Pediatric Radiology

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Human embryo at 9 weeks 2 days of gestation, crown-to-rump length of 25 mm, stained by submersion for 90 h in 1.9% buffered Lugol solution (B-Lugol). Microfocus CT scan was obtained using a Phoenix Nanotom M (Waygate Technologies, Wunstorf, Germany). Scan parameters were 60 kV, 400 µA, 0.5-mm aluminum filter, 8.5-µm voxel size. a Sagittal image shows an overview of the anatomy, indicating the localization of the images in panels (b–e). b Transverse coronal image through the brain shows the parts of the neural tube, ventricles and choroid plexus. 4 fourth ventricle, C choroid plexus, D diencephalon, L lateral ventricle, Me metencephalon, My myelencephalon, T telencephalon. c Coronal image through the trachea and lungs. A aorta, E esophagus, LL left lung, RL right lung, Tr trachea. d Transverse image through the heart. LA left atrium, LV left ventricle, RA right atrium, RV right ventricle. e Sagittal image through the region of the right kidney. G gut, Go gonad, K kidney, SC spinal column, SG suprarenal gland
Volume rendering with a sagittal image of a postmortem 19-weeks-6-days fetus, demonstrating staining over time. Staining was achieved with submersion in 7.5% Lugol–formalin solution [9]. Crown-to-rump length is 150 mm. CT images were obtained using a conventional medical scanner (Somatom Force; Siemens Healthineers, Erlangen, Germany). a–e Unstained image a and images with 25 h of staining b, 45 h of staining c, 119 h of staining d and 241 h of staining e
Microfocus CT (micro-CT) scans of feto-placental vasculature. a Micro-CT volume rendering of intact pregnancy terminated at 6 + 6 weeks post conception. Crown-to-rump length is 22 mm. Scan was derived from the Dutch Fetal Biobank. b Micro-CT volume rendering of a subsample taken from a growth-restricted placenta infused with BriteVu demonstrates an example of unexpected branching characteristics observed at the level of the meso-vasculature. Image adapted from James et al. [28] with permission
Humpback whale fetus before and after staining and de-staining in lateral view. a Initial state stored in 70% ethanol. The white area on the anterior side covers the specimen’s label. The label was removed to avoid damaging it in the staining process. b Specimen after 3 weeks of staining with a solution of 1% metal iodine in ethanol. c Result after 2 weeks of de-staining using a solution of 3% sodium thiosulfate. Adapted from Lanzetti et al. [31] with permission
Over the last few years, fetal postmortem microfocus computed tomography (micro-CT) imaging has increased in popularity for both diagnostic and research purposes. Micro-CT imaging could be a substitute for autopsy, particularly in very early gestation fetuses for whom autopsy can be technically challenging and is often unaccepted by parents. This article provides an overview of the latest research in fetal postmortem micro-CT imaging with a focus on diagnostic accuracy, endovascular staining approaches, placental studies and the reversibility of staining. It also discusses new methods that could prove helpful for micro-CT of larger fetuses. While more research is needed, contrast-enhanced micro-CT has the potential to become a suitable alternative to fetal autopsy. Further research using this novel imaging tool could yield wider applications, such as its practise in imaging rare museum specimens.
Background As the number of conventional radiographic examinations in pediatric emergency departments increases, so, too, does the number of reading errors by radiologists. Objective The aim of this study is to investigate the ability of artificial intelligence (AI) to improve the detection of fractures by radiologists in children and young adults. Materials and methods A cohort of 300 anonymized radiographs performed for the detection of appendicular fractures in patients ages 2 to 21 years was collected retrospectively. The ground truth for each examination was established after an independent review by two radiologists with expertise in musculoskeletal imaging. Discrepancies were resolved by consensus with a third radiologist. Half of the 300 examinations showed at least 1 fracture. Radiographs were read by three senior pediatric radiologists and five radiology residents in the usual manner and then read again immediately after with the help of AI. Results The mean sensitivity for all groups was 73.3% (110/150) without AI; it increased significantly by almost 10% (P<0.001) to 82.8% (125/150) with AI. For junior radiologists, it increased by 10.3% (P<0.001) and for senior radiologists by 8.2% (P=0.08). On average, there was no significant change in specificity (from 89.6% to 90.3% [+0.7%, P=0.28]); for junior radiologists, specificity increased from 86.2% to 87.6% (+1.4%, P=0.42) and for senior radiologists, it decreased from 95.1% to 94.9% (-0.2%, P=0.23). The stand-alone sensitivity and specificity of the AI were, respectively, 91% and 90%. Conclusion With the help of AI, sensitivity increased by an average of 10% without significantly decreasing specificity in fracture detection in a predominantly pediatric population.
The indications for fetal body MRI are amplifying because of the expanding possibilities of fetal and perinatal therapy. However, huge heterogeneity regarding the indications for fetal body MRI is seen among different European countries that is mostly related to local use of US, but also to local fetal MRI expertise and legislation on pregnancy termination. The purpose of this article is to summarize the precise indications for fetal MRI, excluding the central nervous system. MRI indications arise from the sonographic findings, based on the operator’s experience and the various practices in the countries and institutions represented on the European Society of Paediatric Radiology Fetal Task Force. We also highlight the strengths and weaknesses of fetal US and MRI of the fetal body.
Subcutaneous fat necrosis of the newborn is a self-limited disorder predominantly affecting full-term and post-term neonates during the first 6 weeks after birth. Subcutaneous fat necrosis can be focal or multifocal and affect one or both sides with a predilection for areas of pressure in certain anatomical areas. Subcutaneous fat necrosis of the newborn is associated with perinatal asphyxia and other neonatal and maternal risk factors. Subcutaneous fat necrosis of the newborn presents as a self-limited area of dermal edema followed by indurated subcutaneous plaques, or nontender and mobile nodules, sometimes with skin discoloration [1–3]. The diagnosis is based on the child’s history and physical examination, but when in doubt, imaging is helpful. US is the imaging modality of choice to confirm the diagnosis of subcutaneous fat necrosis of the newborn because it provides the best resolution of superficial lesions, requires no sedation and lacks ionizing radiation. US can also help evaluate and characterize other pathologies affecting the superficial subcutaneous soft tissues at this age. Familiarity with subcutaneous fat necrosis of the newborn is important to make a prompt and precise diagnosis and avoid unnecessary imaging tests or invasive procedures.
Because the aorta is the major vessel of the body, basic knowledge of aortic pathology is essential to the pediatric imager. This review divides aortic pathology into anatomical (e.g., congenital abnormalities) and acquired (e.g., vasculitis, trauma) entities, providing a brief description of pathology, technical considerations in CT acquisition and processing, and some pearls and pitfalls of interpretation. The objective of this paper is to familiarize general pediatric imagers with imaging features of common as well as high-impact aortic pathology on CT and prepare them for acquisition and reporting.
Background Hip involvement predicts severe disease in juvenile idiopathic arthritis (JIA) and is accurately assessed by MRI. However, a child-specific hip MRI scoring system has not been validated. Objective To test the intra- and interobserver agreement of several MRI markers for active and chronic hip changes in children and young adults with JIA and to examine the precision of measurements commonly used for the assessment of growth abnormalities. Materials and methods Hip MRIs from 60 consecutive children, adolescents and young adults with JIA were scored independently by two sets of radiologists. One set scored the same MRIs twice. Features of active and chronic changes, growth abnormalities and secondary post-inflammatory changes were scored. We used kappa statistics to analyze inter- and intraobserver agreement for categorical variables and a Bland–Altman approach to test the precision of continuous variables. Results Among active changes, there was good intra- and interobserver agreement for grading overall inflammation (kappa 0.6–0.7). Synovial enhancement showed a good intraobserver agreement (kappa 0.7–0.8), while the interobserver agreement was moderate (kappa 0.4–0.5). Regarding acetabular erosions on a 0–3 scale, the intraobserver agreement was 0.6 for the right hip and 0.7 for the left hip, while the interobserver agreement was 0.6 for both hips. Measurements of joint space width, caput–collum–diaphyseal angle, femoral neck–head length, femoral width and trochanteric distance were imprecise. Conclusion We identified a set of MRI markers for active and chronic changes in JIA and suggest that the more robust markers be included in future studies addressing clinical validity and long-term patient outcomes.
