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ABSTRACT |
Wednesday, May 9, 1:30 PM–3:30 PM
Abstracts 164-174
Moderator(s): Lisa Lowe, Stefan Puig, and Marta Hernanz-Schulman
1:30 PM
Keynote Address: Neurosonography of CNS Ischemia
Marta Hernanz-Schulman, Vanderbilt Children's Hospital, Nashville, TN
1:40 PM
164. MR Imaging Findings in Immunocompromised Children with Human Herpes Virus 6 Encephalitis
Provenzale J. M.*; White L.; Mukundan S.; Lewis D. Duke University Medical Center, Durham, NC
Address correspondence to J. Provenzale (prove001{at}mc.duke.edu)
Objective: To test the hypothesis that patients with human herpesvirus 6 (HHV6) encephalitis have MR imaging features distinguishing them from those with suspected encephalitis who test negative for HHV6.
Materials and Methods: The study population consisted of 11 children (average age 9 years) with suspected HHV6 encephalitis who were immunocompromised for stem cell transplantation and underwent MR imaging and cerebrospinal fluid polymerase chain reaction testing for HHV6 DNA. Seven patients tested + and 4 patients tested -. Two neuroradiologists and a neuroanatomist blinded to HHV6 status reviewed 14 MR scans for abnormal signal in the frontal, temporal and insular cortex, hippocampal formation, amygdaloid complex, basal ganglia, basal forebrain, hypothalamus, thalamus, and frontal, parietal and temporal white matter. Postmortem histology and immunohistochemistry for HHV6 was performed on one HHV6+ child with bilateral hippocampal abnormalities.
Results: Hippocampal signal abnormality was common in both groups (6 HHV6+ and 2 HHV6–patients) but only HHV6+ patients had signal abnormality outside the hippocampus. Among these HHV+ patients, 3 showed widespread abnormalities involving the entire hippocampal formation (hippocampus, subiculum, entorhinal cortex), most of the amygdaloid complex, portions of the insula, and, variably, orbital and medial prefrontal cortex, olfactory cortical areas, septal and basal forebrain nuclei, and medial hypothalamic nuclei. One of these 3 patients showed marked insular and temporal abnormality that extended into the subcortical white matter of central frontoparietal region and temporal lobe. Three other HHV6+ patients showed a less widespread distribution of abnormality restricted mainly to the hippocampal formation and posterior amygdaloid complex. Postmortem examination of one child showed subacute hippocampal sclerosis, severe neuronal loss, reactive astrocytosis and strong immunoreactivity for HHV6 proteins.
Conclusion: Widespread abnormalities in cortical and subcortical limbic structures, including hippocampal formation and amygdaloid complex, were only seen in HHV6+ children, allowing them to be distinguished from HHV–children.
165. Use of MR Imaging Severity Scale to Estimate Neurobehavioral Function in Krabbe Disease
Provenzale J. M.1*; Peddi S.2; Poe M.3; Mukundan S.1; Kurtzberg J.1; Escolar M.3 1. Duke University Medical Center, Durham, NC; 2. Mallinckrodt Institute of Radiology, St. Louis, MO; 3. University of North Carolina, Chapel Hill, NC
Address correspondence to J. Provenzale (prove001{at}mc.duke.edu)
Objective: To compare MR imaging findings with neurobehavioral scores in Krabbe disease infants.
Materials and Methods: Nine Krabbe infants underwent a total of 19 MR studies during first year of life. One child had 4 MR scans, 3 children had 1 scan, 1 child had 2 scans, and 4 children had one scan. All had neurobehavioral testing within 1 month of imaging, consisting of 3 components: developmental quotient (combination of visual motor, receptive and expressive language development), gross motor skills and fine motor skills. MR scans were scored by 2 neuroradiologists blinded to clinical status using the Loes severity scale based on signal abnormality and atrophy [1], which assigns scores at 3 levels: (a) for the entire brain (ranging from 0 [best] to 32 [worst]), and (b) 9 regions divided into (c) 23 brain subregions. We performed 3 types of comparisons: Comparison 1: scores for developmental quotient, fine motor score and gross motor score vs whole brain Loes score, Comparison 2: fine motor and gross motor scores vs single most appropriate brain region (i.e., the pyramidal tract) Comparison 3: fine motor and gross motor score vs single most appropriate brain subregion (i.e., posterior limb of internal capsule). Statistical analysis was performed using Pearson correlation coefficients.
