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Pediatr Radiol (2012) 42 (Suppl 3):S403–S578 DOI 10.1007/s00247-012-2383-5

Founded in 1963 The European Society of Paediatric Radiology 49th Annual Meeting and 35th Postgraduate Course

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May 28 –June 1 2012 The Hilton Hotel Athens, Greece

Table of contents Programme at a glance ESPR General information Officers of the Board Honorary members Gold Medallists Jacques Lefebvre awards Poster awards Young Researcher awards President’s awards Past Presidents and meeting sites Future ESPR meetings European Courses of Paediatric Radiology (ECPR) European Courses of Paediatric Neuroradiology (ECPNR) ESPR 2012 Gold Medallist ESPR 2012 Honorary Members 2012 Jacques Lefebvre lecture Congress Organisation Welcome address Programme Task Forces pages Abstracts of oral presentations Abstracts of poster presentations Author index for abstracts Continuing Medical Education In memory of Clément Fauré

This supplement was not sponsored by outside commercial interests; it was funded entirely by the publisher.

Programme at a Glance

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General Information—European Society of Paediatric Radiology

Officers 2011–2012 President Past President 1st Vice President 2nd Vice President 3rd Vice President General Secretary Treasurer Counsellor for Northern Europe Counsellor for Southern Europe Pediatric Radiology Managing Editor JESPeR delegate Webmaster Head of Education Committee Secretariat

ESPR Executive Assistant

Maria I. Argyropoulou (Ioannina, Greece) Catherine M. Owens (London, United Kingdom) Eva Kis (Budapest, Hungary) Rutger J. Nievelstein (Utrecht, Netherlands) Michael Riccabona (Graz, Austria) Catherine M. Owens (London, United Kingdom) Catherine Adamsbaum (Paris, France) Karen Rosendahl (Bergen, Norway) Paolo Tomà (Roma, Italy) Guy Sebag (Paris, France) Samuel Stafrace (Aberdeen, UK) Rick Van Rijn (Amsterdam, Netherlands) Jean-François Chateil (Bordeaux, France) Catherine M. Owens Department of Radiology Great Ormond Street Hospital for Sick Children Great Ormond Street, London, WC1N 3JH, UK Amanda Dehaye (Pau, France) ESPR-office@espr-org

Honorary members of the Society

1964 John Caffey (USA)

1987 D.C. Harwood-Nash (USA)

1964 Lutz Schall (Germany)

1987 Hooshang Taybi (USA)

1965 Sven R. Kjelberg (Sweden)

1988 Herbert Kaufmann (Germany)

1965 Edward B. D. Neuhauser (USA)

1989 Bryan Cremin (South Africa)

1966 Jacques Lefebre (France)

1989 Klaus D. Ebel (Germany)

1973 Hardy M. Geffert (Hungary)

1989 Helmut Fendel (Germany)

1973 Ksawery Rowinsky (Poland)

1989 Elizabeth Sweet (Scotland)

1974 Frederic Silverman (USA)

1990 Donald Kirks (USA)

1975 Ulf G. Rudhe (Sweden)

1991 Alan Chrispin (England)

1979 John Kirkpatrick (USA)

1991 Edmund Franken (USA)

1979 Arnold Lassrich (Germany)

1991 Daniel Nussle (Switzerland)

1979 Jacques Sauvegrain (France)

1991 Beverly Wood (USA)

1982 Clement Fauré (France)

1992 Walter Berdon (USA)

1982 Andes Giedion (Switzerland)

1993 Javier Lucaya (Spain)

1983 Eberhard Willich (Germany)

1993 Wilhelm Holthusen (Germany)

1984 Roy Astley (England)

1994 Noemie Perlmutter (Belgium)

1987 Jean Bennet (France)

1994 Hans Ringertz (Sweden)

1987 Ole Eklof (Sweden)

1994 Donald Shaw (England)

1987 Charles A. Gooding (USA)

1996 Robert Lebowitz (USA)

1987 John Holt (USA)

1996 Bela Lombay (Hungary)

1987 Andrew Poznanski (USA)

1997 Yan Briand (France)

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1997 Philip Small (England)

2007 Gabriel Benz-Bohm (Germany)

1997 N. Thorne Griscom (USA)

2007 Pedro Daltro (Brazil)

1998 Alan Daneman (Canada)

2007 Richard Fotter (Austria)

1998 Gabriel Kalifa (France)

2008 Jose Fonseca-Santos (Portugal)

1999 Michael Grunebaum (Israel)

2008 Ingmar Gassner (Austria)

2000 Paul Thomas (Ireland)

2008 Tom Slovis (USA)

2000 Noel Blake (Ireland)

2008 Rita Teele (New Zealand)

2000 Peter Kramer (Netherlands)

2009 Reinhart Schumacher (Germany)

2000 Gunnar Stake (Norway)

2009 Nicholas Gourtsoyiannis (Greece)

2001 Janet Strife (USA)

2009 Ines Boechat (USA)

2001 Robert Brasch (USA)

2009 Steve Chapman (United Kingdom)

2001 Max Hassan (France)

2009 Jochen Troeger (Germany)

2001 Yacob Bar-Ziv (Israel)

2010 Ernst Richter (Germany)

2002 Sven Laurin (Sweden)

2010 Veronica Donoghue (Ireland)

2003 Aldo Pelizza (Italy)

2010 Freddy Avni (Belgium)

2003 Giampiero Beluffi (Italy)

2010 François Diard (France)

2003 Helen Carty (England)

2010 Paola Toma (Italy)

2003 Bruce Parker (USA)

2011 Rose de Bruyn (United Kingdom)

2004 Christine Hall (England)

2011 Goya Enriquez (Spain)

2004 Andrzej Marcinski (Poland)

2011 Cristian Garcia (Chile)

2005 Ulrich Willi (Switerland)

2011 Paul Kleinman (USA)

2005 Jean-Philippe Montagne (France)

2011 George Tayor (USA)

2005 Giuseppe Farielo (Italy) 2006 Francis Brunelle (France)

Gold Medallists

2006 Laurent Garel (Canada)

2007 Javier Lucaya

2006 Morteza Meradji (Netherlands)

2008 Gabriel Kalifa

2006 Alan E. Oestreich (USA)

2010 Ulrich Willi

2007 Marianne Spehl (Belgium)

2011 Richard Fotter

Jacques Lefebvre Awards 1977

Ringertz H. (Sweden)

The width of cranial sutures in neonates: an objective method of assessment

1978

Garel L. (France)

Xanthogranulomatous pyelonephritis in children: 19 cases

1979

Brauner M. (France)

Metrizamide myelography in infants with brain injury to the brachial plexus

1980

Spehl-Robberech M. (Belgium)

Ultrasonic study of the pancreas in cystic fibrosis

1981

Garel L. (France)

The renal sinus: an important anatomical landmark in children

1982

Couture A. (France)

Ultrasonographic exploration of cerebral malformations

1983

Brunelle F. (France)

Percutaneous cholecystography in children

1984

Veyrac C. (France)

Ultrasound of normal and pathologic choroid plexus

1985

Avni F. (Belgium)

Ultrasonic demonstration of abnormal and atypical gallbladder content in newborns

1986

Pariente D. (France)

Biliary tract involvement in children with Langerhans cell Histiocytosis

1987

Sellier N. (France)

Focal cortical dysplasia: a rare cause of epilepsy

1988

Deeg K. H. (Germany)

Pulsed Doppler sonographic measurement of normal values for the flow velocities in cerebral arteries of healthy infants

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1989

Winkler P. (Germany)

Major pitfalls in the Doppler examination of cerebral vascular system

1990

Garel C. (France)

Laryngeal ultrasonographic study in infants and children. Pathological findings

1991

Pracros J. P. (France)

Systemic study of superior mesenteric vessels in abdominal ultrasound

1992

Hollman A. (UK)

Colour Doppler imaging of the acute paediatric scrotum

1993

Chami M. (France)

Ultrasound contribution in the analysis of the newborn infant normal foot and club foot: preliminary study

1994

Adamsbaum C. (France)

Vermian agenesis without posterior fossa cyst

1995

Sebag G. (France)

Magnetic resonance angiography of paediatric renal transplants with quantification of allograft blood flow

1996

Rohrschneider W. (Germany)

US, CT and MR imaging. Characteristics in nephroblastomatosis: evaluation of 23 Patients

1997

Hertz-Pannier L. (France)

Non-invasive preoperative motor mapping in children with brain functional MRI

1998

Nicaise N. (Belgium)

Dynamic Gd-DTPA-enhanced T1W turbo field echo imaging: Interest in paediatric renal evaluation

1999

Rypens F. (Belgium)

Fetal lung volume estimation by MRI: normal values and potential use

2000

Ziereisen F. (Belgium)

Doppler assessment of pulsatility index (PI) of the uterine artery in girls around puberty

2001

Lidegran M.K (Sweden)

MRI and echocardiography in assessment of ventricular function in atrially corrected transposition of the great arteries

2002

Cassart M. (Belgium)

The assessment of fetal uronephropathies by MR imaging

2003

Boddaert N. (France)

18F-Fluoro-L-Dopa PET scan of focal forms of hyerinsulinism of infancy

2004

Jourdan C. (Germany)

US evaluation of intima-media thickness (IMT) and elastic properties distensibility, stiffness and incremental modulus of elasticity of the common carotid artery as a marker of early vascular damage in children with chronic renal failure and reference values

2005

Kellenberger C.J. (Switzerland)

Cardiovascular MRI for investigating Newborns and Infants with Congenital Heart Disease

2006

Phalla O. (France)

Detection of coronary complications after arterial switch operation for transposition of the great arteries: first experience with 65-slice CT in children

2007

Sporcq C. (Belgium)

Reappraisal of the sonographic characteristics of the fetal and newborn kidney: introducing the cortico-medullary ratio

2008

Damasio M. B. (Italy)

Which is the best imaging modality to capture bone erosions in juvenile idiopathic arthritis?

2009

McDonald K. (UK)

DWI to assess chemotherapy response in solid tumors

2010

Ording-Müller L.S. (Norway)

Development of the wrist. Normal standards based on MRI for 6–15 year old

2011

Duran C. (Spain)

Voiding urosonography: normal and abnormal appearance of the urethra

Poster Awards 1994

Gomes H. (France)

Neonatal hip sonography from anatomy to sonography

1995

Schmit P. (France)

Imaging of cystic mesenchymal hamartomas of the liver. Review of 13 patients

1997

Schmit P. (France)

Congenital hepatic vascular malformations in children

1998

Brisse H. (France)

In utero MRI. Normal gyral development of the human brain

2000

Valle M. (Italy)

High-frequency ultrasound detection of the brachial plexus in newborns and infants

2001

Rohrschneider W. K (Germany)

Static dynamic MR-urography—simultaneous morphological and functional evaluation of the urinary tract

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2002

Owens C.M (UK)

The utility of MRI in the assessment of symptomatic adenoidal hypertrophy and rhinosinusitis in children. pre and post medical therapy

2003

Schumacher R. (Germany)

Sonographical anatomy of the anal sphincter complex (ASC) and levator ani muscle in neonates and infants

2004

Mentzel H.-J. (Germany)

Comparison of whole body STIR MRI and 99mTc-methylene diphosphonate scintigraphy in the examination of children with suspected multifocal bone lesions

2005

Enriquez G (Spain)

Prenatal assessment of lung hypoplasia in congenital diaphragmatic hernia: correlation between volumetric MRI and biometric ultrasound measurements

2006

de Maupeou F. (France)

Whole body imaging in malignant bone tumours in children: preliminary results

2007

Punwani S. (UK)

Effects of reducing radiation dose on lung nodule detection

2008

Chateil J.-F. (France)

Imaging of acquired spinal cord lesions and spinal canal pathology in children

2009

Barez MG. (Spain)

Spectrum of imaging findings in the brachial apparatus anomalies

2010

Brun M. (France)

Diffusion tension imaging in attention deficit disorders in children treated for posterior fossa tumours: preliminary results

2011

Fonda C. (Italy)

3T arterial spin labelling (ASL) in pediatric patients

Young Researcher Awards 2003

Brun M. (France)

Phonological Decoding in Dyslexic Children: Activation Pattern of FMRI

2004

Barnacle A.B (UK)

Image-guided percutaneous biopsy of soft tissue masses in children

2005

Raissiki M. (Greece)

Eye-lens Bismuth Shielding in Pediatric Head CT Examinations

2006

Sorge I. (Germany)

Reduction of radiotherapy in children with early stages of Hodgkin’s lymphoma, influenced by a new imaging and FDG-PET based strategy

2007

Alison M. (France)

In vivo targeting of macrophagic activity with MRI contrast agent (USPIO) in an experimental model of neonatal brain lesions

2008

Herrmann J (Germany)

Capsular arterial collateralisation after paediatric liver transplantation

2010

Arthurs O. (UK)

MR Voiding cystourethrography for vesico-ureteric reflux in unsedated infants

2011

Gupta N (UK)

Predictors of vesicoureteric reflux in infants with UTI using NICE criteria

President’s Awards 2004

Kilian A.K. (Germany)

Prenatal magnetic resonance (MR) lung volumetry of congenital diaphragmatic hernia (CDH): comparison with the clinical outcome and the necessity of extracorporeal membrane oxygenation (ECMO)

2005

Larke A. (Ireland)

MRI findings as an indication of underlying genetic lesions in congenital malformations of the brain

2007

Duran C. (Spain)

Voiding cystosonography for the study of the urethra

2008

Calder A. (UK)

Computed tomography compared with ultrasound and chest radiography in children with pleural empyema

2009

Senocak E. (Turkey)

MRI and DWI findings in children with hemophagocytic lymphohistiocytosis: tendency for symmetricity

2010

Franchi-Abella S. (France)

Congenital portosystemic shunt: complications and outcome after closure: about 19 pediatric cases

2011

Punwani S. (UK)

MRI vs. PET/CT for detection of focal splenic lesions in paediatric and adolescent lymphoma at initial staging

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Past Presidents and Meeting Sites 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Jacques Lefebvre, Paris, France Ulf Rudhe, Stockholm. Sweden John Sutcliffe, London, England Herbert Kaufmann, Basel, Switzerland Arnold Lassrich, Hamburg, Germany Ksawery Rowinsky, Warsaw, Poland Guido Lannacone, Rome, Italy Gregers Rhomsen, Copenhagen, Denmark Jacques Sauvegrain, Paris, France Roy Astley, Birmingham, UK Per-Erik Heikel, Helsinki, Finland Klaus Knapp, Madrid, Spain Ole Eklof, Stockholm, Sweden Andreas Geidion, Lucerne, Switzerland Noemi Perlemutter-Cremer, Brussels, Belgium Klaus Dieter Ebel, Koln, Germany The Dutch Group of Paediatric Radiologists, The Hague, Netherlands Gunnar Stake, Oslo, Norway Antonin Rubin, Prague, Czechoslovakia Clement Fauré, Paris, France Gianfranco Vichi, Florence, Italy Elizabeth Sweet, Glasgow, Scotland Javier Lucaya, Barcelona, Spain Denis Lallemand (ESPR) and Derek Harwood-Nash (SPR), Toronto, Canada Daniel Nussle, Montreux, Switzerland Noel Blake, Dublin, Ireland Hlemut Fendel, Munich, Germany Hans Ringertz (ESPR) and Donald Kirks (SPR), Stockholm, Sweden Bela Lombay, Budapest, Hungary Donald Shaw, London, UK Fred Avni, Brussels, Belgium Peter Kramer, Utrecht, Netherlands Paul Thomas (ESPR) and Kenneth Fellows (SPR), Boston, USA Ulrich Willi, Lugano, Switzerland Basilos Theodoropoulos, Rhodes, Greece Jacob Bar-Ziv and Gabriel Kalifa, Jerusalem, Israel Jose Fonseca Santos, Lisbon, Portugal Francis Brunelle (ESPR) and Janet Strife (SPR), Paris, France Tore Nordhus, Bergen, Norway Paolo Tomà, Genoa, Italy Jochen Troeger, Heidelberg, Germany