Magnetic resonance urography (MRU) is an important MRI application that provides noninvasive comprehensive morphological and functional evaluation of the kidneys and urinary tract. It can be used to assess congenital anomalies of the kidney and urinary tract, which often present as urinary tract dilation. In children, MRU allows for high tissue contrast and high spatial resolution without requiring ionizing radiation. Magnetic resonance urography requires patient preparation in the form of pre-examination intravenous hydration, placement of a urinary catheter, and the administration of diuretics at the time of the exam. The imaging protocol is based on T2-weighted images for anatomical assessment and dynamic post-contrast images for functional evaluation. These images are then used to generate quantitative and graphic results including contrast transit and excretion time as well as to calculate differential renal function. This review focuses on a simple approach to pediatric MRU acquisition and interpretation based on clinical cases and the authors’ experience.
Advanced cardiorespiratory imaging of the chest with ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) plays an important role in diagnosing respiratory and cardiac conditions in neonates when radiography and echocardiography alone are not sufficient. This pictorial essay highlights the particularities, clinical indications and technical aspects of applying chest US, cardiac CT and cardiorespiratory MRI techniques specifically to neonates, summarising the first session of the European Society of Paediatric Radiology’s cardiothoracic task force.
Background Magnetic resonance imaging (MRI) is often the first modality of choice in the detection of pituitary pathologies due to its excellent contrast resolution and high spatial resolution. However, evaluating the size of the pituitary gland is somewhat difficult since the gland morphology varies widely among individuals.Objective The aim of this study was to provide normal reference values for pituitary volumes in the pediatric population using three-dimensional (3-D) MRI data. We also aimed to compare the volumetric data measured through 3-D images with the mathematical volumes obtained by the ellipsoid formula from 2-D images, considering the demographic subgroups of age and sex.Materials and methodsThis study was performed retrospectively using PACS-archived brain MRIs obtained in the Pediatric Radiology Unit. Eight hundred children under the age of 18 who underwent brain MRI between January 2014 and May 2018 for headaches, seizures or trauma and who had no brain anomaly or endocrine pathology were recruited. Pituitary volumes were separately calculated from those brain MRIs by means of ellipsoid formula and volumetry. The mean, standard deviation, maximum and minimum and median values were achieved for each 1-year age group in both sexes. Normal reference ranges containing 5th -10th -25th -50th -75th -90th -95th percentiles of volumetric pituitary values were tabulated.ResultsPituitary gland volumes in both sexes were found to increase gradually with age. The average 3-D volume values were greater in girls than boys except for the age groups 1–2 years and 8–9 years. Pituitary volumes showed a growth spurt during early puberty, which was more prominent in girls. Moreover, a strong positive correlation was noted between the 2-D calculated and 3-D measured volumes in both sexes.Conclusion Normative data obtained through this study can be used for clinical diagnostic purposes as well as a reference for future research. The 2-D calculated volumes be used where it is not possible to obtain 3-D volumetric values.
Brain magnetic resonance imaging in a 15-year-old boy with Liberfarb syndrome (a) An axial T2-WI shows diffuse hyperintensity of the supratentorial white matter (arrows). b An axial T1-WI shows corresponding mild hyperintensity suggesting hypomyelination (arrows) and global encephalic atrophy. c A coronal reformatted three-dimensional (3-D) T1-WI reveals encephalic atrophy with predominant involvement of the superior vermis (long arrow) and superior portion of the cerebellar hemispheres (short arrows). d A coronal reformatted 3-D T2 fluid attenuated inversion recovery (FLAIR) image shows bilateral optic nerve atrophy (arrows)
Liberfarb syndrome is an extremely rare mitochondrial multisystem disorder, recently described and characterized by early-onset retinal degeneration and sensorineural hearing loss, spondyloepimetaphyseal dysplasia, joint laxity, short stature, microcephaly, developmental delay and intellectual disability, but clinical variability has been observed. We report a case that presented to the hospital with a flare-up of the disease. We describe the brain magnetic resonance imaging findings, which are still not well characterized, to raise awareness of this diagnosis.
Background Deep learning has been employed using brain functional connectome data for evaluating the risk of cognitive deficits in very preterm infants. Although promising, training these deep learning models typically requires a large amount of labeled data, and labeled medical data are often very difficult and expensive to obtain. Objective This study aimed to develop a self-training deep neural network (DNN) model for early prediction of cognitive deficits at 2 years of corrected age in very preterm infants (gestational age ≤32 weeks) using both labeled and unlabeled brain functional connectome data. Materials and methods We collected brain functional connectome data from 343 very preterm infants at a mean (standard deviation) postmenstrual age of 42.7 (2.5) weeks, among whom 103 children had a cognitive assessment at 2 years (i.e. labeled data), and the remaining 240 children had not received 2-year assessments at the time this study was conducted (i.e. unlabeled data). To develop a self-training DNN model, we built an initial student model using labeled brain functional connectome data. Then, we applied the trained model as a teacher model to generate pseudo-labels for unlabeled brain functional connectome data. Next, we combined labeled and pseudo-labeled data to train a new student model. We iterated this procedure to obtain the best student model for the early prediction task in very preterm infants. Results In our cross-validation experiments, the proposed self-training DNN model achieved an accuracy of 71.0%, a specificity of 71.5%, a sensitivity of 70.4% and an area under the curve of 0.75, significantly outperforming transfer learning models through pre-training approaches. Conclusion We report the first self-training prognostic study in very preterm infants, efficiently utilizing a small amount of labeled data with a larger share of unlabeled data to aid the model training. The proposed technique is expected to facilitate deep learning with insufficient training data.
Background Bone age is useful for pediatric endocrinologists in evaluating various disorders related to growth and puberty. Traditional methods of bone age assessment, namely Greulich and Pyle (GP) and Tanner–Whitehouse (TW), have intra- and interobserver variations. Use of computer-automated methods like BoneXpert might overcome these subjective variations.Objective The aim of our study was to assess the validity of BoneXpert in comparison to manual GP and TW methods for assessing bone age in children of Asian Indian ethnicity.Materials and methodsWe extracted from a previous study the deidentified left hand radiographs of 920 healthy children aged 2–19 years. We compared bone age as determined by four well-trained manual raters using GP and TW methods with the BoneXpert ratings. We computed accuracy using root mean square error (RMSE) to assess how close the bone age estimated by BoneXpert was to the reference rating.ResultsThe standard deviations (SDs) of rating among the four manual raters were 0.52 years, 0.52 years and 0.47 years for GP, TW2 and TW3 methods, respectively. The RMSEs between the automated bone age estimates and the true ratings were 0.39 years, 0.41 years and 0.36 years, respectively, for the same methods. The RMSE values were significantly lower in girls than in boys (0.53, 0.5 and 0.47 vs. 0.39, 0.47 and 0.4) by all the methods; however, no such difference was noted in classification by body mass index. The best agreement between BoneXpert and manual rating was obtained by using 50% weight on carpals (GP50). The carpal bone age was retarded in Indian children, more so in boys.Conclusion BoneXpert was accurate and performed well in estimating bone age by both GP and TW methods in healthy Asian Indian children; the error was larger in boys. The GP50 establishes “backward compatibility” with manual rating.