Results: Mean Loes score for the 19 scans was 8.47 + 7.35 (range: 0–24). Comparison 1-Correlations between neurobehaviorial scores and total Loes score: developmental quotient -0.60 (p = 0.019); gross motor score -0.54 (0.036); fine motor score -0.64 (p = 0.007). Comparison 2-Correlations between neurobehavioral scores and Loes scores for pyramidal system: fine motor function -0.50 (p = 0.05) and gross motor function -0.34 (p > 0.05). Comparison 3-Correlations between neurobehavioral scores and Loes scores for internal capsule: fine motor function -0.17 (p = 0.05); gross motor function -0.10 (p > 0.05).
Conclusion: This study provides support for the use of the Loes score to provide an estimate of neurobehavioral function when the Loes score for the whole brain is considered. Correlations between neurobehavioral scores and Loes scores for a single brain region or single brain subregion were less robust. 1. Loes DJ, Peters C, Krivit W. Globoid cell leukodystrophy: distinguishing early-onset from late-onset disease using a brain MR imaging scoring method. AJNR 1999; 20:316–323
166. Neonatal Findings of Fusion of the Forniceal Columns and Absent Cavum Septum Pellucidum
Glanc P.3*; O'Connor S.3; Blaser S. I.1; Asztalos E.2; Raybaud C.1 1. Hospital for Sick Children, Toronto, Canada; 2. Sunnybrook Health Science, Toronto, Canada; 3. Women's College Hospital, Toronto, Canada
Address correspondence to P. Glanc (phyllis.glanc{at}wchospital.ca)
Objective: To evaluate the US and MRI findings in fusion of the forniceal columns and absent cavum septum pellucidum (CSP) with variable septal remnants (SR) in the setting of a normal corpus callosum (CC).
Materials and Methods: Review of the imaging records (site 1: 2000–March 2006, site 2: 2003–2004) identified 10 preterm neonates with fusion of the fornices in association with absent CSP and variable SR, and a normal CC initially identified on US. MRI evaluated the forniceal columns, septal remnants, optic nerve and chiasm, olfactory nerve and sulcus, massa intermedia, pituitary gland and stalk, and hypothalamic orientation. Exclusion criteria were any non midline intracranial anomalies. Brain ultrasound was available in all 10; MRI was available in 9 cases.
Results: MRI confirmed the ultrasound findings of fusion of the forniceal columns in association with a variably deficient CSP, and a normal CC in the 9 survivors. Additional MRI findings included septal remnants in 8/9, vertical orientation hippocampus sulcus in 7/9, hypoplastic optic chiasm 9/9, hypoplastic optic nerve 6/6, normal olfactory sulcus in 9/9, normal olfactory nerve 6/6, normal pituitary stalk in 7/7, normal pituitary gland in 8/9 with 1/9 posterior pituitary ectopia, prominent massa intermedia in 2/9, and borderline ventriculomegaly 1/9 cases. We were unable to assess the optic nerve, olfactory nerve and pituitary stalk in all cases. A small (6 mm) midline vertex meningocele was present in 1/9 cases. No additional intracranial anomalies were identified in this group.
Conclusion: Fusion of the forniceal columns and absent CSP with SR in the setting of a normal CC may be associated with additional congenital midline defects, not identified on US. These findings should prompt further investigation with MRI.
167. Fractures of the Orbital Roof in Children: Frequency and Associated Findings on CT
Chapman V. M.; Fenton L.; Rader S.*; Larson D.; Strain J. The Children's Hospital, Denver, CO
Address correspondence to S. Rader (scott.rader{at}uchsc.edu)
Objective: To describe the relative frequency of orbital roof fractures and associated injuries observed in pediatric patients on computed tomography (CT) following acute non-penetrating trauma.
