To evaluate patterns of advanced imaging utilization and associated costs over an 8-year period in one of the largest pediatric Accountable Care Organizations (ACO) in the US covering over 300,000 children. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Shah Summit, Krishnamurthy Ramkumar, Wang Ling, Krishnamurthy Rajesh

Keywords: Utilization, Cost, Radiation

This study compares the performance of a single free-breathing GRASP sequence to a full C-MRE protocol in pediatric small bowel CD. The high k-trans of affected bowel in CD may allow high spatiotemporal GRASP dynamic contrast-enhanced technique to provide comprehensive diagnostic value in CD, especially in patients with limited breath-hold capacity. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Rees Mitchell, Suman Garima, Krishnamurthy Ramkumar, Krishnamurthy Rajesh

Keywords: Crohn disease, enterography, GRASP

To analyze regional disparities in imaging utilization over an 8-year period in one of the largest pediatric Accountable Care Organizations (ACO) in the US covering over 300,000 children. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Krishnamurthy Ramkumar, Shah Summit, Wang Ling, Krishnamurthy Rajesh

Keywords: Disparities, Economics, Quality

Two major insurance companies have recently enacted policies requiring outpatient advanced imaging at free-standing imaging facilities for adults. Examining the potential clinical and economic implications of non-subspecialized interpretations in children is important. We evaluated the rate of major discrepancies and changes in management arising from second interpretations by a dedicated pediatric facility. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Shah Summit, Krishnamurthy Ramkumar, Kelleher Sean, Krishnamurthy Rajesh

Keywords: Healthcare Policy, Reimbursement, Quality Improvement

Duchenne muscular dystrophy (DMD) is a myopathy with a natural history of progressive cardiomyopathy and vasogenic edema, fatty infiltration, and myocardial fibrosis. We recently identified a group of patients with DMD who presented with acute onset of chest pain (ACP), troponin leak (TL), and new late gadolinium enhancement (LGE), similar in presentation to acute viral myocarditis (AM). It is unclear if these patients have suffered an episode of AM or if this is a different disease process. Given the presumed acute myocardial necrosis in both processes, we hypothesize that native T1 and T2 values would be elevated in AM and DMD patients with ACP compared to asymptomatic DMD patients. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Lee Simon, Krishnamurthy Rajesh, Krishnamurthy Ramkumar, Johnston Thomas, Hor Kan

Keywords: Parametric Mapping, Cardiomyopathy

There is limited understanding and utilization of dynamic contrast enhancement MRI of marrow, periosteum and cartilage for diagnosis of musculoskeletal (MSK) disease in children. This is partly due to limited availability of pediatric disease models of marrow inflammation, infection, infiltration, or involvement by tumor. Herein we explore signal intensity time curves of relevant MSK targets using a 3D Golden-angle RAdial Sparse Parallel (GRASP) MRI technique. GRASP is an accelerated, free-breathing dynamic acquisition that has been shown to reduce the need for sedation. We aim to establish a baseline for normal enhancement characteristics of marrow, cartilage, synovium and periosteum of the growing skeleton in a sheep model as a precursor to translation to children. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Rees Mitch, Milks Kathryn, Krishnamurthy Ramkumar, Krishnamurthy Rajesh, Hu Houchun

Keywords: radial MRI, dynamic contrast enhancement, musculoskeletal

MRI scans are long, and scan durations are unpredictable. Combined with challenges of inter-departmental coordination, this leads to poorer operational efficiency, increased need for sedation (especially in a pediatric population), increased wait time, and overall poorer patient care. There is a need for active, automatic tracking of scan log in a MRI machine to 1) determine operational efficiency, 2)disease specific scan information, 3) identifying patient specific scan metrics. Currently, there exist no customizable open-source solution that can automatically obtain information from MRI scanners. The purpose of this study is to demonstrate implementation of a novel, customizable QI tool that can automatically extract scan log data from a MRI scanner in a pediatric setting. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Krishnamurthy Ramkumar, Wiggins Roy, Hu Houchun, Krishnamurthy Rajesh, Block Tobias

