Stroke in Middle Eastern children with cancer: prevalence and risk factors.

OBJECTIVE: To determine the prevalence and to characterize the different types of strokes in children with cancer at the Children's Cancer Center of Lebanon (CCCL), in addition to assess the factors and clinical findings leading to stroke in children. METHODS: We retrospectively reviewed the medical records and brain images (MRIs and CTs) of children admitted to the CCCL and diagnosed with cancer between years 2008 and 2017. Brain images were reviewed for the strokes' onset, size, location, possible origin, its recurrence and type: intracranial hemorrhage (ICH), acute arterial ischemic stroke, and cerebral sinus venous thrombosis (CSVT) with and without venous infarct. Medical charts of the patients were reviewed for age, sex, their type of cancer, the treatment protocol they followed, and abnormal findings on their laboratory studies and neurological exams. RESULTS: Out of the 905 charts reviewed, twenty-seven children with variable types of cancer had strokes, with a prevalence of 2.9%. Their median age at cancer diagnosis was 9.4 (4.8-13.7) years and the median age at stroke onset was 10.6 (6.7-15.5) years. The median time between the cancer diagnosis and the stroke episode was 6 months. CSVT cases were the most common (60%) followed by acute arterial ischemic (22%) and hemorrhagic strokes (18%), with CSVT being the latest to occur. We observed that the different types of strokes were related to some types of cancer. Of the children that had acute arterial ischemic stroke in this cohort, 83% had brain tumors, of the children who had CSVT, 87.5% had leukemia, and of the children who had hemorrhagic stroke, 40% had leukemia. Neurological abnormalities were more prevalent in acute arterial ischemic stroke (80%). Patients with CSVT recovered better than those with other types of strokes. Strokes recurred in 60% of ischemic strokes. L-Asparaginase was significantly associated with CSVT. CONCLUSIONS: The prevalence of strokes was 2.9% in children with cancer. We were able to identify factors related to the types of the stroke that occurred in children including the type and location of the cancer the type of treatment received, and stroke recurrence.

Pituitary incidentalomas in paediatric population: Incidence and characteristics.

OBJECTIVE: To determine the incidence of pituitary incidentalomas in the paediatric population and among its different age subgroups as well as to identify the characteristics of these lesions. Additionally, we aim to give a perspective on the management and follow-up of these patients. DESIGN AND PATIENTS: We retrospectively studied MRI of children aged 18 years or below who underwent MRI with sellar region within their field of view between January 2010 and December 2018. MEASUREMENTS: Pituitary lesions were considered incidental according to the definition by the Endocrine Society. We reported the size, location and signal characteristics of each lesion. Medical charts of the subjects were reviewed for age, sex, the MRI indication and the hormonal assays levels. RESULTS: We identified 40 pituitary lesions of which 31 were incidental lesions. The incidence of pituitary incidentaloma in our cohort was 22 per 1000 patients with female predisposition ( 64.5%) and a mean age of 11 ± 6 years. Rathke's cleft cyst was the most prevalent lesion, accounting for 67.7% followed by cystic pituitary lesions and microadenomas. The most common indications for imaging were growth disturbance (12.9%) followed by headache (9.7%). Abnormal laboratory workup was present in 13% of the subjects. Incidental lesions were more common in the older age groups compared to young children. CONCLUSION: Incidental pituitary lesions in the paediatric population are relatively infrequent and increases with age. Rathke's cleft cyst is the most common incidentally encountered pituitary lesion followed by cystic pituitary lesions and microadenomas.

Comparison of two single-breath-held 3-D acquisitions with multi-breath-held 2-D cine steady-state free precession MRI acquisition in children with single ventricles.