Materials and Methods: The CT studies of 346 patients (63% male, 37% female; 7 months to 18 years of age) evaluated following acute non-penetrating facial trauma were retrospectively reviewed to evaluate for facial fractures and associated orbital hematomas or contiguous skull fractures. Fracture patterns were characterized as orbital roof, orbital floor, medial orbital wall, nasal bone, naso-orbital-ethmoid (NOE), zygomaticomaxillary complex (ZMC), isolated zygomatic arch, LeFort type (I, II or III), maxillary sagittal, alveolar ridge or mandibular. The correlation between orbital roof fractures and orbital hematomas or contiguous skull fractures was assessed (Kendall tau rank correlation).
Results: CT demonstrated fracture in 188 (54%) patients. The number and frequency of the fractures observed were as follows: orbital roof - 67 (36%), ZMC - 38 (20%), NOE - 30 (16%), orbital floor - 28 (15%), nasal bone - 25 (13%), mandibular - 24 (13%), medial orbital wall - 16 (9%), maxillary sagittal - 11 (6%), alveolar ridge - 8 (4%), isolated zygomatic arch - 3 (2%), LeFort type I - 4 (2%), LeFort type II - 4 (2%) and LeFort type III - 0 (0%). Fifty children (27%) had multiple fractures. Orbital hematomas were seen in 28 patients (15%) and contiguous skull fractures were seen in 54 patients (29%). There was strong correlation between orbital roof fractures and the presence of orbital hematomas (0.62, p < 0.0001) and contiguous skull fractures (0.57, p < 0.0001).
Conclusion: Fractures of the orbital roof are the most common facial fractures observed in pediatric patients following acute non-penetrating trauma and are frequently associated with orbital hematomas and contiguous skull fractures.
168. Significance of Lactate on 1H-MRS in Patients with a Central Pattern of Hypoxic Ischemic Injury on DWI within the First 3 Days of Life
Setty B. N.*; Ratai E.; Sagar P.; Krishnamoorthy K. S.; Grant E. P. Massachusetts General Hospital, Boston, MA
Address correspondence to B. Setty (bsetty{at}partners.org)
Objective: To determine if the presence of lactate portends a worse outcome in patients with decreased diffusion in the ventrolateral (VL) thalamus (central pattern of hypoxic ischemic injury) within the first 3 days of life.
Materials and Methods: A retrospective search of our database from 2001 to 2005 was performed to identify neonates who had decreased diffusion in the VL thalamus within 3 days of birth. All were studied at 1.5 T. Single voxel PROBE 1H-MRS (GE, Milwaukee) was performed with TR/TE = 1500/144 ms in a 2 cm3-region that included the lentiform and VL thalamus. Lactate was graded as trace, mild, moderate or severe. DWI was performed at b = 1000 s/mm2 with 6 gradient directions and 3 NEX. ADC maps were generated. Each region with decreased diffusion in addition to VL thalamus (basal ganglia, dorsal brain stem, cerebellum, corticospinal tract or cortex) was assigned a score of 1 and added to determine extent of changes on DWI. Outcomes were determined by chart review. A chi square test was performed to look for association between lactate on MRS and outcome and ANOVA for extent of changes on DWI with lactate on MRS.
Results: 8 patients met selection criteria (M:F: 4:4, mean age: 37.87 weeks). Mean day for first MRI was 1.62 days (range 1–3 days). Five neonates died and 3 had abnormal neurological outcomes at 2 years. Lactate was present in only 75% (6/8) of patients: trace (1), mild (4) and moderate (1). Two that died had no lactate on MRS but had extensive areas of decreased diffusion in the dorsal brainstem, cerebellum, corticospinal tract and cortex. DWI abnormalities were observed in basal ganglia (50%), dorsal brain stem (87.5%), cerebellum (62.5%), corticospinal tract (100%), and cortex (87.5%). The mean score of DWI was 4.5 when lactate was absent and 3.67 when lactate was present. There was no statistical significance between presence or absence of lactate and outcome or the score on DWI.
Conclusion: In this pilot study, lactate in deep gray nuclei does not predict morbidity or mortality or correlate with extent of DWI abnormalities. The absence of lactate on 1H-MRS within the first 3 days of life does not imply a better outcome in patients with a central pattern of injury on DWI.
