clinical successes (76%), including 7 patients (28%) who required no surgery within 1 year of PAD and 12 patients (48%) who had elective bowel resection within 1 year with no evidence of abscess at surgery or on presurgical imaging. Immunosuppressive therapy was initiated within 8 weeks of drainage in ninr patients in the success group and in zero patients in the failure group; this association was statistically significant (P<0.05). 7/9 (78%) of these patients did not require bowel resection within 1 year of PAD, which was also significant (P<0.001). Conclusions: Percutaneous abscess drainage is an effective treatment for CD-related abscesses in pediatric patients. Resumption of immunosuppressive therapy within 8 weeks of PAD is statistically associated with both clinical success and avoidance of bowel resection, suggesting a clinical role for PAD in facilitating prompt initiation of medical therapy and preventing surgical bowel resection.

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Paper #: 100 Pediatric Percutaneous Nephrostomy – A Multi-Center Experience Sphoorti’ Shellikeri, Master’s in Biomedical Engineering, Madeleine Sertic, Bairbre Connolly, Radiology, Childrens Hospital of Philadelphia, Philadelphia, PA, [email protected]; Mark Hogan, Francis Marshalleck, Anne Marie Cahill, et al. Disclosures: Anna Marie Cahill has indicated a relationship with Siemens AX, Inc as an advisory Board Member. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To describe the technique, outcomes and complication rates of percutaneous nephrostomy (PN) procedures performed at four tertiary pediatric centers. Methods & Materials: Six seventy five PN procedures performed on 441 patients (mean age: 6 years, range: 0.002-18 years; mean weight: 24 kg, range: 0.7-112 kg), over an 11 year period, were retrospectively analyzed. Thirty-one percent procedures were performed on patients less than 1 year old. The most frequent indications included: hydronephrosis (65%), calculus (16%), infection (14%), urine leak (5%) and elevated creatinine (5%). Most commonly, the patients had severe (45%) or moderate (32%) hydronephrosis. Results: Technical success was 99% (n=668) with seven failed insertions due to loss of access during tract dilatation (n=5) and staghorn calculi (n= 2). Seventy-three percent of procedures were performed under general anesthesia. Ninety-nine percent of procedures were performed under ultrasound/fluoroscopy. Of the 668 successful procedures, 561 (84%) were primary catheter insertions, while 107 (16%) were secondary insertions. The calyces accessed were: lower 47%, mid 28%, upper 12% and renal pelvis 11%. 342 (51%) catheters were inserted in the right kidney and 324 (49%) in the left. Twenty-four (4%) were placed in transplant kidneys. The catheter sizes were: 4-6F (n=209), 7-8F (n=352) and >10F (n=103). Eighty-six percent of catheters used were Dawson Mueller, 7% were APD and the other 7% included: Amplatx anchor, Abcession, Centesis, Duane, Foley, Malecot, Meditech, MPD and uresil locking loop. The average dwell time of nephrostomy catheters was 25 days (0-220 day). The total primary catheter days were 14482 with an additional 2241 days with secondary procedures. Follow-up data was available for 653/668 (98%) procedures. 79% of catheters were electively removed. Salvage procedures (21%, 138/653) included: wire exchange 8.7%, nephroureteral stent/catheter conversion 8.8%, and tube upsizing 3.5%. Periprocedural complications occurred in 24% (163/675) of cases. One major complication that occurred was hematuria requiring transfusion. Minor complications included: self-limited hematuria in 19.5%, loss in initial access in 2.2%, site oozing 1.2% and post-obstructive diuresis 1%. Mechanical complications i.e. tube related issues and urine leak occurred in (17%, n=116) and catheter related infectious complications occurred in 9% of procedures (n=63). Conclusions: This is the largest study to date that describes PN procedures in children. PN has been shown to be a safe and technically feasible procedure in the pediatric population.

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Disclosures: Anna Marie Cahill has indicated a relationship with Siemens AX, Inc as an advisory Board Member. Erin Girard has indicated a relationship with Siemens Corporation, Corporate Technology as an employee. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Digital subtraction angiography (DSA) is used to qualitatively evaluate the success of angioplasty for Renal Artery Stenosis (RAS). This retrospective study provides a quantitative comparison of renal parenchymal perfusion changes in children undergoing angioplasty for RAS to perfusion in children without RAS (control group), using the difference in time to peak (dTTP) metric reported in syngo iFlow, an imaging tool that creates a single composite image color-coded by time to peak opacification. Methods & Materials: Renal perfusion in the control group who underwent diagnostic arteriogram (20 patients, 39 kidneys, mean age: 11.6±4.8 years) was quantified by determining the time to peak (TTP) opacity values using syngo iFlow. For each kidney, 4 ROI’s were defined: 3 at the parenchymal poles (upper, middle and lower) and 1 in the aorta. Aortic TTP was subtracted from each of the 3 poles to obtain dTTP values representing parenchymal perfusion at each pole. Overall, 156 ROI’s in 39 kidneys (117 in poles, 39 in aorta) provided a total of 117 dTTP values at the 3 poles. Renal perfusion in 23 hypertensive children who underwent 27 unilateral angioplasty procedures for RAS (mean age: 10.7±6.4 years) were similarly measured, providing a total of 75 dTTP values (examining only the poles affected by angioplasty). Results: ANOVA analyses in controls indicated no pole or laterality perfusion differences (p’s>0.05). Thus, to reduce the number of analyses and simplify group comparisons, a single averaged dTTP value per control was computed. Considering only affected poles for pre and post-angioplasty perfusion comparisons, paired t-tests showed a significant reduction in dTTP values pre- to post-angioplasty (4.18 s±2.26 versus 2.79 s±1.73, p=0.01). Further, independent t-tests showed lower perfusion values in controls (2.62 s±0.722) versus patients pre-angioplasty (4.18 s±2.26), p=0.01. No perfusion value differences were observed in controls (2.62 s± 0.722) versus patients post-angioplasty (2.79 s±1.73), p>0.05. Control versus patient perfusion group difference findings remained unchanged after controlling for BMI, BSA and height (p’s>0.20). Conclusions: The present study showed that after angioplasty in hypertensive children with RAS, parenchymal perfusion values are improved, returning to levels similar to those observed in the control group. This suggests a potential role for quantitative dTTP as an adjunctive objective outcome measure for pediatric renal angioplasty.

Paper #: 101 Quantification and Comparison of Renal Perfusion in Percutaneous Renal Angioplasty Patients with Renal Artery Stenosis and Control Group Using Syngo iFlow at a Single Pediatric Institution Sphoorti Shellikeri, Master’s in Biomedical Engineering, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Erin Girard, Christopher Edgar, Kevin Meyers, Anne Marie Cahill; Disclosures:

Paper #: 102 Differentiating Os Acromiale from Normal Developing Acromial Ossification Center Using Magnetic Resonance Imaging Matthew Winfeld, MD, NYU, New York, NY, [email protected]; Annie Wang, Jenny Bencardino, Rosenberg Zehava.

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: According to current literature, fusion of the acromion may not be complete until the ages of 18-25, making it questionable to diagnose os acromiale in adolescents. We hypothesize that os acromiale may exist in pediatric patients and can be differentiated from a developing acromial ossification center(s) based on magnetic resonance imaging (MRI) findings. Methods & Materials: One hundred twenty eight consecutive MRIs of the shoulder, performed at our institution from 11/2011-11/2013, were randomly and blindly reviewed retrospectively by two musculoskeletal radiologists. The cases included 56 MRIs of os acromiale (mesoacromion) in adults over age 25 (25-74 years-old, mean 50 years) and 72 MRIs in children aged 12-17 (mean 14.5 years). The following variables at the interface between the distal acromion and os acromiale or developing ossification center(s) were assessed: presence of an os acromiale vs. developing acromion, interface orientation, interface margins, and presence of edema within and adjacent to the interface. Based on the literature, os acromiale was defined as having a transverse/ oblique, irregular interface with the rest of the acromion while a normal developing acromion was defined as having an arced, lobulated interface with its ossification center(s). Results: The final cohort comprised 100 cases (51 adults with os acromiale and 49 adolescents). Cases were excluded due to poor image quality or confounding findings (n=7) or because of complete acromial fusion (n=21 adolescents). All adult cases (100%) were accurately diagnosed as having os acromiale by both readers, with predominantly transverse interface orientation and irregular margins (94%, R=0.86, p< 0.00001). Forty-five (92%) of the adolescent cases were accurately diagnosed by both readers as having a normally developing acromion with arced interface and lobulated margins (92%, R=0.92, p<0.000001). Four (8%) adolescent cases (ages 15-17) were diagnosed as having os acromiale, with transverse orientation and irregular margins. Thirty five (69%) and 46 (90%) adult cases had marrow and interface edema, respectively. By comparison, 6 (12%) and 8 (16%) adolescents had marrow and interface edema respectively, including the four cases concluded to be os acromiale. Conclusions: Adolescents may have imaging findings consistent with os acromiale, depicting a transverse, irregular interface with edema at and surrounding the interface. Thus, the MRI diagnosis of os acromiale should be based on specific imaging features and not limited by patient age.

Paper #: 103 Evaluation of Pediatric Long Bone Tumors with a single 3D T2-Weighted Fat-Water Separated Sequence

upper extremities and coronal plane for lower extremities. Both the 3D T2 weighted sequences with two-point Dixon fat-water separation as well as the conventional T2 weighted sequences were evaluated independently by two radiologists for overall image quality, structural delineation and motion artifacts. Five assessments were made for each patient (Table 2), including usefulness of in- and opposed phase imaging, which are sensitive to alterations in the relative fat and water content. A 95% confidence intervals were calculated for the percentage of each category in each evaluation. Results: Minor fat-water separation swap was seen in 4/16 patients (25%, CI 0-50%), but no case had major fat separation swap. In and opposed phase imaging was potentially or definitely useful in characterization of bone lesions in 9/16 (56%, 95% CI 31-81%). Overall fat suppression was equivalent or superior in 3D imaging (13/16 cases) than 2D (3/16 cases). Fat suppression near lesions was equivalent or superior in 3D imaging for majority of cases (15/16 cases) than 2D (1/15 cases). 3D evaluation of extraosseous extension of bone lesions had sensitivity and specificity 100%, with conventional 2D imaging as the gold standard. No cases in this study had joint or neurovascular involvement, so assessment of these features was limited. Conclusions: Pediatric 3D T2-weighted sequence with a Dixon-based fat-water separation image reconstruction technique showed improved quality of fat-water separation and permits extraosseous extension evaluation of tumors of the long bones. This suggests it would suffice as a single sequence protocol.

Age (yrs) 13 18 11

Sex M F F

Indication Osteosarcoma Ewing’s Metastatic ependymoma

Location of tumor Humerus Tibia Femur

13 3 18 18 9 10 18 8 6 16 18 10 16

M F M M F F F M F M F F M

Osteosarcoma Erwing’s Metastatic neuroblastoma Osteosarcoma Osteoid Osteoma A.L.L. UBC ABC ABC Osteochondroma Osteosarcoma Osteosarcoma Fibrous dysplasia Fibrous dysplasia

Fibula Femur Femur Fibula Tibia Humerus Tibia Humerus Humerus Tibia Femur Radius Femur

Christine Kassis, MD, Pediatric Radiology, Stanford University, Menlo Park, CA, [email protected]; Peng Lai, Shanshan Bao, MD, Shreyas Vasanawala, MD,PhD. Disclosures: Peng Lai has indicated a relationship with GE Heatlhcare as a scientist. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: This study assesses feasibility of a single sequence protocol for evaluation of pediatric long bone tumors. Methods & Materials: With IRB approval and informed consent, 16 consecutive patients (Table 1) with tumors of long bones referred for MRI at 3T were recruited. Patients underwent conventional MRI sequences as well as volumetric (3D) T2 weighted imaging with two-point Dixon fat-water separation. The conventional protocol two-dimensional sequences were axial T1, longitudinal T1, longitudinal STIR, and axial fat-suppressed T2 weighted fast spin echo. The 3D T2 scan was acquired in the sagittal plane for

Assessments

Evaluation Criteria Overall Total Swap Volumetric Major Swap Fat Minor Swap Suppression No Swap Overall Fat Volumetric Suppression Same or performance Preferred Fat suppression Volumetric same near lesion or preferred

Number Statistical Results (proportion) Test 1/16 (6%) 95% CI 0-0.18 0/16 (0%) 0-0.17 4/16 (25%) 0-0.50 11/16 (69%) 0.45-0.92 13/16 (81%) 95% CI 0.61-1.0

15/16 (94%)

95% CI

0.82-1.0

Pediatr Radiol (2015) 45 (Suppl 1):S1–S246 Value of in and Potentially or opposed definitely phase helpful images Extraosseous Identified by 3d extension T2 only Identified by conventrional T2 only Identified by both Identified by neither

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9/16 (53%)

95% CI

0.31-0.81

0/16 (0%)

95% CI

0-0.17

0/16 (0%)

95% CI

0-0.17

9/16 (53%)

95% CI

0.31-0.81

7/16 (47%)

95% CI

0.19-0.69

We postulate that represents stress-related changes at the chondro-osseous junction in obese subjects due to increased axial loading.

Paper #: 105 Paper #: 104 Articular Cartilage Changes within the Medial Femoral Condyle in Obese Children As Compared to Normal Weight Children Maria Bedoya, MD, Diego Jaramillo, MD, Bernard Dardzinski, Saba Khan, Nancy Chauvin, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The prevalence of early osteoarthritis in the knees of obese children has not been reported. We sought to determine: a) if early articular cartilage knee abnormalities can be detected using T2 relaxation time mapping in obese children as compared to normal weight children, and b) if there are morphologic articular cartilage changes in obese children using conventional cartilage MR imaging. Methods & Materials: We conducted a prospective cross-sectional study of 9 obese children (5F, median age 14.3 years (12.04-15.83 years), median BMI 37 kg/m2 (>99 percentile)) and 9 age and gender matched, normal-weight controls (5F, median age 14.3 years (12.04-15.75 years), median BMI 21.3 kg/m2 (65.5 percentile)). All children completed a KOOS-Child knee pain survey and underwent a right knee MRI at 3T. Multiplanar conventional MR sequences as well as sagittal T2 mapping sequences were performed. The articular cartilage thickness and mean T2 relaxation time were assessed within the weight-bearing aspects of the femoral condyles. Mean T2 relaxation times were evaluated based on the normalized articular cartilage distance (0.2-0.5=deep surface, 0.5-0.8= superficial surface). Cartilage morphology and signal were assessed on conventional MR imaging. Mann–Whitney U test was used to evaluate T2 relaxation times, age and KOOS-indices between obese and normal weight children. Results: On conventional MR imaging, cartilage morphology and signal were normal in both groups. Obese children demonstrated higher T2 relaxation times (median: 50 msec) within the deep cartilage of the medial femoral condyle in comparison to normal weight subjects (median: 48 msec) (p<0.01) (Figure). T2 relaxation times of the medial femoral condyle superficial cartilage and of the superficial and deep articular cartilage of the lateral femoral cartilage were similar amongst both populations (p values>0.24). Cartilage thickness did not differ between control and obese children (p>0.13). T2 relaxation times and cartilage thickness do not correlate with age (p values>0.23). There were no differences in KOOS indices between obese and normal weight subjects (total scores; obese children: 97.8/100 and controls: 97.6/100). Conclusions: T2 cartilage mapping demonstrated changes in the deep articular cartilage of the medial femoral condyle without morphologic abnormality in obese children as compared to normal weight children.

Characteristic MR Imaging Findings in Patients with Cold Exposure – Making a Case for Phalangeal Microgeodic Disease Rupa Radhakrishnan, MBBS, Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Arnold Merrow, MD, Kathleen Emery. Disclosures: Arnold Merrow, MD has indicated a relationship with Amirsys, Inc. as an author. Purpose or Case Report: Phalangeal microgeodic disease (PMD) is a rare self-limited disorder with characteristic clinical and radiographic features. The pathophysiology of PMD is often osseous ischemia or necrosis secondary to transient peripheral vasoconstriction due to cold exposure. In the appropriate setting, typical imaging findings of PMD may be diagnostic. We describe MR findings in a cohort of patients who presented with the clinical and imaging findings of PMD in the United States. Methods & Materials: We conducted an IRB approved retrospective review of MRI exams of the extremities from 1/2001 - 4/2014, identifying cases with phalangeal signal abnormalities and symptoms with cold exposure. Patients with a known cause for phalangeal signal abnormalities (trauma, osteomyelitis, autoimmune inflammatory conditions, tumors and post-operative cases) were excluded. Images were reviewed by two pediatric MSK radiologists in consensus. Other available imaging, including radiographs (5), nuclear medicine studies (2) and ultrasound examinations (1), and medical charts were also reviewed. Results: There were189 MR exams with phalangeal signal abnormalities with 8 MR exams (two hands, 6 ft) on six patients with a history of cold related symptom exacerbation. All patients were girls with all imaging during fall/winter in the U.S. Bone marrow signal abnormalities included hypointense T1 and hyperintense T2 signal with homogeneous enhancement. T2 signal abnormality was greater in extent than T1 signal abnormality. In one patient, hypoenhancement was noted in the areas of T1/T2 signal abnormality. Involvement was most frequent in the phalanges (45%), and rarely the metartarsals/metacarpals (8%). The distal phalanges were most often involved (70%), followed by the middle (53%) and proximal (25%) phalanges. The pattern of involvement was most commonly diaphysis (38%) followed by metaphysis (32%) and epiphysis (30%). Multiple digits and phalanges were involved in 7 of 8 studies. Cortical/periosteal signal abnormalities (13%), joint fluid, and soft tissue changes were uncommon. MRI showed greater extent of involvement than identified clinically or by other modalities. Conclusions: The presence of extensive marrow involvement of multiple painful phalanges is typical for PMD, especially in the setting of cold sensitivity. Identification of this benign self-limited condition is important

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as this can guide appropriate management of cold avoidance and prevent unnecessary biopsy.

Results: Musculoskeletal involvement was detected in 20 (91%) of 22 extremities. The most common findings were septal thickening in the subcutaneous fat (59%), fascial edema/enhancement (54%), and atrophy of the subcutaneous fat (50%). Muscle edema/enhancement (41%) and bone marrow edema (18%) were less commonly seen. Skin thickening/enhancement was detected in seven extremities (31%). Joint effusion and tenosynovitis were each seen in one extremity. Muscle atrophy was never seen. For detection of abnormalities in the subcutaneous fat, an axial T1 sequence was rated the most useful. For the other findings, axial T2 FS and axial T1 FS post contrast sequences were rated highest. Conclusions: MRI is a sensitive tool to assess the extent of musculoskeletal disease in children with localized scleroderma. Axial T1, axial T2 FS, and axial T1 FS post contrast sequences are the most useful for detecting these findings and should be included in the imaging protocol.

Paper #: 107 Utilization of Chemical Shift MRI in The Diagnosis of Disorders Affecting Pediatric Bone Marrow Matthew Winfeld, MD, Children’s National Medical Center, Washington, DC, [email protected]; Shivani Ahlawat, Nabile Safdar;

Paper #: 106 Localized Scleroderma in Children: Musculoskeletal MRI Findings Eric Eutsler, MD, Medical Imaging, Nemours/A. I. duPont Hospital for Children, Wilmington, DE, [email protected]; Daniel Horton, Monica Epelman, MD, Lauren Averill. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Localized scleroderma, also known as morphea, is an autoimmune disease that is diagnosed clinically as an area of soft tissue hardening, most commonly involving the skin. It has variable degrees of musculoskeletal involvement, which may result in cosmetic changes, functional impairment, and/or pain. MRI has been shown an excellent tool for evaluating the extent of musculoskeletal disease involvement in adult patients; however, the literature on children is scant. The purpose of this paper is to describe the spectrum of MRI features in pediatric patients with localized scleroderma and to evaluate the utility of various imaging planes and sequences for detecting the findings. Methods & Materials: IRB approval was obtained. The EMR of a pediatric health system was searched for children with localized scleroderma who had an MRI of an affected extremity between 2004 and 2014. 16 patients (10 male, 6 female; mean age 9 years) were included in the study with a total of 22 extremities imaged (6 upper extremities, 16 lower extremities). Images were evaluated independently by 2 radiologists (1 pediatric radiologist with 7 years of experience in MSK MRI and 1 pediatric radiology fellow with prior MSK fellowship training) for abnormal signal and/or enhancement involving the skin, subcutaneous tissues, muscular fasciae, muscles, joint and/or tendon sheath synovia, and bone marrow. Also, each imaging plane/sequence combination was rated on a scale of 1 (not useful) to 3 (most useful) for detection of the findings. Any disagreements were resolved by consensus.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Chemical shift magnetic resonance imaging (MRI) allows for separation of water and fat. The presence of fat in normal bone marrow suggests that it will have diagnostic use in marrow imaging. Neoplastic entities replace fat in marrow whereas non-neoplastic disorders cause relative depletion or redistribution of fat. The purpose of this study is to establish the effectiveness of chemical shift imaging (CSI) in differentiating disorders affecting bone marrow in children. Methods & Materials: MRIs of the pelvis and extremities for a 3 month period at a children’s hospital were retrospectively reviewed for performance of CSI. Of these, radiology reports and medical records were assessed to separate cases with normal and abnormal bone marrow. Abnormal cases were further subdivided into marrow-involving and marrow-replacing entities. For the abnormal cases, regions of interest (ROI) were drawn on corresponding in and opposed phase slices of the largest region of marrow abnormality. For normal cases, ROIs encompassed the largest area of marrow. ROIs were also defined in the urinary bladder or skeletal muscle to normalize signal intensity values. Mean signal intensity was recorded. Relative signal intensity ratio (RSIR) was calculated by computing the ratios of mean signal intensity for the primary ROI and the standard and dividing the opposed phase ratio by the in phase ratio. Statistical analysis was performed using ANOVA. Results: Seven marrow-replacing (four malignant neoplasms, one bone cyst, one fibrous dysplasia, and one Langerhans cell histiocytosis), 32 marrow-involving (16 osteomyelitis, seven bone infarcts/AVN, six fractures/stress injuries, and three inflammatory arthropathies), and 35 normals were included. Mean RSIR for the marrow-replacing group was 1.076+/-0.123, the marrow-involving group 0.699+/-0.320, and the normal group 0.613+/-0.218. The marrow-replacing group was statistically significantly different from the others (p<.01), though there was no significant difference between the marrow-involving and normal groups. To exclude the impact of normal children with adult-like marrow patterns which would increase RSIR, those aged 0-9 were analyzed

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separately with mean RSIR 0.522+/-0.230, which remained statistically significantly different from the marrow-replacing but not marrow-involving groups. Conclusions: CSI has the potential to provide quantitative information to help differentiate entities that replace normal bone marrow from other pathologies.

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stratify high-risk patients to decompression procedures and hopefully stave off further deterioration. This study is ongoing to evaluate our findings in a larger patient cohort.

Paper #: 108 Can Bone Marrow Edema Serve as a Predictive Biomarker for Bone Collapse in Patients with Corticosteroid-Induced Epiphyseal Osteonecrosis? Shanshan Bao, MD, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, [email protected]; Sandhya Kharbanda, Stuart Goodman, Diego Jaramillo, MD, Heike Daldrup-Link. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Osteonecrosis (ON) is a potentially devastating complication of pediatric cancer therapy with high dose corticosteroids, affecting 15-47% of leukemia patients. At our institution, clinical interventions are initiated when patients develop pain or impaired joint mobility. While 60-80% of early stage ON may remain stable without invasive intervention, about 20% of epiphyseal ON progress to joint collapse, at which time joint conservation therapy may not be possible. It has recently been described in adult patients that bone marrow edema (BME) adjacent to epiphyseal ON correlated with the presence of micro- or macro-fractures on histopathology. Based on these reports, the purpose of our study was to evaluate if BME would correlate with progressive ON and bone collapse in pediatric cancer patients, as it may help differentiate stable from progressive ON at an early time point, thereby stratifying high-risk patients to jointpreserving interventions. Methods & Materials: We retrospectively reviewed imaging studies of 14 children with leukemia who had undergone high dose corticosteroid therapy with findings of epiphyseal ON on magnetic resonance (MR) imaging. Two experienced radiologists evaluated the presence or absence of subchondral fracture and BME on MR images. Outcomes of articular surface stability or collapse were evaluated based on follow-up MRI or radiographic studies. ON with and without perilesional BME were compared for significant differences in outcome with Fisher’s exact test using a p < 0.05. Results: We identified 51 epiphyseal ON lesions in 36 joints (14 hips, 11 knees, 4 shoulders, 4 ankles, 3 elbows), with 26 lesions in the pre-collapse phase. Twelve lesions showed BME (11 weight bearing [WB], 1 non-weight bearing [NWB]) while 14 lesions showed no BME (13 WB, 1 NWB). Bone collapse on follow-up imaging was noted in 12/12 (100%) lesions with BME (11 WB, 1 NWB) and 1/14 (7%) lesions without BME (1 WB). This difference between the two groups was statistically significant (p<0.001). One patient with BME but no subchondral collapse underwent a decompression procedure with continued stability on post-operative follow-up imaging. Conclusions: The presence of BME adjacent to epiphyseal ON can be used as a predictor of progression to bone collapse in the pediatric population. Our initial results suggest that BME can help

Paper #: 109 Chronic Avulsive Changes of the Inferior Patella in Children with Spastic Diplegia: Frequency and Imaging Appearance David Swenson, MD, Diagnostic Imaging, The Alpert Medical School of Brown University, Brooklyn, CT, [email protected]; Cassandra Sams, Kirsten Ecklund, MD, Travis Matheney, Michele Walters. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Define the frequency and imaging appearance of chronic avulsive injuries to the inferior patella in patients with spastic diplegia, with correlation to patient functional status. Methods & Materials: This was a retrospective study performed following institutional review board approval. The study population included consecutive pediatric patients (<19 years of age) with spastic diplegia who underwent radiographic or magnetic resonance imaging (MRI) examinations of the knee between 6/1/2004 and 6/31/2014. Clinical records were reviewed to establish the indication for imaging and patient functional status, according to the established 5-point Gross Motor Function Classification System (GMFCS). Two board-certified radiologists reviewed all imaging studies in consensus, recording the CatonDeschamps radiographic patellar ratio, as well as the presence of an elongated lower patellar pole, and/or presence of lower pole bony fragmentation. MRI exams were also reviewed for correlation of radiographic findings. Results: Seventy patients (30 female, 40 male) with a mean age 12.9 years (range 7-18 years) were identified who carry a diagnosis of spastic diplegia and had knee radiographs (56 right and 54 left knees). Of these, eight patients also had knee MRI. All patients were imaged for pain, contractures, decreased functional status, or a combination thereof. Forty-nine were at least partially ambulatory (GMFCS score 1-3), while 21 were non-ambulatory (GMFCS score 4-5). 48/110 (43.6%) knee radiographs revealed patella alta (C-D ratio >1.3), and 25/110 (22.7%) revealed

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abnormal elongation of the lower pole. Of ambulatory patients, 9/49 (18.4%) had fragmentation at the lower pole of their patella on radiographs. On MRI, two patients had lower pole fragmentation, but without marrow, tendon, or soft tissue edema to suggest an acute injury. Rather the findings were compatible with a chronically ununited lower pole patella fragment. Of the other six patient with knee MRI, four demonstrated patella alta (corresponding to findings on their radiographs) but otherwise no specific morphologic abnormality. Conclusions: Ambulatory children with spastic diplegia have a high incidence of patella alta, frequent elongation, and occasional fragmentation of the lower pole of the patella, compatible with chronic avulsive changes related to increased muscle tone. Familiarity with this phenomenon will help radiologists distinguish acute from chronic avulsive injuries in this population of patients.

there are associations between length of tracts and percentile of height for both genders.

Paper #: 110 Diffusion-Tensor Imaging and Tractography of the Knee in Children Reveals Changes in Physeal and Metaphyseal Architecture Due to Age, Gender, and Height Maria Bedoya, MD, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Jorge Delgado, Nancy Chauvin, MD, Raul Ramirez, Jeffrey Berman, Diego Jaramillo, MD, et al. Disclosures: Jeffrey Berman indicated a relationship with McGowan Associates as a consultant. Purpose or Case Report: Diffusion-tensor imaging (DTI) depicts the columnar architecture of the physis and adjacent metaphysis. We seek to determine changes of DTI and tractography in the distal femur and proximal tibia related to age, gender, and height. Methods & Materials: We retrospectively analyzed DTI of the knee performed at 3.0T in 104 children. Mean ages of boys (n=55) and girls (n=49) were 13.6 years (6.9-17.9 years) and 13.5 years (6.5-17.3 years), respectively. Age, race and height percentile were similar in girls and boys (p values>0.16). On sagittal echo-planar DTI (20 directions, b values of 0 and 600 s/mm2), regions of interest were placed in the tibial and femoral physes and adjacent metaphyses. Using a fractional anisotropy (FA) threshold of 0.15 and an angle threshold of 40°, we performed tractography and measured apparent diffusion coefficient (ADC), eigenvalues (λ1, transverse diffusion), and tract length. Tractographic changes related to age, gender, and height were evaluated. Results: Tract length and number, ADC, and eigenvalues peak around puberty and then decrease with age (p-values >0.01). This pattern is seen in both bones and occurs earlier in girls. Between 10 and 13 years of age there were no significant differences in parameters between genders; whereas after 13 years of age, girls had shorter and fewer tracts, and lower ADC and eigenvectors in both bones (p-values>0.01) (Figure). Femoral tract length peaked at 10 years in girls and 13 years in boys (Graph), and tibial tract length peaked at 9.5 years in girls and 12.5 years in boys. Femoral tract length increases with higher percentile of height in girls aged 10 to 13 years (p<0.01, R2>0.53), and boys aged 13 to 16 years (p=0.02, R2=0.12) (Table). Conclusions: DTI and tractography show changes that are consistent with physeal and metaphyseal physiology, showing an earlier peak and decay of DTI parameters in girls compared to boys. In both genders, tract length may be related to the period of fastest growth of the distal femur and proximal tibia, showing longer tracts during puberty and early adolescence. At the period of the fastest growth

Graph: Linear regressions showing the relationship between femoral tract length and percentile of height. At the period of the fastest growth there are associations between the length of tracts and the percentile of height for both genders: femoral tract length increases with higher percentile of height in girls aged 10 to 13 years, and boys aged 13 to 16 years. Age group <10 years 10-13 years 13-16 years >16 years

Female p=0.456 R2 =0.12 p<0.01* R2 =0.53 p=0.12 R2 <0.12

Male p=0.65 R2 =0.28 p=0.97 R2 <0.01 p=0.02* R2 <0.23

p=0.92 R2 <0.01

p=0.88 R2 <0.01

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Paper #: 111 Patellofemoral instability (PFI) in Children Part I: T2 Relaxation Time of the Patellar Cartilage in PFI, Compare with Patients without PFI and Correlate with Morphological Grading of Cartilage Damage Hee Kyung Kim, MD, Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Chang Ho Kang, Sahar Shiraj, Christopher Anton, Paul Horn. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: PFI is one of the most common source of cartilage damage in teenager. The purpose of this study is to quantitatively evaluate the patellar cartilage in patients with PFI using T2 map and compare to the values in subjects without PFI. T2 relaxation times of the patellar cartilage will be correlated with morphologic grade in subjects with PFI. Methods & Materials: We included 53 patients with PFI and 53 age and gender matched subjects without PFI (mean age 15.9±2.4 years). Knee MR with axial T2 mapping were performed. Mean T2 relaxation times were obtained at the medal, apex and lateral facets of the patella cartilage and compared between two groups. In the group of PFI, morphologic grading of the patella cartilage (0-4) was performed and were correlated with T2 relaxation times. Results: Mean T2 relaxation times were significantly longer in the group of PFI as compared to the control across the patellar cartilage (Wilcoxon test, P value<0.05) with the longest time at the apex. Positive correlation was seen between mean T2 and morphological grading (Pearson correlation coefficiency, P<0.05). T2 has increase with severity of each morphologic grading from 0 to 3 (Mixed model, P value<0.05), but no difference was seen between grade 3 and 4. Conclusions: In PFI, patellar cartilage damage occurs across the entire cartilage, most severe at the apex. T2 relaxation times directly reflect the severity in low grade cartilage damage, which implies an important role in determination of normal and low grade cartilage damage.

Paper #: 112 Diffusion Tensor Imaging of Vastus Muscle Injury in Children: Preliminary Data Michael Francavilla, MD, Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Maria Bedoya, MD, Diego Jaramillo, MD.

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Diffusion tensor imaging (DTI) elicits information about organization of structures. In order to evaluate whether DTI of the muscle can show muscle injury, we analyzed DTI of the vastus medialis and vastus lateralis muscles at the knee obtained in children with and without muscle injury on conventional magnetic resonance imaging (MRI). We calculated and compared apparent diffusion coefficient (ADC), fractional anisotropy (FA), eigenvalues, and transverse diffusion (TD). Methods & Materials: Nine children (eight females) with vastus muscle injury and 13 age-matched controls (six females) were retrospectively analyzed. The injured patients had contusion, strain, or low-grade partial tear by conventional MRI. Coronal echo-planar DTI was performed in 20 directions at 3T with b values of 0 and 600 s/mm2. In the DTI images, two regions of interest (ROIs) were placed in both vastus muscles. In injured patients, ROIs were placed in the area of maximal abnormality by conventional MRI. Placement of ROIs in controls was similar to that done in corresponding patients. ADC, FA, eigenvalues, and TD were calculated for each ROI. These parameters were compared to the control values. Non-parametric and linear regression models were analyzed Results: Six children (eight females) with vastus muscle injury and 13 age-matched controls (six females) were retrospectively analyzed. The injured patients had contusion, strain, or low-grade partial tear by conventional MRI. Coronal echo-planar DTI was performed in 20 directions at 3T with b values of 0 and 600 s/mm2. In the DTI images, two regions of interest (ROIs) were placed in both vastus muscles. In injured patients, ROIs were placed in the area of maximal abnormality by conventional MRI. Placement of ROIs in controls was similar to that done in corresponding patients. ADC, FA, eigenvalues, and TD were calculated for each ROI. These parameters were compared to the control values. Nonparametric and linear regression models were analyzed. Conclusions: DTI depicts normal and injured microstructure of the vastus muscles at the knee in children. ADC, λ1, and TD values were both significantly higher in children with MRI evidence of muscle injury, likely reflecting edema and change in organization of muscle fibers following injury. FA values were not different, suggesting that muscle fiber arrangement is relatively preserved in low-grade injury. DTI detected evidence of muscle injury in the opposite vastus muscle even when MRI showed no abnormality.

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Paper #: 113

Table 2. Median and p-value of the different variables of the femur and tibia between 1.5Tand 3.0T MRI system. *Significant difference.

DTI of the Femoral and Tibial Physes and Metaphyses, Can it be Done at 1.5T? Jorge Delgado, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Maria Bedoya, MD, Raul Ramirez, Aikaterini Ntoulia, MD, PhD, Jeffrey Berman, Diego Jaramillo, MD, et al. Disclosures: Jeffrey Berman indicated a relationship with McGowan Associates as a consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: It is already known that diffusion tensor imaging (DTI) at 3T depicts the columnar microstructure and provides quantitative data of the physis and adjacent metaphysis. This technique may be useful for evaluation of children with abnormal growth. The purpose of this study was to determine if there are differences in DTI data between 1.5 T (T) and 3.0T MRI systems, in order to use this technique at both field strengths. Methods & Materials: We retrospectively analyzed DTI of the knee of 13 cases, 8 males and 5 females, who underwent imaging in 1.5T MRI systems and 13 age and gender matched children who underwent imaging in 3.0T MRI systems. For all subjects a region of interest (ROI) was placed in the physes of the femur and tibia, and tractography was performed using a fractional anisotropy (FA) threshold of 0.15 and an angle threshold of 40°. We recorded the means of the ROI and tract-based apparent diffusion coefficient (ADC), FA, magnitude of main eigenvector (λ1) and tract length values. Image quality and artifacts of the B0 sequence were evaluated. We documented height, weight and body mass index (BMI). Results: Subjects of the two groups did not differ in age, height, height percentile, weight, weight percentile, BMI or BMI percentile (ps>0.42) (Table 1). In the femur, no differences in ADC, FA, λ1 and tract length values were found (ps>0.07) (Table 2). In the tibia, no differences in ADC, FA and λ1 values were found (ps>0.10). Children scanned in 3.0T scanners had a significantly higher tibial tract length in comparison to 1.5T (p=0.03) (Table 2). Artifacts including the physis were seen in three children at 3T and none at 1.5T. Artifacts not including the physis were seen in five children at 3.0T, and 4 at 1.5T. No artifacts were seen in five children at 3.0T and 9 at 1.5T. No significant difference between the number of artifacts between field strengths was found (p=0.12). Conclusions: ADC, FA and λ1 values of the femur and tibia do not differ between 1.5T and 3.0T MRI systems. Artifacts were not different between field strengths, although there was a trend for less artifacts at 1.5T. No difference in the femoral tract length was found, but a significant difference in the tibial tract length was found. DTI data obtained in 1.5T and 3.0T MRI systems was not different in 12/13 variables recorded in this study. DTI of the physis and metaphysis can be done at 1.5T, but there are slight differences in results from both field strengths. Table 1. Baseline characteristics of the subjects. Variable Gender (M/F) Mean age Mean Height in cm (range) Mean Height percentile (range) Mean Weight in Kg (range) Mean Weight percentile (range) Mean BMI (range) Mean BMI percentile (range)

1.5T 8/5 12.98 (6.96-17.54) 154 (124-182)

3.0T 8/5 13.01 (6.90-17.32) 155 (122-178)

p-value >0.99 0.88 >0.99

58.0 (6.0-98.7)

57.7 (19.81-91.19) 0.77

55.1 (25.9-92.7)

52.2 (25.8-107.0) 0.42

73.1 (41.4-99.15) 65.4 (16.2-99.6)

0.51

22.0 (15.8-28.0) 76.8 (31.8-97.5)

0.38 0.38

20.9 (15.8-34.8) 64.9 (11.2-99.2)

Femur

Tibia

Variable

1.5T

ROI-ADC (mm2/s) ROI-FA

1.47×10−3 1.46×10−3 0.92

Tract-ADC (mm2/s) Tract-FA

1.39×10−3 1.39×10−3 0.61

0.24

0.33

3.0T

0.27

0.38

p-value 1.5T

0.07

0.20

Tract-λ1 1.90×10−3 1.92×10−3 0.58 (mm2/s) Tract length 5.93 6.37 0.58 (mm)

3.0T

p-value

1.40×10−3 1.45×10−3 0.77 0.3

0.21

0.12

1.30×10−3 1.29×10−3 0.35 0.37

0.36

0.73

1.80×10−3 1.70×10−3 0.10 4.19

4.97

0.03*

Paper #: 114 Pre-Authorization Processes Have No Effect on Outcomes in Pediatric Patients Undergoing Knee MRI Ordered by Pediatric Orthopedic Physicians Drew Pierce, MD, Pediatric Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; J. Kan, MD, Megan May, George Bisset, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Insurers have increasingly been utilizing pre-authorization processes with the goal of limiting the amount paid for imaging. The proposed mechanism of reduced cost is by denial of authorization in patients who have insufficient clinical indication for expensive imaging. The purpose of this study is to establish the effectiveness of pre-authorization in eliminating un-indicated pediatric knee MRI exams ordered by pediatric orthopedic specialists. Methods & Materials: A retrospective cohort study was performed on privately insured patients aged 8-25 years at a single institution, who had initial MRI of the knee ordered between January 2011 and July 2014 by pediatric orthopedic specialists. The study population comprised all patients who required preauthorization. The control population consisted of all patients not requiring pre-authorization. Information recorded included whether the study was performed, need for pre-authorization, surgically significant findings on MRI, time between initial visit and MRI or surgery and knee surgery as a result of the MRI findings. Surgically significant findings on MRI included internal derangement inclusive of meniscal or ligament tear, unstable or symptomatic osteochondral lesions, or loose bodies. Statistical methods used to analyze data were student’s t-test for continuous variables and chi-square test for categorizable variables. Results: One hundred twenty-two patients were included. Seventy-five (age range 8.3-22.7) underwent pre-authorization versus 47 (age range 8.2-20.4) that did not. There was no statistically significant difference between study and control groups in regard to the following parameters (Table 1): number of days from MRI order to performance (4.0 versus 3.98 days, p=.94), MRI order to surgery (39.0 versus 36.9 days, p=.91), percent of patients with surgical findings on MRI (20 versus 22%, p=.85), and percent of patients who underwent surgery (20 and 20%, respectively, (p=.95).

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Conclusions: This study demonstrates that utilization of a pre-authorization process is associated with no significant difference in the likelihood of a surgically significant findings found by MRI when an exam is referred from a pediatric orthopedic subspecialist. The role of insurance pre-authorization should be limited for advanced imaging of the knee when studies are referred from pediatric orthopedic subspecialists. Pre-authorization for advanced imaging referred from other subspecialists should also be vetted for their effectiveness in limiting unnecessary examinations and costs.

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quantify these savings and to assess the impact of this intervention on patient/caregiver satisfaction.

Paper #: 116 Prospective Randomized Study of Utilizing Music Therapy For Reducing Patient Anxiety During Pediatric Ultrasound Andrew Kesselman, MD, Michael Bergen, Dimitre Stefanov, Rachelle Goldfisher, MD, Radiology, SUNY Downstate, New York, NY, [email protected]; John Amodio.

Paper #: 115 Pediatric Gastrojejunostomy Tube Replacement: Can Improved Communication Reduce Image Guided Procedures After Hours? Mark Sharafinski, MD, Medical College of Wisconsin, Wauwatosa, WI, [email protected]; Elizabeth Sehnert, David Moe, Nghia Vo. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine if embedding into the radiology report a patient-specific plan in the event of gastrojejunostomy (GJ) tube dysfunction reduces after-hours utilization of pediatric interventional radiology resources for the replacement of GJ tubes. Methods & Materials: Retrospective cross-sectional study of patients presenting for after-hours (5 pm - 7 am) GJ tube related complaints at a large children’s hospital, before and after the inclusion of a patient-specific plan in the radiology procedure note. Results: Over a 6 month period before the inclusion of a patient-specific plan, there were 242 total gastrojejunostomy tube changes performed by the interventional radiology service under image guidance. 26 (10.7%) of these procedures were performed after-hours at the request of the emergency department (ED) (9/26), inpatient service (8/26), or patient/caregiver (12/26). Of the eight inpatients, 3 were admitted from the ED for the purpose of tube replacement. Data were again collected for 6 months following inclusion of a patient-specific plan. During this period, 241 total image guided changes were performed. 15 (6.2%) were performed after-hours at the request of the emergency department (2/15), inpatient service (4/15), or patient/caregiver (9/15). No patients were admitted for GJ tube replacement procedures following implementation of the enhanced reporting policy. These data indicate a reduction in after-hours GJ tube replacement requests by the ED (450%), inpatient service (200%), and patients/caregivers (133%). Reduction of afterhours GJ tube changes resulted in a direct cost savings of 173% at our center. Conclusions: Our single-center data show that the inclusion of patient-specific recommendations at the end of each radiology GJ tube procedure note, generated in collaboration with the feeding service or primary medical provider, reduces off-hour resource utilization in patients that could otherwise have their tubes replaced during standard operating hours with image guidance. Avoidance of tuberelated admissions is likely the greatest source of cost savings, followed by lower radiology technical support costs. Cost savings related to improved ED workflow and reduced patient and family anxiety are difficult to quantify, but likely significant. Future studies should be designed to

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this study was to assess the influence of music therapy during pediatric ultrasound examinations on reducing anxiety measured by heart rate, procedure times and subjective technical assessment. Methods & Materials: The protocol for this study was approved by our institution’s IRB committee. Our inclusion criteria for this study were children between the ages of 1 to 10 years old who were scheduled for pediatric ultrasound either on an inpatient or outpatient basis at Kings County Hospital Center and SUNY Downstate Medical Center. Each participant was randomized to either soft music or no music after parental consent was obtained. Music was set at a low background volume, no headsets were used, as the music was played on a stand-alone speaker system. Pulse oximeters was used to monitor heart rate at 15 s intervals for a duration of 1 min; prior to entering the procedure room, during the procedure, and after the procedure is completed. The total scan time was determined from the initial image acquisition until the last image was saved as recorded by the operator. Additionally, each operator rated the ease of performance on a subjective scale of 1-10. Statistical analysis was subsequently performed on the anonymized collected data set with significance set at p<.05. Results: A total of 44 patients were recruited; 21 controls and 23 experimental. The mean preprocedural heart rates for the control group and experimental group were 95.7 and 100.2 bpm. The mean procedural heart rates for the control group and experimental were 102.5 and 94.6 bpm. The mean postprocedural heart rates for the control group and experimental group were 98.2 and 88.2 bpm. When assessing the mean decrease (delta) from preprocedural to procedural heart rate, the control group demonstrated increase of 6.9 while the experimental group demonstrated decrease of 5.7. For the mean delta from preprocedural to postprocedural heart rate, the control group demonstrated increase of 2.5 while the experimental group demonstrated decrease of 12.0. These results were statistically significant. The mean procedure times and the mean operator assessment scores were not significantly different between the two groups; 22.1 min and 4.3 for the controls and 20.8 min and 3.9 for the experimentals. Conclusions: Music therapy during pediatric ultrasound is an inexpensive intervention that can help lower patient anxiety as demonstrated by heart rate in this small prospective randomized study. GROUP Maximum

N

Obs

Variable

Label Mean Std Dev

Control

21

HR_pre

HR_pre

95.7

19.4

60.5

135

HR_proc

HR_proc

102.5 16.9

79.8

134.3

HR_post

HR_post

98.2

Oper_ Oper_ 4.3 Assesm Assesm time_proc time_proc 22.1

Minimum

16.5

68.8

137.3

2.9

1

8

9.9

10

44

delta12

−6.9

11.9

−38.5

9.8

delta13

−2.5

19.5

−37.5

49

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HR_pre

4.4 HR_pre

13.8

100.2 21.3

−13.8

49.8

53

148.8

HR_proc

HR_proc

94.6

21.6

59.8

147.5

HR_post

HR_post

88.2

18.2

50.3

135.5

Oper_ Oper_ 3.9 Assesm Assesm time_proc time_proc 20.8

2.5

1

9

12.1

6

47

delta12

5.7

16.5

−53

29.3

delta13

12

22.5

−48

72.3

delta23

6.3

16

−9.3

62.3

Paper #: 117 Utilization of Exposure Index for Dose Optimization in Pediatric Chest and Abdominal Radiography Niloy Dasgupta, MD, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, [email protected]; Beverley Newman, David Larson. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Historically, there as been a large amount of variation in dose for x-rays, such that doses in examinations at the upper end of the spectrum have been about four times the doses of those at the lower end of the spectrum. The variability is not based on clinical need but rather lack of tight controls. In an effort to reduce the variation in radiation doses, we hope to evaluate exposure index (EI) as surrogate for a target dose for an xray examination, and evaluate its correlation with patient size and image quality. Methods & Materials: A retrospective review of a random, representative sample of chest and abdominal x-rays acquired on patients of various sizes was performed at a single institution over a 1 month period. Each film was reviewed by three radiologists and given an averaged score based on perceived image quality on the following scale: (1 - poor image quality necessitating repeat examination with increased dose settings, 2 poor image quality without need for a repeat examination but with a probable increase in dose settings on subsequent imaging, 3 - diagnostic image quality, 4 - better than diagnostic image quality with a probable decrease in dose settings on subsequent imaging, 5 - better than diagnostic image quality with a definite decrease in dose settings on subsequent imaging). In addition, measurements of patient size (transverse measurements at the level of the diaphragm) and retrieval of EI values for individual examinations was performed. Results: Sixty five abdominal and 72 chest x-rays were selected. EI values for chest radiographs ranged from 75 to 1985 (mean 397, standard deviation 136) and from 142 to 955 for abdominal radiographs (mean 358, standard deviation of 344). Transverse diameter measurements of patients ranged from 22.2 to 40.7 cm in chest radiography (mean 25.6 cm, standard deviation 8.0 cm) and from 8.6 to 32.9 cm (mean 16.3 cm, standard devation of 6.0 cm) in abdominal radiography. A mildly positive correlation between exposure index and image quality was noted for abdominal radiographs. There was no such correlation for chest radiographs. Conclusions: In abdominal imaging, EI is positively correlated with patient size. However, larger patients have higher measured EIs, suggesting they may be receiving higher dose than necessary. Utilizing EI as a surrogate for target dose based on image quality may be practicable in abdominal radiography. The findings do not support the use of EI as a surrogate for target dose in chest radiography.

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Paper #: 118

Paper #: 119

ED/Outpatient X-Ray Request Form Audit (How to Make a Good Situation Better!)

Assessing the Quality of Outside Institution Abdominal CTs Performed for Pediatric Patients Presenting to the Emergency Department of an Academic Children’s Hospital

Mary-Louise Greer, MBBS, The Hospital for Sick Children/University of Toronto, Toronto, ON, Canada, [email protected]; Michael Aquino, Zoran Bojic, MHSc, Constance Krajewski, Denise Carraretto. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Improving effectiveness of communication between health care providers results in better patient outcomes. The xray request form is integral to this. The purpose of this audit was to improve completeness and accuracy of information entered on requisitions by positive reinforcement endeavors and educational activities, with anticipated benefits to patients. Methods & Materials: Randomly selected emergency (ED) and outpatient (OPD) department x-ray request forms were collated over a 3-month period and scored using a checklist. Eleven checklist items capturing clarity, accuracy and completeness were graded from 0-4, to a maximum of 44. Key diagnostic imaging staff helped generate the items, including bookings coordinators, technologists and radiologists. Each month, the physician completing the highest scoring requisition was notified, awarded a prize and had their name published in a hospital-wide electronic newsletter along with an educational message, e.g. list of essential information on the requisition, accepted abbreviations. The data for the month before the “competition” was announced was compared with subsequent months using a two tail Student’s t-Test of probability. Results: Over 3 months, 413 request forms were graded. Monthly averages increased from 36.8 to 40.5 (p<0.005). One third of requests were from ED and 2/3 OPD, across a range of specialties. Both groups had similar improvement in average scores comparing month 1 with months 2 and 3, independently or in combination (p<0.005). Eight of 11 items on average scored > 3 in month one, 11/11 in month three. Date of request and referrer contact information improved the most. Study limitations included sample size and possible sampling and scoring bias. Request forms were pulled by one technologist and scoring undertaken by one fellow, although final winners were chosen by consensus. Conclusions: Although incomplete or inaccurate x-ray request forms can be addressed by being returned to the referrer or using electronic ordering forced fields via Radiology Information Systems (RIS), we postulated a better outcome could be achieved by education and positive engagement with our referring physicians. This project demonstrated use of positive reinforcement and educational tools improved clarity, accuracy and completeness of information on x-ray requisitions. This data will help in designing a RIS upgrade in our institution. Most importantly, it is expected these improvements translate to better patient care and safety.

Aisling Snow, MD, Radiology, Boston Children’s Hospital, Boston, MA, [email protected]; Rebecca Hehn, Michael Callahan, Valerie Ward, Robert MacDougall, George Taylor, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To evaluate the quality of abdominal CTs performed at outside institutions (OSIs) on pediatric patients who present to the emergency department (ED) of an academic Children’s Hospital (CH). Methods & Materials: The institutional review board (IRB) granted ethical approval for the study. 50 patients who presented to the CH ED and who had a CT abdomen at an OSI immediately prior to presentation were identified. Fifty patients (matched for age, gender and scan indication) who underwent CT abdomen at CH in the same time period were also selected. The referring hospitals were categorized and the OSI reporting radiologists’ board certification status was determined using the American Board of Radiology (ABR) searchable online database. Two fellowship-trained, board-certified pediatric radiologists evaluated the OSI and CH scans in a randomized order. The reviewers were provided the original imaging indication but were blinded to any prior or subsequent imaging and to the clinical notes. Radiation dose and patient size (anteroposterior size at the umbilicus) were recorded and a sizespecific dose estimate (SSDE) was calculated for each patient. Results: Forty-five percent of patients in each cohort were female and the mean age was 12.4 years (CH) and 12.8 years (OSI). 24% of scans in each cohort were performed due to abdominal trauma. Hospitals were categorized as general ED or pediatric-specific ED, based on whether there was a full/partial or absent pediatric-dedicated ED department. All OSI radiologists (n=50) were board certified in diagnostic radiology and 1 was subspecialty certified in pediatric radiology. SSDEs were significantly higher for patients imaged at OSIs (mean 13.3 mGy) than at CH (mean 8.7 mGy), p=0.02. Anatomic coverage was deemed to be excessive on 410% of CH scans and 29-39% of OSI scans (p<0.001 for both reviewers). The phases of imaging performed were deemed necessary in 98% of CH and 96% of OSI studies. Conclusions: Overall, pediatric abdominal CTs performed at OSI EDs impart a higher radiation dose to patients and tend to cover unnecessary anatomy. These studies would be more appropriately performed at pediatric institutions where CT is tailored to the pediatric population.

Paper #: 120 The Inferior Cavoatrial Junction is Located at the T8-T9 Disc Space Level on CT: Implications for Umbilical Venous Catheter Placement Richard Jones, MD, Radiology, University of Minnesota, Saint Paul, MN, [email protected]; Kelly Dietz, MD, Michael Murati, Eric Hoggard Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: The appropriate location of an umbilical venous catheter tip is at the junction of the right atrium and inferior vena cava. We sought to define the anatomic relationship between this site and the thoracic spine with thin-slice CT chest angiography. Methods & Materials: CT angiograms of the aorta or CTs of the chest with contrast (DFOV 201 mm, slice thickness 0.6 mm) on patients aged 0 days to 3 months from our institution from 1 January 2007 to 31 December 2013 were collected and reviewed (n=197). Patients with congenital vertebral anomalies or scoliosis, anomalies of the IVC, or incomplete opacification of the intrahepatic IVC were excluded. Of the 113 examinations (43 female, 70 male) where the inferior cavoatrial junction was seen, the hepatic vein confluence seen in 79 patients. Lines parallel to the axial slice at the level of the junction and confluence were extended posteriorly on a sagittal image. The point where this line intersected the anterior surface of the vertebral body or disc space below, divided into fourths, was recorded. The average patient age at the time of the scan was 32 days. A majority of the patients had congenital anomalies of the heart and aorta, and 29 of the 113 had prior corrective surgery at the time of the CT scan. Results: The mean thoracic vertebral body at the level of the junction of the inferior vena cava and right atrium was 8.93 (95% CI [8.81-9.05]). The mean thoracic vertebral body level at the confluence of the hepatic veins was 9.46 (95% CI [9.31-9.61]). The mean number of thoracic vertebral bodies between the confluence and the junction was 0.59 (95% CI [0.52-0.66]). There was no significant difference between the mean levels between patients with and without surgery (p=0.001). Conclusions: The inferior cavoatrial junction is reliably located at the bottom of the T8-T9 disc space in neonates, and there is a 95% likelihood that the catheter tip is at least at the level of the hepatic vein confluence if it projects at or above the superior 1/3rd of the T9 vertebral body. If during plain radiography an umbilical venous catheter tip is seen in this location and is also at the interface of the liver and heart shadows, there is high confidence that it is in the appropriate location.

Paper #: 121 Ultrasound for Central Vascular Catheter and Endotracheal Tube Position in the NICU - A Pilot Study David Saul, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Samuel Ajayi, David Schutzman, Mindy Horrow. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Newborns in the intensive care unit (NICU) often require considerable support with endotracheal tubes (ETTs), umbilical arterial/venous catheters (UACs/UVCs), and peripherally inserted central venous catheters (PICCs). Support device evaluation with radiographs (CR) exposes neonates to ionizing radiation. This study evaluated the reliability of ultrasound localization for ETTs, UACs, UVCs, and PICCs. Methods & Materials: This blinded, prospective, IRB-approved, HIPAA-compliant study compared US to CR for ETT, UAC, UVC, and PICC localization. Participants were consecutively recruited NICU babies of any weight, gestation, and chronological age who had an ETT, UAC, UVC, or PICC placed or adjusted and had subsequent CR confirmation within 24 h. US evaluation was obtained as soon as possible, without prior review of the radiograph, and results were compared. Results: Twenty-six patients (19 male, 7 female) were imaged for a total of 40 lines and tubes: 14 UVCs, 10 UACs, 9 PICCs, and 7 ETTs. Thirtyfour support devices (92%) were visualized with US, all concordant with CR. US definitively identified UVC location in all 14 cases (100%), UAC location in all 10 (100%), PICC location in 7 (78%), and ETT location in 6 (86%). Conclusions: US reliability was excellent for evaluation of UACs/UVCs and good for PICCs and ETTs. These results support the use of US as a primary modality for umbilical catheter and possibly PICC and ETT assessment. Future directions include clinical training of Pediatricians in bedside US and performing larger studies with greater numbers of support devices.

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pharmacokinetic parameters and comparison with data from population 2 years and older. Methods & Materials: Sparse plasma sampling was performed to evaluate plasma PK in subjects <2 years of age (term newborns to 23 months of age) using a population-based PK approach. Males and females with a clinical indication for MRI of any body region following administration of 0.1 mmol/kg gadobutrol were studied. Safety assessments were done during approximately 7 days post gadobutrol injection and imaging efficacy variables were qualitatively assessed by investigators. Data were compared to available results on population ≥2 years. Results: PK data were evaluated in 43 children <2 years of age, including nine infants younger than 2 months. The PK profile of gadobutrol in pediatric subjects <2 years including term newborns, was similar to the PK profile in older populations. PK parameters (including gadobutrol concentrations at 20 min postinjection) observed were similar across the population <2 years and in range with the known PK profile of gadobutrol in older populations. Safety and efficacy were evaluated in 44 children. Vomiting was reported as a mild adverse event (AE) related to gadobutrol in one subject (2.7%). There were no drug-related serious AEs. The evaluation of gadobutrol-enhanced images provided improved diagnosis, increased confidence in diagnosis, and contributed to subject clinical management. Consistent with PK, the safety and efficacy of gadobutrol in children <2 years of age (including newborns) is similar to the safety and efficacy profiles of gadobutrol established in older populations. Conclusions: Gadobutrol PK, safety and efficacy profile in children <2 years of age is similar to that established in older populations. Clinical trial results support the safe and effective use of gadobutrol at a body weighted standard dose of 0.1 mmol/kg in newborns, infants and toddlers for contrast-enhanced MRI.

Paper #: 123 Effects of Maternal Valium Administration on Fetal MRI Motion Artifact; A Comparison Study at High Altitude Mariana Meyers, MD, Pediatric Radiology, Children’s Hospital Colorado, Aurora, CO, [email protected]; Kimberly Dannull, David Mirsky, Timothy Crombleholme

Paper #: 122 Macrocyclic Gadobutrol – Pharmacokinetics, Safety and Efficacy Evaluation of a Body Weighted Standard Dose in Newborns, Infants and Toddlers Gabriele Hahn, Christian Kunze, Martin Stenzel, Gabriele Sutter, Marta Santiuste, Ravi Bhargava, et al. Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Germany, [email protected] Disclosures: Marta Santiuste - Bayer Healthcare: Employee. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To evaluate pharmacokinetics, safety and efficacy of gadobutrol (Gadavist®) for enhanced MRI at a standard body weighted dose of 0.1 mmol/kg in children <2 years. Determination of

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Fetal MR imaging is most commonly performed without any sedation or anxiolytic medication. In cases of moderate to severe maternal claustrophobia or when reduction of fetal motion is critical, benzodiazepines may be of help. The purpose of our study was to evaluate if the administration of 10 mg of Valium would decrease fetal motion artifact on MR images and to observe if benzodiazepines will pose a clinically significant maternal oxygen level change outside the normal range of 92-100% oxygen saturation. Methods & Materials: We retrospectively studied 137 fetal MRI scans performed from March 2013 through December 2013. Average gestational age was 25.5 weeks. Twenty of the cases were performed after Valium administration. Images were evaluated by three dedicated fetal MRI radiologists and graded using a Likert scale into, good, average, and poor. The oxygen levels were recorded before scanning (in sitting position), during scanning (lowest and highest levels) and after scanning (in sitting position) using pulse oxymetry. Altitude of origin was taken into account although was not found to be a confounding variable.

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Results: Results were analyzed for each category (poor, average and good) combining the three reader’s interpretations. The valium group showed a higher proportion of “poor” ratings and lower proportion of “good” ratings consistently among all three readers. Using a generalized linear model and adjusting for the mother’s position in the scanner as covariant, the odds of the Valium group receiving a poor rating was 2.5 times the odds of the control group (95% CI; 1.0- 6.2). Maternal oxygen levels at different times and positions were compared using independent 2-sample T-Test between the Valium and non-valium groups showing no change in O2 saturation (95% CI; mean 94.2- 97.1%). Conclusions: Administration of Valium at low dose did not decrease fetal motion artifact on MR images. Additionally, Valium did not pose any risk of maternal hypoxemia and is thus unlikely to alter fetal O2 saturation.

Paper #: 124 Comparison Between 1.5T and 3T Fetal Imaging: Is there an Advantage in Imaging at Higher Field Strength? Teresa Victoria, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Ann Johnson, Christopher Edgar, Diego Jaramillo, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 3T fetal MRI is emerging as a promising imaging modality because of the increased in signal to noise ratio (SNR), with the overall goal being more detailed imaging of fetal anatomy. The present study compares two commonly used fetal MR sequences at 1.5T and 3T. We hypothesized that visualization and anatomic detail of fetal structures would be greater at 3T than at 1.5T. Methods & Materials: Following IRB approval, a retrospective search of the radiology database was performed to select fetal MR studies done at 3T for body abnormalities from July, 2012-Feb, 2014, GA 20-37 weeks. Fifty-eight evaluable studies were identified. A comparison age-matched fetal 1.5T group of 58 studies done for body indications was similarly identified. Half-acquisition single-shot fast spin echo (SSFSE) and steady-state free precession (SSFP) sequences were evaluated. Two pediatric radiologists blinded to magnetic field strength independently scored the 1.5T and 3T images for bowel, liver, kidney, airway, cartilage and spine. Each anatomic structure was scored between 1 = poor anatomy depiction, and 4 = excellent anatomy visualization Results: For SSFP, for both raters, all fetal structures except airway were rated higher (i.e., improved visualization) at 3T than at 1.5T (p<0.05). For SSFSE, for both raters, only cartilage and spine had statistically significantly higher score at 3T (p<0.05). Averaging scores across the six evaluated structures showed generally better visualization at 3T than at 1.5T for SSFSE (score: 2.5 vs 2) and SSFE (score: 2.6 vs 1.9). Spearman rank correlations showed that for SSFSE 1.5T imaging, anatomy was better defined with increasing GA, with findings in the same direction but not significant for Rater 2 (p=0.3). At 3T, visualization of anatomy was unrelated to GA. Conclusions: The present study showed an advantage in anatomic depiction at 3T fetal imaging, with the gain observed primarily in the SSFP sequence. Correlation analyses showed improved visualization of fetal anatomy with increasing GA for 1.5T but not 3T, suggesting that anatomic detail is more easily visualized at 1.5T as structures increase in size (i.e., older fetuses), whereas the greater SNR at 3T provided sufficient anatomic detail even in younger fetuses. Further development of 3T software and protocols may allow improved characterization of fetal pathology, with the overall goal of improving diagnostic information to aid in counseling, pregnancy management and surgical planning.

Paper #: 125 Fetal Imaging at 3T: Whole Fetal Body EPI Survey is a Useful Adjunct Sequence Matthew Jones, MD, Radiology, Boston Children’s Hospital, Brookline, MA, [email protected]; Ali Gholipour, Onur Afacan, Simon Warfield, Judy Estroff, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Fetal MRI performed at 3T provides well known significant advantages over 1.5T, including much better delineation of fetal anatomy. To date, there are no known adverse consequences of utilizing 3T technique over 1.5T. However, a frequently cited potential disadvantage of 3T technique is increased specific absorption rate (SAR). In an attempt to maximize tissue definition, keep SAR as low as reasonably achievable (ALARA), and reduce motion artifacts, our institution has begun using a fast whole fetal body EPI survey sequence. We present our experience utilizing this technique, with particular attention paid to quantification of fetal anatomy (measuring fetal lung volumes). Methods & Materials: We present a technical description of a single institution experience utilizing a whole fetal body EPI survey sequence at 3T. We describe the technical components of the sequence, with examples of anatomic structures imaged utilizing EPI and comparison images from other sequences. Furthermore, we provide a comparison of fetal lung volumes measured using the EPI sequence versus conventional T2 HASTE. Results: We show that whole fetal body EPI is a robust sequence for imaging detailed fetal anatomy, particularly when there is significant fetal motion. Acquisition time for a single slice is approximately 50 ms, versus about 500 ms for a conventional T2 HASTE slice. We present images showing differences in fetal motion tolerance between EPI and T2 HASTE. Additionally, we show adequacy of the EPI sequence for performing detailed, quantitative anatomic analysis by showing measurements of fetal lung volumes performed with EPI and T2 HASTE. Conclusions: The whole fetal body EPI survey is a powerful sequence, providing rapid, accurate delineation of fetal anatomy at 3T. Its yield is particularly great in motion-limited second trimester pregnancies. Therefore, it may deserve a place as a standard sequence in second trimester fetal MRIs performed at 3T.

Paper #: 126 Cerebrovascular Abnormalities in Acta2 Knockout Mice: A Model for Pediatric Cerebrovascular Disease Associated with ACTA2 Mutations Zbigniew Starosolski, PhD, Pediatric Radiology, Texas Childrens Hospital, Houston, TX, [email protected]; Ketan Ghaghada, PhD, Carlos Villamizar, Michael Paldino, MD, Ananth Annapragada, PhD, Dianna Milewicz, et al. Disclosures: Ananth Annapragada, PhD indicated a relationship with and Marval Pharma Inc, Alzeca LLC, and Sensulin LLC as a Stockholder. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Mutations in the ACTA2 gene, encoding smooth muscle alpha-actin, lead to pediatric cerebrovascular disease characterized by straightening of the arteries and Moyamoya-like occlusion and stenosis of arteries in the Circle of Willis (CoW). We hypothesized that Acta2 knockout mice (Acta2+/− and Acta2−/−) would exhibit similar vascular anomalies in the vessels of the CoW, including stenoses, occlusions, and abnormal straightening, compared to the wildtype mice. If these hypotheses were found true, Acta2 knockout mice could be used to test drugs to potentially treat pediatric cerebrovascular disease. Methods & Materials: All in vivo procedures were approved by the BCM IACUC. Mating heterozygous males and females, yielded agematched sibling controls in addition to the heterozygous and homozygous offspring. Mice were imaged between 6 and 8 weeks of age. A novel nanoparticle CT contrast agent (~120 nm particle size, PEG surface coating, total iodine ~150 mg/ml, dose ~6 μL/g) was injected via tail vein. CT angiography was performed using a small animal micro-CT scanner with the following scan parameters: 70 kVp, 500 uA, 850 ms exposure, 1440 projections. Ultra-high resolution images at 19 um isotropic voxel size were reconstructed. Diameter, tortuosity and vessel morphology were estimated for the carotids and intracranial vessels. Following imaging, the animals were sacrificed and their brains excised for histological evaluation. Results: The neurovascular architecture was exquisitely visualized by the novel micro-CT technique, enabling detailed morphometry of macroscopic vascular structure, as well as microscopic details of individual vessels. Acta2−/− and Acta2+/− mice exhibited significant narrowing of the CoW, straightening of vessels, and isolated narrowing of individual vessels, compared to the wild type mice (1a). Histopathy of the brains of the mutant mice showed significant vessel wall thickening in both large and small arteries (1b). Conclusions: Micro-CT angiography with a novel nanoparticle contrast agent is a unique tool to study vascular architecture at an unprecedented level of detail. Morphological features of vessel assemblies, e.g. the entire CoW, can be assessed, in addition to individual vessel diameters and lengths. The Acta2−/− mouse recapitulates key characteristics of pediatric cerebrovascular disease in children with ACTA2 mutations, including the CoW anomalies of Moyamoya disease, and could be a suitable model to test therapeutic interventions .

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Table 1. Statistical analysis on vascular morphometric parameters of cerebrovascular arteries determine by CT imaging. In all cases, null hyphotheses H0: WT=Acta2+/−, H0: WT=Acta2−/−, H0: Acta2+/− = Acta2−/− were tested. For radius, length and mean aspect ratio measures, the alternate hypotheses were H1: WT>Acta2+/−, H1: WT>Acta2−/−, H1:Acta2+/− >Acta2−/−. For the middle curvature, arc/length ratio and narrowing count measures, the alternate hypotheses were: H1: WT< Acta2+/−, H1: WT
Radius Length

Middle Arc:Length Narrowing Mean Curvature

Right Internal Carotid WT vs. Acta2+/-

0.536

0.607

0.837

0.470

0.719

0.174

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.005

0.689

0.689

0.328

0.709

0.114

0.014

0.945

0.445

0.101

0.333

0.945

Right Posterior Cerebral WT vs. Acta2+/-

0.470

1.000

0.211

0.536

0.381

0.837

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.272

0.689

0.864

0.864

0.038

0.328

0.366

0.731

0.295

0.366

0.005

0.534

Right Superior Cerebellar WT vs. Acta2+/-

0.681

0.211

0.681

0.114

0.527

1.000

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.088

0.145

0.018

0.026

0.896

0.955

0.138

0.073

0.023

0.008

0.457

0.731

Right Anterior Cerebral WT vs. Acta2+/-

0.299

0.252

0.837

0.837

0.448

0.837

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.066

0.272

0.607

0.388

0.208

0.388

0.445

0.534

0.295

0.366

0.469

0.001

Left Internal Carotid WT vs. Acta2+/-

0.758

0.071

0.003

0.012

0.988

0.023

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.018

0.456

0.050

0.272

0.269

0.864

0.022

0.022

0.001

0.014

0.347

0.138

Left Posterior Cerebral WT vs. Acta2+/-

0.071

0.031

0.002

0.005

0.197

0.252

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.145

0.181

0.145

0.066

0.168

0.776

0.534

0.295

0.101

0.836

0.977

0.445

Left Superior Cerebellar WT vs. Acta2+/-

0.408

0.758

0.681

0.536

0.908

0.681

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.145

0.607

0.955

0.388

0.544

0.776

0.628

0.945

0.945

0.101

0.977

0.445

Left Anterior Cerebral WT vs. Acta2+/-

1.000

0.299

0.408

0.536

0.416

1.000

Acta2+/- vs. Acta2-/WT vs. Acta2-/-

0.328

0.456

0.955

0.864

0.641

0.224

0.234

1.000

0.295

0.731

0.918

0.445

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Paper #: 127 ASL Perfusion Patterns Reflects Chronological Rather than Gestational Age Judyta Loomis, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Matthew Whitehead Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: ASL perfusion has achieved notoriety as a means of evaluating intracranial blood flow noninvasively without intravenous contrast material. ASL intensity patterns evolve dynamically in the developing brain, most dramatically over the first year of life. We have observed the ASL patterns of premature, term-equivalent infants and term neonates to be dissimilar, with perfusion patterns conforming more to chronological age. We evaluated ASL perfusion patterns from a series of former premature, term-equivalent brain MR exams and compared them to those from term neonates. Methods & Materials: The diagnostic imaging report database at a single academic children’s hospital was retrospectively searched for all brain MR exams performed over 1 year in patients younger than 12 months. Exams were excluded on the basis of absent ASL sequences, artifact, abnormalities in brain structure, signal, and/or diffusion, and various medical conditions known to alter cerebral blood flow. Exams were evaluated by a board certified neuroradiologist and a 10 point scale was developed reflecting the typical progression of the ASL perfusion pattern in the neonate. Results: Seventy-five exams from 59 different patients met inclusion criteria, with 43 preterm and 32 term exams. Overall, ASL perfusion patterns appeared more strongly and positively correlated to chronological age (0-38 weeks) than gestational age (31-64 weeks) at exam (n=29 preterm; 30 term patients). ASL patterns were most variable and rose most rapidly during the first 4 weeks of life and stabilized after that time (median ASL grade of 6 vs.10, P-value=0.001 [Mann–Whitney test]). In all 14 patients with multiple exams (13 preterm, 1 term), ASL perfusion scores advanced on consecutive exams, irrespective of age at first exam. Conclusions: ASL perfusion patterns reflect chronological rather than gestational age. Intracranial vascular perfusion accelerates to meet circulatory, metabolic and stimulatory demands of the ex-vivo environment.

Paper #: 128 MRI Staging of Superficial Venous Thrombosis and Infarction in Children Jerome Rusin, Nathan Rusin, Hailey Tiarks, Deanna Horst, Lynne Ruess, MD, Radiology, Nationwide Children’s Hospital, Columbus, OH, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Diagnosis of superficial venous thrombosis (SVT) and infarction (SVI) can be challenging. We present the stages and imaging spectrum of severity of SVT/ SVI seen at presentation in children. Methods & Materials: An institutional review board approved a 14 year retrospective review of medical records and MR images of children with SVT/SVI. Medical records were reviewed for demographic data and onset of symptoms. All imaging studies were reviewed for location, size, and imaging appearance of thrombosis and infarction. Dural or leptomeningeal congestion, pial and/or parenchymal hemorrhage, and parenchymal vasogenic edema were also recorded. Results: One hundred six patients had 136 areas of SVT/SVI. Fifty-eight (55%) were males. Mean age=3 years 11 months. Median age=61 days (range: 0 days - 21 years). Temporal lobe location of SVT/SVI was most common (79, 58%). Patients with multiple SVIs frequently had SVIs of different ages at the time of their first MRI. Imaging findings revealed 5 stages and a spectrum of size and severity of SVT/SVI at time of presentation. STAGE 1 = SVT only, no parenchymal abnormality (37, 27%). STAGE 2 PRE-INFARCTION = SVT and normal DWI: 2A + dural or pial congestion (10, 7%); 2B + vasogenic edema (3, 2%) STAGE 3 ACUTE INFARCTION = SVT + SVI: 3A mild -small parenchymal hemorrhage (26, 19%); 3B moderate -small subpial hemorrhage (28, 21%); 3C severe - large subpial hemorrhage (15, 11%). STAGE 4 SUBACUTE LIQUEFACTION: 4A small (4, 3%); 4B large (4, 3%). STAGE 5 CHRONIC LIQUEFACTION: 5A small (5, 4%); 5B large (4, 3%). Conclusions: SVT/SVI may present at one of five stages. There is variable parenchymal injury and hemorrhage from mild to severe in the early stages. Presentation during the acute infarction stage was most common in our series.

Paper #: 129 Cavernous Sinus Thrombosis in Children: Imaging Characteristics and Clinical Outcome Aaron Lindsay, Children’s Hospital Colorado Department of Radiology, Aurora, CO, [email protected]; Craig Press, Laura Fenton, MD, Nicholas Stence, MD, Timothy Bernard, David Mirsky. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Cavernous sinus thrombosis (CST) is a rare though potentially life-threatening cerebrovascular disease in children. Several imaging features of CST and related complications have been reported in adults. We describe the presenting symptoms, imaging findings, treatment and outcome of CST in the largest reported cohort of children. Methods & Materials: Following IRB approval, the electronic medical record at a tertiary children’s hospital was reviewed for patients with CST from 2003 to 2013. Symptoms, computed tomography (CT) and

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magnetic resonance (MR) images, treatment and outcomes were reviewed. Outcomes were assessed using the modified Rankin Scale (mRS) at discharge and last clinic visit. Results: Eight patients with CST were identified ranging in age from 4 to 17 years (median age 10.5 years; 4 of 8 male). Seven children had associated sinusitis and one had otomastoiditis. The sphenoid sinuses and ethmoid air cells were most frequently involved (7/7). The most common presenting symptom was headache (7/8). Imaging characteristics (Table 1a) included: cavernous sinus (CS) expansion, filling defect and restricted diffusion; superior ophthalmic vein enlargement and thrombosis; orbital cellulitis; pituitary inflammation; carotid artery narrowing; arterial wall enhancement; cerebral infarct and epidural/subdural empyema. Optic neuritis was noted in three cases, all of which were clinically significant. Pituitary involvement was noted in four cases, only 1 of which was clinically significant. Infarcts were embolic and/or hypoperfusion related and did not typically lead to long-term impairment. Four patients became blind in the affected eye/s secondary to optic nerve injury or orbital exenteration. All patients underwent aggressive medical and operative management (Table 1b) with morbidity mostly related to inflammatory/ischemic neuritis. Median mRS was 1 (no significant disability) at discharge (range of 0-3) and 0 (no symptoms) at last clinic visit (range of 0-3). Conclusions: In children, CST most commonly complicates sphenoid and ethmoid sinusitis. The majority of patients with CST had CS expansion and filling defects, carotid artery narrowing, arterial wall enhancement, and enlarged or thrombosed SOV. Carotid artery narrowing and associated inflammation contributed to infarct in five children, however with little long-term impairment. All patients survived following aggressive medical and operative management and most morbidity was related to vision loss from inflammatory/ischemic neuritis. Table 1a

Table 1b

Imaging Characteristics of CST in Children Imaging Characteristic Number of Patients

Management and Outcome of CST in Child ren Medical Management Number of Patients

Cavernous Sinus Expansion Cavernous Sinus Filling Defect

7/8

Aspirin

2/8

8/8

Anti -coagulation

7/8

Restricted Diffusion of CS Enlarged SOV SOV thrombosis Other Sinuses/Veins Involved Orbital Cellulitis Optic Neuritis Pituitary Involvement

4/6 6/8 4/8 5/8 4/8 3/7 4/8

Steroids Calcium channel blocker Antibiotics Operative Management FESS Shunt Orbital Decompression

4/8 2/8 8/8

Carotid Artery Narrowing Arterial Wall Enhancement Cerebral Infarct Intraparenchymal Hemorrhage Extra-axial Hemorrhage Empyema (epidural/subdural) Meningitis Cerebritis/Abscess

8/8 7/7 5/8

Orbital Exenteration Mastoidectomy Craniotomy/irrigation

1/8 1/8 1/8

1/8 3/8*

Cerebral debridement Outcome

1/8

Median mRS at Discharge Median mRS at Last Follow Up Optic Nerve Injury/Blindness

1 0 4/8

8/8 5/8 2/8

7/8 2/8 2/8

CST – cavernous sinus thrombosis. CS – cavernous sinus. SOV – superior ophthalmic vein. FESS –functional endoscopic sinus surgery. mRS – modified Rankin Scale. * Two cases of extra-axial hemorrhage occurred post surgery and shunt revision while the patients were anticoagulated.

Paper #: 130 Vein of Labbé Thrombosis and Infarction in Children Jerome Rusin, Deanna Horst, Hailey Tiarks, Nathan Rusin, Lynne Ruess, MD, Radiology, Nationwide Children’s Hospital, Columbus, OH, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: To characterize the clinical presentation and MRI findings for Vein of Labbé (VOL) thrombosis and infarction. 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 during a 14 year period. Medical records were reviewed for demographic data, onset of symptoms and time to first imaging study. All imaging studies were reviewed for the presence and location of visible venous thrombosis, size and location of venous infarction, associated hemorrhage and any additional MRI finding. Results: Of the 106 patients with superficial venous thrombosis and/or infarction, 32 (30%) had VOL thrombosis and infarction. These 32 children had 40 VOL infarcts. 17 (53%) were female. Most (26, 81%) presented within 14 days of life. Seventeen (53%) had seizures at presentation. There were 11 (34%) right, 13 (41%) left and 8 (25%) bilateral VOL infarcts. Size of infarct varied: small (19, 48%), moderate (7, 18%), large (14, 35%). Most VOL infarcts had associated hemorrhage: parenchymal (32, 80%) and /or subpial (31, 78%) with 8 (20%) blood-blood levels at MRI. Most patients had other areas of hemorrhage: choroid plexus (10, 31%), subdural (10, 31%), intraventricular (9, 28%) and/or subarachnoid (1, 3%). Ten (31%) had other superficial venous infarcts. 12 (38%) also had deep venous thrombosis and 6 (19%) had deep venous infarction. Two (6%) infants had hypoxic ischemic encephalopathy. Conclusions: Patients with VOL thrombosis and infarction share similar clinical and radiological features. Hemorrhage is common.

