Predicting the Difficult Neonatal Airway in Fetuses With Micrognathia, Oropharyngeal or Neck Mass Lesions: Two-Center Experience With Fetal MRI.

OBJECTIVE: Neonatal airway compromise requiring intubation, due to micrognathia or a mass lesion obstructing the fetal airway, remains difficult but important to predict prenatally. We aimed to validate MR predictors of difficult neonatal airway (DNA) in a multicentre retrospective cohort of fetuses with micrognathia and oropharyngeal/neck masses. METHOD: The radiology databases of two large Australian maternal-fetal medicine centers were searched for subjects meeting inclusion criteria: Pregnancies of > 18 weeks' gestation evaluated with prenatal ultrasound and MRI between 2007 and 2022 where either fetal micrognathia or a fetal cervical, oral or oropharyngeal mass was identified on prenatal ultrasound and MRI, and details of delivery/postnatal course were available including: nature of delivery, need for the fetal airway to be secured at delivery, degree of difficulty in airway securement, survival > 24 h postnatally. Imaging predictors of a difficult neonatal airway (DNA) were assessed blinded to these neonatal outcomes. RESULTS: Twenty-six fetuses met the inclusion criteria. Oropharyngeal and neck mass location with polyhydramnios was 100% sensitive and 82% specific for DNA. JI < 5th centile with polyhydramnios was 83% sensitive and 70% specific. JI < 5th centile with polyhydramnios was associated with DNA in 80% of cases delivered by ex utero intrapartum (EXIT) delivery and none with non-EXIT delivery mode. CONCLUSION: A cervical or oropharyngeal mass with polyhydramnios predicted a difficult neonatal airway. Polyhydramnios with jaw index < 5th centile was less sensitive and less specific for a difficult neonatal airway.

Algorithmic approach to neuroradiological diagnosis with pre-natal MRI: non-visualization of the fetal cavum septi pellucidi on mid-trimester screening ultrasound.

ADVANCES IN KNOWLEDGE: A systematic approach by the radiologist to analysis of imaging and other clinical data in the fetus with absent septal leaflets suspected on ultrasound will improve diagnostic efficiency, accuracy, and pre-natal counselling.

Current and future funding streams for paediatric postmortem imaging: European Society of Paediatric Radiology survey results.

BACKGROUND: Perinatal and childhood postmortem imaging has been accepted as a noninvasive alternative or adjunct to autopsy. However, the variation in funding models from institution to institution is a major factor prohibiting uniform provision of this service. OBJECTIVE: To describe current funding models employed in European and non-European institutions offering paediatric postmortem imaging services and to discuss the perceived barriers to future postmortem imaging service provision. MATERIALS AND METHODS: A web-based 16-question survey was distributed to members of the European Society of Paediatric Radiology (ESPR) and ESPR postmortem imaging task force over a 6-month period (March-August 2021). Survey questions related to the radiologic and autopsy services being offered and how each was funded within the respondent's institute. RESULTS: Eighteen individual responses were received (13/18, 72.2% from Europe). Only one-third of the institutions (6/18, 33.3%) have fully funded postmortem imaging services, with the remainder receiving partial (6/18, 33.3%) or no funding (5/18, 27.8%). Funding (full or partial) was more commonly available for forensic work (13/18, 72%), particularly where this was nationally provided. Where funding was not provided, the imaging and reporting costs were absorbed by the institute. CONCLUSION: Increased access is required for the expansion of postmortem imaging into routine clinical use. This can only be achieved with formal funding on a national level, potentially through health care commissioning and acknowledgement by health care policy makers and pathology services of the value the service provides following the death of a fetus or child. Funding should include the costs involved in training, equipment, reporting and image acquisition.

Quality improvement 101 in medical imaging: Why, what, how.

Quality is consistently doing something well; in healthcare, this centres on providing consistently safe, effective and appropriate, timely and accessible, efficient and equitable care. The ability to identify and rectify failures in the delivery of quality care and to continuously improve the quality of the care we provide is a fundamental requirement of healthcare professionals in the 21st century. There is both a scientific and an empirical basis to quality improvement methodology. The project management techniques that underpin these can be taught, and learned, but rarely are, in postgraduate medical curricula. This overview of how to do a quality improvement project will provide medical imaging professionals with a systematic approach to understanding a problem and its causes, assembling the team to fix it, planning interventions, measuring outcomes and sustaining change. Good project management brings order to what can feel like chaos; time, money and relationships may be saved. Like experiments in the kitchen, not every quality improvement project can or does work; however, there is a recipe, and following it is a good start.

Quality use of artificial intelligence in medical imaging: What do radiologists need to know?