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2005 2006 2007 2008 2009 2010 2011

Veronica Donoghue, Dublin, Ireland Richard Fotter (ESPR) and George Taylor (SPR), Montreal, Canada Goya Enriquez, Barcelona, Spain Stephen Chapman, Edinburgh, UK Mithat Haliloglu, Istanbul, Turkey Jean-François Chateil, Bordeaux, France Catherine M. Owens (ESPR) and Dorothy Bulas (SPR), London, United Kingdom

Future ESPR Meetings 2013

Budapest, Hungary, June 3–7

Future SPR Meetings 2013

San Antonio, Texas, May 14–18

2014

Washington, DC, May 13–17

2015

Seattle, Washington, April 27–May 1

European Courses of Paediatric Radiology (ECPR) 1992

F. Brunelle, Biarritz, France

1993

P. Tomà, Genoa, Italy

1994

G. Enriquez, Barcelona, Spain

1995

C. Raybaud, Marseille, France

1996

G. Benz-Bohm, Koln, Germany

1997

H. Carty, Liverpool, UK

1998

C. Adamsbaun, G. Sebag, Montpellier, France

1999

P. Tortori-Donati, Genoa, Italy

2000

R. Fotter, Graz, Austria

2001

S. Laurin, Lund, Sweden

2002

B. Lombay, Budapest, Hungary

2003

E. Martin-Fiori, T Huisman, Zurich, Switzerland

2004

T. Berrocal, Madrid, Spain

2005

M. Spehl, C. Christophe, Brussels, Belgium

2006

J.-N. Dacher, Rouen, France

2007

R. Schumacher, Mainz, Germany

2008

K. Chong, London, UK

2009

R. R. van Rijn, A. Smets & E. Deurloo, Netherlands

2010

C. Fonda, Firenze, Italy

2011

I. Barber, Spain

2012

H-J Mentzel, Germany

European Courses of Paediatric Neuroradiology (ECPNR) Course run jointly by the ESPR, the ESNR and the ESMNR 2011

M. Argyropolou (ESPR), Andréa Rossi (ESNR), Nadine Girard (ESMRN)

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Curricula vitae of Gold Medal award recipient, Honorary Member and Jacques Lefevbre lecturer ESPR 2012 Gold Medal Award The ESPR gold medal is an exceptional award recently instituted to recognise a lifetime’s work and outstanding achievements in Paediatric Radiology within Europe. Four recipients have received it thus far: Professor Javier Lucaya (Spain), Professor Gabriel Kalifa (France), Professor Ulrich Willi (Switzerland) and Professor Richard Fotter (Austria). This year’s award will be presented to Professor Francis Brunelle (France). Professor Francis Brunelle, M.D., France

Professor Francis Brunelle was born on May 29th, 1949. His parents were professors of philosophy, and of Greek, Latin, and French. He graduated from Cochin Medical School in Paris in 1972, and served as a volunteer military surgeon in Togo (Africa), establishing the first nursing school in Togo during his stay. He trained as a paediatrician, neonatologist, and then branched into diagnostic radiology during his residency, whilst acquiring a master’s degree in biochemistry. He went on to spend a year as a visiting fellow in Alex Margulis’ department, University of California, San Francisco, where he trained with Harry Genant, Roy Filly, Hans Newton and David Norman in neuroradiology. On his return to France, he became an Associate Professor of radiology in Dr. Chaumont’s department, Bicetre Hospital, Paris. Professor Daniel Alagille, a world specialist in paediatric liver, inspired him to develop diagnostic and interventional radiology in this domain. Most of today’s abdominal interventional techniques were developed during this period.

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In 1981, he spent 4 months in Derek Harwood-Nash’s department, HSC Toronto, where he trained in paediatric neuroradiology, writing a seminal paper entitled, “Brain vascular malformations in children.” In 1985, Prof Brunelle became a Professor of Radiology at Necker Enfants-Malades Hospital, which proved to be the turning point of his career. Professor Hirsch, a pioneer of paediatric neurosurgery, and Doctor Jean Aicardi, one of the leading figures in paediatric neurology, inspired him to develop diagnostic and interventional neuroradiology techniques in children. He established the first paediatric neuroradiology course in France, which rapidly became the European Course of Paediatric Neuroradiology, now held in conjunction with the European Society of Paediatric Radiology and the European Society of Neuroradiology. In addition, he developed the syllabus for and organised the first European Course of Paediatric Radiology in 1992. His research interests developed within the field of neurogenetic diseases in children and autism. Later, he was (as always) at the forefront of research involving new techniques the department was a pioneer in MRI foetal imaging, the first foetal MRI was performed in 1987. Prof. Brunelle’s brilliance and pioneering spirit has enabled an extra ordinary academic career. He has written 322 peer-reviewed papers and 3 books, amongst them Imaging Children (with Carty, Stringer and Kao). He is a former President of the Medical Board in Necker; Editor of Paediatric Radiology; Secretary of the French College of Radiologists (CERF); and Counsellor of the Minister of Health (2004–2007). He served as President (co-president Janet Strife) of the International Paediatric Radiology (IPR) meeting in Paris in 2001, and Director and Chairman of the Imaging Department at Necker. He continues his inspirational career as one of the founders of a renovation plan for Necker Hospital, due for official opening in July 2012. Prof. Brunelle is one of the three authors behind the drafting of Necker Hospital’s medical strategy. He is also one of the two founders of a university diploma, “Management for Doctors” and a coach in “Management of Change”. Amongst his many civic and medical honours, Prof Brunelle has been made a Knight of the Legion of Honour, and a City counsellor of Sceaux. Prof. Brunelle has 6 children and is much beloved by them and his wife Anne, an architect. MA, CMO

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ESPR 2012 Honorary Member Corinne Veyrac, M.D., (France)

Doctor Corinne Veyrac was born in Rouen, France, on 31st December 1951. She pursued her medical studies in Rouen University from 1968 to 1975, and moved to the University Hospital of Montpellier for her residency (1975 to 1981). She originally trained in Clinical Paediatrics (1975 until 1981), then in Paediatric Radiology (1981 to 1983). Dr Veyrac joined the pediatric radiologists (JL Ferran and A Couture) in the University Hospital of Montpellier in 1983, where she commenced her career as an inspirational teacher, mentor and patient advocate within Paediatric Radiology, and contributed to the creation of the Department of Pediatric Radiology, led by Alain Couture. Doctor Veyrac is a pioneer and world leader in paediatric ultrasonography, her main areas of interest include neonatal brain sonography, urogenital and abdominal sonography. Doctor Veyrac joined the European Society of Pediatric Radiology (ESPR) in 1982, and the French Society of Pediatric and Perinatal Imaging (SFIPP) in the same year. Her participation in external teaching includes courses organized by the MASU (Rabat, Nairobi and Damas), the ESR (through the ESOR Galen Foundation: Athens, Warsaw and Sofia) and the SPR (Orlando and Sao Paulo). Dr Veyrac has delivered approximately 140 lectures in national and international congresses.

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She has published 50 peer-reviewed publications, and 32 book chapters in 18 different textbooks; including her major publications in: Echographie cérébrale du foetus au nouveau-né. Imagerie et hémodynamique (with A. Couture and C. Baud), Transfontanellar Doppler Imaging in Neonates (with A. Couture) and Gastrointestinal Tract Sonography in Fetuses and Children (with A. Couture, C. Baud, JL. Ferran and M. Saguintaah). Dr Veyrac is a leader in clinical excellence, with a steely determination to deliver the best quality of care to children within her sub-speciality. She has devoted herself tirelessly, unselfishly and with passion to her work, and in doing so she is a woman who has captured the hearts and minds of paediatric radiologists worldwide. Her modesty and selflessness have inspired her many pupils; as a dedicated and gifted teacher, and a mentor to several generations of students. Thus her efforts to further the sub-speciality will endure, carried forward by brilliant young paediatric radiologists compelled to follow her example. Any biography would be incomplete without a personal anecdote to describe her spirit of adventure, as beneath her modest exterior she is a legendary adventurer. During a working trip to Syria, whilst on a narrow mountain road, her car ran headlong into a truck. Her crazy driver, perhaps recognizing the amazing determination and strength of character of his passenger, somehow kept the vehicle on the road. Although she turned from pink to green, and her life flashed before her eyes, Dr Veyrac thankfully survived unhurt..... To her profound distress, two subsequent French radiologists, taking the same route 2 years later, did not. Her commitment, and her compassion, has been uplifting to all who have had the pleasure to know her. Outside her working circles, Corinne Veyrac is a devoted and loving mother to her children Nathalie and Nicolas, and a wonderful wife to her husband, Michel, who shares her passion for gastroenterology. We all wish Dr Corinne Veyrac a blissful retirement, amongst the flowers she tends and loves, Her boundless energy will now be spent on her favourite passions—cooking, baking, and…. football (another focus of her brilliant expertise!) MA/CMO/CA/JFC/PP

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2012 Jacques Lefebvre Lecturer

Prof. Nicholas Gourtsoyiannis, M.D., PhD., FRCR (Hon.), FRCSI (Hon.) Professor Emeritus, University of Crete/Greece Professor Gourtsoyiannis was born in Amphissa, Greece, in 1943. He obtained his medical degree from Thessaloniki University in 1967 and his doctoral thesis from Athens University in 1977. After a three-year internship in Internal Medicine at the Red Cross Hospital of Athens, he completed a three-year residency in Radiology at Evagelismos Hospital in Athens, followed by a 2-year fellowship at the Radcliffe Infirmary in Oxford (1977–1979). He served the Hellenic Air Forces Hospital in Athens between 1975 and 1987, where he was appointed head of the Radiology Department in 1981. He was elected Associate Professor of Radiology of the University of Crete in 1986, and was Professor and Chairman of the Department of Radiology from 1990 to 2010. He served as the first Medical Director at the University Hospital of Crete (1997–1999) and spent two terms as Dean of the Faculty of Medicine of the University of Crete (1999– 2001 and 2001–2003). He was appointed Professor emeritus of the University of Crete in 2010.

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Professor Gourtsoyiannis is the founding father of the Hellenic College of Academic Radiology. He has served as its President from 1997 until 2001 and holds the title of its Honorary President. He is also a founding member of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). He was President of two of the annual ESGAR meetings (1990, 1996), President of the Society (1997–2000), and President of the joint European (ESGAR) and American (SGR) Abdominal congress in 2006. His greatest interest has been in the radiology of diseases of the small intestine, and he has made major contributions to the evaluation of small bowel imaging with MR. His work in Radiological-Pathologic Correlation spurred him on to mastermind ECR’s Categorical Course and Syllabi in this discipline, introducing Radiological-Pathologic Correlation at ECR. An active researcher, he has published more than 250 scientific articles in international peer-reviewed journals and he has written or co-written 40 book chapters. He has served on the Editorial Board of numerous journals, including European Radiology, Abdominal Imaging, Investigative Radiology, Acta Radiologica and Magnetic Resonance in Medical Science. He has also been the editor of Hellenic Radiology and a reviewer for several national and international scientific journals on medical imaging and gastrointestinal diseases. He is the editor or co-editor of 4 books, Imaging of Small Bowel Tumors (Elsevier, 1997), Small Bowel Imaging (Springer-Verlag, 2003), RadiologicPathologic Correlations (Springer-Verlag, 2005), and Clinical MRI of the Abdomen (Springer-Verlag, 2011). Nicholas Gourtsoyiannis has been visiting professor at 27 Universities and he has delivered more than 400 invited lectures, and over ten eponymous ones, worldwide. In recognition of his international achievements and the excellence of his work, he has been awarded honorary membership by the following societies: the Radiological Society of North America, the British Institute of Radiology, the French Society of Radiology, the Radiological Society of Switzerland, the Austrian Society of Radiology, the Italian Society of Medical Radiology, the Royal Belgian Radiological Society, the Argentinean Society of Radiology, the Bulgarian Association of Radiology, the Association of Bosnia and Herzegovina Radiologists, the Serbian Society of Radiology, the Turkish Radiological Society, the Hungarian Society of Radiology, the Nordic Radiological Society, the Swedish Society of

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Radiology, the Polish Society of Medical Radiology, the Iranian Society of Radiology, the Portuguese Society of Radiology, the Romanian Society of Radiology, Spanish Society of Radiology, the German Society of Radiology, the Chinese Society of Radiology, and the European Society of Paediatric Radiology. He has also received honorary fellowships from the Royal College of Radiologists (UK) and the Royal College of Surgeons (Ireland), and he is a member of the Russian Academy of Medical Sciences. He is the recipient of the 2000 Gold Medal of ESGAR, the 2001 Olson Medal of Sweden, the 2003 Schinz Medal of Switzerland, the first Gold Medal of the Hellenic Society of Radiology in 2004, the Boris Rajewsky Medal of the EAR in 2007, and the Gold Medal of the European Society of Radiology in 2008.

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He was President of ECR in 2003 and chairman of the ECR Executive Committee in 2004. From 1999 to 2003 he was Chairman of the Subspecialties Committee of the EAR and from 2004 to 2007 he was President of the European Association of Radiology (EAR). He introduced the Electronic Presentation Online System (EPOS™) and the European School of Radiology (ESOR), and he masterminded the creation of the European Society of Radiology (ESR). Nicholas Gourtsoyiannis was the first President of the European Society of Radiology (ESR, 2006 to 2007). He is now the Scientific/Educational Director of the European School of Radiology (ESOR) and the President of the International Society of Radiology (ISR). He and his wife Emmy have two children, Christos and Sofia.

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Congress Organisation

President Maria I. Argyropoulou Secretary Efthymia Alexopoulou Scientific Committee Loukas Astrakas Areti Charissiadi Savvas Defteraios Christiana Hadjigeorgi Paraskevi Kosta Panagiotis Nikolopoulos Marina Papadaki Frederika Papadopoulou Georgia Papaioannou Maria Raissaki Loukia Tzarouchi Vassilios Xydis Anastasia Zikou Organising Committee President Efthymia Alexopoulou Committee Maria Arvaniti Maria Badouraki Maria Chasiotou Nikos Evlogias Christiana Hadjigeorgi Christina Kalogeropoulou Maria Katsikari Chrissoula Koumanidou Ioannis Nikas Panagiotis Nikolopoulos George Pitsoulakis George Tsimitselis Marina Vakaki Maria Zarifi

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Conference Secretariat

102, Michalakopoulou str. Tel: +30 210 7711673 Fax: +30 210 7711289 WebSite: www.prctravel.gr E-mail: [email protected] The organizers acknowledge the support of the following organizations Institutional partners Hellenic Radiological Society Industrial and Commercial partners Agfa HealthCare Bayer HealthCare Pharmaceuticals Bracco Suisse SA EOS Imaging GE Medical Systems Hellas LMT Lammers Medical Technology GmbH PharmaZac Philips Medical Systems The ESPR would also like to thank all further sponsors and exhibitors for their support. This supplement was not sponsored by outside commercial interests. It was funded entirely by the publisher.