Paper #: 131 MR of Infant Subdural Hemorrhage: Incidence, Etiology, and Imaging Differentiation Brandon Speidel, Children’s Hospital and Medical Center, Omaha, NE, [email protected]; Sandra Allbery, MD, Terri Love. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Traditional teaching is that infant subdural hemorrhage (SDH) raises strong suspicion of nonaccidental trauma(NAT). Benign enlargement of subarachnoid spaces of infancy (BESS) has been reported as rare in Neurosurgery literature and is controversial in radiologic literature; its incidence and typical appearance has not been well documented. We observed increased detection of subtle subdural collections and wanted to determine any association with BESS or other etiology and their incidence. Methods & Materials: IRB approval obtained. PACS search of infants < 24 months undergoing Brain MR from 8-01-13 to 4-10-14 yielded 288 exams. Twenty-five followup studies excluded, with remaining 263 cases. Reports searched for terms subdural collection or subdural hemorrhage, identifying 26 cases. MRs reviewed by radiologists to determine SDH location/extent, subarachnoid space(SAS) size, brain edema, or retinal hemorrhages. Chart review recorded exam indications; osseous, fundoscopic, anticoagulation results; Child Advocacy Team (CAT) consult, and final consensus diagnosis. Comprehensiveness of workup rated as 1complete NAT, 2-partial NAT, 3-Neurosurgery or Child Abuse Physician opinion; 4-lab diagnosis of anticoagulation Results: Incidence of SDH in infants < 24 months undergoing Brain MR was 26/263(10%). Final diagnoses were eight NAT, six BESS, four unknown but unlikely NAT, three anticoagulation, three birth trauma and two accidental trauma. Three identifiable patterns emerged. Unilateral or bilateral SDH limited to the cephalad high frontal convexity extending broadly in the anterior interhemispheric fissure without posterior involvement were seen in 6/6 BESS cases. All BESS had arachnoidmegaly,

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anterior SAS mean 10.5 mm (7-14 mm) compared with 3 mm (0-9 mm) with NAT. Normal SAS in literature < 5 mm. Diffuse multicompartmental SDH including extent along posterior convexities were seen in 8/8 NAT cases. Multiple parenchymal microhemorrhages associated with lateral hemispheric SDH were seen in 3/3 anticoagulation cases. Level of workup 1(8/26), 2(7/26), 3(9/26), 4(2/26). Conclusions: Infant SDH is not pathognomonic for abuse, with BESS etiology nearly as common (23%) as NAT (31%). High anterior frontal SDH location abutting the sagittal venous sinus with arachnoidmegaly was typical of BESS compared to diffuse multicompartmental SDH with NAT and lateral hemispheric SDH with parenchymal microhemorrhages seen with anticoagulation. Our study is limited by small sample size and results need to be confirmed with a larger prospective study.

Purpose or Case Report: There are a variety of magnetic resonance enterography (MRE) protocols published in the literature; to our knowledge all suggest the utilization of two intravenous (IV) doses of antiperistaltic agent to avoid bowel motion artifact. Administration of the first dose of antiperistaltic agent occurs after bowel motion study with 3D balanced steady-state free precession sequence and the second dose is administered just before IV contrast media administration. Antiperistaltic drugs have a short window of action, thus two doses are given to avoid peristaltic artifact. In an attempt to simplify the protocol, we aim to assess the impact of omitting the first antiperistaltic dose on the quality of the study. Methods & Materials: MRE studies performed from October 2013 to February 2014 were reviewed. 15 patients were identified as receiving one dose of antiperistaltic agent. The comparison group was 8 patients that received two doses. The MRE sequences were the same and acquired in the same magnet for both groups (Siemens Symphony vb17). The imaging protocol was coronal cinetruefisp, coronal HASTE with fat saturation, axial HASTE, axial diffusion, coronal VIBE pre contrast and axial and coronal VIBE post contrast. The first and second dose were administered after cine-truefisp, and together with IV contrast media administration, respectively. For the group with one dose, the agent was given pre acquisition of coronal VIBE precontrast. Two board certified pediatric radiologists assessed the images, blinded to the number of doses. Bowel motion, distention, and diagnostic quality of the study were assessed. Results: HASTE quality was unaffected by bowel motion in all patients. Thus, the utilization of the first dose in the group with two doses had no significant effect on the assessed variables. Increased bowel motion artifact was noted on the coronal VIBE pre contrast in the group that received two doses of buscopan, p= 0.38. Bowel motion artifact on coronal VIBE post contrast media administration decreased in the group with two doses, however this difference between groups was not statistically significant. Bowel distention was not statistically significantly different between groups. Two studies were considered non diagnostic in the group of one dose and one study was non diagnostic in the group of two doses. Conclusions: The utilization of one dose of antiperistaltic agent instead of two appears to have no significant impact in image quality and can be used as an alternative protocol.

Paper #: 133 Magnetic Resonance Spectroscopy (MRS) in Infants with Non-Accidental Mild Traumatic Brain Injury Mona Tafti, MD, Loma Linda University Medical Center, Loma Linda, CA.

Paper #: 132 Optimization of MR Enterography Protocol: One or Two Doses of Antiperistaltic Agent? Simone Chaudhary, MD, Jorge Davila, Nina Stein, Pediatric Radiologist, Diagnostic Imaging, McMaster University, Mississauga, ON, Canada, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To investigate the role of MRS in NAT/mTBI in infants less than 2 years of age. Methods & Materials: A retrospective single-center review of the clinical and imaging records of 67 infants, who presented to our ED for evaluation for suspected NAT from 2001 to 2008, was conducted. Our inclusion criteria included infants less than 2 years of age with an initial GCS score of 13–15 (i.e., mTBI). Records were examined for the occurrence of initial presenting symptoms and presence of imaging abnormalities in patients who also had 2DCSI (PRESS; TE=144 msec) through the level of the corpus callosum. Regional metabolite ratios (NAA/Cr, NAA/ Cho and Cho/Cr) were measured. Outcomes were recorded as Pediatric

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Cerebral Performance Category Scale (PCPCS) during follow-up examination in a Pediatric Neurology clinic. PCPCS data was dichotomized into good (normal to mild disability) and poor outcome (moderate to severe disability). Correlations between the MRI findings and metabolite ratios were made using the Spearman’s rho test. Differences between group metabolite ratios were tested using the Mann–Whitney U test. Results: In the 67 infants, the mean age was 7 months (±7.7 months) and the mean initial GCS score was 14.6 (±0.6). Forty seven outcomes were recorded with the mean follow-up of 10 months (±13 months). Infants with good outcome (7.3 months±6.9) were significantly older compared to poor outcome (4.2 months±2.3). NAA/Cr ratios were significantly reduced in the corpus callosum, frontal white, frontal and occipital gray matter in the poor outcome group (p<.04). Significant correlations between all regional NAA/Cr ratios and the presence of ischemic injury on MRI (DWI) were found (p<.05). Conclusions: MRS is a valuable tool, which can add clinically significant information regarding outcomes in the pediatric population who present with mild traumatic brain injury.

Paper #: 134 Sensitivity and Specificity of Lipid /Lactate Peaks on MR Spectroscopy for Prediction of Grade in Pediatric Gliomas Farhan Ahmed, Radiology, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada, [email protected]; Nishard Abdeen, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To evaluate the predictive value of lipid/lactate peaks in establishing the grade of pediatric gliomas and correlation with clinical outcome. Methods & Materials: Thirty one pediatric patients with cerebral glioma having undergone MRI with MR spectroscopy were included. MR spectra (single voxel PRESS, voxel size 1 cc, TE 35 ms) were performed at 1.5T on a GE Signa or HDXt scanner at time of initial diagnosis. If a peak was seen at 1.3 or 0.9 ppm, a lipid/lactate peak was considered to be present. Pathology records were reviewed and WHO grade of tumour recorded. Grades 1 and 2 were considered low grade and grade 3/4 as high grade. Tumour relapse, progression, or death of the patient was obtained from the clinical chart, and outcome was considered poor if any of these three were present. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the presence of a lipid/lactate peak for grade and poor clinical outcome were calculated. Results: Of 31 patients, 13 had lipid/lactate peaks on initial MR spectroscopy. Two of these patients had a peak at 1.3 ppm only (both thalamic gliomas) while the remainder had peaks at 0.9 and 1.3 ppm. High grade histology was present in 10/13 while 3/13 were low grade. All three of the low grade tumours were juvenile pilocytic astrocytomas. The 18 patients who had no lipid/lactate peaks included 2 high grade and 16 low grade tumors. Sensitivity of the lipid/lactate peak for presence of high grade tumor was 83%, specificity 84%, PPV 76% and NPV 89%. With respect to clinical outcome, two patients both with high grade tumor and lipid/lactate positive, were undergoing active treatment and excluded from analysis. Of 11 remaining lipid positive patients, 8 had a poor outcome. Of the 18 lipid lactate negative patients, 3 had a poor outcome. PPV for a poor outcome was 73% while NPV was 83%. Conclusions: The presence of lipid /lactate peaks at 0.9 and 1.3 ppm in pediatric gliomas are predictive of higher grade, and also increase the risk of relapse, progression or death. Performing MR spectroscopy at 35 ms TE is therefore useful for prognosis.

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Paper #: 135 MR Imaging Findings Associated with Poorer Outcome in Intracranial Ganglioglioma Laura Fenton, MD, Radiology, Children’s Hospital Colorado, Aurora, CO, [email protected]; Rao Patibandla, Todd Hankinson, Michael Handler, Kathleen Dorris, Nicholas Stence, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The most familiar appearance of intracranial ganglioglioma (GG) is a small, cortically based temporal lobe mass in a child presenting with seizures, typically amenable to gross total resection with excellent outcome. However, gangliogliomas are known to arise in other locations, often with atypical imaging findings. We aim to describe the variable imaging findings of GG and correlate with outcome. Methods & Materials: Following Institutional Review Board approval, in collaboration with the neurosurgical and neuro-oncology departments, the neuro-oncology database was searched from 1996 through 2014 for children with intracranial GG. All imaging was reviewed and MR imaging findings were documented by two board certified pediatric radiologists. The medical record (EPIC) for each child was reviewed for demographics, presenting symptom/s, pathology, treatment and outcome. Patients were categorized as excellent outcome if no further treatment was necessary after surgery, and poorer outcome if tumor progression led to repeat surgery, radiotherapy, chemotherapy, or death. Fisher’s exact test with two-tailed P value was used to compare categorical data. Results: Thirty-six patients with intracranial GG were included. Twenty patients had an excellent outcome. Imaging findings are summarized in Table 1. Findings significantly associated with excellent outcome include temporal lobe location, maximal diameter less than 3 cm and wellcircumscribed appearance. Poorer outcomes were significantly associated with location in brainstem (with or without cervical cord involvement), size greater than 3 cm, expansile/infiltrative appearance, surrounding vasogenic edema, ventriculomegaly, and heterogeneous enhancement. Histopathologically, all excellent outcome GGs were WHO grade I, while 4/16 (25%) tumors in the poorer outcome group had aggressive features. Gross total resection was achieved in 15/20 typical tumors and in 2/16 poorer outcome tumors. There were six deaths (38%) in the poorer outcome group. Conclusions: The tumors in the excellent outcome group corresponded with the classic GG - small, well-circumscribed temporal lobe lesions. Compared to these patients, the tumors in those patients with poorer outcomes were significantly more often located in the brainstem/cervical cord, larger in size, more often infiltrative/expansile, and associated with surrounding edema and ventriculomegaly. Several of these features make these tumors less amenable to gross total resection, at least partially explaining the poorer prognosis. Table 1. GG Imaging Findings

Supratentional Temporal Frontal or Parietal Deep Gray Matter Infratentional Cerebellum

Outcomes Excellent Poorer n=20 n=16 15 0 3 3 1 2 1 0

Brainstem+/−Cervical 0 Cord <3 cm 17

P-value <0.0001 1 0.5742 1

11

<0.0001

1

<0.0001

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Conclusions: Diffusion Tensor Imaging is an effective and reliable tool to demonstrate language lateralization prior to epilepsy surgery

3

15

19 1 12 8 2 2 *6 7

3 13 5 11 9 7 1 2

0.1065

Paper #: 137

0.0042 0.0491 0.6287 0.1251

Routine Imaging in Preparation for Bone Marrow Transplantation: Are Abdominal CTs Necessary?

6

12

0.0204

<0.0001

* 2 Excellent outcome patients did not have post contrast imaging

Paper #: 136 Utility of Diffusion Tensor Imaging for Language Lateralization prior to Epilepsy Surgery Sheena Saleem, DNB, MBBS, Deniz Altinok, Children’s Hospital of Michigan, Detroit, MI, [email protected]; Ammar Al-Ibraheemi, Yaser Al-Qasimi, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Diffusion Tensor Imaging is routinely performed on all Epilepsy patients and unlike Functional MRI(fMRI) is not dependent on patients age and ability to cooperate for fMRI To determine the utility of Diffusion Tensor Imaging as an adjunctive tool for predicting the dominant hemisphere or language lateralization prior to epilepsy surgery Methods & Materials: Pre Epilepsy Surgery Brain MRI exams which included both Functional MRI and Diffusion Tensor Imaging between August 2011 and August 2014 were retrospectively reviewed. We studied the relative fiber density (RFD) of the arcuate fasciculus (AF) using diffusion tensor imaging (DTI) and compared the results to Functional MRI hemispheric language lateralization Results: Twenty patients were identified ranging between 11 and 21 years of age. Twelve patients were right handed and eight patients were left handed. We demonstrated an overall significant degree of AF structural asymmetry that correlated with the degree of functional lateralization Arcuate Fasciculus dominance on DTI was concordant with Language Lateralization on fMRI in 16 patients (80%). This included nine right handed patients and seven left handed patients. Interestingly, one left handed patient demonstrated bilateral symmetrical Arcuate fasciculus relative fiber density, concordant with bilateral language area symmetry on fMRI Discordant Results were as follows: Arcuate Fasciculus dominance on DTI was discordant with Language Lateralization on fMRI in one patient - Left handed patient with Language Lateralization on fMRI on the right and Arcuate fasciculus dominance on DTI on the left Inconclusive Results were as follows and further delineation was made by cortical activation: Right handed patient with bilateral Language Lateralization on fMRI and Arcuate fasciculus dominance on the left Right handed patient with bilateral Language Lateralization on fMRI and bilateral symmetrical Arcuate fasciculus relative fiber density Right handed patient with Language Lateralization on fMRI on the left and bilateral symmetrical Arcuate fasciculus relative fiber density

Sue Kaste, DO, St. Jude Children’s Research Hospital, Memphis, TN, [email protected]; Robert Kaufman, Guolian Kang, Anusha Sunkara, Wing Leung, Ashok Srinivasan. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine whether or not continued use of abdominal CTs is substantiated as routine imaging preparation for bone marrow transplantation to determine presence or absence of infections and fungal disease. Methods & Materials: With IRB approval, two senior pediatric radiologists retrospectively reviewed all CTs of the chest and abdomen performed immediately prior to allogeneic hematopoietic stem cell transplantation (HSCT) from 9-5-2012 thru 9-30-2013. Primary diagnosis was leukemia 51 (76.1%), non-malignancy 13 (19.4%), solid tumor 3 (4.5%). We coded presence, absence and characteristics of pathology (e.g. infiltrates, nodules, metastases, adenopathy), likelihood of infection, particularly fungal disease; we analyzed findings with galactomanaan assay and patient factors (e.g., demographics, diagnosis, treatment protocol) using descriptive statistics, logistic regression and McNemar’s test. Results: Seventy patients underwent pre-HSCT CTs; three were excluded from analysis (N=67 cohort). Median age at HSCT 8.6 years (0.220.4); 36 male. Median absolute neutrophil count 500 (0.0-4400). Seven had prior known fungal disease; two of which had persistent imaging abnormalities. Of 24 abnormal chest CTs, 16 attributed to Infections, (nine consistent with fungus). Of nine abnormal abdominal CTs, four attributed to infections, (one consistent with fungus). There were three cases of normal chest CT and abnormal abdominal CTs: at follow-up, abdomen findings normalized in two, splenectomy revealed infarcts in the third. Older age at time of HSCT (p=0.01) was significantly associated with chest CT abnormalities; no clinical variable was associated with infection/fungus in the chest or abdomen. No variables were significantly associated with abdominal abnormalities. Using McNemar’s test, chest findings were far more prevalent than abdominal (p=0.0006). Older patients had more chest CT abnormalities than younger [odds ratio (95% CI, 1.10; 1.01, 1.20)]. Using McNemar’s test, abnormal chest CT with normal abdomen CT is far more common than normal chest CT and abnormal abdomen CT; frequency of 13.6 vs 1.5%, respectively (p=0.01). Conclusions: in the absence of significant history or clinical findings that suggest intraabdominal disease, and with negative galactomanaan assay, the risks of including the abdomen in routine pre-transplant screening are not justified by the small benefit and may unnecessarily expose children to the risk of added radiation and intravenous contrast administration.

Paper #: 138 Knowledge-Based Iterative Reconstruction vs Hybrid Iterative Reconstruction in Reduced kV Pediatric Body CT: Comparison of Image Quality and Reader Preference Claudia Martinez-Rios, MD, University Hospitals Case Medical Center Case Western Reserve University, Cleveland, OH, [email protected]; Sara Texteira, Dayna Weinert, David Jordan, Philip Yen, Sheila Berlin, et al.

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Disclosures: Claudia Martinez-Rios, Research agreement between Case Western Reserve University and Philips Healthcare, Research Fellow. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare image quality and radiologist preference in reduced kV pediatric body computed tomography (CT) reconstructed with knowledge-based (KIR) and hybrid iterative reconstruction (HIR). Methods & Materials: Sixty-five oncology patients [mean age 9.7± 6.1 year; median weight 31.8 kg (15.5, 51)] underwent enhanced CT of the chest (n=31), and abdominopelvic (n=34). CT protocols were based on body width (BW): 80 kV for BW≤18 cm, 100 kV for BW of 19-30 cm and 120 kV for BW >30 cm. CT data was reconstructed with a standard HIR level and three levels of KIR algorithms at a fixed body region-algorithm. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were estimated. Four blinded readers (three pediatric and one general radiologist) with 28, 19, 2 and 3 years of experience independently reviewed image data sets for image quality and algorithm preference. Statistical analysis included descriptive statistics, frequency analysis, and sign rank test. Results: Mean dose metrics were: CT Dose Index (CTDIvol): 4.8± 2.8 mGy, Size Specific Dose Estimates (SSDE): 7.3±3.1 mGy, Effective Dose (ED): 4.4±3.5 mSv. KIR images had significantly less noise (P< 0.001) compared to HIR (mean 10.1 versus 19.04 HU). CNR and SNR were higher on KIR for the chest (P<0.01) and for the abdomen (P< 0.001), but not statistically significant when comparing HIR to KIR Level 1 for the chest (P=0.07). CNR and SNR for the lung parenchyma were different within both KIR and HIR compared to measurements of the aorta and soft tissues (P<0.001). On average, KIR Level 1 was the preferred image algorithm among readers for chest and abdomen (64.5 and 92.1%), IMR Level 2 (41.9 and 32.3%), and IMR Level 3 (26.9 and 26.4%). Agreement among readers was fair-to-poor for the subjective assessment of KIR images. However their overall image quality and visibility of normal structures with KIR were rated as equivalent to superior compared to HIR in > 74.2% of chest and > 90.1% of abdominal cases. Conclusions: KIR Level 1 demonstrates equivalent to superior diagnostic image quality compared to HIR and is the preferred method of reconstruction among experienced and novice readers to assess reduced kV enhanced body CT in pediatric oncology patients.

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Addition of SPECT/CT should permit accurate localization of sentinel nodes in relation to tissue planes and anatomic structures. Methods & Materials: Thirty-six pediatric and young adult patients (ages 0.2-32 years, median 14 years) with newly diagnosed sarcomas or melanoma underwent lymphoscintigraphy with SPECT/CT under an IRB approved prospective protocol. Five patients were excluded because there was very little or no movement of the injected radiopharmaceutical. Of 31 remaining patients, 27 had sarcomas and 4 had melanoma. Injection sites were head or neck in 2, trunk in 8 and extremities in 21. Four locations around the periphery of the tumors were injected with filtered Tc-99msulfur colloid 0.4 mCi (15 MBq) per injection. Planar gamma camera imaging began immediately with the injection sites at the edge of field of view. Images were repeated every 3 to 5 min. When movement of the radiopharmaceutical was detected, the camera position was advanced towards the expected location of lymphatic drainage. If the drainage pattern required monitoring of more than one lymphatic bed, the camera position was alternated between the two or more potential drainage sites. When the sentinel node was identified, the camera detector was repositioned using the camera’s bed positioning index and including the sentinel node. Then SPECT with low dose co-registered localization CT was performed. All images were reviewed with the treating surgeon preoperatively to aid in anatomic localization. 1.5 to 3 h later, the sentinel node was resected in the operating room with aid of the SPECT/CT localization images and a hand-held gamma probe. Results: Sentinel nodes were identified in all 31 patients with adequate movement of the radiopharmaceutical, and 5/31 (16%) of the sentinel nodes were positive for tumor by microscopy. SPECT/CT facilitated identification of the sentinel node in every patient, potentially reducing anesthetic time and guiding incision placement. In all patients SPECT/CT was found to be essential by the surgeon for accurate anatomic localization of the sentinel node. Comparison of planar and SPECT/CT images was facilitated by use of the bed positioning index. Conclusions: SPECT/CT provides excellent 3D localization for identification of sentinel lymph nodes in the operating room and may decrease operating room time.

Paper #: 140 Paper #: 139 Addition of SPECT/CT to Lymphoscintigraphy Facilitates Sentinel Node Localization in Pediatric Patients Michael Gelfand, MD, Department of Radiology, Cincinnati Children’s Hospital, Cincinnati, OH; Roshni Dasgupta, Lars Wagner, Gregory Tiao, Daniel von Allmen, Susan Sharp, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Serial planar imaging is used for sentinel node identification, but anatomic localization is imprecise on planar images.

Is 18F-DOPA accurate in Localizing Insulinomas within the Pancreas? Theodore Gupton, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Susan Becker, Lisa States. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To retrospectively assess the accuracy of the 18 F-DOPA radiotracer in localizing insulinomas in patients with hyperinsulinism. Methods & Materials: Subsequent to IRB approval, the medical record at our institution was searched for imaging and pathology data related to all patients with clinically suspected insulinoma that had been treated since 2010. Any patient who did not undergo 18F-DOPA PET imaging was excluded. Additionally, all results of non-PET imaging employed in the patients’ work-ups were assessed. A positive PET-CT finding was defined as focal pancreatic parenchymal uptake above background pancreatic activity qualitatively assessed by either a nuclear or clinical radiologist. The results of the PET-CT were correlated with the intraoperative findings and pathologic diagnosis. Results: Between 2010 and 2014, nine patients ages 3-20, with clinically suspected insulinoma, received a PET-CT with 18F-DOPA. Five patients received a pathologically proven diagnosis of insulinoma, and three (60%) of these cases were positive on PET-CT with the scan accurately

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localizing the tumor to the locus found at surgery. The other two patients had negative PET-CTs. Of the three patients who had a positive PET-CT and insulinoma, one (33%) also had positive findings with other imaging modalities (MRI, CT, Octreotide scan, and ultrasound). There were no cases of positive non-PET-CT imaging in the setting of a negative PETCT. One patient with insulinoma and negative imaging, had a diffusely positive trans-hepatic portal venous sampling (THPVS) study, but the exam did not effectively localize the tumor within the pancreas. Three patients did not receive surgery and were treated medically. Conclusions: In a five-year experience at our institution, 18F-DOPA was accurate in localizing insulinoma in a small majority of patients. The two insulinoma cases that were not identified on PET-CT were found at surgery to be located within the head of the pancreas. Physiologic activity is known to be greater in the head compared with other regions of the pancreas. This suggests that a limitation of 18F-DOPA may be the obscuration of small insulinomas located in the head of the pancreas. Furthermore, the small population limits assessment of the true diagnostic yield of 18F-DOPA PET-CT for insulinoma, and further study is needed to more fully evaluate the performance of 18F-DOPA for this indication.

Conclusions: DSRCT is a rare, multifocal peritoneal malignancy with frequently disseminated abdominal disease at presentation. In the abdomen, the disease most commonly involves the omentum and peritoneum, followed by the retroperitoneum. Liver is the most common solid visceral metastatic site. A substantial number of patients have diaphragmatic involvement. In the thorax, nodal and pleural involvement is more common than lung parenchymal involvement. About 13% of cases showed calcifications.

Paper #: 141 Desmoplastic Small Round Cell Tumor: A Comprehensive, Single-Institution Study of 94 Cases Ajaykumar Morani, MBBS, DNB, MD, Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, [email protected]; Andrea Hayes-Jordan, Venkateswar Surabhi, Tharakeshwar Bathala, Winston Huh, Srinivasa Prasad Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Desmoplastic small round cell tumor (DSRCT) is a rare, biologically aggressive, multifocal primary peritoneal sarcoma in pediatric and young adult patients. The characteristic t(11;22)(p13;q12) translocation involving fusion of EWS & WT1 genes and unique pathological findings are important diagnostic features of this tumor. Its imaging features overlap with several aggresive entities, however certain imaging features can suggest its diagnosis and guide treatment. The purpose of this article is to evaluate clinico-pathological and multi-modality, cross-sectional imaging features of a cohort of 94 cases of desmoplastic small round cell tumor (DSRCT). Methods & Materials: An IRB-approved, HIPAA-compliant, retrospective study of patients with DSRCT treated at a tertiary cancer center between 2001 & 2013, yielded 94 cases. Epidemiological, clinical and pathological data as well as imaging findings were recorded. Tumor size, location, morphology, and distribution pattern of metastases at the time of presentation, were analyzed. Results: DSRCT occurred in young patients with a median age of 21.5 years (age range 5-53 years) and a marked male predilection (M:F=86:8). The 89 cases were white (Caucasian or Hispanic), four were African-American, and one of Asian descent. Most patients were symptomatic with abdominal pain being the most common symptom. At initial presentaton, 85 patients showed multifocal, nodular &/or diffuse omental and peritoneal disease. Thirty-eight patients had diaphragmatic involvement. In addition, 32 patients had liver metastases, 2 cases had pancreatic involvement, and 1 had renal involvement. The 49 patients had retroperitoneal involvement in the form of implants, tumoral extension or nodal involvement. In the thorax, 33 had nodal disease, 17 had pleural effusion, and only 2 cases had lung metastases at presentation. One patient had intracranial metastasis and 2 had bony metastases at presentation. Twelve patients showed calcific lesions.

Paper #: 142 The Post-Radiation Quandary: Imaging Characteristics and Implications of Ewing Sarcoma treated only with Chemoradiation Grace Mitchell, MD, MBA, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected];. Andrew Zbojniewicz, MD, Luke Pater, MD, Brian Turpin, Michael Gelfand, MD, Andrew Trout, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Most patients with Ewing sarcoma are treated with chemotherapy followed by surgical resection. Radiation therapy is generally reserved for local control of unresectable primary tumors and symptomatic metastases. We have observed persistent FDG-PET and MR abnormalities of unknown clinical importance at the primary tumor site in these patients. The purpose of this study is to characterize the MR and PET imaging appearance of tumors treated with radiation, and to determine the clinical significance of those findings. Methods & Materials: Oncology records were reviewed to identify all patients treated with radiation for local control between September 2000 and April 2013 at our institution. Patients were excluded if they had subsequent surgical resection or did not have imaging at our institution. FDG-PET and MR examinations of the primary site at diagnosis and throughout therapy were reviewed by radiologists with subspecialty training in nuclear radiology and musculoskeletal imaging. Imaging findings were correlated with clinical and pathologic data, including site and date of disease recurrence. Results: Of 30 patients identified, 13 met inclusion criteria. Twelve patients had both FDG-PET and MRI exams, and one patient had only FDG-PET exams. Seven patients (53.8%) had no findings of metastatic disease at presentation. None of these patients had local or distant recurrence of disease over a mean of 4.6 years follow up (range: 15 months-

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11 years). Six patients (46.2%) had metastases at presentation. Of these patients, 1/6 had no recurrence, 3/6 had recurrence at the primary site and 4/6 had distant recurrences.

All three local recurrences were clearly evident by FDG-PET as increased FDG avidity (SUVmax 3-7.9), and/or as an increase in size of the primary mass by MRI. In patients with distant recurrence only, there were no clear FDG-PET or MR findings at the primary site to suggest recurrence. For the patient without local or distant recurrence, low level FDG uptake persisted at the primary site throughout follow up (SUVmax 1.8-3). On MRI, heterogeneous enhancement of solid components persisted at the primary site in all patients. Conclusions: Ewing sarcoma treated with radiation for local control will show persistent low-level abnormalities by both MR and FDG-PET throughout follow up, even in the absence of recurrence. Local recurrences are obvious by both MR and PET, but the imaging characteristics of the primary site are not predictive of distant recurrence.

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an absent hepatic or celiac artery, 11 with abnormal hepatic venous connections, and 4 with combined hepatic and portal venous abnormalities. The median tumor size for patients with an associated hepatic arterial, portal venous, or hepatic venous abnormality was 10.1 cm while those without an associated abnormality was 8.9 cm. Tumor size was not significantly different between the two groups (Z-score -1.68; p-value: 0.09) although no vascular abnormalities were seen in patients with masses less than 5 cm.

Conclusions: There is a high frequency of hepatic vascular abnormalities in patients presenting with hepatoblastoma. It is uncertain whether these vascular abnormalities occur as a response to the tumor or reflect congenital abnormalities of the hepatic development that predispose the child to develop a malignancy.

Paper #: 144 Paper #: 143 High Frequency of Hepatic Vascular Abnormalities in Children with Hepatoblastoma Matthew Plunk, MD, Radiology, Cincinnati Children’s Hospital, Cincinnati, OH, [email protected]; Andrew Trout, MD, James Gellar, Gregory Tiao, Alexander Towbin, MD, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Hepatoblastoma is the most common hepatic malignancy in infants and children. We have observed that children with hepatoblastoma often have abnormalities of the hepatic vessels including absence of the hepatic artery, abnormal configurations of the hepatic veins, and presence of portosystemic connections (Figure). An association between hepatoblastoma and vascular abnormalities has not been reported in the literature. The purpose of this study was to determine the frequency of these abnormalities in a cohort of patients with hepatoblastoma. Methods & Materials: Two pediatric radiologists retrospectively reviewed all MRI examinations in patients diagnosed with hepatoblastoma at our institution between January 2001 and June 2014. For each patient, the presence of anatomic abnormalities of the hepatic artery, hepatic vein, and portal vein were recorded. The presence of vascular anomalies was correlated to tumor size (maximal diameter) by a two tailed Z test with a p-value<0.05 considered significant. Results: A total of 31 patients were diagnosed with hepatoblastoma during the study period and had an MRI at the time of diagnosis. Of these patients, 15 (48%) were identified to have a co-existent vascular abnormality: 2 with

Do MRI Imaging Features Predict tumor Histology in Hepatoblastoma? Matthew Plunk, MD, Radiology, Cincinnati Children’s Hospital, Cincinnati, OH, [email protected]; Alexander Towbin, MD, Andrew Trout, MD, Anita Gupta, Rachel Sheridan, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Radiogenomics is an emerging field that aims to correlate the radiologic appearance of tumors with tumoral gene expression with the ultimate goal of non-invasively predicting the presence or absence of gene mutations relevant to therapy. While radiogenomics has been applied to several malignancies more common in adults, it has not been explored in pediatric malignancies. The purpose of this study was to begin radiogenomic analysis of hepatoblastoma through correlation of MR imaging features with tumor histology. Methods & Materials: In this IRB approved, HIPAA compliant retrospective study we reviewed MR imaging performed at diagnosis in all patients diagnosed with hepatoblastoma at our institution between January 2001 and June 2014. Patients were included if they received an MRI and biopsy prior to the initiation of chemotherapy. Two pediatric radiologists reviewed all exams for a wide array of imaging features including parameters such as signal intensity and enhancement dynamics as well as morphologic features such as presence of a capsule, internal septations, central scar, and internal T1 or T2 hyperintense foci. Two pediatric pathologists then reviewed each tumor where histology was still available and classified the histology based on the current international pediatric liver

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tumor consensus classification system. Imaging findings were then correlated to histology using chi-square analysis. Results: A total of 32 patients were initially included in this study. Two patients were excluded based on pathologic review. Among the remaining 30 patients, the presence of internal T2 hypointense septations (p value: 0.001) and internal T1 hyperintense foci (p value: 0.046) were significantly associated with presence of mesenchymal elements on biopsy. The presence of a central scar and internal T2 hyperintense foci (p value: 0.098-0.099) approached significance as predictors of mesenchymal elements. Tumor margin, diffusion restriction, and presence of internal fat or capsule were not significantly associated with specific histologies (p values: 0.46-0.50). Conclusions: The presence of T2 hypointense septations and internal T1 hyperintense foci were predictive of mesenchymal tumor components. Other imaging features that are clearly distinct between tumors, however, do not appear to correlate with a specific histology. We suspect that the presence of some of these distinct imaging features will be subsequently identified to correlate with genomic alterations that are not reflected in conventional histology.

to measure peak enhancement (PE), time to peak, rate of enhancement (RE), area under the curve during wash-in (AUC1), AUC during wash-out (AUC2) and AUC2:AUC1. With Cox regression analysis we assessed the correlation between changes in parameters from baseline to follow-up time points and time to progression (TTP) based on conventional response evaluation in solid tumor (RECIST) criteria (tumor size). Injections and ROI analyses were performed by one investigator who was blinded to RECIST response. P-values≤0.050 were considered significant. Results: The four girls and nine boys, mean age 13 years (range, 1.8 to 19.8 years), had diagnoses of; rhabdomyosarcoma (n=2), rhabdoid tumor (n=2), Wilms tumor (n=2), renal cell carcinoma (CA; n=2) and hepatocellular CA, osteosarcoma, synovial sarcoma, epithelioid sarcoma and Ewing sarcoma (n=1 each). Target lesion sites included; liver (n=3), pleura (n=2), and supraclavicular mass, soft tissue component of bone metastasis, lung, retroperitoneum, peritoneum, lymph node, muscle mass and perineum (n=1 each). Changes in PE (p=0.034), RE (p=0.029) and AUC1 (p=0.040) from baseline to end of course 1 were significantly associated with TTP (median TTP, 93 days). Changes in PE between baseline and Day3 (p =0.051) and AUC2 from baseline to Day 7 (p=0.053) were marginally significant. Subjects with smaller decreases, or increases, in these parameters at end of course 1 had shorter TTP. Conclusions: On CEUS, changes in target lesion PE, RE and AUC1 were significant early predictors of TTP in children with recurrent solid tumors treated with anti-angiogenic therapy and occurred before conventional RECIST progression. Our findings provide proof of principal for the role of CEUS in this setting and warrant investigation in larger pediatric clinical trials.

Paper #: 146 Imaging Features of Neuroblastoma in Patients Presenting with Opsoclonus-Myoclonus Syndrome: A Multi-Institutional Experience Robert Jones, MD, Radiology, Duke University, Durham, NC, [email protected]; Charles Maxfield, Michael Paldino, MD.

Paper #: 145 Contrast Enhanced Ultrasound in the Assessment of Pediatric Solid Tumor Response to Anti-Angiogenic Therapy Beth McCarville, MD, St. Jude Children’s Research Hospital, Memphis, TN, [email protected]; Jamie Coleman, Junyu Guo, Yimei Li, Xingyu Li, Fariba Navid. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To investigate the value of contrast enhanced ultrasound (CEUS) in assessing pediatric solid tumor response to antiangiogenic therapy. Methods & Materials: From 11/2008 to 8/2013, 13 children with recurrent solid tumors enrolled on an institutional Phase I study of sorafenib, bevacizumab and metronomic cyclophosphamide, underwent CEUS of target lesions before therapy, on Day3, Day 7 and end of course 1. Contrast was given via bolus injection into central (n=12) or peripheral (n=1) IV lines, in doses of 0.3 mL for subjects < 20 kg and 0.5 mL if ≥ 20 kg. Using contrast specific software, imaging was recorded at 10 frames/s for 60 s after injection. Acoustic data was used for target lesion region of interest (ROI) analysis

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Opsoclonus myoclonus syndrome (OMS) is a rare entity characterized by uncontrollable eye movements (opsoclonus), body jerking (myoclonus), and ataxia. It is often associated with cognitive defects and personality changes. In young children, OMS is most frequently a paraneoplastic presentation of neuroblastoma (NB), likely on an immune basis. Tumors in this setting have a good oncologic prognosis and removal has been shown to improve neurologic outcomes. Therefore, the clinical presentation of OMS should prompt an imaging workup for NB. The goal of this study is to define the typical imaging characteristics of NB occurring in the setting of OMS. Methods & Materials: We retrospectively reviewed imaging and clinical data of all patients from three institutions with NB presenting with OMS. Imaging included computed tomography (CT), magnetic resonance imaging (MRI), ultrasound and nuclear imaging with MIBG. Studies were evaluated for the presence, location, and size of tumors, as well as for their imaging appearance at MRI and CT. Records were reviewed for age at presentation, character and duration of clinical symptoms, tumor histology, as well as oncologic and neurologic outcomes. Results: Nineteen patients (age: 13 months to 4 years) presenting with OMS were found to have NB. All tumors were Grade I (n=13) or II (n= 6), and all but two had favorable histology. Only 1 patient had elevated urinary catecholamines at presentation; 2 had MYCN gene amplification. Although no patient died as a direct result of tumor progression, 15/19

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patients (79%) experienced long-term neurologic deficits. Compared to NB with other presentation, tumors in the setting of OMS tended to be: 1. Small (mean diameter: 2.1 cm; p<0.04); 2. Located in an extra-adrenal, retroperitoneal/paraspinal location (See example, Figure 1); 3. Markedly bright on T2-weighted images suggesting low cellularity; and 4. Homogeneous in CT attenuation, MR signal intensity, and enhancement. Tumors were located: 1. Retroperitoneal but extra-adrenal (n=12); 2. Adrenal (n=4); 3. Posterior mediastinum (n=2); 4. Neck (n=1). Two tumors were missed at initial cross-sectional imaging. Conclusions: NB occurring in the setting of OMS differs in appearance and location from NB with other presentation. These tumors are small and can be subtle or even missed at initial presentation. An understanding of these typical features will aid the radiologist’s search for these tumors.

Paper #: 147 In Vivo Assessment of Nanotherapeutic Delivery to Neuroblastoma in Orthotopic Mouse Models Zbigniew Starosolski, PhD, Pediatric Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Zaowen Chen, Anna Lakoma, Ketan Ghaghada, PhD, Jason Shohet, Ananth Annapragada, PhD, et al. Disclosures: Ananth Annapragada, PhD indicated a relationship with and Marval Pharma Inc, Alzeca LLC, and Sensulin LLC as a Stock holder. Purpose or Case Report: Nanoparticle chemotherapies facilitate specific delivery of highly toxic agents to solid tumors while minimizing systemic exposure and off-target toxicities. However, heterogeneity of nanoparticle uptake and distribution in solid tumors leads to inconsistent delivery, and highly variable outcomes. In this work, we utilized high-resolution CT imaging and a nanoparticle iodinated contrast agent, nanoprobe, to study uptake and distribution of nanoparticles in orthotopic mouse models of high-risk Neuroblastoma (NB), as a predictor of drug distribution in the tumors Methods & Materials: MYCN-amplified human NB cells (NGP) or MYCN non-amplified human NB cells (SH-SY5Y) were surgically injected beneath the renal capsule in female nude mice for generation of orthotopic tumors. The tumors were allowed to grow for 1-4 weeks. A nanoprobe (long circulating liposomal nanoparticle stably encapsulating iodinated contrast agent molecules, 110 mg I/mL) was administered i.v at an iodine dose of 2.2 mg/g. High-resolution CT imaging was performed

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4 days post-contrast administration. A second equivalent dose of nanoprobe was then administered and a high-resolution CT angiogram of tumor vasculature acquired. The mice were then sacrificed and the tumors removed for histological evaluation.

Results: CT imaging demonstrated highly heterogeneous uptake and distribution of nanoprobe within NB tumors (Figure 1-B,C). MYCN-amplified tumors demonstrated higher nanoprobe uptake compared to MYCN non-amplified tumors. In both NB models, the overall uptake of nanoprobe increased with tumor size indicating the presence of highly permeable tumor vasculature in developing tumors. Super-imposition of the nanoprobe distribution pattern on the vascular map suggested a strong association between nanoparticle distribution and neovasculature (Fig 1A,D). The nanoprobe leakage data was correlated with tumor size and age. Quantification of intratumoral nanoparticle delivery was performed based on analysis of CT signal and iodine concentration. Conclusions: High-resolution CT imaging using a nanoprobe enabled assessment of tumor uptake and distribution of nanoparticles in orthotopic mouse models of MYCN-neuroblastoma.

Paper #: 148 Quantitative Analysis of Structural Abnormality of Semicircular Canals in Progressive and Non-Progressive Adolescent Idiopathic Scoliosis using 3D Volumetric MRI Peggy Tang, Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong, [email protected]; Lin Shi, Defeng Wang, Jack Chun Yiu Cheng, Winnie Chiu Wing Chu. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Previous studies suggested that asymmetric growth of the vestibular system (VS) is related to the development of adolescent idiopathic scoliosis (AIS). It provided a possible direction to resolve the unclear etiopathology of AIS and to reveal the difference in vestibular system morphology between progressive and non-progressive AIS patients. The goal of this study is to investigate the morphological difference of semicircular canals between progressive and non-progressive AIS patients as compared with age-matched normal controls using computational morphometric approaches on MR images.

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Methods & Materials: Twenty-five non-progressive (NP-AIS) and 17 progressive (P-AIS) right-thoracic AIS patients and 20 agematched normal controls (NC) were recruited into this study. High resolution T2-weighted images of their VS were obtained. The anatomical variances of the semicircular canals were described using approximated best-fit circle. Lengths and angles of the lines joining centers of the best-fit circles, radius of the circles and the rotational angles around the three major orthogonal axes were used for shape description of the VS. The measurements of the AIS groups were compared with those of the normal control group using one-way ANOVA. Results: Statistically significant differences were observed in the shape analysis of the left-side VS between AIS and normal controls. Firstly, the distance between the centers of the lateral and superior canals was P-AIS < NP-AIS < NC (p=0.0370). Secondly, the angle between the centerjoining lines at the posterior canal was P-AIS < NP-AIS < NC (p= 0.0018). In the right-side VS, no significant group difference was detected. Conclusions: Abnormalities of VS structure affect the postural balance, vestibular and proprioceptive functions. Our results preliminarily confirmed the shape deviations in AIS and the difference is more prominent in the progressive group than the non-progressive group. A longitudinal study will be conducted to establish the association of vestibular dysfunction with curve progression of spinal deformation of AIS.

Paper #: 149 Virtual Endoscopy of the Middle Ear Stephen Little, Damien Grattan-Smith, MBBS, Children’s Healthcare of Atlanta, Atlanta, GA, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Identification and characterization of middle ear pathology can be challenging, particularly when minor ossicular anomalies or other relatively subtle findings are sought. Volume-rendered virtual endoscopy of the middle ear is easily performed and enhances interpretation. In addition, such images may provide a ‘road-map’ for the otologist. Methods & Materials: Volume rendered virtual endoscopy of the middle ear was performed in 15 patients with middle ear pathology. Evaluation of isolated, syndromic and secondary abnormalites of the ossicles was performed and contrasted with standard axial and coronal CT images of the middle ear. Other abnormalities identified included middle ear masses (cholesteatoma, teratoma, benign fibrous tumor) as well as persistent stapedial artery and displaced ossicular prosthesis. Volume rendered virtual endoscopy is easily learnt and typically takes 5 min utilizing a dedicated workstation. Results: Identification and characterization of middle ear abnormalities can be difficult when using standard CT techniques. In particular, the complex configuration and orientation of the middle ear ossicles complicates evaluation on routine high resolution axial and coronal images. Virtual endoscopy was superior in delineation of ossicular abnormalites such as bony erosion or hypoplasia as well as fixation of the incus or malleus. Virtual endoscopy provided superior analysis of abnormalities of ossicular articulation demonstrating bony fixation as well as middle ear masses. Conclusions: Volume-rendered virtual endoscopy of the middle ear is easily learned, quickly performed and provides additonal information in the evaluation of middle ear pathology.

Paper #: 150 The Potential Association among Prematurity, Cochlear Hyperintensity, and hearing loss Michael Wien, MD, Radiology, Children’s National Medical Center, Washington DC, [email protected]; Matthew Whitehead, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Prematurity is a major risk factor for cochlear hair cell injury. Although its etiology is often unknown, various toxic, infectious, and inflammatory insults may be causative. Recent advancements in MR imaging, improved scanner access, and refined treatment regimens have made it possible to evaluate structural details of the membranous labyrinths in premature infants that have heretofore been inaccessible. We have found abnormal cochlear hyperintensity on thin section T1WI in a number of premature patients. The purpose of this study is to compare the prevalence of cochlear hyperintensity in premature and term patients, and to evaluate for a potential link with hearing loss. Methods & Materials: The diagnostic imaging report database at a single academic children’s hospital was retrospectively searched for all consecutive brain MR exams performed in premature (<37 weeks gestation) and term neonates over a 30-month period. 32 exams were excluded on the basis of incomplete exams or artifact. A board certified neuroradiologist evaluated cochlear signal alteration on the following sequences: T1WI, T2WI, PD, and DWI. Each patient’s electronic medical record was reviewed to document demographics, symptomatology, physical exam findings, and potential medical variables that could contribute to cochlear signal alteration. Results: The study cohort contained 148 exams from 148 unique patients (74 preterm and 74 term). Cochlear hyperintensity on T1W was present in 6.8% patients (n=10) overall, but was much more common in preterm than term patients (12.2% (9 of 74) vs. 1.4% (1 of 74), respectively; Pvalue<0.05; Fisher’s exact test). Overall, 13.7% (n=13) of the patients with hearing test results (n=95 of 148, 64%) failed the exam. However, failure was much more common among patients with cochlear hyperintensity on T1W1 than those with normal findings (75% (3 of 4) vs.11% (10 of 91), respectively; P-value<0.01; Fisher’s exact test). Conclusions: Cochlear hyperintensity on T1WI is more common in preterm than term patients, and potentially associated with hearing loss. Cochleae should be closely scrutinized in all premature infants; signal alterations should prompt early otolaryngology referral for potential treatment.

Paper #: 151 Brain Ultrasonographic Findings of Late-onset Circulatory Dysfunction Due to Adrenal Insufficiency in Preterm Infants with Gestational Age Less than 33 Weeks Su-Mi Shin, Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea (the Republic of), [email protected]; In-One Kim, Tae Yeon Jeon, MD, Jung-Eun Cheon, Young-Hun Choi, Woo Sun Kim, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To characterize the brain ultrasonographic findings of late-onset circulatory dysfunction (LCD) due to adrenal insufficiency (AI) in preterm infants.

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Methods & Materials: We studied 257 preterm infants who were delivered at less than 33 weeks of gestation between December 2009 and February 2014. In 35 preterm infants with diagnosed as AI, 21 infants were excluded due to the following causes; expire (n=2), early AI (n=5, < 1 week), sepsis (n=1), and PDA (n=13). In 14 preterm infants [gestational age (GA), 29-32 weeks; male: female= 6:8, birth weight (BW), 540-1790 g], serial cranial sonographic findings were retrospectively analyzed before and after the event of LCD. Results: Fourteen (5.4%) of 257 infants were diagnosed with LCD due to AI. The event of LCD occurred at the mean 19.7 days of age (9-32 days). Serial sonographic findings before and after the event of LCD demonstrated no significant interval change in 8 (57%), newly developed or increased size of germinal matrix hemorrhage in 5 (36%) and interval increased periventricular echogenicity (PVE) in 3 (21%). Two of 5 infants with increased PVE developed cystic periventricular leukomalacia (PVL) and rapid progression to the macrocystic encephalomalacia (Figure). Conclusions: LCD due to AI may be associated with the development of cystic PVL and rapid progression to the macrocystic encephalomalacia.

Paper #: 152 Can Ultrasound Replace X-Rays In The Evaluation Of Cranial Sutures? Katya Rozovsky, MD, Diagnostic Imaging, Hadassah Hebrew University Medical Center, Jerusalem, Israel, Zur Hadassah, Israel, [email protected]; Kristin Udjus, Nick Barrowman, Natalia Simanovsky, Nagwa Wilson, Elka Miller Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine the specificity and inter-reader agreement of ultrasound (US) in the evaluation of cranial sutures (CS) and to assess if US of CS can replace x-rays in the initial assessment of craniosynostosis. Methods & Materials: Institutional review ethics board approval and parental informed consent were obtained. This prospective study included 150 children (0-12 months), who present for radiographic examination (four views of the skull) for assessment of possible craniosynostosis between 2011 and 2013. US of the sagittal, metopic, coronal and lambdoid sutures was performed using Phillips IU22 US equipment and compared with x-rays obtained as per clinical practice. The US and x-rays were interpreted independently and blindly by two pediatric radiologists. Each CS was evaluated for the qualitative appearance (closed/patent/indeterminate) and quantitative measurements on US and X-ray, with correlations with age and gender. A CT was obtained in 11 children; the results were compared with the US findings. Sensitivity, inter-reader agreement and correlations between US, x-rays and age were performed for each suture. Results: 127/150 (84.6%) consecutive children consented to participate in the study (82 male [64.5%], (8-343 days)). Ultrasound detected 8 (6.3%) children with craniosynostosis (sagittal (5), metopic (2) and coronal (1)) and 119 (93.7%) negative studies; all confirmed with x-rays. For all but the metopic suture the readers’ agreement between US and x-ray was 100%. The metopic suture was closed (n=2) and indeterminate (n=1) on US but patent with x-rays (sensitivity 100%, specificity 98% (95% CI 94-100%)). CT (11/127) confirmed US results in all cases (close (6), open (5)). Agreement of ultrasound readers had a weighted kappa value of 0.76 (good to excellent). For all but metopic sutures, the US measurements of the suture gap decreased in the first 6 months, with no change in the second 6 months of life. The metopic suture showed a constant decrease in size. Conclusions: US can be safely used as a first line imaging tool in the investigation of craniosynostosis, reducing the need for radiographs in many young children.

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Paper #: 153 Major Joint Arthrocentesis for Suspected Septic Arthritis: Validation of a Multidisciplinary Protocol Amir Pezeshkmehr, MD, Pediatric Radiology, UAMS, Little Rock, AR, [email protected]; Leah Braswell, Mary Beth Moore, James Aronson, Thomas Abramo, Charles James Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Review single institution experience for major joint arthrocentesis following implementation of a clinical protocol for septic arthritis. Methods & Materials: A multidisciplinary clinical protocol for suspected septic arthritis was developed with input from Orthopedics, Radiology, and Emergency Department teams. The involved staff received education on the protocol which was incorporated into the Radiology resident curriculum to ensure consistency after-hours. The medical record was reviewed for CPT code 20610, (arthrocentesis, major joint) between August 2010 and October 2014. A total of 153 major joint arthrocenteses were identified with 40 cases specific for suspected hip or shoulder joint septic arthritis. The protocol for Radiology Department hip or shoulder joint aspiration consisted of clinical features of septic arthritis, ESR>30 or CRP>20, and joint effusion on diagnostic ultrasound imaging. For the first 10 months, 6 joint aspirations were performed by a general pediatric radiology staff under fluoroscopic guidance. For the latter 40 months, 34 joint aspirations were performed by an IR staff under ultrasound guidance. Aspirated joint fluid was sent for cell count, gram stain, and aerobic/anaerobic cultures. Results: Forty cases (30 male, 10 female), underwent joint aspiration for suspected septic arthritis (38 hips, 2 shoulders). The patients had an age range of 10 months to 16 years (mean age 6.3 years). The distribution of diagnoses was septic arthritis (12), toxic synovitis (28), and migratory polyarthralgia (1). 4/6 cases (66.6%) performed by a pediatric radiologist under fluoroscopic guidance yielded adequate fluid samples. 34/34 cases (100%) performed by an IR staff under ultrasound guidance yielded adequate fluid samples. 10/11 cases (90.9%) of surgically treated septic arthritis fit the clinical protocol based on clinical suspicion with elevated ESR or CRP. The one case of surgically treated septic arthritis with normal ESR and CRP values underwent hip joint aspiration based on overriding high clinical suspicion (severe pain/unable to move hip). Conclusions: A multidisciplinary clinical protocol was implemented and validated for suspected hip or shoulder joint septic arthritis. A systematic approach involving ultrasound guided arthrocentesis by an IR staff increases the probability of an accurate diagnosis and prevents unnecessary procedures.

Paper #: 154 Utility of Image Guided Percutaneous Bone Biopsy in Diagnosis and Management of Osteomyelitis in Children Danella Rodriguez, MD, DABR, Pediatric Radiology, Baylor College of Medicine, Houston, TX, [email protected]; Kamlesh Kukreja, J.Alberto Hernandez Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To review our experience with image guided percutaneous bone biopsy in children with a suspected diagnosis of osteomyelitis, specifically to determine its role in management.

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Methods & Materials: An IRB approved retrospective review of imaging, clinical and pathology databases was performed of all patients who underwent image-guided core bone biopsies for suspected osteomyelitis at our large tertiary care childrens hospital during January 2010 to August 2014. All procedures were performed with general anesthesia or deep intravenous sedation utilizing fluoroscopy or CT guidance. The biopsy needles used were either Ackermann, Jamshidi or OnControl system. Results: Eighty-eight children (38 girls and 50 boys), mean age 8.2 years (range 0-19 years) underwent image guided percutaneous bone biopsies with fluoroscopy guidance in majority (69%). Results of bone biopsy were not available in one patient due to loss of tissue specimen. Of the remaining 87 bone culture results, 24 (28%) were positive. Of the 24 positive cases, 22 (80%) patients had negative blood cultures, while 2 had positive blood culture and the same organism was isolated from bone specimen culture. Adequate tissue was obtained in all patients. There were no procedure related complications in our study. Bone biopsy results altered the management of 31 patients (35%). There was observed change in antibiotic therapy based on the blood culture result for these 22/24 positive cases. Infectious Disease clinicians at our institution factor the histology results for the management decisions. Nine patients with negative bone biopsy culture had histologic findings of chronic osteomyelitis resulting in longer duration of therapy. Conclusions: Imaged guided ( primarily fluoroscopy guided) percutaneous bone biopsy for suspected osteomyelitis in children is safe and yields positive tissue culture in approximately1/4 th of patients, however affected clinical management in 1/3rd of patients.

Paper #: 155 Radiofrequency Ablation of Osteoid Osteomas in a Tertiary Pediatric Center Timothy Donegan, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Ganesh Krishnamurthy, Marc Keller, MD, Emmanouil Grigoriou, John Dormans, Anne Marie Cahill Disclosures: Anna Marie Cahill has indicated a relationship with Siemens AX, Inc as an advisory Board Member. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Percutaneous radiofrequency ablation (RFA) of osteoid osteomas is an established technique with high technical and clinical success rates in both the adolescent and adult populations. In this study, we evaluated the efficacy of RFA of osteoid osteomas at a single tertiary pediatric center in a pediatric population. Methods & Materials: An IRB approved study was performed for patients who underwent RFA of osteoid osteomas from 1/1/2005 through 7/31/2013. Records were reviewed for: demographics, lesion site, lesion histology, RF probe and ablation technique, technical success, clinical success, clinical follow-up, and complications. A prospective telephone questionnaire was performed to further evaluate clinical follow-up. Results: Thirty-seven cases of RFA of osteoid osteomas were identified. Demographics were as follows: 23 males, 14 females, mean age 12.0 +/− 4.6 years (range 3.4 - 20.1 years). A technical success rate of 100% was achieved. Three RF electrodes were used: the Cool-Tip (Covidien, Mansfield, MA; temperature based) and the Soloist and LeVeen (both Boston Scientific, Natick, MA; both impedance based) systems, used in 14, 16, and 7 cases respectively.

Clinical follow-up was available in 36 of 37 cases (mean 36.5 +/− 22.7 months, range 12–112 months). Recurrences occurred in three patients (8%). One patient was successfully retreated with repeat radiofrequency ablation, the other two patients with surgical resection, yielding primary and secondary clinical success rates of 92 and 95% respectively for RFA of osteoid osteomas. All treatment failures occurred with the Soloist electrode, not statistically significant. The impedance based probes, compared to the Cool-Tip probe, required an increased number of ablations per case (3.0 +/− 1.0 burns vs. 1.0 +/− 0 burns, p-value<0.0001) and increased ablation time (12.9 +/− 4.8 min vs. 6.0 +/− 0 min, p-value<0.0001). Conclusions: Treatment of osteoid osteomas with RFA in the pediatric population is a safe and effective technique. While success rates were comparable to the pediatric literature using both temperature and impedance RF electrodes, temperature probes may offer advantages in both number of ablations required and overall ablation time.

Paper #: 156 Image-Guided Core Needle Biopsy of Soft Tissue Lesions in the Pediatric Population: Is it Adequate? Terrence Metz, MD, University of Michigan, Ann Arbor, MI; Ranjith Vellody, Amer Heider, Jason Grove, Jonathan Dillman, MD. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine the adequacy of imageguided core needle biopsy for diagnosing and satisfactorily characterizing benign and malignant soft tissue mass lesions in the pediatric population. For malignant lesions, we also assessed whether sufficient tissue was obtained to perform all necessary ancillary testing, such as immunohistochemical and cytogenetic analyses. Methods & Materials: We retrospectively identified all pediatric patients that underwent image-guided (ultrasound or CT) core needle biopsy of a soft tissue mass lesion in our Department of Radiology between December 2011 and January 2013. Procedure notes, pathology reports, and relevant clinical notes were reviewed in order to document the following data: demographic information, biopsy site, number and size of core needle biopsy specimens obtained, if there was a documented procedural complication, final histopathologic diagnosis, and whether there was sufficient tissue obtained to allow necessary ancillary testing, such as immunohistochemical and cytogenetic analyses. Results: Fifty-four image-guided core needle biopsy procedures on soft tissue mass lesions were performed during the study period (46 children; mean age =12.2±4.8 years). 13 (24%) biopsy procedures were CT-guided and 41 (76%) were ultrasound-guided. Most common biopsy sites were within the extremities (31%), head/neck region (28%), and lung (13%). The mean number of core tissue specimens was 9.2±4.7 (range, 2-22 cores) for ultrasound-guided and 6.3±4.3 (range, 2-12 cores) for CTguided procedures. An exact histopathologic diagnosis was made in all 54 biopsy procedures; 19 (35%) lesions were new malignancy, 13 (24%) were recurrent or metastatic disease, and 22 (41%) were benign. For 17/18 (94%) new malignancies, core needle biopsy provided sufficient tissue to perform all indicated ancillary studies. No significant procedural complication was documented within 5 days of the biopsy. Conclusions: Image-guided core needle biopsy is safe and allows sufficient tissue to be obtained in order to diagnosis and characterize benign and malignant pediatric soft tissue mass lesions.

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Paper #: 157 Pediatric Interventional Radiology (PIR) Fellowship: The Need for Standardization and PIR Survey Implications for a Future Direction Aparna Annam, DO, Children’s Hospital Colorado, Aurora, CO, [email protected]; Leah Braswell, Paul Rochon, Roger Harned Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Fellowships in Pediatric Interventional Radiology are non-standardized. What is the individual institutional variation in case load and what can be done to standardize fellowships? Does variation between programs hinder our ability to define the field’s identity with a common set of pediatric skills? Methods & Materials: Eleven PIR training programs are listed on the SPR website. The expected case volumes and types of procedures reported for each were compared. Audience response survey of Pediatric Interventional Radiologists was conducted at the 2014 Pediatric Interventional Radiology Symposium (PIRS) evaluating preferred training pathways, minimum case numbers, methods to meet case requirements, pediatric clinical exposure in the new Vascular Interventional Radiology (VIR) residency and desire for a separate PIR CAQ. Results: All programs performed at least 2000 examinations per year and reported large numbers of common procedures such as biopsy, drainage, and vascular access. There was wide variation in expected experience with enteric access/cecostomy, tumor therapy and vascular anomalies. Some sites reported very few of these procedures performed. PIRS survey showed there are several pathways to becoming a PIR but that the VIR fellowship and PIR fellowship were preferred. Most PIRs feel that there should be a specific number and type of procedures performed during fellowship and trainees should be sent outside of their home institution to pursue core procedures if needed. The new VIR residency does not offer enough clinical pediatric training and many PIRs did not think a separate PIR CAQ would be necessary. Conclusions: Exposure to essential and frequently unique PIR skills (e.g. vascular anomaly management and cecostomy) varies among training programs. A standardized curriculum including expected minimum number of procedures should be developed to guarantee a defined level of PIR expertise upon fellowship completion. While there are many pathways to become a PIR, the preferred pathway of both VIR fellowship and PIR fellowship may ultimately lack an exposure to Pediatric Diagnostic Radiology which may be a desired skill at hiring institutions. PIR fellowships may need to send trainees to outside institutions to meet minimum case volume requirements within specific defined categories. Additional opportunities for pediatric clinical exposure should be implemented into the VIR residency and a PIR CAQ may not be essential to ensure a level of expertise. SCIENTIFIC EXHIBITS/POSTERS Authors are listed in the order provided. An author listed in bold identifies the presenting author.

Poster #: CR-001 Testicular Torsion: A Case of Mistaken Identity Moe Tun, PhD, DO, University of Missouri-Kansas City, Kansas City, MO, [email protected]; Eugenio Taboada, Stephanie Theut Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Cryptorchidism, or undescended testicle, is the most common genital disorder diagnosed during the newborn examination. Early diagnosis and management of the undescended testicle are needed to preserve fertility, improve early detection of testicular malignancy, decrease chance of torsion, and reduce associated inguinal hernia. Our case involves a 21-year-old male who presented to the emergency department with one week history of abdominal pain. Past medical history given is significant for multiple congenital anomalies and surgical repairs including status post repair of coarctation of aorta and congenital heart disease, congenitally absent left testicle status post right orchiopexy, and vesicoureteral reflux status post ureteral reimplantation. Initial computed tomography of the abdomen and pelvis revealed a 7.8×6.2×7.6 cm well-circumscribed low attention lesion within the pelvis posterior to the bladder, suggestive of a pelvis mass versus a complex fluid collection. Work up with ultrasound revealed a wellcircumscribed, complex fluid collection without internal vascularity and a small amount of free fluid within the pelvis, most suggestive of an abscess or a complicated cyst. Interventional radiology was consulted for cyst/abscess drainage and/or biopsy. Needle placement into the lesion failed to return fluid. Biopsy failed to return tissue. A wire coiled easily within the collection and therefore a pigtail drainage catheter was placed which returned minimal old blood. The patient then underwent a diagnostic laparoscopic surgery. During the procedure, a torsed intra-abdominal left testicle was discovered. Detorsion and laparoscopic ochiectomy were then performed. The pathology yields an extensively hemorrhagic and necrotic 8×7×7 cm left testicle. Immunohistochemical study revealed positive D2-40, CD117 (c-KIT), PLAP, OCT 3/4/4, and negative AFP and CD30, consistent with seminoma. This case demonstrates the importance of the current management for nonpalpable undescended or absent testicles including radiological imaging, laparoscopic exploration and orchiopexy before 18 months of age. In addition, possible testicular torsion should be considered in patients presenting with pain and pelvis mass without prior surgical intervention of congenitally undescended or absent testicle.

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Coronal and axial contrast enhanced CT images show well-circumscribed low-attenuation mass like lesion (black arrow) located superior and posterior to the bladder within the pelvis, which was later proven pathologically as a torsed gangrenous left testicle

Poster #: CR-002 MRI Findings in an Isolated Non-Apical Congenital Left Ventricular Diverticulum Avinash Medsinge, MD, CHP of UPMC, Pittsburgh, PA, [email protected]; Erica Kar, Kevin Ching, Darshit Thakrar, Shobit Madan, Sameh Tadros Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A congenital ventricular diverticulum is a rare cardiac anomaly comprising only 0.05% of all congenital cardiac malformations. It usually arises from the free wall of the left ventricle (LV) near the apex and more commonly is associated with other congenital abnormalities. Only 30% of congenital ventricular diverticula are isolated and these are usually asymptomatic and diagnosed incidentally. This is an unusual case of a patient with an isolated LV free wall diverticulum (muscular type) diagnosed antenataly. She was managed conservatively with baby aspirin as she was asymptomatic. However, the patient suffered a cerebral infarction at the age of 9 years which was thought to be secondary to embolism from intra-cardiac thrombus formation within the diverticulum while she was temporarily off the baby aspirin for H1N1 infection. Follow up 2D echocardiogram re-demonstrated the LV diverticulum and showed decreased LV function. Therefore, Cardiac MR was performed to accurately assess the LV morphology and function. Although 2D echocardiogram is sufficient for the diagnosis of LV diverticulum, the cardiac imager may encounter CT or MR cases of congenital LV diverticulum for complete assessment of the anomaly, its complications and/or evaluation for associated abnormalities. This is a presentation discussing the MR findings in a case of an isolated LV diverticulum with unusual complications.

Poster #: CR-003 Paraneoplastic Anti-NMDA Recepector Encephalitis Associated with Ovarian Teratoma: A Case Report Rohit Khanna, MD, Radiology, Phoenix Children's Hospital, Phoenix, AZ, [email protected]; Deepa Biyyam, MD, Mittun Patel, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Although, not first described until 2007, antiNMDA receptor encephalitis is now a well-documented paraneoplastic syndrome. It remains relatively underrecognized however, due to its lack of specific imaging and cytological characteristics. It has been predominantly described in young females with a constellation of symptoms, including personality changes, autonomic dysfunction and neurologic decompensation. It is commonly associated with mature ovarian teratomas. NMDA receptors are ligand-gated cation channels with crucial roles in synaptic transmission and plasticity. The receptors are heteromers of NR1 subunits that bind glycine and NR2 subunits that bind glutamate. Overactivity of NMDA receptors causing excitotoxicity is a proposed underlying mechanism for epilepsy, dementia, and stroke, whereas low activity produces symptoms of schizophrenia.

Anti-NMDA-receptor encephalitis involves antibodies that work against NR1-NR2 heteromers, resulting in a characteristic neuropsychiatric syndrome. The first patients identified were young women with ovarian teratoma who presented with psychosis or memory problems, rapidly progressing to multiple neurological deficits requiring prolonged intensive care support. Patients often recover after tumor removal and immunotherapy, suggesting an immune-mediated pathogenesis. Brain MRI can be normal in up to half of affected patients, although non-specific T2 or FLAIR signal hyperintensity has been described in various areas of the brain, including the hippocampus, cerebellar or cerebral cortex, basal ganglia, brainstem, and spinal cord. Mild or transient meningeal enhancement can also be seen. Imaging of the pelvis demonstrates unilateral or bilateral ovarian teratomas. Our case describes a previously healthy 14 year old female who presented to the ED with altered mental status. Non-contrast CT of the head was initially performed and was normal. Based on her clinical presentation, anti-NMDA receptor encephalitis was suspected and the patient underwent pelvic ultrasound, brain MRI, lumbar puncture, and EEG. Her brain MRI demonstrated multiple ill-defined focal T2 hyperintensities throughout the supratentorial subcortical white matter, predominantly within the frontal lobes. Pelvic ultrasound showed bilateral fat containing adnexal masses, compatible with teratomas. EEG demonstrated multiple epileptiform discharges localizing to the left cerebral hemisphere. Her CSF subsequently tested positive for NMDAR antibodies.

Poster #: CR-004 Fetal Sub Cortical Cysts During Second Trimester: A Harbinger of Cortical Malformation? Gayathri Sreedher, MD, Radiology, Akron Children’s Hospital, Akron, OH; Lena Naffaa, Emily Janitz, Melissa Mancuso, Shankar Ganapathy Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A 31 years G2 P2 patient was referred for a fetal MRI at 24 weeks of gestation for evaluating abnormal sub cortical cysts seen on sonogram. Fetus had symmetrical intrauterine growth retardation in addition. The sub cortical cysts were more extensive on MRI than on the sonogram. Follow up MRI at 34 weeks demonstrated complete resolution of the sub cortical cysts. At this time, the cortex appeared nodular and irregular with abnormal gyral and sulcal pattern, consistent with polymicrogyria. The postnatal MRI done 13 weeks after birth confirms these findings and depicts the full extent of the bilateral frontotemporoparietal polymicrogyria. Although cortical malformations are now routinely detected by fetal MRI in most institutions, this unique sequence of events provides a clue towards recognizing the pathogenesis of polymicrogyria in this case. Germinolytic cysts are known to be associated with cortical malformation by virtue of their location and involvement of the germinal matrix. Sub cortical cysts during the late migration or cortical organization phase heralding polymicrogyria may suggest either a vascular etiology that resulted in sub cortical encephalomalacia or an infectious etiology. Interestingly, the placenta in our case was found to be abnormal at birth, although a detailed pathological analysis was not available.

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Poster #: CR-005 Glutaric Aciduria Type 1: A Rare Inherited Disorder - A Case Report in a 4 year-old Female John Donatelli, MD, University of South Florida, Tampa, FL, [email protected]; Ryan Murtagh, MD, Claude Guidi, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A 4 year-old female presented to the emergency department after arriving to the United States from India. She had a known inborn error of metabolism however her prior medical records were unavailable for review. She presented with developmental delay, feeding difficulties/malnutrution, seizures, and myoclonic jerks. Physical exam demonstrated a non-verbal, small for age female with baseline 4extremity contractures. Muscle tone was diffusely increased with intermittent dystonic movements. Laboratory analysis of urine organic acids demonstrated results consistent with Glutaric Aciduria Type 1 (GA1). MRI of the brain was performed to further evaluate the patient’s metabolic disorder and symptom severity. Dysmorphic changes of the brain included bilateral fronto-temporal atrophy with enlarged sylvian fissures and prominent CSF spaces anterior to the temporal lobes. An immature gyral pattern with an incomplete falx and interdigitation of frontal gyri was also observed. Abnormal increased signal on T2-weighted sequences was seen symmetrically within both putamen, along with scattered foci within the periventricular and subcortical white matter of both cerebral hemispheres. A small focus of restricted diffusion was observed in the right occipital lobe suggesting acute insult. These imaging findings are high suggestive of GA1, supporting the clinical and laboratory diagnosis. Glutaric aciduria Type 1 is a rare inherited disorder of amino acid metabolism. A deficiency of mitochondrial matrix flavoprotein glutaryl-CoA dehydrogenase results in abnormal degradation of lysine, hydroxylysine, and tryptophan. Accumulation of toxic intermediate breakdown products results in brain damage, predominantly involving the basal ganglia (striatal necrosis) and white matter. These changes lead to the classic MRI appearance of the brain described above, as well as the physical exam findings and symptoms demonstrated by this patient. GA1 has an estimated prevalence of 1 in 30,000-40,000 newborns. The majority of patients have an acute onset of symptoms following a trigger such as infection, surgery, or immunization while approximately 25% of patients have an insidious onset. Most symptomatic patients are severely handicapped with 20% mortality by age 5. Early treatment to prevent episodic crises includes low protein diet, riboflavin, and oral carnitine replacement. Treatment of dystonia includes anticholinergic agents, botulin toxin, and pallidotomy.

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Purpose or Case Report: To highlight the difficulty in the radiographic and clinical recognition of achondroplasia in the preterm infant, mirroring the difficulty in prenatal sonographic diagnosis in the second trimester. Methods & Materials: Retrospective review of the radiographic studies and clinical charts of two premature infants, case 1 born at 23+4 weeks gestational age and case 2 born at 25 weeks gestational age. Results: Both infants had a protracted NICU course over several months including bronchopulmonary dysplasia necessitating tracheostomy. Neither was suspected of having a skeletal dysplasia, without distinct phenotypic characteristics recognized. In case 1, short stature and macrocephaly at 7 months of age led to the diagnostic skeletal survey and CT brain findings of foramen magnum stenosis. In case 2, an MRI at 5 months of age to follow a cyst noted on US revealed foramen magnum stenosis with cord compression, which prompted the diagnostic skeletal survey. In both cases, the skeletal changes of achondroplasia were present including frontal bossing, short nose with depressed nasal bridge, rhizomelia, slightly small thorax, metaphyseal flaring, trident hand, narrowed interpediculate distance in the lower lumbar spine, square iliac crests and flat acetabulae. Retrospectively, despite overlying bowel gas, pelvic bone changes with square (“tombstone”) iliac wings, narrow sacrosciatic notches and flat acetabula were visible on multiple chest and abdominal radiographs done in the NICU on admission and throughout their stay. Minimal metaphyseal irregularity in the distal femora, slight femoral bowing and slightly small thorax were also seen in case 2. Head sonograms and early brain MRI in case 1 were unrevealing. Conclusions: Achondroplasia is a difficult diagnosis to make before the late third trimester. Our 2 cases highlight how the diagnosis may be overlooked in the preterm infant, as well as the second trimester prenatal sonogram. Recognition of subtle pelvic changes may suggest the diagnosis in the preterm infant

Poster #: CR-007 3D Printing of Anatomic Models for Pre-Operative Planning in Children with Scoliosis due to Vertebral Anomalies

Poster #: CR-006 Achondroplasia in the Premature Infant: An Elusive Diagnosis in the Neonatal ICU Kimberly Fagen, Doctor of Medicine, Radiology, Walter Reed National Military Medical Center, Vienna, VA, [email protected]; Anna Blask, Eva Rubio, Dorothy Bulas, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Nathan Hull, MD, Department of Radiology, Mayo Clinic, Rochester, MN, [email protected]; Jane Matsumoto, Jonathan Morris, Larry Binkovitz, Joel Kuhlmann, Anthony Stans Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 3D printing of anatomic models is a relatively new technology which is rapidly expanding in the

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medical arena. Our poster will demonstrate the feasibility and utility of producing accurate individualized life size 3D printed models of the spine for pre-operative planning in cases with children with scoliosis due to vertebral anomalies from our series of 14 cases. The financial cost and time required for segmentation and processing of 3D models will also be discussed. Our presentation will include both the high-resolution CT images, as well as their correlative 3D printed models. These 3D models can be brought for display at the meeting if requested.

Poster #: CR-008 Be Wary of the Round Gastric Bubble in Children with Asplenia Paula Dickson, MD, Emory University, Atlanta, GA; Kiery Braithwaite, Meryle Eklund, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Complex cardiac disease, malrotation with the risk of small bowel volvulus and immunodeficiency with the threat of overwhelming infection are well-known complications of asplenia syndrome. Acute gastric volvulus, however, is a rare consequence of asplenia which is not thought of as often, but which can quickly become devastating. An unassuming round gastric bubble on an abdominal radiograph may be the clue that needs to be recognized to make a timely diagnosis. A 17-month old girl with known asplenia presented to the Emergency Department with intractable vomiting of foamy mucous for 12 h. She and her family had been sick with diarrhea earlier in the week. She had been to an outside emergency room where IV fluids were given, but was transferred to our institution because of her cardiac history. Her initial abdominal radiographs obtained at 1:30 AM revealed a round, mildly distended gastric bubble in the right upper quadrant. Otherwise, a normal bowel gas pattern was present with gas and stool outlining the colon and rectum. Four hours later, the stomach had enlarged into a 13×15 cm oval structure with gastric pneumatosis, portal venous gas and pneumoperitoneum secondary to gastric perforation. The patient arrested in the operating room, requiring prolonged CPR and ECMO with resultant hypoxic brain injury from which she died 3 days later. The round gastric bubble can be indicative of acute mesenteroaxial or mixed-type mesenteroaxial/organoaxial gastric volvulus and should be eyed with caution. A relatively benign-appearing pattern can quickly evolve into a life-threatening event.

Poster #: CR-009 Malignant Ectomesenchymoma of the Scalp Patricia Cornejo, MD, Pediatric Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; John Egelhoff, Robin Kaye, Ruth Bristol, Daphne Demello, Robyn Augustyn. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A 2 year-old male presented with focal swelling of the scalp that rapidly increased in size over a 3 to 4 week period prior to admission. The lesion was no tender on palpation. Computer

tomography (CT) scanning of the head without contrast and magnetic resonance imaging (MRI) of the brain and showed a scalp soft tissue mass over the right vertex. The patient underwent embolization before surgical resection. A small, pink to gray rubbery soft tissue mass was resected. Histopathologic analysis revealed a cellular tumor composed of polygonal cells with round nuclei and moderate amounts of cytoplasm. Ultra-structural examination of the specimen revealed evidence of striated muscle differentiation in the neoplastic cells. The patient was discharged home and no further work-up or treatment was pursued by patient’s family due to his complex medical history and poor prognosis secondary to his underlying comorbidities. CT head without contrast showed a solid, heterogeneous mass in the scalp dermal and subcutaneous tissues near the vertex. On MRI the mass is isohypointense on T1, heterogeneous on T2, minimal restricted diffusion and heterogenous enhancement. The subjacent parietal bone was thin and irregular without frank cortical disruption. The mass was supplied by the right superficial temporal artery and multiple branches on MRA. Cerebral angiogram confirmed vascular supply from superficial temporal artery vessels. Conclusions: Primary scalp lesions are unusual in the pediatric population. We present a rare case of malignant ectomesenchymoma of the scalp in an infant. The differential diagnosis for soft tissue neoplasms in the pediatric age group includes: rhabdomyosarcoma, neuroblastoma, lymphoma, neuroepithelioma, extra-skeletal Ewing’s sarcoma and other round cell sarcomas. In our case, the appropriate histopathological, immunohistochemical and ultra-estructural analysis was critical to rule out other diagnostic possibilities

Poster #: CR-010 A Rare Case of Lupus Leukoencephalopathy: Review of MRI findings and Differential Diagnosis J a r e d Ve r d o o r n , M D , M a y o C l i n i c , R o c h e s t e r, M N , [email protected]; Carrie Carr, Kara Schwartz, Theresa Wampler Muskardin, Shannon Zingula Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A previously healthy 17 year old female presented to our institution with 5 weeks of new severe headaches that were progressively accompanied by nausea and vomiting, neck pain and stiffness, and eventually right eye blurry vision with horizontal diplopia as well as a couple of possible syncopal episodes with associated incoherent speech. Family history was positive for migraines but no other neurological conditions. Before presenting to our institution, the patient was treated presumptively for sinusitis and migraines without any improvement. A head CT 3 weeks after symptom onset was reportedly normal. A brain MRI one month after symptom onset showed diffuse abnormal T2/FLAIR signal symmetrically throughout the white matter of both cerebral and cerebellar hemispheres and the brainstem. There was no associated mass effect, enhancement, or restricted diffusion. Methylprednisolone was prescribed but discontinued after a single dose due to vomiting. Upon presentation to our institution, physical examination revealed inward deviation of the right eye with horizontal diplopia at rest and with all gaze directions but no other neurologic findings. A brain MRI was repeated and demonstrated no change in the diffuse white matter signal abnormality. MRI of the cervical, thoracic, and lumbar spine demonstrated no abnormality. Extensive testing for infection was negative. Cerebrospinal fluid showed elevated white blood cells with lymphocyte predominance but was otherwise normal. Given this finding, post-infectious and autoimmune processes were considered. Anti-dsDNA antibodies were tested and markedly elevated, highly specific for a diagnosis of systemic lupus

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erythematosus (SLE). Treatment was initiated for diffuse leukoencephalopathy secondary to SLE with high dose corticosteroids and cyclophosphamide. The patient’s headaches and visual symptoms were improving at the time of discharge, 5 days after initiation of therapy. There are many potential central nervous system manifestations of SLE, but lupus leukoencephalopathy is quite rare. This case will be presented with specific focus on the MRI findings and review of other conditions that could present with similar MRI findings.

Poster #: CR-011 MRI appearance of Scurvy: Report of Four Cases Deepa Biyyam, MD, Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Mittun Patel, MD, Mostafa Youssfi, Craig Barnes, Scott Jorgensen, Ian Cassell Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Scurvy is caused by deficiency of ascorbic acid (vitamin C). Although considered a very rare disease in the developed countries, sporadic cases of scurvy have been documented. Increased incidence of scurvy has been reported among patients with autism or developmental delay. We present the MRI findings of scurvy in four patients. All four patients presented with bilateral lower extremity pain and weakness with difficulty weight bearing. Initial plain radiographs of two of the four patients demonstrated metaphyseal lucencies with a band of sclerosis. The radiographs of the other two patients demonstrated diffuse osteopenia. MRI of bilateral lower extremities of all four patients demonstrated multifocal symmetric low T1 and high T2 signal abnormalities centered within the metaphysis with varying degree of contrast enhancement. There was periosteal elevation with adjacent signal abnormality and enhancement in three patients. The differential diagnosis based on the MRI findings included osteomyelitis, malignancy such as leukemia and nutritional deficiency including scurvy. Laboratory results of all the four patients demonstrated extremely low levels of Vitamin C, confirming scurvy. Conventional radiographic findings of scurvy have been well documented. MRI appearance of scurvy has been reported recently. The classic radiographic findings of scurvy are often subtle or may not be present depending on the severity of disease and duration. Despite its rarity, pediatric radiologists must consider the diagnosis of scurvy particularly in children with restricted diet presenting with joint or extremity pains. Understanding the MRI findings of scurvy will help in early detection of this potentially lethal but treatable disease.

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usually performed in a child with a history of multiple urinary tract infections or hydronephrosis, in order to detect the presence of vesicoureteral reflux. Early detection is essential since continued chronic reflux of urine into the kidneys over a prolonged period of time can cause irreversible renal damage. Vesicoureteral reflux is by far the most common positive finding on VCUGs performed at our institution. Other commonly identified findings include abnormalities of the bladder and urethra such as posterior urethral valves and voiding dysfunction. In this presentation, we will discuss several cases of more rare pathology diagnosed on voiding cystourethrograms. It is important for the radiologist to be aware of these potential diagnoses in order to appropriately tailor the exam for their detection, while at the same time maintaining the lowest dose possible to the child. Specific cases illustrated include patients with patent urachus, anterior urethral valves, ambiguous genitalia, and iatrogenic injury to the urethra. Failure to detect these rare, but important, findings can lead to adverse outcomes for the patient. We will also discuss a rare normal variant, focal dilatation of the fossa navicularis, that should not be confused for pathology.

