ESR Essentials: imaging of suspected child abuse-practice recommendations by the European Society of Paediatric Radiology.

The goal of this paper is to provide a useful desktop reference for the imaging of suspected child abuse with clear, age-specific pathways for appropriate evidence-based imaging and follow-up. We aim to provide a road map for the imaging evaluation and follow-up of this important and vulnerable cohort of patients presenting with signs and symptoms concerning for inflicted injury. As the imaging recommendations differ for children of different ages, we provide a flowchart of the appropriate imaging pathway for infants, toddlers, and older children, which allows ease of selection of which children should undergo skeletal survey, non-contrast computed tomography (CT) brain with 3-dimensional (D) reformats, and magnetic resonance imaging (MRI) of the brain and whole spine. For ease of review, we include a table of the common intracranial and spinal patterns of injury in abusive head trauma. We summarise search patterns, areas of review, and key findings to include in the report. To exclude skeletal injury, infants and children under 2 years of age should undergo a full skeletal survey in accordance with national guidelines, with a limited follow-up skeletal survey performed 11-14 days later. For children over 2 years of age, the need for skeletal imaging should be decided on a case-by-case basis. All infants should undergo a non-contrast-enhanced CT brain with 3-D reformats. If this is normal with no abnormal neurology, then no further neuroimaging is required. If this is abnormal, then they should proceed to MRI brain and whole spine within 2-5 days. Children older than 1 year of age who have abnormal neurology and/or findings on skeletal survey that are suggestive of inflicted injury should undergo non-contrast CT brain with 3-D reformats and, depending on the findings, may also require MRI of the brain and whole spine. We hope that this will be a helpful contribution to the radiology literature, particularly for the general radiologist with low volumes of paediatrics in their practice, supporting them with managing these important cases when they arise in daily practice. KEY POINTS: The choice of initial imaging (skeletal survey and/or brain CT) depends on the age of the child in whom abuse is suspected. A follow-up skeletal survey is mandatory 11-14 days after the initial survey. If an MRI of the brain is performed, then an MRI of the whole spine should be performed concurrently.

Fetal magnetic resonance imaging at 3 Tesla - the European experience.

BACKGROUND: The Fetal Imaging Taskforce was established in 2018 by the European Society of Paediatric Radiology. The first survey on European practice of fetal imaging published in 2020 revealed that 30% of fetal magnetic resonance imaging (MRI) is performed at 3 tesla (T). The purpose of this second survey was to identify the impact of 3-T fetal MRI with an emphasis on image quality, diagnostic yield, and technical challenges and artifacts at higher field strengths. OBJECTIVE: To describe the prenatal imaging practice at 3-T MRI units in various centres in Europe and to prepare recommendations on behalf of the Fetal Imaging Taskforce. MATERIALS AND METHODS: A survey was sent to all members performing 3-T fetal MRI. Questions included practitioner experience, magnet brand, protocols, counselling, artifacts and benefits of imaging at higher field strengths. RESULTS: Twenty-seven centres replied and reported improved spatial resolution and improved signal-to-noise ratio when performing fetal MRI at 3 T. Shading and banding artifacts and susceptibility to motion artifacts were common problems identified by practitioners at the higher field strength. For all neurological indications, practitioners reported a benefit of imaging at 3 T, most marked for posterior fossa evaluation and parenchymal lesions. CONCLUSION: The use of 3-T magnets in fetal MRI has improved the availability and quality of advanced imaging sequences and allowed for better anatomical evaluation. There remain significant challenges to minimize the impact of artifacts on image quality. This paper includes guidelines for clinical practice and imaging at 3 T.

Fetal ultrasound and magnetic resonance imaging: a primer on how to interpret prenatal lung lesions.