BACKGROUND: Breath-held two-dimensional balanced steady--state free precession cine acquisition (2-D breath-held SSFP), accelerated with parallel imaging, is the method of choice for evaluating ventricular function due to its superior blood-to-myocardial contrast, edge definition and high intrinsic signal-to-noise ratio throughout the cardiac cycle. OBJECTIVE: The purpose of this study is to qualitatively and quantitatively compare the two different single-breath-hold 3-D cine SSFP acquisitions using 1) multidirectional sensitivity encoding (SENSE) acceleration factors (3-D multiple SENSE SSFP), and 2) k-t broad-use linear acceleration speed-up technique (3-D k-t SSFP) with the conventional 2-D breath-held SSFP in non-sedated asymptomatic volunteers and children with single ventricle congenital heart disease. MATERIALS AND METHODS: Our prospective study was performed on 30 non-sedated subjects (9 healthy volunteers and 21 functional single ventricle patients), ages 12.5 +/- 2.8 years. Two-dimensional breath-held SSFP with SENSE acceleration factor of 2, eight-fold accelerated 3-D k-t SSFP, and 3-D multiple SENSE SSFP with total parallel imaging factor of 4 were performed to evaluate ventricular volumes and mass in the short-axis orientation. Image quality scores (blood myocardial contrast, edge definition and interslice alignment) and volumetric analysis (end systolic volume, end diastolic volume and ejection fraction) were performed on the data sets by experienced users. Paired t-test was performed to compare each of the 3-D k-t SSFP and 3-D multiple SENSE SSFP clinical scores against 2-D breath-held SSFP. Bland-Altman analysis was performed on left ventricle (LV) and single ventricle volumetry. Interobserver and intraobserver variability in volumetric measurements were determined using intraclass coefficients. RESULTS: The clinical scores were highest for the 2-D breath-held SSFP images. Between the two 3-D sequences, 3-D multiple SENSE SSFP performed better than 3-D k-t SSFP. Bland-Altman analysis for volumes indicated that variability was more between 3-D k-t SSFP and 2-D breath-held SSFP acquisitions than between 3-D multiple SENSE SSFP and 2-D breath-held SSFP acquisitions. In the non-sedated population, interslice alignment scores were better for 3-D k-t SSFP and 3-D multiple SENSE SSFP than 2-D breath-held SSFP. The blood-myocardial contrast and edge definition scores were better for 2-D breath-held SSFP than 3-D k-t SSFP and 3-D multiple SENSE SSFP. Scan duration was shorter for 3-D acquisition sequences compared to the 2-D breath-held stack. CONCLUSION: Three-dimensional k-t SSFP and 3-D multiple SENSE for ventricular volumetry release the constraints of multiple breath-holds in children and overcome problems related to interslice misalignment caused by inconsistent amplitude of breathing. Three-dimensional multiple SENSE SSFP performed better in our pediatric population than 3-D k-t SSFP. However, these 3-D sequences produce lower-quality diagnostic images than the gold standard 2-D breath-held SSFP sequence.

Clinical validation of free breathing respiratory triggered retrospectively cardiac gated cine balanced steady-state free precession cardiovascular magnetic resonance in sedated children.

BACKGROUND: Cine balanced steady-state free precession (SSFP), the preferred sequence for ventricular function, demands uninterrupted radio frequency (RF) excitation to maintain the steady-state during suspended respiration. This is difficult to accomplish in sedated children. In this work, we validate a respiratory triggered (RT) SSFP sequence that drives the magnetization to steady-state before commencing retrospectively cardiac gated cine acquisition in a sedated pediatric population. METHODS: This prospective study was performed on 20 sedated children with congenital heart disease (8.6 ± 4 yrs). Identical imaging parameters were used for multiple number of signal averages (MN) and RT cine SSFP sequences covering both the ventricles in short-axis (SA) orientation. Image quality assessment and quantitative volumetric analysis was performed on the datasets by two blinded observers. One-sided Wilcoxon signed rank test and Box plot analysis were performed to compare the clinical scores. Bland-Altman (BA) analysis was performed on LV and RV volumes. RESULTS: Scan duration for SA stack using RT-SSFP (3.9 ± 0.8 min) was slightly shorter than MN-SSFP (4.6 ± 0.9 min) acquisitions. The endocardial edge definition was significantly better for RT than MN, blood to myocardial contrast was better for RT than MN without reaching statistical significance, and inter slice alignment was comparable. BA analysis indicates that the variability of volumetric indices between RT and MN is comparable to inter and intra-observer variability reported in the literature. CONCLUSIONS: The free breathing RT-SSFP sequence allows diagnostic images in sedated children with significantly better edge definition when compared to MN-SSFP, without any penalty for total scan time.

CT angiography of neonates and infants: comparison of radiation dose and image quality of target mode prospectively ECG-gated 320-MDCT and ungated helical 64-MDCT.