Poster #: CR-013 Imaging Evaluation of Acute Iatrogenic Intramural Duodenal Hematoma after Endoscopic Biopsy Richard Jones, MD, Radiology, University of Minnesota, Saint Paul, MN, [email protected]; Michael Murati, Eric Hoggard, Tara Holm, Kelly Dietz, MD

Poster #: CR-012

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Acute intramural duodenal hematoma is a rare complication in pediatric patients following endoscopic biopsy. Patients present within days of biopsy with bilious or nonbilious emesis and abdominal distention. Laboratory assessment may show acute anemia and elevated pancreatic enzymes, but infrequently coagulopathy. Patients may also present with pancreatitis, which could be confounding if they also underwent ERCP. We present cases demonstrating the relative strengths of various imaging modalities in the diagnosis of duodenal hematoma. Ultrasound delineates the entire hematoma, can be repeated to assess changes in the size of the hematoma, and uses no ionizing radiation. Upper gastrointestinal series localizes the point of obstruction, but not the full extent of hematoma, and uses a small amount of ionizing radiation. CT can be very useful in the acute setting and can better demonstrate additional complications, such as pancreatitis and perforation, but with the use of ionizing radiation and IV contrast. At our institution we attempt ultrasound as the first-line imaging modality for patients with clinical signs of acute or subacute proximal bowel obstruction following endoscopic duodenal biopsy.

Exploring the Void: Uncommon Findings on Voiding Cystourethrograms

Poster #: CR-014

Swetha Dasari, MD, Radiology, Westchester Medical Center, Valhalla, NY, [email protected]; Jeffrey Gnerre, MD, Leslie LeCompte, Adele Brudnicki Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Voiding cystourethrograms (VCUG) are one of the most common fluoroscopic examinations performed in the daily practice of pediatric radiology. These dynamic imaging studies are

Case Report: Complete Bladder Duplication and Lung Sequestration Supplied by Celiac Artery Patrick Bacon, Brandon Speidel,Children’s Hospital and Medical Center, Omaha, NE, [email protected]; Sandra Allbery, MD, Terri Love Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: We present a case report of a 7 month old infant with UTIs diagnosed with both 1) rare complete bladder and urethral duplication and 2) malformed right lung with sequestration supplied by the celiac artery. Complete bladder and urethral duplication is very rare and to the best of our knowledge, this is only the third reported case in the literature. VCUG was performed after catheterizing two separate urethras, with the left urethra located in the normal expected site on the perineum and the right urethra located at the crevace next to the meatus. Two completely separate bladders were filled, with the right mildly smaller than the left. Incidentally, the patient had a chest xray for an upper respiratory infection, with lateral view showing a two centimeter round structure below the right hilum. Subsequent CT showed a malformed right lung with malpositioning of all of the right lung lobes. The most caudal right lung lobe was supplied by an enlarged celiac artery, accounting for the chest xray abnormality, and indicating Pryce type 1 intralobar bronchopulmonary sequestration. The patient had other anomalies including right sensorineural hearing loss, T3 and T7 butterfly vertebra, tracheomalacia, and pharyngomalacia.

Purpose or Case Report: Barth Syndrome is an X-linked recessive disorder caused by mutations in the tafazzin (TAZ) gene. Also known as 3-methylglutaconic aciduria type II, it is characterized by cardiomyopathy; neutropenia; underdeveloped skeletal musculature; growth delay; and 3-methylglutaconic aciduria. Median life expectancy is approximately 3 years of age. We present a 28 year-old male with Barth syndrome which initially presented at 6 months of age with growth and motor delay. At two years of age he was found to be in heart failure, at which time he was formally diagnosed with Barth Syndrome. Over time, this has manifested as dilated cardiomyopathy; gastroparesis; osteoporosis; and recurrent infections. He has required AICD placement, a gastrostomy tube, and jejunostomy tube. He has further required chronic TPN via long-term indwelling catheters, which have been subject to recurrent infections. His medical history is further complicated by MTHFR deficiency and factor V and fibrinogen deficiency. We review the initial presentation, diagnosis, key features, genetic basis and associations, and management of Barth Syndrome. Through 13 years of imaging, we demonstrate the adolescent and later radiographic findings associated with Barth Syndrome. Historically, these have been rarely encountered due to early mortality; however, with increasing skill in managing cardiac disease, patients are living much longer. Given the paucity of adult cases, many of these patients continue to be managed in pediatric settings.

Poster #: CR-016 Fetal Brain MRI in Thanatophoric Dysplasia Pamela Ketwaroo, MD, Boston Children’s Hospital / Harvard Medical School, Boston, MA, [email protected]; Judy Estroff, MD, Edward Yang

Poster #: CR-015 Barth Syndrome in the Adolescent and Adult Marc Michael Lim, MD, Radiology, New York Medical College/ Westchester Medical Center, Valley Cottage, NY, [email protected]; Perry Gerard, Leslie LeCompte, Adele Brudnicki Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Disclosures: Edward Yang has indicated with Corticometrics, LLC as a research consultant. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of our study is to highlight key findings on fetal brain MRI which may lead to increased confidence in the prenatal diagnosis of thanatophoric dysplasia, a lethal short-limbed skeletal dysplasia caused by mutations in the FGFR-3 gene. Methods & Materials: Using a computerized departmental search engine, we retrospectively identified all cases of suspected thanatophoric dysplasia in pregnancies evaluated through the Advanced Fetal Care Center at Boston Children’s Hospital from September 2012 to October 2014. In this time span, six women carrying fetuses with suspected thanatophoric dysplasia were identified, five of whom underwent both fetal ultrasound and fetal MRI. The sixth patient only had ultrasound imaging and was excluded. Of the remaining five patients, one initially referred for cloverleaf skull was determined after imaging to more likely have Pfeiffer Syndrome, an FGFR associated craniosynostosis, than thanatophoric dysplasia. The four other cases were given a clinical diagnosis of suspected thanatophoric dysplasia. All five

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subjects with fetal MRI were compared to controls at the same gestational age and to one another by three readers. Results: Brain MRI in all four fetuses with the typical musculoskeletal findings of thanatophoric dysplasia demonstrated a highly characteristic transverse folding of the temporal and occipital lobes resembling a localized form of polymicrogyria. One patient subsequently had genetic analysis, confirming the FGFR-3 mutation. While this abnormal folding pattern has been described in the pathology and radiology literature in postmortem thanatophoric dysplasia specimens, this series is, to our knowledge, the first to demonstrate that this can be recognized reliably in utero. The presence of the transverse temporo-occipital folding as early as 17 weeks in our series suggests that it can be detected early in the second trimester. Conclusions: On MR imaging, all four fetuses with thanatophoric dysplasia demonstrated an unusual cortical folding abnormality in the temporal and occipital lobes as early as 17 weeks. This abnormal folding pattern, typical of patients with FGFR-3 mutations evaluated at fetopsy, was seen in all fetal MRI evaluations in our series. Therefore, these characteristic brain MRI findings should not be viewed as unexplained or discordant in patients with evidence of thanatophoric dysplasia, and conversely, detection of this pattern should suggest the diagnosis of thanatophoric dysplasia when encountered in a fetus with suspected skeletal dysplasia.

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Poster #: CR-019 Pulmonary Arterio Venous Fistulas in Pleuropulmonary Blastoma: A Report of Two Cases

Poster #: CR-017 Congenital Portocaval Shunt: A Rare Entity Arash Zandieh, MD, Dept. of Radiology, MedStar Georgetown University Hospital, Washington, DC, [email protected]; Christabel Lee, Frank Volberg Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Congenital portocaval shunts are extremely rare vascular anomalies in which the portal venous blood bypasses the normal hepatic sinusoids and directly enters the hepatic venous outflow track and/or systemic circulation. In this case-based exhibit, we submit three cases of congenital portocaval shunt seen on newborn evaluations encountered in our practice. We review the sonographic findings with correlation to CT and MR findings in these cases, and briefly review the literature on the topic.

Gayathri Sreedher, MD, Radiology, Akron Children’s Hospital, Akron, OH; Godfrey Gaisie, Shankar Ganapathy Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We present a unique imaging feature seen in two cases of pleuropulmonary blastoma seen in our institute. Abnormal dilated vessels were seen within the tumor. On multiplanar reconstructions, these were found to be dilated veins associated with a pulmonary arteriovenous fistula within the tumor. Both cases of pleuropulmonary blastomas demonstrated this unique finding which has not been described thus far in literature. Diagnosis of pulmonary and pleural based tumors in pediatric age group is challenging, because the imaging appearance closely overlaps infectious processes such as empyema, lung abscess and other cystic masses. When the diagnosis is in doubt a detailed analysis of the pulmonary vasculature, in addition to routine imaging may provide a clue towards the diagnosis of this aggressive tumor and thereby aid the surgeon in preoperative planning.

Poster #: CR-018 Spontaneous Rupture of a Type I Choledochal Cyst in an Infant. A Rare Complication with Multimodality Evaluation Sara Lay, MD, Indiana University School of Medicine, Indianapolis, IN, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Choledocal cysts in the infant population is a well-known but uncommon entity. While these may present with pain or jaundice secondary to obstruction, rupture is an extremely rare complication. We describe a case of spontaneous rupture of a choledochal cyst, involving a 7 month old previously healthy female infant who presented to the emergency department with 6 days of vomiting and general duress. Findings are presented with ultrasonographic, computed tomographic, and scintigraphic imaging. Intraoperative and pathology results showed an anomalous biliary system with a large type I choledochal cyst demonstrating perforation, with secondary marked bilious ascites.

Poster #: CR-020 Periostitis Secondary to Prolonged Voriconazole Therapy in a Child with Lung Transplantation for Cystic Fibrosis Patricia Cornejo, MD, Pediatric Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Smita Bailey, MD, Gerald A. Mandell, MD, Deepa Biyyam, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 14-year old girl with significant past medical history of cystic fibrosis, neurofibromatosis type 1, status post lung transplant 2 years ago presented with 6 months of generalized body pain, fatigue and swelling of the small joints of the hands. Patient also complained of leg and foot pain for 2 years. On examination, patient had decreased flexion and extension in all of the digits of her hands. The joints of hands were warm, swollen, and painful. She had bilateral swelling in her knees, and warmth in the left ankle. Bilateral hand radiographs demonstrated nodular

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periostitis involving multiple phalanges of both hands. Associated bilateral soft tissue swelling was present. Similar nodular periostitis was also seen involving multiple metatarsals. Bone scan was remarkable with linear areas of increased radiotracer uptake in the long bones, most conspicuous in the forearm bones and along the tibia bilaterally. In addition, there were multiple areas of focal increased uptake in the small bones of the hands and feet corresponding to the periostitis seen on the radiographs. Patchy areas of increased uptake were also seen in the clavicles, left scapula, sternum and the pelvic bones. Clinical history, imaging findings and history of prolonged Voriconazole therapy led to diagnosis of periostitis secondary to Voriconazole therapy. Conclusions: Long-term use of Voriconazole therapy in children with lung-transplant and its association with painful periostitis is a relative unknown entity due to the novelty of this therapy and uncommon indications for chronic use. The periostitis is thought to be related to the fluoride as the major component of voriconazole. To our knowledge, this complication has not been reported in children. Recognition of the radiologic and clinical manifestations of voriconazole-related periostitis is important for helping to narrow an otherwise broad differential diagnosis. Symptoms resolve after discontinuation of voriconazole, so it is important that clinicians are aware of this association, since switching to similar, non-fluoric therapy such as itraconazole is a readily available alternative.

Poster #: CR-021 MRI-Guided Biopsy of a Femoral Cartilaginous Epiphyseal Lesion in a Child Paul Thacker, MD, Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, [email protected]; Meryle Eklund, Anil Rao, MBBS, DMRD, DNB, James Mooney Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Lesions involving the cartilaginous epiphysis of very young children are rare with only scattered case reports and case series within the medical literature. Generally, if discovered, these are either managed surgically or biopsied percutaneously under ultrasound (US) or computed tomography (CT) guidance. However, in some instances, they may be sonographically and radiographically-occult and only demonstrated on magnetic resonance imaging (MRI). We present the case of 15 month-old Hispanic female evaluated by our pediatric orthopedic surgery department with the complaint of left knee pain and inability to extend her knee. Plain radiographs were normal with a subsequent MRI revealing an 8 mm well-circumscribed heterogenous lesion within the cartilaginous epiphysis of the medial femoral condyle. There was no associated edema surrounding the lesion, and the differential diagnostic considerations included a Brodie’s abscess, Langerhan cell histiocystosis, atypical chrondroblastoma, or possibly a very unusual secondary ossification center. Due to the lesion’s size, the orthopedic surgeon felt that such a small mass would be difficult to localize operatively, possibly requiring extensive surgical resection. Both CT and US imaging failed to demonstrate the lesion. Thus, an MRI-guided biopsy was performed, an extremely rare procedure outside of the central nervous system in the pediatric population with only a few cases reported in the world. Biopsy was successful, and the time required was comparable to that of CT-guided biopsy given the usage of an ultra-fast MR-biopsy protocol. Pathology was consistent with chronic changes of a Brodie’s abscess. The patient’s mother reported on next clinical follow-up that her child had significant and nearly immediate symptomatic improvement following the procedure, likely from lesion decompression. The patient received antibiotic therapy and has remained asymptomatic. Due to the success of this case and given the fact that overall procedural length was comparable to CT-guided biopsy, MRI guided biopsy may serve as an

alternative to CT even in those lesions classically demonstrated on CT, potentially reducing radiation exposure to our children during biopsy.

Poster #: CR-022 Adrenal Cortical Hyperplasia with Cytomegaly in BeckwithWiedemann Syndrome: A Multi-Modality Radiological-Pathological Correlation Matthew O’Dell, MD, MPH, Florida Hospital, Orlando, FL; Michele Edison, MD, Dzmitry Fursevich, MD, Gary LiMarzi, Laura Varich Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We present a case of a neonate with hemihyperplasia and presumed Beckwith-Wiedemann syndrome (BWS) who was diagnosed with an adrenal mass shortly after birth. Imaging workup included ultrasound, contrast enhanced CT and MRI. The adrenal mass was surgically removed for concern of malignancy and pathology revealed an enlarged adrenal gland with adrenal cortical hyperplasia and cytomegaly. Genetics workup initiated prior to surgery eventually confirmed BeckwithWiedemann syndrome. While this pathological finding has been reported in the literature, it has not been described in association with imaging findings from CT and MR. Furthermore, in the few cases where adrenal cortical hyperplasia with cytomegaly was described, it was in association with adrenal hemorrhagic cysts. In this case report we will discuss the imaging findings of adrenal cortical hyperplasia with cytomegaly correlated with gross pathology and histology. If imaging can exclude malignancy, perhaps surgical intervention can be avoided.

Poster #: CR-023 Splenogonadal Fusion Mimicking a Supernumerary Testis: Ultrasound and MR Features Jie Nguyen, MD, Pediatric Radiology, University of Wiscosin, Madison, WI, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Scrotal enlargement can be caused by a variety of intra-testicular and extra-testicular processes including inflammatory, congenital, neoplastic, or acquired. Splenogonadal fusion is a rare benign congenital cause which can mimic a supernumerary testis on US. However, MR can help to problem solve and suggest the true diagnosis of ectopic splenic tissue. Awareness of this entity and pre-operative Tc-99 m sulfur colloid imaging can confirm this diagnosis and prevent unnecessary orchiectomy. Methods & Materials: A 17 year-old-male presented with a painless left scrotal mass, which was initially diagnosed as a supernumerary testis. Subsequent MRI shows signal intensity compatible with that of the normal spleen, particular on T2-weighted images. Results: There are about 170 cases of published splenogonadal fusion, which can be continuous or discontinuous. In the discontinuous form, the ectopic splenic tissue can mimic another testis. Particularly, in older pediatric patients, where the normal nodular follicular pattern of the splenic parenchyma is less conspicuous, ultrasound cannot reliably distinguish between these two entities. Our patient underwent pre-operative MRI, which clearly showed different signal intensity between the normal testis and the ectopic splenic tissue. With the increase use of MRI, awareness of the normal appearance of splenogonadal fusion is critical and helpful for surgical planning and to avoid unnecessary orchiectomy. Conclusions: Splenogonadal fusion is a benign congenital cause of extratesticular scrotal mass. Awareness of this entity and familiarity with its imaging appearance on US and MRI can help ensure appreciate preoperative evaluation and avoid unnecessary orchiectomy.

Poster #: CR-024 Piriform Sinus Fistula as Cause for Suppurative Thyroiditis, “Not always left sided…” Joost van Schuppen, Academic Medical Center, Amsterdam, Netherlands, [email protected]; Heather Bray, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Suppurative thyroiditis is a rare entity in pediatric patients, but potentially life threatening. This infectious thyroiditis in children is usually left sided and associated with an underlying branchial cleft fistula extending from the left piriform sinus to the left lobe of the thyroid gland. In patients presenting with suppurative thyroiditis, an underlying piriform sinus fistula must be ruled out. Suppurative thyroiditis may recur if the underlying fistula is not treated. This poster reviews the imaging characteristics of suppurative thyroiditis associated with a piriform sinus fistula in pediatric patients. Three cases are discussed of the more typical left sided fistula as well as one example of a right sided fistula. Different imaging modalities are discussed in acute phase, follow up and recurrence, as well as imaging guided treatment options.

Poster #: CR-025 Imaging Findings of Calcineurin-Inhibitor Induced Pain Syndrome (CIPS) after Bone Marrow Transplant in a Child with Beta Thalassemia Major Rama Ayyala, MD, Columbia University Medical Center, New York, NY, [email protected]; Jahannaz Dastgir, Staci Arnold, Monica Bhatia

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Calcineurin-inhibitor Induced Pain Syndrome (CIPS) is an entity recognized in patients on immunosuppressive therapy after transplantation. Diagnosis is characterized by onset of pain beginning in the setting of an elevated calcineurin-inhibitor trough level and relief of symptoms with reduction of the medication dose. The hypothesized mechanism of CIPS is calcineurin-inhibitor induced vascular changes causing abnormal bone perfusion and permeability, leading to intraosseous vasoconstriction and resultant bone marrow edema. Here we present a unique case of CIPS in a pediatric patient and review the imaging findings. A 2 year-old female underwent matched sibling bone marrow transplant (BMT) for b-thalassemia major. The patient received a myeloablative conditioning regimen with tacrolimus and mycophenolate as her initial immunosuppressive therapy. At ~100 days post-BMT, routine laboratory testing showed supra-therapeutic tacrolimus trough levels with subsequent normal levels after medication modifications. A few weeks later, the patient was admitted to the hospital with preceding viral illness, unexplained irritability, bilateral leg pain, weakness, difficulty bearing weight, and sensitivity to touch, which was uncontrolled with opioids and gabapentin. Physical examination was remarkable for pain with light palpation of the extremities and absent reflexes at the knees and ankles. Strength, though difficult to assess, appeared normal. Laboratory values showed normal CSF studies, viral PCRs, inflammatory markers, and creatinine kinase levels. Lower extremity radiographs demonstrated focal periosteal bone formation in the bilateral tibia and fibula. Subsequent MRI of her lower extremities was notable for focal bone marrow edema with periosteal bone formation and adjacent muscle edema and normal MRI imaging of the lumbar spine and bilateral feet. Given the imaging findings and lack of support for other diagnoses such as infection, Gullian-Barre Syndrome, or stress injuries, the diagnosis of CIPS was presumed. She was started on a tacrolimus taper and initiated on steroids, with some relief. The plan included starting a calcium channel blocker if her pain continued. Transplantation is becoming more common in pediatric patients given recent advances and better long-term outcomes. In light of this, radiologists should be cognizant of CIPS and work closely with clinicians as to not overlook medications as a possibly etiology for these radiologic finding.

Poster #: CR-026 A Case Of Bow Hunter Syndrome: Bilateral Rotational Extrinsic Compression-Related Vertebrobasilar Insufficiency Presenting As Recurrent Stroke In A Young Child Thomas Savage, FRCR, Dept of Radiology, BC Children’s Hospital, Vancouver, BC, Canada, [email protected]; Firoz Myanji, Manraj Heran Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Strokes are rare in children and posterior circulatory strokes even more so. We present the clinical and imaging findings and management of an otherwise healthy 3-year-old female with recurrent posterior circulation strokes secondary to rotational vertebrobasilar insufficiency (Bow Hunter Syndrome) due to extrinsic compression at the C1/2 level bilaterally.

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Initial Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) demonstrated focal thromboembolic infarction in the right posterior cerebral artery territory (thalamus and right occipital lobe). A dissection was demonstrated of the left vertebral artery, which correlated with neurological findings of left sided weakness and incoordination. Treatment was initiated with therapeutic anticoagulation, with clinical improvement and the patient discharged home. Imaging, done as routine follow-up, 9 weeks later demonstrated that another left thalamic infarct had occurred silently in the interval, with another new symptomatic infarct in the right thalamus occurring three days later. Due to the concern of extrinsic compression-related dissection, raised by CT, and to determine optimal treatment planning, formal angiography was performed. This revealed dynamic extrinsic compression of both vertebral arteries due to subtle abnormality in the bony anatomy at the patient’s atlantoaxial articulation. The bony abnormality produced extrinsic compression of the V2 segments bilaterallyupon rotational motion at the atlanto-axial articulation. Given the marked extrinsic compression of both vertebral arteries with associated dissection, endovascular management was not considered an option, and our patient underwent posterior spinal fusion of C1-C2. The patient is currently well with limited residual deficit and no further episodes. She is on combined antithrombotic therapy. Bow Hunter Syndrome is a rare entity in the general population, with only a few cases reported in the paediatric population on review of published literature. Analysis of available series and reports reveals this patient as the youngest to present with such pathology, and is even more rare given the bilateral compression, which has not been reported before in a child. This case highlights the need to consider a dynamic process as a possible aetiology for vertebral artery dissection in a child, and the importance of different imaging modalities, including catheter angiography.

Poster #: CR-027 Evolution of an Unusual Shrinking T2-Dark Skull Lesion: Calvarial Desmoplastic Fibroma T Shawn Sato, University of Iowa Hospitals and Clinics, Iowa City, IA, [email protected]; Lillian Lai, MD, Patricia Kirby, Yutaka Sato, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We present a rare case of desmoplastic fibroma involving the calvarium in a 16 year-old male, with CT and MR documentation of its evolution over 2 years and pathological correlation. A 14 year-old boy presented with occasional headaches. On CT, he was found to have a 6 cm diameter right parietal lytic skull lesion with nonsclerotic, well-defined borders. The lesion expanded the diploic space with smooth remodeling of the inner and outer skull tables, and had no extraosseous component. Over the first 6 months, the lesion exhibited increased diploic expansion. After 2 years, the lytic areas coalesced and the lesion shrunk to 5 cm in size. On MRI, the lesion showed isointense T1 and hypointense T2 signal with mild peripheral enhancement, and no intracranial involvement. Given the progressive erosion of the parietal bone over 2 years, a right parietal cranioplasty and excision of the lesion was performed. On histology, the lesion was composed of dense fibrous connective tissue with struts of laminated bone peripherally and scattered islands of woven bone with focal osteoblastic rimming and occasional osteoclasts. There was little inflammation and no cytological atypia or

mitotic activity. Final diagnosis favored desmoplastic fibroma given the lesion’s local aggressiveness, with a differential diagnosis of atypical fibrous dysplasia. The patient did well post-operatively. Bone scan was negative for other sites of disease. Desmoplastic fibroma is rare, intraosseous, locally aggressive tumor with predilection for the long bones and mandible with rare involvement of the calvarium. It occurs in young adults with peak incidence in the second decade. It is the bony counterpart to soft tissue fibromatosis and is also known as desmoid tumor of the bone. The treatment of choice for desmoplastic fibroma is wide local excision or resection given its local aggressiveness. In this case, the shrinking size with coalescing lytic areas suggested a benign but locally aggressive lesion, and the hypointense T2 signal reflected its fibrous nature. It is important to consider desmoplastic fibroma in the differential for fibrous skull lesions with locally aggressive features, as surgical resection is the treatment of choice.

Poster #: CR-028 Primary Muscle Lymphoma: Imaging Suggests a Clinically Unsuspected Diagnosis Elijah Burton, BA, Feinberg School of Medicine, Northwestern University, Chicago, IL, [email protected]; Jonathan Samet, Kristian Schafernak Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: This patient is a 17-year-old boy who presented with a four-week history of intermittent back and thigh pain. The pain had progressively worsened, awakening him at night, and there was swelling in the thigh and buttocks. He also reported fevers and night sweats. Past medical history, physical exam, and initial labs were irremarkable. His pediatrician referred him for MRI after failing conservative therapy. MRI demonstrated diffuse unilateral expansion of the right-sided paraspinal and gluteal musculature without a focal measurable mass. There was a striking effacement of the normally identified fatty strands within the affected muscles. Relative to other muscles, the signal was isointense on T1. The muscle was diffusely mildly T2 hyperintense, with more dominant linear T2 hyperintense signal in a striated pattern along the muscle fibers. Following administration of gadolinium, the involved muscles exhibited diffuse enhancement with additional linear hyperenhancement in a striated pattern. Additionally, small enhancing soft tissue nodules adjacent to the affected muscles were seen in the overlying subcutaneous tissues. Although small, the presence of soft tissue masses was a clue pointing toward a neoplastic process, and would be atypical for inflammatory or infectious myositis. These nodules were located over the buttocks, an atypical site for lymph nodes. This appearance was suspicious for an infiltrative process, specifically lymphoma, which promptly led to ultrasound-guided biopsy of the involved gluteal musculature. A high-grade CD10 positive B-cell lymphoma was diagnosed, however additional fresh tissue was required for precise subclassification through flow cytometry immunophenotyping, conventional cytogenetic analysis and fluorescence in situ hybridization, and it was ultimately determined to represent an atypical variant of Burkitt lymphoma. CT scan of the chest, abdomen, and pelvis was obtained for staging purposes and similar to the MRI, there was diffuse unilateral enlargement of the gluteal and paraspinal muscles but no other sites of involvement or lymph node enlargement were seen. Bone marrow biopsy and lumbar puncture were negative for lymphoma. The patient was subsequently started on a chemotherapy regimen for lymphoblastic lymphoma. He entered remission shortly after initiation of therapy but 6 months later relapsed and eventually died of progressive disease.

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A 4 week old male was transferred from an outside facility after presenting with cardiac arrest. The infant was in pulseless electrical activity upon arrival to the outside emergency department with return of spontaneous circulation achieved after administration of epinephrine and intubation. Bruising and petechiea were present on the child’s face and asphyxia was suspected. An investigation of possible child abuse was pursued. Computed tomography (CT) of the head was performed, revealing sharp, branching linear lucencies in the bilateral parietal bones initially concerning for complex fractures (see Figure). On the right, there were five linear lucencies joined centrally in a nearly stellate pattern, with dominant orthogonal components oriented vertically and longitudinally. On the left, three dominant lucencies joined centrally, also with orthogonal orientation. An additional noncontiguous parietal lucency was seen extending anteriorly from the left lambdoid suture, smaller in size but similar in orientation to the contralateral calvarium. Overall, the lucencies had a somewhat symmetric pattern. There was no associated diastasis of the coronal, sagittal, or lambdoid sutures. No blood products were identified intracranially, and there was no overlying soft tissue swelling of the scalp. The patient had refractory seizure activity and subsequently acquired magnetic resonance imaging of the brain revealed findings of hypoxic ischemic encaphalopathy. The patient showed no signs of recovery and ultimately he was removed from life support and expired. Autopsy was performed, demonstrating unequivocally that the parietal lucencies seen on CT had histological features of cranial sutures rather than fractures. There was no evidence of bony healing, and no blood products were seen in the immediately adjacent soft tissues. Although accessory intraparietal sutures are relatively common in infants, most attention is given to single incomplete, vertical, horizontal or oblique accessory sutures. This case serves as an example of complex, bilateral accessory parietal sutures in a child undergoing workup for nonaccidental trauma, and highlights the importance of the pediatric radiologist being aware of the varied appearance of ossification variants in the parietal bone. While linear lucencies extending through the skull can be very difficult to interpret, symmetry and location of the lucencies can point toward developmental variant rather than fracture.

Poster #: CR-029 ATypical Accessory Intraparietal Sutures Mimicking Fractures Meryle Eklund, MD, Radiology and Radiological Sciences, M e d i c a l U n i v e r s i t y o f S o u t h C a ro l i n a , C h a r l e s t o n , S C , [email protected]; Michael Taylor, Ellen Riemer, Jeanne Hill, Seth Stalcup

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Poster #: CR-030 A Unique Case of Ruptured Appendicitis with Fecalith Migration causing Lung Abscess Erica Yang, MD, Texas Children’s Hospital, Houston, TX, [email protected]; Martha Munden, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Appendicitis is a commonly encountered diagnosis in the pediatric age group, but the complication rate is highest in young children. This poster illustrates a unique case of appendicitis complicated by lung abscess, with several companion cases that collectively will make the reader think “outside the box” in regards to this diagnosis in young children. This is a 2 year old female who presented to our emergency department for abdominal pain for 4 days and low grade fever for 1 week. Limited RLQ ultrasound was performed showing very pronounced and diffuse bowel wall thickening with echogenic interloop fluid and a complex structure in the right lower quadrant with a mostly rounded configuration and surrounding hyperemia. Sonographic findings are suggestive of a perforated appendicitis versus Meckel’s diverticulum. The patient was then taken to the operating room for laparoscopic appendectomy, which revealed perforated, gangrenous appendicitis with multiple abscesses and fecaliths. She otherwise had an uncomplicated postoperative course in the hospital and was discharged home after 5 days. One month later the patient returned to the ED with complaints of emesis and decreased p.o. intake for 2 days and intermittent subjective fevers for 2 weeks. Abdominal and chest films revealed small bowel obstruction and a right pleural effusion with right lower lobe pneumonia. US of the chest showed a 5 cm complex collection within the lung compatible with a parenchymal abscess which communicated with a sub diaphragmatic collection via a defect in the right hemi diaphragm. Chest CT confirmed the above with additional finding of 4 mm calcification within the lung abscess likely representing migration of a retained appendicolith, which served as a nidus of infection. The patient then went to the IR suite and underwent technically successful ultrasound-guided breakage and partial removal of the appendicolith and drainage of the lung abscess, with demonstration of a bronchopleural fistula after contrast injection at the end of the procedure. She had a good postoperative course and was discharged home after 14 days, and was doing well without complaints on follow up visit 2 weeks later. Appendicitis in young children can have unusual clinical and sonographic findings with unexpected complications. Knowledge of these complications is helpful to the radiologist in describing pertinent imaging findings as well as to the clinician and surgeon in developing treatment strategies.

Poster #: CR-031 Syntelecephaly: Review of Two Cases in Children with Additional Associated Findings Yakup Akyol, Nemours Alfred I DuPont Hospital for Children, Wilmington, DE; Vinay Kandula, Arabinda Choudhary Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this presentation is to review the MR imaging characteristic of syntelencephaly, or the middle interhemispheric variant of holoprosencephaly (MIH) which is consists of an abnormal midline connection of the cerebral hemispheres in the posterior

frontal and parietal regions, with interhemispheric separation of the basal forebrain, anterior frontal lobes, and occipital regions. Although the neuroradiology features of this subtype have been recently detailed, our patient’s brain MRI study demonstrated multiple additional findings which haven’t been describe in the literature before. Methods & Materials: Brain MRI images of the 3 month old male with sensorineural hearing loss and 3 years 6-month-old female with developmental delay were retrospectively analyzed.

Results: First patient’s brain MRI demonstrates failure of cleavage of the posterior frontal and anterior parietal regions of the brain across the midline. The body of the corpus callosum was hypoplastic. There was separation of the posterobasal forebrain with presence of interhemispheric fissure anteriorly and posteriorly. There were clear cleavage of the hypothalamus, thalami, lentiform nuclei and caudate nuclei. Patient also had bilateral cystic cochleovestibular malformation (incomplete partitioned type I, IP-1), absence of the cochlear nerve and lateral semicircular canal on the left, persistent falcine sinus and atretic small parietal encephalocele. Second patient had classic MRI findings of the syntelencephaly. Conclusions: Syntelencephaly is a rear congenital malformation with characteristic MRI findings. The coexistence of the syntelencephaly and cystic cochleovestibular malformation, persistent falcine sinus and parietal encephalocele raises the question of pathogenic association or coincidence between them.

Poster #: CR-032 Unique Positioning for CT Cisternography of Suspected CSF Leak: A Case Report David Aria, MD, Phoenix Children’s, Phoenix, AZ; Patricia Cornejo, MD, Trevor Davis, DO, Robin Kaye, Carrie Schaefer, Richard Towbin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A 3 year-old Caucasian female presented with a chief complaint of headache. Her past medical history was significant for streptococcal meningitis approximately months previously complicated by a left MCA territory stroke. She had no history of surgey but a positive history for remote, nonspecific trauma. On workup, the patient had a lumbar puncture revealing recurrent meningitis but CT of the head was normal. Given the above history, there was clinical suspicion for congenital versus traumatic CSF leak. The patient was therefore referred to interventional radiology for lumbar drain placement to lower CSF pressure and cisternogram to localize the source of leak.

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Methods & Materials: A 14-gauge Tuohy needle was advanced into the thecal sac at L3-L4 using fluoroscopic guidance. After return of CSF, a lumbar drain was advanced through the Tuohy needle with tip placement in the thecal sac at the level of the thoracic spine. Via the lumbar drain, Isovue-200-M was injected into the thecal sac and the patient transferred to CT. CT cisternography was performed with the patient in provocative positioning (prone and Trendelenberg). The field of view included the paranasal sinuses and temporal bones with thin (1-mm) axial images and coronal and sagittal reformats. Results: Axial CT cisternogram images demonstrated retrograde tracking of contrast from the tip of the nose back into the left nasal cavity, to the left eustachian tube and left middle ear. Coronal reformats better demonstrated the middle ear opacification resulting from an anomalous direct communication with the internal auditory canal. The left cochlea was enlarged and featureless with expanded semi-circular canals consistent with a Mondini Malformation. The patient underwent subsequent tympanoplasty with closure of the CSF leak 12 days later and has had an uneventful course since. Conclusions: CT cisternography is very helpful in identifying and localizing CSF leak. To maximize its diagnostic value, it should be performed with provactive manuevers such as prone and Trendelenberg positioning. In addition, the field of view should include the paranasal sinuses as well as the temporal bones.

Poster #: CR-033 Withdrawn

Poster #: CR-034 Ancient Naval Disease Making a Comeback? A Case Report and Review of the Unique MRI Findings of Scurvy Takman Mack, MD, Radiology, Naval Medical Center San Diego, San Diego, CA, [email protected]; Jerry Dwek Disclosures: Rajesh Krishnamurthy indicated a relationship with Koninklijke Philips Electronics as a Principal Investigator. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Case Report Methods & Materials: Scurvy is a condition caused by severe dietary Vitamin C deficiency. Most animals can synthesize Vitamin C, however, humans lack a critical enzyme in the biosynthesis process and therefore rely on a dietary source of Vitamin C. The classic symptoms of scurvy include loose teeth, bleeding gums, lethargy, and skin spots. Scurvy reached epidemic proportions during the “Age of Sail,” leaving an indelible mark in naval history. Scurvy is occasionally still seen in malnourished populations, but now rarely occurs in developed countries. Moreover, the MRI appearance of this disease has seldom been reported in medical literature. The authors present an unusual case of scurvy in a 12 year old female with Jacobsen’s syndrome. Jacobsen’s syndrome is a rare congenital disorder (deletion of terminal chromosome 11q) characterized by developmental delay, cognitive impairment, various congenital anomalies, and abnormal bleeding, among other features. At baseline, our patient exhibited behavioral and cognitive impairment, and also suffered from iron deficiency anemia and thrombocytopenia. She was referred for MRI evaluation after

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her pediatrician noticed unexplained bruising and swelling of her left knee. Further assessment revealed that the patient’s diet consisted solely of pancakes, macaroni with cheese, and bean and cheese burritos. Additional physical exam revealed severe gum disease and a vitamin C level was subsequently drawn. Vitamin C levels were undetectable in her blood sample. On subsequent follow up, her gum disease and leg swelling had markedly improved. Although her diet had been significantly modified, she remained on Vitamin C and iron supplementation. Results: Although the plain radiographic findings of scurvy have been well established, sporadic case reports have demonstrated an emerging subtle pattern of MRI findings. Although somewhat variable, findings that have been consistently described include metadiaphyseal marrow signal abnormalities and/or enhancement, increased periosteal signal and/or enhancement and increased surrounding soft tissue signal. Our patient highlighted a combination of these findings thoughout the lower extremities (see figures 1-3). Conclusions: A subset of the pediatric population with food avoidance behavior and/or developmental delay is at higher risk for nutritional deficiencies. As such, pediatric radiologists should consider the possibility of scurvy in the proper clinical setting when evaluating nonspecific musculoskeletal pain.

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We present a case of an 8-year-old girl with no medical history, who presented to her pediatrician with neck pain and headache of approximately 6 months duration. An MRI was performed demonstrating a complex mass in the posterior elements of C1 prompting admission to the hospital for surgical evaluation and treatment. Preoperative workup consisted of an initial computed tomographic angiography of the neck and cervical spine. This study demonstrated an aggressive appearing, hypervascular, expansile lytic lesion involving the bilateral pedicles and posterior elements of C1. A working differential of aneurysmal bone cyst versus telangiectatic osteosarcoma was made. The patient was then referred to neurointerventional for a preoperative angiogram with embolization. Embolization of several vertebral artery branches was performed with obliteration of vascular supply to the mass of approximately 90%. The patient was then taken to surgery where intraoperative MRI/MRA were performed and registered to the intraoperative neuronavigation system to avoid damage to the adjacent vertebral arteries. Complete surgical excision was achieved and the patient was discharged home several days later. Surgical pathology demonstrated an aneurysmal bone cyst. A followup MRI obtained 14 weeks after the procedure demonstrated adequate resection with no residual or recurrent tumor.

Poster #: CR-035 Poster #: CR-037 Twist and Shout! Imaging findings in Isolated Fallopian Tube Torsion, An Unusual Cause for Severe Abdominal Pain in Pediatric Girls Yeamie Kousari, MD, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Richard Bellah, Nancy Chauvin, MD, Sudha Anupindi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Isolated fallopian tube torsion is a rare clinical entity that occurs most often in young women in their reproductive years. Isolated fallopian tube torsion is often not considered in the differential diagnosis of a pediatric patient presenting with pelvic pain, such that the diagnosis is often not made preoperatively. However, in the pediatric girl with severe pelvic pain, the imaging finding of a para-ovarian cystic abnormality, in the setting of a normal ipsilateral ovary with lack of signs of other pelvic pathologic processes, should strongly suggest the diagnosis of isolated fallopian tube torsion. Ultrasound is the mainstay of initial imaging for pediatric patients presenting with pelvic pain, while, in some instances, when the symptomatology/diagnosis is unclear or when ultrasound is technically limited, MRI can be of proven value. We present imaging findings in a series of surgically proven cases of isolated fallopian tube torsion, preoperatively diagnosed with US and/or MRI.

Poster #: CR-036 Aneurysmal Bone Cyst of Atlas Treated with Preoperative Embolization and Intraoperative MR Guided Excision Matthew O’Dell, MD, MPH, Diagnostic Radiology, Florida Hospital, Maitland, FL; Michele Edison, MD, Dzmitry Fursevich, MD, Gary LiMarzi, Laura Varich

Massive Torsed Hemorrhagic Ovarian Follicular Cyst Presenting as Palpable Abdominal Mass in an Anemic Neonate Matthew O’Dell, MD, MPH, Diagnostic Radiology, Florida Hospital, Maitland, FL; Michele Edison, MD, Dzmitry Fursevich, MD, Laura Varich Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We report a case of a neonate presenting at birth with palpable abdominal mass and anemia. Ultrasound images demonstrated a massive complex cystic structure without internal color flow occupying the entire right hemiabdomen. A differential diagnosis of mesenteric lymphangioma, enteric duplication cyst, neuroblastoma and ovarian cyst was given; subsequent abdominal MRI was performed to determine the origin and signal characteristics of the mass. MRI demonstrated a cystic mass that appeared to arise from the right adnexa with increased T1 signal and fluid-debris levels, narrowing the differential. Surgical resection was recommended and the patient was taken to the operating room for laparoscopic resection. The mass was determined to arise from a torsed left ovary. The cyst was resected and the ovary was detorsed. Both ovaries were grossly viable and well perfused at the end of the procedure. Surgical pathology demonstrated a hemorrhagic follicular cyst.

Poster #: CR-038 Neuroimaging Features of Haberland’s Syndrome Matthew O’Dell, MD, MPH, Diagnostic Radiology, Florida Hospital, Maitland, FL; Michele Edison, MD, Dzmitry Fursevich, MD, Laura Varich Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Haberland’s syndrome, also known as encephalocraniocutaneous lipomatosis (ECCL), is a rare, sporadically occurring neurocutaneous disorder first described in the 1970s. Since then, approximately 60 cases have been reported in the literature. The syndrome is caused by ectomesodermal dysgenesis and results clinically in seizures in one half of patients, and mental retardation in one third of patients. We present the MR and radiographic imaging findings of a neonate with classic neurocutaneous manifestations of this condition. These imaging features include dilated ventricles, porencephalic cyst, cortical dysplasia, arachnoid cysts, asymmetric cerebral atrophy, as well as extensive intracranial and spinal lipomas. Our discussion will include the characteristic neurological imaging features of this syndrome and a review of the literature.

Poster #: CR-039 Pediatric Case Presentation of Schwannomatosis, A Rare but Distinct form of Neurofibromatosis Anna Thomas, MD, Pediatric Imaging, Phoenix Children’s Hospital, Phoenix, AZ; John Egelhoff, Padmaja Naidu, John Curran, Jeffrey Miller, Richard Towbin, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Schwannomatosis has been recognized as the third major form of neurofibromatosis relatively recently. It is a rare clinical condition with annual incidence of 0.58 per 1 million persons. Schwannomatosis is clinically and genetically distinct from neurofibromatosis type 2 (NF2) and neurofibromatosis type 1(NF1). We present a case of a previously healthy teenager who upon imaging workup for Chiari 1 malformation was found to have multiple spinal schwannomas and an enhancing right parotid mass. Fine needle biopsy of the parotid lesion was conclusive for an intraparotid schwannoma. This patient meets the existing diagnostic criteria for presumptive schwannomatosis. This case report aims to show case the characteristic molecular and physical manifestations seen in this rare disease, review criteria involved in definite and presumptive diagnosis of this condition, and compare this entity with NF1 and NF2. To date, this is the first detailed case report of schwannomatosis in the pediatric population and the third reported pediatric case of an intraparotid facial nerve schwannoma.

Poster #: CR-040 Traumatic Celiac Artery Dissection in an Adolescent Diagnosed using a Computed Tomography Split Bolus “Afghan” Technique Michael Paddock, MBBS, Sheffield Children’s Hospital, Sheffield, United Kingdom, [email protected]; Ramdas Senasi, MBBS, FRCR, Michelle Hare, Rebecca Ward, Jennifer Hough, Ashok Raghavan Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Traumatic celiac artery (CA) dissection was diagnosed in a 14-year-old female following a road traffic accident using a newly introduced computed tomography (CT) split bolus “Afghan” technique.

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Methods & Materials: Glasgow Coma Scale was 14-15 on arrival. Airway and breathing were stable. The patient required fluid resuscitation for fluctuating hypotension. She complained of pain in her right iliac fossa and legs: no obvious fractures were evident on examination. Cervical spine, chest and pelvic X-rays were normal. A CT head, abdomen and pelvis were performed with multiplanar reformats, as per the United Kingdom Pediatric Trauma Protocol guidelines. We employed a newly introduced “Afghan” technique, in which split boluses of contrast were given at different volumes and flow rates to demonstrate arterial and venous phases in a single scan acquisition. Prior to introducing this technique, all our trauma scans consisted of a single portal venous phase acquisition. Salient findings included mild soft tissue thickening around the aorta and at the level of the CA that were suspicious for dissection at the origin of the CA. This was confirmed on Doppler ultrasound and it was managed conservatively. There were also multiple pelvic fractures that were treated surgically. Results: Traumatic CA dissection is rare in children. It is more common in penetrating than blunt trauma and is associated with a high mortality. Delayed diagnosis can lead to increased morbidity and mortality, as one case report has highlighted. Reliable diagnosis of acute hemorrhage is usually made on arterial phase CT. Standard portal venous techniques risk missing subtle areas of hemorrhage, such as CA dissection, as there is inadequate arterial vessel demonstration. The advantage of the “Afghan” technique is the ability to demonstrate both the arterial and portal venous phases during a single scan acquisition, in place of two separate scans, halving the radiation burden. This technique was developed in Afghanistan for imaging traumatic injury in the military and local civilian population. Conclusions: This case highlights the potential role of this novel technique in pediatric trauma, which can improve diagnostic accuracy of arterial hemorrhage whilst mitigating radiation exposure. More data is needed to ascertain the reliability of this technique, however, it is clear that it has an emerging role in major pediatric trauma.

Poster #: CR-041 Intradiploic Pseudomeningocele Yakup Akyol, Nemours Alfred I DuPont Hospital for Children, Wilmington, DE; Vinay Kandula, Arabinda Choudhary Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Intradiploic pseudomeningocele is usually associated with head trauma in childhood or can be iatrogenic. They present with a defect of the inner table and the dura but an intact outer table. We highlight 2 cases of intradiploic pseudomeningocele which presented as an large osseous prominence involving the posterior aspect of the skull. Physiology of intradiploic pseudomeningocele, the imaging finding and suggested management will be reviewed. Patient 1: Evelen years old ambidextrous male with previous history of craniocervical decompression for Chiari malformation at the age of 2. At the 10 years old, patient start complaining for cluster type headache with no associated vomiting. Physical examination showed large osseous prominence involving the entire left posterior aspect of the skull. Both optic discs appeared normal. Pupillary reactivity and ocular motility were normal. There was no evidence of drift, tremor or dysmetria on physical exam. Initial x-ray of the skull showed a large expansile, well circumscribed lucent lesion with peripheral sclerotic rim centered within the occipital bone. Head CT examination confirmed that there was fluid filled expansile occipital bone lesion extending from midline to the left occipital bone and measuring 7.1 × 2.2 × 5.6 cm in transverse-APcraniocaudal dimensions respectively. There was small focal bone discontinuity near the midline at the level of prior Chiari decompression.

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Based on imaging findings diagnoses of intradiploic pseudomeningocele was made and CSF shunt procedure was considered. Patient 2: Eighteen years old male with past medical history of scoliosis and craniocervical decompression for Chiari type I malformation at age of 9 and second decompression at age of 14. Patient was not complaining for headache or other neurological symptoms, however have some back pain which was associated with the scoliosis. His routine annual x-ray demonstrated wellcircumscribed lucent lesion with peripheral sclerotic rim centered within the occipital bone. Cervical spine MRI examination confirmed that there was a occipital bone lesion extending from midline to the right occipital bone appearing isointense to the cerebrospinal fluid (CSF) on T1 and T2-weighted images. The lesion was measuring 3.6×0.9 cm in craniocaudal and AP dimensions respectively. Based on these imaging findings diagnoses of intradiploic pseudomeningocele was made. Since the patient was symptom free clinical followup is recommended.

Poster #: CR-042 Duodenal Intussusception Secondary to Web Presenting as Recurrent Pancreatitis in a Seven-Year-Old Girl L o n g Tu , U n i v e r s i t y o f C o n n e c t i c u t , F a r m i n g t o n , C T, [email protected]; Gustavo Villalona, Robert Coles, Cicero Silva Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Duodenal intussusception is a rare entity in children, with less than a dozen reports in the English literature to our knowledge. Most reported cases are associated with a neoplastic lead point and the presenting symptoms are chronic and non-specific. We report a case of duodenal intussusception in a seven-year-old girl secondary to a duodenal web, and review the imaging findings. The patient presented to an outside hospital with a bout of recurrent pancreatitis, manifested as acute exacerbation of chronic abdominal pain, and was transferred to our facility after an abdominal sonogram and an abdominal CT scan had been interpreted as concerning for a bowel mass. Evaluation at our emergency department confirmed increased lipase consistent with acute pancreatitis. The outside sonogram and CT were reviewed, and an upper GI contrast study performed. The constellation of imaging findings suggested a duodenal intussusception secondary to a web near the ampulla of Vater; this was confirmed with endoscopy and subsequent surgical exploration. Surgical correction involved division of the web, along with duodenoduodenostomy to ensure patency of the proximal small bowel. The patient recovered uneventfully.

Poster #: CR-043

An 8 year old girl presented with 1 week of fever. Following a course of antibiotics for cystitis, she developed progressive back pain and anorexia. Renal ultrasound incidentally revealed a 6.9 cm midline cystic and solid hypervascular anterior abdominal mass separate from kidneys, bladder, bowel and liver. By history, this mass had been palpable for approximately 5 years, was thought to represent stool, and had grown little in the interim. IV contrast enhanced CT of the abdomen and pelvis in the venous phase confirmed a single anterior abdominal mass without evidence of metastatic disease, specifically no liver lesion was visible. She was taken to surgery for laparoscopic excisional biopsy. The mass was attached to the umbilical vein and completely resected. Palpable lesions were identified in both lobes of the liver which prompted a superficial left lobe liver nodule resection. Pathology revealed PEComa of the primary mass and angioinvasive liver metastases. To further evaluate the liver, dynamic contrast enhanced abdominal MRI with diffusion weighted imaging was performed, revealing 5 sub centimeter lesions in left liver segments 2, 4b, and medial right lobe liver segment 8. Identification of liver metastases was crucial in planning surgical resection as these tumors are not known to be readily responsive to chemotherapy or radiation therapy. PEComa is classified as a mesenchymal cell tumor with unknown malignant potential consisting of microscopic perivascular epithelioid cells. Genetically, PECs are linked to the tuberous sclerosis genes TSC1 and TSC2. These tumors are known for their hypercellularity and hypervascularity and may have necrosis with cellular atypia, and therefore have potential for infiltrative growth. Conclusions: PEComa is a rare hypercellular, hypervascular mesenchymal tumor that can be indolent but have subtle liver metastases. The liver metastases are best visualized on pre contrast T1 MRI, diffusion weighted imaging and early angiographic phase imaging.

Poster #: CR-044 Two Recent Cases of Menkes Kinky Hair Disease Brian Wilson, Radiology, UTSW, Dallas, TX, [email protected]; Dr. Katie Wiertel, Dr. Korgun Koral Disclosures: Ketan Ghaghada indicated a relationship with Marval Pharma Inc as a Contracted Researcher. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Two recent cases of Menkes Disease will be reviewed. Each patient’s clinical presentation, hospital course, laboratory workup, and imaging findings will be discussed. The diagnostic dilemma for the radiologist during each stage of workup will be emphasized as the cases both had potential misleading pathologic findings on the original imaging before the classical findings described in Menkes disease were noted on later exams. CT, MRI, and MRA images in these patients showing the classical features of the disease will be presented along with the discussion.

Indolent Malignant PEComa Kari Hayes, MD, Pediatric Radiology, Children’s Hospital Colorado, Denver, CO, [email protected]; Frederick Karrer, Laura Fenton, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Perivascular epithelioid cell tumor (PEComa) is a relatively rare tumor of unknown precursor cell which can be found anywhere in the body. Our aim is to present the unique imaging features and surgical implications of this rare tumor as well as review of the literature.

Poster #: CR-045 Be Aware and Beware: Marked Respiratory Motion Resulting In Displacement of Voxels Mimicking Renal Obstruction on Functional MR Urography David Saul, MD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Dmitry Khrichenko, Julie Dobkin, Kassa Darge, MD, PhD

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Disclosures: Claudio Salim indicated a relationship with Guerbet as a Independent Contractor. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Functional MR Urography (fMRU) provides comprehensive morphologic and functional information. It is essential to understand potential pitfalls of fMRU to correctly interpret it. This is a case study of a child in whom significant respiratory motion spuriously created an obstructive pattern on the enhancement curve. A 7-month-old male infant with hypoplastic left heart syndrome was evaluated by urology for management of hydronephrosis. FMRU was requested for assessing the renal function (Fig. 1). Standard fMRU in supine position with pre- and post-contrast dynamic sequences was carried out with sedation. Initial static morphologic images revealed severe pelvicaliectasis and cortical thinning on the right, and moderate pelvicaliectasis without cortical thinning on the left. Post-contrast dynamic images were acquired, and enhancement and excretion curves were generated using the CHOP-fMRU freeware. The enhancement curves showed persistently elevated enhancement on the right, and only a minimal decrease of enhancement initially with subsequent plateauing on the left. Cortical transit times were normal, but renal transit times were markedly delayed on both sides. Inspection of the source images revealed significant respiratory motion artifact, with errant displacement of enhanced pixels in the phase encoding direction (left-right) from the pelvicalyces onto the renal parenchyma on the later dynamic series. This resulted in falsely elevated enhancement values on all time points in which there was contrast in the collecting systems. Consequently the enhancement curve resembled that of obstruction. Urology elected to maintain watchful waiting because of the patient’s compromised cardiac status. A MAG-3 study 9-months later revealed that no obstruction was indeed present on the left, and that obstruction on the right was incomplete (Fig 1).

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Poster #: CR-046 Investigation of Suspected VP-Shunt-related Pseudocyst Reveals Rare Complication of Distal Shunt Erosion into the Small Bowel Kelsey Bourm, MD, Diagnostic Radiology, University of Kansas-Wichita, Wichita, KS, [email protected]; Cory Pfeifer, MD, Debra DesiletDobbs, Adam Zarchan Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Our patient is an 8-year-old female born at 29 weeks gestational age with a history of cerebral palsy and three prior ventriculoperitoneal shunt revisions who presented with a 2-day history of nonbilious emesis, fever, and cephalgia. The head CT upon admission demonstrated ventriculomegaly which was greatest in the left lateral ventricle at the cephalic terminus of the shunt. A subsequent nuclear medicine shuntogram verified the patentcy of the distal shunt tubing, however, there was central organization of radiotracer in the abdomen in a pattern commonly seen with pseudocyst formation. The follow-up CT of the adomen and pelvis revealed that the shunt tubing was now intraluminal within multiple small bowel loops, and the finding was later verified surgically. The VP shunt fluid analysis revealed gram-negative bacteria. Conclusions: Bowel perforation is a rare complication of ventriculoperitoneal shunt placement. When seen, it most commonly affects the large bowel and stomach. We thus report the exceedingly uncommon instance of small bowel perforation by a VP shunt catheter. This case also highlights a differential consideration for the central organization of intra-abdominal radiotracer when seen on a nuclear medicine shuntogram.

Poster #: CR-047 Encephalocraniocutaneous Lipomatosis - A Rare Neurocutaneous Syndrome Alfred Delumpa, MD, Neuroradiology, Baylor College of Medicine, Houston, TX, [email protected]; Lee Nakamura, MD, Brandon Tran

Respiratory motion on fMRU can introduce error in functional results. Specifically, it can mimic falsely delayed parenchymal retention of contrast by displacing hyperintense voxels in the phase encoding direction from the collecting system onto the parenchyma. This effect intensifies toward the end of the study as sedation begins to wear off and is reflected as a persistently elevated enhancement curve, implying obstruction. It is important to increase the sedation just before contrast injection to reduce motion artifacts at the end of the dynamic series and try to avoid such a pitfall.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Encephalocraniocutaneous lipomatosis (ECCL) is a rare neurocutaneous syndrome characterized by central nervous system lipomas accompanied by characteristic dermal and ocular abnormalities. The major clinical manifestations of this syndrome suggest a congenital disorder of mesenchymal elements, especially neural crest derivatives. Naevus psiloliparus, focal fatty areas of alopecia on the scalp, are the characteristic dermatological manifestation. Epibulbar choristomas are the most common ocular finding. Neurologic presentation is variable as some patients can be normal and others can have variable degrees of mental and/or psychomotor retardation. Furthermore, some patients may present with seizures. This case report poster exhibit will present three cases of ECCL from our institution. The goal of this exhibit is to illustrate the spectrum of physical exam and imaging findings of this syndrome. Additionally, a quick review of the literature in the context of these case presentations will aim to highlight the clinical implications of ECCL. Specifically, this exhibit will help clinicians recognize the salient clinical and physical exam findings of this syndrome, which should alert them to the possibility of intraorbital, intracranial and intraspinal pathology.

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Poster #: CR-048

Poster #: CR-050

Rhabdomyosarcoma of the Cervix and Type 1 Pleuropulmonary Blastoma: A DICER 1 Gene Mutation

Febrile Infection-Related Epilepsy Syndrome (FIRES): A Rare But Very Severe Epileptic Encephalopathy

Mark Bittman, Radiology, Long Island Jewish Medical Center, New Hyde Park, NY, [email protected]

Lee Nakamura, MD, Pediatric Neuroradiology, Texas Children’s Hospital/Baylor School of Medicine, Houston, TX, [email protected]; Jill Hunter

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We report a case of pathologically proven rhabdomyosarcoma of the cervix in an adolescent female found to have a regressed type 1 pleuropulmonary blastoma (PPB) on a staging chest CT. Subsequently, the patient tested positive for the DICER 1 mutation. She underwent hysterectomy and was treated with both chemotherapy and radiation therapy. Follow-up scans demonstrate recurrence at the vaginal cuff and postoperative imaging examinations also demonstrate radiation induced enteritis and obstructive uropathy. B Methods & Materials: The MRI of the abdomen and pelvis at presentation and follow-up exams are presented. The initial staging CT of the chest is shown. Images from interventional radiology procedures are presented. Correlative laboratory values, and genetic markers are discussed. Results: A case report of recurrent cervical rhabdomyosarcoma in a patient with type I PPB and DICER 1 gene mutation. Conclusions: MRI findings of cervical rhabdomyosarcoma plus a cystic lesion in the chest should prompt genetic testing for DICER 1 mutation.

Poster #: CR-049

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Febrile infection-related epilepsy (FIRES) syndrome is a severe epileptic encephalopathy of unknown etiology. This disease affects previously healthy children, who initially present with a febrile infection followed by highly recurrent focal seizures, which often progress to refractory status epilepticus. Imaging findings are non-specific, with MRI imaging demonstrating abnormal signal within the hippocampus. Follow-up imaging usually shows generalized progressive atrophy and/or mesial temporal sclerosis. The seizures are very difficult to control, with no successful treatment. We present a case of a previously healthy 4-year-old boy presenting with new onset seizures, a recent history of fever associated with an otitis media infection. An extensive workup ruled out any structural, metabolic, autoimmune, or infectious etiology. Despite multiple treatments, which included antiepileptic regimens, IV immunogloblulin, plasma exchange, steroids, vagus nerve stimulator, and cooling regimen, there was a protracted 5 month hospital course with no prolonged amount of time without seizures. While rare with non-specific imaging findings, this is an important case to present, as the radiologist should suggest the diagnosis when the history of recent fever and severe medically refractory status epilepticus is known. We hope to educate and raise awareness of FIRES syndrome, a severe epileptic encephalopathy.

Bilateral Ovary-Containing Inguinal Hernias in a Premature Infant Jonathan Wood, MD, Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Lily Wang Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The female processus vaginalis is formed by evagination of the parietal peritoneum and normally fuses before birth. In premature infants the processus vaginalis may not fuse prior to birth, forming the canal of Nuck. This allows herniation of pelvic contents which can become incarcerated or strangulated. We present a case of a 5 month-old female, born at 26 weeks and 5 days, who was brought into the Emergency Department by her grandmother who noticed a mass in the patient’s right groin while changing her diaper. Physical examination in the ED was positive for palpable masses within the regions of the right as well as the left labia majora. An ultrasound was performed which demonstrated ovaries within the inguinal canals with normal Color and pulsed Doppler flow. No normal ovaries were seen within the pelvis and there was a normal appearing uterus. To our knowledge, this is the first reported case of bilateral ovary-containing inguinal hernias. Recognition of this entity is important given the high rate of ovarian incarceration. There is an increased incidence of ovarian infarction which would necessitate emergent surgery. It is vital that an incarcerated ovary not be confused with other masses that would be located within inguinal region such as a lymph node, canal of Nuck hydrocele, or bowel. Prompt diagnosis is essential to prevent complications such as ovarian infarction.

Poster #: CR-051 Familial Hepatic Veno-Occlusive Disease with Immunodeficiency: A Unique Mutation in Sp110 Lee Nakamura, MD, Texas Children’s Hospital, Houston, TX, [email protected]; Alfred Delumpa, MD, Brandon Tran, Prakash Masand Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Familial hepatic veno-occlusive disease with immunodeficiency (VODI) is a rare form of severe combined immune deficiency with hepatic failure due to veno-occlusive disease, first reported in 1976. This autosomal recessive disorder presents in infants, usually before 12 months, and is caused by a homozygous mutation in the promyelocytic leukemia nuclear body protein, Sp-110. Most of the reported cases are within the Australian Lebanese population. The first case in the Western hemisphere was reported in 2012. We describe a genetically proven case of VODI in a 7 month old Hispanic boy with failure to thrive, loss of milestones, and paternal consanguinity. MRI brain imaging revealed abnormal enhancement and restricted diffusion in the basal ganglia and medial temporal lobes. The CSF analysis revealed enteroviral encephalitis. This opportunistic infection was the first clue to diagnosing VODI in this patient.

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The additional criteria for diagnosis were seen as incidental findings on the workup, which included narrowing of the central hepatic veins and hepatic interstitial fibrosis (seen on the spinal MR imaging) which suggested hepatic veno-occlusive disease. In addition, there was absence of adenoidal tissue on the brain imaging, a finding to suggest an immunodeficient state in this patient prior. There was also dural venous sinus thrombosis which may relate to the pathogenesis of the overall venoocclusive disease. Overall, this rare form of combined immunodeficiency should be suspected when there is evidence of immunodeficiency and hepatic veno-occlusive disease in an infant with consanguineous parents. A radiologist’s role is important as the imaging findings may be the first clues to suggest this disease.

Poster #: CR-052 Olfactory Groove Schwannoma Patricia Cornejo, MD, Pediatric Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Ratan Bhardwaj, David Aria, M.D., Paul Dickman, Jeffrey Miller Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Sixteen year-old female with past medical history of migraines and seizures presented to the Emergency Department after an episode of altered mental status following bilateral upper extremity paresthesias. The physical and neurological exams were normal except for mild bilateral hyposmia. CT scan of the head without contrast showed a peripherally calcified mass centered at the cribiform plate with extension to the anterior cranial fossa and nasal cavity. MRI showed a solid, T2 heterogeneous lesion with avid, homogenous enhancement with mild mass effect upon the inferior frontal lobes. Brain MRI performed 8 years earlier was normal. The mass was totally resected. The olfactory bulbs and tracts were not identified. Histological examination demonstrated proliferation of spindled cells arranged in fascicles with palisading nuclei alternating with parallel fibrillary areas, characteristic of the Antoni A pattern. No atypia, mitotic activity or necrosis was seen. The tissue showed diffusely positive immunohistochemical staining for -S100 protein and negative staining for glial fibrillary acidic protein (GFAP), characteristic of Schwann cells. Conclusions: Olfactory groove Schwannomas (OGS) are rare tumors of the anterior cranial fossa with a controversial origin due to the lack of Schwann cells in the olfactory nerves. Developmental and non-developmental theories, including its potential origin from cranial nerve zero which is part of the ancestral olfactory system, have not reached a scientific consensus. OGS should be considered in the differential diagnosis of all anterior cranial fossa tumors in children and young adults. Further analysis of the tumor pathogenesis and an increased number of reported cases are required to avoid confusion and misdiagnosis.

Poster #: CR-053 A Case of Prenatal Diagnosis of Frontonasal Dysplasia Sherelle Laifer-Narin, Rama Ayyala, M.D., Columbia University Medical Center, New York, NY, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Frontonasal dysplasia (also known as median facial cleft syndrome) is a rare congenital anomaly associated with midline phenotypic abnormalities such as midline facial clefting involving nose, upper lip, and/or palate. We present a case of a patient with 23-week intrauterine gestation who was referred for fetal MRI to evaluate for a suspected nasal mass and possible agenesis of the corpus callosum detected on prenatal screening ultrasound. Multi-planar fetal MRI was performed demonstrating agenesis of the corpus callosum, mild hypertelorism, bifid nose with lack of formation of a nasal tip, and soft tissue protuberance at the tip of the nose. Postnatal imaging confirmed absence of the corpus callosum and physical examination confirmed abnormal bifid nose with soft tissue protuberance. We propose the diagnosis of frontonasal dysplasia should be considered when agenesis of the corpus callosum is seen in conjunction with 2 or more of these findings; abnormal central clefting of the nose, hypertelorism, cleft lip/palate, or incomplete formation of the anterior cranium (with or without encephalocele). It is important for radiologists to be aware of these prenatal imaging findings for prompt diagnosis. This can aid in providing appropriate prenatal counseling and directing prenatal and early postnatal care.

Poster #: CR-054 Acute Synthetic Opioid Cerebellitis in an Abused Infant

Alison Sheridan, MD, Diagnostic Imaging, Yale School of Medicine, Hamden, CT, [email protected]; Gordon Sze, Robert Messina Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Oxycodone is a synthetic opioid whose mechanism of action is thought to predominantly involve activation of mu and possibly kappa opioid receptors in the central nervous system. Histologic studies have localized these receptors to the molecular layer of the cerebellum. Respiratory depression is a known side effect of opiate overdose leading to anoxic brain injury in cases of prolonged hypoxemia. Imaging findings in cases of hypoxic ischemic injury in children under the age of one include restricted diffusion in the deep grey matter, perirolandic cortex and watershed territories. The cerebellum, however, is relatively spared even in severe cases of anoxic injury by a suggested redistribution of blood flow to the posterior circulation as well as Purkinje cell immaturity. We report here a child with findings of anoxic brain injury as well as marked cerebellar injury after an accidental oxycodone overdose thought to represent acute synthetic opioid cerebellitis, a pathology only rarely reported.

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A 10 month old previously healthy female was found unresponsive by her mother on the day of presentation. Initial evaluation revealed an SpO2 of 80%, prompting intubation upon arrival to the emergency room. Laboratory studies indicated a metabolic acidosis with a superimposed respiratory acidosis, hypoxemia, transaminitis and leukocytosis. Initial head CT showed diffuse cerebellar and left perirolandic cortex edema. A urine toxicology screen was positive for oxycodone. Narcan was administered leading to immediate clinical improvement and extubation. However, on day 2 of admission, the patient developed hypertonia and ocular bobbing on exam. MRI revealed symmetric and diffuse restricted diffusion in the cerebellar grey matter, right parietal lobule, left perirolandic cortex, caudate heads and right posterior putamen. In addition, there was marked cerebellar edema with tonsillar herniation, effacement of the fourth ventricle and hydrocephalus which prompted an emergent suboccipital decompressive craniotomy and external ventricular drain placement. Subsequent MRA and MRV of the head were normal. Ophthalmic exam following her craniotomy revealed bilateral retinal hemorrhages that were highly concerning for a shaking injury. Upon multidisciplinary review, the extent of cerebellar involvement was felt to be out of proportion for that expected from anoxic brain injury alone or from nonaccidental trauma and to represent acute synthetic opioid cerebellitis.

Poster #: CR-055 Choriocarcinoma in an Ectopic Pregnancy Mark Bittman, Radiology, Long Island Jewish Medical Center, New Hyde Park, NY, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We report a rare case of an adolescent female patient presenting with nausea, vomiting and abdominal distention. Laboratory values show an elevated beta-hCG level of great than 1, 000,000 mIU/mL. Ultrasound demonstrates large multiloculated cystic ovarian masses, a solid right adnexal mass and a normal uterus. CT findings mirror the sonographic evaluation. The patient underwent surgical exploration and was found to have a choriocarcinoma in the fallopian tube. Postoperative scans show normalization of her ovaries and b-hCG levels. Methods & Materials: Pre- and postoperative ultrasound and CT scans. Intraoperative photos. Results: Gestational trophoblastic disease (choriocarcinoma) in an ectopic pregnancy with large bilateral theca luteal cysts Conclusions: Markedly elevated b-hCG levels suggests the diagnosis of choriocarcinoma, which can be in an ectopic location as in this case.

Poster #: CR-056 Plexiform Gastric Schwannoma Young Park, Mark Bittman, Radiology, Long Island Jewish Medical Center, New Hyde Park, NY, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: We present a case of a 16 year old female who presented with abdominal pain non-responsive to proton pump inhibitors. Subsequently she developed melanotic stools and lab values were significant for anemia. She underwent an endoscopy with biopsies which showed nonspecific mucosal inflammation. MRI of the abdomen was performed which demonstrates marked circumferential wall thickening of the distal stomach with nodular infiltration of the omentum. A distal gastectomy, omentectomy and gastrojejunostomy was performed. Pathology showed a plexiform schwannoma with no evidence of malignancy. Follow-up scans are negative for recurrent disease. Methods & Materials: Pre- and postoperative MRI examination are shown. Intraoperative photos and pathologic specimens are reviewed. A literature search of gastric schwannoma is performed and presented. Results: Plexiform gastric schwannoma Conclusions: The differential diagnosis of a submucosal gastric mass includes schwannoma. This case is unusual because of the age of presentation and infiltrative nature of the lesion.

Poster #: CR-057 Congenital Thoraco-Abdominal Extralobar Sequestration (Broncho-Pulmonary Foregut Malformation-Hybrid Lesion): A Diagnostic Dilemma Avinash Medsinge, MD, CHP of UPMC, Pittdburgh, PA, [email protected]; Kevin Vaughan, Erika Kar, Abhay Srinivasan, Fernado Escobar, Sameh Tadros Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Extralobar sequestration is a rare congenital anomaly, accounting only for 0.5 to 0.6% of all congenital lung lesions. Of this extra-lobar type, only 10-15% sequestrations are found within or below the diaphragm. Combined thoraco-abdominal sequestration is exceedingly rare. Sequestrations are often hybrid lesions and have associated features of type II CPAM on pathology. The present case illustrates MR and CT findings of a thoraco-abdominal extra-lobar sequestration in association with features of CPAM in a neonate. A well-defined lobulated enhancing thoraco-abdominal mass was

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seen extending from left suprarenal region to right posterior mediastinum through the diaphragmatic crus. Though dedicated systemic arterial supply was not convincingly identified on imaging, it was confirmed intraoperatively. The thoraco-abdominal mass was excised and pathology confirmed the diagnosis of extralobar sequestration with features of congenital airway malformation -small cyst type (CPAM-II). Though combined thoraco-abdominal hybrid lesions are exceedingly rare, it should be considered in the differential diagnosis in the appropriate clinical settings and suggestive imaging findings.

Poster #: CR-058 15-year-old Male with Early Nonspecific Abdominal Symptoms Causes a Delay in Diagnosis of Intussusception Kimberly Weatherspoon, MD, Radiology, Baystate Medical Center/Tufts University, Springfield, MA, [email protected]; Stanley Polansky, Tara Catanzano Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Intussusception is caused by the prolapse of a bowel segment and its mesentery into a distal bowel segment. Although most intussusceptions are idiopathic, an identifiable lead point is found in approximately 2-12% of cases. The purpose of this case presentation is to present an atypical case of intussusception in a 15-year-old male with undiagnosed underlying Puetz Jegher disease, found to have a small bowel polyp lead-point during surgery. This case will highlight the vague, nonspecific symptoms that may accompany early intussusception and mimic appendicitis or early small bowel obstruction, thereby delaying diagnosis. Early intussusception diagnosis is essential to prevent complications such as bowel ischemia and necrosis.

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Poster #: CR-059 Trichobezoar Causing Small Bowel Obstruction: Case Report Ravjot Dhatt, MD Candidate 2015, University of Toronto, Toronto, BC, Canada, [email protected]; Ashwin Hegde, Thomas Savage, FRCR, Lila Yewchuk Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We describe a case of a previously healthy 6year-old-girl presenting with a one-day history of bilious emesis, periumbilical pain and feeding intolerance. Initial abdominal radiographs were unremarkable. Following continued episodes of bilious vomiting an upper GI series was performed, which demonstrated coating of a non-occlusive intraluminal mass within the proximal jejunum. Serial abdominal radiographs document movement of the mass from the left upper quadrant to the right upper quadrant along with progressive dilatation of the proximal small bowel, suggesting small bowel obstruction. An abdominal CT confirmed a small bowel obstruction at the level of the barium coated intraluminal mass. At surgery the obstruction was discovered to be due to a jejunal trichobezoar. Upon further retrieval of clinical history, it was determined that the patient had a history of eating her hair and couch cushions. A jejunal bezoar is a rare cause of small bowel obstruction. It can be a diagnostic challenge and can lead to significant complications if there is a delay in diagnosis. Through this case we describe the clinical presentation of the patient and demonstrate the progression of radiographic findings of a small bowel trichobezoar.

Poster #: CR-060 Fetal Lung Interstitial Tumour (FLIT) Sultan Al-Busaidi, MD, BC Children Hospital, Vancouver, BC, Canada, [email protected]; Heather Bray, MD, Pana Popescu Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The aim of this case report is to share the radiological and pathological features of our case with our colleagues elsewhere and to provide more data that can help in better understanding and characterization of this rare neonatal lung tumour. Fetal Lung Interstitial Tumour (FLIT), a rare lung tumour first described by Dishop et al. in 2010, is usually detected during the prenatal period or in the first 3 months of life. The differential diagnosis includes Congenital Pulmonary Airway Malformation, bronchogenic cyst and pleuropulmonary blastoma. In the prenatal period FLIT can be associated with fetal hydrops. In the peri and postnatal period, patients may be asymptomatic or present with respiratory symptoms such as shortness of breath, increased work of breathing or recurrent chest infections. The pathologic features in Dishop’s series of FLIT were of solid or mixed solid/cystic lung mass composed of immature interstitial mesenchyme in association with irregular airspace-like structures mimicking abnormal incompletely developed lung. The radiologic features of FLIT have not been well addressed in the literature. In this case report we present a full term baby boy incidentally found to have a right lower lobe mass while undergoing ultrasound scan as part of neonatal hypoglycemia workup. Subsequent chest radiographs and CT chest demonstrated a homogeneous solid soft tissue mass in the right lower lobe.

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The baby had gradually increasing work of breathing and ultimately underwent right lower lobe resection. Histologic findings were in keeping with FLIT.

Poster #: CR-061 Challenging Pediatric Splenic Hilum Cystic Lesions: A Case Report and Review of Management Ravi Sharma, MD, Radiology, Integris Baptist Medical Center, Oklahoma City, OK, [email protected]; Neal Sharma Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Introduction-Many imaging modalities may be used in characterizing pediatric abdominal masses, and it is important to understand the workup and management of splenic cysts. Here we present a case of a true epithelial lined splenic cyst in a patient who had indeterminate and worrisome imaging findings. Case Report - A 15 year old white female presented with abdominal pain which was not localized to any particular region and could be made worse with eating with occasional diarrhea. She had no past medical history, medications, or prior surgeries. The patient was previously healthy with no pertinent family history. She was found to have a mass on computerized tomography. An MRI was obtained, and the lesion measured up to 5 cm in maximum dimesnion and demonstrated high T1 and low T2 signal, low diffusion signal, and no enhancement. The lesion was indeterminate based on location and imaging characteristics and possibly represented a pseudopapillary tumor at the tail of the pancreas or a developmental cyst in the spleen. The patient pursued surgical treatment, tolerated the surgery well with no complications and was discharged in stable condition on post operative day two. Per the surgical operative report, a laparoscopic splenectomy was performed after the cyst was identified and looked to be in the spleen itself in the hilum. The spleen was then removed piecemeal through a 15 port wound. The pathology gross specimen revealed the cyst had a fibrous tunica and was lined by a monolayer of attenuated cubical epithelium witnessed as cells with pink cytoplasm and round evenly staining nuclei. There was no evidence of significant epithelial stratification or atypia associated with the cyst. There was no evidence of malignancy. Conclusions: Even with our greatest technologies to date, imaging in the pediatric population can be challenging and does have an important impact on patient care and management. Although followup MRI imaging after CT can be a powerful tool to provide more detailed information, cases such as this pose a challenge for the pediatric radiologist and we can benefit from correlating our pathology with our imaging findings to improve our understanding of variable presentaations.

Poster #: CR-062 MRI evaluation of Uterine Mass-Like Lesions in Pregnancy Douglas Martin, MD, PhD, Radiology, University of Minnesota, Savage, MN, [email protected]; Tara Holm, Jessica Kuehn-Hajder, Kelly Dietz, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: MRI offers many advantages over ultrasound and CT in the evaluation of the gravid patient, including a lack of ionizing radiation, large field of view, multiplanar capability, and intrinsic tissue contrast. Because of these traits, MRI has become integral in the evaluation of congenital abnormalities, improving the diagnostic accuracy of antenatal imaging. Maternal pathology, whether derived from or incidental to the pregnancy, can have a similar or greater impact on the health of the developing fetus. MRI offers similar advantages over other imaging modalities and can provide critical information for the diagnosis and staging of these maternal conditions. Here we present several different uterine masses evaluated by MRI, including cases of placental abruption, chorioangioma, complete hydatidiform mole, and uterine leiomyomas. We will discuss both their characteristic imaging findings and the role of MRI in the simultaneous evaluation of maternal and fetal pathology.

Poster #: CR-063 Endovascular Rescue of Malfunctioning Surgical Shunts Used in Treatment of Children with Portal Hypertension: Case Report and Review of Portal Vein Thrombosis Management in Children Rajat Chand, MD, Children’s National Medical Center, Washington, DC, [email protected]; Bhupender Yadav, Parvathi Mohan, Karun Sharma Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Portal vein thrombosis (PVT) is a cause of portal hypertension in children. Surgical shunts are created to treat portal hypertension when more conservative options fail. Although these shunts are effective, they can be complicated by stenosis and/or thrombosis, leading to shunt malfunction and eventual failure. Current endovascular approaches allow percutaneous treatment and repair of shunt stenosis and/or thrombosis, potentially avoiding surgical revision or the need to place a new shunt. We present endovascular management of shunt malfunction in two cases and also review management of portal hypertension in children. Case 1: 10-year old male with history of biliary atresia status post Kasai procedure and liver transplantation, which was complicated by portal vein thrombosis and cavernous transformation. A distal splenorenal shunt was surgically created. He presented later in life with chronic low-grade lower GI bleeding. A CT venogram raised concern for shunt stenosis. Diagnostic venography confirmed the stenosis resulting in an elevated pressure gradient, which was successfully treated with percutaneous balloon angioplasty leading to improvement in the stenosis and flow dynamics and resolution of his lower GI bleeding. Case 2: 8-year old male with history of prematurity and necrotizing enterocolitis who developed portal vein thrombosis with cavernous transformation. A mesocaval shunt was surgically placed at 5 years of age. Two years later, he presented with shunt thrombosis leading to encephalopathy, marked splenomegaly and abdominal pain. He was successfully treated with percutaneous pharmacomechanical thrombectomy (PMT) and angioplasty resulting in restoration of flow through the shunt and clinical improvement. Methods & Materials: Retrospective review of clinical history, imaging and procedural details. Results: Two patients underwent successful percutaneous endovascular shunt recanalization with symptomatic clinical improvement. No complications were encountered. Conclusions: Malfunctioning mesocaval and splenorenal shunts can be managed using current percutaneous endovascular techniques.

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Poster #: CR-064 Extrapulmonary Intra-Abdominal Pulmonary Sequestration-CPAM-Hybrid Lesion Allen Acomb, MD, Radiology, Baylor Scott and White, Temple, TX, [email protected]; Krista Birkemeier, MD Disclosures: Krista Birkemeier has indicated a relationship with Lippincott, Williams and Wilkins as a contributing author. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We present a case of a 19-week gestation antenatal screening ultrasound, demonstrating a homogeneous echogenic left suprarenal mass that extends across midline over the aorta. No feeding vessel is identified. It is separate from the kidney, but the adrenal gland is not seen separately. Fetal MR at 24 weeks’ gestation demonstrates a T2 hyperintense mass with 3 tiny fluid signal cysts, flow void of a possible feeding vessel, extrarenal and extra-adrenal origin, and lack of intraspinal extension. There is no T1 hyperintense signal of hemorrhage. The MRI is consistent with a hybrid lesion (sequestration + congenital pulmonary airway malformation), since there are cysts in addition to the typical appearance of a sequestration. Follow-up prenatal ultrasound at 29 weeks confirms cysts and a feeding vessel typical of a hybrid lesion. Postnatally, the infant was managed conservatively with serial ultrasounds, demonstrating progressive decreasing size of the mass. The mass was surgically excised at 6 months of age, and pathology confirmed a hybrid lesion. The sonographic differential diagnosis for an extra-renal subdiaphragmatic mass encompasses both benign and malignant etiologies, such as congenital neuroblastoma (NB), subdiaphragmatic extralobar pulmonary sequestration (SEPS) or hybrid lesion, and adrenal hemorrhage. NB is 2 ½ times more common than SEPS on prenatal ultrasound. SEPS usually presents as a left-sided echogenic mass in the second trimester on ultrasound. Conversely, NB is usually a heterogeneous right-sided mass that can cross midline and is more often discovered in the third trimester. Adrenal hemorrhage is more likely seen in the third trimester. In this case, the prenatal sonographic appearance favors subdiaphragmatic extralobar pulmonary sequestration, though the extent across midline is concerning for neuroblastoma. Prenatal delineation of benign etiologies that can be managed conservatively from malignancies such as NB that require more immediate treatment is necessary for prognosis and management decisions. In atypical cases such as this, fetal MRI adds valuable information about lesion extent, adrenal and spinal involvement, and signal characteristics of the mass to make the diagnosis.

