Sawyer David,  Mushtaq Raza,  Vedantham Srinivasan,  Udayasankar Unni

Final Pr. ID: Paper #: 096

Acute appendicitis represents an important cause of abdominal pain in pediatric patients. Although imaging plays an increasingly important role in the rapid diagnosis and management of this condition, there is no universally accepted strategy for imaging children suspected of having acute appendicitis. Ultrasound and computed tomography have been used most commonly, but there is rising interest in the use of magnetic resonance imaging (MRI) due to its lack of ionizing radiation or need for intravenous contrast. Recent research has shown that MRI has high diagnostic performance when employed as a first-line test. However, when considering the generalizability of MRI outside of a specialized tertiary care center, the question of operator dependence arises. To determine the performance of MRI when interpreted by readers with limited experience, we performed a retrospective review of preliminary MRI interpretations rendered by radiology residents at our institution, compared with final (attending radiologist) interpretations. Read More

Authors:  Sawyer David , Mushtaq Raza , Vedantham Srinivasan , Udayasankar Unni

Keywords:  Acute appendicitis, Magnetic resonance imaging

Ayvazyan Sona,  Petrosyan Lilit

Final Pr. ID: Poster #: CR-052

Pediatric stroke is a relatively rare disease, but remains one of the most common causes of death in childhood.
A higher homocysteine level raises the risk of vascular disease, including stroke.
In the setting of heavy alcohol consumption, the risk for all major types of strokes is increased, especially those of ischemic etiology.
A 17-year-old boy who had used a large amount of cigarettes and alcohol the previous evening, presented to our clinic. Upon admission, the patient’s condition was critical, with impaired consciousness. Left-sided facial nerve paresis and left-sided hemiparesis were observed. An CT examination of the brain was performed, no gross changes were found and was indicates an urgent MRI. On MRI there was irregular configuration of the dorsal posterior limb of the internal capsule and ventrolateral parts of the right thalamus, with a focus of diffusion restriction and increased MR signal intensity on T2-weighted FLAIR sequences. MR findings are consistent with an acute ischemic stroke in the territory of the right anterior choroidal artery. No neurological deficits were detected after treatment.
Alcohol intoxication and hyperhomocysteinemia are significant risk factors for ischemia.
The combination of hyperhomocysteinemia with alcohol and nicotine abuse presents an even higher and more persistent risk for ischemia. Read More

Authors:  Ayvazyan Sona , Petrosyan Lilit

Keywords:  Stroke, Acute, Brain

Hendi Aditi,  Harty Mary,  Grissom Leslie

Final Pr. ID: Poster #: SCI-061

Colonic volvulus in the pediatric population is very rare with 40% mortality making timely diagnosis imperative. Radiologists should operate with a high degree of clinical suspicion in patients with risk factors for large bowel volvulus. Recognition of colonic volvulus on plain film, contrast enema and CT is paramount to work-up and definitive management. This case series is the largest from any single institution and describes the clinical course and imaging findings in cases of volvulus, with the goal of familiarizing the radiologist with the appearance of this disease entity on several imaging modalities. Read More

Authors:  Hendi Aditi , Harty Mary , Grissom Leslie

Keywords:  Colonic Volvulus, Pediatric, Large Bowel Volvulus, Colonic Obstruction, Acute Abdomen