Keywords: MRI scan, MRI log, MRI analytics

DMD is X-linked cardiac and skeletal myopathy caused by dystrophin protein deficiency with early death by cardiomyopathy. Cardiac magnetic resonance imaging (CMR) with myocardial fibrosis by late gadolinium enhancement (LGE) precedes decline in ejection fraction (LVEF) and may alter management in DMD. Muscle weakness limits ability to perform consistent breath-hold (BH) in traditional LGE sequences. Free-breathing (FB) LGE with motion correction (MOCO) allows improved visualization. We hypothesize that FB LGE with MOCO provides equivalent diagnostic quality with similar scan time to traditional LGE sequence. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Diaz Eric, Hor Kan, Krishnamurthy Ramkumar, Lee Simon, Krishnamurthy Rajesh

Keywords: LGE, MOCO, CMR

To determine if a 3-minute Golden-angle RAdial Sparse Parallel (GRASP) dynamic contrast enhanced (DCE) MRI sequence with 8-10 second temporal resolution is equivalent in diagnostic performance to a conventional MR sequences (CS) in the assessment of osteomyelitis (OM) in children. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Milks Kathryn, Rees Mitchell, Krishnamurthy Ramkumar, Hu Houchun, Krishnamurthy Rajesh

Keywords: osteomyelitis, GRASP, MRI

Cardiomyopathy is the leading cause of mortality for Becker Muscular Dystrophy (BMD).Risk stratification is challenging due to the wide variation of cardiomyopathy onset, progression, and severity; with cardiomyopathy developing independent of skeletal myopathy progression. Current guidelines recommend “complete cardiac evaluation” at ten years of age, but do not specify the type of imaging modality. We have been performing cardiac magnetic resonance imaging (CMR) routinely by 10 years of age. We sought to determine the progression of BMD cardiomyopathy during the adolescent years among patients who have evidence of fibrosis by late gadolinium enhancement(LGE). Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Johnston Thomas, Lee Simon, Krishnamurthy Ramkumar, Krishnamurthy Rajesh, Hor Kan

Keywords: Cardiomyopathy, LGE

Children with Duchene muscular dystrophy (DMD) have increased risk for osteoporosis and fragility fractures due to progressive muscle weakness with eventual loss of ambulation and chronic corticosteroid therapy. Their fracture prevalence is 40-60%, and increases with age. Bone Mineral Density (BMD) is not reflective of fracture risk. Recent studies showed that cortical thickness and area were associated with increased facture risk. Digital X-ray measurement of the cortical thickness of the metacarpal bones can be used as a marker for metacarpal cortical health. To our knowledge, this marker of bone health has not been evaluated in DMD patients. The purpose of this study was to assess bone age (BA), cortical thickness and area of metacarpal bones in relation to age in children with DMD. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Bowden Jonathan, Bowden Sasigarn, Adler Brent, Hu Houchun, Krishnamurthy Rajesh, Krishnamurthy Ramkumar

Keywords: Bone health, DMD, Duchenne

The likelihood of sedation for an MRI exam in a patient under 8 years is high. Disadvantages of sedation usage include direct complications, suspected long-term effects, and higher costs. Sedation reduction techniques include the use of an MRI simulator, accelerated MRI scans, abbreviated protocols, and swaddle and sleep techniques. We evaluated the clinical image quality and cost effectiveness associated with an MRI simulator training program. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Shah Summit, Mcgonagill Phillip, Hu Houchon, Sankaran Akila, Krishnamurthy Rajesh, Krishnamurthy Ramkumar

Keywords: MRI Sedation, Quality Improvement, Cost

Dynamic Contrast Enhanced MR Lymphangiography (DCMRL) allows evaluation of the central conducting lymphatics in patients with central lymphatic flow dysfunction. Direct injection of gadolinium contrast into inguinal lymph nodes followed by serial imaging allows visualization of lymphatic channels and lymphodynamics. This study reviews the DCMRLs performed at our institution over a 2 year period including indications, findings and impact on clinical management. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Lillis Anna, Krishnamurthy Ramkumar, Boe Brian, Setty Bhuvana, Sena Laureen, Krishnamurthy Rajesh

Keywords: MR Lymphangiography, Thoracic Duct, Lymphatic

Conventional cardiac MRI (CMR) acquisitions in children are limited by long acquisition time, need for sedation, and an inefficient workflow. A conventional cine SSFP short-axis stack typically takes 5-7 minutes to complete and is ineffective for subjects with arrhythmias. Available alternatives like free-breathing, real-time cine (RT-cine) SSFP have suboptimal temporal and spatial resolution. Recent advances in compressed sensing (CS) MRI techniques may overcome this limitation. We hypothesize that a CS-based approach will allow the scan time for a short axis RT-cine stack to be shortened to less than a minute without compromising spatial or temporal resolution. Read More