Poster #: CR-065 Trick or Treat: Neoplasms Masquerading as Infection Lindsay Williams, Radiology, University of Kentucky, Lexington, KY, [email protected]; Steven Krohmer, Edward Richer, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The first case is a 16 year old male who presented to the Emergency Department with clinical symptoms of a 3 week history of nonproductive cough and intermittent back and chest pain. An initial chest x-ray was consistent with right lower lobe

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pneumonia and a right parapneumonic effusion. After further clinical and radiographic investigation, he was diagnosed with T-cell lymphoma. The second case involves a 13 year old female who was transferred from an outside facility with cauda equine syndrome superimposed on 2 months of left leg pain. A MRI spine performed at the transferring hospital was concerning for epidural abscess at L3-L5. She was emergently taken to the OR with neurosurgery for laminectomy and decompression due to her neurologic deficits. Further radiographic investigation after surgery was worrisome for a neoplastic process. IR performed a soft tissue biopsy, which was diagnostic of Ewings sarcoma.

Poster #: CR-066 Subclavian Steal Syndrome Jeffrey Scrugham, MD, Radiology, LeBonheur Children’s Hospital, Memphis, TN, [email protected]; Asim Choudhri, Stephen Miller Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Subclavian steal syndrome (SSS) is a result of restricted blood flow at the origin of the left subclavian artery (LSA). The result is a decrease in pressure distal to the stenosis and subsequent retrograde flow in the left vertebral artery (arises from the LSA distal to the level of the stenosis). This retrograde flow of blood in the left vertebral essentially “steals” blood from the posterior cerebral circulation and can result in vertebrobasilar insufficiency. Classically, patients present with “drop attacks” (i.e. syncopal episodes), though presenting symptoms can vary and in some circumstances can predispose to ischemic injury. The etiology of SSS is most commonly atherosclerosis; plaque build up at the origin of the LSA results in a hemodynamically significant stenosis. For this reason, it is uncommon to see this phenomenon in children. When it is seen in the pediatric population, it is typically the result of a congenital aortic arch anomaly. We submit the case of 13-year-old male who presented with vertebrobasilar symptoms. He had undergone repair of an aortic arch anomaly as an infant per report; further details were not available. The patient underwent numerous imaging studies at our institution. CTA revealed a hypoplastic proximal segment of the LSA. Ultrasound exams clearly demonstrated retrograde flow in the left vertebral artery on color and spectral Doppler images. This was supported by magnetic resonance angiography (MRA). 2D TOF MRA performed with a saturation band superior to the imaging slice showed no flow related signal in the left vertebral artery, however when the saturation band was below the imaging slice there was normal flow related signal, consistent with a cranial-tocaudal direction of flow. Dynamic MRA imaging (time resolved imaging of contrast kinetics, TRICKS) was diagnostic of subclavian steal, clearly demonstrating hypoplasia of the origin of the LSA and retrograde flow in the left vertebral artery with delayed filling of the left subclavian artery. Surgical correction was performed and the patient did well. The diagnosis of subclavian steal syndrome has typically been confirmed on catheter angiography due to the surgical need for detailed anatomic characterization, as well as the need for definitive diagnosis. Multimodality concordance of structural and dynamic flow related information allowed this diagnosis to be made with confidence, and provided appropriate anatomic detail to allow surgical planning.

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Poster #: CR-067 Meckel-Gruber Syndrome on Prenatal MRI: A Case Report Ryan Gnesda, Radiology, University of South Florida, Tampa, FL, [email protected]; John Donatelli, MD, Claude Guidi, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: A 24 year-old female presented after having an abnormal prenatal ultrasound at an outside facility. Repeat ultrasound demonstrated multiple fetal malformations including polycystic kidney disease, an occipital encephalocele, polydactyly, club feet, microcephaly, and oligohydramnios. At approximately 26 weeks gestation, a prenatal MRI was also performed. The kidneys were symmetrically enlarged with increased T2weight signal, consistent with infantile polycystic disease. Additionally, an occipital skull defect was identified with extruding brain contents, compatible with an occipital encephalocele. Additional noted abnormalities included a nonspecific cystic lesion within the liver and hypotelorism with abnormal appearing globes, as well as prominent fluid posterior to the globes. The known abnormalities of the extremities were poorly seen on the MRI examination. The incidence of Meckel-Gruber syndrome varies from 1 in 13,250 to 1 in 140,000 live births, and its inheritance is autosomal recessive. The most common features include multicystic kidneys, occipital encephalocele, and polydactyly. The diagnosis is generally considered when polycystic kidneys are present with at least one of the above other abnormalities. Multiple additional abnormalities may be present, including hepatic fibrosis, eye and facial abnormalities, microcephaly, heart defects, club foot, and abnormal genitalia. The final prenatal ultrasound was performed at 38 weeks gestation, again demonstrating these abnormalities. The fetus was carried to term, at which time a C-section was performed. Affected fetuses are commonly stillborn or only survive a few hours after birth. Given the poor prognosis, it is important to recognize the combination of abnormalities as MeckelGruber syndrome for clinical planning, family preparation, and future genetic counseling.

Poster #: CR-068 Extrarenal Malignant Rhabdoid Tumor Sarah Deraney, Radiology, University of Kentucky, Lexington, KY, [email protected]; Edward Richer, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We present a case of malignant rhabdoid tumor (MRT) in the neck of an infant. A two month old female presented after acutely exhibiting signs of Horner’s syndrome and left upper extremity weakness with a small palpable neck mass. Multiple modality imaging, including chest radiograph, ultrasound, computed tomography, and magnetic resonance imaging, demonstrated a large, infiltrative left neck mass with extensive pulmonary metastases. Differential considerations included neuroblastoma, lymphoma, or a sarcomatous tumor. Histopathology confirmed the diagnosis of an extrarenal MRT. Extrarenal MRT is a tumor on the same spectrum as central nervous system atypical teratoid rhabdoid tumor (CNS AT/RT) and MRT of the kidney. These are extremely rare, highly aggressive malignancies, with most patients demonstrating extensive metastatic spread at the time of diagnosis. There are few documented cases of MRT with extrarenal,

extraCNS primary sites, including the liver, tongue, chest, heart, pelvis, and extremities. The largest series of such tumors in the literature is a collection of nine cases. This is an example of primary MRT in the neck with pulmonary metastases at diagnosis. MRT should remain on every radiologist’s differential when dealing with an aggressive tumor with metastatic disease in early childhood, as the final diagnosis is primarily determined by the histopathologic characteristics.

Poster #: CR-069 Chondroblastic Osteosarcoma with Tumor Thrombus, a Case Report of Two Pediatric Patients Tuan Doa, Patricia Cornejo, M.D, Deepa Biyyam, MD, Paul Dickman, Craig Barnes, Mittun Patel, M.D., Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Osteosarcoma with its many subtypes is not an uncommon diagnosis in a tertiary care pediatric hospital. We will present a case series of two different pediatric patients with Chondroblastic Osteosarcoma with extensive tumor thrombus. Tumor thrombus with Osteosarcoma has only been reported in the literature in a handful of cases, and it is even more uncommon in the pediatric population. Regardless of age, the Chondroblastic Osteosarcoma subtype has been shown to develop tumor thrombus. The first patient to present was a 13 year old boy initially seen by neurology for a 4 month history of worsening paroxysmal leg pain and weakness. Lumbar spine MRI was performed demonstrating both the primary tumor and extensive tumor thrombus within the IVC and bilateral common iliac veins. A CT was then obtained demonstrating additional metastatic disease in calcified regional lymph nodes. The second child to present to our facility with Chondroblastic Osteosarcoma was a 15 year old female. She was initially seen at an outside hospital for respiratory distress and diagnosed with extensive pulmonary emboli. After failed treatment with tPA, she was transferred for higher level of care. Upon arrive to our hospital, she was immediately placed on ECMO but quickly had bleeding complications and soon passed. Postmortem autopsy revealed patient’s pulmonary emboli to be tumor and not bland thrombus. A postmortem CT was then performed demonstrating the unknown primary. Our two cases are in keeping with the few documented cases in the literature. Of the subtypes of osteosarcoma, it is Chondroblastic Osteosarcoma that has a propensity to develop extensive tumor thrombi, with or without pulmonary embolism.

Poster #: CR-070 Dobutamine Stress Cardiac MRI for Assessment of Myocardial Perfusion in Pediatric Patients with a Diagnosis of Intramyocardial Coronary Course Cory Noel, MD, Texas Children’s Hospital, Houston, TX, [email protected]; Ramkumar Krishnamurthy, PhD, Brady Moffett, Emmett Dean Mckenzie, Sara Kristen Sexson Tejtel, Rajesh Krishnamurthy Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Clinical Presentation: Patient one, aged 16 years, presented with fatigue and chest pain during activity and was found by CT

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angiography to have a left anterior descending coronary artery (LAD) that was intramyocardial for a length of 1.4 cm. His family history was also significant for his father having sudden cardiac death and intramyocardial coronary found at autopsy. The second patient, aged 19 years, had a diagnosis of D-TGA and had previously undergone arterial switch procedure during early childhood that presented with ECG changes concerning for ischemia. His LAD was intramyocardial for 3.4 at 1.7 cm from the origin. Methods & Materials: Diagnostic Technique and Findings:To assess myocardial perfusion, a dobutamine stress cardiac magnetic resonance imaging (CMR) examination was performed. Because myocardial contractility was believed to possibly contribute to the etiology of myocardial ischemia given the described diagnosis, dobutamine was thought to be the best pharmacologic stressor. Rest and stress perfusion were assessed with T1-weighted, saturation-recovery, GRE sequence at three ventricular levels during the administration of 0.1 mmol/kg of Gd. To achieve pharmacologic stress, dobutamine was initiated at 10 mcg/kg/min and increased by 10 mcg/kg/min every 4 min to a max of 40 mcg/kg/min. A dose of atropine at 0.01 mg/kg was given to both patients to achieve peak stress. At each interval, wall motion was assessed with cine SSFP images. Myocardial viability was assessed with delayed-enhancement imaging. Patient one demonstrated an inducible wall motion abnormality at peak stress and a reversible perfusion defect in the corresponding coronary territory (Figure 1). The patient has subsequently undergone coronary unroofing surgery and is clinically well. Patient two was shown to have an irreversible perfusion deficit with myocardial scar demonstrated on delayed enhancement imaging (Figure 2). Conclusions: Learning Point:Stress CMR is a highly sensitive method to evaluate myocardial ischemia in adults, but is a rarely used modality within pediatrics. With increased survival of congenital heart disease and increased diagnosis of pediatric acquired heart disease, an accurate method to assess myocardial perfusion in pediatrics is needed. This case demonstrates the feasibility and effectiveness of utilizing dobutamine stress CMR in a pediatric patient to demonstrate myocardial ischemia where contractility was thought to contribute to the etiology of the ischemia.

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Poster #: EDU-001 The Pediatric Clavicle Shrita Smith, MD, Staten Island University Hospital, Staten Island, NY, [email protected]; Jeremy Neuman, Ruby Lukse Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The clavicle is an unusual horizontal long bone with unique embryologic and anatomic features. The clavicle is formed by two primary ossification centers and articulates with the manubrium and acromian via synovial joints. Abnormalities of the clavicle include congenital, traumatic, infectious, inflammatory, metabolic, and neoplastic etiologies. This pictorial review will illustrate radiographic manifestations of disorders of the clavicle encountered in pediatric patients. Normal variants as well as pathologic lesions of the clavicle will be illustrated including rhomboid fossa variant, congenital pseudoarthrosis, cleidocranial dysostosis, distal clavicle physeal injury, sternoclavicular and acromioclavicular injury, osteomyelitis, hyperparathyroidism, aneurysmal bone cyst, osteochondroma, lymphoma, Ewing’s sarcoma, Langerhans cell histocytosis and metastasis. In addition unique radiologic findings of the clavicle in rare entities such as Caffey disease, asphyxiating thoracic dysplasia, osteogenesis imperfecta, Holt-Oram syndrome, thrombocytopenia with absent radius (TAR) syndrome, SAPHO syndrome, and mucopolysaccoridosis will be discussed.

Poster #: EDU-002 Intrathecal Baclofen Pump Access and Evaluation: How To For The Pediatric Radiologist Allison Harris, MD, Radiology, Memorial University Medical Center, Savannah, GA, [email protected]; Deborah Conway, MD, Peter Britt, MD, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Intrathecal Baclofen is indicated in the treatment of intractable spasticity secondary to cerebral palsy and spinal cord injuries. In the setting of pump complications, radiologist performed fluoroscopic evaluation is the second line procedure following plain radiographs. Our educational poster will teach how to access and evaluate a Medtronic Intrathecal Baclofen Pump under fluoroscopic guidance. The poster will include a step-by-step tutorial, including images demonstrating the tools and methods used to access the intrathecal pump. We will further illustrate how to evaluate the pump once access has been obtained with images necessary to document pump patency. The poster will educate readers on when an exam should be terminated without evaluating pump patency. It will also discuss the role a Medtronic Representative plays in the process. Finally, our poster will explain the pharmacology of Baclofen as well as how to avoid and manage complications of Baclofen over dose. Methods & Materials: Digital Radiography and Fluoroscopy Room. Sterile gloves, 10 ml of 300 mgl/ml contrast, Medtronic Cather Access Port Kit, Betadine, 10 cc syringe, Lidocaine. Results: Tutorial on access and evaluation of Intrathecal Baclofen pump. Conclusions: The access and evaluation of an Intrathecal Baclofen Pump is an important skill for the pediatric radiologist. Our educational poster will provide the pediatric radiologist with the confidence to perfom this procedure.

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Poster #: EDU-003 Imaging Review of Caudate Nucleus Lesions in Children Ashish Parikh, MD, Radiology, Mayo Clinic, Jacksonville, FL, [email protected]; Chetan Shah Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To review a number of lesions involve the caudate nucleus in the pediatric population. The purpose of this educational exhibit is to review computed tomography (CT) and magnetic resonance (MR) imaging findings of caudate lesions in the pediatric population. Methods & Materials: We retrospectively reviewed MR and CT images of multiple children with caudate lesions diagnosed at our tertiary care children’s hospital. We illustrate disease entities involving the caudate nucleus using 3.0 T and 1.5 T MRI. Differential diagnosis for the imaging findings and salient imaging features of each entity are discussed. We performed a literature review to generate discussion of disease entities with a focus on advanced MR imaging. Results: The caudate nuclei are paired symmetric structures which are a component of the basal ganglia. The basal ganglia play a crucial role in the regulation of motor functions. The caudate nuclei are susceptible to a variety of pathology, some of which are predominantly seen in the pediatric population. We reviewed the unique imaging features of neoplastic, congenital, traumatic and inflammatory insults to the caudate nucleus with specific example cases. These lesions include low grade astrocytoma, infarcts, hypoplastic caudate nucleus, arteriovenous malformations and other pathologies that involve the caudate nucleus. Conclusions: Awareness of the disease processes and diagnostic imaging features of caudate lesions in the pediatric population are important to recognize in order to provide timely and appropriate management.

Poster #: EDU-004 Ultrasound of the Acute Pediatric Scrotum Anna Thomas, MD, Phoenix Children’s Hospital, Phoenix, AZ; Deepa Biyyam, MD, Tammam Beydoun, DO, Mittun Patel, MD, Richard Towbin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 1. Review practical ways to optimize scrotal ultrasound imaging technique. 2. Provide a pictorial review of common diagnostic entities for the 4 main clinical presentations of the acute pediatric scrotum (pain, trauma, swelling, and scrotal mass). 3. Highlight pitfalls and pearls which aid in differentiating testicular torsion from other causes of acute pediatric scrotum. Methods & Materials: Retrospectively reviewed scrotal ultrasound examinations performed on pediatric patients presenting with acute scrotum at various pediatric hospitals, the authors have worked at as well as our current institution over the past 10 years. Cases selected for presentation have characteristic imaging findings and whenever possible, also have surgical and/or pathologic confirmation. Results: The imaging features of the following entities discussed: 1. In the presentation of scrotal pain: testicular torsion (partial/complete and fixed/intermittent), epididymitis/orchitis, torsed appendage. 2. In the presentation of trauma: Hematocele, Testicular hematoma, and testicular rupture.

3. In the presentation of swelling: scrotal hydrocele, funicular/encysted spermatic cord hydrocele, communicating hydrocele, bowel hernia, Amyand’s hernia, mesenteric fat hernia. 4. In the presentation of scrotal mass: leukemia, lymphoma, nonseminomatous germ cell tumors, granulosa cell tumor, rhabdomyosarcoma, testicular adrenal rests. Conclusions: Acute pediatric scrotum is a common reason for performing scrotal ultrasound in children. It is a broad topic that covers many disease entities but classifying this topic into the four main clinical presentations of pain, trauma, swelling, and scrotal mass enables a thorough review. The presented pictorial review with emphasis on pitfalls and pearls seen with imaging of various disease entities as well as discussion on optimizing ultrasound scanning technique can aid the radiologist in rapid diagnosis of emergent causes of the acute pediatric scrotum.

Poster #: EDU-005 Systematic Radiographic Evaluation of Patients with Tibial Hemimelia Relevant to the Orthopedic Surgeon Katia Kaplan-List, MD, Rochester General Hospital, Rochester, NY, [email protected]; James Sanders, Nina Klionsky, Johan Blickman, et al. Disclosures: James Sanders has indicated a relationship with Abbott Labs & GE as a stock holder and The Pediatric Orthopedic Society of North America as a board member. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Define tibial hemimelia. Describe associated conditions. Describe the classification systems for tibial hemimelia with radiographic correlation. Describe the algorithm for the assessment of a patient with tibial hemimelia on plain radiographs. Describe the radiographic findings that may influence the choice of treatment and that are important to include in the report. Describe current treatment approaches. Methods & Materials: We reviewed the most commonly used classification systems for tibial hemimelia with radiographic correlation in six patients seen in the pediatric orthopedic clinic at our institution. Based on this information we developed recommendations for radiologist reporting of relevant radiographic features of tibial hemimelia in order to provide accurate, consistent, and standardized information and to assist the orthopedic surgeon with development of a treatment strategy. Results: The diagnosis of tibial hemimelia relies on imaging and physical examination. Conventional radiographs are usually obtained for initial evaluation. In patients with tibial hemimelia it is not always possible to tell whether any portion of the non-ossified tibia is present at birth. Presence of the cartilaginous anlage can be deduced from the normally developed distal femur (normal width of the femoral metaphysis and normal ossification of the epiphysis). Ultrasound or MR can be helpful to detect the non-ossified fragments. The relevant radiographic features of tibial hemimelia were summarized as an algorithm for radiologist reporting. Note presence or absence of the ossified tibia. If the tibia is absent or incompletely formed, which part is present: proximal, middle or distal? If the proximal tibia is absent, evaluate the distal femur (width of the femoral metaphysis and ossification of the epiphysis). Evaluate for proximal migration of the head of the fibula.

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Since the patella begins to ossify at 3 years of age, it will not be present on initial radiographs, but, if present, should be mentioned. Presence or absence of a functional knee joint allows the surgeon to make the decision to proceed with knee disarticulation or reconstruction, so the child can be fitted for a prosthesis by the time he/she reaches the walking stage. Conclusions: Systematic interpretation of radiographs in patients with tibial hemimelia can facilitate communication between the radiologist and the surgeon in order to assist with the choice of the treatment strategy and preoperative planning.

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Poster #: EDU-006 Imaging the Epiphyses and Epiphyseal Equivalents: Review of Epiphyseal Normal Developmental Variants and Pathologic Processes that Occur in the Pediatric Patients Mona Ranade, MD, Radiology, Medical College of Wisconsin, Brookfield, WI, [email protected]; Arthur Meyers Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: There are a number of developmental variants within the epiphyses and epiphyseal equivalents in the pediatric skeleton, which can be mistaken for pathological processes on imaging exams. The purpose of this educational exhibit is to demonstrate this variety of normal epiphyseal appearances and review the pathological entities that occur in the epiphyses in children. Methods & Materials: We reviewed conventional radiographs, computed tomography (CT), nuclear scintigraphy and magnetic resonance imaging (MRI) examinations of pediatric patients performed at a large pediatric medical center. Relevant images from these studies were obtained to review the variety of normal developmental appearances and pathology seen in the epiphyses and epiphyseal equivalents of the pediatric skeleton. Results: The variety of normal developmental appearances of the epiphyses include: normal irregular ossification that occurs in various epiphyses commonly seen on conventional radiographs, as well as, the developmental bone marrow changes and heterogeneous signal intensity within epiphyseal cartilage which are seen on MRI. Pathologic processes that affect the epiphyses in children include: skeletal dysplasias, osteochondroses, osteonecrosis, injuries (both acute traumatic injuries and chronic overuse injuries), infection, inflammatory diseases, tumors and tumor- like conditions (both benign and malignant). Conclusions: Radiologists interpreting imaging studies performed on children need to be familiar with the normal developmental appearances and the variety of pathologic processes that occur in the epiphyses and epiphyseal equivalents.

Poster #: EDU-007 MR Imaging of Congenital Spinal Anomalies in the Pediatric Population: Normal Versus Abnormal Kathleen Carey, MD, Radiology, Mayo Clinic, Jacksonville, FL, [email protected]; Chetan Shah Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To provide a pictorial review of frequently encountered congenital spinal anomalies with an emphasis on relevant MR anatomy and pathologic correlates. Methods & Materials: Methods and Materials: Cases were collected from a tertiary care center from 2009-2014 and selected for inclusion into the presentation based on imaging merit. In particular studies demonstrating pertinent spinal anatomy were included. Embryologic and clinical data including demographics and outcome were obtained either through prospective or retrospective analysis. A focused literature review was than performed to better characterize each anomaly and the associated syndromic and nonsyndromic features. Results: Results: Congenital spinal anomalies are complex however detection and classification is crucial. Correct and detailed knowledge about spinal malformations is essential for early recognition and this demands an

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understanding of the anatomical features present in the normal and abnormal prenatal and pediatric spine. Through retro- and prospective collection, a composite of cases were selected which illustrate frequent pediatric spinal anomalies. These cases include but are not limited to: diastematomylia, lipomyelocele, cranciovertebral junction anomaly, os odentideum dystopic, syrinx with membranes in the subarachnoid space, sacral agenesis, and basilar impression. The syndromes associated with these imaging findings are described as well as the corresponding clinical features. When appropriate, additional imaging modalities are also depicted and described if clinically relevant. Conclusions: Conclusion: For optimal patient care it is necessary to understand the anatomy of the pediatric spine and common as well as uncommon anomalies. The development of the spine is highly complex and involves multiple embryologic steps. Early and accurate identification of abnormal features of the developing spine is critical as it may impact patient management dramatically. We present a series of illustrative cases which demonstrate both normal and abnormal pediatric and neonatal spinal anatomy with an emphasis on frequently encountered malformations.

Poster #: EDU-008 Atlantoaxial Rotatory Subluxation, Dislocation, and Fixation in the Pediatric Population: An Educational Review Stephanie Vincent-Sheldon, Mayo Clinic, Rochester, MN, [email protected]; Carrie Carr, Felix Diehn, Larry Eckel, Amy Kolbe, Alice Patton Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Recognition of pediatric cervical spine abnormalities is important in the complete and accurate evaluation of pediatric cervical spine imaging. To assist the interpretation, the spectrum of atlantoaxial rotatory subluxation, dislocation, and fixation are described in text and images. These abnormalities are most often the result of injuries, but non-traumatic conditions can also be a cause. We review the spectrum of these atlantoaxial abnormalities using a case based approach to discuss appropriate imaging, findings and management. Methods & Materials: After approval from our Institutional Review Board, we retrospectively reviewed the imaging and clinical presentation of pediatric patients from infancy to age 18 years old with atlantoaxial rotatory subluxation, dislocation, or fixation. Results: Atlantoaxial subluxation involves a variable degree of rotary displacement of the atlas on the axis with or without anterior displacement and potential ligamentous injury. This is often traumatic in etiology, but congenital conditions such as Down syndrome and Morquio syndrome, inflammatory arthritides such as rheumatoid arthritis, and acquired inflammatory processes like Grisel’s syndrome leading to pathologic relaxation of atlantoaxial ligaments are shown as well. Dislocation can be considered a severe manifestation of subluxation with complete anterior displacement of the C1 lateral mass relative to C2 and a larger degree of aberrant alignment is seen. In fixation, the normal rotation of the atlantoaxial joint cannot occur as the vertebrae are fixed suspending independent rotation. Differentiation of these entities is illustrated using a variety of imaging. Conclusions: The major teaching points of this exhibit are: 1. Review of imaging for the spectrum of atlantoaxial rotary subluxation, dislocation, and fixation, 2. Normal anatomy of the atlantoaxial articulation and potential pitfalls in recognizing normal/abnormal anatomy as well as other potential mimickers, 3. Mechanism of injury or pathogenesis for these conditions.

Poster #: EDU-009 Colonic Atresia: Expanding the Classic Differential for Low Intestinal Obstruction in the Neonate Vera Mayercik, MD, Radiology, Tufts Medical Center, Boston, MA, [email protected]; Donald Tracy, Anastasia Hryhorczuk, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Classic teaching has emphasized four diagnoses in the differential for low intestinal obstruction in newborn infants: meconium ileus, ileal atresia, Hirschsprung disease, and functional immaturity of the colon. However, colonic atresia can present in a nearly identical fashion with reported incidence ranging from 1.8 to 15%. Methods & Materials: We compiled a case series from a database of cases of lower GI studies in neonates performed at our instuituion over the last 10 years. Results: Several cases from our institution are presented to illustrate salient imaging features of colonic atresia, comparing and contrasting them with other entities in this differential. The classification system for colonic atresia is also reviewed. Conclusions: With heightened awareness of this condition, the astute physician may make a timely diagnosis leading to prompt surgical intervention. This may avoid potential costly delay in diagnosis, unnecessary rectal biopsy and repeat examinations. As mortality in colonic atresia has been shown to increase after 72 h of surgical delay, acknowledging this entity as a potential cause of low intestinal obstruction may be a lifesaving consideration.

Poster #: EDU-010 Gasp! Fetal Imaging of Congenital Airway Anomalies Grace Mitchell, MD, MBA, Cincinnati Childrent’s Hospital Medical Center, Cincinnati, OH, [email protected]; Arnold Merrow, MD, Maria Calvo-Garcia, MD, Usha Nagaraj, MD, Beth Kline-Fath, MD Disclosures: Arnold Merrow, MD has indicated a relationship with Amirsys, Inc. as an author. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: The dramatic transition from fetal to neonatal life is dependent on a number of key developments in utero. The formation of an unobstructed and normally functioning airway is paramount in this successful transition. Yet many congenital airway anomalies can be difficult to detect on the routine screening second trimester ultrasound, potentially leading to unanticipated life-threatening airway management issues at delivery. The purpose of this exhibit is to review intrinsic and extrinsic obstructive lesions of the fetal airway, from the nostrils to the mainstem bronchi, which can be diagnosed on prenatal imaging. Methods & Materials: IRB approval was waived. A literature search was performed on congenital airway abnormalities to collect a list of previously defined entities and any associated imaging descriptions. Using our institution’s medical records search software, fetuses and neonates with congenital anomalies affecting the airway were identified. Associated pre- and post-natal imaging studies on these patients were then collected and reviewed. Relevant imaging findings were captured and correlated with any available clinical, surgical and pathology notes. Results: A variety of congenital airway anomalies, ranging from the incidental to the lethal, were found in our search. For purposes of our review, these entities were divided by specific anatomic locations within the upper and lower airway. Broad categories of intrinsic and extrinsic lesions included benign and malignant masses and structural malformations, some of which were syndromic. The resulting exhibit outline is as follows: 1. Background 2. Review of normal fetal airway anatomy as depicted by prenatal ultrasound and MRI 3. Review of congenital airway anomalies, including prenatal imaging findings, postnatal correlation, lesion prognosis, and therapeutic options. Entities will include structural malformations such as piriform aperture stenosis, micrognathia and tracheal agenesis; intrinsic masses such as epignathus and salivary anlage tumor; and extrinsic lesions such as cervical teratoma and goiter. Conclusions: Advances in prenatal imaging have led to improved assessment of the fetal airway. Familiarity with congenital airway anomalies and their often subtle prenatal imaging clues will allow the radiologist to guide further imaging and direct perinatal parental counseling, particularly in regards to advanced airway management techniques that may be required at delivery.

Poster #: EDU-011 Radiology of Disorders of Sex Development: Taking the Ambiguity out of Intersex Imaging Hollie West, MD, Vanderbilt Univers ity, Nashville, TN, [email protected]; Gabriella Crane, Marta Schulman, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Disorders of Sexual Development (DSD) in a newborn infant, although not medically emergent in the majority of patients, generate a great deal of anxiety for families who remain uncertain of the gender identity of their child. The pediatric radiologist is an integral member of the diagnostic team, and it is important for us to understand the evolving classification and the genetic and molecular basis of these complex conditions. We will illustrate imaging findings in patients with DSD within the context of the current classification and of our current understanding. Methods & Materials: A literature review was performed to highlight the most up-to-date information regarding disorders of sexual development with an emphasis on that information most clinically relevant to the interpreting radiologist. Representative cases were identified from our departmental database, with images selected to provide high-yield illustration of the spectrum of GU and neoplastic abnormalities associated with these disorders.

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Results: We will discuss and illustrate disorders of sex chromosomes: 45X, 45X/46XY, 46XX/46XY; 46XY disorders of testicular differentiation, including mutations of the WT1 gene, sex reversal DAX 1 duplications and Desert Hedgehog (DHH) mutations; 46XY disorders of androgen synthesis or action; and 46XX DSD such as congenital adrenal hyperplasia and maternal hyperandrogenism. Ultrasonography remains the primary imaging modality used in evaluating these patients, with genitograms and MR imaging providing additional information in complicated cases. Examples of potential findings include streak gonads, ectopic gonads, urogenital sinus, and abnormal adrenal morphology. Conclusions: The radiologist plays a key role in the multidisciplinary approach to the diagnosis and treatment of children with DSD. Familiarity with the appropriate diagnostic approach and imaging findings is critical for success and optimal care of these complex patients and their families.

Poster #: EDU-012 The Pediatric Neurogenic Bladder: What the Radiologist Should Know Benjamin Yam, MD, Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, [email protected]; Stephen Zderic, Kassa Darge, MD, PhD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pediatric neurogenic bladder is a dynamic disease process that may be classified according to the anatomic level of neurologic disease (upper and/or lower motor neuron) or the functional aspects of voiding (detrusor hyperreflexia and/or areflexia). Causes of neurogenic bladder dysfunction in children are varied, the most common being neurospinal dysraphism. Additional causes involving the spine include sacral agenesis, tethered spinal cord associated with imperforate anus, cloacal malformations, and traumatic cord injuries. Central nervous system abnormalities such as cerebral palsy and learning disabilities may also lead to neurogenic bladder. Children with neurogenic bladder are at increased risk of urologic morbidity and mortality. Main management goals are to preserve renal function and optimize urinary continence; delays in diagnosis and treatment can result in irreversible sequelae to the urinary tract. The role of radiologic evaluation and surveillance in these patients has evolved from a descriptive role to one that incorporates functional information, helping predict those at higher risk of upper tract deterioration. We review the spectrum of radiologic findings and roles of various imaging modalities in evaluation of the pediatric neurogenic bladder and upper urinary tract. Epidemiology, etiology, pathophysiology, complications, clinical findings, and treatments are discussed. Methods & Materials: We present the multimodality imaging findngs of neurogenic bladder in children with attention to classification, anatomy, pathophysiology, predictive indicators for upper tract deterioration, and complications. The utility of various modalities is reviewed, including voiding cystourethrogram, videourodynamics, ultrasound, MRI/MR urography, and renal scintigraphy, with emphasis on functional evaluation and the strengths and limitations of each technique. Results: A comprehensive approach should be used to evaluate each case of pediatric neurogenic bladder encountered in practice, which includes both morphologic and functional imaging evaluation of upper and lower urinary tracts. Conclusions: Understanding the various disorders comprising the pediatric neurogenic bladder, management goals, predictors of deterioration, potential complications, and the utility of various dynamic imaging techniques enables prompt identification of disease and those with higher risk of upper urinary tract deterioration, thereby directing appropriate clinical management.

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Poster #: EDU-013 The Utility of MR Urography to Characterize Morphology and Function of Pediatric Urinary Tract Abnormalities Mathew Cherny, MD, Radiology, North Shore LIJ, New York, NY, [email protected]; Mark Bittman, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: MR urography’s (MRU) ability to depict urinary tract morphology and renal function without ionizing radiation is a valuable tool in guiding diagnosis/management of pediatric urinary tract pathology, which traditionally requires multiple imaging modalities to evaluate. MRU utilizes heavily T2-weighted and dynamic post contrast sequences which can rapidly define the anatomy and quantify renal enhancement and excretion. Augmentation with hydration and diuretics is a useful tool to ensure uniform and timely contrast distribution for optimizing excretory phase imaging. The pediatric population presents specific challenges for MRI, notably being patient cooperation and motion sensitivity often requiring sedation. Methods & Materials: Discuss a spectrum of pediatric urinary tract anatomic abnormalities such as urinary tract obstruction, duplication anomalies, renal ectopia, ectopic ureters, primary megaureter, calyceal diverticulum, and ureteropelvic junction obstruction. Review appropriateness/indications of MRU in pediatric patients. Discussion of MRU protocols, including patient preparation, sequence selection, and selection of contrast agents and diuretics. Review of MRU clinical applications and discussion of benefits/advantages highlighting both the anatomic and functional information which influences clinical decision making. Results: Review of MR urography in the evaluation of pediatric urinary tract abnormalities such as ureteropelvic and ureterovesicular obstruction, ureterocele, duplication anomalies, renal ectopia, primary megaureter, calyceal diverticulum, infundibular stenosis demonstrates that MRU provides anatomic and functional information to not only diagnose but also characterize such entities supplanting the need for evaluation with multiple modalities and exposure to ionizing radiation. Conclusions: MR urography’s ability to depict urinary tract morphology and renal function without ionizing radiation is a valuable tool in guiding diagnosis/management of pediatric urinary tract pathology, which traditionally requires multiple imaging modalities for comprehensive evaluation (US, fluoroscopy, nuclear medicine scintigraphy, CT, MR). Additionally, MR Urography is now increasingly utilized to provide functional information. Parameters such as differential renal function can be calculated from sequential post contrast perfusion/excretory sequences similar to renal scintigraphy

Poster #: EDU-014 Get Wise about Cracks: Pictorial Review of Pediatric Skull Base Fractures, Their Resultant Complications, and Normal Variant Lucencies of the Pediatric Skull Base Anna Thomas, MD, Pediatric Imaging, Phoenix Children’s Hospital, Phoenix, AZ; John Egelhoff, John Curran, Jeffrey Miller, Richard Towbin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: 1. Review skull base anatomy with special attention to central skull base foramina and their contents. 2. Review normal skull base lucencies in pediatric patients and normal ossification patterns of the anterior, middle, and posterior skull base. 3. Using standard bony algorithm CT images and 3-D volume shaded surface postprocessed images, present pictorial review of normal skull base lucencies and skull base fractures in pediatric patients. 4. Use all available imaging for pictorial demonstration of common and a few uncommon complications from pediatric skull base fractures. 5. Review frequently associated complications associated with specific skull base fracture locations. Methods & Materials: Retrospectively reviewed all available imaging performed on pediatric patients presenting with skull base fractures at our institution over a ten year time frame. Cases selected for presentation have characteristic imaging findings and the whenever possible, also have surgical and/or pathologic confirmation. Images were anonymized to protect patient information. Results: The imaging features of the following entities discussed: 1. Anatomy of the skull base with review of central skull base foramina and their contents. 2. Normal ossification patterns of the anterior, middle and posterior skull base. 3. Normal lucencies of the pediatric skull base caused by entities such as sutures, fissures, synchondroses, vascular channels, and clefts. 4. Common and uncommon complications from pediatric skull base fractures with review of specific complications associated with the specific location of the skull base fracture. Conclusions: Basilar skull fractures can be associated with numerous critical complications. Rapid recognition of these fractures is imperative for optimal management of these complications. However in pediatric patients, developmental or normal variant skull base lucencies from sutures, fissures, synchondroses, vascular channels, and clefts can often be confused for fractures. Distinguishing between fractures and these normal lucencies is imperative for all practitioners involved in interpreting imaging for pediatric head trauma. This pictorial review hopes to aid the radiologist in differentiating between basilar skull fractures and normal skull base lucencies. It also aims to aid in the rapid recognition of critical complications due to skull base fractures.

Poster #: EDU-015 The Utility of MR Imaging for Evaluating the Spectrum of Pars Iinjuries in the Pediatric Population Esther Ro, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Maura Ryan, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Spondylolysis is a common cause of back pain in the pediatric population, in particular the athletic adolescent. Historically, computed tomography (CT) and single photon emission computed tomography (SPECT) have been the methods used for the diagnosis of spondylolysis. Recently, magnetic resonance (MR) imaging has come into favor as a primary method because of its sensitivity to marrow edema and lack of radiation exposure to the patient. The use of MR reveals the earliest manifestation of pars injuries as stress reactions, allowing early treatment, which may prevent progression to complete fracture and chronic nonunion. This exhibit aims to provide a pictorial review of MR findings for the spectrum of pars injuries from acute to chronic forms. The advantages, disadvantages, and potential

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pitfalls of using MR for detecting spondylolysis will be presented. Relevant grading systems and their clinical implications toward management and prognosis will be discussed. Methods & Materials: The presentation will be based on a retrospective review of patients at Ann & Robert H. Lurie Children’s Hospital of Chicago who underwent MR spine exams for back pain or suspected spondylolysis from 1/2006 to 8/2014. The MR imaging features will be evaluated and compared to other available imaging modalities such as CT and SPECT. Additional clinical data will be analyzed. Images and case examples in the exhibit will be drawn from this study pool. Results: A total of fifty-five patients were identified who had MR imaging for back pain or suspected spondylolysis, and had additional CT or SPECT exams performed. Multiple pars lesions at varying stages were found, ranging from stress reaction, partial or complete fracture, to chronic nonunion. Some of the MR exams that detected pars stress injuries had negative comparison CT exams. However, MR was found to be inferior to CT in evaluating the cortical integrity of pars lesions. Conclusions: MR imaging is gaining favor as the modality of choice for the diagnosis of spondylolysis in pediatric sports medicine. The pediatric radiologist’s understanding of the imaging features, benefits and limitations of MR is important for both diagnostic purposes and for guiding the referring clinician to order the appropriate study, avoiding unnecessary radiation exposure. Knowledge of the clinical implications can help the radiologist aptly report the salient findings; and thus, have a meaningful impact on the care of the young patient.

Poster #: EDU-016 The Lateral Chest Radiograph: An Underused Problem-Solving Tool for Identification of Malpositioned Endovascular Catheters Jennifer Talmadge, MD, Radiology, Boston Children’s Hospital, Falmouth, ME, [email protected]; George Taylor Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this educational poster is to demonstrate the value of a lateral chest radiograph to ascertain the location of vascular catheters and endovascular pacemaker leads when the position is uncertain based on the frontal view alone in patients with altered anatomy, or malfunctioning devices. Methods & Materials: We will present nine cases from our institution with vascular catheters in place (seven venous, two arterial), and four cases with endovascular pacemakers in which the position of the endovascular device is uncertain based on the frontal radiograph alone. Both the frontal and lateral radiographs will be shown in each case, along with a description of the position of the catheter and when applicable, a description of the altered anatomy. Results: In each of the thirteen cases we will present, the lateral chest radiograph is the only view to show or confirm a normal or aberrant location of the vascular catheter or endovascular pacemaker lead.

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Conclusions: The lateral chest radiograph is a valuable but underused tool for identification of unsafe or sub-optimally positioned endovascular devices. It is less expensive than obtaining cross sectional imaging for trouble shooting endovascular device positioning and has significantly less radiation than CT.

Poster #: EDU-017 A History Lesson for Physicians: The Importance of Providing Accurate Clinical History for Pediatric Imaging Interpretation Jeffrey Gnerre, MD, Westchester Medical Center, Valhalla, NY, [email protected]; Swetha Dasari, MD, Leslie LeCompte, Adele Brudnicki, Andrzej Jedynak Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In the daily practice of pediatric diagnostic radiology, imaging findings are often encountered that have a vast differential diagnosis. When this diagnostic dilemma arises, a radiologist must use all of the tools at their disposal in order to narrow the differential diagnosis. This includes reviewing the available patient history as well as comparing with any prior imaging studies. In many instances, however, patients may not have available prior imaging. In these cases in particular, the provided patient history becomes a crucial tool to assist in diagnosis. At our institution, we have found that the history provided on the radiology order itself is often minimal, if any relevant history is given at all. This may occur when an attending physician, fellow, or senior resident delegates the ordering of a radiographic study to a less experienced resident who may not be fully aware of the patient’s medical history. Additionally, generic “drop down” menus for online ordering of radiographic studies also often results in a vague, unhelpful clinical history. As the number of diagnostic radiology exams continues to grow at a rapid pace, radiologists simply do not have the extra time to spend searching through the electronic medical record or tracking down the ordering physician to obtain an accurate clinical history. A traditionally pathologic appearing finding may actually be benign in the right clinical setting and vice versa. As a result of inadequate history, the radiologist may recommend follow up studies that may actually be unnecessary, and as a result causing further radiation exposure, patient anxiety, and increased healthcare costs. In this presentation, we will present several pediatric cases where the initial diagnosis based on radiographic findings and history was drastically changed after further clinical history was discovered. Methods & Materials: Literature review and review of cases performed at our institution. Results: Specific examples that we will discuss include: 1) Large pelvic abscess initially misdiagnosed as a right adnexal mass, 2) Renal contusion initially misdiagnosed as medullary nephrocalcinosis, 3) Esophageal rupture initially misdiagnosed as a retropharyngeal

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abscess, 4) Healing fracture of the clavicle initially misdiagnosed as an aggressive bone tumor. Conclusions: We hope our presentation will encourage other radiologists to demand accurate clinical history for their pediatric imaging studies.

Poster #: EDU-018 T1 Mapping in Children and Young Adults - A Virtual Myocardial Biopsy Keyur Parekh, MD, Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, [email protected]; Michael Markl, Roger deFreitas, Jie Deng, Cynthia Rigsby, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The causes and mechanisms of cardiac failure are significantly different between children and adults. The clinical presentation in children and young adults is often non-specific and it can be misdiagnosed as respiratory disease, infection or dehydration. Congenital heart disease and cardiomyopathy are the commonest causes of cardiac failure in children and young adults. A high clinical index of suspicion is required for early diagnosis. Deposition of collagen matrix is considered as an end-point for a wide range of cardiomyopathies. Myocardial fibrosis can precipitate malignant arrhythmias and sudden death. Various studies have shown that fibrosis as an independent predictor of adverse cardiac outcomes in adults. Endomyocardial biopsy and echocardiography have several limitations for detection of myocardial fibrosis. Cardiac magnetic resonance imaging can be used to measure myocardial longitudinal relaxation time (T1 mapping). T1 mapping is commonly used in adults to detect myocardial fibrosis in various pathologies. In this exhibit, we will discuss T1 mapping in children and young adults. Methods & Materials: Outline of the exhibit: 1. Explanation of the MR physics of T1 mapping and specifications needed for imaging children and young adults 2. Description of various T1 mapping techniques 3. Calculation of native T1 and extracellular volume fraction (ECV) 4. Potential applications of cardiac T1 mapping in children and young adults 5. Review of published T1 mapping studies in children 6. Limitations of T1 mapping Results: This exhibit will demonstrate examples of T1 mapping in a control pediatric and young adult population with no underlying myocardial disease. Examples will be shown of T1 mapping and ECV in myocardial tissue characterization for patients with 1. Congenital heart disease 2. Non-ischemic dilated cardiomyopathy 3. Hypertrophic cardiomyopathy 4. Acute myocarditis 5. Aortic valve disease and connective tissue disease involving thoracic aorta 6. Coronary artery aneurysm/dilation

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7. Scleroderma 8. Pompe disease 9. Fabry diseae 10. Heart transplant Conclusions: T1 mapping can provide non-invasive assessment of fibrosis resulting from disease processes affecting the myocardium in children and young adults, and can be used to quantify and localize the extent and severity of the myocardial abnormality. Further work to determine the impact of T1 mapping on clinical care in children and young adults is required.

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Poster #: EDU-019 The True Double Bubble…and its Imposters Michael Brinkley, MD, Duke University School of Medicine, Durham, NC, [email protected]; Charles Maxfield Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The double bubble is a roentgen classic, familiar to the most junior of residents and useful to experienced radiologists. The “true double bubble” is seen in the brand newborn as two large, rounded lucencies in the upper abdomen, a distended stomach to the left of midline and a distended duodenum to the right, and no distal bowel gas. Identification of a “true double bubble” allows the confident diagnosis of duodenal atresia, obviating additional diagnostic imaging studies and allowing for elective, rather than emergent, surgery, preceded by a preoperative workup for congenital anomalies that often coexist with duodenal atresia. The term is often used, however, to include cases where there is bowel gas distal to the two bubbles, and in cases where the second, right sided bubble is not large and rounded. With these patterns, the diagnosis of duodenal atresia cannot be assumed, and in fact, may be unlikely. In such case, additional pre-operative imaging is indicated, most importantly to investigate for the possibility of malrotation and midgut volvulus, a finding that would prompt emergent surgery. The purpose of our poster is to review examples of the “true double bubble” and contrast it from mimics which should be distinguished for appropriate workup. Methods & Materials: All surgically proven cases of congenital duodenal obstruction since 2002 at our institution were reviewed, including all preoperative radiologic and fluoroscopic imaging when available. Results: The “true double bubble,” as strictly defined, reflects long standing and complete duodenal obstruction and always represents duodenal atresia. However, in cases where the strict definition is not met, alternative causes of duodenal obstruction are more likely. The widened differential then includes both congenital and acquired etiologies of both intrinsic and extrinsic duodenal obstruction. Most importantly, malrotation with midgut volvulus must be considered, and further evaluation with UGI is indicated. Duodenal atresia can occasionally present with distal gas or with a small second bubble. Examples of double bubble mimics and atypical radiographic patterns of duodenal atresia are presented. Conclusions: By adhering to the strict definition of the “true double bubble,” the radiologist can confidently diagnose duodenal atresia, allowing for elective surgery without unnecessary imaging, while at the same time, remaining alert for double bubble imposters that suggest an alternative diagnosis and necessitate additional imaging.

Poster #: EDU-020 Evaluation and Interventional Radiology Management of Prehepatic Portal Hypertension in Children Pooja Thakrar, MD, Radiology, Children’s Hospital of Wisconsin, Wauwatosa, WI, [email protected]; David Moe, Nghia Vo Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To describe interventional radiology (IR) management strategies useful in addressing complications associated with prehepatic portal hypertension in children. Methods & Materials: The medical records and imaging of three pediatric patients with complicated prehepatic portal hypertension of varying etiologies

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were retrospectively reviewed. The pathophysiology of prehepatic portal hypertension is discussed in the setting of each patient’s complications. The percutaneous IR techniques used for their respective treatments are described. Results: The first child was diagnosed with chronic splenic vein thrombosis secondary to pancreatitis, complicated by recurrent bleeding gastric varices. She was treated by balloon-occluded retrograde transvenous obliteration (BRTO) of the varices with subsequent resolution of her hematemesis. The second child had gastrointestinal hemorrhage and thrombocytopenia secondary to massive splenomegaly resulting from chronic main portal vein occlusion and cavernous transformation. She underwent partial splenic artery embolization with resultant resolution of her thrombocytopenia and gastrointestinal bleeding. The third child had bleeding gastric and esophageal varices and thrombocytopenia resulting from idiopathic portal vein occlusion and cavernous transformation. He was treated by transsplenic embolization of the varices and had subsequent resolution of thrombocytopenia and hemorrhage. Conclusions: Prehepatic portal hypertension in children can have a number of etiologies and is associated with complications of gastric and esophageal variceal hemorrhage and splenomegaly-related thrombocytopenia. A variety of IR techniques are available to address these complications and alleviate the patients’ symptoms.

Poster #: EDU-021 Whole-Body MRI & DWI in Adolescents With Lymphoma Nagwa Wilson, MD,PhD, Medical Imaging, Montreal Children Hospital, Montreal, QC, Canada, [email protected]; Elka Miller, Jorge Davila, Donna Johnston, Berry Smith, Karen Mandel Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Evaluate the role of whole body MRI, including Diffusion weighted images (DWI) sequence to assess adolescents with lymphoma and consider the potential value of DWI in initial staging and follow up. Methods & Materials: Explain the protocol and technique of whole body MRI & DWI with back ground suppression DWIBS. Describe the role of whole body MRI and DWI in the initial evaluation and follow up of lymphoma children and adolescents. Discuss the future role of MRI in providing more functional information using contrast media like ultra-small supra- paramagnetic iron oxide particles Describe the advantages and disadvantages of the technique Results: Whole body MRI allows allow evaluation of nodal disease, bone marrow and solid organ involvement in a single examination DWI has great potential for use in tumor staging and assessment of response to chemotherapy, without the use of radiation The study is time consuming but achievable for adolescents. Conclusions: Whole-body MR imaging with DWI appears to be a good radiation-free alternative for lymphoma staging and follow-up

Poster #: EDU-022 Improving the Static: Overview of Neurosonography of Premature Neonates using High Resolution Images David Podhaizer, MD, Radiology, Boston University Medical Center, Boston, MA, [email protected]; Karen Buch, Amy Tsai, Bindu Setty, Ilse Castro-Aragon

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this exhibit was to review normal anatomic and neurosonographic findings of common disease processes that affect premature neonates and to demonstrate that these abnormalities are more clearly visualized, and sometimes only captured, on high-resolution imaging. Methods & Materials: In our institution, in addition to representative views using a curved array transducer, our ultrasonographers include highresolution coronal and sagittal sweeps using a linear array transducer. In this exhibit, we will review neurosonographic findings using standard and highresolution images of diseases processes that commonly afflict premature infants such as germinal matrix hemorrhages, choroidal hemorrhages, intraparenchymal hemorrhages, and hypoxic ischemic encephalopathy. Results: The addition of high-resolution sweeps allows for greater spatial resolution of disease processes when compared to standard neurosonography making subtle findings that may have even been overlooked on representative views more conspicuous. This superior morphologic detail results in increased diagnostic confidence of early or small hemorrhages and cystic change. The high resolution sweeps are also important for troubleshooting when retrospectively, an abnormality is found on representative views that was overlooked at the time of scan but found during time of analysis. Conclusions: Pediatric neurosonography is commonly used as initial screening for diagnosing and monitoring intracranial abnormalities in premature neonates. Knowledge of normal neuroanatomy and recognition of common disease processes is critical when interpreting these studies. At the end of this exhibit, one will be more comfortable and confident in diagnosing disease processes such as germinal matrix hemorrhages, parenchymal hemorrhages, hypoxic-ischemic encephalopathy, and periventricular leukomalacia. In addition, one will appreciate the utility of implementing high-resolution sweeps for further characterization of abnormalities visualized on the standard representative views and its ability to pick up subtle abnormalities that were overlooked or not found on routine images.

Patients often have right lower quadrant pain, which carries a wide differential. CF patients can have marked appendiceal dilatation, which in the absence of extraintestinal inflammatory changes should not be mistaken for acute appendicitis. Due to mural thickening and vigorous peristaltic movement to encourage transit of viscous intraluminal contents, CF patients are at risk for intussception Conclusions: CF patients’ bowels predominantly demonstrate mucosal infolding with a corrugated appearance involving the terminal ileum and right colon with severity of changes dependent on previous bowel issues. The most striking findings were seen in patients with meconium ileus at birth with long segment ileal wall corrugation and luminal dilatation, cecal corrugation, and occasionally involvement of the remainder of the colon. Bowel ultrasound proved sufficient to characterize disease extent in the majority of patients with MRE helpful in a select population. We are developing clinical guidelines to determine the most appropriate imaging study to perform based on clinical history in the CF paediatric patient.

Poster #: EDU-023 Bowel Characterization with Clinical Relevance in Patients with Cystic Fibrosis: Ultrasound and Magnetic Resonance Enterography findings Clara L Ortiz-Neira, MD, Alberta Health Services, Calgary, AB, Canada; Gillian Shiau, Helen Machida, Samarjeet Bhandal, Priya Gupta, Meghan McIvor Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this retrospective study is to describe the ultrasound and magnetic resonance enterography (MRE) features of bowel wall in pediatric cystic fibrosis (CF) patients. We correlated pertinent clinical history such as meconium ileus, distal intestinal obstructive syndrome (DIOS), bowel surgery and bacterial overgrowth with imaging findings. Methods & Materials: Thirty CF pediatric patients with bowel symptoms were examined with both bowel ultrasound and magnetic resonance enterography to characterize the location and extent of disease. Pertinent clinical history was collected. Results: The most specific finding was bowel wall mucosal infolding involving the terminal ileum and cecum. Nonspecific findings include mural thickening predominantly involving the terminal ileum, cecum and proximal colon. Signs of active inflammation were generally absent without hyperemia on Doppler interrogation nor restricted diffusion or hyperenhancement on MRE. When inflammatory changes were seen, there was typically a history of inflammation from chronic DIOS.

Poster #: EDU-024 Ultrasound-Guided Peripheral Intravenous Cannula Placement in Children; A Pictorial Review Mahmoud Zahra, MD, FRCR, St. Vincent’s Medical Center, Bridgeport, CT, [email protected]; Terence Hughes, Ara Karamanian, MD, Keni Augustin, Anne Marie Cahill, Ganesh Krishnamurthy Disclosures: Anna Marie Cahill has indicated a relationship with Siemens AX, Inc as an advisory Board Member. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Describe the indications, technique, and complications of ultrasound guided peripheral line placement in children with special attention for technique Methods & Materials: The indication for ultrasound guided peripheral intravenous cannula placement is failure to place by conventional technique. This could be secondary to severe dehydration, obesity, severe edema, extensive burn, severe positional contracture due to cerebral palsy or history of multiple intravenous catheter placements in the past with obliteration of most peripheral veins Results: US-guided peripheral line placement can be performed in four steps Step I: Ultrasound examination

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Preliminary ultrasound examination is performed to evaluate and choose a suitable vein for the cannula insertion and to differentiate an artery from the vein Step II: Preparation Preparation the equipment . Ultrasound probe and the skin of the insertion are cleansed using alcohol swabs Step III: Insertion the peripheral intravenous cannula under ultrasound guidance Technique: Best ultrasound approach for peripheral placement in children is transverse approach. A single wall puncture technique should be always used. The vein is placed in the middle of the ultrasound screen. The needle is inserted at an acute angle towards the vein, the angle dependent on the depth of the vein from the skin. Needle tip can be followed using two maneuvers 1. Angling the probe: This is performed when the vein is superficial. The probe is angled toward the needle. The needle is advanced with continuous angling of the probe to follow the needle tip to the vein 2. Moving the probe: This is performed when the vein is deep. The probe is placed overlying the needle tip. The needle and the probe advance simultaneously towards the vein When the needle tip reaches the vein, a gentle pressure over the needle is applied to tent the anterior wall and confirm a proper position of the needle tip. Puncture the vein is done with a quick stick. After penetration of the three layers of the vein, the needle should appear free in the lumen. The needle/cannula combination is advanced all the way inside the vein under US guidance. The needle is then removed Step IV: Flushing and securing the line Conclusions: Ultrasound-guided peripheral intravenous cannula placement in children is feasible. The only complication could be seen is arterial puncture. Careful ultrasound examination would differentiate between artery and vein. Following appropriate technique, the success rate can be high in experienced hands

Poster #: EDU-025 Head-to-Toe Prenatal Evaluation of Skeletal Dysplasias-Clues to Diagnosis and Outcome Kimberly Fagen, Doctor of Medicine, Radiology, Walter Reed National Military Medical Center, Vienna, VA; Anna Blask, Eva Rubio, Dorothy Bulas, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Prenatal diagnosis of skeletal dysplasia is a diagnostic challenge. Identifying key features that predict lethality allows for more informed counseling and decision-making. The prenatal imaging findings may be used to guide specific prenatal and postmortem genetic testing. We provide an organized approach for prenatal assessment of skeletal dysplasias and review the potential differential diagnoses. Methods & Materials: A retrospective review of our data base at a major fetal referral center was utilized to identify the full gamut of skeletal dysplasias, both common and uncommon. Many cases were diagnosed based on sonographic imaging features. In selected cases, 3D CT, MRI and prenatal or postnatal radiographs assisted in the analysis. Key features were analyzed using a “Head-to-Toe” Approach. Lethality prediction was based on a combination of small thorax and ribs, chest-abdomen circumference ratio < 0.6, severe long bone shortening , femur length to abdominal circumference (<0.16),and/or distinctive head shape. Findings were correlated with autopsy and DNA analysis.

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Results: Our exhibit will show our diagnostic approach and representative images of the most common skeletal dysplasias including achondroplasia, thantophoric dysplasia, osteogenesis imperfecta, and asphyxiating thoracic dystrophy (Jeune’s). Chondrodysplasia punctata, achrondogenesis, diastrophic dysplasia, campomelic dysplasia, and short rib poldactyly (including Ellis van Creveld), will also be highlighted. Key fetal imaging features are divided into the following categories: Head, Face, Thorax, Abdomen, Spine, Pelvis, Long bones, and Hands/feet. The findings that suggest lethality will be emphasized. Conclusions: Skeletal dysplasias are a complex group of disorders with over 400 possible diagnoses and require an organized approach to obtain an appropriate prenatal differential diagnosis. Accurately predicting lethality is critical. Recognizing key features by using a logical “Head-to Toe” approach will assist in predicting lethality and in some cases may provide a definitive diagnosis. This approach will benefit prenatal counseling, will allow more informed parental decision making, and clarify delivery options and postpartum expectations.

Poster #: EDU-026 MRI Findings in Sickle Cell Disease: From Head to Toe Cara Morin, Wendy Kim, MD, Jane Kim, Narendra Shet, MD, University of Maryland, Baltimore, MD, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The utilization of MRI in the pediatric population has substantially increased over the past several years. The purpose of this educational poster is to illustrate MRI findings seen in sickle cell disease across a variety of organ systems, including brain, gastrointestinal, musculoskeletal, and genitourinary systems. Findings related to treatment are also included. Methods & Materials: We compiled a number of representative cases of pathology on MRI in sickle cell disease patients and present these cases, with discussion of relevant imaging findings. Results: In this exhibit, the following entities with associated imaging will be described: 1. Neuro -Moya Moya -Cerebral Infarction 2. MSK -Long bone infarction -Vertebral body endplate infarction -Marrow replacement -Osteomyelitis / Septic Arthritis 3. Cardiac -Iron deposition 4. Gastrointestinal -Gallstones -Splenic infarction -Liver and spleen transfusion-related iron deposition -Gamna-Gandy bodies 5. Genitourinary -Renal intravascular hemolysis Conclusions: With the increasing use of MRI in the pediatric population, knowledge of different MR manifestations in sickle cell patients including treatment-related effects is important. With this educational poster, we have demonstrated the more common entities seen in the sickle cell population with a systems based approach.

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Poster #: EDU-027 NICU Catheter Crash Course: A Guide to Neonatal Vascular Catheters and their Potential Complications Arash Zandieh, MD, MedStar Georgetown University Hospital, Washington, DC, [email protected]; Christabel Lee, Frank Volberg Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In critically ill neonates, abdominal and chest radiographs are frequently ordered to examine vascular catheters such as umbilical venous catheters, umbilical artery catheters, and other peripherally inserted central catheters. Therefore, it is essential for radiologists and clinicians to understand the radiographic appearance of these catheters and the implications when they are malpositioned. The purpose of this educational exhibit is to review the catheters commonly encountered in the neonatal intensive care unit (NICU), discuss their usual radiographic features and normal vascular course, and explore the possible abnormal pathways and potential iatrogenic complications related to their improper positioning. Proper catheter positioning is an important and often challenging feat. A malpositioned catheter has the potential for great harm, if unrecognized and uncorrected. Potential complications include intrahepatic perforation, vascular injury including venous thrombosis, and unintentional infusion into extravascular spaces such as the pleural cavity or pericardial space. A working knowledge of the normal vascular course and radiographic appearance is essential for prompt recognition and avoidance of these catastrophic complications. Methods & Materials: The educational objectives of this exhibit are the following: 1. To educate the viewer about the types of vascular catheters commonly encountered in the NICU and depict their normal anatomic course 2. To provide examples of malpositioned catheters and review anatomic variants and alternate pathways in which the catheters may travel 3. To provide concrete, verified examples of complications related to catheter malposition, including examples of TPN that were infused in the pleural cavity and pericardial cavity and examples of other visceral injury Results: N/A Conclusions: Vascular catheters are commonly placed in the neonatal intensive care unit and they are frequently assessed radiographically. It is essential for radiologists and clinicians to understand the normal appearance of neonatal vascular catheters and to recognize malpositioned catheters and their potential complications. Prompt recognition and early action can lead to better outcomes and decreased morbidity.

Poster #: EDU-028 All that Twists is Not Midgut: Imaging of Non-Midgut, Pediatric Gastrointestinal Volvulus T S h a w n S a t o , U n i v e r s i t y o f I o w a , I o w a C i t y, I A , [email protected]; Lillian Lai, MD, Geetika Khanna, Shunske Nosaka, MD, Graeme Pitcher, MD, Yutaka Sato, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pediatric gastrointestinal (GI) volvulus can be difficult to diagnose clinically, and often depends on a radiologist for accurate diagnosis. While midgut volvulus associated with malrotation is the most common type of GI volvulus, it is important to be familiar with other areas where volvulus can occur in the GI system.

Methods & Materials: We present a series of various gastrointestinal volvuli collected from three major teaching institutions (two in the United States, one in Japan) with clinical and radiological correlation. Cases to be presented include mesenteroaxial and organoaxial gastric volvulus, small bowel volvulus with and without malrotation, as well as cecal, transverse and sigmoid colon volvulus. Results: Although midgut volvulus in the setting of malrotation is well recognized and extensively reviewed in the literature, gastrointestinal volvulus without malrotation has not been systematically reviewed partly because of its rarity, despite potential mortality and significant morbidity. Mesenteroaxial gastric volvulus and colonic volvulus show marked distention of involved intestine on radiographs. The diagnosis of gastric volvulus was confirmed by an oral contrast study, and colonic volvulus was confirmed with a rectal contrast study. Clinical correlation was the key to differentiate organoaxial gastric volvulus from physiologic horizontal stomach of infancy. Sonographic or CT demonstration of the “whirl sign” of twisted mesenteric vessels is helpful to establish diagnosis of small intestinal and colonic volvulus. Detailed analysis of sectional imaging enables further clarification of the direction of the torsion and fixation of involved intestinal segments. Conclusions: Because the clinical presentation of GI volvulus is nonspecific, radiologists play an important role in astute differentiation of various presentations of volvulus, which is essential for timely diagnosis and treatment.

Poster #: EDU-029 - Withdrawn Poster #: EDU-030 Pediatric Meckel Diverticulum: Retrospective Review and Pictorial Essay of a Major Pediatric Center’s Experience Amy Kolbe, Mayo Clinic, Rochester, MN, [email protected]; Jennifer McDonald, Kristen Thomas, Shannon Zingula, Jane Matsumoto, Larry Binkovitz Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Meckel diverticulum (MD) is a common congenital abnormality of the small bowel which is usually insignificant, but can present with various complications and present a challenging radiologic diagnosis. The objective of this educational exhibit is to review the embryology and pathophysiology of MD, and to summarize our institution’s experience through examples illustrating of the spectrum of radiologic abnormalities. Methods & Materials: After IRB approval, a HIPPA compliant retrospective review was conducted of surgically and pathologically confirmed MD in pediatric patients with pre-operative radiologic imaging. Patient demographics, clinical presentation, imaging findings, and outcomes were examined. Results: Through our review, we identified 58 patients with a median age of 5 years (range: 1-14 years) who had a MD diagnosed from 1996 to March 2014. Of these, 16 were considered incidental at surgery. Of the 42 non-incidental MD, the most common presentations were abdominal pain with or without vomiting or diarrhea (n=24, 41%), abdominal symptoms with gastrointestinal bleeding (GIB) (n=4, 7%), and GIB alone (n=13, 22%). In the 28 patients presenting with abdominal symptoms, preoperative imaging correctly diagnosed MD in two cases (1 on CT scan and 1 on nuclear scintigraphy) and included MD in the differential diagnosis in an additional five cases. Eighteen of the 28 patients had a CT scan and the most common findings were small bowel obstruction (n=11, 61%) determined at surgery to be due to obstructing bands or volvulus associated

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with a MD, and phlegmon/abscess in the right lower quadrant (n=7, 39%) found at surgery to be caused by inflammation of a MD. An additional seven of these 28 patients were found to have a non-reducible ileocolic intussusception on air or contrast enema, with a MD found during surgical reduction. In the 17 patients presenting with GIB, nuclear scintigraphy was performed in 14 patients and was positive in 10 cases (71%). Five patients had complications including three reoperations for small bowel obstruction, one abscess, and one death. Conclusions: This educational exhibit will review the embryology and pathophysiology of MD, as well as the presentation and spectrum of radiologic findings associated with MD. A high index of clinical suspicion should be maintained for MD in the appropriate setting, as the clinical presentation and radiologic findings may be nonspecific.

Poster #: EDU-031 Demystifying Abnormal Myelination Russell Kosik, MD, Radiology, Santa Clara Valley Medical Center, Stanford University, San Jose, CA; Priya Krishnarao, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Dysmyelination is caused by an inherent inability to properly form or maintain myelin. Less well known than its more commonly discussed counterpart demyelination, the spectrum of diseases that collectively comprise dysmyelinating disorders are more colloquially referred to as leukodystrophies. This educational exhibit offers the viewer a glimpse of the various leukodystrophies and a chance to become familiar with the more common ones. Leukodystrophies can be classified based on the site of defect. Metachromatic leukodystrophy, Krabbe’s globoid cell leukodystrophy, GM1 gangliosidosis, and the mucopolysaccharidoses are all due to lysosomal defects. Zellweger’s syndrome, Adrenoleukodystrophy, and Infantile Refsum’s disease are caused by malfunctioning peroxisomes. Mitochondrial defects are responsible for MELAS, Kearns-Sayre syndrome, Alper’s, and subacute sclerosing encephalopathy. PKU, Lowe’s, and maple syrup urine disease are all caused by an inability to metabolize certain amino acids. Finally, Canavan’s, Alexander’s, Perlizaeus-Merzbacher, Cockayne, galactosemia, Wilson’s, and Hallervorden-Spatz comprise the miscellaneous group of leukodystrophies. Methods & Materials: We review both the imaging features and clinical findings that can help the radiologist and/or clinician differentiate the above leukodystrophies. We also present selected cases from our hospital. As there is not sufficient space in the abstract to discuss them all, a brief description of the more common leukodystrophies is provided below. Results: Perlizaeus-Merzbacher disease is due to an X-linked genetic mutation. MRI demonstrates a distinct “striped” pattern due to alternating vessels and areas of incomplete myelination. Children present with microcephaly, spasticity, and nystagmus. Adrenoleukodystrophy manifests on MRI as diffuse abnormal T2 hyperintensity. Males under ten develop vision or hearing abnormalities, resultant learning difficulties, and characteristic skin spots. Metachromatic leukodystrophy also maifests on MRI as diffuse T2 hyperintensity, though it spares certain subcortical regions. Alexander’s disease presents with macrocephly. MRI usually shows characteristic signal abnormality in the frontal white matter. Canavan disease is progressive and MRI demonstrates diffuse T2 signal abnormality, though unlike metachromatic leukodystrophy, there is involvement of certain subcortical regions. Conclusions: Leukodystrophies, though similar in etiology, comprise a diverse spectrum of both radiologic and clinical findings.

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Poster #: EDU-032 Rapid MRI for Pediatric Appendicitis: Challenges, Tips, Pitfalls, and Lessons Learned from Implementation at a Large Combined Adult and Pediatric Academic Tertiary Medical Center Lauren May, MD, San Antonio Military Medical Center, Fort Sam Houston, TX, [email protected]; James Covelli, Christian Carlson Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In recent years rapid MRI has been utilized at more institutions to evaluate for pediatric appendicitis. Given the increased awareness of radiation exposure, ALARA, and the Image Gently campaign, rapid MRI has evolved as a feasible non-ionizing alternative to CT to evaluate appendicitis when ultrasound is equivocal or when appendicitis ultrasound expertise is lacking. Literature to date has shown that rapid MRI can be an accurate imaging alternative to traditional CT when ultrasound findings are equivocal. The purpose of this educational exhibit is three-fold. First, we discuss the rapid MRI protocol implemented at our institution along with protocol modifications instituted over the last two years to optimize diagnostic accuracy and exam efficiency. We discuss additional sequences and protocols presented in the literature and methods of maximizing spatial resolution, limiting motion artifact in non-sedated patients, and adjusting protocol technique depending on patient size. Second, we discuss the educational methods used to inform/educate (and gain by-in from) our surgeons, emergency physicians, pediatricians, and even radiologist regarding the benefits of rapid MRI in the evaluation of appendicitis. Third, we discuss the challenges of implementing a rapid MRI appendix protocol at a large combined adult and pediatric tertiary medical center. Methods & Materials: Literature discussing the utility of MRI for acute appendicitis has almost exclusively been reported from stand-alone academic pediatric hospitals with examinations interpreted exclusively by pediatric radiologists. At our institution rapid MRI exams are interpreted not only by pediatric radiologists, but also by diagnostic radiology residents, general radiologists, and various other sub-specialized radiologists. Results: Rapid MRI protocols are gaining increased popularity at more institutions with the benefit of decreasing ionizing radiation exposure. Understanding the challenges and limitations of implementing a rapid MRI appendix protocol at a large combined adult and pediatric tertiary hospital can have a significant impact in expanding rapid MRI for appendicitis beyond the confines of stand-alone academic pediatric hospitals. Conclusions: In conclusion, careful and deliberate adjustments in MRI technique as well as clear communication and effective education of clinicians and interpreting radiologists are critical to guaranteeing the success of rapid MRI for evaluating appendicitis at all institutions caring for children.

Poster #: EDU-033 Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs Dhanashree Rajderkar, MD, Radiology, University of Florida, Gainesville, FL; Robert Dubuisson, Jonathan Williams Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: There are many recognized complications resulting in shunt malfunction in a patient with a VP catheter. Most

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malfunctions are mechanical but there are also functional causes for failure. Radiological evaluation of shunt failure may require a multimodality approach. Recognizing the mechanical causes of malfunction with plain radiographs has proven to be very helpful in triggering following steps in management. The purpose of our study was to emphasize the importance of the plain radiographs in the diagnosis in the mechanical failure of the VP shunt catheters. Methods & Materials: A retrospective study for mechanical causes of VP shunt device failures was done. Plain radiographs were obtained as a baseline examination in the evaluation of shunt malfunctions. Depending upon the interpretation of the plain radiographs, tailored studies were performed and unnecessary tests were avoided. If the mechanical failure is diagnosed on plain x-rays, the follow up studies with functional/ dynamic studies such as nuclear medicine procedures could be avoided. We present some common diagnosed mechanical complications of VP shunts on initial plain radiographs and include uncommon causes correctly interpreted on plain films. Results: Mechanical failure of VP shunts was often revealed on plain radiographs. Shunt tubing fractures, migration and abnormal coiling (entrapment) of the catheters were the most commonly diagnosed. Pseudocyst formation with/without secondary infection and subdural hematomas were also interpreted correctly. Size of the fluid collection was a limiting criterion for these diagnoses. Conclusions: Recognizing the cause of VP shunt failure is vital to determine the next steps in diagnosis. Appropriately indicated studies can be based on the initial baseline plain radiographic interpretation.

Purpose or Case Report: Appendicitis is the most common cause of a surgical abdomen in the pediatric population. Accurate diagnosis is critical to assure timely surgical management, identify related complications, such as perforation and abscess, and recognize alternative diagnoses requiring different clinical treatments. While children with suspected appendicitis are most often evaluated using ultrasound and computed tomography (CT), both modalities have drawbacks. In particular, CT exposes children to ionizing radiation, while ultrasound is operator-dependent and limited by patient body habitus. MRI is an emerging tool for evaluating children with clinically suspected appendicitis, with recent studies showing both high sensitivity and negative predictive value. This educational exhibit will present our noncontrast imaging protocol for MRI evaluation of suspected appendicitis and offer numerous examples of positive cases, highlighting imaging features of uncomplicated (nonperforated) and complicated (perforated) appendicitis. We will also illustrate several alternative diagnoses revealed by MRI that explained clinical signs/symptoms. Methods & Materials: All pediatric patients (≤18 years-old) that underwent abdominal MRI for suspected appendicitis between November 2013 and October 2014 were retrospectively identified. Imaging reports were reviewed, and pertinent examinations were selected for presentation. Results: Eighty children were identified that underwent abdominal MRI for suspected appendicitis during the study period. Several examples of nonperforated and perforated appendicitis will be presented along with relevant clinical data. We will also illustrate the MRI appearances of several alternative diagnoses in these children with right-sided abdominal pain, including obstructing urolithiasis, pyelonephritis, ovarian torsion, hemoperitoneum due to ruptured ovarian cyst, and enteritis/colitis. We will also present any false positive or false negative examinations, in order to present “lessons learned”. Conclusions: MRI of the appendix has emerged as an effective imaging modality for the assessment of pediatric appendicitis, allowing accurate diagnosis of appendicitis while excluding other causes for patients’ symptoms. This educational exhibit outlines our institution’s experience over the past year with the implementation of a rapid, noncontrast MRI appendicitis protocol that is used in the setting of equivocal ultrasound imaging.

Poster #: EDU-035 Pediatric Posterior Fossa Abnormalities: A Pictorial Review Michael Daugherty, MD, Radiology, University of South Florida, Riverview, FL, [email protected]; Jennifer Kucera, MD, MS

Poster #: EDU-034 Suspected Acute Appendicitis in Children: MRI Appearances, Alternative Diagnoses, and Lessons Learned Jessica Leschied, MD, C.S. Mott Children’s Hospital, Division of Pediatric Radiology, University of MIchigan Medical Center, Ann Arbor, MI, [email protected]; Jonathan Dillman, M.D., Ethan Smith, Peter Strouse, MD, FACR, Samir Gadapelli, Nicole Sroufe Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Abnormalities of the posterior fossa in pediatric patients include an expansive list and can be intimidating, with many of the abnormalities having overlapping characteristics. The ability to properly identify these malformations is vital in the clinical realm for determining prognosis, treatment options, and scheduling image surveillance. The purpose of this exhibit is to describe and differentiate the more commonly encountered posterior fossa malformations using a multimodality approach. Methods & Materials: Posterior fossa abnormalities detailed in the exhibit are illustrated using MRI, ultrasound, CT, and fetal imaging. The abnormalities are described, with emphasis on the specific imaging characteristics which help distinguish each abnormality. Results: The pictorial review is divided into three broad categories: cystic, hypoplastic, and dysplastic abnormalities. The specific examples that are presented in this review are the most common abnormalities that will be encountered by a typical pediatric radiologist. The following abnormalities will be presented:

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1. Cystic Posterior Fossa Malformations: Dandy Walker Malformation, Vermian-Cerebellar Hypoplasia, Mega Cisterna Magna, and Arachnoid Cyst 2. Hypoplastic Posterior Fossa Abnormalities: Chiari Malformations I, II, III, and IV. 3. Dysplastic Posterior Fossa Abnormalities: Joubert Syndrome, Rhombencephalosynapsis, and Lhermitte-Duclos-Cowden syndrome. Conclusions: Congenital abnormalities of the posterior fossa are a relatively common finding in the pediatric population. It is important for radiologists to be familiar with the imaging findings that distinguish these entities as each diagnosis may have important prognostic information.

Poster #: EDU-037 Poster #: EDU-036

Fetal MRI of the Holoprosencephaly Spectrum

Key Imaging Findings in Median Arcuate Ligament Syndrome

Michael Wien, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Matthew Whitehead, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this educational exhibit is to showcase multiple cases referred to a fetal imaging center regarding brain anomalies that fit along the holoprosencephaly spectrum. Cases range from clear-cut examples of the most severe form of holoprosencephaly (alobar), to more ambiguous examples of less severe forms (semilobar, lobar, syntelencephaly (middle interhemispheric variant), and septo-optic dysplasia). Where available, correlation with followup neontal imaging or post-mortem pathology will be made. Methods & Materials: Cases were found retrospectively by searching a research database at a Children’s Hospital with a dedicated fetal imaging center. Cases range from 1/1/2008 through 10/10/2014. Results: Multiple cases of classic alobar holoprosencephaly were identified. Individual cases were found that demonstrate features of semilobar & lobar holoprosencephaly as well as cases questioning possible syntelencephaly. Other cases question septo-optic dysplasia. Some of these cases are confirmed on followup neonatal imaging. Conclusions: The prenatal diagnosis of holoprosencephaly can range from straightforward in the most severe cases to more challenging in the less severe forms. Some findings necessitate pathological analysis or neontal followup imaging in order to establish a final diagnosis. While exact diagnoses may not be possible in some of these subtle cases, MRI can still help to present a clearer picture of what the final outcome may be so that accurate prenatal counseling can be provided.

Summer Kaplan, MD, Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Kassa Darge, MD, PhD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Compression of the celiac artery has been associated with post-prandial pain and many other GI symptoms. There are several causes of celiac artery compression, but in children the most common is impingment by the median arcuate ligament (MAL) of the diaphragm. Median arcuate ligament syndrome (MALS) is a challenging diagnosis, and radiological evaluation is critical to proper patient selection for surgery. Radiologists should be familiar with the imaging approach and key findings in evaluating patients for MALS. Methods & Materials: We have reviewed literature on celiac artery compression, focusing on the diagnostic criteria of MALS. Our search emphasized sonographic findings, as ultrasound is the preferred imaging method in evaluation of pediatric MALS. Pediatric and adult studies were reviewed, including investigative research, case series, and case reports. We surveyed ultrasound studies at our institution for images illustrating a diagnosis of MALS. Results: Sonographic description of MALS largely focused on identifying peak systolic velocity (PSV) >200 cm/s in the celiac origin with an increase in velocity on expiration. However, several authors noted poor specificity with these criteria. Some proposed expiratory PSV >350 cm/s, inspiratory PSV >150 cm/s, and angle of deflection in the distal celiac >50° during expiration (Fig. 1) as more specific criteria. Other authors suggest assessing PSV in both supine and upright positions. Both sonographic and cross-sectional studies describe post-stenotic dilatation (Fig. 2) and presence of collaterals as supporting evidence. The classic description of a “J” or “hook” shape of the celiac artery was a finding primarily described on cross-sectional imaging (Fig. 2). Conclusions: Diagnosis of MALS is challenging and warrants a systematic imaging evaluation. For children, ultrasound should be the mainstay of radiological diagnosis. Sonographic diagnosis of MALS can be suggested with increased confidence when supine PSV >350 cm/s in expiration and >150 cm/s in inspiration. Velocities should decrease with upright position. Angle of deflection should be >50°. On CT or MR, severe compression and kinking of the proximal celiac artery should be evident. In the appropriate clinical setting, accurate radiological evaluation is key to the selection of candidates who are likely to benefit from surgical repair.