169. The Abdominal Radiograph in Evaluating Pediatric Patients with Acute Nontraumatic Abdominal Complaints
Chang S.1*; Cassese J. A.2; Sabra R.3; Wallach M. T.2 1. Brown Medical School, Providence, RI; 2. Hasbro Children's Hospital/Rhode Island Hospital, Providence, RI; 3. Rhode Island Medical Imaging, East Providence, RI
Address correspondence to S. Chang (HChang{at}Lifespan.org)
Objective: To evaluate the diagnostic yield of abdominal radiographs in pediatric patients with acute nontraumatic abdominal complaints.
Materials and Methods: We reviewed the records of 510 emergency room patients who had abdominal radiographs for common abdominal complaints. One hundred sixty four patients underwent additional imaging studies (US, CT or fluoroscopy). The reports of all studies were classified into three categories; normal, abnormal, and nonspecific. Patients were stratified for age = 3 years versus >3 years as well as by discharge diagnosis. Comparison with the discharge diagnosis allowed for the calculation of predictive values and the sensitivity of the abdominal radiograph for specific diagnoses
Results: The abdominal radiograph was reported normal in 293/510 (58%) with a negative predictive value (NPV) of 94%, abnormal in 124/510 (24%) with a positive predictive value (PPV) of 85% and nonspecific in 93/510 (18%). For those patients = 3 years the positive predictive value of the exam was 80% compared to 90% for those >3 years. The negative predictive value for the exam was 91% and 90%, respectively. The abdominal radiograph was most sensitive for the diagnosis of intussusception (83%), enteritis (67%) and appendicitis (53%).
Conclusion: Although abdominal radiographs lack sensitivity for a specific diagnosis, they demonstrate a high NPV when interpreted as normal and a good PPV when interpreted as abnormal. Therefore, the abdominal radiograph is a useful initial screening exam for pediatric patients presenting with acute nontraumatic abdominal complaints.
170. Can Focused Follow-up CT of Abdomen and Pelvis Provide Required Information and Allow Reduction of Radiation Dose?
Simoneaux S.1*; Karsli T.1; Udayasankar U.1; Lorenzo R.1; Small W. C.1; Hahn P.2; Kalra M. K.2 1. Emory University School of Medicine, Atlanta, GA; 2. Massachusetts General Hospital, Boston, MA
Address correspondence to S. Simoneaux (stephen.simoneaux{at}choa.org)
Objective: Radiation dose depends on the scan length. The purpose of our study was to evaluate if follow-up CT of abdomen and pelvis can be focused to the location of lesion(s) seen on initial CT study.
Materials and Methods: IRB approval was obtained. In an ongoing study of 65 patients (age range 1-18 years, M:F 33:32) who underwent at least two abdominal-pelvic CT studies for nonmalignant clinical indications within a period of three months were included in our study. Two pediatric radiologists independently reviewed initial and follow-up CT studies in three sessions. In the first session, initial CT studies were reviewed for number of clinically significant and insignificant findings, and their size(s), region(s) and image location(s). Similar assessment was then performed for only those images of follow-up CT (focused CT), where lesions were recorded on the initial CT. Lastly, all images of follow-up CT were reviewed. Radiation dose reduction was evaluated by comparing the total tube current values of the all images of entire follow-up CT with those of focused follow-up CT. Data were analyzed using nonparametric statistical tests.
Results: Review of targeted follow-up and entire follow-up CT studies revealed 112 and 124 clinically significant abdominal findings, respectively. In 54 patients (83%, 54/65), entire follow-up CT did not add any additional information to the focused follow-up CT. Clinically significant findings that were not seen on focused, follow-up CT included fluid collection (n = 5), gastric-bowel wall thickening (n = 2), intussusception (n = 1), pneumatosis coli (n = 1), and pelvic abscess (n = 1). Average tube current values for the initial and follow-up CT studies were 128.31 mA (128.3 ± 36.22) and 124.61 mA (124.61 ± 37.95), respectively. Evaluation of tube current values showed a 57.19 % reduction in radiation dose with focused CT.
Conclusion: In most children (83%), a focused, follow-up abdominal-pelvic CT can be used to reduce radiation dose and interpretation time while obtaining relevant information. However, pre-identification of patients for focused, follow-up CT may require extra efforts from radiologists.
