Bao Rina,  Grant Ellen,  Ou Yangming

Final Pr. ID: Poster #: SCI-030

Hypoxic Ischemic Encephalopathy (HIE) is a brain injury caused by a lack of blood and oxygen supply to the brain. HIE affects 4,000,000 term-born neonates per year worldwide, with an estimated 2 billion/year cost in the US, let alone family burdens. Therefore, reducing mortality and morbidity for HIE patients remains an important public health concern. Therapeutic hypothermia (TH) was established in 2005 as a standard therapy by cooling patients to 33-34°C in the first six postnatal hours for 72 hours. However, 35–50% of the patients still experience adverse outcomes, defined as death or cognitive Bayley Scales of Infant Development by age two years. Ongoing HIE-related trials worldwide are testing whether new therapies can supplement TH and further reduce adverse outcomes. However, therapeutic innovation is slow and inconclusive, for 1) before therapy, patients at high risk of developing adverse outcomes cannot be identified; 2) after therapy, outcomes cannot be measured until age two years. Besides, public MRI data exists for hundreds of patients with brain tumors, Alzheimer’s Disease, and other diseases, fueling AI’s success in MRI-based diagnosis and prognosis of brain tumor, Alzheimer’s Disease, and other disorders. In contrast, annotated MRIs with linked clinical and bio-marker data do not exist publicly for HIE. Our previous work has collected multi-site HIE MRI data. Therefore, to fill the gap in HIE diagnosis with MRI data, target high-risk patients, increase efficiency, evaluate therapeutic effects early, and expedite therapeutic innovations, in this work, we propose to predict 2-year neurocognitive outcomes in neonates using brain MRIs by deep learning methods. Read More

Authors:  Bao Rina , Grant Ellen , Ou Yangming

Keywords:  Brain MRIs, Brain injury, Hypoxic Ischemic Encephalopathy

Haddad Sophie,  Foran Ann,  Tierradentro-garcia Luis,  Ho Fung Victor M,  Hwang Misun

Final Pr. ID: Poster #: CR-025

Hypoxic ischemic encephalopathy (HIE) is a significant cause of severe long term neurological impairment and mortality in the newborn. It develops in two stages; the ischemic phase caused by hypoxia leading to cytotoxic edema, followed by the reperfusion phase with the release of reactive oxygen species leading to oxidative damage and vasogenic edema. Imaging plays a key role in diagnosis, management, and treatment of HIE. It also offers important prognostic information. MRI remains the preferred imaging modality.
Microvascular imaging (MVI) is a novel advanced Doppler ultrasound (US) technique that permits visualization of the microvasculature without the administration of contrast agents. It enhances the visualization of flow signal in the microvessels and helps reveal functional insights into the brain at high resolution.

A female newborn of 32 weeks of gestation was delivered by urgent C-section following absent fetal movements and suspected placental abruption. She was born to a mother with a reported exposure to cocaine with a last use the week prior to delivery. At birth, no pulse was detected, and CPR was initiated immediately. O2 saturation remained low during resuscitation despite intubation and a FiO2 of 100%. Return of spontaneous circulation was noted 50 minutes after birth. Following birth, the patient was diagnosed with severe HIE and had multiple seizures. Her physical exam revealed fixed and cloudy pupils with a diameter of 4 mm and no brainstem reflexes. At one day of life, a brain US was done and displayed diffusely increased echogenicity of the parenchyma and crowding of the cortical gyri concerning for cerebral edema. MVI revealed markedly increased microvascular perfusion in the basal ganglia, thalami, and periventricular region consistent with post-ischemic reperfusion in the setting of HIE. MRI showed diffusion restriction throughout the brain including the medial temporal lobes, hippocampi, thalami, basal ganglia, and frontoparietal cortex. Also noted was extensive hyperintense signal abnormality on T2-weighted sequences within both the gray and white matter with loss of the gray-white matter differentiation and moderate sulcal effacement. These findings confirmed the diagnosis of severe HIE.

