Pediatrics

White Matter Injury and General Movements in High-Risk Preterm Infants

Fellows’ Journal Club

Cerebral palsy has been predicted by analysis of spontaneous movements in the infant termed “General Movement Assessment.” The authors evaluated the utility of General Movement Assessment in predicting adverse cognitive, language, and motor outcomes in very preterm infants and attempted to identify brain imaging markers associated with both adverse outcomes and aberrant general movements in 47 preterm infants using MRI volumetric analysis and DTI. Nine infants had aberrant general movements and were more likely to have adverse neurodevelopmental outcomes, compared with infants with normal movements. In infants with aberrant movements, Tract-Based Spatial Statistics analysis identified significantly lower fractional anisotropy in widespread WM tracts. They conclude that aberrant general movements at 10–15 weeks’ postterm are associated with adverse neurodevelopmental outcomes and specific white matter microstructure abnormalities for cognitive, language, and motor delays.

Abstract

Figure 1 from paper
Differences in white matter at term-equivalent age between infants with normal and aberrant fidgety movements at 10–15 weeks. Mean FA skeleton, in green, is overlaid on the mean FA map. Superimposed are pseudocolored voxels having significantly greater anisotropy in infants with normal than in infants with aberrant fidgety movements. Color bar shows the range of P values represented by the pseudocolors. Significantly higher regions of FA can be observed in the splenium (ccs) and genu (ccg) of the corpus callosum, inferior (ilf) and superior longitudinal fasciculus (slf), fronto-occipital fasciculus (fof), anterior (alic) and posterior (plic) internal capsule, corona radiata (cr), cerebellar peduncles (cp), and fornix/stria terminalis (fx/st). Z represents the MR imaging axial section coordinates (zero is the center of the anterior commissure).

BACKGROUND AND PURPOSE

Very preterm infants (birth weight, <1500 g) are at increased risk of cognitive and motor impairment, including cerebral palsy. These adverse neurodevelopmental outcomes are associated with white matter abnormalities on MR imaging at term-equivalent age. Cerebral palsy has been

Limited Dorsal Myeloschisis and Congenital Dermal Sinus: Comparison of Clinical and MR Imaging Features

Editor’s Choice

These investigators retrospectively reviewed the clinical and MR imaging findings of 12 patients with limited dorsal myeloschisis and 10 patients with congenital dermal sinus. A crater covered with pale epithelium was the most common skin lesion in limited dorsal myeloschisis (83%). Infectious complications were common in congenital dermal sinus (60%), but not found in limited dorsal myeloschisis. They show that limited dorsal myeloschisis has distinct MR imaging features including a visible intrathecal tract with dorsal tenting of the cord at the tract-cord union.

Correlation of MRI Brain Injury Findings with Neonatal Clinical Factors in Infants with Congenital Diaphragmatic Hernia

Fellows’ Journal Club

The authors evaluated MRIs performed before hospital discharge in 53 infants with congenital diaphragmatic hernia that were scored forbrain injury by 2 pediatric neuroradiologists. Potential associations with perinatal and clinical variables from the neonatal intensive care unit stay were probed. The most common findings were enlarged extra-axial spaces (36%), intraventricular hemorrhage (23%), ventriculomegaly (19%), white matter injury (17%), and cerebellar hemorrhage (17%). Brain injury score was associated with extracorporeal membrane oxygenation, lack of oral feeding at discharge, use of inotropes, and gastrostomy tube placement before hospital discharge.

Abstract

Figure 2 from paper
A, Coronal T2-weighted image demonstrates ventriculomegaly, scored as grade 2 on our scale; B, Coronal T2-weighted image demonstrates enlarged extra-axial spaces, scored as grade 2 on our scale. C, SWI shows evidence of grade 2 intraventricluar hemorrhage (arrows). D, SWI shows evidence of parenchymal hemorrhage, grade 1 on our scale (arrow). E, SWI shows foci of cerebellar hemorrhage, grade 2 on our scale (arrows). F, Axial T1 weighted images demonstrate foci of bilateral white matter injury, grade 2 on our scale (arrows).

BACKGROUND AND PURPOSE

Infants with congenital diaphragmatic hernia are reported to have evidence of brain MR imaging abnormalities. Our study aimed to identify perinatal clinical factors in infants with congenital diaphragmatic hernia that are associated with evidence of brain injury on MR imaging performed before hospital discharge.

MATERIALS AND METHODS

MRIs performed before hospital discharge in infants with congenital diaphragmatic hernia were scored for brain injury by 2 pediatric neuroradiologists. Perinatal variables and clinical variables from the neonatal intensive care unit stay were analyzed for potential associations with brain MR imaging findings.