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Dear Colleagues, Dear friends It is my great honour and privilege to welcome you to Athens for the 35th Postgraduate Course & 49th Annual Meeting of the European Society of Pediatric Radiology. The foundation of Athens goes back some 3,000 years, since then the city has lived through times of glory and times of decline. The times of glory have given birth to philosophy, literature, science, arts and politics, defining the matrix and momentum for modern western civilization. Today, decline wears a global mantle, yet the goddess Athena still watches over us from her Parthenon, and shares her wisdom and days of glory with us all. Days of Glory, the ESPR 2012 days. ESPR 2012 begins with the postgraduate course, covering topics on cardiothoracic, skeletal, gastrointestinal, genitourinary, neuro and interventional radiology. Highly qualified paediatric radiologists, all excellent teachers, will explore the theoretical aspects of each thematic area, whilst sharing practical ‘tips’ garnered from years of experience. The JESPeR lecture is dedicated to Tuberculosis, building up A to Ω familiarity with all the key imaging findings of this disease. During the congress, high-quality research undertaken since last year’s meeting will be communicated as oral or poster presentations. Of particular interest are the task force sessions, where updates and guidelines relating to the imaging of different systems and radioprotection issues will be presented. Practical issues are extremely important, but knowledge of the theory behind our imaging applications is at the core of good science and practice. Thus a comprehensive review of state of the art imaging of the brain and spine will be presented in the Symposium: Brain and Spinal MR: from the technique to application. Knowledge is acquired not only to be used, but more importantly, to be imparted to future generations. Thus the experience, wisdom and knowledge of world-renowned paediatric radiologists will be offered to junior and senior pediatric radiologists alike during the session “The top ten lessons learnt from my life”. Education is the corner stone of science, and the creation of educational opportunities is the on-going task of the European family of radiology. The ESPR lecture is given by the father of the European School of Radiology, Professor Nicholas Gourtsoyiannis, and is dedicated to the European experience of striving for education in radiology. Hippocrates is the father of western medicine, and the Hippocratic Oath defines ethics in medical practice. “The Application of Hippocratic Principles to Pediatric Radiology” will be presented by a famous American paediatric radiologist (albeit European in his heart), Professor Bruce Parker. Thank you for coming to Athens, and thank you for being part of this venture. We shall doubtless prove once again that our democratic societies, in the manner of this city’s ancient Acropolis, promote and protect good science, thus paying homage to Athens’ timeless splendour, that resists the rigours of time. Sincerely

Prof Maria I Argyropoulou President ESPR2012

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ESPR 2012, ATHENS 35th POSTGRADUATE COURSE May 28th–May 29th

Monday 28 May 08:45 Introduction & welcome 09:00–10:30 Chest and Heart Chaired by: C Bakoula, V Donoghue 09:00 Neonatal Chest: What the neonatologist needs to know from the pediatric radiologist G Enriquez Civicos, Bracelona/ES 09:30 Top ten lesions of the pediatric lung H Ducou le Pointe, Paris/ FR 10:00 Morphological and functional assessment of congenital heart disease with MRI N Kelekis, Athens /GR 10:30 Coffee Break 11:00–12:30 Gastrointestinal Chaired by: N Evlogias, M Anooshiravani 11:00 Congenital malformations of the GI tract: How to use imaging V Donoghue, Dublin/IE 11:30 Biliary atresia: Investigation and management D Pariente, Paris /FR 12:00 Inflammatory bowel disease: advances in imaging E Alexopoulou, Athens/GR 12:30 Lunch 13:30–15:00 Skeletal Chaired by: M Arvaniti, H Ducou le Pointe 13:30 How to image musculoskeletal infection M Raissaki, Iraklion/GR 14:00 Arthritis in children; How to start and when to finish with imaging K Rosendahl, Bergen/NO 14:30 Benign Bone Lesions: How far should we go with imaging? K Oudjhane, Toronto/CA

15:00 Coffee Break 15:30 Special lecture Chaired by: MI Argyropoulou, A Gouliamos Imaging the pediatric brain: the past, the present, the future F Brunelle, Paris/FR 16:00–17:30 Genito-urinary System Chaired by: M Papadaki, P Toma 16:00 Urinary tract infection revisited F Avni, Brussels/BE 16:30 MR Urography: How to do it and when to use it C Kanavaki, Geneva/CH 17:00 Voiding dysfunction in children M Riccabona, Gratz/AU 17:30 Special Lecture Chaired by: I Nikas, JF Chateil Spinal trauma: when and how to image P Sundgren, Lund/SE Tuesday 29 May 08:30–10:00 Fetal Chaired by: S Andronikou, C Adamsbaum 08:30 All about fetal brain: from A to Ω N Girard, Marseille/FR 09:00 Urogenital anomalies: US/ MRI F Avni, Brussels/BE 09:30 The liver, the pancreas and the spleen: US/MRI M Cassart, Brussels/BE 10:00 Special Lecture Chaired by: F Avni Fetal imaging: Should we measure and what C Garel, Paris/FR

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10:30 Coffee Break 11:00–12:30 Oncology: Don’t forget the fundamentals and learn about the future Chaired by: H Brisse, E Stiakaki 11:00 Bone tumors G Papaioannou, Athens/GR 11:30 Hematologic malignancies RA Nievelstein, Utrech/NL 12:00 Brain tumors T Huisman, Baltimore/USA 12:30 Lunch 13:30–15:00 Neuroimaging from A to Ω Chaired by: A Zikou, A Rossi 13:30 US of the brain C Veyrac, Montpellier /FR 14:00 All about Stroke JF Chateil, Bordeaux/FR 14:30 Non accidental injury C Adamsbaum, Paris/FR

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15:00 Coffee Break 15:30–17:00 Skull base Chaired by: M Katsikari, N Girard 15:30 Fetal head and neck: Pre-postnatal imaging correlation E Vasquez, Barcelona/ES 16:00 The petrous bone A Rossi, Genova/IT 16:30 The pituitary gland C Garel, Paris/FR 17:00 Special lecture Chaired by: F Brunelle, D Pariente Liver vascular anomalies: imaging, treatment and pitfalls J Dubois, Montreal/CA 17:30 JESPeR lecture Chaired by: C Hadjigeorgi, S Stafrace Tuberculosis from A to Ω S Andronikou, Cape Town/ZA

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35th Postgraduate Course Presentations

Neonatal chest: what the neonatologist needs to know from the pediatric radiologist Goya Enriquez Pediatric Radiology Department, Hospital Infantil Vall d’Hebron, Barcelona/Spain Chest X-ray continues to be the first radiologic examination performed to assess chest lesions in neonates and it requires a meticulous technique. Proper positioning of the patient and X-ray tube is extremely important to avoid a distorted chest image. Upward angulation of the tube can result in a bizarre configuration of the ribs, whereas lordotic patient positioning produces an abnormally prominent cardiac apex, simulating right ventricular hypertrophy. If the infant is rotated to one side the upper lung may appear hyperlucent and be misinterpreted as a pathologic finding. To ensure that the chest is not rotated, the operator should verify that the ribs and the medial borders of the clavicles are symmetrical. It is also essential to know that the features of films obtained in expiration often simulate cardiomegaly or increased lung density, mimicking pulmonary disease. Hence, the chest examination must be performed in appropriate inspiration, which can only be determined with the experience of reading numerous radiographs. The nasogastric tube is the chosen nutritional technique in premature infants. It is essential to check the position of feeding tubes because it can provide important diagnostic information regarding esophageal atresia and traumatic esophageal pseudodiverticulae. Inability to properly advance an oral tube may indicate esophageal atresia. Traumatic pharyngeal perforation should be suspected when the feeding tube is seen outside the esophagus in unexpected locations. These iatrogenic lesions can occur when the tube comes into contact with the fragile pharyngeal wall tissue, causing cricopharyngeal spasm and perforation. The endotracheal tube position should also be checked. Improperly positioned tubes can cause lobar or lung atelectasis or hyperaeration, or lead to long-term complications of tracheal stenosis or granuloma formation. Furthermore, visualization of the tracheobronchial tube in the stomach while the lungs are well aerated in a newborn is the key to establishing the diagnosis of tracheal agenesis.

Clinical conditions leading to respiratory distress in the first days of life can be divided into two groups: those that can be treated medically and those requiring surgery. The radiologic patterns of several medical conditions, such as hyaline membrane disease, also known as respiratory distress syndrome (RDS), transient tachypnea (TRDN), meconium aspiration and neonatal pneumonia, have been extensively reported. Ultrasound is particularly useful in the diagnosis of RDS and some authors speculate that it may serve as a screening method for early administration of surfactant in preterm infants with this condition. A huge increase in lung echogenicity (“white lung”) is the US diagnostic hallmark. Pulmonary lymphangiectasis is a less common condition that also produces severe respiratory distress. It can occur as an isolated abnormality, as a part of generalized lymphangiectasis or associated with heart lesions (hypoplastic left heart syndrome, anomalous venous return or pulmonary vein atresia). The lymphatic vessels are dilated in this condition and appear as nodular or somewhat reticular images on plain films. Positive-pressure ventilation is often a part of the treatment for these conditions and related complications such as interstitial emphysema, pneumothorax, and pneumomediastinum can be recognized on plain films. The variety of air-leak patterns produced should not be interpreted as pulmonary malformations. Interstitial blebs can simulate lung adenomatoid malformation and air in the anterior portion of the chest seen in patients in supine position (“anterior pneumothorax”) may simulate lobar emphysema. In patients with pneumomediastinum, air sometimes elevates the thymus, producing the so-called “angel wings” or “spinnaker sail” sign, simulating a mediastinal mass. Congenital lung malformations are usually detected prenatally, and most newborns are asymptomatic at birth and show normal chest plain films. To postnatally confirm the malformation, US, CT, or MRI should be performed. On US, an echogenic mass with systemic vascularization is seen in cases of pulmonary sequestration, whereas abnormal aeration with increased and heterogeneous parenchymal echogenicity is common in cystic adenomatoid malformation. In asymptomatic patients, contrast-enhanced CT or MRI can be performed later on (6–8 months) for complete characterization of the malformation. There is considerable debate in the

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literature on the management of patients with these congenital malformations. Most authors agree that solid sequestrations can regress spontaneously, and conservative management is recommended. However, cystic or hybrid lesions usually persist and may increase in size or develop infection; therefore surgical management may be more appropriate. Last, conditions causing respiratory distress in the neonatal period requiring surgery usually manifest on plain films as mediastinal displacement to the contralateral side. Congenital diaphragmatic hernia is a major surgical emergency in the newborn. The prenatal assessment, which mainly focuses on the degree of pulmonary hypoplasia and determines the postnatal management, is based on US and MRI study. In more severe cases, prenatal tracheal plug placement can be applied to increase the volume of the affected lung. The differential diagnosis of diaphragmatic hernia should be established, particularly with congenital adenomatoid malformation and pulmonary lymphangiomatosis. Top ten lesions of the pediatric lung H. Ducou le Pointe Department of Pediatric Radiology, Hôpital d’Enfants ArmandTrousseau, Paris/France Selecting 10 pediatric lung lesions is a hard challenge! Our choice was based on some of the lesions most commonly found in children, or lesions concerned by a new classification. Respiratory distress in newborn infants can be related to numerous causes. Hyaline membrane disease, also called respiratory distress syndrome, remains one of the major causes of death in live-born infants. Hyaline membrane disease affects premature infants. It is the clinical expression of surfactant deficiency in neonates. Infants are usually symptomatic within minutes following birth. Neonates present with non-specific tachypnea, grunting and cyanosis. Classic radiologic findings are observed in untreated patients and reflect generalized acinar collapse. Chest radiograph demonstrates underaeration of the lungs and diffuse consolidation (fine granular appearance) with air bronchograms. Mechanical ventilation and exogenous surfactant therapy have modified the radiological appearance of the disease. Bronchopulmonary dysplasia remains a long-term consequence of this disease. The incidence has not changed significantly, but the severity in infants born before 28 weeks of gestation is less important due to improved management and treatment. Pediatric diffuse lung disease, also called interstitial lung disease (ILD), encompasses a heterogeneous group of uncommon disorders characterized by impaired gas exchange and widespread pulmonary parenchymal pathology. It is now widely accepted that the idiopathic interstitial lung disease described in adults is not applicable to children. A new and specific pediatric classification was proposed in 2007 by the Child Research Cooperative group. This new classification is largely based on clinicopathologic findings. Radiologists must be aware of this classification so as to work with clinicians and pathologists and define characteristic imaging patterns. Genetic disorders of

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surfactant should be highlighted. They currently represent a well known cause of chronic diffuse lung disease in the neonatal period and childhood. Most frequent genetic defects involve adenosine triphosphate binding cassette A3 (ABCA3), surfactant protein B (SP-B), surfactant protein C (SP-C) and thyroid transcription factor 1 (TTF-1). Congenital pulmonary malformations also represent a challenging topic. Their classification depends on investigators’ specialties. Some investigators classify congenital pulmonary malformations according to embryological considerations (the lesions are defined as lesions of defective budding, differentiation and separation of the primitive foregut). Other investigators consider that congenital pulmonary malformations result from airway obstruction with secondary pulmonary dysplastic changes. Vascular theory has also been supported. Some authors have developed a very practical approach based on morphological findings in radiology and pathology. Three groups have been defined: parenchymal lesions, vascular lesions and a combination of both. Three malformations need highlighting: congenital lobar emphysema, congenital pulmonary airway malformations and pulmonary sequestrations. Congenital lobar emphysema may cause respiratory distress in the neonatal period. Classification of congenital pulmonary airway malformations, previously known as congenital cystic adenomatoid malformations, has been updated to include 5 types by Stocker 2002. This new classification highlights two points: the term “adenomatoid” should not be used any longer, as it refers to one of the 5 types only. Moreover, the term “cystic” refers to 3 types only (1, 2 and 4). Pulmonary sequestrations combine parenchymal and vascular lesions. They are classified into two types (intralobar and extralobar). They are mostly located in lower lobes. Children with intralobar sequestration usually present with recurrent infections in the lower lobes. Extralobar pulmonary sequestration is diagnosed during the neonatal period and presents as a lung mass. This malformation is characterized by a systemic arterial supply. The pulmonary tissue of intralobar pulmonary sequestration has roughly the same appearance as that of CPAM and up to 50% of extralobar pulmonary sequestrations are associated with type 2 CPAM. Pneumonia is a very frequent infection in children (more than 150 million pediatric cases reported each year, according to the estimation of the World Health Organization). Numerous types of infectious agents are responsible for pneumonia in children. The radiological findings are rarely specific. Frontal chest radiographs are frequently the only required imaging modality. The lateral view is useful for visualizing hilar lymph nodes. CT is useful in pulmonary complications, in case of tuberculosis or in immunocompromised children. Bronchiolitis is a major cause of morbidity in children younger than 2 years of age. Respiratory syncytial virus is the most common cause of bronchiolitis. X-ray findings are related to a small airways obstruction (hyperinflation, peribronchial thickening, subsegmental atelectasis). Performing chest Xrays rarely impacts on the treatment and X-ray is recommended only for severe cases. Lung abscess is a complication of pneumonia. Lung abscesses used to be related to congenital pulmonary malformations with primitive lung abscesses being less frequent. Due to prenatal diagnosis, these malformations are now commonly

