Biliary Disorders, Anomalies, and Malignancies in Children.

Biliary abnormalities in children are uncommon, and the spectrum of biliary disorders is broader than in adult patients. Unlike in adults, biliary disorders in children are rarely neoplastic and are more commonly rhabdomyosarcoma rather than cholangiocarcinoma. Pediatric biliary disorders may be embryologic or congenital, such as anatomic gallbladder anomalies, anomalous pancreaticobiliary tracts, various cholestatic processes, congenital cystic lesions, or genetic conditions. They may also be benign, such as biliary filling anomalies, biliary motility disorders, and biliary inflammatory and infectious disorders. Distinguishing these entities with a single imaging modality is challenging. US is the primary imaging modality for initial evaluation of biliary abnormalities in children, due to its wide availability, lack of ionizing radiation, and low cost and because it requires no sedation. Other examinations such as MRI, CT, and nuclear medicine examinations may provide anatomic and functional information to narrow the diagnosis further. Hepatobiliary-specific contrast material with MRI can provide better assessment of biliary anatomy on delayed images than can traditional MRI contrast material. MR cholangiopancreatography (MRCP) allows visualization of the intra- and extrahepatic biliary ducts, which may not be possible with endoscopic retrograde cholangiopancreatography (ERCP). Suspected biliary atresia requires multiple modalities for diagnosis and timely treatment. Determining the type of choledochal cyst calls for a combination of initial US and MRCP. Many benign and malignant biliary masses require biopsy for definitive diagnosis. Knowledge of the imaging appearances of different pediatric biliary abnormalities is necessary for appropriate imaging workup, providing a diagnosis or differential diagnosis, and guiding appropriate management. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Contribution of fetal magnetic resonance imaging in fetuses with congenital heart disease.

BACKGROUND: Increasing evidence supports an association among congenital heart disease (CHD), structural brain lesions on neuroimaging, and increased risk of neurodevelopmental delay and other structural anomalies. Fetal MRI has been found to be effective in demonstrating fetal structural and developmental abnormalities. OBJECTIVE: To determine the contribution of fetal MRI to identifying cardiovascular and non-cardiovascular anomalies in fetuses with CHD compared to prenatal US and fetal echocardiography. MATERIALS AND METHODS: We performed a retrospective study of fetuses with CHD identified by fetal echocardiography. Exams were performed on 1.5-tesla (T) or 3-T magnets using a balanced turbo field echo sequence triggered by an external electrocardiogram simulator with a fixed heart rate of 140 beats per minute (bpm). Fetal echocardiography was performed by pediatric cardiologists and detailed obstetrical US by maternal-fetal medicine specialists prior to referral to MRI. We compared the sensitivity of fetal MRI and fetal echocardiography for the diagnosis of cardiovascular anomalies, as well as the sensitivity of fetal MRI and referral US for the diagnosis of non-cardiac anomalies. We performed statistical analysis using the McNemar test. RESULTS: We identified 121 anomalies in 31 fetuses. Of these, 73 (60.3%) were cardiovascular and 48 (39.7%) involved other organ systems. Fetal echocardiography was more sensitive for diagnosing cardiovascular anomalies compared to fetal MRI, but the difference was not statistically significant (85.9%, 95% confidence interval [CI] 77.8-94.0% vs. 77.5%, 95% CI 67.7-87.2%, respectively; McNemar test 2.29; P=0.13). The sensitivity of fetal MRI was higher for diagnosing extracardiac anomalies when compared to referral US (84.1%, 95% CI 73.3-94.9% vs. 31.8%, 95% CI 18.1-45.6%, respectively; McNemar test 12.9; P<0.001). The additional information provided by fetal MRI changed prognosis, counseling or management for 10/31 fetuses (32.2%), all in the group of 19 fetuses with anomalies in other organs and systems besides CHD. CONCLUSION: Fetal MRI performed in a population of fetuses with CHD provided additional information that altered prognosis, counseling or management in approximately one-third of the fetuses, mainly by identifying previously unknown anomalies in other organs and systems.

CT Findings of Pediatric Handlebar Injuries.