171. Growth Outcomes and Complications Post Gastrostomy in 120 Children
Lewis E. C.; Amaral J. G.*; Connolly B.; Temple M.; John P.; Chait P. G. The Hospital for Sick Children, Toronto, Canada
Address correspondence to J. Amaral (joao.amaral{at}sickkids.ca)
Objective: To assess growth outcomes of pediatric patients following retrograde percutaneous gastrostomy (RPG) and compare technical success and complications with other gastrostomy methods.
Materials and Methods: Retrospective review of 120 patients randomly selected who underwent G tube insertion via RPG from 2002 to 2003. All procedures were completed by one of four interventional radiologists. All procedural and postprocedural complications were recorded. Tube maintenance issues (TMIs) were also recorded separately. Mean follow-up was 2.7 years. Patient weights were recorded at four different time intervals: insertion and then 0–5 months, 6–12 months and 18–24 months postinsertion. Weights were converted to growth percentiles and the results from insertion to 18–24 months were compared using a paired Student t test.
Results: All 120 G tube insertions were successful. There were 59 men and 61 women. Mean age was 4.3 years (range - 1 day to 16 years; median = 1.3 years). The most common underlying diagnosis was a neurologic disease (29%, 35/120) and the main indication for gastrostomy was inadequate caloric intake (24%, 29/120). Procedural complications occurred in 7 patients. There were 11 major complications including 2 peritonitis, 2 stoma infections and one death. A total of 100 minor complications were noted with 58 patients experiencing at least one minor complication. There were a total of 169 TMIs. At insertion, 33 boys and 28 girls were below the 3rd growth percentile and mean growth percentiles were 16.65 for boys and 15.36 for girls. By 18–24 months, 13 boys and 16 girls were below the 3rd growth percentile and mean growth percentiles were 30.47 for boys and 21.43 for girls. The increase in growth percentile was statistically significant (boys p = 0.01; girls p = 0.044).
Conclusion: RPG provides appropriate, long-term enteral nutrition in the pediatric population and increases growth percentiles significantly two years after intervention. Minor complications and tube maintenance issues are a frequent occurrence with RPG; however, it is a safer technique than surgical gastrostomy and PEG and has fewer incidences of major complications although death can still result.
172. Utility of Ventriculoperitoneal Shunt Series for Evaluation of Suspected Abnormalities: A Comparison with Head CT Findings
Thomas C.; Trivedi Y.*; Jaffe B.; Irwin G. Winthrop University Hospital, Mineola, NY
Address correspondence to Y. Trivedi (ytrivedi{at}winthrop.org)
Objective: To determine the utility of the ventriculoperitoneal (VP) shunt series in relation to CT scan of the head in the routine work-up of suspected shunt malfunction.
Materials and Methods: A retrospective review of imaging reports for patients who underwent VP shunt series and head CT presenting to the Emergency Department between June 1999 and June 2005 at our institution was performed. Results of the head CT and the shunt series were recorded as normal, abnormal, or inconclusive. A total of 120 studies were done on 53 patients. The ages ranged from less than 1 year of age to 79 years of age.
Results: Of the 120 studies 113 were normal on both VP shunt series and CT scan of the head. Three cases were inconclusive of continuity of the shunt; of these three, 2 patients had abnormal CT results and 1 patient had a normal CT result. Four studies were found to be normal on VP shunt series but abnormal on CT scans. There were no cases of definite abnormal shunt series. The average entrance skin radiation (mRad) and effective radiation doses (mSv) from a shunt series were calculated: skull 10-25 mRad/10-20, chest 3 mRad/30mSV, and abdomen 30 mRad/60 mSV. The average entrance skin radiation and effective dose from a CT scan of the head were calculated at 1400 mRad and 4000 mSv respectively. Probability of a normal VP and an abnormal CT were calculated as 1/114 (0.9% chance) as well an abnormal VP and a normal CT 2/6 (33% chance).
Conclusion: We conclude that a ventriculoperitoneal shunt series would be better indicated after initial evaluation with a CT scan of the head that demonstrates significant abnormality such as increased ventricular size. This would save time and minimize radiation exposure (often cumulative) in a patient population that is usually young.
