European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (1) pre-transplant evaluation.

BACKGROUND: Liver transplantation is the state-of-the-art curative treatment in end-stage liver disease. Imaging is a key element for successful organ-transplantation to assist surgical planning. So far, only limited data regarding the best radiological approach to prepare children for liver transplantation is available. OBJECTIVES: In an attempt to harmonize imaging surrounding pediatric liver transplantation, the European Society of Pediatric Radiology (ESPR) Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phase. This paper reports the responses on preoperative imaging. MATERIAL AND METHODS: An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted and 22 institutions from 11 countries returned the survey. From 2018 to 2020, the participating centers collectively conducted 1,524 transplantations, with a median of 20 transplantations per center per annum (range, 8-60). RESULTS: Most sites (64%) consider ultrasound their preferred modality to define anatomy and to plan surgery in children before liver transplantation, and additional cross-sectional imaging is only used to answer specific questions (computed tomography [CT], 90.9%; magnetic resonance imaging [MRI], 54.5%). One-third of centers (31.8%) rely primarily on CT for pre-transplant evaluation. Imaging protocols differed substantially regarding applied CT scan ranges, number of contrast phases (range 1-4 phases), and applied MRI techniques. CONCLUSION: Diagnostic imaging is generally used in the work-up of children before liver transplantation. Substantial differences were noted regarding choice of modalities and protocols. We have identified starting points for future optimization and harmonization of the imaging approach to multicenter studies.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (2) intraoperative imaging.

BACKGROUND: Liver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of intraoperative and postoperative complications. So far, only limited data regarding the best radiological approach to monitor children during liver transplantation is available. OBJECTIVE: To harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra- and postoperative phase. This paper reports the responses related to intraoperative imaging. MATERIALS AND METHODS: An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey. RESULTS: Intraoperative ultrasound (US) is used by all sites to assess the quality of the vascular anastomosis in order to ensure optimal perfusion of the liver transplant. Vessel depiction is commonly achieved using color Doppler (95.3%). Additional US-based techniques are employed by fewer centers (power angio mode, 28.6%; B-flow, 19%; contrast-enhanced US, 14.3%). Most centers prefer a collaborative approach, with surgeons responsible for probe handling, while radiologists operate the US machine (47.6%). Less commonly, the intraoperative US is performed by the surgeon alone (28.6%) or by the radiologist alone (23.8%). Timing of US, imaging frequency, and documentation practices vary among centers. CONCLUSION: Intraoperative US is consistently utilized across all sites during pediatric liver transplantation. However, considerable variations were observed in terms of the US setup, technique preferences, timing of controls, and documentation practices. These differences provide valuable insights for future optimization and harmonization studies.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (3) postoperative imaging.

BACKGROUND: Liver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of postoperative complications. So far, limited data is available regarding the best radiologic approach to monitor children after liver transplantation. OBJECTIVE: To harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phases. This paper reports the responses related to postoperative imaging. MATERIALS AND METHODS: An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey. RESULTS: All sites commence ultrasound (US) monitoring within 24 h after liver transplantation. Monitoring frequency varies across sites, ranging from every 8 h to 72 h in early, and from daily to sporadic use in late postoperative phases. Predefined US protocols are used by 73% of sites. This commonly includes gray scale, color Doppler, and quantitative flow assessment. Alternative flow imaging techniques, contrast-enhanced US, and elastography are applied at 31.8%, 18.2%, and 63.6% of sites, respectively. Computed tomography is performed at 86.4% of sites when clarification is needed. Magnetic resonance imaging is used for selected cases at 36.4% of sites, mainly for assessment of biliary abnormalities or when blood tests are abnormal. CONCLUSION: Diagnostic imaging is extensively used for postoperative surveillance of children after liver transplantation. While US is generally prioritized, substantial differences were noted in US protocol, timing, and monitoring frequency. The study highlights potential areas for future optimization and standardization of imaging, essential for conducting multicenter studies.

Low dose pediatric chest computed tomography on a photon counting detector system - initial clinical experience.