In our case, MVI demonstrated marked hyperperfusion in the basal ganglia, thalami and periventricular region. Whether this MVI flow signature can prognosticate poor clinical outcomes, it warrants further investigation. Read More

Authors:  Haddad Sophie , Foran Ann , Tierradentro-garcia Luis , Ho Fung Victor M , Hwang Misun

Keywords:  Microvascular Imaging, Hypoxic ischemic encephalopathy

Oros Joseph,  Moredock Elisabeth,  Parish David,  Pfeifer Cory

Final Pr. ID: Poster #: EDU-053

The goals of this educational exhibit are to: 1. Explain the basis for the cause of diffusion restriction on brain MRI in children. 2. Discuss the broad differential diagnosis for diffusion restriction in pediatric emergency neuroradiology. 3. Emphasize causes of diffusion restriction unrelated to vascular occlusive disease in the brain. 4. Describe patterns of diffusion restriction commonly encountered in post-ictal states and posterior reversible encephalopathy syndrome. Read More

Authors:  Oros Joseph , Moredock Elisabeth , Parish David , Pfeifer Cory

Keywords:  Diffusion Restriction, Posterior Reversible Encephalopathy Syndrome, Seizure

Hill Ann,  Hirsig Leslie,  Yazdani Milad,  Collins Heather,  Jenkins Dorothea

Final Pr. ID: Poster #: SCI-015

MRS is the best prognostic indicator for hypoxic-ischemic encephalopathy (HIE) but is difficult to obtain early after injury. We investigated whether cerebral blood flow measures of resistive indices (RI) and time average maximum velocities (TAMx) shortly after birth would relate to later degree of neural injury by MRI in hypothermic HIE newborns. We predicted that abnormally high/low blood flow would be associated with poor outcomes. Read More

Authors:  Hill Ann , Hirsig Leslie , Yazdani Milad , Collins Heather , Jenkins Dorothea

Keywords:  Cerebral Blood Flow, Hypoxic Ischemic Encephalopathy (HIE), Magnetic Resonance Spectroscopy (MRS)

Bao Rina,  Grant Ellen,  Ou Yangming

Final Pr. ID: Poster #: SCI-027

Hypoxic ischemic encephalopathy (HIE) is a brain injury that occurs in 1 ∼ 5/1000 term-born neonates. HIE lesion detection is a crucial step in clinical care of HIE. It could lead to a more accurate estimation of prognosis, a better understanding of neurological symptoms, and a timely prediction of response to therapy in this population. In addition, the rise of Artificial Intelligence (AI) brings hope to objectively and accurately finding HIE lesions. With public MRI data for brain tumors, Alzheimer’s Disease, and other diseases, AI has achieved significant success in MRI-based diagnosis and prognosis of these diseases. To facilitate the early prognosis and diagnosis of HIE, in this work, we focus on HIE lesion detection with MRI data using deep learning methods. Read More

Authors:  Bao Rina , Grant Ellen , Ou Yangming

Keywords:  Brain MRIs, Brain injury, Hypoxic Ischemic Encephalopathy

Skelton Hales,  Hedlund Gary

Final Pr. ID: Poster #: CR-009

The purpose of this case report is to familiarize the radiologist with the MR imaging findings of fatal heat stroke.

Heat stroke is a severe illness characterized by a core temperature > 40 degrees Celsius, with clinical manifestations of delirium, seizures, and coma, resulting from environmental exposure or physical exertion. This report focuses upon environmental, or classical, fatal heat stroke in the case of a 4 year old male who was left alone for 30 minutes in a vehicle with ambient exterior temperatures of greater than 37.8 degrees Celsius.

As a form of hyperthermia, heat stroke ensues from thermoregulatory failure in addition to systemic inflammatory and coagulation phase responses, and conceivably, from modified manifestation of heat shock proteins. Infants and young children comprise a population specifically vulnerable to heat stroke due to their large surface area to volume ratio, underdeveloped thermoregulatory system with small blood volume relative to body size, and decreased sweat production.

