key: cord-0909889-vf1b8aai
authors: nan
title: SPR 2018
date: 2018-04-30
journal: Pediatr Radiol
DOI: 10.1007/s00247-018-4130-z
sha: 340e4a9947bddbadc7e8ae274f46cb8b2f918c09
doc_id: 909889
cord_uid: vf1b8aai

nan

I am extremely pleased to welcome you to the 61 st meeting of The Society for Pediatric Radiology in the beautiful, vibrant city of Nashville, Tennessee.

We live in exciting, dynamic and challenging times. The world of medicine continues to evolve and advance at a remarkable and hectic pace. Radiology is at the center of this turmoil and affected in myriad ways. Imaging technology advances at a pace that is difficult to manage. New machines obtain more numerous and better images. New techniques allow for imaging of structures and diseases previously thought impossible. Imaging increasingly guides intervention and therapy. Imaging and imaged-guided interventional procedures are truly integral to modern pediatric healthcare delivery.

Many challenges persist. We constantly strive to achieve better images more efficiently (time and money), safely and with compassion. We challenge ourselves to maximize patient throughput, decrease reporting turnaround time, manage and limit radiation exposure, use contrast judiciously and safely, and address increasing concern with the use of sedation and anesthesia in children. Our clinical colleagues ask tough questions and want answers. Our researchers continually push the envelope of discovery.

Many important themes run through this meeting. Everything, however, comes back to the overriding theme of "Value-added Pediatric Radiology." Everything that we do in our daily work is aimed at improving the healthcare of the children that we serve. Everything that you will see and experience at this meeting will aid you to become a better pediatric radiologist or pediatric imaging technologist and take better care of your patients.

This meeting occurs at a time when our nation, inexplicably, is taking a deep look into issues of race, gender, diversity and inclusion. The SPR has always prided itself on being a welcoming, diverse, inclusive society. Ill-conceived laws in the states of Tennessee and California have forced the SPR to directly deal with this issue. As a professional society, we welcome this as a positive opportunity. We have created an SPR Diversity and Inclusion Committee, co-chaired by Ashok Panigrahy and Stephanie Spottswood. This important committee will help the SPR to evaluate itself. How are we doing as a society with diversity and inclusion? What can we do better? How can we help members to promote diversity and inclusion in their home institutions and in the care of our patients and their families? Dr. Spottswood, Associate Vice Chair for Diversity in the Department of Radiology at Vanderbilt University and Chair of the Office of Inclusion and Health Equity Advisory Board at Vanderbilt Children's Hospital, will deliver a keynote address "The Power of Diversity: Meeting Today's (and Tomorrow's) Greatest Healthcare Challenges" to the whole society on Wednesday, immediately prior to the Neuhauser lecture. There will be a workshop on diversity on Friday. I think that you will find these presentations thought-provoking and enlightening.

In current times, the health and well-being of children is under substantial threat by a small, but growing swell of child abuse denialism. For those of us that work in children's healthcare, this challenge is difficult to understand and rationalize. We work very hard to diagnose, to treat and to protect children and their families. We are extraordinarily careful to get the diagnosis right, be it child abuse or something else. However, there is much to be learned. We need to be careful, deliberate, regimented, collaborative and compassionate. I am delighted to have Paul Kleinman deliver this year's Neuhauser lecture. The lecture will be a capstone of a remarkable and impactful career. Paul's lecture, "Curious Bones: Sustaining Discovery in the Face of Doubt", will be an erudite look at where we have been, where we are and where we will go in child abuse imaging. A sequence of workshops will also address the important topic of child abuse.

I am indebted to Janet Reid and Jonathan Dillman for organizing and directing a spectacular Postgraduate Course. There will be two concurrent tracks, one on body imaging and the other on general pediatric radiology. Each topic will be a presented by paired speakers as a brief didactic followed by a response with cases. The paired speakers have diligently coordinated their presentations. I think that you will find this novel presentation mode exciting and educational. We are excited to include an updated version of RSNA Diagnosis Live™. We have dedicated a half day of one track to an update on Image Gently, organized by Don Frush and Keith Strauss, Chair and Vice Chair of the Image Gently Alliance, respectively.

Her early research was mentored by George Taylor, and included work with Carlos Sivit on trauma related to motor vehicle accidents and cranial ultrasound findings on ECMO. Since her first publications in 1984, she has published 131 papers, one of her most recent as a coauthor on "Neuroimaging findings in normocephalic infants with Zika virus" in Pediatric Neurology. This paper is an example of her intellectual curiosity on a cutting-edge topic combined with an international collaboration with physicians in Barranquilla, Colombia.

Dorothy views her role in the advancement of fetal imaging as her most significant professional contribution. She sees the progress in fetal medicine as a collaborative effort, and her involvement in this field as "one of the most exciting times". Her enthusiasm to share this knowledge resulted in the Society for Pediatric Radiology supporting a three-day fetal/neonatology meeting during her year as President of the Society for Pediatric Radiology in 2011. These meetings have now become highly successful biannual events. At Children's' she has been director of fetal imaging since she completed her fellowship, helping grow the program from its infancy. Besides numerous papers on fetal imaging, Dorothy is co-author with Beth Kline Fath on the textbook entitled Fundamental and Advanced Fetal Imaging. She has authored 35 book chapters and was prenatal/neonatal section editor with Tom Slovis for the 11 th edition of Caffey's Pediatric Imaging. Tom Slovis said of Dorothy, "Dorothy has been an outstanding partner throughout her career in pediatric radiology. She is fun to work with and a superb team member. She represents the best of pediatric radiology." Dorothy's passion for education is renown. She has been described as an "extraordinary teacher". In 2002, she a received a certificate as a Master Teacher through a George Washington University leadership development program. She has served as Program Director of the Fellowship Program at Children's National (2005-present) where she has impacted medical students, residents and fellows from the United States and abroad. She has served as education track chair for the RSNA and co-chaired the first and subsequent Education Summits of the SPR. She was a committee member of the ACGME radiology residency milestone committee and chaired the pediatric radiology milestone committee. She currently co-chairs the ACR pediatric radiology education committee. She was a founding member of the Image Gently Alliance, chairing the outreach campaign to parents, writing brochures, web material and articles to reach this most importance of audiences. She has been honored as an outstanding teacher with the Singleton-Taybi award from the SPR and this past fall, was awarded the Outstanding Educator from the RSNA.

Dorothy's role in international outreach in pediatric radiology is significant and impactful. In the words of Maria Ines Boechat MD, Founding President of the World Federation of Pediatric Imaging (WFPI), "From the time the concept of the WFPI was raised, Dorothy was a supporter and collaborator, playing an important role in convincing different societies' leadership that the WFPI was a feasible undertaking. As co-President of the London IPR in 2011, Dorothy and Cathy Owens officially launched the organization. She presided over the Education Committee for 4 years." Dorothy is now Chair of the ACR International Outreach Committee. She has given over 200 abstracts and scientific presentations nationally and 42 international invited lectures and 19 visiting professorships. Some of the countries she has taught in include Haiti, Ghana, Eritrea, South Africa, Poland, Russia, Brazil, Colombia, Thailand, Japan, and China. It is notable that for many of the international lectures she has given up to 20 lectures in a single week.

In her words, her involvement with the Society for Pediatric Radiology was a "gamechanger" in developing her career as a researcher, educator and advocate. Dorothy says, "Wonderful mentors such as Joanna Seibert, Janet Strife and Carol Rumack encouraged me to get involved. Working with mentors George Taylor, Tom Slovis and Marilyn Goske has been inspiring and made the work fun. The support SPR members have for new ideas, the flexible infrastructure SPR has for innovation plus the amazing execution by those involved particularly Jennifer Boylan, Karen Schmitt and Angela Davis have been amazing motivators. The SPR has been another family to me through the years."

Neil Johnson was born in Ballarat, Australia in 1952, the second of three children to parents who were not materially wealthy but highly valued education, achievement and hard work. Neil won scholarships to a local private school where students with a focus in science and related subjects were strongly supported. He and his older brother taught themselves basic mechanics, electronics, and backyard science. The occasional explosion, model aircraft crash or electrical short circuits were a feature of life in the Johnson household. Their younger sister, on the other hand, was a balancing model of common sense, tolerance and reason.

He attended medical school at the University of Melbourne where he graduated in 1976. During a neurology clerkship, he admitted one of the first patients to be scanned on the first CT scanner in Australia -the original "EMI Scanner". While that revolutionary but primitive machine clunked and rotated around the patient's head, images of a brain tumor with associated hydrocephalus magically appeared on the monitor and his future medical specialty became clear.

Neil moved to Hobart, Tasmania for his intern year where he developed a special interest in orthopedics, approaching it as a human version of motorcycle maintenance, a longtime passion that helped hone his mechanical skills. Neil also developed a passion for a nurse named Lorraine, who would become his lifelong partner and loyal mother of their three children. She may have made a different decision had she known that she and the children would be dragged backwards and forwards across the Pacific and end up in Cincinnati, Ohio! Moving back to Melbourne in 1977, Neil was a pediatric intern at the Royal Children's Hospital, but decided to switch his career focus from pediatrics back to radiology. He took a year off clinical service and worked as an instructor in anatomy where he helped to develop the teaching materials for a new undergraduate course in radiological anatomy. Moving on to the Royal Melbourne Hospital, Neil completed his radiology training and was lucky enough to do his final year as a trainee of Dr. Ken Thomson, an Australian pioneer of what would become interventional radiology.

Dr. Thomson arranged a fellowship for Neil at the University of Rochester, NY, Strong Memorial Hospital intending that he would return to Melbourne as an adult interventional radiologist. But Neil met and was inspired by Dr. Beverly Wood at Rochester and combined interventional and pediatric radiology training. A month after Neil arrived in Rochester in 1985, an MRI clinical and research magnet was commissioned and for the next two years, some of the earliest work on pediatric MRI was done at Rochester. Neil's 1988 SPR presentation on MRI anatomy of the infant hip was recognized with a Caffey award.

Neil and Lorraine arrived in Rochester in the middle of a blizzard with their first child, Christopher. They departed Rochester to return to Melbourne in 1988 with the addition of Luana and David. Returning to the Royal Children's Hospital in Melbourne, Neil was influenced by Dr. John DeCampo who developed an early radiology information system and who taught and practiced a common sense business approach to the organization of radiology services.

Neil was recruited back to the US in 1988 by Donald Kirks, who patiently waited nearly three years for the family to get green cards. When Don made the first offer while visiting Melbourne, Neil and Lorraine had to rush home and look up an atlas to find out just where Cincinnati was! So the family packed up and crossed the Pacific again in 1991, settling in Cincinnati and planning to look for a "real" pediatric radiology job on one of the coasts. Twenty-seven years later he is still at Cincinnati Children's Hospital, having worn many different hats in addition to that of an outstanding pediatric radiologist.

Neil was appointed Associate Director under Janet Strife and changed the entire workflow, installing the first radiology information system, holding radiologists accountable for timely radiology reports to referring clinicians. Neil proposed the installation of PACS in 1998, which led to filmless operations in 2002, followed by integrated electronic radiology orders and soon after, voice recognition.

In 1993, Neil and his brother's IT company in Australia developed a radiology report rapid word search system named "Radsearch," which enabled fast retrieval of the basic data behind many of the clinical research projects at Cincinnati. Later, with University of Cincinnati business school partners, a system called "Radstream" was developed and patented that prioritized the reading list so that the most urgent radiology studies were read first and also provided effective and rapid communication of radiology repots to referring physicians. Neil was asked to become the first medical director of hospital information systems in 2000 and proceeded to lead the planning and implementation of the hospital's first electronic medical information system, winning the prestigious HIMSS Davies Award in 2003.

He returned to radiology full time in 2007 and then became the first medical director of vascular access, contributing to the organization and implementation of an integrated nursing, interventional radiology and surgical vascular access service, which remains a national model. He also created and led the implementation of a system for prevention of peripheral IV injuries, which has now become widely adopted nationally and internationally.

All the time, Neil was becoming more involved with service to the SPR. He was the first chair of the SPR Informatics Committee. Neil and his son Christopher supported by family and especially by Jennifer Boylan, developed and maintained the SPR web site for many years. Neil and Christopher were awarded the SPR President's award in 2001 for that work.

Neil was President of the SPR in 2010 during the recession, yet was able to raise commercial support to help put on an excellent scientific, educational, and social annual meeting in Boston. Later, as Chair of the SPR Board, Neil convened the first face to face meeting and helped establish what would become Image Gently, as well as supporting the formation of the World Federation, co-chairing the foundation meeting of WFPI at the London IPR.

Despite all his success in systems organization, hospital and SPR leadership, Neil's first professional priority is individual patient care in interventional radiology. He has always been driven by the idea that "we should always do for patients what we would do for our own families and children." He has used his early experiences in orthopedics, medical imaging and motorcycle maintenance to develop a unique system of tools and methods for image-guided orthopedic procedures. He moved the IR service to the operating room in 2000 and helped create and execute the vision to integrate IR fully into the operating room.

Although work, individual patient care and career are important to Neil, mentoring junior colleagues, people and family are more important. Most important is his wife Lorraine, family and friends. The success of his children in their new country has been a great pleasure and comfort. When Neil sees junior colleagues spending a bit too much time and effort at work, one of his favorite sayings is "remember -your family will be at your funeral, but the hospital will not." Lorraine and Neil have been through occasional tough times as first generation immigrants with the nearest grandparents and family nearly 9000 miles away, but the toughest time was when 26 week premie grand-twins were born in Rochester, NY. Lorraine selflessly spent months living in Rochester, supporting the twins and the family. Although they struggled through many obstacles, the twins, who are now almost 9 years old, are excelling physically and academically.

Pioneer Honorees were first acknowledged in 1990 as a means to honor certain physicians who made special contributions to the early development of our specialty. The Pioneer Award now honors individuals who have advanced pediatric radiology through innovation, forethought and leadership.

"I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain." -Frank Herbert, Dune Richard Towbin, M.D. is being awarded the 2018 Society for Pediatric Radiology Pioneer Award for his significant role in the development and promotion of Pediatric Interventional Radiology. His contributions and commitment to this area of Pediatric Radiology have been influential in changing the way pediatric patients are treated and have benefited thousands of children.

Rich was born and raised in Brooklyn, New York. After high school, he moved to Cincinnati where he pursued his undergraduate studies, and he received a Bachelor of Science degree in Microbiology from the University of Cincinnati. He continued on there for medical school receiving his medical degree in 1974. Like many pediatric radiologists of his generation, Rich first completed a residency in pediatrics at Los Angeles Children's Hospital. However, while there he saw the light, and he returned to the University of Cincinnati to do a second residency in radiology, followed by a fellowship in pediatric radiology. During his radiology residency Rich was introduced to Interventional Radiology. Under the tutelage and mentorship of Dr. Corning Benton, at Cincinnati Children's Hospital, Rich performed his first interventional cases on pediatric patients, and he was hooked. He entered the world of Interventional Radiology in the late 1970's and early 1980's, just as the specialty was coming into its own, as a result of significant advancements in imaging and catheter and device technology. It was not lost on him that most, if not all, of the techniques and procedures being used to treat adult patients could be used to treat pediatric patients as well.

The above quote from Frank Herbert's Dune, one of Rich's favorite books, became a guiding principle for him during his career, and indeed, in his life. Fear of the unknown, fear of failure, fear of complications, fear of ridicule -none of these were seen by him as reasons to accept the status quo. During the early part of his career, spent at Cincinnati Children's Hospital and Children's Hospital of Michigan, he was among the first to introduce GI, biliary, and GU interventions in pediatric patients. He, along with a few others, developed the technique for percutaneous antegrade gastrostomy tube placement. He worked with many of the companies that manufacture the catheters and devices used in IR to modify them for use in pediatric patients. He invented several devices, including a neonatal pigtail catheter, a magnetic catheter, an over-the-wire magnetic catheter, and a button J tube.

During his career Rich has served as the Radiologist-in-Chief at Phoenix Children's Hospital, Children's Hospital of Philadelphia, and Children's Hospital of Pittsburgh, where under his leadership, each of these radiology departments, and in particular the IR sections, flourished and grew. He has published over 225 peer-reviewed articles, over 37 chapters or reviews, and one of the most comprehensive books on pediatric interventional radiology published to date. Recognized as a leader in pediatric interventional radiology, he has given over 250 invited lectures. He is a Fellow of the American College of Radiology, the Society of Interventional Radiology, the American Academy of Pediatrics, and the Society for Gastrointestinal Radiology. He has worked with the ACR and the SIR spearheading the development of standards for the practice of pediatric IR. He has served as the President of the Society for Pediatric Radiology and on the Society's Board of Directors. He has also served as the Treasurer of the Society of Interventional Radiology.

On a personal note Rich is the person who introduced me to the world of Pediatric Interventional Radiology. He has been a mentor, role model, colleague and friend for over 25 years. For me, what stands out about Rich is his boundless energy, his enthusiasm, and his passion for taking care of patients. He is an imaginative and creative individual, both professionally and personally, and he has a wild sense of humor. He has always enthusiastically promoted his trainees and has never been afraid of their successes, but rather, obviously feels a sense of pride in their accomplishments.

Rich has been a tireless advocate for pediatric IR and its continued growth, and he continues to push the boundaries of what can be done for pediatric patients in the IR suite. He has been an outstanding teacher and mentor not only for me, but for dozens of residents, fellows, and colleagues throughout his career. Many people who today practice Pediatric Interventional Radiology have been directly or indirectly influenced by him. It is without a doubt that the field of Pediatric Interventional Radiology would not be what it is today without the contributions of Richard Towbin, MD, FACR.

-Robin Kaye, MD

In the early stages of Dr. Avni's career in medicine, radiography was of paramount importance and ultrasound was an emerging, experimental technology. As an "early user" and pioneer in exploring the diagnostic capabilities of ultraound--especially abdominal, obstetrical, and pediatric ultrasound-Fred pushed the field forward with determination and a level of enthusiasm that was contagious. In fact, he was so gripped by the potential of ultrasound to enable the safe, rapid, accurate diagnosis of so many illnesses affecting women and children, that he returned to the Université Libre de Bruxelles (ULB), and in 1992, completed his PhD, magna cum laude, with the publication of his doctoral thesis on the "Contribution of obstetrical ultrasound to our knowledge of the natural course of some congenital diseases" -a work that simultaneously advanced our understanding of the capacity of obstetric ultrasound to evaluate fetal anomalies, and cemented the role of the pediatric radiologist as a natural fetal imager.

With the mentorship of John Kirkpatrick, Jacques Sauvegrain, and other luminaries in pediatric radiology, Fred developed an ever growing passion for the field during these early years of training-a passion which has not abated with time and is evident in every setting where Dr. Avni has worked.

As Chief of the Department of Pediatric Imaging at Queen Fabiola Children's University Hospital Brussels, from 1997-2002 , and then as Chairman of the Medical Imaging Department at Erase Hospital (ULB), Brussels from [2002] [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] , Fred has focused on developing Pediatric Radiology as a specialty-one that fosters close collaboration with other medical and surgical disciplines aimed at achieving the best possible outcomes for their young patients. Of Dr. Avni's many accomplishments, perhaps the greatest is his rare ability to cultivate and share his passion for the field, or, as he would say in his native French, "allumer la flamme chez les autres " (ignite the flame in others), especially the next generation of pediatric radiologists. ESPR 2010, Cathy Owens, Veronica Donoghue, and Mrs. Francois Diard Photo with John Kirkpatrick: ESPR, Florence, 1984 Dr. Avni currently serves as Professor Emeritus in Medical Imaging (ULB-Brussels), and as Senior Consultant and Director of the Ultrasound Division at the Pediatric Radiology Department of the Jeanne de Flanders (Mother and Child) University Hospital in Lille, France. In addition to spending time with his family and close friends, Fred enjoys genealogy, gardening and photography; traveling around the world (most recently practicing his Spanish in Mexico and planning a trip to South America); reading books (especially crime and historical novels); visiting modern art museums and exhibits; and going to the theatre and movies in Brussels and Paris.

When his closest radiologist friends were asked to say a few words about him, they offered these comments:

 Clever free spirit, curious, dynamic and fast, always in action, but unable to stay more than 5 minutes sitting during a congress.  Passionate, generous with his ideas, having contributed to the formation and education of numerous residents, medical doctors and radiologists, and responsible for numerous careers in pediatric radiology and prenatal imaging.  Excellent teacher and mentor, constantly participating in scientific societies, appreciated speaker in international meetings, and remaining involved in the day to day clinical work, helping pregnant women, neonates, infants and children.  Insisting on quality in his work and teaching and able to obtain the best from his colleagues. 

Favoring team work, a constant and efficient leader, able to federate individuals, and always ready to help the youngest and most timid. 

The wisest, most perspicacious, courageous and honorable man.  Fervent partisan of conciliation and discussion, in opposition to confrontation, and always present for friends and family.  A friend, who has favorably influenced a generation of radiologists from all over the world. Dr. John P. Caffey was regarded throughout the world as the father of pediatric radiology. His classic textbook, "Pediatric X-Ray Diagnosis", which was first published in 1945, has become the recognized bible and authority in its field. The seventh edition of this book was completed several months before his death in 1978. It has been among the most successful books of its kind in the medical field.

Dr. Caffey was born in Castle Gate, Utah on March 30, 1895. It is interesting that he was born in the same year that Roentgen discovered the x-ray. Dr. Caffey was graduated from University of Michigan Medical School in 1919, following which he served an internship in internal medicine at Barnes Hospital in St. Louis. He spent three years in Eastern Europe with the American Red Cross and the American Relief Administration, and returned to the United States for additional training in medicine and in pediatrics at the Universities of Michigan and Columbia, respectively.

While in the private practice of pediatrics in New York City at the old Babies Hospital of Columbia University College of Physicians and Surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in 1929. He frequently expressed appreciation and admiration for Ross Golden, Chairman of Radiology at Columbia Presbyterian Hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him.

Dr. Caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in 1945.

Dr. Caffey received many awards in recognition of his achievements. Outstanding among these were the Dr. Caffey's contributions to the pediatric radiologic literature were many. He was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. Infantile cortical hyperostosis was described by him and is called "Caffey's Disease". Dr. Caffey in 1946 first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. It was Dr. Caffey who first recognized and descried the characteristic bony changes in vitamin A poisoning. He recognized and described the findings associated with prenatal bowing of the skeleton.

In 1963, 3 years after his retirement from Babies Hospital, he joined the staff of the Children's Hospital of Pittsburgh as associate radiologist and as Visiting Professor of Radiology and Pediatrics at the University of Pittsburgh School of Medicine. Although Dr. Caffey came to Children's Hospital and the University of Pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. In Pittsburgh, he made four major new contributions to the medical literature. He described the entity, "idiopathic familial hyperphosphatasemia". He recognized and described the earliest radiological changes in Perthes' Disease. He called attention to the potentially serious effects of shaking children, and used this as a subject of his Jacobi Award lecture. He described, with the late Dr. Kenny, a hitherto unrecognized form of dwarfism which is now known as the Caffey-Kenny dwarf. The John Caffey Society, which includes as its members pediatric radiologists who have been intimately associated with Dr. Caffey, or who have been trained by his students, was established in 1961. This society is now among the most prestigious in the field of radiology. His book and the society named in his honor will live on as important memorials to this great man.

His greatness was obvious to all who worked with him. He was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. His dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. He was concerned with the written and spoken word and was a skilled semanticist. His book and his articles are masterpieces of language and construction. He stimulated and was stimulated and loved by all who had the privilege of working with him. Radiology and Pediatrics have lost a great man, but they shall ever have been enriched by his presence.

Bertram R. Girdany, MD JOHN P. CAFFEY AWARD PAPERS Gaussian noise simulating reduced X-ray dose does not affect sensitivity of a Neural Network trained to detect tibial fractures in X-ray images P031 9:30 9:40 Starosolski, Zbigniew

Toddler tibial fractures computer-aided diagnosis by convolutional neural network and transfer learning P032 9:40 9:50 Alsharief, Alaa Can combined diffusion-weighted imaging/conventional MRI replace post gadolinium-based contrast-enhanced MRI in the assessment of pediatric osseous sarcomas? P033 9:50 10:00 Ecklund, Kirsten Bone Marrow MR and MRS Evidence of Adrenal and Gonadal Hormone Replacement Therapy Efficacy in girls with Anorexia Nervosa P034 10:00 10:10 Eutsler, Eric Metal artifact reduction in pediatric dual energy CT using monoenergetic extrapolation MD, Facilitating a Radiology Curriculum in Haiti Using Tablet PCs: Progress and Challenges Jennifer L. Nicholas, Diagnostic performance of quantitative MRI parameters for predicting radiologic portal hypertension in autoimmune liver diseases P076 4:50 5:00 Stefek, Heather Relationship between 2D phase contrast MRI Rex shunt blood flow, Rex shunt diameter, and clinical indicators of portal hypertension P077 5:00 5:10 Romberg, Erin Validation of LI-RADS in Evaluation of Pediatric Liver Masses Malignancy risk stratification of pediatric thyroid nodules using ACR Thyroid Imaging, Reporting and Data System (ACR TI-RADS) P133 2:50 3:00 Low, Samantha

Streamlining primary care referrals for ultrasound assessment of paediatric cervical nodes in a NHS (UK) District General Hospital: Preliminary results from an ongoing study P134 3:00 3:10 Shah, Summit Hepatobiliary scintigraphy vs. ultrasound for assessment of gallbladder ejection fraction in pediatric patients with suspected biliary dyskinesia P135 3:10 3:20 Sharp, Susan Solid gastric emptying: does the 4 hour examination add value in children? Hands-on Exercise 9:00-9:20 a.m.

What Makes a Good Teaching Philosophy? Janet R. Reid, MD, FRCPC 9:20-9:50 a.m.

Hands-on Exercise 9 50-10:00 a.m.

Questions and Answers 10:00-10:10 a.m.

Break 10:10-10:20 a.m.

What Counts as Teaching Janet R. Reid, MD, FRCPC 10:20-10:50 a.m.

Hands-on Exercise 10:50-11:10 a.m.

Anh-Vu H. Ngo, Purpose or Case Report: To assess inter-radiologist agreement using newly devised consensus recommendations for reporting CT/MR enterography exams in pediatric small bowel Crohn disease (CD), which were developed by the SAR-AGA and endorsed by several organizations including the Society for Pediatric Radiology.

A single investigator identified 25 CT and 25 MR pediatric enterography exams (January 2015 -April 2017) with the following distribution of ileal CD severity based on clinical interpretations: normal or chronic CD without active inflammation (40%), active inflammatory CD (20%), stricturing CD (20%), and penetrating CD (20%). 5 fellowship-trained pediatric radiologists, blinded to one another and imaging reports, documented major imaging findings and impressions based on SAR-AGA consensus recommendations. Interradiologist agreement was evaluated using Fleiss' multi-rater kappa.

Results: Inter-radiologist agreement ( Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Magnetic Resonance Enterography (MRE) is often performed in Pediatric Inflammatory Bowel Disease (PIBD), in accordance with the Porto Criteria. While primarily focused upon assessing small bowel, MRE also includes the colon. The purpose of this study was to obtain sensitivities and specificities of MRE findings in unprepared colon in comparison with post-colectomy histopathology. We aimed to determine whether MRE was an effective modality for assessing the colon in these patients.

This study has Ethics Board approval. A retrospective review was performed to identify all patients who underwent MRE < 2 years prior to colectomy for PIBD, between 2000 and 2014. Pre-colectomy MRE was independently reviewed in a segmental fashion by two pediatric radiologists, blinded to the initial radiology reports, clinical and pathology data. The five segments assessed were the cecum/ ascending colon, transverse, descending, sigmoid colon and rectum. Bowel wall MRE findings for review included thickening >3mm, T2 hyperintensity, gadolinium enhancement, diffusion restriction, ulceration, penetrating lesions and colonic stricturing (Fig. 1) . Mesenteric MRE findings reviewed were 'comb sign', fibrofatty proliferation, T2 hyperintensity and gadolinium enhancement. This was reviewed with histopathology findings of acute or chronic inflammation or fibrosis. Frequency, sensitivity and specificity of MRE findings, relative to abnormal histopathology, were calculated per colonic segment. P-values were obtained using Fisher's exact test (P-value < 0.05 significant). Results: Twenty patients (M:F = 8:12) met the inclusion criteria. The mean age was 11.8 years (SD 8.0 -15.6 years) at clinical diagnosis of PIBD and 14.0 years Purpose or Case Report: Small bowel ultrasound (SBUS) is emerging as first line imaging for Crohn's disease given its wide availability, low cost, lack of radiation and ability for dynamic imaging. The purpose of this study is to evaluate the use of SBUS in pediatric Crohn's disease to assess response to infliximab therapy in conjunction with inflammatory markers and markers of mucosal healing.

Children with Crohn's disease requiring infliximab therapy were prospectively enrolled. Clinical activity, laboratory tests (ESR, CRP and fecal calprotectin) and SBUS were evaluated at baseline (T0) and following 14 weeks of therapy (T1). Quantitative and qualitative ultrasound parameters were evaluated: disease extension (cm); bowel wall thickness (mm); presence of bowel wall hyperemia, strictures, creeping fat, free fluid, abscess, and / or obstruction; and degree of bowel dilatation, peristalsis, and stool burden. Results: 13 patients were included. All patients achieved clinical remission at T1 (p < 0.01) as well as statistically significant decrease in ESR and CRP (p < 0.01). Patients with decreased fecal calprotectin (69%) showed a decrease in bowel wall thickness and disease extension at T1 (4.9 ± 1.5 mm and 6.8 ± 3.8 cm versus 5.5 ± 1.0 mm and 11.3 ± 1.4 cm at baseline, respectively). In patients with increased fecal calprotectin (31%) there was an increase in bowel wall thickness and disease extension at T1 (3.9 ± 0.7 mm and 4.6 ± 2.3 cm versus 2.6 ± 1.0 mm and 3.2 ± 3.2 cm at baseline, respectively), despite clinical remission. The number of patients with bowel wall hyperemia, free pelvic fluid and creeping fat decreased at T1. The presence of stricture and degree of bowel dilatation, stool burden and peristalsis did not change at T1. Conclusions: Although caution is needed due to the small sample size, data suggests that SBUS in conjunction with fecal calprotectin can predict response to therapy with infliximab, despite clinical remission. Imaging results were correlated with colonoscopy, histopathology, genetics and inflammatory markers. Imaging protocols were also evaluated to optimize study quality. Safety profile and dosing for each patient were recorded. Results: For our cohort, diagnoses were Crohn disease (n=8) and indeterminate colitis (n=3). One (n=1) was too early in the disease process for definitive diagnosis. We identified a total of 23 diseased bowel segments. CEUS qualitatively identified at least one segment of active bowel inflammation in all subjects correlating with clinical and gray-scale evaluation. Quantitative analysis was performed in all subjects. In four patients, time to peak confirmed active inflammation, which correlated with grayscale features of bowel wall thickening, hyperemia, with pathology performed within 0-10 months of sonogram, and with positive inflammatory markers (CRP, ESR, fecal calprotectin). Adaptations of our protocol were made throughout the study in response to reassessment of image quality with our average contrast dose per injection being 1.07 mL/ 0.044 mL/kg (range 0.016-0.078mL/kg). The average number of injections performed per exam was three. No adverse events occurred with contrast injection.

Conclusions: Our pilot study shows CEUS is feasible and can easily and safely identify actively inflamed bowel in IBD patients. With technique optimization, CEUS can be a promising alternative to conventional MRE, obviating the need for sedation or gadolinium.

Inter-reader Reliability Study of a New MRI Scoring System for TMJ Evaluation in JIA with the Use of Measurement Aids: Special Interest Group from the MRI in JIA in OMERACT Purpose or Case Report: Contrast-enhanced MRI remains the best available modality to detect and monitor juvenile idiopathic arthritis (JIA)-related inflammation and damage in the temporomandibular joint (TMJ). A multi-institution, multidisciplinary group recently drafted a new MRI scoring system for TMJ in JIA for standardizing diagnostic assessment and for use as an outcome measure. Objectives: 1) To test the inter-reader reliability of the new consensus scoring system, 2) to compare its reliability to previous independently-developed scoring systems, 3) to assess the effect of measurement aids (atlas and tutorial) on improving inter-reader reliability among radiologists and non-radiologists.

Thirty-one MRI exams of bilateral TMJs were scored independently using the new scoring system by 15 radiologists, 2 oral-maxillofacial surgeons, 2 pediatric rheumatologists, and 1 orthodontist. Thirteen readers were randomized into two groups: group 1 read without, and then with a pictorial grading atlas; group 2 read twice using the atlas, but with a calibration tutorial between readings. Group 3, consisting of 7 readers who participated in a previous study testing existing scoring systems, read once post-tutorial with the atlas. Singlemeasure, absolute agreement intraclass correlation coefficients of domain and total scores were calculated within the 5 radiologists in each group, and within the non-radiologists. Results: Among radiologists, 5-reader reliabilities ranged from .60-.73 across reading methods for the inflammatory domain, .79-.82 for the damage domain, and .76-.86 for total score. Inflammatory domain reliability of initial reading improved with atlas between groups 1 and 2 (.60 vs .73, p<.01), though this was not observed within group 1 before and after using atlas. Among non-radiologists, 2-or 3-reader reliabilities ranged from .40-.69 for inflammatory, .49-.70 for damage, and .51-.76 for total scores. Inflammatory score improved after using atlas (.40 vs .68, p<0 .001). When tested using the same readers (group 3) and subset of cases as the previous study, the inter-reader reliability of inflammatory domain improved compared to 3 existing scoring systems (.66 vs .34-.53, p<0.016). Reliability of radiologists in group 3 (long-term involvement in development), and group 2B (newer members) did not differ.

The new consensus scoring system showed goodto-excellent levels of inter-reader reliability, with improved reliability in the inflammatory domain compared to 3 previous scoring systems. Purpose or Case Report: We described the normal appearance and anatomy of the lateral carpus and base of the thumb by ultrasound in infants, to establish normative references based on age and body surface area (BSA). We hypothesize that characterization of the normal sonographic appearance of the pediatric base of the thumb and carpus will aid in preoperative assessment of infants with thumb hypoplasia.

Institutional review board (IRB) approval was obtained for this single-center pilot study. Healthy infants less than 12 months of age were enrolled. Infants with a known syndrome or musculoskeletal disorder were excluded. All enrolled participants underwent an ultrasound exam of the base of the thumb from the distal radial epiphysis through the first metacarpal was performed using a high frequency linear transducer. A pediatric radiologist acquired images. Longitudinal and transverse images as well as still and cine clips were obtained. Tissue contact was enhanced with the use of either a waterbath or standoff pad. Results: Ultrasonographic evaluation of the base of the thumb was performed in 9 healthy infants (aged 8.9 ± 4.5 weeks, BSA 0.27 ± 0.032 m 2 , 56% female). Our protocol measured craniocaudal (CC) and anterior-posterior (AP) dimensions in the scaphoid (triangle), trapezium (plus), and first metacarpal epiphysis (diamond); measurement were successful among all participants (Fig.1&2 ). The first metacarpal epiphysis was measured in three planes (CC, AP, and transverse). Assuming an elliptical shape, the areas of the scaphoid, trapezium, and first metacarpal epiphysis measured (mean ± SD) 0.23 ± 0.042 cm 2 , 0.19 ± 0.066 cm 2 , 0.11 ± 0.021 cm 2 , respectively. Area of the trapezium correlated well with age (by ordinary least squares regression, r 2 = 0.592) and BSA (r 2 = 0.602). Areas of the scaphoid and first metacarpal epiphysis demonstrated fair correlation with age (r 2 = 0.389 and 0.178, respectively) and relatively poorer correlation with BSA (r 2 = 0.326 and 0.116, respectively). The area ratio of the scaphoid/trapezius (mean ± SD, 1.31 ± 0.34) exhibited the least variability. Conclusions: Our data suggest that ultrasound is well suited for the evaluation of the carpus and base of thumb in infants. Data serves as a reference against which wrist and thumb abnormalities can be compared. To our knowledge, this is a novel acquisition protocol and the first description of ultrasonographically-derived normative data of this sort, which represent the study's primary strengths.

Purpose or Case Report: Stunted growth (height-for-age Z < -2) is an indicator of chronic undernutrition. Worldwide, over 155 million children under five years are stunted. Undernutrition contributes to almost half of all deaths in young children. This project aimed to test the use of portable ultrasound technology in the field to determine bone age in rural Ecuadorian children and investigate the association of the ultrasound measures with nutritional status of the children.

Ecuadorian children (n=129) from Cotopaxi Province in Ecuador participated in the Lulun II study which was a cohort follow-up to Lulun I, a randomized controlled study that evaluated the impact of eggs in early complementary feeding. Targeted ultrasounds of the hand and wrist were performed by a pediatric radiologist, a medical student, or a graduate student in public health within the children's homes and schools. Unique search pattern algorithms were developed for girls and boys based upon to the expected ossification centers at each interval defined by Greulich and Pyle. A Philips Lumify L12-4 broadband linear array transducer connected to a Samsung Galaxy tablet with an Android platform was used to perform the ultrasounds. Images were stored on the hard drive of the Samsung tablet and were evaluated by a pediatric radiologist who was blinded to the age of the child at the time of the interpretation. Linear regression modeling demonstrated that HAZ, female sex of the child, and frequency of intake for milk and eggs significantly and positively predicted bone age Z for children (R 2 =0.17; p<0.001).

Bone age in children around 3 years of age determined using a portable ultrasound device correlates to height-for-age in children with stunted growth and may prove to be an important tool in the evaluation of children's nutritional status and response to nutrition intervention in the field. Purpose or Case Report: Dual X-ray absorptiometry (DXA) is the most widely accepted and used technique to asses bone mineral density. However, in our country its use is limited by the high costs and lack of equipment with pediatric software. The BoneXpert software provides an automated radiogrammatic method to assess skeletal age. The program calculates the Bone Health Index (BHI), a measure of cortical thickness and mineralization, which is obtained from indices of three metacarpal bones. The purpose is to evaluate the correlation and concordance between BHI and DXA in healthy Mexican children and adolescents.

A cross-sectional study was conducted. We included 409 participants between 5 to 18 years, recruited from public and private schools in Mexico City. We obtained an anteroposterior radiography of the non-dominant hand for all participants. The images were analyzed using the BoneXpert® to obtain the BHI. In addition, we obtained a DXA readings of total body and lumbar vertebrae using a pediatric iDXA GE/V.15. We analyzed the correlations (Pearson correlation coefficients) and the concordance (Bland-Altman plots) between BHI and DXA. Local Committee approval HIM2015-055 / HIM2017-058. In all MRG and FG cases, the joint distension was optimal. Gadolinium extravasation rates were also similar between the groups: grade 0 in one FG case (2%); grade 1 in 24 MRG (63%) and 28 FG cases (67%); grade 2 in 9 MRG (24%) and 10 FG cases (24%), grade 3 in 5 MRG (13%) and 3 FG cases (7% Results: ICG demonstrated NIR-II fluorescence emission that strongly depended on the media. ICG fluorescence imaging in liver tissue phantom demonstrated visualization of structures at 3mm and 6mm depth in NIR-II window; the 6 mm structure was not visible in the clinically-used NIR-I window (Fig 1) . CNR values were significantly (p < 0.05) higher in NIR-II window (18.4 +/-0.6 at 3 mm depth and 5.6 +/-0.4 at 6 mm depth) compared to NIR-I window (11.2 +/-0.7 at 3 mm depth). In vivo vascular imaging in nude mouse demonstrated higher vessel conspicuity in NIR-II window compared to NIR-I window ( Fig  2) . Delayed abdominal imaging (~ 1 h post-administration of ICG) demonstrated higher CNR and improved edge conspicuity of bowel and intestines in NIR-II (Fig 3) . Conclusions: Strong ICG fluorescence in the NIR-II window permits visualization of deep structures with improved contrastto-noise ratio when compared to clinically used NIR-I imaging.

Translation of NIR-II imaging to the clinic is indicated. 42.5% and 40% of the cases had diffusion restriction in the corpus callosum and rest of the brain parenchyma respectively. Correlation analysis using Pearson Chi square test showed a significant association between the findings of diffusion restriction in the corpus callosum with diffusion restriction in the rest of the brain parenchyma and cervical spinal ligament injury (p -0.000002 & p -0.008 respectively). No significant association was found between diffusion restriction in the rest of the brain parenchyma and cervical spinal ligament injury. Conclusions: Diffusion restriction within the brain is welldocumented in relation to AHT and is thought to result from hypoxic ischemic injury. However our results suggest that diffusion restriction within the corpus callosum shares a common mechanism of trauma with cervical spinal ligament injury. Purpose or Case Report: Recent research on pediatric ependymoma has established two distinct major molecular subgroups of posterior fossa tumors, PFA-1 and PFA-2. PFA-1 ependymomas have a genetic profile that suggest an origin in the lower brainstem while the molecular signature of PFA-2 lesions points to a source in the rostral posterior fossa. We examined whether brain imaging and reported location of tumor at surgery support distinct sites of origin for these subgroups of posterior fossa ependymoma.

A board certified pediatric neuroradiologist, without knowledge of molecular or neurosurgical findings, reviewed preoperative MRI examinations of the brain for 40 children with proven posterior fossa ependymoma. Tumor location was classified as central or lateral based on whether the mass was centered in the fourth ventricle or outside the fourth ventricle. Hydrocephalus was graded on a four-point scale: grade 0 -no evidence of hydrocephalus, grade 1 -mild ventricular enlargement, grade 2 -substantial ventricular enlargement, grade 3 -substantial ventricular enlargement with transependymal flow of cerebrospinal fluid. Operative records were reviewed by two pediatric neurosurgeons who were unaware of the molecular and neuroradiological findings.

Putative tumor origin was classified as floor of the fourth ventricle, roof of the fourth ventricle, or lateral recess/cerebellopontine angle based on the operating surgeon's description in the neurosurgical record and the reviewing neurosurgeon's judgment of imaging and clinical data. Statistical analysis was performed for associations between the ependymoma subgroups and tumor location, origin, hydrocephalus, age at diagnosis, extent of resection and relapse. Results: More PFA-1 ependymomas were located laterally than PFA-2 tumors (p=.012) and the tumor subgroups differed in site of origin (p=.049) and pattern of relapse (p=.032). The PFA-1 and PFA-2 ependymomas did not differ in age at diagnosis, the presence of hydrocephalus, or extent of resection. Conclusions: Radiologic and neurosurgical criteria suggest that PFA-1 and PFA-2 ependymomas have distinct sites of origin. MRI findings indicate that the subgroups may have difference relapse patterns. Additional analysis with a larger cohort of patients is needed to truly establish these relationships. Purpose or Case Report: Palpable lymph nodes are a normal finding in the healthy paediatric population, particularly in the head and neck, with authors quoting figures over 90%. Additionally, true lymphadenopathy (LN) is most often benign, infections the commonest cause. This is a common cause of concern, with numerous referrals for radiological investigations, namely ultrasound. Different sizes and a round nodal shape with a short to long axis ratio (ratio S/L) over 0.5 have been suggested to correlate with an ominous diagnosis. This has been demonstrated for supraclavicular LN but no such association between lymph node size or morphology was shown for nodes at other sites. Furthermore, measuring methods are often unclear.

Our aim is to determine normal size range of head and neck lymph nodes in a healthy paediatric population.

Retrospective review of head and neck MRI studies of 200 patients aged between 5 months and 16 years. Exclusion criteria included fever, malignancy, surgery and other possible causes for LN. All studies were previously reported as normal. Eight different areas were assessed for the presence of lymph nodes (e.g. Image 1 and 2) and the short and long axis of the largest lymph node in each area was measured by two radiologists and the S/L ratio calculated. Results: Lymph nodes were most commonly identified in the posterior and deep cervical, submandibular and occipital regions. Table 1 shows mean size and ratio for all regions. The largest nodes are located in the areas where they are also most frequently identified. Ratios differ according to location, with a rounder shape in the pre-auricular and occipital areas. Groups were created, according to NICHD Paediatric Terminology and statistically significant differences in size and shape were demonstrated between them. Namely, size differences in the deep and posterior cervical regions were found between the Infant/Toddler and Early Childhood groups and the remainder of the groups. Significant differences in shape were found in these same regions, with nodules showing a rounder morphology, represented by a higher S/L ratio, in the Infant/Toddler group.

Conclusions: This is the first study to characterize the normal distribution, size and shape of head and neck lymph nodes in a healthy paediatric population. While MRI is not the standard method of radiological assessment of lymphadenopathy, it allows for accurate and operator independent measurements and this will hopefully serve as a reference for future studies. Purpose or Case Report: The neuroimaging yield in defining the etiology of sensorineural hearing loss (SNHL) is relatively poor, somewhere between 20-50%. In patients without structural defects or cochlear signal changes, there could be differences in gray-scale data below the threshold of the human eye. Gray-scale images can be post-processed to enhance perception of tonal difference using pseudo-color schemes. We aim to retrospectively evaluate a series of unilateral SNHL patients and otherwise normal MR exams for labyrinthine color differences after pseudo-color post-processing.

Methods & Materials: The brain MR database at an academic children's hospital was queried for "hearing loss". Exams from patients with deficits other than unilateral SNHL were excluded. 68 exams were reviewed; 42 were excluded due to motion, asymmetric soft tissue signal, structural abnormalities, and/or lack of high-resolution T2WI or FIESTA labyrinthine images. Thirteen aged-matched normal MR exams from patients without hearing loss were chosen for comparison. Pseudo-color was applied with assignment of specific hues to each gray-scale intensity value using Functool software of ADW 4.3 workstation. Gray-scale and pseudo-color images were qualitatively evaluated for signal asymmetries by a board certified neuroradiologist blinded to the side of SNHL. Results: 26 SNHL (mean 7.6+/-3 years old) and 13 normal control exams (mean 7.3+/-4 years old) met inclusion criteria. All SNHL and controls had normal gray-scale cochlear signal and all controls had symmetric pseudo-color signal. However, in 42% of the patients pseudo-color images revealed occult asymmetries localizing to the affected ear with "colder" hues (lower values), possibly reflecting complicated intralabyrinthine fluid in patients with SNHL. In the other 58%, no discernible cochlear color differences were present. No discordant findings were present. Purpose or Case Report: To evaluate the reliability of skeletal survey radiographs at detecting rib fractures compared to computed tomography (CT).