BACKGROUND: With the clinical release of a photon counting detector-based computed tomography (CT) system, the potential benefits of this new technology need to be evaluated clinically. Literature concerning this new generation of detector is sparse, especially in the field of pediatric radiology. Therefore, this study outlines our initial experience with ultra-low dose chest CT imaging on the new photon counting CT system. MATERIALS AND METHODS: A pediatric phantom (1-year old, CIRS ATOM phantom, model 704 [CIRS-computerized imaging reference system, Norfolk, VA]) was scanned at different dose levels and different image quality levels to define a protocol for clinical examinations. Next, 20 consecutive pediatric non-contrast ultra-low dose chest CT examinations were evaluated for radiation dose and diagnostic image quality using a 4-point Likert-scale-1 = excellent, 4 = bad image quality-by two radiologists in a consensus reading. This retrospective analysis was approved by the local research ethics committee. RESULTS: Chest CT examinations performed at ultra-low radiation dose (effective dose 0.19 ± 0.07 mSv; size-specific dose estimate 0.45 ± 0.14 mGy) in pediatric patients ages (2.6 ± 1.8 years) show good to excellent image quality for lung structures (1.4 ± 0.4) and moderate image quality for soft tissue structures (2.8 ± 0.2). CONCLUSION: Pediatric ultra-low dose chest CT examinations are feasible with the new generation photon counting detector-based CT system. The benefits of this technology must be evaluated for pediatric patients from the outset.

Balloon angioplasty versus stent placement for the treatment of portal vein stenosis in children: a single center experience.

PURPOSE: To evaluate the safety and efficacy of percutaneous interventional treatment of portal vein stenosis in children. MATERIAL AND METHODS: A retrospective analysis of all interventional treatments for portal vein stenosis in pediatric patients at a single institution from 2010 to 2021 was conducted. Platelet count, spleen size and portal vein flow velocity were assessed during the follow-up period. Primary and primary assisted patency time were determined. RESULTS: A total of ten children (median age 28.5 months, interquartile range (IQR): 2.75-52.5 months) with portal vein stenosis after Mesorex-Shunt (n = 4), liver transplantation (n = 3) and other etiologies (n = 3) underwent 15 interventional procedures. There were five reinterventions and one discontinued intervention. The technical success rate was 93.3% (14/15) and clinical success of treated patients was 100% (14/14). Median follow-up was 18 months (IQR: 13.5-81 months). The median primary patency time for stent placement was 70 months (IQR: 13.5-127.25 months). For balloon angioplasty, the median primary patency time was 9 months (IQR 7.25-11.5 months), while the median assisted primary patency time was 14 months (IQR: 12 to 15 months). Platelet count, spleen size and portal vein flow velocity reliably corresponded to recurrence of portal vein stenosis in asymptomatic patients during follow-up. CONCLUSION: Interventional treatment is a safe and efficient method to treat portal vein stenosis with long patency times, regardless of etiology. Primary stent placement shows a higher primary patency time than balloon angioplasty. Implementation of stent placement as the primary interventional method may improve patency times and reduce the need for repeat reinterventions in pediatric patients.

Prevalence of pathological FFRCT values without coronary artery stenosis in an asymptomatic marathon runner cohort.

OBJECTIVES: To evaluate computed tomography fractional flow reserve (FFRCT) values in distal parts of the coronaries in an asymptomatic cohort of marathon runners without any coronary stenosis for potentially false-positive values. METHODS: Ninety-eight asymptomatic male marathon runners (age 53 ± 7 years) were enrolled in a prospective monocentric study and underwent coronary computed tomography angiography (CCTA). CCTA data were analyzed for visual coronary artery stenosis. FFRCT was evaluated in 59 participants without coronary artery stenosis in proximal, mid, and distal coronary sections using an on-site software prototype. RESULTS: In participants without coronary artery stenosis, abnormal FFRCT values ≤ 0.8 in distal segments were found in 22 participants (37%); in 19 participants in the LAD; in 5 participants in the LCX; and in 4 participants in the RCA. Vessel diameters in participants with FFRCT values > 0.80 compared to ≤ 0.80 were 1.6 ± 0.3 mm versus 1.5 ± 0.3 mm for distal LAD (p = 0.025), 1.8 ± 0.3 mm versus 1.6 ± 0.5 mm for distal LCX (p = 0.183), and 2.0 ± 0.4 mm versus 1.5 ± 0.2 mm for distal RCA (p < 0.001). CONCLUSIONS: Abnormal FFRCT values of ≤ 0.8 frequently occurred in distal coronary segments in subjects without any anatomical coronary artery stenosis. This effect is only to some degree explainable by small distal vessel diameters. Therefore, the validity of hemodynamic relevance evaluation using FFRCT in distal coronary artery segment stenosis is reduced. KEY POINTS: • Abnormal FFRCT values (≤ 0.8) occurred in over a third of the subjects in the distal LAD despite the absence of coronary artery stenosis.. • Therefore, the validity of hemodynamic relevance evaluation in distal coronary artery segment stenosis is reduced. • Decision-making based on abnormal FFRCT values in distal vessel sections should be performed with caution and only in combination with visual assessment of the grade of stenosis..

