Ovarian torsion: diagnosis, surgery, and fertility preservation in the pediatric population.

Ovarian torsion is rare in the pediatric population. Delayed diagnosis can significantly impact fertility. The aim of this review is to highlight current knowledge regarding clinical presentation, diagnosis, surgical management, and follow-up in the pediatric population. Whilst the presentation is often very unspecific, most children will present with sudden severe unilateral pelvic pain associated with vomiting. A key diagnostic test is pelvic ultrasonography, which may help demonstrate an asymmetric enlarged ovary with peripherally displaced follicles. In the pediatric population, ovarian torsion may occur in a normal ovary. However, underlying lesions can be found in half of cases. Benign neoplasms (teratomas or cystic lesions) represent the commonest etiology, with the risk of malignancy being less than 2%. Surgical management should be focused on fertility preservation. This is achievable through ovarian detorsion ± ovarian cystectomy ± oophoropexy to avoid recurrence. Follow-up studies demonstrate excellent recovery rates of detorsed ovaries including those with ischemic appearances. What is Known: • Ovarian torsion is a rare diagnosis in the pediatric population. • Aspecific symptoms and differential diagnoses lead to missed or delayed diagnosis increasing the risk of oophoprectomy and further infertility. What is New: • Reviewing the latest knowledge about clinical presentation, diagnostic, surgical management, and follow-up of ovarian torsion in the pediatric population. • Adiponectin was negatively associated with diastolic blood pressure and HOMA-IR, and chemerin was negatively associated with glucose.

Bone Health in Pediatric Patients With Crohn Disease.

OBJECTIVE: The aim of our study was to examine longitudinal changes in bone mineral density (BMD) of children and adolescents with Crohn disease (CD), and risk factors related to low BMD. PATIENTS AND METHODS: All patients ages from 2 to 18 years with CD who underwent dual-energy X-ray absorptiometry (DXA) at diagnosis and at the end of follow-up between 1999 and 2018 were considered for inclusion in this retrospective study. Factors related to changes in BMD at diagnosis and during follow-up were investigated. RESULTS: One hundred and ninety-three patients had the two DXA required. At diagnosis, 36 patients (18.7%) had a low BMD.At the end of follow-up, 31 patients (16%). One hundred and sixty-four patients did not have the two DXA required.In included CD, BMD values were lower in the lumbar spine (LS) than in total body less head (TBLH), as well at diagnosis (P < 0.0001) or at the end of follow-up (P = 0.001).At diagnosis, only growth impairment or low BMI was associated with low BMD (P < 0.0001), only cumulative dose of corticosteroid at the end of follow-up (P = 0.01). CONCLUSION: The high prevalence of low BMD in children and adolescents with IBD highlights the importance of evaluating BMD in these patients at the time of diagnosis and throughout the course of their treatment. Special attention must be given to patients with height delay or low BMI at diagnosis. Long-term glucocorticoid therapy is the main clinical risk factor associated with low BMD at the end of follow-up.

Prophylactic hydrocortisone in extremely preterm infants and brain MRI abnormality.

OBJECTIVE: To determine whether early low-dose hydrocortisone treatment in extremely preterm infants is associated with brain damage assessed by MRI at term equivalent of age (TEA). PATIENTS AND OUTCOMES: This is a predefined secondary analysis of brain abnormalities, observed by MRI at TEA, of patients randomly assigned to receive either placebo or hydrocortisone in the PREMILOC trial. Outcomes were based on brain abnormalities graded according to Kidokoro scores. RESULTS: Among 412 survivors at TEA, 300 MRIs were performed and 295 were suitable for analysis. Kidokoro scoring was completed for 119/148 and 110/147 MRIs in the hydrocortisone and placebo groups, respectively. The distribution of the Kidokoro white matter (WM) subscore and other subscores was not significantly different between the two groups. There was, however, a significant association between a higher overall Kidokoro score and hydrocortisone treatment (5.84 (SD 3.51) for hydrocortisone and 4.98 (SD 2.52) for placebo; mean difference, 0.86; 95% CI 0.06 to 1.66; p=0.04). However, hydrocortisone was not statistically associated with moderate-to-severe brain lesions (Kidokoro overall score ≥6) in a multivariate logistic regression model accounting for potential confounding variables (adjusted OR (95% CI) 1.27 (0.75 to 2.14), p=0.38). Bronchopulmonary dysplasia at 36 weeks postmenstrual age significantly predicted both WM damage (adjusted OR (95% CI) 2.70 (1.03 to 7.14), p=0.04) and global brain damage (adjusted OR (95% CI) 2.18 (1.19 to 3.99), p=0.01). CONCLUSIONS: Early hydrocortisone exposure in extremely preterm infants is not statistically associated with either WM brain damage or overall moderate-to-severe brain lesions when adjusted for other neonatal variables. TRIAL REGISTRATION NUMBER: EudraCT number 2007-002041-20, NCT00623740.