The CNS is especially susceptible to hyperthermia as cerebral edema and cerebrovascular congestion may lead to increased intracranial pressure, and ischemia or hemorrhage. The cerebellum is the area most sensitive to heat injury, with known direct injury to Purkinje cells, and resultant cerebellar atrophy, often leading to neuronal dysfunction, including ataxia.

MR imaging findings in heat stroke are typically multifocal reflecting the complex interplay of direct thermal injury, hypoxic ischemic injury, endothelial damage, cytokine mediated inflammation and coagulopathy.

MRI in our case of fatal heat stroke demonstrates diffuse signal abnormality within the peripheral cerebellar hemispheres (eg. Purkinje cell regions). MRI recapitulates the known pathology of fatal heat stroke with injury to Purkinge cells and adjacent Bergmann glia. Other reported heat stroke related MRI findings include T2 prolongation and restricted diffusion involving the paramedian thalamic nuclei, dentate nuclei, basal ganglia, hippocampii, and cerebral cortex particularly the vascular watershed zones.

If the health history for heat stroke is uncertain, the imaging differential diagnosis includes other cerebellar syndromes including: toxic - metabolic (eg. opiate toxicity), infectious-autoimmune (eg. Varicellar zoster cerebellitis), histiocytic neoplastic-like (eg. histiocytoses) and neoplastic (eg. leptomeningeal PNET) should be considered in the imaging differential diagnosis. Read More

Authors:  Skelton Hales , Hedlund Gary

Keywords:  Hyperthermia, Encephalopathy, Fatal

Misiura Anne,  Urbine Jaqueline,  Mallon Mea,  Malik Archana,  Kazmi Faaiza,  Poletto Erica

Final Pr. ID: Poster #: EDU-082

Hypoxic-ischemic encephalopathy is a potentially devastating neurological diagnosis for which prompt recognition is crucial for patient management. The appearance of HIE on imaging depends on the duration and severity of the hypoperfusion injury, which can range from global to subtle. As such, the differential diagnosis is wide, including infectious, metabolic, and congenital dysmyelination causes. It is also critical for the pediatric radiologist to be aware of possible confounding cases when presented with imaging features seen in HIE which would significantly change management. Read More

Authors:  Misiura Anne , Urbine Jaqueline , Mallon Mea , Malik Archana , Kazmi Faaiza , Poletto Erica

Keywords:  Hypoxic, Infection, Encephalopathy

Hanquinet Sylviane,  Morice Claire,  Merlini Laura,  Cousin Vladimir,  Mclin Valérie,  Anooshiravani Mehrak

Final Pr. ID: Poster #: SCI-008

The diagnosis of hepatic encephalopathy is mainly detected by neuropsychological tests. These tests, however, do not always apply depending on the status of the child (age, social and cultural environment) and are therfore not reliable for subtle changes. We propose to detect minimal hepatic encephalopathy (minHE) in children with chronic liver disease and/or porto-systemic shunting, using MRI with Diffusion-weighted (ADC) and ¹H- spectroscopy in the globus pallidum. Read More

Authors:  Hanquinet Sylviane , Morice Claire , Merlini Laura , Cousin Vladimir , Mclin Valérie , Anooshiravani Mehrak

Keywords:  hepatic encephalopathy, 1H- spectroscopy, brain MRI, chronic liver disease, porto-systemic shunting

A Ebinesh,  Manchanda Alpana,  Dixit Rashmi,  Das Prince,  Kumar Ajay,  Krishna Ganesh

Final Pr. ID: Poster #: EDU-021

Insult to developing neonatal brain can significantly impair motor, cognitive, language and behavioral functions. MR imaging is an indispensable investigation for the evaluation of neonatal encephalopathy due to its high sensitivity, specificity and prognostic utility. MRI with its recent advancements can yield valuable information on morphology, neuronal connectivity, structural and functional architecture of gray and white matter. Read More