Following IRB approval, a retrospective review was performed on all patients who had experienced trauma and who had undergone both a skeletal survey and a CT of the chest and/or abdomen and pelvis within 30 days of one another from January 2009 -July 2017. All skeletal surveys were performed according to ACR-SPR guidelines using high resolution computed radiography. Images and reports were reviewed by a pediatric radiology fellow. Images were assessed for presence of rib fractures, location and evidence of healing in each modality. Results: Data was collected on 57 patients who met inclusion criteria. Patients ranged in age from newborn to 8 years old. 25 (43%) of patients analyzed had a total of 225 rib fractures confirmed on CT. 49 (22%) of these rib fractures were acute. 62 (28%) of these rib fractures were anterior, 118 (52%) were posterior, and 45 (20%) were lateral. 10 of these 25 patients (40%) had 38 fractures not visualized on chest radiographs but demonstrated on CT, yielding a miss rate of 17%. 24 of the 38 missed fractures were acute (63%) and 14 were healing or chronic (27%). Acute rib fractures were much more likely to be missed on radiographs and this discrepancy was statistically significant (p < 0.01). 4 of the 38 missed fractures were anterior (11%), 24 were posterior (63%), and 10 were lateral (26%). Posterior rib fractures made up the majority of overall rib fractures as well as the majority of missed rib fractures. The ratios between these two groups was not statistically significant. All rib fractures were best see on the axial plane on CT. 8 patients had experienced accidental trauma; 35 cases were confirmed cases of non accidental trauma; and 14 cases were suspected non accidental trauma or unknown mechanism. Conclusions: Skeletal survey radiographs in cases of accidental and non accidental trauma fail to demonstrate rib fractures in 17% of cases, compared to CT. Acute fractures are more likely to be missed than healing fractures and this difference is statistically significant. Location of rib fractures-anterior, posterior, lateral-did not affect the miss rate of rib fracture. Low-dose CT used in conjunction with radiography may be helpful. without fractures was identified from the parent set. Gaussian noise was then added to each test image, with relative standard deviations of 1, 2, 5, 10, and 20% respectively, resulting in a total of 6 superimposed noise levels ( Figure 1 ). Each image was then classified by the two CNN's. Results: CNN-16 returned a sensitivity of 81.8% and a specificity of 59.5%. CNN-64 returned an increased specificity of 79% but the sensitivity surprisingly dropped to 68.2%. When noise was superimposed on the images, CNN-16 showed no change in sensitivity, but the specificity steadily dropped from 59.5% to 43%. Similarly, CNN-64 showed practically no change in sensitivity, but the specificity dropped from 79% to 45%. (Figure 2 ) Conclusions: Reducing X-ray dose leads to increased noise levels in images. Yet, CNN's trained on images with no superimposed noise, were capable of reading noisy images with no change in sensitivity, although the specificity dropped significantly. The drop in specificity could be associated with the lack of superimposed noise in the training sets. CNN's have the potential to dramatically reduce the required X-ray dose for the radiographic identification of fractures. The positive ramifications as CNN accuracy improves with time will be less radiation burden to patients when radiographs are optimized for computer learning and diagnosis rather than for the human eye. Figure 3 ). The false positive exams were felt to be related to accentuated trabeculation which could mimic a nondisplaced fracture.

Our feasibility study on the use of CNN for CAD of tibial toddler's fractures has promise to automate and improve workflow for radiologists. Errors were primarily related to features not well represented in the training set. The training set in our study was relatively small, and we expect that with larger sets the overall accuracy will improve. Results: There was no significant difference in age (11 -18 yrs, mean 15.5 yrs), duration of amenorrhea (median 5 months), BMI (18.8 kg/m 2 ), or hormonal measures between the 2 groups at baseline. At 1 yr, mean T1 decreased by 2 ± 14 msec (estimate ± SE) in the active group, vs 25 ± 14 msec in the placebo group.

The 12-month change in T1 and T2 unsat increased with BMI in the active group but decreased in the placebo group (p=0.01 for interaction; figure) . Decline in UI from baseline to 1 year was greater in the active group than in the placebo group (p=0.02). There was no significant difference in change in total lipid between the 2 groups. T2 water showed a greater decrease in the placebo group than in the active group (p=0.02).

In our study population of adolescent girls with mild to moderate AN, there was no significant difference in total marrow lipid content change between control and hormone therapy groups by MRS. However, greater decrease in the unsaturated fat index as well as a greater increase in the T1 measurements in the hormone therapy group indicating less fatty marrow were seen. Decrease in T2 water in the placebo group may indicate more restricted water mobility with less red marrow. Our results suggest that combined adrenal/gonadal hormone replacement therapy impacts marrow fat composition and seems to arrest increased conversion of red to yellow marrow known to occur in girls with AN. Purpose or Case Report: Prenatal ultrasound has become the standard of care for prenatal screening and assessment of fetal anomalies; while fetal MRI is often obtained for equivocal findings or for further characterization of fetal anomalies seen on ultrasound. Congenital lung malformations, including foregut duplication cysts, congenital pulmonary airway malformations, sequestrations and hybrid lesions, are usually discovered on prenatal ultrasound and further evaluated with prenatal MRI and postnatal CTA prior to surgical resection. The goal of our study is to assess the potential added diagnostic value of postnatal CTA in the evaluation of congenital lung malformations by comparing the imaging findings from prenatal US and MRI with postnatal CTA and correlating them to those found in surgery.

Retrospective evaluation of pediatric patients who have undergone postnatal CTA and prenatal US or MRI between July 2004 and 2017 for a prenatally diagnosed congenital lung malformation. Surgical and pathologic findings were obtained from the patient's medical records. Each pre-and post-natal diagnostic exam was reviewed for lesion size, appearance, margin, and presence of abnormal artery or vein. Patients without pre-or post-natal imaging preformed at our institution were excluded. Results: The final study cohort consisted of 83 patients, 21 of which did not undergo surgical resection. Of the remaining 62 patients (22 females, 40 males; mean age at CTA, 5.0 ± 3 [SD] months; range, 1day -13months), histopathologic diagnoses included congenital pulmonary airway malformations (n = 40, 64%), sequestrations (n = 11, 18%), hybrid lesions (n = 8, 13%) and foregut duplication cysts (n = 3, 5%). 21/62 (34%) and 12/62 (19%) were found to have an abnormal artery or vein, respectively, associated with the congenital lung malformation at surgery. For the detection of anomalous arterial feeder, CTA was found to have a higher diagnostic accuracy compared to prenatal imaging: 21/21(100%) for CTA, 11/18(61%) for US, and 9/18(50%) for MRI. Similarly, for the detection of anomalous veins, CTA was also found to be more sensitive: 10/12(83%) for CTA, 1/9(22%) for US and 0/10(0%) for MRI. Conclusions: Prenatal US and MRI allows early detection and evaluation of congenital lung malformations but additional postnatal CTA adds diagnostic value in the detection of associated anomalous vessels, particularly in pre-surgical planning. Purpose or Case Report: Noonan's syndrome is a congenital multisystem disorder characterized by short stature, cardiac defects, and skeletal abnormalities. In 15-20% of patients, lymphatic abnormalities such as lymphedema, protein losing enteropathy, pulmonary lymphangiectasia, and chylothorax are described. In this study, we aim to demonstrate the central lymphatic imaging findings in Noonan's syndrome using both non-contrast T2 weighted imaging and dynamic contrast MR lymphangiography (DCMRL).

A retrospective review of children with a confirmed history of Noonan's syndrome who underwent DCMRL with a three-dimensional T2 weighted imaging between 1/2013 and 7/2017. Imaging was evaluated in consensus by a pediatric radiologist and pediatric interventional cardiologist who subspecialize in lymphatic imaging. T2 imaging was evaluated for pleural effusions and ascites along with increased signal in the soft tissues of the upper chest and neck, mediastinum, lungs in an interstitial distribution, periportal region, mesentery, and body wall. Anomalous lymphatic flow was identified on DCMRL and subjects were classified as central lymphatic flow disorder (CLFD) or pulmonary lymphatic perfusion syndrome (PLPS). The size and presence or absence of the thoracic duct (TD) was noted. The medical record was retrospectively reviewed. Medical management and lymphatic interventions along with outcomes including mortality were noted.

Results: A total of 5 subjects with a diagnosis of Noonan's syndrome underwent DCMRL with T2 weighted imaging. All subjects had some form of congenital heart disease. Subjects demonstrated abnormal T2 signal within the neck/axilla, mediastinum, interstitium of the lungs, and body wall. Pleural effusions were seen in all subjects and large volume ascites was seen in 2/5. An absent or hypoplastic TD was present in 3/5. 4 subjects with anomalous lymphatic flow to the lungs were classified as PLPS and 1 with multi-compartmental anomalous lymphatic flow as CLFD. All 4 subjects classified as PLPS improved, 2 were treated with lipiodol embolization and 2 were managed medically. The 1 CLFD subject expired following embolization.

Patients with Noonan's syndrome demonstrate central lymphatic flow disorders that can be successfully imaged with DCMRL. All patients imaged had anomalous lymphatic flow and half of the patients demonstrated an absent or hypoplastic central TD. Multi-compartmental anomalous lymphatic flow as seen in CLFD suggests a poor prognosis. Purpose or Case Report: Radiographic evaluation of cystic fibrosis currently relies on chest radiography or computed tomography. Recently, digital chest tomosynthesis has been proposed as an alternative. We have demonstrated the feasibility of a stationary digital chest tomosynthesis (s-DCT) system based on a carbon nanotube (CNT) linear x-ray source array. This system enables tomographic imaging without movement of the x-ray tube and allows for physiological gating. This is the first in-human study of s-DCT in cystic fibrosis patients. Methods & Materials: CF patients undergoing chest radiography were also imaged on the s-DCT system Three board-certified pediatric radiologists reviewed both CXR and s-DCT images for technique and image quality. CF disease severity was assessed by Brasfield score on CXR and chest tomosynthesis score on s-DCT. Disease severity measures were also assessed against subject pulmonary function tests. Results: Fourteen patients underwent s-DCT imaging following chest radiography. Readers scored the visualization of proximal bronchi, small airways and vascular pattern higher on s-DCT than CXR. Correlation between the averaged Brasfield score and averaged tomosynthesis disease severity score for CF was -0.73, p=.0033. The CF disease severity score system for tomosynthesis had high correlation with FEV1 (-0.685), FEF 25-75% (-0.719), and good correlation with FVC (-0.582).

We demonstrate the potential of CNT x-ray based s-DCT for use in the evaluation of cystic fibrosis disease status, in the first clinical study of s-DCT. Purpose or Case Report: We propose using the 'target mode' prospective EKG gating technique with volumetric 320-detector scanner for respiratory motion and gross motion compensation for routine lung and mediastinal CT in pediatric patients who cannot cooperate with volitional breath-holding, thereby avoiding the need for IV sedation or general anesthesia.

All chest and cardiovascular CT studies in patients ages 0-4 years performed at our institution between the period of January 2016 and September 2017 were included in the analysis. The target mode protocol was instituted in November 2016, with exposure time of 350ms, half-scan reconstruction, 80-100 kV and 30-150 mA (indication based). Heart rate was used to determine target phase and ImageExact (Toshiba, Tustin, CA) used to reconstruct a motionless phase of the cardiorespiratory cycle for the organ/s of interest (lung, mediastinum, vasculature). Rate of sedation for chest CT before and after the institution of the target mode protocol was compared using a test of proportions. Rate of call-back of patients for diagnostic inadequacy after an unsedated scan was monitored. Image quality grading by two radiologists on a 4point scale, and quantitative image quality assessment by a physicist are pending. Results: From Jan-Nov 2016, 232 out of 358 studies (65.3%) were performed with sedation/GA. From Dec 2016-Sep 2017, after the institution of the target mode protocol, 109 out of 310 patients (35.2%) were sedated. The 46% reduction in sedation rate was statistically significant (p<0.01) ( Figure 1 ). All unsedated studies were done free-breathing and were diagnostic for the clinical indication, with no callbacks. From November 2016 to July of 2017, the unsedated target mode protocol was implemented for all chest indications, but allowing for radiologist/clinician preference for use of sedation, accounting for most of the remaining sedated cases. Starting in July 2017, unsedated CT protocol was made mandatory for all indications except high resolution CT, inspiratory-expiratory CT and coronary stenosis evaluation. Further data collection after this change and quantitative image quality assessment are ongoing.

Volumetric imaging with target mode prospective EKG gating provides diagnostic studies with adequate cardiac, respiratory and gross motion compensation for most chest and cardiovascular indications in awake, free-breathing children aged 0-4 years, and almost halved the sedation rate at our institution. Purpose or Case Report: To characterize the imaging patterns of pediatric pulmonary blastomycosis.

Retrospective study included patients aged 0-18 years with pulmonary blastomycosis, who underwent chest x-rays or chest CT from 2005 to 2016, divided by age: 0-1 year, 1-5 years, 5-12 years, and 12-18 years. The following data was collected: age, gender, clinical information, imaging findings during the first two weeks of admission, extrapulmonary involvement, and presence of scarring on follow-up exams. Concordance between chest x-rays and CT was analyzed. Results: 36 patients were identified (28 males (78%)), age 3 month-17 years (mean 10.5 years). 0-1 year (2 patients, 1 male), 1-5 years (3 patients, 2 male), 5-12 years (12 patients, 12 male), 12-18 years (19 patients, 13 male). 35/36 patients had chest xrays, 12/36 had x-rays and CT, 1 patient had CT. Air space consolidation was found in 94. 4%, 76.5% unilateral (17 unilobar, 9 multilobar) . Right lung was more frequently involved. The predominant distribution included upper and middle lobes. 76% had air bronchogram. In 55.9% consolidation was mass-like. 38.2% had cavitation measured more than1 cm. Cavitation was present in male patients exclusively. "Bubbly" pattern (multiple small cavities, distributed along the bronchial tree) was seen in 32.4%. In 69.5% consolidations were associated with other abnormal findings: pulmonary nodules (50%, (70.6% bilateral, 76.5% measured 0.3-1 cm in diameter)), diffuse patchy opacification (26.5%), interstitial reticulonodular pattern (41.2%), hilar lymphadenopathy (23.5%), pleural effusion (20.6%) and subsegmental or segmental atelectasis (5.9%). Extrapulmonary disease was present in 5/36 patients: ribs osteomyelitis (2 cases), multifocal osteomyelitis, skull lesion and brain mass-like lesion. Pulmonary scarring on follow-up exams was found in 70.4%. In two patients younger than 1 year no pulmonary nodules, hilar lymphadenopathy or extrapulmonary involvement was found. Concordance between x-rays and CT was excellent for location and extension of consolidation, diagnosis of cavitation, "bubbly" pattern and nodules; good for air bronchogram and pleural effusion, fair for atelectasis; and poor for hilar lymphadenopathy and reticulonodular pattern.

We present the imaging features of pediatric pulmonary blastomycosis. In our series the most frequent pattern of lung involvement was the combination of consolidation with bilateral medium size lung nodules, accompanied by interstitial reticulonodular pattern. Purpose or Case Report: Retained Gadolinium (Gd) in bone tissue has been demonstrated pathologically in adults from gadolinium based MRI contrast agents (GBCA). Bone Gd deposition has not been yet demonstrated pathologically in children. The long term effects of retained Gd are unknown, but may be of potentially greater concern in children given their expected longer period of exposure. Several factors may influence Gd retention. Generally, greater accumularion is suggested with linear agents compared with macrocyclic chelates, attributed to lower chelate affinity. The purpose of this study was to investigate whether Gd bone deposits are present in pediatric patients receiving GBCA and to quantify the amounts present.

Following IRB approval, bone fragments preserved in either formalin and/or saline solution from craniotomies in 17 pediatric patients between 6 months and 20 years of age were analyzed for elemental Gd using inductively coupled plasma-mass spectrometry (ICP-MS). Eleven subjects underwent at least one contrast-enhanced MR exam, with six subjects having no known exposure to GBCA serving as controls. Two subjects, one of each group, were excluded due to insufficient bone samples. Type and dose of contrast agent, number and timing of contrast-enhanced MR exams relative to the surgery and absence of evidence of renal failure were documented for patients with known GBCA exposure. Results: Patient exposures ranged from 1 to >19 doses of GBCA including both macrocyclic and linear ionic agents. Gd was found to be present in bone tissue in all exposed patients, with concentrations ranging from <0.01 to 0.449 ng/g for saline preserved samples and 0.01 to 0.765 ng/g for formalin preserved samples. Those who received only macrocyclic agents showed lower levels of Gd retention compared to patients who received both macrocyclic and linear GBCA.

Conclusions: This study demonstrates the first pathologic confirmation of Gd retention in bone tissue of pediatric patients exposed to GBCA including both macrocyclic and linear ionic agents. While the significance of these deposits remains unknown, at this point it would be prudent to avoid unnecessary use of GBCA in pediatric patients. Purpose or Case Report: To assess safety and efficacy of gadoterate meglumine (Dotarem®) in patients <2 years of age by evaluating adverse reactions and image quality following contrast administration.

Pediatric patients < 2 years of age undergoing MRI with and without contrast were prospectively enrolled and received a weight-based intravenous dose of Dotarem (0.1 mmol/kg). Almost all patients (96.3%) received sedation/anesthesia before MRI. The occurrence of adverse events (AE) was assessed at the time of injection, up to 2 hours after MRI, and by phone contact using a standard questionnaire 24 hours after MRI. AEs were documented including time of onset, duration of symptoms, intensity, causality, and subsequent outcome.Three radiologists blinded to the patients' clinical histories evaluated image quality by comparing pre-contrast images to combined pre-and post-contrast images in order to assess improvement in border delineation, internal morphology, and lesion enhancement following contrast administration. Results: A total of 112 exams were completed in 111 patients (median 12 months; range 0.5 -23 months; males 56%). There were no reactions at the injection site within the initial 2 hours. A total of 14 patients (12.5%), who had all received sedation/anesthesia, reported minor reactions within 24 hours (median age 11 months, range 5-23 months; male 78.6%). Six patients (5.4%) reported emesis during the 24-hour period with 1 case (0.9%) occurring within the initial 2 hours, likely related to drinking formula after anesthesia. Mild rashes were reported for 1 patient (0.9%) at the injection site and 3 patients (2.7%) at remote sites. Four patients (3.6%) reported a flushed face/warmth. No patient experienced anaphylaxis. Image quality was evaluated in 110 exams, as no similar precontrast sequences were obtained in 2 exams. There was complete inter-reader agreement that post contrast images resulted in a 100% improvement in border delineation, internal morphology, and contrast enhancement.

No patient experienced AEs directly related to Dotarem, and the delayed onset of AEs was very limited. The higher reported rate of AEs in this study may be related to concomitant sedation/anesthesia as well as to over-reporting from parents due to 24-hour follow-up questionnaire. The study confirms a good safety profile for Dotarem in this very sensitive population. Use of Dotarem improved image quality and anatomic characterization compared to the pre-contrast images. Purpose or Case Report: One of the often described reasons against performing MR Urography (MRU) is the risk of sedation or anesthesia necessary to keep children motion-free. However, motion free imaging is crucial, especially during the dynamic contrast enhanced imaging. The purpose of our study was to perform MRU without sedation in infants using the feed-andwrap technique (FW-MRU) and motion-robust dynamic radial VIBE (DRV) imaging to test if this method can be used as a successful alternative to MRU.

The departmental protocol for feed-andwrap studies was used for infants undergoing MRU under 6 months of age. The protocol includes having the families arrive one hour prior to the scan timed to nap-times, 3 hours of fasting, feeding just prior to scanning, tightly swaddling and rocking the child to sleep. Patients were given IV hydration (10 ml/kg/hr NS) and Lasix (1mg/kg) prior to the start of scanning. MRU study included localizers, 3 plane T2FS, heavily T2 weighted 3D sequence, and dynamic contrast enhanced images using DRV and post contrast T1-FS axial images. DRV is used with compressed sensing image reconstruction to achieve motionrobust high spatiotemporal resolution imaging (3 secs/volume) with improved image quality, reducing streaking artifacts. The data was processed after the study using Sourbon's tracer kinetic model analysis to calculate differential renal function. Results: 7 infants attempted FW-MRU on a 3T Siemens scanner between April 2016 to August 2017 with a mean age of 3.0 months (range 1.9 to 4.5). Sequence scan time was 45 minutes. In 6 of 7 patients, the infant was able to complete the study. In these patients, diagnostic anatomical and functional information could be obtained which led to useful data for medical/surgical management. Sample images showing different phases of contrast enhancement are shown in two patients ( Figure 1&2 ). Sample Gadolinium concentration curve is shown in Figure 3 .

One patient was unable to fall-asleep and thus did not complete FW-MRU. 5/7 studies were performed for the indication of prenatal hydronephrosis. 2 studies were performed for complex genitourinary anomalies. Conclusions: In all infants who were able to sleep, FW-MRU succeeded in obtaining anatomical and functional information useful for clinical decision-making. Initial experience with FW-MRU demonstrates it to be a safe and effective means of obtaining anatomic and functional imaging of the urinary tract in infants under 6 months of age without the use of sedation or anesthesia. Purpose or Case Report: To assess the utility of the Urinary Tract Dilation (UTD) Classification System for grading postnatal hydronephrosis in predicting clinical outcomes.

We retrospectively reviewed charts of pediatric patients who presented with postnatal hydronephrosis from 2007 to 2017. We included patients diagnosed prenatally and those with urinary tract dilation discovered incidentally during the first year of life. Patients with neurogenic bladder and chromosomal anomalies, with extraurinary congenital malformations, or with followup of less than 24 months without resolution were excluded. Urinary tract dilation was graded using the UTD classification system followed by selection of a management protocol. Results: Preliminary results show high reliability and validity of the UTD classification system in predicting the need for surgical intervention or assessment of renal function. Conclusions: The UTD classification system can be used to accurately predict clinical outcomes in patients who need further assessment of renal function, antibiotic prophylaxis, or surgical intervention. Purpose or Case Report: Children with complex anorectal and genitourinary malformations undergo a multitude of tests often involving radiation and sedation/anesthesia throughout their lifetime. Contrast enhanced ultrasound (CEUS) is a radiation and sedation/anesthetic-free imaging technique that has been used in evaluation of the genitourinary system. We compared the results of intracavitary CEUS to traditional fluoroscopic/cone beam CT tests and surgical results in patients with complex anorectal and genitourinary malformations.

Six children with complex congenital anorectal and genitourinary anomalies (3 cloacal malformations, 2 anorectal malformations, 1 urogenital sinus) had traditional fluoroscopic contrast studies or cone beam CT and CEUS studies performed sequentially often using the same catheters to introduce the contrast. For CEUS, 0.5 mL Lumason in 500mL NS was instilled and imaged using ultrasound contrast mode and transperineal, anterior and posterior sagittal techniques. Anatomical relationships and measurements based on fluoroscopic studies, CEUS and surgery/endoscopy were compared. Results: In 5 of the 6 patients, the fistulous connections and anatomical relationships were identified both on CEUS and fluoroscopic or cone beam CT studies. In one male patient with imperforate anus, the rectourethral communication was only identified by fluoroscopic VCUG. However both CEUS and fluoroscopy revealed a urethral duplication. In the three patients with cloacal malformation, the length of the common channel, confluence of the vagina and rectum where they entered the common channel, and distance to the perineum were identified by both CEUS and contrast studies. All measurements and anatomical relationships were similar on fluoroscopic, CEUS and endoscopic/operative findings. Conclusions: CEUS is a novel way to image the child with complex anorectal and genitourinary malformations. As many of these children undergo many radiologic procedures and interventions requiring radiation and sedation/anesthesia in their lifetime, CEUS represents an attractive, radiation-free and sedation/anesthesia-free alternative imaging technique. Our comparison study shows that this method provides an accurate means of imaging these children without the need for radiation or anesthesia. Purpose or Case Report: The purpose of our project was to 1) design a life-like simulator for urinary catheterization in infant females 2) to evaluate clinician impressions of the currently available model (Fig 1) Purpose or Case Report: In pediatric patients with prior unilateral oophorectomy, physiologic changes are known to occur in the remaining un-resected ovary. However, the effect on the imaging appearance of the remaining ovary is not well described. Normative pediatric measurements are needed in the setting of a remaining unilateral ovary because size is an important indication of ovarian torsion and 15% of cases of ovarian torsion occur in pediatric patients. If there is a concern for torsion in patients with prior unilateral oophorectomy, it is not possible to compare the remaining ovary size to the contralateral ovary. Our aim was to determine the average remaining ovarian volume in pediatric patients with prior oophorectomy categorized by decade of life in comparison to patients with two normal ovaries. Conclusions: Although the mean ovarian volume is higher in patients of all ages with prior unilateral oophorectomy, the average volume remains <20mL, which is the reported volume previously correlated with torsion. The provided normative volumes can be used if there is concern for ovarian torsion in pediatric patients with unilateral oophorectomy. Purpose or Case Report: To estimate the frequency of multiple congenital thoracic anomalies at our center; determine prenatal ultrasound (US) and magnetic resonance imaging (MRI) features of multifocal congenital lung lesions (congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS), and hybrid lesions); and determine the most common distribution or site of origin.

Single center, retrospective IRBapproved searches of radiology and clinical databases were performed from 2008-2017 for prenatally diagnosed thoracic anomalies that had multiple surgically-proven abnormalities, including congenital diaphragmatic hernia (CDH) with BPS, lung lesions with a final diagnosis of more than one congenital lung lesion, and lung lesions associated with foregut duplication cysts (FDC). Lesion location, size, echotexture and signal characteristics were assessed on prenatal imaging and correlated with postnatal surgical pathology. Results: Of 410 CDH, 9 (2.2%) were associated with BPS. Of 817 lung lesion cases, 14 (1.7%) were multifocal with referral diagnoses indicating possible multifocality in 3/14 (21.4%). An additional 4 (2 CPAM and 2 BPS) were associated with FDC. Mean gestational age was 23 weeks (range, 19.2-36.6 weeks). All BPS were ipsilateral to the CDH (8 left and 1 right). Multifocal lung lesions were bilateral in 2 cases, unilateral multilobar in 7, and unilobar multisegmental in 5. Mean total CVR for multifocal lung lesions on US was 0.84 (range, 0.16-1.54). Lesion combinations were CPAM-CPAM in 9 cases, CPAM-hybrid in 3, CPAM-BPS in 1, and hybrid-hybrid in 1. Prenatal US and MRI both correctly identified multifocality in 7/14 cases (50%). Multifocality was identified postnatally in the remaining 7. Of the 5 unilateral lesions prospectively identified, multifocality was established through intrinsic differences in lesion imaging features in 1 case and through identification of a band of normal intervening lung in the remaining 4. Conclusions: Multiple thoracic abnormalities were infrequently encountered but can be detected prenatally. Of multifocal lung lesions, the most common combination was CPAM-CPAM, with a unilateral multilobar distribution. Differences in intrinsic lesion imaging features and identification of normal intervening lung between lesions allowed for prospective prediction of multifocality in almost half of the unilateral lesions. Prenatal recognition of multiple thoracic abnormalities is important for pregnancy counseling and postnatal surgical management. Purpose or Case Report: The prognostic value of multiple prenatal imaging biomarkers in the diagnosis and treatment of CDH has been well-established. Our purpose was to combine qualitative and volumetric analysis of the various fetal MR biomarkers within a single population and use weighted indices from these biomarkers to calculate a severity score in patients with CDH. This score might then be used to estimate risk of mortality in high-risk CDH patients and to assist in family counseling.

We retrospectively identified all cases of prenatally-diagnosed CDH at a single institution during 2004-2016. Factors identified on MRI included observed-to-expected total fetal lung volume (O/E TFLV), percent predicted lung volume (PPLV), and spleen, liver, and stomach position. Prenatal factors were compared with mortality. The ROC was optimized for O/E TFLV of 24% for mortality (sensitivity 64%, specificity 82%, AUC 0.72). Analysis was performed using bivariate and multivariate regression methods. Using weighted and normalized coefficients from the logistic regression of mortality, severity scores were calculated. The probability of mortality used to determine relative risk within this population was estimated using the method described in Figure 1 . Results: 41 patients were included in the study. Within our cohort of CDH patients, Mean (±SD) O/E TFLV was 32% ±22%, and survival was 41% (n=17). 48% had major comorbidities. Bivariate analysis identified O/E TFLV (p=0.007) and stomach position (p=0.049) as significantly associated with mortality. Multivariate regression revealed a relative weighting of prognostic factors as follows: O/E TFLV, stomach position, liver position, PPLV, and spleen position. These factors contributed to the probability of mortality results, as demonstrated in the Figure 2 . Conclusions: Using qualitative and volumetric assessment of various MRI biomarkers in patients with CDH, multiple of these biomarkers were found to be valuable collectively when assigned relative weighting, and multivariate analysis appears to stratify mortality. When combined into an algorithm after weighting, they can be used to estimate the probability of neonatal mortality and guide prenatal family counseling. Further studies are required for prospective validation. 27-30 weeks: 9.94 mm (SD 1.73); 31-34 weeks: 9.79 mm (SD 1.34); 35-37 weeks: 11 mm (SD 2.00). In the second trimester, the adrenal glands on T2W images were markedly hypointense and surrounded by bright perirenal fat. In the third trimester, the signal intensity on T2W images increased, the surrounding fat was obliterated and the glands became less conspicuous. They were bright on T1W images throughout the second and third trimester.

Conclusions: Normal adrenal gland sizes and signal intensities by prenatal MRI are reported. The ability to discretely identify adrenal glands on T2W images is high up to 30 weeks, but declines in the latter part of the third trimester. The visibility on T1W images increases with gestational age. The adrenal gland size increases with gestational age. Purpose or Case Report: Fetal Magnetic Resonance Imaging (MRI) is increasingly utilized in the evaluation of suspected or confirmed congenital anomalies. Ultrasound assessment of amniotic fluid volume (AFV) is standardized and widely used, however concurrent results may not be available at the time of MRI interpretation. Assessment of AFV is crucial but no quantitative technique is currently available for MRI. We developed and evaluated the performance of a novel analytic technique to quantify AFV on fetal MRI.

This is a retrospective IRB-approved study. A 3D steady-state free precession (SSFP) sequence on a 1.5 Tesla MRI system (Siemens Medical Solutions, Erlangen, Germany) obtained clinically as part of the standard fetal MRI protocol was used for measurement of AFV. AFV-measuring software was developed in a Windows (Microsoft, Redmond, WA) environment using Interactive Data Language (IDL, Harris Geospatial, Broomfield, CO). The entire SSFP MRI sequence was loaded into the program in DICOM format. Several parameters such as minimum and maximum signal intensity were set empirically. After a satisfactory region of interest (ROI) was produced and confirmed visually, the calculated volumes were saved in a tabulated text format per slice. To evaluate the performance of the program, a pediatric radiologist, blinded to the results, used a hand-tracing method to calculate AFV per slice. To assess for agreement between the radiologist-and computer-generated measurements, Bland-Altman plots were created and intraclass correlation analysis was performed by slice and by total volume, respectively. Results: AFV measurements were performed in six subjects in the late second and early third trimester (mean 25.6 weeks; range 23.0-28.6 weeks). Computer-analyzed AFV measurement is shown in Figure 1 . Results of each volumetric assessment are shown in Table 1 and Figure 2 . Bland-Altman plots for each subject by MRI slice demonstrated agreement between the radiologist and computer within normal variation. The intraclass correlation coefficient for total AFV was 0.883 where 0.75-0.90 represents "good reliability" (CI: 0.34-0.94; p=0.002)].

This novel computerized analysis quantifies AFV in fetal MRI and is concordant with radiologist-generated measurements thus offering a promising technique for objective MRI evaluation of AFV. Purpose or Case Report: Invasive placental disease (IPD), is a growing cause of maternal and perinatal morbidity in the setting of increasing Cesarean section deliveries. Failure to accurately diagnose this condition can have devastating effects on both fetal and maternal health. Presently, prenatal ultrasound is used for initial evaluation, with selected high-risk patients undergoing additional MR imaging. However, studies have shown both US and MRI to be limited in their ability to accurately detect the morbidly adherent placenta. We evaluated whether multi-b-value diffusion weighted MR imaging (DWI) and quantitative intravoxel incoherent motion (IVIM) analysis techniques can accurately detect a difference in perfusion between normal and abnormally invasive placentae.

In our PACS database, all patients who received DWI MR imaging over the past 12 months for suspected IPD (based on prenatal US) were identified, yielding 11 cases, and 29 normal volunteers were recruited to serve as a control group. Patients underwent MR imaging between 14-30 weeks gestational age, with the mean at 25 weeks for the disease group and 26 weeks for the control group. Multi-b-value (0, 25, 50, 100, 150, 200, 300 and 400) DWI sequences were obtained for all patients, and intensity normalized to the b-0 image (nDWI). A subset of cases were used as model priors for a multispectral neural networking classification (MSNN) model, where regions of interest for placenta, fat, high intensity areas, and background were defined manually and nodal weights backpropagated and stored for future classification. Using the training weights, each nDWI case was voxel-wise classified yielding a 3D object map for placenta, fat, high intensity, and background regions. Post segmentation, average regional IVIM analysis was performed, using the following model: Purpose or Case Report: Although the relative limb-length discrepancy (LLD) between unaffected and affected limbs in children with congenital skeletal anomalies is constant from birth to skeletal maturity (known as "constant inhibition"), the developmental pattern in utero is unknown. The widely used prenatal multiplier method to predict LLD at birth assumes constant inhibition in utero to be true. Verifying the in utero developmental pattern of LLD and thus, confirming the prenatal multiplier method for these fetuses is crucial for meaningful prenatal parental counseling. This study's objective is to elucidate the in utero developmental pattern in fetuses with lower limb congenital skeletal anomalies and LLD.

Clinical indications of 3605 lower extremity radiographs performed on infants (<1-year-old) at a large tertiary hospital over a 17 year period were reviewed. Inclusion criteria were: diagnosis of a lower limb congenital skeletal anomaly with LLD at birth, bilateral lower limb postnatal radiographs documenting the LLD, and mother's prenatal ultrasound documenting the LLD. Available measurements of femur, tibia, and fibular lengths on prenatal ultrasounds and postnatal radiographs were collected, and ratios between unaffected and affected bones were calculated. Prenatal and postnatal length ratios for each bone and their aggregate were compared. Results: Eighteen infants met inclusion criteria. Diagnoses were: posteromedial tibial bowing=6, proximal focal femoral deficiency=4, fibular hemimelia=3, tibial hemimelia=3, and congenital short femur=2. The postnatal and prenatal ratios between unaffected and affected tibias (n=17), fibulas (n=17), and femurs (n=13) were calculated. The correlation coefficients between the postnatal and prenatal length ratios were high for the tibia (R=0.987, p<0.0001, Fig. 1 ), fibula (R=0.982, p<0.0001, Fig. 2 ), femur (R=0.991, p<0.0001, Fig. 3 ), and their aggregate (0.984, p<0.0001). The relative differences in the postnatal and prenatal length ratios were small for the tibia (average=-0.026, SD=0.051), fibula (average=-0.025, SD=0.068), femur (average=0.012, SD=0.039), and their aggregate (average=-0.015, SD=0.057).

Our data indicate that the postnatal length ratios were equivalent to prenatal length ratios, supporting the constant inhibition pattern of LLD in utero. The constant inhibition pattern of LLD in congenital skeletal anomalies begins not at birth, but rather earlier in utero and validates the popular prenatal multiplier method for predicting LLD. : same as 1 and 2 except fixed 100 kVp; Protocols 5 and 6: same as 1 and 2 except fixed 80 kVp. Calculated radiation doses were set as 100% for Standard and estimated to be 100% for protocols 3, 5, and 50% of Standard for protocols 2,4, 6. Images were postprocessed using 3 different Seimens Safire iterative reconstruction (IR) algorithms (1, 3, 5) . Contrast to noise ratio (CNR) was calculated. Visualization of different anatomical body parts (vertebral body, long bones, ribs, mandible, hand, clavicle, spine) was scored on scale of 1 (poor) to 5 (best). Nonparametric Friedman test examined visualization of anatomy among protocols. Repeated-measure ANOVA analysis assessed differences in CNR. Exploratory analyses examined CNR differences between Standard and all protocol Safire 5 images Results: Friedman analysis showed significant difference in visualization of fetal anatomy between the Standard and other protocols (p<0.001), with simple effect Wilcoxon Signed Ranks tests showing that, except for Protocol 6, visualization for all other protocols differed from Standard (protocols 1,3, 5 > Standard; 2,4 < Standard; ps < 0.05). Exploratory analyses showed no significant differences in visualization of anatomy between Standard and Protocol 6 (p = 0.29) and Standard and Protocol 3 (p = 0.18), suggesting that these protocols could be interchanged, noting that Protocol 6 had 50% less radiation than Standard and Protocol 3. When evaluating CNR IR across protocols, analysis showed a marginally significant effect, with Safire 5 tending to have higher CNR than Safire 1 (p < 0.05) and Safire 3 (p = 0.09)

Conclusions: Using Protocol 6, similar visualization of fetal body parts is attained while radiation dose is decreased by 50%. Across protocols, Safire 5 IR tended to provide highest contrast. When translated to actual patients, these findings can help achieve further dose reduction while maintaining diagnostic accuracy Purpose or Case Report: Imaging autopsy (IA) in the perinatal period is an emerging service for providers and families, though little is known about how it compares with conventional autopsy (CA). Our purpose is to compare the two modalities using full unrestricted conventional autopsy (UCA) as the gold standard.

Following IRB approval, all patients who underwent imaging autopsy between May 2013 and September 2017 at our large tertiary children's hospital were enrolled. Review of the electronic medical record, including imaging and conventional autopsy findings, was performed. Findings at imaging autopsy, including suspected cause of death, were compared to those at conventional autopsy and subdivided by organ system. Results: Eighty patients underwent IA between May 2013 and September 2017 at our institution. Of those, 62 (78%) also underwent conventional autopsy, including 30 (40%) unrestricted and 32 (38%) with restrictions. Mean gestational age of the IA/UCA combination cohort at birth was 31.6 ± 4 weeks. Twenty-two infants (73%) with IA/UCA were liveborn, with survival ranging from 5 minutes to 6 months. Causes of death related to structural abnormalities were well characterized by both IA and UCA ( Figure 1 ). Seven (24%) discordant causes of death between IA and UCA were identified, with 6 accounted for by fulminant sepsis which was occult by IA ( Figure 1 ). One case of hydranencephaly by UCA was thought to be severe acqueductal stenosis by IA. Surface anatomy and intracardiac anatomy were more fully detailed at UCA and often not well visualized by IA. Placental information was included at UCA but not IA. Conclusions: Imaging autopsy may be a more palatable alternative to CA for some families, and determination of cause of death in the absence of perimortum infection is similar between the two modalities. In occasions in which CA is not authorized by the family, the combination of IA interpreted by an experienced reader, perimortum culture data, and external exam may be an alternative method to UCA.

Gaging Potential Risk to Patients in Pediatric Radiology by Review of Over 2,000 Incident Reports Elizabeth Snyder, MD 1 , elizabeth.j.snyder@gmail.com; Wei Zhang, PhD 1 , Kimberly Jasmin 1 , Sam Thankachan 1 , Lane Donnelly, MD 1 ; 1 Texas Children's Hospital, Houston, TX Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: One way to study the potential risk for a patient entering a pediatric imaging department is to perform a common cause analysis of submitted incident reports.

We studied incident reports submitted over a 5-year period in a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports.

During a 5-year period (2013-2017) , all incident reports filed were reviewed and categorized by modality: X-ray (XR), CT, ultrasound (US), MRI, Nuclear Medicine (NM) and interventional radiology (IR). Other factors also noted included whether the patient was inpatient (IP), outpatient (OP), or Emergency Center (EC) patient as well as whether they were or were not under sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between modalities, sedation and non-sedation, and inpatient vs outpatient were performed using a chi-square test. For modalities, a pair-wise comparison with adjusted p-value for multiple comparison by Bonferrioni method was also performed. Results: During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. Difference in rates by modality were statistically significant (p = 0.0001). There was a greater rate of incident reports in IR (1.54%) (p = 0.0001) and in MRI (p = 0.001) as compared to other imaging modalities (Table 1) .

There was a higher incident report rate for inpatients (0.34%) as compared to outpatient or EC (p = 0.0001) ( Table 2 ). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (p = 0.0001) ( Table 3 ). Harm was perceived as being done in 1,302 of the incident reports although there were only 2 events during this 5year period that were considered serious safety events by the institution, in which errors in radiology were primary contributing factors. Conclusions: Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential harm are IR, sedated patients, and inpatients. The areas associated with the least risk are US and XR. Safety improvement efforts should be focused on the high risk areas.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Daily Readiness Huddle (DRH) is a common way of assessing a department's ongoing ability to care for patients in a safe and efficient manner. Issues that arise are classified as a quick hit or a complex issue based on the ability to use existing policies/protocols and specialist input. In this work, we prospectively analyze quick hits, complex issues, time to resolution, impact on department workflow and describe our DRH experience.

We implemented DRH to improve the communication, accountability and address concerns promptly using the "S-MESA" approach. We used a unique "dyad" based approach, with dyads composed of a radiologist combined with a modality manager on the operational side, and a specialty clinician on the clinical side. Dyads were created for all major endeavors of the department, had a strategic role in programmatic growth, and were owners of complex issues. Quick hits were managed by quality coordinators with expert input for dyad members. Issues were classified as a quick hit if they fell into one of the following categories: Safety-including patient safety/employee safety Methods-dealing with existing protocols, policies or standard of practice for imaging Equipment-availability and functioning of equipment and technology Supplies-availability based on daily need Associates-staffing base on daily need The quick hits were followed to resolution, with the type of issues and days to resolution being documented. Results: Quick hits were tracked from Mar-Oct 2017. A total of 567 issues were classified as quick hits, with a majority (66.7%) involving methods and equipment (Fig1). Of the 220 methodrelated issues, the largest subcategories were care coordination, communication, unexpected high volume, scheduling errors, system errors and lack of policies or protocols for common situations (Fig2). The average days to resolution was 16.1 days (Fig3) with longer time to resolution noted in the early stages, and a progressive decline thereafter.

The DRH is a reliable format to discuss and resolve daily issues pertaining to safe and efficient patient care. A strategic approach to resolve quick hits is to empower quality coordinators to own the issues while seeking input from dyad specialists. This resulted in a progressive reduction in the time to resolution, a greater number of issues classified as quick hits rather than complex issues, and more efficient management of resources.

Ramesh Iyer, MD 1 , rameshsiyer@gmail.com; A. Luana Stanescu, MD 1 ; 1 Radiology, Seattle Children's Hospital, Sammamish, WA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Since the 2002 introduction of RADPEER, radiology peer review has been central to quality improvement programs. Peer review programs may be implemented in a variety of formats with variable levels of acceptance by practitioners. Current implementations carry some concerns including fear that punitive action may follow subpar performance, and the sense that the RADPEER process has little value beyond merely completing accreditation requirements. In an effort to understand concerns and opportunities to improve collaborative learning, the Society for Pediatric Radiology (SPR) Quality and Safety committee conducted a survey to aggregate member perspectives on peer review programs. Objectives: To evaluate the current state of peer review programs in pediatric radiology practices, including implementation methods, perceived functions, strengths and weaknesses, and potential opportunities for improvement.

An online 16-question survey was distributed to SPR members. Survey questions pertained to type of peer review system, the use of numerical scores and review comments with perceptions on the utility of each, how feedback on interpretive discordances is given, and the use of peer learning conferences. Ample opportunity for free-entry responses was provided.

Results: A total of 219 responses were collected (15.3% of survey invitations), 80.2% of these from children's hospitals. 50% of respondents use a PACS-integrated system. 35.3% report that departmental quality conferences are held every month, while 19.3% report that they do not occur. 85.6% report that comment-enhanced feedback for interpretive discordances is either very important or somewhat important to performance improvement. 67.7% of respondents either rarely or never check their numerical scores. 81.73% either strongly or somewhat agree that comments are more effective feedback than numerical scores. 93.3% either strongly or somewhat agree that peer learning conferences would be beneficial to their practice. 47.7% feel that their current peer review system should be modified.

Survey results demonstrate that peer review systems in pediatric radiology practices are implemented in a wide variety of ways, and a large fraction of respondents think that their systems should be modified. Most respondents feel that feedback in form of comments and peer learning conferences are preferred over numerical scores, and are beneficial for performance improvement. Purpose or Case Report: In recent years, there has been a movement towards more judicious use of computed tomography (CT) imaging in an attempt to limit patient exposure to ionizing radiation. Pediatric patients are particularly vulnerable to the detrimental effects of cumulative radiation exposure, and many efforts to delineate thoughtful use have been developed with this specific population in mind. The Image Gently Alliance created a campaign in the late 2000s advocating for safe and high-quality pediatric imaging worldwide. The landmark study by the Pediatric Emergency Care Applied Research Network (PECARN) in 2009 validated prediction rules to identify children at low risk for clinically-important traumatic brain injuries and thus avoid head CTs altogether in such patients. It is in the context of these efforts that review the CT utilization rates in the pediatric emergency department (ED) at an academic medical center from 2008-2017 and compare them with utilization rates from 2000-2006.

We examined ED admission data and identified patients under 19 years of age who underwent imaging procedures within one day of ED admission. We analyzed five different categories of CT imaging-head, cervical spine, chest, abdomen (including abdominopelvic), and miscellaneous-as well as selected categories for magnetic resonance imaging (MRI) and ultrasound. , we observed decreases in CT utilization across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT utilization were observed in infants (patients less than 3 years of age) than in children (3-12 years) or adolescents (greater than 12 years). Total utilization of abdominal and pelvic ultrasound increased, with the rise in abdominal ultrasound driven entirely by a steep uptick in the number of limited abdominal studies. Brain MRI utilization also increased over the final two years of the study period.

Our results suggest that recent efforts have in fact played a role in decreasing utilization rates of several major categories of CT imaging. Purpose or Case Report: To establish the institutional cost of imaging adolescent female patients with suspected appendicitis, improve the ultrasound (US) workflow by identifying and correcting systematic inefficiencies, and compare the cost of US versus MRI for imaging this patient population.

Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients with suspected appendicitis ages 11-18 undergoing non-contrast US or MRI exams of the abdomen and pelvis. Our institutional protocol is to evaluate for ovarian torsion in all adolescent females with suspected appendicitis. Using time-driven activity based costing (TDABC), capacity cost rates for each resource in the process map were established from institutional accounting data incorporating personnel, equipment, and facility costs. The cost of each process step was determined by multiplying step-specific capacity costs by the average time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each process pathway. Analyzing US technologist cycle time variation presented an opportunity to improve the US protocol. Through use of Plan-Do-Study-Act (PDSA) cycles, a revised, standardized ultrasound protocol was implemented and total US pathway costs recalculated. Results: Process maps for US and MRI pathways were generated from 248 US and 52 MRI patient encounters ( Figures  1 and 2 ). Mean total pathway time for patients undergoing US exams was 92 minutes longer than those undergoing evaluation with MRI. Total cost for US exams ranged from $171 to $367 (mean=$269), depending on whether the patient's bladder was full enough to perform the pelvic and appendix US exams concurrently. Following implementation of the revised appendix US protocol, average appendix scan times decreased by seven minutes (Figure 3 ). This resulted in a cost savings of $10 for all pathway routes, with total costs ranging from $161 to $357 (mean=$259). Total cost for MRI exams ranged from $159 to $167 (mean=$162), depending on whether MRI screening forms were completed prior to arrival at the MRI suite.

Our results show that MRI can be a faster and potentially less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While the cost of performing these exams will vary by institution, MRI may be a viable and in certain cases preferable alternative to US in this patient population. Purpose or Case Report: The purpose of this study was to identify what radiology services are provided after-hours in children's hospitals and how radiology departments deliver this coverage.

A web-based survey was developed and asked respondents to provide detailed information on their afterhours radiology coverage. A delegate from each hospital represented in the Society of Chairs of Radiology at Children's Hospitals (SCORCH) was invited to complete the survey. Results: Responses were submitted by 59% (47/79) of hospitals. Over 80% of respondents (39/47) indicated that their hospital provides contemporaneous interpretations of pediatric body radiology studies (radiographs, ultrasound, computed tomography) 24 hours a day, 7 days a week ("24/7"). The contemporaneous interpretations are provided by attending radiologists in 51% (20/39) of hospitals and 95% (19/20) of these interpretations are delivered in the form of final reports. The remaining 49% (19/39) of these hospitals rely on preliminary reports from radiology residents or fellows to provide contemporaneous interpretations. Emergency radiology sections are used by 36% (14/47) of hospitals to staff the overnight duration of the "24/7" coverage. In 79% (11/14) of these hospitals, these sections are composed of pediatric radiologists. Teleradiology services are used by 8% (4/47) for overnight service. Overall, 55% (26/47) of hospitals described scheduling at least 1 attending pediatric radiologist on a late-shift that extends variable durations beyond 5 PM to provide contemporaneous interpretations after-hours. Only 4% (2/47) provide strictly beeper-call coverage after 5 PM. The option to work remotely rather than in-house is offered to radiologists working after-hours in 21% (10/47) hospitals. Additional benefits such as increased income, more time off, or academic time is offered by (21/47) hospitals.