Shukla Neal,  Kim Joseph,  Hammer Matthew,  Tu Long,  Rao Balaji

Final Pr. ID: Poster #: CR-051

Reversible cerebral vasoconstriction syndrome (RCVS) is commonly seen in middle-aged patients. This syndrome is characterized by thunderclap headaches which may not be apparent or recognized in pediatric patients, posing a challenge in diagnosis. Several medications have been associated with the development of RCVS, though they are not reliably known to cause it: highlighting the potential influence of other underlying predisposing factors. RCVS is self-limiting with treatment focused on reducing the degree of vasoconstriction.
A 7-year-old male patient with a medical history of B-cell acute lymphoblastic lymphoma, currently undergoing treatment with intrathecal methotrexate, cytarabine, and IV vincristine was admitted to our institution for acute perforated appendicitis. On the second day of hospitalization, the patient developed left arm weakness which prompted evaluation with MRI/MRA brain. Imaging revealed restricted diffusion in the left superior frontal gyrus with corresponding low ADC values and mild T2/FLAIR signal suggestive of an acute ischemic infarct. Vascular imaging showed a beaded appearance of the supraclinoid ICA, ACA and MCA bilaterally. Transcranial doppler study of the arteries confirmed elevated velocities consistent with multifocal stenoses. Initial differential diagnoses included acute ischemic infarct secondary to vasculitis with infectious causes considered due to the patient’s neutropenic state. Although, there was no evidence of vasculitis in other regions of the body and a primary CNS vasculitis typically presents with bilateral infarcts. Methotrexate leukoencephalopathy was also considered, although it typically affects white matter, primarily in the centrum semiovale. Posterior reversible encephalopathy syndrome was another possibility, but the absence of cerebral microhemorrhages argued against this. Given the vascular and ischemic findings, RCVS was ultimately suspected. A follow-up MRI performed several days later revealed a new infarct in the right frontal lobe. Notably, repeat CTA imaging showed complete resolution of the arterial stenoses, further supporting the diagnosis of RCVS.
This case illustrates the diagnostic challenge of RCVS in a pediatric patient with comorbidities that initially pointed towards a neoplastic or infectious etiology. Although not performed in the presented case, vessel wall MRI may be a useful tool in differentiating between arterial narrowing from vasculitis versus RCVS or atherosclerosis. Read More

Authors:  Shukla Neal , Kim Joseph , Hammer Matthew , Tu Long , Rao Balaji

Keywords:  RCVS, Acute Lymphoblastic Leukemia, Neuroradiology

Kim Joseph,  Shukla Neal,  Hammer Matthew,  Lozano Richard,  Hajibeygi Ramtin,  Tu Long

Final Pr. ID: Poster #: CR-049

A 16-year-old boy was transferred to our institution after experiencing a week of worsening numbness and weakness in his left lower extremity. Initially diagnosed with sciatica at an outside facility, he was treated with steroids. However, as his symptoms progressed, including difficulties with bowel movements, he returned for further evaluation.

Outside MRI studies of the lumbar spine and brain revealed hyperintensities and enhancement at T11-T12, raising concerns for transverse myelitis. Subsequent MRI of the cervical and thoracic spine and brain demonstrated extensive T2-weighted cord edema extending from C7 to the conus medullaris, along with a long segment of intramedullary hemorrhage, most pronounced from T8-T9. The differential diagnosis based on these findings included long-segment transverse myelitis complicated by cord hemorrhage or an intramedullary neoplasm, such as ependymoma or astrocytoma.

Comprehensive laboratory testing, including serologic and cerebrospinal fluid studies, ruled out infectious, autoimmune, metabolic, and demyelinating causes. Given the presence of intramedullary hemorrhage, a vascular etiology, such as an arteriovenous shunt, was considered; however, a diagnostic spinal angiogram showed no evidence of an aneurysm or vascular malformation.
Multi-specialty conferences involving radiology, infectious diseases, rheumatology, neuroimmunology, and neurosurgery were conducted, but no consensus was reached regarding the underlying etiology of the lesions. Ultimately, the patient was treated empirically for transverse myelitis with steroids, intravenous immunoglobulin (IVIG), and plasmapheresis.

Hemorrhagic transverse myelitis can result from a variety of etiologies, including infectious, neoplastic, demyelinating, vascular, autoimmune, and idiopathic factors. Key MRI sequences for evaluation include T2-weighted and post-contrast images, which are essential for assessing spinal cord edema, inflammation, and hemorrhagic changes. Additionally, gradient echo (GRE) sequences are vital for detecting subtle blood products, as blood degradation products display greater hypointensity and blooming on GRE images compared to T2-weighted images. By understanding this rare condition and its potential underlying causes, radiologists can play a crucial role in guiding clinical teams toward accurate diagnosis and timely management of patients with hemorrhagic transverse myelitis. Read More

Authors:  Kim Joseph , Shukla Neal , Hammer Matthew , Lozano Richard , Hajibeygi Ramtin , Tu Long

Keywords:  Spinal Cord, MRI, Emergency/Acute

Jordan Kathryn,  Killerby Marie,  Patel Arjun,  Cassella Katharyn,  Greene Elton,  Johnstone Lindsey,  Leschied Jessica