A diagram of the first and second U-Net models in a 13-year-old boy. Anteroposterior teleroentgenogram. a The first U-Net was trained for coarse segmentation of the upper pelvic bone and (b) the second U-Net was trained for fine segmentation of the iliac crests, respectively
An example of the model results in a 12-year-old girl. a Anteroposterior teleroentgenogram. b With the 1st U-Net, the upper pelvic bone was segmented. With the 2nd U-Net, each iliac crest was segmented. c The original right iliac crest and the segmented right iliac crest (white contour). d The original left iliac crest and the segmented left iliac crest (white contour). Segmentation results were overlaid on the input images. Iliac crest height difference was calculated from the difference between the highest y-coordinates of each segmented iliac crest. In this patient, the difference was + 12 mm (right side was 12 mm higher than left)
A case example of the model-assisted measurement in a 16-year-old boy. Anteroposterior teleroentgenogram. a The original teleradiograph and (b) the iliac crest segmentation images overlayed on the teleradiograph results were presented side-by-side to simulate the model-aided measurement. The reader determined whether the segmentation result is acceptable
Scatter diagrams between the ground truth measurement (R1) and (a) human measurement (R2) or (b) deep learning (DL) stand-alone measurement or (c) deep learning-assisted (Assisting) measurement
Background Leg length discrepancy (LLD) is a common problem that can cause long-term musculoskeletal problems. However, measuring LLD on radiography is time-consuming and labor intensive, despite being a simple task. Objective To develop and evaluate a deep-learning algorithm for measurement of LLD on radiographs. Materials and methods In this Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study, radiographs were obtained to develop a deep-learning algorithm. The algorithm developed with two U-Net models measures LLD using the difference between the bilateral iliac crest heights. For performance evaluation of the algorithm, 300 different radiographs were collected and LLD was measured by two radiologists, the algorithm alone and the model-assisting method. Statistical analysis was performed to compare the measurement differences with the measurement results of an experienced radiologist considered as the ground truth. The time spent on each measurement was then compared. Results Of the 300 cases, the deep-learning model successfully delineated both iliac crests in 284. All human measurements, the deep-learning model and the model-assisting method, showed a significant correlation with ground truth measurements, while Pearson correlation coefficients and interclass correlations (ICCs) decreased in the order listed. (Pearson correlation coefficients ranged from 0.880 to 0.996 and ICCs ranged from 0.914 to 0.997.) The mean absolute errors of the human measurement, deep-learning-assisting model and deep-learning-alone model were 0.7 ± 0.6 mm, 1.1 ± 1.1 mm and 2.3 ± 5.2 mm, respectively. The reading time was 7 h and 12 min on average for human reading, while the deep-learning measurement took 7 min and 26 s. The radiologist took 74 min to complete measurements in the deep-learning mode. Conclusion A deep-learning U-Net model measuring the iliac crest height difference was possible on teleroentgenograms in children. LLD measurements assisted by the deep-learning algorithm saved time and labor while producing comparable results with human measurements.
Transjugular liver biopsy in a 9-year-old girl. a Angiography posteroanterior (PA) projection shows the correct position of the catheter in the right internal jugular vein. b Fluoroscopy PA projection shows the biopsy needle set (14–18 G/7 Fr; Cook Medical, Bloomington, IN) with Colapinto needle open to perform transjugular biopsy. c axial US image demonstrates needle guidance during biopsy from right internal jugular vein
Wedged hepatic venous portography in a 2-year-old girl. a, b Digital subtraction images on posteroanterior (PA) (a) and right PA oblique (b) projections through catheterization of the left suprahepatic vein (lsv) show the Rex recess (R) and the communication between the left (lpv) and right (rpv) portal veins
Endovascular treatment of stenotic meso-Rex bypass (MRB) in a 5-year-old girl. a Contrast-enhanced multi-detector-row sagittal CT image shows a stricture within the MRB (arrow). lpv left portal vein, mv mesenteric vein, R Rex recess. b–d Posteroanterior images during percutaneous transhepatic balloon angioplasty (digital subtraction scans in b and d). Mesenteric portogram (b) shows stenosis (arrow) within the left portal vein anastomosis of the MRB and vicariant collateral veins (vcv) arising from the mesenteric vein before the shunt. Balloon angioplasty of the anastomotic stricture (arrow) under fluoroscopic view (c). Fluoroscopy (d) shows the disappearance of the stenosis and collateral circulation after endovascular dilatation
Partial splenic embolization in a 7-year-old girl with portal hypertension and hypersplenism. a Splenic artery posteroanterior (PA) pre-embolization arteriogram shows an enlarged and globus spleen. b PA selective arteriograms performed before embolization show the microcatheter tip (black arrow) and the lower pole arterial branches (white arrows) targeted for selective embolization with particles. c Post-embolization splenic artery angiogram (PA projection) demonstrates an area of reduced angiographic blush of the lower splenic pole (arrows) and the preserved perfusion of the remaining parenchyma
Transjugular intrahepatic portosystemic shunt (TIPS) placement in a 9-year-old girl with liver cirrhosis. a Posteroanterior (PA) portal venogram. b PA fluoroscopy image shows balloon dilation of the intrahepatic tract. Note the proximal and distal balloon notches indicating the length of the hepatic tract. c Portal PA venogram after stent positioning shows good flow through the TIPS. d Three-month follow-up axial Doppler US shows good patency of the TIPS with no late complications
Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric–intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.
Study flow diagram. US ultrasound
Appendiceal diameters on ultrasound at 3- and 6-month follow-up
Comparison of appendiceal diameters at initial diagnosis of uncomplicated acute appendicitis (baseline), at 3- and 6-month follow-up and at the time of recurrence
Comparison of appendiceal diameters between children with and without recurrent acute appendicitis
Association of different ultrasound parameters and enlargement of the appendiceal diameter in children with and without recurrent acute appendicitis (at 3-month follow-up ultrasound)
Background Ultrasound is an accurate tool for diagnosing acute appendicitis. Conservative treatment for uncomplicated acute appendicitis is feasible and safe in children. However, no sonographic follow-up results from children with nonoperatively managed acute appendicitis have been reported. Objective To describe the sonographic appearance of the appendix at follow-up ultrasound and to attempt to identify signs predictive of recurrent acute appendicitis. Materials and methods Children diagnosed with uncomplicated acute appendicitis and treated conservatively in our hospital from 2014 to 2019, and who presented for follow-up ultrasound at 3, 6 and 9 months, were included in our study. Clinical, laboratory and ultrasound data were recorded. Results By the end of follow-up, 29 (14.2%) of 204 children in the cohort had developed recurrent acute appendicitis and 175 had recovered uneventfully. On follow-up ultrasound, appendiceal diameter measured > 6 mm in 56/204 (27.5%) cases at 3 months and in 9/26 (34.5%) at 6 months. After 3 months, 102/204 (50%) children had normal appendiceal diameter on ultrasound. Appendiceal diameter > 6 mm was associated with intraluminal fluid or sludge in the appendiceal lumen at 3- and 6-month follow-up (P < 0.001, P = 0.002, respectively). Comparing cases with and without recurrence, at 3-month follow-up, appendiceal diameter > 6 mm was found in 17/29 (58.6%) cases vs. 39/175 (22.3%), respectively (P < 0.001). Appendiceal diameter returned to normal in 12/19 (63.2%) cases in the nonrecurrent acute appendicitis group compared with 2/7 (28.6%) in the recurrent acute appendicitis group (P = 0.05) at the 6-month follow-up. Intraluminal fluid or sludge was detected more frequently in the recurrent acute appendicitis versus the nonrecurrent acute appendicitis group at 3- (P < 0.001) and 6-month (P = 0.001) follow-up. Conclusion Progressive normalization of appendiceal diameter was noted on follow-up ultrasound. The prevalence of both appendiceal diameter > 6 mm and intraluminal fluid or sludge were found to be increased in children who later developed recurrent acute appendicitis. Ultrasound appears to be a useful tool for follow-up in children with conservatively treated uncomplicated acute appendicitis and possibly might help predict recurrence.
Primary percutaneous gastrostomy and gastrojejunostomy tube placements are fundamental procedures performed in pediatric interventional radiology, with both antegrade and retrograde techniques described. In pediatric patients, however, challenges may arise due to smaller patient size and anatomical variations. Several adjunctive techniques may facilitate safe percutaneous access in the setting of a limited percutaneous gastric access window. These include the intra-procedural use of cone beam computed tomography (CT), percutaneous needle decompression in the setting of distended air-filled bowel interposed between the stomach and abdominal wall, post-pyloric balloon occlusion to facilitate gastric distension, ultrasound-guided gastric puncture, and intra-gastric contrast-enhanced ultrasound (ceUS) to define the relationship of the gastric wall and the anterior abdominal wall. Adjunctive techniques may increase successful primary percutaneous gastroenteric tube placement and may improve operator confidence in safe placement.