Authors:  A Ebinesh , Manchanda Alpana , Dixit Rashmi , Das Prince , Kumar Ajay , Krishna Ganesh

Keywords:  Neonatal encephalopathy, Neonatal brain, Hypoxic ischemic encephalopathy

Goncalves Fabricio,  Khrichenko Dmitry,  Zheng Qiang,  Hwang Misun

Final Pr. ID: Paper #: 161

Ultrasound (US) is a powerful imaging tool in the evaluation of neonates with suspected hypoxic-ischemic encephalopathy (HIE). US evaluation of the neonatal brain has been mainly performed qualitatively, comparing intracranial structures with different echotextures. Qualitative US analysis of the neonatal HIE brain may vary according to technical variations, the severity of the injury and the presence of coexistent complications. Quantitative analysis of the neonatal brain echotexture has been seldom attempted. Our aim was to compare the echotextures of specific brain regions between HIE patients and controls. Read More

Authors:  Goncalves Fabricio , Khrichenko Dmitry , Zheng Qiang , Hwang Misun

Keywords:  Ultrasound, Hypoxic-ischemic encephalopathy

Lakatos Andrea,  Kolossvary Marton,  Szabo Miklos,  Kiss Mate,  Gyebnar Gyula,  Bagyura Zsolt,  Kozak Lajos Rudolf

Final Pr. ID: Poster #: SCI-017

The radiology report is a tool to communicate information to the referring physician and record data for follow-up or research purposes. With structured reporting templates information becomes uniform, comprehensive and easily manageable. In collaboration with neonatologists and information technologists we developed a structured MRI reporting template for neonatal hypoxic-ischemic encephalopathy (HIE). Read More

Authors:  Lakatos Andrea , Kolossvary Marton , Szabo Miklos , Kiss Mate , Gyebnar Gyula , Bagyura Zsolt , Kozak Lajos Rudolf

Keywords:  Hypoxic-ischemic encephalopathy, Neonates, Magnetic resonance, Diffusion-weighted imaging, Structured reporting

Cielma Tara,  Bandarkar Anjum,  Demshur Lesley,  Bulas Dorothy

Final Pr. ID: Poster #: EDU-002 (T)

Background: Duplex sonography is a critical portion of intracranial hemodynamics evaluation. Serial Doppler examination allows real-time assessment of disease progression or improvement.

The goals of this exhibit are:
1. Describe the technical approach of performing neonatal/infant transcranial Doppler ultrasound.
2. Review tips, and up to date technology that assist in optimizing studies.
3. Discuss changes in flow patterns with various pathologies, providing examples of clinical indications.
4. Review future potential techniques and applications. Read More

Authors:  Cielma Tara , Bandarkar Anjum , Demshur Lesley , Bulas Dorothy

Keywords:  Neurosonography, Cerebral Doppler, Hypoxic Ischemic Encephalopathy

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

Beavers Angela,  Allbery Sandra

Final Pr. ID: Poster #: CR-041

Wernicke’s encephalopathy, traditionally a clinical diagnosis, may present a diagnostic conundrum, particularly those cases that do not present with the clinical triad of ataxia, ocular abnormalities, and mental status changes. MR imaging is often employed in the work-up of patients with altered mental status, and although the imaging findings of Wernicke’s encephalopathy are non-specific, suggestion of the diagnosis on imaging in conjunction with clinical findings can enable treatment of a potentially reversible encephalopathy, which may otherwise result in significant morbidity and mortality if the diagnosis is delayed or missed. A case is presented with MR images characteristic of Wernicke's encephalopathy, in which the patient had clinical resolution of her symptoms following thiamine administration. The patient in this case had short gut syndrome complicated by sepsis, which likely contributed to her thiamine deficiency. Given the underdiagnosis of Wernicke's encephalopathy in the pediatric population and the general safety of intravenous thiamine, being able to suggest the diagnosis based on MR imaging can potentially significantly influence patient outcomes. Read More

Authors:  Beavers Angela , Allbery Sandra

Keywords:  Wernicke's Encephalopathy