Direct bicycle handlebar injuries are a significant cause of chest and abdominal trauma and morbidity in the pediatric population. However, these injuries have been underemphasized. While blunt abdominal trauma has been described well, the literature is limited in reviewing trauma imaging specifically related to direct handlebar injuries in the pediatric population. Major chest injuries include lung contusions, pneumatoceles, and pneumothorax. In the abdomen, injuries to the pancreas, small bowel, mesentery, liver, and spleen are the more common abdominal injuries attributed to direct handlebar trauma. Traumatic abdominal wall hernias and groin injuries, which may be associated with vascular injuries, are other known injuries. The challenge is in both clinical and radiographic diagnosis. The physical findings are often underwhelming, and laboratory values in many studies are shown to be not very sensitive or specific. As a result, there is a risk of delay in imaging, diagnosis, and treatment of significant and sometimes life-threatening injuries. CT is considered the standard examination to delineate intra-abdominal trauma, with a reported sensitivity of 60%-88% and a specificity of 97%-99%. Moreover, CT helps in grading some types of injury and helps guide the surgical treatment course. It is important for radiologists who perform imaging in adults and children to be aware of the significance of direct handlebar injuries and their imaging findings. ©RSNA, 2020.

Imaging of fetal brain tumors.

Congenital brain tumors, defined as those diagnosed prenatally or within the first 2 months of age, represent less than 2% of pediatric brain tumors. Their location, prevalence and pathophysiology differ from those of tumors that develop later in life. Imaging plays a crucial role in diagnosis, tumor characterization and treatment planning. The most common lesions diagnosed in utero are teratomas, followed by gliomas, choroid plexus papillomas and craniopharyngiomas. In this review, we summarize the pathogenesis, diagnosis, management and prognosis of the most frequent fetal brain tumors.

Cutaneous metastases of infantile choriocarcinoma can mimic infantile hemangioma both clinically and radiographically.

Infantile metastatic choriocarcinoma is a rare tumor of placental origin that can be observed with or without maternal metastases. A single cutaneous mass may be the only clinically observed sign. Reports of imaging findings are scarce given the extreme rarity of the tumor, and the disease can be rapidly fatal in the absence of prompt diagnosis. In order to promote timely consideration for this malignancy as a differential consideration in the approach to skin lesions in infancy, we present the findings of this neoplasm in an infant. While imaging and clinical characteristics similar to infantile hemangioma were demonstrated at presentation, biopsy and further radiologic investigation revealed multifocal metastatic choriocarcinoma. This case also highlights important differences between these entities, as the T2 hyperintensity and contrast enhancement observed with this choriocarcinoma were predominantly peripheral in location.

Magnetic resonance imaging of the pediatric mediastinum.

The mediastinum, the central anatomical space of the thorax, is divided by anatomical landmarks but not by physical boundaries. The mediastinum is a conduit, a space through which cranial nerves, important nerve branches, the sympathetic chain, vascular structures, and visceral structures, the trachea and esophagus pass. This arrangement allows contiguous extension or communication of disease along facial planes and through potential spaces to and from the head and neck or cervical spine, to and from the superior mediastinum, between superior and inferior mediastinal levels, and between inferior mediastinal spaces into the intra- and retroperitoneal spaces. Magnetic resonance imaging (MRI) of the mediastinum in children poses technical challenges, in particular cardiac and respiratory motion, and diagnostic challenges, including a broad range of tissue types and possible diagnoses. In this paper we review mediastinal anatomy, MRI sequences and protocol choices and include a short discussion of features and MRI findings of some of the congenital and acquired pathologies that are most often encountered in the pediatric mediastinum.

Shear-wave ultrasound elastography of the liver in normal-weight and obese children.