RESULTS

Fifty-three infants with congenital diaphragmatic hernia (31 boys) were included. At least 1 abnormality was seen on MR imaging in 32 infants (60%). The most common MR imaging findings were enlarged extra-axial spaces (36%),

Full Dose-Reduction Potential of Statistical Iterative Reconstruction for Head CT Protocols in a Predominantly Pediatric Population

Fellows’ Journal Club

The authors set out to determine the maximum level of statistical iterative reconstruction that can be used to establish dose-reduced head CT protocols in a primarily pediatric population while maintaining similar appearance and level of image noise in the reconstructed image. Dose-reduced head protocols using an adaptive statistical iterative reconstruction were compared for image quality with the original filtered back-projection reconstructed protocols in a phantom and CT dose index and image noise magnitude were assessed in 737 pre- and post-dose-reduced examinations. Implementation of 40% and 60% adaptive statistical iterative reconstruction led to an average reduction in the volume CT dose index of 43% for brain, 41% for orbit, 30% for maxilla, 43% for sinus, and 42% for temporal bone protocols for patients between 1 month and 26 years of age, while improving the contrast-to-noise ratio of low-contrast soft-tissue targets.

Abstract

Figure 4 from paper
Images of the 3-, 5-, 7-, and 9-mm low-contrast targets in the Catphan 700 phantom are acquired with FBP and dose-reduced ASIR reconstruction up to 60% ASIR for the soft reconstruction kernels at both 100 and 120 kVp and up to 40% for the standard reconstruction kernel at 100 kVp.

BACKGROUND AND PURPOSE

A statistical iterative reconstruction algorithm provides an effective approach to reduce patient dose by compensating for increased image noise in CT due to reduced radiation output. However, after a point, the degree to which a statistical iterative algorithm is used for image reconstruction changes the image appearance. Our aim was to determine the maximum level of statistical iterative reconstruction that can be used to establish dose-reduced head CT protocols in a primarily pediatric population while maintaining similar appearance and level of image noise in the reconstructed image.

MATERIALS AND METHODS

Select head examinations (brain, orbits, sinus, maxilla, and temporal bones) were investigated. Dose-reduced head

Differentiation of Speech Delay and Global Developmental Delay in Children Using DTI Tractography-Based Connectome

Editor’s Choice

This study investigated whether diffusion tensor imaging tractography-based connectome can differentiate global developmental delay from speech delay in young children. Twelve children with pure speech delay, 14 children with global developmental delay, and 10 children with typical development underwent 3T DTI. Whole-brain connectome analysis was performed by using 116 cortical ROIs. Network metrics were measured at individual regions: strength, efficiency, cluster coefficient, and betweeness. Compared with typical development, global and local efficiency were significantly reduced in both global developmental delay and speech delay. Nodal strength of the cognitive network was reduced in global developmental delay, whereas the nodal strength of the language network was reduced in speech delay. This finding resulted in a high accuracy of >83% to discriminate global developmental delay from speech delay.

Abstract

ROIs showing significantly altered network metrics in the group comparison of TD > GD. In the 2D connectogram, the color of anatomic label scales the P value of group difference in the AAL template. Similarly, the color of each circle represents the P value of individual metrics. The 3D connectogram shows individual pair-wise pathways having significant group differences in nodal strength (ie, the greater radius of the sphere, the greater the group difference). In both 2D and 3D connectograms, block arrows indicate the hippocampal network whose nodal properties are significantly reduced in GD compared with TD.
ROIs showing significantly altered network metrics in the group comparison of TD > GD. In the 2D connectogram, the color of anatomic label scales the P value of group difference in the AAL template. Similarly, the color of each circle represents the P value of individual metrics. The 3D connectogram shows individual pair-wise pathways having significant group differences in nodal strength (ie, the greater radius of the sphere, the greater the group difference). In both 2D and 3D connectograms, block arrows indicate the hippocampal network whose nodal properties are significantly reduced in GD compared with TD.

BACKGROUND AND PURPOSE

Pure speech delay is a common developmental disorder which, according to some estimates, affects 5%–8% of the population. Speech delay may not only be an isolated condition but also can be part of a broader condition such as global developmental delay. The present study investigated whether diffusion tensor imaging tractography-based connectome can differentiate global developmental delay from speech delay in young children.

MATERIALS AND METHODS

Twelve children with pure speech delay (39.1 ±

Surgical Pediatric Otolaryngology, 2nd Edition

Potsic WP, Cotton RT, Handler SD, Zur KB, eds. Surgical Pediatric Otolaryngology. 2nd ed. Thieme; 2016; 694 pp; 900 ill; $169.99

Cover of Surgical Pediatric Otolaryngology, edited by Potsic, Cotton, Handler, and ZurSurgical Pediatric Otolaryngology, edited by William P. Potsic, Robin T. Cotton, Steven D. Handler, and Karen B. Zur, is the second edition of this textbook dedicated to the surgical procedures involved it the Pediatric Otolaryngology subspecialty. The first edition, published in 1997, has been an essential tool for most pediatric otolaryngologists. This new edition helps brings updated information involving new technology that has made routine procedures more effective as well as advancements in tech, particularly in the field of hearing. The surgical procedures explained include the surgical protocols used by 24 other faculty members at Children’s Hospital of Philadelphia and Cincinnati Children’s hospital.