The majority of children's hospitals surveyed provide contemporaneous interpretations of pediatric body radiology studies with final or preliminary reports 24 hours a day, 7 days a week. Late-shifts staffed by attending radiologists are used by most surveyed hospitals to extend coverage for variable durations beyond 5 PM. Dedicated pediatric emergency radiology sections are commonly used to bridge late night and day shifts. Some hospitals provide additional incentive benefits for working after-hours including increased income, more time off, and the option to work remotely from home. Purpose or Case Report: Burnout is a psychological syndrome that is characterized by three major components: emotional exhaustion, depersonalization, and perceived lack of accomplishment. There are multiple stressors that have been shown to play a role in the development of burnout in medicine. The purpose of this study is to evaluate the impact of various causes of stress on the prevalence of burnout in pediatric radiologists.

An anonymous survey was sent to Society for Pediatric Radiology members that included adapted questions from the Maslach Burnout Inventory (MBI) measuring aspects of burnout including emotional exhaustion, depersonalization and perception of low accomplishment. Data on demographics and questions regarding multiple stressors that contribute to development of burnout were included, which are based on previous studies regarding burnout in medicine. Topics evaluated include the call burden, financial stress, work-life balance, healthcare evolution and job market changes, and radiology overall as a career choice. Results: The response rate was 460/1453 (32%). 50% of responding pediatric radiologists were female and 42% were practicing at academic institutions. Prevalence of emotional exhaustion was 66% (286/435), of depersonalization was 61% (265/433) and perceived lack of personal accomplishment was 15% (67/436). Work-life imbalance and stress related to caring for dependents were more prevalent among female radiologists (75%, p-value=0.019 and 45%, p-value=0.011). After hours call and competitive radiology job market were more prevalent stressors among female radiologists than male counterparts (53%, p-value=0.002 and 17%, p-value=0.030). In a multivariable logistic regression model predicting emotional exhaustion and depersonalization, after hours call and concerns about work-life balance were consistent and statistically significant predictors of burnout (ORs=2.3-7.6; p-value <0.001). Decreasing rates of reimbursement was an independent stressor associated with emotional exhaustion (OR=2.7; p-value=0.030) and financial strain was an independent stressor associated with depersonalization (OR=2.3; p-value=0.020). Conclusions: Emotional exhaustion and depersonalization are prevalent among the community of pediatric radiology. On call responsibilities, work-life imbalance, and financial concerns were strong stressors contributing to the burnout. These stressors were more prevalent among female radiologists. Purpose or Case Report: The 2016-2017 academic year represented a significant recovery of the diagnostic radiology job market. As the available number of jobs has increased, however, the number of pediatric radiology fellows has declined. This study examines the recent supply and demand for pediatric radiologists as well as implications for fellows and employers moving forward.

The Society for Pediatric Radiology (SPR) and American College of Radiology (ACR) Career Centers were analyzed each day from July 1, 2016 through June 30, 2017. Job advertisements for fellowship positions were excluded. Fellowship occupation rates were derived from data reported by the Accreditation Council for Graduate Medical Education. Projected fellowship interest was assessed using chief-resident-derived survey data from the American Alliance of Academic Chief Residents in Radiology.

Results: There were 97 unique full-time attending-level jobs for pediatric radiologists advertised on the SPR Career Center during the 2016-2017 academic year. Of these openings, 72% were advertised by universities or free-standing children's hospitals. Distinct peaks in job openings in November 2016 and March 2017 were apparent. Positions were posted for a median of 2 months and an average of 2.9 months. California and Texas were the states with the most openings. There were 96 jobs for pediatric radiologists posted on the ACR Career Center with a daily average of 16.2 pediatric radiology jobs, representing 3% of the average number of total diagnostic radiology jobs. The number of total jobs and pediatric radiology jobs have continued to increase in 2017. There were less than 2 pediatric radiology fellows for every 3 advertised positions in 2016-2017. Progressive declines in the number of pediatric fellows have been observed since 2013. Resident survey data forecasts continued decreases in the number of radiology graduates opting for pediatric radiology fellowships. Conclusions: Progressive declines in the number of pediatric radiology fellows creates a favorable job market for current trainees, however, employers should expect significant declines in the number of new graduates over the coming years. Stakeholders should devote efforts to improving the appeal of pediatric radiology to current and future diagnostic radiology residents.

Jonathan Dillman, MD, MSc 1 , jonathan.dillman@cchmc.org; Rakesh Patel, MD 1 , Tom Lin 1 , Alexander Towbin, MD 1 , Andrew Trout 1 ; 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Endoscopic retrograde cholangiopancreatography (ERCP) is considered the referencestandard for evaluation of biliary and pancreatic duct abnormalities. However, its use in children is limited by its invasive nature and small number of experienced providers. Magnetic resonance cholangiopancreatography (MRCP) is a well-recognized alternative that is able to provide high-quality images of the pancreatic and biliary system noninvasively. The purpose of this study was to determine the diagnostic performance of MRCP for detecting biliary and pancreatic abnormalities in a pediatric population, using ERCP as the reference standard.

Institutional review board approval with a waiver of informed consent was obtained for this retrospective, HIPAA-complaint investigation. Records from the Division of Gastroenterology and Department of Radiology were used to identify patients ≤18 years-old who had undergone both ERCP and MRCP within a four-week interval between January 1, 2013 and May 15, 2017. Biliary and pancreatic duct findings were documented for each modality to determine the diagnostic performance of MRCP (with 95% confidence intervals), using ERCP as the reference standard. Results: 54 patients met inclusion criteria. Mean patient age at time of ERCP was 10.4±4.9 years, and 25 (46%) were boys. Mean interval between ERCP and MRCP was 11.2 ± 9.7 days. For detection of any abnormality (n=99), MRCP had a sensitivity of 76.8% (67.5-84.0%) and a positive predictive value (PPV) of 81.7% (72.7-88.3%) ( Purpose or Case Report: Magnetic resonance cholangiopancreatography (MRCP) with secretin administration has been described as a non-invasive method of assessing pancreatic exocrine function. Normative data for pancreatic secretory response as measured by MRCP exist for adult patients but not for children. The purpose of this study was to prospectively determine normal secretory function as measured by MRCP for the pediatric population.

Methods & Materials: IRB approval was obtained for this prospective study of 50 pediatric volunteers ages a 6-16 years without a history of pancreatic disease. Volunteers underwent MRCP with secretin administration for calculation of normal pancreatic secretory function. Secretory function was quantified in terms of total secreted fluid volume through 15 minutes and in terms of secretion rate (mL/min) based on linear regression of the secretion curve from 0-15 minutes. Relationships between secretory function and size measures (age, height, weight, body mass index, body surface area [BSA]) were assessed with Spearman's rho and with step-wise multivariate regression. Results: Total secreted fluid volume through 15 minutes ranged from 32 to 162 mL with a median of 79 mL (5 th percentile = 43 mL). Secretion rate ranged from 2 to 9.4 mL/min with a median of 5.1 mL/min. Secretory function correlated with subject age and all measures of subject size. The greatest correlation was to BSA (rho=0.54 for total volume and 0.59 for secretion rate, p<0.0001) [ Figure] and BSA was the only predictor of secretory function in multivariate analysis. Effect size for BSA was a 38 mL increase in total secreted volume for every 1 m 2 increase in BSA.

Conclusions: Pancreatic secretory response as measured by MRCP with secretin is dependent on patient size, particularly BSA. Based on our population, total secreted fluid volume <43 mL (<5 th percentile) can likely be considered abnormal for a child. That said, normal secretory function in children <16 years of age is lower than previously described in adults suggesting the need for more granular age or size based normative cut-offs to asses pancreatic exocrine function in the pediatric population. Purpose or Case Report: Accumulating fibrosis in chronic liver diseases increases the resistance to blood flow through the liver and results in portal hypertension. Portal hypertension is an important source of morbidity and mortality in children with chronic liver diseases, including autoimmune liver diseases (ALDs). The purpose of this study was to determine the diagnostic performance of multiple quantitative MRI parameters for predicting the presence of radiologic portal hypertension in ALD patients.

29 patients with autoimmune liver disease (e.g., autoimmune hepatitis, primary sclerosing cholangitis) were enrolled in a prospective registry. Multiparametric MRI was performed on all subjects using a 1.5T imager (Ingenia; Philips Healthcare). Quantitative MRI sequences were performed through the mid liver, including ironcorrected T1 mapping (cT1), T2 mapping, T1rho mapping, and diffusion-weighted imaging (DWI, quantified as apparent diffusion coefficients [ADC]). MR elastography (60 Hz) of the liver and spleen was also performed. Anatomic MR imaging was reviewed by a single board-certified, fellowship-trained pediatric radiologist to document the presence of portal hypertension (based on the presence of at least 2 of the following 3 findings: ascites, splenomegaly, and portosystemic collateral vessels). Receiver operating characteristic curve analyses were used to determine the diagnostic performance of quantitative MRI parameters for predicting radiologic portal hypertension. Purpose or Case Report: The meso-Rex bypass (Rex shunt) shunts blood from the superior mesenteric vein to the left portal vein and restores physiological blood flow to the liver in patients with extrahepatic portal vein thrombosis. While the majority of shunts remain patent for years, a subset develop stenoses and may require intervention to restore flow. Compromised shunt flow can cause coagulopathy and variceal bleeding, but complications occur on a spectrum, making it difficult to definitively assess shunt function and plan intervention timing.

Our purpose is to determine the relationship between 2D phasecontrast MRI (PC-MR) measurement of Rex shunt blood flow and shunt diameter and compare shunt flow with platelet count, a clinical indicator of portal hypertension.

MR studies of all children with Rex shunts who underwent PC-MR (Siemens 1.5T Aera) from 2013-2017 were retrospectively analyzed. Minimum Rex shunt diameter was measured in 2 planes on contrast-enhanced MR angiography and was used to calculate cross-sectional area (π x r1 x r2) which was normalized to body surface area (BSA). Shunt flow (L/min) calculated from PC-MR (retrospectively ECG-triggered, 30 phases per heart beat, post-processed in QFlow, Medis) was divided by ascending aortic flow (L/min) to obtain the shunt to systemic blood flow ratio. Platelet counts drawn the same day as the MR were recorded. Correlations between minimum Rex shunt cross-sectional area, shunt to systemic flow, and platelet count were calculated. P < 0.05 was considered significant. Results: 25 children (median age 9.5yrs, range 2. 5-19yrs) with Rex shunts underwent MRI with PC-MR, most for routine Rex shunt surveillance. Median time between Rex shunt surgery and MR was 53 months (range 9-106 months). Median platelet count in 19 patients was 121 K/uL (range 42-232 K/uL). Significant relationships were seen between 1) minimum Rex shunt crosssectional area normalized to BSA and shunt to systemic flow and 2) between platelet count and shunt to systemic flow, with decreased flow corresponding to smaller shunt area (p = 0.027, r = 0.44) and lower platelet count (p = 0.021, r = 0.52).

Rex shunt blood flow correlates with shunt area and platelet count indicating a physiologic relationship between insufficient flow and development of complications related to portal hypertension such as thrombocytopenia. Rex shunt flow may represent a biomarker for shunt intervention need. Larger studies are needed to determine flow thresholds that will trigger intervention. 

Previous studies have demonstrated that pediatric coronary arteries can be adequately evaluated using a prospectively gated "step and shoot" technique. This technique acquires data during a fixed portion of the R-R interval over 3-5 heart beats with considerably lower radiation doses than the traditional retrospective method. Further advances in dual source CT, allow an ultrafast prospectively ECG triggered high pitch acquisition of the entire heart during a single heart beat with a sub-millisievert effective radiation dose. This technique has been shown to provide excellent coronary detail in adults with heart rates <65bpm, however its performance in children with higher heart rates is unknown. The purpose of this study was to evaluate if this gated ultrafast acquisition could be used to evaluate the proximal coronary arteries in children.

In this retrospective IRB approved study, the radiology database was searched for patients who underwent a clinically indicated prospectively ECG-triggered high-pitch dual-source CT between 2014 and 2016. Patients ≥18 years were excluded. The following data from the CT was recorded: age, sex, BSA, indication, average heart rate (HR), DLP, and CTDI vol. Images were then blindly assessed by two independent readers for overall image quality and quality of visualization of the proximal right and left coronary arteries using previously validated criteria. Interobserver variability and multivariate statistical analysis was performed. Results: 100 scans were assessed (age range: 1 day to 18 y, median 0.26 y), 58 males and 42 females. Mean DLP: 18.6 mGy-cm, mean CTDIvol:0.61 mGy, mean effective radiation dose: 0.7 mSv. There was moderate interobserver agreement, Krippendorff's α= 0.49. When multivariate analysis was performed, only HR remained significant predictor of image quality (p<0.001). When HR < 100bpm, image quality was adequate for coronary artery evaluation in 93% of cases compared to 66% for HR >100. Sub analysis of patients with HR >100bpm, showed when the BSA was ≥0.4 m2, coronary arteries were adequately visualized in 83% of cases.

In pediatric patients with heart rates < 100bpm, ultrafast prospective ECG-triggered high-pitch CT can routinely provide diagnostic quality imaging of the proximal coronary arteries with a sub-millisievert effective dose and may be considered in patients with even faster heart rates when the BSA ≥ 0.4m2. Purpose or Case Report: The incidence of myocardial bridging (MB) varies depending on the imaging modality utilized for coronary artery imaging. It is defined as a coronary artery coursing within the myocardium, completely surrounded by cardiac muscle fibres instead of along the epicardial surface. Computed Tomographic Angiography (CTA) is the most widely used non-invasive imaging test to diagnose this condition. Although usually silent, it can lead to myocardial ischemia, arrhythmias and even sudden cardiac death. We sought to determine the incidence of MB in a cohort of pediatric patients undergoing CTA for coronary anomaly evaluation.

The study was designed as a prospective evaluation following protocol IRB approval. We performed 184 CTAs for AAOCA using a uniform algorithm from 12/2012 to 02/2017. All the CTAs were performed without sedation, on a 320-detector volume CT scanner, with retrospective ECG gating.

No pharmacologic agents were used to lower the heart rate. All exams were performed with iodinated contrast, administered via a peripheral extremity line. All exams were timed to the descending thoracic aorta, using a manual bolus track technique to achieve optimal left heart opacification. Dedicated 3-Dimensional post processing was performed on a separate workstation.

Results: A total of 184 patients underwent CTA with 27 (15 %) positive for MB (16 males, 59%): 17 with AAOCA and MB (63%) and 10 with MB (37%) only. The median age was 12.4 (4-16.6) yrs, with 13 (48%) presenting as an incidental finding, 6 (22%) with exertional symptoms (5 with syncope), 6 (22%) with non-exertional symptoms, and 2 (8%) with signs of myocardial ischemia . The median length for MB on CTA was 25 mm (range of 15-30 mm) with the left anterior descending coronary artery being the commonest affected vessel. 12 patients underwent cardiac catheterization with 6 exhibiting positive fractional flow reserve (FFR). Of these 5 have undergone surgery with 4 patients receiving unroofing of the MB segment and 1 undergoing bypass graft. Conclusions: MB is often diagnosed in a pediatric patient undergoing coronary CTA for investigating an anomaly. In this prospective evaluation of pediatric patients, MB involving a coronary artery was diagnosed in 15% of patients. We saw a high co-incidence of AAOCA and MB (63%), which had a direct impact on patient management. As pediatric radiologists we need to be aware that AAOCA and MB often coexist. Echocardiography was performed in the cardiology echo lab, and a pediatric cardiologist interpreted each exam. The echocardiographic coronary artery measurements were documented and compared with corresponding measurements on CTA. The presence and location of coronary artery aneurysms was recorded. To determine aneurysmal dilatation on CT, in addition to z-score (echocardiography based) extrapolation, we compared the size of the dilated segment to the native apparently normal coronary artery segment. Results: 45 patients met the inclusion criteria. 30 patients were male (67%) with a mean age of 6.4 +/-6 years and median age of 4.3 years at the time of imaging (Table 1) . Wilcoxon signed rank test was applied to compare the echocardiographic and CTA measurements. Coronary artery measurements showed a statistical difference in the left main coronary artery, proximal left anterior descending (LAD) and distal right coronary artery (RCA) (Table 1, Figure 1 ). CTA detected a total of 63 aneurysms as compared to 53 on echocardiography. Echocardiography missed 2 aneurysms each in the proximal LAD, mid RCA and distal RCA, and one aneurysm each in the proximal RCA, proximal circumflex, mid LAD, and conal branch. The aneurysm missed in the proximal RCA was heavily calcified on CTA. Conclusions: CTA is complementary to echocardiography in evaluation of coronary arteries in the setting of Kawasaki disease, especially the distal course. In patients with known distal coronary artery involvement CTA should be considered for follow-up. Purpose or Case Report: Delayed myocardial enhancement (DME) is a well-established method to assess myocardial fibrosis. In the pediatric population, utilization of the traditional segmented fast gradient echo inversion recovery technique (IR-GRE) is often limited by inability to breath-hold due to its long acquisition over several heartbeats. Single shot imaging (SS-GRE), wherein a slice is imaged in a single heartbeat, may overcome this limitation. However, establishment of utility and comparison to traditional DME methods is lacking in the pediatric population. We sought to evaluate the feasibility of using free-breathing (FB) SS-GRE for DME evaluation in a population with Duchenne muscular dystrophy (DMD), and to compare it with conventional breath-held (BH) IR-GRE technique.

Methods & Materials: Cardiovascular magnetic resonance imaging studies from fifteen consecutive patients with DMD imaged from August 2017 to October 2017 were retrospectively analyzed. All subjects were scanned with both BH IR-GRE and FB SS-GRE sequences in the short-axis plane, 6-10 minutes after Gadavist injection to assess for presence of DME. IR-GRE slices were acquired over 8-10 heart beats (~50 ms per heartbeat), while SS-GRE slices were acquired in one heartbeat (~250 ms). Both sequences had a spatial resolution of 1.8x1.8x8 mm 3 . Image quality was evaluated in blinded fashion by two independent readers using a Likert scale scoring system of 1-5 (1= non-diagnostic, 5= excellent), and the presence of DME was similarly assessed. Wilcoxon Rank-sum tests were used to compare the two sequences. Purpose or Case Report: Despite improved survival, many patients after total cavopulmonary connection (TCPC) will develop end organ dysfunction including the lymphatic system. In this study, we aim to demonstrate that lymphatic imaging using a highly T2 weighted sequence in patients post superior cavopulmonary connection (SCPC) is associated with post TCPC outcomes.

A retrospective review of all patients with history of surgical palliation with SCPC who underwent magnetic resonance (MR) imaging with a three-dimensional (3D) T2 weighted Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) sequence. Images were scored, blinded to clinical outcomes, based on the location of increased T2 signal on a scale of 1 to 4. Type 1 was interpreted as little or no increased T2 signal, type 2 as increased T2 signal within the supraclavicular region only, type 3 as supraclavicular T2 signal with extension into the mediastinum, and type 4 as supraclavicular T2 signal with extension into both the mediastinum and interstitium of the lung. The medical record was reviewed for the rate of TCPC completion, TCPC take-down, duration of post TCPC hospitalization and pleural effusion, postoperative diagnosis of plastic bronchitis, need for transplant, and mortality. Results: A total of 83 subjects were identified. 64% of the subjects (n=53) were classified as type 1 or 2, 20% (n=17) were classified as type 3, and 16% (n=13) Purpose or Case Report: Although computed tomography and interventional procedures are known high dose radiological examinations, fluoroscopic exams are overlooked in their contribution to patient radiation dose. Fluoroscopic exams are often misperceived as being equivalent in dose to an x-ray. Clinicians are unaware that these exams consist of multiple images and are operator dependent in the amount of dose administered. Furthermore, clinicians are unaware of the doses administered and dose reduction campaigns. The purpose of this study is to assess referring clinician knowledge before and after an educational session addressing pediatric radiation dose, dose awareness campaigns and the performance of fluoroscopic examinations.

A voluntary 12-question multiplechoice examination, covering topics of pediatric fluoroscopic examinations, radiation dose exposure, and dose awareness campaigns was given to pediatric residents, fellows and faculty from the Department of Pediatrics at our institution. The residents, fellows and attendings were then given a one-hour long education session. The same test was given to the subjects after the education session to assess knowledge gained. A student's independent sample t-test was used to compare the preand post-test scores.

Results: A total of 30 participants completed the pretest examination resulting in an average score of 5.67/12. The highest score achieved on the pre-test was 11/12. Only 23 participants completed the post-test examination resulting in an average score of 9.78/12. Of the 23 post -test participants, only 2 achieved a perfect score. Student t-test revealed a statistically significant increase in knowledge points after the educational session.

Conclusions: This project revealed clinical gaps of knowledge in regards to fluoroscopy in the pediatric population as well as pediatric dose awareness campaigns. In fact, only 8 out of 30 pediatric clinicians were aware of the "Imaging Gently" campaign. Lack of knowledge in set up of the fluoroscopic suite and amount of radiation administered during these exams also revealed that clinicians were not aware of how these exams are performed. However, it was determined that an educational session is effective in increasing overall awareness of radiation, dose administered and dose reduction campaigns amongst pediatric clinicians in regards to pediatric fluoroscopy. It is our hope that radiation dose awareness amongst clinicians will result in reduced overall radiation exposure in the pediatric population. Purpose or Case Report: Placement of a transesophageal feeding tube is a routine procedure for inpatients. Rarely, malpositioning in the airway may result in feeds being delivered into the lung, a critical adverse event. Radiography (XR) is the most accurate way to check feeding tube position, but its use is not standard. Care providers may be reluctant to order XR due to concern over radiation or uncertainly about which exam to order. Because the radiopaque tip of feeding tubes used at our institution is easily visualized under lower dose conditions, we developed a reduced dose and limited field of view XR protocol for focused evaluation of feeding tube placement.

This work was conducted as a quality improvement project. We identified the area of interest as being between the mid-chest and iliac crests. For each age group, we maintained standard kV and set mAs as low as possible. Three reviewers assessed visibility of a Corpak Viasys 6 French feeding tube at the lower limits of mAs in anthropomorphic phantoms. We then began 2 weeks of monitored clinical use in the pediatric intensive care unit. For each age-based XR protocol, we compared kV, mAs, and exposure index (EI) for the new protocol to the most recent abdomen XR in an index patient. Three radiologists assessed tip visibility, tip location, and image quality. Image quality was defined as routine diagnostic, somewhat limited, very limited, or non-diagnostic. Results: Tip of the feeding tube was visible at the lowest mAs setting in all phantoms. During our 2-week monitoring period, 14 exams were performed. Age groups examined were 0 -6months (group 1), 6-months -2-years (group 2), and 6 -10-years (group 3), the majority in group 2. For an index patient in group 1, mAs was reduced by 66% and EI by 81%, while reviewers rated tip visible, location identifiable, and image quality "routine diagnostic". Group 2 results were the same as group 2, except image quality was "somewhat limited". In Group 3, mAs decreased by 71% and EI by 87%, while tube tip remained visible, location identifiable, and image quality "somewhat limited".

We show that focused evaluation of feeding tube tip location is possible using 66 -71% lower mAs and EI reduction of 81 -87%. Further protocol development will focus on statistical population doses, wider age range, and tabletop technique. Our preliminary work offers clinicians a simple, lowrisk method for verifying tube placement, reducing barriers to safe feeding tube use. reviewed the images in the axial and coronal planes, and then marked the appendix on the best axial image. They rated the likelihood for appendicitis on a 6-point scale (1-definitely normal to 6-definitely appendicitis) and the visualization of the appendix (1-well-visualized to 6-obscured). ROC curves were created for the diagnostic accuracy. Then, using a sliding scale, they changed the amount of noise in the study, adjusting it until diagnostic confidence decreased (Fig 1) . Marked appendix region stochastic noise was calculated at baseline and toleration level (Fig 2) . The noise tolerance for cases ranked 1-2, definitely or probably normal, was 2.19, for 3-4, possibly normal or appendicitis was 1.80, and for 5-6, probably or definitely appendicitis was 2.01. The easy to visualize appendixes noise tolerance was 2.15, appendixes that needed coronal images to confirm was 1.85, and appendixes that were difficult or obscured was 1.80. Conclusions: High ROC results are similar to published studies. Baseline appendix region stochastic noise was nominally 6.75 HU. The 2-fold noise tolerated by observers suggests a dose reduction potential of 75%. Easier to diagnose or visualize cases tolerated more noise than borderline diagnostic or difficult to visualize cases, indicating the need for challenging cases to avoid overestimating dose-reduction potential. These findings will be used to set the noise ranges to be tested in future dose simulation studies to achieve ALARA. . We compared brain CTs referred from the emergency room imaged on both scanners for reconstruction times, image quality, radiation dose, and physician diagnostic confidence.

This retrospective, HIPAA compliant and IRB approved study included 400 consecutive patients imaged with standard age-based protocols (<1.5 years, 1.5-6 years, 7-12 years, >13 years) using FBP image reconstruction (Brilliance 64), or using new low dose protocols designed for use with IMR image reconstruction (iCT 256). Patients with repeat studies, scans with excessive motion, metallic implants, or when the incorrect age-based protocol was used were excluded (n=27).

Regions of interest (ROI) were drawn on the right thalamus and the right frontal white matter of each scan, and signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were calculated. Patient age and estimated radiation dose (CTDI) were recorded. Study reconstruction times were determined by comparing the image creation times of the first image and the last image reconstructed.

Results: A total of 173 patients were imaged in the ED using FBP and 190 children were imaged in the main department using IMR reconstruction. The average reconstruction time of cases performed with FBP was 100 seconds, and with IMR was148 seconds. CTDI was reduced in all 4 age groups (14.5%, 20.3%, 28.0% and 34.1%) using IMR protocols, while SNR and CNR both improved two-fold. Conclusions: IMR knowledge-based iterative reconstruction allowed us to reduce radiation dose an average of 24% for children undergoing emergency head CT exams, with only minimal increase of study reconstruction times, while improving image quality SNR and CNR two-fold. Purpose or Case Report: Investigations on impact of tube current (mA) reduction on detection of pediatric hepatic lesions have faced numerous obstacles including different phases of enhancement, lesion validity, exposure to additional radiation and the risk of a non-diagnostic exam. Our goal was to create a systematic, highly controlled observer performance paradigm for evaluation of simulated, subtle abnormalities (liver lesions) in pediatric CT affording creation of subtle lesions (truth), insertion of high fidelity noise (including texture) without additional radiation exposure, and an efficient and effective observer interface for study evaluation.

Methods & Materials: 30 normal pediatric (ages 0-10 yr) contrast-enhanced de-identified abdominal CT scans were retrospectively collected from the clinical database (IRB approved). 0-3 simulated anthropomorphic, low attenuation liver lesions (≤ 6mm) (Fig 1) were inserted into scans using

proprietary LesionTool. Noise, validated as equivalent in magnitude and texture to reduced mA, was added to simulate reduced mA of 75% and 50% of the original scan. Three pediatric and three adult abdominal radiologists with 7-20 yrs of experience reviewed 90 data sets in 3 sessions spaced 2 weeks apart, e-marked the location of any lesions and rated their confidence using a scale of 0 to 100. Readers were surveyed after completion about the software interface. Results: 83% (5/6) of readers felt the images were similar quality to diagnostic images and that the tools in the web interface were adequate. 100% of readers felt the interface was an efficient and effective method of recording lesion location and that the interface was easy to use. 67% of readers reported spending equal time per case compared to a reading room and 50% reported reviewing studies with an equal sensitivity as compared to their usual sensitivity. 33% felt that their sensitivity was higher and only 1 (16%) felt that sensitivity was lower than typical.

The existing validated simulation paradigm provides opportunity for evaluation of a wide variety (size, location, heterogeneity, attenuation; Fig 2) of lesions, risk-free dose reduction assessment and observer performance for pediatric CT. This paradigm allows a systematic, highly controlled evaluation of specific lesions with an efficient user interface. Tracking of response metrics, such as study review time, number of clicks and response location for accuracy, also allows for assessment of important performance metrics beyond simple detection. Purpose or Case Report: In the companion abstract, we described an innovative simulation paradigm and effective observer interface combining previously developed tools for systematic evaluation of CT dose reduction with subtle pediatric liver lesions. Our purpose was to test this paradigm to delineate the effect of dose reduction on diagnostic accuracy and reader confidence, the latter often minimized in importance.

Methods & Materials: 30 normal pediatric (ages 0-10 yr) contrast-enhanced de-identified abdominal CT scans were retrospectively collected from the clinical database (IRB approved). 0-3 simulated low-contrast liver lesions (≤ 6mm) were inserted using LesionTool (proprietary) and noise was added to simulate reduced tube current (mA) that was 75% and 50% that of the original scan. Three pediatric and three adult abdominal radiologists with 7-20 yrs of experience reviewed 90 data sets in 3 sessions and were asked to mark the location of lesions and rate their confidence on a scale of 0 to 100. Statistical analysis was performed using JMP Pro 13. Conclusions: Academic pediatric and adult specialists did not differ in performance for subtle liver lesions. As expected, diagnostic accuracy significantly decreased as noise increased. However, confidence in the presence of a lesion did not change between the full dose and 75% dose scans. This suggests that readers are unaware of this decrease in performance, which should be accounted for in dose reduction efforts. Interestingly, higher noise studies did not take any longer to review, but the number of clicks decreased as noise increased, which may, in part, reflect less effort due to perceived decreased discrimination. Purpose or Case Report: To describe the development of a novel device designed to aid the radiologic technologist in reducing exposure variation and repeat imaging in computed and digital radiography.

The device consists of four generic components: 1) a 3-D depth-sensing camera with high-resolution color video and infrared depth sensor, 2) a processing unit where all real-time computations are performed, 3) an application programming interface to communicate with the processing unit and 4) the user interface displayed on a control room monitor. A schematic of the system architecture and components is provided in Figure 1 . Proprietary processing software was developed in C++ using the Qt, OpenCV and FFMPEG libraries to analyze, in real time, the color and depth video streams from the 3-D depthsensing camera. The 3-D depth camera was mounted to the tube assembly housing of a Philips Digital Diagnost digital radiography system.

The prototype device uses a Microsoft Kinect™ V2 consisting of a 1,080p color video and time-of-flight infrared depth sensor. An Intel NUC personal computer was used for the processing unit and the user interface was displayed on a 19.5″ HD touchscreen monitor. At start-up, the device requires calibration, which runs in less than 2 seconds and is fully automatic. A computer vision algorithm precisely localizes the imaging equipment via pattern matching of visual markers of the automatic exposure control chambers and image receptor. Once calibrated, the software calculates patient thickness and tracks in real time (15 fps) the patient positioning and patient motion. Motion estimation is achieved by assessing the position of the tracked body part or by using an optical flow algorithm. During the exam, the user interface displays real-time video of the patient along the central ray axis with overlays of automatic exposure control chambers, image receptor, body part thickness, patient skeleton tracking and motion tracer ( Figure 2 ). The software is designed to alert the technologist when a problem arises, such as when the body part is not centered correctly on the detector or the patient has moved off the automatic exposure control chambers ( Figure 3 ). Alerts can be visual, auditory, or both.

The device empowers the technologist by providing critical, real-time information to set the x-ray technique, enhance the workflow and to alert the technologist of issues that may result in repeat imaging before the patient is exposed. Purpose or Case Report: Pediatric liver transplant (LT) recipients are at risk for many transplant-related complications. A variety of histological changes has been reported in post-LT biopsies, with abnormalities more frequent in for-cause biopsies investigating allograft dysfunction. Importantly, abnormal graft histology is also seen in protocol biopsies from children who are clinically well with normal liver biochemistry. Shear-wave elastography (SWE) is a noninvasive, rapid method to assess liver tissue stiffness as a surrogate marker for fibrosis. Its utility has been validated in adults; however, data in pediatrics is lacking. Our aim was to assess the utility of SWE for the evaluation of liver fibrosis in hepatic allografts of pediatric patients and correlate with histology.

Median SWE velocity measurements (in m/s) were obtained in pediatric patients undergoing hepatic allograft biopsy for either surveillance, clinically suspected, or follow up of known graft dysfunction. SWE was performed using a GE Logiq E9 machine and C1-6 transducer within 3 days of biopsy. Histological reports were reviewed for the presence of fibrosis and/or rejection. When available, data was extracted from the medical record that correlated with testing. Continuous data were normally distributed. Mean was calculated and analyzed using two-tailed Student's t-test. Results: From 10/1/2016 to 9/30/2017, 56 pediatric (mean age 11.7 yrs) LT recipients underwent allograft biopsies. Histological findings included fibrosis (17/56, 30%) and rejection (22/56, 39%). Higher median SWE velocity was seen in liver transplant patients with fibrosis than without (1.52 vs 1.40, p<0.05). No additional biochemical parameters distinguished fibrotic vs non-fibrotic subjects. (Table 1) . Neither median SWE nor biochemical parameters could distinguish between subjects with rejection vs those without. (Table 2) Notably, in a sub-analysis of subjects with near-normal liver biochemistry (ALT, AST <1.5 ULN) and without markers of fibrosis (platelet >150, APRI < 0.7) SWE velocity was significantly higher ( Purpose or Case Report: To evaluate the feasibility of shear wave elastography (SWE) ultrasound as a potential complimentary non-invasive tool to facilitate early diagnosis of hepatic veno-occlusive disease (HVOD) in a pediatric population undergoing hematopoietic stem cell transplantation (HSCT).

Under IRB approval, HSCT patients with a clinical suspicion of HVOD were recruited for the study (N=14, age: 9.9 ± 6.3 y). Diagnosis of HVOD was made by fulfillment of the Revised Seattle Criteria as determined by a physician using the following clinical and ultrasonography criteria: right upper quadrant pain, total bilirubin, percent weight gain, and ascites, as well as the detection of portal venous flow reversal. All patients underwent serial ultrasound examinations, which included evaluation by grayscale, Doppler, and SWE. Ten exams were performed every other day using a GE Logic-E9 ultrasound unit with linear and curvilinear transducers. Four elastography measurements each were made in Couinaud's liver segments 5, 6, 7 and 8 (16 total for each patient). All exams were performed with the patient being NPO for 4 hours prior to the SWE evaluation. Results: Of the 14 recruited patients, six completed fewer than 8 exams due to discharge or withdrawal of consent. Figure 1 displays each patient's average SWE velocity (m/s) over all exams obtained in liver segments 5 through 8 and the spleen. The average SWE velocity in the liver from all patients in this population was 1.77 ± 0.24 m/s (range: 1.39 to 2.40 m/s), which was higher than the vendor specified cut-off value for normal hepatic stiffness (1.35 m/s). The patient with the highest measured SWE velocity (2.18 ± 0.28 m/s), Pt. 10, was the only patient to die due to multi-organ failure as a fatal complication of HVOD. This patient's SWE measurements were significantly higher than the rest of the cohort with more than three exams (p=0.00085), with a mean SWE velocity greater than 2.10 m/s. Figure 2 displays the average SWE measurement in the entire liver for each patient over the course of the study.

Conclusions: This study demonstrated elevated liver stiffness values with SWE in pediatric patients undergoing HSCT with clinically suspected HVOD, and the potential ability to delineate severe disease in this population. However, maximum liver stiffness was significantly higher in individuals without focal liver lesions, an unexpected finding. Our findings raise the possibility that liver stiffening and development of liver lesions may proceed independently in Fontan patients.

Magnetic resonance elastography of the liver in children: variations in regional stiffness Purpose or Case Report: Magnetic resonance elastography (MRE) is a non-invasive and reliable method for measuring liver stiffness. In this work, we hypothesize that MRE is sensitive to variations in tissue stiffness across the organ. We believe that liver fibrosis is heterogenous due to differences in portal blood supply and that consequently the certain hepatic lobes have a higher propensity to develop fibrosis than others. We test our hypothesis in pediatric patients by measuring MRE using global and local region-of-interest (ROI) analyses.

MRE was performed on a GE Signa 3T platform using the commercial product "MR Touch". Eight axial slices were acquired, which were co-localized to anatomical DWI and Dixon water-fat sequences. We obtained data in 19 patients (avg: 14y, range: 1-22y) referred for clinical liver exam. Liver stiffness measurements were made via two approaches: (1) Global -one large ROI was drawn on each of the eight MRE slices encompassing all visible liver using co-registered DWI and Dixon images for guidance. The average stiffness across the eight slices was then computed;

(2) Local -smaller ROIs were drawn on each of the eight slices corresponding to the Couinaud classification. The average of each of the eight segments was computed. With both approaches, care was taken to avoid vessels and non-liver structures. Conclusions: Liver and pancreatic fat fraction are both weakly but significantly correlated with visceral fat thickness suggesting a relationship between visceral, but not subcutaneous, adiposity and liver and pancreatic steatosis in children. Hepatic steatosis appears to have a softening effect on liver stiffness as measured by MRE, and increased visceral fat thickness appears to be associated with increased liver stiffness. None of our imaging findings could predict diabetic status. (Figure 1 ). Twin B demonstrated progressively increased TTP enhancement within the brain and brainstem at 115 and 129 days GA and post-mortem MRI confirmed hydranencephaly. Conclusions: CEUS of the brain is feasible in fetal lambs maintained on the EXTEND system and changes in perfusion can be quantified. These findings establish a foundation for further evaluation of this promising technique with potential applications in the setting of fetal hypoxia. Purpose or Case Report: Prenatal diagnosis of dystroglycanopathy relies strongly on the identification of a hypoplastic kinked brainstem, especially when evaluation of brain sulcation is limited by early gestational age. Although this finding is specific, it is not pathognomonic. Our purpose is to evaluate the predictive value of additional posterior fossa findings on prenatal MRI in patients diagnosed with dystroglycanopathy. We also access the reproducibility of prenatal detection and compare prenatal and postnatal MRI.

Fetuses with posterior fossa abnormalities were retrospectively identified from our referral database between January 2008 and August 2017. Only cases with both prenatal and postnatal MRI were included. The disease group included cases of dystroglycanopathy confirmed either by genotype or by postnatal phenotype. The control group included all remaining cases of prenatally diagnosed posterior fossa anomalies seen during the same period. Two fetal radiologists randomly reviewed all pre-and postnatal MRI studies, evaluating for the presence of selected posterior fossa findings common to dystroglycanopathies. Posterior fossa findings were analyzed first on axial plane, blinded to diagnosis and to any additional findings. Brainstem kinking was evaluated on the sagittal plane only after axial analysis was recorded. Sensitivity, specificity and negative and positive predictive values were calculated. The agreement between the two readers and between pre-and postnatal imaging was analyzed using Cohen's Kappa coefficient.

Results: A total of 37 patients were identified, of which 10 were diagnosed with dystroglycanopathy. All evaluated variables, except vermian hypoplasia, were statistically significant discriminators (p < 0.0001) between the study and control groups ( Table 1) . Findings of pontine cleft and cerebellar dysplasia (abnormal signal and irregular contours) were highly specific (Figure 1 ), similar to brainstem kinking (Table 2 ). There was excellent agreement between pre and post-natal MRI for all the evaluated variables and good to excellent agreement between the readers (Table 1) . Conclusions: Pontine cleft and cerebellar dysplasia are highly specific findings of dystroglycanopathy, especially when seen in conjunction. Identification of these findings adds diagnostic confidence when evaluating a fetus for suspected dystroglycanopathy and can be adequately identified on prenatal MRI. (Figure 1a ) were obtained from fetal MR studies of normal brains performed for indications other than suspected posterior fossa anomalies from 2009 to 2017. For this initial assessment, 78 fetal brains were included in the retrospective analysis. Gestational age was determined by last menstrual period or earliest US measurements. Four radiologists reviewed images independently and recorded the following measurements for each case: the posterior fossa perimeter (Figure 1b) , the tegmento-vermian angle (TVA - Figure 1c) , and the superior posterior fossa angle (SPFA - Figure 1d) . Results: For each feature, the mean of the measurements, the percentage of absolute difference of the reader measurement compared to mean measurement, and the interclass correlation (ICC) were calculated. Values are reported as mean ± standard deviation (Table 1 ). Perimeter appears to be very linear with age ( Figure 2, Results: A total of 11 ONTD patients were imaged during the studied period. EPI sequences were considered non-diagnostic in 2 patients. Of the 9 diagnostic studies, the reviewers' assessment of the upper level of spinal bony defect was identical to the level determined by ultrasound in 8 (88.8%) of 9 evaluated cases (Figures 1 and 2) . The single misinterpreted case was in retrospect felt to be at least in part secondary to a technical error, as the coronal plane was centered at the thoracic spine rather than at the lumbosacral spine. Conclusions: EPI sequence during fetal MRI may be a complimentary or an alternative tool to ultrasound in the assessment of the upper level of spinal defects in patients with ONTD seeking in-utero repair. Optimal technique includes the use of axial and coronal planes performed sequentially and perpendicular to each other. The coronal plane should be centered at the lumbosacral region. This ongoing pilot study may serve as the starting point for a collaborative prospective multicenter study. Future directions include comparison with postnatal imaging and assessment of functional levels. (Fig. 1) . In the subgroup of patients who underwent ≥6 exams and received a median cumulative GB dose of 11 mL (range 3.9-31 mL) between the 1 st and 5 th , there were no significant changes in signal intensity ratios: +0.018±0.087 (P=0.17) and -0.015±0.11 (P=0.44) for the GP and DN, respectively. Figure 2 compares the group average of ratios between the 1 st and 5 th GB exams. In the subgroup of patients who underwent ≥14 exams (Fig. 3) and

received a median cumulative GB dose of 64 mL (range 40-91) mL by the time of their last exam, there was no statistically significant change in signal intensity ratio in the GP (p=0.15) or the DN (p=0.50) with increasing number of doses of GB.

There is no increase in T1-weighted signal in the globus pallidus or dentate nucleus following the administration of multiple doses of Gadobutrol. Purpose or Case Report: Ferumoxytol, an iron oxide nanoparticle coated by a carbohydrate shell, is increasingly reported as an off-label blood pool contrast agent for MR angiography (MRA). We explore its use in the central nervous system (CNS) and whole-body vascular imaging in pediatric patients.

Use of ferumoxytol for MRA was approved by the pharmacy and therapeutics committee. We retrospectively included patients from our initial three cases undergoing whole body and brain MRI for vascular abnormalities such as Takayasu's arteritis and Loeys-Dietz Syndrome in 2017. Three children underwent MRA examinations at 3.0 T MRI after administration of diluted ferumoxytol at a dose of 3 mg/kg over 15 minutes. Whole body vascular imaging focused on the brain, chest, abdomen, and selected extremities based on clinical history. (fig 1, 2. ) Two blinded radiologists independently scored 11 named arteries on ferumoxytol-enhanced MRA according to a three-point subjective score where a score > 2 was considered diagnostic. The three-point scale was as follows: 1=Poor, precluding confident assessment; 2=Adequate for confident assessment of stenosis or occlusion, and 3=Excellent vascular definition sufficient for evaluation of fine detail. A total of 11 arteries in the head, neck, chest and abdomen were assessed for vessel caliber, tortuosity, stenosis and wall thickening. Results: In all patients, the arteries were clearly visualized from the circle of Willis to the lower extremities with excellent signalto-noise ratio. The average image quality scores for selected arteries was between 2.6 and 2.9. (fig 3. ) The radiologists were also able to confidently detect and characterize vascular abnormalities including tortuosity, stenosis, and wall thickening. None of the patients had an adverse reaction to the ferumoxytol. Conclusions: Ferumoxytol-enhanced MRA is a promising agent for the detection of vascular abnormalities in the brain or whole body. Additionally, the radiologist can interrogate multiple territories in one study, due to ferumoxytol's highly stable intravascular time. Therefore, from our early experience, ferumoxytol is a potential alternative to gadolinium-based contrast agents for high resolution neuro-and whole body MR angiography. Purpose or Case Report: With increasing interest in rapid MRIs aimed to reduce sedation in pediatric imaging, the purpose of this study was to evaluate a 3D golden-angle radial "stack of stars" gradient echo scan (i.e., RAVE -RAdial Volumetric Encoding) and to compare results with a conventional 3D inversion recovery sequence in post contrast brain imaging.

Studies were performed on a 3T Siemens Prisma system using either a 20 or 64-channel head array. Unlike traditional Cartesian acquisitions, MRI data in RAVE is acquired with consecutive k-space spokes that are rotated by the golden-angle (111.25 deg) to maximize k-space coverage efficiency. As a result of the radial trajectory, the center of k-space is oversampled and this feature affords RAVE's robustness to motion. When coupled with compressed sensing and parallel imaging, RAVE data can further yield time-resolved images during contrast passage. We evaluated RAVE in 20 patients (average age: 12.5y, range 2.2-21y) referred for brain MRI exams with contrast. Upon injection of standard dose contrast media (Gadavist), data from a RAVE acquisition and a conventional 3D IR-GRE (i.e., MPRAGE) were implemented (MPRAGE first). The two scans were matched in 1 mm native isotropic spatial resolution and volume coverage. On average, the MPRAGE acquisition took 5-6 minutes to complete, whereas the RAVE scan is ~25-30% faster. Three radiologists independently compared the data in terms of conspicuity of contrast-enhancing lesions and diagnostic image quality with respect to motion-related artifacts. A 3-point scale was used: -1=RAVE is superior, 0=RAVE and MPRAGE are equivalent, +1=MPRAGE is superior. Results: All evaluators found the RAVE with MPRAGE reformats to be similar when presenting contrast-enhanced details in 15 cases (score= 0). In the remaining 5, RAVE was preferred (score= -1). RAVE was notably more resistant to subject motion and pulsation artifacts. No significant artifacts were noted in RAVE. Figures 1 and 2 show data in non-sedated 13y and 11y old patients, respectively, with significant head movements. Figure 3 illustrates time-resolved images from RAVE in a 7y old, 20s apart, showing an enhancing lesion (arrow). Conclusions: Our study demonstrates the potential clinical utility of an accelerated 3D T1-weighted RAVE MRI sequence in unsedated pediatric brain imaging. The complementary technique is particularly useful in patients prone to head (and body) motion. Further evaluation in neonatal imaging and body and spine applications are warranted. Purpose or Case Report: With increasing concerns over intracranial Gd deposition, the purpose of this study was to evaluate a new quantitative 3D multi-phase arterial spin labeling (ASL) technique that yields cerebral blood flow, arterial transit time, and cerebral blood volume in neonates and children via a single acquisition. While the technique has been reported in adult populations, feasibility and application in pediatrics has not been previously demonstrated.

All studies were performed on a 3T Siemens Prisma platform and data were successfully reconstructed offline. We evaluated the technique in 3 neonates (5d-4mo) and 8 children (2.3y-17.8y). The multi-phase pseudo continuous ASL technique employed in this work consisted of a 5 post-labeling delay (PLD) scheme (300-2500ms with ~500ms intervals), with a label duration of 1500ms placed above the carotid bifurcation. The sequence used a hybrid 3D gradientspin-echo (i.e., GraSE) design to acquire data across the whole brain using a voxel size of 2.5mm in-plane and 3-4mm slices. We used a labeling distance of 75-90mm. Typical scan time was 6 minutes. Fitting of the multi-PLD signals subsequently yields cerebral blood flow (CBF), arterial transit time (ATT), and cerebral blood volume (CBV) maps. Three radiologists evaluated the ASL data in two categories: image quality (1-significant artifacts, 2-negligible artifacts, 3-no artifacts), and diagnostic utility in providing relevant information towards patient care (0not useful, 1-useful). Results: Figure 1 shows representative results in a normal 2y.