Fetal lung lesions include common lesions such as congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS) and combined CPAM-BPS hybrid lesions, as well as less common entities including congenital lobar emphysema/obstruction, bronchial atresia, bronchogenic cysts and rare malignant pulmonary lesions such as pleuropulmonary blastoma. Fetal lung lesions occur in approximately 1 in 15,000 live births and are thought to arise from a spectrum of abnormalities related to airway obstruction and malformation, with the lesion type depending on the timing of insult, level of bronchial tree involvement, and severity of obstruction. Lesions vary from small and asymptomatic to large and symptomatic with significant mass effect on surrounding structures. Accurate diagnosis and characterization of these anomalies is crucial for guiding patient counseling as well as perinatal and postnatal management. The goal of this review is to provide an overview of normal fetal lung appearance and imaging features of common and uncommon lesions on both ultrasound and MR imaging, and to discuss key aspects in reporting and evaluating the severity of these lesions.

Computed tomography and upper gastrointestinal series findings of esophageal bronchi in infants.

BACKGROUND: Esophageal bronchus is a rare form of communicating bronchopulmonary foregut malformation and a rare but important cause of an opaque hemithorax on chest radiography. A higher incidence of esophageal bronchus is associated with esophageal atresia, tracheo-esophageal fistula (TEF) and VACTERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) association. In the presence of these conditions, the pediatric radiologist may be the first to consider the diagnosis of esophageal bronchus or esophageal lung. OBJECTIVE: To describe the imaging features in five children with esophageal bronchus. MATERIALS AND METHODS: We reviewed hospital records and teaching files at two large pediatric tertiary referral centers over the 24-year period from January 1992 to January 2016. We reviewed all imaging studies and tabulated findings on radiography, fluoroscopic upper gastrointestinal (GI) series and CT. We then described the imaging features of esophageal bronchi with emphasis on CT and upper GI findings in four infants and one toddler. RESULTS: Three cases were identified from one institution (cases 2, 3, 4) and two from another (cases 1, 5). All five cases occurred in association with other midline malformations: four of the five had VACTERL association and three of the five had esophageal atresia and TEF. CONCLUSION: Lung opacification, ipsilateral mediastinal shift, and an abnormal carina and anomalous vascular anatomy suggest an esophageal bronchus or an esophageal lung on CT. While esophageal bronchus is a rare cause of an opaque hemithorax, CT and upper GI imaging play key roles in its diagnosis. Associations with esophageal atresia with tracheo-esophageal fistula and VACTERL association are particularly pertinent. Early diagnosis of esophageal bronchus might prevent complications such as aspiration and infection, which can allow for parenchymal sparing surgery as opposed to pneumonectomy.

Imaging in the diagnosis of pediatric urolithiasis.

Pediatric urolithiasis is an important and increasingly prevalent cause of pediatric morbidity and hospital admission. Ultrasound (US) is the recommended primary imaging modality for suspected urolithiasis in children. There is, however, widespread use of CT as a first-line study for abdominal pain in many institutions involved in pediatric care. The objective of this review is to outline state-of-the-art imaging modalities and methods for diagnosing urolithiasis in children. The pediatric radiologist plays a key role in ensuring that the appropriate imaging modality is performed in the setting of suspected pediatric urolithiasis. Our proposed imaging algorithm starts with US, and describes the optimal technique and indications for the use of CT. We emphasize the importance of improved communication with a greater collaborative approach between pediatric and general radiology departments so children undergo the appropriate imaging evaluation.

Intrarenal Reflux: Diagnosis at Contrast-Enhanced Voiding Urosonography.

Vesicoureteral reflux (VUR) is a childhood condition that is usually diagnosed by fluoroscopic voiding cystourethrography (VCUG). Intrarenal reflux (IRR) of infected urine is believed to play an important role in the pathogenesis of reflux-associated pyelonephritis and subsequent parenchymal scarring and is traditionally depicted by fluoroscopic VCUG. This case series describes the phenomenon of IRR occurring in association with VUR in 4 children as depicted by contrast-enhanced voiding urosonography. The ability of contrast-enhanced voiding urosonography to show IRR when it occurs in conjunction with VUR compares favorably to that of fluoroscopic VCUG.