123Iodine-metaiodobenzylguanidine scintigraphy versus whole-body magnetic resonance imaging with diffusion-weighted imaging in children with high-risk neuroblastoma - pilot study.

BACKGROUND: The prognostic value of the International Society of Paediatric Oncology European Neuroblastoma Research Network (SIOPEN) skeletal score using 123iodine-metaiodobenzylguanidine (MIBG) has been confirmed for people with high-risk neuroblastoma. Whole-body MRI with diffusion-weighted imaging is used increasingly. OBJECTIVE: To compare the original SIOPEN score and its adaption by diffusion-weighted imaging in high-risk stage 4 neuroblastoma and to evaluate any consequences of score differences on overall survival. MATERIALS AND METHODS: This retrospective observational study included pediatric patients who underwent MIBG scintigraphy and whole-body MRI, including diffusion-weighted imaging, between 2010 and 2015. Semi-quantitative skeletal scores for each exam were calculated independently. A difference of two or more points was defined as clinically relevant and counted as M+ (more in diffusion-weighted imaging) or S+ (more in MIBG). In cases of a negative result in one of the studies, residual disease of 1 point was also rated as relevant. We tested correlation and differences on an exam basis and also grouped by different therapeutic conditions. Overall survival was used to evaluate prognostic relevance. RESULTS: Seventeen children with 25 paired examinations were evaluated. Median MIBG scintigraphy score was 0 (interquartile range [IQR] 0-4, range 0-25) vs. a median whole-body MRI score of 1 (IQR 0-5.5, range 0-35) (P=0.018). A relevant difference between whole-body MRI and MIBG scintigraphy was noted in 14 of the 25 paired examinations (M+: n=9; S+: n=5). After treatment, the median survival of cases with M+ was 14 months (IQR 4-59, range 1-74 months), while S+ cases showed a median survival of 49 months (IQR 36-52, range 36-52 months) (P=0.413). CONCLUSION: The SIOPEN scoring system is feasible for whole-body MRI but might result in slightly higher scores, probably because of MRI's superior spatial resolution. Further studies are necessary to validate any impact on prognosis.

Reduction of radiation exposure in scoliosis monitoring using flat detector and pulsed fluoroscopy technology.

A new flat detector and pulsed fluoroscopy technology is available to further reduce radiation exposure in radiological monitoring during scoliosis treatment in children and adolescents. The aim of this study is to compare different settings of the system (opening area(OA) and image quality settings (IQS)) in order to find the optimal parameters with high image quality and the lowest possible radiation exposure. Therefore, we examined four cadaver spines (T1 to sacrum) with the flat detector technique using digital pulsed fluoroscopy and simulated the abdominal soft tissues. The images were merged and evaluated by three different investigators using an established scoring system. For comparison, we used digital radiography images of the cadaver spines. The values for the DAP increased from the small OA (33% ; 0.56 µGy·m²) to the maximum OA (100% ; 0.82 µGy·m²) by 45% (p = .003) and from the low image quality setting (0.57 µGy·m²) to the high setting (0.84 µGy·m²) by 48% (p = .028). Despite the low DAP, the setting 33% OA achieved the best point values for image quality, therefore this setting is clearly preferred. Using a digital fluoroscopy system allows a significant reduction of radiation exposure by a factor of 7.5 (3.88µGy·m² to 0.5µGy·m²) compared to slot- scanning x-ray (EOS). Due to this success, the flat detector and pulsed fluoroscopy technology can be an alternative to established methods such as X-ray and EOS in clinical use.

New variant in the IL1RN-gene (DIRA) associated with late-onset, CRMO-like presentation.