Fatal Course of Abdominal Neonatal Intestinal Fibrosarcoma.

Infantile fibrosarcoma (IFS) is a rare nonrhabdomyosarcoma soft tissue tumor and accounts for less than 1% of childhood cancers. Forty per cent are present at birth and only 10% of IFS occurs in the abdomen. Our case of neonatal fibrosarcoma presented as a distal small bowel stenosis complicated with meconium peritonitis. The diagnosis was by histology of the surgical resection. The diagnosis of IFS is challenging as there are no specific features of IFS on imaging. Any unexpected solid lesion should raise the suspicion of complicated bowel tumoral lesion. If a neoplastic lesion is suspected extensive, surgery may be postponed until the final diagnosis is made.

Renal parenchyma impairment characterization in partial unilateral ureteral obstruction in mice with intravoxel incoherent motion-MRI.

Ureteropelvic junction obstruction constitutes a major cause of progressive pediatric renal disease. The biological mechanisms underlying the renal response to obstruction can be investigated using a clinically relevant mouse model of partial unilateral ureteral obstruction (pUUO). Renal function and kidney morphology data can be evaluated using renal ultrasound, scintigraphy and uro-magnetic resonance imaging (uro-MRI), but these methods are poorly linked to histological change and not all are quantitative. Here, we propose to investigate pUUO for the first time using an intravoxel incoherent motion diffusion sequence. The aim of this study was to quantitatively characterize impairment of the kidney parenchyma in the pUUO model. This quantitative MRI method was able to assess the perfusion and microstructure of the kidney without requiring the injection of a contrast agent. The results suggest that a perfusion fraction (f) reduction is associated with a decrease in the volume of the renal parenchyma, which could be related to decreased renal vascularization. The latter may occur before impairment by fibrosis and the findings are in accordance with the literature using the UUO mice model and, more specifically, on pUUO. Further investigation is required before this technique can be made available for the diagnosis and management of children with antenatal hydronephrosis and to select the optimal timing of surgery if required.

High-resolution heavily T2-weighted magnetic resonance imaging for evaluation of the pituitary stalk in children with ectopic neurohypophysis.

BACKGROUND: In anterior pituitary deficiency, patients with non visible pituitary stalk have more often multiple deficiencies and persistent deficiency than patients with visible pituitary stalk. OBJECTIVE: To compare the diagnostic value of a high-resolution heavily T2-weighted sequence to 1.5-mm-thick unenhanced and contrast-enhanced sagittal T1-weighted sequences to assess the presence of the pituitary stalk in children with ectopic posterior pituitary gland. MATERIALS AND METHODS: We retrospectively evaluated the MRI data of 14 children diagnosed with ectopic posterior pituitary gland between 2010 and 2014. We evaluated the presence of a pituitary stalk using a sagittal high-resolution heavily T2-weighted sequence and a 1.5-mm sagittal T1-weighted turbo spin-echo sequence before and after contrast medium administration. RESULTS: A pituitary stalk was present on at least one of the sequences in 10 of the 14 children (71%). T2-weighted sequence depicted the pituitary stalk in all 10 children, whereas the 1.5-mm-thick T1-weighted sequence depicted 2/10 (20%) before contrast injection and 8/10 (80%) after contrast injection (P=0.007). CONCLUSION: Compared with 1.5-mm-thick contrast-enhanced T1-weighted sequences, high-resolution heavily T2-weighted sequence demonstrates better sensitivity in detecting the pituitary stalk in children with ectopic posterior pituitary gland, suggesting that contrast injection is unnecessary to assess the presence of a pituitary stalk in this setting.

EOS microdose protocol for the radiological follow-up of adolescent idiopathic scoliosis.