Current reimbursement streams for medical (i.e. non-forensic) postmortem imaging (PMI) by modality. Other = cost paid by referring hospital. Total responses: X-ray 20; computed tomography (CT) 16, magnetic resonance imaging (MRI) 15 and ultrasound (US) 5
Current reimbursement streams for forensic postmortem imaging (PMI) by modality. Other = forensic institute/police/coroner. Total responses: X-ray 14; computed tomography (CT) 12, magnetic resonance imaging (MRI) 4 and ultrasound (US) 1. One “not sure” response not shown
Respondent opinions regarding how and where future funding should be prioritised in terms of acquisition modality for postmortem imaging (PMI). Respondent number = 18. CT computed tomography, MRI magnetic resonance imaging, USS ultrasound scan
Respondent opinions regarding priority areas for future funding of postmortem imaging (PMI). Respondent number: radiologist training = 17; radiographer training = 16; radiologist availability = 18; radiographer availability = 15; equipment availability = 17, support staff availability = 16 and local/national guidance = 12. CT computed tomography, MRI magnetic resonance imaging, US ultrasound
Background Perinatal and childhood postmortem imaging has been accepted as a noninvasive alternative or adjunct to autopsy. However, the variation in funding models from institution to institution is a major factor prohibiting uniform provision of this service.Objective To describe current funding models employed in European and non-European institutions offering paediatric postmortem imaging services and to discuss the perceived barriers to future postmortem imaging service provision.Materials and methodsA web-based 16-question survey was distributed to members of the European Society of Paediatric Radiology (ESPR) and ESPR postmortem imaging task force over a 6-month period (March-August 2021). Survey questions related to the radiologic and autopsy services being offered and how each was funded within the respondent’s institute.ResultsEighteen individual responses were received (13/18, 72.2% from Europe). Only one-third of the institutions (6/18, 33.3%) have fully funded postmortem imaging services, with the remainder receiving partial (6/18, 33.3%) or no funding (5/18, 27.8%). Funding (full or partial) was more commonly available for forensic work (13/18, 72%), particularly where this was nationally provided. Where funding was not provided, the imaging and reporting costs were absorbed by the institute.Conclusion Increased access is required for the expansion of postmortem imaging into routine clinical use. This can only be achieved with formal funding on a national level, potentially through health care commissioning and acknowledgement by health care policy makers and pathology services of the value the service provides following the death of a fetus or child. Funding should include the costs involved in training, equipment, reporting and image acquisition.
A 3-month-old boy with abusive head trauma. a An axial diffusion-weighted magnetic resonance (MR) image shows diffuse cytotoxic edema throughout the supratentorial brain (arrowheads), largely sparing the deep gray nuclei. Axial T2-weighted (b) and (c) gradient recalled echo MR images reveal subdural hematomas about the bilateral convexities (arrows). d A sagittal contrast-enhanced, fat-suppressed, T1-weighted MR venogram image demonstrates a filling defect within the superior sagittal sinus (arrowheads)
An 8-month-old boy with abusive head trauma. a An axial diffusion-weighted magnetic resonance (MR) image shows faint cytotoxic edema involving the supratentorial cortices, most evident posteriorly (arrowheads). b An axial T2-weighted MR image demonstrates subdural hematomas about the bilateral convexities (arrows), left larger than right. c An axial T2-weighted MR image, at the cranial vertex, illustrates abnormal signal intrinsic to a left-side bridging vein that extends into the superior sagittal sinus (arrows). d A coronal contrast-enhanced, fat-suppressed, T1-weighted MR venogram image confirms thrombus within a left-side bridging vein extending into the superior sagittal sinus (arrowheads)
Background Cerebral sinovenous thrombosis (CSVT) has been proposed in legal settings to be an atraumatic mimic of abusive head trauma (AHT). Objective The objective of this study was to determine the prevalence of CSVT and subdural hemorrhage (SDH) in a large AHT population. Materials and methods This retrospective cohort study measured the prevalence of CSVT and SDH on magnetic resonance venograms in 243 patients diagnosed with AHT at a single center. We also reported additional intra- and extracranial injuries, head injury severity and length of hospital stay. Results Among 243 patients diagnosed with AHT, 7% (16/243) had CSVT. SDH was present in 94% (15/16) of the CSVT cases. Cytotoxic edema and subarachnoid hemorrhage were in 88% (14/16) and 69% (11/16) of the CSVT cases, respectively. Extracranial signs of abuse were also in 100% (16/16) of the patients with CSVT. Critical to maximal head injury severity (abbreviated injury scale >=5) was in 75% (12/16) of the CSVT population vs. 33% (82/243) in the total AHT population. Length of hospital and pediatric intensive care unit stay was greater in those with CSVT (10 vs. 21.9 and 3.5 vs. 7.3 days). Conclusion These findings suggest that CSVT is uncommon in AHT and is associated with additional traumatic injuries and greater injury severity.
The developmental stages of molars on panoramic radiographs according to the London Atlas. a Initial cusp formation. b Coalescence of cusps. c Cusp outline complete. d Crown half completed with dentine formation. e Crown three-quarters complete. f Crown completed with defined pulp roof. g Initial root formation with diverging edges. h Root length less than crown length with bifurcation area visible. i Root length equals crown length. j Root length more than crown length with diverging ends. k Root length completed with parallel ends. l Apex closed with a wide periodontal ligament. m Apex closed with normal periodontal ligament wide
Regression-based 95% limits of agreement for chronological age (CA) and dental age (DA). a Males. b Females. Solid lines represent the mean difference between DA and CA, and dotted lines represent 95% limits of agreement. D Demirjian method, L London Atlas
The prediction intervals and confidence intervals of chronological age (CA) for each dental age (DA) estimated using the London Atlas. a Males. b Females. In females, only two samples were in DA group 5.5; thus, the prediction and confidence intervals were not calculated. Further, one sample (CA = 19.2), assigned to DA group 20.5, was not shown in the figure. *CA in these DA groups is not normally distributed
Background Dental age estimation is important for developmental assessment and individual identification. The London Atlas, a recently proposed method for dental age estimation, has been reported to perform satisfactorily in various populations.Objective In this study, we assessed the reproducibility, repeatability and applicability of the London Atlas method in the East China population and compared it with the Demirjian method.Materials and methodsWe assessed panoramic radiographs of 835 pediatric patients ages 6.0–19.9 years using the London Atlas and the Demirjian method. We employed the intraclass correlation coefficient and Bland–Altman analysis to evaluate reproducibility and repeatability, respectively. We assessed the agreement between dental age and chronological age and calculated 95% and 80% prediction intervals for each dental age stage. Sensitivity, specificity and predictive values were calculated to assess the performance of both methods for identifying threshold ages.ResultsThe London Atlas has better reproducibility and repeatability (intraclass correlation coefficients: 0.98 and 0.99; 95% limits of agreement: − 1.34 to 1.56 and − 1.22 to 0.88, respectively). Dental age estimated using the London Atlas was closer to chronological age in both genders (median absolute error = 0.58). The 95% prediction intervals for chronological age were wide (0.99 to 9.89 years).Conclusion The London Atlas has excellent reproducibility and repeatability. Thus, it might offer an alternative method for developmental assessment. We observed considerable variation in dental development in the East China population, which needs further research.
A 5-month-old boy with raccoon eyes (periorbital ecchymosis) due to extensive bone marrow metastasis from abdominal neuroblastoma. An axial T2-weighted image (a) and a coronal short tau inversion recovery (STIR) image (b) of the skull base show extensive bone marrow metastases around both orbits (arrows). c A coronal T2-weighted image shows the primary tumour arising from the left adrenal gland with vascular encasement of the renal pedicle (Image Defined Risk Factors positive). d A sagittal STIR image illustrates diffuse bone marrow metastasis of the spine
A 1-month-old girl with enlarged abdominal girth, thrombocytopenia and anaemia. A sagittal short tau inversion recovery (STIR) image (a) shows the relatively small primary tumour arising from the right adrenal gland (arrow) with diffuse liver metastases. b A coronal T2-weighted image illustrates enlargement of the liver due to diffuse liver metastases. Treatment was started due to respiratory compromise. The liver metastases show impeded diffusion (c: axial b1,000 diffusion-weighted image; d: axial apparent diffusion coefficient map)
Neuroblastoma is the most common extracranial solid malignancy of childhood. The prognosis is highly variable ranging from spontaneous involution in infants to fatal outcome, despite aggressive treatment, in disseminated high-risk neuroblastoma. This paper provides a comprehensive review of the crucial role of imaging during the extensive treatment course.
Pediatric neuroradiology is a subspecialty within radiology, with possible pathways to train within the discipline from neuroradiology or pediatric radiology. Formalized pediatric neuroradiology training programs are not available in most European countries. We aimed to construct a European consensus document providing recommendations for the safe practice of pediatric neuroradiology. We particularly emphasize imaging techniques that should be available, optimal site conditions and facilities, recommended team requirements and specific indications and protocol modifications for each imaging modality employed for pediatric neuroradiology studies. The present document serves as guidance to the optimal setup and organization for carrying out pediatric neuroradiology diagnostic and interventional procedures. Clinical activities should always be carried out in full agreement with national provisions and regulations. Continued education of all parties involved is a requisite for preserving pediatric neuroradiology practice at a high level.