OBJECTIVE: To report a chronic recurrent multifocal osteomyelitis (CRMO)-like clinical phenotype with multisystem inflammation associated with a novel gene variant in the spectrum of IL-1-mediated diseases. METHODS: A 3-year-old boy presented with recurrent episodes of fever, serositis, pancreatitis and high inflammatory markers with onset at age 13 months. At age 3 years, he started limping. Imaging revealed multifocal pelvic bone inflammation suggestive of CRMO. Autoinflammation panel testing was non-contributory. Whole exome sequencing (WES) and advanced IL-1 pathway analysis was conducted. RESULTS: WES identified a novel homozygous interleukin receptor 1 (IL1RN) variant (c.62C>G; p. Ser21*) (NM_173842.2). Functional analysis of IL1RN mRNA and IL-1 receptor antagonist (IL-1RA) protein confirmed the diagnosis of a deficiency of the IL-1 receptor antagonist (DIRA). Treatment with the nonselective IL-1 inhibitor anakinra resulting in rapid remission; switch to the selective IL-1ß antagonist canakinumab led to a flare within 6 weeks. Re-start of anakinra recaptured remission, last documented at the recent 19-month follow-up. CONCLUSION: This is the first report of a novel late-onset DIRA confirmed by advanced diagnostic testing. In patients with systemic inflammation and CRMO-like bone lesions, IL1RN testing should be considered; even in the absence of skin manifestations. Non-selective IL-1 inhibition is an effective therapy.

Forensic age estimation in living adolescents with CT imaging of the clavicula-impact of low-dose scanning on readers' confidence.

OBJECTIVES: Computed tomography (CT) imaging of the clavicula displays the reference standard for forensic bone age diagnostics in adolescents and young adults. Consequently, highest efforts on radiation reduction are warranted. Therefore, the aim of this study was to investigate the feasibility of low-dose (LD) CT imaging of the clavicula for age estimation in living adolescents. METHODS: A total of 207 non-contrast chest CT of 144 patients born between 1988 and 2012, performed in 2018 due to various clinical indications, were included in this retrospective study. The mean patient age was 16.9 ± 6.6 years. Patients were divided into a LD (n = 146) and standard-dose (SD; n = 61) group. Image quality, confidence levels, and ossification stages (using the 5-stage classification including the subgroups 2a-3c) were assessed by two radiologists independently. Radiation dose was determined via dosimetry software. RESULTS: Dose simulation with z-axis reduction to depict the clavicula only resulted in a median exposure of 0.1 mSv (IQR: 0.0) in LD compared with 0.9 mSv (IQR: 0.6) in SD (p < 0.001). The median image quality was rated by both readers significantly worse in LD compared with SD on a Likert scale ranging from 1 to 4 with a median of 3 (IQR: 1) versus 4 (IQR: 0; p < 0.001 for both readers). There was an almost perfect agreement for the ossification stages between both readers with a Cohen's kappa of 0.83 (p < 0.001). Median confidence levels of both readers were not significantly different between LD and SD in the decisive subgroups 2a-3c. CONCLUSIONS: Low-dose CT imaging of the clavicula for age estimation in living adolescents is possible without loss of readers' confidence. KEY POINTS: • Radiological bone age diagnostics in young delinquents with unknown exact chronological age is important as the judicial systems differentiate between youths and adults. • Low-dose computed tomography scanning of the medial clavicular joint for forensic age estimation is feasible in living adolescents without loss of readers' confidence. • Sufficient image quality of the medial clavicular joint for forensic bone age diagnostics in living adolescents is achievable using a median dose of 0.1 mSv.

New severity assessment in cystic fibrosis: signal intensity and lung volume compared to LCI and FEV1: preliminary results.

OBJECTIVES: Magnetic resonance imaging (MRI) aids diagnosis in cystic fibrosis (CF) but its use in quantitative severity assessment is under research. This study aims to assess changes in signal intensity (SI) and lung volumes (Vol) during functional MRI and their use as a severity assessment tool in CF patients. METHODS: The CF intra-hospital standard chest 1.5 T MRI protocol comprises of very short echo-time sequences in submaximal in- and expiration for functional information. Quantitative measurements (Vol/SI at in- and expiration, relative differences (Vol_delta/SI_delta), and cumulative histograms for normalized SI values across the expiratory lung volume) were assessed for correlation to pulmonary function: lung clearance index (LCI) and forced expiratory volume in 1 s (FEV1). RESULTS: In 49 patients (26 male, mean age 17 ± 7 years) significant correlation of Vol_delta and SI_delta (R = 0.86; p < 0.0001) during respiration was observed. Individual cumulated histograms enabled severity disease differentiation (mild, severe) to be visualized (defined by functional parameter: LCI > 10). The expiratory volume at a relative SI of 100% correlated significantly to LCI (R = 0.676 and 0.627; p < 0.0001) and FEV1 (R = - 0.847 and - 0.807; p < 0.0001). Clustering patients according to Vol_SI_100 showed that an amount of ≤ 4% was related to normal, while an amount of > 4% was associated with pathological pulmonary function values. CONCLUSION: Functional pulmonary MRI provides a radiation-free severity assessment tool and can contribute to early detection of lung impairment in CF. Lung volume with SI below 100% of the inspiratory volume represents overinflated tissue; an amount of 4% of the expiratory lung volume was a relevant turning point. KEY POINTS: • Signal intensity and lung volumes are used as potential metric parameters for lung impairment. • Quantification of trapped air impacts on therapy management. • Functional pulmonary MRI can contribute to early detection of lung impairment.