PURPOSE: Imaging plays a key role in adolescent idiopathic scoliosis (AIS) to determine the prognosis and accordingly define the best therapeutic strategy to follow. Conventional radiographs with ionizing radiation have been associated with 1-2 % increased lifetime risk of developing cancer in children, and physicians, therefore, need a sensitive but harmless way to explore patients at risk, according to the "as low as reasonably achievable" concept. The EOS system (EOS imaging, Paris, France) is available in routine clinical use since 2007, and allows 3D reconstructions of the trunk in standing position with significant radiation reduction. With recent technical advances, further dose reduction can be obtained, but at the cost of image quality that might alter the reliability of 3D reconstructions. The aim of the present study was to analyze the reproducibility of a "microdose" protocol, and evaluate its use in clinical practice. METHODS: 32 consecutive patients followed for AIS were prospectively included. Biplanar radiographs were obtained with the EOS system according to the new microdose protocol. From the microdose images obtained, three experienced operators performed 3D reconstructions, two times for each subject in a random order (total, 192 reconstructions). The intraoperator repeatability and interoperator reproducibility were evaluated, as recommended by the International Organization for Standardization, for the most clinically relevant 3D radiological parameters. RESULTS: The identification of the required anatomical landmarks for the "fast spine" reconstruction process was possible in all cases. None of the patients required a second acquisition for 3D analysis. Mean time for reconstruction was 5 ± 2 min. The intraoperator repeatability was better than interoperator reproducibility for all parameters, with values ranging between 3° and 8° for frontal and sagittal spinal parameters, and between 1° and 8° for pelvic measurements. The agreement was very good for all clinical measurements. No correlation was found between the BMI and the reliability of the measurements. CONCLUSIONS: Because children are notably more sensitive to the carcinogenic effects of ionizing radiation, judicious use of imaging methods and a search for newer technologies remain necessary. Results of the current study show that the new microdose acquisition protocol can be used in clinical practice without altering the quality of the images. Relevant clinical measurements can be made manually, but the landmarks are also visible enough to allow accurate 3D reconstructions (ICC >0.91 for all parameters). The resulting radiation exposure was 5.5 times lower than that received with the prior protocol, corresponding now to a 45-fold reduction compared to conventional radiographs, and can, therefore, almost be considered negligible.

Periosteum: characteristic imaging findings with emphasis on radiologic-pathologic comparisons.

The periosteum covers most bone structures. It has an outer fibrous layer and an inner cambial layer that exhibits osteogenic activity. The periosteum is a dynamic structure that plays a major role in bone modeling and remodeling under normal conditions. In several disorders such as infections, benign and malignant tumors, and systemic diseases, the osteogenic potential of the periosteum is stimulated and new bone is produced. The newly formed bone added onto the surface of the cortex adopts various configurations depending on the modalities and pace of bone production. Our aim here is to describe the anatomy, histology, and physiology of the periosteum and to review the various patterns of periosteal reaction with emphasis on relations between radiological and histopathological findings. A careful evaluation of the periosteal reaction and appearance of the underlying cortex, in combination with the MRI, clinical, and laboratory data, provides valuable information on lesion duration and aggressiveness, thereby assisting in the etiological diagnosis and optimizing patient management. A solid reaction strongly suggests a benign and slow-growing process that gives the bone enough time to wall off the lesion. Single lamellar reactions occur in acute and usually benign diseases. Multilamellar reactions are associated with intermediate aggressiveness and a growth rate close to the limit of the walling-off capabilities of the bone. Spiculated, interrupted, and complex combined reactions carry the worst prognosis, as they occur in the most aggressive and fast-growing diseases: the periosteum attempts to create new bone but is overwhelmed and may be breached.

Multiparametric optical and MR imaging demonstrate inhibition of tumor angiogenesis natural history by mural cell therapy.

PURPOSE: To determine whether functional imaging using MRI and fibered confocal fluorescence microscopy (FCFM) could be used to monitor cell therapy by mural progenitor cells (MPC). METHODS: Fifty mice bearing TC1 murine xenograft tumors were allocated into: control (n = 17), sham (phosphate buffer saline, n = 16), and MPC-treated (MPC, n = 17) groups. MRI was performed before (D0 ) and 7 days (D7 ) after injection measuring tumor size, R2 * under air, oxygen, and carbogen using blood oxygen level dependent (BOLD) and f (fraction linked to microcirculation), D* (perfusion related coefficient) and Dr (restricted diffusion coefficient) using diffusion-weighted sequences based on the IVIM (intravoxel incoherent motion) method. FCFM was performed at D7 measuring "index leakage" (capillary permeability). RESULTS: Tumor growth was significantly slowed down in the MPC-treated animals (P = 0.002) on D7 . R2 *air significantly decreased in controls between D0 and D7 (P = 0.03), reflecting a decrease in tumor oxygenation. ΔR2 *O2CO2 significantly increased in controls between D0 and D7 (P = 0.01) reflecting loss of vessel response to carbogen. D* significantly decreased in controls between D0 and D7 (P = 0.03). Finally, "index leakage" was lower in the MPC-treated tumors (P = 0,009). CONCLUSION: Treatment by MPC resulted in slowing down of tumor growth, capillary permeability decrease, and stabilization of tumor angiogenesis.

Is fetal cerebral MRI worthwhile in antenatally diagnosed isolated cleft lip with or without palate?