Poster #: EDU-038 Multimodal Review of Pediatric Vascular Variants: Rings and Slings Candace Scace, Hahnemann University Hospital, Philadelphia, PA, [email protected]; Jason Shames, Erica Poletto, Kathryn Jarrett, Eric Faerber, Mea Mallon Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Many congenital anomalies can occur during aortic arch and pulmonary arterial development that can lead to chronic and sometimes life threatening disease in children. It may be challenging for the radiologist to differentiate among these variants. The purpose of this exhibit is to review, utilizing a multimodal approach, the imaging findings of variant aortic arch and pulmonary arterial development that lead to vascular rings and slings. Methods & Materials: A retrospective review of pediatric vascular variants was performed at St. Christopher’s Hospital for Children. A series of

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cases with abnormal aortic arch and pulmonary arterial anatomy were collected on multiple diagnostic modalities for review and presentation. Results: Examinations with variant aortic arch and pulmonary arterial anatomy in children were collected in multiple modalities, including X-ray, fluoroscopy, computed tomography and magnetic resonance imaging. The distinguishing features of these abnormalities are presented, including double aortic arch, double aortic arch with atretic left aortic arch, right aortic arch with aberrant left subclavian artery, right cervical/circumflex aortic arch with aberrant left subclavian artery, left aortic arch with aberrant right subclavian artery and pulmonary sling. These findings are contrasted with the normal embryologic development and appearance of the aortic arch and pulmonary vessels in children. Conclusions: A variety of congenital anomalies can affect aortic arch and pulmonary vascular anatomy leading to a vascular ring or sling in children. Knowledge of normal vascular development and the distinguishing imaging characteristics of these vascular anomalies can aid the radiologist in timely and accurate diagnosis.

radiologist would undoubtedly satisfy the ACR Imaging 3.0 initiatives and the essence of “meaningful use” in health care practice. Conclusions: Increased use of patient health records will alter the essence of the radiology report and empower patients and their respective families with simple, transparent and meaningful results and recommendations.

Poster #: EDU-039 Patient-and Parent-Facing Radiology Reports for the Pediatric Personalized Health Record Patrick Lai, Wayne State University School of Medicine, Detroit, MI, [email protected]; Matthew O’Brien, Chad Klochko, Marcus MacNealy, Safwan Halabi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The American College of Radiology (ACR) Imaging 3.0 initiative includes enhancement of radiology results reporting and patient understanding. With increased health consumer utilization of personalized health records, there is a unique opportunity for pediatric radiologists to provide a structured, image/resource-rich and readable radiology report in addition to developing a direct relationship with the pediatric patient and their family or guardian. This exhibit will discuss ideal and novel reporting practices in keeping with the ACR Imaging 3.0 iniatiatives for pediatric patients and their families. Methods & Materials: 1. Discussion of current radiology reporting requirements 2. Discussion of structured reporting methods based on body systems and imaging modalities 3. Discussion of verbiage that should and should not be included in the patient/parent-facing reports including common grammatical rules of thumb 3. Discussion of key image inclusion and annotation within the radiology report 4. Discussion of report impressions and recommendations including providing references and resources (this section will also include radiation dose reporting and references) 5. Discussion of documenting communication with the patient, family, and referring health provider 6. Discuss how to provide department and radiologist contact information to allow the patient and family to communicate questions and concerns 7. Discuss how radiology departments and radiologists can communicate safely and securely with patients and their families Results: Today’s radiology report will not suffice in the era of the personalized health record and health information transparency to the health consumer. There are numerous reporting structures and customizations that radiologists can implement to provide patients and families with the information they need to make informed decisions in regards to their health care. If executed correctly, the incorporation of structured reporting, simple verbiage and terminologies, key images, links to patient friendly medical resources, explanation of radiation risks, and providing direct communication methods to the radiology department and

Poster #: EDU-040 Pediatric Lucent Lesions of The Squamous Skull Nadja Kadom, MD, Boston University Medical School, Boston, MA, [email protected]; Gregory Fenton Purpose or Case Report: To show the imaging findings in anatomical variants, benign and malignant lucent lesions in the squamous portion of the skull in children Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Methods & Materials: This case series did not meet IRB human subjects research criteria. The presentation is HIPAA compliant. Images were retrieved from pediatric teaching files at our institution, including a historic teaching film-based teaching file that spans from 1950 to 2000 and that was recently digitized. Results: Plain skull radiographs in children are nowadays rarely indicated; therefore, our case collection of radiographic lucent skull lesions is rare. Some cases start with a CT survey image when no radiograph was available, one case starts with a reformatted 3D skull CT image. We are using the following classification for the cases in this series: 1) Anatomic variants, 2) Benign lesions, 3) Malignant lesions. A schematic cartoon of the calvarium illustrating the skin surface, subcutaneous fat, outer table, diploic space, inner table, subarachnoid space, falx and brain is shown. All lesions are presented first as a single image with a short history, followed by an annotated image with description of findings and differential diagnoses, followed by the diagnosis with pertinent clinical and radiographic information, and several cases will have cross-sectional imaging correlations from the same or a companion case. Here is the list of cases in this presentation: (1) Anatomic variants: Parietal foramina, Venous lakes, Arachnoid granulations. (2) Benign lesions: Copper beaten skull, Lückenschädel, Encephalocele, Epidermoid cyst (Figure 13), Leptomeningeal cyst, Eosinophilic granuloma. (3) Malignant lesions: Metastatic neuroblastoma. Conclusions: The differential diagnosis for pediatric lucent skull lesions is broad and includes malignancies, such as metastatic neuroblastoma, leukemia and lymphoma. Skull radiographs can

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hold important clues to the diagnosis. Frequently a diagnosis can be made in conjunction with the clinical history. Plain skull radiographs in children are rarely indicated, but understanding plain film lesions can help in identifying them on cross-sectional imaging studies.

Poster #: EDU-041 Pediatric Spectral Doppler Waveforms Simplified Mesha Martinez, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Richard Bellah, Sabah Servaes Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Simplify interpretation of pediatric spectral Doppler waveforms and identify technical errors that may simulate pathology or cause an examination to be non-diagnostic/inaccurate. Methods & Materials: Extensive review of the literature was performed to assess the information available to pediatric radiologists pertaining to spectral Doppler waveforms and the pediatric patient. The information was compiled and simplified into a 5-step algorithm created to guide and/ or assist pediatric radiologists in interpreting spectral Doppler waveforms. Technical pitfalls that may mimic pathology or render an examination non-diagnostic/inaccurate are reviewed. Example cases are given to measure retention. Results: This educational exhibit will describe a systematic process for interpretation of Doppler waveforms. We will review the expected Doppler findings for clinical scenarios, including - but not limited to - normal children, children post liver and kidney transplant, children with renal artery stenosis and children with congenital heart disease. Conclusions: Interpretation of spectral Doppler waveforms is important in the care of pediatric patients and this educational exhibit serves to solidify this skill by outlining a five step approach with application of this method through examples cases with interactive questions.

Poster #: EDU-042 Review of Imaging Findings in Pediatric Patients with Auxilary Partial Orthotopic Liver Transplant (APOLT) Rama Ayyala, MD, Columbia University Medical Center, New York, NY, [email protected]; Mercedes Martinez, Tomoaki Kato, Steven Lobritto, Carrie Ruzal-Shapiro Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Auxilary partial orthotopic liver transplant (APOLT) is a treatment technique for patients with fulminant hepatic failure who may ultimately recover normal liver function. The patient receives a partial allograft while retaining part of the native liver. The method is devised to allow immunosuppression withdrawal once the native liver recover hepatic function without the patient needing longterm immunosuppression, which is typically needed in the standard posttransplant setting. The post procedure surveillance of vascular complications is complex given the need to evaluate vessels of the native liver as well as the allograft, which may be in an unusual location. The purpose this study is to review the imaging findings in pediatric patients with auxiliary partial orthotopic liver transplant. Methods & Materials: A retrospective review of the electronic medial records of four patients (age range 3 months - 7 years) who underwent APOLT between 2008 and 2014 was conducted. Information obtained includes date of surgery, reason for procedure, and preoperative and postoperative abdominal imaging studies performed. Multimodality imaging approach involving computed tomography (CT), ultrasound (US), and nuclear medicine was implemented to characterize imaging features, including complications. esults: Postoperative imaging in two patients show homogenous appearance of the transplant and native livers, consistent with recovery of native liver function with functioning transplant liver. One patient had failure of recovery of the native liver, resulting in involution, with normal imaging appearance of the functioning transplant liver. The last patient has imaging findings demonstrating rejection of the transplant liver with normal appearance of the functioning native liver. One patient had a postoperative biloma. Conclusions: Patients who have undergone APOLT experience various stages of hepatic function of the native and transplant livers. Postoperative imaging can be challenging given both the native and allograft liver vasculature needs to be optimally visualized. Imaging findings reflect this, therefore it is important to familiarize radiologists with these unique characteristics.

Poster #: EDU-043 Gray Matter Matters: Ultrasonography of Migrational and Organizational Brain Abnormalities Mark Baskin, Indiana University School of Medicine, Indianapolis, IN, [email protected]; Megan Marine, MD, Chang Ho, Boaz Karmazyn, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To illustrate the sonographic findings of several common migrational and organizational abnormalities affecting the neonatal brain. Methods & Materials: Ultrasonography is frequently used in the neonate to assess for ventricular enlargement and intracranial hemorrhage. Less commonly, sonography may uncover congenital anatomic anomalies such as disorders of neuronal migration and cortical organization. Radiologists at our institution gathered cases in the course of clinical practice that illustrate common migrational abnormalities of the neonatal brain, including heterotopic gray matter, lissencephaly, polymicrogyria, and schizencephaly. Whenever available, comparison prenatal sonograms and both pre- and postnatal MRI examinations were also evaluated. Results: We describe characteristic sonographic findings of several migrational and organizational abnormalities, including heterotopic gray matter, lissencephaly, polymicrogyria, and schizencephaly. We include representative sonographic images. In several cases, prenatal sonograms and/or MRI are included for comparison.

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Conclusions: Ultrasonography can characterize migrational and organizational anomalies during the newborn period. Recognition of some anomalies depends on knowledge of the normal appearance of the brain at different stages of prematurity.

Poster #: EDU-044 Surgical Intervention for Children and Young Adults with Sickle Cell Disease and Femoral Head Osteonecrosis; A Pictorial Essay Heather Gale, MD, Boston Medican Center, Boston, MA, [email protected]; Charles Colip, Bindu Setty, Akira Murakami, Ali Guermazi, Ilse Castro-Aragon

Methods & Materials: From a teaching file collection we chose representative cases demonstrating the use of ultrasound to characterize injuries to bone, cartilage, muscles and tendons. We correlated the ultrasound findings with other imaging modalities when necessary. Results: Illustration of the normal ultrasound anatomy of the immature bone and variety of injuries to the immature bone including injuries to the metaphysis, growth plate and cartilaginous fractures, fascial defect with muscle herniation, and injuries to the muscles and tendons. In selected cases we show correlation with radiographs, CT and MRI. Conclusions: Ultrasound has unique advantages in evaluation of the immature skeleton and can demonstrate injuries not detected by other imaging modalities.

Poster #: EDU-046 Spectrum of Radiologic Findings in Gorlin-Goltz Syndrome

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To illustrate the surgical interventions used to treat osteonecrosis in young patients with sickle cell disease and femoral head osteonecrosis. We will discuss current literature regarding surgical treatment and discuss potential complications using cases from our institution. We will show outcomes, including cases of patients who needed multiple procedures and arthroplasty, and those who have only required less invasive intervention such as core decompression and bone marrow grafting. Methods & Materials: This pictorial essay is IRB approved and HIPAA compliant. Informed consent requirements were waived. We reviewed records of patients with SCD ages 0-21 at radiologic diagnosis of femoral head osteonecrosis between January 1999 and December 2013. Demographics, hospital courses, and radiologic and surgical reports were collected. Results: Eight patients ages 16-19 at radiologic diagnosis of osteonecrosis who underwent surgical hip procedure were identified. The eight patients underwent 16 total procedures, including 1 resurfacing arthroplasty, 1 revision of partial hip arthroplasty, 7 total hip arthroplasties, and 7 bone marrow grafts and core decompressions. Five patients had bilateral procedures. The mean length of follow-up after the most recent procedure per hip was 3.38 years. Per current recommendations, bone marrow graft and core decompression were reserved for patients without femoral head collapse. Of the seven hips treated with bone marrow graft, one required subsequent total hip arthroplasty, which was performed within 1 year of initial procedure. Conclusions: Surgical intervention is required in many patients with osteonecrosis of the femoral heads, including young patients with sickle cell disease. In our pictorial review we saw eight such patients, six of whom required at least one arthroplasty for femoral head collapse. Bone marrow grafting was used successfully in patients with osteonecrosis and preservation of the articular surface.

Judyta Loomis, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Gorlin-Goltz or basal cell nevus syndrome is a rare autosomal dominant disorder with variable penetrance and expressivity. We aim to demonstrate radiographic findings of this syndrome with a focus on the variable severity of maxillofacial findings. Methods & Materials: The diagnostic imaging report database at a single academic children’s hospital was retrospectively searched for all studies with keyword variations on Gorlin-Goltz and basal cell nevus syndrome. The search yielded 57 exams, from 27 different patients, with 15 patients excluded on the basis of incorrect categorization of the patient at the time of the study or no corraborative testing or documentation for the diagnosis. All images were reviewed for radiographic findings with a focus on processes either specific or commonly associated with the syndrome. Results: Representative findings specific to the syndrome included multiple odontogenic keratocysts associated with unerupted teeth and intracranial dural and ligamentous calcifications. The spectrum of odontogenic keratocysts varied from subtle cystic lucencies to multiple disfiguring lesions of the mandible and maxilla. Intracranial calcifications were progressive in patients with multiple studies and varied from subtle linear calcifications at the sella to sheetline falcine calcifications. Associated, but nonspecific radiographic findings included rib fusion anomalies and medulolblastoma. Conclusions: Gorlin-Goltz or basal cell nevus syndrome is a rare syndrome with a spectrum of radiographic findings and variable expressivity. Early recognition of this syndrome aids in limiting ionizing radiation to these radiosensitive patients and early dermatologic surveillence.

Poster #: EDU-047 Poster #: EDU-045 Trauma and Transducers - Ultrasonography in the Setting of Pediatric Musculoskeletal Injury Joseph Davis, MD, Indiana University, Indianapolis, IN, [email protected]; Boaz Karmazyn, MD, George Gantsoudes, Christine Caltoum Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To demonstrate the applicability of ultrasonography in the diagnosis of osseous and soft tissue injury in children

Diaphragmatic Hernia Beyond the Neonatal Period: Imaging Findings Jonathan Rassi, Ellen Park, Neil Vachhani, Sabiha P Karakas, MD, Unni Udayasankar, MD, Radiology, Cleveland Clinic Childrens, Cleveland, OH, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Diaphragmatic hernias are unusual in children, with congential diaphragmatic hernia (CDH) being the most well described entitity having a high mortaltity rate. CDH is often detected in antenatal imaging and clinically presents as respiratory distress and

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pulmonary hypoplasia in the neonatal period. Diaphragmatic hernias are extremely rare in children beyond the neontal period with a few reported cases in the four major categories described in the literature. The purpose of this exhibit is to describe the causes of diaphragmatic hernia in an older child and illustrate the radiological findings. Methods & Materials: Diaphragmatic hernia in an older child: Describe embryology and relevant anatomy State the incidence and common etiologies. Etiologies: 1. Late presentation of Congential Diaphragmatic Hernia 2. Acquired Diaphragmatic Hernia Sliding Paraesophageal Combined 3. Traumatic Diaphragmatic Hernia 4. Delayed Post-surgical Diaphragamatic Hernia Results: Radiological features of diaphragmatic hernia will be explained with relevant radiographic/cross sectional images as well cartoons. Differential diagnostic considerations including diaphragmatic eventeration and other chest/abdominal pathologies will be described with suitable imaging examples. Conclusions: Diaphragmatic hernias are unusual in children beyond the neonatal period. This exhbit will familiarize the authors to potential causes and radiological features that are helpful in identifying this disorder in an older child.

Poster #: EDU-048 Juxtacortical Lesions of the Bone: Beyond Scratching the Surface Ashwin Hegde, MD, FRCPC, Radiology, BC Children’s Hospital, Vancouver, BC, Canada, [email protected]; Heather Bray, MD, Robyn Cairns, MSc Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 1. To describe the typical imaging appearance of a variety of surface lesions of bone, benign and malignant 2. To describe distinguishing features of particular surface lesions allowing accurate diagnosis from imaging findings Methods & Materials: A retrospective review of our imaging database was performed to identify pediatric patients with various surface lesions of the bone. Representative images were obtained as examples of each lesion. Results: The search of our database yielded surface lesions of multiple different etiologies. The surface lesions include periosteal osteosarcoma, parosteal osteosarcoma, juxtacortical chondroma, parosteal lipoma and mimics (osteochondroma, healing avulsion fracture, Ewing sarcoma of the cortex, soft tissue slow flow venous malformation). Representative cases of each of these lesions were obtained and described along with their multimodality imaging appearance, including pathologic correlation when available. Conclusions: Awide spectrum of surface lesions of the bone exist and are relatively common in pediatric patients. While some of these lesions are malignant, there are many which are benign and can be diagnosed with imaging, which can advise appropriate surgical management of the tumors. Pediatric radiologists should be familiar with these surface lesions and be able to guide the appropriate management.

Poster #: EDU-049 Take the 1 to the 5, then Head to the VI, VII and VIII: A Review of the Major Cranial Nerve Highways and Accidents to Look for in the Pediatric Population Mark Escudero, Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Rachel Griggs, M.D., Priya Sharma, MD, Skorn Ponrartana, MD, MPH

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives:We will provide a pictorial review of normal anatomy for cranial nerves I, II, III, IV, V, VI and VII/ VIII. We will demonstrate their normal appearance on CT and/or MRI, and supplement this discussion with companion cases to demonstrate congenital and/or pathologic abnormalities related to these cranial nerves. Methods & Materials: Before pediatric neuroradiologists can be accurate in diagnosing cranial nerve abnormalities, they first must be able to recognize normal cranial nerve anatomy and relationships. With this educational exhibit, we present imaging studies which delineate the normal appearance of the selected cranial nerves. We will supplement these normal studies with images demonstrating developmental or pathologic cranial nerve abnormalities seen in the pediatric population. Results: The following cranial nerves will be delineated and accompanied by descriptions and depictions of the the listed anomalies or pathologic entities: CN I: CHARGE syndrome and absence of the olfactory bulbs, Esthesioneuroblastoma. CN II: Septo-optic dysplasia, Optic pathway glioma and gliomatosis/recurrence, Optic nerve drusen, Absence of the optic chiasm in holoprocencephaly, Optic nerve calcification in Coffin Lowry Syndrome. CN III: Miller-Fisher variant of Guillain-Barre, CN III inflammation in multiple sclerosis. CN V: Perineural tumor spread entering Meckel’s cave. CN VII/VIII: Bell’s Palsy, Mobius syndrome, Cochlear nerve hypoplasia/aplasia, Scwhannommas in NF2, Labarynthitis ossificans. Bonus Case: Osteopetrosis with narrowing of multiple neural foramina. Conclusions: Mastery of cranial nerve anatomy is crucial to a neuroradiologist’s fund of knowledge. This understanding facilitates recognition of the complex congenital and pathologic entities afflicting the cranial nerves and enhances our ability to accurately diagnose pathology in the pediatric population.

Poster #: EDU-050 Pictorial Overview of the Multidisciplinary Consensus on the Prenatal and Postnatal Urinary Tract Dilation Classification System Susan Back, MD, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Jeanne Chow, Beverly Coleman, Kassa Darge Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Urinary tract dilation (UTD) affects 40-80,000 children annually in the United States. Ultrasound (US) is the most common imaging modality used to detect and monitor urinary tract abnormalities in both fetuses and children. However, there is a lack of consensus and uniformity in the definitions and classifications of grades of UTD within and between prenatal and postnatal periods confounding communication among providers caring for these patients. A multidisciplinary consensus created a classification system with standardized terminology that can be applied to

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prenatal and postnatal US in order to guide future imaging. This overview will familiarize pediatric radiologists with this new classification. Methods & Materials: Representatives from the American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Pediatric Nephrology, Society for Fetal Urology, Society for Maternal-Fetal Medicine, Society for Pediatric Radiology, Society for Pediatric Urology, and Society of Radiologists in Ultrasound held a consensus conference in March 2014. The participants reviewed and summarized current literature and created a UTD classification system and imaging algorithm. Results: Anterior posterior renal pelvic diameter, calyceal dilation, renal parenchymal thickness and appearance, bladder and ureteral abnormalities and amniotic fluid volume were the criteria used to assess the urinary tract. Findings were correlated to postnatal urological pathology. Risk groups were stratified into two prenatal and three postnatal tiers. The statement gave recommendations about further US imaging for all risk groups and voiding cystourethrography, prophylactic antibiotics and functional imaging for postnatal risk groups. Conclusions: A unified classification system for UTD with standardized terminology based on parenchymal quality and associated anomalies will improve communication between medical providers and facilitate outcomes research.

Poster #: EDU-051 Twist and Shout: Common and Unusual Cases of Intestinal Volvulus Jeannine Ruby, MD, Radiology, University of Wisconsin, Madison, WI, [email protected]; Kara Gill, Jie Nguyen, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pediatric volvulus is a surgical emergency that can occur anywhere along the gastrointestinal tract. Often the clinical presentation is confusing. Therefore, radiologists play a critical role in prompt diagnosis. The more common midgut volvulus typically occurs in the setting of intestinal malrotation. However, there are other congenital and developmental predisposing factors which can lead to volvulus along any part of the gastrointestinal tract. The purpose of this exhibit is to review the pathophysiology and imaging appearances of bowel volvulus using various imaging modalities. Additionally, we will supplement our cases with a review of the current literature. Methods & Materials: Surgically-confirmed cases of intestinal volvulus from a single children’s hospital over the past five years are retrospectively reviewed by a Pediatric Radiologist and categorized based on their underlying cause: malrotation, lead point, or idiopathic. A literature review was conducted on PubMed for various causes, incidence, and appearance of intestinal volvulus. Results: The most common etiology of pediatric volvulus is midgut volvulus due to malrotation. Upper GI series is well established to be the gold standard for its diagnosis. At times, abnormal relationship of the superior mesenteric vessels and/or the presence of the “whirlpool” or “swirl” sign of twisted mesenteric vessels can be incidentally detected on ultrasound and CT performed for other indications. Prompt recognition of these abnormal signs allows prompt diagnosis and immediate surgical intervention. Intestinal volvulus can occur despite normal positioning of the ligament of Treitz; therefore, in the setting of an extremely sick infant, the less common causes of small bowel volvulus should be considered, including mesenteric cyst, meconium ileus, ileal atresia, extreme stool impaction, and Meckel’s diverticulum. Gastric and colonic sources of volvulus are less common than small bowel sources. Colonic volvulus occurs most

frequently in the sigmoid colon, followed by the cecum and transverse colon. Conclusions: Awareness of the varying presentations, locations throughout the gastrointestinal tract, and underlying etiologies of pediatric volvulus is necessary to aid timely diagnosis of this critical condition. Familiarity of the classic findings of malrotation and volvulus on fluoroscopy, ultrasound, and computed tomography will assist in reaching the correct diagnosis.

Poster #: EDU-052 The Menacing Meckel’s Diverticulum Matthew Christy, MD, Washington University, St. Louis, MO, [email protected]; Rebecca Hulett Bowling, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: After viewing this exhibit, the reader will be more familiar with the findings of Meckel’s diverticulum and be better equipped to make the diagnosis prospectively. Meckel’s diverticulum is the most common congenital abnormality of the small intestine occurring in 2-4% of the population. Due to the varied presentation it can be a diagnostic challenge. In this educational electronic poster we will discuss the embryology of the Meckel’s diverticulum and the various presentations of its subsequent complications. To demonstrate the various imaging findings we have a series of cases in the pediatric age group which include surgical and gross pathological correlates. Modalities include plain film, ultrasound, CT and nuclear imaging. Presenting symptoms include fussiness, fever, abdominal pain, vomiting, GI bleeding and an ingested wedding ring. Our case presentations include partial and closed -loop small bowel obstruction, free intraperitoneal air, a retained foreign body, findings mimicking perforated appendicitis and periumbilical pain in a patent with malrotation who had previously had an appendectomy and Ladd’s procedure. There is also one case of giant Meckel’s diverticulum.

Poster #: EDU-053 Applications of SPECT/CT in Pediatric Oncology and Infection Michael Gelfand, MD, Department of Radiology, Cincinnati Children’s Hospital, Cincinnati, OH; Susan Sharp, MD, Andrew Trout, MD, Crysta Clements, Bessie Ganim, Nicole Mormile Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To illustrate several applications of SPECT/ CT in pediatric patients with oncologic disease and infection Methods & Materials: From March, 2006 to October, 2014, we have performed 1263 SPECT/CT studies including 750 studies in patients with oncologic disease or possible infectious processes. The first 47 studies were performed using a GE Hawkeye SPECT/CT camera (Waukesha, WI). The remaining 703 studies were performed using a Siemens Symbia 2 SPECT/CT camera (Hoffman Estates, IL). For the Siemens camera, SPECT/CT was acquired using 64 stops at 20-30 sper stop. The SPECT field of view was 38.7 cm in the z-direction, but the CT field of view was reduced to less than 38.7 cm whenever the disease process identified on SPECT and planar imaging permitted a smaller CT volume. Low dose CT was performed at 110 kVp and reference mAs settings varying from 22 to 48 mAs in pediatric patients, depending on body weight. Later in the series, in patients where soft tissue detail was of less concern, the

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reference mAs setting was limited to the minimum for the camera (22 mAs). Radiopharmaceuticals that were used included I-123-MIBG, I-131-MIBG, Na-I-123, Na-I-131, filtered Tc-99m-sulfur colloid, Tc99m-MAA, Y-90-Sirspheres, In-111-octreotide and Tc-99m-HMPAO white blood cells. Results: Studies performed included I-123-MIBG and I-131-MIBG imaging for neuroblastoma and pheochromocytoma (including a small number of post-therapy I-131-MIBG scans), Na-I-123 and Na-I-131 imaging in patients with thyroid cancer, filtered (limited particle size) Tc-99msulfur macroaggregated albumin hepatic arterial perfusion studies prior to Y-90 Sirsphere therapy, Y-90 brehmstrahlung imaging of the liver after Y-90 Sirsphere therapy, In-111-octreotide imaging of neuroendocrine tumors and Tc-99m-HMPAO white blood cells imaging of inflammatory processes. Examples of each application will be presented including technical and clinical information. We have found SPECT/CT to be consistently useful in these applications. Conclusions: SPECT/CT imaging is a useful addition to many imaging studies that use single photon emitting radiopharmaceuticals. Additional applications are limited by the availability of appropriate single photon emitting radiopharmaceuticals.

Poster #: EDU-054 MRI Spectrum of Deep Medullary Vein Anatomy and Pathology in Infants at 1.5T and 3T Mark Sturgill, DO, Radiology, Children’s Hospital Colorado, Denver, CO, [email protected]; Nicholas Stence, MD, David Mirsky, Laura Fenton, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Background The cerebral deep medullary veins (DMV) are an important bridge between the peripheral pial and central subependymal veins. The literature detailing normal MRI anatomy and pathology of DMVs is sparse. Objective Our goals are to demonstrate the normal MRI appearance of DMVs at 1.5T and 3.0T, detail a spectrum of DMV pathology including engorgement, thrombosis, ischemia, hemorrhage, and adjacent white matter injury/volume loss as well as correlate imaging findings with demographics and co-morbidities. Methods & Materials: Materials and methods Following IRB approval, the electronic case file was searched from 2004-2014 for infants with DMV abnormalities. Maternal and fetal demographics and comorbidities were collected from the electronic medical record (EPIC). All neuroimaging was reviewed. A normal comparison group of 25 infants was evaluated. Results: Results 12 infants (10 male) with abnormal DMVs were identified ranging in age from 1 day to 78 days at time of first MRI (9 imaged in the first week). The majority (9/12, 75%) were born at term. Seven (58%) were born via C-section. Average birth weight was 2.57 kg. One infant had complex congenital heart disease and 3 had thrombophilia. The mean maternal age was 28 years (range 16-44). One mother had preeclampsia and one factor V deficiency. All infants had engorged/thrombosed DMVs, more conspicuous at 3T MR imaging, especially susceptibility weighted imaging (SWI), compared to 1.5T. 7/12 (58%) had associated hemorrhage (five parenchymal, four intra-ventricular, three extra-axial; three had hemorrhage at more than one site). 6/12 (50%) had restricted diffusion (five cerebral hemisphere and one thalamic). Right sided frontal predominance of DMV associated abnormalities were noted in 6, followed by diffuse bilateral pattern in 5 and isolated left side in 1. There was coexistent deep venous sinus thrombosis in 2/12. Follow up imaging in 7/12 showed

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periventricular white matter volume loss in 88%. In the two infants without volume loss, DMV engorgement rather than thrombosis was favored. Conclusions: There is increased conspicuity of both normal and pathologically engorged or thrombosed DMV’s on 3T imaging compared to 1.5T. DMV engorgement/thrombosis may be associated with ischemia, hemorrhage, deep venous sinus thrombosis and less often a solitary finding of transient engorgement. There is a continuum between transient engorgement to thrombosis with periventricular white matter injury, the latter is evident on follow up imaging.

Poster #: EDU-055 Who Knows the Pediatric Nose? Rachel Griggs, MD, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Priya Sharma, MD, Mark Escudero, Skorn Ponrartana, MD, MPH Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives: To review embryology, pathology and associated imaging findings regarding the pediatric nose. Methods & Materials: Background: Pathology of the pediatric nose is not entirely common. Yet, when pathology is suspected, assistance from the pediatric radiologist is frequently requested. Many pathologic entities of the nose are associated with nonspecific clinical features, but have pathognomonic imaging findings, making the radiologist indispensable in the evaluation of these entities. In addition, an observant and descriptive radiologist may also be of assistance in guiding surgical approach and therapy. Pediatric radiologists who are familiar with and cognisant of nasal pathology can also identify clinically unsuspected nasal pathology as a cause of nonspecific symptoms such as respiratory distress. For these reasons the pediatric radiologist should be familiar with the imaging findings associated with pathologic entities affecting the nasal cavity, nasal bones, nasopharynx, and nasofrontal region. Results: Imaging Findings: We review the basic embryology of the nose followed by a presention of the following cases:nasal glioma, nasal dermoid, frontonasal encephalocele, nasal septal perforation, piriform aperature stenosis, choanal atresia, frontonasal dysplasia, nasal polyposis, esthesioneuroblastoma, sinonasal primitive neuroectodermal tumor, juvenile nasal angiofibroma, and nasopharyngeal synovial sarcoma. We describe the classic imaging findings and briefly review the pathologic entities. Conclusions: While pediatric nasal pathology is not frequently encountered, a pediatric radiologist who is cognisant of and familiar with the imaging features of nasal pathology can play a key role in the diagnosis and managment of these entities.

Poster #: EDU-056 Circling the Globe: A Review of Pediatric Orbital Pathology Priya Sharma, MD, Pediatric Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Rachel Griggs, MD, Mark Escudero, Skorn Ponrartana, MD, MPH Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives: This educational exhibit will review a variety of pediatric orbital pathology through discussion of the epidemiology, clinical manifestations and specific multimodality

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imaging findings as seen on computed tomography (CT) and magnetic resonance imaging (MRI). Methods & Materials: Background: There are a variety of congenital and acquired conditions of the pediatric orbit that can have a significant impact on morbidity and mortality if left too long unrecognized. While recognition of these orbital pathologies is often times based on history and clinical examination, the pediatric radiologist can play a significant role in facilitating prompt diagnosis and treatment. Characteristic imaging findings on CT and MRI allow for non-invasive evaluation of orbital lesions as well as precise anatomical delineation. This education exhibit will review congenital globe abnormalities, ocular and orbital tumors, as well as inflammatory and infectious processes of the pediatric orbit. Results: Imaging Findings: The following categories of pediatric orbital pathologies and their specific disease processes will be illustrated: Congenital Globe abnormalities: Congenital glaucoma Morning Glory Disk Drusen Anopthalmos Persistent Hyperplastic Primary Vitreous Coat’s Disease Coloboma Staphyloma Ocular tumors Retinoblastoma Medulloepithelioma Retinal Astrocytic Hamartoma Ocular melanoma of the iris Metastatic tumors: ALL relapse to the iris Orbital Tumors Orbital dermoid cyst Eyelid and periorbital hemangiomas Orbital malformation Retrobulbar Yolk Sac Tumor Optic nerve glioma Inflammatory/Infectious involving the orbit Dacrocystocele and dacrocystitis Orbital cellulitis with subperiosteal abscess Orbital pseudotumor Orbital Langerhans cell Histiocytosis Conclusions: There is a large spectrum of orbital pathology found in the pediatric population which can present with various clinical and imaging manifestations. Knowledge of the typical imaging appearance and key features of these lesions will assist the pediatric radiologist in providing important diagnostic information to referring clinicians, and lead to timely referral to eye specialists to prevent vision loss or metastatic spread of tumor/infection.

Poster #: EDU-057 Pediatric Vasculitis: The Role of the Radiologist Through Case Review Tammam Beydoun, DO, Radiology, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Tuan Dao, MD, Mittun Patel, MD, David Aria, MD, Richard Towbin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Vasculitis is a broad term covering a wide range of entities involving inflammation of the vascular wall. Our aim is to revisit the imaging appearance of vasculitis in the pediatric population. In the same breath we evaluate the role of the radiologist in aiding the diagnosis of vasculitides by presenting an overview of pediatric

vasculitis with an emphasis on imaging through multiple cases and modalities. Methods & Materials: Cases were obtained by search of the radiologic database over the last 14 years. This was followed by a retrospective review with correlative and updated clinical findings. Results: Case representations of the different vasculitides were collected and organized based on the Chapel Hill classification. Many cases initially presented to the radiology department without diagnosis or a working diagnosis on prospective read. When available, multiple imaging modalities are presented with their respective supporting role. In most cases there is overlap in findings and, when possible, distinguishing features are discussed. Conclusions: Radiologists play a critical role in the diagnosis and management of vasculitis through imaging and intervention within a multidisciplinary approach. Although at times the specific diagnosis is radiologically elusive, it is often sufficient to suggest vasculitis as a working diagnosis. This is especially important in cases that present de novo, where recognition of the subtle, and not so subtle, imaging features can narrow the teams focus and effectively expedite treatment.

Poster #: EDU-058 - Withdrawn Poster #: EDU-059 Abdominal Cocoon Syndrome in Pediatric Oncology Patients; Looking for the “Invisible” Sac Atsuko Fujikawa, Radiology, National Center for Child Health and Development, Kawasaki, Japan, [email protected]; Osamu Miyazaki, Kimikazu Matsumoto, Kentaro Matsuoka, Yutaka Kanamori, Shunsuke Nosaka Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Abdominal cocoon syndrome is a rare disease, which causes recurrent attacks of small bowel obstruction (SBO), and is usually difficult to diagnose with certainty before surgical intervention. Many cases have been reported in the literature. Although it occurs at any age and in various contexts, there has to our knowledge been no prior report in pediatric oncology patients. We encountered three pediatric cases with abdominal cocoon associated with a malignant neoplasm. The purpose of this presentation is to review the findings on imaging of the abdominal cocoon and to inform other pediatric radiologists so that they can identify the condition in similar pediatric oncology patients Methods & Materials: We retrospectively reviewed imaging findings and clinical information in three cases with abdominal cocoon confirmed at surgery performed at the National Children’s Hospital in Tokyo between 2012 and 2014. Contrasting information in the literature and our cases, we considered ways of making a definitive diagnosis before surgery. Results: The characteristics of patients were as follows. Case 1: a 2-yearold boy undergoing chemotherapy for neuroblastoma, and who underwent a laparotomy and biopsy 8 months before SBO developed; Case 2: a 3-year-old girl who had a history of advanced rhabdomyosarcoma with widespread peritoneal dissemination, treated with multimodal therapy. SBO occurred 6 months after surgery; Case 3: a 4-year-old girl treated for advanced neuroblastoma. SBO occurred 1 year after surgery, following neoadjuvant chemotherapy. The tentative CT diagnosis was postoperative small bowel obstruction in all cases. All patients underwent surgical treatment as symptoms did not improve with conservative management, and diagnosis of abdominal cocoon was established based on the intraoperative finding of a fibrous sac encasing the small bowel.

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We retrospectively reviewed all CT images after surgical confirmation, and findings were suggestive of abdominal cocoon: dilated loops of small bowel gathered in clusters, the edges of which had sharp margins, and absence of mesenteric strangulation. These findings represented the presence of the membranous sac of the cocoon, as the real membrane is invisible on CT imaging. Conclusions: To make a definitive diagnosis of abdominal cocoon syndrome, it is important to identify the presence of the cocoon membrane, whether it is visible or not. Equally important is to be aware that abdominal cocoon occurs in pediatric oncology patients.

Poster #: EDU-060 Central Nervous System Imaging after Bone Marrow Transplantation in Children: A Review of Complications with an Emphasis on History and Engraftment Status Jonathan Wood, MD, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, [email protected]; Christopher Dandoy, Luke Linscott Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Bone marrow transplantation (BMT) is a frequently used procedure to restore a patient’s bone marrow after treatment for a wide range of pediatric malignancies and inherited immunologic or hematologic disorders. For imaging professionals, the extremely wide range of possible complications following BMT presents a diagnostic challenge. The usefulness of key clinical information such as time since transplant, neutropenia, and engraftment status are emphasized to help develop an appropriate differential diagnosis. Methods & Materials: Our PACS was queried for CT and MRI examinations of the CNS in patients with history of bone marrow transplants from January, 2004 through September, 2014. The results were recorded and correlated with clinical notes and pathology reports from the electronic medical record. Results: A wide variety of pathology was discovered including infectious (e.g. fungal, viral, and bacterial), vascular (e.g. vasculitis and PRES), metabolic (e.g. Wernicke encephalopathy and osmotic demyelination), drug-induced (Methotrexate encephalopathy), and neoplastic (e.g. PTLD and primary brain tumors) complications. These results were correlated with symptoms and time from engraftment. Conclusions: It is essential that imaging professionals understand the role of clinical history and time from engraftment in developing a differential diagnosis. This educational exhibit is designed to help the imaging professional combine key imaging and clinical features to allow a confident approach to the differential diagnosis in children who have received a bone marrow transplant.

Poster #: EDU-061 Withdrawn Poster #: EDU-062 Don’t Stumble on the Metatarsal Base of the Pinky Toe; Recognize the Variants and Diagnose the Fractures S a r a L a y, M D , I n d i a n a U n i v e r s i t y, I n d i a n a p o l i s , I N , [email protected]; George Gantsoudes, Boaz Karmazyn, MD

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To illustrate the common anatomical variations that can mimic pathology and guide how to diagnose the different types of fractures at the base of the fifth metatarsal. Methods & Materials: From the teaching file and radiology information system we will collect radiographs with normal anatomic variation and variety of fractures at the base of the fifth metatarsal. Results: Presents the anatomy of the three zones of the base of the fifth metatarsal, examples of the apophysis from appearance to fusion, Os Vesalianum, accessory ossicles and Iselin’s apophysitis. We will also show different types of fractures (tuberosity avulsion, Jones, and stress fracture) and review the treatment of each of them. Conclusions: There are unique normal variations in the immature base of the fifth metatarsal that can mimic a fracture. Correct recognition and classification of the fractures direct optimal treatment.

Poster #: EDU-063 The Value of Ultrasound Evaluation of the Right Lower Quadrant for Acute Appendicitis Outside of the Academic Children’s Hospital: Don’t Let it Become a Throwaway Exam Cory Pfeifer, MD, Diagnostic Radiology, University of Kansas-Wichita, Wichita, KS, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this study is to investigate and evaluate the factors which limit the role of ultrasound in diagnosing acute appendicitis as well as to evaluate the usage of the right lower quadrant ultrasound itself in the diagnosis of acute appendicitis in a community hospital. Methods & Materials: A retrospective review of all focused right lower quadrant ultrasound exams ordered from the emergency department between January 1, 2014 and March 31, 2014 was undertaken. The examinations were compared with respect to sonographer experience, time spent scanning the patient, patient age, shift in which the exam was performed, final diagnosis, follow-up testing, and whether or not a radiologist participated in the scan. Results: Of the 42 cases reviewed, a normal or abnormal appendix was seen in only 19% of the cases which is well below that reported in the larger multicenter study by Mittal et al. A final diagnosis of acute appendicitis was rendered in 5 (12%) of the cases, all of which were also suggested by the ultrasonographic findings. A striking difference in scanning practices were noted in which sonographers with greater than 25 years of experience spent an average of 11.3 min scanning the patient while sonographers with less than 2 years of experience spent an average of only 2.9 min scanning the patient. A follow-up CT scan was obtained in only 6 (14%) of the cases with CT confirming the positive ultrasound findings in 2 of these cases, detecting appendicitis in the setting of an equivocal ultrasound in 1 case, and providing a negative result in the remaining 3 cases, all of which were equivocal by ultrasound. In 30 cases (71%), the patient was discharged following an equivocal ultrasound result without further imaging or surgical consultation. Patient age and involvement of the radiologist were not significant contributors. Conclusions: In this retrospective study, glaring differences in the amount of time spent scanning the patient based on sonographer experience were uncovered which undoubtedly had an effect on the sensitivity of ultrasound at our institution and subsequent confidence of our clinicians. Furthermore, an overwhelming majority of patients for which the right lower quadrant ultrasound was ordered were discharged based on equivocal ultrasound findings which may suggest that emergency providers are ordering ultrasounds even when pretest probability is low.

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Poster #: EDU-064 A Stitch in Time Saves Radiation Exposure: Scoliosis Radiographs With Stitching Artifact Result in Distortion of Anatomy Necessitating Further Imaging Studies; A Quality Improvement Project Kathryn Henault, MD, Connecticut Children’s Medical Center, Hartford, CT; Michael Baldwin, Mark Lee, Jenna Downes Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Scoliosis is an osseous abnormality which requires routine monitoring involving separate exposures of the thoracic and lumbosacral spine that are then stitched together through a computer software program. Errors in this process can result in diagnostic inaccuracies that ultimately cause additional unwarranted medical intervention. At Connecticut Children’s Medical Center (CCMC), one such incident occurred. A scoliosis film revealed a small, irregularly shaped T10 vertebral body, and the subsequent MRI showed it to be completely normal. Scrutiny of the initial spinal radiograph revealed a blurry stitch line present along the superior border of the T10 vertebral body causing anatomical distortion. Methods & Materials: At CCMC, inconstancies and technical procedural errors were resulting in inadequately stitched films. The observed consequences included misaligned anatomy, a blurry horizontal white line across the width of the radiograph, or exposure differences between the separate films resulting in anatomy distortion. The educational quality improvement intervention emphasized the importance of using the ruler/teeth to guide film alignment, making sure the breast plates were not covering the spine or markers, double checking the cassettes before each study to ensure proper alignment, choosing correct exposure settings for individual films, and dealing with mechanical processing problems. Results: The sample size for the pre-educational data was 141 films, 11 (7.8%) had stitching errors with anatomical distortion. The post-training sample size was 171 films, 20 (11.7%) had errors. A two-proportions test was implemented, calculating a P-value of 0.243 - no significant difference between the two samples. Conclusions: Despite re-training on proper stitching techniques, the number of errors did not change significantly. This indicates that perhaps the issue was not necessarily an educational one, but rather a ‘systems-based problem’. Future considerations will include examination of the following: Is there enough time allotted for each exam to allow technicians to reprocess the films if errors occur? By the time the technicians realize they need to repeat an exposure, is the patient still in the department? If the suboptimal study makes it to the PACS system without intervention, are radiologists notifying the technicians and asking them to reprocess it? These are all processes within the system that need to be analyzed to further the quality improvement of scoliosis radiographs at CCMC.

Poster #: EDU-065 Imaging Review of Pediatric Segmental Multicystic Dysplastic Kidney Lillian Lai, MD, T Shawn Sato, University of Iowa Hospitals and Clinics, Iowa City, IA, [email protected]; Yutaka Sato, MD, Simon Kao Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Segmental multicystic dysplastic kidney (MCDK) is also known as partial or focal MCDK and only involves part of the kidney. While total MDCK affecting the entire kidney is a common and well-known renal dysplasia occurring in 1/4300 children, segmental MCDK is a rare subtype occurring in only 4% of MDCK cases. Segmental MCDK has an overall good prognosis, and management is non-surgical as most cases eventually involute. It is important for radiologists to recognize the imaging features of segmental MDCK to give clinicians insight into the expected management and clinical outcome for patients. The purpose of this exhibit is to elucidate the imaging spectrum, associated anomalies, clinical presentation, management, and outcomes of segmental MCDK in children. Methods & Materials: Retrospective chart analysis of several pediatric cases of segmental MCDK at our institution was performed. All patients had ultrasound examinations, three had voiding cystourethrograms, three had renal scintigraphy, and one had computed tomography. Results: A range of unique cases of pediatric segmental MCDK will be presented, including segmental MCDK involving the upper moiety in duplicated collecting systems with associated ureteroceles/hydroureter and vesicoureteral reflux in the lower pole moiety; segmental MCDK as multiple cysts replacing the lower two-thirds of a kidney; and segmental MCDK involving the upper pole of one of the kidneys in cross-fused ectopia. All cases were managed non-surgically, and the three cases with renal scintigraphy showed differing degrees of function loss in the affected kidney. One case with longer clinical followup showed eventual involution. Comparison will be made to literature review of imaging findings of segmental MCDK. We will also discuss the etiology, clinical presentation, management, and outcomes of this entity. Finally, we will highlight key differences between segmental MCDK and the more common total MCDK.

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Conclusions: After reviewing this exhibit, the reader will become familiarized with imaging appearances of segmental MCDK across different modalities and have a good understanding of its expected clinical course and management.

Poster #: EDU-066 Not Your Father’s Lincoln Penny: Xray-Guided Triage and Management of Ingested Foreign Objects in the 21st Century Molly Downey, Oregon Health & Science University, Portland, OR; Sarah Green, Katharine Hopkins, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: While coins have long been the foreign object most frequently ingested by children, ingestions not encountered in past generations are on the rise, and some such ingestions have the potential to cause morbidity or death in a very short period of time. Because early recognition, accurate differentiation, and appropriate triage are key to preventing complications, pediatric radiologists have a critical role. The aim of this educational exhibit is to facilitate their role by reviewing evolving principles of foreign object diagnosis and management. Methods & Materials: Foreign object ingestions from a busy pediatric tertiary referral center serve as illustrative examples from which participants learn distinguishing radiographic features, pitfalls in diagnosis, and potential complications. Endoscopic and surgical correlation is provided when appropriate. Moreover, based on comprehensive literature review, practical algorithms for management and radiographic follow-up are generated and then reinforced by interactive case-based simulations. Results: The following categories of object are discussed: button and cylindrical batteries; rare earth (neodymium) magnets; long or sharp objects; beverage can pull tabs, glass, and other poorly radiopaque objects; illicit drugs; mobile phone subscriber identity module (SIM) cards; and others. Conclusions: Pediatric radiologists play a critical role in prompt diagnosis, effective triage, and appropriate follow-up of foreign object ingestions. This educational exhibit prepares them for that role by providing up-to-date experience in an evolving field.

Poster #: EDU-067 Flaccid Paralysis and the Pediatric Patient: Differentiating Polio-like Viral Myelitis from other Spinal Cord Pathology Rachel Griggs, MD, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Mark Escudero, Priya Sharma, MD, Benita Tamrazi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives: In light of recent outbreaks of polio-like viral myelitis, the aim of this presentation is to familiarize the radiologist with pathologic entities affecting the spinal cord and their typical imaging appearances. Methods & Materials: Background: The United States Centers for Disease Control and Prevention reported outbreaks of suspected polio-like viral myelitis in the states of California and Colorado in the year 2014. The clinical diagnosis of this entity can be challenging; these patients present acutely with similar neurologic deficits, including flaccid paralysis. Imaging may be the key to making or confirming the diagnosis. As polio-like viral myelitis is managed differently than other spinal

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pathologies, such as Guillian Barre and acute disseminated encephalomyelitis, and treating with the wrong therapy can be of detriment to the patient, it is important that the radiologist be able to differentiate these entities. In this exhibit we review the pathology and imaging features associated with polio-like viral myelitis as well as other differential pathologic entities involving the spinal cord. Results: Imaging Findings: Here we present cases of Enterovirus myelitis with a review of imaging findings and discussion of the pathology, clinical presentation, and diagnostic work up. So as to readily distinguish this entity from other spinal cord pathology, we also present cases of other spinal infections, as well as inflammatory and demyelinating diseases of the spinal cord, intramedullary neoplasms, neoplastic leptomeningeal disease, and syringohydromyelia. We discuss the typical imaging findings and pathology related to each of these entities. Conclusions: Conclusion: Polio-like viral myelitis is a rare, but emerging entity. Pediatric radiologists should be familiar with the disease process and should be able to differentiate this entity from other pathologic processes involving the spinal cord presenting with similar symptoms warranting emergent imaging.

Poster #: EDU-068 Potpourri of Pediatric Port Problems Priya Sharma, MD, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Mark Escudero, Rachel Griggs, MD, Chadi Zeinati Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives: This educational exhibit will review the multimodal imaging findings of complications associated with the implantation and use of pediatric chest ports inserted via the subclavian versus the jugular vein approach, as well as discuss therapeutic interventional radiology techniques geared toward preventing these complications. Methods & Materials: Background: The use of chest port-a cath (PAC) devices has allowed for convenient long-term venous access for the administration of cytotoxic medications (chemotherapy or antibiotics), intravenous targeted agents or frequent blood draws. Given the ease of medication delivery, the ability for long term use and decreased infection risks, PACs are sometimes preferred to other forms of central venous access. Pediatric PACs are classically placed via a subclavian vein approach by pediatric surgeons but recently, younger surgeons have adopted the jugular approach. The latter approach has historically been used by interventional radiologists because of the use of image guidance and fewer acute and chronic complications. Although PACs are associated with better quality of life, the use and placement of these devices has not been without complication. In this educational exhibit we will review the imaging findings associated with these complications and the techniques used to alleviate these problems. Results: Imaging Findings: Focusing on the two approaches of PAC placement the following cases will be shown: Early/Short-term complications: Pneumothorax Catheter tip/port malposition Arrhythmia Pocket hematomas Catheter leakage Vein thrombosis Long-term complications Infection Stenosis or occlusion of the host vein Catheter tip thrombosis

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Fibrin sheath formation Pinch off syndrome Catheter fracture, migration and leak Twiddler syndrome Port erosion/Skin breakdown Conclusions: In the pediatric population PACs are still placed by both Surgeons and Interventional Radiologists via different approaches. Despite the success of PACs in providing long-term venous access, complications in both the short and long-term settings do arise. For that reason, it is important for the diagnostic pediatric radiologist to recognize the imaging appearances of the different techniques of port placement and their respective complications. By understanding the interventional radiologist’s role in placement of these ports and management of the complications, the pediatric radiologist will help direct the referring clinician in subsequent steps in management.

Poster #: EDU-069 Problem Solving in MRI: Use of Alternative Contrast Agents Jonathan Loewen, MD, Emory University, Atlanta, GA; Kiery Braithwaite, Sarah Milla, Kelley Marshall, Adina Alazraki Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Conventional gadolinium based contrast agents (GBCAs) are formed when the paramagnetic ion gadolinium is chelated, producing a gadolinium containing macromolecule. GBCAs have become an essential part of modern imaging by improving sensitivity and/or specificity. The purpose of this educational exhibit is to highlight cases in which less conventional FDA-approved MR contrast agents aided in rendering a diagnosis. In particular, the use of gadoxetate (Eovist) in hepatobiliary imaging and gadofosforveset (Ablavar) in intravascular (blood pool) imaging will be presented. Methods & Materials: An IRB-approved retrospective search at a large free-standing pediatric hospital was performed, in order to isolate clinical MR examinations during which either Eovist or Ablavar was used as the solitary GBCA. Representative cases will be provided. Results: Representative cases will be demonstrated. The use of Eovist in focal liver lesion characterization, biliary trauma, and hepatic transplantation will be presented. The use of Ablavar in cardiac and vascular imaging including thoracic outlet syndrome and popliteal artery entrapment syndrome will similarly be highlighted. Conclusions: Non-conventional GBCAs have a valuable role in clinical diagnostic imaging. Knowledge of anatomic bio-distribution of these contrast agents is important, particularly when clinical MR exams are being protocolled.

Poster #: EDU-070 Different Pathological Appearances of the Large Bowel on Ultrasound Ramdas Senasi, MBBS, FRCR, Radiology, Alberta Children’s Hospital, Calgary, AB, Canada, [email protected]; Semmab Haider, Clara L Ortiz-Neira, Meghan McIvor, Samarjeet Bhandal Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We are a tertiary paediatric hospital and our imaging department performs an average of 160 bowel ultrasound studies a year. We would like to demonstrate the various ways in which ultrasound can be useful in the evaluation of the large bowel.

Methods & Materials: The indications for bowel ultrasound in our hospital are for inflammatory bowel disease, infection, cystic fibrosis, vasculitic disorders and other conditions that can manifest as bowel abnormalities. Patient preparation is to not have anything to eat or drink for 6 h. Our technologists usually take 45 min for a complete scan which will include the entire abdomen and bowel. We use an appropriate frequency curvilinear probe for an overall abdominal survey and a high frequency linear probe for detailed bowel visualisation. Large bowel visualisation includes the terminal ileum, ilieocecal valve, cecum and its position, the entire colon and rectum. The large bowel is assessed for bowel wall thickness, architectural appearance, hyperemia , surrounding free fluid, echogenic fat stranding and lymphadenopathy. An assessment of the small bowel is made for general appearances and peristalsis. We looked through our database for cases that were referred for a bowel ultrasound study. We reviewed our cases for educational value and selected those that would be useful to others who regularly perform ultrasound investigations. Results: Among the cases to be presented are ulcerative colitis, Crohn’s disease, cystic fibrosis, infection, vasculitic conditions and laxative abuse. Conclusions: The ultrasound is an effective tool in visualising the various presentations of bowel disorders. Its advantages are is that it is cheap and readily accessible. The disadvantages would include the time required and high degree of operator skills.

Poster #: EDU-071 A - Z Imaging Atlas to Pediatric Seizures: A Compilation of Epileptogenic Entities and What the Radiologist Needs to Know Mark Escudero, Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Priya Sharma, MD, Rachel Griggs, MD, Benita Tamrazi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives: We will provide a systematic review of a multitude of seizure causes and seizure related disorders organized in an alphabetical list. The list of entities will encompass the following broad categories: tumors, metabolic/mitochondrial disorders, congenital malformations, phakomatoses and infectious/inflammatory conditions. Methods & Materials: The wide range of etiologies for seizure development can create a diagnostic dilemma for physicians encountering a patient with the new onset of seizures. This dilemma faces clinicians frequently, as according to the Centers for Disease Control, approximately 1 in 10 Americans will suffer from a seizure at some point in their life. Oftentimes, diagnostic imaging plays a key role in the evaluation of new onset seizures and radiologists need to maintain an understanding of the varied causes of epileptogenesis and their potentially characteristic radiographic appearance. With this educational exhibit, we will systematize a wide selection of seizure etiologies into an alphabetic rubric as a means to provide an easily recognizable and organized guide for a spectrum of seizure causes. Results: Each alphabetically listed entity will include a brief definition and background information pertaining to its epileptogenesis characteristics. Representative imaging examples will supplement each epileptogenic entity’s description. Conclusions: The new onset of seizures is a common clinical presentation encountered by many pediatricians and often invokes diagnostic imaging as a means to discover the underlying cause for the seizure. We provide this wide assortment of epileptogenic entities in an alphabetical list in order to aid and inform interpreting radiologists of the multitude of causes for this diagnostic dilemma.

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Poster #: EDU-072 Neonatal Gastrointestinal Emergency Imaging Pranav Vyas, Amy Ellenbogen, MD, George Washington University, Washington, DC, [email protected]; Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: This is an educational exhibit aimed at educating providers and trainees in identifying neonatal gastrointestinal emergencies. We discuss perforation and obstruction in both the upper and lower gastrointestinal tract, using cases to illustrate the pathogenesis of such diagnoses, appropriate imaging modalities, associated findings, and whether treatment involves surgery or medical management. We also comment on the prevalence of such diagnoses at our institution in the past 9 years. Many of these neonatal gastrointestinal emergencies require immediate intervention and our hope is to better educate providers and trainees to ensure rapid diagnosis and decrease infant morbidity and mortality due to delays in treatment. Methods & Materials: We used the radiology search engine Montage to determine the frequency of certain gastrointestinal emergencies at our institution as well as to obtain some of our images.

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Purpose or Case Report: Torticollis is often encountered in the pediatric population. Although some etiologies of torticollis have pathognomonic imaging findings, others can be somewhat more challenging to diagnose. A pictorial review of the spectrum of pediatric causes of torticollis is demonstrated. Methods & Materials: A retrospective review of our imaging database over a ten year period was performed to identify studies obtained in pediatric patients presenting with torticollis. Various imaging studies such as ultrasound, CT, and MRI were reviewed when available. Medical records were reviewed and radiologic studies were correlated with clinical history and surgical/pathologic correlation when available. Results: A retrospective study over a ten year period demonstrated multiple causes of torticollis elucidated by Ultrasound, MRI, and CT. Etiologies include: foreign body in the hypopharynx, osteomyelitis, fibromatosis colli, lymphoma, rotary subluxation, CNS infection, Grisel’s syndrome, cervical syrinx, spinal cord tumors, Lemierre’s syndrome, lymphadenitis, and retropharyngeal abscesses. Conclusions: Torticollis is a relatively common complaint in infants and young children. Radiologic evaluation - including CT, Ultrasound, MRI, and even Fluoroscopy - can be very helpful in determining the underlying cause of the patient’s twisted neck and in guiding treatment.

Poster #: EDU-074 Lower Gastrointestinal Obstruction Etiologies Over 9 Year Period Diagnosis Frequency (# of patients) Jejunum Jejunal Atresia 156 Ileum Meconium Ileus 122 fs Colonic Atresia 31 Hirschsprung Disease 232 Post-NEC Colonic Stricture 64 Neonatal Small Left Colon 6 Anus Imperforate Anus 338

Poster #: EDU-073 Torticollis: A Pain in the Neck Erin Horsley, DO, Radiology, St. Christopher’s Hospital for Children, Cherry Hill, NJ; Jacqueline Urbine, Mea Mallon, Erica Poletto, Archana Malik, Eric Faerber Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Ultrasound Tutorials in Under 10: Tour of a Comprehensive Curriculum with Assessment for Hands On Ultrasound Skills Susan Back, M.D., Lawrence Blank, Maria Bedoya, MD, Laura Poznick, Janet Reid, MD, FRCPC, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The radiology trainee must master handson skills and knowledge in multiple modalities and body systems. Skills training is acquired through an apprenticeship model of “see one do one” and often there is no adjunctive material to prepare for this. This web-based program was created to optimize the mastery of hands-on Ultrasound (US) skills by trainees in pediatric radiology. Methods & Materials: The top ten US examinations performed at our hospital were identified as: RUQ, renal/bladder, pylorus, hips, brain, intussusception, thyroid, appendicitis, female pelvis and scrotum. A webbased delivery of US educational tutorials was fully vetted in Version 1.0 as the best choice for ease of access at point of care. The program was linked to the hospital learning management system to enable tracking and provide notification. Real time imaging was incorporated to best simulate the clinical setting. Results: The program was created in Storyline (Articulate)® and housed on the Learning Link® learning management system in our hospital. Each module contains a pretest, posttest, tutorial and posttest survey. Tutorials include instruction on study indications, patient preparation, positioning and draping, transducer selection, scanning technique and planes, image acquisition and optimization. Format includes three simultaneous video feeds showing real time images, US console and patient scan. Scrolling text option describes all aspects of the study, with voiceover to further emphasize the proper steps in performing the study. Skills testing can be conducted on models or patients during the daily workflow. Each tutorial can be completed in 10 min or less. The electronic poster will provide a guided tour of the program.

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Conclusions: Through this electronic presentation, the attendee will learn that this web-based US curriculum includes focused high fidelity tutorials for the top 10 pediatric US studies and is available at point-of-care during daily workflow as a highly effective adjunct to pediatric US skills training.

DECT. Indications for DECT in pediatric patients will be discussed with consideration of radiation exposure implications. Issues involving integrating DECT into routine clinical imaging practice will be considered. Imaging from clinical cases will be presented. Results: DECT can be utilized for artifact reduction in pediatric patients with metallic hardware. One study evaluated DECT in children with spinal fusion hardware demonstrating improved image quality and significant artifact reduction. Similar studies in adults have demonstrated artifact reduction and improved image quality without a radiation exposure penalty. A recently presented study on radiation exposure from DECT using pediatric phantoms showed dose neutrality for CT imaging of the head, but a dose penalty for CT imaging of the chest and abdomen in small patients, specifically those younger than 5 years of age. Despite a dose penalty, DECT may be warranted for some indications where DECT can improve image quality by reducing artifacts or offer information not available with routine CT imaging. Conclusions: DECT does not always maintain “dose neutrality” in small children, however DECT has important potential in pediatric imaging. Specifically DECT can benefit in metallic artifact reduction, renal stone evaluation, bone removal for CTAs, and for virtual non-contrast in CT urography, CT cystography and the evaluation of abdominal tumors with suspicion of calcifications.

Poster #: EDU-076 Fetal MRI of Hemimegalencephaly; A Report of 4 Cases Sherelle Laifer-Narin, Rama Ayyala, MD, Columbia University Medical Center, New York, NY, [email protected]

Poster #: EDU-075 Implementation of Dual-Energy Computed Tomography in Pediatric Imaging William McCullough, MD, MBA, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Arastoo Vossough, Kassa Darge, MD, PhD, Xiaowei Zhu, Sabah Servaes Disclosures: William McCullough indicated a relationship with General Electric Corporation as a stockholder. All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The use of dual-energy computed tomography (DECT) for material decomposition was first proposed in the 1970s, but DECT scanners have only been commercially available for clinical use since 2006. Three distinct technologies are used in currently available DECT scanners: sequential acquisition, dual-source dual-energy and fast voltage switching dual-energy. Several specific applications of DECT have been studied in the adult population, to include renal stone composition determination, virtual non-contrast imaging, and the detection of uric acid deposition in the diagnosis of gout. Some of these applications are less appropriate in children, however in certain populations and for some indications, DECT capabilities may benefit the pediatric population. This educational exhibit aims to discuss currently available DECT technology and the implementation of a DECT program for clinical imaging in a pediatric hospital. Methods & Materials: We reviewed the literature regarding DECT in pediatrics and also included our own experience with the Siemens Flash

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Ultrasound is the first line imaging modality for performing a structural survey in the pregnant patient. MRI is utilized as a complementary modality for evaluating questionable/suspicious findings seen on ultrasound. This can be particularly helpful in evaluating the fetal central nervous system, with capability for delineating and diagnosing complex CNS anomalies such as cortical dysplasias. Hemimegaloencephaly is a rare congenital disorder manifesting as enlargement and overdevelopment of one cortical hemisphere with other associated CNS abnormalities. The purpose of this exhibit is to review the prenatal imaging findings of this entity. Methods & Materials: A retrospective review of fetal MRI database was performed to identify patients with prenatal imaging diagnosis of hemimegalalencephaly. A total of four patients were identified and imaging findings were reviewed. All patients underwent MRI on a 1.5T system. MR sequences obtained include single shot fast spin echo T2, gradient echo, T1, and diffusion weighted sequences. Results: Pertinent imaging findings in these patients include cerebral hemispheric asymmetry, midline shift, specifically of the occipital lobe across the midline, and abnormal cortical gyration with either increased or decreased gyri. Additional findings identified include ventriculomegaly and the presence of cortical and subependymal tubers. Conclusions: Major clinical features of hemimegalencephaly include intractable seizures, developmental delay, psychomotor retardation, and progressive hemiparesis. Recognition of this entity is crucial for providing accurate patient counseling and management. Early prenatal diagnosis may alter management with decision to terminate the pregnancy. Alternatively, in a pregnancy carried to term, proper care and treatment can be offered to the neonate in a quick and efficient manner.

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Poster #: EDU-077 Unusual Cancers of Childhood: Rare Abdominopelvic and Thoracic Tumors Mark Bittman, Cohen Children’s Medical Center of New York, NS-LIJ Health System, New Hyde Park, NY, [email protected]; Andrew Doan, Carolyn Fein Levy Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this exhibit is to present the imaging features of rare types of cancer in children and to increase the awareness of uncommon tumors which are encountered in a busy oncologic practice. We present a diverse group of masses in the thorax, abdomen and pelvis with an emphasis on advanced imaging. Each case highlights the imaging features of the neoplasm and describes the correlative clinical and genetic associations. A practical differential diagnosis on the basis of clinical and imaging findings is provided. Rarely encountered mass lesions which mimic malignancy are described. Methods & Materials: We performed a search of the radiology, oncology and pathology databases to find rare types of childhood cancer and cancer mimics which presented to our facility, a tertiary care children’s hospital. Results: We identified many exceedingly rare childhood cancers of the thorax, abdomen and pelvis all with clinical, histologic and imaging correlation. Cases presented in this exhibit include but are not limited to: thymic carcinoma, small cell lung cancer, type III pleuropulmonary blastoma (PPB), pancreatic cancer, colon cancer, gastric schwannoma, abdominal germ cell tumor, desmoplastic small round cell tumor, ectopic choriocarcinoma, and stage IV ovarian germ cell tumor. Conclusions: Childhood cancer is uncommon, however the incidence is increasing. It is important to be aware of the imaging features and clinical associations of both common and rare forms of childhood cancer.

Poster #: EDU-078 A Spectrum of Pediatric Orbital Imaging: A Real Eye Opener Faaiza Kazmi, MD, Radiology, St. Christopher’s Hospital for Children, Cherry Hill, NJ; Mea Mallon, Archana Malik, Jacqueline Urbine, Erica Poletto, Eric Faerber Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Radiologists play a key role in aiding clinicians and patients by providing timely and accurate diagnosis of pediatric orbital conditions leading to prompt and appropriate patient management where indicated. The purpose of this presentation is to retrospectively review the spectrum of orbital pathology that can be seen in the pediatric population and that has presented to our institution. Methods & Materials: We retrospectively identified pediatric patients who presented with orbital conditions. Medical records were reviewed and radiologic studies were correlated with clinical history and surgical findings, and pathological results where indicated. Selectively chosen is an array of conditions affecting the eye consisting of congenital, traumatic, inflammatory and neoplastic etiologies. Results: Pertinent imaging findings as well as clinical, epidemiological, and patient management information will be described regarding each entity. In particular, a pictorial review with key CT and MR imaging features necessary to guide timely and accurate radiological diagnosis are discussed and demonstrated in detail.

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Conclusions: Expeditious diagnosis and reporting of orbital pathology in the pediatric population is imperative to avoid delay in treatment or complications that may potentially lead to functional vision loss or physical deformity.

Poster #: EDU-079 The Many Faces of Neurofibromatosis Type I Judit Machnitz, Resident, Pediatric Radiology, St. Christopher’s Hospital for Children, Cherry Hill, NJ; Jacqueline Urbine, Archana Malik, Erica Poletto, Mea Mallon, Eric Faerber Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Neurofibromatosis Type I (NF-1), also known as von Recklinghausen disease; is the most common inherited phakomatosis, with diverse clinical presentations and radiologic findings. In the absence of a preexisting NF-1 diagnosis, positive family history or typical clinical signs, the diagnosis can be challenging for referring physicians and may not be apparent at the time of initial imaging. This multimodality, pictorial review demonstrates both the typical and less typical findings associated with NF-1. Methods & Materials: We retrospectively identified patients with NF-1 with either known diagnosis of neurofibromatosis or undiagnosed patients with variety of complaints. Medical records were reviewed and correlated with clinical history, radiologic images and, in cases with atypical imaging findings, with pathology results. Results: Our multimodality review illustrated the pathognomonic findings of neurofibromatosis type I; including: plexiform neurofibromatosis, optic pathway glioma, NF bright objects, solitary and multiplex cutaneous and spinal neurofibromas, sphenoid hypoplasia, short segment, and painful scoliosis. Additionally, less common findings related to NF-1 were also discussed, including: solitary intrathoracic/intraabdominal masses, lower extremity bowing, pseudoarthrosis, and lateral meningocele. Conclusions: Neurofibromatosis type I, the most common neurocutaneous syndrome, can present in many ways and can mimic a large variety of disorders. Pediatric radiologists often play a critical role in the early diagnosis of these patients, especially when the clinical picture is atypical.

Poster #: EDU-080 A Radiographic Review of Pediatric Sellar and Parasellar Lesions Amrita Arneja, MD, Radiology, Westchester Medical Center, Valhalla, NY, [email protected]; Priya Krishnarao, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Lesions of sellar and parasellar regions are a common childhood problem. These lesions represent a variety of unique oncologic, congenital, and vascular lesions. They also display vastly different imaging features compared to adult lesions of this region. An understanding of the anatomy, imaging characteristics and differentials of each particular seller and parasellar lesion is vital in making an accurate diagnosis. Methods & Materials: We present a comprehensive review of the anatomy of the region of the sella turcica. We review common and rare pathologies found in this anatomical region. We further discuss a casebased review of the CT and MR findings of pediatric lesions within the

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sellar and parasellar regions, including pituitary adenoma, craniopharyngioma, rathke’s cleft cyst, arachnoid cyst, germinoma, hypothalamic hamartoma, optic chiasm glioma, and metastatic lesions. Results: We provide an educational radiographic review of pediatric sellar and parasellar lesions. We use a multi-modal approach to evaluating each lesion and its extent, utilizing CT, MR ultrasound and PET imaging. We further discuss the important role of the radiologist in initial imaging, diagnosis, follow-up evaluation and evaluation of potential complications. We evaluate key pre-operative imaging findings and post-operative complications. Conclusions: Pediatric sellar and parasellar lesions present unique radiographic features and result in a complicated constellation of findings. The radiologist’s role in accurate diagnosis of these lesions and understanding of their imaging characteristics plays a crucial role in patient care and management.

Poster #: EDU-081 Neuromuscular Disorders: How Radiologists Have Enabled Neurologists to Go Beyond “Diagnose and Adios” Cindy Miller, MD, Yale New Haven Hospital, New Haven, CT, [email protected]; Cynthia Fleming, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: While therapies for neuromuscular diseases are still in their nascent stages, much has been accomplished in terms of categorization of the diseases based on symptomatology, modes of inheritance, and specific defects underlying the disorders. Imaging has allowed for improved distinction based on specific patterns of e.g. white matter involvement as in the leukodystrophies and in merosin deficient congenital muscular dystrophy; additional features such as occipital encephaloceles in a specific type of congenital muscular dystrophy (Walker Warburg); and patterns of involvement of muscles in the various muscular dystrophies as can be distinguished with ultrasound and with MRI. This exhibit will trace the imaging evaluation from the time of plain film when imaging was used essentially to monitor scoliosis which so often accompanies the disorders to the advent of CT when various patterns of hypomyelination were first recognized allowing for distinction between e.g. congenital muscular dystrophy with merosin deficiency and metachromatic leukodystrophy to the introduction of MRI into the imaging armamentarium with the ability to image mitochondrial disorders and to further assess them with MR spectroscopy to the current time when ultrasound and MRI are being utilized to a greater extent not only to document patterns of involvement of muscle in the various muscular dystrophies, but also to monitor response to experimental therapies. Conclusions: A variety of imaging modalities has greatly improved neurologists’ ability to make specific diagnoses; the value of imaging will also be evident as therapies are developed such that there will be evidence beyond merely manual testing to document their efficacy.

Poster #: EDU-082 Interpretation Pitfalls When Imaging a Child For Headaches Lee Nakamura, MD, Pediatric Neuroradiology, Texas Children’s Hospital/Baylor School of Medicine, Houston, TX, [email protected]; Jeremy Jones, Michael Paldino, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Imaging in a child presenting with headaches is often normal. However, imaging correlates for certain well described causes of pediatric headache may be more subtle and, therefore, potentially overlooked. Furthermore, overlap of imaging patterns may result in the potential for misinterpretation. The purpose of this exhibit is to highlight some of the entities where findings are subtle and/or misinterpreted in this population of children with headache. Methods & Materials: The topics to be discussed will include: Inferior cerebellar tonsillar ectopia and its mimics, vascular pathologies, and migraine variants. Specific examples of each disease entity will be provided to illustrate the findings in pediatric headache imaging. Results: For cerebellar tonsillar ectopia we will discuss Chiari 1 and “complex Chiari” malformation. In addition, intracranial hypotension and hypertension will be discussed, as these patients are managed very differently, but can present with headaches and cerebellar tonsillar ectopia. For vascular etiologies of headache we will include Moyamoya and dural venous sinus thrombosis. Headache often accompanies the stroke symptoms in patient’s with undiagnosed Moyamoya, which emphasizes the important of evaluating the Circle of Willis on routine imaging. In addition, dural venous sinus thrombosis can easily be missed on routine CT head imaging. For migraine variants, there are specific imaging findings in hemiplegic and ophthalmoplegic migraine which will be discussed and illustrated. Conclusions: This educational exhibit will highlight important disease entities to be aware of when assessing a child presenting with headaches. The knowledge and awareness of what to look for will hopefully aid in accurate diagnoses and appropriate clinical management.

Poster #: EDU-083 Imaging of Pediatric Spinal Abnormalities: Solving the Puzzle Faaiza Kazmi, MD, Radiology, St. Christopher’s Hospital for Children, Cherry Hill, NJ; Archana Malik, Erica Poletto, Mea Mallon, Jacqueline Urbine, Eric Faerber Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Approaching the intricate realm of pediatric spinal anomalies may seem daunting at first. A solid systematic framework forming the basis of knowledge regarding these complex entities, however, can increase understanding of and ease the difficulty in accurate diagnosis, allowing the radiologist to play a vital role in aiding clinicians in appropriate care. The purpose of this presentation is to provide an educational review of a broad spectrum of pediatric spinal abnormalities that have presented to our institution. Methods & Materials: We retrospectively identified pediatric patients who presented with spinal abnormalities. Medical records were reviewed and radiologic studies were correlated with clinical history, surgical findings, and pathological results where indicated. The specific cases selected for this pictorial review include an array of spinal anomalies spanning from normal variants to closed neural tube defects as well as open neural tube defects, and spinal masses. Multimodality spinal imaging with strong emphasis on sonography and MRI, both prenatal and postnatal, is displayed. Results: Key imaging and anatomic features pertaining to each of the spinal abnormalities discussed in this pictorial essay are demonstrated in detail including relevant facts and pertinent negatives to focus on the most precise interpretation. Common pitfalls in differentiating the wide, complicated range of pediatric spinal normal variants from pathologic conditions are addressed with the advanced tools at hand for the radiologist, in particular focusing on advancements in sonography and MR imaging techniques.

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Conclusions: The complexity and variety of congenital malformations affecting the spine and spinal cord can be challenging. An organized approach to radiologic evaluation, however, leads to accurate diagnosis and characterization of pediatric spinal abnormalities guiding appropriate and timely therapeutic intervention.

Poster #: EDU-084 Imaging of Fetal Brain at 3 T: Our Experience Sw at i Mo dy, MD , Way ne St at e Un iv er sit y, Det roi t, MI , [email protected]; Jaladhar Neelavalli, PhD, Ewart Haacke, Sonia Hassan, Roberto Romero Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this educational exhibit is to present our early experiences with imaging of fetal brain on 3 T magnet. Magnetic Resonance Imaging (MRI) is increasingly used for prenatal diagnosis over the last three decades. Traditional fetal MR imaging is performed on 1.5 Tesla (T) magnets although reports of fetal imaging at 3 Tesla (T) are slowly increasing. Imaging at 3 T has advantages including improved signal to noise ratio (SNR) and, as a result, improved resolution and shorter imaging time. This also improves MR Spectroscopy and BOLD (Blood Oxygen Level Dependent) Imaging. However, there are drawbacks to imaging at 3 T including increased susceptibility artifacts and most importantly, increase in radiofrequency energy deposition in tissue measured as SAR (Specific Absorption Rate). We have scanned more than 80 pregnant subjects on a 3 T Siemens Verio system as part of an ongoing research study. Fetal brain and in some cases fetal body as well were imaged using the following sequences: T2 weighted single shot fast spin echo (SSFSE) sequence, T1 weighted spoiled gradient (SPGR) sequences, Diffusion weighted imaging (DWI) and Susceptibility Weighted Imaging (SWI). MR angiography sequences were also applied in some cases. Sequences were adapted and modified for fast imaging and to reflect changing relaxation times of the tissue. High resolution imaging of the brain, compared to conventional 1.5 T scan parameters was possible using these modified sequences. These sequences had a maximum average whole body specific absorption rate (SAR) value of <1.5 W/Kg, as measured by the MRI system. All data was reviewed by an experienced pediatric neuroradiologist. Diagnostic images of the fetal brain could be obtained on 3 T with improved SNR. However, there was an increase in susceptibility and B1 inhomogeneity related artifacts. These could be avoided with appropriate repositioning of the patient and the coils and in some cases subject-specific changes in sequence parameters. Conclusions: Diagnostic imaging of the fetal brain can be performed on 3 T with lower SAR values and improved image quality.

Poster #: EDU-085 Danger as Cute as a Button: Radiographic Findings of Ingested Button Batteries Swetha Dasari, MD, Radiology, Westchester Medical Center, Valhalla, NY, [email protected]; Angela Tong, Lauren Ostry, Jeffrey Gnerre, MD, Adele Brudnicki, Leslie LeCompte Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Button battery ingestion is unfortunately an all too common problem in the pediatric population. Unlike other foreign bodies, swallowed button batteries are capable of producing much more serious and even life threatening adverse effects. This occurs for several

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reasons including leakage of battery contents causing erosive damage, electrical currents causing mucosal burns, and pressure necrosis from prolonged stasis of the battery in one location. Complications of ingestion range from mild esophagitis to perforation to fistulas. Early diagnosis of the complications is imperative and can significantly decrease morbidity and mortality. In this educational exhibit, we will utilize several cases of battery ingestion to illustrate the relevant radiographic findings that should be reported in every such case. Methods & Materials: Literature review and review of cases from our institution. Results: In this educational exhibit, we will utilize several cases of battery ingestion to illustrate the relevant radiographic findings that should be reported in every such case. For example, careful evaluation of the battery for signs of erosion is crucial. Erosion can manifest as irregular lucencies along the edge and face of the battery, and may indicate the possibility of leakage of battery contents. Additionally, the surrounding structures should be carefully assessed. For example, a decrease in the caliber of the trachea can indicate either direct compression or edema from erosive changes. Pneumomediastinum or pneumoperitoneum may suggest perforation of the GI tract. We also discuss radiographic findings that should be sought in follow-up examinations performed after battery removal. These include leakage of contrast from a site of previous coin impaction suggestive of fistula or perforation. Additionally, irregularity of the bowel wall may be identified, indicating the development of erosive esophagitis. Conclusions: After reviewing this exhibit, the reader should have a better understanding of the radiographic findings associated with button battery ingestion and consequently be better able to communicate the relevant information to the referring physician.

Poster #: EDU-086 Volvulus in Infants and Children: Unraveling the Twist Faaiza Kazmi, MD, Radiology, St. Christopher’s Hospital for Children, Cherry Hill, NJ; Mea Mallon, Jacqueline Urbine, Erica Poletto, Archana Malik, Eric Faerber Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Volvulus of various organs is frequently encountered in infants and children. Radiologists play a key role in the prompt, accurate diagnosis in these clinical settings, obviating significant morbidity and mortality. Methods & Materials: We retrospectively identified pediatric patients who presented with assorted organs that can twist and risk ischemia. Medical Records were reviewed and radiologic studies were correlated with clinical history, surgical findings, and pathological results where indicated. Selectively chosen is a wide range of conditions consisting of torsed organs and their associated complications. Results: Key imaging and anatomic features across multiple modalities including plain radiographs, ultrasound, CT and MRI are demonstrated in detail as they pertain to each of the cases of volvulus depicted in this pictorial essay. The conditions discussed include mesoaxial gastric volvulus, small bowel volvulus, cecal volvulus, cecal bascule volvulus, sigmoid volvulus, epiploic appendagitis, splenic torsion, ovarian torsion, testicular torsion, and torsion of the appendix testis in the pediatric population at our institution. Conclusions: Rapid, accurate diagnosis of volvulus in an involved organ is crucial for appropriate surgical intervention in order to obviate complications such as ischemia and loss of a torsed organ, or mortality. The radiologists play a vital role in aiding clinicians for providing optimal care and management.

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Poster #: EDU-087 Spleen Behind the Heart Complicates Lung-to-Head Ratio Measurement in Left-Sided Congenital Diaphragmatic Hernia Amaya Basta, MD, Diagnostic Radiology, Oregon Health & Science University, Portland, OR, [email protected]; Leslie Lusk, Roberta Keller, Roy Filly Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: In fetuses with left-sided congenital diaphragmatic hernia, intrathoracic herniation of the spleen is a common occurrence. The herniated spleen can reside posterior to the left atrium of the heart in the right hemithorax and is increasingly differentiated from lung with the use of newer sonographic equipment. Estimation of neonatal prognosis relies on accurate measurement of fetal lung size, particularly with commonly used measurements such as the lung-to-head ratio (LHR). Here we describe how herniation of the spleen behind the heart can complicate the measurement of the LHR on sonography and lead to overestimation, with implications for perinatal prognostication and management.