Retrospective accuracy analysis of MRI based lesion size measurement in neuroblastic tumors: which sequence should we choose?

BACKGROUND: MR imaging of neuroblastic tumors is widely used for assessing the effect of chemotherapy on tumor size. However, there are some concerns that MRI might falsely estimate lesion diameters due to calcification and fibrosis. Therefore, the aim of our study was to compare neuroblastic tumor size based on MRI measurements to histopathology measurements of the resected specimens as standard of reference. METHODS: Inclusion criteria were diagnosis of a neuroblastic tumor, MR imaging within 100 days to surgery and gross total resection without fragmentation of the tumor between 2008 and 2019. Lesion diameters were measured by two radiologists according to RECIST 1.1 in axial plane in T2w turbo spin echo (TSE), diffusion-weighted imaging (DWI), and in T1w pre- and postcontrast sequences. Furthermore, the largest lesion size in three-dimensions was noted. The largest diameter of histopathology measurements of each specimen was used for comparison with MRI. RESULTS: Thirty-seven patients (mean age: 5 ± 4 years) with 38 lesions (neuroblastoma: n = 17; ganglioneuroblastoma: n = 11; ganglioneuroma: n = 10) were included in this retrospective study. There was excellent intra-class correlation coefficient between both readers for all sequences (> 0.9) Tumor dimensions of reader 1 based on axial MRI measurements were significantly smaller with the following median differences (cm): T1w precontrast - 1.4 (interquartile range (IQR): 1.8), T1w postcontrast - 1.0 (IQR: 1.9), T2w TSE: -1.0 (IQR: 1.6), and DWI -1.3 (IQR: 2.2) (p < 0.001 for all sequences). However, the evaluation revealed no significant differences between the three-dimensional measurements and histopathology measurements of the resected specimens regardless of the applied MRI sequence. CONCLUSIONS: Axial MRI based lesion size measurements are significantly smaller than histopathological measurements. However, there was no significant difference between three-dimensional measurements and histopathology measurements of the resected specimens. T2w TSE and T1w postcontrast images provided the lowest deviation and might consequently be preferred for measurements.

Diagnostic value of whole-body MRI in Opsoclonus-myoclonus syndrome: a clinical case series (3 case reports).

BACKGROUND: Opsoclonus-myoclonus syndrome (OMS) is a rare clinical disorder and typically occurs in association with occult neuroblastic tumor in pediatric patients. I-123 metaiodobenzylguanidine (mIBG) scintigraphy is widely adopted as screening procedure in patients with suspected neuroblastic tumor. Also, contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) are involved in the imaging workup, primarily for the assessment of the primary tumor region. However, the diagnostic value of whole-body MRI (WB-MRI) for the detection of occult neuroblastic tumor in pediatric patients presenting with OMS remains unknown. CASE PRESENTATION: We present three cases of patients with OMS, in whom WB-MRI revealed occult neuroblastic tumor masses, whereas scintigraphy was inconclusive: In a 17 months old girl with OMS, WB-MRI revealed a paravertebral mass. After thoracoscopic resection, histopathology revealed a ganglioneuroblastoma. A 13 months old boy presenting with OMS WB-MRI detected a tumor of the left adrenal gland; histopathology demonstrated a ganglioneuroblastoma after adrenalectomy. In a 2 year old boy with OMS, immunoscintigraphy at the time of diagnosis was inconclusive. At the age of 13 years, a WB-MRI was performed due to persistent neurological symptoms, revealing a paravertebral retroperitoneal mass, which was classified as ganglioneuroblastoma. CONCLUSION: In OMS, particularly in the setting of inconclusive scintigraphy, WB-MRI may be considered as a valuable alternative in the early phase of diagnostic work-up.