Background The identification and subsequent management of liver diseases in children is challenging due to the lack of non-invasive imaging biomarkers. Ultrasound shear-wave elastography (US-SWE) is an emerging imaging technique which can quantitatively assess liver stiffness and may be useful as a tool in the management of liver disease in overweight and obese children. Purpose To evaluate US-SWE velocities of the liver in normal-weight and obese children, to correlate US-SWE findings with age and body-mass-index (BMI), and to compare US-SWE values with qualitative assessment (i.e. normal versus abnormal echogenicity) of the liver by conventional US. Material and Methods A cohort of 300 children (mean age, 9.9 ± 5.3 years; age range, 0.06-18.9 years) were studied, comprising 176 normal-weight and 124 obese participants. In each patient, both US-SWE and conventional US of the liver were obtained. Three pediatric radiologists individually and in consensus determined whether liver parenchyma was of normal or abnormal echogenicity. Results US-SWE velocities differed between normal-weight and obese children (1.08 ± 0.14 versus 1.44 ± 0.39 m/s; P < 0.001), but not by gender. Multivariate linear regression demonstrated US-SWE velocity to be primarily associated with age in normal-weight children ( P < 0.05) and with BMI in obese children ( P < 0.001). In the obese group, mean US-SWE velocity was statistically higher in participants with abnormal echogenic livers than in those with normal-appearing livers (1.53 ± 0.38 vs. 1.17 ± 0.27). The difference was not significant in the normal-weight group. Conclusion US-SWE provides a useful quantitative imaging biomarker for evaluating liver stiffness in children.

Calcifying nested stromal-epithelial tumor of the liver: Case report of a rare primary liver tumor.

Calcifying nested stromal epithelial tumor is a very rare primary liver tumor in children. To our knowledge, few cases have been reported in literature. We describe the imaging appearance and histopathologic features of this tumor incidentally detected in a 2-year-old girl. This tumor should be considered in the differential when a large heterogeneous liver tumor with central scar and coarse/chunky calcifications is identified at imaging in the absence of elevated alpha-fetoprotein in a child.

T1-weighted imaging of the brain at 3 tesla using a 2-dimensional spoiled gradient echo technique.

RATIONALE AND OBJECTIVES: The objective of this study was to evaluate a 2-dimensional spoiled gradient echo (GRE) imaging approach using a very short in-phase TE for routine T1-weighted imaging of the brain at 3 T. MATERIALS AND METHODS: Patient examinations were compared from a 3 T magnetic resonance (MR) unit located immediately adjacent to a similarly equipped 1.5 T unit. Pre- and postcontrast T1-weighted images were evaluated and compared at 1.5 versus 3 T with a 2-dimensional (2-D) spin echo sequence used at 1.5 T and a 2-D GRE sequence at 3 T. The 2 MR systems used are from the same vendor, use similar 8-channel coils, and use identical gradients. The T1-weighted GRE sequence, used at 3 T, relies on a short TE (2.4 ms) to limit flow-related and susceptibility artifacts. Region-of-interest analysis was performed on 16 different sagittal patient examinations at both field strengths (32 total) and similarly on 10 different pre- and postcontrast axial examinations (40 total). Four blinded neuroradiologists also evaluated these studies. RESULTS: Using an off-midline sagittal slice depicting the caudate nucleus (signal-to-noise ratio [SNR] 163 +/- 28 vs. 70 +/- 7, 3 T vs. 1.5 T) and corona radiata (SNR 214 +/- 35 vs. 82 +/- 10), 3 T markedly outperformed 1.5 T in both SNR and contrast-to-noise ratio (CNR) (51 +/- 14 vs. 12 +/- 5). On axial imaging, despite a reduction in slice thickness (5 to 3 mm) and scan time (5 to 1 minute), there was no significant difference pre- or postcontrast in SNR and CNR comparing 3 and 1.5 T. On blinded film review, 3 T performed slightly better on sagittal scans than 1.5 T in regard to motion artifacts (reduced), gray-white matter differentiation, and overall image quality. On axial scans, 3 T performed markedly better in all 3 categories both pre- and postcontrast. In regard to overall image quality, 3 T was preferred 9:2 precontrast and 4:1 postcontrast. CONCLUSIONS: High-quality, thin-section (3-mm) T1-weighted imaging can be readily performed at 3 T using a short TE 2-D GRE technique. This approach offers superior SNR and CNR with reduced motion artifacts and scan time as compared with imaging at 1.5 T and is advocated for routine brain imaging at 3 T. It is robust (used in over 1500 patients to date) and does not experience significant specific absorption ratio limitations, poor tissue contrast, or accentuated motion artifacts like encountered with spin echo T1-weighted imaging at 3 T.