Mesenchymal hamartoma in a 2-week-old boy at diagnosis (patient 1) treated with microwave thermoablation. a Axial CT scan with contrast agent shows an inhomogeneously hypodense oval lesion involving the 5th–6th left ribs. b, c The boy underwent two microwave thermoablation sessions (axial CT images) followed by a dimensional increase in the mass, requiring surgical resection. d After 21-month follow-up, axial contrast-enhanced CT scan demonstrates almost complete resection of the lesion
Mesenchymal hamartoma in an 11-month-old boy (patient 2) treated with microwave thermoablation. a, b He presented with a clinical mass of the 9th–10th left ribs, as confirmed on axial CT (with contrast agent) at diagnosis (a), and he underwent microwave thermoablation (axial CT, b). c, d Follow-up MRI. At first (1-month) follow-up, axial T1-weighted MRI (c) shows an inhomogeneous hyperintense lesion, which decreased in dimension on the 9-month follow-up axial T1-weighted MRI (d)
Mesenchymal hamartoma in a 6-month-old girl (patient 3) treated with radiofrequency thermoablation. She presented with persistent respiratory distress requiring diagnostic studies including chest radiograph and, successively, CT scan. a Axial CT shows a inhomogeneous oval mass arising from the 1st–2nd right ribs. b Two sessions of radiofrequency thermoablation were performed (axial CT). c, d Six-month follow-up images show a significant dimensional decrease of the tumor, as a smaller inhomogeneous mass with calcifications at axial CT (c) and as hypo/isointense residual disease on axial T1-weighted MRI (d)
Incidental mesenchymal hamartoma in a 163-month-old boy (patient 4) treated with cryoablation. The mass, involving the 6th–7th–8th right ribs, was found at chest radiography. a Axial chest CT with contrast agent confirms the finding. b, c The boy underwent two sessions of cryoablation (intraoperative axial CT, b) with a slight dimensional increase in the lesion, as shown by the axial CT scan at last 18-month follow-up (c)
Mesenchymal hamartomas in a 4-month-old boy (patient 5) who was treated with cryoablation followed by radiofrequency thermoablation. He presented with acute respiratory distress and chest radiograph revealed bilateral masses of the thoracic wall. a, b Contrast-enhanced CT shows inhomogeneously hypodense oval lesions, with calcifications, arising from 4th–5th–6th right ribs and 4th left rib (a, axial; b, coronal). c He had cryoablation (axial CT image). Initial treatment was unsuccessful (tumor development and persistent dyspnea were seen), and he later underwent radiofrequency thermoablation. d, e Results were very good at 2-year follow-up, confirmed by contrast-enhanced axial (d) and coronal (e) CT images
Background Thoracic mesenchymal hamartomas are rare benign lesions. Rarely symptomatic, they may compress pulmonary parenchyma, leading to respiratory distress. Although spontaneous regression has been documented, the more common outcome is progressive growth. The treatment of choice is en bloc excision of the involved portion of the chest wall, frequently leading to significant deformity. Objective The aim of our study was to describe percutaneous techniques to treat these lesions. Materials and methods We collected data of children with thoracic mesenchymal hamartomas who were treated at our institution from 2005 to 2020 using various percutaneous techniques. Techniques included radiofrequency thermoablation, microwave thermoablation (microwave thermoablation) and cryoablation. Results Five children were treated for chest wall hamartomas; one child showed bilateral localization of the mass. Two children underwent microwave thermoablation, one radiofrequency thermoablation and two cryoablation; one child treated with cryoablation also had radiofrequency thermoablation because mass volume increased after the cryoablation procedure. The median reduction of tumor volume was 69.6% (24.0–96.5%). One child treated with microwave thermoablation showed volumetric increase of the mass and underwent surgical removal of the tumor. No major complication was reported. Conclusion Percutaneous ablation is technically feasible for expert radiologists and might represent a valid and less invasive treatment for chest wall chondroid hamartoma, avoiding skeletal deformities.
Panoramic radiograph of a fully developed pair of lumbar ribs accompanied by a lumbosacral transitional vertebra in a 17-year-old boy. a Anteroposterior projection. b Lateral projection
Background Williams–Beuren syndrome is a rare multisystemic genetic disorder with an incidence of 1 in 7,500 live births. Because these children often have scoliosis, they undergo routine radiographic examinations of the spine. During these examinations we have found many children with supernumerary lumbar ribs arising from the first lumbar vertebra, often associated with lumbosacral transitional vertebrae.Objective To describe the incidence of supernumerary ribs and transitional vertebrae in children with Williams–Beuren syndrome and compare it to the incidence in a general population. Our hypothesis is that these findings are common, but they have not been described in the literature concerning Williams–Beuren syndrome.Materials and methodsFrom January 2015 to October 2021, 308 patients (138 male) with Williams–Beuren syndrome were treated at our hospital. Of these, 106 (47 male) underwent diagnostic imaging, mostly for suspected scoliosis. Panoramic radiographs of the whole spine were performed in 88 patients and radiographs of regions of the spine, chest radiographs, CT, MRI or fluoroscopy in 18 patients. We retrospectively analysed the images concerning the number of ribs and vertebrae. We correlated the frequency of lumbar ribs and transitional vertebrae in comparison to a general population as described in the literature.ResultsAfter exclusions for insufficient imaging, we analysed imaging in 91 patients. Of these, 67 patients (73.6%) had 13 ribs, of which 85% were located on both sides, 9% on the right and 6% on the left side. Of the 67 patients with supernumerary lumbar ribs, 38 (57%) also had transitional vertebrae.Conclusion Supernumerary lumbar ribs arising from the first lumbar vertebra, often accompanied by lumbosacral transitional vertebrae, are common in children with Williams–Beuren syndrome.
Liver cirrhosis in children is a rare disease with multifactorial causes that are distinct from those in adults. Underlying reasons include cholestatic, viral, autoimmune, hereditary, metabolic and cardiac disorders. Early detection of fibrosis is important as clinical stabilization or even reversal of fibrosis can be achieved in some disorders with adequate treatment. This article focuses on the longitudinal evaluation of children with chronic liver disease with noninvasive imaging tools, which play an important role in detecting cirrhosis, defining underlying causes, grading fibrosis and monitoring patients during follow-up. Ultrasound is the primary imaging modality and it is used in a multiparametric fashion. Magnetic resonance imaging and computed tomography are usually applied second line for refined tissue characterization, clarification of nodular lesions and full delineation of abdominal vessels, including portosystemic communications.
An 11-month-old boy was hospitalized for recurrent fever and cough. a, b An axial chest computed tomography shows pulmonary interstitial changes (arrows) with multiple small nodules (arrowheads)
A 1-year-old girl was hospitalized for a urinary tract infection. a An axial T2-weighted image shows a mass in the left renal parenchyma, manifested as slight hypointensity (arrow). b An axial fat-suppressed T1-weighted image shows isointensity (arrow). c An axial contrast-enhanced fat-suppressed T1-weighted image shows slight (or mild) homogeneous enhancement (arrow). d, e An axial diffusion-weighted image with apparent diffusion coefficient show the lesion with decreased diffusivity (arrow)
A 7-year-old boy was hospitalized for central diabetes insipidus. a An axial T2-weighted image shows bilateral nodular masses in the cerebellar hemispheres, with post-biopsy changes on the right side. The left lesion was slightly hypointense (arrow). b An axial T1-weighted image shows isointensity (arrow). c An axial fluid-attenuated inversion recovery image shows slight hypointensity (arrow). d An axial contrast-enhanced T1-weighted image shows marked enhancement (arrow). e A sagittal T1-weighted image shows pituitary enlargement, thickening of the pituitary stalk and disappearance of hyperintensity in the neurohypophysis on T1-W imaging (arrow)
A 4-month-old boy was hospitalized for obstructive jaundice. a Axial contrast-enhanced computed tomography shows a hypodense mass in the head of the pancreas with mild enhancement (arrow). b An axial T2-weighted image shows slight hypointensity (arrow). c An axial fat-suppressed T1-weighted image shows slight hyperintensity (arrow). d Coronal magnetic resonance cholangiopancreatography shows irregular dilation of the pancreaticobiliary duct (arrows) and changes after cholecystostomy (arrowhead)
Background Juvenile xanthogranuloma is rare in children and there are limited data on its imaging features.Objective To analyze the computed tomography (CT) and magnetic resonance imaging (MRI) features of juvenile xanthogranuloma in children.Materials and methodsA retrospective review was performed of clinical and radiographic data of histologically confirmed juvenile xanthogranuloma between January 2009 and June 2020.ResultsFourteen children (4 girls, 10 boys; age range: 1 day to 13 years, mean age: 73 months) were included in the study: 4/14 had CT only, 5/14 had MRI only and 5/14 had CT and MRI. Sites of extracutaneous juvenile xanthogranuloma involvement included subcutaneous soft tissue (8/14), liver (2/14), lungs (2/14), kidney (2/14), nose (2/14), pancreas (1/14), central nervous system (1/14) and greater omentum (1/14), mainly manifested as single or multiple nodules or masses in different organs. On CT, the lesions mainly manifested as an iso-hypo density mass with mild or marked enhancement. On MRI, the lesions mainly manifested as slightly hyperintense on T1 and slightly hypointense on T2, with decreased diffusivity and homogeneous enhancement. Juvenile xanthogranuloma was not included in the imaging differential diagnosis in any case.Conclusion Juvenile xanthogranuloma mainly manifests as single or multiple nodules or masses in different organs. Slight hyperintensity on T1 and slight hypointensity on T2 with decreased diffusivity and homogeneous enhancement are relatively characteristic imaging findings of juvenile xanthogranuloma. Combined with its typical skin lesions and imaging features, radiologists should include juvenile xanthogranuloma in the differential diagnosis when confronted with similar cases.