5. Provide clinical correlation including pathological and surgical findings, and the patients’ neurologic status. Methods & Materials: Using a third-party PACS-linked search engine, MR spine studies were queried using keywords such as thoracic dysraphism, myelocele, myelocystocele, lipomyelomeningocle, etc. The resultant cases were reviewed by pediatric radiologists, and representative images were selected for this exhibit. Reviews of the available pathology, operative reports and clinical notes were performed. A robust current literature review on cervicothoracic dysraphism was carried out simultaneously. Results: Eight patients were identified with spina bifida cystica of the cervicothoracic region and are outlined in the supplemental table. Conclusions: Dysraphism of the cervicothoracic region is very rare, but does occur. It differs from the much more common lumbosacral dysraphism in appearance and structure, and usually portends a better prognosis due to absent or less severe intracranial anomalies. We present cases from our own experience and suggest classification based on the description of structures within the herniated sac and association with Chiari II malformation. Such an approach may serve as a useful guide to the surgical and clinical management algorithms in these rare and complex cases.

Findings

Brain

Relevant Associations

1 Cervical Meningocele with Stalk Normal Reported versus remeasured LHR and neonatal outcomes of fetuses with left CDH and spleen behind the heart Patient

Gestational

Reported

Remeasured

no.

age

LHR

LHR

*

at US

(includes

(excludes

spleen)

spleen)

Survival

Pulmonary

Prolonged

Home

hypertension†

ventilation‡

oxygen

**

ECMO

1

34 5/7

1.9-2.0

1.2-1.28

Survived

No

No

No

No

2

37

1.8-1.9

0.87-0.94

Survived

No

Yes

Yes

No

3

35 4/7

1.6-1.7

0.95-1.07

Died

Yes

Yes

n/a

n/a

4

29 2/7

1.2

0.95

Died

No

Yes

n/a

n/a

5

27 4/7

0.9-1.4

0.61-0.65

Died

Yes

Yes

n/a

n/a

6

19 4/7

0.9

0.4-0.47

Died

Yes

Yes

n/a

n/a

7

23 6/7

0.7-0.9

0.51

Survived

No

Yes

Yes

Yes

8

21 2/7

0.7

0.34-0.39

Survived

No

Yes

Yes

No

*

Refers to the first sonogram that the herniation of the spleen posterior to the heart was evident ** ECMO: extracorporeal membrane oxygenation † Pulmonary hypertension persisting greater than 2 weeks ‡ Ventilation greater than 2 weeks

Poster #: EDU-088 A Rare Opening: Cervicothoracic Spinal Cystic Dysraphism Natalie Valeur, University of Washington Medical Center, Seattle, WA, [email protected]; Ramesh Iyer, Gisele Ishak Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 1. Review normal embryology of the spine and proposed etiology of cervicothoracic cystic dysraphism. 2. Describe the imaging features of cervical and upper thoracic cystic dysraphism. 3. Explain the challenges of classification of this entity and propose a classification based on dysraphic sac contents. 4. Describe the associated intracranial findings.

2 Cervical Meningocele with Stalk Normal 3 Thoracic Meningocele with Stalk Chiari Malformation 4 Cervical Lipomyelocele

Normal

Poster #: EDU-089 Imaging of the Ductus Arteriosus: Review of Normal Anatomy, Variants and Clinical Implications Erin Opfer, DO, Children’s Mercy Hospital, Kansas City, MO; Sanket Shah, Joshua Knowlton Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Familiarity with the anatomy of the ductus arteriosus (DA) and flow pattern is important because of its relevance in perinatal life and cardiac surgeries. Frequently, as an isolated lesion, a patent DA requires occlusion in the postnatal life due to left ventricular volume load and potential for pulmonary hypertension. Also common is the need for pharmacological or catheter based methods to preserve the patency of the DA in the presence of congenital heart diseases like pulmonary atresia, interrupted aortic arch, hypoplastic left heart syndrome and others. It is more important for physicians interpreting the results of computed tomographic (CT)/MRI examinations dedicated to the heart to be able to identify normal variants and associated congenital anomalies, as well as to understand their clinical importance. Abnormalities of the DA range from numerical and morphologic variations to clinically significant anomalies. It can be important to identify these variations, to ensure appropriate preprocedural planning. Echocardiography, CT and magnetic resonance imaging provide excellent noninvasive depiction of the anatomy and anomalies of the DA. We review the normal anatomy, embryology and physiological of the DA. We will discuss and illustrate the CT and MR appearance of several clinically significant variations of the DA and discuss anomalies of the DA in terms of number, site, shape, course and size. Additionally, we will suggest techniques for CT and MR imaging of the DA with emphasis on their hemodynamic significance and importance in pre-procedural planning.

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Poster #: EDU-090 Imaging Marrow Involvement in Gaucher Disease: MRI, Fat Fraction, and Bone Marrow Burden Alison Sheridan, MD, Diagnostic Imaging, Yale School of Medicine, Hamden, CT, [email protected]; Andrew Lischuk Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Gaucher disease is the most prevalent inherited lysosomal storage disease and is characterized by multi-organ system complications. Effects of this disease process on the skeletal system are the least understood of all organ involvement but are the most disabling. The purpose of this presentation is to illustrate and review the role of MRI in the characterization of skeletal complications, measurement of disease burden and progression, and assessment of response to therapy for Gaucher disease. Methods & Materials: Based on a review of cases at our institution, we present a pictorial essay of the spectrum of acquired bone marrow and skeletal abnormalities in Gaucher disease, highlighting the effectiveness of MRI. Particular focus is made on the utility of quantitative and semiquantitative methods for objective disease assessment and monitoring. Results: Representative cases of osseous involvement in Gaucher disease are presented, including osteonecrosis, avascular necrosis, infection, hemorrhage and infarction. The spectrum of MRI findings of axial marrow infiltration and associated complications are shown in detail. The importance of fat fraction measurement and its utility in disease surveillance is highlighted with exemplative cases. Conclusions: Teaching points: 1) MRI is exquisitely sensitive in the evaluation of patient’s with Gaucher’s disease to monitor disease extent, complications, and response to therapy. 2) Quantitative and semi-quantitative techniques allow for objective monitoring of disease and future monitoring of enzyme replacement therapy.

Poster #: EDU-091 A Multi-modality Review of Normal Abdominal Anatomy in Situs Anomalies Michele Edison, MD, Matthew O’Dell, MD, MPH, Diagnostic Radiology, Florida Hospital, Maitland, FL; Dzmitry Fursevich, MD, Laura Varich Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Situs inversus and situs ambiguous (heterotaxia) have been thoroughly described in the literature. In clinical practice, the situs “variants” can create diagnostic problems when the radiologist or clinician doesn’t understand the “new normal” that these conditions create. This can pose several diagnostic questions. What is a normal duodenal sweep on upper GI? How does acute cholecystitis or appendicitis present, and where are these structures located? Where should the SMA and SMV be on abdominal ultrasound? What about the pancreatic head and hepatobiliary tree? We will illustrate the “new normal” in patients on the situs inversus spectrum. Methods & Materials: The authors have collected a series of cases with multiple modalities to help describe the “new normal” anatomy in patients with situs variants. We performed a literature review to further describe clinical dilemnas that situs anomalies can create.

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Results: Situs anomalies represent a spectrum of anatomical variants. Situs inversus patients typically have mirror-image anatomy, therefore, the normal upper GI and barium enema would appear as horizontally inverted images. The appendix would be located in the left lower quadrant; the sigmoid colon in the right lower quadrant. Acute pathology with the gallbladder and biliary tree would create left upper quadrant pain. Heterotaxy syndromes will sometimes create significant abnormalities with the IVC and spleen, which could become critical information for the interventionalist to know. Conclusions: The situs spectrum represents a group of normal anatomical variants and mutations that can create many clinical and diagnostic dilemnas if the radiologist isn’t able to “think backwards.”

Poster #: EDU-092 Adrenocortical Carcinoma In Children: Imaging Of A Rare Adrenal Tumour And Experiences In The Role Of Fludeoxyglucose Positron Emission Tomography (FDG-PET CT) In Staging and Follow Up Thomas Savage, FRCR, Dept of Radiology, BC Children’s Hospital, Vancouver, BC, Canada, [email protected]; Helen Nadel, MD FRCPC Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: While the investigation of adrenal masses is a relatively common problem in the pediatric population the incidence of Adrenocortical Carcinoma (ACC) as a cause is rare. The incidence of ACC varies with age but is quoted as between 0.1 and 0.4 per million in children younger than 15 years. A higher incidence is reported in a region of Brazil (3.4-4.2 per million), related to a specific germline mutation, as well as in other genetic syndromes. The low incidence of pediatric ACC and an intrinsic high mortality limits standardization of imaging at presentation and follow-up: an important consideration in management. We initially aim to describe the common presentations and course of pediatric ACC, its investigative work up and the management and outcome as illustrated by our patients in this series. As a second and principle aim we review the imaging findings of each of our patients and examine published evidence on the initial staging and follow up of pediatric ACC. In particular we look at the role of [ 18F]Fludeoxyglucose Positron Emission Tomography Computed Tomography (FDG-PET CT) imaging in this. We describe how this was undertaken and the specific findings in our patients and compare and contrast this against concurrent modalities and published data on the imaging of ACC. Methods & Materials: We present a series of five patients who underwent investigation and treatment of ACC at a tertiary referral center (BC Childrens Hospital, Vancouver) over a 12-year period (2002–2014). Our patients (four females, one male) were aged between 6 months and 16 years (mean 10.2 years). All had presentations related to hormone excess. There was a mean follow up of 32 months (2.2 to 52 months) from initial diagnosis (Fig. 1). All but the initial patient in this series, underwent functional imaging using FDG-PET CT as part of their initial and follow-up imaging, as is the local standard. A total of 27 FDG-PET CT studies were performed for ACC in the period reviewed, with a mean of 6.8 studies per patient in those undergoing FDG-PET

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CT.At time of writing two patients (40%) are deceased and 3 (60%) are in remission. Conclusions: ACC is a rare tumour with important clinico-radiological characteristics. FDG-PET CT has an important role in the staging and follow up of ACC, facilitating early detection of recurrence and therefore impacting on-going management. Standardization of imaging protocols and their application would enable efficient and effective use of this developing modality in the management of ACC in children.

Poster #: EDU-094 Pitfalls and Practical Challenges in Imaging of the Pediatric Scrotum Henrietta Rosenberg, MD, Radiology, The Mt. Sinai Medical School, New York, NY, [email protected]; Neil Lester, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: This educational poster provides a review of a wide gamut of causes of scrotal abnormalities in the pediatric age range and how sonography (US) is used to limit the differential diagnosis and aid in therapeutic decision making. The ultrasound appearance of numerous pathological processes affecting the pediatric scrotum are described and multiple illustrative US examples are provided. The exhibit provides information regarding the embryological development of the testis, scrotal anatomy, optimization of the US examination, and discusses cryptochidism, hydrocele, inguinal hernia, testicular torsion, torsion of the various appendices, epididymo-orchitis, intra-testicular and paratesticular tumors (primary and secondary) and cysts, varicocele, venolymphatic malformation, and several other miscellaneous conditions.

Poster #: EDU-095 Poster #: EDU-093 Dynamic CT Imaging for Pediatric Upper Airway Examination Atsuko Fujikawa, Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan, [email protected]; Juichi Mori, Junichi Matsumoto, Yasuyoshi Ogawa, Hideki Shima, Yasuo Nakajima Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: An accurate examination of the upper airways based on computed tomography (CT) in children is challenging because the anatomical structure of the upper airway dynamically changes, especially in smaller children, who often cannot coordinate their breath according to the radiological technician’s instructions. Because of the availability of a 320-detector row CT scanner in our institution, several dynamic airway examinations have been performed. This dynamic airway CT scanner can cover all respiratory cycles, ensuring an accurate examination of potential patient airway stenosis. The purpose of this report is to display the results obtained in our department after introducing dynamic pediatric airway CT imaging, including some clinical case examples. Methods & Materials: Since 2013, we have been operating the 320-detector row CT scanner at our institution. At first, a phantom study was performed to determine the optimal scanning sequence. Using low kVp settings and an iterative reconstruction method, we managed to reduce the radiation dose. Clinical evaluation of upper airway movements during respiratory cycles was required, and thus several patients underwent the dynamic airway scan, including children. Results: The contents of our presentation include # Scanning sequences # Cases: tracheal stenosis, laryngomalacia Conclusions: Although the radiation dose is a matter of concern, the CTbased evaluation of dynamic airway movements is useful.

BROWN BEAR, BROWN BEAR, WHAT DO YOU SEE?: ANIMAL INSPIRED SIGNS IN PEDIATRIC IMAGING Ryan Braun, Rachelle Goldfisher, MD, Radiology, SUNY Downstate, Great Neck, NY, [email protected]; John Amodio, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pareidolia is psychological phenomenon denoting a form of patternicity used to organize and evaluate random data. This concept has long been used in medical practice as a way to recognize both normal anatomical and pathologic processes. Radiology, and Pediatric Radiology in particular, continues to utilize many of these patterns in modern diagnostic interpretation. One such subset of pattern recognition is the comparison of a radiographic finding to an animal or part of an animal that the finding resembles. This presentation will provide a biographical background on the animal descriptors, a comparison of the classic imaging finding to its namesake and a discussion of the clinical importance of each finding. Methods & Materials: Many eponymous animal findings related to Pediatric Radiology are presented on radiograph, CT, MRI and/or fluoroscopy. Biographical background, illustrative images and the pathophysiology behind the image characteristics accompany each eponym. The animalistic signs to be discussed include: Cardiology: Gooseneck Sign (Endocardial Cushion Defect) Gastrointestinal: Birds Beak Sign (Achalasia) Caterpillar Sign (Intussusception) Genitourinary/Renal: Bear Paw Sign (xanthogranulomatous pyelonephritis) Claw Sign (Wilms Tumor vs Neuroblastoma) Cobra Head Ureter Manta Ray Sign (bladder extrophy) Musculoskeletal: Butterfly Fragment Butterfly Vertebra Fish (mouth) Vertebra (Sickle Cell Disease) Fishtail Deformity of the Elbow

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Mickey Mouse Pelvis (Down Syndrome) Vertebral Scalloping Winking Owl Sign (congenital absence of a vertebral pedicle) Conclusions: The concept of pareidolia, with particular regard to animalistic comparisons, continues to thrive in the practice of Pediatric Radiology. Familiarity with the described findings will aid in diagnostic accuracy and guide patient management.

Poster #: EDU-096 Do you remember Retrograde Ureteropyelogram? Nina Stein, Pediatric Radiologist, Diagnostic Imaging, McMaster University, Mississauga, ON, Canada, [email protected]; Luis Braga Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Retrograde ureteropyelogram (RU) is a forgotten technique by radiologists. In part, this happens because it is an exam usually performed by urologists. However, even in the era of special magnetic resonance (MR) urography and high resolution ultrasound probes, there is no better imaging technique to assess some congenital abnormalities in the ureter than retrograde studies (vesicoureterogram and retrograde ureteropyelogram). Ultrasound is a sensitive method to detect hydronephrosis and to assess details in the renal parenchyma. However, vesicoureterograms are complementary to differentiate vesicoureteral reflux and ureteropelvic or ureterovesico obstruction. And, it is for the complex hydronephrosis cases that potentially need surgical correction that RU is helpful. Cases of ureteropelvic junction can sometimes involve a long segment of ureter. In addition, there are rare cases of ureteric obstruction that are caused by ureteric polyp and not strictures. RU better characterize cases of ureteric obstruction. The pressure of retrograde contrast injection is helpful to distend the ureteric lumen. It allows anatomical details that not even MR studies would have the habilit to assess. RU also can be transoperatory performed which helps surgeons to determine appropriate surgical approach to the ureter, stablishing the level of the obstruction and the length of abnormal segment. This educational exibit aims to review the main indications and to review RU imaging findings for different ureteric pathologies. Methods & Materials: Eighty cases of ureteric pathology surgery had the pre operatory and transoperatory images reviewed. Ultrasound, computed tomography, vesicoureterogram, MRI and retrograde ureterograde were assessed when ever available. Results: It was observed different ureteric appearances in cases of UPJ obstruction. In one case, ureteric polyps was the reason for obstruction. The polyps were only identified on the RU study. Conclusions: RU is an old imaging technique that is performed by urology surgeons due to the need of associated cystoscopy procedure. However, radiologists should not assume that they are not needed for this examinations. The knowledge of imaging acquisition and imaging interpretation principles makes radiologists an asset to improve the quality and to detect and better characterize ureteric pathologies. Therefore, here we review the principles and indications of this technique, as well as characterization of ureteric pathology with some ilustrative RU cases.

Poster #: EDU-097 When Water Stops Flowing: Diffusion Weighted Imaging in Pediatric Tumors Angela Tong, Westchester Medical Center, White Plains, NY, [email protected]; Adele Brudnicki, Hasit Mehta, Leslie LeCompte

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: MRI has become an important modality in pediatric imaging primarily for its great spatial resolution without ionizing radiation. Multiecho application allows for tumor tissue characterization, which can be helpful for surgical and treatment planning. Specifically, diffusion weighted imaging (DWI) has emerged recently as a key sequence to help better delineate soft tissue neoplasm as well as to help monitor tumor/ metastatic progression and treatment response. Methods & Materials: In this educational exhibit, we will discuss the physics of DWI, which will allow for better understanding of its function in imaging pediatric tumors. In particular, tumors with highly cellular matrix, such as small blue round cell tumors, demonstrate avid restricted diffusion allowing for localization and characterization. We will present several examples utilizing DWI to monitor treatment efficacy as well as tumor progression over time. Results: Because the DWI sequence is a relatively short sequence to obtain, serial whole body DWI scans may be adequate to monitor for metastasis in conjunction with bone scans and possibly replacing PET CTs. An added benefit of DWI is that patients are not exposed to additional radiation, an important factor in the pediatric population. To present a well-rounded perspective on the utility of the DWI sequence, we will also discuss the limitations of its use. Conclusions: From this exhibit, the reader will gain an understanding of DWI physics, the use of DWI to monitor neoplasms for treatment efficacy and tumor/metastatic progression, as well as its limitations in order to better facilitate care for pediatric oncologic patients.

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Poster #: EDU-098

Poster #: EDU-099

Benign and Malignant Abnormalities of the Pediatric Peritoneal Cavity (including mesentery, and omentum)

Unraveling Coronary Artery Anomalies: Investigation of Anatomy, Diagnosis, and Management

Ajaykumar Morani, MBBS, DNB, MD, Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX; Ethan Smith, Winston Huh, Najat Daw Bitar, Andrea Hayes-Jordan, Jonathan Dillman, MD

Angela Tong, Westchester Medical Center, Valhalla, NY, [email protected]; Jennifer Thomas, Lauren Ostry, Leslie LeCompte, Suvro Sett, Amar Shah

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Peritoneal (including mesenteric-omental) tumors are rare in children. These include group of benign and malignant tumors. Our objectives are to, 1) describe the clinical features and imaging patterns of peritoneal tumors in pediatric age group, and 2) discuss the differential diagnosis of peritoneal tumors in children based on imaging features with illustrations. Methods & Materials: Peritoneal anatomy will be reviewed. The differential diagnosis of pediatric peritoneal (including mesenteric, and omental) masses and mass-like lesions can be based on their solid or cystic nature as follows. 1. Solid or complex lesions : a. Neoplastic: i. Malignant lesions: Metastatic tumors : rhabdomyosarcoma/other sarcomas, germ cell tumor, Wilms tumor, lymphoma/leukemia, carcinoid, gastrointestinal stromal tumor Primary tumors: desmoplastic round cell tumor, lymphoma, mesothelioma ii. Benign lesions: teratoma, inflammatory pseudotumor, neurofibroma, desmoid tumor (aggressive fibromatosis) b. Non-neoplastic lesions: mesenteric lymphadenitis, infection (abscess), omental infarction, epiploic appendagitis 2. Cystic lesions: omental/mesenteric cyst (including lymphatic malformation), enteric duplication cyst, meconium pseudocyst, mesothelial cyst, benign cystic mesothelioma, infection (abscess) Multiple representative peritoneal lesions from each category will be reviewed with illustrative cases presented. Results: 1. Peritoneum is a common blind spot & peritoneal lesions are often missed. 2. Most pediatric cystic peritoneal masses are benign. Solid masses (& mass-like abnormalities) may be non-neoplastic or neoplastic. 3. Benign & malignant peritoneal neoplasms are uncommon in children. Metastatic lesions are more common than the primary, & rate of recurrences are higher with malignancies of peritoneum compared to other anatomic sites. Conclusions: Pediatric peritoneal masses & mass-like lesions can be entirely benign to highly malignant. Imaging plays a critical role in not only detection, but also in characterization, staging and follow-up of these lesions.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Congenital abnormalities of the coronary arteries are uncommon, however, they may pose significant diagnostic and management challenges when manifesting in the pediatric population. A thorough understanding of the types of coronary artery anomalies, significance and treatment options are important for the radiologist to understand. Methods & Materials: In this educational exhibit, we will review the types of coronary artery anomalies, the role of imaging in diagnosis including cardiac CTA, catheter angiography, and MRA, and how anomalies are managed with a review of surgical treatments. In addition, focus on how imaging findings are integrated into surgical planning will be discussed. Results: We will present several cases along with diagrams that describe normal coronary anatomy and the anatomies of the common and symptomatic coronary anomalies. Emphasis will be placed on specific anatomic and functional information that clinicians use to make treatment decisions. Conclusions: From this exhibit, readers will gain a knowledge of the normal coronary artery anatomy, how to diagnose anomalies, and how to designate clinically relevant information for the treating physician.

Poster #: EDU-100 Imaging Atlas of Non-Accidental Trauma of the Neuro-Axis: What the Radiologist Needs to Know Priya Sharma, MD, Pediatric Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Rachel Griggs, MD, Mark Escudero, Benita Tamrazi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Learning Objectives: In this presentation we will review the multimodality imaging findings associated with non-accidental trauma to the head and spine through a series of cases from our institution. Additionally we will seek to differentiate these findings from those patterns typically found in accidental trauma. Methods & Materials: Background: Unfortunately the incidence of child abuse continues to rise, especially in Los Angeles. At Children’s Hospital Los Angeles approximately 500-600 cases of child abuse are reported annually. Each year there are 30-35 mortalities secondary to child abuse. Approximately 85% of these victims are under the age of five and 43% of them are under the age of one. Non-accidental head injury is the most common cause of traumatic death in infancy. Additionally there has been increasing evidence of spinal injuries on autopsy or MRI in abused children. Results: Imaging Findings: We will present the multimodality imaging findings of both abusive and accidental trauma to the head and spine with a concentration on specific imaging findings to help the viewer differentiate the two mechanisms of injury. In this presentation we will review

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entities such as scalp injury, bony cranial and spine injuries, intracranial injuries, as well as intra- and extra- spinal pathologies. Specifically we will focus on patterns and mechanisms of injury that can differentiate accidental versus non-accidental trauma. For example patterns of injury and pathologic findings will include entities such as diffuse cerebral edema, hypoxic ischemic injury, shear injury and atrophy. When reviewing traumatic spinal injuries we will demonstrate spinal cord injury, fracture dislocations, intradural and extradural hematomas, and soft-tissue/ligamentous injury. Conclusions: In cases of non-accidental trauma, an accurate history is rarely provided at the time of presentation. Physical examination provides little insight to underlying brain injury. The pediatric radiologist can be the first to suggest the diagnosis based on CTs for the evaluation of lethargy or seizures. A subsequent MRI may then show findings of intraparenchymal injuries of the brain and bony spine, cord, ligamentous and vascular structures. Pediatric radiologists play a critical role in identifying specific imaging findings that can suggest abuse and help clinicians safely manage the patient.

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aortic arch are not patent and are unopacified. Observers will learn that the presence of Diverticulum, a Dimple or a Descending aorta opposite the side of the arch indicate the presence of a vascular ring.

Poster #: EDU-101 Vascular Rings for “D”ummies Sharon Gould, Cynthia Rigsby, MD, Lane Donnelly, Michael McCulloch, Christian Pizarro, Monica Epelman, MD, Nemours/ A . I . d u P o n t H o s p i t a l f o r C h i l d re n , Wi l m i n g t o n , D E , [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Vascular rings refer to congenital anomalies in which the trachea and esophagus are encircled by vessels or their atretic portions. These vessels may include the aortic arch or arches, aortic arch branch vessels, pulmonary branch arteries, and the ductus arteriosus or the ligamentum arteriosum. The purpose of this educational exhibit is to describe a simple identification method utilizing readily recognizable anatomic findings. Methods & Materials: Cross-sectional imaging techniques to diagnose and characterize vascular rings are based on the opacification of flowing blood. However, this may not always be the case, as the atretic portions would not become apparent in CTA or MRA. In these cases, where the compressed airway and esophagus are not encircled by patent vessels, there are three useful secondary signs beginning with the letter “D” that should be considered and should raise suspicion for the presence of a vascular ring. These secondary signs include dimple, diverticulum and the course of the descending aorta. A diverticulum refers to a large outpouching off the descending aorta, on the contralateral side of the aortic arch where the smaller caliber distal subclavian artery originates. A dimple denotes a small outpouching that ends blindly. The course of the descending aorta opposite to the side of the aortic arch, refers to cases in which the distal arch courses behind the esophagus to the opposite side of the chest describing an acute turn and constituting the descending aorta, which is different from the characteristic right aortic arch, in which the descending aorta gradually moves towards the left side. All these aforementioned “D” findings should always be noted in the contralateral side of the aortic arch, and if these structures are found, anchoring and tethering by a non-resolvable ligamentum arteriosum or an atretic segment of arch could be inferred. Results: A brief overview of aortic arch embryology will be given followed by a brief discussion of CTA and MRA techniques, including image reformatting. Assessment of tracheal and/or bronchial compression will also be addressed. Conclusions: Vascular rings are often not readily apparent by imaging when the ligamentum arteriosum or atretic portion of the

Poster #: EDU-102 Foreign Bodies, What are They Doing Here? R e x P i l l a i , M D , R a d i o l o g y, U C L A , B e v e r l y H i l l s , C A , [email protected]; Shahnaz Ghahremani, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Foreign bodies are more common in pediatric patients than adults. If foreign bodies are overlooked, can be a source of infection, foreign body reaction granuloma formation, debilitating condition or a life threatening situation. The clinical history in many of the cases is unclear and identification of foreign bodies by imaging characteristics can provide critical information. Not all of the foreign bodies are radio opaque enough to be detected by radiographs and fluoroscopy, ultrasound, CT scan or MRI exam, each might play a role in this regard. The foreign bodies can be classified in different categories. Foreign body ingestions: examples of this group are magnets, batteries, sharp objects and ingestion of harmful fluid and pills in kids. Aspirated foreign bodies: This is a known scenario in kids, but can be overlooked easily, if parents or caregiver is not a good historian. Foreign body injuries: Pediatric patients are prone to puncture wounds from splinters, needles, and thorns and cut with glass, mostly because of sport activities. However the foreign body injuries to the extremities or other parts of the body might happen in routine daily activities. Foreign body insertions: These types of insertions in children are mostly because of curiosity or may be as a result of abuse. They might attempt to insert something into themselves or allow others to insert a foreign object into their opening. The rectum, vagina, urethra, nose, and ear are favorite sites. Methods & Materials: We are reviewing different types of foreign bodies, diagnosed by imaging. We include the radiographic, ultrasound and MRI findings of these foreign bodies. Conclusions: Clinical diagnosis of a foreign body might be difficult, particularly when the patient or the patient’s family did not pay attention to a previous trauma. Even with clinical suspicion for a foreign body, imaging plays a pivotal role in confirming the diagnosis and providing important information about the location, morphology, size, material involved and site of trauma.

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Poster #: EDU-103 The Lateral Soft Tissue Neck X-ray in Children: Much mMore than a Prelude to CT Amelie Damphousse, Radiology, CHU Sainte Justine, Montreal, QC, Canada, [email protected]; Ramy El Jalbout, MD, Laurent Garel Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: This exhibit aims to review the technical adequacy of lateral soft tissue neck x-ray in order to detect pitfalls. We will present our experience and tips to improve confidence in diagnosis when facing abnormalities on a lateral x-ray in order to decrease the false positive rate and avoid radiation from un-needed CT scans. Methods & Materials: We reviewed lateral soft tissue neck radiographs from patients presenting to the emergency department. Our teaching objectives are presented through the following outline: - Clinical indications for a lateral soft tissue neck x-ray - Technique : Position, breathing, swallowing and x-ray parameter - Anatomy : Description of normal anatomic landmarks on radiograph and normal measurements for the retropharyngeal soft tissues in pediatrics at C2, C3 and C6 - Pitfalls; ways to recognize them and maneuvers to resolve them - Pathologic findings in a pediatric university hospital in correlation with cross-sectionnal techniques : retropharyngeal abscess and cellulitis, croup, epiglottitis, exudative tracheitis, vascular anomalies, foreign bodies, soft tissue tumoral process, tonsil and adenoid enlargement and prevertebral hematoma. Results: Several radiographs were false positive due to inadequate techniques. In this perspective full extension and cricoid pressure lateral views should be considered when radiographs show possible pseudoretropharyngeal thickening. Knowing that obliquity in positioning may lead to an apparent enlarged epiglottis called an Omega epiglottis, help avoid unnecessary further imaging and treatment. The correlation between the findings on an adequate radiograph and the CT scan show the importance of the lateral soft tissue neck radiograph as a screening modality. The need to decrease the false positive rate of the lateral soft tissue neck radiograph through an adequate technique prevails as more normal CT scans are being obtained in the pediatric population. Conclusions: Being familiar with the technical problems and challenges of a lateral soft tissue neck X-ray is important to reach the right diagnosis and suggest the adequate recommendations for further imaging. Hence, this will increase the positive predictive value of the subsequent test and decreases the number of unnecessary CT scans.

Poster #: EDU-104 Posterior Sternoclavicular Joint Dislocation in the Pediatric Patient Andrew Schapiro, MD, Radiology, University of Wisconsin, Madison, WI, [email protected]; Michael Kim, Jie Nguyen, MD, Kara Gill

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Sternoclavicular joint dislocations are rare, reportedly representing just 1% of all dislocations in the body. Anterior sternoclavicular dislocations are reportedly far more common than posterior dislocations, with published ratios ranging from 3:1 to 20:1. However, because of the close proximity of the posteriorly dislocated medial clavicle to subjacent important mediastinal and thoracic cavity structures posterior dislocations can have associated substantial and potentially even life-threatening complications. Potential injuries to the mediastinal vascular structures, trachea, esophagus, and recurrent laryngeal nerve, as well as pneumothorax and pulmonary contusion can occur in the setting of posterior sternoclavicular dislocation. In this exhibit the mechanism of injury, clinical presentation, imaging appearance, radiologic work-up, and treatment of posterior sternoclavicular dislocation is reviewed with the intent of educating others about this uncommon but clinically important condition. Methods & Materials: Cases of posterior sternoclavicular joint dislocation in patients under the age of 18 years identified at a single institution from 2012 through 2014 with available imaging were identified utilizing PACS. Details about the mechanism of injury, clinical presentation, and treatment course were reviewed using the institution’s electronic medical record. Results: Eight cases of sternoclavicular joint dislocation were identified with imaging evaluation including radiography, CT, and MRI. Conclusions: Posterior sternoclavicular joint dislocation is an uncommon entity with initial imaging findings that can be subtle and often missed. Timeliness of detection can affect operative approach and minimize the risk of serious complications. Awareness of this entity, its imaging presentation, and optimal radiologic evaluation can expedite management of this potentially life threatening condition.

Poster #: EDU-105 White Matter Matters Cynthia Fleming, MD, Riley Hospital for Children, Indianapolis, IN; Dr. Stephen Kralik, Chang Ho Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pediatric white matter abnormalities identified by imaging present a clinical and radiological challenge. This educational poster will demonstrate the spectrum of focal and diffuse pediatric white matter disease, emphasizing pattern recognition, expected change over time, and vital clinical information that help differentiate the following etiologies: sequelae of prematurity or perinatal hypoxic-ischemic event, infectious or inflammatory, and inborn errors of metabolism. Methods & Materials: Classic and atypical cases of each white matter pathology will be presented with respect to the imaging pattern and MRI characteristics of white matter involvement, change in imaging over time, and helpful clinical history. Pathologies will range from the most common etiologies, such as hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia (PVL), intrauterine infections, and acute disseminated encephalomyelitis (ADEM) to the uncommon metabolic diseases, such as adrenoleukodystrophy, metachromatic leukodystrophy, and mitochondrial diseases. Results: In the setting of an appropriate clinical history, HIE, PVL, and intrauterine infections each tend to have characteristic locations, and demonstrate static findings on followup imaging. By contrast, ADEM typically presents with a viral prodrome, involves white matter and central gray matter in a bilateral but asymmetric distribution, and in the majority cases will have improvement of imaging findings. Metabolic diseases tend to be diffuse and symmetric, and progress over time with predilection for frontal, central, or posterior white matter tracts, depending on the specific pathology.

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Conclusions: The goal of this education poster will be to develop a better appreciation, approach, and working understanding of the manifestations of the most important pediatric white matter pathologies potentially encountered in practice. Imaging patterns and characteristics, in addition to vital clinical history, will help the radiologist generate a more specific differential diagnosis for improved clinical management.

Poster #: EDU-106 Initial Clinical Experience of Fetal MRI on 3T with Multi-transmit Radiofrequency (TX) Technology S. Pinar Karakas, MD, UCSF Benioff Children’s Hospital at Oakland, CA, Oakland, CA, [email protected]; Kenneth Martin, Dave Hitt, Taylor Chung, MD Disclosures: Taylor Chung MD, has indicated a relationship with Philips Healthcare, Honorarium and travel support for academic conference. David Hill indicated a relationship with Philips Healthcare as an employee. Purpose or Case Report: The aim of fetal MRI is to obtain the highest quality diagnostic images in order to make the best-informed decisions for the management of the fetus. In this e-poster presentation, we would like to share our clinical experience with 3T fetal MRI with TX and discuss its benefits and remaining challenges. Methods & Materials: All fetal imaging obtained on 3T Philips Achieva magnet with Multi-transmit radiofrequency (TX) technology. This retrospective review shows fetuses ranging from 22 to 37 weeks gestation. We imaged fetal brain for ventriculomegaly, tuberous sclerosis, intracranial solid or cystic masses; fetal spine for spinal dysraphism and masses; fetal chest for diaphragmatic hernia, lung and cardiac masses; fetal abdomen for variety of abnormalities including gastrointestinal and urinary tract pathologies and fetal body wall for various defects and masses. Results: The inherent higher signal-to-noise ratio in a 3T environment allows for higher in-plane spatial resolution and thinner slices. Coupled with the use of parallel imaging to minimize blurring from long echo-train length in single shot acquisition technique, the 3T scanner can yield high quality diagnostic images. This significant benefit can only be clinically useful if the challenge of the unpredictable dielectric artifacts due to B1 field inhomogeneity in the 3T environment can be minimized. Inhomogeneous B1 field can cause local loss of signal in fast spin echo sequences (single shot T2 images) and loss of tissue contrast in fast gradient echo sequences (SSFP images). The TX technology can achieve a more homogeneous B1 field, adaptive to each patient’s body size and shape, and thus minimize the shading artifacts. The SAR hot spots are theoretically also minimized by the increased homogeneity of the B1 field. In this e-poster presentation, we would like to share our clinical experience with 3T fetal MRI with TX and discuss its benefits and remaining challenges. Conclusions: Our initial clinical experience suggest that fetal imaging on a 3T MR scanner with multi-transmit RF technology is robust and consistently yields high quality, high-resolution images with great patient acceptance.

Poster #: EDU-107 Pearls and Pitfalls in Imaging of Pediatric and Adolescent Breast Masses Priya Krishnarao, MD, Santa Clara Valley Medical Center, San Jose, CA, [email protected]; Patrick Do, MD, Amrita Arneja, MD, Vanessa Starr, MD, Long Trinh, Evan Zucker, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: Pediatric and adolescent breast masses are rare and usually benign. However, palpable breast masses in this population can cause significant clinical concern for healthcare providers, parents, and children. The diagnosis of breast masses in the pediatric and adolescent population remains a challenge. Ultrasound is the primary imaging modality of choice. We aim to review key anatomic relationships and imaging features of benign and malignant processes that affect the pediatric breast. Methods & Materials: The radiology database at a community hospital and a university teaching hospital from January 2010-September 2014 was searched for pediatric and adolescent patients who had undergone ultrasound examinations for palpable pediatric breast abnormalities. Selected cases are used to illustrate educational points of benign and malignant breast abnormalities in the pediatric and adolescent population. Results: Benign and malignant breast pathologies may present in various forms in the pediatric population. Ultrasound can help distinguish between normal physiological changes of the breast during development and benign and malignant lesions of the breast. A complete history is important in determining key factors such as recent trauma, lactation history, and a strong family history of breast disease. We will review normal breast development, developmental breast lesions such as abnormalities during embryogenesis, gynecomastia, asymmetric breast bud development, and benign lesions such as breast cysts, mastitis, fibroadenomas, juvenile fibroadenomas, hemangiomas, and juvenile papillomatosis. Although the majority of lesions are benign, a rare number of cases may be attributed to primary malignancies and metastatic processes that affect the pediatric breasts which have characteristic imaging features depending on the histologic type of the malignancy. We will review malignant breast lesions such as malignant phyllodes tumors, primary breast carcinoma, and metastatic disease. Metastatic disease to the breast from pediatric malignancies such as lymphoma, leukemia, and rhabdomyoscaroma are more common than primary breast malignancies. Children who have received radiation to the chest are also at increased risk of developing primary breast carcinoma. Conclusions: Understanding the key radiological features of pediatric and adolescent masses within the appropriate clinical setting is necessary for the correct diagnosis and management of these diseases.

Poster #: EDU-108 Radionuclide Brain Imaging of Epilepsy in Children, A Pictorial Review Mahmoud Zahra, MD, FRCR, St. Vincent’s Medical Center, Bridgeport, CT, [email protected]; Feraas Jabi, Thomas Olsavsky, Matthew Wagner, Kristi Oatis, Reza Fardanesh Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Describe radionuclide brain imaging techniques for pre-surgical evaluation of epilepsy in children. Methods & Materials: Epilepsy is a common neurologic disease in children and young adults. Most patients’ symptoms are controlled with anticonvulsants. However, many patients fail anticonvulsant therapy. Identification of an epileptogenic focus amenable to surgical resection may be the best alternative for this subgroup. Radionuclide brain imaging is well established as a superb modality for identification of active seizure foci as part of the presurgical evaluation of drug-resistant epilepsy patients. Ictal and inter-ictal single photon emission computed tomography (SPECT) with perfusion radiotracers and inter-ictal positron emission tomography (PET) with F18fluorodeoxyglucose (FDG) are the imaging methods of choice. Ictal SPECT has the highest sensitivity of approximately 97-100%, followed by postictal SPECTwith a sensitivity of 75-77% and inter-ictal SPECT the least sensitive (43-44%). The greatest sensitivity is for temporal lobe epileptogenic foci. Despite the superior spatial resolution of PET compared to SPECT, PET is limited to inter-ictal imaging.

Results: In this poster we will describe: Basic principles of PET and SPECT, including technique and instrumentation. Causes of epilepsy. Radiotracers applied in SPECT and PET brain imaging of epilepsy. Analysis and interpretation of SPECT and PET scans for epilepsy. Brief description of MRI of epilepsy. Conclusions: Radionuclide brain imaging is an essential part of pre-surgical evaluation of patients with intractable epilepsy. A thorough understanding of radionuclide brain imaging methodology is important for the radiologist to accurately identify the epileptogenic focus as surgical resection of the focus offers the best chance for alleviation of symptoms in these patients.

Poster #: EDU-109 Imaging of Pediatric Portal Hypertension Zeeshaan Bhatti, MD, Ethan Smith, MD, Department of Radiology Section of Pediatric Radiology, University of Michigan - C.S. Mott Children’s Hospital, Ann Arbor, MI, [email protected]; Jonathan Dillman, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Pediatric portal hypertension, while relatively rare, results in significant complications and morbidity in affected patients. There are multiple etiologies for pediatric portal hypertension, including congenital and acquired causes. The purpose of this exhibit is to systematically review the clinical and radiologic features of the most common causes of pediatric portal hypertension, the associated complications and comorbid conditions, and to review the imaging appearance of commonly employed treatment strategies. Methods & Materials: An institutional review board approved, HIPAA compliant retrospective review of imaging records of patients less than 18 years of age will be performed. In addition, a thorough review of the existing literature on pediatric portal hypertension will be undertaken. Results: The information will be presented in a systematic manner, beginning with the causes of portal hypertension and proceeding to discussion of complications and then treatment. Topics covered will include the following: Post-hepatic causes: Budd-Chiari syndrome Congenital heart disease/right-sided heart failure Constrictive pericarditis Sinusoidal causes: Cirrhosis (numerous etiologies) Congenital hepatic fibrosis Nodular regenerative hyperplasia Pre-hepatic causes: Arterioportal fistula Extrahepatic portal vein thrombosis Congenial portal vein stenosis/atresia Complications: Varices/collaterals vessels Congestive splenomegaly/hypersplenism Intractable ascites Intestinal congestion Treatments: Surgical shunts TIPS Portal vein recanalization Splenic artery embolization Variceal embolization

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Conclusions: Pediatric portal hypertension has a variety of causes and results in significant morbidity in affected children. Knowledge of the imaging features of the various causes, complications and treatments of pediatric portal hypertension is important for the practicing pediatric radiologist.

Poster #: EDU-110 Pediatric Intramedullary Spinal Tumors and Tumor Mimics Cynthia Fleming, MD, Riley Hospital for Children, Indianapolis, IN; Stephen Kralik, Chang Ho Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Intramedullary neoplasms account for a small percentage of pediatric central nervous system tumors, and differentiating neoplasms from tumor mimics is crucial for early treatment and management. The goal will be to provide further understanding of these neoplasms and non-neoplastic processes, which may be encountered in the pediatric patient population. Methods & Materials: This educational poster will demonstrate the neuroradiological spectrum of common and uncommon intramedullary pediatric spine neoplasms and syndromes associated with intramedullary tumors, as well as demonstrate intramedullary spinal pathology that may simulate neoplasms. Results: The most frequent pediatric intramedullary neoplasms encountered are astrocytomas and ependymomas, followed by gangliogliomas. Unlike in adult patients, primitive neoplasms of atypical teratoid rhabdoid tumor (ATRT) and primitive neuroectodermal tumor (PNET) may present as an intramedullary mass. Syndromes of neurofibromatosis type-1 (NF1), neurofibromatosis type-2 (NF-2), and von Hippel-Lindau (VHL) may also present with characteristic intramedullary spinal tumors in the pediatric population. Lastly, non-neoplastic intramedullary processes such as inflammatory myelitis may simulate tumors, and should be considered in the differential diagnosis in a pediatric patient with an intramedullary mass. Conclusions: Differentiating pediatric spinal cord neoplasms (and potentially-associated neurocutaneous syndromes) from spinal cord tumor mimics is crucial for early diagnosis and treatment.

Poster #: EDU-111 MR Imaging Features of Hepatobiliary Cystic Masses Arising in the Pediatric Age Group with Radiologic-Pathologic Correlation Maddy Artunduaga, MD, Baylor College of Medicine, Houston, TX, [email protected]; Amy Mehollin-Ray, MD, Karen Lyons, MB, BCh, BAO, BMedSc, MRCPI, FFRRCSI, Alicia Roman-Colon, Prakash Masand Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: It is imperative that pediatric radiologists recognize the cystic mass lesions arising from the hepatobiliary system. These masses can be benign or malignant, and the differential diagnosis often has surgical implications. After initial evaluation with ultrasonography, these lesions often get characterized for appearance, enhancement characteristics and number by cross-sectional imaging techniques, especially MR. Our exhibit focuses on the MR imaging characteristics of these lesions, with pathologic correlation for those that were resected.

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Methods & Materials: IRB approval was obtained for this study. We reviewed the clinical charts and MR imaging studies of 20 patients (age range: 2 weeks to 18 years; M:F 14:6). MR exams were performed on a 1.5T scanner (Philips Achieva or Intera) using standard sequences including pre- and post-gadolinium T1weighted imaging, T2-weighted imaging and DWI, with use of sedation in patients less than 6 years. The following imaging features were analyzed: size and extent of lesion, origin from liver, biliary tree or pancreas, internal characteristics including septations and any solid component, and post-contrast features including enhancement of the rim, septations or solid components. Pathologic correlation was available in 14 patients. Results: Lesions identified included mesenchymal hamartoma, choledochal cyst, Caroli disease, simple hepatic cyst, mesothelial cyst, echinococcal cyst, biloma in the setting of hereditary hemorrhagic telangiectasia, liver abscess, hematoma, intrahepatic pseudocyst, cystic hepatoblastoma, embryonal sarcoma and solid pseudopapillary epithelial neoplasm (SPEN). The malignant lesions had enhancing solid components, helping to differentiate them from benign cystic masses. Conclusions: Our exhibit reviews the MR imaging features of benign and malignant cystic pathologies arising from the hepatobiliary system in the pediatric age group. With this knowledge, a limited differential diagnosis can be provided in most cases, in conjunction with the patient’s age and clinical picture.

Poster #: EDU-112 Withdrawn Poster #: EDU-113 Pediatric Encephalitis: A Road Less Travelled Sumit Pruthi, Allison Johnsen, Vanderbilt University, Nashville, TN, [email protected]; Lindsay Pagano, Natasha Halasha, Karen Bloch Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this educational exhibit is to describe an organized clinico-radiologic approach to pediatric encephalitis with emphases on neuroimaging findings, clinical and laboratory results, and associated complications of pediatric encephalitides. Methods & Materials: Despite extensive testing, the etiology of encephalitis remains unknown in most patients. The main purpose of this exhibit is to outline a systematic approach to a case of suspected encephalitis. Cases of clinically diagnosed encephalitis in patients aged 0-18 years will also be presented with emphasis on clinical and imaging workup, highlighting special and/or specific imaging features pertaining to a particular pathology. Results: Encephalitis is defined as inflammation of the brain parenchyma associated with neurologic dysfunction. Of the pathogens reported to cause encephalitis, the majority are viruses. We aim to provide an organized review in approaching pediatric encephalitis, with brief descriptions of specific imaging features of infectious and autoimmune causes of encephalitis. Though the specific etiology of encephalitis remains unknown in a large number of cases, an organized approach is extremely helpful in narrowing the differential and guiding prompt therapy. Conclusions: We present a diagnostic algorithm for pediatric encephalitis in effort to provide a dependable methodology in treating this rare but potentially fatal condition.

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Poster #: EDU-114 Imaging Findings of Suspected Retained Surgical Materials in Postoperative Pediatric Patients; How can the radiologist become aware? Aikaterini Ntoulia, MD, PhD, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Joanne Kerwood, Soroosh Mahboubi Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To become familiar with the radiographic appearance of the most common surgical materials intended for use during surgical procedures in children and identify the frequency of queries for missing or incorrect count of surgical materials in clinical practice. Methods & Materials: We performed in-vitro X-rays of surgical materials, including needles, sutures, sponges, cotton balls, and compresses, intended for use during pediatric surgical procedures. Additionally, during an 8-year-period (2005-2013) we retrospectively reviewed medical records of children who underwent surgery and intra- or post-operative imaging examinations for suspected retained surgical material(s). Results: Thirty-eight queries for suspected retained surgical materials were identified in 20 male and 18 female patients, mean age 7.6 years (range:5 days-24.5 years), who underwent abdominal (n=18), cardiothoracic (n=13), brain (n=1), head and neck (n=3), upper extremity (n=1), or complex (n=2) surgical procedures. Queries were for missing needle (n=29) or needle tip (n=2), missing sponge (n=4), missing forceps (n=1), and indeterminate incorrect count (n=2). In all cases portable x-rays were performed in the operating room and findings were correlated with in vitro obtained X-rays. Thirty-eight cases were negative for retained material, and in seven cases accurate localization of the material was provided to the surgical team, while the patient was still in the operating room. Conclusions: Awareness of the radiographic appearance of surgical materials commonly used in pediatric surgery, allows for correct diagnosis and appropriate management before the patient leaves the operating room, preventing potential complications. The providing history of incorrect count or missing of surgical materials increases radiologists’ diagnostic suspicion.

Poster #: EDU-115 Pediatric Radiology Economics and Politics in Jeopardy: A Primer David Swenson, MD, Diagnostic Imaging, The Alpert Medical School of Brown University, Brooklyn, CT, [email protected]; Cassandra Sams Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To encourage interest and participation in healthcare economics and politics as they relate to pediatric radiology, with a recognition that as pediatric radiologists we are obliged to (1) provide quality/valuable services, and to (2) advocate for our pediatric patients, who frequently have limited economic resources and political power. Methods & Materials: Background preparation for this educational exhibit has occurred in several ways: (1) during attendance of the American College of Radiology (ACR) Annual Meeting and Chapter Leadership Conferences (AMCLCs) and quarterly state chapter meetings over the past 5 years; (2) through reading of educational materials available on the American College of Radiology website; (3) via reference to multiple

articles in Radiology, the Journal of the American College of Radiology, the Journal of the American Medical Association, and Health Affairs; and (4) through current participation by one of the authors as an ACR representative to a state Medicaid Medical Advisory Panel. Results: This power-point presentation is based on a variation of a “Jeopardy” game board with five columns and four rows. Participants can select from questions in the following subject areas: (1) Acronyms - Review of a selection from the alphabet soup that comprises much of the parlance in healthcare economics and politics as is relates to trainees and practicing physicians. (2) Economics - Presentation of “the iron triangle” of healthcare economics, and the ideas underpinning the patient protection and affordable care act (PPACA, “Obamacare”). (3) Lawgivers - A photo-based series of questions, introducing key players in the current political process as it relates to implemantation of PPACA. (4) Payers - Introduction to the various roles of Medicare, Medicaid, Private Insurers, and “self-pay” individuals, and how they arrive at price points for medical services. 5) Hope - A selection of references to lay-press and medical journal articles that present hope for the empowering role of radiolgists in the evolving healthcare climate. Conclusions: Pediatric radiologists must develop a familiarity with the language and ongoing debates within healthcare economics and politics in order to best serve their patients through (1) appropriate valuation of quality diagnostic services, and (2) through an enhanced ability to advocate for the needs of a patient population that generally has limited economic resources and political power.

Poster #: EDU-116 Chylothorax in Children: Bringing Clarity to an Opaque Topic Sarah Farley, MD, University of Washington, Seattle, WA, [email protected]; Jeffrey Otjen Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: While relatively uncommon in older children, chylothorax is one of the most frequent causes of pleural effusion in neonates, and may result in respiratory distress, fluid and electrolyte imbalances, malnutrition, and immunodeficiency. Chylothoraces may be congenital (e.g., lymphangiomatosis, lymphangiectasia); post-traumatic; post-surgical; associated with hydrops fetalis, thoracic masses, or syndromes (e.g., Down, Noonan, Turner, Gorham-Stout); or may be secondary to altered venous drainage (e.g., venous thrombosis, elevated central venous pressure status-post Fontan procedure). While chest radiography and ultrasound readily demonstrate the presence of a pleural effusion, the chylous nature of the fluid cannot be ascertained by imaging. Thoracentesis yields a milky white fluid containing chylomicrons and triglycerides. Additional imaging with lymphoscintigraphy, lymphangiography, computed tomography or magnetic resonance imaging is performed to delineate the lymphatic anatomy, identify sites of chyle leakage, and determine the underlying cause of the chylothorax; however, if pulmonary lymphangiomatosis or lymphangiectasia are suspected, lung biopsy may be necessary for confirmation. Goals of chylothorax management are to drain the pleural fluid to minimize respiratory distress, determine and treat the underlying cause, and prevent malnutrition and immunodeficiency. Following chest tube placement, further management may be medical, with diet modification and use of pharmaceuticals to reduce chyle flow and allow spontaneous healing, or procedural, with ligation of the thoracic duct and/or obliteration of the pleural space.

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Methods & Materials: A literature review was performed and illustrative patient cases were collected. The information provided in this educational exhibit will allow the reader to: 1) Describe the normal anatomy and physiology of the lymphatic system 2) List causes of chylothorax in infants and children 3) Appreciate the range of imaging modalities available for evaluation of the lymphatic system, and their limitations 4) Understand the goals of chylothorax management Results: The appearance of a chylous pleural effusion on imaging is nonspecific. Cross-sectional or functional imaging may be warranted following identification of a chylothorax to determine the underlying etiology, especially in cases that are refractory to medical management. Conclusions: Knowledge of the causes and management of chylothorax in children will aid in the selection of an appropriate imaging workup.

Poster #: EDU-117 Playing the Hand You are Dealt: Classification and Structured Differential Diagnosis of Hand Congenital Anomalies

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Inflammatory myofibroblastic tumor (IMT) is a rare sub-type of fibroblastic lesions primarily occurring in the viscera and soft tissues of children and young adults (average 10 years of age). It was once debated whether these tumors are neoplastic or reactive conditions, recent research has shown IMT to contain rearrangements in anaplastic lymphoma kinase (ALK-1) supportive of a neoplastic process. Despite this finding, IMT typically follows a benign clinical course with of local recurrence and/or distant metastasis, being unusual. IMT has been called “the great mimicker” as it can present simulate multiple disease entities given its wide anatomic distribution and indolent nature. Clinical presentation and radiologic findings are often nonspecific, making diagnosis difficult and often delaying treatment. We present a case based approach to this rare tumor in different anatomic sites with gross and microscopic pathology correlation. After viewing this educational exhibit, the participant will better understand the various clinical presentations and natural history of IMT; be able to recognize IMT through imaging features in various anatomic locations; and finally be able to integrate these variables into clinical practice by considering IMT in more targeted differential diagnoses.

Matthew Winfeld, MD, Hansel Otero, MD, Children’s National Medical Center, Washington, DC, [email protected]; Dorothy Bulas, MD

Poster #: SCI-001

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: 1. To review the embryologic classification of congenital hand anomalies 2. To illustrate the key findings and useful descriptors for congenital hand anomalies. 3. To highlight the most common syndromic diagnoses and needed additional imaging and genetic work ups. 4. To describe the indications for cosmetic, palliative and corrective surgery Methods & Materials: All illustrations of this education exhibit are from review of hand radiographs in patients with congenital anomalies. Additional prenatal and post natal ultrasound, CT, and MR studies present the most common associations. Differentiation between findings requiring additional genetic and imaging work up versus the ones that do not is shown. The indications, timing and results of palliative and corrective surgery are described through imaging examples. Results: Hand malformations can be simple or complex and single or multiple. Additionally, genetic classification can be divided into sporadic (associated to a single gene mutation) or familial (usually not associated with specific gene mutation). Key features and descriptors of hand congenital anomalies include syndactyly, brachydactyly and polydactyly. Conclusions: Congenital hand anomalies are not uncommon and a basic understanding of their origin and classification is needed by the practicing pediatric radiologist. Pre and post natal imaging plays and important role in identification and classification of hand anomalies. Additional imaging and genetic work ups are needed only in selected cases.

Appendicitis Ultrasound: Comparison Study of Performance of the On Call Junior Radiology Resident to the Technologist and Attending

Poster #: EDU-118 Inflammatory Myofibroblastic Tumor: Imaging Features and Pathologic Correlation Brent Roach, MD, Radiology and Radiological Sciences, Vanderbilt Univeristy, Brentwood, TN, [email protected]; Melissa Hilmes, Sumit Pruthi, Hernan Correa, Sudha Singh, MB BS, MD

Atabak Allaei, M.D., Matthew Neimark, Rachelle Goldfisher, Radiology, State University of New York, Downstate, New York, NY, [email protected]; John Amodio Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The effectiveness of an ultrasound examination for appendicitis maybe limited by the skill of the practitioner performing the study. Limited resources and/or teaching institutional guidelines may leave performance of the initial ultrasound study after hours to a junior radiology resident. In this study we compare ultrasound performance by the radiology residents after hours to the technologists and radiology attendings. Methods & Materials: A retrospective analysis was undertaken of 573 patients who were initially evaluated by ultrasound for clinical suspicion of appendicitis, from April 2008 to March 2014. Studies were distinguished by either resident or technologist and attending performing the procedure. The junior resident was a resident in the first to third years of training and had received at least 4 weeks of ultrasound rotation experience. If the initial ultrasound did not confirm appendicitis, follow-up cross sectional studies and operative reports were reviewed to determine if appendicitis was later confirmed. Results: Of 462 studies in the pediatric non-pregnant group, ages one to eighteen, 261 (56%) were performed by a junior resident and 201 (44%) were performed by a technologist/attending. Resident and technologist/attending groups confirmed appendicitis on the first test in 35 (13.4%) and 22 (11%), respectively (p=0.477). Additional testing ordered after a negative finding was higher in the resident group than the technologist/attending group, 85 (39.5%) and 46 (26.4%), respectively (p<0.01). The number of cases in which appendicitis was confirmed on the follow up study in the resident and technologist/attending groups were 24 (9.2%) and 11 (5.5%), respectively (p=0.157).

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Conclusions: Although appendicitis ultrasound has been traditionally touted as operator dependent, there was no statistical difference in this study between residents and attendings of varying levels of experience. Performance of the junior resident was on par with the attending in the cases that initially confirmed appendictis by ultrasound. Additionally, more follow up studies were ordered when the initial study was negative and performed by the resident.

Poster #: SCI-002 Four Cases of Congenital Bilateral PDA’s Diagnosed with Cardiac CT Angiography Erin Birmingham, Creighton University School of Medicine, Phoenix, AZ, [email protected]; Kimberly Lavin, Randy Richardson Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The ductus arteriosus is a normal prenatal vascular connection between the pulmonary artery and proximal descending aorta or brachiocephalic artery. A single patent ductus arteriosus (PDA) is one of the most common congenital cardiac pathologies. However, rarely a PDA may be separate and bilateral, arising from the left brachiocephalic artery and aorta. These patients typically have complex congenital heart disease with several other anomalies [1]. Computed tomography angiography (CTA) is a cross sectional imaging modality that can be very useful for the anatomic and functional evaluation of such complex congenital cardiac anomalies such as bilateral PDA’s. In this report we present four cases of bilateral PDA’s diagnosed with CTA, and compare the efficacy of cardiac CTA with echocardiogram. Methods & Materials: We retrospectively reviewed records of four neonates who underwent both cardiac CTA and echocardiogram for evaluation of their complex congenital heart diseases. Research protocol was approved by the Institutional Review Board for Human Research at St. Josephs Hospital and Medical Center. There was no violation of animal or human rights in this study. Literature was accessed through PubMed. Results: Four neonates who underwent multiple imaging modalities were reviewed. When first assessed using transthoracic echocardiogram, 0/3 (0%) of the patients were correctly diagnosed. The fourth patient had unobtainable echocardiogram records. While 100% of patients (4/4) were correctly diagnosed with congenital bilateral PDA using cardiac CTA. Conclusions: Review of the literature reveals minimal information regarding bilateral patent ductus arteriosi. Furthermore, inaccuracy in diagnosis secondary to poor visualization on echocardiogram, rarity of the disease, and confounding comorbidities may contribute to the lack of literature available. While angiography, MRA and CT may allow for a more accurate imaging, there are currently no studies indicating a reliable imaging modality for this type of congenital heart disease. The four cases presented highlight the inefficiency of echocardiogram and the disparity between cardiac CT angiogram and echocardiogram findings in infants with multiple congenital cardiac defects. Although our numbers are small, it would appear that cardiac CTA is the superior imaging modality in the detection of this anomaly. Utilization of CTA in complex congenital heart disease is a valuable tool in the accurate diagnosis of unsuspected extra cardiac anomalies such as bilateral PDAs.

Figure 1: Case 1, A. Bilateral PDAs (green) giving rise to pulmonary arteries (blue) – Anterior View B. Post View C. Entire heart (Anterior View) showing single left ventricle (light red). D. Entire heart (Posterior View) E. View of coronary (neutral) coming off of non-coronary sinus F. Total Anomalous Venous Return.

Poster #: SCI-003 The Uniqueness of Right-Sided Congenital Bochdalek Diaphragmatic Hernias: A Ten Year Review T Shawn Sato, University of Iowa, Iowa City, IA, [email protected]; Lillian Lai, MD, Dr. Graeme Pitcher, Patricia Kirby, Dr. Simon Kao, Dr. Yutaka Sato, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare the imaging findings, locations, and associated anomalies seen in right versus left sided Bochdalek type congenital diaphragmatic hernias (CDH), and to elucidate unique features of right sided hernias. Methods & Materials: We reviewed and analyzed cases of CDH seen at our institution from 2005-2014. Results: There were 30 left-sided CDH and 10 right-sided CDH (25%) over this 10-year period. Significant contralateral mediastinal shift was present in 40% of right-sided CDH while 100% of the left-sided CBH showed contralateral mediastinal shift. Among right-sided CDH, unique anomalies including ipsilateral anomalous pulmonary vessels (systemic arterial supply and/or systemic venous drainage) in 3 (30%) patients and fusion of the herniated liver and lung tissue (hepatopulmonary fusion) in 2 (20%) patients. There were no cases of anomalous pulmonary vessels or hepatopulmonary fusion in the left sided CDH patients. Conclusions: Right-sided congenital diaphragmatic hernias are less common than hernias on the left side. Our review indicates that they are associated with anomalies including hepatopulmonary fusion, anomalous systemic arterial supply and systemic venous drainage. These features may explain some of the unique morbidity and mortality observed in right sided lesions. Awareness of the unique features of right-sided congenital diaphragmatic hernias can help direct appropriate imaging and surgical planning.

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Poster #: SCI-004 Pathologic Arterial Sonographic Changes in Neurovascularly Intact Gartland III Supracondylar Humerus Fractures Mary Yang, MD, Radiology, Children’s Medical Center, Dallas, TX; Surehka Patel, Christine Ho, David Podeszwa, Anthony Riccio, Brandon Ramo, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: This study was performed to describe changes in arterial flow in completely displaced neurovascularly intact Gartland III pediatric supracondylar humerus fractures (SCHFx) using ultrasound. Methods & Materials: This is an IRB-approved prospective study from October 2012 through August 2013 of eleven Gartland type III SCHFx (supracondylar fracture with disruption of the posterior cortex and no cortical continuity) with palpable radial pulses and normal neurologic exams. Ultrasound was performed on injured and uninjured arms, preoperatively and post-CRPP (closed reduction percutaneous pinning). Ultrasound wrist/brachial indexes (WBI) were calculated using the higher value of the radial/brachial or the ulnar/brachial index. Results: Two patients (Patients #1 and #2) had normal arterial flow comparable in the brachial, radial, and ulnar arteries of the affected arm, compared to the unaffected arm, both pre-operatively and post-pinning. Pre-operatively, six patients (Patients #3-8) had stenosis of the brachial artery at the fracture site (22-60% narrowing) with elevated peak systolic velocity (PSV) (1.52-2.98 times higher) when compared to the brachial artery proximal to the fracture. Flow of the radial and ulnar arteries was preserved. Of these six patients, two had decreased WBI in the affected arm compared to the unaffected arm, three had minimally lower WBI, and one had higher WBI. Postoperatively, for these six patients, one patient had no change post-CRPP, one patient had improved artery narrowing but continued elevated PSV, one had improved artery narrowing and PSV, and three did not have a post-CRPP exam performed. Patient #9 had brachial artery narrowing with decreased PSV in the distal arm and markedly decreased WBI compared to the unaffected arm. Post-CRPP, there was improved brachial artery narrowing but with elevated PSV and minimally improved flow to the wrist. Patient #10 had brachial artery narrowing but normal PSV and intact ultrasound wrist/brachial index, without much change post-CRPP. Patient #11 had a pink pulseless hand after anesthesia induction. Duplex revealed narrowed brachial artery with decreased PSV of brachial, radial, and ulnar arteries and decreased ultrasound WBI with no significant improvement post-CRPP. Conclusions: Type III supracondylar fracture patients with a normal neurovascular exam and an intact radial pulse may have abnormal ultrasound with brachial artery stenosis and elevated PSV pre-operatively although distal flow remains comparable to the contralateral side.

Poster #: SCI-005 Model-Based Iterative Reconstruction for Fetal CT: Achieving Ultra-Low-Dose CT for Prenatal Diagnosis of Bone Dysplasia – Pilot Study Osamu Miyazaki, Radiology, National Center for Child Health and Development, Tokyo, Japan, [email protected]; Rumi Imai, Gen Nishimura, Haruhiko Sago, Shunsuke Nosaka Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To assess the image quality and radiation dose of ultra-low-dose fetal CT (ULDCT) for prenatal diagnosis of skeletal dysplasia using model-based iterative reconstruction (Veo™ GE Medical Systems, Milwaukee, WI). Our hypothesis is that ULDCT can reduce the

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radiation dose by 80% compared with that required for adaptive statistical iterative reconstruction (ASIR™) without loss of image quality. Methods & Materials: Raw data that were obtained using three different protocols were reconstructed into separate image datasets using Veo™ and ASIR™ algorithms. The three protocols were as follows; current protocol (CP, CTDIvol=2.5 mGy, two cases), low-dose protocol (LDP, CTDIvol= 1.3 mGy, half the CP dose, two cases), ultra-low-dose protocol (ULDP, CTDIvol=0.5 mGy, 20% of the CP dose, two cases). Two pediatric radiologists evaluated images using a 4-point Likert scale (excellent, good, poor, not acceptable). We compared the standard deviation of the Hounsfield unit density of amniotic fluid for the three protocols (Veo™, VS, and ASIR™ algorithms respectively) on 0.625 mm slice images. Fetal radiation doses were estimated based on the absorbed uterine dose using computer software (CT-Expo “Light” Pro version 1.1- Dark Edition). Results: All LDP and ULDP cases examined by Veo™ were classified as “excellent”, while LDP and ULDP cases examined by ASIR™ were classified as “not acceptable” based on volume rendering. Minimal changes in image noise (SD) were observed for Veo™ through CP to ULDP, while image noise was obviously higher when ASIR™ was used (Fig 1). Fetal dose was 1.8 mSv for LDP and 0.7 mSv for ULDP. Conclusions: ULDCT appears to be acceptable and renders superior image quality even though the radiation dose is 80% lower than that required for ASIR™. It was demonstrated that sub-mSv fetal radiation doses can be achieved.

Poster #: SCI-006 Cumulative Radiation Dose in Esophageal Atresia Patients: A 10 year Cohort Study Paul Zamiara, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada, [email protected]; Karen Thomas, MD, Bairbre Connolly, Eveline Lapidus-Krol, Margaret Marcon, Priscilla Chiu Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Esophageal atresia +/− tracheo-esophageal fistula (EA) patients represent a cohort of complex care patients requiring multiple imaging studies related to their esophageal and in many cases, VACTERL morbidities. Many of these studies expose them to ionizing radiation (IR), and are performed in the neonatal and infantile periods, a time when patient radiosensitivity is high. The quantity and modality distribution of IR exposure among EA patients in infancy and early childhood has not yet been investigated. Methods & Materials: Retrospective review of institutional imaging history was performed for the first 3 years of life of EA patients born between July 1999 and June 2009. The number and Cumulative Effective Dose

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(CED) of imaging studies involving IR [radiography, diagnostic fluoroscopy, interventional radiology, computed tomography, nuclear medicine, cardiac catheterization] as well as the number of studies not involving IR [ultrasound and magnetic resonance imaging] were recorded. Age-related Effective Dose estimates were assigned for each study, using institutionspecific data wherever possible, and accounting for equipment updates and the introduction of new dose-saving technologies during the study period. Results: In total, 151 EA patients were treated, including 37 with VACTERL anomalies. Patients were exposed to a mean CED of 14.8 mSv (median 10.9, range 0.1-59.9) from a mean number of 42 studies (median 25, range 5-177) over the first 3 years of life. Diagnostic fluoroscopy was the largest contributor to total dose (mean CED of 9.9 mSv from a mean six studies per patient). The introduction of equipment with pulsed fluoroscopy capability during the study period resulted in a significant reduction in fluoroscopy-related dose (median CED 9.9 mSv before vs 4.2 mSv after, p<0.05). Conclusions: Diagnostic investigation and interventional therapy of EA patients exposes these complex patients to a considerable number of imaging studies involving ionizing radiation. Determinants of total dose include clinical imaging algorithms, equipment factors including advances in dose-saving technologies and protocols, and the complexity of individual clinical course and co-morbidities. A multidisciplinary approach involving diagnostic imaging, surgical, gastroenterology and other participating services may identify routes to improve care through attention to study justification, greater co-ordination of imaging requests and further dose optimization.

by 8%. MRI GA average appointment wait time was reduced by 21% during the pilot project. Conclusions: The results of the pilot project indicate that melatonin given in combination with sleep deprivation can be an effective alternative to conventional GA for eligible patients. Successful introduction of the new practice required organizational focus on priorities, meaningful staff involvement, coordinated planning and execution of interdependent activities, interprofessional collaboration, and effective communication at all levels. A structured and data driven approach was used to add value to the patient experience and empower staff and clinicians to affect change in their processes.

Poster #: SCI-007 Reducing the Need for MRI GA Using Melatonin Albert Aziza, Zoran Bojic, MHSc, Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada, [email protected] Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The optimal acquisition of diagnostic images during a MRI examination requires patient immobility. For a paediatric patient population and patients who are uncooperative due to their medical condition this expectation presents unique challenges. General Anaesthesia (GA) is usually needed to ensure patient immobility and successful acquisition of diagnostic images. The main purpose of the project was to assess the effectiveness of oral melatonin on patients requiring GA for their MRI examination, decrease the number of patients requiring GA and ultimately reduce patient wait time for MR imaging. Methods & Materials: Parents/caregivers of patients that required GA were offered the option of trying melatonin as an alternative prior to their original GA-MRI appointment. The patients were given an evening appointment which aligned with their normal sleep time. Upon receiving an informed consent, patients weighing ≤20 Kg were given 3 mg and patients weighing >20 Kg were given 6 mg of melatonin. If melatonin induced sleep within the designated time the MRI was performed; if melatonin was ineffective the patients were discharged and would return on the date of their original appointment. Balanced scorecard was used to measure success of the project. Results: The results of the pilot project indicate that melatonin given in combination with sleep deprivation can be an effective alternative to conventional GA for eligible patients. MR scan was completed successfully for 53 (87%) of the 61 patients participating in the pilot project. The average time to fall asleep was 39 min and the average scanning time was 60 min. There were no complications or adverse events associated with the use of melatonin and departmental patient satisfaction score increased

Poster #: SCI-008 Diagnosis of Fetal Hypospadias: Accuracy and Outcome Yan Epelboym, MD MPH, Brigham & Women’s Hospital, Boston, MA, [email protected]; Dr. Carlos Estrada, Judy Estroff, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To assess the diagnostic accuracy of a prenatal ultrasound diagnosis of hypospadias when compared to postnatal clinical evaluation. Methods & Materials: We retrospectively identified all pregnant patients from 2004 to 2014 who were either referred to the Advanced Fetal Care Center (AFCC) at our institution for a diagnosis of hypospadias, ambiguous genitalia, short phallus, buried penis, penoscrotal transposition, or who had a diagnosis of any of these findings after fetal ultrasound in our center. Referral diagnosis, gestational age, associated genitourinary (GU) and non GU anomalies, penile length and configuration were documented. After birth, GU findings on physical exam and imaging and other nonGU abnormalities were documented. Accuracy of prenatal diagnosis was then assessed by comparison to postnatal findings. Results: A total of 38 fetuses were identified. Prenatal and postnatal clinical information was available at our institution for 32 fetuses (84%). Of these, AFCC ultrasound suggested hypospadias in 22 cases (69%). Of the 22, 15 infants were confirmed to have hypospadias on postnatal clinical exam, reflecting a concordance rate of 68%. Of the clinically confirmed hypospadias cases, 11 of 15 (73%) were proximal, 2 of 15 were distal (13%), and 2 of 15 were glanular (13%). 12 of the 15 (80%) cases of confirmed hypospadias demonstrated a blunt penile tip on fetal ultrasound. Chordee was documented on fetal ultrasound in 3 of the 15 (20%) confirmed hypospadias cases.

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Infants with confirmed hypospadias often had several associated GU anomalies on postnatal clinical exam. The most common findings were chordee in 10 of 15 (67%) and bifid scrotum in 5 of 15 cases (33%). In 7 of 22 cases (32%), fetal ultrasound and postnatal clinical diagnosis were discordant, though only one newborn was normal, without any GU anomaly. Of the 7 discordant cases, 3 infants had phimosis, 1 had mild penoscrotal transposition, 1 had bladder exstrophy, 1 had penopubic epispadias, and 1 had a normal penis. Conclusions: Our single center experience with the prenatal ultrasound diagnosis of hypospadias demonstrates a high level of accuracy for a penile anomaly (21/22, 95%), and a moderately high level of accuracy for the specific diagnosis of hypospadias (15/22, 68%) when compared to the postnatal clinical diagnosis. In this cohort, there was a strong association between the ultrasound diagnosis of a blunt penile tip and a clinical diagnosis of hypospadias. Fetal Ultasound Findings in Confirmed Fetal Hypospadias Patients

Tier 3: 1.3%; PPV 100% Tier 4: 7.1%; NPV 100% Tier 5: 56%; NPV 100% The prevalence of appendicitis was 41/153 (27%) and the appendix was found in 128/153 ultrasounds (84%). There are limited data for tiers 1, 3, and 4 because of the high rate of detection of the appendix at our institution, but we feel this will be adequately addressed by increasing the number of cases included in the final review, increasing the robustness of the statistical analysis. Conclusions: Formal tiered reporting has the potential to add further value to the ultrasound in clinical decision making during the workup of the pediatric acute abdomen. If the PPV or NPV is provided for ultrasounds where the appendix was not seen, the exam can still potentially guide clinical decision making and reduce the rate of subsequent CT, thereby decreasing radiation exposure.

Total confirmed Median Gestational Meidian Penile Length (cm) cases Age at scan (weeks)

Poster #: SCI-010

N=15

26 (range 20-36)

Ultrasound finding Ultrasound of blunt penile tip finding of chordee

0.7 (range 0.4-2.7) 12/15 (80%)

3/15 (20%)

Poster #: SCI-009 Performance Metrics for Tiered Reporting of Ultrasound for Acute Appendicitis Harry Conley, MD, Radiology, Seattle Children’s Hospital, Seattle, WA, [email protected]; Dr. Jason Nixon, Jennifer McBroom Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Sonographic evaluation for acute appendicitis remains a mainstay in evaluating the pediatric acute abdomen. As the appendix is not always directly visualized, secondary findings may be valuable. This study has two aims: 1) to define tiers for reporting an ultrasound for appendicitis and 2) report the positive predictive value (PPV) and negative predictive value (NPV) of each tier. The tiers are as follows: 1-Right lower quadrant not evaluable (e.g. patient intolerance of the exam, excessive bowel gas) 2-Positive (exam consistent with acute appendicitis) 3-Appendix not seen, secondary signs present 4-Appendix not seen, no secondary signs 5-Negative (normal appendix) Methods & Materials: Between 10/2013 and 6/2014, 1,005 ultrasounds were performed at our institution to evaluate for appendicitis. Structured reporting for ultrasound of the appendix had been implemented, so all radiologist reports–and the sonographer worksheets–included specific details on the appendix itself (e.g. AP diameter and wall thickness at various points along the appendix) and on secondary signs (e.g. inflamed mesenteric fat, complex free fluid). The reports were reviewed and assigned a tier by a pediatric radiologist and a fellow. For unusual cases or discrepancies within the report or between the report and clinical outcome, the images were reviewed. Clinical follow up of at least 4 months, including disposition and operative and pathology reports, where applicable, were retrieved from our electronic medical records. Results: Thus far, 153 of the 1,005 ultrasounds have been assigned tiers. The preliminary data are as follows: Tier 1: 7.8% Tier 2: 28%; PPV 91%

Clinical Utility of Dual-Energy X-Ray Absorptiometry for Assessment of Fractures in Pediatric Osteoporosis: Evidence-Based Knowledge Synthesis Kuan Chung Wang, The Hospital for Sick Children, Tortonto, ON, Canada, [email protected]; Sohaib Munir, Khashayar Shariati, Tamsin Adams-Webber, Andrea Doria Disclosures: Andrea Doria has indicated a relationship with Baxter Healthcare Inc, as a speaker. Purpose or Case Report: Although dual-energy X-ray absorptiometry measurements can respond to interventions (i.e. bisphosphonate), insufficient evidence are currently available to support their use for osteoporotic fracture assessment in children. This study semi-quantitatively assesses the clinical utility of DXA for evaluating pediatric osteoporosis according to the U.S. Preventive Services Task Force guideline. Methods & Materials: We retrieved articles for assessing abnormal bone quality or quantity in patient of mean age ≤18 years from MEDLINE, EMBASE and Cochrane Library CCTR databases (1946-2014). Evidence were analyzed for criterion validity (concurrent and predictive validity) and responsiveness of DXA according to the following questions: (1) Is DXA a good predictor and/or indicator of bone fragility fracture risk in patients with osteoporosis treated by corticosteroids? (2) Is DXA responsive to an intervention (bone-active treatment such as bisphosphonate, calcitriol, or exercise) in patients with osteoporosis treated by corticosteroids? Two reviewers independently evaluated the quality of reporting and methodological quality using the Standards for Reporting of Diagnostic Accuracy (STARD) and the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tools. Results: Out of 1304 retrieved references we included 18 studies (1870 patients; 963 reported boys and 907 girls, others unspecified; reported mean age, 0-18 years). The mean quality of reporting score was “moderate” (69.8% of articles); the mean methodological quality score was “high” (88.3%). Recommendation is made against the use of DXA for diagnosis of vertebral fracture (concurrent validity) (Grade D), insufficient evidence is available to make a recommendation regarding the value of DXA for prediction of future fractures (Grade I), and fair recommendation exists for the use of areal lumbar spine bone mineral density to assess the effect of bisphosphonate therapy (Grade B). Gaps in the literature included lack of information concerning differences in DXA utility for peripheral vs. vertebrae fracture and advantages/disadvantages of different measurement types (areal vs. volumetric).

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Conclusions: Considering the relatively high methodological quality of available articles, there is no definite evidence on the clinical utility of DXA for assessing pediatric osteoporosis presently. Although DXA-based measurements can respond to interventions (fair evidence), insufficient evidence has been accrued to support other clinimetric properties of this technique.

Levels of evidence and recommendations according to the guidelines of the U.S. Preventive Services Task Force’s (USPSTF) recommendation guidelines Maneuver (Fig. 1)

Focus Area (1, 2, or 3)

Concurrent validity of 1 DXA to diagnose fracture (1)

3

Predictive ability of DXA to predict future fracture (1)

Responsiveness of DXA to intervention (2)

Evidence

USPSTF categorization

Six studies reported non-diagnostic Six cross-sectional studies, ability of various DXA parameters two prospective cohort (aLSBMD (n=6), aTBBMD studies, and one (n=3), aFBMD (n=2), vLSBMD retrospective cohort (n=2), LSBMC (n=2)) for studies; Level II-2 (n=9) diagnosis of vertebral fracture. Two studies reported borderline ‘poor’ diagnostic ability of aLSBMD. One study reported adequate diagnostic ability of aLSBMD Grade I: Insufficient evidence (particularly in quantity) to make recommendation for the 3 gaps

The following 3 gaps were noted: (i) diagnosis for peripheral fracture; (ii) diagnostic ability of changes in DXA measurement; (iii) difference between area vs. volumetric measurement 3 Four studies investigated the predictive ability for future fracture, but with very heterogeneous clinical settings. Nevertheless, all 4 studies demonstrated adequate predictive ability of DXA. The following 4 gaps were noted: (i) predictive value for peripheral vs. vertebral fracture; (ii) difference between single time-point measurement vs. multi time-point in measurements; (iii) choice of region of interest; (iv) difference between area vs. volumetric measurement 1 Four studies investigated the responsiveness of DXA measurements to bisphosphonate therapy, and 3 studies investigated organ transplantation. Overall, aLSBMD was reported to be responsive to intervention regardless of baseline diseases

Recommendations Grade D: Recommendation against the use of DXA for diagnosing vertebral fracture

Three prospective cohort studies, and one retrospective cohort studies; Level II-2 (n=4)

Grade I: Insufficient evidence (particularly in quantity) to make recommendation for the 4 gaps

One experimental nonrandomized control trial, 2 prospective cohort studies, and 1 double blind RCT; Level II-1 (n=1), II-2 (n=2), I (n=1)

Grade B: Fair recommendation for DXA to be responsive to bisphosphonate therapy and organ transplantation

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Maneuver (Fig. 1)

Focus Area (1, 2, or 3)

2

Three studies investigated Five prospective cohort studies; DXA measurement to Level II-2 (n=5) corticosteroid treatment, and 2 studies investigated chemotherapy. The results were too heterogeneous in terms of treatment protocol and baseline diseases to be synthesized and further categorized The following 2 gaps were – noted: (i) difference/choice between areal or volumetric measurements; (ii) the choice of region of interest

3

Evidence

USPSTF categorization

Recommendations

Grade C: No recommendation for or against routine provision of the service due to conflicting evidence

Grade I: Insufficient evidence (particularly in quantity) to make recommendation for the 2 gaps

Abbreviations: DXA, dual-energy absorptiometry; aLSBMD, areal lumbar spine bone mineral density; aTBBMD, areal total body bone mineral density; aFBMD, areal femoral neck bone mineral density; vLSBMD, volumetric lumbar spine bone mineral density; LSBMC, lumbar spine bone mineral content Note: Focus Area 1 represents areas in the existing literature that have enough knowledge (in quantity and quality) to be synthesized; Focus Area 2 represents areas that are too heterogeneous or scarce to provide clinically useful information and that require further standardization of imaging and research methods; Focus Area 3 represents gaps in the literature.