Top row panes show individual images at the 5 PLDs. Note symmetry in the quantitative CBF, ATT, and CBV data that are shown in color in the lower row. Figure 2 shows select slices in a 10y with history of rhabdomyosarcoma, using the same color scale. Note asymmetry in the CBF map (thick arrow) and longer ATT (thin arrow), resulting in greater CBV posteriorly. Figure 3 shows a 17y patient with a history of stroke. There are two perfusion deficits (thick arrows) in the right anterior lateral frontal lobe, which corresponds to foci of cystic encephalomalacia seen on anatomical images. All radiologists found the ASL data to be clinically informative. One case had significant artifacts. Two cases had negligible artifacts. The remainder had no perceivable artifacts. Conclusions: Our preliminary study demonstrates the feasibility of multi-phase ASL in pediatrics. Further evaluation in patients with seizures, strokes, tumors, and vascular malformations is warranted. Purpose or Case Report: Intra-operative arthrography is commonly performed during closed hip reduction for the treatment of developmental dysplasia of the hip (DDH) to confirm hip location and identify potential intrinsic obstacles to reduction. While an arthrographic limbus sign has been described in the literature, in some cases, a "sliver" of contrast can be also identified extending along the superolateral recess of the femoroacetabular joint ( figure) . The aim of this study was to identify the prevalence and MR anatomic correlation of the spica hip arthrographic sliver sign after closed reduction for the treatment of DDH Methods & Materials: A total of 51 hips in 42 patients, 37 females and 5 males less than 2 years of age who underwent closed reduction for DDH, were identified between 1/2011-9/2017. Syndromic and neuromuscular hip dysplasias were excluded. All patients had intra-operative arthrogram and subsequent spica MRI and were reviewed by a pediatric musculoskeletal radiologist. For intra-operative arthrography, the presence of sliver sign (figure), inverted limbus sign, or normal was determined. Findings were then correlated with spica MRI as reference and chondrolabral pathology was then categorized Results: For the 51 hips, arthrographic sliver sign, inverted limbus sign, and normal were present in 10/51 (20%), 35/51 (69%), and 6/51 (12%), respectively. The prevalence of any labral pathology in the setting of a sliver sign, inverted limbus sign and normal arthrography were 6/10 (60%), 33/35 (94%) and 4/6 (67%), respectively (P=0.0136). For the sliver sign, 4 true positive studies represented a chondrolabral junction tear and 2 reflected a labral tear. In re-review of false positive intraoperative arthrograms for the sliver sign with correlation with spica MRI, this false positive finding was attributed to a normal labrocapsular recess projecting over the lateral column due to obliquity of the pelvis to the beam (N=4) rather than a chondrolabral junction or labral tear Conclusions: We describe a new finding entitled the sliver sign, which is seen in approximately 20% of all arthrographic cases after closed hip reduction for the treatment of DDH. This sign corresponds to a chondrolabral junction tear in the majority of the cases although with a high false positive rate. It is important to obtain true AP views of the pelvis during arthrography as overlay of the normal labrocapsular recess along the lateral acetabular column can mimic the sliver sign. Purpose or Case Report: Intra-operative arthrography is routinely performed during closed reduction of developmental dysplasia of the hip (DDH). When present, an arthrographic inverted limbus sign (figure) is thought to represent interposed hypertrophied fibrocartilaginous labral tissue that may prevent concentric reduction of a dysplastic hip. The purpose of this study was to investigate the prevalence and anatomic MRI correlation of an inverted limbus sign identified by arthrography in children treated with closed hip reduction for DDH Methods & Materials: This is a retrospective descriptive study. A total of 51 hips in 42 patients, 37 females and 5 males less than 2 years of age who underwent closed reduction for DDH, were identified between 1/2011-9/2017. Syndromic and neuromuscular hip dysplasias were excluded. All patients had intra-operative arthrogram and subsequent SPICA-MRI, which were reviewed by a pediatric musculoskeletal radiologist independently. For intra-operative arthrography, the presence or absence of an inverted limbus sign was documented. Afterward, MR findings of intrinsic superior femoroacetabular soft tissue interposition was evaluated and categorized based on pathology when present Results: An arthrographic inverted limbus sign (figure) was identified in 35/51 hips (69%). When an inverted limbus sign was arthrographically found, an inverted labrum was present in 20 hips by MRI (57%). Alternative diagnoses on MRI (N=15) were a displaced or sheered-off superior labrum (N=2), a chondrolabral junction tear (N=11), and an entirely normal superior labrum (N=2). For the 16 hips that did not have an arthrographic inverted limbus sign, the range of MRI findings included a chondrolabral junction tear (N=7), an inverted labrum (N=2), a destroyed superior labrum (N=1), and an entirely normal superior labrum (N=6). The sensitivity and specificity of an arthrographic inverted limbus sign to detect labral pathology were 77% and 76%, respectively Conclusions: An intra-operative arthrographic inverted limbus sign is a common arthrographic finding after closed reduction of DDH but is an unreliable indicator of an inverted superior labrum. Arthrography after closed hip reduction plays a valuable role in confirming concentric reduction of the hip intraoperatively. However, its role in identifying intrinsic obstacles to full reduction is limited when compared to post-reduction SPICA MRI Purpose or Case Report: Prior studies have shown that Diffusion-Tensor imaging (DTI) parameters (ADC, track length and volume) are higher in children who are at ages when the growth is fastest. Our purpose is to determine longitudinally the correlation between DTI tractography in the distal femur with growth rate and final height in children.

We identified retrospectively all children without physeal pathology and available DTI of the knee who were imaged at puberty age (girl ≥ 11 years, boys ≥ 13 years) according to their bone age. We recorded the heights at the moment of imaging and at maturity. Growth rate (cm/year) and height change from DTI to final height were calculated. We only included children who had reached their final height according to their growth chart and whose last measurement was at least 12 months after the MRI. On sagittal echo-planar DTI (20 directions, b values of 0 and 600 sec/mm 2 ), region of interest was placed in the femoral physis. Using a fractional anisotropy threshold of 0.15 and an angle threshold of 40°, we performed tractography and measured track number, length, volume and apparent diffusion coefficient (ADC). We used Mann-Whitney U test to compare DTI parameters with growth rate and Spearman Rho to assess correlation between DTI parameters and height change.

We analyzed DTI images of 28 girls and 14 boys (42 subjects) with a mean age of 14.4 ± 1.5 (mean ± SD, range 11 -17) and 15.1 ± 1.32 (range 12 -17), respectively. The mean follow-up time was 28.4 ± 11.9 months between DTI and final height. Average growth rate and height change were 0.9 ± 1.5 cm/year and 2.4 ± 4.2 cm, respectively. Children with greater than the 50 th percentile of growth rate had longer tracts, greater tract volumes and higher tract numbers compared to those below the 50 th percentile of growth rate (Figure 1, ps<0. Purpose or Case Report: A closed degloving injury is often referred to as a Morel-Lavellée injury regardless of location despite traditionally being associated with the hip in adult patients. Classically this has been described as a shearing type injury resulting in separation of fascial layers with fluid filling a potential space in the subcutaneous soft tissues. There is scant literature with descriptive findings in pediatric patients.

A retrospective analysis of the medical records was performed. All patients with a traumatic injury to the lower extremities and a subcutaneous fluid collection seen on MRI were evaluated. Patient demographics including age and gender, mechanism of injury and time delay from injury to imaging, and subsequent treatment was recorded. The fluid collections were assessed by two radiologists for location, size, shape, and signal characteristics including the presence of internal fat, blood, septations, and crossing vessels. Results: 23 patients ranging in age from 7 to 19 years old were seen to have findings of degloving type injury on MRI. Patients were more often male (17/23, 73.9%) and had sports related injury (21/23, 91.3%), or less commonly related to motor vehicle collisions (2/23, 8.7%). The anterior knee was most often affected (19/23, 82.6%). Most lesions were ovoid and centered over the medial retinaculum 8/23 (34.8%) or lateral retinaculum 7/23 (30.3%), or horseshoe in shape, spanning the anterior knee draped over the patella. All lesions were located at the subcutaneous fat and fascial interface and contained internal fat lobules. The most common internal signal was simple fluid, and most commonly an incomplete capsule was observed. Several lesions had internal blood products and crossing vessels.

Morel-Lavellée injuries most commonly occur in pediatric patients in a location not classically described, the anterior knee, and most commonly occur after a sports related injury. The MRI findings are similar for all patients in that there is an ovoid or horseshoe shaped fluid collection at the fat/fascial interface containing internal fat droplets. Recognition of this entity with these specific imaging characteristics in a common location after a sports injury can allow for early identification. While most patients recover well with conservative management, patients may need additional intervention with aspiration or even debridement. Purpose or Case Report: Posterior ankle impingement (PAI) syndrome is a cause of ankle pain related to entrapment of soft tissue or osseous anatomical structures in the hindfoot and most commonly presents with plantar flexion predominant activities in athletes. The purpose of this study is to describe our experience with pediatric PAI as a clinically and radiologically underdiagnosed entity.

We prospectively followed all patients undergoing posterior ankle arthroscopy for suspected posterior ankle impingement since August 2016. Medical records were reviewed for demographics, presentation, physician referral history, initial diagnoses, imaging performed, and duration between presentation and diagnosis of posterior ankle impingement. Pre-and post-arthroscopy visual analog scale (VAS) pain scores and American Orthopedic Foot and Ankle Society (AOFAS) scores were also documented. Results: 42 ankles in 32 patients underwent arthroscopic debridement for the treatment of PAI. The patients had previously been given several alternative diagnoses including peroneal subluxation/tendonitis, Achilles tendonitis, chronic regional pain syndrome, sural neuralgia, and chronic ankle sprain. Average patient age was 13.2 years (7.7-18.7 years) and 17 (53%) were male. The average delay in diagnosis from initial presentation was 20.2 months (range 24-60 months). 24 patients had a total of 27 pre-operative ankle MRIs (3 bilateral) and 20/24 had at least one normal pre-operative radiograph. The diagnosis of PAI was not specifically suggested on pre-operative imaging or initial clinical evaluation. All patients had arthroscopic confirmation of the diagnosis. They reported significant pain relief with debridement and showed improvement in average pre-to post-operative VAS pain scores (7.1 to 1.3) and AOFAS ankle scores (64.8 to 91.7) at average follow up of 3.0 months (range 1-6 months), further confirming the diagnosis.

Conclusions: PAI as a cause of posterior ankle pain in young athletes is a frequently overlooked diagnosis both clinically and radiologically. Patients with PAI are also often misdiagnosed, which leads to delays in care and associated morbidity. This condition is well described in the adult population, and although it presents similarly, is not as recognized in pediatric patients. Increased awareness about PAI is needed amongst orthopedic surgeons, primary care sports physicians, and radiologists involved in treating young athletes for timely diagnosis and management. Purpose or Case Report: MR PET is a relatively new technology with many theoretical advantages over PET/CT, especially in children. However, it is an expensive modality with reimbursement and workflow issues slowing its introduction into general paediatric imaging practice. The purpose of this paper is to document the successful introduction of a clinical MR PET scanner into a dedicated children's hospital, and report on the lessons learned during the first 18 months of operation.

The data comes from review of the hospital PACS files, and the RIS. Analysis is provided by critical Medical Imaging Specialist review of the images, feedback from referring clinicians and patients, and from MR PET team technologist and physician discussions. Results: Oncology imaging was the most common indication with 22% of studies performed on patients with sarcomas, 21% on Lymphoma patients, 4% on patients with LCH and 3% on patients with other tumours. One third of studies were performed for the investigation of epilepsy, about 9% for the investigation of inflammation or infection, and 8% other indications. About 30% of studies were performed with a general anaesthetic. The radiation dose received by patients was usually about one half of that expected from a PET/CT offered off site at an adult hospital. Teamwork was considered important, with the interaction between the MR and Nuclear Medicine Technologists and their discussions with the medical imaging specialists critical in performance of diagnostic studies. Nurses, anaesthetists and educational play therapists also played important roles. Taking time to optimise patient comfort in the scanner is considered an important investment and anxiolytics are now used more frequently in older children during awake scans. MR generated attenuation correction maps were improved during the time period under review with better anatomical correlation observed, however a range of artefacts can be seen and must be dealt with in the same manner as accepted MR and PET/CT artefacts. The MR sequences must be chosen selectively to keep total imaging time within an acceptable range but still provide the required imaging information. Conclusions: MR PET is a complex imaging technology that can be successfully introduced into a clinical paediatric imaging practice. Advances in technology and faster MR sequences will facilitate wider adoption, but teamwork, patient comfort and appropriate imaging protocol selection are likely to be ongoing requisites of any successful MR PET imaging service.

The role of routine imaging in childhood melanoma (MM) Purpose or Case Report: There are four defined subtypes of hepatocellular adenoma: inflammatory, HNF-1α inactivated, βcatenin activated, and mixed type. Specific MR imaging features have been described for three of the four subtypes in adults. However, to our knowledge, there has not been a description of the imaging features of adenoma subtypes in children. The purpose of this study was to define the typical MR imaging findings each of hepatocellular adenoma subtype in a pediatric population.

A pathology database was used to identify all patients with hepatocellular adenomas diagnosed and subtyped between 1/1/2000 and 5/15/2017. Patients were included if they had an MRI performed with the use of a hepatocyte specific contrast agent before biopsy/resection. MRI examinations were reviewed in consensus by two pediatric radiologists based with assessment of previously described imaging features. The frequency of imaging findings for each adenoma subtype was compared using a chi-squared test with a p-value of <0.05 considered to be significant. Results: 20 hepatocellular adenomas in 16 patients (12 females [75%], mean age at MR imaging: 14.9 ± 6.1 years) were included in this study. There were 9 HNF-1α inactivated adenomas, 3 inflammatory adenomas, 4 β-catenin activated adenomas, and 4 mixed type adenomas. The imaging features of each adenoma subtype are detailed in Table 1 . Of note, 6 adenomas (30%) were iso-or hyperintense in the hepatobiliary phase, including 1 inflammatory, 1 HNF-1α inactivated, 2 βcatenin activated, and 2 mixed type adenomas. Only the frequency of diffuse tumoral steatosis (p=0.004) and heterogenous hepatocyte phase appearance (p=0.005) significantly differed between adenoma subtypes. Diffuse tumoral steatosis was present in 89% (8/9) of HNF-1α inactivated adenomas, but in none of the inflammatory or βcatenin activated adenomas and in only 25% (1/4) of the mixed type adenomas. Hepatocyte phase heterogeneity was present in each (3/3) inflammatory adenoma, 50% (2/4) of the β-catenin activated adenomas, and 75% (3/4) of the mixed type adenomas, but in none (0/9) of the HNF-1α inactivated adenomas. Conclusions: Of 20 molecularly subtyped hepatic adenomas, 30% were iso-or hyperintense in the hepatocyte phase, including 2 of 4 β-catenin activated adenomas which have the highest risk of malignant degeneration. HNF-1α inactivated adenomas can be distinguished from other adenoma subtypes by the presence of tumoral steatosis and a lack of hepatocyte phase heterogeneity. Results: The xenograft model showed a low degree of tumor angiogenesis regardless of tumor size (Fig 1) . Spontaneous tumors in transgenic mice demonstrated a high degree of heterogenous vasculature throughout the tumor volume that was evident at all stages of tumor growth (Fig 2) . Intratumoral vessel diameter progressively increased with tumor size and age; vessels as small as 70 µm were delineated on CT images. The density of large, highly tortuous venous structures(>500 µm) increased with tumor age. Unlike xenograft NB mice, transgenic NB mice demonstrated vessel occlusion, most likely due to tumor intrusion into nearby vessel (Fig 3) Results: There were 117 requests and 101 sonographic studies performed. 82 studies showed normal or reactive nodes, 11 were abnormal within which 2 necessitated invasive sampling and did not reveal underlying malignancy. 3 studies were cancelled due to patient distress. We hypothesised whether the referral quality could be improved with the application of specific criteria.

The clinical criteria was produced with consensus from the paediatric medical and surgical team. If any response to the question(s) is "Yes", the ultrasound study would be performed.

• Is the lymph node >10mm in long axis or >5mm in short axis?

• Has the patient's symptoms been ongoing for >12 weeks/ 3 months?

• Is the node increasing in size?

• Are there new nodes appearing?

• Does the patient have systemic symptoms?

• Clinically, this is not a node i.e. not along the lymphatic drainage pathway? Using these criteria on existing referrals, we found that the number of unnecessary ultrasound studies performed could be reduced by 21% (24 patients).

Conclusions: Ultrasound assessment for paediatric cervical nodes cannot replace clinical assessment and follow-up. We will be implementing the referral criteria into our online radiology requesting system. Results will be analysed in 6 to 12 months' time to assess if this would improve the quality of referrals and minimise the number of inappropriate and unnecessary ultrasound studies. 

Patients who were referred for HIDA with CCK were consented and prospectively enrolled to also receive US before and after CCK administration. Standard of care HIDA scan was performed with weight based dosing of 99m-Tc Mibrofenin. Dynamic anterior imaging was performed until gallbladder was visualized, up to 1 hour. Intravenous CCK was administered over 45 minutes with dynamic imaging in the LAO position for 60 minutes. Gallbladder US was performed and volume calculated using the prolate ellipsoid formula immediately prior to CCK administration and following post-CCK nuclear medicine imaging.

Results: 20 patients were evaluated with demographic information listed in Figure 1 . HIDA GBEF ranged from 37-98% while US GBEF ranged from (-12%)-84% (Figure 2 ). Graphical correlation of HIDA and US GBEF with fitted linear trendline is shown in Figure 3 . Pearson correlation coefficient for HIDA and US EF was calculated at 0.19 ( Figure 3 ). Pearson correlation coefficient for BMI and relative difference between NM and US GBEF was 0.35. Conclusions: This is the first direct comparison of scintigraphy vs. sonography for sincalide augmented GBEF in pediatric patients. Our prospective study found a poor correlation between these two modalities with US GBEF both over and underestimating HIDA GBEF in various patients. There was a weak correlation with increasing BMI and increasing relative difference between GBEF measured on HIDA compared to US.

Our study suggests US with ejection fraction may not be a suitable replacement for sincalide enhanced HIDA in the evaluation of biliary dyskinesia. When US is used as a screening examination, the potential for both false positive and negative exams exist and follow-up HIDA should be considered in clinically suspicious cases. Future investigation with an increased sample size including cases of abnormal EF on HIDA, and more accurate volumetric ultrasound measurements may better determine the optimal role of US as a radiation sparing alternative. Purpose or Case Report: The excess of unfiltered information on the internet together with high volume workloads in radiology departments can adversely affect the quality of education in residency and fellowship. This LMS, a tool to help manage and increase timely access to educational and training content that also tracks utilization and progress overtime, could transform radiology education by identifying and consolidating valuable resources and incorporating them into daily practice.

Step 1: Needs Assessment-Identified and interviewed stakeholders within the department with a focus on students, residents, fellows, attendings, nurses, and technologists. Recognizing market forces shaping the demand for online radiology education (learning innovation, global engagement, health technologies, and health economics), a vision for our LMS and list of desired features was developed.

Step 2: Existing Resources Inventory-All current learning content was identified: texts, online programs, conferences, articles, external links, etc.

Step 3: Choosing a Platform-List of 95 system features was sent as a Request for Information to 10 North American LMS companies. A subset of superusers reviewed and scored detailed proposals from the top three companies, settling by consensus based on desired features, ease of use and self-governance opportunities.

Step 4: Implementation readiness assessment and roadmap-Developed a plan for development, internal and external release of key system features including: curriculum management, content creation, tracking/notification, and network/collaboration. A timeline for staged rollout and scalability beyond our institution was also developed. Results: In October 2017 we launched RADIAL (Radiology's Intelligent Adaptive Learning), an innovative LMS connected to our institutional Picture Archiving and Communication System (PACS) for easy navigation. Content is organized in tiles pointing to unique resources including: protocols, courses, links, teaching files, e-books, lectures, articles, interpretation tools, and question banks. Learning analytics assess navigation/use that when paired with learning profiles will assist in the development of adaptive learning. Conclusions: Through a deliberate and thorough process, a fullservice LMS was created with the future goal to transform learning and enable subject mastery. Most patients are also critically ill. These variables make it extremely important to create an environment which is synchronous and safe for patient care. A periodically occurring simulation was initiated in IR at our institution to bring together intelligent, improvement-oriented personnel to develop a team based practice in the interest of patient and employee safety.

Every simulation exercise involved real time enactment of an interventional procedural scenario coordinated by simulation facilitators. Scenarios were provided to a selected team consisting of an interventional radiologist (attending and fellow), anesthesiologist (attending and fellow), IR nurse, IR technologist. Interactive trainer mannequins were used as patients during the procedures. Participants were placed in a real life like situation. Scenario enactment was followed by debriefing session to the participants. Results: Several important issues such as team communication, problem recognition and management, team integration were uncovered during these simulation sessions. Possible solutions were discussed. These recommendations were summarized and provided to divisional administration to affect policy changes. Conclusions: IR simulation program is very essential in building a safe psychological and physical environment for patients and the IR personnel. Purpose or Case Report: Social media has become the dominant window for individuals into the Internet, supplanting the World Wide Web. Some medical educators have followed their learners from the Web to social media through the Free Open Access Medical Education (FOAM) movement which promotes and | or distributes free and openly accessible medical educational content through social media. FOAM also tries to bring order to the chaos of medical social media through the use of hashtags. The purpose of this study is to determine whether social media is a growing or declining educational method in pediatric radiology by measuring usage of common FOAM hashtags on social media platforms over time.

Monthly usage of five FOAM hashtags were studied on Twitter and Instagram over one year including those related to general medical education (#FOAMed, #MedEd), pediatric education (#FOAMPed), radiology education (#FOAMRad) and pediatric radiology education (#PedsRad). Data gathered included the number of participants and posts using the hashtags and the number of impressions generated by the posts. On Facebook, overall hashtag usage could not be measured. Results: On Twitter, overall usage of the hashtags was significant and stable to slightly increased over the course of the study. #FOAMRad was used on average by 925 participants per month who made ~ 2,500 posts per month which led to an average of 5 million post impressions per month. #PedsRad was used on average by 90 participants per month who made ~ 200 posts per month which led to an average of 0.23 million post impressions per month. On Instagram, overall usage of the hashtags was minimal and stable over the course of the study. #FOAMRad was used on ~ 200 posts per month and #PedsRad was used on ~ 60 posts per month. Conclusions: While social media use overall continues to increase rapidly, its use in pediatric radiology education does not appear to be increasing as rapidly. Indeed, its use as an educational method in pediatric radiology appears to have matured and reached a steady state. The reasons may include that both medical educators and learners are unaware of FOAM and thus do not tag and search for content with relevant hashtags, that Twitter, where the majority of FOAM occurs, is the only major social media platform that is not growing, and that individuals may not want to use, or are apprehensive to use, social media for work-related activities. Purpose or Case Report: Radiology trainees today may get less hands-on scanning experience than peers in Emergency Medicine (EM) or Critical Care. However, it is critical that radiologists maintain scanning expertise to better care for patients and to consult for or supervise point of care US. To improve our pediatric radiology fellows' scanning skills, we developed a 5-hour hands-on US course to teach them to scan the 10 most commonly ordered EM exams. We assessed fellows' prior scanning experience and the impact of the course on fellows' confidence for performing US. We also summarized the time and financial resources needed for this course.

Fellows participating in the course completed surveys immediately before and after the course. Confidence for performing US in general and for specific exams was assessed using a 5-point scale. Neonatal brain protocol not in the course was used as a control. Changes in scanning confidence were assessed statistically with two-tailed t-tests.

Radiologists participating in course organization were surveyed retrospectively for length of time spent on preparing handbook protocols, lectures, and in course organization. Costs for the course were itemized.

Most fellows reported scanning 0 -10 times during residency and 2 of 8 had no scanning experience prior to fellowship. Prior to the course, mean confidence for ultrasound scanning was: overall, 2.1/5; appendicitis, 2.0/5; pelvis, 1.7/5; neonatal brain, 2.1/5. After the course, fellow confidence for scanning was: overall, 3.3/5 (p < 0.01); appendicitis, 3.6/5 (p < 0.005); pelvis, 3.3/5 (p < 0.005); brain, 2.9/5.0 (p = 0.13). For the 5-hour course, 4 faculty spent a mean 2.6 hours each preparing lectures. Handbook materials for 10 protocols were compiled by 3 attendings and 4 fellows, with mean 2 hours spent per protocol. Course organization required 18 hours over 3 months. The largest amounts of time were spent formatting course book (7.5 hours) and setting up the room for scanning (2 hours). Cost for the course was $3040, with the largest sums for technologist overtime ($936) and food ($633). Cost for the course was covered by the Department of Radiology. Conclusions: After a 5-hour hands-on US scanning course, pediatric radiology fellows were significantly more confident in their ability to scan. The cost and time burden is sustainable for our department, and the course will be continued in the future. To better serve patients, pediatric radiology fellows should gain a comprehensive understanding of body MRI that allows them to seamlessly transition into independent practitioners and future leaders. We conducted a needs assessment survey followed by a focus group interview to identify knowledge gaps and aid development of a curriculum resource for pediatric body MRI.

A comprehensive anonymous needs assessment survey was developed and distributed electronically in October 2016 to Society for Pediatric Radiology members who are current fellows and recent (<5 years) graduates from our ACGME accredited pediatric radiology fellowships. A follow up was sent in January 2017. We conducted a focus group with current fellows at our institution in October 2017 to help us better understand the survey findings. Results: 81 pediatric radiologists (8 fellows and 73 attendings) completed the needs assessment survey and 5 current fellows participated in the focus group. The areas most commonly identified with limited or no instruction during training were technical including: setting up MR service, coil selection, and field inhomogeneity correction. The most commonly identified areas needing increased attention and inclusion within the curriculum were: coil choice and patient positioning (n=42, 52%); differences between contrast agents (n=40, 49%); field strength (n=33, 41%); and strategies for motion correction (n=33, 41%). Most fellows are uncomfortable with: setting up an MR service (n=57, 70%); correcting field inhomogeneity (n=56, 69%); and adjusting sequences to improve image quality (n=50, 62%). In the focus group, there was consensus about insufficient MR training in residency to prepare them for fellowship. The group preferred shorter lectures with ability to reference and watch repeatedly with an emphasis on learning via video education/tutorials.

While traditional instruction emphasizes image interpretation, this study shows that recent trainees of pediatric radiology fellowships need a curriculum with strong instruction in the technical and practical aspects of MRI. Based on these data, we created a short gestational MRI educational video. The video will be shown to all radiology trainees and all pregnant women who receive MRI over a 6month period from (November 2017-April 2018). The patient will then be given a brief survey to indicate how well informed she felt and how well the video prepared her for the exam. At the end of the study period, residents will be surveyed again to determine whether the use of the video was an effective educational tool. Results: Initial results yielded 38 respondents. 55% felt only "somewhat comfortable" counseling pregnant women, and 11% felt "not comfortable at all." When asked about the current ACR stance on MRI safety, 79% answered incorrectly that "MRI should only be performed during certain trimesters," while only 21% answered correctly that MRI can be performed at any trimester. When asked about Gadolinium-based contrast use during pregnancy, 68% answered incorrectly "under no circumstances due to safety concerns," while only 29% answered correctly "only if critical." When asked "which of the following are known significant MRI-associated fetal risks," 24% of respondents chose "hearing loss," 5% chose "stillbirth/death," 0% chose "developmental" and "neoplasm," and 3% chose "all of the above." The remaining 71% of respondents correctly chose "none of the above." Finally, when asked if it would be helpful to have an MRI video for pregnant patients, 37 of 38 residents chose "yes." Results on the pregnant patient population are currently being collected.

The information pregnant women receive prior to MRI can be highly variable. Resident knowledge is frequently incorrect regarding MRI during pregnancy. Our solution has been to create a short video which will help to accurately educate pregnant patients in a consistent manner, and the video may also be used as an educational tool for radiology training. The video will be included as part of this presentation. Purpose or Case Report: Our practice is geographically dispersed and composed of radiologists in many sub-specialties, including pediatric. Since it is not feasible to have all pediatric imaging exams interpreted by a pediatric radiologist, we created a practice sub-group to develop ways to assist non-pediatric radiology colleagues when interpreting pediatric imaging exams. This presentation explains our process.

(referred to as the Pediatric User Group, or "PUG") was created, composed of the fellowship-trained pediatric radiologists in our practice as well as several non-pediatric radiologists. The physicians in the PUG meet virtually on a regular basis, approximately every other month, to work on projects.

There are two categories of projects. In the first group, certain exams and conditions were identified as high-priority by radiologists in the practice, and dictation templates were created along with supporting documents intended to assist the interpreting radiologist. The second type of project is intended to support general education of pediatric radiology topics for physicians throughout the practice. This is accomplished through creation of PowerPoint presentations placed on our internal website.

The PUG was started in July 2016. Through July 2017, the group has created 6 dictation templates and associated supporting documents. These include: neonatal renal ultrasound, cranial sonography, hip sonography, spine ultrasound, pyloric stenosis imaging and pediatric upper GI exam with an emphasis on malrotation. While the radiologists are not required to use the dictation templates, many say they do employ them. A 7 th project on intussusception diagnosis and management was also completed. In addition, 3 PowerPoints were created and placed on our internal website. These are on pediatric musculoskeletal imaging, ultrasound and neck/chest imaging. Questions were written for these PowerPoints such that physicians may claim CME credit for their review time.

Conclusions: Within a large, geographically dispersed practice we created a pediatric sub-specialty virtual group for supportive and educational purposes. Feedback from non-pediatric radiologists about these resources has been uniformly positive. Based on the success of this model, other sub-specialties in the practice are now developing similar user groups. 

The NSDB was launched in August 2016 with 30,000 age-and gender matched normal radiographs available as a single-click resource from PACS at all workstations in our department. In August 2017, an anonymous survey was distributed to 35 pediatric body attendings and fellows in our institution. The survey included questions regarding whether they had heard about or used NSDB, alternatives to NSDB, and their opinion regarding speed, ease of use, and reliability compared to alternatives such as web search, reference textbooks, other web sites, and search of our institutional PACS using a 5-point Likert scale. Anonymous NSDB access analytic logs were reviewed for utilization patterns. The logs were de-anonymized for a period of 30 days for analysis of user roles. Descriptive statistical analysis and nonparametric tests for differences between the attending and fellow groups were performed. Results: Thirty-one survey responses (24 attendings and 7 fellows) were received (89% response rate). Users agreed that the NSDB is clinically useful (weighted mean 4.6) and that it is faster, easier to use, and more reliable than alternatives (weighted means 3.8-4.4) with no significant difference between attendings and fellows. Reported alternative resources included bonepit.com, eanatomy.com, headneckbrainspine.com, Google, Elsevier STATdx, Greulich and Pyle, and Keats & Kahn's Atlas of Skeletal Maturation. Of 1,238 search sessions, the most commonly searched body parts were the ankle (n=144, 12% searches), knee (n=111, 9% searches), and elbow (n=101, 8% searches) followed by the hand, foot, chest, and femur. Thirtytwo (3%) searches were initiated from skeletal surveys. Searches are becoming more frequent and are most common in infants and pre-teen-aged children. During the 30-day de-anonymized period, 17 attendings, 6 fellows, and 9 residents performed 115 (34%), 64 (21%), and 155 (45%) total searches, respectively.

The NSDB is an image database of normal radiographic anatomy and is regarded as being clinically useful and faster, easier to use, and more reliable than alternatives. Used by pediatric radiologists and trainees alike, it is most commonly used during the evaluation of the lower extremity.

Reducing the sedation rates in MRI for pediatric patients utilizing an MRI simulator preparation session facilitated by a child life specialist. Purpose or Case Report: An MRI simulator was used to reduce the number of patients requiring sedation by allowing them the opportunity to have a realistic experience of an actual MRI prior to their MRI scan. A child life specialist engaged each patient in a simulator session to prepare them and allow them to become familiar with the MRI equipment and process.

Patients were identified by reviewing the MRI sedation schedule and the patient's chart. Simulator candidates were selected by assessing the type of scan, proximity to the hospital, age, and developmental or behavioral barriers. Each patient's parents were then consulted to make a final assessment of their child's potential for success in completing a non-sedated MRI. Parents showing interest were given the opportunity to have their child experience a simulator session. Prior to acquiring the MRI simulator, sedation was standard for patients under the age of 7 and whose chart showed past developmental or behavioral factors. Implementing the MRI simulator program decreased the number of patients requiring sedation. Practice time and education empowered patients to succeed without sedation due to being confident and aware of what an MRI entails. Results: Since August of 2014, 416 patients have utilized the MRI simulator. Patients who utilized the MRI simulator were between the ages of 5-18. All of the patients chosen had scans that were scheduled to be one hour or less in length. Of the 416 patients that utilized the simulator, 354 of them were able to complete their scans without anesthesia which resulted in an 85% success rate. The 15% that were not able to complete their scans without sedation were unable to hold still or became too anxious during the actual scan. The success rate shows the benefit of allowing patients to practice and become familiar with the MRI before the actual scan. The MRI simulator reduced the number of patients requiring sedation and therefore increased patient safety, created a positive patient experience and reduced the cost for many families. Based on our current capacity for performing patient training on our MRI simulator and the observed rate of sedation required for these patients, we estimate an annual cost savings of approximately $200,000 for families. Conclusions: Patients have a high success rate in completing their MRIs without sedation when it is paired with an MRI simulator session facilitated by a child life specialist.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Of the 22 cases of accidental trauma or unknown mechanism, 9 patients had soft tissue injuries on CT (41%) and 13 did not. This difference was statistically significant (p = 0.05) with cases of NAT being more likely to have soft tissue injuries than accidental or unknown mechanisms. Soft tissue injuries included 17 cases of liver laceration, 5 cases of splenic laceration, 6 cases of bowel injury, 3 cases of kidney injury, 3 cases of adrenal hematoma, 2 cases of pancreatic laceration, 1 case of retroperitoneal hematoma, and 1 case of abdominal wall hematoma. There was no significant difference between NAT and accidental trauma for any of these injury types. Soft tissue injuries were statistically associated with rib fractures (p = 0.02) but not with other fractures, such as long bone fractures. Conclusions: Although skeletal surveys are the mainstay of imaging in NAT, intraabdominal soft tissue injuries can also occur in NAT. These injuries occur at statistically significant higher rate than that of accidental trauma and may be missed on radiographs. The most common intraabdominal soft tissue injury to occur in both NAT and accidental trauma is liver laceration but a variety of other injuries can also be seen. Furthermore, the type of soft tissue injuries appear to be similar for NAT and accidental trauma without a difference injury profiles. Purpose or Case Report: The distinction between perforated and non-perforated appendicitis is beginning to be clinically relevant as a deciding factor of whether to surgically intervene on a pediatric patient or not. Perforation is treated in some institutions conservatively initially while non-perforated appendicitis would require an emergent surgery. While CT scans have proven to be a good imaging modality for differentiating perforated from non-perforated appendicitis, they expose pediatric patients to ionizing radiation. On a previous study performed in our institution a scoring system that incorporates clinical, laboratory, and ultrasound findings was developed (see attached table) , with a high specificity (91%) and low-moderate sensitivity (29-61%, depending on the score cutoff value). We therefore performed a retrospective study from two institutions to validate this scoring system.

After receiving IRB approval (IRB# 2016-7083), we searched our data base for pediatric appendiceal ultrasound studies from June 2015 through June 2017 and the clinical (Tmax, days of fever, days of pain, age, presence of vomiting/diarrhea) laboratory (WBC, CRP, and ESR), and ultrasound findings (appendix size, loss of submucosal layer, complex free fluid, amount of echogenic fat, and abscess) were documented. This data was incorporated into the scoring system and compared to the gold standard, surgical and pathological evaluation. 149 cases were found, 44 patients with equivocal scores were missing data parameters that would possibly increase their score to be consistent with perforation. They were therefore excluded. Purpose or Case Report: To evaluate the clinical efficacy of a rapid non-contrast enhanced MR protocol for evaluation of abdominal and pelvic abscesses in children.

All patients having undergone clinically indicated MRI between June 1 2013 and July 30, 2017 for suspected abdominal and pelvic abscesses were identified through a keyword search of the radiology information system. The MR protocol comprised axial and coronal T2 weighted SSFSE, sagittal T2 with fat suppression and axial DWI of the abdomen and pelvis. Clinical chart and radiologic images were reviewed by a pediatric radiologist and fellow. Location of abscess or collection, presence of restricted diffusion (minimum ADC) and size were recorded. The route of drainage was also recorded if a drainage procedure was performed. Clinical out come and need for repeat procedures were also recorded. Results: There were 53 patients with a mean age of 11 years. Three patients had tubo-ovarian abscesses, one had pelvic extension of a psoas abscess, and one had a post-operative abscess following ileoanal anastomosis. The remainder of the patients had perforated appendicitis or post appendectomy abscesses. The duration of the MRI study was 34 minutes. The average abscess volume was 120 cc with a mean ADC value of 1319 mm2/s.In 38 patients (72%), there was a collection in the pelvis, including 5 patients with both abdominal and pelvic collections. 35 patients underwent drainage by interventional radiology. Of these, 29 (82%) were drained transrectally, 3(9%) trans-abdominally and 3 (9%) had both transabdominal and transrectal drainages. All of the transrectally drained abscesses had a clear drainage path established on MRI, whereas ultrasound failed to demonstrate drainability in the 26 of these cases (89%). Of the 15 patients who had abscesses in the abdomen but not the pelvis, 12 (80%) underwent a percutaneous drainage while in 3 patients the collection was judged too small to drain. All patients had resolution of abscess although one patient required two drainage procedures for a recurrent abscess. In one patient the abscess collapsed during drainage and no catheter was left in place. None of the patients required CT. Conclusions: Rapid non-contrast MRI is easy to perform, and can guide the appropriate treatment, particularly in the case of trans-rectal drainage where ultrasound is equivocal in most cases, with good clinical outcomes. The main advantage is avoidance of CT with concomitant radiation exposure and contrast administration. Purpose or Case Report: Ileocolic intussusception is an emergent condition with concern for bowel ischemia prompting rapid treatment. Therapeutic enema performed by a pediatric radiologist, with progression to surgery if reduction fails is standard of care. However, many hospitals do not have pediatric radiologists available and require transfer, delaying treatment. Despite increased concern for risk of bowel complication, there is limited data evaluating the effect of increased time to therapeutic enema and patient morbidity/mortality. Our purpose is to determine if there is increased patient morbidity/mortality associated with prolonged time between diagnosis and treatment of intussusception.

A retrospective evaluation of pediatric patients treated for intussusception at a children's hospital over a 10-year period was performed. Florida Hospital for Children is part of a multi-hospital system, and serves as a referral center for 12 community hospitals. Patient's records were reviewed for time of presentation, onset of symptoms, time of radiographic diagnosis, hospital transfer (if applicable), time of attempted enema reduction, success of reduction, and surgical outcomes (if applicable). Results: A total of 147 presentations of intussusception occurred, of which 30 cases (20%) required surgery due to unsuccessful reduction. Nineteen cases (13%) resolved spontaneously. Ninety-five (65%) cases had enema attempts in up to 3 hours; of which 22 (23%) required surgery. Twenty-eight cases occurred greater than 3 and up to 6 hours (19%); of which 6 (21%) required surgery. Five (3.4%) had enema attempts over 6 hours from time of diagnosis; of which 2 (40%) required surgery. A chi square test of independence showed no statistically significant difference in surgical rates between the groups (p-value=0.660). Four (3%) patients required bowel resection secondary to ischemia. All 4 cases had reduction attempts in less than 3 hours and reported symptoms for over 24 hours.

There was no increase in morbidity as measured by need for surgical reduction of intussusception in patients treated in under 3 hours from time of diagnosis versus those treated between 3 and 6 hours from time of diagnosis. Additionally, risk for ischemic bowel injury was not associated with increased time between radiographic diagnosis and therapeutic enema attempt in our review. Further evaluation of patients treated greater than six hours from the time of diagnosis is needed given the low sample size of this group in this study. Purpose or Case Report: To assess the diagnostic accuracy of CT and MRI in malrotation and to determine the most reliable cross-sectional criteria to exclude malrotation.

All patients who underwent an UGI during 2016-2017 were identified using keyword search tools in the radiology information system. 175 patients who underwent UGI also had relevant prior cross-sectional CT or MRI. These studies were blindly reviewed to determine superior mesenteric artery-vein relationship (SMA/SMV), the position of the 3rd portion of the duodenum (D3), the uncinate process of the pancreas and the location of the cecum, to diagnose malrotation. These results were compared to the UGI findings. Results: 175 Patients who underwent UGI also had a relevant CT or MRI. Malrotation was found in 17 patients using crosssectional imaging. All but one was confirmed on UGI. The remaining 158 cases were negative on cross-sectional imaging and confirmed on UGI. Using a combination of SMA/SMV relationship, the uncinate process of the pancreas, D3, and the location of the cecum, the sensitivity of cross-sectional imaging for malrotation was found to be 100% and the specificity was 97%.

Conclusions: Malrotation can be diagnosed on cross-sectional imaging based on the following 4 criteria: SMA/SMV relationship, the retroperitoneal position of D3, a normal uncinate process of the pancreas and the location of the cecum in the right lower quadrant; thus obviating the need for a subsequent upper GI examination. 3-3.6 ) and 20 LVNC negative patients (age 16±7.4, range 8-39 yrs, 11 m) were analyzed retrospectively using a novel automated tool. The only user interaction required was to select the most basal and apical slice to be included in the analysis. The tool automatically tracks the LV size and shape. Otsu's thresholding algorithm delineates papillary and trabecular muscles. FD were computed on the resultant edge images using the box counting method. A piecewise closed Bézier curve of 2 nd order geometric continuity was fitted through the salient points of the convex hull of these edges to obtain endocardial contours (Fig 1) . The ratio of length of blood pool edges to endocardial contour perimeter (PR) was computed for each slice. Paired t-tests were performed between FD & PR and FD & FD*PR for all slices. Global LVNC index was calculated as the mean of the top half (MTH) of the slices sorted by particular index. Two sample t-tests were performed for FD, PR, and FD*PR between LVNC positive and negative patients.

The analysis was performed successfully in all subjects (149 apical, 165 mid-ventricular, and 136 basal slices) with a computation time of 5±2 sec per subject. The mean±SD, p values and % change in median values with 95% confidence intervals are shown in Table 1 . Figure 2 shows a one to one line plot and box plots for all indices along with a scatter plot for all slices. Conclusions: In this study we described a novel tool as well as a novel index to automatically quantify LV trabecular complexity and irregularity. Both FD and PR indices distinguish LVNC patients from negative controls, while the PR and FD*PR respectively provide 6 and 11 times higher dynamic ranges. Purpose or Case Report: Cardiac magnetic resonance imaging is used for assessment of ventricular function by ejection fraction (EF) and myocardial fibrosis by late gadolinium enhancement (LGE) for DMD patients. Earlier studies have shown that LGE precedes decline in EF 1-2 . However, there is limited data on quantitative regional fibrosis variability in DMD that might help disease monitoring. In this study, we sought to determine the regional variability between different slice locations, and hypothesize that apical LGE is associated with a later stage of the disease, when EF is abnormal.

LGE images of 87 DMD children acquired from November 2015 until June 2017 were analyzed. An observer drew contours on three short axis slices (basal, midlevel and apical), delineating the endocardium and epicardium, as well as a remote normal region (Figure 1 ) yielding mean and standard deviation. Area of fibrosis (scar) was defined as regions with signal intensity > 6X standard deviations from the remote normal mean. The scar burden (%) was defined as the ratio of area identified as scar within the slice to total area of the slice. This was calculated globally at the base, mid-ventricular and apical levels, as well as septal and lateral walls, and compared with EF.

The age, ejection fraction and regional scar burden at three short axis levels are shown in table 1 and figure 2. It can be seen that a. There is minimal scar present in the apical slices (8 /34 patients with scar). Patients with scar at apical slice always had scar at basal or mid-ventricular locations. Apical scar occurs at a later age. b. The scar burden is high at the lateral walls when compared to the septal walls (17.1% in lateral vs 0.7 % in septal walls in patients >19 years old) (Figure 2 ). c. Scar burden increases with age ( Figure 2 , table 1), while EF decreases with age and increasing scar burden. Conclusions: Septal involvement occurred in older patients with reduced EF.

LGE is more significant at the basal and midventricular level and spares the apical level until older age, when EF is abnormal. Apical LGE only occurs in conjunction with basal and mid-ventricular LGE and never in isolation. Future studies are needed to assess the mechanism of this pattern of LGE.

Demonstration of linear correlation between R2* and liver iron concentration across multiple MR acquisition parameters at 1.5T and 3T. 3 for an example mean R2*/LIC linear regression analysis, using 1 of 10 acquisition parameters at 1.5T). Conclusions: R2* is a consistent measure of liver iron concentration independent of liver segment, MR parameters, and magnet strength. As such, R2* may be considered a robust noninvasive biomarker of LIC, and represents an improvement over Ferriscan's greater cost, longer acquisition time, and longer post-processing time, and over SQUID, which has limited geographic availability. Purpose or Case Report: Interventional radiology is becoming a clinical specialty by performing preprocedural consultation and also providing longitudinal care for patients to improve quality of care. The objective of this educational paper is to describe the process of establishing an inpatient consult service and aborting the old fashioned order based service for pediatric interventional radiology (PIR) Methods & Materials: At our large tertiary care children's hospital, PIR service had been a order based service for 10 years since its establishment. We performed approximately 4200 procedures in 2015, approximately 60 % of which were inpatients. We created an inpatient consult service starting October 1, 2016 at our medical center campus by allowing referring providers to only place a consultation order for PIR. Every consultation would then result in patient being evaluated by PIR team { Physician Assistant (PA) /Nurse practitioner (NP) / Medical Doctor (MD)} followed by a consultation note and a procedure order (one of 6 generic imaging orders) if a procedure was indicated, Results: Between 10/2016 to 09/2017, 1912 consults were performed resulting in total revenue of approximately 135,000. The consult service improved patient, IR staff and referring clinician satisfaction. Despite fears of significant delays in patient care, no delays were noticed in providing procedural care to the patients. We will describe the process as well as the lessons learnt such as omission of orders for feeding tubes (gastrojejunostomy and nasojejunal tubes), creation of consult notes in Epic and 6 generic IMG orders to improve efficiency of service, weekend consultation issues as well as introduction of consultation service at 2 other community hospitals since April 2017. Conclusions: Providing inpatient consultation for pediatric IR procedures can be achieved. This service shifts the model of PIR from "procedural" to "clinical consultant" and generates additional revenue for the division. Purpose or Case Report: The Society of Interventional Radiology's (SIR) classification grading system has been the standard for reporting adverse events in interventional radiology procedures since it was published in 2003. In response to concerns about inter-observer reliability, an updated grading system was developed by the SIR based on the Clavien-Dindo classification criteria used in surgery. The goal of this study was to measure the inter-observer reliability of the two SIR adverse event classification systems in a pediatric cohort.