The textbook is divided into 8 different sections. Each section begins with highlights regarding the disease processes covered. The first section encompasses ear surgical procedures for chronic otitis media, congenital malformations, trauma, hearing restoration with cochlear implants, and bone anchor hearing aids. An additional chapter on perilymphatic fistula management was surprising due to the rare nature of this entity. The second section deals with problems of the nose, including the management of nasal deformities and trauma, tumors of the nasal cavity, and repair of nasal stenosis, including choanal atresia. This section contrasts the endoscopic versus open approaches for the surgical management of narrowing of the nasal passages. The endoscopic portion provides key instruments that can ease the surgical process.

The next section of the atlas encompasses the surgical management of tumors in addition to structural and functional problems of the nasopharynx, oral cavity, and oropharynx, particularly the management of nasopharyngeal angiofibroma, where it provides a thorough explanation on endoscopic assisted techniques. Tonsillectomy and adenoidectomy procedures are discussed using multiple surgical techniques and advancements in …

How to Reduce Head CT Orders in Children with Hydrocephalus Using the Lean Six Sigma Methodology: Experience at a Major Quaternary Care Academic Children’s Center

Fellows’ Journal Club

The authors describe a Lean Six Sigma project with the goal of reducing the relative use of pediatric head CTs in their population of patients with hydrocephalus by 50% within 6 months. The existing baseline imaging practice for hydrocephalus was outlined in a Kaizen session, and potential interventions were discussed. An improved radiation-free workflow with ultrafast MR imaging was created. Baseline data were collected for 3 months by using the departmental radiology information system and data collection continued postintervention and during the control phase. The improved workflow resulted in a 75% relative reduction in the percentage of hydrocephalus imaging performed by CT between the pre- and postintervention/control phases. The authors conclude that the lean interventions in the pediatric hydrocephalus care pathway resulted in a significant reduction in head CT orders.

Abstract

Improved workflow for the hydrocephalus imaging pathway. Imaging technologists are required to respond in a timely fashion. In case they could not respond on time, their phone numbers are outlined so that the ordering units can follow-up on their orders. HMED indicates HealthMatics Emergency Department (Allscripts, Chicago, Illinois); POE, Physician Order Entry; EPIC, Epic Systems (Madison, Wisconsin); ASCOM, tel.
Improved workflow for the hydrocephalus imaging pathway. Imaging technologists are required to respond in a timely fashion. In case they could not respond on time, their phone numbers are outlined so that the ordering units can follow-up on their orders. HMED indicates HealthMatics Emergency Department (Allscripts, Chicago, Illinois); POE, Physician Order Entry; EPIC, Epic Systems (Madison, Wisconsin); ASCOM, tel.

BACKGROUND AND PURPOSE

Lean Six Sigma methodology is increasingly used to drive improvement in patient safety, quality of care, and cost-effectiveness throughout the US health care delivery system. To demonstrate our value as specialists, radiologists can combine lean methodologies along with imaging expertise to optimize imaging elements-of-care pathways. In this article, we describe a Lean Six Sigma project with the goal of reducing the relative use of pediatric head CTs in our population of patients with hydrocephalus by 50% within 6 months.

MATERIALS AND METHODS

We applied a Lean Six Sigma methodology using a multidisciplinary team at a quaternary care academic children’s center. The existing baseline imaging

Diagnostic Value of Prenatal MR Imaging in the Detection of Brain Malformations in Fetuses before the 26th Week of Gestational Age

Fellows’ Journal Club

The authors retrospectively evaluated 109 fetuses within 25 weeks of gestational age who had undergone both prenatal and postnatal MR imaging of the brain between 2002 and 2014, and using the postnatal MRI as the reference standard, they calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the prenatal MRI in detecting brain malformations. Prenatal MR imaging failed to detect correctly 11 of the 111 malformations. They conclude that diagnostic value of prenatal MRI for brain malformations within 25 weeks of GA is very high, despite limitations of sensitivity in the early detection of disorders of cortical development, such as polymicrogyria and periventricular nodular heterotopias.

Abstract

fjc_conteBACKGROUND AND PURPOSE

In several countries, laws and regulations allow abortion for medical reasons within 24–25 weeks of gestational age. We investigated the diagnostic value of prenatal MR imaging for brain malformations within 25 weeks of gestational age.

