Neonatal Cranial Ultrasound Findings among Infants Born Extremely Preterm: Associations with Neurodevelopmental Outcomes at 10 Years of Age.

OBJECTIVE: To examine the association between neonatal cranial ultrasound (CUS) abnormalities among infants born extremely preterm and neurodevelopmental outcomes at 10 years of age. STUDY DESIGN: In a multicenter birth cohort of infants born at <28 weeks of gestation, 889 of 1198 survivors were evaluated for neurologic, cognitive, and behavioral outcomes at 10 years of age. Sonographic markers of white matter damage (WMD) included echolucencies in the brain parenchyma and moderate to severe ventricular enlargement. Neonatal CUS findings were classified as intraventricular hemorrhage (IVH) without WMD, IVH with WMD, WMD without IVH, and neither IVH nor WMD. RESULTS: WMD without IVH was associated with an increased risk of cognitive impairment (OR 3.5, 95% CI 1.7, 7.4), cerebral palsy (OR 14.3, 95% CI 6.5, 31.5), and epilepsy (OR 6.9; 95% CI 2.9, 16.8). Similar associations were found for WMD accompanied by IVH. Isolated IVH was not significantly associated these outcomes. CONCLUSIONS: Among children born extremely preterm, CUS abnormalities, particularly those indicative of WMD, are predictive of neurodevelopmental impairments at 10 years of age. The strongest associations were found with cerebral palsy.

Utilization of computed tomography imaging in the pediatric emergency department.

BACKGROUND: In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s. OBJECTIVE: In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center. MATERIALS AND METHODS: We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006. RESULTS: A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008-2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study. CONCLUSION: CT utilization decreased throughout the 2008-2017 study period.

Initial clinical evaluation of stationary digital chest tomosynthesis in adult patients with cystic fibrosis.

OBJECTIVE: The imaging evaluation of cystic fibrosis currently relies on chest radiography or computed tomography. Recently, digital chest tomosynthesis has been proposed as an alternative. We have developed a stationary digital chest tomosynthesis (s-DCT) system based on a carbon nanotube (CNT) linear x-ray source array. This system enables tomographic imaging without movement of the x-ray tube and allows for physiological gating. The goal of this study was to evaluate the feasibility of clinical CF imaging with the s-DCT system. MATERIALS AND METHODS: CF patients undergoing clinically indicated chest radiography were recruited for the study and imaged on the s-DCT system. Three board-certified radiologists reviewed both the CXR and s-DCT images for image quality relevant to CF. CF disease severity was assessed by Brasfield score on CXR and chest tomosynthesis score on s-DCT. Disease severity measures were also evaluated against subject pulmonary function tests. RESULTS: Fourteen patients underwent s-DCT imaging within 72 h of their chest radiograph imaging. Readers scored the visualization of proximal bronchi, small airways and vascular pattern higher on s-DCT than CXR. Correlation between the averaged Brasfield score and averaged tomosynthesis disease severity score for CF was -0.73, p = 0.0033. The CF disease severity score system for tomosynthesis had high correlation with FEV1 (r = -0.685) and FEF 25-75% (r = -0.719) as well as good correlation with FVC (r = -0.582). CONCLUSION: We demonstrate the potential of CNT x-ray-based s-DCT for use in the evaluation of cystic fibrosis disease status in the first clinical study of s-DCT. KEY POINTS: • Carbon nanotube-based linear array x-ray tomosynthesis systems have the potential to provide diagnostically relevant information for patients with cystic fibrosis without the need for a moving gantry. • Despite the short angular span in this prototype system, lung features such as the proximal bronchi, small airways and pulmonary vasculature have improved visualization on s-DCT compared with CXR. Further improvements are anticipated with longer linear x-ray array tubes. • Evaluation of disease severity in CF patients is possible with s-DCT, yielding improved visualization of important lung features and high correlation with pulmonary function tests at a relatively low dose.