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treated before infectious complications occur. Recognizing the primitive nature of lung abscesses at diagnosis is challenging even when a chest CT is performed. In our experience, the CT should be performed much later, after the acute episode, so as to detect an underlying pulmonary malformation. The prognosis of lung abscesses in children is usually good without sequelae. Pediatric tuberculosis remains a worldwide challenge. About 1 million annual cases occur in children younger than 15 years of age. The great majority (95%) of infected children will not develop the disease, and a disseminated form of the disease is more frequent in children younger than 2 years of age. The association between chronic pneumonia and hilar lymphadenopathies should raise suspicion for tuberculosis. Chests radiographs remain very effective for detecting parenchymal lesions and lymphadenopathies. CT is useful in case of equivocal chest X-ray, complicated presentation or disseminated disease. In immunocompromised children, chest CT is helpful for the evaluation of lung infection, particularly when X-ray does not contribute. CT findings in keeping with pulmonary fungal infection are characterized by nodules with poorly defined margins. Cavitation of the nodules and ground-glass opacity surrounding the nodules strongly suggest this diagnosis. Cavitation occurs in half of all cases and is characterized by the air-crescent sign. The halo sign is related to haemorrhage around a nodule or to inflammatory infiltration within the lung parenchyma. This sign may also be observed in other diseases such as viral infections and bacterial abscesses. Cystic fibrosis is caused by mutation in the CFTR gene and remains the most common cause of pulmonary insufficiency in children. Low-dose high-resolution technique computed tomography is the technique of choice (the gold standard) for the evaluation of lung disease in cystic fibrosis. However, there are concerns about the cumulative radiation dose in these patients. MRI seems to be a valuable technique to replace CT in the near future for the evaluation of cystic fibrosis. Recently, an MR-scoring system based on morphological and functional data was suggested for annual follow up. Reference Stocker JT: Congenital pulmonary airway malformation: a new name and an expanded classification of congenital cystic adenomatoid malformation of the lung. Histopathology 2002, 41:424–431. Morphological and functional assessment of congenital heart disease with MR N. L. Kelekis 2nd Department of Radiology, General University Hospital “ATTIKON” National and Kapodistrian University of Athens, Athens/Greece Introduction: Advances in diagnostic modalities and treatment have led to increased survival in patients with congenital heart disease (CHD) through adulthood. Diagnosis and follow-up in patients with CHD relies greatly on imaging studies. Until relatively recently, these relied principally on plain X-rays, echocardiography and angiography, the latter two being almost exclusively practiced by cardiologists. Nowadays, multislice CT

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and MRI play an evolving role in the management of patients with CHD. Morphology: A morphologic systematic approach to CHD includes assessment of the atrial situs in conjunction with abdominal and thoracic anatomy, atrioventricular connections, morphology of the ventricles, ventriculoarterial connections and anatomy of the great vessels, venous connections to the cardiac chambers, and finally the presence of valvular abnormalities, as well as abnormal communications such as atrial or ventricular septal defects. Specific anatomical features of various cardiac components used in morphological assessment of CHD are described below. The normal position with the cardiac apex situated in the lower anterior left hemithorax is described as levocardia; the term dextrocardia refers to the cardiac apex being on the right, while the rare mesocardia consists of a centrally positioned heart with both the base and the apex along the midline with the former more cranial and the latter more caudal (such as in mammalian quadripeds). The position of the apex is independent from the situs of the heart, lungs and viscera. The situs of viscera and lungs does not depend on the position of the cardiac apex (levo-, meso-, or dextrocardia). It always correlates with the position of the morphological right or left atrium. There are five categories, determined by the position of the morphologically right or left atrium:

1. Situs solitus (right atrium on the right) 2. Situs inversus or mirror image (right atrium on the left) 3. Right isomerism (asplenia, bilateral right atria and morphological right main bronchi)

4. Left isomerism (polysplenia, bilateral left atria and morphological left main bronchi)

5. Situs ambiguous (inability to accord atrial characterization) Regarding the external topography of the heart, the atrioventricular groove defines the plane of the base of the heart (4 cardiac valves) and defines the short-axis plane of the heart, containing the right coronary artery and left circumflex artery in the right and left atrioventricular grooves respectively. The left anterior coronary artery courses along the anterior interventricular groove, while the posterior descending coronary artery courses along the inferior interventricular groove. As a general rule, morphological right chambers are more coarsely trabeculated and morphological left chambers smoother in their interior surfaces. The morphological right atrium is a right posterolateral chamber. Its posterior aspect receives the two caval veins and has a veinlike appearance, in keeping with its embryologic origin from the venous sinus (sinus venosus), while the coronary sinus enters the right atrium anteriorly (Thebesian valve) in front of the inferior vena cava ostium (Eustachian valve). It has a wide-based pyramidal-shaped appendage, contains the limbs of the septum secundum (oval fossa limbs), and has free-wall and septal components. A prominent C-shaped ridge of muscle forms the terminal crest (or crista terminalis), which

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separates the two regions and forms one of the tracts for internodal conduction. The right atrium is characterized by the presence of numerous pectinate muscles, which arise from the terminal crest and travel as parallel ridges along the anterior aspect of the free wall. The interatrial septum, when viewed from the right, has an interatrial component and an atrioventricular component (RA-LV). The interatrial portion is relatively small and contains the oval fossa, which consists of a horseshoe-shaped muscular rim (limb), containing a pathway of internodal conduction, and a central thin fibrous membrane (valve of the oval fossa). The morphological left atrium receives the pulmonary veins, has a narrow-based finger-like appendage and contains the remnants of the septum primum, while it does not have a crista terminalis or pectinate muscles but rather demonstrates a smooth internal surface. The atrioventricular valves always accompany their reciprocal ventricles. The tricuspid valve has three cusps, three papillary muscles with a septal cusp and papillary muscle, and is separated from the pulmonary valve by a muscular infundibulum. It may, however, have a conal, rather than septal, papillary muscle. The mitral valve has two cusps and two papillary muscles with an absence of septal attachments and has a fibrous continuity with the aortic valve. In congenital heart disorders, there may be a single common atrioventricular valve. The ventricles consist of three well-developed parts: the inflow tract, the body and the outflow tract, which is of conotruncal origin. In congenital heart disorders, hypoplastic ventricles may consist of one or two of the above parts, or a single ventricle may be present. The morphological right ventricle has coarse trabeculations. The most prominent of the septomarginal trabeculae is termed the moderator band, which contains part of the electrical conduction system and is one of the most important right ventricular landmarks on imaging studies. The right ventricle has a muscular infundibulum, three papillary muscles (usually anterior, posterior and septal), and a tricuspid valve, with its diaphragmatic cusp closer to the apex. The morphological left ventricle has a cylindrical shape and smooth interior surface with small and thin trabeculae mainly at the apex, two papillary muscles (anterior and posterior), and a bicuspid mitral valve with fibrous continuity between it and the aortic valve. The semilunar valves connect the ventricles to the great arteries. They consist of an annulus, cusps, and commissures without tensor apparatus (tendinous cords and papillary muscles). Behind each cusp there is an outpouching of the great artery, known as a sinus of Valsalva, that imparts a tribulbous, or cloverleaf, shape to the arterial root. The junction between the sinus portion of a great artery and its distal tubular portion forms a prominent ridge, the sinotubular junction. From the right and left aortic sinuses, adjacent to the pulmonary artery and proximal to this junction, arise the right and left coronary arteries respectively, while the third sinus is termed the noncoronary sinus.

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Function: MR imaging in addition to morphology provides functional parameters such as volumes and function of cardiac chambers throughout the cardiac cycle, ventricular mass and flow through aorta, pulmonary artery, atrioventricular valves and virtually any vessel, permitting non-invasive quantification of flow and volumes, and pulmonary to systemic flow ratio (Qp/Qs), thus yielding a comprehensive assessment of patients with CHD. MRI is superior to ultrasonography in situations with poor acoustic windows such as postoperative or obese patients, conduits calcified or not, always providing objective anatomic and functional data. It is, however, a time-consuming and expensive modality and inferior to ultrasonography in the assessment of valve leaflets and small vegetations. Assessment of right ventricular function, including volume, mass, ejection fraction, hypertrophy, systolic and diastolic function, is of relevance in the diagnosis and follow-up of many clinical situations; primarily in congenital heart disease such as in tetralogy of Fallot, or systemic right ventricle in various conditions, such as congenitally-corrected transposition of the great arteries, transposition of the great arteries following atrial switch operations, and single right ventricle. MRI, using breath-hold multislice-multiecho gradient echo acquisitions, reliably measures RV volume throughout the cardiac cycle, and provides ejection fraction, wall motion and right ventricular mass measurements. Using phasecontrast flow-encoded gradient echo acquisitions’ maximum velocities in the pulmonary and tricuspid valve, pulmonary and tricuspid blood flow can be quantified. MRI is the only modality able to quantify the regurgitant volume, which is of importance in patients with surgically-corrected tetralogy of Fallot. The combination of pulmonary regurgitant and tricuspid flow reflects the diastolic function of the right ventricle, while ejection fraction and end systolic volume estimate the systolic function of the ventricle. Assessment of LV volumetric, velocity, and flow parameters permits evaluation of the functional status of the LV, which is often impaired in conditions affecting primarily the RV. Future perspectives include improved anatomical imaging at 3 T, efforts to adequately visualize valve leaflets, real-time velocity-encoded sequences and the development of single whole-heart scanning with cine and flow sequences encoded in the three directions. Congenital malformations of the GI tract: how to use imaging. V Donoghue, Children’s University Hospital, Temple Street, Dublin/ Ireland. There is a large spectrum of congenital abnormalities that affect the GI tract. The abnormalities that present in the newborn and early infant period are the most symptomatic and some represent true emergencies. In the adolescent period the abnormalities are often discovered incidentally at imaging or during surgical exploration. Some congenital lesions are suspected on routine antenatal ultrasonography and small bowel dilatation, polyhydramnios and

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hyperechogenic intestinal contents are the most common findings. These findings may only occur late in pregnancy, and are sometimes transient and non-specific. The normal signal characteristics of the bowel contents on MR examination of the fetal GI tract have been reported. However, the extent of the bowel loop dilatation and the changes of the MR signal characteristics have been shown not to be sufficiently characteristic to accurately determine the type and location of bowel obstruction. There is therefore a requirement for postnatal imaging in the vast majority of congenital lesions. As intrinsic bowel obstruction at the various levels is the most common congenital abnormality, plain radiography and contrast examinations remain the most important imaging studies required. The instances where a contrast examination is required will be discussed together with the type of examination and contrast agents used. Where obstruction due to meconium ileus is diagnosed, the role of the paediatric radiologist includes the therapeutic use of high-osmolar contrast medium. Ultrasonography is particularly helpful in evaluating lesions extrinsic to the bowel such as duplication cysts. Congenital tumours of the GI tract are extremely rare and most commonly involve the liver. Cross-sectional MR or CT imaging is often required to help characterize the abnormality and to evaluate its extent. Nuclear medicine imaging may be helpful in the diagnosis of Meckel’s diverticulum but is otherwise not required. In all instances, close collaboration with paediatric surgeons is advisable. Biliary atresia: investigation and management D Pariente and S Franchi-Abella Pediatric Radiology department Hôpital de Bicêtre Hôpitaux Universitaires Paris Sud, Paris/France Despite continuous progress in imaging and knowledge, the diagnosis of biliary atresia remains a challenge and its management will eventually conclude end up with liver transplantation in most cases. Imaging has a role to play in the initial investigation of a cholestatic neonate and in the evolution of the disease. We would like to present our experience as a Reference Centre for this disease in France, and compare it with the current literature. Biliary atresia (BA) is an obliterative cholangiopathy of neonates that affects varying lengths of both extra and intrahepatic bile ducts. Its origin is still unknown, most likely multifactorial, but its onset is most probably antenatal. Its incidence varies around the globe, being rare in Europe (approximately 40 cases per year in France) and much more frequent in the Pacific area. Up to 20% of cases are syndromic forms, associated with other congenital anomalies, the most common being the splenic malformation syndrome. If left untreated, BA has a progressive course to cirrhosis and end-stage liver failure. The treatment of choice is the Kasai portoenterostomy, performed as early as

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possible. Liver transplantation is indicated in case of failure and BA accounts for half of the indications for liver transplantation in children. The diagnosis of BA should be considered in every infant presenting with persistent cholestasis (conjugated hyperbilirubinemia), acholic stools, dark urine and hepatomegaly. Differential diagnosis includes all other causes of extrahepatic lesions, in which there is dilatation of bile ducts, and intrahepatic medical causes. These latter are often grouped in the literature under the term of “neonatal hepatitis,” but in fact correspond to a large variety of causes that are infectious, metabolic, ischemic and genetic diseases. Ultrasonography (US), with high-frequency transducer and colour Doppler, remains the best radiologic investigation, and the most specific parameters that have to be carefully searched for are, in our experience, a blind macro or microcyst at the porta hepatis, elements of the splenic malformation syndrome, the presence of a triangular cord sign and an abnormal gallbladder, atretic or with irregular and hyperechoic contour and walls. However, the many pitfalls must be recognised and the diagnosis of BA should not be completely ruled out on US unless there are dilated bile ducts. Other investigative studies that could be helpful before surgery are ERCP and percutaneous cholecystography when the gallbladder is large enough to be punctured. Scintigraphy, MRI and biopsy have limitations, in our experience. After Kasai procedure, complications may occur in the course of the disease, in some cases hastening liver transplantation; they mainly include cholangitis, portal hypertension with gastrointestinal bleeding and ascites, acute liver ischemia, hepatopulmonary syndrome, and rarely hepatocellular carcinoma. US is still the best screening modality, but MDCT with contrast enhancement has replaced angiography for the thorough assessment of hepatic vasculature before palliative surgery or interventional radiology, or in a pretransplantation work-up, particularly in the syndromic forms of BA, in which anatomical anomalies are frequent. MRI is the examination to perform for better characterization of a regenerative nodule, in cases of increased alpha fetoprotein level or for a global evaluation of the bile ducts and bile lakes. In conclusion, although many aspects of BA remain poorly understood, there is evidence that early diagnosis and prompt surgery are needed to provide children with the best chance to survive with their native liver and avoid liver transplantation. Therefore, it is essential for the paediatric radiologist to be aware of all the anatomic variants of BA and the limitations of every study. Inflammatory bowel disease: advances in imaging 2nd Department of Radiology, General University Hospital "ATTIKON" National and Kapodistrian University of Athens, Athens/Greece Introduction: The diagnosis of inflammatory bowel disease (IBD) in children and adolescents is based on the integration of clinical, biological, endoscopic, histological and radiological

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data. Histological examination of endoscopic samples remains the gold standard. However, the application of small bowel imaging in the IBD context has evolved in recent years. The goals of imaging are primarily to determine the extent of small bowel involvement, assess complications and define candidates for surgery. Imaging techniques are divided into conventional and cross-sectional. Conventional imaging (barium studies): The small bowel follow through (SBFT) was, and probably remains, the commonest examination of the small bowel, with a sensitivity and specificity of 90% and 96% respectively for the diagnosis of Crohn disease. However ulcers, erosions and polyps are frequently reported as missed. The method still plays a major role in the diagnosis of small bowel obstruction in children, due to the high radiation dose of CT. Recently either the use of the Patency Capsule in children or the low dose Multi-Detector CT (MDCT) has tended to replace this last indication for SBFT. Small bowel enteroclysis has limited use in children, due to both its high radiation dose and the stress and discomfort it causes. Both barium studies are unable to demonstrate extraluminal disease, and have the disadvantage of high radiation dosage. Ultrasonography (US): In children with unknown IBD, US is considered to be the first choice imaging technique and is performed before endoscopy. The absence of bowel wall thickening has a strong negative predictive value. The main advantages of the technique are availability, low cost, lack of radiation and good tolerance by the pediatric patient. Disadvantages to be considered include: the examination is operator-dependent and not reproducible; the difficulty in examining the whole GI tract; US challenges in obese children; and situations of excessive gas distension of the bowel. Bowel wall thickening, location and length of the disease, echogenicity of the bowel wall, the presence or not of normal stratification, ulcers, bowel stiffness, stricture or distention can often be detected with US. Additional information regarding the surrounding fat and the presence or absence of mesenteric nodes can also be obtained. In children, the sensitivity for IBD varies from 74– 93% and the specificity from 78–93%. Bowel wall thickness is one of the most important signs of IBD, with different thickness values used as a threshold for a positive diagnosis. The sensitivity and specificity of US is dependent on the threshold of bowel wall thickness used. For the terminal ileum, the cut off measurement varies between 1.5–3 mm, whereas for the colon it varies between 2–3 mm. Color Doppler US can provide information about the disease activity. The estimation of “vessel density” appears to be an indicator for disease activity whereas measurement of the Resistive Index (RI) of the Superior Mesenteric Artery has been proposed by some authors as an alternative indicator. In the followup, US has a place in monitoring medical treatment and in detecting complications (abscess, fistula or stenosis) in cases with relapse. Computed tomography (CT) has become a widely used technique in adults for small bowel investigation, either by CT enterography or by CT enteroclysis. According to a recent study, the radiation dose from SBFT is on average half the dose