Poster #: SCI-011 Hip Click and Developmental Hip Dysplasia: Correlation Between Physical Exam Findings and Hip Ultrasound Trevor Davis, DO, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Christie Moss, Lee Segal, Smita Bailey, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Hip ultrasound (US) is often performed on infants with certain risk factors to evaluate for developmental dysplasia of the hip (DDH). The importance of a “hip click” found on newborn physical examination is somewhat controversial, particularly in relation to DDH. At our institution “hip click” remains a common indication for hip US. The goal of this study is to determine the correlation between an isolated hip click found on physical examination and the sonographic diagnosis of hip dysplasia. The experience of the referring physician and those with specific musculoskeletal/orthopedic training were also evaluated. Methods & Materials: All hip US studies performed at a large children’s hospital were reviewed over a 4 year period (2010–2013) for infants referred for “hip click.” Referrals for other indications including breech, family history and + Barlow/Ortolani signs on exam were excluded. Hip US studies were performed according to current American College of Radiology (ACR) recommendations. All pediatric hip ultrasounds were interpreted by fellowship trained pediatric radiologists using acetabular morphology, position of the femoral head and stability. Referring physician experience was determined by the number of years in practice after medical school graduation and specific orthopedic or musculoskeletal training. IRB approval was obtained for this study. Results: A total of 1120 hip US studies were performed. Two hundred forty studies were identified as being referred for hip click alone (21.4%). One hundred sixty five were female infants (86%), and 75 were male (14%) The mean age at the time of the study was 54 days (range, 15-208.” Referrals for other indications including breech, family history anddays). Thirty-five (14.6%) of

the studies were abnormal (8 pathologic immature, 15 mild, 6 moderate, and 6 severe hip dysplasia). We found no statistically significant difference in prevalence of abnormal hip US studies with respect to referring physicians number of years in practice (p = 0.53); or those physicians with additional orthopedic/MSK training (p=0.77). Conclusions: Our study found ultrasound findings of DDH in 14.6% in patients referred for hip click alone. We found no increase in prevalence of DDH in those infants referred by orthopedic surgeons or pediatricians with more years of experience.

Poster #: SCI-012 Impact of 4th Generation Iterative Reconstruction on Multi-Detector Pediatric Head CT: Effects on Image Quality and Radiation Exposure Anna Thomas, MD, Phoenix Children’s Hospital, Phoenix, AZ; John Egelhoff, Houchun Hu, John Curran, Jeffrey Miller, Richard Towbin, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Compare effects on image quality and radiation exposure between pediatric head CT examinations performed using standard filtered back projection with those using a 4th generation iterative reconstruction (IR4) technique. Methods & Materials: We retrospectively reviewed 126 head CT exams performed with standard filtered back projection and 158 pediatric head CT exams performed with iDose4 level 2, an IR4 developed by Philips Healthcare. All exams were obtained on a 256-slice Brilliance iCT scanner (Philips Healthcare). These were stratified into four age categories based on age in years (01.5, 1.5-7.0, 7-13, and over 13). A single axial slice through the basal ganglia at the level of the foramina of Monro was reviewed for each exam. Circular regions of interest measuring 0.6 +/− 0.05 cm2 were drawn in the region of the mid right thalamus (grey matter) and the right frontal white matter. This allowed

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for quantification of mean Hounsfield Units (HU) and standard deviation (SD) for grey matter (GM) and white matter (WM) which were used in standard equations to calculate our objective parameters. Objective parameters of image quality compared between the two techniques were signal to noise ratio (SNR) for GM, SNR for WM, and contrast to noise ratio (CNR) between GM and WM. CTDIvol (value calculated by the CT machine) and effective dose (ED) were used as quantitative parameters for dose comparison between the two techniques. Equations used were: ED=k (CTDIvol), SNRGM = mean HU GM/SD GM, SNRWM = mean HU WM/SD WM, and CNR = (mean HU GM - mean HU WM)/ ((SD GM)2 + (SD WM)2)0.5. The k used for calculating ED is an established age dependent variable coefficient. Results: Comparisons of SNR of GM in the age group of 0 to 1.5 years showed statistically significant improvement for IR4 (p < 0.05). The remaining age groups had no statistically significant differences between the two imaging techniques for SNR of GM. Differences in SNR of WM and CNR gray-white were statistically insignificant between the two imaging techniques in all four age groups. The radiation dose parameters of ED and CTDIvol were significantly lower for IR4 across all age groups (p < 0.01). There was 25.9% average CTDIvol dose reduction for all pediatric patients scanned with IR4. Conclusions: Compared to standard FBP, the IR4 technique utilized in this study demonstrates statistically significant dose reduction for all pediatric patients undergoing head CT examinations while maintaining and in some instances, improving objective image quality.

Effective Dose (mGy)

7

ED FBP

6

ED iDose

5 4 3 2 1 0

0-1.5

1.5-7.0 7.0-13 Age (Years)

>13

Figure 1: Bar plot of average and standard deviation of effective dose (ED) between filtered back projection (FBP) and iDose (4th generation, level 2) as a function of age groups. In each age group, the difference in effective dose between FBP and iDose4 are statistically significant (p<0.01).

Poster #: SCI-013 Transluminal Absorption of Doxycycline Following Catheter Sclerotherapy Treatment of Large Neonatal and Infant Lymphatic Malformations Miriam Toaff, Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, [email protected]; Sphoorti’ Shellikeri, Master’s in Biomedical Engineering, Natalie Rintoul, Anne Marie Cahill Disclosures: Anna Marie Cahill has indicated a relationship with Siemens AX, Inc as an advisory Board Member. All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To study transluminal absorption of doxycycline following catheter sclerotherapy treatment of lymphatic malformations in infants weighing less than 10 kg and to assess for correlation between weight, doxycycline dose and development of hypoglycemia, metabolic acidosis, and hemolytic anemia. Methods & Materials: A retrospective review was performed to identify patients with macrocystic lymphatic malformations who were treated with doxycycline catheter instillation. Data collection included the following: doxycycline dose, dwell time, serum doxycycline level, and doxycycline related systemic complications. Serum doxycycline levels were obtained during the instillation period. Results: Nineteen patients undergoing 47 doxycycline instillations were included. The median Doxycycline dose was 200 mg per instillation (range: 30-500 mg). In all cases, serum doxycycline increased during the instillation period of 2-8 h (mean: 6 h). Serum doxycycline levels ranged from 2.3 mcg/ mL to >40 mcg/mL, significantly exceeding the normal therapeutic range of 1.5-2.1 mcg/mL. These levels were obtained between 40 min and 9 h post-instillation of doxycycline (median: 6 h). Post-procedural complications encountered during these 47 instillations were: metabolic acidosis (19/47), reduction in hemoglobin (14/47) and hypoglycemia (12/47). Reticulocyte counts (11/14) were elevated in 10/11 instillations in which there was a drop in hemoglobin indicating possible hemolytic anemia. In this pilot study, there was no relationship identified between doxycycline dosage, serum doxycycline level, and the incidence of these complications (p’s > 0.05). Conclusions: This study demonstrates transluminal systemic absorption of doxycycline during catheter sclerotherapy in infants and neonates. The systemic complications of hemolytic anemia, metabolic acidosis, and hypoglycemia in this study was not related to doxycycline dose but should be monitored closely in this population.

Poster #: SCI-014

Age (Years) CTDI FBP (mGy) CTDI iDose (mGy) % Dose Reduction 0-1.5

31.2

22.3

28.6

1.5-7.0

29.8

23.0

22.7

7.0-13

37.0

27.3

26.3

>13

39.5

29.2

26.0

Table 1: Summary of CTDI vol (mGy) measurements between filtered back projection (FBP) and iDose (4th generation, level 2) as a function of age group, along with percent change.

The Efficacy of Propranolol Therapy on the Proliferative Phase of Infantile Hemangiomas David Aria, MD, Phoenix Children’s, Phoenix, AZ; Trevor Davis, DO, Robin Kaye, Carrie Schaefer, Richard Towbin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To demonstrate the effectiveness of propranolol therapy in treating infants with infantile hemangiomas in their proliferative phase

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Methods & Materials: In a retrospective review over a 6 month period in 2013 at a large, tertiary care pediatric hospital in the Southwest United States, 96 infants less than 1 year of age with infantile hemangiomas diagnosed clinically or via imaging studies were treated with daily oral propranolol. Although no generally accepted standardized protocol has been established, our institution’s protocol is as follows: • Pre-treatment baseline vital signs obtained • Weight based dosage (1-2 mg/kg/day) given orally on the inside of the cheek 3 times/day with feeding • Clinical follow-up at the following predetermined time intervals: • 1 week & 5 weeks post initiation • Then once a month for 2-3 months • Then every 2 months until discontinued • No imaging unless clinical concern for PHACES syndrome • Follow-up monitoring includes: • Evaluating for wheezing and lethargy • Obtaining vital signs • Updating weight to adjust dosing • Dosages adjusted or temporarily discontinued if an upper respiratory infection is present • Treatment terminated at the child’s first birthdate or earlier if significant side effects develop • At completion of therapy, propranolol dose tapered to half dose for 1 week with discontinuation the subsequent week Results: Of the 96 patients, 5 were lost to follow-up. Of the remaining 91 patients, 83 (90%) demonstrated a reduction in size or size stability at the termination of their propranolol treatment regimen. The remaining 8 patients had the following side-effects causing early treatment termination: • Wheeze/cough 4 • Poor perfusion to extremities 1 • Sleep disturbance 1 • Deceased (not therapy related) 1 • Acute life-threatening emergency 1 Conclusions: • Propranolol therapy is safe and effective and has become the first-line therapy for children with infantile hemangiomas • Surgery and embolotherapy are now reserved for failed medical treatment or high-risk lesions

Poster #: SCI-015 Clinician Perception of Radiology Reports and Communication in the Pediatric/Neonatal ICU Setting Cara Morin, Wendy Kim, MD, Nicholas Morin, Jane Kim, University of Maryland Medical Center, Baltimore, MD; Narendra Shet Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: - Assess clinician perception of radiology reports and communication for daily pediatric and neonatal intensive care unit (PICU/NICU) radiographs - Tailor reporting and communication style based on the needs and preferences of the clinicians Methods & Materials: An initial 16 question anonymous survey was distributed electronically to residents, fellows, nurse practitioners, and attendings in the NICU and PICU. Survey questions were aimed to identify the role of radiology reports in clinical management, possible shortcomings in radiology report style and communication of emergent findings, and ways to improve the utility and efficiency of radiology reporting. Radiology reporting style and communication methods were changed to reflect the needs of the clinician for a trial period of 8 months. A 17

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question follow-up survey was distributed to assess change in clinician satisfaction with radiology reports. Results: The initial survey yielded 30 responses: 100% view images every/nearly every time, 84% read at least some portion of the radiology report every/nearly every time, 77% preferred structured reporting, 73% prefer more quantitative measure of describing invasive line position, and 23% were unsatisfied with timeliness of report finalization. An action plan was instituted for 8 months and included structured reporting with quantitative description of invasive lines and timely communication of major critical findings to the team by the radiology attending before clinical rounds. Follow up survey yielded 29 responses: 86% found structured reporting easier to read, 66% were more likely to read the report if structured, and 7/10 people who had participated in both surveys thought communication improved. Conclusions: Our survey demonstrated that in the neonatal/pediatric intensive care setting the majority of clinicians rely on radiology reports and prefer a structured report format, including specific descriptions of invasive line position. In the ICU setting, the clinician is the main client of the radiology department. It is important to provide timely, useful reports to ensure clinician satisfaction and ultimately better patient care. Numerous studies have been published that advocate the need for structured reporting without documenting clinician preference. Our study provides needed data to support that pediatricians prefer structured reports.

Poster #: SCI-016 Imaging Findings in Acute and Chronic Bilirubin Encephalopathy Li-tal Pratt, MD, Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Prakash Muthusami, Aideen Moore, William Halliday, Adrian James, Susan Blaser Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Neonatal hyperbilirubinemia is associated with risk for acute and chronic bilirubin encephalopathy (BE). Long-term BE sequelae include movement disorders and auditory neuropathy. Characteristic neuropathologic damage involves globi pallidi (GP), subthalamic nuclei (STN), substantia nigra (SN), hippocampi (HC), brainstem nuclei and cerebellum [Fig. 1]. Imaging clues are acutely high T1 signal [Fig. 1] and chronically high T2 signal and volume loss within GP, STN and HC. GP findings explain the movement disorders, while imaging confirmation of damage to the auditory apparatus has been difficult. We retrospectively evaluate and describe MRI features in a large cohort of BE patients and illustrate these findings with pathologic specimens. Methods & Materials: Seventy-nine MRI studies of 44 children with acute (group 1) or chronic (group 2) BE were evaluated. Group 1 included 16 neonates (<1 month old) with increased bilirubin levels or BE encephalopathy (mean age ± SD, 38.9 ± 3.2 weeks gestation), while group 2 consisted of 39 infants (≥1 month old) and children imaged for movement disorders or auditory neuropathy in whom features of BE were found (mean age±SD, 28.4±39.2 months). The studies were evaluated qualitatively for presence of BE related and non-related findings by two reviewers. Additionally, quantitative HC volumes were performed and compared with 61 age-matched controls.

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Results: Bilateral symmetric high T1 signal in GP, without volume loss, was observed in 16/16 group 1 patients (100%). Symmetric acute high T1 signal changes were observed in STN (94%), SN (94%), lateral geniculate body (31%), HC (31%) and dentate nuclei (6%). In group 2, 30/39 (77%) and 32/ 39 (82%) showed bilateral symmetric GP volume loss and high T2 signal, respectively. Additional T2 hyperintensities were seen in STN (54%), SN (31%), lateral geniculate body (5%), HC (49%) and dentate nuclei (3%). HC volumes were significantly lower in group 2 patients compared to healthy controls (Mean hippocampal volume±SD, patients and controls: 1503± 443 mm3 and 2350±527 mm3 respectively, p<0.0001). [Fig. 2] Conclusions: Acutely increased T1 and chronically increased T2 signal and volume loss in typical areas provide clues to diagnosis of BE. Documentation of typical damage patterns may alert to the presence of acute BE, as normal total bilirubin levels may be toxic in the presence of other clinical complications such as sepsis. Documentation chronically may help to confirm the diagnosis of BE in survivors with movement disorders and auditory neuropathy.

Poster #: SCI-017 Reducing Radiation Dose in Neonatal Intensive Care Unit Imaging Ravi Sharma, MD, Radiology, Integris Baptist Medical Center, Oklahoma City, OK, [email protected]; Georgianne Snowden, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: There has been a surge of interest in the public which parallels the pediatric radiology community’s drive to improve standards of pediatric radiation exposure. National media and government emphasis has put the spotlight on pediatric imaging with a high level of concern for remote cancers from radiation exposure during a young age. It is our responsibility to take the forefront in such patient safety issues in our hospitals to demonstrate the Radiologist’s leadership role with a results driven response. Based on a project published in the Journal of the American College of Radiology January 2014, a similar effort was initiated between our department and our Neonatal Intensive Care Unit to initiate higher standards of imaging techniques and improve interdepartmental communication and patient safety. Methods & Materials: We implemented four core principles which were applied at another institution as published in the JACR article to decrease radiation dose to NICU patients who receive frequent imaging: 1. We used interdepartmental meetings with neonatal nursing, neonatologists, radiation technicians, and radiologists to increase awareness of the need for specific orders regarding body parts to be imaged. We took measures to increase compliance between staff to allow proper visualization of patient anatomy. 2. We implemented collimation guidelines to include lead collimation lines seen on the images to ensure compliance. We defined the specific anatomic landmarks for images and intervally reviewed films to track compliance with these standards. 3. We increased the use of gonadal shielding for the male NICU patients. Gonadal shielding in female patients has been found to obscure necessary pelvic anatomy and therefore was not used on all exams. 4. With the guidance of the medical physicist, data was collected to monitor reductions in radiation dose. Results: We were able to demonstrate improved patient safety by reducing unnecessary radiation exposure. This was achieved by tracking reduction in radiation dosage as well as demonstrating a significantly increased compliance with the collimation guidelines. The project also improved interdepartmental cooperation and support to build a foundation for future projects. Conclusions: This project is a primary way to further establish the Radiologist’s responsibility in radiation safety over the course of several months. It serves to educate clinical staff on radiation safety issues and to objectively improve the quality and safety in pediatric radiology.

Poster #: SCI-018 Residual Subependymal Germinal Matrix Tissue in Very Premature Neonates and its Association with Germinal Matrix Hemorrhage David Podhaizer, MD, Radiology, Boston University Medical Center, Boston, MA, [email protected]; Karen Buch, Amy Tsai, Bindu Setty, Ilse Castro-Aragon Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: The germinal matrix is a cellular and highly vascular structure from which cells migrate out to form the brain during embryologic development. Because of their high vascular supply, the germinal matrix in the caudothalamic groove is prone to hemorrhage making it a common finding on screening head ultrasounds of premature neonates. In very premature neonates, we believe there is residual subependymal germinal matrix tissue that can be found on the floor of the lateral ventricle anterior to the caudothalamic groove. It is unknown if the presence of this subependymal germinal matrix is associated with higher incidence of germinal matrix hemorrhage. Methods & Materials: From January, 2008 to December, 2013, head ultrasounds of 407 preterm neonates born before 37 weeks were retrospectively reviewed for the presence of subependymal germinal matrix tissue and germinal matrix hemorrhage. The occurrence of these two entities and the age at which the subependymal germinal matrix tissue resolved was recorded. Subependymal germinal matrix was defined as a linear echogenic structure on the floor of the lateral ventricle anterior to the caudothalamic groove that resolved on subsequent ultrasounds without cystic evolution. In contrast, germinal matrix hemorrhages, which are also echogenic and can be found in a similar location, undergo cystic degeneration with time. A Fisher’s exact test was applied for statistical analysis. Results: When compared to preterm neonates without subependymal germinal matrix, there is no significant association between subependymal germinal matrix tissue and germinal matrix hemorrhages (P = 0.23). There was also no significant association between subependymal germinal matrix and each grade of germinal hemorrhage (P=0.09 for grade 1, P=1 for grade 2, P=0.5 for grade 3, and P=0.38 for grade 4). Conclusions: Subependymal germinal matrix tissue can be seen in very premature neonates on screening head ultrasounds as a linear echogenic structure on the floor of the lateral ventricle anterior to the caudothalamic groove. Because of its appearance and location, in can be mistaken for a germinal matrix hemorrhage. It is differentiated from a hemorrhage by its resolution without cystic evolution. The presence of residual germinal matrix is not significantly associated with germinal matrix hemorrhage nor a risk factor for intracranial hemorrhage in premature neonates.

Poster #: SCI-019 Long Segment Hirschsprung Disease: A Diagnostic Dilemma Benjamin Fakharzadeh, MD, Radiology, Children’s National Medical Center, Washington, DC, [email protected]; Eva Rubio, Dorothy Bulas, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this study is to examine the imaging findings in patients with long segment Hirschsprung disease and determine the concordance between radiologic and pathologic transition points. A secondary goal is investigation of concurrent conditions or genetic abnormalities in this patient population. Methods & Materials: This retrospective study was submitted for Institutional Review Board approval. Montage healthcare

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solutions search software was used to identify cases of long segment Hirschsprung disease (HD) from January 2000 through September 2014 at a tertiary care academic pediatric hospital. Thirteen patients were identified. Two patients lacked preoperative imaging or medical records and were excluded. The remaining 11 patients were included. Ten of the 11 patients underwent contrast enema (CE) prior to surgery; 1 patient developed massive pneumoperitoneum on day of life 3, and had no CE. Imaging and reports were reviewed for accuracy and separately analyzed by two pediatric radiologists (1 fellow and 1 attending). Other data recorded included presenting symptoms, age at presentation, age at diagnosis, pathology findings, surgical reports, and concurrent diagnoses. Results: This series was comprised of 9 males and 2 females. Ten presented with symptoms by 3 days of life: 7 with emesis/ bilious emesis, 1 with spontaneous pneumoperitoneum. In 4 patients the diagnosis was not made for 10 days or more after initial presentation. Two patients were diagnosed at 2 months of age. Ten patients underwent CE; 3 CE reports definitively stated a diagnosis of HD, although only 1 suggested long segment HD. Three additional studies stated HD could not be excluded. In 5 studies the rectosigmoid ratio was interpreted as normal. No report accurately identified the pathologic transition point. Imaging studies commonly revealed a featureless pipe-like colon with broad based curves of colonic flexures, and no clear transition point. Only 1 CE depicted a microcolon. Five patients had concurrent diagnoses: malrotation (2), genetic syndromes (3). One patient had a family history of HD. Consanguinuity was noted in two cases. Conclusions: Long segment HD is a challenging diagnosis easily missed on CE. There is poor concordance between the perceived radiologic transition point and pathologic findings. Familiarity with the pipe-like contours and potential imaging pitfall of a normal-appearing rectosigmoid may help avoid misdiagnosis. Radiologists should also be aware of a higher rate of additional anomalies in this population.

ID # Clinical presentation M/F CE interpretation

Path transition pt

Additional Diagnoses

1

Bilious emesis

Distal ileum

Malrotation

2

Bilious emesis

M

Meconium pseudocyst Hepatic flexure

3

Bilious emesis

M

Normal

Ileocecal junction Malrotation

4

Bilious emesis

M

Normal

Ascending colon

S 5

Bilious emesis

M

Ileocecal junction None

6

M

7

Failure to pass meconium Fever, poor feeding

Meconium plug; Hirschsprung not excluded Distal Hirschsprung

M

8

Pneumoperitoneum

M

9

Failure to thrive Vomiting

M

Cannot exclude Hirschsprung

10

Emesis

F

Long segment Hirschsprung

Ileocecal junction Family history Hirschsprung Disease

11

Emesis

F

Suggesting of distal Hirschsprung

Ileocecal junction None

M

Normal

None

Cartilage Hair Hypoplasia

Distal ileum

Pierre Robin Sequence

Distal Hirschsprung

Hepatic flexure

None

Pneumoperitoneum

Mid to terminal None ileum Ileocecal junction Waardenburg syndrome

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mesenteric vascular engorgement (p < 0.0001), and mesenteric inflammatory stranding (p = 0.0005) also decreased. Mesenteric vascular engorgement was the only MRI finding to significantly decrease between 1- and 6-months (bivariate analysis, p = 0.048). Multivariate analysis showed that c-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and short pediatric Crohn’s disease activity index decreased during the study period as well (p-values < 0.05). The presence of a penetrating complication (fistula or abscess, p = 0.017), more severe mesenteric inflammatory stranding (p = 0.028), and higher sPCDAI score (p = 0.031) at baseline were significant predictors of eventual surgery at univariate analysis. Conclusions: MRI and clinical markers of disease activity both decrease in pediatric small bowel Crohn’s disease patients treated with infliximab upon longitudinal follow-up, although they only moderately correlate at best. These decreases most often occur between baseline and 1-month. Table 1 – Summary (means and standard deviations) and repeated measure multivariate model results of Continuous MRI and Clinical Markers of Disease Activity in Pediatric Small Bowel Crohn’s Disease. Significant changes over time are shaded in gray. Patient 9. AP Radiograph following contrast enema, demonstrating broadened flexures and pipe-like appearance of the colon, in this 2 month old presenting with failure to thrive. Length (cm)

Poster #: SCI-020 Defining the Radiologic and Clinical Longitudinal Natural Histories of Newly Diagnosed Pediatric Small Bowel Crohn’s Disease Treated with Infliximab Soudabeh Fazeli Dehkordy, MD, MPH, Department of Radiology, Section of Pediatric Radiology, University of Michigan, Ann Arbor, MI, [email protected]; Jonathan Dillman, MD, Ethan Smith, Shokoufeh Khalatbari, Aishwarya Parameswaran, Jeremy Adler, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To define the radiologic and clinical longitudinal natural histories of newly diagnosed pediatric small bowel Crohn’s disease treated with infliximab. Methods & Materials: Twenty-eight children (mean age=15.3 years) treated with infliximab for newly diagnosed small bowel Crohn’s disease were prospectively longitudinally followed with MRI, with imaging performed prior to therapy and at 1-and 6-months after treatment initiation. Spearman correlation (ρ) was used to assess the relationships between MRI findings and clinical markers of disease activity. Bivariate and multivariate (repeated measure mixed model) analyses were used to evaluate changes in MRI and clinical markers of disease activity over time. Univariate logistic regression models were used to determine if any baseline imaging findings or clinical markers predicted eventual surgery. Results: The highest correlation among an MRI finding and clinical marker of disease activity was ρ = 0.58 (maximum bowel wall thickness (BWT) vs. fecal calprotectin; p < 0.0001). Length of disease (p < 0.0001), maximum BWT (p = 0.001), bowel wall T2W signal intensity normalized to muscle (p = 0.023), and relative arterial-phase postcontrast enhancement (p = 0.05) decreased during the study period based on multivariate analysis. The proportion of children demonstrating bowel wall postcontrast stratification (p = 0.02), ulcerations/pseudopolyps (p = 0.002),

Thickness (mm) T2-weighted signal intensity normalized to muscle Arterial phase enhancement (%) Delayed phase enhancement (%) CRP ESR Fecal calprotectin sPCDAI

Baseline 1-Month 6-month Baseline Follow-up Follow-up 1-Month Mean±Std. Mean±Std. Mean±Std. Follow-up [N] [N]* [N]** p-value 20.4 ± 10.3 12.4 ± 9.8 8.2 ± 8.1 0.0065 [28] [23] [20]

1-Month

Baseline

Overall 6-Month 6-Month p-value Follow-up Follow-up p-value p-value 0.29

<0.0001

<0.0001

7.8 ± 2.5 [28]

5.7 ± 2.9 [23]

4.6 ± 3.1 [20]

0.039

0.45

0.0016

0.001

3.2 ± 0.7 [28]

2.9 ± 0.8 [23]

2.6 ± 0.7 [18]

0.27

0.47

0.026

0.023

278 ± 55 [27]

239 ± 74 [23]

230 ± 72 [19]

0.16

0.91

0.081

0.05

287 ± 54 [27]

268 ± 63 [23]

267 ± 54 [18]

0.60

1.0

0.63

0.51

2.9 ± 3.5 [28] 27.9 ± 18.6 [27] 1283 ± 673 [19] 19.8 ± 9.4 [28]

0.4 ± 0.6 [23] 9.8 ± 10.1 [21] 314 ± 358 [20] 8.5 ± 8.3 [23]

0.3 ± 0.6 [20] 9.7 ± 10.0 [20] 343 ± 368 [11] 9.8 ± 9.2 [20]

0.0005

0.99

0.001

<0.0001

0.0003

1.0

0.0004

<0.0001

<0.0001

1.0

0.0002

<0.0001

0.003

0.83

0.018

<0.0001

CRP = C - reactive protein; ESR = erythrocyte sedimentation rate; sPCDAI = short pediatric Crohn’s disease activity index. *: 34.0±10.1 days after initiation of Remicade therapy. **: 186.7±20.0 days after initiation of Remicade therapy.

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Poster #: SCI-022 Comparison of the Incidence of Complications of Techniques in Placement of Peripherally Inserted Central Catheters in Children Niloy Dasgupta, MD, Lucile Packard Children’s Hospital Stanford, Stanford, CA, [email protected]; John Racadio, MD, Manish Patel, Neil Johnson, Matthew Lungren

Poster #: SCI-021 Improved Fetal Magnetic Resonance Spectroscopy Using Selective Combination Pavan Jella, Jaladhar Neelavalli, Ph.D., Swati Mody, MD, Wayne State University, Detroit, MI, [email protected]; Ewart Haacke, Sonia Hassan, Roberto Romero Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Evaluating brain metabolite concentration profile in the fetal brain using magnetic resonance spectroscopy (MRS) has great clinical utility. For example the presence of lactate in MRS signal is an indicator of metabolic acidosis possibly consequent to fetal hypoxia. Nevertheless, MRS acquisition in the fetal brain is often severely affected by fetal motion. This inturn affects the ability to obtain quantifiable spectra in the fetus. In this work we report a simple approach to overcome this problem in part using slightly modified acquisition and reconstruction paradigm. Methods & Materials: All data was acquired on a 3.0T Siemens Verio system. MRS data from the fetal brain was acquired as part of an ongoing fetal MRI research study. Single voxel spectroscopy data was acquired with the volume placed in the central basal ganglia region. Six measurements, each with 16 averages were obtained and reconstructed offline using custom code in Matlab. Quality of each measurement was visually evaluated and those without excessive noise and/or large non-local baseline shifts were chosen for combination. The selected measurements were then averaged to obtain the final spectra and signal to noise ratio (SNR) of individual metabolite peaks - N-acetyl aspartate (NAA), choline (Cho) and creatine (Cr) was measured. Results: Fetal brain MRS was acquired in 51 pregnant subjects. Quantifiable data, defined as a spectra having a minimum SNR of at least 2:1 among the three metabolite peaks was obtained in 36 subjects, corresponding to a success rate of 70%. This is better than the success rate reported in literature. Conclusions: Selective combination of individual MRS measurements is a simple technique that could improve the success rate of obtaining quantifiable MRS data in fetal MRI studies.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To retrospectively evaluate all peripherally inserted central catheter (PICC) placements for the technique used and incidence of follow up complications at a large pediatric tertiary care center. Methods & Materials: A retrospective review of all PICC catheter placements at a single institution was performed over a 3.5 year period. Patient records were reviewed for the technique used to place the PICC line, brand of PICC line, catheter size, and the incidence of complications (multiple attempted puncture sites, migration of catheter, phlebitis and vessel thrombosis). Statistical analysis of complication rates between two placement techniques was performed using a Chi Squared test. Results: A total of 12619 PICC catheter placements were identified. A direct peel-away sheathed needle vessel puncture technique (DSPT) was utilized in a total of 11833 (94%) placements and the modified seldinger technique (MST) was utilized in a total of 786 (6%). The total incidence of complications using DSPT was 1552 (13.1%) versus 117 (14.9%) using MST (p = 0.15). Line migration problems occurred in 1020 (8.6%) DSPT lines compared with 75 (9.5%) MST (p=0.37). Multiple puncture sites were required in 277 (2.3%) of attempted DSPT placements compared with 20 (2.5%) of attempted MST placements (p= 0.72). Phlebitis occurred in 188 (1.5%) DSPT placements versus 14 (1.7%) of MST placements (p=0.68). Vessel thrombosis occurred following 67 (0.5%) DSPT placements versus 8 (1.0%) of MST placements (p= 0.11). Conclusions: The direct peel-away sheathed needle vessel puncture technique and modified seldinger technique are two methods of placing PICC lines in children, with similar complication rates.

Poster #: SCI-023 Study of Concordance in Bone Age Estimation between Pediatric Endocrinologists vs. Pediatric Radiologists Rajan Senguttuvan, Dorothy GilbertsonDahdal, University of Arizona Pediatric Endocrinology, Tucson, AZ, [email protected]; Cindy Chin, Sarah Desoky, Mark Wheeler Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: There is a concern that Bone Age readings done by Pediatric Endocrinologists differed from those done by radiologists. Given these concerns, a survey was framed and sent to 67 pediatric endocrinologists in the USA. Of the survey recipients, 24 took the survey. About 70.8% of pediatric endocrinologists chose the option that they do ‘sometimes have discrepancy’ and 25% of them chose the option that they have discrepancy ‘most of the time’ between the bone age x-rays as read by the radiologist and their personal reading.

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Objective: Our objective was to Study the Concordance in Bone Age Estimation between Pediatric Endocrinologists Vs. Pediatric Radiologist by the Greulich and Pyle (GP) Method and the University of Virginia (UV) Method. Methods & Materials: After IRB approval, a sample of 40-bone age xrays were selected from the Philips PACS Imaging system. The sample consisted of 20 x-rays in the 2-10 age group and 20 in the 11-18 age groups. The sample also had an equal number of males and females. The x-rays were de-identified and distributed in groups of 10. A period of atleast 1 week was allotted to read each group. Two pediatric endocrinologists and two pediatric radiologists read the 40 x-rays by each of the two methods (GP and UV). The results of the study were then compiled on excel spreadsheets and the data was analyzed. Results: Bone age readings by pediatric endocrinologists and radiologists using GP method and UV method did not show significant difference, but showed very high linear correlations with a Pearson Correlation Coefficient (r)>0.98 with p value<0.0001. We utilized Lin’s concordance correlation coefficient (rc) for measuring agreement of bone age reading by pediatric endocrinologists and radiologist by GP and UV methods. The Lin’s concordance correlation coefficient (rc) for all investigators was greater than 0.98 with p value<0.0001, which means that for both UV and GP method, bone age readings from pediatric endocrinologists and radiologists are in very good agreement. Conclusions: In conclusion, there is no significant difference and very good agreement between the bone age reading by pediatric endocrinologists and pediatric radiologists under test conditions.

Poster #: SCI-024 Infant Bone Age Estimation Based on Fibular Shaft Length: A Validation Study Andy Tsai, MD, PhD, Boston Children’s Hospital, Boston, MA; Catherine Stamoulis, PhD, Sarah Bixby, MD, Micheal Breen, MBBChBAO (Hons) BMedSc MRCPI FFRRCSI, Susan Connolly, Paul Kleinman, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To validate a new infant bone age estimation technique based on fibular shaft length, and compare it to two conventional atlas methods. Methods & Materials: Two hundred sixty two consecutive high-detail radiographic skeletal surveys were retrospectively collected from normal birth weight term infants with a low suspicion of child abuse. Three pediatric radiologists measured fibular shaft lengths on antero-posterior computed radiographs and the bone ages were estimated from a look-up table generated from an earlier study using mixed effects modeling. Additionally, the readers performed conventional radiographic bone age assessment on these infants using the atlases of the hand/wrist (Greulich and Pyle) and the knee (Pyle and Hoerr). Continuous fibular shaft length data were then discretized to permit comparisons with the two atlas methods. Using chronological age as the reference standard, accuracies of these three methods were evaluated and intra- and inter-reader agreement was assessed via correlation. Results: Intra- and inter-reader agreement was excellent for all three bone age methods. Statistical comparisons showed that the fibular shaft length method outperformed the conventional atlas methods in accuracy and reproducibility. The root-mean-square error of the fibular shaft length method was <36 days, mean absolute error was <30 days, and the variability of this error was ~20 days. Overall, error and variability were lower than those obtained with the hand/wrist and knee methods. Reader agreement and performance were not affected by the radiologists’ level of experience.

Conclusions: This study provides strong support for an infant bone age estimation technique based on fibular shaft length as an alternative to two conventional atlas methods.

Poster #: SCI-025 Liver Fibrosis in the Pediatric Population. Correlation of Elastography and Percutaneous Liver Biopsy Trevor Davis, DO, Phoenix Children’s Hospital, Phoenix, AZ, [email protected]; Smita Bailey, MD, David Aria, MD, Carrie Schaefer, Robin Kaye, Richard Towbin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To compare sheer wave elastography (SWE) with liver biopsy in evaluating liver fibrosis in children. Methods & Materials: From January 2014 to March 2014, SWE was performed on a total of 12 children prior to percutaneous liver biopsy. A total of 15 velocity measurements were obtained (10-Right lobe and 5-Left Lobe) for each child using Philips IU22 Elast PQ system. In addition, qualitative assessment (normal vs. abnormal echogenicity) of the gray-scale images of the liver was performed by two experienced pediatric radiologists. Qualitative assessment was performed prior to review of quantitative SWE data to avoid reader bias. Twelve percutaneous liver biopsies were performed on 12 patients (9 male: 3 female) ranging in age from 1.5 to 21.5 years (mean of 12.4 years). The indications for biopsy included abnormal liver enzymes (11), steatosis (3), hepatitis (3), jaundice (1), sclerosing cholangitis (1) and transplant rejection (1). All liver biopsies were performed with ultrasound guidance by an interventional radiologist. All biopsy specimens were reviewed by a pediatric pathologist. Results: All liver biopsies were performed without complication. Pathologic results included steatohepatitis (6), hepatitis (5), and mild transplant rejection (1). Fibrosis ranged from grade 0 (n=3, mean velocity 1.41 m/s), grade 1 (n=2, mean velocity 1.45 m/s), and grade 2 (n=7, mean velocity 1.68 m/s), with no specimens of grade 3 or 4 fibrosis. No correlation was noted between steatosis and fibrosis. Qualitative liver assessment of echogenic liver correlated with a steatosis grade ≥2. Conclusions: Abnormal, elevated liver velocities (based on a normal upper limit of 1.3 m/s), were noted in all abnormal livers with or without the presence of fibrosis. Velocities, nevertheless, were generally higher in livers with fibrosis and correlated with fibrosis grade. Based on this pilot data, there is a general correlation between increased liver fibrosis and higher elastogram velocities in children. Data also suggests that some liver disease may be reversible with a single case of grade 3 steatosis and grade 0 fibrosis. A prospective study is needed to validate our impressions.

Poster #: SCI-026 Sensitivity of Mastoid Approach Cranial Ultrasound for Detecting Posterior Fossa Abnormalities: Cine-Loop Acquisition versus Static Images Alone Marharshi Patel, Samuel Bezold, DO, Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, [email protected]; Leann Linam, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

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Purpose or Case Report: To investigate the sensitivity of cine-loop acquisition versus static images alone for detecting posterior fossa (PF) abnormalities obtained via the mastoid approach (MA) at routine cranial ultrasound (CUS) in a cohort of infants admitted to the neonatal intensive care unit (NICU) utilizing magnetic resonance (MR) imaging as a reference standard. Methods & Materials: Prior cranial US and MR images from a cohort of 93 infants admitted to the NICU in a pediatric hospital were reviewed. Forty of these patients had undergone routine CUS with an anterior fontanelle (AF) approach as well as static images of the PF through the mastoids. The remaining 53 infants underwent CUS in the same manner, but with additional cine-loop imaging of the PF performed with MA. Note was made of abnormal findings in the PF, including congenital and acquired abnormalities. All of the patients underwent subsequent MR imaging of the head, the results of which were compared against those from the patients’ prior CUS. Sensitivity and specificity values of routine CUS with and without MA cine-loop image acquisition were calculated. Results: Review of CUS images performed with MA with static images alone showed 0 infants with PF abnormalities. MR images demonstrated 4 PF abnormalities which were not appreciated with static MF images. Review of CUS studies which included cine-loop images through the PF with MA revealed abnormalities in 1 infant; subsequent MR was confirmatory in this case and demonstrated 3 PF abnormalities which were not appreciated with cine-loop MA images. One hundred percent of findings were missed with static MA images alone compared to 75% with cineloop images. Sensitivity / specificity of MA US with cine calculated to 0 / 1.0 (95% CI 0.03-0.25 / 0.88-1.0) and 0.25 / 1.0 (95% CI 0.24-0.19 / 0.911.0) with static imaging alone. Conclusions: PF abnormalities are not uncommonly seen in infants requiring admission to the neonatal intensive care unit. While CUS via mastoid approach has been previously shown to demonstrate findings missed by using the routine AF views, we conclude that cine-loop imaging with the MA is may be more sensitive than with static images alone. The number of patients in our cohort is currently insufficient to prove statistical significance; we will continue to gather data in the interval towards this end.

Poster #: SCI-027 Pediatric AML Patients with Fungal Disease: Prevalence of Findings on Chest CT Natalie Mahieu, MD, Radiology, Children’s Hospital Los Angeles, Los Angeles, CA, [email protected]; Susana Felsenstein, Susan Harlan, Skorn Ponrartana, MD, MPH Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Opportunistic invasive fungal infection can be a difficult and controversial diagnosis. The European Organization for Research and Treatment of Cancer and the Mycosis Study Group (EORTC/MSG) developed revised consensus definitions for possible, probable, and proven diagnosis of invasive fungal infection, based largely on adult data. Clinical criteria include the following imaging signs on chest CT: dense, well-circumscribed lesion(s) with or without halo sign, air crescent sign, and cavity. We sought to describe the prevalence of certain chest CT findings in pediatric AML patients determined to have at least possible invasive fungal disease. Methods & Materials: Pediatric patients with AML and possible, probable, or proven invasive fungal disease with chest CT exams between January 2008 and May 2013 were identified. The chest CT exams were retrospectively reviewed for the presence of macronodule (greater than

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1 cm), micronodule (less than 1 cm), cluster of micronodules, halo sign, air crescent sign, and cavity. Tree-in-bud pattern was included as cluster of micronodules for this review. Results: Thirty five patients with AML and possible, probable, or proven fungal disease were identified. These patients had a total of 91 chest CTs for evaluation. There were 6 (6.6%) with a macronodule(s), 11 (12%%) with micronodule(s), 28 (30.8%) with cluster of micronodules, 12 (13.2%) with halo sign, 7 (7.7%) with cavity, and 1 (1.1%) with air crescent sign. Conclusions: The most prevalent of these lung CT findings in pediatric AML patients with at least possible invasive fungal infection was cluster of micronodules. Macronodule, halo sign, cavity, and air crescent sign were relatively infrequent in this pediatric population.

Poster #: SCI-028 Normal Pediatric Left and Right Ventricular Functional Parameters Measured by Cardiac Magnetic Resonance Imaging Michelle Noga, MD, Radiology, University of Alberta, Edmonton, AB, Canada, [email protected]; Risa Namsechi, Kumaradevan Punithakumar Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Cardiac Magnetic Resonance (CMR) is currently used to assess anatomic and functional information of the heart in children with congenital and acquired heart disease. More advanced measures of cardiac function can be assessed noninvasively using CMR, providing additional functional data. Some of these assessments require additional nonstandard CMR sequences such as myocardial tagging or strain imaging or time consuming manual post-processing. In addition, no normal pediatric values exist for nonstandard functional parameters. Our objective was to determine normal pediatric values of volumetric and functional cardiac parameters from standard cine steady state precession (FISP) sequences, thereby serving as a basis for more detailed measures left and right ventricle (LV and RV) systolic and diastolic function in children. Methods & Materials: Cardiac MR data from 39 normal children were obtained from our clinical database. A novel semi-automatic segmentation program based on a diffeomorphic nonrigid registration algorithm was created, which computes endocardial and epicardial contours for phases of the cardiac cycle based on a single manually drawn contour of end-diastole. The program was implemented using the Visualization Toolkit (Kitware, Inc.), Python programming language and Qt user interface and can be used with any form of cine imaging. An expert user manually edited the automated contours to determine end-systolic volume, end-diastolic volume, stroke volume, ejection fraction, global circumferential strain, vertical long axis strain, early and late filling rate and ratio, and diastolic deceleration time. The results were standardized using body surface area (BSA) to determine pediatric mean values and standard deviations. Results: Data from 39 normal pediatric CMR studies resulted in analysis of 39 LVs and 36 RVs. There were 18 males and 21 females, average age 11.64 years, standard deviation (sd) 5.4 years, with a range of 10 days to 17 years. Weight ranged from 3.0 to 114.8 kg (mean 54.2 kg, sd 29.4 kg), height 0.50 to 1.85 m (mean 1.49 m, sd 0.33 m) and body surface area 0.2 to 2.31 mL/m2 (mean 1.46 m2, sd 0.54 m2). Standard and novel values have been summarised in Table 1. Conclusions: Normal values for left and right ventricular functional measures have been calculated from standard CMR cine FISP sequences. Standard measures of ejection fraction and ventricular volumes are

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consistent with previous literature. More novel measures may provide additional useful information. Table 1. Normal values left and ventricular functional parameters. BSA = Body Surface Area, E’ = early diastolic ventricular filling rate, A’ = atrial phase diastolic ventricular filling rate, ** not calculated due to inconsistent velocity peaks during right ventricular filling

Ejection Fraction (%) End diastolic volume/ BSA (mL/m2) End systolic volume/ BSA (mL/m2) Stroke volume/ BSA (mL/m2) E’/A’ ratio Maximum global circumferential strain (%) Diastolic deceleration time (msec) Maximum long axis strain (%)

Left Ventricle (mean, standard deviation, range) 59.7, 4.4, 52 to 73.8 74.6, 15.7, 38.2 to 111.6 30.1, 7.5, 14.8 to 46.8 44.5, 9.5, 5.2 to 145.2 3.6, 1.4, 1.1 to 6.0 −30.1, -10.7,- 27 to -37.7

Right Ventricle (mean, standard deviation, range) 54.59, 5.4, 47.2 to 64.6 74.6, 15.5, 35.3 to 99.5 35.4, 9.1, 12.3 to 57.5 51.5, 8.1, 21.5 to 61.2 n/a** −28.6, -11.4, -24 to -38.3

129, 45, 38 to 261

n/a**

−20.8, 2.25, -17.6 to -26.16

−16.3, -1.98, -14.2 to -18.7

Poster #: SCI-029 Assessment of Motion Corrected T2-Weighted MRI for Abdominal Imaging of Non-Anesthetized Pediatric Patients Gonca Koc, MD, Erciyes University Faculty of Medicine, Kayseri, Turkey, [email protected]; John MacKenzie, Andrew Phelps, MD, Peter Marcovici, Jesse Courtier, MD Disclosures: John MacKenzie has indicated a relationship with with General Electric. Purpose or Case Report: The objective of this study is to compare the potential relative advantages of T2 weighted periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) to breath-hold T2-weighted fast relaxation fast spin echo (FRFSE) pulse sequence for abdominal imaging of non anesthetized pediatric patients at 3T MRI. Methods & Materials: Twenty pediatric patients (mean age 12.8± 4.1 years, age range 3-18 years) undergoing abdominal MRI with various clinical indications were included for this institutional review board approved study. Fat suppressed axial T2-weighted FRFSE and PROPELLER images were acquired at a 3T MR unit (Discovery MR750 3.0T, GE Healthcare). These two image sets were rated independently on a three-point scale for type and degree of artifacts, delineation of anatomic structures (e.g. renal cortico-medullary discrimination) by three pediatric radiologists. Inter-reader agreement was measured by Fleiss Kappa statistics. Wilcoxon signed rank test was implemented to compare the data of FRFSE and PROPELLER of each reader. Results: Qualitative assessment of three readers revealed that PROPELLER sequence was superior for the reduction of

pulsation artifact and depiction of anatomic structures (p = 0.01, ϰ = 0.60 and p = 0.03, ϰ = 0.43 respectively) while respiratory motion and bowel blurring did not statistically differ (p = 0.82 and 0.80, respectively). Streak artifact was found to be associated with PROPELLER images but did not cause significant image quality degradation (p = 0.02, ϰ = 0.63). Acquisition time was extended with PROPELLER compared to FRFSE (3.9 ± 1.3 vs. 0.2 ± 0 min). Conclusions: In comparison to FRFSE that uses a traditional breath hold strategy, T2-weighted PROPELLER shows improved image quality with reduction of pulsation artifacts. However, its effect on respiratory and bowel blurring artifacts may not be appreciable on pediatric abdominal imaging and acquisition with PROPELLER means a time compromise up to 6 min.

Poster #: SCI-030 Long Term Outcomes of Hepatic Arterial Interventional Procedures in Children: Single Center Experience Jose Hernandez, Interventional Radiology, Texas Childrens Hospital, Houston, TX, [email protected]; Kamlesh Kukreja, Daniel Ashton, Sheena Pimpalwar, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To present the role and outcomes of hepatic arterial interventional procedures at a tertiary care children hospital. Methods & Materials: We performed a retrospective review of patients who underwent hepatic arterial intervention between 2006 and 2014. Patient demographics, liver pathology, indication, technique including embolic agents, technical success, immediate results and long term follow-up were recorded. Results: Twenty procedures were performed in 14 patients (M:F= 7:7) between 21 days - 17 years of age. The clinical presentations included traumatic liver laceration (1/14), post transplant hepatic artery thrombosis (1/14), peliosis hepatis with intra-abdominal bleeding (1/14), post-operative bleeding (2/14) congenital arterioportal fistula (3/14) and hepatic tumor (6/14). Interventions were performed electively in 6/20, urgently in 9/20 (GI bleeding, subcapsular hematoma, post-operative bleeding) and emergently in 5/20 (acute intra-abdominal bleeding) procedures. Four patients required multiple procedures. All procedures were performed under general anesthesia via femoral (19/20) or axillary (1/20) arterial access combined with trans-venous (2/20) and trans-hepatic (2/20) approach. The patient with post transplant thrombosis was managed with thrombectomy and angioplasty. A variety of embolic agents were used including doxorubicin (3/20), particles (11/20), coils (4/20), liquids (5/20) and Amplatzer vascular plug (2/20). Ninety-five percent (19/20) procedures were technically successful. There were 2 intra-procedural complications: pulmonary embolization of Onyx managed with snare retrieval and vasospasm managed with vasodilators and angioplasty. Immediate post-procedure outcome included cessation of intra-abdominal bleeding (7/20), improvement in hyperammonemia (1/20) and control of GI bleed (4/20). Regarding long-term outcome, 6/14 patients underwent successful liver transplantation and 2/14 patients had partial resection between 14 and 240 days post intervention. 2/14 patients died within 30 days post intervention from multi-organ failure. The remainder 4/14 patients are well at a median follow-up of 4 (2-7.5) years. Conclusions: Hepatic arterial interventions are useful in the management of a variety of clinical conditions in children. These procedures are valuable in providing a bridge to liver transplantation and salvaging life threatening emergencies. They can be

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performed with high technical success and good immediate and long-term outcomes.

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Conclusions: The visibility of complete lung fissures on CT increases with infant age, with nearly all fissures visible by 5 months of age.

Percent Visibility of Each Lung Fissure Right

Right

Right

Left

Left

Average All

Anterior

Posterior

Minor

Anterior

Posterior

Fissures

Major

Major

Major

Major

<2 months

87%

90%

77%

93%

90%

87%

5-6 months

100%

98%

92%

98%

98%

97%

7-9 months

100%

100%

97%

93%

93%

97%

Percent of Visible But Incomplete Lung Fissures Right

Right

Right

Left

Left

Average All

Anterior

Posterior

Minor

Anterior

Posterior

Fissures

Major

Major

Major

Major

<2 months

13%

20%

13%

20%

17%

17%

5-6 months

2%

2%

8%

6%

4%

5%

7-9 months

2%

5%

7%

0%

2%

3%

Poster #: SCI-032 Do Plain Radiographs of the Skull Distinguish Vitamin D Insufficiency/Deficiency from Vitamin D Sufficiency in Infants 6 Months of Age or Younger? Molly Downey, Diagnostic Radiology & Pediatrics, Oregon Health & Science University, Portland, OR; Katharine Hopkins, MD, Thomas Valvano

Poster #: SCI-031 Computed Tomographic Detection of Lung Fissures in Infants; When is it best to scan? Saveen Ahuja, MD, Radiology, University of California San Francisco, Orinda, CA, [email protected]; Dean Kolnick, MD, Cynthia Tan, Jesse Courtier, MD, John MacKenzie, Andrew Phelps, MD Disclosures: John MacKenzie has indicated a relationship with with General Electric. Purpose or Case Report: In patients with congenital lung masses, computed tomography (CT) is performed prior to surgery. At our institution, surgery is delayed until 6 months of age, with the presumption that lung fissures will be easier to see in older infants. This study asks the question: are fissures truly easier to see in older infants? Methods & Materials: A total of 46 patients (23 days - 9 months) who underwent a computed tomographic examination of the chest at our institution were organized into three groups, <2 months (N=10), 5-6 months (N=16), and 7-9 months (N=20). Minimum slice thickness was 1.25 mm and CTDI ranged from 1.0 - 162 mGy-cm. Three pediatric radiologists reviewed the cases and recorded the presence or absence of the fissure and if present, whether the fissure was complete or incomplete. A two-population proportion Z test analysis was performed. Results: Lung fissures were visualized more frequently in the older infants compared with younger infants (87% in <2 month group versus 97% in both the 5-6 and 7-9 month groups, p<0.05). Of the lung fissures that were visualized, a lower percentage were considered incomplete in the older infants compared with younger infants (17% in <2 month group versus 5% in 5-6 month group and 3% in 7-9 month group, i<0.05).

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To determine if a discernable spectrum of radiographic skull abnormalities exists in vitamin D (25(OH)D) insufficiency and deficiency before onset of florid radiographic rickets in infants 6 months of age or younger. Methods & Materials: We reviewed skull radiographs and laboratory values in infants 0–6 months of age for whom skeletal surveys and contemporaneous serum 25(OH)D levels were either performed at or sent to our institution between January 2010 and July 2014. Occipital bone thickness, sagittal suture width, and temporal bone convexity (sagitta of the arc) were measured with calipers on PACS (AGFA, Greenville, SC). Based on 25(OH)D levels within 5 days of imaging, subjects were assigned to 1 of 3 groups: A, sufficiency (≥30 ng/mL); B, insufficiency (between 20 and 30 ng/mL); and C, deficiency (≤20 ng/mL). Age, gender, and radiographic data were compared between groups. Statistical analysis was performed using the Fisher exact test and one-way Analysis of Variance. Results: A total of 42 patients were identified. Eight patients were excluded, 1 with classic radiographic findings of rickets, 5 with genetic skeletal dysplasias altering skull appearance, and 2 with severe postmortem sutural widening associated with diffuse cerebral edema. The final study group consisted of 34 patients: A) 38.2% (13/34) with sufficiency, B) 26.5% (9/34) with insufficiency, and C) 35.3% (12/34) with deficiency. As expected, mean serum 25(OH)D was significantly different between groups (P<0.01): A) 38.1±4.2 ng/mL, B) 24.3± 2.6 ng/mL, and C) 12.9±5.3 ng/mL. Age (P=0.64) and gender (P>0.41) were not significantly different. Likewise, there was no significant difference between groups in mean occipital bone thickness: A) 1.9±0.6 mm, B) 2.0±0.2 mm, and C) 2.0±0.4 mm (P=0.79); mean sagittal suture width: A) 2.7±1.1 mm, B) 3.2± 1.9 mm, and C) 2.9±1.2 mm (P=0.72); or temporal bone convexity (sagitta of the arc): A) 3.5±1.3 mm, B) 2.8±0.9 mm, and C) 3.6±1.2 mm (P=0.27). Conclusions: Occipital bone thickness, sagittal suture width, and temporal bone convexity on skull radiographs were not significantly different in 25(OH)D sufficient, insufficient, and deficient infants 6 months of age or younger who lacked classic long bone and rib findings of rickets.

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Accordingly, these measurements should not be used to make a diagnosis of rickets in 25(OH)D insufficient or deficient infants in the absence of classic radiographic abnormalities and conclusive laboratory evidence of the disease.

Comparison of CT Angiography (CTA) with Surgery In Anomalous Aortic Origin Of The Coronary Arteries (AAOCA) In Children

Poster #: SCI-033 Comparison of Relative Pancreatic to Splenic Signal Intensity for Detection of Acute Pancreatitis on MRI in Pediatric Patients Saveen Ahuja, MD, Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, [email protected]; Andrew Phelps, MD, John MacKenzie, Jesse Courtier, MD Disclosures: John MacKenzie has indicated a relationship with with General Electric as a Principal Investigator. All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Diagnosis of acute pancreatitis can be challenging by magnetic resonance imaging (MRI) in the absence of obvious sequela such as free fluid or other evidence of complication. We set out to determine if the spleen could be used as a valid internal control for assessing both T2 and T1 signal changes in the pancreas. Furthermore, we investigated whether a relationship existed between T2 signal intensity and corresponding pancreatic enzyme levels taken near the time of exam. Methods & Materials: We retrospectively selected patients interpreted as acute pancreatitis on MRI (1.5 and 3T) at our institution from 2001-2014. Two groups were evaluated, those interpreted as acute pancreatitis (N=23, mean age: 12.7 years; median age: 13.1 years; 11 males, 12 females) and those without imaging evidence of disease (N=23, mean age: 13 years; median age: 13.8 years; 11 males, 12 females). Based on measured region of interest (ROI) values, ROI ratios of the pancreas relative to the spleen on T2 weighted (fast spin echo with fat saturation) and T1 weighted (ultra fast gradient echo sequences with fat saturation) were calculated. A Wilcoxon signed rank test was utilized to determine statistical significance of the ratios between the two groups. For cases of acute pancreatitis, lipase values collected within 48 h of the MRI were chosen. Results: A higher ratio of pancreatic T2 signal relative to the spleen exists in acute pancreatitis (average ratio=0.86, σ2 =0.12) when compared to diseasefree pancreas (average ratio=0.53, σ2 =0.10) (p<0.05). A lower ratio of pancreatic T1 signal to the spleen is seen with acute pancreatitis (average ratio=1.05, σ2 =0.26) when compared to disease-free pancreas (average ratio=1.41, σ2 =0.27) (p<0.05). For cases of acute pancreatitis, higher lipase levels do not correspond to higher ratios of pancreatic T2 signal to the spleen. Conclusions: The spleen is a useful internal reference for determining both T2 and T1 signal changes of the pancreas in cases of acute pancreatitis.

Lipase (U/L)

Pancreatic to Splenic Signal Ratio versus Lipase (Acute Pancreatitis)

450 400 350 300 250 200 150 100 50 0

0.00

Poster #: SCI-034

T2 Signal T1 Signal

1.00

2.00

Pancreas to Spleen Signal Ratio

Rajesh Krishnamurthy, Radiology, Texas Children’s Hospital, Houston, TX, [email protected]; Prakash Masand, Siddharth Jadhav, MD, Wei Zhang, Silvana Molossi, Carlos Mery, et al. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Evaluate diagnostic accuracy of retrospective EKG gated CTA with 320 detector array by comparing to surgery for relevant pathologic targets in children with AAOCA. Methods & Materials: Diagnostic performance of CTA was evaluated in 25 consecutive patients who underwent surgery for AAOCA. Pathologic variables in AAOCA, including type of AAOCA, radial location, height and shape of ostium, presence of ostial stenosis, and presence and length of intramurality were assessed by three independent blinded readers, using a numerical coded system. Two signs for the presence of intramurality were studied, including oval shape of the proximal coronary, and a new ‘peri-coronary fat’ sign. All targets were assessed similarly at surgery, the reference standard. Diagnostic performance of CTA was evaluated for each feature, and accuracy calculated on a per-target basis using weighted or unweighted kappa (range -1 to 1). Intra-class correlation coefficient analyzed the length of intramurality based on shape or fat. Results: CTA correctly identified AAOCA in all 25 coronaries. Diagnostic performance of CTA for individual targets in AAOCA is listed in figure 1a, on a per-reader basis. Scatter plots with regression lines for length of intramurality based on shape and pericoronary fat, compared with surgery, is provided on figure 1b and 1c. For the three readers, CTA had 100% accuracy for detection of type of AAOCA, accuracy of 98, 96 and 92% respectively for detection of intramurality using the pericoronary fat sign, and 98, 94 and 92% respectively for detection of intramurality by shape. For the three readers, the intra-class correlation coefficient for prediction of intramural length using pericoronary fat was 0.67, 0.75, and 0.81 respectively using pericoronary fat, and 0.69, 0.50, and 0.81 respectively using shape. Conclusions: CTA reliably identified AAOCA in all patients, detected the presence of intramurality with high accuracy, and identified other pathologic targets in AAOCA with moderate to high accuracy

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Poster #: SCI-035 Using Monte Carlo Simulation to Understand Radiation Doses in Pediatric Image Guided Therapy Procedures Khanh Nguyen, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Bairbre Connolly, Christopher Gordon Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Radiation effects in children are important with the use of modern diagnostic imaging. The purpose of this study was to understand the radiation risks involved in IR procedures, by estimating effective doses for common Interventional Radiology (IR) procedures (n=731) using Monte Carlo simulation, applied to 2 years of dose metrics outputted from an IR suite. Methods & Materials: Radiation dose metric data from 731 patients who underwent different common IR procedures at Sick Kids were analyzed. Children were assigned into age groups [<1, 1, 5, 10, 15 years]. Procedures were grouped into body region [chest, abdomen, and head]. Dose metric data was applied to PCXMC, a Monte Carlo simulation program, to calculate both organ and effective doses. Doses for each procedure were listed as median values with inter-quartile values indicating the uncertainty. Results: Fluoroscopy only: Common procedures (n=593) resulted in low doses (medians<1 mSv). Dose medians of chest procedure were lower (<0.18 mSv) compared to abdominal procedures (<0.7 mSv). Single Shot Acquisition (SSA): Occasional use of SSA (n=76) resulted in slightly higher doses (medians of chest procedures < 0.2 mSv and abdominal procedures < 0.9 mSv). Digital Subtraction Angiography (DSA): Dose medians were significantly higher. Three groups of procedures (n=62) include: a) minimal use of DSA (n=30) (e.g. Linogram, a run during PICC or CVL insertion, Percutaenous Tranhepatic Cholangiography) resulted in dose medians < 0.8 mSv; b) moderate use of DSA (n=18) (e.g. Cerebral Angiogram or Varicocele Embolization) resulted in dose medians < 3 mSv and c) procedures with intense use of DSA (n=14) (e.g. Pulmonary Angiogram, IVC Filter Placement and Removal) resulted in dose median range from 7.8 mSv to a maximum of 97.2 mSv in Pulmonary Angiogram. Conclusions: Effective doses for most common pediatric IR procedures are low. Doses varied according to body regions, case complexity, imaging modality used, and operators. High effective doses resulted with use of DSA and complex procedures.

Poster #: SCI-036 The Effect of Radiology Residency Program Structure on Resident Interpretation of Pediatric Fractures: Canadian Experience Lydia Bajno, Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada; Rochelle Albert, Andrea Doria, Jennifer Stimec Disclosures: Andrea Doria has indicated a relationship with Baxter Healthcare Inc, as a speaker. Purpose or Case Report: By assessing the medical education system issues can be identified and changes can be made to improve medical training. Our purpose was to identify factors in the structure of radiology residency programs that may affect resident performance and confidence levels in the area of pediatric radiology (PR) according to: 1) Early (PGY2 or PGY3) vs late (PGY4/PGY5) initial exposure to formal PR training in residency. 2) Exposure to pediatric radiology cases on-call throughout the residency vs only during formal PR rotations. Methods & Materials: Radiology residency program directors were sent letters requesting participation in the study. Upon agreement, they received

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study packages containing questionnaires regarding the structure of PR training in their program, consent documents, questionnaires for residents regarding their exposure to PR and confidence levels in this area. Forty unknown cases of pediatric fractures (mock OSCE) were sent for the residents to complete. Results: 12/13 residency programs agreed to participate (169 residents at different levels (PGY2-PGY5)). 137/146 residents had early and 32/146 had late initial exposure to formal PR. 109/169 and 60/169 residents provided on-call coverage for PR studies throughout their residency versus only during formal PR rotations. In PGY2/3 s and PGY4/5 s, average scores for mock OSCE were 37.6 and 53.3%, respectively. Programs that offered early versus late initial exposure to PR had an average score of 38.0% and 36.1%, respectively in PGY2/3s, and 54.2 and 48.4% in PGY4/5s. Programs that offered exposure to PR oncall throughout residency versus only during formal rotations scored 40.3 and 33.1% respectively in PGY2/3s, and 52.9 and 54.2% in PGY4/5s. In PGY2/3s and PGY4/5s, average confidence level (CL) (range:1–5, novery confident) in PR was 2.2 and 3.2 respectively. Programs that offered early versus late initial exposure to PR had average CLs of 2.3 and 1.9 in PGY2/3s, and 3.3 and 2.8 in PGY4/5s. Conclusions: Early versus late initial exposure to PR in residency improved mock OSCE performance in PGY4/5s, and improved CLs in PR in both PGY2/3s and PGY4/5s. Exposure to PR on-call throughout residency versus only during formal rotations improved mock OSCE performance in PGY2/3s.

Poster #: SCI-037 Assessing Scattered Radiation to Operators during Interventional Radiology Procedures Khanh Nguyen, Hospital for Sick Children, Toronto, ON, Canada, [email protected]; Richard Gu, Bairbre Connolly Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Risks to operators from scattered radiation during interventional radiology (IR) procedures is a concern for interventional radiologists. Various soft shields are available to reduce scatter dose to operators from patients. The purpose of this study are: a) to determine the effectiveness of two commercially available soft shields (RadPad & Radionex) in reducing scattered exposure during pediatric IR procedures and b) to assess the impact, if any, of such soft shields on patients’ doses. Methods & Materials: Gastrotomy (G) and Gastrojejunostomy (GJ) maintenance procedures were chosen (frequent procedures, non-sterile, associated with scatter to the hands). Scatter radiation exposure during 100 G/GJ maintenance procedures, performed with (n=50) and without (n=50) soft shields, were analyzed. Anthropomorphic phantom simulations with and without soft shields were also performed to verify the above results. Results: Using soft shields, scattered exposures to operators’ hands were reduced by 45 to 49% in clinical cases, and 70 to 90% in phantom simulations. However, the use of soft shields was associated with an increase in phantoms’ doses by 6 to 28% depending on the shield types and their thicknesses. Conclusions: Soft shields are effective but have important implications to patients’ doses.

Poster #: SCI-038 Retrospective Review of Neuroimaging Findings in Pediatrics ICU Patients with Sustained Refractory Status Epilepticus Ramy Ashmawy, Hospital for Sick Children, Richmond Hill, ON, Canada, [email protected]; Cecil Hahn, Eric Crawford, Suzanne Laughlin

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Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To summarize the spectrum of neuroimaging findings in a cohort of pediatric ICU patients with Sustained Refractory Status Epilepticus (SRSE), which is a neurologic emergency, over an 8-year period in a tertiary pediatric center, whose clinical management included extensive work up and continuous EEG (cEEG) monitoring. Multiple previous papers have described the imaging findings in status epilepticus. There is no large case series for imaging findings in patients with SRSE (Status Epilepticus which is refractory to conventional anticonvulsants and is sustained for more than 24 h despite high dose suppressive therapy) in the pediatric population. Methods & Materials: Retrospective imaging analysis of 54 pediatric ICU patients with SRSE presenting to our center was performed using a standardized data collection form. Neuroimaging including head CT and brain MRI studies performed during the SRSE episode and the follow up neuroimaging performed during or immediately following the PICU stay were analyzed. Studies were assessed for the presence of any imaging abnormities. When present the anatomical localization of the imaging abnormality was documented as well as the number of lesions present. Follow up imaging when available was assessed for interval change or new findings. Results: The etiologies for SRSE in our well-defined clinical population were varied. In our 54 cases the suggested etiology based on imaging included 13 with infectious / inflammatory causes, 8 with metabolic / genetic etiologies, 4 with cortical malformations, 8 with vascular / ischemic, 3 had suspected abusive head trauma, 2 neoplastic, 2 hemorrhagic and included 2 with normal imaging. Eight cases had imaging findings which were indeterminate for etiology on the basis of imaging alone and 4 cases had no neuroimaging performed during there ICU stay. Out of the 50 patients 33 had a head CT and 17 had brain MRI as their initial neuroimaging study, of the 33 patients that had initial head CT; 24 also had a brain MR done within the next 72 h on average. These MRIs added important information in about 50% of the cases. Conclusions: Findings in SRSE could be related to various etiologies including congenital, metabolic, vascular, traumatic and neoplastic etiologies and also could be the result of seizure activity. Special attention to clinical stability is recommended for deciding on the optimal imaging procedure and obtained sequences. CT is the usual initial investigation due to easy access and short time.

Poster #: SCI-039 A Systematic Review of Ultrasound Imaging as a Tool for Evaluating Hemophilic Arthropathy in Children Carolina Ligocki, Sick Kids Hospital, Toronto, ON, Canada, [email protected]; Aryan Abadeh, Kuan Chung Wang, Tamsin Adams-Webber, Andrea Doria Disclosures: Andrea Doria has indicated a relationship with Baxter Healthcare Inc, as a speaker. Purpose or Case Report: To semi-quantitatively assess the evidence on the value of ultrasound (US) for assessment of pediatric hemophilic arthropathy (HA) based on the following questions: (1) Are currently available US techniques accurate for early diagnosis of pathological findings? (2) Can treatment reduce the incidence of US-detectable findings in HA? (3) Do US scores correlate with clinical/US constructs in the evaluation of HA? (4) Are US findings associated with functional status of joints? Methods & Materials: Articles were screened using MEDLINE (n=519), EMBASE (n=493), and the Cochrane Library (n=24) (1946-2014). Relevant studies were retrieved and independently assessed by 2 reviewers using the tools: Standards for Reporting of diagnostic Accuracy (STARD), and the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS2). Different protocols for assessment of hemophilic joints were compared based on extension of assessment/scanning time. Scoring methods were compared according to number of evaluated domains/items. Results: Out of 12 references, 5 diagnostic accuracy studies were selected (236 boys with hemophilia A, B and von Willebrand’s disease, reported mean age, 118 years). The STARD-based quality of reporting of articles was excellent in 60%, fair in 20%, and poor in 20% of the articles. The QUADAS-2-based methodological quality of articles was high in 60% of articles and moderate, in 40%. Concerning 6 articles on scores, (297 patients with hemophilia A, B or von Willebrand’s disease, reported mean age, 1-80 years), all incorporated ‘synovial hypertrophy’, 83% ‘cartilage modifications’, and 33% ‘hemosiderin deposition’ in their scoring systems. The quality of report was excellent in 50%, fair in 33%, and poor in 17% of the articles. We also assessed 4 articles on protocols, of those, 75% suggested extended US scanning of up to 30 min per joint, and 25%, a more simplified technique (non-reported scan time). Out of all articles included in this study 83% evaluated knees, 58% ankles, 42% elbows, and 8% shoulders. Conclusions: There is insufficient evidence (Grade I) to recommend US as an accurate technique for early diagnosis of pathologic findings, to demonstrate that US scores correlate with clinical/US constructs, that treatment can reduce the incidence of US-detectable findings in HA, and to prove an association between US findings and the functional joint status. Further validation of protocols and scores and comparisons between extended/point of care protocols of joints is needed for HA.

Poster #: SCI-040 Incidence of Cervical Spine Injury in Children with Abusive Head Trauma Charles Pluto, MD PhD, Nationwide Children’s Hospital, Columbus, OH Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Recognition of cervical spine (c-spine) injury in abusive head trauma (AHT) patients who survive to hospital admission is rising. Increasingly, c-spine MRI is used to characterize forensic and clinical injury. We sought to identify the incidence of c-spine injury in AHT patients at Nationwide Children’s Hospital.

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Methods & Materials: A child protection team database identified all children less than 5 years-old diagnosed with AHT from 1/1/2004-12/31/13. A trauma database identified clinically-evident c-spine injuries and surgeries in the AHT patients. For AHT patients with c-spine MRI, images and clinical records were reviewed by pediatric neuroradiology and neurosurgery. Results: There were 250 AHT cases (median age 5 months). Of 240 with Glasgow Coma Scale (GCS) data, 86 (35.8%) were severe (GCS:3-8), 35 (14.6%) were moderate (GCS:9-12), and 119 (49.6%) were mild (GCS:13-15). Mortality was 16.8% (42). Thirty-four (13.6%) underwent c-spine MRI, mostly for neck pain or possible ligamentous injury on x-ray. Eleven patients (32.4%) had 20 findings. Cord edema was present in 1 (2.9%), hematoma in 2 (5.9%), prevertebral edema in 3 (8.8%), longitudinal ligament edema in 0, facet edema in 2 (5.9%), flavum edema in 1 (2.9%), occiput-C1-C2 edema in 1 (2.9%), and interspinous or muscular edema in 10 (29.4%). Zero of 250 had clinically-evident c-spine injury, clinically unstable cspine, or c-spine surgery. This includes those with c-spine MRI findings later “cleared” by clinical exam or flexion-extension x-ray. Conclusions: C-spine MRI is important in the forensic evaluation of AHT patients who survive to hospital admission. No MRI findings resulted in clinical c-spine injury, commensurate with a zero incidence of clinical c-spine injury in the larger study population.

Poster #: SCI-041 Computed Tomography (CT) Imaging Parameters of the Cranio-Cervical Junction in Achondroplasia Kedar Patil, Medical Doctorate, Diagnostic Imaging, McGill University Health Centre, McGill University, Montreal, QC, Canada; Nagwa Wilson, MD,PhD, Christine Saint-Martin Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Achondroplasia is a genetic disorder characterized by abnormal bone growth, leading to short stature and multiple osseous deformities. Pediatric mortality is secondary to brainstem compression. Life-saving cervical spine decompression may be performed if early neurological deficits occur, however often these patients die suddenly without preceding symptoms. We define CT-imaging parameters that may be used to characterize the cranio-cervical junction in pediatric achondroplasia, in order to prognosticate which patients would benefit from early surgical intervention and thereby reduce morbidity and mortality. Methods & Materials: In this retrospective study, included were pediatric patients (less than 18-years-old) with achondroplasia, who had CT-imaging involving the cranio-cervical junction, from January 2006 to October 2014 at our institution. Two pediatric-fellowship-trained radiologists evaluated each patient for quantitative and qualitative parameters. These parameters included: Clivus orientation, clival-supraoccipital angle, opisthion hypertrophy, sagittal cervical canal diameter, powers ratio, and basion-axial interval. Age-gendermatched patients, in whom the CT-imaging results were unremarkable for intracranial findings, were used as the control group. Correlation with the clinical outcome of each patient, including surgical treatment, was made. Results: Eleven achondroplasia and eleven control patients were included in the analysis. Achondroplasia patients displayed a consistently abnormal clivus orientation and greater clivus-supraoccipital angle mean (110.1 +/− 9.3°) compared to controls (88.5 +/− 9.6°). The opisthion was typically hypertrophied and extended anteriorly to the posterior arch of C1 in achondroplasia patients, resulting in a smaller sagittal diameter, and a larger mean powers ratio (ratio 1.67 +/− 0.57) compared to controls (ratio 0.80 +/− 0.12). Patients with significantly thickened opisthion, developed clinically relevant neurological symptoms and required surgical decompression. Conclusions: This is the first study to define specific parameters for the CT-imaging characterization of the cranio-cervical junction in pediatric achondroplasia patients and correlating with outcomes. Identifying these

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quantitative and qualitative features on initial CT-imaging will assist in determining which patients are at greater risk of morbidity and mortality, and thus may benefit from prophylactic cervical decompression surgery.

Poster #: SCI-042 Withdrawn Poster #: SCI-043 Non-Contrast CT Attenuation of Blood vs. Myocardium and Correlation with Hemoglobin and Hematocrit as a Sign of Anemia Costas Stavrakis, DO, Radiology, Albany Medical Center, Albany, NY, [email protected]; Amy Scheller, Maria Boulos Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: The purpose of this abstract is to provide the reader with a helpful and insightful tip in the interpretation of non contrast enhanced CT examinations of the chest or abdomen. The difference in hounsfield units between blood and the myocardium can serve as a correlate with hemoglobin and hematocrit. Our data will show that a larger difference in attenuation is seen with a decrease in both the hemoglobin and hematocrit. Methods & Materials: Retrospective analysis was performed utilizing 4 years of CT examinations on 122 patients, all under 18 years old. Examinations included any study in which the heart was included within the field of view. The hounsfield units of the blood and myocardium were measured and compared. These values were then correlated with the patient’s hemoglobin and hematocrit at the time of the study. Results: Analysis of the data demonstrated that a decrease in hemoglobin and/or hematocrit results in a larger difference between the attenuation values of the myocardium and blood. This difference is particularly appreciated as the hemoglobin and hematocrit fall below 12 and 36, respectively. Conclusions: Assessing the difference in Hounsfield units between blood and myocardium can serve as a useful tool during the interpretation of examinations in which the heart is included within the field of view. We have demonstrated that as the hemoglobin and hematocrit decrease, the difference in attenuation inversely increases. This can be a useful indicator of anemia and thus help provide insight to the interpreting radiologist during times when clinical history is limited. As a result, the radiologist’s report will be of more value to the referring clinician.

Poster #: SCI-044 The Distribution of Neuroblastoma Cancer Stem Cells Within Solid Tumors Ketan Ghaghada, PhD, Texas Children’s Hospital, Houston, TX, [email protected]; Saurabh Agarwal, Zbigniew Starosolski, PhD, Siddharth Ray, Jason Shohet, Ananth Annapragada, PhD, et al. Disclosures: Ananth Annapragada, PhD indicated a relationship with and Marval Pharma Inc, Alzeca LLC, and Sensulin LLC as a Stockholder. All other authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: We have recently characterized a highly tumorigenic and chemo-resistant cancer stem cell (CSC) subpopulation in high-risk neuroblastoma (NB) patients, overexpressing CD114, the GCSF receptor. The distribution of these CSC’s within solid tumors has a huge impact on their susceptibility to nanoparticle-delivered

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chemotherapy. Prior studies suggested that CSC’s preferentially reside in the perivascular niche of solid tumors. Proximity to the sites of vascular leak would suggest treatability. We therefore tested the locations of the CSC’s and compared them to locations of vascular leak. Methods & Materials: MYCN-amplified human NGP cells or MYCN non-amplified human SH-SY5Y cells were surgically injected beneath the renal capsule in female nude mice for generation of orthotopic NB tumors. At 3 weeks post-tumor inoculation, a nanoprobe (110 mg I/mL), liposomal nanoparticles encapsulating iodinated contrast agent molecules, was injected intravenously at a dose of 2.2 mg I/g of body weight. The animals were sacrificed 5 days post-contrast, the tumors excised and placed on a specimen holder (Fig 1A) designed to permit radial sectioning of the tissue. CT imaging of the tumor specimen was performed on a small animal micro-CT scanner using the following scan protocol: 70 kVp, 0.5 mA, 850 ms X-ray exposure, 540 projections, 35 um isotropic spatial resolution. Immediately thereafter, the tumor was segmented into sub- volumes of low CT signal and high CT signal based on analysis of the CT images. The sub-volumes were flow sorted using CD56 as a neuroblastoma marker and CD114 as the CSC marker. Results: Nanoprobe-enhanced CT imaging demonstrated a heterogeneous pattern of signal enhancement within the excised tumor (Fig 1B). CT image-guided dissection of tumor mass separated the tumor into low CT signal and high CT signal regions (Fig 1C) with a five-fold average difference in vascular leak between the two sub-volumes. Flow cytometry demonstrated a larger number of cancer stem cells in high CT signal tumor sub- volume compared to the low CT signal sub-volume. Conclusions: In high risk NB, CSC’s appear to preferentially reside in the regions of high vascular leak.

Figure 1. Detection of cancer stem cell distribution within neuroblastoma (NB) using a nanoparticle CT contrast agent. (A) 3D-printed specimen holder for ex vivo CT imaging and image-guided dissection

(B) Orthogonal maximum intensity projection (MIP) images demonstrated distribution of nanoparticles. (C) Top view showing planes for dissecting the tumor based on B-1 image. (D) Dissection of tumor into low CT signal and high CT signal sub-volumes. Flow cytometry data showing distribution of NB cancer stem cells in the two sub-volumes.

Poster #: SCI-045 Prospective Observational Post-marketing Study on the Safety Profile of Gadoterate Meglumine - Final Results in over 1,600 Pediatric Patients and Patients with Renal Impairment Deepak Patkar, Nanavati Super Specialty Hospital, Mumbain India Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: To prospectively assess the safety profile of gadoterate meglumine and the overall incidence of nephrogenic systemic fibrosis (NSF). Methods & Materials: This global, prospective, observational postmarketing study enabled the recruitment of over 35,000 unselected adults and children scheduled for routine contrast-enhanced magnetic resonance (MR) imaging using gadoterate meglumine (Dotarem®). Risk factors, MR indications, conditions of use of the contrast material and adverse events were recorded. A large pediatric sub-population of 1,631 patients (53.5% male, mean age of 10.2 years, range 0-17) from nine countries and involving 106 (6.5%) children less than 2 years old was analyzed. Patients included with moderate to severe renal impairment had to be followed up for at least 3 months for detection of any suspicion of NSF. Results: The main MR indication for the pediatric population was examination of the central nervous system (78.1%) followed by musculo-skeletal imaging (10.6%) and the most frequent risk factors were central nervous system disorders (16.4%), impaired renal function (9.8%, mean estimated creatinine clearance or eGFR = 74.1 mL/min (/1.73 m2), range 28-89 mL/min (/1.73 m2)) and allergies (5.2%). Only one pediatric patient (<0.1%), 2 years old with brain tumor, experienced one adverse event (vomiting), reported as non-serious, mild in intensity and doubtfully related to gadoterate meglumine. A total of 515 patients, including 3 children, presented moderate to severe renal impairment. The followup was retrieved for 477 patients (92.6%) and no suspicion of NSF was reported. Conclusionsn This worldwide study analysis confirmed the very good safety profile of gadoterate meglumine in a large pediatric population of all ages.