Pediatric contrast-enhanced ultrasound in the United States: a survey by the Contrast-Enhanced Ultrasound Task Force of the Society for Pediatric Radiology.

BACKGROUND: The United States Food and Drug Administration (FDA) recently approved an ultrasound (US) contrast agent for intravenous and intravesical administration in children. OBJECTIVE: Survey the usage, interest in and barriers for contrast-enhanced US among pediatric radiologists. MATERIALS AND METHODS: The Contrast-Enhanced Ultrasound Task Force of the Society for Pediatric Radiology (SPR) surveyed the membership of the SPR in January 2017 regarding their current use and opinions about contrast-enhanced US in pediatrics. RESULTS: The majority (51.1%, 166) of the 325 respondents (26.7% of 1,218) practice in either a university- or academic affiliated group. The most widely used US contrast agent was Lumason® 52.3% (23/44). While lack of expertise and training were reported barriers, all respondents who are not currently using US contrast agents are considering future use. CONCLUSION: Interest in pediatric contrast US is very high. Education and training are needed to support members who plan to adopt contrast US into practice.

Radiation dose associated with CT-guided drain placement for pediatric patients.

BACKGROUND: To date, there are limited radiation dose data on CT-guided procedures in pediatric patients. OBJECTIVE: Our goal was to quantify the radiation dose associated with pediatric CT-guided drain placement and follow-up drain evaluations in order to estimate effective dose. MATERIALS AND METHODS: We searched the electronic medical record and picture archiving and communication system (PACS) to identify all pediatric (<18 years old) CT-guided drain placements performed between January 2008 and December 2013 at our institution. We compiled patient data and radiation dose information from CT-guided drain placements as well as pre-procedural diagnostic CTs and post-procedural follow-up fluoroscopic abscess catheter injections (sinograms). Then we converted dose-length product, fluoroscopy time and number of acquisitions to effective doses using Monte Carlo simulations and age-appropriate conversion factors based on annual quality-control testing. RESULTS: Fifty-two drainages were identified with mean patient age of 11.0 years (5 weeks to 17 years). Most children had diagnoses of appendicitis (n=23) or inflammatory bowel disease (n=11). Forty-seven patients had diagnostic CTs, with a mean effective dose of 7.3 mSv (range 1.1-25.5 mSv). Drains remained in place for an average of 16.9 days (range 0-75 days), with an average of 0.9 (0-5) sinograms per patient in follow-up. The mean effective dose for all drainages and follow-up exams was 5.3 mSv (0.7-17.1) and 62% (32/52) of the children had effective doses less than 5 mSv. CONCLUSION: The majority of pediatric patients who have undergone CT-guided drain placements at our institution have received total radiation doses on par with diagnostic ranges. This information could be useful when describing the dose of radiation to parents and providers when CT-guided drain placement is necessary.

Working Face-to-Face for Pediatric CT Dose Reduction: A Community Toolkit.

Although children are especially vulnerable to the health risks of ionizing radiation, approximately 8 million CTs are performed on children in the USA. Widespread dose variation is common, particularly in non-pediatric focused facilities. In this article we present our rationale and hands-on approach in developing and refining a toolkit aimed at helping a community hospital with pediatric CT dose reduction.

A Toolkit for Pediatric CT Dose Reduction in Community Hospitals.

Pediatric CT radiation dose optimization is a challenging process for pediatric-focused facilities and community hospitals alike. Ongoing experience and trial-and-error approaches to dose reduction in the large academic hospital setting may position these centers to help community hospitals that strive for CT quality improvement. We describe our hands-on approach in a pilot project to create a partnership between an academic medical center and a community hospital to develop a toolkit for implementing CT dose reduction. Our aims were to (1) assess the acceptability of an interactive educational program and electronic toolkit booklet, (2) conduct a limited test of the efficacy of the toolkit in promoting knowledge and readiness to change, and (3) assess the acceptability and practicality of a collaborative approach to implementing dose reduction protocols in community hospitals. In partnering with the community hospital, we found that they had size-specific radiation doses two to three times higher than those at our center. Survey results after a site visit with interactive educational presentations revealed an increase in knowledge, stronger opinions about the health risks of radiation from CT scans, and willingness and perceived ability to reduce pediatric CT doses.