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of abdomen/pelvis MDCT in pediatric populations with Crohn disease. Therefore for radiation protection reasons, MDCT is avoided by most pediatric radiologists. However it remains an examination of choice for abscess drainage, to obtain accurate images of the exact extension and to select the most appropriate access route for drainage. MDCT is also utilized to detect other, usually acute, complications of the disease such as bowel obstruction, peritonitis, post-operative leaks, perforation and anastomotic complications. Magnetic resonance imaging (MRI) of the small bowel is a recent technique, which is now widely applied in adult populations and to a significant degree in children. It is performed either as MR enterography or as MR enteroclysis. In children, due to its simplicity and the lack of radiation exposure (no requirement to advance a catheter in the jejunum under fluoroscopic guidance), MR enterography is the preferred technique. However, problems such as imaging artifacts due to bowel peristalsis and motion or poor cooperation from the child taking the oral contrast agent can cause an examination to be of poor quality. For these reasons the technique is applied in older children, preferably above the age of 7. The sensitivity and specificity of MR enterography has been reported as 81 % and 100% respectively. According to our protocol, requirements are that the child is given a bowel cleansing preparation 3 days prior to examination followed by a a low residue diet (ample fluids, no milk products) and nil-by-mouth on the day of the examination. Several oral contrast agents can be used for bowel distension, Manitol solution is currently used in our practice. The IV injection of glucagon or buscopan provides further improvement of image quality as bowel motion is suppressed. Examination is performed with the patient in the prone position. The MR sequences should include a combination of fast axial and coronal T1- and T2-weighted sequences to cover the entire gastrointestinal tract. Typically thin slice (3–4 mm) plain and fatsuppressed 2D or 3D T2-weighted true fast imaging with steady-state in the free precession (true FISP) sequences and 3D T1-weighted fat-saturated unenhanced and contrastenhanced gradient-echo sequences (slice thickness 2.5–3 mm) are acquired. The field of view (FOV) and matrix are optimized for each individual patient on the basis of body size. The fatsaturation technique increases contrast resolution by reducing the chemical shift–induced black boundary artifacts along the bowel wall. Injection of IV gadolinium–based contrast agents further increases detection of active inflammation. MR findings to look for include the following: a) Bowel loop appearance (fixed, dilated, strictured, pseudo sacculation appearance), b) Bowel wall (thickness, focal lesions such as ulceration, pseudopolyps and mural abscess, type of signal on T2-W sequences and pattern of enhancement after IV contrast injection) c) Extramural signs (fibrofatty proliferation, “comb sign,” fistula, abscess, mesenteric nodes). Controversies exist concerning the prediction of disease activity due to the lack of a gold standard examination to compare with, the different MR techniques used and the fact that acute and chronic lesions may coexist in the same bowel loop. Diffusion-weighted image (DWI) sequences

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with high b-values open new horizons in the detection and quantification of bowel wall inflammation and searching for extramural disease. In the adult population, detection of IBD with DWI sequences has a sensitivity of 95% and specificity of 82% (reported to be the highest sensitivity but lowest specificity, compared to previous techniques). According to some authors, the real role of this sequence is in the detection and, more interestingly, the differentiation between fibrosis and persistent inflammation. In conclusion US should be the first choice examination in children with suspected IBD and should be performed before endoscopy, while MR enterography is the technique of choice in children with known IBD, for the investigation of the small bowel and the whole GI tract, as it is a reproducible and well tolerated examination, lacking radiation and providing excellent information about bowel disease. CT should be kept for use in cases in which MRI is contraindicated or in acute-emergency situations, when US is inadequate. SBFT now has a questionable role, as it appears to have been widely replaced by MRI enterography in the pediatric population, despite its lower cost. It should be applied in younger children in whom performing MR enterography is impossible. How to image musculoskeletal infection in children M Raissaki, MD. University of Crete, Heraklion/Greece Classification of pediatric musculoskeletal infection: Musculoskeletal infections in children can be classified as osteomyelitis, septic arthritis and soft tissue infection depending on the anatomic location of the primary focus. In acute Osteomyelitis subacute or chronic. The source of the infection is usually hematogenous, while direct spread from a penetrating wound or adjacent infected structures may also occur. Congenital osteomyelitis may be due to syphilis or viral agents (rubella, cytomegalovirus (CMV), varicella). Acquired infection may be due to bacteria, mycobacteria (tuberculosis), on rare occasions to fungi and may also be idiopathic in chronic recurrent multifocal osteomyelitis. Staphylococcus aureus, Streptococcus, Salmonella, Meningococcus, Hemophilus Influenzae and Enterobacter are the main pathogens. Role of Imaging: In children, clinical presentation may be typical. Localized hyperemia, tenderness, pain, swelling and limitation of movement, often coupled with positive radiographs, abnormal laboratory and/or ultrasound examinations may suffice to establish diagnosis and initialize treatment. However, assessment of these children may be difficult, especially when they present systemically unwell; with a nonspecific limp, persistent pain or in cases when the disease has been altered by antibiotic administration. It is in these children that urgent imaging should establish the diagnosis and avoid delay in treatment and subsequent complications. In cases of marked tenderness and diffuse soft-tissue swelling, accurate mapping of infection is important for the surgeon

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who will invariably administer antibiotics but does not wish to open a joint with the potential of introducing infection if the focus is in the metaphysis, or to drill the bone unnecessarily if the infection is in fact in the joint. Therefore, imaging is often able to confirm the suspected diagnosis of musculoskeletal infection, to evaluate the site and extent of disease and to determine the most appropriate mode of therapy. Imaging findings in osteomyelitis and septic arthritis: The rational use of imaging in children with suspected osteomyelitis should be based on an understanding of the strengths and limitations of the different techniques. Skeletal scintigraphy provides evidence of infection within 14–72 h while plain radiographs will demonstrate no change for 7–14 days. In acute osteomyelitis all three phases of bone scans using 99-m technetium (99Tcm) methylene diphosphonate (MDP) show increased uptake with the abnormal “hot” area being well defined and matched. The combination of osteomyelitis and cellulitis produces increased bone and soft-tissue uptake in later phases. The normal growth plate has a linear appearance on scintigraphy with a sharply demarcated transition to the shaft uptake. In metaphyseal infection, loss of this sharp demarcation is accompanied by a flare of increased activity in the shaft. In septic arthritis there is increased uptake around the joint in both early and later phases and no focal osseous lesion on the static images. A fourth phase scan, 24 h after injection, may prove useful as osteomyelitis usually provokes further increased activity. Radiographs are important for the exclusion of trauma or tumor. Features of osteomyelitis on plain film radiography comprise osteopenia in the early course of the disease, softtissue swelling and fat plane loss and/or displacement, followed by development of an ill-defined area of bone destruction. A permeative or sclerotic pattern is a characteristic of subacute or chronic osteomyelitis, where pus penetrates the cortex via a cloaca and may elevate the periosteum or extend beneath it, causing vascular deprivation and dense periosteal reaction, known as involucrum. Sequestra are seen as devitalized bone within osteopenic areas. A Brodie’s abscess is seen as an elongated radiolucent lesion in the long bones, measuring 1–4 cm in length with surrounding sclerosis, occasionally simulating an osteoid osteoma. Plain films have a limited value for the diagnosis of joint effusion in septic arthritis; however they may demonstrate fat plane displacement around joints, epiphyseal lucency due to local hyperemia and dislocated or subluxed joints. High-resolution ultrasound has been increasingly utilized for the demonstration of periosteal reaction and subperiosteal abscess formation in long bones before radiographically detectable changes, of joint effusion with or without synovial hyperemia in suspected septic arthritis and for guidance of drainage. CT accurately accesses features of osteomyelitis such as sequestrum, involucrum, cloaca and abscess. Increased bone marrow density is due to purulent material replacing normal fatty marrow. CT is not performed routinely in pediatric

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osteomyelitis, due to increased radiation burden and is reserved for the evaluation of the subacute and chronic stages of infection, as well as for particular sites of osteomyelitis including sterno-clavicular junction and hidden areas in the pelvis or shoulder. MRI offers excellent contrast resolution and delineation of morphological changes in bone marrow, joints and soft tissue and is especially useful for children with pelvic or vertebral osteomyelitis. Its sensitivity in diagnosing early osteomyelitis is equal to scintigraphy and is considered the modality of choice in many centers. Disadvantages include increased scanning time, the need for sedation, and increased cost. In practice, MRI could be reserved for difficult clinical diagnoses and for optimal preoperative planning. Imaging findings of acute osteomyelitis include areas of low signal intensity on T1-weighted sequences turning bright on T2-weighted sequences representing edema, inflammation and/or purulent material, the latter not enhancing following contrast material administration intravenously. Subperiosteal fluid collections and abscesses may appear as non-enhancing or rim-enhancing areas respectively, while cellulitis as ill-defined areas of enhancing strands, exhibiting low signal intensity on T1-weighted sequences turning bright on T2-weighted sequences. In addition to bone abnormalities, myositis or pyomyositis contiguous to the site of osteomyelitis is readily detected. Diffusion imaging may prove useful in outlining areas of soft-tissue abscesses. Joint effusion

Table 1

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with synovial enhancement is a non-specific sign of arthritis and the diagnosis of septic arthritis can only be confidently made coupled with bone marrow changes and the relevant clinical/laboratory findings. Differential diagnosis of osteomyelitis comprises septic arthritis, cellulitis, acute rheumatic fever, and indolent fractures. Malignant conditions that may mimic osteomyelitis both clinically and radiologically include Langerhans cell histiocytosis, Ewing sarcoma, leukemia, osteosarcoma and metastatic neuroblastoma. Imaging findings should always be interpreted considering all pertinent clinical and laboratory data. Pathways for imaging suspected musculoskeletal infection: When osteomyelitis is suspected (Table 1), an AP and lateral radiograph of the affected region is performed and if positive, prompt treatment is initiated, while scintigraphy and MRI may be needed for management planning. If radiographs are negative, and the area in question is the long bones, a positive ultrasound prompts initiation of treatment while a negative ultrasound indicates further investigation with scintigraphy and/or MRI. In cases of spinal or pelvic involvement in neonates with negative scintigraphy and unresponsive to treatment after 48h, MRI is indicated. CT is reserved for preoperative planning in cases of chronic osteomyelitis and for differentiating cortical lesions. Ultrasonography is being increasingly utilized for the diagnosis and monitoring of musculoskeletal infection in children.

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When septic arthritis is suspected (Table 2), radiographs exclude osteomyelitis and other diagnoses. A positive radiograph and a negative ultrasound for effusion suggest osteomyelitis. The pres-

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ence of effusion under the appropriate clinical and laboratory context indicate aspiration or surgical debridement while followup is done with X-rays or MRI, depending on the clinical course.

Table 2

Arthritis in children: how to start and when to finish imaging K Rosendahl Department of Pediatric Radiology, Haukeland University Hospital, Bergen/Norway Arthritis, i.e. inflammation of a joint, usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances or other causes, occurs in various forms. In children, reactive arthritis (secondary to viral infections, f.i.), bacterial arthritis and juvenile idiopathic arthritis (JIA) are most common. JIA is a heterogeneous condition encompassing all forms of chronic arthritis of unknown origin, >6 weeks’ duration and with onset before 16 years of age. It is characterized by chronic synovial inflammation, with potential risk of developing progressive joint destruction and serious functional disability. The reported incidence varies from 0.6 to one in 1,000 children, and JIA thus represents an important cause of acquired disability in the paediatric age group. During the last decade, new, potent therapeutic agents have become available to children with JIA, underscoring the need for accurate monitoring of therapeutic response on both disease activity and structural damage to the joint, the latter being considered the gold standard in treatment efficacy studies.

Thus, the role of the (paediatric) radiologist is first to aid in making a correct diagnosis, and in cases of JIA, to monitor disease activity / treatment effect and occasionally to provide markers for chronic change for use in clinical trials. Diagnosis: In children presenting with one “swollen” joint, initial imaging should include a radiograph to exclude bone involvement (osteomyelitis > 10–12 days’ duration? tumour? other?) and an ultrasound scan to look for joint effusion and/ or synovial hypertrophy. Findings should be interpreted in light of symptoms, clinical and laboratory findings, and if consistent with reactive arthritis, no further imaging is needed as part of the initial workup. However, if bacterial arthritis cannot be excluded, an ultrasound-guided aspiration should be performed, preferably after discussion with an orthopaedic surgeon. On the other hand, if the initial examinations are normal, a limited MRI examination (STIR and T1-w sequences) might be considered to exclude osteomyelitis. If the initial examinations are suggestive of JIA, an additional MRI would include pre- and post Gd sequences to assess disease activity and the full disease extension. A stepwise approach as outlined here, rather than going directly for an MRI, has proved efficient in our practice, as a number of problems can be solved based on the initial radiograph and ultrasound scan.

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Juvenile idiopathic arthritis Disease activity: In children with JIA, monitoring disease activity is important to make informed choices for further treatment. But stop for a second; which is the best marker for disease activity— the amount of joint effusion, the degree of synovial hypervascularity or a combination of the two? The fact is that we really don’t know. If the amount of joint effusion is an important marker, an ultrasound would do for most joints. However, if the degree of synovial hypervascularity is a more important marker, a post contrast magnetic resonance imaging (MRI) scan would be more appropriate—although its accuracy and clinical validity have been questioned. Chronic change: Joint damage evaluation in JIA is traditionally performed by radiographic scoring methods assessing joint space narrowing and erosions, but are however quite insensitive, in part due to the growing skeleton. Wrist disease has been associated with a more severe course of arthritis and a poorer functional outcome, and is the only joint in which suitable radiographic measures of disease progression have been reported. Much effort has been spent recently on validating existing scoring systems or devising new ones, of which the Adapted Version of the Sharp/van der Heijde Score has gained most acceptance. The value of MRI, as an advanced method to evaluate both disease activity and disease damage in adults with rheumatoid arthritis, is under active investigation by a research consortium called Outcome Measures in Rheumatology Clinical Trials (OMERACT). However, the results drawn from OMERACT studies are not directly applicable to children, because adult rheumatoid arthritis is different from JIA and the growing skeleton of children requires a different approach. Indeed, in children, ossification is incomplete and joint space width varies with age. Thus, despite technical progress in the imaging of cartilage (development of ultra-short TE sequences, driven equilibrium, Fourier transform [DEFT] imaging, and steady-state free precession [SSFP] sequences for the detection of subtle surface irregularities and tiny focal defects of the articular cartilage, diffusion-weighted techniques to assess degradation of collagen fibres, delayed gadolinium-enhanced cartilage imaging [dGEMRIC] to detect changes in cartilage proteoglycan content and T2 relaxation time mapping to detect integrity of collagen in the extracellular matrix), the potential helpfulness of these techniques has yet to be seen. The same goes for sophisticated analysis of 3-D image data to provide articular surface contour mapping and 3-D rendering as well as volumetric quantification of articular cartilage to evaluate the progression and response to treatment in patients with chronic arthritis. Progress in the assessment of synovitis, including dynamic contrast-enhanced MRI to assess the degree of inflammation, is also flawed, with methodological difficulties, although voxelby-voxel analysis of signal intensity versus time curves has proved more accurate than the region-of-interest (ROI) approach in adults with RA. Another technique for assessment of inflammation using a semiautomated segmentation program technique of dynamic contrast-enhanced MRI (DCE-MRI) has also been described. Thus, although MRI is a potential powerful imaging tools to assess joint inflammation and the progression of joint damage, standardized, validated, and feasible assessment systems are lacking.