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2015 AUTHOR INDEX

Abadeh, Aryan SCI-039 Abdeen, Nishard PA-134 Abramo, Thomas PA-153 Acomb, Allen D. CR-064 Adams, Janet M. PA- 084 Adams-Webber, Tamsin SCI-010, SCI-039 Adler, Jeremy SCI-020 Afacan, Onur PA-014, PA-125 Agarwal, Saurabh SCI-044 Aggabao, Patricia PA-018 Ahlawat, Shivani PA-107 Ahmed, Farhan PA-134 Ahuja, Saveen SCI-031, SCI-033 Ajayi, Samuel PA-121 Akyol, Yakup CR-031, CR-041 Al-Busaidi, Sultan A. CR-060 Al-Ibraheemi, Ammar PA-136 Al-Qasimi, Yaser PA-136 Alazraki, Adina L. EDU-069 Albert, Rochelle SCI-036 Ali, Sayed PA-037 Ali, Sumera PA-034 Allaei, Atabak SCI-001 Allbery, Sandra M. CR-014, PA131 Altinok, Deniz PA-136 Amodio, John EDU-095, SCI001, PA-116 Anderson, Megan E. PA-081 Annam, Aparna PA-157 Annapragada, Ananth SCI-044, PA-126, PA-147 Anton, Christopher PA-111 Anupindi, Sudha A. CR-035 Appiawiah, Nana PA-026 Aquino, Michael PA-118 Aria, David CR-052, EDU-057, SCI-025 Aria, David J. CR-032, SCI-014 Arneja, Amrita K. EDU-080, EDU-107 Arnold, Staci CR-025 Aronson, James PA-153 Artunduaga, Maddy EDU-111 Ashmawy, Ramy SCI-038 Ashton, Daniel J. SCI-030 Atweh, Lamya PA-031 Augustin, Keni EDU-024 Augustyn, Robyn CR-009 Averill, Lauren PA-106 Ayyala, Rama CR-025, CR-053, EDU-042, EDU-076 Aziza, Albert SCI-007 Baad, Michael PA-039 Back, Susan PA-085 Back, Susan J. EDU-050, EDU074, PA-047, PA-049 Bacon, Patrick CR-014 Bahouth, Sara M. PA-025 Bai, Harrison PA-096

Bailey, Smita S. CR-020, SCI-011, SCI-025 Bajno, Lydia SCI-036 Baldwin, Michael EDU-064 Bandi, Krishna PA-033 Bao, Shanshan PA-103, PA-108 Bardo, Dianna M. PA-032 Barnacle, Alex M. PA-093 Barnard, Hannah PA-044 Barnes, Craig E. CR-011, CR-069 Barnewolt, Carol E. PA-021 Barrowman, Nick PA-152 Barth, Richard PA-016, PA-058, PA-061 Baskin, Mark EDU-043 Basta, Amaya M. EDU-087, PA-013 Bathala, Tharakeshwar PA-141 Becker, Susan PA-140 Bedoya, Maria A. EDU-074, PA-049, PA-052, PA-053, PA-104, PA-110, PA-112, PA-113 Bellah, Richard EDU-041, CR-035, PA-085 Bencardino, Jenny PA-102 Bergen, Michael PA-116 Berlin, Sheila PA-043, PA-044, PA-067, PA-138 Berman, Jeffrey I. PA-052, PA-053, PA-110, PA-113 Bernard, Timothy J. PA-129 Bernbeck, Matthew PA-058 Beydoun, Tammam EDU-004, EDU-057, PA-008 Bezold, Samuel L. SCI-026 Bhandal, Samarjeet EDU-023, EDU-070 Bhardwaj, Ratan CR-052 Bhargava, Ravi PA-122 Bhatia, Monica CR-025 Bhatti, Zeeshaan EDU-109 Biko, David M. PA-082 Binkovitz, Larry A. CR-007, EDU-030 Birkemeier, Krista L. CR-064 Birmingham, Erin SCI-002 Bisset, George S. PA-065, PA-073, PA-114 Bittman, Mark EDU-013 Bittman, Mark CR-048, CR-055, CR-056, EDU-077 Bixby, Sarah D. SCI-024, PA-080, PA-081 Biyyam, Deepa R. CR-003, CR011, CR-020, CR-069, EDU-004 Blank, Lawrence EDU-074 Blaser, Susan SCI-016 Blask, Anna CR-006, EDU-025 Blickman, Johan G. EDU-005 Bloch, Karen C. EDU-113 Bojic, Zoran SCI-007, PA-118 Botelho, Marcos P. PA-033 Boulos, Maria SCI-043 Bourm, Kelsey CR-046 Brady, Samuel PA-006 Braga, Luis EDU-096

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Braithwaite, Kiery CR-008 Braithwaite, Kiery A. EDU-069 Braswell, Leah PA-153, PA-157 Braun, Ryan EDU-095 Bray, Heather J. CR-024, CR-060, EDU-048 Breech, Lesley L. PA-087 Breen, Michael A. SCI-024, PA-076, PA-080 Brinkley, Michael F. EDU-019 Bristol, Ruth CR-009 Britt, Peter EDU-002 Brody, Alan S. PA-068 Browne, Lorna PA-026, PA-071 Bruch, Steven W. PA-097 Brudnicki, Adele CR-012, CR-015, EDU-017, EDU-085, EDU-097 Bruno, Costanza PA-089 Buch, Karen EDU-022, SCI-018 Buchmann, Robert F. PA-034, PA-045 Bulas, Dorothy CR-006, EDU-025, EDU-117, SCI-019 Bulat, Evgeny PA-080 Bulman, Julie PA-077 Burton, Elijah J. CR-028 Cahill, Anne Marie EDU-024, SCI-013, PA-096, PA-100, PA101, PA-155 Cairns, Robyn EDU-048 Callahan, Michael PA-119 Caltoum, Christine EDU-045 Calvo-Garcia, Maria A. EDU-010 Caprio, Martha PA-046 Carey, Kathleen E. EDU-007 Carlson, Christian L. EDU-032 Carpenter, Jennifer L. PA-011 Carr, Carrie CR-010, EDU-008 Carraretto, Denise PA-118 Carson, Robert H. PA-052, PA-053 Cassady, Christopher PA-017 Cassell, Ian CR-011 Castro-Aragon, Ilse EDU-022, EDU-044, SCI-018 Catanzano, Tara CR-058 Chakravarti, Sujata PA-046 Chan, Sherwin S. PA-072 Chand, Rajat CR-063 Chaudhary, Simone PA-132 Chauvin, Nancy CR-035, PA-082, PA-104, PA-110 Chen, Zaowen PA-147 Cheng, Edwin K. PA-078 Cheng, Jack Chun Yiu PA-148 Cheon, Jung-Eun PA-066, PA-151 Cherny, Mathew EDU-013 Chin, Cindy SCI-023 Ching, Kevin CR-002 Chiu, Priscilla P. SCI-006 Cho, Hyun-Hae PA-066 Choi, Young-Hun PA-151 Choi, YoungHun PA-066 Chong, Suzanne T. PA009, PA057

Choudhary, Arabinda K. CR-031, CR-041 Choudhri, Asim CR-066 Chow, Jeanne S. EDU-050 Christensen, Robert E. PA-062 Christy, Matthew E. EDU-052 Chu, Winnie Chiu Wing PA-148 Chu, Zili D. PA-050 Chung, Taylor EDU-106 Ciancibello, Leslie PA-067 Clarke, Rebekah PA-075 Clements, Crysta L. EDU-053 Coleman, Beverly G. EDU-050 Coleman, Jamie L. PA-145 Coles, Robert A. CR-042 Colip, Charles EDU-044 Conley, Harry N. SCI-009 Connolly, Bairbre L. SCI-006, SCI-035, SCI-037, PA-098, PA100 Connolly, Susan A. SCI-024, PA021 Conway, Deborah EDU-002 Cornejo, Patricia CR-009, CR020, CR-032, CR-052, CR-069 Correa, Hernan EDU-118 Courtier, Jesse SCI-029, SCI-031, SCI-033, PA-041, PA-060, PA063 Covelli, James D. EDU-032 Crane, Gabriella EDU-011 Crawford, Eric SCI-038 Creeden, Sean PA-036 Cromblehome, Timothy PA-123 Crowe, James PA-065 Curran, John CR-039, EDU-014, SCI-012 Daldrup-Link, Heike E. PA-108 Damphousse, Amelie EDU-103 Dandoy, Christopher EDU-060 Dannenberg, Bernard PA-058 Dannull, Kimberly A. PA-123 Dao, Tuan EDU-057, PA-008 Dardzinski, Bernard J. PA-104 Darge, Kassa PA-047 Darge, Kassa CR-045, EDU-012, EDU-036, EDU-050, EDU-075, PA-049, PA-052, PA-053, PA-085 Dasari, Swetha B. CR-012, EDU017, EDU-085 Dasgupta, Niloy SCI-022, PA-117 Dasgupta, Roshni PA-139 Dastgir, Jahannaz CR-025 Daugherty, Michael W. EDU-035 Davenport, Matt S. PA-009 Davila, Jorge EDU-021, PA-132 Davis, Joseph EDU-045 Davis, Trevor Z. CR-032, SCI011, SCI-014, SCI-025 Daw Bitar, Najat EDU-098 deFreitas, Roger A. EDU-018 Degenhardt, Karl PA-022 Delgado, Jorge PA-110, PA-113 Delumpa, Alfred E. CR-047, CR051

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Demello, Daphne CR-009 Deng, Jie EDU-018, PA-033 Depinet, Holly PA-056 Deraney, Sarah CR-068 Desilet-Dobbs, Debra CR-046 Desoky, Sarah SCI-023 Dharmavaram, Naga PA-018 Dhatt, Ravjot CR-059 Dickman, Paul CR-052, CR-069 Dickson, Paula CR-008 Diehn, Felix EDU-008 Dietz, Kelly CR-013, CR-062, PA-120 Dillman, Jonathan R. EDU-034, EDU-098, EDU-109, SCI-020, PA-009, PA-057, PA-062, PA-097, PA-156 DiMaria, Michael PA-026 Do, Patrick EDU-107 Doa, Tuan CR-069 Doan, Andrew EDU-077 Dobkin, Julie CR-045 Dodd, Nicholas A. PA-073, PA074 Dodge, Cristina PA-038 Donatelli, John CR-005, CR-067 Donegan, Timothy L. PA-155 Donnelly, Lane F. EDU-101 Dori, Yoav PA-095 Doria, Andrea S. SCI-010, SCI036, SCI-039 Dormans, John PA-155 Dorris, Kathleen PA-135 Downes, Jenna EDU-064 Downey, Molly EDU-066, SCI032 Dubois, Josée PA- 020 Dubuisson, Robert EDU-033 Dwek, Jerry CR-034 Eckel, Larry EDU-008 Ecklund, Kirsten PA-109 Edgar, Christopher J. PA-101, PA124 Edison, Michele N. CR-022, CR036, CR-037, CR-038, EDU-091 Egelhoff, John CR-009, CR-039, Poster #: EDU-014, Poster #: SCI-012 Ehman, Eric C. PA-063 Eklund, Meryle CR-008, CR-021, CR-029, PA-036 El Jalbout, Ramy EDU-103 Ellenbogen, Amy L. EDU-072 Emery, Kathleen PA-105 Epelboym, Yan SCI-008 Epelman, Monica EDU-101, PA-106 Escobar, Fernado CR-057 Escudero, Mark EDU-049, EDU-055, EDU-056, EDU-067, EDU-068, EDU-071, EDU-100, Espinoza, Jimmy PA-017 Estrada, Carlos SCI-008

Estroff, Judy A. CR-016, SCI-008, PA-014, PA-015, PA-083, PA-125, PA-021 Eutsler, Eric PA-106 Faerber, Eric EDU-038, EDU-073, EDU-078, EDU-079, EDU-083, EDU-086 Fagen, Kimberly E. CR-006, EDU-025 Fakharzadeh, Benjamin SCI-019 Fardanesh, Reza EDU-108 Farley, Sarah A. EDU-116 Fazeli Dehkordy, Soudabeh SCI-020 Federico, Sara PA-006 Fefferman, Nancy R. PA-046 Fein Levy, Carolyn EDU-077 Feinstein, Kate A. PA-039 Feldman, Henry PA-015 Felice, Marc A. PA-037 Felsenstein, Susana SCI-027 Fenton, Gregory EDU-040 Fenton, Laura Z. CR-043, EDU-054, PA-129, PA-135 Filly, Roy A. EDU-087, PA-013 Fleck, Robert J. PA-068 Fleming, Cynthia EDU-081, EDU-105, EDU-110 Fonseca, Brian PA-026 Forsting, Michael PA-064 Fox, Karin PA-017 Francavilla, Michael PA-112 Fujikawa, Atsuko EDU-059, EDU-093 Fursevich, Dzmitry M. CR-022, CR-036, CR-037, CR-038, EDU-091 Gadapelli, Samir PA-057 Gadapelli, Samir K. EDU-034 Gaisie, Godfrey CR-019 Gale, Heather I. EDU-044 Ganapathy, Shankar S. CR-004, CR-019 Ganim, Bessie C. EDU-053 Gantsoudes, George EDU-045, EDU-062 Garel, Juliette PA-020 Garel, Laurent EDU-103, PA-020 Garriga, Matias PA-094 Gee, Michael PA-088, PA-099 Gelfand, Michael J. EDU-053, PA-139, PA-142 Gellar, James I. PA-143 Gerard, Perry CR-015 Ghaghada, Ketan B. SCI-044, PA126, PA-147 Ghahremani, Shahnaz EDU-102 Gholipour, Ali PA-014, PA-125 GilbertsonDahdal, Dorothy SCI-023 Gill, Kara EDU-051, EDU-104 Gilsanz, Vicente PA-018 Girard, Erin PA-101 Gladstone, Airewele PA-050 Gnerre, Jeffrey M. CR-012, EDU-017, EDU-085

Gnesda, Ryan CR-067 Goerner, Frank PA-038 Goette, Matthew PA-002, PA004 Goldfisher, Rachelle EDU-095, SCI-001, PA-116 Golriz, Farahnaz PA-024 Goodman, Stuart PA-108 Gordon, Christopher SCI-035 Gorfu, Yocabel PA-049 Gould, Sharon W. EDU-101 Grattan-Smith, Damien PA-051, PA-149 Green, Sarah EDU-066 Greenberg, S Bruce PA-034, PA-045, PA-069 Greer, Mary-Louise C. PA-118, PA-005 Griggs, Rachel EDU-049, EDU-055, EDU-056, EDU-067, EDU-068, EDU-071, EDU-100 Grignon, Andrée PA-020 Grigoriou, Emmanouil PA-155 Grove, Jason J. PA-156 Grove, Jason J. PA-097 Gu, Richard SCI-037 Guermazi, Ali EDU-044 Guidi, Claude CR-005, CR-067 Guillerman, Robert PA-011, PA-012 Guo, Junyu PA-145 Gupta, Anita PA-144 Gupta, Priya EDU-023 Gupton, Theodore B. PA-140 Haacke, Ewart EDU-084, SCI-021, PA-023 Hahn, Cecil SCI-038 Hahn, Gabriele PA-122 Hahnemann, Maria PA-064 Haider, Semmab EDU-070 Halabi, Safwan EDU-039 Halasha, Natasha EDU-113 Halliday, William SCI-016 Handler, Michael PA-135 Hankinson, Todd PA-135 Hare, Michelle CR-040 Harlan, Susan SCI-027 Harned, Roger K. PA-157 Harris, Allison E. EDU-002 Hassan, Soni EDU-084, SCI-021 Hayes, Kari CR-043 Hayes-Jordan, Andrea EDU-098, PA-141 Heath, Alana PA-078, PA-079 Hegde, Ashwin CR-059, EDU-048 Hegde, Shilpa PA-045 Hehn, Rebecca PA-119 Heider, Amer PA-097, PA-156 Henault, Kathryn J. EDU-064 Heran, Manraj K. CR-026 Hernandez, J. Alberto PA-154 Hernandez, Jose A. SCI-030 Heyworth, Benton PA-081

Hill, Jeanne CR-029, PA-036, PA-086 Hill, Robert PA-032 Hilmes, Melissa EDU-118 Hippe, Daniel S. PA-072 Hitt, Dave EDU-106 Ho, Chang Y. EDU-043, EDU-105, EDU-110 Ho, Christine SCI-004 Hogan, Mark PA-100 Hoggard, Eric CR-013, PA-120 Holm, Tara CR-013, CR-062 Hope, Michael PA-041 Hopkins, Katharine EDU-066, SCI-032 Horn, Paul PA-111 Horrow, Mindy PA-121 Horsley, Erin M. EDU-073 Horst, Deanna M. PA-128, PA-130 Horton, Daniel PA-106 Hough, Jennifer CR-040 Hryhorczuk, Anastasia EDU-009 Hsiao, Albert PA-030 Hu, Houchun H. SCI-012 Hughes, Katrina S. PA-017 Hughes, Terence EDU-024 Huh, Winston EDU-098, PA-141 Hulett Bowling, Rebecca EDU-052 Hull, Nathan CR-007 Hunter, Jill V. CR-050 Hurst, Robert PA-096 Imai, Rumi SCI-005 Imler, Dan PA-058 Infante, Juan C. PA-042 Ishak, Gisele EDU-088 Itkin, Maxim PA-095 Iyer, Ramesh EDU-088 Iyoob, Suzanne PA-022 Jabi, Feraas EDU-108 Jacot, Jeffrey PA-029 Jadhav, Siddarth PA-012 Jadhav, Siddharth PA-074 Jadhav, Siddharth P. SCI-034, PA-025, PA-073 James, Adrian SCI-016 James, Charles PA-153 Janitz, Emily CR-004 Jaramillo, Diego PA-019, PA-082, PA-085, PA-104, PA-108, PA-110, PA-112, PA-113, PA-124 Jaremko, Jacob L. PA-078, PA-079 Jarrett, Kathryn EDU-038 Je, Bokyung PA-084 Jedynak, Andrzej EDU-017 Jella, Pavan SCI-021, PA-023 Jeon, Tae Yeon PA-151 Jiang, Xia PA-039 Jin, Ning PA-033 Johnsen, Allison M. EDU-113 Johnson, Ann PA-022, PA-052, PA-082, PA-124

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Johnson, Neil SCI-022 Johnston, Donna EDU-021 Jone, Pei Ni PA-026 Jones, Jeremy Y. EDU-082 Jones, Matthew M. PA-125 Jones, Richard H. CR-013, PA-120 Jones, Robert PA-146 Jordan, David PA-043, PA-138 Jorgensen, Scott CR-011 Kadom, Nadja EDU-040 Kan, J. H. PA-114 Kanamori, Yutaka EDU-059 Kandula, Vinay CR-031, CR-041 Kang, Chang Ho PA-111 Kang, Guolian PA-137 Kao, Simon SCI-003 Kao, Simon EDU-065 Kaplan, Jess PA-099 Kaplan, Summer EDU-036 Kaplan, Summer L. PA-037 Kaplan-List, Katia EDU-005 Kar, Erica CR-002, CR-057 Karakas, S. Pinar EDU-106 Karakas, Sabiha P. EDU-047 Karamanian, Ara EDU-024 Karmazyn, Boaz EDU-043, EDU-045, EDU-062 Karrer, Frederick CR-043 Kassis, Christine PA-103 Kaste, Sue C. PA-006, PA-137 Kato, Tomoaki EDU-042 Kaufman, Robert PA-006, PA-137 Kaye, Robin CR-009, CR-032, SCI-014, SCI-025 Kazmi, Faaiza K. EDU-078, EDU-083, EDU-086 Keller, Marc S. PA-095, PA-155 Keller, Roberta L. EDU-087, PA-013 Kerwood, Joanne EDU-114 Kesselman, Andrew J. PA-116 Ketwaroo, Pamela D. CR-016 Khalatbari, Shokoufeh SCI-020 Khan, Saba PA-104 Khanna, Geetika EDU-028 Khanna, Rohit CR-003 Kharbanda, Sandhya PA-108 Khrichenko, Dmitry CR-045, PA-052, PA-053 Kicska, Greg PA-072 Kim, Ha Yan PA-059 Kim, Hee Kyung PA-084, PA111 Kim, Heung PA-021 Kim, Hyun Gi PA-059 Kim, In-One PA-066, PA-151 Kim, Jane SCI-015 Kim, Jane S. EDU-026 Kim, Michael K. EDU-104 Kim, Myung-Joon PA-059 Kim, Wendy EDU-026, SCI-015 Kim, Woo Sun PA-066, PA-151 Kim, Young-Jo PA-080, PA-081 Kinner, Sonja PA-064 Kirby, Patricia CR-027, SCI-003

Kleinman, Paul K. SCI-024, PA076 Kline-Fath, Beth M. EDU-010 Klionsky, Nina B. EDU-005 Klochko, Chad EDU-039 Knowlton, Joshua EDU-089 Koc, Gonca SCI-029 Kolbe, Amy EDU-008 Kolbe, Amy B. EDU-030 Kolnick, Dean SCI-031 Koral, Korgun CR-044 Koral, Korgun PA-077 Kosik, Russell EDU-031 Kousari, Yeamie M. CR-035 Krajewski, Constance W. PA-118 Kralik, Stephen F. EDU-105 Kralik, Stephen EDU-110 Kraus, Steven PA-084 Krausert, Amanda PA-071 Krishnamurthy, Ganesh EDU-024, PA-155 Krishnamurthy, Rajesh CR-070, SCI-034, PA-002, PA-003, PA-004, PA-024, PA-025, PA-027, PA-028, PA-029, PA-031, PA-050, PA-073, PA-074, PA-090 Krishnamurthy, Ramkumar CR070, PA-001, PA-002, PA-003, PA-004, PA-027, PA-028, PA-029, PA-031 Krishnamurthy, Uday PA-023 Krishnarao, Priya M. EDU-031, EDU-080, EDU-107 Krohmer, Steven CR-065 Kucera, Jennifer N. EDU-035, PA-087 Kuehn-Hajder, Jessica CR-062 Kuhlmann, Joel CR-007 Kuhn, Ryan PA-033 Kukreja, Kamlesh SCI-030 Kukreja, Kamlesh U. PA-154 Kunze, Christian PA-122 Lai, Lillian CR-027, EDU-028, EDU-065, SCI-003 Lai, Manda E. PA-062 Lai, Patrick EDU-039 Lai, Peng PA-103 Laifer-Narin, Sherelle L. CR-053, EDU-076 Lakoma, Anna PA-147 Lapidus-Krol, Eveline SCI-006 Lapierre, Chantale PA-020 Larson, David PA-117 Lauenstein, Thomas C. PA-064 Laughlin, Suzanne SCI-038 Lavin, Kimberly SCI-002 Lay, Sara E. CR-018, EDU-062 LeCompte, Leslie CR-012, CR-015, EDU-017, EDU-085, EDU-097, EDU-099 Lee, Christabel CR-017, EDU027 Lee, Edward Y. PA-055 Lee, Mark EDU-064 Lee, Mi-Jung PA-059

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Lee, So Mi PA-066 Leschied, Jessica R. EDU-034, PA-009 Lester, Neil EDU-094 Leung, Wing PA-137 Levine, Deborah PA-015 Lewis, Alex PA-058 Li, Xingyu PA-145 Li, Yimei PA-145 Ligocki, Carolina SCI-039 Lim, Marc Michael D. CR-015 Lim, Ruth PA-088 LiMarzi, Gary CR-022, CR-036 Linam, Leann E. SCI-026, PA-045 Lindsay, Aaron J. PA-129 Linscott, Luke EDU-060 Lischuk, Andrew EDU-090 Little, Stephen PA-149 Liu, Yu PA-042 Lobritto, Steven EDU-042 Loewen, Jonathan M. EDU-069 Loomis, Judyta EDU-046, PA-127 Lopez, Monica PA-011 Love, Terri CR-014, PA-131 Lu, Zheng Feng PA-039 Lukse, Ruby EDU-001 Lungren, Matthew SCI-022 Lusk, Leslie A. EDU-087, PA-013 Lyons, Karen EDU-111, PA-002, PA-003, PA-004, PA-025, P-028, PA-031, PA-073, PA-074 Mabee, Myles PA-078, PA-079 MacDougall, Robert D. PA-119 Machida, Helen EDU-023 Machnitz, Judit EDU-079 Mack, Takman CR-034 MacKenzie, John D. SCI-029, SCI-031, SCI-033, PA-041, PA060, PA-063 MacNealy, Marcus EDU-039 Madan, Shobit CR-002 Magill, Dennise PA-037 Mahboubi, Soroosh EDU-114, PA-091 Mahieu, Natalie SCI-027 Mahmood, Nadia PA-001, PA-012 Malik, Archana EDU-073, EDU078, EDU-079, EDU-083, EDU086 Malkin, David PA-005 Mallon, Mea EDU-038, EDU073, EDU-078, EDU-079, EDU083, EDU-086 Mancuso, Melissa S. CR-004 Mandel, Karen EDU-021 Mandell, Gerald A. CR-020 Mangona, Kate Louise M. PA-011 Manning, David A. PA-071 Marcon, Margaret A. SCI-006 Marcovici, Peter SCI-029 Marine, Megan B. EDU-043 Markl, Michael EDU-018, PA007 Marshall, Kelley EDU-069 Marshalleck, Francis PA-100

Martin, Douglas CR-062 Martin, Kenneth EDU-106 Martinez, Mercedes EDU-042 Martinez, Mesha L. EDU-041 Martinez-Rios, Claudia PA-043, PA-067, PA-138 Masand, Prakash CR-051, SCI-034, PA-025, PA-073, PA-074 Masand, Prakash M. EDU-111 Maskatia, Shiraz PA-028 Matheney, Travis H. PA-109 Matsumoto, Jane M. CR-007, EDU-030 Matsumoto, Junichi EDU-093 Matsumoto, Kimikazu EDU-059 Matsuoka, Kentaro EDU-059 Maxfield, Charles M. EDU-019, PA-146 May, Collin PA-081 May, Lauren A. EDU-032 May, Megan M. PA-114 Mayercik, Vera EDU-009 Mazza, Michael B. PA-009, PA-057 McBroom, Jennifer SCI-009 McCarville, M. Beth PA-145 McCulloch, Michael EDU-101 McCullough, William P. EDU-075 McDonald, Jennifer S. EDU-030 McIvor, Meghan EDU-023, EDU-070 Mckenzie, Emmett Dean CR-070 Medsinge, Avinash CR-002, CR-057 Mehollin-Ray, Amy R. EDU-111, PA-017 Mehta, Hasit EDU-097 Merrow, Arnold C. EDU-010, PA-105 Mery, Carlos SCI-034 Messina, Robert CR-054 Metz, Terrence PA-156 Meyers, Arthur B. EDU-006 Meyers, Kevin PA-101 Meyers, Mariana L. PA-123 Michael, Braun PA-050 Milewicz, Dianna M. PA-126 Milla, Sarah S. EDU-069 Miller, Cindy EDU-081 Miller, Elka EDU-021, PA-152 Miller, Jeffrey CR-039, CR-052, EDU-014, SCI-012 Miller, Stephen CR-066 Millis, Michael B. PA-080 Mirsky, David M. EDU-054, PA-123, PA-129 Mitchell, Grace EDU-010, PA142 Miyazaki, Osamu EDU-059, SCI-005 Mody, Swati EDU-084, SCI-021, PA-023 Moe, David C. EDU-020, PA-115 Moffett, Brady CR-070, PA-027 Mohan, Parvathi CR-063

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Moineddin, Rahim PA-005, PA043 Mollard, Brett PA-062 Molossi, Silvana SCI-034 Mooney, James CR-021 Moore, Aideen SCI-016 Moore, Mary Beth PA-153 Morani, Ajaykumar C. EDU-098, PA-141 Mori, Juichi EDU-093 Morin, Cara EDU-026, SCI-015 Morin, Nicholas SCI-015 Mormile, Nicole C. EDU-053 Morris, Jonathan CR-007 Morriss, Michael C. PA-075 Moss, Christie SCI-011 Moudgil, Pranav PA-097 MRazek-Pugh, Barbara PA-016 Munden, Martha M. CR-030 Munir, Sohaib SCI-010 Murakami, Akira EDU-044 Murati, Michael CR-013, Paper #: 120 Murtagh, Ryan CR-005 Muthusami, Prakash SCI-016 Myanji, Firoz CR-026 Nadel, Helen R. EDU-092 Naeger, David M. PA- 041 Naffaa, Lena CR-004 Nagaraj, Usha D. EDU-010 Naidu, Padmaja CR-039 Nakajima, Yasuo EDU-093 Nakamura, Lee CR-047, CR-050, CR-051 Nakamura, Lee M. EDU-082 Namsechi, Risa SCI-028 Navid, Fariba PA-145 Neelavalli, Jaladhar EDU-084, SCI-021, PA-023 Neimark, Matthew SCI-001 Neuman, Jeremy EDU-001 Newman, Beverley PA-117 Nguyen, Jie C. CR-023, EDU-051, EDU-104 Nguyen, Khanh SCI-035, SCI-037 Nicholas, Jennifer L. PA-048 Nishimura, Gen SCI-005 Nixon, Jason SCI-009 Noel, Cory CR-070, PA-027, PA028, PA-029 Noga, Michelle SCI-028 Nosaka, Shunske EDU-028 Nosaka, Shunsuke EDU-059, SCI-005 Ntoulia, Aikaterini EDU-114, PA085, PA-091, PA-113 O’Brien, Matthew EDU-039 O’Dell, Matthew C. CR-022, CR036, CR-037, CR-038, EDU-091 O’Hara, Sara M. PA-084 Oatis, Kristi EDU-108 Ogawa, Yasuyoshi EDU-093 Ohliger, Michael A. PA-063 Olsavsky, Thomas EDU-108 Opfer, Erin EDU-089

Orscheln, Emily PA-054 Orth, Robert C. PA-011, PA-012, PA-038 Ortiz-Neira, Clara L EDU-023, EDU-070 Ostry, Lauren EDU-085, EDU-099 Otero, Hansel J. EDU-117 Otjen, Jeffrey EDU-116 Paddock, Michael CR-040 Pagano, Lindsay M. EDU-113 Paldino, Michael J. EDU-082, PA-001, PA-126, PA-146 Pappo, Alberto PA-006 Parad, Rebecca PA- 015 Parad, Richard B. PA-083 Parameswaran, Aishwarya SCI-020 Parekh, Keyur EDU-018, PA-007 Parikh, Ashish K. EDU-003, PA-040 Parikh, Roshni PA-044 Park, Ellen EDU-047 Park, Young CR-056 Parra, Dimitri PA-098 Pass, Jonathan H. PA-093 Patel, Amani H. PA-093 Patel, Manish SCI-022 Patel, Marharshi H. SCI-026 Patel, Mittun CR-003, CR-011, CR-069, EDU-004, EDU-057 Patel, Premal A. PA-093, PA-098 Patel, Surehka SCI-004 Pater, Luke E. PA-142 Patibandla, Rao PA-135 Patil, Kedar SCI-041 Patkar, Deepak SCI-045 Patton, Alice EDU-008 Pednekar, Amol PA-029, PA-031 Perito, Emily PA-060 Pezeshkmehr, Amir PA-153 Pfeifer, Cory CR-046, EDU-063 Phelps, Andrew SCI-029, SCI-031, SCI-033, PA-041, PA-060, PA-063 Phewplung, Teerasak PA-088 Pi, Yeli PA-078, PA-079 Pierce, Drew PA-114 Pignatelli, Ricardo Paper #: 029 Pillai, Rex M. EDU-102 Pimpalwar, Sheena SCI-030 Pitcher, Graeme EDU-028, SCI003 Pizarro, Christian EDU-101 Plunk, Matthew R. PA-143, PA-144 Pluto, Charles SCI-040 Podberesky, Daniel J. PA-056 Podeszwa, David SCI-004 Podhaizer, David EDU-022, SCI-018 Polansky, Stanley CR-058 Poletto, Erica EDU-038, EDU-073, EDU-078, EDU-079, EDU-083, EDU-086

Ponrartana, Skorn EDU-049, EDU-055, EDU-056, SCI-027, PA-018 Popek, Edwina PA-017 Popescu, Andrada PA-007 Popescu, Oana CR-060 Poznick, Laura EDU-074 Prabhu, Sanjay PA-014 Prasad, Srinivasa PA-141 Pratt, Li-Tal SCI-016 Press, Craig PA-129 Prithiani, Chandan PA-046 Pruthi, Sumit EDU-113, EDU-118 Pugmire, Brian S. PA-099 Punithakumar, Kumaradevan SCI-028 Racadio, John SCI-022 Radhakrishnan, Rupa PA-105 Raghavan, Ashok CR-040 Rajaram, Veena PA-077 Rajderkar, Dhanashree A. EDU-033 Ramachandran, Raga PA-060 Ramirez, Raul PA-053, PA-110, PA-113 Ramo, Brandon SCI-004 Ranade, Mona EDU-006 Rao, Anil G. CR-021, PA-035, PA-036 Rassi, Jonathan EDU-047 Ray, Siddharth SCI-044 Recht, Michael P. PA-046 Reid, Janet R. EDU-074, PA-047, PA-049, PA-085 Reiser, Ingrid PA-039 Reyenga, William M. PA-034 Rhee, Sue J. PA-063 Riccio, Anthony SCI-004 Richardson, Randy SCI-002 Richer, Edward CR-065, CR-068 Riemer, Ellen CR-029 Rigsby, Cynthia K. EDU-018, EDU-101, PA-007, PA-033, PA-042 Rintoul, Natalie SCI-013 Ro, Esther EDU-015 Roach, Brent A. EDU-118 Rochon, Paul PA-157 Rodriguez, Danella M. PA-154 Rodriguez, Alexis PA-061 Roh, Yun Ho PA-059 Rohren, Eric PA-003 Roman-Colon, Alicia M. EDU-111 Romero, Roberto EDU-084, SCI-021, PA-023 Ronsky, Janet L. PA-079 Rose, Michael PA-007 Rosenberg, Henrietta K. EDU-094 Rosenthal, Philip PA-060 Rozovsky, Katya PA-152 Ruangwattanapaisarn, Nichanan PA-030 Rubesova, Erika PA-016, PA-019, PA-061

Rubio, Eva CR-006, EDU-025, SCI-019 Ruby, Jeannine EDU-051 Ruess, Lynne PA-128, PA-130 Rusin, Jerome A. PA-128, PA-130 Rusin, Nathan C. PA-128, PA-130 Ruzal-Shapiro, Carrie EDU-042 Ryan, Maura EDU-015, PA-048 Rychik, Jack PA-022 Rypens, Françoise PA-020 Safdar, Nabile PA-107 Sagar, Pallavi PA-070 Sago, Haruhiko SCI-005 Saint-Martin, Christine SCI-041 Saleem, Sheena PA-136 Samet, Jonathan CR-028 Sams, Cassandra M. EDU-115, PA-109 Sanders, James O. EDU-005 Santiuste, Marta PA-122 Sato, Yutaka EDU-028, SCI-003 Sato, T Shawn CR-027, EDU-028, EDU-065, SCI-003 Sato, Yutaka CR-027, EDU-065 Sattar, Abdus PA-067 Saul, David CR-045, PA-022, PA-121 Savage, Thomas CR-026, CR-059, EDU-092 Scace, Candace EDU-038 Scanlon, Mary PA-047 Schaefer, Carrie CR-032, SCI-014, SCI-025 Schafernak, Kristian CR-028 Schapiro, Andrew EDU-104 Scheller, Amy SCI-043 Schooler, Gary R. PA-055 Schulman, Marta EDU-011 Schutzman, David PA-121 Schwartz, Beth I. PA-087 Schwartz, Kara CR-010 Schweiger, Bernd PA-64 Scott, William PA-075 Scrugham, Jeffrey CR-066 Segal, Lee SCI-011 Seghers, Victor PA-001, PA-002, PA-003, PA-004 Sehnert, Elizabeth PA-115 Senasi, Ramdas CR-040, EDU-070 Senguttuvan, Rajan SCI-023 Sertic, Madeleine PA-100 Servaes, Sabah EDU-041, EDU-075 Setser, Randolph PA-096 Sett, Suvro EDU-099 Setty, Bindu EDU-022, EDU-044, SCI-018 Sexson Tejtel, Sara Kristen CR-070 Shah, Amar EDU-099 Shah, Chetan EDU-003, EDU-007 Shah, Chetan C. PA-040 Shah, Sanket EDU-089 Shailam, Randheer PA-070

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Shames, Jason EDU-038 Sharafinski, Mark E. PA-115 Share, Jane PA-083 Shariati, Khashayar SCI-010 Sharma, Karun V. CR-063 Sharma, Neal CR-061 Sharma, Priya G. EDU-049, EDU-055, EDU-056, EDU-067, EDU-068, EDU-071, EDU-100 Sharma, Ravi CR-061, SCI-017 Sharp, Susan EDU-053, PA139 Shellikeri, Sphoorti PA-096, PA-101 Shellikeri, Sphoorti SCI-013, PA-100 Sher, Andrew PA-001, PA-002, PA-003, P-004 Sheridan, Alison D. CR-054, EDU-090 Sheridan, Rachel M. PA-144 Shet, Narendra EDU-026, SCI-015 Shi, Lin PA-148 Shiau, Gillian EDU-023 Shima, Hideki EDU-093 Shin, Hyun Joo PA-059 Shin, Su-Mi PA-151 Shiraj, Sahar PA-111 Shohet, Jason M. SCI-044, PA-147 Sibley, Richard PA-061 Sierre, Sergio D. PA-094 Silva, Cicero T. CR-042 Simanovsky, Natalia PA-152 Simmons, Cephus E. PA-035, PA-092 Singh, Sudha EDU-118 Singh, Sumit PA-069 Sirin, Selma PA-064 Sivit, Carlos PA-044 Smith, Berry EDU-021 Smith, Ethan A. EDU-034, EDU-098, SCI-020, PA-009, PA-057, PA-062, EDU-109 Smith, Shrita M. EDU-001 Snow, Aisling PA-119 Snowden, Georgianne SCI-017 Sorensen, James PA-074 Soriano, Stephanie PA-044 Speidel, Brandon CR-014, PA-131 Sreedher, Gayathri CR-004, CR-019 Srinivasan, Abhay CR-057 Srinivasan, Ashok PA-137 Srivaths, Poyyapakkam PA-050 Sroufe, Nicole PA-057 Sroufe, Nicole S. EDU-034 Stalcup, Seth CR-029 Stamoulis, Catherine SCI-024, PA-015, PA-055 Stans, Anthony CR-007 Starosolski, Zbigniew A. SCI-044, PA-126, PA-147

Starr, Vanessa EDU-107, PA-016, PA-061 States, Lisa J. PA-140 Stavrakis, Costas G. SCI-043 Stefanov, Dimitre PA-116 Stein, Jill M. PA-068 Stein, Nina EDU-096, PA-132 Stence, Nicholas V. EDU-054, PA-129, PA-135 Stenzel, Martin PA-122 Stimec, Jennifer SCI-036 Strouse, Peter EDU-034 Strubel, Naomi PA-046 Stuart, Sam PA-093 Sturgill, Mark E. EDU-054 Sunkara, Anusha PA-137 Surabhi, Venkateswar PA-141 Sutter, Gabriele PA-122 Swenson, David W. EDU-115, PA-055, PA-109 Sze, Gordon CR-054 Taboada, Eugenio CR-001 Tadros, Sameh CR-002, CR-057 Tafti, Mona A. PA-133 Talmadge, Jennifer EDU-016 Tamrazi, Benita EDU-067, EDU071, EDU-100 Tan, Cynthia SCI-031 Tang, Peggy PA-148 Taylor, George EDU-016 Taylor, George A. PA-119 Taylor, Michael CR-029 Telesmanich, Morgan E. PA-012 Teplisky, Dario J. PA-094 Texteira, Sara PA-043, PA-067, PA-138 Thacker, Paul CR-021, PA-035, PA-036, PA-086 Thakrar, Darshit CR-002 Thakrar, Pooja EDU-020 Tharakan, Sasha PA-091 Theut, Stephanie CR-001 Thomas, Anna K. CR-039, EDU004, EDU-014, SCI-012 Thomas, Jennifer EDU-099 Thomas, Karen E. SCI-006 Thomas, Kristen B. EDU-030 Thompson, Richard B. PA-078, PA-079 Tiao, Gregory M. PA-139, PA-143 Tiarks, Hailey J. PA-128, PA130 Tijerin Bueno, Marta PA-005 Toaff, Miriam SCI-013 Tong, Angela EDU-085, EDU097, EDU-099 Towbin, Alexander J. PA-056, PA087, PA-143, PA-144 Towbin, Richard CR-032, CR039, EDU-004, EDU-014, EDU057, SCI-012, SCI-014, SCI-025 Tracy, Donald EDU-009 Tran, Brandon CR-047 Tran, Brandon H. CR-051 Traum, Avram Z. PA-088 Trinh, Long EDU-107

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Trout, Andrew T. EDU-053, PA-054, PA-056, PA-087, PA-142, PA-143, PA- 144 Truong, Uyen PA-026 Tsai, Amy EDU-022, SCI-018 Tsai, Andy SCI-024, PA-076 Tu, Long H. CR-042 Tun, Moe CR-001 Turpin, Brian K. PA-142 Udayasankar, Unni EDU-047 Udjus, Kristin PA-152 Ulualp, Seckin PA-077 Urbine, Jacqueline EDU-073, EDU-078, EDU-079, EDU-083, EDU-086 Vachhani, Neil EDU-047 Valeur, Natalie EDU-088 Valvano, Thomas SCI-032 van Schuppen, Joost CR-024 Varich, Laura CR-022, CR-036, CR-037, CR-038, EDU-091 Vasanawala, Shreyas S. PA-030, PA-058, PA-103 Vaughan, Kevin CR-057 Velasco-Annis, Clemente PA-014 Vellody, Ranjith PA-097, PA-156 Verdoorn, Jared CR-010 Victoria, Teresa PA-022, PA-124 Villalona, Gustavo CR-042 Villamizar, Carlos A. PA-126 Villani, Anita PA-005 Villanueva-Meyer, Javier PA-041 Vincent-Sheldon, Stephanie A. EDU-008 Vo, Nghia EDU-020, PA-115 Volberg, Frank CR-017, EDU-027 von Allmen, Daniel PA-056, PA-139 Vossough, Arastoo EDU-075 Vyas, Pranav EDU-072 Wagner, Lars M. PA-139 Wagner, Matthew EDU-108 Walkup, Laura L. PA-068 Wallihan, Daniel B. PA-056 Walters, Michele M. PA-109 Wampler Muskardin, Theresa CR-010 Wang, Annie PA-02 Wang, Defeng PA-148 Wang, Kuan Chung SCI-010, SCI-039 Wang, Lily CR-049 Ward, Rebecca CR-040 Ward, Valerie PA-119 Warfield, Simon PA-014, PA-125 Weatherspoon, Kimberly CR-058 Weinert, Dayna PA-043, PA-138 Weinman, Jason PA-071 Weiss, Pamela F. PA-082 West, Hollie EDU-011 Wheeler, Mark SCI-023 Whitehead, Matthew EDU-037, PA-127, PA-150 Wien, Michael EDU-037, PA-150 Wiertel, Katie CR-044

Williams, Jonathan L. EDU-033 Williams, Lindsay E. CR-065 Wilson, Brian CR-044 Wilson, Nagwa EDU-021, SCI-041, PA-152 Winfeld, Matthew J. EDU-117, PA-102, PA-107 Wood, Jonathan R. CR-049, EDU-060 Woods, Jason C. PA-068 Wu, Jianrong PA-006 Yadav, Bhupender CR-063 Yam, Benjamin L. EDU-012 Yang, Edward CR-016 Yang, Erica CR-030, PA-001, PA-090 Yang, Mary SCI-004 Yen, Philip PA-044, PA-067, PA-138 Yen, Yi-meng PA-080, PA-081 Yewchuk, Lila CR-059 Youssfi, Mostafa CR-011, PA-008 Yu, Alvin PA-070 Zaffanello, Marco PA-089 Zahra, Mahmoud EDU-024, EDU-108 Zamiara, Paul SCI-006 Zandieh, Arash R. CR-017, EDU-027 Zarchan, Adam CR-046 Zbojniewicz, Andrew M. PA-142 Zderic, Stephen A. EDU-012 Zehava, Rosenberg PA-102 Zeinati, Chadi EDU-068 Zewdneh, Daniel PA-049 Zhang, Wei SCI-034, PA-011, PA-012, PA-025 Zhu, Xiaowei EDU-075, PA-037 Zingula, Shannon CR-010, EDU-030 Zucker, Evan J. EDU-107, PA-061 Zurakowski, David PA-083

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PEDRAD2015 KEYWORD INDEX

18FDGPET/CT EDU-092 3 Tesla EDU-084 320-Detector Row CT EDU-093 3D MRI PA-014, PA-031 3D printing CR-007 3D SSFP PA-031 3T PA-103 3T MRI PA-124 3Tesla EDU-106 4D Flow PA-007 Abdominal SCI-029 Abdominal Cocoon EDU-059 Abdominal CT PA-044 Abdominal Imaging EDU-077 Abdominal Mass CR-037 Abdominal Pain EDU-036, EDU-052 Abdominal Radiography PA-117 Abdominal Tumors EDU-092 Aberrant Subclavian Artery EDU-038 Ablavar EDU-069, PA-034 Abruptio Placenta CR-062 Abscess CR-024 Abusive Head Trauma EDU-100, SCI-040 Achondroplasia CR-006, SCI-041 Acromion PA-102 ACTA2 PA-126 Acute Appendicitis EDU-032, PA-044 Acute Cholecystitis EDU-091 ADC PA-052, PA-053 ADEM EDU-105 Adolescent Breast Masses EDU107 Adrenal Cortical Hyperplasia CR-022 Adrenal Cortical Tumor EDU-092 Adrenal Insufficiency PA-151 Adrenoleukodystrophy EDU-031 Advocacy EDU-115 Affordable Care Act EDU-115 Afghan Protocol CR-040 After-Hours PA-115 Airtight PA-092 Airway EDU-010, PA-073 ALARA EDU-103, SCI-017, PA-006, PA-039, PA-040 ALL PA-098 Ambiguous EDU-011 Ambiguous Genitalia CR-012, SCI-008 AML SCI-027 Anatomy EDU-049, PA-125 Anemia CR-037, SCI-043 Aneurysmal Bone Cyst CR-036 Angiography CR-026 Angioplasty CR-063, SCI-030 Animal Model PA-034 Anomalous Coronary SCI-034 Anomaly CR-017

Anterior Urethral Valves CR-012 Aortic Arch Anomaly CR-066 Aortic Arch Reconstruction PA024 Apparent Diffusion Coefficient PA-112 Appendicitis EDU-034, EDU-063, EDU-091, SCI-009, PA-043, PA-054, PA-055, PA-056, PA-057, PA-058 Appendicitis Complications CR-030 Appendicitis in Young Children CR-030 Appendicolith CR-030 Appendictis SCI-001 Appendix SCI-009, PA-011, PA-012, PA-054, PA-055 Approach EDU-113 Arachnoid Cyst CR-038 Arterial SCI-030 Arteriovenous Fistula CR-019 Arthrocentesis PA-153 Artifact CR-045 ASIR SCI-005 ASL PA-127 Atlantoaxial Fixation EDU-008 Atlantoaxial Injuries EDU-008 Atlantoaxial Subluxation EDU008 Attending SCI-001 Atypical Intussusception CR-058 Auxilary Partial Orthotopic Liver Transplant EDU-042 AVN PA-080 Balloon Catheter PA-092 Barium Meal PA-035 Barth CR-015 Basal Cell Nevus EDU-046 Basic Principles of PET and SPECT EDU-108 Beckwith-Wiedemann CR-022 Benign Enlargement CSF Spaces of Infancy PA-131 BESS PA-131 Bezoar CR-059 Bilateral Patent Ductus Arteriosus EDU-089, SCI-002 Biliary Duct PA-094 Bilious Vomiting PA-008 Biomechanics PA-029 Biopsy SCI-025, PA-097, PA-156 Bladder Catheterization PA-084 Blood SCI-043 Blood Pool PA-030 Bochdalek SCI-003 Body Composition PA-018 Bone EDU-048, PA-019 Bone Age SCI-023, PA-076 Bone Age Estimation SCI-023, SCI-024, PA-076 Bone Biopsy PA-154 Bone Culture PA-154 Bone Length SCI-024 Bone Marrow EDU-090, PA-107 Bone Marrow Edema PA-105

Bone Marrow Transplant CR-025 Bone Marrow Transplantation PA137 Bone Tumors PA-103 Bowel EDU-070 Bowel MRI PA-064 Brain CR-016, PA-001 Brain Imaging PA-015 Brain MRI SCI-016 Brain Ultrasonography PA-151 Brainstem PA-135 Breast Diseases EDU-107 Bronchial Atresias PA- 020 Broncho-Pulmonary Foregut Lesion CR-057 Bronchoceles PA- 020 BRTO EDU-020 Burkitts Lymphoma CR-028 Button Battery EDU-066 C-Spine SCI-040 Calcineurin Inhibitor Induced Pain Syndrome CR-025 Call Preparation PA-048 Calvarium CR-027 Canavan’s EDU-031 Cancer Predisposition PA-005 Cancer Stem Cell SCI-044 CAQ PA-157 Cardiac PA-028 Cardiac CT PA-025 Cardiac CTA PA-032 Cardiac MRI PA-025 Cardiomyopathy CR-015, EDU018 Cartilage PA-111 Catheter EDU-027, PA-121 Caudate EDU-003 Caudate Nucleus EDU-003 Cavernous Sinus Thrombosis PA129 Cavoatrial Junction PA-120 CDH EDU-047, SCI-003 Celiac Axis Dissection CR-040 Central Line EDU-016 Central Venous Catheter EDU016, PA-098 Cerebellar EDU-035 Cerebellum PA-015 Cerebral AVM Embolization PA096 Cerebral Deep Medullary Veins EDU-054 Cerebral Infarction PA-128, PA130 Cerebral Perfusion PA-127 Cerebral Peri AVM Perfusion PA096 Cerebral Vasculature EDU-058, PA-128, PA-130 Cervical CR-024, EDU-088 Cervical Spine EDU-008 CEVUS PA-085 Challenging Case CR-061 CHD SCI-034 Chemical Shift PA-107 Chemoembolization SCI-030

Chest SCI-003, SCI-027, PA-066, PA-072 Chest CT PA-006 Chest Radiograph PA-065 Chest Radiography PA-117 Chiari EDU-035, EDU-082 Chilblains PA-105 Child CR-042 Child Abuse CR-029, EDU-100 Childhood vasculitis EDU-057 Children EDU-018, EDU-042, EDU-047, EDU-065, EDU-086, PA-053, PA-057, PA-071, PA082, PA-094 Cholangiography PA-094 Choledochal Cyst PA-021 Chondroblastic Osteosarcoma CR-069 Chordee SCI-008 Chorioangioma CR-062 Choriocarcinoma CR-055 Chylothorax EDU-116 Circumflex Aorta EDU-038 Cirrhosis EDU-109 Clavicle EDU-001 Clavicle Fracture EDU-017 Clear Cell CR-043 Clinical Effectiveness PA-057 Clinical Significance PA-088 Clinimetric Property SCI-010 Cold Exposure PA-105 Colon PA-063 Colonic Atresia EDU-009 Communicating Hydrocele/Spermatic Cord Hydrocele/ Scrotal Hydrocele EDU-004 Communication PA-046, PA-118 Community Hospitals PA-045 Comparison PA-059 Complete Bladder Duplication CR-014 Complication CR-013, CR-046 Complications EDU-027 Computed Tomography CR-040, SCI-044, PA-009, PA-045, PA066, PA-137 Congenital CR-017, CR-023, EDU-010 Congenital Anomalies CR-014, CR-015, EDU-117 Congenital Diaphragmatic Hernia EDU-087, PA-013 Congenital Diverticulum CR-002 Congenital Globe EDU-056 Congenital Heart disease EDU-089, SCI-002, PA-025, PA-032 Congenital Lung Lesions PA-020 Congenital Malformations CR067 Congenital MSK Deformity EDU005 Congential Diaphragmatic Hernia SCI-003 Contrast Agent SCI-044 Contrast Enema PA-091

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Contrast Enhanced Ultrasound PA-145 Contrast Enhanced Voiding Urosonography PA-085 Core PA-156 Coronaries PA-026 Cranial Nerve Injury EDU-014 Cranial Nerves EDU-049 Cranio Cervical Junction SCI-041 Craniocervical Junction CR-036, EDU-008 Craniocervical Junction Injury EDU-014 Craniosynostosis PA-152 Crohns Disease PA-099 Crohn’s Disease PA-064 Cryptorchidism CR-001 CSF Leak CR-032 CT CR-055, EDU-040, EDU-059, SCI-005, SCI-027, SCI-038, SCI041, PA-054, PA-073, PA-074, PA-119 CT Angiography SCI-002 CT Cisternogram CR-032 CT Dose PA-042 CT Guidance PA-154 CT Image Quality PA-042 CT Radiation Dose Reduction in Pediatric Patients PA-042 CTA EDU-101, SCI-034 Curriculum EDU-074 Cyst PA-087 Cyst Characteristics PA-088 Cystic Fibrosis EDU-023, EDU070 Dandy EDU-035 DDH SCI-011 Deep Medullary Veins EDU-054 Desmoplastic Fibroma CR-027 Desmoplastic Small Round Cell Tumor PA-141 Development PA-019 Developmental Delay CR-005 Device PA-092 Diaphragmatic EDU-036, EDU047 DICER 1 CR-048 Differential EDU-071 Diffuse Renal Disease PA-050 Diffusion Tensor Imaging PA-113 Diffusion Tensor Imaging (DTI) PA-110 Diffusion Weighted Imaging PA064 Diffusion-Weighted PA-058 Dimple EDU-101 Direct Sheath Puncture SCI-022 Direct/Indirect Inguinal Hernias CR-049 Direct/Indirect Inguinal Hernias with Bowel and/or Mesenteric Fat EDU-004 Dislocation EDU-104, PA-080 Distress PA-086 Diverticulum EDU-030, EDU101

DMV EDU-054 DMV Thrombosis EDU-054 Dobutamine CR-070 Doppler Indices EDU-041 Doppler Ultrasound CR-040 Dose PA-038 Dose Optimization PA-117 Dose Reduction PA-040, PA-041 Double Aortic Arch EDU-038 Doxycycline Absorption SCI-013 Doxycycline Dose in Sclerotherapy SCI-013 DSRCT PA-141 DTI PA-136 DTI/ADC PA-050 Dual Energy CT EDU-075 Dual Source CT PA-066 Dual Ventricle PA- 029 Dual-Energy X-ray Absorptiometry (DXA) SCI-010 Ductus Arteriosus EDU-089, SCI-002 Duodenal Atresia EDU-019 Duodenum CR-013 Duplication Cyst PA- 021 DWI EDU-021, PA-052, PA-053 Dynamic Airway PA-074 Dynamic Airway Imaging PA-073 Dynamic CT EDU-093 Dysmyelination EDU-031 Dysplasia PA-019 Dysraphism EDU-088 ECCL CR-038 ECG-Gating PA-032 Echo Planar Imaging PA-033 Echocardiogram SCI-002 Economics EDU-115 Ectopic Spleen CR-023 ED PA-119 Education PA-118 Effective Dose SCI-006 Elastography SCI-025, PA-059, PA-060 Elusive CR-006 Embolization EDU-020, SCI-030 Embryology EDU-038 Emergency EDU-028, PA-115 Encapsulating Peritoneal Sclerosis EDU-059 Encephalitis CR-003 Endotracheal PA-121 Enema PA-035 Enterography PA-062 Enterovirus CR-051, EDU-067 Eovist EDU-069 Epibulbar Choristoma CR-047 Epilepsy CR-050, EDU-108, PA001, PA-136 Epileptogenic EDU-071 Epiphyseal Equivalents EDU-006 Epiphysis EDU-006 Esophageal Atresia SCI-006 Esophageal Perforation EDU-085 Esophageal Rupture EDU-017 Ewing PA-142 Exposure Index PA-039, PA-117

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Extralobar Sequestration CR057 F-DOPA PA-140 Facial Nerve EDU-049 Failed Reduction PA-091 Fallopian Tube CR-035 Fast MRI EDU-032 Fat Fraction EDU-090 FDG-PET PA-142 Feasibility PA-056 Fellowship PA-157 Ferumoxytol PA-030 Fetal CR-016, CR-053, EDU-010, EDU-076, EDU-087, EDU-106, SCI-021, PA-013, PA-022, PA023, PA-125 Fetal Imaging EDU-084, PA-014, PA-015, PA-124 Fetal MRI CR-062, PA-016, PA123 Fetal Subcortical Cysts CR-004 Fetus SCI-005, PA-019, PA-020 Fibroosseous CR-027 Fibrosis SCI-025 Fibrous CR-027 Fibrous Dysplasia CR-038 Field Strength PA-113 Fine Needle PA-097 Fires Syndrome CR-050 Fistula EDU-085 Flouroscopy PA-036 Flow PA-033 Fluoroscopy SCI-006, PA-038 Fluoroscopy Guided PA-154 FMRI PA-136 FMRU CR-045 Follicular Bronchiolitis PA-071 Fontan PA-095 Foreign Body EDU-066, EDU085, EDU-102, PA-072 Foreign Object EDU-066 Fracture SCI-010 Fracture/Migration EDU-033 Free Breathing PA-031, PA-073, PA-074 FRFSE SCI-029 Frontonasal EDU-055 Frontonasal dysplasia CR-053 Function SCI-028 Fungal EDU-060, SCI-027 Fungus PA-137 Gadofosveset Trisodium PA-034 Gadolinium EDU-069 Gadoteric Acid SCI-045 Ganglioglioma PA-135 Gastric EDU-028 Gastric Volvulus CR-008 Gastrointestinal EDU-026, EDU028 Gastrojejunostomy PA-115 Gaucher’s Disease EDU-090 General Anesthesia PA-062 Genetics CR-015 Genital Anomaly SCI-008 Genitalia EDU-011 Genitourinary System EDU-012

Gestational Trophoblastic Disease CR-055 Glioma PA-134 Gonadal Shielding PA-037 Gorlin EDU-046 Gorlin-Goltz EDU-046 Gray Matter EDU-043 Greulich and Pyle SCI-023, SCI-024 Growth PA-083 Guide EDU-002 Haberland’s Syndrome CR-038 Haller Index PA-069 Hand EDU-117 Head and Neck CR-036 Head CT CR-029 Head Ultrasound EDU-022, SCI-018 Headache EDU-082 Hematoma CR-013 Hemihyperplasia CR-022 Hemihypertrophy CR-022 Hemimegalencephaly EDU-076 Hemiplegic Migraine EDU-082 Hemolytic Anemia PA- 050 Hemophilic Arthropathy SCI-039 Hemorrhagic Ovarian Follicle CR-037 Hepatic Fibrosis PA-061 Hepatic Trasplant PA-094 Hepatoblastoma PA-143, PA-144 Hernia EDU-047 HIE EDU-105 High Altitude PA-123 High Resolution Computed Tomography PA-071 High Temporal PA-028 Hip PA-081 Hip Click SCI-011 Hip Dysplasia SCI-011 Hip Fracture PA-080 Hip Injury PA- 080 Hirschsprung SCI-019 Histiocytosis PA-002 HLHS PA-022 Holoprosencephaly EDU-037 Hybrid PA-067, PA-138 Hybrid Iterative Reconstruction PA-043 Hybrid Lesion CR-057 Hydronephrosis EDU-050, PA-051 Hyperbilirubinemia SCI-016 Hyperinsulinism PA-140 Hypersplenism EDU-109 Hypervascular Mass CR-043 Hypoplastic Left Heart PA-022 Hypospadias SCI-008 Iatrogenic EDU-027 IBD PA-063 Image Gently SCI-012 Image Guided Therapy SCI-035 Image Quality PA-032 Image-Guided PA-115 Image-Guided Biopsy CR-021, CR-028

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Imaging EDU-042, EDU-078, EDU-083, EDU-086, EDU-102, PA-153 Imaging 3.0 EDU-039 Immunodeficiency CR-015, CR-051 In Vivo PA-147 In-Phase PA-103 Incidence PA-131 Incidental Renal Cyst PA-088 Incorrect Count EDU-114 Independent Study PA-048 Infant PA-127 Infant Bone Age SCI-024, PA-076 Infantile Hemangioma SCI-014 Infants EDU-086, PA-025, PA-152 Infectious CR-024 Inferior Vena Cava PA-120 Inflammation SCI-033, PA-063, PA-082 Inflammatory EDU-118 Inflammatory Bowel Disease EDU-070, PA- 099, PA-132 Infliximab SCI-020 Information PA-093 Ingestion EDU-066 Innovative PA-092 Insulinoma PA-140 Insurance PA-114 Intellectual Property PA-047 Inter-Observer Agreement PA-009 Interdepartmental SCI-017 Internet PA-093 Intersex EDU-011 Interstitial Lung Disease PA-071 Interventional PA-156, PA-157 Interventional Radiology EDU-068, PA-095, PA-099 Interveous EDU-024 Intestinal Obstruction EDU-052 Intracranial Hypotension EDU-082 Intracranial Lipoma CR-047 Intradiploic CR-041 Intralobar Sequestrations PA-020 Intramural CR-013 Intraoperative MR CR-036 Intraorbital EDU-056 Intraorbital Injury EDU-014 Intraspinal Lipoma CR-047 Intussusception CR-042, PA-091, PA-092 Intussusception Complications PA-090 Intussusception Outcomes PA-090 Iron PA-030 Iron Deposition PA-050 Ischemia EDU-036 Iterative Reconstruction PA-042, PA-067, PA-138 Iterative Reconstruction CT PA044

IV EDU-024 Jones Classification EDU-005 Joubert EDU-035 Juxtacortical EDU-048 Kawasaki PA-026 Keratocysts EDU-046 Key Features EDU-025 Kidney PA-053 Kinky Hair CR-044 Knee PA-110, PA-113 Knee Cartilage PA-104 Knee MRI PA-114 Knockout Mouse Model PA-126 Knowledge-Based PA-043, PA-067, PA-138 Lactate PA-134 Laparotomy CR-059 Late-Onset Circulatory Dysfunction PA-151 Lateral Soft Tissue Neck X-ray EDU-103 LCH PA-002 Lead Point CR-042 Lead-Point CR-058 Learning PA-047 Left Anterior Basal Segment Hyperinflation PA-069 Left Main-Stem Bronchus Compression PA-024 Left Ventricle CR-002 Leiomyoma CR-062 Length PA-083 Lesion PA-087 Lesion Detection PA-064 Less than 6 months Old Intussusception PA-090 Lethality EDU-025 Leukemia PA-108 Leukodystrophies EDU-031 Leukoencephalopathy CR-010, EDU-060 Li-Fraumeni Syndrome PA-005 Line EDU-024 Lipid PA-134 Lipoma CR-038, CR-047 Liver SCI-025, SCI-030, PA-143, PA-144, PA-010 Liver Metastasis CR-043 Long Segment SCI-019 Low Dose PA-041, PA-073, PA-074 Low kV CT PA-067, PA-138 Low kVp PA-043 Lucency EDU-040 Lumbar Drain CR-032 Lung Mass SCI-031 Lung-to-Head Ratio EDU-087 Lupus CR-010 Lymphangiectasia PA-022 Lymphangiography EDU-116 Lymphatic EDU-116 Lymphoma EDU-021, PA-003, PA-004 Lymphoscintigraphy EDU-116 Magnetic Resonanace Enterography PA-063

Magnetic Resonance Angiography CR-066 Magnetic Resonance Enterography SCI-020 magnetic resonance imaging EDU-018, SCI-029, PA-014, PA-015, PA-055, PA-064 Malformed Lung CR-014 Malrotation EDU-019, EDU-051, EDU-091 Mass EDU-080 Masses EDU-098 Mastoid SCI-026 MCDK EDU-065 Measurement PA-054 Mechanical Malfunction EDU-033 Meckel EDU-030 Meckel’s EDU-030 Meckels EDU-030 Meconium EDU-009 Meconium Pseudocyst PA-021 Medtronic EDU-002 Melanoma PA-139 MELAS EDU-031 Meningitis CR-032 Meningocele EDU-088 Menkes CR-044 Metabolic Disorders CR-005 Metal Artifact EDU-075 Micro-CT PA-126, PA-147 Microvascular Imaging PA-084 Midgut EDU-028 Midgut Volvulus EDU-051, PA-008 Migrational EDU-043 Missing Needle EDU-114 Mitochondrial Disorders EDU-105 Model Based Iterative Reconstruction PA-041 Model-Based Iterative Reconstruction SCI-005 Modified Seldinger SCI-022 Molar Pregnancy CR-062 Monte Carlo Simulation SCI-035 Morbidity PA-013 Morbidly Adherent Placenta PA-017 Morphometry PA-126 Motion Artifact Reduction PA-123 Moyamoya EDU-082, PA-126 MR PA-033, PA-056 MR Angiography PA-023 MR Contrast PA-082 MR Enterography EDU-023, PA-132 MR Protocol PA-132 MR Spectroscopy SCI-021, PA-134 MR Urography PA-051 MRA EDU-101 MRE PA-062 MRI CR-002, CR-010, CR-011, CR-016, CR-023, CR-034, CR-

048, CR-053, CR-056, CR-061, EDU-010, EDU-026, EDU-032, EDU-034, EDU-040, EDU-076, EDU-077, EDU-106, SCI-028, SCI-038, SCI-040, PA-017, PA018, PA-026, PA-031, PA-050, PA-057, PA-058, PA-075, PA095, PA-107, PA-108, PA-125, PA-142, PA-143, PA-144 MRI and CT CR-028 MRI-Guided Biopsy CR-021 MRU CR-045 Musculoskeletal CR-021, EDU026, EDU-073, SCI-011 Musculoskeletal MRI EDU-044 Music Therapy PA-116 Myelitis EDU-067 Myelomeningocele EDU-088 Myocardial Ischemia PA-026 Myocardium SCI-043 Myoclonus PA-146 Myofibroblastic EDU-118 Naevus Psiloliparus CR-047 Nanoparticle SCI-044 Nanotherapeutic Delivery PA-147 Nasal EDU-055 NAT EDU-100, PA-131 Neck CT PA-040 Neck Pain EDU-073 Neonatal PA-121 Neonatal Ovarian Cyst CR-037 Neonate PA-018, PA-127, PA-150 Neonates PA-025 Nephrogenic Systemic Fibrosis SCI-045 Nephrostomy PA-100 Neuroblastoma SCI-044, PA-006, PA-146, PA-147 Neurocutaneous Syndromes CR-039 Neurofibromatosis Type I. EDU-079 Neurogenic Bladder EDU-012 Neuroimaging EDU-026, EDU-113 Neuromuscular EDU-081 Neuroradiology EDU-003 Neurosonography SCI-018 Neurospinal Dysraphism EDU-012 Neurotoxicity CR-005, CR-054 New Onset EDU-071 NICU EDU-027, SCI-017, PA-039, PA-046 NICU Quality Assurance SCI-015 Noise Reduction PA-138 Nomogram PA-083 Non-Accidental Trauma EDU-100 Non-Inferiority PA-001 Nonaccidental Trauma CR-029 Normal SCI-028 Normal Variants CR-029 Nose EDU-055 Nuclear Imaging EDU-092 Nutmeg PA-022

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Nutritional Deficiency CR-034 Obese Children PA-104, PA-010 Obstruction CR-045 Occipital Encephalocele CR-067 Ocular EDU-056 Odontogenic EDU-046 Oligohydramnios CR-067 Oncologic Chest PA-067 Oncology CR-048, CR-055, EDU-077, PA-143, PA-144 Operators SCI-037 Opioid Cerebellitis CR-054 Opposed-Phase PA-103 Opsoclonus PA-146 Optic Nerve EDU-049 Optison® PA-085 Oral Contrast PA-062 Orbit EDU-056 Orbital EDU-078 Orbital Tumor EDU-056 Orbits PA-014 Organ EDU-086 Organ-Based Dose Modulation PA-066 Organizational EDU-043 Orthopedic PA-114 Orthotopic Mouse Models PA-147 Os Acromiale PA-102 Ossification Centers PA-102 Osteoid Osteoma PA-081 Osteoid Osteomas PA-155 Osteomyelitis PA-105, PA-154 Osteonecrosis EDU-044, PA-108 Osteoporosis SCI-010 Osteosarcoma CR-036 Ovarian Cyst PA-021 Ovarian Torsion CR-037 Ovary CR-049, PA-087 Oxygen Level Change PA-123 PAC EDU-068 Pacemaker EDU-016, PA-075 Pain PA-086 Paley Classification EDU-005 Pancreas SCI-033, PA-140 Pancreatitis CR-042 Para-Ovarian Cyst CR-035 Parent-Facing EDU-039 Parosteal EDU-048 Patella Alta PA-109 Patella Instability PA-111 Patellar Fracture PA-109 Patellar Fragmentation PA-109 Pathology CR-061 Patient Safety EDU-064, SCI-017, PA-075, PA-118 Patient’s Safety EDU-114 Patient-Facing EDU-039 Pe EDU-013 Peak Systolic Velocity EDU-041 PEComa CR-043 Pectus Excavatum PA-069 Pedaitric EDU-001 Pediatric CR-025, EDU-042, EDU-055, EDU-059, EDU-071, EDU-075, EDU-078, EDU-080, EDU-083, EDU-098,

EDU-102, SCI-045, PA-043, PA066, PA-071, PA-095, PA-097, PA-145 Pediatric Airway EDU-093 Pediatric Bladder EDU-012 Pediatric Brain Imaging SCI-012 Pediatric Breast Masses EDU-107 Pediatric Chest Radiograph EDU016 Pediatric Congenital EDU-007 Pediatric Crohn’s Disease SCI020 Pediatric Encephalits EDU-113 Pediatric Endocrinology SCI-023 Pediatric MRI PA-113 Pediatric Nephrostomy PA-100 Pediatric Neuroimaging CR-026 Pediatric Peritoneal Masses PA141 Pediatric Peritoneal Tumors PA141 Pediatric Radiology EDU-115, SCI-023 Pediatric Scrotum EDU-094 Pediatric Spine CR-026, EDU-007 Pediatric Stroke CR-026 Pediatric Trauma CR-040, PA-080 Pediatric Ultrasound PA-116 Pediatric Uterus and Ovary-Containing Hernia CR-049 Pediatric Vascular Pathology CR026, EDU-036 Pediatrics EDU-003, PA-088 Pediatrics ICU SCI-038 Pelvic Abscess EDU-017 Pelvicalyceal Dilation PA-052 Perforation PA-011 Perfusion CR-070, PA-027 Periosteal EDU-048 Peripheral EDU-024 Peritoneal EDU-098 Perivascular Epithelioid Cell CR043 Periventricular Hemorrhage EDU054 Personal Health Record EDU-039 PET PA-140 Pet CT PA-001 Pet MRI PA-001 PET/CT PA-002, PA-003, PA-004 PET/MR PA-002, PA-003, PA004 PET/MRI PA-003 Phakomatoses CR-039 Phantom PA-038, PA-059 Phase Contrast PA-033 Phimosis SCI-008 Physis PA-110, PA-113 PICC EDU-016, SCI-022 Pictorial Review EDU-001 PICU Quality Assurance SCI-015 Pilomatricoma PA-077 Pilomatrixoma PA-077 Piriform Sinus Fistula CR-024 Pitfall EDU-087 Pituitary EDU-080

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Placent Accreta PA-016 Placenta Accreta PA-017 Plain Radiograph EDU-033 Plastic Bronchitis PA-095 Pleural Effusion EDU-116 Pleuropulmonary Blastoma CR019 Pneumomediastinum EDU-085 Polcystic Kidney Disease CR-067 Politics EDU-115 Polycystic Kidney Disease PA088 Polydactyly CR-067 Polymicrogyria CR-004 Port PA-098 Port Complications EDU-068 Port-a-Cath EDU-068 Portal Hypertension EDU-109 Portal Vein PA-007 Porto-Systemic Shunt PA-007 Portocaval CR-017 Portosystemic CR-017 Portosystemic Shunt CR-063, EDU-109 Post Sclerotherapy Doxycycline Absorption SCI-013 Post-Contrast Enhancement PA-058 Post-Marketing Study SCI-045 Post-Traumatic Meningoencephalocele EDU-014 Posterior Fossa SCI-026 Postoperative Imaging EDU-114 Practice Improvement, Consensus Development EDU-050 Pre-Authorization PA-114 Pre-Term PA-150 Premature Brain PA-127 Prematurity PA-070, PA-089 Prenatal CR-053, EDU-076, EDU-117 Prenatal Diagnosis EDU-050 Prenatal Ultrasound PA-016 PRES EDU-060 Preterm Infants PA-151 Prognosis PA-013 PROPELLER SCI-029 Propranolol SCI-014 Pseudocyst CR-046, EDU-033 Pseudomeningocele CR-041 PTLD EDU-060 Pulmonary Hemorrhage PA-070 Pulmonary Sling EDU-038 Pulsed Wave Doppler EDU-041 QUADAS-2 SCI-039 Quality PA-119 Quality Improvement EDU-064, SCI-015, PA-153 Radiation PA-035, PA-036, PA037, PA-084, PA-119, PA-142 Radiation Dose EDU-075, SCI-006, PA-032, PA-040 Radiation Doses SCI-035 Radiation Exposure PA-041, PA-045 Radiation Reduction SCI-017

Radiation Safety PA-152 Radiofrequency Ablation (RFA) PA-155 Radiogenomics PA-144 Radiography EDU-040, EDU-103 Radiology PA-046 Radiology Benefit Managers PA-114 Radiology Requisitions PA-118 Radionuclide Brain Imaging of Epilepsy EDU-108 RAS Gene Mutation CR-039 RDD PA-002 Real Time PA-033 Reflux PA-083 Regadenoson PA-027 REMOVAL PA-098 Renal PA-083 Renal Angioplasty PA-101 Renal Angioplasty Perfusion Changes iFlow PA-101 Renal Contusion EDU-017 Renal Dysplasia EDU-065 Renal Function PA-089 Renal Perfusion PA-101 Reporting EDU-039 Residency PA-157 Resident SCI-001 Resistive Indices EDU-041 Respiratory Distress Syndrome PA-070 Respiratory Motion CR-045 Respiratory Triggered PA-031 Response PA-145 Retrograde Ureteropyelogram EDU-096 Rhabdomyosarcoma CR-048 Rickets SCI-032 Right Aortic Arch PA-065 Right Atrium PA-120 Right Lower Quadrant Pain EDU-034 Rounds PA-046 Sacroiliitis PA-082 Safety SCI-045, PA-075 SAFIRE PA-042 Sarcoma PA-139 Scatter PA-038 Scattered Radiation SCI-037 Schwannoma CR-056 Sclerotherapy PA-093 Scoliosis CR-007, EDU-064 Scoring Systems SCI-039 Scout Abdomen Aadiograph PA-035 Scrotal Masses EDU-004, EDU-094 Scurvy CR-011, CR-034 Sedation PA-086 Segmental Muticystic Dysplastic Kidney EDU-065 Seizure EDU-071 Sella Turcica EDU-080 Seminoma CR-001 Septic Arthritis PA-153

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Sequestration CR-014 Shear Wave PA-059 Sheer Wave Elastography PA-010 Shielding PA-038 Shoulder PA-102 Shunt CR-017 Shunt Malfunction CR-063 Sickle Cell Disease EDU-026, EDU-044 Simulation PA-072 Single Ventricle PA-029 Situs Inversus EDU-091 Skeletal Dysplasia EDU-025, SCI-005 Skeletal Survey CR-006 Skeletally Immature PA-076 Skills PA-049 Skull EDU-040, SCI-032 SLE CR-010 Small Bowel CR-046 Small Bowel Obstruction CR-059, EDU-059 Soft Shields SCI-037 Solid Tumor PA-145 Sonoelastography PA-061 Sonogram EDU-043 Sonography PA-011, PA-012 Sp110 Mutation CR-051 Spastic Paraplegia PA-109 Spasticity EDU-002 Spinal Abnormalities EDU-083 Spinal Cord EDU-067 Spinal Neoplasm EDU-110 Spine EDU-007, EDU-110, PA018 Spine MRI EDU-110 Spleen CR-061, EDU-087, SCI033 Spleen Injury PA-009 Splenic Cyst CR-061 Splenogonadal Fusion CR-023 Splenomegaly EDU-020 SSDE PA-119 Staging EDU-092 STARD SCI-039 Steady State Sequence PA-034 Steatosis SCI-025 Sternoclavicular EDU-104 Stitching Artifact EDU-064 Stomach CR-056, PA-013 Strain PA-028, PA-029 Stress CR-070, PA-027

Stress Perfusion PA-026 Striatal Necrosis CR-005 Stricture EDU-085 Structured Practice PA-048 Structured Reporting SCI-009, SCI-015 Subclavian Steal Syndrome CR066 Subdural Hemorrhage PA-131 Supernumerary Testis CR-023 Suprasellar EDU-080 Surface EDU-048 Surfactant PA-070 Surgical Correlation SCI-034 Surgical Management PA-091 Surgical Planning EDU-117 Surveillance Imaging PA-006 Suspected Retained Surgical Materials EDU-114 Sustained Refractory Status Epilepticus SCI-038 SUV PA-004 Swirling PA-008 Symmetric Basal Ganglia Abnormality CR-005 Syntelencephaly CR-031 Synthetic Opioid CR-054 Systematic Review SCI-010 T2 Hypointense CR-027 T2 Mapping PA-111 T2 Relaxation Time Mapping PA104 Technology Life Cycle PA-047 Temporal Bone PA-149 Teratoma CR-003 Terminal Ileum PA-063 Testicle CR-001 Testicular Pain EDU-004 Testicular Torsion CR-001 Testicular Trauma EDU-004 Testis EDU-094 Thanatophoric CR-016 Thoracic EDU-088, PA-121 Thoracic Imaging EDU-077 Thrombectomy CR-063 Thrombolysis CR-063 Thyroid Nodules PA-097 Thyroiditis CR-024 Tibial Hemimelia EDU-005 Tissue Strain Techniques PA- 089 Tomosynthesis PA-072 TORCH EDU-105

Torsion CR-035 Torticollis EDU-073 Toxic Synovitis PA-153 Tractography PA-110 Trauma PA-009 Traumatic Spinal Injury EDU-100 Trichobezoar CR-059 Trichophagia CR-059 TRICKS CR-066 Tumor PA-087 Tumor Thrombus CR-069 Tutorial EDU-074 Ultrasonography PA-011, PA-012, PA-015 Ultrasound CR-013, CR-055, EDU-041, EDU-043, EDU-050, EDU-063, EDU-070, EDU-074, EDU-107, SCI-001, SCI-009, SCI-011, SCI-026, SCI-039, PA017, PA-019, PA-021, PA-049, PA-054, PA-059, PA-061, PA084, PA-087, PA-094, PA-121, PA-152 Ultrasound Contrast Agent PA085 Ultrasound Findings EDU-023 Ultrasound Guided EDU-024 Ultrasound Scrotum EDU-094 Ultrasound-Guided PA-097 Umbilical Vein Catheter PA-120 Underlying Bowel Etiology PA091 Unsedated PA-074 UPJ Obstruction EDU-096 Upper Airway EDU-093 Upper GI EDU-051, PA-036 Urachus CR-012 Ureteric Pathology EDU-096 Urethral Duplication CR-014 Urinary Tract Dilation EDU-050 Uterus and Ovary-Containing Hernia CR-049 Utilization PA-115 Validation SCI-024 Valium PA-123 Value PA-046 Variants EDU-001, EDU-089 Varices EDU-020, EDU-109 Vascular EDU-027, PA-143, PA157 Vascular Injury from Head Trauma EDU-014

Vascular Rings EDU-101 Vasculitides EDU-057 Vasculitis EDU-057, EDU-060 Vatimin D Deficiency SCI-032 VCUG PA-036 Veno-Occlusive Disease CR-051 Venous Access EDU-068 Venous Malformation PA-034, PA-093 Venous Thrombosis PA-128, PA130 Vertebral Anomalies CR-007 Vesicoureteral Reflux PA-084, PA-085 Vestibulocochlear Nerve EDU049 Video EDU-074, PA-049 Videourodynamics EDU-012 Virtual Endoscopy PA-149 Virtual Non-Contrast EDU-075 Vitamin D Insufficiency SCI-032 Voiding Cystourethrogram PA-086 Voiding Cystourethrography PA-035 Volume PA-014 Volumetric MR PA-103 Volvulus EDU-019, EDU-028, EDU-051, EDU-086, EDU-091 VP Shunt CR-046 VP Shunt Catheters EDU-033 Walker EDU-035 Warmer PA-039 Web CR-042, EDU-074, PA-049 Weber Classification EDU-005 Whirlpool PA-008 Whirlpool Sign EDU-051 White Matter CR-010 White Matter Disorders EDU-105 Whole Body MRI EDU-021, PA-005 X-ray PA-152 Z-length PA-040