MATERIALS AND METHODS

We retrospectively included fetuses within 25 weeks of gestational age who had undergone both prenatal and postnatal MR imaging of the brain between 2002 and 2014. Two senior pediatric neuroradiologists evaluated prenatal MR imaging examinations blinded to postnatal MR imaging findings. With postnatal MR imaging used as the reference standard, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the prenatal MR imaging in detecting brain malformations.

RESULTS

One-hundred nine fetuses (median gestational age at prenatal MR imaging: 22 weeks; range, 21–25 weeks) were included in this study. According to the reference standard, 111 malformations were detected. Prenatal MR imaging failed to detect correctly 11 of the 111 malformations: 3 midline malformations, 5 disorders of cortical development, 2 posterior fossa anomalies, and 1 vascular malformation. Prenatal MR imaging misdiagnosed 3 findings as pathologic in the posterior fossa.

CONCLUSIONS

The diagnostic value of prenatal

Brain Structural and Vascular Anatomy Is Altered in Offspring of Pre-Eclamptic Pregnancies: A Pilot Study

Editor’s Choice

The authors assessed the brain structural and vascular anatomy in 7- to 10-year-old offspring of pre-eclamptic pregnancies compared with matched controls (n=10 per group). TOF-MRA and a high-resolution anatomic T1-weighted MPRAGE sequence were acquired for each participant. Offspring of pre-eclamptic pregnancies exhibited enlarged brain regional volumes of the cerebellum, temporal lobe, brain stem, and right and left amygdalae. These offspring displayed reduced cerebral vessel radii in the occipital and parietal lobes. The authors conclude that these structural and vascular anomalies may underlie the cognitive deficits reported in the pre-eclamptic offspring population.

Abstract

Visual 3D representation of the vessel radii calculated for a segmented TOF-MRA dataset of a single female, 8-year-old PE-F1 participant who was born at 34 weeks of gestation.
Visual 3D representation of the vessel radii calculated for a segmented TOF-MRA dataset of a single female, 8-year-old PE-F1 participant who was born at 34 weeks of gestation.

BACKGROUND AND PURPOSE

Pre-eclampsia is a serious clinical gestational disorder occurring in 3%–5% of all human pregnancies and characterized by endothelial dysfunction and vascular complications. Offspring born of pre-eclamptic pregnancies are reported to exhibit deficits in cognitive function, higher incidence of depression, and increased susceptibility to stroke. However, no brain imaging reports exist on these offspring. We aimed to assess brain structural and vascular anatomy in 7- to 10-year-old offspring of pre-eclamptic pregnancies compared with matched controls.

MATERIALS AND METHODS

Offspring of pre-eclamptic pregnancies and matched controls (n = 10 per group) were recruited from an established longitudinal cohort examining the effects of pre-eclampsia. Children underwent MR imaging to identify brain structural and vascular anatomic differences. Maternal plasma samples collected at birth were assayed for angiogenic factors by enzyme-linked immunosorbent assay.

RESULTS

Offspring of pre-eclamptic pregnancies exhibited enlarged brain regional volumes of the cerebellum, temporal lobe, brain stem, and right and left amygdalae. These offspring displayed reduced cerebral vessel radii in the occipital and parietal lobes. Enzyme-linked immunosorbent assay analysis revealed underexpression of the placental growth factor

Pediatric Interventional Radiology

Towbin R, Baskin KM, eds. Pediatric Interventional Radiology. Cambridge University Press; 2015; 493 pp; 692 ill; $175.00

Cover of Pediatric Interventional Radiology, edited by Towbin and BaskinPediatric interventional radiology is a unique subspecialty that bridges pediatric radiology and adult interventional radiology.  Children have a unique set of pathology and challenges when compared to adults; children are not just small adults. Pediatric Interventional Radiology provides a comprehensive overview of this unique subspecialty, perfect for the trainee or radiologist whose practice encounters pediatric patients in need of a procedure.

The first chapter provides a great introduction and approach to pediatric interventional radiology. This section includes many pediatric-specific details, which would be useful for anyone performing pediatric procedures or fluoroscopy, not just the pediatric interventionalists. For example, in the absence of underlying pathology, routine labs are not always required prior to a pediatric procedure. There is a detailed discussion of analgesia and sedation in the pediatric patient, along with the weight-based doses and reversal agents, which is a very useful reference for any practitioner performing pediatric cases with sedation. There are specifics on how to minimize radiation while optimizing imaging, which is always key for pediatric imaging. Also included in the introduction is a thorough list of suggested equipment for a pediatric ready angiography suite, such as smaller French catheters and wires.

The book includes helpful photographs of images demonstrating techniques and devices. However, that being said, some of the images leave something to be desired. Not all of the images are appropriately cropped or windowed, making it difficult to see the finding. On occasion, an arrow was chosen in a color very close the background, making the reader search the image. A few older images appeared grainy and not what you would expect in a publication. The figure captions provided good detail but were not always on the same page …