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Conclusion: For a correct diagnosis, a stepwise approach as that outlined above may be helpful. In JIA, US and MRI may aid the assessment of disease activity and extension, although, unlike for rheumatoid arthritis, there is no widely used MR wrist scoring system for JIA. Benign bone lesions: how far should we go with imaging? K Oudjhane MD MSc Department of Pediatric Radiology, Hospital for Sick Children University of Toronto, Toronto/Canada Diagnosis of bone neoplasms in children is a challenge and a source of apprehension, as bone lesions are commonly seen in pediatric patients. Radiography frequently gives rise to the initial encounter with a bone abnormality, but more and more bone lesions are detected on CT and MR examinations. The presence of patient symptoms, one of which is pain, warrants the careful collection of imaging information as specific radiographic features may influence the clinical decision: biopsy versus clinical monitoring. An appropriate clinical approach from a radiologist’s point of view entails 3 steps: the clinical step, involving the gathering of important clinical data; a second stage of meticulous radiographic analysis of the abnormality and consideration of differential diagnosis from a few mimickers; and the third step, based on an evaluation of the aggressiveness of the bone lesion, which cross-sectional imaging may characterize further, with bone biopsy remaining an eventuality (Table 1). At a clinical level, specific bone tumors are prevalent in specific age groups. In general, bone lesions have equal sex predilection; however giant cell tumor, enchondroma, have a female / male ratio of 1.5, fibrous dysplasia of 1.2. The presence of symptoms (mainly pain) in addition to the radiographic abnormality, suffices to warrant further imaging. A possible complication is a pathologic fracture. If pain is experienced at night, and is unresponsive to NSAID, osteoid osteoma is likely. A benign-looking enchondroma may need biopsy if pain forms part of the clinical picture, in order to exclude chondrosarcoma. Systemic signs such as cafe au lait spots associated with a bone tumor may lead to the diagnosis of fibrous dysplasia and McCune-Albright syndrome. A family history may reveal possible NF1, or multiple hereditary exostosis. The radiographic analysis first takes into account the location of the lesion, both in the skeleton and within a specific bone. The radiographic elements to study include the size of the lesion, its matrix nature (osteoid, chondroid, fibrous or other), the appearance of its margins, the status of the cortical bone, the presence of periosteal reaction and the association of a soft-tissue mass. The rate of growth / degree of aggressiveness is best depicted at its margins and in the morphology of the osteolysis. Lodwick classification is still useful for forming a global assessment: geographic pattern type I (A/B/C), moth-eaten type II, permeative type III. Depending on the lesion’s site, considering potential mimickers is a necessary step to exclude possible normal anatomic variants such as a venous channel foramen or a dorsal defect of the patella. The herniation pit of the femoral neck should not be taken as osteoid osteoma. An asymmetric ischio-pubic synchondrosis may mimic an expansile bone tumor. Pseudotumors may be present as physiologic lucencies in the bone (greater tuberosity of humerus head, proximal end of ulna, neck-body junction of the calcaneum).

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Traumatic injuries of stress fractures may be discussed, along with possible osteoid osteoma. Post traumatic pseudotumors of the bone may include cortical lucencies and osteochondral lesions of the elbow (capitellum, trochlea). The issue becomes more complex, as simple bone cysts that have undergone a pathologic fracture are no longer so straightforward, imaging-wise. An infectious process is a great simulator of bone tumors, be it as an acute, sub acute or chronic form of osteomyelitis. Chronic recurrent multifocal osteomyelitis (CRMO) should be considered when the preferred location is at the metaphyses of long bones and the medial clavicle. A miscellaneous group of differential diagnoses include osteonecrosis, intra-osseous ganglia, regional osteoporosis, bone stigmata of secondary hyperparathyroidism, hemophiliac pseudotumor and melorheostosis. Appreciation of the degree of aggressiveness of a bone lesion will ultimately guide the pattern of further imaging and the follow-up and treatment options. The bone lesion may be considered at a latent benign stage (stage 1 of Enneking classification), active benign (stage 2) or aggressive benign stage (stage 3). Stage 1 lesions need no additional workup or treatment; regular follow-up is required, however. An active / aggressive bone lesion may only be best depicted on MRI. Hence, after conventional radiography, MRI is considered the next best modality because of its higher sensitivity in detecting marrow-based lesions, identifying other diagnoses such as radiographically occult fracture and osteonecrosis, and defining the extent of bone marrow disorders and possible soft-tissue involvement. MRI may suggest a histologic diagnosis as in intra-osseous lipoma or aneuysmal bone cyst. CT is preferable to MRI for assessing the matrix pattern of the bone lesion and depicting cortex-based abnormalities as in osteoid osteoma with more clarity. Bone scintigraphy is useful in the case of multifocal disease (polyostotic fibrous dysplasia, for example). Whole-body MR is an elegant method of assessing the bone marrow of the entire body without ionizing radiation. A Local / regional cross-sectional imaging is preferable before any biopsy. No biopsy is advised when clear radiographic diagnosis is made of a non-ossifying fibroma or enchondroma. Benign conditions such as infection can have an aggressive pattern. Percutaneous biopsy is usually image-guided. The indications of cross-sectional imaging are variable depending on the matrix nature of the lesion. Boneforming tumor may require CT assessment, as is the the case for osteoma with frontal sinus obstruction and an osteoid osteoma (often missed on MR). MRI will be of clinical help for a local complication of spinal osteoblastoma. MRI is useful to assess cartilage-forming bone tumors such as an epiphyseal chondroblastoma (diagnosis and local extent), an enchondroma (differential with chondrosarcoma), chondromyxoid fibroma, and an osteochondroma (complication, cartilage cap thickness threshhold). MRI is not required in non-ossifying fibroma or simple fibrous dysplasia. CT is best to define the matrix of fibrous dysplasia. MRI appearances are characteristic in lipoma, cystic lesions (ABC with fluid /fluid levels), giant cell tumor (pattern of dynamic contrast enhancement), Langerhans cell histiocytosis (T1 signal higher than muscle signal, T2 signal abnormality and degree of enhancement and soft-tissue involvement in the acute phase) and osteofibrous dysplasia of the tibia. On MR, soft tissue disease in a bone process is a concern, reflecting the extension of an infection, Langerhans disease or a malignant disorder.

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In summary, a diagnostic strategy for a bone lesion is needed to ensure effective management and follow-up. The frequency of unrecognized infections and incidental trauma must be borne in mind. The patient’s age, the location of the abnormality and the various imaging features are key elements in zooming in on the differential diagnosis. After initial radiographic evaluation, additional imaging may be needed. Advanced imaging is critical in differentiating aggressive lesions and usually helps in guiding biopsy. Table 1: Benign bone lesions: step-by-step imaging approach

A- Clinical Evaluation: – –

Symptomatic or not Pathologic fracture

B- Radiographic Analysis: Benign vs malignant (slow growing vs aggressive)

– – – – – – –

Location of the lesion Characteristics: size, margins, matrix, cortex, periosteal reaction Lodwick classification Differential Diagnosis: The mimickers Normal variants Traumatic injuries Infection Miscellaneous

C- Advanced Cross-Sectional Imaging: – – –

The modalities : MRI, CT, bone scintigraphy Enneking classification To biopsy or not

D- Follow-up / Monitoring of therapy

Paediatric neuroradiology: past, present, and future F Brunelle, M Zylbovicius, D Grevent, N Boddaert Imaging department Necker-Enfants-Malades Hospital, Paris/France A child is not merely a small adult. This aphorism cited by John Caffey and Derek Harwood Nash speaks volumes. What were they trying to say? The aphorism can be understood in many ways: pathologies affecting children differ from those of adults. The child is a developing person, and pathologies have a deep impact on his or her development, especially that of the brain. This concept of neoteny is an important one. Indeed, the small man is basically immature when compared to other mammals that walk and run soon after delivery, such as horses. This fragility has been held up as one of the reasons why humans have developed their brain and skills. The brain reaches maturity at about 7 years of age. During this period of maturity, the child acquires most of the knowledge to be used for the rest of his or her life.

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The process of brain maturation has been well documented using MRI, and the pattern of “myelinisation” is now widely known. Any diseases involving the brain will affect this process of maturation. Trauma, hydrocephalus, brain tumour and vascular anomalies all affect brain development.. Thus in children, it is mandatory to diagnose and treat them early. The Past Now that I have reached the status as a man of the past, let me share my memories of being a medical student with Jean Aicardi. The first tool we had to diagnose hydrocephalus was “transillumination.” A lamp was applied to the head of the child and the light would diffuse into the dilated ventricle, giving a “venetian lantern” effect. Ultrasound, like light, uses the same basic physical principles of diffusion, refraction and reflection. Air was the only injectable media we had to elucidate the cause of obstruction within the ventricular system. It was introduced via a lumbar puncture or directly through a fontanel, sometimes even through the sub occipital approach! Third ventricle ventriculostomy was performed on a special table under general anaesthesia in the radiology department. The ventricles were punctured with a trocar and a drop of lipiodol or contrast medium was injected to visualize the floor of the third ventricle.The basilar artery was very close…as we all know! One of the big revolutions was the invention of iso osmolar contrast media, the first to replace air in the visualisation of CSF spaces. In the 1980s, several papers were published and a book on CT metrizamide in children was brought out by the Toronto school. New diagnosis were discovered, notably “thick filum” syndrome, using metrizamide, was first injected into the subarachnoid spaces and then the CT performed; hydrocephalus and external hydrocephalus were studied using this method. In parallel, transfontanellar ultrasound was developed, partially by radiologists, along with neonatologists. This was one of the earliest examples of sharing an imaging technique with nonradiologists. Intracranial haemorrhages of the premature were diagnosed and classified. Prognosis was established accordingly. Thus one of the very first fields in which imaging not only made a “diagnosis” but tried to establish a prognosis, came into being. Antenatal imaging started slowly with ultrasound. Corpus callosum agenesis and mild ventricular dilatation were “seen” during antenatal care. Then MRI appeared. Today; Paediatric neuroradiology today is MRI. MRI development changed our perception of neuro-images. We discovered a “direct” vision of the brain anatomy. Before MRI, we were seeing the anatomy indirectly, even with the CT scanner. A large number of papers have gone on to describe paediatric brain anatomy. MRI in medical school is used to teach anatomy. Neuroradiologists were accustomed to “reading” CT scans of the brain on axial planes. Books were published to teach “axial” anatomy. The

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3D nature of MRI images allowed oblique, curvilinear and surface 3D reconstructions. Sonographists learned a lot from MR images, mainly from antenatal MR images of the brain. Anomalies of the posterior fossa began to be diagnosed by antenatal MRI, rapidly followed by ultrasounds. Joint meetings involving mixing obstetricians, radiologists and neonatologists flourished. Because of the natural anxiety of parents when a malformation was diagnosed, imagers started trying to establish a prognosis. A diagnosis alone was no longer sufficient. To answer these new types of questions, we had to change our way of thinking:

& & &

Build up “database” cohorts of patients Follow them up over a long period of time, because in paediatrics only long-term follow-up is significant. Collaborate with obstetricians, paediatricians, neurosurgeons

The term “imaging” progressively replaced “radiology.” Development of antenatal imaging also changed our understanding of the malformations we were used to seeing during postnatal care. Cerebellar clefts are now known to be secondary to antenatal cerebellar haemorrhage. The term cerebelloschisis was used to describe malformations similar to schizencephaly. Patterns of the white matter maturation were established; these patterns are now well known to all paediatric neuroradiologists and paediatric neurologists. One has to bear in mind that 25 years ago, they did not even exist. It was purely research at that time. The outbreak of enormous chapters on “leucodystrophies” and metabolic diseases of the brain began. Understanding of hydrocephalus progressed rapidly with sequences that show not only the CSF spaces, but also their dynamics. MRI was the technique of choice to perform a third ventricular ventriculostomy in the event of aqueduct stenosis. The basilar artery was seen better than with pneumoencephalography! MRI images served as an aid for neurosurgeons. Images were loaded in computers that piloted robots holding an operating microscope. “MRI aided neurosurgery” was born. Functional MRI using the “BOLD (blood oxygenation level dependent contrast) effect” allowed us to map the functional region of the brain prior to surgery with precision. Motor, visual and language areas were localized prior to surgery in cases of brain tumours in close proximity. 3D reconstruction enabled us to measure and monitor volumes of CSF and their changes in hydrocephalus. There was a major shift towards 3D instead of 2D, to functional images instead of anatomy. An everyday example in our department would be an emergency case of a child with headaches and vomiting. A CT scan performed in a county hospital reveals a brain tumour. An emergency MRI is performed in sterile conditions with gadolinium injection. A perfusion study is conducted for research as well as spectroscopy. The MRI data are sent to the operating room computer, to aid the neurosurgeon. A new MRI is performed the following day, “day one,” to check the completeness of the resection. Statistical analysis of the brain morphology has changed our diagnostic power. Visual inspection of the brain is difficult, as

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many inter-individual variations exist. Pediatric neuroradiologists always dreamt of being able to diagnose small anomalies of brain structure, particularly in patients with epilepsy or mental retardation. MRI is now the first examination of choice for epilepsy and mental retardation. CT is only performed to check for the presence of calcification. Voxel-based morphometry (VBM) now allows us to statistically compare, voxel by voxel, any individual brain with normals ones. A large number of papers were published on structural anomalies of white and grey matter in patients with genetic syndromes and autism. Such results could not have been reached by simple visual analysis of MRI. Spectroscopy, due to its ability to measure several chemicals in the brain, led to a giant step being taken in the diagnosis of metabolic disease such as mitochodriopathies, creatine deficiency and others. MRI is now used as a “screening” tool for these. Brain iron measurement is also a very powerful tool in classifying iron deposition diseases. Tomorrow Several techniques are currently used for research; tomorrow, they will be routine. Some techniques will probably serve as research tools for a longer period, as they are non-automatic, and therefore timeconsuming. A routine technique should be simple to use and rapid with results, to obtain and display for communication purposes. This is true for tractography, which is now available as a technique, but remains cumbersome. Tractography is useful in some cases of brain tumours, for visualizing the relationships between the tumour and the pyramidal tract. It is still, however, difficult to use for optic nerve gliomas, where it would be useful to separate the normal optic nerve fibres from the tumour. This technique demonstrates abnormal organization of the white matter in several brain malformations, corpus callosum agenesis, Joubert syndrome etc. Arterial spin labelling ASL is a relatively new technique in paediatric neuroradiology. It uses “tagging” of spins in the carotid arteries. These “tagged” spins are then sampled in the brain and a quantitative measurement of brain perfusion is obtained. The real revolution is twofold: this technique does not require any injection of tracers, contrast medium or radio nuclides. To keep things short, as a whole chapter could be and surely will be written on this technique, it replaces SPECT and PET images. It is now used by our team for epilepsy. It shows a per critic hyperperfusion and an inter critic hypo perfusion. It allows the precise localization of epileptic foci. This technique will merely replace all the techniques necessitating contrast injection: brain tumour perfusion, AVMs, head and neck angiomas, perfusion studies in brain ischemia (sickle cell disease, moyamoya diseases, stroke etc.…) and more. We discover a new application almost every day. Imaging genetics This is a brand new concept in neuroradiology. The goal is to try to correlate and fuse three medical approaches. The first is clinical, the second is genetics and the third is neuroimaging.