Final Pr. ID: Poster #: EDU-014

The majority of children’s hospitals reside in urban settings, and the most common animal related injuries seen in these areas are induced by cats or dogs. However, urban medical centers serve patients from large surrounding rural areas where a more diverse array of animal or agriculture related injuries can occur. Although an altercation with an angry horse, pig, or cow could result in severe trauma in adults, animal related injuries pose an even greater danger to children given their smaller stature and growing bodies. The natural curiosity of children also increases the risk of severe injury when living or playing around industrial agricultural equipment. Even partaking in outdoor sports or leisure activities confers risk for exposure to a variety of injury mechanisms. Depending on the specifics of the surrounding ecosystem, radiologists may also care for patients exposed to envenomation from snakes, scorpions, spiders, and various other insects, resulting in local or systemic complications. When incorporating a mechanism of injury, radiologists may anticipate complications of exposure to these animals or insects and can recommend further imaging evaluation. For example, in addition to characterizing imaging findings, such as local necrosis, from a brown recluse bite injury in a patient transferred from an outlying hospital, the radiologist would anticipate the urgency with which to assess for more systemic complications such as angioedema, rhabdomyolysis, or internal hemorrhage due to disseminated intravascular coagulopathy. To best serve our patients, pediatric radiologists should exhibit familiarity with possible mechanisms of injury related to wildlife, their various imaging manifestations, and potential complications in order to help guide clinicians in managing these potentially devastating injuries. This educational exhibit aims to demonstrate key findings of such pediatric injuries through a series of cases. Read More

Authors:  Jordan Kathryn , Killerby Marie , Patel Arjun , Cassella Katharyn , Greene Elton , Johnstone Lindsey , Leschied Jessica

Keywords:  Pediatric Trauma, Image Findings, Emergency/Acute

Gnesda Ryan,  Lewis Heidi,  Kucera Jennifer

Final Pr. ID: Poster #: EDU-091

Intraperitoneal focal fat infarction is an umbrella term used to describe numerous pathologies with the two most common encountered in clinical practice being epiploic appendagitis and omental infarction. The clinical presentation often mimics an acute abdomen, which can lead to inappropriate management of the patient. While there is ample literature regarding the imaging appearance of focal fat infarction in adults, little exists regarding the imaging findings in children. The purpose of this exhibit is to demonstrate the imaging features which will allow radiologists to confidently diagnose focal fat infarction and differentiate it from more emergent causes of an acute abdomen. We will also discuss the prognosis and appropriate management, usually conservative, which is a significant difference from other causes of an acute abdomen. Read More

Authors:  Gnesda Ryan , Lewis Heidi , Kucera Jennifer

Keywords:  Acute Abdomen, Epiploic Appendagitis, Omental Infarct

Cummings Terrence,  Kadom Nadja,  Holder Chad

Final Pr. ID: Poster #: EDU-115

An acute stroke MRI protocol is used when a paediatric patient presents to the emergency department with stroke like symptoms. Rapid imaging is needed in order to ascertain the presence of stroke, exclude stroke mimics, the extent of the stroke, and exclude any complications, such as haemorrhage. An acute stroke protocol which consist only of a diffusion weighted sequence enables quick diagnosis and does not significantly delay treatment of the patient. Read More

Authors:  Cummings Terrence , Kadom Nadja , Holder Chad

Keywords:  MRI, Stroke, Acute

Gilligan Leah,  Davenport Matthew,  Trout Andrew,  Su Weizhe,  Zhang Bin,  Goldstein Stuart,  Dillman Jonathan

Final Pr. ID: Paper #: 089

Acute kidney injury (AKI) remains a concern in hospitalized children undergoing computed tomography (CT) examinations with intravenous (IV) iodinated contrast material (ICM). Adult studies have shown frequencies of AKI after CT with IV ICM to be similar to propensity score-matched ICM unexposed cohorts. The purpose of this study is to evaluate the association between IV ICM exposure and AKI in hospitalized pediatric patients with stable kidney function undergoing computed tomography (CT). Read More

Authors:  Gilligan Leah , Davenport Matthew , Trout Andrew , Su Weizhe , Zhang Bin , Goldstein Stuart , Dillman Jonathan

Keywords:  contrast induced nephropathy, acute kidney injury, iodinated contrast material

Durfee Teela,  Cielma Tara

Final Pr. ID: Poster #: CR-003 (T)

Pediatric scrotal ultrasound pathology can be difficult because of the similar presentation of different pathology such as scrotal torsion, epididymitis, inguinal hernia, epididymal appendix torsion, and trauma. Identifying key factors of each condition is paramount to providing a clear diagnostic picture in the setting of an atypical presentation of any pathology.

Epididymitis is an inflammatory process precipitated by bacterial or viral infections. Symptoms typically present as increasing scrotal pain with swelling of the epididymis. Depending on degree of severity imaging presentation can mimic other pathology.