Implementation of the patient-specific 3-D-printed cutting guide in the clinical workflow for pediatric renal tumors. ─── clinical care, --- implementation of the cutting guide
An example of the visual matching of radiologic slices and histopathological macroscopy and microscopy. An 80-month-old girl with a left regressive Wilms tumor (98% therapy effect) and nephrogenic rest after 4 weeks of preoperative chemotherapy. Axial slices at two levels (a-e and f-j) are shown on post-contrast T1-weighted magnetic resonance imaging (MRI) (a, f), diffusion-weighted MRI b1000 (b, g), apparent diffusion coefficient MRI (c, h), macroscopic histopathology (d, i) and microscopic histopathology with hematoxylin and eosin stain (e, j). Images (a-c) show a nephrogenic rest that was directly correlated to the macroscopy and microscopy (d, e,1.0/40 × magnification). In (f–h), the ventral tumor component was correlated with histopathology (i, j,0.4/44 × magnification)
Background Pediatric renal tumors are often heterogeneous lesions with variable regions of distinct histopathology. Direct comparison between in vivo imaging and ex vivo histopathology might be useful for identification of discriminating imaging features. Objective This feasibility study explored the use of a patient-specific three-dimensional (3D)-printed cutting guide to ensure correct alignment (orientation and slice thickness) between magnetic resonance imaging (MRI) and histopathology. Materials and methods Before total nephrectomy, a patient-specific cutting guide based on each patient’s preoperative renal MRI was generated and 3-D printed, to enable consistent transverse orientation of the histological specimen slices with MRI slices. This was expected to result in macroscopic slices of 5 mm each. The feasibility of the technique was determined qualitatively, through questionnaires administered to involved experts, and quantitatively, based on structured measurements including overlap calculation using the dice similarity coefficient. Results The cutting guide was used in eight Wilms tumor patients receiving a total nephrectomy, after preoperative chemotherapy. The median age at diagnosis was 50 months (range: 4–100 months). The positioning and slicing of the specimens were rated overall as easy and the median macroscopic slice thickness of each specimen ranged from 5 to 6 mm. Tumor consistency strongly influenced the practical application of the cutting guide. Digital correlation of a total of 32 slices resulted in a median dice similarity coefficient of 0.912 (range: 0.530–0.960). Conclusion We report the feasibility of a patient-specific 3-D-printed MRI-based cutting guide for pediatric renal tumors, allowing improvement of the correlation of MRI and histopathology in future studies.
Skeletal anomalies are rare, requiring a systematic ultrasound (US) examination of each skeletal part when there is suspicion of a skeletal dysplasia. Although US examination can provide good evaluation of the fetal bones and cartilage, ultra-low-dose three-dimensional (3-D) multi-detector computed tomography (CT) is a useful complementary tool that can significantly improve prenatal diagnostic accuracy in select cases. Given that ultra-low-dose fetal CT remains an irradiating technique, indications should result from a multidisciplinary consensus, acquisition protocols should be optimized and the reporting standardized. In this paper we discuss guidelines from the Fetal Imaging Task Force of the European Society of Paediatric Radiology for indications, protocols and reporting of ultra-low-dose fetal CT.
The novel X-ray radiation protective trolley for newborns. a-c Clinical images show the width of the top (a), width of the bottom (b) and lengths and heights (c) of the protective trolley. d Application during radiographic examination. Once the detector is placed against the newborn’s back, the upper layer of the protective trolley and the front lead rubber roller shutter are raised. The protective trolley covers the entire newborn bed during radiographic examination
Clinical images of the three protection scenarios for scatter radiation: (a) no protection, (b) protection with radiation personal protective equipment and (c) the protective trolley for newborns
Graph shows a comparison among protection methods and the scattered radiation dose to each radiosensitive organ of the human phantom. a–c Graphs represent the three distances, 0.75 m (a), 1.5 m (b) and 3.0 m (c). A no protection, B protection with radiation personal protective equipment (RPPE), C protective trolley for newborns. When using the protective trolley during radiologic imaging (i.e. radiography) the scatter radiation dose received by the operator was not statistically different from the environmental background dose (P>0.05) at any distance
Graph compares the scattered radiation incurred by each sensitive organ of the human phantom, as well as the environmental background dose, at the three distances
Chest radiography is commonly performed as a diagnostic tool of neonatal diseases. Contact-based radiation personal protective equipment (RPPE) has been widely used for radiation protection, but it does not provide full body protection and it is often shared between users, which has become a major concern during the coronavirus disease 2019 (COVID-19) pandemic. To address these issues, we developed a novel trolley to protect radiographers against X-ray radiation by reducing scatter radiation during neonatal radiographic examinations. We measured the scatter radiation doses from a standard neonatal chest radiograph to the radiosensitive organs using a phantom operator in three protection scenarios (trolley, radiation personal protective equipment [RPPE], no protection) and at three distances. The results showed that the scatter radiation surface doses were significantly reduced when using the trolley compared with RPPE and with no protection at a short distance (P<0.05 for both scenarios in all radiosensitive organs). The novel protective trolley provides a non-contact protective tool for radiographers against the hazard of scatter radiation during neonatal radiography examinations.
Intravenous contrast-enhanced ultrasound (CEUS) can serve as a diagnostic or problem-solving tool in pediatric imaging. CEUS of abdominal solid organs has been reported for a number of indications. The approach to the examination broadly falls into two categories: evaluation of a focal lesion or surveillance of an organ or organs for lesions or perfusion abnormalities. A consistent, technical imaging protocol for both of these clinical scenarios facilitates integration of routine use of CEUS in an imaging department. Here we review the CEUS imaging protocols for abdominal organs in children, including technical and solid-organ-specific considerations.
Congenital lung lesions are a rare group of developmental pulmonary abnormalities that are often first identified prenatally on routine second-trimester US. Congenital pulmonary airway malformation (CPAM) is the most common anomaly while others include bronchopulmonary sequestration, congenital lobar overinflation, bronchogenic cyst and bronchial atresia. Clinical presentation is highly variable, ranging from apparent in utero resolution to severe mass effect with resultant hydrops fetalis and fetal demise. Differentiation among these lesions can be challenging because overlapping imaging features are often present. The roles of the radiologist are to identify key imaging findings that help in diagnosing congenital lung lesions and to recognize any ominous features that might require prenatal or perinatal intervention. High-resolution US and complementary rapid-acquisition fetal MRI provide valuable information necessary for lesion characterization. Postnatal US and CT angiography are helpful for lesion evaluation and for possible surgical planning. This article reviews the embryology of the lungs, the normal prenatal imaging appearance of the thorax and its contents, and the prenatal and neonatal imaging characteristics, prognosis and management of various congenital lung lesions.