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To be clear, the initial approach was to correlate clinical findings with brain anatomy. This approach was successful, but relatively rough. An example is Joubert syndrome, in which it was discovered that the brain findings were heterogeneous in a relatively well identified syndrome. Then descriptions emerged that the genetics of Joubert syndromes were heterogeneous as well. It became clear that this approach was not efficient enough. Comparisons were made with groups of patients that either displayed the same anatomy, or the same clinical findings, or the same genetic anomaly. The concept of “endophenotype” to describe a homogeneous group of brain anatomy anomalies was born. This approach transpired to be very powerful in the analysis of genetic syndromes, mitochondriopathies and other malformations. We now know that patients with mental retardation and a thick corpus callosum should be tested for genetic anomalies with CGH array (x % of anomalies found). Integrated imaging or “whole imaging” The future of imaging in neuropaediatrics could be called global imaging. We will soon observe a fusion of all modalities to demonstrate not only anatomy but networks, function, bio dynamics, electroencephalography and MEG. To date, it is still difficult to merge all the modalities. Brain perfusion with ASL while EEG is recorded is just getting off the ground in our institution. Resting state studies will have an important impact on the understanding of mental retardation and autism, for example. At present, we can merge antenatal MRI and ultrasounds. We can thus see the vessels on Doppler in real time, along with a precise anatomy. Cardiac gating of the foetus will allow us to understand the CSF dynamics of arachnoids cysts, amongst others. We anticipate that it will become possible to image neurotransmittors, synaptogenesis, genes and protein expression in the brain. Dynamic networking will follow. An entire area of research has opened. The exploration of the brain is the new “terra incognita” to discover. This will be an endless quest, I think. Conclusion: In 30 years of professional life, neuroradiology has evolved dramatically. The novelties that appear on an almost yearly basis (CT, US, MRI) incite us to pursue our daily work with enthusiasm and passion. The paediatric environment is very special, and an emotional one; we are treating the future of the world. We are not only dealing with a patient, but with a whole family. This experience is incredibly rich, as it provides insight into the deepest foundations of humanity. As it is said: “to save one child is to save the world” Urinary tract infection revisited F E Avni, M Cassart, M Hall, K Ismaili ULB—Erasme Hospital Departments of Imaging and pediatric nephrology Brussels/Belgium Urinary tract infection (UTI) is one of the commonest bacterial diseases in children, with 5% of girls and 2% of boys affected.

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However, a lack of agreement continues to exist with respect to the role of imaging following a first febrile UTI (or suspicion of). Guidelines vary greatly in the literature. For instance, in children younger than 2 years old, the focus is directed towards detection of vesico-ureteric reflux (VUR) and therefore on the necessity to perform voiding cysto-urethrography (VCU). For some other authors, VCU should only be performed if ultrasound (US) or radionuclide renal scan (RRS) are abnormal. The reasons for the lack of consensus are probably related to:

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The poor correlation between the severity of UTI and the presence and degree of VUR The debated role of VUR in the development of renal scars The debated yield of any imaging test in improving the longterm prognosis

The present course is intended to summarize current knowledge and propose guidelines for the evaluation of UTI. In the acute phase, the role of imaging is primarily intended to demonstrate parenchymal damage and the presence of VUR. Once the treatment is initiated, imaging should provide information whenever the clinical progression is unfavorable. In the long term, imaging should identify if renal scars have developed. It should be noted that for each imaging technique, there are arguments for and against their use. 1. Should ultrasound be performed? Most authors agree that a sonographic examination should be performed as the first imaging technique in the case of febrile UTI. High resolution transducers should be used with settings suited to the child’s size. The technique allows re-evaluation and detailed analysis of prenatally detected anomalies or detection of unrecognized congenital malformations. It may show lithiasis and pyonephrosis. These findings would prompt supplementary examinations (and adapted treatment). Interestingly, the demonstration of ureteral dilatation is apparently the best predictor of the presence of VUR. Clearly, ultrasound is able to demonstrate other abnormalities potentially associated with UTI such as signs of dysplasia, parenchymal abnormalities, abnormal color Doppler and evidence of previous infection. The significance of a normal sonographic examination is another controversial area. For many authors, a normal ultrasound examination does not exclude parenchymal damage and/or VUR whereas others (in recent articles) stress that in cases of normal ultrasound, the risk of significant disease is minimal and therefore a complementary examination is unnecessary. Ultrasound should also be performed whenever the response to antibiotic therapy is unsatisfactory and or a complication is suspected. Again, the technique is able to demonstrate renal abscesses but a normal ultrasound is not sufficient to exclude disease (see below). Finally, the role of ultrasound for the detection of late complications of UTI such as renal scars is also debated, with most authors concluding that the technique lacks sensitivity and specifity for this purpose.

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2. Should a systematic VCU be performed? Most authors agree that a systematic VCU should be avoided, and the indications should be restricted to patients with risk factors (Table 1). Furthermore, the age of the patient should guide whether to perform a VCU. One would be keener to perform VCU under the age of 6 months (or even 2 years) whereas in school age girls with suspicion of UTI, the priority would be to assess voiding dysfunction. VCU (and RRS) must be performed in cases of recurrent UTI. The choice of technique depends on local expertise. Cystosonography should be the first choice due to its lack of radiation; yet the use of sonographic contrast is not permitted universally in children and is relatively expensive. For the time being, VCU remains the gold standard in spite of its higher radiating dose, potential for acquired infection and pain. Therefore, one should optimize the technique reducing irradiation and pain as much as possible. 3. Should a systematic radionuclide renal scan be performed? Although RRS is the presently accepted gold standard for detecting acute and late parenchymal lesions, there is no consensus on its use or on the best time to perform this examination. In this debate, some authors favor a systematic use of DMSA scan in the acute phase of febrile UTI. Yet, in many places, it is not possible to perform this examination during nights or weekends. Furthermore, the technique involves irradiation and therefore, many authors prefer a more restricted approach, limiting the use of RRS to patients at risk, namely those with abnormal ultrasound or with high grades of VUR. RRS is presently considered as the gold standard for the detection of renal scars and should be performed 6 months after the initial episode of UTI to verify their presence. 4. What is the role of CT and MR imaging? In children with UTI, CT should not be used as part of the initial armament of examination. The technique can be helpful in cases of unfavorable clinical progression and high suspicion of renal abscess not previously demonstrated by ultrasound, particularly if MR imaging is not available. MR imaging could become the gold standard examination for the assessment of both uncomplicated and complicated UTI, utilising the various sequences, with and without gadolinium injection. The technique allows for a detailed evaluation of both the renal parenchyma and cavities; whenever necessary functional information can be provided as a result of Gd injection. More recently, diffusionweighted sequences have proved useful for the detection of renal abscesses. MR imaging can detect renal scars and other long-term complications of UTI. In conclusion: Controversies, especially in the choice of imaging techniques for patients with febrile UTI, remain unresolved. Based on the present knowledge, it seems reasonable to base our imaging evaluation on ultrasound first. A completely normal sonographic examination (and no risk factors) would render further investigations unnecessary. An abnormal sonographic examination (or presence of risk factors) should lead to VCU. In case of high grades reflux or unfavorable prognosis, RRS or MR imaging should be performed.

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Table 1 Risk factors for vesico-ureteric reflux indicating voiding cysto urethrogram

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Abnormal prenatal ultrasound Age6 weeks), were studied. All patients underwent blood tests, chest x-ray(s), HRCT, and FB/BAL. HRCTs were evaluated with the Bhalla scoring system and the bronchoscopic findings were categorized according to severity into five groups (I–V). Results. On bronchoscopy visible abnormalities were found in 91 children (97.8 %), while positive HRCTs were found in 70(75.2 %). A positive correlation was found between the Bhalla score and the cough duration (>00.23, p00.028). The Bhalla score correlated positively with type-III (OR: 5.44, 95 %CI: 1.92–15.40, p00.001) and type IV (OR: 8.91, 95 %CI: 2.53–15.42, p00.001) bronchoscopic groups; it also correlated positively with the neutrophils’ percentage in the BAL (>00.23, p00.036). Discussion and conclusions. HRCT detected airway wall thickening and bronchiectasis and the severity of the findings correlated positively with the length of clinical symptoms and the intensity of neutrophilic inflammation in the airways. However, HRCT was less sensitive than FB/BAL in detecting airway abnormalities. The two modalities should be considered complementary in the evaluation of prolonged wet cough.

6 - SP Interstitial lung disease in children: high-resolution CT findings in 14 patients proven histopathologically Xinyu Yuan,Huizhong Chen, Jizhen Zou, Rongyan Huang Capital Institute of Pediatric, Beijing (China) Purpose - Objective. To assess the high-resolution computed tomography (HRCT) features of childhood interstitial lung disease (ChILD). Material and methods. Fourteen patients with ChILD proven histopathologically were enrolled in the current

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study. Among them, there were 10 boys and 4 girls, aged from 1y3m to 13y1m (the median age was 6y). The final diagnoses of this series included nonspecific interstitial pneumonia, NSIP (NSIP) (n06), lymphocytic interstitial pneumonia (LIP) (n03), pulmonary alveolar proteinosis (PAP) (n02), respiratory bronchiolitis interstitial lung disease (RB-ILD) (n01), acute interstitial pneumonia (AIP) (n01), and Eosinophilic Pneumonia (EP) (n01). Results. The most common HRCT patterns of NSIP included reticulation, ground-glass opacity and peribronchiolar thickness (6/6, 100 %). Nodules were always present on the HRCT of children with LIP (3/3, 100 %). In the two PAP patients, there was the specific sign, named “crazy-paving sign”, (2/2, 100 %) could be found. The nodules with hazy margin in EP were different from that in LIP. Nodule, reticulation and GGO were present in the boy with AIP. The reticulation, GGO, consolidation and peribronchiolar thickening were present in RB-ILD patient. Through the analysis with logistic regression, the nodule was regarded as the specific negative-pattern for NSIP (P00.047, OR0−2.71) in our study. Discussion and conclusions. HRCT scanning is the primary imaging modality for ChILD. So far, however, there is no sign that could be identified as the specific pattern for any subsets of childhood interstitial lung disease.

7 - LP Computed Tomography demonstration of the complications and associations of lymphobronchial Tuberculosis in children Susan Lucas1, Savvas Andronikou1, Pierre Goussard2, Robert Gie2 1 University of the Witwatersrand, Johannesburg; 2Stellenbosch University (South Africa) Purpose - Objective. Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children. The aim was to describe the CT findings of LBTB in children, the parenchymal complications and associated abnormalities. Material and methods. CT scans of 98 children with LBTB were retrospectively reviewed. Lymphadenopathy, bronchial narrowing, parenchymal complications and associations were documented. Results. : Infants comprised 51 % of patients. The commonest lymphadenopathy was subcarinal (97 % of patients). Bronchial compressions (259 in total) were present in all patients, of which 23 % were severe/complete stenoses and 28 % affected bronchus intermedius. Parenchymal complications were present in 94 % of patients, including consolidation (88 %), breakdown (42 %), air trapping (38 %), expansile pneumonia (28 %), collapse (17 %) and bronchiectasis (9 %),

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all predominantly right-sided (63 %). Associations included oval focal bodies, miliary nodules, pleural disease and intracavitory bodies. Discussion and conclusions. The most important CT finding of children with LBTB is visible airway compression as a result of lymphadenopathy. CT of children with LBTB showed that airway compressions were more severe in infants and most commonly involved bronchus intermedius. Numerous parenchymal complications were documented, all showing rightsided predominance. Several associations were identified.

8 - LP Incidence and acute complications of asymptomatic central venous catheter-related deep venous thrombosis in critically ill children Cicero Silva1, Philip Spinella2, Simon Li3, Matthew Pinto3, Petronella Stoltz 4, Joana Tala 5, Mary Card1, Veronika Northrup1, Kenneth Baker1, Thomas Goodman1, Lei Chen1, Edward Faustino1 1 Yale University School of Medicine, New Haven; 2Washington University, St. Louis; 3Maria Fareri Children’s Hospital, Valhalla 4 Connecticut Children’s Medical Center, Hartford 5Yale-New Haven Children’s Hospital, New Haven (United States) Purpose - Objective. Asymptomatic central venous catheter (CVC)-related deep venous thrombosis (DVT), detected only by ultrasound, is significantly more common than symptomatic CVC-related DVT. The clinical significance of asymptomatic CVC-related DVT is unknown. We determined the incidence and acute complications of asymptomatic CVC-related DVT in critically ill children. Material and methods. Muiticentric prospective cohort. Sequential pediatric intensive care unit (PICU) patients with newly inserted un-tunneled CVC were included. Patients underwent DVT assessment with Doppler ultrasonography of the central vein where the CVC was inserted, on the day of enrollment and at study exit (CVC removal, day 28 after CVC insertion, PICU discharge or prior to demise). Patients were divided in two groups: with no DVT (A) and with DVT (B) at study exit. Mortality adjusted duration of mechanical ventilation was used as a surrogate for pulmonary embolism, the main complication of DVT. Results. Asymptomatic CVC-related DVT was diagnosed in 16 (15.8 %) children. Mortality-adjusted duration of mechanical ventilation was similar between the 2 groups (23± 7 days in children with no DVT vs. 22±9 in children with DVT, P00.24). Discussion and conclusions. Asymptomatic CVC-related DVT is common in critically ill children. However, the acute complications in children with DVT are similar to children with no DVT.

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9 - SP Interrupted aortic arch: CT findings Tetyana Yalynska, Raad Tammo, Ievgeniia Iershova, Nadya Rokitska, Oleksandr Kondrachuk Ukrainian Children’s Cardiac Centre, Kyiv (Ukraine) Purpose - Objective. Interrupted aortic arch (IAA) is an uncommon congenital anomaly, characterized by a lack of luminal continuity between the ascending and descending thoracic aorta. It represents a critical ductus-dependent congenital heart disease, which without surgery is associated with high mortality in the neonatal period. The purpose of this study was to determine the accuracy of CT in the diagnosis of the IAA. Material and methods. Thirty-seven neonates (from 2 h to 1 month) with suspected or proven IAA after echocardiography underwent non-gated CT. 9 patients underwent CT before and after surgery. Nonionic iodinated contrast material (300 mg ml) was injected at a rate varying from 1.5 ml/s to 2.5 ml/s. Results. Type A of IAAwas in 19 patients (51,4 %); type B had 18 patients (48,6 %), 8 of them had an aberrant right subclavian artery and 2 had right aortic arch. Associated abnormalities included: patent arterial duct (n037), atrial septal defect (n0 7), ventricular septal defect (n016), aortopulmonary window (n04), truncus arteriosus (n03), double outlet right ventricle with ASD and VSD (n02), transposition of the great arteries (n01). 3 neonates had DiGeorge syndrome. Surgery was done in 34 of 37 patients; CT findings were confirmed surgically. Discussion and conclusions. CT as a non-invasive technique provided the critical anatomic information required for preoperative assessment of the IAA in pediatric patients.

10 - SP The role of CT in pediatric patients with congenital heart disease: new clinical and radiological perspectives using high-pitch dual source spiral acquisition Aurelio Secinaro1, Benedetta Leonardi1, Silvia Cacaci2, Giacomo Pongiglione1, Paolo Tomà1 1 Bambino Gesù Pediatric Hospital, Rome; 2Policlinico Gemelli, Rome (Italy) Purpose - Objective. To investigate the diagnostic accuracy, clinical advantages and radiation exposure of high-pitch dual source CT in pediatric patients compared with cardiac catheterization. Material and methods. Twenty patients (4 females and 16 males, aged between 3 months and 15 years) underwent cardiovascular CT and invasive catheterization at our institution. All CT scans were performed with a second-generation dual-source CT system (Somatom Definition Flash, Siemens Healthcare, Forchheim, Germany), permitting data acquisition

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at a high-pitch (3.2–3.4). Diagnostic accuracy was assessed in terms of image quality and anatomical definition (course/ caliber of great vessels and origin/proximal course of coronary arteries) using invasive catheterization as a standard reference. Radiation dose values were calculated using the dose length product (DLP). We assessed the clinical advantages as the need for sedation/general anaesthesia. Results. Diagnostic accuracy was achieved in 90 % of the patients. Mean DLP value was 49 (standard deviation of +/− 17.3) with a mean time of exposure of 0.35 ms (standard deviation of +/− 0.09 ms). All scans were performed unsedated during free-breathing. Discussion and conclusions. High-pitch dual source CT protocol in pediatric patients with congenital heart disease provides a non-invasive high diagnostic accuracy with low radiation exposure. It could be a promising tool to support cardiac catheterization in pediatric age.