OBJECTIVE: This study aims to evaluate the use of fetal brain magnetic resonance imaging (MRI) following an antenatal sonographic diagnosis of isolated cleft lip with or without cleft palate (CL/P). METHOD: This was a retrospective study of 92 fetuses antenatally diagnosed with isolated CL/P on screening ultrasound. All patients underwent expert diagnostic antenatal ultrasound, fetal brain MRI, and karyotype analysis. RESULTS: Five cases were excluded from the study as associated abnormalities were detected on expert ultrasound: corpus callosum agenesis (n = 1), retrognathism (n = 3), and ectrodactyly (n = 1). Fetal MRI diagnosed unsuspected midline cerebral abnormalities in four out of the 87 remaining cases (4.6%): vermis agenesis (n = 1), isolated arhinencephaly (n = 2), and suspicion of pituitary abnormality (n = 1). All karyotype analyses were normal. CONCLUSION: In CL/P, the incidence of associated cerebral abnormalities overlooked on ultrasound is 4.6%. Careful evaluation of midline structures by expert ultrasound in CL/P is necessary and may be sufficient. MRI can be useful if the US examination is limited or in case of family history. However, the choice to proceed to fetal MRI may vary from institution to institution.

Vascular anomalies: what a radiologist needs to know.

Most haemangiomas and vascular malformations are identified according to clinical criteria. A good knowledge of the classification and clinical characteristics of the vascular anomalies is necessary when managing these patients. However, some cases are challenging either because of an atypical presentation (e.g., soft-tissue mass with normal overlying skin) or because of classification difficulties. Doppler US and MRI are the two main imaging modalities that allow classification of the vascular anomalies and are useful in those clinically uncertain cases to establish the correct diagnosis. This aids the choice of the most appropriate treatment and to inform the parents of the prognosis. High-resolution grey-scale and Doppler US allow excellent visualization of most superficial masses. Doppler US is the easiest way to assess the haemodynamics of a vascular lesion and to clarify a doubtful diagnosis between a haemangioma and vascular malformation. MRI is the best technique for evaluating the extent of the lesions and their relationship to adjacent structures. While newly developed drugs from angiogenesis research labs are awaited, radiologists have an important role in the treatment of haemangiomas and vascular malformations. Intervention remains crucial in cases of alarming haemangiomas and venous malformations (VM), lymphatic malformations (LM) and arteriovenous malformations (AVM). A multidisciplinary team, including paediatricians, haematologists, surgeons and radiologists, must manage the problem cases both in terms of diagnostic work-up and therapeutic options. This paper will briefly discuss the imaging findings and treatment of vascular anomalies.

In vivo assessment of experimental neonatal excitotoxic brain lesion with USPIO-enhanced MR imaging.

PURPOSE: To assess the feasibility of magnetic resonance imaging (MRI) enhanced with ultrasmall superparamagnetic particles of iron oxide (USPIO) for assessing excitotoxic brain lesions in an experimental model of neonatal periventricular white matter (PWM) lesions. MATERIALS AND METHODS: Brain lesions were induced by intracerebral injection of ibotenate in 14 newborn rats. Pre- and post-USPIO T2-weighted MRI was performed in seven of them (group A) and in five control newborns (group C). In seven newborns with induced cerebral lesions, USPIO-enhanced MRI was not performed (group B). We compared the signal intensity of the lesion to the contralateral unaffected brain (lesion-to-brain contrast, LBC) and the lesion signal-to-noise ratio (SNR) before and after USPIO injection. MR imaging was correlated with histology. RESULTS: USPIO injection significantly (P<0.05) decreased LBC and SNR of brain lesion but induced no changes in normal controls. The densities of macrophages and iron-laden cells were higher on the lesion side than on the contralateral side (P<0.05). Neither lesion size nor the surrounding macrophage infiltrate was significantly different between groups A and B. CONCLUSION: Post-USPIO T2-weighted MRI demonstrated negative enhancement of neonatal excitotoxic brain lesion. USPIO injection does not appear to exacerbate brain lesions.

Ultrasonography of Crohn disease in children.

US is increasingly performed in Crohn disease (CD) in children as a first line imaging modality. It reduces the use of other more invasive examinations such as endoscopy, CT or contrast enema. We describe bowel ultrasonography technique, normal bowel appearances on US and pathological patterns in CD. We discuss the current role and limitations of bowel US in CD in children including diagnosis, extent of disease, assessment of disease activity, follow-up and detection of complications. The diagnostic accuracy of US is discussed according to the literature and compared to other imaging modalities. US is currently used for screening in children with the suspicion of inflammatory bowel disease (IBD) with a good negative predictive value. In follow-up, US has a role in monitoring medical treatment by evaluating disease activity, extent of disease and for detecting complications.