Residual intravesical iodinated contrast: a potential cause of false-negative reflux study at contrast-enhanced voiding urosonography.

A 9-month-old girl underwent conventional cyclic voiding cystourethrography (VCUG) followed immediately by cyclic contrast-enhanced voiding urosonography (ceVUS). Although the VCUG showed unilateral grade II reflux, the ceVUS showed no reflux. Images from the ceVUS showed posterior dependent layering of the denser iodinated contrast in the bladder. This layering likely prevented reflux of US microbubbles resulting in a false-negative ceVUS. To our knowledge, this potential pitfall has not yet been reported.

Acute nontraumatic spinal intradural hematoma in a patient on warfarin.

BACKGROUND: Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences. OBJECTIVE: The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas. CASE REPORT: We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively. CONCLUSIONS: Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.

International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse.

Importance: Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse. Objective: To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse. Evidence Review: This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021. Findings: Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child. Conclusions and Relevance: This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.

A pilot study of burnout and long covid in senior specialist doctors.

BACKGROUND: Covid-19 has placed unprecedented demand on healthcare systems and on healthcare professionals. There have been concerns about the risk of distress, moral injury and burnout among healthcare professionals, especially doctors. AIM: To assess the effect of the ongoing Covid-19 pandemic on Irish doctors by investigating the incidence of burnout and long covid among senior medical staff in Ireland. METHODS: This is a cross-sectional pilot study of the prevalence of burnout and long covid among senior physicians. A survey was sent by email to members of the Irish Hospital Consultant's Association. The survey included measures of mental and physical health and the 2-item Maslach Burnout Scale (MBS-2). The study explored the experience of delivering health care in the context of a pandemic and experience of the long covid syndrome. RESULTS: A total of 114 responses were received. Three-quarters 77% (N = 88) screened positive for burnout on the MBS, with mean score of 5.6 (SD3.3), nearly double the cut-off for burnout. Nearly two-thirds (64%, n = 72) reported that Covid-19 has had an adverse effect on their mental health. One-quarter reported that they or colleagues had experience of 'long-covid' secondary to the virus. CONCLUSION: More comprehensive evaluation of the effect of the pandemic on front-line staff is needed to identify the extent of the problem and the factors which contribute to it. This will inform measures to mitigate these effects.

Pneumomediastinum in a child with severe COVID-19.

The current global pandemic of the novel coronavirus SARS-CoV2 is a threat to the health and lives of millions of people worldwide. The latest statistics from the World Health Organisation show that there have been 6,515,796 confirmed cases worldwide with 387,298 confirmed deaths (last update 5 June 2020, 10:41 CEST). The majority of critically unwell patients with SARS-CoV2 are adults and the radiological findings associated with them are consistent throughout the literature. However, the reported paediatric cases are few, and as such, there is a limited body of evidence available. More international data is needed, not only on the clinical presentation, but also the radiological findings, so that health-care providers are better able to understand and diagnose this pandemic disease. We describe a case of a previously healthy 9-year-old female who presented to the Emergency Department with symptoms suggestive of raised intracranial pressure. Her CT revealed a medulloblastoma and post-operatively she tested positive for SARS-CoV2. She had a rapid deterioration in her clinical condition and required admission to the intensive care unit (ICU). We provide the supporting radiology along her clinical course in order to demonstrate important insights into this disease in children, including the unusual pnemomediastinum complications which occurred as part of her clinical course. This case is the first reported of its kind.

Whole-body magnetic resonance imaging: assessment of skeletal metastases.

The concept of a rapid whole-body imaging technique with high resolution and the absence of ionizing radiation for the assessment of osseous metastatic disease is a desirable tool. This review article outlines the current perspective of whole-body magnetic resonance imaging in the assessment of skeletal metastatic disease, with comparisons made to alternative whole-body imaging modalities.

Whole-body magnetic resonance imaging: emerging applications.