Meeting name: SPR 2018 Annual Meeting & Postgraduate Course , 2018

Authors: Krishnamurthy Ramkumar, Liu Yingmin, Hu Houchun, Krishnamurthy Rajesh, Hor Kan, Ahmad Rizwan

Keywords: COmpressed Sensing, Cine, MRI

Functional MRI (fMRI) for preoperative language mapping of Wernicke’s and Broca’s areas in clinical pediatric epilepsy presents various challenges resulting in poor patient compliance. We hypothesized that higher fMRI success rates can be achieved using intensive patient preparation in a fMRI practice session using a mock MRI scanner. Read More

Meeting name: SPR 2018 Annual Meeting & Postgraduate Course , 2018

Authors: Long Alexander, Buskirk Tricia, Smith Mark, Krishnamurthy Ramkumar, Hu Houchun, Halverson Mark

Keywords: Epilepsy, fMRI, Mock Scanner

Free-breathing MRI scans are attractive in pediatric imaging as they reduce the need for sedation and breath-holds. In this work, we evaluate a 3D T1w radial "stack of stars" gradient echo (GRE) acquisition (RAVE-RAdial Volumetric Encoding) in post-contrast abdomen and spine protocols and compare results with conventional Cartesian MRI of similar spatial resolution and volume coverage. Read More

Meeting name: SPR 2018 Annual Meeting & Postgraduate Course , 2018

Authors: Hu Houchun, Block Kai Tobias, Benkert Thomas, Krishnamurthy Ramkumar, Smith Mark, Rusin Jerome, Young Cody, Adler Brent H., Milks Kathryn, Krishnamurthy Rajesh

Keywords: Motion Insensitive, Accelerated MRI, Free-Breathing MRI

<b>Background: </b>Image quality in MRI is often degraded by patient motion. To reduce the need for repeat exams, sedation or general anesthesia is used in pediatric patients. This requires additional clinical staff, and leads to increased scheduling wait times and overall procedure times that impact workflow. Many institutions prepare children for MRI using mock-up replicas. While effective in acclimating patients to the MRI environment, the availability of mock-up practices are often limited. Mock-ups also require physical space and do not simulate the full MRI environment and exam experience. <b>Purpose:</b> We build an affordable, scalable, and portable immersive virtual reality (IVR) platform for simulating MRI exams. Specifically, we designed an IVR environment that accurately mimics a Siemens 3 Tesla suite within our Radiology practice, including intricate details such as room size, color, lighting, ancillary equipment, pulse sequence audio, and background noise. The IVR platform also attempts to simulate the complete sequence of events and environments a child will experience during an exam, including the check-in process, interactions with staff (e.g., nurses, technologists), the waiting area and changing rooms, the positioning and motion of the MRI table, placement of coils, and within-exam instructions, such as breath-holds. Our platform also allows the patient to move around in the VR space and interact with the environment. Additionally, the platform can be easily converted to mimic any other MR suite. We hypothesize that our platform can be easily adopted by Child Life and hospital staff to quickly acclimate a patient and assess whether he/she can suitably undergo an MRI exam without sedation or general anesthesia. We believe the IVR platform can overcome the limitations of mock-up replicas. First, IVR has a smaller footprint and is scalable and portable across the hospital. This allows multiple IVR sessions to be held in parallel. Second, IVR can give the patient a hospital-specific and scan-specific first-person experience. The patient can interact with realistic 3D representations of the MRI environment and processes. Our current implementation of IVR was developed using HTC VIVE headsets with a dedicated laptop for control. To further improve portability, the IVR setup can be adopted using simple goggles and handheld devices. This will enable future IVR sessions to be conducted at the bedside, in patient’s homes, and in referring physician offices. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Huang Yungui, Krishnamurthy Rajesh, Hu Houchun, Luna John, Krishnamurthy Ramkumar, Lubeley Lacey, Buskirk Tricia, Karczewski Arleen, Garrett Whitney, Lin Simon, Mcallister Aaron

Keywords: magnetic resonance imaging, virtual reality, simulation