The application of artificial intelligence, and in particular machine learning, to the practice of radiology, is already impacting the quality of imaging care. It will increasingly do so in the future. Radiologists need to be aware of factors that govern the quality of these tools at the development, regulatory and clinical implementation stages in order to make judicious decisions about their use in daily practice.

Ethylmalonic encephalopathy masquerading as meningococcemia.

Ethylmalonic encephalopathy (MIM #602473) is a rare autosomal recessive metabolic condition caused by biallelic variants in ETHE1 (MIM #608451), characterized by global developmental delay, infantile hypotonia, seizures, and microvascular damage. The microvascular changes result in a pattern of relapsing spontaneous diffuse petechiae and purpura, positional acrocyanosis, and pedal edema, hemorrhagic suffusions of mucous membranes, and chronic diarrhea. Here, we describe an instructive case in which ethylmalonic encephalopathy masqueraded as meningococcal septicemia and shock. Ultrarapid whole-genome testing (time to result 60 h) and prompt biochemical analysis facilitated accurate diagnosis and counseling with rapid implementation of precision treatment for the metabolic crisis related to this condition. This case provides a timely reminder to consider rare genetic diagnoses when atypical features of more common conditions are present, with an early referral to ensure prompt biochemical and genomic diagnosis.

L1CAM variants cause two distinct imaging phenotypes on fetal MRI.

Data on fetal MRI in L1 syndrome are scarce with relevant implications for parental counseling and surgical planning. We identified two fetal MR imaging patterns in 10 fetuses harboring L1CAM mutations: the first, observed in 9 fetuses was characterized by callosal anomalies, diencephalosynapsis, and a distinct brainstem malformation with diencephalic-mesencephalic junction dysplasia and brainstem kinking. Cerebellar vermis hypoplasia, aqueductal stenosis, obstructive hydrocephalus, and pontine hypoplasia were variably associated. The second pattern observed in one fetus was characterized by callosal dysgenesis, reduced white matter, and pontine hypoplasia. The identification of these features should alert clinicians to offer a prenatal L1CAM testing.

Exploring the Intersection of Isolated-CNS Hemophagocytic Lymphohistiocytosis and Pediatric Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids.

CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an extremely rare neurologic inflammatory condition. Fewer than 10 pediatric cases have been described.Debate persists as to whether it is a distinct disease or a clinical, radiologic, and histologic phenotype evolving into another disorder. We propose that CLIPPERS may be a clinical manifestation of an underlying state of immune-dysregulation.We describe the case of the youngest known report of CLIPPERS, an 18-month-old infant from Melbourne, Australia. Reviewing the literature for all reported pediatric cases, we identified that robust investigation and whole exome sequencing was underutilized and proposed diagnostic criteria were frequently unmet. Particular focus should be paid to genes known to cause familial hemophagocytic lymphohistiocytosis (HLH), with the CLIPPERS phenotype manifesting as a form of isolated central nervous system (CNS)-HLH in some patients. Curative treatment options such as hematopoietic stem cell transplantation may be appropriate for some patients and should be considered early.

Bilateral congenital pulmonary airway malformation in an extremely preterm infant.

We present the case of a baby boy, with antenatal finding of bilateral enlarged echogenic lungs, who developed severe postnatal respiratory failure. Two important differential diagnoses, which have an impact on antenatal and postnatal management, are discussed. Fetal ultrasound, MRI and postmortem MRI images are presented and findings correlated with the autopsy findings.

Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children.

OBJECTIVE: Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. METHODS: A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. RESULTS: The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. CONCLUSIONS: The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.

Imaging triage of acute stroke patients for endovascular clot retrieval: Effect of increased therapeutic window on the utilization of CT perfusion.

INTRODUCTION: Recent randomized trials showing improved outcomes for later-presenting acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO) treated with endovascular clot retrieval (ECR) may result in substantial increases in CTP utilization. This 3-hospital, single-institution cohort study aimed to compare 2017 and 2018 patient cohorts for the following: CTP use in AIS. Prevalence of LVO in all patients having CTP. Number and clinical characteristics of patients triaged to ECR. Number of patients receiving CTP relative to similar-acuity total ED presentations. METHODS: Inclusion criteria: Consecutive adult emergency (ED) patients receiving CTP for suspected AIS. Study period 1:1 January-30 June 2017; Period 2:1 January-30 June 2018. DATA COLLECTION: age, gender, triage category, NIHSS (National Institute of Health Stroke Score), symptoms/signs, time elapsed since last seen well (TESLSW) to triage, disposition (home/other). RESULTS: A 38.7 % increase in CTP (512 in 2017, 710 in 2018) occurred with 39/512 (7.6%) and 72/710 (10.1%) having intended ECR. CTPs per intended ECR declined from 13.1 to 9.9. 36/512 (7.0%) and 58/710 (8.2%) patients had ECR (61.1% increase) and 22/36 (61.1%) and 25/58 (43.1%) of these were discharged home in 2017 and 2018, respectively, an increase of 3/22(14%). CONCLUSION: Despite a 38.7% increase in CTP utilization, we experienced a reduction in the number of CTPs performed/patient triaged to ECR. This did not reflect higher LVO prevalence among later presenters but may reflect changed selection criteria for CTP and/or decision making about suitability for ECR.