Functional magnetic resonance urography in infants: feasibility of a feed-and-sleep technique.

BACKGROUND: Functional magnetic resonance (MR) urography has been well established in the diagnostic workup of congenital anomalies of kidneys and urinary tract, though long acquisition time requires sedation or general anesthesia in infants. OBJECTIVE: To evaluate the success rate of an optimized functional MR urography protocol in infants carried out in natural sleep. MATERIALS AND METHODS: We retrospectively evaluated all functional MR urographies performed under general anesthesia or during natural sleep in infants younger than 1 year between 2010 and 2017 and rated image quality in both cohorts using a 3-point Likert scale. We tested the analyzability of functional sequences using a free available software. We also calculated examination time. Finally, we compared examinations in natural sleep and those with general anesthesia using independent t-test for continuous data and Mann-Whitney U test for categorical data. RESULTS: Functional MR urography could be performed successfully during natural sleep in 38 of 42 (90%) infants younger than 10 months. Four examinations were aborted before contrast medium was administrated. In the same period, 19 functional MR urographies were performed successfully under general anesthesia. Although image quality was significantly better in this group (P<0.0001), image quality was at least diagnostic in all finished examinations in natural sleep, and the functional analyzability was given in all completed examinations. There was a significant saving in examination time during natural sleep (P<0.001). CONCLUSION: Functional MR urography can be successfully performed in natural sleep in infants younger than 10 months.

A semiquantitative MRI-Score can predict loss of lung function in patients with cystic fibrosis: Preliminary results.

OBJECTIVES: To evaluate the applicability of a semiquantitative MRI scoring system (MR-CF-S) as a prognostic marker for clinical course of cystic fibrosis (CF) lung disease. METHODS: This observational study of a single-centre CF cohort included a group of 61 patients (mean age 12.9 ± 4.7 years) receiving morphological and functional pulmonary MRI, pulmonary function testing (PFT) and follow-up of 2 years. MRI was analysed by three raters using MR-CF-S. The inter-rater agreement, correlation of score categories with forced expiratory volume in 1 s (FEV1) at baseline, and the predictive value of clinical parameters, and score categories was assessed for the whole cohort and a subgroup of 40 patients with moderately impaired lung function. RESULTS: The inter-rater agreement of MR-CF-S was sufficient (mean intraclass correlation coefficient 0.92). MR-CF-S (-0.62; p < 0.05) and most of the categories significantly correlated with FEV1. Differences between patients with relevant loss of FEV1 (>3%/year) and normal course were only significant for MR-CF-S (p < 0.05) but not for clinical parameters. Centrilobular opacity (CO) was the most promising score category for prediction of a decline of FEV1 (area under curve: whole cohort 0.69; subgroup 0.86). CONCLUSIONS: MR-CF-S is promising to predict a loss of lung function. CO seems to be a particular finding in CF patients with an abnormal course. KEY POINTS: • Lung imaging is essential in the diagnostic work-up of CF patients • MRI serves as a powerful, radiation-free modality in paediatric CF patients • Observational single-centre study showed significant correlation of MR-CF score and FEV 1 • MR-CF score is promising in predicting a loss of lung function.

Contrast-Enhanced High-Pitch Computed Tomography in Pediatric Patients Without Electrocardiography Triggering and Sedation: Comparison of Cardiac Image Quality With Conventional Multidetector Computed Tomography.

OBJECTIVE: The aim of this study was to compare image quality of anatomical cardiac details without electrocardiography triggering, sedation, or heart rate-regulating drugs in contrast-enhanced pediatric chest computed tomography (CT), using high-pitch CT (HPCT) versus conventional pitch-mode technique (multidetector CT [MDCT]). METHODS: After written informed consent, 55 patients (median age, 11 years; range, 3-17 years) were prospectively included in this institutional review board-approved study. Patients underwent clinically indicated, contrast-enhanced MDCT or HPCT of the chest.Image quality was assessed evaluating morphological criteria on a 3-point scale (from 1, high, to 3, low detail) and summed up in a global score (from 4, best, to 12, poor image quality). Artifacts were analyzed correspondingly (from 3, low, to 9, severe artifacts). Effective dose and size-specific dose estimate were calculated for all scans. RESULTS: Cardiac image quality was higher in HPCT than in MDCT (7.1 [1.6] vs 8.8 [1.9], P < 0.001). Nevertheless, HPCT showed limitations in image quality, especially concerning the heart valves (2.5 [0.6] and 1.7 [0.5]) and coronary arteries (1.8 [0.6). Artifact score (3.4 [0.6 vs 5.1 [0.9, P < 0.001), effective dose (1.6 [1.3] vs 2.3 [1.6] mSv, P = 0.047), and size-specific dose estimate (2.5 [1.7] vs 4.1 [2.3] mGy, P = 0.002) were lower in HPCT compared with those in MDCT. CONCLUSIONS: In pediatric patients, contrast-enhanced HPCT of the chest provides high image quality without electrocardiography triggering or sedation, although image quality is somewhat limited for a detailed depiction of cardiac anatomy.