Observer variability assessing US scans of the preterm brain: the ELGAN study.

BACKGROUND: Neurosonography can assist clinicians and can provide researchers with documentation of brain lesions. Unfortunately, we know little about the reliability of sonographically derived diagnoses. OBJECTIVE: We sought to evaluate observer variability among experienced neurosonologists. MATERIALS AND METHODS: We collected all protocol US scans of 1,450 infants born before the 28th postmenstrual week. Each set of scans was read by two independent sonologists for the presence of intraventricular hemorrhage (IVH) and moderate/severe ventriculomegaly, as well as hyperechoic and hypoechoic lesions in the cerebral white matter. Scans read discordantly for any of these four characteristics were sent to a tie-breaking third sonologist. RESULTS: Ventriculomegaly, hypoechoic lesions and IVH had similar rates of positive agreement (68-76%), negative agreement (92-97%), and kappa values (0.62 to 0.68). Hyperechoic lesions, however, had considerably lower values of positive agreement (48%), negative agreement (84%), and kappa (0.32). No sonologist identified all abnormalities more or less often than his/her peers. Approximately 40% of the time, the tie-breaking reader agreed with the reader who identified IVH, ventriculomegaly, or a hypoechoic lesion in the white matter. Only about 25% of the time did the third party agree with the reader who reported a white matter hyperechoic lesion. CONCLUSION: Obtaining concordance seems to be an acceptable way to assure reasonably high-quality of images needed for clinical research.

Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006.

The objective of this study is to characterize changes in computed tomography (CT) utilization in the pediatric emergency department (ED) over a 6-year period. CT scans ordered on pediatric (ages 0 to 17 years) ED patients from July 2000 to July 2006 were analyzed in five groups: head, cervical spine, chest, abdomen, and miscellaneous. Pediatric ED patient volume and triage acuity scores were determined. There were 6,073 CT scans performed on 4,138 pediatric patients in the ED during the study period. During this same period, 78,932 pediatric patients were evaluated in the ED. From 2000 to 2006, pediatric ED patient volume increased by 2%, while triage acuity remained stable. During this same period, head CT increased by 23%, cervical spine CT by 366%, chest CT by 435%, abdominal CT by 49%, and miscellaneous CT by 96%. Increases in CT utilization were most pronounced in adolescents ages 13 to 17 years. Increases in CT utilization in this age group met or exceeded increases seen in the adult population. In children less than 13 years of age, increases were substantially smaller. Pediatric ED CT utilization particularly in the adolescent population has increased at a rate far exceeding the growth in ED patient volume, mimicking the adult trend. This increase has occurred despite considerable discussion in the medical literature about the radiation risks of CT in the pediatric population and may reflect increased availability of CT, improvements in CT diagnostic capabilities, and increased desire on the part of physicians and patients for diagnostic certainty. Whether this increased utilization results in improved patient outcomes is uncertain and deserves further study.

The fetal dandy walker complex: associated anomalies, perinatal outcome and postnatal imaging.

OBJECTIVE: This study compares the diagnostic accuracy of prenatal ultrasound with postnatal imaging and evaluates for associated fetal anomalies and their impact on immediate neonatal outcome in fetal Dandy Walker complex (DWC). METHODS: Cases of fetal DWC diagnosed in a single ultrasound unit from January 2000 through July 2004 were reviewed for associated fetal anomalies, fetal karyotype, immediate neonatal outcome and postnatal head imaging. RESULTS: A total of 55 fetuses with DWC were identified. Of liveborn cases, postnatal imaging confirmed prenatal intracranial findings in 50% of Dandy Walker variant (DWV) and 100% of Dandy Walker malformation (DWM), with additional central nervous system findings noted in 21% of all cases. Additional fetal anomalies were seen in 26/40 (65%) cases of DWV and 15/15 (100%) cases of DWM. Immediate neonatal survival was predicted by karyotype and associated fetal anomalies. CONCLUSION: The sonographic diagnosis of fetal DWM is accurate. Significant discrepancies exist in prenatal and postnatal diagnosis of DWV. Comprehensive fetal ultrasound and karyotype should be offered for all fetuses with DWC. Postnatal imaging should be performed on all fetal DWC.