OBJECTIVE. The purpose of this study was to evaluate the radiation dose and image quality of target mode prospectively ECG-gated volumetric CT angiography (CTA) performed with a 320-MDCT scanner compared with the radiation dose and image quality of ungated helical CTA performed with a 64-MDCT scanner. MATERIALS AND METHODS. An experience with CTA for cardiovascular indications in neonates and infants 0-6 months old was retrospectively assessed. Radiation doses and quantitative and qualitative image quality scores of 28 CTA examinations performed with a 320-MDCT scanner and volumetric target mode prospective ECG gating plus iterative reconstruction (target mode) were compared with the doses and scores of 28 CTA examinations performed with a 64-MDCT scanner and ungated helical scanning plus filtered back projection reconstruction (ungated mode). All target mode studies were performed during free breathing. Seven ungated CTA examinations (25%) were performed with general endotracheal anesthesia. The findings of 17 preoperative CTA examinations performed in target mode were also compared with surgical reports for evaluation of diagnostic accuracy. RESULTS. All studies performed with target mode technique were diagnostic for the main clinical indication. Effective doses were significantly lower in the target mode group (0.51 ± 0.19 mSv) compared with the ungated mode group (4.8 ± 1.4 mSv) (p < 0.0001). Quantitative analysis revealed no statistically significant difference between the two groups with respect to signal-to-noise ratio (of pulmonary artery and aorta) and contrast-to-noise ratio. Subjective image quality was significantly better with target mode than with ungated mode (p < 0.0001). CONCLUSION. Target mode prospectively ECG-gated volumetric scanning with iterative reconstruction performed with a 320-MDCT scanner has several benefits in cardiovascular imaging of neonates and infants, including low radiation dose, improved image quality, high diagnostic accuracy, and ability to perform free-breathing studies.

Assessing the Diagnostic Accuracy of TI-RADS in Pediatric Thyroid Nodules: A Multi-institutional Review.

PURPOSE: Thyroid nodules are uncommon in children and adolescents but carry an increased risk of malignancy when present. The Thyroid Imaging Reporting and Data System (TI-RADS) is an adult-validated ultrasound-based risk assessment providing a prediction of malignant potential for thyroid nodules, thereby guiding recommendations for fine needle aspiration biopsy (FNAB). Minimal data exist regarding the applicability of TI-RADS to predict malignancy in pediatric thyroid nodules. This study aims to analyze the performance of TI-RADS for children and adolescents with thyroid nodules, hypothesizing that applying TI-RADS criteria would improve accuracy and reduce the number of recommended FNAB compared to American Thyroid Association (ATA) size criteria alone. METHODS: A multi-institutional retrospective analysis was conducted including patients ≤21 years with a thyroid nodule by sonographic thyroid imaging between 2015 and 2020. TI-RADS scores were assigned at each institution by a pediatric radiologist trained in thyroid imaging and TI-RADS criteria. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy of TI-RADS scoring were compared to existing ATA size-based recommendation for performing a FNAB. Accounting for relative size differences between adults and children, a novel PED TI-RADS category was developed and tested, recommending FNAB for thyroid nodules with a TI-RADS 3 and ≥ 1.5 cm, TI-RADS 4 and ≥ 1.0 cm, and TI-RADS 5 any feasible size. RESULTS: 291 nodules from 260 patients (median age 14.9 years, 78.8% female) were assessed using TI-RADS. Applying adult TI-RADS criteria resulted in recommendation of FNAB for 35.1% of nodules, in contrast to 76.6% recommended by ATA guidelines (p < 0.0001) (Table). Utilizing the adult TI-RADS score ≥3 as an FNAB indicator resulted in 100% sensitivity and 28.5% specificity, with 0 cases of missed malignant nodules on pathology. When novel PED TI-RADS criteria were applied, 88 patients would have been spared an unnecessary FNAB with improved sensitivity and accuracy over ATA criteria. CONCLUSIONS: The application of adult and PED TI-RADS scoring to thyroid nodules in pediatric patients enhances the accuracy of malignancy prediction compared to current American Thyroid Association size criteria alone. The utilization of PED TI-RADS scoring eliminated unnecessary biopsies in many children while not missing a single thyroid malignancy. LEVEL OF EVIDENCE: Level III.

Multimodality imaging of developmental dysplasia of the hip.

Developmental dysplasia of the hip (DDH) is a spectrum disorder resulting in underdevelopment of the acetabulum. Radiographs and ultrasound are the mainstays for screening, with CT and MRI playing important roles in assessing outcome after treatment. The purpose of this article is to illustrate the use of multimodality imaging in the diagnosis and management of DDH.

MR imaging of children and young adults with classic findings of osteonecrosis on unenhanced MR images: do contrast-enhanced sequences help?