173. Frequency of Pericardial Effusions Detected on CT and Echocardiography in Children with Parapneumonic Effusions or Empyema
Winger D. I.; Katz D. S.*; Shah R. A.; Roberts J.; Montoya C.; Bezack B. Winthrop-University Hospital, Mineola, NY
Address correspondence to D. Katz (dsk2928{at}pol.net)
Objective: To determine the frequency of pericardial effusion or thickening detected retrospectively on CT and echocardiography in children with severe pneumonia causing either parapneumonic effusion or empyema.
Materials and Methods: A retrospective review of all pediatric patients, aged 0–21, admitted over the past 6 years with the diagnosis of parapneumonic effusion or empyema to a teaching hospital was performed. All chest CT scans performed on these patients were reviewed by consensus by 3 radiologists who determined the presence or absence of pericardial effusion or thickening. This was quantified by measuring its thickest portion in the axial plane, as well as its location. The radiologists were blinded to the clinical patient information, and to the official CT and echocardiography reports. All demographic, clinical, and radiographic data were collected, and statistical analysis was done with Student's t-tests and chi-square analysis.
Results: Forty-four of 59 patients reviewed had 59 CT scans of the chest (75%). Thirteen patients (29.5%) had evidence of pericardial effusion, with an additional 2 patients (total of 34%) having either pericardial effusion or thickening on CT. Mean pericardial effusion thickness was 4.8 mm, and maximum thickness was 10 mm. The thickest portions of the pericardial effusions were usually on the same side of the chest as the effusion or empyema. Twenty of the 59 children underwent echocardiographic evaluation, and 16 of these (80%) had pericardial effusion, with 13 categorized as small and 3 as moderate. Patients with pericardial effusion on either echocardiography or CT had longer hospital stays (p = 0.02) and an increased incidence of chest tube insertion or surgical intervention (p < 0.01).
Conclusion: Children with parapneumonic effusions are at an increased risk of developing pericardial effusions, which can be identified on either chest CT or echocardiography. The mechanism behind these pericardial effusions or thickening may relate to a transudative, sympathetic response to the adjacent pleural infection.
174. MDCT Diagnosis of Tracheomalacia in Pediatric Patients with Symptomatic Airway Compression from Mediastinal Aortic Vascular Anomalies
Lee E. Y.2*; Mason K. P.; Waltz D. A.; Ralph A.; Riaz F.; Boiselle P. M. 1. Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; 2. Children's Hospital Boston and Harvard Medical School, Boston, MA
Address correspondence to E. Lee (Edward.Lee{at}childrens.harvard.edu)
Objective: The purpose of this study is to evaluate the prevalence of tracheomalacia (TM) among symptomatic pediatric patients with mediastinal aortic vascular airway compression using MDCT.
Materials and Methods: The study group consisted of 12 symptomatic pediatric patients (9 M/3 F; mean age of 5.1 years; age range of 2 weeks to 16 years) with mediastinal aortic vascular airway compression who were referred for evaluation of clinically suspected TM and underwent MDCT with acquisition of images in two different phases of respiration: end-inspiration and end-expiration. CT angiography was also concurrently performed during the end-inspiration phase of the study. Two pediatric radiologists in consensus reviewed all CT images in a randomized and blinded fashion. Both end-inspiration and end-expiration CT images were reviewed for the type of mediastinal aortic vascular anomalies compressing the trachea and severity of tracheal compression. A diagnosis of TM was established by using CT criterion of 50% or more reduction in cross-sectional luminal area between end-inspiration and end-expiration CT images.
Results: Mediastinal aortic vascular anomalies included: right aortic arch with aberrant left subclavian artery (n = 4), innominate artery compression (n = 4), double aortic arch (n = 3), and left aortic arch with aberrant right subclavian artery (n = 1). TM was diagnosed in 6 (50%) of 12 patients, including 4 (100%) of 4 with innominate artery compression, 1 (33.3%) of 3 with double aortic arch, and 1 (25%) of 4 with right aortic arch with aberrant left subclavian artery.
Conclusion: Symptomatic pediatric patients with mediastinal aortic vascular airway compression, particularly innominate artery compression, have a high association with TM, an important preoperative finding. Paired inspiratory-expiratory MDCT should thus be performed routinely to assess for TM in symptomatic pediatric patients with mediastinal aortic vascular airway compression.
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