11 - SP Cardiovascular magnetic resonance (CMR) in patient with repaired tetralogy of Fallot: the gold standard in assessment of injectable pulmonary V-valve implantation and follow up Aurelio Secinaro1, Benedetta Leonardi1, Stefano Marianeschi2, Giacomo Pongiglione1, Paolo Tomà1 1 Bambino Gesù Pediatric Hospital, Rome; 2 Niguarda Hospital, Milan (Italy) Purpose - Objective. Severe pulmonary regurgitation, progressive dilatation and dysfunction of the right ventricle are the most frequent late morbidity after tetralogy of Fallot repair. Consequently pulmonary valve replacement is often indicated in these patients. Biointegral Injectable Pulmonary Valve (IPV) is an innovative, less invasive technique, often performed off a cardiopulmonary bypass. However, not all patients with severe pulmonary regurgitation are suitable for IPV insertion and CMR is fundamental in assessing pulmonary trunk dimensions, right ventricular volume and pulmonary regurgitation. Material and methods. We performed a full CMR on three patients, pre and 6 months post IPV insertion. The suitability of an IPV approach required a pulmonary trunk length of more than 20 mm and a diameter of between 15 and 31 mm. Using the 3D SSFP navigator sequence, we measured the diameters at the following sites: right ventricular patch, pulmonary valve and pulmonary bifurcation and the length of the pulmonary trunk. Results. Three patients had implanted IPV. Post IPV insertion CMR showed that all three patients demonstrated an improvement in the right ventricle end-diastolic volume. In all patients, the IPV was continent and fully assessable at CMR. Discussion and conclusions. CMR is a necessary tool before IPV insertion, both to exclude contraindications and to

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determine the need for cardiopulmonary bypass. CMR is a safe and effective method in the follow up of patients with repaired tetralogy of Fallot treated with IPV.

12 - SP Gd-free MRA in coarctation—can ce-MRA be replaced? Peter Kalmar, Erich Sorantin Medical University Graz (Austria) Purpose - Objective. Coarctation of the aorta (CoA) accounts for 5–10 % of all congenital heart defects. MRA represents an accepted imaging modality for monitoring vessel size in detection of late complications such as aneurysm formation. New MRA developments enable Gd-free angiographic imaging (native-MRA). The purpose of this study was to compare contrast enhanced MRA (ce-MRA) with native-MRA in the follow-up of CoA patients. Material and methods. In 18 patients (6 female, 12 male, aged 12 to 35 years) orthogonal to vessel direction were reconstructed in ce-MRA and native-MRA cross sections on the following positions: aortic bulb (1), ascending aorta (2), just before origin of brachiocephalic trunk (3) and left carotid artery (4), before (5), inside (6) and after coarctation (7), descending aorta (8). Vessel area and perimeter served as parameters for vessel size and were derived from region of interests (ROIs) defined by manual outlining of the vessel periphery. For ceMRA and native-MRA in all corresponding positions, both parameters were compared by paired Student t-test. Results. Differences (area and perimeter) on corresponding positions were (1) 3.4 % and 2.0 %, (2) 2.8 % and 1.3 %, (3) 2.7 % and 1.4 %, (4) 4.1 % and 2.1 %, (5) 3.7 % and 1.9 %, (6) 4.6 % and 2.6 %, (7) 3.1 % and 1.2 %, (8) 4.6 % and 3.2 % (p>> 0.05). Discussion and conclusions. Our results show that measurements of vessel size using native-MRA are equivalent to ce-MRA (no statiscally significant difference) whilst proving faster and less invasive. 13 - SP Imaging congenital heart disease(CHD) in paediatric patients by high field open (HFO) 1.0 Tesla MRI scanner: a pictorial essay Dimitra Loggitsi1, Georgia Papaioannou1, Ioannis Spandonis2, Nikolaos Kritikos1, Aphrodite Tzifa1 1 Mitera Maternity and Children’s Hospital, Athens; 2Philips Healthcare (Greece) Purpose - Objective. MR imaging is a well-established modality for the evaluation and monitoring of CHD. Advanced cardiac MRI (cMRI) is traditionally performed in closed bore

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MR scanners of 1.5Tesla. To our knowledge this is the first study concerning cMRI in paediatric patients with CHD performed in HFO 1.0Tesla magnet. Material and methods. During an 11-month period 45 paediatric patients aging from 6-days to 18-years old (mean age0 8.49 year, m:f028:17, mean BSA01.07 kg/m2) underwent cMRI in a HFO 1.0Tesla MRI scanner (Panorama, Philips). The indications for the examination included Tetralogy of Fallot, transposition of great arteries, aortic malformations, pulmonary atresia/stenosis, aortic valve disease, single ventricle, cor triatriatum, ASD, Kawasaki disease. cMRI consisted of Black-blood sequences, Cine imaging, Velocity-encoded phase contrast mapping, Gadolinium-enhanced MR angiography and 3D SSFP wholeheart when possible. Results. In all patient,s morphology and anatomy was assessed. Biventricular volumetry and function was evaluated (mean LVEDVI070.4 ml/m2, LVESVI023.7 ml/m2, LVEF065.1 %, RVEDVI0102.2 ml/m2, RVESVI044.7 ml/ m2, RVEF055.4 %), as well as aortic and pulmonary valve function and Qp/Qs measurement. In patients with aortic valve disease or malformations of the aortic arch LV wall mass was calculated (meanLV wall mass02,02gr/kgr). Discussion and conclusions. Advanced cMRI is an invaluable tool in the evaluation of CHD with high reproducibility. HFO 1.0Tesla MRI provides functional assessment and excellent image quality comparable to 1.5Tesla conventional MRI scanners. 14 - SP Antenatal cardiac sonography: a systematic approach Manish Bajaj1, Mukesh Garg1, Tushar Chandra2, Amit Gupta3 1 Geetanjali Medical College, Udaipur, (India); 2Childrens Hospital of Wisconsin (United States); 3Ravindra Nath Tagore Medical College, Udaipur (India) Purpose - Objective. This educational exhibit aims to: 1.Describe embryology of Heart and normal fetal circulation, 2.Illustrate the optimal sonographic technique for antenatal evaluation of heart, 3.Discuss the normal appearance of heart on routine sonographic views, 4.Illustrate imaging features of common congenital heart diseases on antenatal ultrasound, 5.Elucidate common pitfalls in interpreting fetal cardiac sonography Material and methods. Transabdominal ultrasound was performed to evaluate fetal heart for detection of anomalies using routine 3–5 MHz transducer. Four chamber and other standard views of fetal heart were obtained. Examples of normal ultrasound anatomy and common pathologies will be depicted along with differential diagnoses. Results. Obtaining standard views of the heart on antenatal ultrasound is a relatively simple approach that allows assessment of the major cardiac anomalies. A knowledge of normal embryology of heart appearance on prenatal ultrasound is very important to detect cardiac anomalies.

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Discussion and conclusions. Structural abnormalities of the heart are not uncommon. Incorporating a proper sonographic technique using standard views during routine antenatal scans can go a long way in shortening the learning curve and thus help in timely diagnoses and deciding upon appropriate management and counselling. Awareness of the common pitfalls is of utmost importance in this respect.

15 - SP Use of multidetector CT for asessing anatomical relation of tracheobronchial and cardiovascular anomalies associated with left pulmonary artery sling Xihong Hu, Guoying Huang, Mier Pa Children’s Hospital of Fudan University, Shanghai (China) Purpose - Objective. The study was to demonstrate the role of multidetector computed tomography (MDCT) in diagnosing and assessing anatomical relationships with tracheobronchial tree in LPAS. Material and methods. Fourteen patients (ten infants, four children) with LPAS were evaluated. They ranged in age from 3 days to 4 years (median age, 7 months) and in weight from 3.0 to 18.0 kg (median weight, 9 kg). MDCT was performed to determine the tracheobronchial and cardiovascular anatomy and identify tracheobronchial stenosis. Results. According to the Wells classification of LPAS, there were three cases of type IA, five cases of type IIA and six cases of type IIB. All patients had substantial tracheobronchial stenosis and ten cases of type II had a long segment of tracheobronchial stenosis. MDCT found pulmonary abnormalities including right upper pulmonary hypoplasia (n02), and right pulmonary hyperlucent (n01). Cardiacovascular abnormalities included PDA (n02), DORV (n01), TOF (n02), VSD (n03), ASD (n02), RPA stenosis (n01), LPA stenosis (n01). Nine patients had reanastomosis of the left pulmonary artery. Discussion and conclusions. We concluded that MDCT were ideal noninvasive imaging modalities for assessing the anatomical relationships of the tracheobronchial tree and cardiovascular in LPAS.

R16 64-slice multidetector computed tomography assessment of coronary artery lesions in children with Kawasaki disease: initial experience Xihong Hu, Guoying Huang, Mier Pa, Qiong Yao Children’s Hospital of Fudan University, Shanghai (China) Purpose - Objective. To evaluate the value of 64-slice multidetector computed tomography (MDCT) as a non-

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invasive diagnostic modality in the young children suspected of coronary artery aneurysm due to Kawasaki disease. Material and methods. Twenty patients (mean age 4.0 years, range 0.6 to7 years) with Kawasaki disease suspected of coronary artery aneurysm underwent 64-slice MDCT ECG-gated coronary angiography from 2007 to 2011. The data of twenty patients who were younger than 4 years old was acquired without breath holding. Two pediatric radiologists independently assessed image quality and the diameter of all coronary segments were measured. The number, position, shape and size of each coronary artery aneurysm were observed and compared with those of echocardiography (ECHO) performed previously. Results. There is no significant difference in inter-observer and intra-observer. A total of 60 branches permitted visualization with diagnostic image quality. A total of 31 coronary artery aneurysms were identified. Ten tumors were small, fourteen were medium and seven were giant. The affected branches included 17/20 of LAD, 1/20 of LCX; 13/20 of RCA. Calcification was found in two cases and one case with thrombosis; five stenotic segments were found. ECHO failed to detect 6 tumors in LAD, 1 in LCX and 2 in RCA, and those included 6 small aneurysms. Discussion and conclusions. 64-slice MDCT is a useful modality for assessing young children with Kawasaki disease.

Scientific Session 2: Urogenital 17 - SP Unilateral hydronephrosis: morphological findings in MR urography Kassa Darge, Leslie LeCompte, Melkamu Adeb, Dmitry Khrichenko, Sarah Lambert, Pasquale Casale The Children’s Hospital of Philadelphia (CHOP) (United States) Purpose - Objective. To review morphological findings in MR urography (MRU) of high-grade unilateral pelvicalyceal dilatation (PCD) with a contralateral normal kidney. Material and methods. A retrospective morphologic evaluation of 22 cases, 10 males/12 females (0.1–17.3 years) with high-grade unilateral PCD was conducted. The MRU studies were carried out according to a standard protocol. Pre-contrast sequences included fat saturated axial/coronal T2 and 3D T2 urogram. Following parameters were evaluated: PCD grade, pelvic/calyceal neck diameter (mm), ureteropelvic junction (UPJ) angle relative to a horizontal reference line, crossing vessels, corticomedullary differentiation (CMD), parenchymal thickness and T2 parenchymal signal intensity.

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Results. Distribution of the PCD was 4 grade 3, 10 grade 4 and 8 grade 5. Mean intrarenal pelvic, extrarenal pelvic and calyceal neck diameters were in mm 25.5, 35.7, and 15.8 mm, respectively The average UJP angle in the dilated systems was 32 (−34–58) versus 27 (5–50) on the contralateral side. A crossing renal vessel was identified in 3/16. Decrease in CMD was seen in 7, with parenchymal thinning identified focally in 3 and diffusely in 17. Increased T2 signal was found subjectively in 4/20 dilated systems and qualitatively in 7/20. Discussion and conclusions. Multiple morphological features need to be assessed in the evaluation of hydronephrosis on the MRU. It is essential to incorporate these findings in subsequent combined interpretation with the functional part of the MRU.

18 - LP Unilateral hydronephrosis: functional results in MR urography Kassa Darge, Leslie LeCompte, Melkamu Adeb, Dmitry Khrichenko, Sarah Lambert, Pasquale Casale The Children’s Hospital of Philadelphia (CHOP) (United States) Purpose - Objective. To review functional results of MR urography (fMRU) in high-grade unilateral pelvicalyceal dilatation (PCD) with a contralateral normal kidney. Material and methods. A retrospective evaluation of functional results in 16 cases, 8 males/8 females (0.1-17.0 years) with high-grade unilateral PCD was conducted. The fMRU studies were carried out according to a standard protocol and post-processing using the CHOP-fMRU software. Fifteen minutes after diuretic administration, a dynamic coronal 3D fat saturated T1 sequence was performed over 15 min. A sagittal 3D T1 and delayed single coronal T1, both fat saturated, followed. The following functional features were evaluated: visualization of the ureter, presence of contrasturine level and swirling of contrast in the dilated renal pelvis. The functional results included calyceal transit time (CTT), renal transit time (RTT), time-to-peak (TTP), parenchymal volume (PV), differential renal functions (volumetrictovDRF, Patlak-pDRF and volumetric PatlaktovpDRF). Results. The ureter was visualized in 10, 3 during the dynamic sequence, 4/9 during supine delay and 3/7 only in prone position. A contrast-urine level was present in 14 and swirling in 6. A significant (p_gradeIII), either primary (18 cases) or secondary(10), underwent scintigraphy and ultrasound with ARFI. The results were compared with those obtained in 12 age-matched healthy controls. The results of ARFI were expressed as speed (m/sec)of wave propagation through the tissue: the stiffer a tissue the faster the wave propagation. A global ARFI value was calculated for each kidney through the sum of the values obtained at the upper, middle and lower third. The t-test per paired data was adopted. P values 0.05 were considered statistically significant. All data are reported as mean ± standard deviation.

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Results. The ARFI values obtained in the affected kidneys of the patients with renal disease (17.6± 4.5 m/s) were significantly higher than those measured in the contralateral unaffected kidneys of the same patients (13.2±4.76 m/s:p 0.017) and those measured in the kidneys of the healthy controls (9.3±0.18 m/s:p 0.001). The difference between the ARFI values in the unaffected kidneys of the patients with renal disease (13.2±4.76 m/s) and the kidneys of the healthy controls (9.3±0.18 m/s) was statistically significant too(p 0.04). Discussion and conclusions. These preliminary data demonstrate that ARFI quantification can provide reliable information about the severity of renal damage.

25 - SP Diffusion-weighted imaging of the kidneys in patients with haemolytic uremic syndrome (HUS): initial findings. Jochen Herrmann, Ulrich Wenzel, Stephanie Galler, Jun Oh, Markus Kemper, Sebastian Loos, Knut Helmke, Gerhard Adam, Christian R. Habermann University Clinic Hamburg-Eppendorf (Germany)) Purpose - Objective. To evaluate kidney function in patients with HUS using diffusion-weighted imaging (DWI) in comparison to healthy volunteers. Material and methods. Between Mai-Dec 2011, eight children (mean age 8y) and fifteen adults (mean age 33.3y) with acute diarrhea-positive HUS were evaluated using DWI focused on the kidneys. For comparison, age and sex matched volunteers were investigated. Echo-planar DWI was performed with a 1.5T system. Results. Mean ADC values (x 103 mm2/s) of the renal cortex were significantly lower in patients with HUS compared to healthy controls (adult patients, ADC cortex 1.79±0.23 vs. 2.02±0.1, p-value