Ultra low-dose VCUG in children using a modern flat detectorunit.

OBJECTIVES: To assess dose area products (DAP) and effective doses (ED) of voiding cystourethrography (VCUG) in children using optimized protocols on a modern flat detector unit. METHODS: DAP and ED were evaluated in 651 VCUG (316 girls, median age: 2.25 years) between 2009 and 2012. DAP was analyzed in relation to patient characteristics (gender, age, presence of pathological findings) and experience of performing physician using analysis of variance. ED values were estimated using adapted conversion factors from the literature. Diagnostic image quality was validated by two experienced physicians using a 3-point scale. RESULTS: Median DAP/ED was 0.5 cGycm(2)/4.56 µSv (boys: 0.6 cGycm(2)/6.16 µSv; girls: 0.4 cGycm(2)/3.54 µSv). In 300 studies without pathologic findings DAP was 0.35 cGycm(2), whereas 351 studies with pathologic findings had a median DAP of 0.7 cGycm(2). No significant relationship between DAP and experience of radiologist was observed. Image validation resulted in an overall good to excellent rating. CONCLUSIONS: DAP and ED can be markedly reduced in paediatric VCUG performed with optimized protocols on modern equipment without a noticeable decrease in diagnostic image quality. KEY POINTS: • Voiding cystourethrography is a comprehensive examination in diagnosing vesicoureteral reflux (VUR). • Radiation reduction is achieved in VCUG through modern equipment and optimized protocols. • Low-dose VCUG is possible without noticeable decrease in diagnostic image quality.

Noise-optimized virtual monoenergetic images and iodine maps for the detection of venous thrombosis in second-generation dual-energy CT (DECT): an ex vivo phantom study.

AIMS AND OBJECTIVES: Deep venous thrombosis (DVT) can be difficult to detect using CT due to poor and heterogeneous contrast. Dual-energy CT (DECT) allows iodine contrast optimization using noise-optimized monoenergetic extrapolations (MEIs) and iodine maps (IMs). Our aim was to assess whether MEI and IM could improve the delineation of thrombotic material within iodine-enhanced blood compared to single-energy CT (SECT). MATERIALS AND METHODS: Six vessel phantoms, including human thrombus and contrast media-enhanced blood and one phantom without contrast, were placed in an attenuation phantom and scanned with DECT 100/140 kV and SECT 120 kV. IM, virtual non-contrast images (VNC), mixed images, and MEI were calculated. Attenuation of thrombi and blood were measured. Contrast and contrast-to-noise-ratios (CNRs) were calculated and compared among IM, VNC, mixed images, MEI, and SECT using paired t tests. RESULTS: MEI40keV and IM showed significantly higher contrast and CNR than SE120kV from high to intermediate iodine concentrations (contrast:pMEI40keV < 0.002,pIM < 0.005;CNR:pMEI40keV < 0.002,pIM < 0.004). At low iodine concentrations, MEI190keV and VNC images showed significantly higher contrast and CNR than SE120kV with inverted contrasts (contrast:pMEI190keV < 0.008,pVNC < 0.002;CNR:pMEI190keV < 0.003,pVNC < 0.002). CONCLUSIONS: Noise-optimized MEI and IM provide significantly higher contrast and CNR in the delineation of thrombosis compared to SECT, which may facilitate the detection of DVT in difficult cases. KEY POINTS: • Poor contrast makes it difficult to detect thrombosis in CT. • Dual-energy-CT allows contrast optimization using monoenergetic extrapolations (MEI) and iodine maps (IM). • Noise-optimized-MEI and IM are significantly superior to single-energy-CT in delineation of thrombosis. • Noise-optimized-MEI and IM may facilitate the detection of deep vein thrombosis.