From an existing departmental IR procedure database, 30 case scenarios were selected that reflected a broad spectrum of adverse event severity across a range of procedures. The case scenario topics included: central line placement as well as bone, liver, lung and renal biopsies. Four pediatric interventional radiologists scored all thirty pediatric clinical case scenarios according to both the standard and updated adverse event classification systems. Readers were provided with criteria for both classification systems at the time of their interpretation. Inter-observer agreement was assessed using Fleiss' kappa. The weighted degree of association of assessments by readers was measured using the Kendall's coefficient of concordance (KCC). Results: Patient age from the case scenarios ranged from 2 months-20 years (mean 8.36 years). Fleiss' kappa statistic for inter-observer agreement in classification of adverse events according to the standard and updated SIR systems are presented in Table 1 . The two systems were similar in terms of interobserver agreement overall, demonstrating fair agreement. Agreement across the severity categories ranged widely for both systems. Perfect agreement was observed for patient death. Otherwise, kappa values for each severity category ranged from poor to substantial for the standard system and from poor to moderate for the updated system (Table 1 ). The KCC for the standard and updated classification systems were 0.77 and 0.55 respectively.

We observed overall fair inter-observer agreement for both the standard and updated SIR adverse event classification systems when applied in a pediatric cohort. Our findings support the need for a pediatric specific adverse event classification system. Purpose or Case Report: For patients unable to maintain normal PO intake, gastrojejunostomy tubes represent a lifesaving and life-prolonging intervention. Maintenance of these tubes, however, does not always adhere to a regimen. Lack of a structured exchange schedule for pediatric gastrojejunostomy tubes results in problematic exchanges, often scheduled only when the original tube becomes clogged or falls out. This results in more complex exchanges and delays in feeding which sometimes require interim hospitalization for parenteral nutrition. We developed a structured tube exchange program with the pediatric gastroenterology service to improve patient experiences and outcomes for children reliant on gastrojejunostomy feedings.

We introduced scheduled tube exchanges q3 months to preemptively change gastrojejunostomy tubes before problems developed. We measured fluoroscopy time of cases, wait time for tube exchange (measured from order date to case date), case time in the fluoroscopy suite (measured from KUB/scout time stamp to case completion), and number of de novo tube replacements (defined as a tube which had completely fallen out and could not be exchanged over a guidewire) before and after this intervention. The study was conducted over a period of 12 months with n = 9 cases pre intervetion and n = 10 cases post intervention. Results: Before our intervention, mean fluoroscopy time was 48 seconds; mean case time was 82 minutes; mean wait time was 44.8 hours; and percentage of de novo replacements was 19%. After this intervention, mean fluoroscopy time was 34 seconds; mean case time was 29 minutes; mean wait time was 35 hours; and percentage of de novo replacements was 0%. Overall, fluoroscopy time was reduced by 29%. Case time was reduced by 65%. Wait time was reduced by 22%. De novo tube replacements were reduced by 100%. Conclusions: Implementing scheduled gastrojejunostomy tube exchanges results in a better experience for patients with decreased radiation dose and wait time for tube replacement. Efficiency of the fluoroscopy suite was also improved, with shorter overall duration of cases and fewer de novo replacements. 54.9 ± 6.4, p = 0.29; and mean EF = 58.8 ± 5% vs 54.9 ± 6.4 % ;p = 0.03 ); see figure 1. The scan times were significantly shorter for RT-cine (2 heart beats/slice; ~45 seconds for entire 14 slice acquisition) compared with BH-cine acquisition (6-8 beats/slice; ~5:38 minutes for 14-slice acquisition, p< 0.01). Figure 2 shows representative images acquired. Conclusions: CS-based free-breathing RT-cine technique is feasible and provides images of comparable quality and diagnostic value when compared to conventional BH-cine SSFP, while significantly reducing scan time. It offers a potential solution to avoid the need for sedation for functional evaluation, improve diagnostic utility of MRI in arrhythmia, and improve CMR efficiency and workflow. Future reduction in reconstruction times, is needed prior to implementation of CSbased RT techniques into clinical practice. Purpose or Case Report: There are multiple variations of Conjoined twins. Prenatal and postnatal imaging is crucial in defining the shared structures, vascularity, and identifying any other significant anomalies. The determination of the shared organs is instrumental in helping the physicians and parents make the decision or potential for separation. In this specific case the twins were referred to our institution and had an MRI, and Ultrasound. At this time not only were the shared structures identified but also two rather significant anomalies were found, a congenital diaphragmatic hernia and an omphalocele. A specific plan for delivery and immediate postnatal care was made based on this imaging. Additionally extensive postnatal imaging was performed shortly after birth to help guide the physicians in their decisions for the management of the twins care.

The mother was first referred to our institution at 26 4/7wks gestation with having a monochorionic/monoamniotic conjoined twin pregnancy. A fetal MRI was performed. This showed that they were conjoined twins dicephalic parapagus. The fetus had separate brains which were normal, airways, spines, hearts (although small fusion difficult), Aortic roots with right twin's being small and a single descending thoracic aorta, stomachs, and gallbladders. Each fetus seemed to have two lungs however the more medial lungs possibly fused. Baby A was also found to have a diaphragmatic hernia containing liver, spleen and stomach.The twins shared an abdomen with a fused liver, two kidneys, single colon, single bladder, single 3 vessel umbilical cord, omphalocele containing bowel, and 4 extremities with hypogenetic limb central upper thoracic/lower neck. She returned at 34 5/7wks gestation and a fetal ultrasound and another fetal MRI were performed. The MRI and ultrasound findings were the same except the ultrasound provided some additional vascular information. It showed there is a single 3VC with a single umbilical vein and single ductus venosus which connects to the IVC of Twin B and that the peak systolic velocities in the MCAs of both fetuses were elevated, which can be seen with fetal anemia.

Conclusions: Based on the findings from all of the imaging it was decided that these particular twins would not be separated. The CDH and omphalocele were both repaired without complication. The twins are currently still inpatient receiving ongoing medical treatment.

David Curran, BSc Radiography 1 davecradiog@gmail.com; 1 Nuclear Medicine, Our Lady's Children's Hospital Crumlin, Dublin, Ireland

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: lower limb lymphoscintigraphy is a nuclear medicine examination of the lymphatics and their drainage pattern. It is an infrequently performed nuclear medicine examination in children. Due to its rarity, it is important to review its practice and have robust protocols in place. The aim of this study was to review the practice that was used for our previous examinations and gain an insight into areas that could be improved and optimised.

A retrospective review of all paediatric lower limb lymphoscintigrams between 2015 and 2017 (n=8) was performed. Data was extracted that included dose, injection technique, timing of imaging and scanning protocols.

The information gained from reviewing our practice lead to a reduction in administered dose and a change to the scanning protocol.

Conclusions: On review of the previously performed examinations, an insight was gained into the different aspects of this infrequently performed examination. By optimising the different aspects of this examination, we were able to build a robust protocol to improve the imaging of paediatric patients that are referred to this imaging department for lower limb lymphoscintigraphy. Post-processing techniques will be explained in a step-by-step manner and examples of pathology from neuro, musculoskeletal, liver, bowel, renal, and vascular pathology will be shown. Results: 3D post processed images help to visualize and give a better understanding and representation of the pediatric anatomy and pathology and expedites pre-surgical planning. Conclusions: New advances in MRI pulse sequences enable 2D and 3D post-processing. 3D image post processing improves patient care. Healthcare, Cleveland, OH). Results: Noise suppression in IR techniques increases edge detection of anatomical structures and therefore increases efficiency of 3D image post-processing. This effect is superior when using model based IR compared to hybrid IR due to the greater degree of noise reduction.

In preliminary experience we have discovered features of multi energy CT which are advantageous for image post-processing. These include mitigation of beam-hardening artifact with high mono-energetic imaging and the use of low mono-energetic imaging to boost iodine density to improve angiographic images which may be limited by contrast or bolus timing. Conclusions: IR and new spectral MECT imaging techniques are effective in improving image quality and therefore in increasing efficiency of 3D image post-processing.

Rocco Pazienza 1 rmpaz@sbcglobal.net; 1 Medical Imaging, Lurie Children's Hospital, Chicago, IL Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: To explain the various imaging modalities and techniques used by both physicians and radiographers and to correlate them to both acute and chronic accidental and non-accidental traumas with the diagnostic modality that best demonstrates that particular injury. The author will show the importance and usage of various imaging modalities and techniques to both the novice radiographer to the most experienced physician.

1. various textbooks 2. various internet articles 3. interviews with both physicians and radiographers specializing in their respective disciplines Results: The author discovered that there are specific indications when selecting the proper imaging modality to be utilized to aid in the differentiation of accidental and non-accidental trauma. Some injuries require several imaging procedures to aid in the confirmation of a specific trauma. Some injuries may require follow-up examinations to be performed several weeks later to support a specific injury. But nearly all imaging modalities play a role --large or small, chronic or acute, in the final identification and diagnosis of any accidental or non-accidental traumas.

Conclusions: Not all traumas can be diagnosed by any one imaging modality. Ultimately, it is the final decision of the physician to order the most appropriate imaging procedure. The decision may also lie with all of the imaging specialists involved in the final images to be used for specific traumas. We as imaging specialists have the responsibility and an obligation to speak for the pediatric population. Purpose or Case Report: Ensuring patient safety is the first and foremost priority of any MRI department. It is imperative that the institution has established guidelines to achieve its MRI safety initiative. It is our objective to present a detailed MRI clearance procedure used in our institution, the different departments involved, and the essential resources required to ensure patients' safety.

The presentation is based upon our institution's actual process of screening and clearing a patient for MRI -from the arrival of the patient to the institution to the completion of the MRI scan, and the necessary postdocumentation. The process will be supported by the use of our internal database with frequently encountered implants, MRI Safety websites, and the departmental staff -the MRI Safety Expert, Radiologists, Nursing Surgical Services Pre-screening Staff, and Program Coordinators. This is a study of an actual patient arriving to our institution for an MRI procedure, which presents challenges involving unknown implants. Potential displacement and heating of these implants will cause a life threating situation.

To clear the patient for MRI, our screening and clearance forms and operative reports are necessary for identification of the implants in question. To work in conjunction with these documents, plain-film radiography will be done on the patient (if no previous imaging is available) to exclude potentially dangerous metallic foreign objects and devices. The roles of the key players (the coordinators, MRI technologists, radiologists, and the MRI Safety Expert) on the screening and clearance of the patient will also be highlighted during the presentation. Results: After facing the challenges of clearing the patient, and eliminating possible safety issues, the end result is a successful completion of MRI scan without any metal incidents or medical risk to the patient's health. In addition to our intended result, post documentation -such as the MRI Sharepoint Implant List, and updates to the patient's Power Chart -will be used as helpful tools to assist when the patient returns for a follow-up MRI appointment.

Comprehensive MRI safety clearance process is paramount for patient safety. Through a meticulous screening and clearing process, higher confidence in identifying implants, less cancelled exams which equates to higher efficiency, and the reduction or elimination of risks to patient health and safety are achieved. (1977) (1978) (1979) (1980) (1981) (1982) (1983) (1984) (1985) (1986) (1987) (1988) (1989) (1990) (1991) (1992) (1993) (1994) (1995) and 1% is Generation Z (1996present) . However, when asked what generation each employee considers themselves to be, the results show 3% as Traditionalists, 14% as baby boomers, 59% as Generation X and 25% are Millennials. When asked how they like to receive information, 53% prefer to be communicated to by email and 30% prefer to be communicated to by text message. The top 3 social media websites that the staff uses are e-mail (92%), Facebook (67%) and Instagram (37%). The majority of staff take between 2-3 weeks of vacation a year (57%). Most people like to receive praise by email (37%), in private (28%) or in the department newsletter (24%). When looking into career advancement, 25% of staff want to stay in the same position that they are in currently, 12% want to be involved in leadership within their role, 14% want to be in leadership within the organization, 5% want to go into quality management, 24% want to return to school and further their education, 2% want to teach within the radiology field, 8% want to go into another industry and 10% hope to be retired.

Our study showed that there are generational differences and they do have an effect in the workplace. The differences effect the way that staff are communicated to, the amount of vacation that is taken, the way that staff likes to be recognized and career development and growth.

Authors are listed in the order provided. An author listed in bold identifies the presenting author. Purpose or Case Report: Scimitar syndrome and subdiaphragmatic total anomalous pulmonary venous connections (TAPVC) are congenital pulmonary vascular anomalies that are not typically diagnosed on routine abdominal sonography. We present three cases of ultrasound diagnosis of neonates with subdiaphragmatic pulmonary veins diagnosed on abdominal ultrasound; to the best of our knowledge, this is the first reported case of abdominal ultrasound diagnosis of previously unknown scimitar syndrome. Case 1: 16 day old girl born at term with cardiac dextroposition and right lung hypoplasia. On abdominal ultrasound, a large vascular structure was seen draining into the inferior vena cava (IVC) near the hepatic confluence, arising in lung above the diaphragm. Doppler confirms venous flow into the IVC ( Figure  1) ; an arterial aortic branch with pulmonary spectral Doppler signature, extended into the base of the right lung. The diagnosis of scimitar syndrome was made, confirmed several weeks later with CT angiography. Case 2: One day old girl born at 29 weeks gestation had a prenatal diagnosis of complex congenital heart disease. Abdominal ultrasound demonstrated asplenia. As part of the complex, the examination demonstrated the common pulmonary vein draining into the left portal vein, decompressing into the heart via the ductus venosus, with color and spectral demonstration of flow direction and velocity. (Figure 2 ) Closure of the ductus venosus contributed to the demise of this child who was inoperable due to her extreme prematurity and her other congenital cardiac lesions. Case 3: Eight day old term infant with multiple congenital anomalies. An abdominal ultrasound for heterotaxy evaluation demonstrated a large anomalous vessel arising in the chest between the descending aorta and esophagus posteriorly, and the atrium anteriorly, descending into the abdomen draining into the portal vein, with a partially obstructing membrane near the insertion point. (Figure 3 ). The TAPVC was repaired on day 9 of life with direct anastomosis to the left atrium.

In conclusion, subdiaphragmatic vascular components of thoracic anomalies should be recognized at abdominal sonography by pediatric radiologists, who may be the first to both recognize and diagnose these conditions. 

A 24-year-old G 5 P 2 gravid female presented for fetal MRI following an abnormal antenatal ultrasound which showed a complex abdominal mass. The MRI was obtained 34 weeks, 5 days. The child was later born at term, and serial radiographs were acquired followed by a CT of the abdomen and pelvis on the 4th day of life. Upper GI was performed on the 6th day of life. Results: Fetal MRI revealed a lobulated, predominantly cystic mass occupying nearly the entire left hemiabdomen with internal septations and T2 hypointense nodules. The mass appeared to circumscribe the stomach. A normal distribution of meconium was present throughout the bowel. The patient was counselled by the radiologist at the time of the MRI who informed the patient that the most likely etiology for the mass was a meconium pseudocyst. Following delivery, an abdominal radiograph supported this diagnosis, as a large upper abdominal mass containing scattered internal calcifications was observed displacing multiple gas-filled bowel loops. The subsequent CT showed these central calcified components within both lobes of a bilobed upper abdominal mass. The left lobe of the mass was predominantly fluid attenuation, and the right lobe exhibited thickening and enhancement of the septations. Contrast flowed freely into the stomach and circumscribed the right lobe of the mass during an upper GI. The left lobe of the mass was not intraluminal. Contrast emptied into the duodenum and small bowel without evidence of obstruction. The mass was shown to represent an immature gastric teratoma following surgical resection. Conclusions: Immature gastric teratoma is an exceedingly rare diagosis. Several imaging features suggested the much more common entity of meconium pseudocyst, and even CT failed to show macroscopic fat within the lesion. This case highlights the value of a multimodality approach to a case of an unusual pathology. Purpose or Case Report: Acute colocolic intussusception is a rare in the pediatric population and generally involves a pathologic lead point, which usually necessitates surgical or endoscopic intervention. No prior published reports have demonstrated presurgical imaging findings of colonic polyp in cases of pediatric colocolic intussusceptions. We will present two pediatric cases from our institution that feature colocolic intussusception with an intestinal polyp as a lead point, with a goal to demonstrate specific sonographic and MR findings.

Case 1 -A 2-year-old girl with recurrent "intussusceptions" (s/p multiple enema reductions as well as negative work-up with EGD and an elective exploratory laparotomy) was brought to the emergency department. An ultrasound and MRI abdomen/pelvis demonstrated a short segment colocolic intussusception at the hepatic flexure with suggestion of a polypoidal leadpoint. The ileocolic junction was normal. She was admitted to surgery for a second exploratory laparotomy, which revealed a colocolic intussusception involving the hepatic flexure with a polyp (3.4 x 2.2.cm) acting as a lead point which was resected. The patient did well after the procedure and was discharged to her home. Case 2 -A 5-year-old boy initially presented to the emergency department with acute exacerbation of chronic abdominal pain and bloody diarrhea. An MRI abdomen/pelvis showed a short segment transient colo-colic intussusception with possibility of an intraluminal polypoidal mass. The patient returned a week later with worsening symptoms and an ultrasound study showed intussusception involving the transverse, descending and sigmoid colon as well as a pedunculated, well-defined heterogeneous intraluminal mass (measured 1.9 x 1.8 cm). An air enema successfully reduced the intussusception. Colonoscopy was performed the following day, which revealed a 2-cm transverse colonic polyp that was removed endoscopically. T Conclusions: Colocolic intussusception is a rare subtype in the pediatric population, and when present can suggest the presence of a pathologic lead point. While colocolic intussusception is difficult to differentiate from ileocolic intussusception on ultrasound imaging alone, a mass acting as a lead point should make it a diagnostic consideration. MRI abdomen/pelvis may be helpful as a complementary examination to better delineate the colocolic nature of the intussusception as well as the mass acting as a lead point, thereby directing the appropriate treatment.

Calcifying Nested Stromal Epithelial tumor of the liver: Case report of a rare primary liver tumor Deepa Biyyam, MD 1 , dbiyyam@phoenixchildrens.com; Mostafa Youssfi, MD 1 , Gerald Mandell, MD 1 , Steve Taylor, MHS, PA 1 , Mittun Patel, MD 1 ; 1 Radiology, Phoenix Children's Hospital, Phoenix, AZ Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Calcifying nested stromal epithelial tumor (CNSET) is a very rare primary liver tumor in children.

To our knowledge, about 30 cases have been reported in literature. We describe the imaging appearance and histopathologic features of this tumor detected in a 2 year old girl who presented with an incidentally detected calcified liver lesion on a chest x-ray which was obtained for cough.

Computed tomography (CT) demonstrated a 5.5 centimeter sized heterogeneous mass with large coarse calcifications. MRI better demonstrated the margins of the lesion, which was predominantly hyper-intense on T2-weighted images. Large areas of signal void were seen in the superior aspect of the lesion, corresponding to the calcifications seen on CT. The lesion demonstrated restricted diffusion. Post-contrast, the lesion demonstrated enhancement in the portal venous phase with washout on the delayed phase. Initial diagnosis based on imaging findings and patient's age was hepatoblastoma. However, serum alpha-fetoprotein (AFP) was normal, which is unusual with hepatoblastoma. Patient underwent subsequent wedge biopsy, which was proven to represent calcifying nested stromal epithelial tumor of the liver. PET/CT, obtained to evaluate for metastatic disease, demonstrated increased FDG activity within the primary hepatic lesion, with SUV Max of 3.5, with no evidence of FDG avid metastatic disease. She then underwent right hepatectomy and cholecystectomy. No sign of tumor recurrence has been noted to date on the follow up abdominal ultrasound examination in the past 2.5 years.

Calcifying nested stromal epithelial tumor should be considered in the differential when a large heterogeneous liver tumor with coarse/ chunky calcifications is identified at imaging in the absence of elevated serum AFP in a child. Currently the standard treatment in complete surgical excision and liver transplantation if excision is not possible. Purpose or Case Report: Fetal abdominopelvic cystic lesions have various etiologies but are most commonly ovarian or gastrointestinal in origin. Congenital pancreatic cysts are rare entities that typically arise from the pancreatic body and tail, more often in females. In contrast, pancreatic heterotopia or an ectopic pancreas is defined as pancreatic tissue found outside the normal region of the pancreas without a vascular or anatomic connection to the pancreas. It is most commonly associated with the gastrointestinal tract, with >90% of cases located in the stomach, duodenum, or jejunum, and has been known to form cystic structures. We describe an unusual case of a term female neonate with a prenatal diagnosis of an abdominopelvic cyst. The patient had episodes of hypoglycemia secondary to hyperinsulinism requiring a continuous glucose infusion. On surgical resection, the cyst was found to extend from the retroperitoneum towards the left colon without connection to the pancreas or gastrointestinal tract. Histopathological evaluation showed components of pancreatic heterotopia including islets of Langerhans surrounded by acinar cells and dilated pancreatic ducts. The immunostain for Chromogranin showed numerous alpha and beta cells confirming pancreatic tissue. Hypoglycemic episodes improved following cyst resection. This is the first reported case of retroperitoneal cystic pancreatic heterotopia in a neonate in the English literature. We will present the ultrasound findings as well as surgical and histopathologic images.

Our case is derived from the records from a tertiary children's care hospital.

The etiologies and imaging findings of neonatal abdominopelvic cysts will be reviewed as well as relevant potential imaging techniques for workup of abdominopelvic cysts with an emphasis on the radiologic, surgical, and histopathologic findings of cystic pancreatic heterotopia. Conclusions: Abdominopelvic cysts are commonly found on prenatal ultrasound and have a wide variety of etiologies. Pancreatic heterotopia is rare outside of the gastrointestinal tract but should be considered in the differential for abdominopelvic cysts, especially in the setting of hyperinsulinemia.

Yi-ming Teo 1 yi_ming_teo@nuhs.edu.sg; ; 1 National University Hospital, Singapore

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Intestinal lymphangiectasia is a rare disease characterised by dilated intestinal lacteals causing loss of lymph into the small bowel lumen and resultant hypoproteinemia, hypogammaglobulinemia, hypoalbuminemia and lymphopenia. The disease may occur as a primary / congenital form (primary idiopathic intestinal lymphangectasia / Waldmann disease) or as a secondary form resulting from causes of lymphatic obstruction, such as tumor or fibrosis. Our case report describes the workup of an adolescent girl with known Primary Intestinal Lymphangiectasia (Waldmann disease) presenting with an acute history of abdominal pain and vomiting. We present her prior imaging leading to her initial diagnosis of Waldmann disease, as well as at the time of acute presentation, with imaging features raising suspicion for, and eventually leading to histo-pathologic confirmation of small bowel B-cell lymphoma. Via this case report poster, we hope to create awareness of this rare disease, as well as its feared association of lymphoma. Typical imaging features are presented and discussed.

Purpose or Case Report: Wilm's tumor (nephroblastoma) is the most common pediatric renal mass, with rare reports of extrarenal Wilm's tumors which primarily arise elsewhere in the retroperitoneum. We present a small series of patients who have recently been treated at our institution with histologically-proven extra-renal Wilm's tumors. The first patient is a six year old female who initially presented to an outside hospital with a draining "perianal abscess", who on subsequent workup was found to have a large infiltrative pelvic mass and multiple pulmonary metastases (image 1). The second patient is a six year old female who initially presented with abrupt onset of rightsided abdominal pain which woke her from sleep, and who was found on imaging to have a large right-sided retroperitoneal hemorrhage originating from a hemorrhagic suprarenal mass (images 2 and 3). We will review the pertinent imaging and histological findings from these patients, as well as briefly review what has been previously published about this rare rumor. The imaging features of extra-renal Wilm's tumor are heterogeneous and not specific, making it important that the radiologist consider this etiology when presented with a retroperitoneal mass in a pediatric patient within the first decade of life. Purpose or Case Report: An infant was born at 36 weeks, 3 days gestation with a known lethal skeletal dysplasia, diagnosed on prenatal ultrasound. The infant was born alive with APGARs of 5 and 3. Comfort care was initiated, and the infant expired one hour later. Plain films of the skeletal system were obtained, which showed short, horizontal ribs and a small thorax. They also showed hypoplastic iliac bones, flattened acetabula, and postaxial polydactyly. The metaphyses of the long bones had convex central areas with lateral metaphyseal spikes. The constellation of findings was consistent with Short Rib Polydactyly Syndrome type III (Verma-Naumoff). Inherited in an autosomal recessive pattern, SRPS is a group of rare, lethal osteochondrodysplasias caused by mutations in the DYNC2H1 gene, a component of the cytoplasmic dynein complex, which is involved in the generation and maintenance of cilia. This mutation results in dyskinesia involving the chondrocytes, leading to arrested maturation of cartilage and generalized loss of synchrony in cartilage removal and osteogenic differentiation. Common anomalies that span all types of SRPS include a triad of micromelia, short horizontal ribs, and polydactyly. Four types of short-rib polydactyly syndrome have been described, which differ based on visceral involvement and the appearance of the metaphyses. Some have phenotypic overlap with various types of Short Rib-Thoracic Dysplasia. The four types of SRPS are: Saldino-Noonan (type I), Majewski (type II), Verma-Naumoff (type III), and Beemer-Langer (type IV). Type I (SN) is characterized by hypoplastic iliac bones, flattened acetabular roofs, rounded vertebrae with coronal clefts, and postaxial polydactyly. The long bones can have varied appearance of the metaphysis, including: pointed ends, convex central areas with lateral metaphyseal spikes, or ragged-appearing ends. A key distinguishing factor with type I is the absence of fibulae. Type III (VN) is very similar to type I, however, the fibulae are present. Visceral anomalies are less common with the Verma-Naumoff type. Type II (Majewski) presents with either pre-or postaxial polydactyly. The long bone metaphyses have smooth ends, the tibiae are ovoid and shorter than the fibulae, and the iliac bones are normal. Type IV (BL), like type II, can also have pre-or postaxial polydactyly and smooth metaphyses in the long bones. The distinguishing characteristics of the Beemer-Langer type include small iliac bones and bowed radii/ulnae. Purpose or Case Report: The purpose of this case report is to familiarize the radiologist with the MR imaging findings of fatal heat stroke. Heat stroke is a severe illness characterized by a core temperature > 40 degrees Celsius, with clinical manifestations of delirium, seizures, and coma, resulting from environmental exposure or physical exertion. This report focuses upon environmental, or classical, fatal heat stroke in the case of a 4 year old male who was left alone for 30 minutes in a vehicle with ambient exterior temperatures of greater than 37.8 degrees Celsius.

As a form of hyperthermia, heat stroke ensues from thermoregulatory failure in addition to systemic inflammatory and coagulation phase responses, and conceivably, from modified manifestation of heat shock proteins. Infants and young children comprise a population specifically vulnerable to heat stroke due to their large surface area to volume ratio, underdeveloped thermoregulatory system with small blood volume relative to body size, and decreased sweat production. The CNS is especially susceptible to hyperthermia as cerebral edema and cerebrovascular congestion may lead to increased intracranial pressure, and ischemia or hemorrhage. The cerebellum is the area most sensitive to heat injury, with known direct injury to Purkinje cells, and resultant cerebellar atrophy, often leading to neuronal dysfunction, including ataxia. MR imaging findings in heat stroke are typically multifocal reflecting the complex interplay of direct thermal injury, hypoxic ischemic injury, endothelial damage, cytokine mediated inflammation and coagulopathy. MRI in our case of fatal heat stroke demonstrates diffuse signal abnormality within the peripheral cerebellar hemispheres (eg. Purkinje cell regions). MRI recapitulates the known pathology of fatal heat stroke with injury to Purkinge cells and adjacent Bergmann glia. Other reported heat stroke related MRI findings include T2 prolongation and restricted diffusion involving the paramedian thalamic nuclei, dentate nuclei, basal ganglia, hippocampii, and cerebral cortex particularly the vascular watershed zones. If the health history for heat stroke is uncertain, the imaging differential diagnosis includes other cerebellar syndromes including: toxic -metabolic (eg. opiate toxicity), infectiousautoimmune (eg. Varicellar zoster cerebellitis), histiocytic neoplastic-like (eg. histiocytoses) and neoplastic (eg. leptomeningeal PNET) should be considered in the imaging differential diagnosis. Purpose or Case Report: An 11-year-old female presented with 3-weeks history of intractable vomiting, nausea, blurred vision, vertical nystagmus and ataxia with gait instability. A CT scan revealed a small calcification at the left craniocervical junction (CJJ) and mild effacement of the fourth ventricle (Figure) . MRI showed a partially-enhancing medulla oblongata lesion and a non-enhancing cystic exophytic lesion abutting the left premedullary cistern. There was avid thick enhancement along the ventrolateral surface of the medulla oblongata. No restricted diffusion was present. MR spectroscopy demonstrated decreased NAA and elevated lactates. Based on imaging findings, a brainstem glioma with exophytic component was suspected. The CBC, CMP, ESR and CRP were normal. The patient underwent suboccipital craniectomy with C1 laminectomy, and an exophytic pale gray mass was identified. Multiple specimens were taken, and frozen diagnosis showed only necrosis. The cyst wall was resected. Resection of the brainstem component was limited by neurophysiology. Histologically, the lesion consisted of a fibrous cyst wall lined by columnar to pseudostratified columnar epithelium, findings reflecting a neuroenteric cyst. No glial tissue was identified. Gram stain and Grocott stain were negative for bacterial and fungal specimens. An empiric treatment with wide spectrum antibiotic was started. Follow-up MRI demonstrated near complete resolution of edema in the medulla oblongata, and substantial decrease in enhancement in anterolateral exophytic component and patient has substantially improved clinically. In retrospect, a sinus tract extended from the cystic lesion at the craniocervical junction into the brainstem causing edema, inflammation and enhancement which resolved once the cyst was surgically decompressed. Conclusion: This case shows a neuroenteric cyst connected to the brainstem, through a sinus tract leading to chronic inflammation and infection, resulting in imaging findings resembling a brainstem glioma. Surgical decompression of the cyst and antibiotic treatment resulted in resolution of the brainstem lesion. Purpose or Case Report: Propionic acidemia is a rare autosomal recessive disorder in which a genetic mutation results in the abnormal function of propionyl co-enzyme A (CoA) carboxylase, an enzyme involved in protein breakdown and lipid catabolsim. This results in the accumulation of metabolites which can have devastating neurologic consequences. The incidence in the United States has been reported as 1 in 100,000 births. The genetic and metabolic factors contributing to this disorder are discussed.

Brain MRI findings in propionic acidemia are described in 2 patients. The first patient is a 5month-old male who was transferred from an outside hospital on respiratory support with severely elevated ammonia and metabolic acidosis. The second patient is a 15-year-old female who presented to the emergency department with a mild headache and increased sleepiness. Following admission, she decompensated significantly, and her serum ammonia level was shown to be three times the normal limit. Results: MRI of the brain in the first child demonstrated diffusion restriction in a subcortical pattern evenly distributed throughout both cerebral hemispheres. In the second patient, MRI revealed cortical diffusion restriction throughout the entire left cerebral hemisphere, however, the right cerebral hemisphere was affected to a much lesser extent. Interestingly, parenchymal volume loss was prominent throughout the right cerebral hemisphere. The basal ganglia and thalami were not affected in either child. Follow-up MRI obtained in both children after appropriate therapy showed improvement in diffusion restriction. There was diffuse cerebral atrophy on follow-up of the first patient. Follow-up MRI of the second patient showed resolution of diffusion restriction and continued volume loss throughout the contralateral (right) cerebral hemisphere. Conclusions: These cases illustrate unique and distinct patterns of diffusion restriction in propionic acidemia crises. Commonly reported findings in the literature include involvement of the basal ganglia and/or thalami which were not seen in these two children. The cases shown here further expand the differential diagnosis for nonspecific diffusion restriction and demonstrate uncommon presentations of an already rare disease entity. Purpose or Case Report: We will present imaging findings of segmental spinal dysgenesis in a series of 3 cases of this rare congenital abnormality. We will also describe the embryological basis and pertinent clinical features.

Case 1: 8-year-old female recently adopted from China with history of severe scoliosis, neurogenic bladder, and chronic kidney disease. Plain radiographs demonstrate severe destroscoliosis in thoracolumbar region with associated kyphosis. MRI reveals multiple segmentation/formation anomalies in the lumbosacral region. The coccyx was not identified, likely representing associated partial sacrococcygeal dysgenesis. The spinal cord was severely dysgenetic in the lower thoracic region (Figure 1, white outlined arrow) . The superior segment of the spinal cord extends from the cervicomedullary junction to the level of T8, where it ends abruptly. No intervening cord tissue is seen between the T8 level and lumbar region. There is an enlarged spinal cord segment at the level of the sacrum in the spinal canal, separate from the superior segment ( Figure 2 , solid white arrow). CT with 3D reconstruction better demonstrated multiple segmentation/formation anomalies in the thoracic and lumbosacral region, including butterfly vertebrae, hemivertebrae, and block vertebrae. There were 10 ribs on the right noted with the superior 2 ribs fused.

Spinal segmental dysgenesis is a congenital developmental abnormality with severe hypoplasia/absence of variable length of the spine and spinal cord. The spinal cord in the involved portion may be severely hypoplastic to totally absent. There are no associated dorsal defects of meningomyelocele at the involved level Purpose or Case Report: Metronidazole is a commonly used and effective antimicrobial agent for gastrointestinal and genitourinary infections throughout the world. Common side effects of nausea, taste/appetite changes, and headache are well known, however, CNS side effects such as cerebellar dysfunction, dysarthria, and seizures have been reported even at therapeutic levels in rare instances. A previous review of the case literature concluded that resolution of symptoms was independent of age, however, evaluation of the pediatric population is limited.

The patient is a 17-year-old autistic male who presented with one day history of ataxia and leaning to the right during ambulation. He was afebrile, and lumbar puncture revealed no evidence of meningitis. There were no recent illnesses or sick contacts. Past medical history was significant for Hirschsprung's Disease. Results: There is diffuse T2 signal abnormality throughout the cerebellar hemispheres with notable involvement of the cerebellar cortex and dentate nuclei. Symmetrical regions of abnormal FLAIR/T2 signal hyperintensity are also present within the dorsal pons and medulla. There is ill-defined T2 signal hyperintensity within the callosal splenium which demonstrates corresponding restricted diffusion. There is no associated contrast enhancement. Review of the patient's medical record showed long-term use of metronidazole. MRI changes and mental status improved following withdrawal of the medication.

Conclusions: Unexplained change in mental status often prompts imaging evaluation. The MR imaging findings of metronidazole induced CNS toxicity in this case expands on the limited literature of this condition in the pediatric population. Additionally, the unique imaging findings discussed will serve to initiate prompt cessation of therapy in an otherwise reversible disease course.

severe respiratory compromise requiring immediate advanced airway placement, or astonishingly, they may be asymptomatic. Tracheal transection may be identified when laryngoscopic intubation fails, during the placement of a surgical airway, or during initial CT or bronchoscopic evaluation. We describe an 8-year-old male who experienced blunt neck trauma and was intubated successfully in the pre-hospital setting. Initial radiographic evaluation was significant for severe subcutaneous emphysema and pneumomediastinum. Bilateral thoracostomy tubes were placed. Initial CT evaluation again showed extensive pneumomediastinum without pneumothorax. Four days after initial hospitalization the patient was extubated without difficulty. Post-extubation chest x-ray showed irregular tracheal borders with focal hyperlucency adjacent the midcervical trachea in the former position of the endotracheal tube cuff. Repeat CT of the chest showed complete tracheal transection of the mid-cervical trachea. The patient subsequently underwent surgical repair and was discharged without complication. This is the first reported case of traumatic tracheal transection not identified on initial CT examination secondary to the position of the endotracheal balloon, with subsequent discovery of the complete transection on the post-extubation radiograph.

There is 1 reported case of tracheal transection identified on initial CT evaluation in the presence of a well-positioned endotracheal tube. Additionally, there is 1 reported case of tracheal transection not identified on initial CT evaluation, however the patient was not intubated and had minimal symptoms. Tracheal transection was confirmed via bronchoscopy in that case. Tracheal transection is rare traumatic injury that can be difficult to identify. High clinical suspicion and careful examination with multiple modalities is often necessary to make a definitive diagnosis. 

A 15 year old female with no significant past medical history except for long standing dysphagia and intermittent chest pain presented for a frontal and lateral radiograph. The x-ray showed a long segment density along the right heart border concerning for mediastinal mass.

The patient subsequently underwent a contrast enhanced CT. Diffuse circumferential thickening of the esophagus began just below the thoracic inlet and extending for approximately 17cm to the level of the esophageal hiatus. Evaluation of the esophageal lumen was performed at our institution utilizing reduced pediatric dose pulsed fluoroscopy with a barium esophagram. While the cervical and upper 1/3 of the thoracic esophagus had a normal lumen diameter and contour, there was irregular contractility and motility throughout the upper esophagus. The lower 2/3 showed narrowing which did distend with barium passage. At this juncture a biopsy of the lesion was performed with the resulting pathology consistent with a leiomyoma. Preoperative planning MRI was then undertaken. As seen with the CT, diffuse circumferential thickening of the esophagus began just below the thoracic inlet with progressive thickening continuing distally to a maximum thickness just above the GE junction.

The patient subsequently went on to have an Ivor-Lewis esophagectomy with gastric pull through. The diagnosis of diffuse esophageal leiomyomatosis was confirmed by pathology. Diffuse esophageal leiomyomatosis (DEL) was probably first described by Hall in 1916 in a case report of a 17 year old female who died of starvation due to dysphagia, with the diagnosis subsequently made on autopsy. While some cases of DEL are sporadic, as in our case, there is a well-established association with the x-linked Alport Syndrome, especially in the pediatric population. Up to 5% of Alport patients are affected by DEL and as much as 2/3 of pediatric patients with DEL carry the diagnosis of Alport Syndrome. Esophageal-Vulvar syndrome, characterized by leiomyomata of both the vulva and esophagus, presents with findings of DEL on imaging in many cases, often in young adult females. While presentations may vary, the majority of patients present with long standing dysphagia. An Iver-Lewis esophagectomy with a gastric pull-through is the treatment of choice. Purpose or Case Report: Spectral or multi-energy CT (MECT), obtains raw data at more than one energy spectra which allows the decomposition of materials into their constituent elements. As opposed to conventional CT which yields data based on linear attenuation, MECT yields both structural and materialspecific information. Only limited experience and literature are available regarding use and applications of MECT in the pediatric patient population. Our institution has recently installed a spectral MECT scanner which uses a single x-ray source modified multilayered detector CT, in our emergency department (ED). It is currently the only such scanner used for routine clinical pediatric imaging in the US, and 4 th such unit in a children's hospital in the world. In this educational exhibit we will review the basic physics of MECT, the benefits and limitations of the single-source multi-layered detector geometry, and clinical applications of MECT and our experience to date in the pediatric population.

A Philips IQon Spectral MECT (Philips Healthcare, Cleveland, OH) was installed in our facility in October, 2017. Though positioned in the ED, routine inpatients and outpatients are also examined. Results: We present cases in which MECT aided in diagnosis through use of spectral data and propose areas of further clinical diagnoses and research. Clinical cases thus far examined include children suffering acute trauma, abdominal pain, renal stones, congenital heart disease, headache, and tumor. Features of MECT advantageous to pediatric patients include reconstruction of virtual non-contrast images, perfusion imaging, mitigation of beam-hardening artifact with high mono-energetic imaging, the use of low mono-energetic imaging to boost iodine density to improve angiographic images which may be limited by contrast or bolus timing, and urinary stone analysis and renal mass characterization.

The use of Spectral MECT at our institution has provided a significant advance in our ability to confidently diagnose various disease processes. As we gain more experience in the use of MECT in the pediatric population, we will be able to better define its role and uncover further areas of research.

cardiac magnetic resonance (MR) studies performed using this method. The feed and wrap technique in which feeding and warmth are used to induce sleep and swaddling is used to reduce motion is described. Indications and contraindications as well risks and benefits of this method versus general anesthesia and deep sedation are discussed. Multiple examples of congenital heart disease including atrial and ventricular septal defects, atrioventricular canal defects, and double outlet right ventricle are provided, with sequences used, length of scan, and diagnostic quality also summarized. The example shown in Figures 1-3 is a 12-day-old female. The scan was completed in 12 minutes without intravenous contrast. Figure 1 is the scout image showing situs inversus. Figure 2 is a gated axial steady state free procession (SSFP) image showing a membranous ventricular septal defect (yellow arrow), an atrial septal defect (yellow arrowhead), and atrial inversion. Figure 3 is a 4D flow reconstruction showing the superior and inferior vena cava entering anatomic right atrium on the left, a right aortic arch with mirror branch pattern, and relationship to the main pulmonary artery (MPA). Conclusions: After reviewing this educational exhibit, the reader will be able to implement the feed and wrap method as an alternative to general anesthesia or sedation in CT and MRI scans of infants. Examples are provided in cardiovascular imaging, of particular interest because the risk of adverse events under general anesthesia is higher in congenital heart disease patients and because of the complexity of disease being evaluated. Purpose or Case Report: CHD (congenital heart disease) occurs in approximately 1% of all live births with more than 90% survival into adulthood. Prevalence of coronary artery disease has been reported to be similar to general adult population. Patients with complex CHD may be subjected to non-atherosclerotic premature coronary artery disease due to anomalous coronaries, peri-coronary region interventions, or coronary re-implantation. Cardiac MRI (CMR) may provide valuable myocardium health information with pointers towards a coronary distribution in unsuspected chronic or acute cases. Acquisition of delayed enhancement sequences (LGE) and T1 mapping should be considered routine in CMR studies for assessment of interval ischemic events. Patients with complex CHD are also at risk for sudden cardiac arrest and LGE data may assist in further risk stratification of these patients. Three complex CHD patients who all suffered myocardial infarctions at a young age as a result of their multifaceted cardiac history are highlighted to illustrate the importance of this (see included table, Figure 1 ). Two CMR images (Figures 2,3 ) demonstrate delayed enhancement throughout the septum at the base to midcavity in a patient with truncus arteriosus type 1 who presented with a non-ST-elevation myocardial infarction (NSTEMI). Focal area of low-signal sub-endocaridum within the enhancement on Figure 3 favors microvascular obstruction. CMR is a vital component of surgical planning and postoperative care of patients with CHD, providing accurate anatomical, functional, and flow information that assists in clinical management. Delayed enhancement sequences and postgadolinium T1 mapping allow assessment of ischemic injury or infarct, and therefore should be considered part of routine follow up CMR studies in patients with complex CHD. Purpose or Case Report: The purpose of this educational presentation is to provide a pictorial review to promote recognition and understanding of the embryology, anatomy and spectrum of interruption of the aortic arch (IAA) in children.

Interruption of the aortic arch will be classified according to the the Celoria-Patton system. There are 3 main categories of IAA (A, B and C), which are defined by the location of the discontinuity. In addition to the three categories, there are 3 subtypes for each, for a total of nine types. Illustrative examples will be provided from clinical case material. Results: Imaging findings will be reviewed, with an emphasis on CT/MR appearances, and discussion of important associated conditions and findings. Specific syndromes associated with IAA will be highlighted, and attention will be given to surgical intervention and post-operative imaging. Conclusions: After reviewing this educational exhibit the reader will have a framework for recognizing and understanding IAA in the pediatric age group. They will have reviewed pre-and postoperative CT/MR imaging findings as well as the context and important associated findings.

Vandad Saadat, MD 1 , vandad.saadat@gmail.com; Soni Chawla, MD 3 , Johnathan Chen 2 , Paul Iskander, MD 2 , Shahnaz Ghahremani, MD 2 ; 1 Internal Medicine, University of Miami, West Palm Beach, FL, 2 UCLA, Los Angeles, CA, 3 Olive View Medical Center, Los Angeles, CA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Awareness of abdominal aorta abnormalities in pediatric patients is essential for appropriate diagnosis and management of the patients suffering from these conditions. Due to a nonspecific presentation, and sometimes being asymptomatic earlier in life, imaging has an important role in diagnosis of these abnormalities. Aneurysm and dissection are excluded, as they are not specific to children and with few exceptions mostly present in older patients. We review the clinical presentation and show imaging findings of mid aortic syndrome, Takayusu arteritis, rare entities such as idiopathic infantile arterial calcification. Also we show imaging of the anatomic variants of the distal aorta such as middle sacral artery, persistent sciatic artery, abdominal aorta coarctation and blind ending aorta, with a short review of embryologic development of abdominal aorta. These anomalies are not common, however if remain undiagnosed might have serious consequences.

-Midaortic syndrome is an uncommon disease with progressive narrowing of the abdominal aorta and its major branches, typically involving interrenal segment of the aorta; it affects mostly children and young adults, the cause is not clear, might be the result of an intrauterine insult to the intima and subintimal tissues. Aside from diagnosis, imaging has a major role in endovascular treatment of mid aortic syndrome.

-Takayusu arteritis, also predominantly involves aorta and its major branches of younger patients, with strong female predominance, and frequently found in Asian patients. Destruction of arterial medi leads to aneurysm formation and uncommonly rupture of the involved artery.

-Idiopathic infantile arterial calcification, a rare entity presenting with extensive calcification and stenosis of large and medium sized arteries, usually leads to early death from coronary artery occlusion.

-The aortoiliac variants are rare and not commonly discussed in the imaging literature. Some anomalies might be asymptomatic in young ages, but might complicate surgeries like heart, renal transplant, or hip surgery and increases the risk of morbidity and mortality. Some of these anomalies such as persistent sciatic artery need long term follow-up, given the possibility of aneurysmal degeneration.

Isolated unilateral absence of a pulmonary artery: imaging appearance from birth to adolescence Jordan Rapp, MD 1 , jrapp24@gmail.com; Erica Poletto, MD 2 , Jaqueline Urbine 2 , Archana Malik 2 , Faaiza Kazmi 2 , Mea Mallon 2 ; 1 Children's Hospital of Philadelphia, Philadelphia, PA, 2 St. Christopher's Hospital for Children, Philadelphia, PA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: The rare entity of an absent pulmonary artery has appeared in the literature since 1868, with most cases associated with congenital heart disease of various types. It has also long been observed that the absent pulmonary artery is contralateral to the aortic arch in almost every case. Isolated absence of a single pulmonary artery without associated congenital heart disease is less common, and these patients may present at any time from prenatal screening, neonatal period, early childhood, or even adolescence and adulthood. We will discuss the embryologic origins, clinical presentations, expected imaging findings, and treatment options based on patient ages from newborn to adolescence. In neonates with an isolated absent pulmonary artery, a patent ductus arteriosus will allow for continued systemic blood supply. Even early on, narrowing of the PDA may be seen as involution is inevitable without intervention. The lung parenchyma is typically preserved, without yet evidence of hypoplasia or oligemia. Once the PDA has closed, robust collateral formation will occur. As patients age without repair, the lung parenchyma may become hypoplastic with diminished lung volumes and vascular markings. Findings suggestive of recurrent infection such as bronchiectasis may also be evident. Early discovery and treatment is ideal as this will allow for prevention of long term sequelae and the greatest restoration of lung function as the options for repair are limited in the older patient. There is no universal standard approach for repairing the underlying mechanism of providing blood flow to the intrapulmonary pulmonary artery. Early intervention in neonates included PDA stenting or anastomosing the main pulmonary artery with the intrapulmonary pulmonary artery using a synthetic graft. Patients that present after the neonatal period are not likely to be eligible for surgical repair. The most common long term effect of an absent pulmonary artery is pulmonary hypertension, seen in 40% of patients. The entity of isolated unilateral absence of a pulmonary artery is rare, however demonstrates typical cardiothoracic findings depending on age at presentation. Understanding of embryology, specifically the 4th and 6th primitive aortic arches, allows one to understand why this malformation occurred and what findings to expect on imaging. The maintained PDA is vital for early lung blood supply and development and can aid in repair.