A 5 year old male transferred to a pediatric facility from an area hospital to assess suspected incarcerated hernia with outside CT and ultrasound images.
Read More

Authors:  Durfee Teela , Cielma Tara

Keywords:  epididymitis, pediatric scrotal Ultrasound, Acute scrotal pain

Krauss Jillian,  Cole Tiffany,  Wyers Mary

Final Pr. ID: Poster #: EDU-045

Torsion and volvulus can affect a variety of organ systems throughout the body, ranging from pathology involving the gastrointestinal tract to the reproductive organs and even the lymphatic system. Torsion and volvulus, regardless of the affected organ, often presents acutely, prompting pediatric patients to seek urgent clinical evaluation either through their pediatrician or the Emergency Department. Accurate and timely diagnosis of these conditions and prompt surgical intervention is critical for both preserving organ viability and preventing patient morbidity and mortality. In these patients, there is a high reliance on imaging for confirmation of the diagnosis.

The purpose of this educational exhibit will be to discuss commonly encountered types of torsion and volvulus in pediatric patients in the emergent setting, with a focus on the imaging features and important clinical and radiologic associations in these conditions. The exhibit will highlight pathologies including midgut volvulus, gastric volvulus, sigmoid volvulus, splenic torsion, testicular torsion, and ovarian torsion, among others, in a case-based format. It is important that the radiologist be able to quickly and reliably diagnosis these potentially life-threatening conditions, as well as recognize any other potential conditions the patient may be at risk for.

This educational exhibit is designed to improve reader comfort and awareness with respect to these various conditions. In addition to reviewing the traditional imaging approach in diagnosing these pathologies, the exhibit will also address some emerging methods in detection of volvulus and torsion, including ultrasound for diagnosis of malrotation with midgut volvulus and rapid MRI for the diagnosis of ovarian torsion. Read More

Authors:  Krauss Jillian , Cole Tiffany , Wyers Mary

Keywords:  Volvulus, Emergency/Acute, Ovarian Torsion

Guo Grace,  Marcelo Karina,  Clarion Michael,  Naun Christopher,  Rooks Veronica

Final Pr. ID: Poster #: CR-034

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe reaction to a drug that manifests with a wide variety of symptoms, typically several weeks after initial drug exposure. DRESS can involve multiple organ systems in addition to skin rash, eosinophilia, fever, renal, and liver abnormalities. Posterior reversible encephalopathy syndrome (PRES) is a cerebrovascular autoregulatory disorder hypothesized to occur from breakdown of the blood-brain barrier with multiple risk factors including hypertension as a common component. Neuroimaging findings of PRES in children have been noted to vary from those in adults. Children tend to have atypical findings of edema in regions such as the frontal, temporal, basal ganglia, brainstem, and cerebellum, in contrast to adults who usually present with parieto-occipital distribution. We present a unique case of DRESS and discuss imaging findings of atypical PRES in a child complicating treatment of an intracranial subdural empyema. A 5-year-old male patient underwent craniotomy and functional endoscopic sinus surgery for initial management of left pansinusitis complicated by a subdural empyema. The patient presented to the emergency room 3 weeks later with fever and a morbilliform rash and was diagnosed with DRESS, presumed secondary to a phenobarbital reaction. Initial imaging findings on abdominal ultrasound included hepatosplenomegaly, gallbladder wall thickening with cholelithiasis, pleural effusion, and findings consistent with bilateral nephritis. Subsequent imaging corroborated findings with increasing renal size and echogenicity commensurate with renal dysfunction in conjunction with steroid treatment for DRESS resulting in hypertensive crisis. Together with worsening encephalopathy, brain MRI confirmed presumed diagnosis of atypical PRES with diffusion negative increased cortical and subcortical white matter T2/FLAIR signal, indicating edema in an pattern involving watershed zones including bilateral posterior parietal, temporal, occipital lobes, left frontal lobe, and cerebellum. This report illustrates an interesting case of PRES as a complication of DRESS syndrome in a pediatric patient formerly treated with craniotomy for an intracranial subdural empyema. We highlight the importance of including PRES on the differential in a patient with severe hypertension. The radiologist should be familiar with the atypical PRES pattern which is more commonly seen in children compared to adults. Read More

Authors:  Guo Grace , Marcelo Karina , Clarion Michael , Naun Christopher , Rooks Veronica

Keywords:  Acute hypertensive encephalopathy, Cerebrovascular autoregulatory disorder