Multiparametric MR evaluation of uterine leiomyosarcoma and STUMP versus leiomyoma in symptomatic women planned for high frequency focussed ultrasound: accuracy of imaging parameters and interobserver agreement for identification of malignancy.

OBJECTIVE: To assess accuracy of and interobserver agreement on multiparametric MR findings to distinguish uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS) and soft tissue tumour of unknown malignant potential. METHODS: Inclusion criteria: All females over 18 years with least one uterine mass measuring 5 cm or more in at least one of the three standard orthogonal dimensions on MR with histopathological confirmation of LM, LMS, or soft tissue tumour of unknown malignant potential (STUMP) in the 3 months following MR. Patients with LMS were drawn from a larger cohort being assessed for MR-guided focussed ultrasound (MRgFUS) suitability. Image evaluation: Assessed variables were: lesion margin, margin definition, T2 signal homogeneity, >50% of lesion with T2 signal brighter than myometrium, haemorrhage, restricted diffusion, contrast enhancement (CE), CE pattern, local lymphadenopathy and ascites. RESULTS: 32 LM, 10 LMS and 1 STUMP were evaluated. Ill-defined (p-value = 0.0003-0.0004) or irregular (p = 0.003-0.004) lesion margin, T2 hyperintensity >50% (p = 0.001-0.004), and peripheral CE (p = 0.02-0.05) were significantly more common in LMS/STUMP than LM for both radiologists. 10/11 (Reader 2) and 11/11 (Reader 1) LMS/STUMP displayed restricted diffusion but so did 63-80% of LM. Agreement was greatest for margin characteristics (κ = 0.73-0.81). CONCLUSION: Irregular/ill-defined lesion margin best distinguished LMS/STUMP from LM with good interrater reliability. ADVANCES IN KNOWLEDGE: Assessment of agreement regarding MR parameters distinguishing LM from LMS and STUMP has not previously been undertaken in a cohort including a large number of patients with LMS. This will help inform evaluation of females considering minimally invasive LM treatment.

Current state of perinatal postmortem magnetic resonance imaging: European Society of Paediatric Radiology questionnaire-based survey and recommendations.

BACKGROUND: Postmortem magnetic resonance imaging (MRI) in perinatal and childhood deaths is increasingly used as a noninvasive adjunct or alternative to autopsy. Imaging protocols vary between centres and consensus guidelines do not exist. OBJECTIVE: Our aim was to develop practical, standardised recommendations for perinatal postmortem MRI. MATERIALS AND METHODS: Recommendations were based on the results of two surveys regarding local postmortem MRI practices sent electronically to all 14 members of the European Society of Paediatric Radiology (ESPR) Postmortem Imaging Task Force and 17 members of the International Society of Forensic Radiology and Imaging Task Force (25 different centres). RESULTS: Overall, 11/14 (78.6%) respondents from different institutions perform postmortem MRI. All of these centres perform postmortem MRI for perinatal and neonatal deaths, but only 6/11 (54.5%) perform imaging in older children. CONCLUSION: We propose a clinical standard for postmortem MRI sequences plus optional sequences for neuroimaging and cardiac anatomy depending on available scanning time and referral indications.

RSNA International Trends: A Global Perspective on the COVID-19 Pandemic and Radiology in Late 2020.

The coronavirus disease 2019 pandemic has challenged and changed health care systems around the world. There has been a heterogeneity of disease burden, health care resources, and nonimaging testing availability, both geographically and over time. In parallel, there has been a continued increase in understanding how the disease affects patients, effectiveness of therapeutic options, and factors that modulate transmission risk. In this report, radiology experts in representative countries from around the world share insights gained from local experience. These insights provide a guidepost to help address management challenges as cases continue to rise in many parts of the world and suggest modifications in workflow that are likely to continue after this pandemic subsides.

Radiology in the era of value-based healthcare: A multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR and RSNA.

BACKGROUND: The value-based healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Radiology in the Era of Value-Based Healthcare: A Multi-Society Expert Statement From the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

BACKGROUND: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.