BACKGROUND: The added value of routine contrast-enhanced MR imaging in children with classic findings of osteonecrosis on unenhanced MR images has not been determined. OBJECTIVE: Our purpose was to determine the added value of routine contrast-enhanced MR sequences for identifying complications of osteonecrosis. MATERIAL AND METHODS: Sixty-four patients who underwent 139 contrast-enhanced MR examinations were retrospectively identified. Unenhanced images and subsequently both unenhanced and enhanced images were reviewed in consensus. The location of osteonecrosis and the presence of complicating features (epiphyseal collapse, marrow edema, joint effusion, soft tissue edema) were recorded. Cohen's kappa coefficients (κ) were calculated to assess agreement. RESULTS: A diagnosis of classic osteonecrosis was made in 22.3% of unenhanced examinations and 28.1% of enhanced examinations (κ = 0.734, P < 0.001). Among patients with complicated osteonecrosis, unenhanced images interpreted without and with contrast-enhanced images showed epiphyseal collapse in 51.2% and 42.5% (κ = 0.796, P < 0.001), marrow edema in 50.4% and 46.8% (κ = 0.727, P < 0.001), joint effusion in 44.9% and 51.2% (κ = 0.686, P < 0.001), and soft tissue edema in 12.2% and 10.1% (κ = 0.674, P < 0.001). CONCLUSION: The high observed agreement between the unenhanced MR images interpreted without and with contrast-enhanced images shows little marginal benefit from the use of routine contrast-enhanced imaging in children and young adults with classic findings of osteonecrosis on unenhanced MR images.

Workflow Interruptions and Effect on Study Interpretation Efficiency.

BACKGROUND: Interruptions have been shown to adversely impact efficiency, accuracy, and patient safety. OBJECTIVE: To analyze the frequency and types of interruptions and effect on report interpretation efficiency. MATERIALS AND METHODS: A business process improvement team was consulted to make detailed recordings of the activities of the radiologists. Activities were categorized as interpreting studies, active interruptions initiated by the radiologist, and passive interruptions initiated by an external source. RESULTS: Thirteen board-certified, pediatric radiologists were observed for 61 hours. Radiologists spent 52% of their time interpreting studies, 29% on active interruptions, and 18% on passive interruptions. Approximately 50% of non-interpretive time involved in-person conversations or consults and 16% involved phone calls of which 67% were incoming. The longest time period without an interruption was 20 minutes. 85% of the time, an interruption came within 3 minutes of beginning an interpretation and lasted 1 minute or less 70% of the time. Interruptions increased the time a radiologist needed to read a study by 1 minute for radiographs, 2 minutes for ultrasounds, 6 minutes for CTs, and 10 minutes for magnetic resonance imaging. CONCLUSION: Total interruption time nearly equaled the total time interpreting studies for radiologists, and interruptions decreased efficiency and increased report interpretation times for all modalities studied. This study highlights the type and extent of interruptions in radiology and examines the effect on report interpretation times. With the frequency of interruptions and impact on efficiency, there is a need to dedicate resources to manage the radiologist workflow. Strategic interventions may ultimately improve outcomes, efficiency, and the overall work environment.

Acute NSAID-related transmural duodenitis and extensive duodenal ulceration.

BACKGROUND: A 40-year-old previously healthy white man presented to the emergency department at American University of Beirut Medical Center, Beirut, Lebanon, with severe upper abdominal pain of 36-hour duration. The pain started a few hours after the intake of a single tablet of tiaprofenic acid and became more intense after the intake of another tablet 24 hours later. He had no other symptoms. He had no prior upper gastrointestinal (GI) symptoms, ulcer disease, steroidal or nonsteroidal anti-inflammatory drug use, or ethanol intake. Physical examination revealed mild upper abdominal tenderness. Complete blood count, amylase, lipase, and liver function tests were unremarkable. Computed tomography of the abdomen showed marked thickening of the duodenal wall with surrounding mesenteric streaking. Upper GI endoscopy revealed extensive ulceration involving the duodenal bulb, apex, and proximal D2, as well as a few gastric erosions. Histopathologic examination of duodenal biopsy samples showed extensive epithelial cell necrosis and infiltration of the lamina propria with neutrophils and eosinophils. The patient responded well to rabeprazole 20 mg BID and remains well 5 months later. METHODS: We performed a literature search of PubMed for all English-language articles published between January 1970 and present (June 2007) using the key words tiaprofenic acid, nonsteroidal anti-inflammatory drugs, NSAID, duodenitis, duodenal erosion, duodenal ulcer, gastritis, gastric erosion, gastric ulcer, or peptic ulcer. We reviewed all randomized controlled trials involving NSAIDs found using PubMed, with a focus on their GI adverse effects. RESULTS: Based on the PubMed search, there were no published reports of acute transmural duodenitis and complicated duodenal ulcers associated with short-term exposure to tiaprofenic acid or other NSAIDs. The Naranjo adverse drug reaction (ADR) probability scale was used and a score of 6 was obtained, indicating a probable ADR from tiaprofenic acid use. CONCLUSION: We report a patient who developed symptomatic severe transmural duodenitis and periduodenal mesenteric streaking, consistent with a complicated ulcer, probably associated with very short-term exposure to tiaprofenic acid.