Surgically Created Cardiac Shunts Amy Farkas, MD 1 , afarkas@umc.edu; Candace Howard-Claudio 1 ; 1 Department of Radiology, University of Mississippi Medical Center, Jackson, MS Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Congenital heart diseases alter the normal flow of blood through the heart. Conditions range in severity, from those that may simply require routine monitoring, to devastating lesions whose natural history is fatal. These complex conditions often require complicated surgically created cardiac shunts as treatment. Various diseases are often managed with the same procedure, with the goal of altering the abnormal hemodynamics. These surgeries may attempt to repair the lesion and restore normal physiology, or palliate the lesion as a bridge to future treatment including transplantation. This electronic poster provides a case based review of surgically created cardiac shunts. Cases include patients who have undergone bidirectional Glenn, Fontan completion, Rastelli, and Norwood procedures and the Blalock-Taussig shunt. The poster will review the congenital heart abnormalities corrected by these procedures and the anatomy of the shunts on CT and MRI.

Candace Scace 1 candace.scace@gmail.com; 1 Children's Hospital of Philadelphia, Philadelphia, PA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: To provide a working knowledge of normal cardiac anatomy and a systematic guide to findings in common and uncommon congenital heart disease as seen on cardiac CTA.

A retrospective review of congenital cardiac anomalies was performed. A series of cardiac CT angiography cases with identified presurgical congenital heart disease was collected for review and presentation. Results: Cardiac CTA findings and distinguishing imaging features of atrial and ventricular septal defect, coarctation of the aorta, transposition of the great vessels, double aortic arch, hypoplastic left heart, tetralogy of fallot, truncus arteriosus, anomalous coronary arteries and total anomalous pulmonary venous return are discussed.

Conclusions: This educational exhibit increases pediatric radiologists and trainees exposure to basic pediatric cardiovascular imaging and provides a basic framework for identification and interpretation of cardiac and extracardiac CT angiographic findings of congenital heart disease. Purpose or Case Report: The posterior fossa houses the brainstem and cerebellum. These vital and complex parenchymal structures contain many important white matter tracts, nuclei, and neurons responsible for both basic fundamental and higherlevel functions. A number of disease processes can interfere with rhombencephalic development, including genetic malformations and disruption such as hypoxia, toxins, infections, trauma, and vascular disorders. Structural changes associated with fetal imaging pathology that deviate from the normal gestational-age specific developmental patterns can define the etiology, improve our understanding of the disease, and help with prognostication. A comprehension of basic embryology and developmental anatomy is necessary to achieve a true understanding of posterior fossa anomalies and normal variants. In this exhibit, we aim to illustrate common and rare anomalies of the brainstem, cerebellum, meninges, and meningeal spaces visible on fetal MRI, presented in a temporal manner based on the embryologic development of the posterior fossa.

Fetal MRI and correlative fetal ultrasound and post-natal images with didactic value will be procured from the teaching file of a pediatric medical center in order to demonstrate developmental anatomy and posterior fossa pathology.

Results: Normal anatomy of the posterior fossa in various stages of developement will be shown and contrasted against the following entiites: elicit further evaluation with MRI, as MRI can provide more detail and information to the radiologist and clinician. Chest and cardiac pathologies are among the most common findings on prenatal ultrasound and often warrant additional imaging. Consequently, an understanding of these findings and how they appear on different modalities is essential to the pediatric imager. This electronic exhibit features fetal ultrasound and MRI of mediastinal lymphangioma, type I-III congenital pulmonary airway malformations, intralobar, extralobar, and subdiaphragmatic sequestrations, left and right sided congenital diaphragmatic hernias, hypoplastic left heart, heterotaxy, AV canal defect, and rhabdomyoma. In addition to reviewing the correlation of findings on ultrasound and MRI, prognosis as well as conditions and syndromes commonly associated with these chest and cardiac anomalies will be examined. The goal of this exhibit is to provide an overview of common fetal cardiopulmonary abnormalities on different, complementary imaging modalities. Familiarity with these conditions is necessary for the radiologist to provide critical information to clinicians to allow prompt intervention in the postnatal period. These findings can additionally serve as an indication to the radiologist to search for associated findings, allowing prognostication and appropriate counseling of parents.

The Purpose or Case Report: With the increasing utilization of imaging in prenatal diagnosis, the fetal MR appearance of omphalocele has been well-described. However, as fetal MR plays a critical role not only for diagnosis but also for planning and family counseling, the radiologist is required to risk stratify the range of presentations of this anomaly. There is a broad spectrum of severity within this single diagnosis: ranging from a small and covered bowel-only defect, to a large and ruptured multi-organ hernia, to a complex omphalocele within a nonkaryotype fetal syndrome. Outcomes are highly variable, ranging from a simple hernia repaired with primary closure, to a protracted postnatal course with staged surgical repairs, to expected intrapartum demise. Further, neonatal pulmonary hypoplasia and hypertension often complicate more severe cases. Thus, accurate prognostication is essential to properly equip and prepare families, and thereby add value to perinatal care. In this presentation, we outline a 7-point, systematic method for analyzing the varied presentations of omphalocele, as seen on both 1.5T and 3T MR field strengths. The approach we describe details the following diagnostic criteria: (1) the size of the defect, (2) type and volume of herniated organ contents, (3) presence/absence of an intact membrane, (4) presence/absence of hernia sac ascites, (5) associated pulmonary hypoplasia, (6) insertion of the umbilical cord, and (7) presence of irregular cord vessels. Finally, we demonstrate how this diagnosis can correlate with associated ischemic changes in the placenta, a finding which can further aid delivery planning and prognostication. Purpose or Case Report: Immunoglobulin4 related disease (IgG4RD) is an inflammatory condition involving multiple regions of the body resulting in fibrosis which can lead to eventual organ failure. This entity was originally described with autoimmune pancreatitis. Recently many other previously described lesions have been brought under the umbrella of IgG4RD. These include a spectrum of conditions involving the head and neck region (orbits, salivary and lacrimal glands), thyroid gland (Riedel's thyroiditis), vasculature (periaortitis), kidneys, lungs, retroperitoneum, mesentery, pituitary gland, biliary tract, pericardium, lymph nodes and pachymeninges. Reports of IgG4RD are quite rare in the pediatric literature, however this may be due to potential unawareness about the condition as well as the variable presentations and non-specific imaging features of IgG4RD. The prevalence in pediatric population is poorly described.

The exact pathophysiology of IgG4RD is yet to be completely elucidated. The imaging manifestations are non-specific, and primarily consist of tumefactive enlargement of involved organs and homogenous contrast enhancement and associated lymphadenopathy. IgG4RD may manifest in single organ or may present as widespread disease involving multiple organs. These features overlap with other mass forming conditions like malignancy or lymphoma. However, the presence of multifocal disease with more than one organ involvement may point towards possible IgG4 related disease. Other than IgG4 related autoimmune pancreatitis, there is no consensus on diagnostic criteria based upon imaging. Definitive diagnosis of IgG4RD is made with biopsy and the histology characterized by infiltration of lymphocytes and IgG4 plasma cells with storiform fibrosis and obliterative phlebitis. According to Boston consensus, the ratio of IgG4 /IgG in tissue should be more than 0.4 with more than 10 IgG4+ cells per high power field. Serum IgG4 levels range from normal to elevated. Steroids are effective as first line treatment in majority of patients. Our aim in this presentation is to familiarize radiologists with the spectrum of imaging features, and areas of involvement in IgG4 related disease using cases of IgG4RD collected at three different pediatric hospitals. It is important for pediatric radiologists to be familiar with this relatively newly described disease entity and be aware of the spectrum of manifestations of IgG4RD, ensuring prompt recognition and early treatment.

Taking "AIM" at bowel obstruction in children and infants: Not always the usual culprits Adam Goldman-Yassen 1 , adgoldmanyassen@gmail.com; Jessica Kurian, MD 1 , Einat Blumfield 1 , Terry Levin, MD 1 ; 1 Montefiore Medical Center, Bronx, NY Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Common causes of bowel obstruction (BO) in infants and children include appendicitis, adhesions, intussusception, inguinal hernia, midgut volvulus, and Meckel's diverticulum, for which the mnemonic "AIM" is used. We present uncommon causes of BO in infants and children and review the clinical presentation, imaging findings, and surgical diagnoses.

The hospital database was searched for cases of BO in infants and children under age 10 years during the years 2013-2017, excluding appendicitis, post-surgical adhesions, intussusception, inguinal hernia, midgut volvulus, and Meckel's diverticulum. Patient age, comorbidities, clinical presentation (including duration of symptoms), imaging findings, and surgical diagnoses were reviewed. Results: Nine uncommon causes of BO were identified and included cecal volvulus (2 cases), primary midgut volvulus with normal bowel fixation (1 case), isolated ileal volvulus (1 case), congenital bands (2 cases), internal hernia (1 case), and radiolucent foreign bodies (2 cases). Patients ranged in age from 10 weeks to 11 years. Symptom duration was variable.

Underlying comorbidities were present in 2 cases (Down's syndrome and Cornelia de Lange syndrome). Plain abdominal radiographs were available in all cases. Four patients underwent computed tomography, 2 patients underwent upper gastrointestinal series, and 1 underwent a contrast enema.

Abdominal radiographs in cecal volvulus demonstrated right sided and midline colonic distension. In both the case of closedloop obstruction with bands and primary volvulus, abdominal films demonstrated a midline mass containing air and displacing the colon laterally. The remainder of cases presented with dilated stacked small bowel loops indistinguishable from other causes of small bowel obstruction. Plain film findings of pneumatosis mimicking necrotizing enterocolitis (NEC) were present in an infant with isolated ileal volvulus. CT was the imaging modality most likely to aid in diagnosis but did not affect management. All patients underwent emergent surgery.

We discuss the unusual and often confusing imaging findings in uncommon causes of BO in infants and children. In some cases, radiographs mimic NEC, resulting in diagnostic delay. Awareness of characteristic plain films findings, such as those seen in cecal volvulus, may aid in diagnosis. In acutely ill patients, additional imaging may delay prompt surgical intervention.

Alex Essenmacher, MD 1 , alex-essenmacher@uiowa.edu; Simon Kao 1 , T. Shawn Sato, MD 1 ; 1 University of Iowa Hospitals and Clinics, Iowa City, IA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: The management of acute appendicitis is most often surgical with appendectomy; the blindending, inflamed appendix is removed, usually laparoscopically. There is growing awareness of the potential for a delayed complication if only the tip or otherwise subtotal length is removed. A remnant portion of the base of the appendix, referred to as a stump, if long enough can become obstructed and symptomatic similar to the etiology of acute appendicitis. In cases of recurrent right lower quadrant pain in a patient with a surgical history of appendectomy, appendicitis remains on the differential diagnosis alongside non-appendiceal causes such a colitis and epiploic appendagitis. Imaging diagnosis by computed tomography or ultrasound of stump appendicitis is similar to acute appendicitis with right lower quadrant inflammation and stump distension and wall thickening. In this educational exhibit we will review the imaging features of stump appendicitis as well as developments in surgical techniques relevant to this delayed complication. Relevant anatomy and differential diagnosis for right lower quadrant pain will also be summarized. Purpose or Case Report: There are a variety of masses in neonates, infants and young children that may disappear spontaneously without active intervention. However, there has been no published review of what type of masses could disappear and what the spectrum of their imaging features is. It is essential for radiologists to understand imaging features of these entities in order to provide pediatrician and pediatric surgeons with critical information that will enable them to manage these patients expectantly without surgical intervention.

The entities that will be illustrate in this review include, among others: multicystic dysplastic kidneys, suprarenal masses (including intraabdominal sequestration, neuroblastoma and adrenal hemorrhage), ovarian cyst and torsion, duplication cyst of gastrointestinal tract, cyst of liver and kidneys. Purpose or Case Report: In this educational exhibit we plan: 1. To identify and illustrate the spectrum of blastomas on various imaging modalities 2. To review the pathogenesis of these tumors 3. To describe and illustrate the typical and atypical imaging appearances and organ-wise differential diagnosis Methods & Materials: Blastomas are rare childhood tumors that can affect any organ system in the body and at times can be devastating if left untreated. Controversy surrounds their nomenclature and there is no globally accepted classification. They are thought to arise from immature, primitive tissues with persistent embryonal elements on histology. These tumors affect a younger population and are usually malignant. Imaging is often non-specific but plays an important role in identification, management and follow-up. In this exhibit, we discuss the characteristic imaging features and pathogenesis of select blastomas. manifestations and consider the diagnosis of IBD as the etiology for their pathology.

A case review of the imaging features of some common and uncommon extra-intestinal manifestations of pediatric IBD will be presented. A brief overview of pediatric IBD, its pathophysiology, clinical features, and the key imaging findings on various modalities will be provided. The role of imaging as a whole in making the diagnosis and guiding the management of IBD will also be described.

In this educational exhibit, a series of cases will be presented to illustrate the imaging findings in pediatric IBD with emphasis on the extra-intestinal manifestations. We will review some well-known manifestations of IBD such as primary sclerosing cholangitis (PSC) and IBD related spondyloarthropathies, and highlight their key imaging characteristics. Additionally, we will also present cases of some uncommon extra-intestinal manifestations such as granulomatous hepatic abscesses and non-infectious lung parenchymal involvement, which may mimic other disease entities thus creating potential pitfalls for the radiologist. Conclusions: Pediatric IBD is frequently associated with extraintestinal involvement. These findings may be discovered when imaging the bowel or IBD may be suspected based on the combination of intestinal and extra-intestinal findings. It is therefore important for radiologists to consider these manifestations to provide an accurate assessment of the patient to the referring physician. Purpose or Case Report: Chronic pancreatitis (CP) is characterized by permanent damage to the pancreas resulting in endocrine and exocrine deficiencies. CP is often associated with a history of acute recurrent pancreatitis. Pediatric CP is most commonly linked to known genetic mutations, such as PRSS1 or CFTR, and there is an increased risk of pancreatic adenocarcinoma in patients with hereditary pancreatitis. The mainstay of CP management involves controlling chronic pain and preserving quality of life. Total pancreatectomy and islet auto-transplantation (TPIAT) is an option for managing pain in pediatric patients with uncontrollable pain or pancreatitis secondary to genetic causes. TPIAT was first performed at the University of Minnesota in 1971. Currently there are more than 15 academic institutions in the US performing TPIAT and that number continues to rise. TPIAT has been shown to be effective for pain relief as well as maintaining insulin independence in adults and young pediatric patients. The timing of TPIAT in a patient's disease course is critical because islet cell yield is inversely correlated with pancreatic fibrosis, and postoperative diabetes outcomes depend on islet yield. Imaging prior to transplant is aimed at assessing changes of pancreatitis, vessel patency, and identifying vessel and pancreatic ductal anatomic variants. Preoperative imaging can also confirm adequate liver volume for the procedure and identify postoperative changes from previous procedures such as distal pancreatectomy or Puestow procedure (pancreaticojejunostomy). Routine postoperative imaging consists of liver Doppler ultrasound screening because elevated infusion pressures during autotransplantation can result in endothelial injury and portal vein thrombosis. Delayed gastric emptying and small bowel ileus are common postsurgical complications, and targeted crosssectional imaging, radiography, and fluoroscopy may be performed based on patient symptoms. Once bowel function has returned, enteral feeds are started via gastrojejunostomy tube and can sometimes be complicated by GJ tube-related intussusception. The largest retrospective review in pediatric patients showed a 20% surgical complication rate, with the most common complication being post-splenectomy thrombocytosis.

We present pertinent imaging findings for surgical planning in patients with CP prior to TPIAT, expected postoperative imaging findings, and imaging of postoperative complications. Purpose or Case Report: Kids put all sorts of things in their mouths. Foreign body ingestion is a common occurrence in children, and diagnostic imaging plays an important role in determining the nature of the foreign body and the need for emergent removal. This presentation uses a question and answer format to provide high-yield clinically relevant information on the most commonly encountered foreign bodies including management guidelines for things like coins, batteries, and magnets. Both GI and airway foreign bodies are discussed. The presentation is catered mostly to trainees, but even experienced radiologists will enjoy challenging themselves to identify uncommon foreign bodies on imaging.

Twists 

Torsion or volvulus of upper abdominal viscera is rare and related to incomplete development and laxity of suspensory ligaments, or to poorly developed supernumerary accessory lobes. Clinical symptoms at presentation can be confusing and nonspecific, yet prompt recognition is essential to avoid lifethreatening complications. Radiologists play an essential role in prompt recognition of these conditions. Our exhibit will review congenital anomalies of upper abdominal solid viscera that can lead to volvulus within an embryologic and anatomic framework. As examples, we include cases of mesenteroaxial gastric volvulus (Figure 1) , torsion of an accessory hepatic lobe (Figure 2) , and splenic torsion in the setting of polysplenia ( Figure 3 ). Our cases include radiologic-pathologic correlations and therapeutic implications of solid visceral torsions. Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: The diagnosis of malrotation is heavily reliant on imaging. Upper GI series remain the gold standard with the normal position of the duodenojejunal junction lateral to the left-sided pedicles of the vertebral body, at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. However, a variety of conditions might influence the position of the duodenojejunal junction, potentially leading to a misdiagnosis of malrotation. Such conditions include gastric over distension, splenomegaly, renal or retroperitoneal tumors, liver transplant, small bowel obstruction, the presence of properly or malpositioned enteric tubes and scoliosis. All of these may cause the duodenojejunal junction to be displaced. We present a series of cases highlighting conditions that mimic malrotation to increase the practicing radiologist awareness and help minimize interpretation errors. Purpose or Case Report: Omental infarction and epiploic appendagitis are subtypes of a broader entity of abdominal fat necrosis known as intraperitoneal focal fat infarction (IFFI). IFFI is an uncommon cause of acute abdominal pain in children, and a known mimicker of acute appendicitis. The CT appearance of IFFI is well described, but the appearance is less familiar on MRI and is a potential imaging pitfall. Familiarity with the MRI appearance of IFFI is particularly timely, given the growing use of MRI in the evaluation of right lower quadrant pain in children.

The purpose of this educational exhibit is to review the clinical history, pathologic appearance and treatment of IFFI, and describe MRI features that will allow the radiologist to make the correct diagnosis. Purpose or Case Report: IHPS has a history that is intimately related to the evolution of Ultrasound(US). US was first used to diagnose IHPS as far back as 1977 (Teele and Smith), and as US technology advanced, the diagnosis of IHPS became more refined. We can make precise measurements for the pyloric muscle wall thickness (MWT), pyloric canal length (CL), and transverse pyloric diameter (TPD), and we have highly sensitive and specific signs (i.e. target, shoulder, double-track signs, etc) to aid us in the diagnosis of IHPS (Hernanz- Schulman 1998) .

Why: IHPS is the most common cause of gastric outlet obstruction and one of the most common conditions requiring surgery in infants. The exact pathogenesis of IHPS is unknown, but it is an acquired, gradual and progressive disorder. Who: The classic picture is 5 to 8-week old Caucasian male (4:1 M:F) who presents with non-bloody, non-bilious projectile vomiting. Classic physical exam findings including visible peristalsis and palpable pyloric olive are present in less than 50% cases. Delay in diagnosis can cause serious consequences. When: We can typically do US at any age at the time of the next feed and as the baby is being bottle fed (ideally). How: We use a linear 12-5 or curved 8-5 transducer, with 2D and cine imaging. The baby is placed in supine position, and we begin scanning at the epigastric region. We find the gastroesophageal junction and trace the lesser curvature of the stomach medially to find the pylorus. What: Once we find it; we measure the MWT, CL, and TDP, and look for all the signs. One way to remember the normal limits is our "Rule of 4s". In IHPS, MWT is more than 4mm, CL is 4x4 = 16mm, and TDP is 4+4+4 = 12+mm. The signs include target sign (hypertrophied hypoechoic muscle surrounding echogenic mucosa), shoulder/nipple sign (bulging of hypertrophied pyloric muscle into the lumen of the antrum), and double-track sign (elongated pylorus with hypoechoic lumen, sandwiched between echogenic mucosa). If the measurements do not meet our "rule of 4s" and there are none of the signs, we can confidently rule out IHPS, or we may consider another differential diagnosis, like pylorospasm and mucosal hypertrophy due to other causes like prostaglandins. We've come a long way with refining and defining US diagnosis of IHPS until finally ultrasound is now the gold standard diagnostic modality for IHPS. Purpose or Case Report: Iatrogenic upper gastrointestinal (GI) injuries are rare occurrences with predisposition in premature births, low birth weight, multiple attempts at OGT placement. Medical literature on the topic consists of case reports and mostly has been from the perspective of management with very limited literature on diagnostic evaluation. As the clinical presentation of such iatrogenic injuries is nonspecific, the radiographic appearance may be the only clue for diagnosis and the typical findings should be recognized and diagnosed by radiologists and neonatologists. The purpose of this presentation is to describe the radiographic findings and a diagnostic approach to guide the radiologist. A retrospective case-review was performed from 2009-2017, of neonates with upper GI injuries associated with naso/orogastric tube placement or with pharyngeal auctioning at birth (a single case). Seven cases were found comprising of five females and two males. Six of seven neonates were premature with gestational ages ranging from 24 weeks and 2 days to 28 weeks, and birth weights spanning 515-1085 grams. The 38 week neonate weighed 3500 grams. We report three types of injury: 1) posterior pharyngeal rupture, 2) non-complicated esophageal rupture with formation of a false lumen, 3) complicated esophageal rupture with penetration into the right pleural space. Management has evolved over time from a primarily surgically oriented approach to a more conservative approach involving TPN and antibiotics. Purpose or Case Report: Accidental traumatic injuries of the pancreas are rare but dangerous. In children, blunt abdominal trauma is the most common mechanism. The goal of this presentation is to review, through a series of cases, the diagnosis, imaging findings, classification, and management of accidental traumatic pancreatic injuries in children.

Our cases include an 18-year-old football player with traumatic pancreatitis and pseudocyst formation, a 12-year-old pinned between two vehicles who sustained a pancreatic laceration with full transection of the pancreatic duct, a 15-year-old soccer player with a pancreatic laceration and truncated duct on ERCP, and a 5-year-old boy who was run over by a car and developed shock pancreas. Traumatic injuries, as graded by the guidelines of the American Association for the Surgery of Trauma, span a gamut including contusion, laceration, transection, duct injury, ampulla injury, and massive destruction of the pancreatic head. Complications include fistula, pancreatitis, and the development of pseudocysts. Through multiple imaging modalities -including CT, MR, MRCP, ERCP, and ultrasound -our cases illustrate many of these injuries and subsequent complications. While nonoperative treatment of minor pancreatic injuries is widely accepted, the management of more severe pancreatic injuries, such as those involving the pancreatic duct, is more controversial. Duct injury, for example, has been reported to be predictive of failure of non-operative management. The radiologist, therefore, has the opportunity to play a pivotal role in patient care by characterizing the injury. Pancreatic organ and duct injuries can be subtle and correlation with multiple modalities as well as multidisciplinary discussion between the radiologist, surgeon, and gastroenterologist, are often required. Purpose or Case Report: Intussusception is a common cause of bowel obstruction in the pediatric population that is important for the radiologist to recognize. A delay in diagnosis can lead to bowel obstruction and necrosis and ultimately bowel perforation. Radiographs and sonography are the primary modalities for diagnosis of the condition. Computed tomography use is of limited use due to radiation exposure but may be helpful when a pathologic lead point is suspected. The purpose of this educational review is to describe the clinical and characteristic radiographic and sonographic findings of intussusception in the pediatric population. Classic ileocolic intussusceptions will be discussed as well as imaging features that may predict failure to reduce with air enema. Small bowel small bowel intussusceptions and intussusceptions with lead points will also be reviewed. Finally, intussusceptions due to gastrojejunostomy tubes will be discussed.

A search of the radiology reports at our institution was performed from February 1, 2013 through October 1, 2017 for intussusception. Radiographs, ultrasounds, and, if applicable computed tomography and air contrast enema images were evaluated. Radiographs were evaluated for the presence of a soft tissue mass, absence of gas in the right lower quadrant on a decubitus image, and evidence of a small bowel obstruction. Additionally, in patients with gastrojejunostomy tubes, abnormal course of the tube was noted. Ultrasound images were evaluated for the size of the intussusception, the presence of color Doppler flow, trapped fluid within the intussusception, bowel wall edema, and free fluid. These findings were correlated with the ability to reduce with fluoroscopically assisted air enema.

Results: A variety of cases were obtained demonstrating: a. Ileocolic intussusceptions reducible by air contrast enema b. Ileocolic intussusceptions not reducible by air contrast enema c. Small bowel small bowel intussusceptions d. Ileocolic intussusceptions secondary to pathological lead points e. Small bowel small bowel intussusceptions secondary to pathological lead points f. Small bowel intussusceptions secondary to a gastrojejunostomy tubes Conclusions: Accurate and timely diagnosis of intussusception is critical. The radiologist must maintain a high index of suspicion, particularly when reviewing emergency abdominal radiographs as classic findings may not be apparent. Knowledge of typical findings on radiographs and ultrasound will be helpful in making the diagnosis of intussusception. Purpose or Case Report: Children, especially toddlers, are the most frequent victims of foreign body (FB) ingestion because of their natural curiosity, tempting them to put everything into their mouths. Anything within arm's reach is fair game, from simple coins to the more dangerous button batteries and magnets. This study aims to provide a thorough review of plain radiographic findings of a myriad of foreign bodies (FBs) and associated complications. With the "Rule of 3-5", we aim to help radiologists and clinicians develop a rationale and systematic approach in managing FB ingestions.

A curated number of items were compiled to demonstrate the vast range of ingested objects. Items included categories such as food, wood, plastic, sand, chalk, crayon, playdough, glass, metal and magnets. The items were placed on cardboard in order of expected radiographic densities from radiolucent to radiopaque to radiodense and plain radiographic images were obtained. The images were postprocessed to least contrast and maximum brightness to improve visualization and characterization of different FBs. Results: On plain radiography, most FBs are visible to varying degrees depending on density. Lucent objects such as food, wood and plastic can be delineated by adjusting contrast and brightness. High-density, radiopaque items were readily visualized and better characterized by changing the contrast and brightness.

Although the majority of ingested FBs pass the gastrointestinal (GI) system spontaneously, some require emergent intervention due to the triple threat of perforation, SBO and morbidity. These emergencies can be remembered by the "Rule of 3-5": All long, linear or sharp objects measuring 3-5 cm in length; round, oval or polygonal objects measuring 3-5 cm in diameter; and multiple magnets or button batteries 3-5 in number require emergent attention.

Conclusions: Plain radiography from the level of the adenoid to anus is the best initial choice of imaging because of its easy availability, portability and ability to visualize objects of different densities. "Intelligent neglect" is suggested and uneventful expulsion is expected for all FBs, except those that fall within our "Rule of 3-5," which pose a triple threat and require emergent GI/surgical consultation. Further evaluation with upright/decubitus imaging to exclude free air and SBO or CT may be performed as clinically indicated. Results: On radiographic imaging, the internal components of different FS vary widely in shape, size and density. Adjusting contrast and brightness on plain radiography allows for better visualization of the different densities and components within the FS. Conclusions: FS have become an increasingly popular toy among children this year and have been recognized as a foreign body internationally. FS comprise of small components that may lead to aspiration, small bowel obstruction and perforation, and caustic chemical injury due to the button batteries. The growing diversity among FS design may delay recognition and management. Along with obtaining a thorough clinical history, identification of FS on radiographic imaging is essential in early management and prevention of complications associated with foreign body ingestion.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Sickle cell disease (SCD) is characterized by repeated episodes of vaso-occlusion and hemolysis beginning in the pediatric period that result in serious multi-organ system complications. In particular, renal complications are often the cause of morbidity and reduced life expectancy of patients with SCD. Therefore, it is essential that radiologists be able to identify the imaging features early to help guide prompt and appropriate treatment. Sequelae in pediatric patients include sickle cell nephropathy, infarction and papillary necrosis, and assorted glomerulopathies. These in turn can lead to altered hemodynamics, impaired urinary concentrating ability, hematuria, proteinuria, and acute and chronic kidney injury. Children with SCD are also at increased risk of asymptomatic bacteriuria and urinary tract infection. Even those children and young adults who only have sickle cell trait (SCT) rather than SCD may develop chronic kidney disease later in life and carry markedly increased risk for renal medullary carcinoma. Segmental testicular infarction can compromise fertility in patients with both SCD and SCT. The genitourinary manifestations of SCD and SCT in the pediatric patient will be reviewed in this educational exhibit, with an emphasis on radiologic appearances. For each entity, the clinical presentation, pathophysiology, and differential diagnosis of the imaging findings will also be briefly reviewed. The renal complications covered will include renal infarction, papillary necrosis, renal vein thrombosis (as a complication of nephrotic syndrome), urinary tract infection, hematuria, renal medullary carcinoma, and acute and chronic kidney disease. Testicular and penile sequelae of SCD including segmental testicular infarction and priapism will also be discussed. A variety of imaging modalities will be used to illustrate the various complications, including ultrasonography, computed tomography, and magnetic resonance imaging. Purpose or Case Report: The ability to provide quick, realtime, easily accessible and radiation free diagnostic assessment makes ultrasound (US) imaging one of the most versatile imaging modalities. With the introduction and development of microbubble based ultrasound contrast agents (UCAs) in the early 90's the ability to detect and visualize complex vascular structures became a reality, overcoming some of the limitations that were existent with grayscale and Doppler imaging. UCA's are used extensively in the adult population for visualization of vasculature and evaluating vascular kinetics in solid organs and lesions. Although contrast-enhanced ultrasound (CEUS) can provide a powerful alternative approach to evaluate various pathologies in the pediatric population that would otherwise require radiation-based computed tomography (CT) or strenuous magnetic resonance imaging (MRI), it is important to understand the interaction between US and the microbubbles to optimize imaging and derive clinically relevant quantitative measures of vascularity.

This educational poster will outline the structural properties of microbubbles and the effects of various US imaging parameters on the behavior of these microbubbles. The various methods to perform dynamic CEUS in order to generate qualitative and quantitative measures will be introduced, including certain troubleshooting mechanisms. Finally, an overview of existing applications for CEUS in pediatrics based on experience at our institution will also be presented via cases, and the future of CEUS based on existing pre-clinical research will be briefly described. Purpose or Case Report: To describe the ultrasonographic appearances of the gubernaculum in boys, review its utility in diagnosing cryptorchidism and provide a functional illustration of the gubernaculum as it conducts the testis into the scrotum. We will elucidate this process with a review of the relevant embryology.

This is a retrospective review of 26 imaging studies obtained as part of scrotal ultrasound evaluations of male patients for cryptorchidism, infection and masses, between 2007-2016. High-resolution linear ultrasound probes were used to demonstrate the scrotum, inguinal canal, pelvis and abdomen to evaluate the pathway of descent of the testis so that the undescended testis might be located. The gubernaculum was identified in this process. The patients were referred from NICU, maternity unit and outpatient settings. Results: These 26 male patients ranged in age from 0 days to 59 months. We examined 4 preterm and 22 full term patients. 23/26 had undescended testes. Bilateral undescended testes were seen in 20/23 patients and a unilateral undescended testis in 3/23 patients. The gubernaculum was identified in 23/26 patients. It was seen bilaterally in 15/26 patients, of whom 12/15 were cryptorchid and 3/15 were descended. The gubernaculum was seen unilaterally in 8 cryptorchid boys. This provides a total of 38 gubernacula. It was not seen in 3 cryptorchid boys. The gubernaculum is homogeneous in echogenicity and less echogenic than the adjacent testis. The echo-pattern is loosely aggregated. It is soft and compressible. It is not vascular on color Doppler evaluation. It has a slippery behavior and variable shape. In cross-section, it's size is similar to or slightly greater than the testis. It lies distal to and contiguous with the testis. It can be demonstrated passing to and through the internal (deep) ring, into the inguinal canal and to the base of the scrotum, therefore it's length varies. It should not be confused with the testis as it does not have the characteristic testicular features of a mediastinum testis or strictly ovoid configuration.

The gubernaculum is a normal embryological structure not often described in the pediatric radiological literature. Confident demonstration of the gubernaculum can assist in locating the undescended testis and provides a more detailed diagnosis of cryptorchidism. Ultrasonographic demonstration of the arrested process of testicular descent also provides a beautiful illustration of the normal physiological mechanism of descent.

Timothy Alves, MD 1 , talves@med.umich.edu; Kathleen Gebarski, MD 1 ; 1 Radiology, University of Michigan, Ann Arbor, MI Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: While hydroceles, patent processus vaginalis, inguinal hernias, varicoceles, epididymitis, orchitis, torsion of testes and appendages are common in pediatric radiological practice, other pathology and anatomical variants are unusual and may not be included in every day practice. We composed a pictorial guide of a wide variety of variants and diseases for education and reference.

Illustrative cases of ectasia of rete testes, testicular adrenal rests, tunica albuginea cyst, scrotal calcinosis, abdominoscrotal hydrocele, hematocele, meconium periorchitis, testicular epidermoid cyst, calcifying Sertoli cell tumor, lymphoma and paratesticular rhabdomyosarcoma were chosen from over ten years of imaging at our institution. Results: Reviewing these cases provides an experience of a wide variety of unusual scrotal anatomy and pathology and improves the accuracy of interpretation.

A pictorial review of a wide variety of unusual scrotal anatomy and pathology improves the accuracy of interpretation.

Poster #: EDU-045

Ami Gokli 1 , aag298@nyu.edu; Christian Barrera, MD 1 , Richard Bellah, MD, FAAP 1 ; 1 Children's Hospital of Philadelphia, Philadelphia, PA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: The complete ultrasound (US) evaluation of the urinary tract in a pediatric patient should include both the urinary bladder and kidneys. Evaluation of the bladder as part of that overall US examination, however, can be deemphasized or incomplete due a number of factors, such as one's neglecting to fully image the bladder from dome to bladder neck, suboptimal bladder distension, incomplete distension due to presence of an indwelling drainage catheter or vesicostomy, or in some instances, because the bladder is not included as part of the routine kidney ultrasound exam. True masses arising from the urinary bladder in children are generally rare, and at times, subtle and non-specific, and potentially mimicked by so-called pseudomasses, so we emphasize that correlation of findings with patient history is of paramount importance. This pictorial review will illustrate and describe the US appearances (along with selective cross-sectional imaging), clinical manifestations, and tumor growth patterns of common and uncommon conditions arising from the pediatric urinary bladder, i.e. path-proven masses that include leiomyosarcoma, pheochromocytoma, nephrogenic adenoma, vascular malformation, low grade urothelial neoplasms, neurofibromatosis, fibroepithelial polyps, rhabdoid tumor, and rhabdomyosarcoma. Pseudomasses of the bladder that will also be illustrated and briefly discussed include hematomas, urachal remnants, complex ureteroceles, Deflux injection sites, foreign bodies, and cystitis (viral, eosinophilic, parasitic) . In addition to emphasizing the importance of the complete bladder examination, the purpose of this review is to increase radiologist's awareness of the US appearances of the common and uncommon conditions which afflict the pediatric urinary bladder, as well as those conditions that can mimic bladder masses, in order to determine proper clinical management. Purpose or Case Report: The duplication of structures in the body has been a curious topic to the field of medicine for centuries. It is rare to find a radiologist who has not seen at least one duplicated or partially duplicated organ, usually of the genitourinary system, and often incidentally. While implications of GU duplication have been study previously, often due to infertility or renal issues, other organ system duplications and their implications to the patient often remain a mystery.

A retrospective analysis of multimodality imaging in patients with duplicated structures presenting to an urban children's hospital since 2005. Imaging and clinical history are correlated with clinical, surgical, and pathologic findings where applicable. A variety of organ and structural duplications are selected for imaging review. Results: An enthralling visual array of organ/structure duplication will include cases such as duplicated duodenum, gallbladder, vessels, urinary bladder/genitalia, among others. Clinical implications of each will be discussed as available on a case by case basis, as well as surgical and pathologic findings where applicable. Conclusions: Organ/structure duplication is a spellbinding topic to the pediatric radiologist, as they are usually incidentally discovered, and the implications are often unknown. Each case is an opportunity for creation of mesmerizing reconstructed images and discussion with colleagues in other clinical areas.

Purpose or Case Report: Since 2008, the Children's Hospital of Philadelphia (CHOP) Department of Radiology has conducted pediatric radiology international education outreach in Ethiopia. In 2008, there was not a single Ethiopian pediatric radiologist in a country of 100 million people, where 60% of the population is under the age of 20. As such, children are a major population for diagnostic imaging and the majority of radiologists are confronted with pediatric imaging. However, there was a lack of emphasis on much-needed training of pediatric imaging in radiology residencies. With an increasing number of pediatric subspecialties, the need for adequate pediatric imaging service had grown. This was particularly true at Black Lion Hospital (BLH), the country's main referral center, affiliated with Addis Ababa University (AAU). Radiology faculty at AAU saw value in a pediatric radiology fellowship. The partnership goals between CHOP and AAU were to support and expand the pediatric radiology component in the BLH radiology residency and to carry out regular national pediatric radiology continuing medical education. The purpose of our project was to establish an accredited local pediatric radiology fellowship training in the Department of Radiology at BLH.

Core values were to ensure sustainability and self-sufficiency and included: 1-making the local radiology staff lead the curriculum design, 2-Formal accreditation from AAU, 3-Primary site of training in Ethiopia, and, 4-On-the-jobtraining of faculty in a format of "teaching the teachers". Results: A two-year fellowship was successfully launched with its primary base in Addis Ababa, with components of distance learning, local instruction, a limited observership at CHOP, and pediatric radiology-focused research requirements. The training culminated in a final oral examination conducted by international visiting faculty. In 2017, Ethiopia graduated its first two pediatric radiologists after two years of fellowship. They are currently based at BLH, established a Pediatric Radiology Section with a director, and are actively recruiting the next fellow candidates. Conclusions: Establishing a pediatric radiology fellowship through outreach is both doable and feasible. Our experience showed the request for a fellowship must arise from the host country. In order to optimize success, one must identify the needs of key stakeholders in the host country, engage them in the process, ensure accreditation, and base the fellowship there. Purpose or Case Report: Learning the skills used to master pediatric fluoroscopic exams can be challenging. Hand-eye coordination and specific timing is required while at the same time being mindful of radiation dose and interpreting the images generated in real time. Training on live neonates will often mean less diagnostic exams and increased radiation dose for those exams.

An inexpensive reusable simulator model was devised to allow residents practice of upper GI fluoroscopic exams to increase efficiency using ALARA principles and utilizing 3D printing technology off-the-shelf dolls. Generic gastrografin provided a cost effective contrast medium as its concerns in real UGI studies are of no issue on the training models. A 30ml bottle of generic gastrografin can be purchased for less than $20, which would last for several simulated exams. The 3D model was based on a computer generated imagery (CGI) mesh of a stomach which was modified in Blender™ to try to best replicate the full duodenum and effect of the ligament of Treitz. The final iteration of the model was printed in polylactic acid polymer (PLA) in a size that would fit inside the plastic doll, which already contained portions of the necessary tubing. The model was sealed to be watertight.

Testing under fluoroscopy showed that the model behaved similar enough to an infant when placed in various positions then filled with an appropriate volume contrast.

There are several limitations of this model including the lack of the distractions of a real pediatric patient. Also, the flow of contrast is purely gravity dependent without the effects of sphincters and peristalsis. Overlying skeletal structures and bowel gas are not represented, however these could also be simulated in various ways. Future work on this and similar projects could include expansion into other organ systems such as the colon Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: To assess the awareness and knowledge of Radiologists, Pediatricians, Orthopedists and Emergency Physicians regarding child abuse incidence, imaging, and management in Sudan, Africa.

A descriptive cross-sectional survey study was performed. A 16-question paper and electronic survey were distributed to currently practicing resident and faculty Radiologists, Pediatricians, Orthopedists and Emergency Physicians in Sudan, Africa. 4 cases with radiographs were submitted as part of the survey to assess participants' knowledge regarding physical abuse findings. Answers were reported and statistical analysis comparing different specialties was performed using chi-square test.

Results: A total number of 400 physicians completed the survey, including 364 residents and 36 faculty physicians. 16.8% of physicians indicated there were no cases of child abuse in Sudan, Africa. 88.3% of physicians reported having seen at least 1 case, but less than 5 cases of physical abuse in their career. 46% of physicians indicated that they are not aware of existing child protection units in Sudan and 50.5 % admitted that they do not know how to contact child protection units. 77% of physicians reported that they have not received training regarding the identification of child abuse, and 53.8% indicated that there is no standard imaging protocol to evaluate cases of suspected physical abuse at their institution. 99% of the physicians who took the survey indicated that a training workshop would be helpful.

There is a gap in awareness and thus training of physicians regarding detection, evaluation, and management of child abuse in Sudan, Africa. While more research is needed to identify the causes and extent of the problem, there is an urgent need for educating physicians at different levels of training across different specialties regarding identification, imaging, and management of child abuse. Purpose or Case Report: This educational exhibit will review 1) challenges of CT imaging near metal, 2) current acquisition and reconstruction methods for reducing metallic artifacts, and 3) our initial experience using a GE Revolution CT system for Dual-energy scanning combined with metal artifact reduction (MAR) image reconstruction. Artifacts caused by metallic implants have limited clinical diagnoses for decades using single-energy CT (single kVp, polyenergetic beam) with standard image reconstruction. Low-energy photons in the beam are absorbed by metal, leaving only high-energy photons passing through (ie. beam hardening). Beam hardening due to metal, along with photon starvation and scatter, result in dark shading and bright/dark streaking, as well as lower signal-to-noise levels. Dual-energy CT (DECT) has demonstrated promise for beam hardening reduction because it enables reconstruction of a monoenergetic image, similar in theory to acquiring data with a monoenergetic beam. Recent developments in CT data reconstruction have also achieved better image quality near metal by mitigating shading and streaking artifacts. On our Revolution CT, MAR reconstruction is available solely in dualenergy mode. For our patients with metallic prostheses, we perform DECT and review monoenergetic images with and without MAR. MAR images typically show markedly reduced artifacts from metal and thereby improved image quality. Fig 1  displays 70 keV monoenergetic images both with and without MAR for a patient with a pacemaker. Streaking artifacts arising from the pacemaker were apparent throughout anatomy without MAR, while significantly reduced streaking and improved visualization of the aortic bifurcation is observed in the MAR reconstructed image. Images from a patient with pedicle screws and metallic rods in the spine are shown in Fig 2. Although present, shading and streaking was noticeably reduced with MAR allowing better visibility of the paraspinal soft-tissue structures and the main portal vein. On occasion, however, MAR yielded more severe artifacts for certain slices, such as in the thigh for a patient with a metallic femoral rod just above a total knee replacement (Fig 3) . In summary, recent technical advancements incorporated into the Revolution CT system have improved image quality for many of our patients with metallic implants. Predicting a priori when MAR will be worse is not yet possible, so viewing monoenergetic images with and without MAR is recommended.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Review the experience teaching pediatric radiology to first year radiology residents in the first year of a new residency program in Rwanda.

One of the goals of the Human Resources for Health (HRH) program is to build a residency-trained physician workforce to create a sustainable health education infrastructure in Rwanda. Establishing a radiology residency program in a resource-poor African nation is a challenge being addressed by combining curricula from South Africa, Kenya, and United States and supplemented with ACGME materials. In Rwanda, the pediatric specialty is especially critical due to the high pediatric population as the country continues to recover from the 1994 genocide. Approximately 12 months of general radiology training, visiting faculty offered a two-month rotation in pediatric radiology. To assess efficacy, a pre-and post-rotation evaluation program was implemented. Objective, case-based tests consisting of 100 cases were implemented on the first and last day of the eight-week rotation, which comprised from nine to fifteen hours of formal lecture and case-based teaching each week. A paired t-test was used to compare pre-and post-rotation test results.View box examination scores for four first-year residents were recorded. Purpose or Case Report: It is essential that budding pediatric radiologists have well-honed ultrasound (US) skills in order to provide correct image interpretation and excellent patient care.

The lack of hands-on US experience is a critical gap in current radiology training. We sought to create an interactive, portable tool to remedy this issue.

A previously published needs assessment survey revealed a dearth of US hands-on skills amongst pediatric radiology fellows, where fewer than 45% had access to hands-on tutorials with sonographers, and only 23% had scanning responsibilities while on call. Most trainees reported their scanning skills has never been formally evaluated.

To fill the learning gap, an electronic application (app) was designed with a user interface (UI) that optimized content delivery, through mobile or stationary devices using the principles of "just-in-time" (JIT) learning. A list of the requisite knowledge and skills for the top 10 emergency pediatric US scans was developed. All key resources and content were collected and assembled in the UI.

The top ten emergency studies include-renal, RUQ, pylorus, intussusception, appendix, pelvis, hip, scrotum, spine, brain. A checklist-based UI was created in our LMS (Absorb, Calgary, Canada) including: protocols, image planes, images of normal and pathology, case log, links to previously created video-based micro-tutorials, "tips" for scan modification, evaluation by instructors, and transcripts. Through responsive design the app conforms to all mobile devices and desktop configuration and is operating system agnostic. Conclusions: Our interactive mobile POC/JIT app is relatively simple to construct, with an appealing and easy-to-use interface and has potential to fill a gap in US skills during radiology training.

Seeing and measures related to efficiency and radiation dose are detailed.

The traditional use of radiography to assess umbilical catheter placement in the neonatal population involves ionizing radiation and considerable lag time, yet the two-dimensional data included in this technique still results in only an approximate location for the catheter tip. Atypical vascular anatomy complicates this further, leading to the acquisition of additional radiographs before proper positioning is achieved. Furthermore, the sterile field created for catheter placement is typically maintained during the time of image acquisition and review, and the time lag in imaging interpretation may increase risk for procedure-related infection. US-guided UC placement has been demonstrated to have equal or often better ability to identify accurate catheter tip positioning, with the added benefit of being performed real-time during the procedure, significantly limiting delays in care and radiation exposure. This has been shown to be particularly true in patients of increased birthweight. This represents an opportunity for radiologists to provide value in the care of these patients. Now that ultrasound resources are increasing in pediatric tertiary care centers, training and comfort with the procedure remain the only significant barrier to adoption.

The use of US guidance for UC placement has significant potential to improve catheter placement accuracy and clinical turnaround time from procedure beginning to final completion. This is an opportunity for radiologists to improve value via ultrasound-guided umbilical catheter placement while minimizing radiation dose to these young patients as consistent with the ALARA principle. Purpose or Case Report: Pediatric Interventional Radiology biliary procedures are mainly performed on patients with liver transplant. Percutaneous transhepatic cholangiogram (PTC) is very useful for diagnosis of post-surgical development of strictures while at the same time allowing access for therapeutic measures such as biliary dilatation and diversion. Although postsurgical anatomy and non-dilated bile ducts may provide a challenge, biliary procedures have a high rate of success. The purpose of this exhibit is to review the biliary anatomy, discuss the available biliary procedures, including step-by-step explanation of the more common procedures and discussion of goal and outcomes of these procedures.

A single institution retrospective review was conducted to identify pediatric patients with prior biliary procedures. Selected patients were correlated with imaging findings and/or surgical findings, and/or clinical course. Results: Review and discussion of biliary anatomy, PTC procedure with step-by-step explanation, discussion of other biliary procedures as well as discussion of goals and outcomes are presented. Sample cases from our institution are shown to illustrate our approach to biliary procedures. Cased-based examples are supplemented with a review of the current literature.

Interventional radiology biliary procedures are an essential part of pediatric liver transplant care. Knowledge of the how these procedures are done, empower not only the pediatric interventional radiologist performing the procedure, but also the pediatric radiologist who can aid in providing important information about post-surgical biliary anatomy as well as by identifying complications related to biliary procedures. The associated new bone formation and bone grafts often preclude traditional lumbar puncture. In these patients, we order pre-procedure CT of the lumbar spine and MR of the cervical spine. Images are evaluated for possible trans-foraminal or cervical (C1-C2 or occiput-C1) puncture. Some institutions have reported the surgical creation of an access point for injection by drilling through the posterior bony mass. This places the patient at risk of surgery and the burr hole has a tendency to close up in time.