Thymic carcinoma in a child with HIV infection.

HIV infection predisposes to cancer during childhood. In addition to the AIDS-defining non-Hodgkin lymphoma (NHL) and Kaposi sarcoma, a range of other lymphoid malignancies and solid tumors have been described. We report the first case of an HIV-positive child with thymic carcinoma in the setting of regressing thymic cysts. The tumor expressed CKIT but failed to respond to imatinab mesylate after a transient response to multiagent chemotherapy. This case extends the spectrum of pediatric malignancy in the setting of HIV and suggests that patients with presumed benign thymic cysts require ongoing surveillance.

Multifocal gastrointestinal stromal tumor (GIST) of the stomach in an 11-year-old girl.

A previously healthy 11-year-old girl presented with an 8-month history of anemia and left upper quadrant abdominal pain. US examination demonstrated a 9-cm cystic mass with a fluid-fluid level in the left upper quadrant with unclear organ of origin. Abdominal MR imaging demonstrated a complex cystic mass, likely arising from the stomach. Additional T2 hyperintense submucosal lesions were identified in the gastric wall. Surgical excision confirmed the diagnosis of multifocal gastric gastrointestinal stromal tumor (GIST). MR imaging was helpful in suggesting a gastric origin of the primary mass and in demonstrating multifocal disease within the stomach.

Visceral larval migrans masquerading as metastatic disease in a toddler with Wilms tumor.

A 22-month-old girl with a renal mass had multiple small pulmonary nodules on CT at her initial presentation. After biopsy and neoadjuvant chemotherapy, a Wilms tumor was resected and the pulmonary nodules were shown to have regressed on CT. Follow-up imaging 4 months after initial diagnosis demonstrated multiple new liver lesions and new pulmonary nodules with peripheral eosinophilia. Lung biopsy revealed granuloma formation with prominent eosinophils. The serum antibody titers for Toxocara canis were elevated. This case illustrates that toxocariasis should be considered as a rare differential diagnostic possibility for multiple liver lesions and multifocal peripheral pulmonary opacities in young children with Wilms tumor.

Imaging of the esophagus in children.

The main role of the esophagus is to facilitate passage of food from the mouth to the stomach. A number of conditions can alter esophageal structure or function including congenital anomalies, trauma, infection, and neoplasm. This article reviews the anatomy, imaging evaluation, and common problems seen in the pediatric thoracic esophagus.

Ticks and tick paralysis: imaging findings on cranial MR.

Tick paralysis is an acute, progressive, and potentially fatal muscle paralysis secondary to a toxin secreted by a pregnant tick during a bite. Although tick bites can occur anywhere on the body, ticks are frequently overlooked on the scalp because of overlying hair. Children with acute neurologic symptoms frequently undergo MR scanning that may incidentally reveal the offending tick. Timely identification and removal of the tick leads to rapid recovery from tick paralysis. We report the MRI findings at 1.5 T of tick paralysis with an attached tick.

Congenital abnormalities of the musculoskeletal system: perinatal evaluation and long-term outcome.

Many musculoskeletal malformations can be detected by prenatal US. Whether isolated or part of a syndrome, these anomalies can have a significant impact on the entire life of the individual. Nonfatal conditions may be subtle and become more recognizable in the second and third trimester. After delivery, radiography helps confirm the diagnosis. US, CT, and MRI all have a role in imaging the primary abnormality, the follow-up effects of treatment, and in monitoring for potential complications that may develop over time. Three-dimensional imaging has an increasing role, in US, CT, and MRI, both in the prenatal and postnatal periods.