The figure illustrates eight types of expertise that are often required for the research team. A multidisciplinary collaborative approach is needed when composing a research team for artificial intelligence in health care. It is worth focusing on skill sets rather than titles when composing the team. IT information technology
Artificial intelligence research in health care has undergone tremendous growth in the last several years thanks to the explosion of digital health care data and systems that can leverage large amounts of data to learn patterns that can be applied to clinical tasks. In addition, given broad acceleration in machine learning across industries like transportation, media and commerce, there has been a significant growth in demand for machine-learning practitioners such as engineers and data scientists, who have skill sets that can be applied to health care use cases but who simultaneously lack important health care domain expertise. The purpose of this paper is to discuss the requirements of building an artificial-intelligence research enterprise including the research team, technical software/hardware, and procurement and curation of health care data.
Background A series of 31 radiographs is recommended by the Royal College of Radiologists (RCR) when investigating suspected physical abuse (SPA). Objective To determine the radiation dose delivered for skeletal surveys performed for SPA in Victorian radiology departments based on their local protocols. Materials and methods A 5-year-old paediatric bone fracture phantom was radiographed at five radiology sites using both the RCR recommended protocol and, where applicable, the local departmental SPA protocol. The radiation doses were measured and recorded. These were scaled down to estimate the effective radiation doses for a 2-year-old child at each site and the associated radiation risks estimated. Results The median effective dose for all radiographic projections in the RCR skeletal survey radiographic series was 0.09 mSv. The estimated risk of radiation-induced cancer and radiation-induced death from cancer for 2-year-old children is classified as “very low,” with girls having a higher risk than boys. Conclusion The median effective radiation dose for the RCR skeletal survey for imaging in SPA was 0.09 mSv resulting in a “very low” additional risk of radiation-induced cancer. The authors will now aim to ascertain whether whole-body CT skeletal survey can replace the radiographic series for imaging in SPA while maintaining a comparable radiation dose.
Midsagittal three-dimensional (3-D) T1-weighted image of a 22-month-old girl shows the anatomical structures limiting the third ventricle used in this study and the measurements between these structures. The ratio of the anterior triangle of the third ventricle was calculated by dividing mammillary body to anterior commissure distance (MB–AC) by optic chiasm to anterior commissure distance (OC–AC). If the ratio was below 0.9, the anterior triangle of the third ventricle was classified as type A, between 0.9 and 1.1 as type B, and above 1.1 as type C. The posterior triangle ratio of the third ventricle was calculated by dividing mammillary body to posterior commissure distance (MB–PC) by anterior commissure to posterior commissure distance (AC–PC). If the posterior triangle ratio of the third ventricle was below 0.75, it was classified as type E, between 0.76 and 0.99 as type F, and above 1 as type G. AC anterior commissure, MB mammillary body, OC optic chiasm, PC posterior commissure
Anterior third ventricle shapes on midsagittal three-dimensional (3-D) T1-weighted brain MRI. a Third ventricle of a 22-month-old girl with a type A anterior triangle (B/A ratio less than 0.9). b Third ventricle of a 9-year-old girl with a type B anterior triangle (B/A ratio of 0.9–1.1). c Third ventricle of a 6-year-old boy with a type C anterior triangle (B/A ratio over 1.1)
Posterior third ventricle shapes on midsagittal three-dimensional T1-weighted brain MRI. a Third ventricle of a 10-year-old boy with a type E posterior triangle (F/G ratio below 0.75). b Third ventricle of a 6-year-old boy with a type F posterior triangle (F/G ratio between 0.75 and 0.99). c Third ventricle of a 30-month-old boy with a type G posterior triangle (F/G ratio over 1)
Third ventricle triangle shapes on three-dimensional (3-D) MR images of anterior and posterior third ventricles, created by the MRICloud pipeline. a–c Type F posterior triangular shape of the third ventricle in (a) a 22-month-old girl, (b) a 9-year-old girl and (c) a 6-year-old boy. d–f Type G posterior triangular shape of the third ventricle in (d) a 3-year-old boy, (e) a 14-year-old girl and (f) an 18-year-old woman. The type A anterior triangular shape of the third ventricle is in (a) and (d); type B is in (b) and (e); type C is in (c) and (f). g, h Hydrocephalic third ventricle in an 8-year-old boy (g) and a 10-year-old boy (h). The type B anterior triangle and type E posterior triangle are demonstrated in (g) and the type C anterior triangle and type E posterior triangle are demonstrated in (h). In these 3-D images of the third ventricle, the posterior part of the anterior region appears to enlarge from type A to type C. In addition, the superior edge of the posterior region of the third ventricle appears to narrow from type E to type G
Age relation of the mean distances of the third ventricle in individuals ages 0–18 years. a–g The distance between the optic chiasm and anterior commissure (a), the distance between the optic chiasm and the mammillary body (c), the anterior triangle ratio of the third ventricle (f), and the posterior triangle ratio of the third ventricle (g) measurements are consistent with the polynomial trend lines as a function of age. The distance between mammillary body and posterior commissure (d), the distance between anterior commissure and posterior commissure (e), and the third ventricle volume (h) fit logarithmic trend lines as a function of age. The distance between mammillary body and anterior commissure (b) fits the exponential trend line as a function of age. Most trend lines in the graphs of third ventricle data increase with age; however, the distance between the optic chiasm and anterior commissure (a) and the posterior triangle ratio of the third ventricle (g) show decreasing trend lines with age
Background Third ventricle morphological changes reflect changes in the ventricular system in pediatric hydrocephalus, so visual inspection of the third ventricle shape is standard practice. However, normal pediatric reference data are not available. Objective To investigate both the normal development of the third ventricle in the 0–18-year age group and changes in its biometry due to hydrocephalus. Materials and methods For this retrospective study, we selected individuals ages 0–18 years who had magnetic resonance imaging (MRI) from 2012 to 2020. We included 700 children (331 girls) who had three-dimensional (3-D) T1-weighted sequences without and 25 with hydrocephalus (11 girls). We measured the distances between the anatomical structures limiting the third ventricle by dividing the third ventricle into anterior and posterior regions. We made seven linear measurements and three index calculations using 3DSlicer and MRICloud pipeline, and we analyzed the results of 23 age groups in normal and hydrocephalic patients using SPSS (v. 23). Results Salient findings are: (1) The posterior part of the third ventricle is more affected by both developmental and hydrocephalus-related changes. (2) For third ventricle measurements, gender was insignificant while age was significant. (3) Normal third ventricular volumetric development showed a segmental increase in the 0–18 age range. The hydrocephalic third ventricle volume cut-off value in this age group was 3 cm³. Conclusion This study describes third ventricle morphometry using a linear measurement method. The ratios defined in the midsagittal plane were clinically useful for diagnosing the hydrocephalic third ventricle. The linear and volumetric reference data and ratios are expected to help increase diagnostic accuracy in distinguishing normal and hydrocephalic third ventricles.
Electronic cigarette or vaping product use–associated lung injury (EVALI) is a toxic inhalational injury that surged in late 2019 and early 2020, immediately prior to the coronavirus disease 2019 (COVID-19) pandemic. Although EVALI cases have significantly decreased, they are still encountered, especially among adolescents. While several characteristic imaging findings and patterns of EVALI have been described, some of them can overlap with the imaging features of COVID-19 pneumonia. We provide a comprehensive review of EVALI that includes the latest updates and highlight the important role of radiologists as contributors to the appropriate and timely care of pediatric patients with this diagnosis.
Whole-body MRI is increasingly used in the evaluation of a range of oncological and non-oncological diseases in infants, children and adolescents. Technical innovation in MRI scanners, coils and sequences have enabled whole-body MRI to be performed more rapidly, offering large field-of-view imaging suitable for multifocal and multisystem disease processes in a clinically useful timeframe. Together with a lack of ionizing radiation, this makes whole-body MRI especially attractive in the pediatric population. Indications include lesion detection in cancer predisposition syndrome surveillance and in the workup of children with known malignancies, and diagnosis and monitoring of a host of infectious and non-infectious inflammatory conditions. Choosing which patients are most likely to benefit from this technology is crucial, but so is adjusting protocols to the patient and disease to optimize lesion detection. The focus of this review is on protocols and the elements impacting image acquisition in pediatric whole-body MRI. We consider the practical aspects, from scanner and coil selection to patient positioning, single-center generic and indication-specific protocols with technical parameters, motion reduction strategies and post-processing. When optimized, collectively these lead to better standardization of whole-body MRI, and when married to systematic analysis and interpretation, they can improve diagnostic accuracy.