Results: In all patients with spinal fusion and hardware, a location for safe needle access was identified. Given our lack of comfort with transforaminal access initially, we began performing these with cone beam guidance. In time, we became comfortable with fluoroscopy alone. Additionally, we initially successfully performed three injections via cervical puncture. However, with the success of the transforaminal approach, these patients have now been converted to fluoroscopic transforaminal technique. In several patients, a small window in the otherwise fused posterior elements was identified by pre-procedure CT. Using 3D reconstructions, these windows were identified fluoroscopically and accessed via midline or interlaminar approach.

The presence of extensive bony fusion and spinal hardware should not preclude a patient from therapy or necessitate the surgical creation of an route for Nusinersen injection, given the available non-surgical alternative routes of administration. Cone beam CT is not generally needed, but may be reserved for difficult cases. Purpose or Case Report: Femoroacetabular impingement (FAI) results from incongruence of the femoral head and acetabulum, and is a clinical diagnosis supported by imaging findings.

Despite the traditional categorization of FAI into "pincer" and "cam" types in young and middle-aged adults, the etiology is often unclear with contributing factors from both sides of the hip joint, as well as the surrounding muscles and tendons. Many patients first become symptomatic during adolescence. Comprehensive early treatment, which includes both surgery and intensive physical therapy, both relieves symptoms and prevents the premature onset of osteoarthritis. Pediatric radiologists must provide relevant and actionable reporting on pre-operative imaging in order to maintain value. In addition to a descriptive assessment, the most commonly used quantitative measurements are acetabular version, α angle, and femoral version. This image-rich exhibit reviews common acetabular and femoral morphologies associated with FAI , outlines our low-dose CT protocol, and simplifies obtaining proper reformations and measurements. At our institution, we utilize a low-dose CT protocol (equivalent to approximately 3-5 AP pelvis radiographs) for pre-operative planning, which allows for easy creation of the 2-D and 3-D reformatted images.

Normally, the acetabulum is anteverted 10-15 degrees to allow for physiologic movement. Decreased anteversion is correlated with pincer-type FAI. Measurement requires correction for pelvic tilt and is explained in Fig. 1 . This method has been shown to be equivalent to the more complicated 3-D measurements.

The α angle is obtained from radial reformations. A normal α angle is 55-60 degrees or less, and an increased α angle is associated with cam-type FAI. Cam-type FAI most often results from deficient femoral head-neck offset in the anterosuperior quadrant, and α angles should be reported for each position in that quadrant. Creation of radial reformations and measurement of the α angle are explained in Fig. 2 .

Assessing femoral version is important because many pediatric conditions that lead to FAI are associated with abnormal femoral version, including developmental hip dysplasia, Legg-Calve-Perthes disease, slipped capital femoral epiphyses, and septic arthritis/osteomyelitis. The femur is normally 10-20 degrees anteverted. Both decreased and increased femoral version are associated with FAI. The method for calculating femoral version is explained in Fig. 3 . Purpose or Case Report: The number of reconstruction surgeries of the anterior cruciate ligament (ACL) in pediatric patients has risen dramatically over the past two decades as a result of changes in treatment philosophy and perhaps frequency of injury. It is therefore important for pediatric radiologists to recognize the normal postoperative appearance of the different surgeries as well as their complications. This educational exhibit will review the types of reconstructive methods used in both skeletally immature and mature patients (physeal-sparing, partial transphyseal and transphyseal), complications (growth disturbances, graft failure, impingement, arthrofibrosis, intraarticular bodies) and relevant imaging findings on plain radiography and MRI.

The The child protective team in our tertiary children's hospital reviews approximately 6,000 cases from all over the state every year. Many children with a positive skeletal survey will undergo a 14-day follow up survey. The purpose of this study is to share our experience on patterns of CML healing by comparing the primary survey with its follow up. We have identified a few distinct patterns: Bone formation and sclerosis along the proximal metaphyseal zone, angular deformity of the metaphyseal corner, and subchondral metaphyseal lucencies. These patterns are represented by the accompanying supplemental figures and are described below. Figure 1 is the 14-day follow up radiograph of an acute distal tibial CML diagnosed on the primary skeletal survey. This radiograph reveals increased sclerosis along the entire length of the metaphyseal zone, a common pattern of CML healing. Figure 2 is 14-day follow up of a different patient who sustained a CML of the distal tibia. Healing in this case is denoted by the angular deformity and periosteal reaction along the metaphyseal corner. Figure 3 is a radiograph of the left wrist from a patient's primary skeletal survey. The subchondral lucency identified along the lateral metaphysis is another common pattern indicative of a healing CML. Interestingly, the 14-day follow up skeletal survey of this patient demonstrated complete resolution of this finding with no signs of prior injury. In several other cases, the metaphysis on follow up exam appeared completely normal.

In summary, knowledge of the radiographic patterns of CML healing can help to identify these lesions as their classic imaging characteristics change. It is also important to recognize that if the first radiograph demonstrates CML, a normal 14-day follow up radiograph does not exclude the diagnosis. process can also be a primary pain generator within the shoulder. This educational poster will address normal coracoid anatomy and development, as well as pathologic conditions affecting the coracoid in the pediatric population, including fractures, infection, and neoplasm. The coracoid is a beak-like projection that extends anteriorly from the ventral scapula. It serves as the origin for the pectoralis minor, coracobrachialis, and short head of the biceps. Ligamentous attachments extend from the coracoid to the clavicle (coracoclavicular ligaments), acromion (coracoacromial ligament), and humerus (coracohumeral ligament). Additionally, the transverse scapular ligament attaches to the coracoid base.

The growth plate at the coracoid base is considered a "bipolar growth plate" and is made up of the primary ossification centers of the coracoid and the adjacent ventral scapula, similar to the tri-radiate cartilage of the acetabulum. The coracoid appears within the first year of life with fusion of the coracoid base growth plate occurring by age 14 to 15. Physeal injuries occur at the base of the coracoid with imaging characteristics similar to other more typical locations (i.e. the proximal humerus in Little Leaguer's shoulder). Key features include physeal widening with irregular bony margins, thought to be secondary to chronic repetitive pull from the attached musculature. Additionally, coracoid fractures occur in acute trauma and can be easily overlooked as they are frequently associated with other fractures. Direct blunt trauma by either an external object or the humeral head are associated with fractures of the base of the coracoid. Avulsions of the coracoid tip are seen with acromioclavicular separations with injury to the cocacoclavicular ligaments, more commonly seen in the pediatric population as the ligaments are relatively stronger than their osseous attachments. While tumors of the coracoid are rare and more commonly occur in adults, primary tumors of the coracoid are seen in the pediatric population with case reports of osteoid osteomas, osteoblastomas, giant cell tumors, and aneurysmal bone cysts. Awareness of pathology affecting the coracoid process is helpful to the radiologist and clinician caring for the child with shoulder pain.

disease progression, treatment response or treatment-induced changes. Purpose or Case Report: Chronic cerebrovascular disease is common in pediatric sickle cell patients, and these children often require serial imaging to assess cerebral blood flow perfusion. ASL MRI has been shown to be an effective technique to assess cerebral blood flow, but the evaluation of perfusion reserve is also of value to ordering clinicians. This educational exhibit describes the use of the vasodilator acetazolamide to gauge potential changes in perfusion as determined by ASL MRI. The biochemical basis for cerebrovascular autoregulation and mechanism of acetazolamide are discussed.

MRA is performed, and baseline cerebral blood flow perfusion is evaluated using dynamic pseudo-continuous Arterial Spin Labeling (pCASL). Acetazolamide (15 mg/kg) is given intravenously over a 3-5 minute period, and additional pCASL images are acquired 10-15 minutes after injection. Intravenous contrast is not given. Perfusion maps are calculated and compared. Cerebrovascular reserve is defined as the change in perfusion divided by the baseline perfusion.

healthcare providers find these entities can be difficult to learn and efficiently retain. We aim to present a clear and streamlined approach to organizing these disorders within a differential. In the process we use high resolution imaging and original artwork to provide: -A basic overview of the major steps of cortical development.

-A simplified classification of developmental abnormalities based on the affected stage of development.

-An overview of the underlying pathology, imaging appearance, and clinical relevance of each entity discussed.

-Tips for distinguishing malformations with similar imaging appearances and for understanding the nomenclature used in describing the abnormalities. Conclusions: Neurocristopathies are common among pediatric populations. However, the concept of neurocristopathies is not well known among pediatric radiologists. These diverse set of disorders seem unrelated; however, they share common developmental origin and certain imaging features.

Understanding the embryological origins of these spectrums of conditions as well as their imaging appearance enables deeper understanding of these common pediatric disorders and associated conditions. Conclusions: This exhibit will allow the viewer to review the causes of CPP, understand why and when to scan those patients as well how to best use their imaging resources. After reviewing the interactive case series, the viewer will learn the imaging characteristics of the most common CPP pathologies and will be better equipped to identify these lesions in their work routine. Purpose or Case Report: The clinical implications of craniosynostoses reach far beyond their striking cosmetic deformities. If untreated, craniosynostoses can lead to increased intracranial pressure, restriction of brain growth, and developmental delay, making the recognition of the findings and appropriate diagnosis critical. This electronic poster will provide an overview of various craniosynostoses including trigonocephaly, scaphocephaly, plagiocephaly, brachycephaly, and the various combinations of abnormally fused sutures, with an emphasis on 3D reconstruction imaging. In addition, the expected timing of the fusion of sutures will be described, as well as potential pitfalls in the interpretation of craniosynostosis, including metopic ridge. A brief review of Crouzon, Pfeiffer, and Apert syndromes, those syndromes most commonly associated with craniosynostosis, will be provided. Purpose or Case Report: Epilepsy can be a progressive, debilitating illness, particularly in the pediatric population. More than half of brain tumors are associated with epilepsy, and 30% of these tumors will not respond to pharmacologic therapy. Recognizing lesions that cause seizures is imperative, as providing an accurate diagnosis can identify patients with surgically treatable disease. In the appropriate patient population, epilepsy surgery can be an effective management option that prevents significant morbidity and mortality from epilepsy and dramatically improves quality of life. This electronic poster will provide an overview of pediatric epileptogenic tumors including gangliogliomas, dysembryoplastic neuroepithelial tumors, pleomorphic xanthoastrocytoma, papillary glioneuronal tumor, pilocytic astrocytoma, and oligodendroglioma. Cases featuring these tumors and their distinguishing characteristics will be reviewed, as both tumor subtype and location contribute to the epileptogenicity of pediatric brain tumors. The goal of this poster is to provide a framework for the evaluation of pediatric epileptogenic tumors to establish a focused differential diagnosis when these lesions are identified. This is particularly important for trainees and well as those who do not commonly encounter epileptogenic tumors in their practice.

Pediatric cervical spine trauma revisited.

Yasmin Akbari, MD 1 , akbariys@upmc.edu; Subramanian Subramanian, MD 1 , Andre Furtado 1 , Ashok Panigrahy 1 , Giulio Zuccoli 1 ; 1 Diagnostic Radiology, UPMC, Pittsburgh, PA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Pediatric cervical spine trauma, although rare with an incidence of only 1-2%, can have very high morbidity and mortality. The leading causes are motor vehicle collision, sports related injury and child abuse in infants. The incidence of upper cervical spine injury is more common in children than adults due to differences in biomechanics, with the pediatric head size being proportionally larger when compared to adults. Although conventional radiographs remain the standard initial imaging evaluation, CT has become an important modality to detect bony injury and subtle signs of underlying ligamentous injury and hemorrhage (although consideration must be made for the increased radiation exposure). The presence of ligamentous injury, dens synchondrosis fracture, spinal cord evaluation, and spinal cord injury without radiographic abnormality (SCIWORA), meanwhile, are better evaluated with MRI. We will review the normal appearance of the pediatric cervical spine including normal measurements on radiographs and CT, including the importance of the basion-dens interval, powers ratio, and atlanto-occipital distance with illustrations. The normal development of the cervical spine as well as CT and MRI anatomy of cervical spine ligaments will be reviewed with illustrations. Imaging findings of atlanto-occipital and atlantoaxial distraction and pediatric cervical spine fractures including clay shoveler's fracture and dens synchondrosis fractures will be illustrated with CT and MRI. Finally, a review of clinical decision criteria for pediatric cervical spine trauma and imaging approach will be presented. The importance of obtaining MRI in children under 5 years and appropriate use of imaging will also be discussed. Image 1: Sagittal CT image demonstrates increased basion to dens distance and normal atlanto-dental interval, consistent with atlanto-occipital dissociation. Image 2: T2-weighted sagittal MR image demonstrates injuries to the tectorial and posterior atlanto-occipital membranes with atlanto-occipital dissociation. There is associated epidural hemorrhage. Image 3: Sagittal CT reconstruction demonstrates a powers ratio greater than 1, raising suspicion for anterior atlanto-occipital dissociation. 

To review magnetic resonance imaging (MRI) safety considerations in pediatric patients with cochlear implants (CIs) and to demonstrate feasibility of safely performing MRI of the brain in pediatric patients with CIs that have been deemed MRI conditional by the manufacturer. Conclusions: MRI scanners use powerful magnets to create high resolution images. MRI safety is always paramount, and patients with implanted devices that are deemed MRI conditional, such as particular types of CIs, may be safely scanned with MRI only under very specific conditions, which will be reviewed in detail. Artifacts created by the implants can be extensive and we will also review artifact-reduction strategies. It must be emphasized that scanning patients with CIs without strictly adhering to the stipulated manufacturer's guidelines may result in severe patient injury and/or device malfunction. The objective of this electronic exhibit is to present the clinical and imaging findings of vascular tumors encountered in a large children's hospital over a 10-year period. These will be grouped according to the ISSVA benign, locally-aggressive, and malignant classification of vascular tumors. We will include unusual presentations of infantile and congenital hemangiomas, as well as the clinical features and imaging appearances of the less commonly encountered vascular tumors (tufted angioma, spindle cell hemangioma, pyogenic granuloma, epithelioid hemangioma, kaposiform hemangioendothelioma, and angiosarcoma). Treatment options and prognosis will also be discussed. Staging System. The new system shifts away from surgicopathologic classification to describe tumors according to radiologic findings. In addition to differentiating local from metastatic disease, the new system further delineates local disease based on the presence or absence of "image defined risk factors" (IDRF). With this, there is a recommendation for specific terminology to be used in order to accurately characterize an IDRF. These include the words: separation, contact, encasement, compression, infiltration, and invasion. Conclusions: As the care for Neuroblastoma patients evolves, radiologists must continue to provide value in the multidisciplinary efforts to advance the most up to date approach to staging of the disease. Now more than ever, the use of accurate and uniform language in reports will have a significant impact on the treatment of these patients. Conclusion: Through this exhibit, readers will gain familiarity with technical aspects of DECT of the lungs in children, understand the basics of post processing and recognize focal or regional perfusion defects, segmented perfusion analysis, and focal lesion perfusion characteristics as well as identify future applications. Purpose or Case Report: Interpretation of chest radiographs requires a good understanding of anatomy, the physiology of the lungs and cardiovascular system as well as good pattern recognition. Additionally, it requires a systematic approach to search for pathologies and pertinent clinical details for interpretation. With frequent use of CT / MRI, the residents (and even practicing radiologists) have become less skilled in the interpretation of chest x-rays, making one of the most commonly ordered exams the most challenging. With challenges of decreasing radiation exposure (especially in pediatric population), it is important that the relatively lost skill set of chest radiographs interpretation be revisited, for trainees (radiology and non-radiology services) and the practitioners. OUTLINE • Historical perspective.

• Overall approach towards a chest x-ray and importance of clinical details.

• PA/AP and lateral radiograph anatomy and radiographic lines and stripes. Purpose or Case Report: Post-traumatic intercostal lung herniation (ICLH) is defined as a protrusion of lung tissue through a defect in the intercostal space musculature and is a rare result of chest trauma. Due to its rarity, the management and imaging work up has been based on the adult experience, with Computed Tomography (CT) the most common diagnostic tool and surgery the primary management approach. The purpose of this study is to describe the sonographic appearance and technique utilized in diagnosis of post-traumatic ICLH and to support their inclusion in a proposed imaging algorithm to aid in management in the pediatric population.

We present a recent case of posttraumatic ICLH with follow-up and systematic review of all 15 cases in the literature found through a Pubmed, Embase, Ovid, Scopus and Cochrane search. Extracted data includes mechanism of trauma, clinical presentation, imaging performed, treatment and outcomes. Data was compared with the adult population. Results: On Sonography, ICLH typically appears as loss of fascial plane delineation involving the external, internal and innermost intercostal muscles. The degree of disruption of this latticework of structures and the resulting loss of structural support determines the severity of the lung herniation, which is best depicted on real time assessment with utilization of maneuvers to increase intrathoracic pressures. ICLH usually presents as a soft non-tender mass exaggerated by coughing and/or straining and may present long after the initial injury. ICLH was located in the anterior chest wall in 81% of pediatric patients. The most common mechanism of trauma was blunt handlebar injury. Chest radiograph was used to diagnosis in 88% and CT scanning in 44% of patients. Sonography was utilized in 19% of cases. Management was surgical in 63% of patients, with thoracotomy with primary closure the preferred treatment. The remainder of the patients received non-surgical management with chest strapping, with resolution in 2-6 weeks. Conclusions: Given the rarity of ICLH in pediatric patients and the lack of diagnostic and management guidelines, pediatric surgeons have mostly relied on published reports in the adult literature to guide work-up and management. The recent literature supports the feasibility of non-surgical management and the proposed imaging guidelines (Fig. 1) Purpose or Case Report: Stillbirth is a sad complication of pregnancy. Establishing the cause of death in intrauterine fetal demise (IUFD) is important to bring psychological closure to the family and crucial for reproductive counseling. The gold standard to establish the cause of IUFD is perinatal autopsy. However, perinatal autopsy rates are falling worldwide, largely attributed to patients and physicians discomfort with death and discussion of postmortem examinations as well as social and religious reasons. There is a lack of experience with minimally invasive perinatal autopsy in the United States and even more limited publications in the subject. Our main goal was to investigate the added value of postmortem MRI to conventional autopsy in the clinical setting. Our program has had successes and failures, of which learning opportunities exist for other institutions that desire to implement similar programs. This paper will discuss the timeline of our progress and share examples of potential roadblocks and keys to success in implementing such a program.

In 2013, our research team at Beaumont Health realized that we have the capability to implement a postmortem MRI program here in the United States, similar to those already underway in the United Kingdom. We sought out a partnership with the anatomic pathology department to brainstorm how we could work together to contribute to the growing body of research in the postmortem diagnostic branch of medicine. We received IRB approval in 2014 and started meeting with the bereavement specialists and maternal fetal medicine physicians to identify prospective subjects. Results: Since then, we have continued to adjust our protocol and inclusion criteria to optimize our number of subjects. This paper will discuss the hurdles that we have overcome and detail ways we have optimized this project in hopes of smoothing the transition period for institutions that aspire to contribute to this growing field of research. Conclusions: Through our experiences with implementation of a post mortem MRI program at Beaumont Health, we have found early successes and failures. We have worked closely with the multidisciplinary team involved to overcome the early roadblocks that we had faced and continue to fine-tune our program in order to further the knowledge in this growing field. We hope that our experiences will be enlightening to other institutions that wish to join us in this venture. Figure 3 shows pre-and postcontrast axial RAVE images in a 14y patient. Conclusions: Our data demonstrates the potential utility of a free-breathing accelerated 3D T1w RAVE sequence in unsedated pediatric imaging. The technique is particularly useful in patients who are unable to follow breath-hold instructions and suspend respiration, and it is 30-50% faster in scan time than conventional methods. increased risk of hepatocellular carcinoma. The exact pathogenesis of NAFLD remains poorly understood, though it is known to progress to various chronic liver diseases, the most prevalent being hepatic fibrosis. The current gold standard for quantifying fat in the liver is via a core biopsy, which is expensive and carries an inherent risk of morbidity and mortality which makes it unsuitable for screening and monitoring purposes. We propose that MRI can be an effective, fast, and non-invasive method of screening and monitoring pediatric NAFLD. This would allow for earlier diagnosis and monitoring of pediatric NAFLD which would aid in treatment and management of this disease.

Children between the ages of 7 and 17 years old with a BMI > 85 th percentile were recruited and consented for a fast MRI. Each of these patients underwent a limited MRI of the abdomen which included a Multi-echo 2point Dixon imaging protocol covering the liver using a 3T Skyra MR-scanner (Siemens, Germany). The liver proton density fat fraction (PDFF) is calculated based upon the multiecho method estimation where the fat fraction is based upon multiple pairs of opposed phase and in-phase echoes.

Preliminary data in 10 patients shows that in a high risk pediatric population (BMI > 85 th percentile) signs of NAFLD are present. The fat fraction in these patients ranged from 6.2% to 33.7% with an average of 18.8%. A fat fraction of > 5% is generally considered to be pathologic with higher numbers indicating more severe disease. Conclusions: In a high risk pediatric population (BMI > 85 th percentile), MRI can be used as a fast and non-invasive way of screening for pediatric NAFLD. This can be used to provide earlier diagnosis and monitoring of pediatric NAFLD helping to treat and manage this disease. Purpose or Case Report: Although ultrasound has advantages for bowel assessment in infants, the majority of bowel evaluation still takes place by radiograph. Although radiographic signs of advanced necrotizing enterocolitis (NEC) have been well documented, there is poor understanding of gas patterns in less severe NEC or other causes of feeding intolerance. Progressively abnormal appearance of gas patterns in NEC has been described, but it is unclear what role a gastric sump plays. Because a sump decompresses bowel and changes the gas pattern, its role in the progression of abnormal bowel gas patterns warrants attention.

We retrospectively reviewed bowel gas patterns in babies < 1 year old in the neonatal intensive care unit (NICU) over a one-year period. We selected infants whose abdomen or chest/abdomen radiographs were performed for reasons including: NEC, necrotizing, enterocolitis, pneumatosis, distension, or perforation. To assess how the sump affected progression of bowel gas pattern, we randomly selected 11 infants with 5 -20 radiographs for the above indications performed < 24 hours from each prior. We evaluated supine radiographs using the Duke Abdominal Assessment Score (DAAS) and noted sump presence in the images. Chi-square tests assessed differences in proportions of infants with presence/absence of sump having positive/negative DAAS score. Results: Our review included 107 exams on 11 patients. DAAS score 4 (Separation or focal thickening of bowel loops) was associated with presence of a sump in 88% of exams (p = 0.01). DAAS scores 0 (Normal gas pattern) and 2 (Moderate distention) were associated with absence of a sump in 62% of exams (p < 0.01) and 78% of exams (p < 0.05), respectively. DAAS score 3 (Focal moderate distention of bowel loops) had a trending significance with a sump present in 77% of exams (p = 0.07). Remainder of the DAAS scores ≤ 7 had no association with sump. No DAAS scores > 7 were recorded in our study.

Conclusions: Presence of a sump was associated with the appearance of separation or focal thickening of bowel loops and may correlate with focal moderate distention in a larger sample. It is therefore worth considering whether these gas patterns truly represent progression of disease or simply bowel decompression with a sump. In such cases, ultrasound may help differentiate fluid-filled bowel from partially decompressed bowel. A better understanding of the pathophysiology underlying these gas patterns may help guide management before the advanced stage of NEC. (2014) (2015) (2016) . Patient records were reviewed for pertinent clinical information and information related to the GJ-tube including type of tube, presenting symptoms of GJI, and management of the GJI. Results: During the study period, a total of 123 patients had at least one GJ-tube tube placed or replaced. Of those patients, 17 developed a GJI. The median patient age was 3.3 years (range 0.4-15.1 years). All patients had complex medical histories ( Table 1 ). The last tube manipulation prior to intussusception occurred a median of 38 days prior to GJI, with 8 occurring <30 days after manipulation, and 5 occurring between 30-60 days after manipulation. Imaging was obtained after suspicious signs and symptoms (Table 2) . Abdominal ultrasound was ordered and diagnosed 10 cases (56%), CT 6 cases, and MRI 2 cases. There was a wide variety of tubes seen in patients with GJI (Table 3) . The initial management plan included GJ-tube removal in 11 patients, removal and replacement of a different tube in 3 patients, and monitoring in 4 patients, 2 of which were asymptomatic. A total of 9 patients either kept or required their GJ-tube be replaced, with replacement an average of 10.8 days after GJI. In 50% of patients, gastrostomy tube feeds were tolerated and replacement of the GJ-tube was not required. Conclusions: Given intussusceptions were observed across various GJ tubes, a specific device safety issue was not identified. We found a 14% rate of intussusception in our complex patient population, which is similar to previously published GJI rates. An unexpected finding was that 50% of patients went on to tolerate gastrostomy tube feeds, not requiring replacement of their GJ tube. A positive outcome of our research project has been an increased awareness of this complication throughout the hospital, and after education an increased utilization of abdominal ultrasound in patients with GJ-tubes and any suspicious symptoms.

Poster #: SCI-022

Carl Flink, MD 1 , flinkcc@uc.edu; Deborah Jacobson 2 , Earl Cheng, MD 2 , Emilie Johnson, MD, MPH 2 , Elizabeth Yerkes, MD 2 , Max Maizels 2 , Bruce Lindgren 2 , Dennis Liu 2 , Ilina Rosoklija, MPH 2 , Edward Gong 2 ; 1 University of Cincinnati, Cincinnati, OH, 2 Lurie Children's Hospital/Northwestern University, Chicago, IL Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Serial renal ultrasound (RUS) is often used as a surrogate for functional renal imaging among patients followed for hydronephrosis. However, it is unclear whether a lack of progression on serial RUS safeguards against loss of renal function. This study was performed to better characterize the association between findings on serial RUS and diuretic renography (DR) among children with unilateral high-grade hydronephrosis.

We retrospectively reviewed imaging among children <18 years with a history of unilateral Society of Fetal Urology (SFU) 3-4/Urinary Tract Dilation (UTD) P2-3 hydronephrosis. All patients underwent 2 RUS and 2 DR. Patients were excluded for comorbidities associated with bladder-level dysfunction, uninterpretable DR, or diuretic usage during only one RUS. Each RUS was paired with a contemporaneous DR and compared with a subsequent study pair. All studies were reviewed by an independent, blinded diagnostic radiologist. Change in hydronephrosis was determined by either (1) change in SFU/UTD grade or (2) any change noted by the radiologist. This was compared with change in DR, with a ≥5% change considered significant. Chi-squared and Spearman's correlation analyses were performed. Results: 85 patients aged 0-14 years (mean 12 months) were included in the final analysis. Patients were predominantly male (73%) with SFU 3/UTD P2 hydronephrosis (85%). Time between DR ranged from 1-112 months (mean 20). Worsening hydronephrosis was noted in 10/85 patients (12%) by SFU/UTD grade and in 28/85 patients (33%) by radiologist interpretation. Differential renal function decreased by ≥5% in 15/85 patients (18%). Changes in DR were significantly associated with changes in SFU/UTD grade on RUS among all patients (p=0.004, Table 1 ) and among patients with SFU 3/UTD P2 hydronephrosis (p=0.005, Table 2 ). Less substantial changes were not associated with DR findings (p=0.2). 10/70 (13%) patients with stable or improved SFU/UTD grade developed worsening renal function during the study period. When RUS and DR were directly compared, the Spearman's correlation was poor (r=0.2, CI [0.03-0.4]). Conclusions: While substantial changes in RUS findings were associated with corollary changes on DR, the overall correlation between imaging modalities was poor. 13% of children with SFU 3-4/UTD P2-3 hydronephrosis experienced a loss of renal function despite stable longitudinal RUS imaging. These findings are important to consider when counseling conservatively managed patients followed without DR. spatial resolution allow for better identification and measurement of ovaries and precise measurements and depictions of anatomic details. The purpose of this study was to re-evaluate normal pediatric ovarian volumes in relation to patient age with a larger dataset and newer technology.

After IRB approval at a freestanding children's hospital, a database of radiology examinations was queried to pull sequential pelvic ultrasounds for girls that presented to the emergency room with abdominal or pelvic pain from April 2015 to May 2016. Due to limited numbers of younger patients, the database was re-queried for girls from 2006-2017, ages 6 years old or less. Cases with identified ovarian or pelvic pathology including torsion, masses, cysts, and also those with appendicitis were excluded, as were patients with prior oophorectomy. In total, 420 cases were evaluated. Results: In this cohort the average patient age was 12.2±5.1 years old. A slight majority of the patients had larger right ovaries (53.3%) with on average the dominant ovary being 2.1±3.1 times larger than the contralateral side. Ovarian size was found to increase with age with a linear fit to the data revealing an approximate 0.7 cc increase in volume per year of age (figure who opted to perform less fluoroscopy felt it negatively impacted their professional relationships and/or career. After witnessing a pregnant co-worker perform less fluoroscopy,16% of female and 0.04% of male respondents observed a subsequent negative impact on her professional relationships and/or career.

The majority of responding SPR female members have performed fluoroscopy during pregnancy. Of the respondents who performed less fluoroscopy during pregnancy, twenty percent reported a negative impact on their professional relationships and/or career. Interestingly, even fewer respondents reported witnessing a negative impact on a co-worker with significant differences in male and female responses. The negative impact of avoiding fluoroscopy during pregnancy is either under-discussed or over-estimated by pregnant radiologists. Purpose or Case Report: Additive manufacturing (also called 3D printing and rapid prototyping) in medical research and clinical applications is expanding. This study aims to quantify the imaging characteristics (Ultrasound, Magnetic Resonance Imaging, and Computed Tomography scan) of available materials on a common additive manufacturing technology and discuss potential opportunities to fabricate imaging phantoms, which can be utilized in: -Training residents and technologists on the equipment and techniques -Practice for unique case studies and interventions -Planning procedures for complex surgical and interventional cases -Quality assurance of equipment for safety These would be high accuracy and cost-effective models, providing significant savings for purchased phantoms, which can cost over $3k. Moreover, printed phantoms allow custom phantoms for specific applications or anatomy unique to specific patient beyond pre-fabricated options.

A material sample phantom was fabricated by embedding printed materials and blends into silicon. Technologists scanned the material phantom using 3 scanning modalities (Ultrasound, Magnetic Resonance Imaging, and Computed Tomography). The images were then evaluated for echogenicity, relaxation, and radiodensity, respectively. Dimensional accuracy of the printed phantoms was also evaluated. Results: Ultrasound phantom scanning produced clearly defined edges of the material but did not provide a range of different echogenicities. MRI scanning showed distinct signal intensity between model (14.7 grayscale value) and printer support (789.33 grayscale value), but no distinguishing signal between different print materials. CT scans showed variation in plastic and rubber materials between 93 to 160 Hounsfield units. Dimensional measurements confirmed the accuracy of printed phantoms to the original design.

The imaging properties of additive manufacturing offer an opportunity to create simple phantoms applicable. These materials cannot currently be extended to complex multimaterial application as realistic as the imaging properties of human tissue. However, in this developing field, we anticipate new density varied materials that will better approximate the imaging characteristics of the anatomy. Particularly promising are the ongoing studies into composites and fiber laced materials. This report supports the potential of additive manufacturing to create simple, accurate, and cost-effective imaging phantoms, which could expand with further material research.

Justin Glavis-Bloom 1 , justingb@gmail.com; Daniel Nahl 1 , Amit Sura, MD, MBA 1 ; 1 Children's Hospital Los Angeles, Los Angeles, CA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: To study the frequency of discrepancies between interpretations of radiologists at outside referring hospitals, overnight residents preliminarily interpreting imaging, and pediatric fellowship trained attending radiologists at a tertiary children's hospital.

We retrospectively reviewed all requests for second opinion interpretations of plain film and computed tomography (CT) imaging at our institution in 2016 that occurred between the hours of 4:30pm to 6:00am, when on-call radiology residents provide preliminary interpretation. Our hospital is a pediatric, tertiary referral, level I trauma center with multiple transplantation services and approximately 80,000 emergency department visits each year. Patients are frequently transferred to our emergency department and inpatient services from a large catchment area extending to Northern California, Nevada, and Arizona, and often arrive with outside hospital diagnostic imaging and radiologist interpretations. Using the RADPEER Scoring System (Table 1) , we compared the interpretations of the outside hospital radiologist, overnight radiology resident, and attending pediatric radiologist. Results: There were 158 requests for second opinion interpretations, of which 149 were CT scans and 9 were plain films. The overnight radiology resident and attending pediatric radiologist concurred in their interpretations (RADPEER score 1) in 145 studies (92%), had discrepancies that were not ordinarily expected to be made (RADPEER 2) in 12 studies (8%), and had a discrepancy that should have been made and was likely clinically significant (RADPEER 3b) in 1 study. Of the 12 RADPEER 2 studies, 9 were likely clinically significant (2b). The radiologist at the outside referring hospital and attending pediatric radiologist concurred in their interpretations (RADPEER score 1) in 146 studies (92%), had discrepancies that were not ordinarily expected to be made and were likely clinically significant (RADPEER 2b) in 11 studies (7%), and had a discrepancy that should have been made but was likely not clinically significant (RADPEER 3a) in 1 study.

There was a high degree of concordance between interpretations provided by outside hospitals, overnight radiology residents, and attending pediatric radiologists at our institution. year IRB approved observational study (control, Group A), the IR team developed the following dosing protocol for pleural tPA based on chest ultrasound findings: Grade 1, <50% pleural echogenicity, 1 mg BID; Grade 2, > 50% pleural echogenicity, 2 mg BID. Study period: IRB modification was obtained to review subsequent retrospective data and prospective data of patient characteristics and treatment responses during two discrete time periods: Group Bduring pathway development: (July 2015-April 2017); and Group Cfollowing pathway implementation: (May 2017 -October 2017 . Data elements of the review included diagnostic ultrasound, IR procedure note and daily IR rounding notes for chest tubes inserted exclusively for pneumonia. The following patient information was captured: age, gender, weight, tPA dose (1mg, 2mg), dose frequency, duration of tPA therapy, positive culture/PCR, subsequent IR procedure, need for surgery and hospital stay. Findings of the retrospective data review (Table 1) were leveraged to develop a hospital-wide clinical pathway for parapneumonic effusion. Statistical analysis included comparison of ultrasound grade and outcomes of the two discrete times periods listed above. In calculating hospital stay, subjects with co-morbid conditions that may have prolonged the hospital stay were excluded from the analysis. Results: In Group B, duration of tPA therapy for Grade 1 (2.1 days) was lower than that of Grade 2 (3.8 days, p=0.03); positive cultures/PCR were more common in Grade 2 patients (p=0.03 Purpose or Case Report: Slow-flow vascular malformations, most commonly multifocal or diffuse venous (VM), venouslymphatic (VLM) and capillary-lymphatic-venous malformations (CLVM), are associated with coagulation abnormalities affecting hemostasis and thrombosis and increase risk of hematological complications with procedural interventions. Although not completely understood, pathogenesis of this coagulopathy, termed localized intravascular coagulopathy (LIC), is presumed secondary to stagnant blood in abnormal vessels and consumption of coagulation factors. LIC is characterized by elevated D-dimer, low fibrinogen, and/or mild thrombocytopenia and may progress to disseminated intravascular coagulopathy following surgical procedures. In patients with high-risk malformations, hematologic complications of sclerotherapy and use of low molecular weight heparin (LMWH) as a preventative measure have not been well studied.

This study reviewed medical records of patients with slow-flow vascular malformations who underwent sclerotherapy at our institution from July 2008 to December 2016 with LIC as defined by high D-dimer (5 times upper limit of normal), fibrinogen <150mg/dL and/or platelet count <150K/mcL. Hematologic complications included any clinically relevant bleeding or clotting abnormality that occurred 2 weeks post-sclerotherapy and/or while on LMWH prophylaxis, up to 2 weeks, prior to sclerotherapy. Relevant hematuria included gross and large microscopic hematuria. Use of LMWH including dose, frequency and course length was evaluated. Results: Forty of 300 patients had slow-flow vascular malformations with associated LIC and underwent a total of 241 sclerotherapy procedures. In 87% of cases, LMWH was administered at 0.5mg/kg/dose once daily for 2 weeks before and after sclerotherapy. One patient on LMWH developed pulmonary emboli, presumably from deep vein thrombosis of the treated extremity. Two patients developed transient, asymptomatic hematuria. In 5 patients fibrinogen levels dropped below 100 mg/dL post-sclerotherapy for which cryoprecipitate was administered. No intra-op bleeding or thrombotic events occurred. Conclusions: Prophylactic LMWH use was common in this patient population and did not appear to increase the risk of significant bleeding before, during or after sclerotherapy. In children receiving LMWH, thrombotic complications after sclerotherapy appear rare but may still occur. Purpose or Case Report: Ultrasound guided percutaneous liver biopsy is frequently performed in pediatric patients. Published post-biopsy complication rates range between 0.3 -3.3% according to Society of Interventional Radiology Standards of Practice. Post-biopsy tract embolization has been prophylactically used to theoretically decrease the bleeding risk, but is not the current standard of care at our institution. The goal of this study is to determine if there is a need for prophylactic biopsy tract-embolization after ultrasound guided liver biopsy in the pediatric population.

Retrospective chart review on patient's ages 0-18 years, who received an ultrasound guided percutaneous liver biopsy for routine standard of care between January 2008 and August 2016 at dedicated academic pediatric institution. Clinical, radiographic, procedural and pathology data were collected on each subject meeting inclusion criteria. Subjects with a focal liver mass were excluded. Local institutional review board approval was obtained for this study.

Results: A total of 512 liver biopsy procedures on 209 subjects were evaluated for post-procedural complications. The average age was 8.3 (SD ± 6.1) years and a little over half of the patients were male (n=119, 56.5%). Majority of patients had a liver biopsy for increased liver enzymes (n=115, 55.8%) and 74 (5.4%) for prior liver transplant. Pre-and post-biopsy hemoglobin (Hgb) values were evaluated and one (0.2%) subject experienced a Hgb drop of >2.0 g/dL, twenty (3.6%) subjects experienced a Hgb drop of >1.0 g/dL and six (7.23%) subjects did not have a change in Hgb pre-and post-biopsy. We examined the average platelet count and INR for biopsies resulting in a drop of >1.0 g/dL. No statistically significant difference was observed between the pre-and post-procedure coagulation labs between patients with and without an Hgb drop of >1.0 g/dL. Average platelet count drop was 230 mL for those with >1.0 g/dL drop in Hgb and 226.5 mL for those without a change in Hgb (p=0.918). INR (normal <1.10) was 1.05 for those with >1.0 g/dL drop in Hgb and 1.03 for those without >1.0 g/dL drop (p=0.459). Conclusions: Ultrasound guided liver biopsies are safe and routinely performed by pediatric interventional radiology practices. Our results indicate that prophylactic trackembolization in pediatric liver biopsy patients is not necessary in patients with normal coagulation parameters.

Single-center longitudinal experience with percutaneous management of biliary stenosis complicating pediatric liver transplantation. Purpose or Case Report: Biliary stenosis continues to be an important source of morbidity in pediatric liver transplantation. Percutaneous transhepatic cholangiography (PTC) with cholangioplasty and placement of an internal/external biliary drainage catheter has been the standard of care for biliary stenosis at our institution for over twenty years. The purpose of this article is to present the largest and most comprehensive pediatric series to date detailing the percutaneous management of liver transplants complicated by biliary stenosis.

We retrospectively reviewed a consecutive series of 74 patients with liver transplant complicated by biliary stenosis who underwent PTC with cholangioplasty and internal/external biliary drain placement between 1997 and 2013. Each biliary drain was evaluated for possible removal after a standard three-month dwell time.

Absence of a symptomatic biliary stricture for at least two years post biliary drain removal was considered a treatment success. Management of recurrent biliary stenosis, percutaneous or surgical, was tracked. Variables of interest included transplant graft type, location of biliary stricture, time to drainage catheter removal, and number of recurrences. Results: Subjects included 32 males and 41 females with a mean age at transplant of 3.4 years and median follow-up of 5.7 years. The most common etiology of liver failure leading to liver transplant was biliary atresia (n=37). 64% of patients (n=47) were successfully managed percutaneously, including 43% (n=32) successfully managed via a single trial. Success rate did not significantly decrease with subsequent trials of percutaneous treatment. Success rate of PTC was higher in anastomotic strictures than in non-anastomotic strictures (71% vs. 31% success rate, p<0.01). Conclusions: Percutaneous management of biliary strictures complicating pediatric liver transplantation allows for successful treatment of most patients, precluding the need for surgical revision. An optimal treatment protocol remains unknown, but we have shown that a minimal dwell time of 3 months is sufficient. (6 patients) all with conventional spinal rods and some degree of spinal fusion required either CT or CBCT. The remainder of the procedures were performed with conventional fluoroscopy. 14 procedures (5 patients with conventional spinal rods), required trans-foraminal approach. After initial procedures were performed with CBCT or CT guidance, several patients had subsequent procedure performed with conventional fluoroscopy utilizing a trans-foraminal approach. 71 of the 73 procedures (97%) were technically successful with intrathecal injection. The two non-successful procedures were initially performed with conventional fluoroscopy and subsequently performed with technical success using CT (one with trans-foraminal approach). One complication of a CSF leak and one complication of persistent back pain 5 days post procedure were identified. Both complications were self-limited and resolved. Conclusions: In SMA patients with complex scoliosis or extensive spinal hardware with fusion, successful intrathecal can be achieved utilizing a trans-formainal or trans-pedicle approach. Some patients may require CBCT with fluoroscopy overlay or conventional CT with CT fluoroscopy and laser guide. Results: 25 hips in 21 patients (16 female, 5 males, mean age 0.99 years, range 0.4-3.1 years) were included in our study. The mean follow-up period was 2.7 years (range 0.7-5.1 years). 8 of 25 hips (32%) went on to develop osteonecrosis. The development of epiphyseal osteonecrosis was more likely with <80% enhancement (sensitivity 87.5%, specificity 88.25%, positive predictive value 78%, negative predictive value 94%). The mean contrast enhancement for patients developing osteonecrosis compared to those who did not was 37.5% and 86.5% respectively; p=0.001. The development of epiphyseal osteonecrosis trended, but was not statistically significant when the abduction angle was greater than 55 degrees (P=0.1). The odds of osteonecrosis is 9% lower with every 1% increase of perfusion. There were 3 hips (12%) that underwent reintervention based on the immediate post-reduction SPICA MRI results. For this subset, one (33%) went on to develop epiphyseal osteonecrosis.

Conclusions: Immediate post-SPICA MRI with gadolinium is a useful prognostic tool for determining future risk for epiphyseal osteonecrosis in children treated for DDH. Our data complements existing literature, and suggests that even in cases where there may be partial epiphyseal enhancement, epiphyseal osteonecrosis may still develop which has not been well explored in the literature. When epiphyseal enhancement is less than 80%, it is recommended that SPICA cast revision be considered.

The influence of age on pediatric fracture healing: a radiographic approach Purpose or Case Report: Skeletal fractures may go undetected and untreated in physically abused children for significant periods of time. When discovered later through radiographic survey, the time since injury (TSI) may be important for the medical diagnosis of physical abuse and have implications for child protection. Prior research suggests that clinical and biological variables, such as fracture location and age, may influence pediatric fracture healing. However, radiographic determination of TSI has been poorly studied until recently. It has been commonly understood that in general younger patients heal faster and lower extremity fractures heal slower than upper extremity fractures. However, the influence of patient age and fracture location on fracture healing has only been explored on a limited scale and not between pediatric age groups. This study examines the effect of age on specific features of pediatric fracture healing through radiographic analysis.

Four hundred ninety-eight upper and lower limb skeletal fractures (>1355 radiographs) of children ages 0 to 5.99 years old were evaluated for features of fracture healing at a large tertiary care center. Abuse-related fractures and individuals with co-morbidities or disorders affecting bone were excluded. Subperiosteal new bone formation (SPNBF) and callus were evaluated along with the time to complete healing. The presence, thickness, matrix, and character were recorded based on modified parameters set by Walters et al. (2014) . Results: Independence and goodness of fit frequency tests revealed correlations between age and the thickness and character of SPNBF as well as callus matrix and fracture margin definition, in addition to within bone location and bone type and rate of healing. Mean comparisons reveal significant differences in callus matrix thickness between younger and older age groups (p < 0.001). Statistical tests reveal no significant differences between sex and other variables of fracture healing. Conclusions: These results may provide an improved method of determining the age of fractures and TSI. Future research may provide better guidelines for radiographic characterization of fracture healing, and improved confidence in the estimation of TSI. Methods & Materials: Two musculoskeletal radiologists evaluated high resolution (HR), 3-dimensional with multiplanar reconstruction (MPR), and radially reformatted (RR) magnetic resonance images (MRI) of 33 patients who later underwent surgical treatment for FAI. Raters reviewed each MRI sequence for the presence of labral tear or injury to the transition zone or true acetabular cartilage as well as the size of the injury. An orthopedic surgeon reviewed intra operative images to assess for intra articular injury. Bland-Altman methods were used to estimate agreement between the percentage of hips affected by injury as measured by MRI relative to direct visualization. Bias or mean difference between MRI and arthroscopic visualization as well as the limit of agreement was also calculated for each of the three formats in assessing size of injury. The 12 o'clock to 2 o'clock positions within the acetabulum were used for comparison, the most common locations for intra-articular pathology in femoroacetabular impingement (FAI). Results: MPR was most accurate at identifying labral injuries (accuracy: 88%, sensitivity: 92%, specificity: 25%) compared to HR (accuracy: 82%, sensitivity: 87%, specificity: 0%) and RR (accuracy: 83%, sensitivity: 89%, specificity: 0%). MPR (accuracy: 38%, sensitivity: 38%, specificity: 50%) and RR formats (accuracy: 38%, sensitivity: 38%, specificity: 50%) were also more accurate at identifying transition zone injuries compared to HR images (accuracy: 29%, sensitivity: 27%, specificity: 100%). HR was more accurate at identifying articular cartilage injuries (accuracy: 65%, sensitivity: 40%, specificity: 76%) compared to MPR (accuracy: 56%, sensitivity: 30%, specificity: 67%) and RR (accuracy: 61%, sensitivity: 40%, specificity: 70%) formats. MPR had performed best in determining the size of labral injury (bias -0.10), while MPR and RR performed best in identifying transition zone (bias -0.06) and acetabular cartilage (bias -0.31) injuries. Conclusions: Labral injuries were best identified with the MPR format while transition zone cartilage injuries were best identified with MPR and RR formats, and the HR format was best to identify true articular cartilage pathology. 3D with MPR and RR are a less commonly utilized though beneficial approach in the evaluation of the labrum and transition zone injuries. Purpose or Case Report: MRI is the gold standard for the diagnosis of acute septic sacroiliitis. However, appropriate timing of the procedure has not been addressed in the literature. MRI is highly sensitive for detecting long tubular bone osteomyelitis as early as 24-48 hours of symptom onset. The hypothesis of this study is that the onset of bone marrow edema of acute hematogenous osteomyelitis (AHO) of pelvis might be delayed as compared with long bone. The purpose of this study is to evaluate the optimum timing of MRI examination from the onset of disease.