Beyond established roles in the assessment of skeletal metastatic disease, in muscle diseases and in myeloma, WBMRI has the potential to offer many further valuable clinical applications. This article presents an overview of emerging clinical applications of WBMRI emphasizing its role in the assessment of musculoskeletal ailments, ranging from the assessment of arthropathy through to body composition research.

How we read pediatric PET/CT: indications and strategies for image acquisition, interpretation and reporting.

PET/CT plays an important role in the diagnosis, staging and management of many pediatric malignancies. The techniques for performing PET/CT examinations in children have evolved, with increasing attention focused on reducing patient exposure to ionizing radiation dose whenever possible and minimizing scan duration and sedation times, with a goal toward optimizing the overall patient experience. This review outlines our approach to performing PET/CT, including a discussion of the indications for a PET/CT exam, approaches for optimizing the exam protocol, and a review of different approaches for acquiring the CT portion of the PET/CT exam. Strategies for PACS integration, image display, interpretation and reporting are also provided. Most practices will develop a strategy for performing PET/CT that best meets their respective needs. The purpose of this article is to provide a comprehensive overview for radiologists who are new to pediatric PET/CT, and also to provide experienced PET/CT practitioners with an update on state-of-the art CT techniques that we have incorporated into our protocols and that have enabled us to make considerable improvements to our PET/CT practice.

Late-onset paraplegia after complete response to two cycles of ipilimumab for metastatic melanoma.

BACKGROUND: Ipilimumab has been shown to improve overall survival in patients with metastatic melanoma; however, complete responses (CRs) are uncommon. Immune-related side effects usually involve the skin or gastrointestinal tract. Neurologic events occur less frequently but are well described. CASE REPORT: We report the case of a 58-year-old man with metastatic melanoma who commenced ipilimumab post spinal decompression and radiation. He developed a colitis post cycle 2 and ipilimumab was discontinued. Imaging, however, documented a radiological CR. 8 weeks later, he developed paraplegia and a myelitis despite an ongoing radiological CR. Steroid use resulted in some improvement radiologically, without clinical improvement. CONCLUSION: We report myelitis with consequent paraplegia as a potential neurological immune-related side effect of ipilimumab. We further describe a patient with a CR after 2 cycles of ipilimumab in the setting of radiation.

Hypersensitivity to mesalazine in a patient with inflammatory bowel disease: a case report.

A 32-year-old male presented with diarrhoea, mucus and bleeding per rectum. On the basis of sigmoidoscopy, rectal mesalazine was commenced uneventfully, and subsequently changed to oral mesalazine due to failure to improve.He re-presented 4 days later with frequent rigors, lethargy, palpitations and was generally unwell. His condition settled with conservative management and IV antibiotics.Oral mesalazine was withheld during the first 24 hours but was recommenced on day 2. After 2 doses he developed rigors, pyrexia, tachycardia and vomiting.Oral mesalazine was discontinued thereafter and his condition progressively improved. Mesalazine has not been re-introduced.

Management of anterior triangle swellings in a tertiary vascular centre with emphasis on the roles of duplex ultrasound, computed tomography angiogram and magnetic resonance angiogram: a case series.

BACKGROUND: Anterior triangle masses pose an important clinical dilemma. It is very difficult to distinguish the potential pathologies pre operatively by clinical and radiological assessment. CASE REPORT: The first case highlights the management of a bilateral chemodectoma, the second case is a presentation of castleman's disease and the third is that of metastatic tonsillar adenocarcinoma. All three cases had a similar presentation and radiological appearance pre-operatively. CONCLUSION: Anterior triangle masses span the clinical spectrum of pathologies from chemodectoma to castleman's disease to carcinoma. Expert vascular and radiological management is required for optimum patient care and should take place in a tertiary referral centre. Duplex US, CTA and MRA are important pre operative assessment tools to ensure that adequate information regarding the relationship of the lesion to the carotid artery is available to the operating surgeon who should have vascular expertise as deliberate practice volume has been repeatedly shown to result in improved patient outcome.