The lymphatic system has been poorly understood and its importance neglected for decades. Growing understanding of lymphatic flow pathophysiology through peripheral and central lymphatic flow imaging has improved diagnosis and treatment options in children with lymphatic diseases. Flow dynamics can now be visualized by different means including dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), the current standard technique to depict central lymphatics. Novel imaging modalities including intranodal, intrahepatic and intramesenteric DCMRL are quickly evolving and have shown important advances in the understanding and guidance of interventional procedures in children with intestinal lymphatic leaks. Lymphatic imaging is gaining importance in the radiologic and clinical fields and new techniques are emerging to overcome its limitations.
Process map for image transfer between three platforms. EHR electronic health record, MRN medical record number
Background There is no streamlined approach for sharing radiologic images among medical institutions. Common methods to transfer imaging between facilities include electronic image-sharing platforms and physical media, such as compact discs (CDs). The prompt and secure transfer of imaging is vital for patient safety as demand for imaging increases. Objective Use a survey-based study to outline the methods and difficulties of image sharing among U.S. children’s hospitals. Materials and methods A multi-question survey regarding radiologic image sharing was distributed to children’s hospital department chairs in the United States in August 2021. Descriptive statistical analyses of the results were performed. Results Our results reveal 78% of responding U.S. children’s hospitals have an electronic image-sharing platform. Twenty-seven percent of surveyed institutions experience daily difficulties with radiologic image sharing. Most of the difficulties are with CDs (67%) and a lack of interoperability among electronic image-sharing platforms (51%). Conclusion Our study identified the various methods used by U.S. children’s hospitals for radiologic image sharing and quantified the ongoing challenges with these systems.
Setup for the use of wall air in intussusception reductions. a The proximal end of the tube is connected to the yellow “wall air” outlet. The air flow can be adjusted to ensure the pressure through the tube is approximately 120 mmHg. Frontal (b) and side (c) views of the pressure gauge. The tubing from the wall air connects to a three-way stopcock (labeled as #1). The first three-way stopcock also connects to the pressure gauge, allowing for visual confirmation of the pressure. The first three-way stopcock connects to a second three-way stopcock that connects to the safety valve (arrowhead) from the port labeled #2. The rectal tube is connected to the second three-way stopcock at the port labeled as #3 (arrow)
Background Pneumatic reduction of ileocolic intussusception is commonly performed with manual insufflators. The challenge of operating a handheld device while controlling the fluoroscope and monitoring the reduction could be obviated if the manual insufflation could be eliminated.Objective The aim in this retrospective study was to describe and evaluate the use of medical wall air in intussusception reduction.Materials and methodsWe retrospectively reviewed all intussusception reductions over a period of years: from 2015 to 2018 using the manual insufflator and from 2018 to 2021 using medical air. We compared success rates, complication rates and time to reduction as documented on fluoroscopic image time stamps. Demographic data were obtained from the medical record. Attending radiologists and fluoroscopic technologists indicated their preference between methods, ease of use, perceived duration of reduction and perceived difference in success rates through an anonymous internal survey.ResultsThere were 179 first reduction attempts in 167 patients (93 attempts during the period using the manual insufflator and 86 after converting to wall air). There was no difference in reduction duration (8:23 min for insufflation, 8:22 min for wall air, P=0.99) and no statistically significant difference in success rate (66.8% for insufflation and 79.1% for wall air, P=0.165). All survey respondents preferred the wall air method. The vast majority (93%) perceived that the wall air method was faster.Conclusion Hospital wall air can be used to successfully reduce intussusceptions without incurring time burden or loss of effectiveness. The method leads to a perception of increased efficiency.
Initial skeletal survey 2017 Royal College of Radiologists guidelines effective dose contribution. AP anteroposterior
Breakdown of the findings in patients who had initial skeletal surveys
Breakdown of the number of patients requiring repeat imaging due to technical factors, such as poor positioning or patient movement
BackgroundA skeletal survey is an important diagnostic tool for patients presenting with suspected physical abuse. A relatively recent change in guidelines for skeletal surveys by the Royal College of Radiologists (RCR) in 2017 has led to more initial and follow-up images for these patients, which would be expected to have led to an increase in effective radiation dose.Objective To estimate the effective dose following the change in guidelines and to ascertain the difference between doses before and after the change in guidelines.Materials and methodsData were collected retrospectively on children younger than 3 years old referred for skeletal surveys for suspected physical abuse at a tertiary paediatric centre. A Monte Carlo radiation patient dose simulation software, PCXMC v 2.0.1, was used to estimate the effective dose, expressed in millisieverts (mSv).ResultsSixty-eight children underwent skeletal surveys for suspected physical abuse. The total estimated effective dose for skeletal surveys with the previous RCR guidelines was found to be 0.19 mSv. For initial skeletal surveys with the current RCR guidelines, the estimated effective radiation dose was 0.19 mSv. Eighteen children had both initial and follow-up skeletal surveys as indicated by the current RCR guidelines, with an estimated effective total radiation dose of 0.26 mSv.Conclusion Skeletal surveys deliver a relatively low estimated effective radiation dose equivalent to 1 month of United Kingdom background radiation, with no significant change in dose following the change in guidelines. Therefore, the benefits of having a skeletal survey outweigh the main radiation risk. However, accurate data regarding the radiation dose are important for clinicians consenting parents/guardians for imaging in suspected physical abuse.
Magnetic resonance (MR) angiography and MR venography imaging with contrast and non-contrast techniques are widely used for pediatric vascular imaging. However, as with any MRI examination, imaging the pediatric population can be challenging because of patient motion, which sometimes requires sedation. There are multiple benefits of non-contrast MR angiographic techniques, including the ability to repeat sequences if motion is present, the decreased need for sedation, and avoidance of potential risks associated with gadolinium administration and radiation exposure. Thus, MR angiography is an attractive alternative to CT or conventional catheter-based angiography in pediatric populations. Contrast-enhanced MR angiographic techniques have the advantage of increased signal to noise. Blood pool imaging allows long imaging times that result in high-spatial-resolution imaging, and thus high-quality diagnostic images. This article outlines the technique details, indications, benefits and downsides of non-contrast-enhanced and contrast-enhanced MR angiographic techniques to assist in protocol decision-making.
Amid the coronavirus disease 2019 (COVID-19) pandemic, numerous publications of imaging findings in children have surfaced in a very short time. Publications discuss populations of overlapping age groups and describe different imaging patterns. We aim to present an overview of the quantity and type of literature available regarding COVID-19 chest imaging findings in children according to a 2020 publication timeline. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We searched terminology related to COVID-19, chest, children and imaging modalities in PubMed and Embase. The included papers were published online in 2020 and described imaging findings specific to children and reported five or more cases. Two researchers reviewed each abstract to determine inclusion or exclusion, and a radiologist reconciled any disagreements. Then we reviewed full articles for the main analysis. Eligible study designs included original articles, case series (≥5 cases), systematic reviews and meta-analyses. We excluded non-English manuscripts, retracted articles, and those without available full text. The remaining articles were distributed to four pediatric radiologists (on the Society for Pediatric Radiology Thoracic Committee), who summarized chest imaging findings. Eighty-two articles were included in the final analysis — 28% in radiology journals and 71% in non-radiology journals; 71% contained original data and 29% were review-style papers. There was a disproportionate contribution of review-style papers in April (55%), considering the paucity of preceding publications with original data in March (5 papers). June had the highest number of publications (n=14), followed by April (n=11) and July (n=11). Most (52%) original papers were from China and most individual pediatric imaging descriptions were from China (57%), while the majority of review papers (83%) were international. Imaging descriptions were available for 2,199 children (1,678 CT descriptions and 780 chest radiography descriptions). Findings included a 25% normal CT scan reports vs. 40% normal chest radiography reports. Ground-glass opacification was the most common CT finding (33%) and was reported in only a minority of chest radiographs (9%). A significant amount of information on pediatric COVID-19 chest imaging has become rapidly available over a short period. Most publications in 2020 were original articles, but they were published more often in non-radiology journals. A disproportionate number of review articles were published early on and were based on little original pediatric imaging data. CT scan reports, which represent the standard, outnumbered radiographic reports and indicated that ground-glass opacification is the main imaging finding and that only a quarter of scans are normal in children with COVID-19.
Top-cited authors
Jonathan Dillman
  • Cincinnati Children's Hospital Medical Center
Alexander J Towbin
  • Cincinnati Children's Hospital Medical Center
Andrew Trout
  • Cincinnati Children's Hospital Medical Center
Diego Jaramillo
  • Columbia University
Savvas Andronikou
  • The Children's Hospital of Philadelphia