Nine patients (8 -16 years, median 14 years, four male and five female) with AHO of pelvis were selected from our radiology database between 2004 and 2016. We compared signal intensity of sacral/iliac bone marrow (BM) and gluteal muscle (M) (BM/M ratio) on the fat suppressed T2Weighted image (T2WI) and T1weighted image (T1WI) respectively. We also calculated the days elapsed from onset to MRI examination. Regression methods were used to evaluate the relationship between BM/M ratio and days elapsed. We also evaluated other five findings (subperiosteal infiltration, muscle infiltration, laba cleft phenomenon, erosive destruction, joint space enhance). Results: BM/M ratio and elapsed days in patients with AHO of pelvis showed a statistically correlation (R 2 = 0.57). In five cases where MRI was performed twice, the BM/M ratio increased without exception. This tendency seemed to be more prominent in those who underwent initial MRI before day 7. The average BM/M ratio within the first 7 days was 3.6 ± 0.7 (mean ± SD), but increased markedly in those who underwent MRI more than one week after onset (6.5 ± 0.7 [mean ± SD]). There was a statistically significant difference in the BM/M ratio before and after day 7 (p ≤ 0.001). The BM/M ratio on the T1WI showed an inverse relationship to that on the T2WI with a statistically correlation (R 2 = 0.59) on the T2WI as well. All nine cases showed bone marrow edema, otherwise, un-even incidence of other five findings were identified.

The present research suggests that until day 7 there might be false negative or subtle finding of bone marrow edema in AHO. A follow-up MRI should be performed after seven days where the diagnosis is still in doubt.

Purpose or Case Report: Hip pain in the active adolescent can be a diagnostic challenge. Labral tears are a common cause of pain, but on average, a lag time of greater than 2 years exists before a diagnosis is achieved. Leading etiologies of labral pathology include: trauma, femoroacetabular impingement, and dysplasia. A better understanding of hip pathology, in this age group and the development of less-invasive hip arthroscopy and surgical repair, has led to an increased number of pediatric MR hip arthrograms (MRA) being performed. The purpose of this investigation was to evaluate the accuracy of our MRA reports with arthroscopic findings and create a pictorial radiologic-arthroscopic correlation. This study will assist both radiologists whom may be formally trained in pediatric radiology but have variable experience and/or training in musculoskeletal radiology, as well as our clinical colleagues to better understand the diagnostic utility of MRA.

A retrospective review of the MRA reports was performed at our institution between January 1, 2015 and October 1, 2017. The EMR was utilized to ascertain clinical management. The diagnostic efficacy of the MRA radiology reports is determined based on the arthroscopic report findings; the absence or presence of labral pathology is identified. A third category separating labral pathology into either definite labral tear verses labral fraying/irregularity is also evaluated. The appearance of the adolescent acetabular labrum is demonstrated in a pictorial review including MRA and arthroscopic images. Results: 99 MRA exams were performed during the study time frame. Most common indication for the MRA was hip pain and/or signs of impingement. 78% of the patients who obtained an MRA were female. The average age at the time of imaging was 16 years (from 12 to 22 years). More than 50% of the patients had labral pathology on MRA, and at least 29 underwent arthroscopic repair at our institution. The overall agreement was 79% between MRA and arthroscopic findings, with three false negatives and three false positives. Free marginal Kappa coefficient was 0.59.

A labral tear is a not infrequent cause of hip pain in the adolescent, and an increasing number of MRA exams are routinely being performed. MRA can accurately diagnose the presence of labral pathology and is a useful tool prior to arthroscopy. The pediatric radiologist plays a key role in the diagnosis of labral pathology. Purpose or Case Report: Purpose: The evaluation of epileptic foci with FDG PET can be challenging, particularly when epileptic foci are subtle. We sought to determine if an agematched database of normative cerebral FDG PET uptake can be used to automatically identify epileptic foci.

Methods & Materials: Materials and Methods: Through an IRB-approved study, we constructed an in-house normative database for FDG cerebral uptake using the brain portion of total Body PET scans (n=84) performed for oncology assessment with no known neurologic pathology. We separated the data into age bins (0-2, 3-5, 6-8, 9-11, 12-14, 15-17 years), and nonlinearly co-registered the studies to an age-matched MRI atlas by age (18 mo, 4 yr, 7 yr, 10 yr, 13 yr, 16 yr) using BioImage Suite. Within each age bin, each registered brain image was normalized such that the mean of the PET voxels within the MRI mask was the same across patients. The mean and standard deviation for each age bin formed the normative atlas. This atlas was applied to PET brain studies performed for epilepsy assessment (n=10). Assessment of the epilepsy studies followed the same processing as entries for the atlas (registration, normalization within each age bin), and were then compared to the normative atlas in terms of ratio from mean and number of standard deviations from mean (z-scoring). The detection performance was evaluating by comparing the automatically identified epileptic zones to the original radiologist report. Results: Results: The FDG PET atlas was generated with 84 normal studies and tested with 10 abnormal epilepsy exams (age 2-16 yrs). The radiologist reports identified 15 epileptic foci in the abnormal studies. Using regions exceeding 4 standard deviations as a threshold for epileptic foci, the automatic identification with the normative atlas identified 14 of these sites (93% Sensitivity) and also identified 7 additional false positive sites. Conclusions: Conclusions: An age-matched normative FDG PET Brain database can provide a highly sensitive tool to help identify FDG PET abnormalities in epilepsy exams. Additional refinements are needed to improve the specificity of this approach. Purpose or Case Report: CHARGE syndrome is a genetic disorder with multisystemic congenital anomalies, most commonly including coloboma, heart malformations, choanal atresia, developmental delay, and genital and ear anomalies. The diagnostic criteria for CHARGE syndrome has been refined over the years. However, there are limited reports describing skullbase and craniocervical junction abnormalities. Recently, a coronal clival cleft has been identified in association with CHARGE syndrome. The aim of our study is to assess the prevalence of coronal clival clefts in patients with CHARGE syndrome.

In this retrospective study, the CT/MRI database at a single academic children's hospital was queried for the phrase "CHARGE syndrome" over a 17-year period (2001-2017) . Electronic medical records were reviewed to confirm the diagnosis. Images were assessed for skull base anomalies, specifically clival hypoplasia and dysplasia. Results: The search yielded 42 exams (21 CTs and 21 MRIs) from 15 distinct patients (mean ages 4.1 ± 5.6 years; range 2 days to 19 years). Diagnosis of CHARGE syndrome was confirmed either by clinical and genetic testing (n=6) or by clinical diagnosis only (n=9). A coronal clival cleft was identified in 87% of patients (n=13; 37 exams), either partial particularly with utilization of crunch and push maneuvers, is an effective and reproducible tool for the diagnosis of SRS. Purpose or Case Report: To provide MRI staff education on MRI fetal exams for sacrococcygeal teratomas. Sacrococcygeal teratoma (SCT) is a congenital germ cell tumor located at the base of the tailbone in newborns. This birth defect is generally not malignant. A SCT is most often diagnosed prenatally using routine obstetric ultrasonography, and further anatomical evaluation may require MRI. A SCT can grow during pregnancy and develop large blood vessels requiring more work for the fetal heart. SCT are more common in females than in males and occur in about 1 in 35,000 live births.

Ann & Robert H. Lurie Children's Hospital of Chicago scanned approximately 100 fetal MRI exams in fiscal year 2016. Lurie Children's new Chicago Institute of Fetal Health program has increased the volume of fetal cases being performed in our MR department. Now with more cases being scanned we are seeing more rare pathology and diagnosis than prior. One of the recent cases was diagnosed as a fetal sacrococcygeal teratoma. Evaluation of this case has led to a modification of our fetal scanning protocol to accommodate previously identified SCT.

Results: MR staff will need to identify and properly scan sacrococcygeal teratomas that may be indicated amongst our fetal cases. Sacrococcygeal teratoma requires the technologist to identify the pathology and extend the scan field of view to include the extent of the tumor. Patient position may need to be modified to optimize the image quality. Radiologist surveillance at the scanner may assist in ensuring images are of sufficient diagnostic quality. Conclusions: Fetal sacrococcygeal teratomas are rare but the imaging performed in MRI may yield helpful results to prepare for the next steps if the MRI protocol is adjusted appropriately.

Title: Role of Ultrasound in Diagnosis Pediatric Acute Appendicitis with a secondary sign of an early perforation Falguni Patel, Associates 1 fpatel0807@yahoo.com; ; 1 Medical Imaging (Ultrasound), Lurie Children's Hospital of Chicago, Chicago, IL Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: To demonstrate Pediatric Acute Appendicitis with a secondary sign of an early perforation based on ultrasound findings. Methods & Materials: 11 years old patient presented to our Emergency department with severe abdominal pain for past two days, constipation for four days, inability to tolerate food intake and non-bloody emesis. STAT portable abdomen ultrasound was ordered on this patient to rule out Acute Appendicitis by the Emergency department. Results: Ultrasound findings demonstrated markedly dilated appendix with the AP diameter of 2.5cm in right lower quadrant with a large shadowing Appendicolith near the tip of the appendix. It also demonstrated a small echogenic focus near the wall of the appendix which could represent an early perforation. After ultrasound findings, patient was rushed to the Operating room without further imaging and post-operative diagnosis demonstrated perforated appendix with fecalith and extensive pus in the intraperitoneal cavity. Conclusions: Ultrasound should be an initial imaging study of choice for pediatric appendicitis. With the presence of secondary signs such as appendicolith, periappendiceal fat, free fluid and extra luminal air along the margin of the appendicular wall. Ultrasound plays an important role in diagnosis acute appendicitis in pediatric patients. 3 . Provide examples of soft tissue lesions, hydrocephalus, craniosynostosis, micrognathia and midline cleft cases. 4. To look into future technology and potential applications.

Second and third trimester prenatal ultrasound exams were performed on patients referred for suspected abnormalities. Volume sweeps were acquired on each patient and representative cases chosen to illustrate technical aspects and clinical indications for this procedure were selected. Post-acquisition rendering was performed to illustrate modes to analyze the skeletal system, fluid filled structures, soft tissue, and internal structure contours. Correlation was made with follow up radiology studies, clinical and/or surgical outcomes. Results: Thorough evaluation and timely diagnosis is essential for optimal management and site of delivery. Common sites for multiplanar imaging include the bony face and soft tissue anatomy. Demonstration of the methods will be explored and the impact of their clinical application discussed. Conclusions: Through this exhibit, participants will gain familiarity with the use of multiplanar and spatial volume imaging, and utilize volume imaging as an effective adjuvant tool to routine 2D cross-sectional imaging.

Poster Purpose or Case Report: Necrotizing enterocolitis (NEC) is one of the most leading causes of morbidity and mortality in premature infants. It usually develops within the first days following birth. NEC is a gastrointestinal disease, that can affect any part of the large or small bowel but most commonly affects the terminal ileum and colon. It causes inflammation and tissue death of the affected area and can lead to bowel perforations and a need for surgical resections. In severe cases, bacteria and waste products can pass through the perforated intestine and enter the baby's bloodstream or abdominal cavity which can cause a life threatening infection and shock. In a pediatric hospital, that treats premature infants, signs and symptoms of necrotizing enterocolitis are very important to diagnose quickly. Most common symptoms include poor feeds, bloating or swelling in the abdomen, bloody stools and diarrhea. In order to manage the disease medically and surgically, prompt diagnostic tests such as ultrasounds and xrays need to be performed. Abdominal X-rays are the gold standard of diagnosis and treatment planning. Therefore it is crucial, to recognize the radiographic signs of NEC. The purpose of this abstract is to describe radiographic appearances associated with NEC, which include: dilated bowel loops, thickened bowel walls with edema, pneumatosis intestinalis, abdominal free air, portal venous gas, absence of bowel gas. I will present confirmed cases that show radiographic signs of NEC.

Lynn Gazzi, associates 1 gazzi@sbcglobal.net ; 1 Lurie Children's Hospital, Chicago, IL Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: Intestinal malrotation is a defect that occurs in the 10th week of gestation. During this stage the intestines normally migrate back into the abdominal wall following a brief period where they are temporarily located in the base of the umbilical cord. As the intestines returns to the abdomen it makes two rotations and becomes fixed into its normal position. The small bowel is located in the center of the abdomen and the large intestine drapes around the top and sides of the small intestine. When rotation is incomplete and intestinal fixation does not occur, this creates a defect known as malrotation. Malrotation occurs in one of every 500 births in the United States. Up to 40 percent of patients with this show signs of the disease within the first week of life. By one month of age 50-60 percent are diagnosed. 75 to 90 percent are diagnosed by age 1. The remaining cases are diagnosed into adulthood. Some symptoms of malrotation include vomiting and bilious emesis, fussiness, crying in pain, a swollen abdomen that's tender to the touch, fever, diarrhea and bloody stool or none at all. If malrotation is not treated, it can lead or turn into a midgut Recognition/retention, education opportunities for staff, staff support to our patients, having input into decisions and communication within the department. Results: With this knowledge at hand, we relooked at our past shared governance model and design a program by which these themes could be addressed, while improving patient care and the work environment. We set up eight committees which balanced staff and the following leadership concerns: Recognition and retention, Patient centered care, Policy and procedures, Ancillary partnerships, Education, Quality improvement, Research/Equipment and Imaging protocols. Each group provided a mission, developed by them. Meetings and, topics are managed by staff. . Committees are supported by Team Leaders in the form of coverage to attend meetings, time to work on projects, dollars for projects, and ensuring that solutions meet hospital standards and policies. Leadership views this as a great opportunity to vet complaints and process and work issues to these groups to look for solutions. Conclusions: Challenges associated with the introduction of a nurse driven professional practice model into a technologist practice model suggests that greater attention to implementation may be required much more than a top down approach.

Understanding what drives your staff, collaboration on these ideals and supporting this practice model makes for a successful program.

Driving the path to easing anxiety for pediatric Radiology patients Dana Brinson, BHA, RT(R)(ARRT) 1 , Dana.brinson@choa.org; Nikki Butler, BMSc, RT(R)(QM) 1 ; 1 Radiology, Children's Healthcare of Atlanta, Atlanta, GA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

Purpose or Case Report: For pediatric patients, the hallway leading to a radiology imaging room may be just as anxietyinducing as the exam itself. In an effort to counteract a child's anxiety, rideable remote control cars were purchased to begin the distraction process at the child's first step towards the Radiology Department.

Through charitable donations, two cars were purchased for $400 each to be used in a trial for patient transport throughout Radiology. Six staff members, across different shifts, were identified as Super Users and trained based on the Operation Manual provided by the manufacturer. Competency was deemed through staff demonstration of operating the remote control cars safely and practicing all safety measures associated with patient riders. The riders must wear the safety belt, keep all body parts inside the vehicle, be age three years or older and weigh under 60 pounds. There is a switch to deactivate the foot pedals; however there is not a mechanism to deactivate the steering wheel. Therefore, patients are asked to place their hands by their sides. Another consideration was storage of the cars, as multiple cars require a significant amount of space for parking and electrical outlet needs for recharging the batteries. Storing the cars in a publicly accessible location was not ideal for safety concerns. Ultimately, an alcove by a set of elevators was selected for easy access by staff during the day and the MRI Mock Scanner Room was utilized for recharging at night.

The success of the rideable remote control car program was evident through positive feedback received on customer service surveys. A video posting on Facebook resulted in a local news story highlighting the cars and the fun experience for one patient, thus providing marketing exposure affirmative of the care being provided. The project returned favorable results, prompting the facility to add the rideable cars to a wish list that is shared with charitable donors. A total of 20 cars are now available for use throughout Radiology and other departments across the system. Conclusions: While the project initially centered on the reduction of patient anxiety, additional benefits identified were stress alleviation for the parents and entertainment for patient's siblings. The ride from the Radiology Waiting Room to the exam room also allowed the technologists to develop a rapport with the patient that allowed for more cooperation during the imaging study. Purpose or Case Report: The objective for a low dose imaging protocol was to eliminate patient risks and to reduce radiation doses. Tube placements are confirmed via imaging thereby avoiding utilization of malpositioned tubes. Reduced technical parameters lessen the absorbed skin dose. A limited field of view which includes distal espohagus and airway allows accurate assessment of feeding tube position. The new region of interest eliminates unnecessary exposure to hypersensitive organs including, thyroid and reproductive structures. This coned down view requires a lower image quality thereby allowing a lower dose approach.

A multidisciplinary team discussed current workflows, process improvements. and anticipated obstacles. Workflows were mapped out for all patient visit types, providers and services. Exam codes were developed with associated CPT charges. Order panels for providers were updated. Macro templates for the Radiologist were developed and loaded at workstations. Lucite block and phantom testing were conducted using equivalent sized infant, toddler and adolescent phantoms on dedicated and portable units. Testing concentrated on portable units but table bucky techniques were also established. A 40" source to image distance (SID) was used for table (grid) testing and a 36" SID for portable/tabletop. A 6fr feeding tube was used to simulate placement. Established abdomen techniques were selected for corresponding phantom. The KVP factors were unchanged and mAS settings were decreased to lowest outputs by the units. The lowest mAs 1.25 mAs (table grid) was 0.32 for portable (non-grid). The field of view was mid-chest to iliac crest with proper collimation. Radiologist reviewed images and approved for trial. Exams performed using the new protocol. Image quality remained comparable to phantom testing with same technical factors.

The ongoing trial of portable images reflects optimal for tube confirmation using the lowest mAs setting on unit (0.32 mAs). The abdominal KVP settings remained constant for adequate penetration.

The new protocol has a huge benefit to patients. The objective for chest and abdomen imaging is impressively different than a tube check therefore less dose can be utilized. Full dose images are essential for accurate clinical correlations. Mid chest to crest region reduces potential risk of malpositioned tubes as well as significantly reduces unnecessary dose to hypersensitive organs. This is vital when multiple images are required to confirm tube placements.

Feldman, Brian M. 

most current information on state-of-the-art pediatric imaging and the practice of pediatric radiology. 2. Describe and apply new technologies and imaging findings for pediatric imaging

Discuss trends in research and education concerning the care and imaging of pediatric patients. 4. Identify common challenges facing pediatric radiologists, and possible solutions

Describe and apply basic principles for implementing quality and safety programs in pediatric radiology 6. Evaluate and apply means of managing radiation exposure and the need for sedation/anesthesia during diagnostic imaging and image guided therapy

Legg Perthes Disease: The Scientific Basis for the Various Methods of Treatment and Their

Roles for Imaging in the Age of Precision Medicine" 2013-Psychometric Function: A Novel Statistical Analysis Approach to Optimize CT Dose

2001 -Aneurysmal Bone Cysts In Children: Percutaneous Sclerosing Therapy, An Alternative To Surgery

Diagnostic Imaging, Texas Children's Hospital, Houston, TX 2005 -Evaluation of High Resolution Cervical Spine CT In 529 Cases of Pediatric Trauma: Value Versus Radiation Exposure

PhD 2007 -Evaluation of Single Functioning Kidneys Using MR Urography. Damien Grattan-Smith, MBBS, Department of Radiology, Children's Healthcare of Atlanta

Stephen Muething 2015 -Contrast Enhanced Ultrasound in the Assessment of Pediatric Solid Tumor Response to Anti-Angiogenic Therapy; Beth McCarville, MD, Department of Radiological Sciences, Division of Diagnostic Imaging, St. Jude Children's Research Hospital

1995-Evaluation of Suspected Air Trapping with Dynamic CT Densitometry

BG 2001-Mitochondrial Disorders Of Oxidative Phosphorylation In Children: Patterns Of Disease Palasis S

Volumetric Localization of Somatosensory Cortex in Children Using Synthetic Aperture Magnetrometry. Xiang J, MD, PhD, The Hospital for Sick Children

The Hospital for Sick Children -Toronto 2009-Case Report: Multi-Modality Imaging Manifestations of the Meckel's Diverticulum in Pediatric Patients

For increasing age categories of 0-3, 4-6, 7-10

Imaging reports were reviewed for presence, number, size, and location of kidney stones. Diagnostic performance of ultrasound (reference standard = CT) was calculated per renal unit (left/right kidney) and per renal sector (four sectors per kidney)

Adre Paper 103

Poster EDU-008 (T)

Aaditya Paper

Pneumatosis Poster SCI-013

Polyjet Poster SCI-028

Polyp Poster

The Society for Pediatric Radiology gratefully acknowledges the support of the of the following companies in presenting the 61 st Annual Meeting & Postgraduate Course. 

Ashley Brondell 1 , brondlab02@gmail.com; C. Matthew Hawkins, MD 1 , Anne Gill, MD 1 ; 1 Interventional Radiology, Children's Healthcare of Atlanta Egleston, Atlanta, GA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.

To describe the logistical and technical aspects to implementing an MRI Lymphangiography program at a large, tertiary children's hospital.

MRI Lymphangiography requires intra-nodal injection of gadolinium to allow for dynamic visualization of the central conducting lymphatics of the chest and abdomen. The most common indications include chylous leak (into a variety of body cavities) and plastic bronchitis. Because of the length of the procedure and need for breath holds, patients require general anesthesia. The patient is induced in the MR suite on a detachable MR scanner gantry. Once anesthetized, the patient and gantry are moved out of the MRI suite for ultrasoundguided, bilateral, inguinal lymph node access, which is performed by a pediatric interventional radiologist with 22 or 24gauge angiocatheters. Once placed, the angiocatheters are connected to long tubing and a three way stopcock. A test injection of 1-2mL of saline is used to confirm intra-nodal access. The angiocatheters and tubing are stabilized, and the patient/gantry are wheeled back into the MR suite. MR imaging then ensues with injection of 0.1 mmol/kg of gadolinium based contrast at a dilution of one-part contrast to 2 parts normal saline. Rapid sequence, dynamic 3D gradient echo imaging is then performed of the abdomen and pelvis with a diagnostic radiologist performing the examination, while an interventional radiologist is in the suite injecting the diluted contrast. Results: MR Lymphangiography examinations have been performed in 5 patients (mean age: 27 months (range: 2-89 months); mean weight: 13 kg (range: 3.1-26 kg) at Children's Healthcare of Atlanta. Presenting symptoms included: plastic bronchitis (2), chylous pleural effusion(s) (2), and chylous pericardial effusion (1). Four examinations successfully identified the lymphatic anatomic abnormality accounting for chylous leak; all of which were endovascularly or surgically repaired, subsequently. One MR lymphangiogram demonstrated normal central conducting lymphatics. (The child was later found to have plastic bronchitis from an aspirated foreign body.) Conclusions: MR lymphangiography with intra-nodal gadolinium contrast injection is logistically and technically feasible in a pediatric hospital setting.

Paul Grundlehner, MD 1 , Paul.Grundlehner@beaumont.org; Donald Gibson, MD 2 ; 1 Beaumont Health, Royal Oak, MI, 2 Beaumont Children's Hospital, Royal Oak, MI Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Wilms tumor is a common malignant renal neoplasm in children and accounts for the vast majority of renal tumors in children. Modern treatment regimens have increased overall survival for Wilms tumor to over 90% [1] . Despite this, 10-15% of patients with favorable histology and up to 50% with anaplastic histology will experience primary progression or recurrence. The most common site of recurrence is to the lungs and the liver [2] . Peritoneal disease and recurrence has been described [3] [4] . We present an interesting case of a 13-year-old female with extensive peritoneal recurrence of Wilms tumor. The patient initially presented at the age of 12 with a 3-day history of abdominal pain. CT revealed a 13 cm right renal mass with no other lesions in the chest, abdomen, or pelvis. She underwent right nephrectomy, during which she was upstaged to stage 3 when tumor rupture occured. Histology was favorable. She completed chemo and radiotherapy. CT CAP at 6 months followup showed no recurrent disease. Approximately 7 months later or 13 months after initial diagnosis the patient presented with constipation and abdominal pain. Initial non-contrast CT demonstrated filling of the abdomen and pelvis with a high density material (Figure 1 ). Given the patient's history and concern about some nodularity to the density, MRI was performed and demonstrated extensive heterogeneous mass-like peritoneal disease filling the abdomen and pelvis (Figure 2 ). There were additional areas of peritoneal caking and thickening( Figure 3 ). Ultrasound guided biopsy was performed and the pathology was identical to that of the excised Wilms. While unusual recurrent Wilms tumor should be included in the differetial diagnosis of massive intraperitoneal neoplasia 1. Metzger, M. L. (2005) . Current Therapy for Wilms Tumor. The Oncologist, 10(10), 815-826. doi:10.1634/theoncologist.10-10-815 2. Dome, J. S., Rodriguez-Galindo, C., Spunt, S. L., & Santana, V. M. (2014) . Pediatric Solid Tumors. In Abeloff's Clinical Oncology (5th ed.). Philadelphia: Churchill Livingstone/Elsevier. 3. Brisse, H. J., Schleiermacher, G., Sarnacki, S., Helfre, S., Philippe-Chomette, P., Boccon-Gibod, L., . . . Neuenschwander, S. (2008) . Preoperative Wilms tumor rupture. Cancer, 113(1), 202-213. doi:10.1002/cncr.23535 4.Slasky, B. S., Bar-Ziv, J., Freeman, A. I., & Peylan-Ramu, N. (1997) . CT appearances of involvement of the peritoneum, mesentery and omentum in Wilms tumor. Purpose or Case Report: Traumatic laryngotracheal transection is an uncommon occurrence most often secondary to blunt trauma to the neck. The most commonly described mechanism is a "clothesline" injury or strangulation, involving high speed impact of the neck across a chain, rope, chord, or strap, usually associated with the use of a motor or recreational vehicle. It is often instantaneously fatal, and those who survive may have Purpose or Case Report: Genitourinary abnormalities are frequently detected on prenatal ultrasound, with findings detected on 1 in 500 routine prenatal sonograms. Early detection of abnormalities of the genitourinary system is essential as it allows planning for further work-up and intervention and appropriate counseling of parents. Findings on prenatal ultrasound often trigger further evaluation with fetal MRI, as MRI can provide superior anatomic detail and better assess for associated findings. An understanding of the appearance of genitourinary abnormalities on fetal MRI is important to enable accurate diagnoses and effectively guide clinicians in patient management. This educational poster highlights fetal MRI cases that demonstrate genitourinary abnormalities including bilateral renal agenesis with Potter sequence, crossed fused renal ectopia, multicystic dysplastic kidney, duplex collecting system, posterior urethral valves, patent urachus, allantoic cyst, prune belly syndrome, congenital megaureter, cloaca, bladder exstrophy, ureteropelvic junction obstruction, horseshoe kidney, and sirenomelia. The goal of this exhibit is to provide familiarity with these findings and their clinical implications, which is particularly important for those with less fetal MRI experience. In addition, the exhibit will provide an overview of the embryology of the genitourinary system as it relates to the abnormalities to provide further context of the pathophysiology of these complex congenital conditions.

Absence of the ductus venosus and the expected but abnormal course of umbilical venous lines.Ryan Blagdon, MD, MSc 1 , ryanbla@gmail.com; Deborah Thompson, MD 1 , Pierre Schmit, MD 1 ; 1 Dalhousie University and IWK Health Centre, Halifax, NS, CanadaDisclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: The ductus venosus is a part of the fetal circulation that permits oxygenated blood in the umbilical vein to bypass the liver and provide oxygenated blood to the fetal brain and heart. Absence of the ductus venosus is a rare anomaly associated with a number of serious, life-threatening and often deadly conditions. Studies have evaluated the use of ultrasound for prenatal evaluation and detection of absent ductus venosus; however, no studies have reported non-ultrasound postnatal radiological findings of absent ductus venosus. Here, we describe the expected anatomy in those with absent ductus venosus and present abdominal x-rays of 3 infants to illustrate an expected but abnormal course of umbilical venous lines in these patients. As many as 15.6% of patients with absent ductus venosus have it in isolation and with 67-100% postnatal survival when occurring in isolation. Thus, the postnatal incidental identification of absent ductus venosus is a clinical possibility for pediatric radiologists that review abdominal x-rays to check catheter/line placement. Familiarity with this abnormal course of umbilical venous lines may assist in making this rare postnatal diagnosis and avoid potentially life-threatening complications secondary to line malposition/repositioning. Purpose or Case Report: As an inexpensive modality that does not require ionizing radiation, ultrasound is the preferred method for screening for fetal anomalies. When an abnormality is detected on ultrasound, the limitations of the modality often Purpose or Case Report: In this educational exhibit we will present a series of gastrointestinal (GI) emergencies encountered in the neonatal period. We will focus on typical presentations but will also include atypical cases and discuss multi-modality approach to imaging these patients. Methods & Materials: GI emergencies are unfortunately a mainstay in the neonatal intensive care unit. Accurately diagnosing these potentially catastrophic disease processes is of paramount importance. Given that history and physical is extremely limited, accurately diagnosing neonatal GI emergencies can be quite the challenge often requiring the assistance of the radiology through x-rays and subsequent confirmatory fluoroscopic examinations, ultrasound or less commonly, computed tomography (CT) or magnetic resonance imaging (MRI). Since early diagnosis is associated with a substantially better outcome, imaging is essential in forming the proper management plan for these patients. Results: We will use a case based approach to discuss the following neonatal emergencies of the gastrointestinal tract: Malrotation Duodenal atresia Duodenal web Jejunal or ilieal atresia Meconium ileus Meconium plug syndrome Hirschsprung's disease Necrotizing enterocolitis Intestinal perforation Meconium peritonitis and complications Conclusions: Neonatal GI emergencies are all too common and remain associated with a high mortality and morbidity. Early diagnosis via knowledge of the classic as well as atypical radiographic findings combined with confirmatory tests can result in prompt diagnosis and management of these potential catastrophic events in the neonate.

Hena Joshi 1 , hjoshi2@emory.edu; Adina Alazraki, MD 1 , Bradley Rostad, MD 1 ; 1 Emory University, Atlanta, GA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Ulcerative colitis (UC) and Crohn disease are chronic, immune-mediated, inflammatory disorders of the gastrointestinal tract collectively referred to as inflammatory bowel disease (IBD). As many of 20-25% of patients with IBD initially present in childhood or adolescence, and the incidence of pediatric IBD is increasing. IBD primarily affects the bowel, but other organs can be involved. Nearly onethird of patients will have at least one extra-intestinal manifestation. Some extra-intestinal manifestations, such as that between UC and primary sclerosing cholangitis (PSC), are wellestablished. Others are less understood and may mimic more common pathology, particularly infection. Therefore, pediatric radiologists must become familiar with these extra-intestinal Purpose or Case Report: Timely sonographic diagnosis of appendicitis can be critical for pediatric patients, as perforation rate is inversely related to the child's age, and atypical signs and symptoms can commonly obscure the clinical diagnosis. 1 In experienced hands, pediatric sonography for appendicitis has a high sensitivity and specificity and spares the child radiation. 2 Our educational poster entitled "Unusual Appendicitis Presentations" has been authored by experienced sonographers and will cover the following: Purpose or Case Report: To summarize our experience in diagnosis neonatal bowel obstruction in cystic fibrosis (CF) patient using contrast enema study. This pictorial review will illustrate and discuss several aspects of imaging findings in noncomplicated and complicated meconium ileus as well as the mimicker. Key imaging findings, pearls and pitfalls in diagnosis and guided treatment will be made, emphasizing what radiologists need to know. Correlation with intraoperative findings and follow-up images will also be provided. Methods & Materials: Using our radiology database, a retrospective review of barium enema studies in neonate with delayed pass meconium from 2010-2017 was obtained. Clinical data and imaging finding were reviewed. We will demonstrate imaging findings of non-complicated and complicated meconium ileus in CF neonate with delayed pass meconium, as microcolon secondary to meconium ileus, meconium plug, meconium peritonitis, colonic volvulus and ileal atresia. Imaging of the mimicker of meconium ileus will be discussed including microcolon secondary to very low birth weight and prematurity and total colonic Hirschsprung's disease. Imaging checklists for diagnosis and guided either therapeutic enema or surgery will be demonstrated. Results: Delayed pass meconium is the first sign of neonatal bowel obstruction. Approximately 20% of neonates with CF present with meconium ileus or meconium plug syndrome at birth due to abnormally thick and impacted meconium at the distal ileum or left-sided colon. However in some patients, it can present with complications such as meconium peritonitis or colonic volvulus which need immediate surgical intervention. Optimal imaging technique is important to generate a correct diagnosis and therapeutic treatment. Conclusions: Contrast enema plays an important role in diagnosis and guided treatment in CF neonate with delayed pass meconium. Understanding imaging findings of non-complicated, complicated and mimicker of meconium ileus are crucial for radiologist to generate a correct diagnosis and guide treatment.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Teaching Points 1. To review the normal imaging appearance of the spleen on ultrasound, CT and MRI. 2. Discuss the imaging characteristics of various pediatric splenic pathology. 3. Learn the epidemiology, appropriate imaging workup, and management of congenital pediatric splenic abnormalities. Introduction The spleen can be involved in a wide range of pathologies, yet can be frequently overlooked on imaging. Splenic disorders can be seen in isolation or may be secondary to a systemic disease. Different imaging modalities can be utilized to evaluate the spleen and include ultrasound, CT, and MRI. We will perform a case-based review of the imaging characteristics of various types of pediatric splenic pathologies. After completing this educational exhibit, the reader will be able to recognize the various causes and imaging characteristics of pediatric splenic diseases. The following topics will be discussed: Congenital splenic anomalies -asplenia, polysplenia, accessory spleen Splenomegaly Purpose or Case Report: The prevalence of fibrosing diseases is uncommon in adult patients, and significantly more rare in the pediatric population. The spectrum of fibrosing diseases may be subdivided into two sub-categories: Inflammatory pseudotumors (IMT) and multifocal fibrosclerotic diseases. IMT has a predilection for visceral soft tissues and the most common sites of involvement include lung, abdominopelvic region, but virtually any site may be involved, including the somatic soft tissues, bone, larynx, uterus and CNS. Multifocal fibrosclerotic diseases encompasses retroperitoneal fibrosis, mediastinal fibrosis, reidel's thyroiditis, orbital pseudotumor, and sclerosing cholangitis to name a few. IMT's are predominantly neoplastic but may be post-traumatic or post-infectious. Fibrosclerosing diseases may be associated with inflammatory diseases (inflammatory bowel disease), autoimmune conditions (juvenile rheumatoid arthritis, systemic lupus erythematosus), malignant tumors (lymphoma), vasculitis and may arise secondary to drugs, toxins, trauma or radiation. Some may be idiopathic with no underlying cause. The clinical presentation can be quite variable and often depends upon the site of involvement as well which adjacent structures are affected by the fibrosis. Initial diagnosis can be suggested by imaging, but imaging findings are often non-specific. They can appear as mass forming and may be mistaken for more aggressive malignancy. Tissue is often needed for confirmation. Histopathology shows evidence of lymphocytic infiltration, activated fibroblasts, spindle shaped cells and granulation tissue. The key issue for the pediatric radiologist is to be aware of these rare conditions and thus include them in their differential diagnosis. This diagnosis should be considered to avoid over aggressive biopsy, operation and chemotherapy. In addition, it may warrant work up for other associated fibrosing diseases in the appropriate clinical scenario. In this presentation, we will provide a case based review of the features of pediatric inflammatory pseudotumors and fibrosclerotic diseases including myofibroblastic tumors, fibromatosis, fibrosarcomas, nodular and cranial fascitis as well as fibrotic conditions involving mediastinum, retroperitoneum, biliary tract and thyroid gland with their appropriate diagnostic work-up. Our aim is to make people aware of these rare presentations, so that they are not lost in the long differential!

Ultrasound for problem solving in pediatric musculoskeletal emergencies Timothy Alves, MD 1 , talves@med.umich.edu; Ramon Sanchez 1 ; 1 Radiology, University of Michigan, Ann Arbor, MI Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: While radiographs, and to a lesser extent MRI, remain the mainstay imaging techniques for the evaluation of pediatric musculoskeletal emergencies, ultrasound can be a useful modality for problem solving. The purpose of this educational exhibit is to provide several illustrative cases in which ultrasound was helpful in clinical/diagnostic problemsolving in order to emphasize the importance of ultrasound in these scenarios and to ultimately improve diagnostic accuracy and efficiency.

Illustrative cases demonstrating the utility of ultrasound in problem-solving pediatric musculoskeletal emergencies were chosen from those seen in clinical practice at a tertiary care academic medical center. Examples include the use of ultrasound to differentiate shoulder and elbow dislocation from epiphysiolysis, for the detection of radiographically occult fractures, for the detection of osteomyelitis/brodie's abscess and subperiosteal abscess, for the evaluation of nursemaid's elbow, for the detection of classic metaphyseal lesions, and for the detection of pelvic apophyseal avulsion injury. Results: Review of these illustrative cases highlights the important role of ultrasound in the evaluation of pediatric musculoskeletal emergencies and can improve the accuracy and efficiency of diagnosis. Conclusions: A pictorial review of illustrative cases in which ultrasound was instrumental in problem-solving pediatric musculoskeletal emergency cases can improve the accuracy of interpretation and efficiency of diagnostic work-up. Purpose or Case Report: 1. To review the contemporary literature and present an updated list of musculoskeletal and nonmusculoskeletal imaging findings of patients with autoinflammatory diseases in our hospital. Most of these patients are found to have a genetic mutation that is responsible for their disease. 2. To present follow-up imaging findings, when available, and correlate those with patients' symptoms and type of treatment administered in approximately 40 patients with autoinflammatory diseases such as Cryopyrin-associated autoinflammatory syndrome, familial Mediterranean fever, PAPA (pyogenic arthritis, pyoderma gangrenousum, and acne) syndrome and much more. These findings can be related to Results: Perfusion changes in response to acetazolamide occur in three patterns. In the first, there is normal blood flow at baseline with acetazolamide-induced increased perfusion. Patients with the second pattern have a decreased baseline perfusion, but the vasodilator improves flow. In the third pattern, there is also a decreased baseline perfusion, but acetazolamide exacerbates the relative regional blood flow deficit. In the third pattern, the chronically ischemic territory is felt to be perfused by vessels that are already maximally dilated, and the apparent paradoxical response to the vasodilator is due to a steel phenomenon. Conclusions: Acetazolamide challenge is a useful technique in the diagnostic evaluation of pediatric sickle cell patients with chronic cerebrovascular disease. Arterial-spin labeling obviates the need for intravenous contrast which is an important factor in the sickle cell population due to the inherent renal vulnerability of these patients.

Optimizing pediatric leptomeningeal metastasis detection: technical considerations Julie Harreld, MD 1 , julie.harreld@stjude.org; Muhammad Ayaz, PhD 1 , Claudia Hillenbrand 1 , Ralf Loeffler 1 , Zoltan Patay, MD, PhD 1 ; 1 Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Detection of leptomeningeal metastasis (LM) is critical to staging and prognosis of childhood CNS cancers like medulloblastoma and ependymoma. 1 Though CSF examination is the historical gold standard for diagnosis, technological advances have earned MRI a central role in metastasis detection; recent work finds MRI more predictive of survival than CSF analysis. 2-4 However, not all sequences are created equal for detection of tumor in the CSF, and pediatric MR imaging presents additional unique challenges such as patient motion, acoustic noise and scan time reduction. In this exhibit, we discuss the strengths and weakness of common sequences for LM detection; technical alternatives for reduction of motion, acoustic noise and scan time; and present a suggested targeted imaging protocol based on current best imaging practice.With visual examples, we will discuss: 1. Signal characteristics of LM and role of complementary sequences for detection 2. Optimizing scan planes and slice thickness for tumor/metastasis location and patient size 3. Strengths and weaknesses of T1 FLAIR, SE, FSE/TSE, gradient echo and ultrafast spoiled gradient echo (VIBE/FAME/LAVA/THRIVE) sequences in terms of time, resolution, SNR and CSF artifact 4. Utility and optimization of post-contrast FLAIR, DWI, TrueFISP/bSSFP, and subtraction images for metastasis detection 5. Reducing imaging time: targeted sequences, k-space undersampling (HASTE, partial Fourier imaging), parallel imaging 6. Reducing acoustic noise: lowering bandwidth, longer echo spacing, modified gradient wave forms, alternate encoding (PETRA, SWIFT, zero-TE) 7. Reducing motion artifact: 2D vs. 3D, non-Cartesian acquisition schemes, motion correction Purpose or Case Report: The purpose of educational exhibit is to summarize the radiological appearances of various conditions causing basal ganglia (BG) calcification in children. The pathogenesis for symmetric BG calcification is diverse and ranges from benign physiological calcifications to a variety of pathological disorders including metabolic, infectious and genetic diseases. We present a practical approach to further narrow the differential diagnosis based on associated musculoskeletal imaging findings in patients with BG calcification. Parathyroid disorders are the most common causes of pathological BG calcification. In hyperparathyroidism, distinctive subperiosteal bone resorption can be seen in phalanges on hand radiographs. Tapering of the clavicles, brown tumors and salt-and-pepper appearance of the skull are also classic radiographic features. In the Albright hereditary osteodystrophy phenotype of pseudohypoparathyroidism, shortening of the fourth and fifth metacarpals as well as advanced bone age can aid in diagnosis. Tumoral calcinosis is another radiographically distinct disease that can cause BG calcification, characterized in the extremities by periarticular calcific deposits. Cockayne syndrome is a rare autosomal recessive (AR) disorder with 4 overlapping subtypes, all with BG calcification as well as diffuse skeletal abnormalities that become apparent in the toddler years. Carbonic anhydrase deficiency type 2 is another rare AR disorder with intracranial calcification including the BG, as well as osteopetrosis and pathologic fractures. Coat's plus syndrome has characteristic rock-like intracranial calcifications paired with leukodystrophy and brain cysts. It manifests skeletally with osteopenia, delayed fracture healing, bowing of long bones, scoliosis, midface hypoplasia and femoral head avascular necrosis. Other common conditions such a Down syndrome and HIV, and rare disorders such Fahr's disease, malignant phenylketonuria, and Aicardi-Goutieres syndrome are in the differential diagnosis of BG calcifications.

Anjeza Chukus 1 , anjac18@gmail.com; Arastoo Vossough, PhD, MD 2 , Hisham Dahmoush, MD 1 ; 1 Stanford University, Redwood City, CA, 2 Children's Hospital of Philadelphia, Philadelphia, PA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Sinonasal tumors in the pediatric population are uncommon. Tumors affecting the nasal cavity and paranasal sinuses in children can arise from either soft tissue or bony structures and differ substantially from adult sinonasal masses. The aim of our exhibit is to review imaging features of a myriad of sinonasal neoplasms and tumor-like masses unique to the pediatric population ranging from the more well-known rhabdomyosarcoma and Ewing's sarcoma to rarer lesions such as desmoplastic fibroma, nasal chondromesenchymal hamartoma, and melanotic neuroectodermal tumor of infancy.

A multimodality diagnostic imaging approach to sinonasal masses utilizing high-quality representative images with emphasis on CT and MRI will be highlighted. Histopathologically-proven cases from two large teaching children's hospitals will be presented encompassing an array of imaging modalities. Results: 1. Highlight imaging features of tumors in the nasal cavity and paranasal sinuses that present in children either from soft tissue or bony origins. Lesions include but will not be limited to: melanotic neuroectodermal tumor, rhabdomyosarcoma, leukemia, lymphoma, pPNET/Ewing's sarcoma, nasal glioma, giant cell granuloma, nasal chondromesenchymal hamartoma, and lobular capillary hemangioma. 2. Distinguish benign and malignant sinonasal lesions in children and demonstrate cases where imaging features may overlap. 3. Review relevant anatomic landmarks and complications of sinonasal tumors such as invasion of adjacent critical structures and neurovascular involvement. Conclusions: Sinonasal tumors are uncommon in children. They often present with nonspecific symptoms of nasal obstruction, pain, nasal secretions, or epistaxis. Imaging plays a crucial role in narrowing down the differential diagnosis when a child presents with clinical signs and symptoms referable to the sinonasal region. This review aims at familiarizing radiologists with the diagnostic possibilities in the pediatric population and raises awareness of the salient radiologic features.

Genetic Perforin Defect and Immunopathology: CNS Involvement and Imaging Manifestations Alec Hedlund 2 , alec.hedlund@gmail.com; Sara Stern, MD 3 , John Bohnsack, MD 3 , Gary Hedlund, DO 1 ; 1 Primary Children's Hospital, Salt Lake, UT, 2 Boise State University, Boise, ID, 3 University of Utah, Salt Lake City, UT Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: To familiarize the pediatric radiologist with the important role that the perforin gene plays in lymphocyte cytotoxicity, to discuss the diversity in clinical presentation, and review the scope of neuroimaging abnormalities that may arise in the setting of a missense perforin genetic defect. The brain MRI findings and relevant clinical information of two remotely related children with the same novel missense mutation in the perforin gene represent the basis of this educational poster. Perforin is a glycoprotein (encoded by the PRF-1 gene) involved in several human cellular functions, including, immune response and stored mainly in CD8-positive T-cells as well as natural killer (NK) cells. Normally, T-cells and NK cells are responsible for attacking dead cells. In the clinical setting of perforin deficiency, T-cells and NK cells attack the healthy immune system. This arises from a missense mutation of the PRF-1 gene. Links between perforin deficiency and the autoimmune clinical syndrome of hemophagocytic lymphohistiocytosis (HLH), have been reported. MR imaging abnormalities in patients with perforin gene mutations, are diverse and complex as the defect may occur in the setting of familial hemophagocytic lymphohistiocytosis, primary necrotizing lymphocytic CNS vasculitis or associated with CNS infections such as the Epstein Barr virus. To date, MRI abnormalities that have been reported include mimics of septic cerebral emboli, confluent white matter abnormalities involving the cerebral hemispheres and cerebellum invoking the consideration of diffuse demyelinating disease, and multifocal infratentorial and supratentorial intraaxial lesions with "necrotic-like" character and marginal enhancement. Multifocal sites of perivascular space pathological enhancement has also been reported. Common to many of these reports is cerebellar involvement. The imaging differential diagnosis includes atypical infection, histocytic disorders of the CNS, lymphomatous granulomatosis, neurosarcoidosis, and primary CNS lymphoma. Purpose or Case Report: Spectral or multi-energy CT (MECT), obtains raw data at more than one energy spectra which allows the decomposition of materials into their constituent elements. As opposed to conventional CT which yields data based on linear attenuation, MECT yields both structural and materialspecific information. Only limited experience and literature are available regarding use and applications of MECT in the pediatric patient population. Our institution has recently installed a spectral MECT scanner which uses a single x-ray source modified multilayered detector CT, in our emergency department (ED). It is currently the only such scanner used for routine clinical pediatric imaging in the US, and 4 th such unit in a children's hospital in the world. In this educational exhibit we will review the basic physics of MECT, the benefits and limitations of the single-source multi-layered detector geometry, and clinical applications of MECT and our experience to date in the pediatric population. Methods & Materials: An IQon Spectral MECT (Philips Healthcare, Cleveland, OH) was installed in our facility in October, 2017. Though positioned in the ED, routine inpatients and outpatients are also examined. Results: We present brain, spine, facial trauma, and neck cases in which MECT aided in diagnosis through use of spectral data and propose areas of further clinical diagnoses and research. Clinical cases thus far examined include children suffering acute trauma, headache, and tumor. Features of MECT advantageous to pediatric patients include reconstruction of virtual non-contrast images, perfusion imaging, mitigation of beam-hardening artifact with high mono-energetic imaging, the use of low mono-energetic imaging to boost iodine density to improve angiographic images which may be limited by contrast or bolus timing, and urinary stone analysis and renal mass characterization. Conclusions: The use of Spectral MECT at our institution has provided a significant advance in our ability to confidently diagnose various disease processes. As we gain more experience in the use of MECT in the pediatric population, we will be able to better define its role and uncover further areas of research.

Pediatric neurosurgical shunts: a primer for the radiologist and radiology resident Gregory Vorona, MD 2 , gregory.vorona@vcuhealth.org; Shareh Hallaji 1 , John Collins 2 , Ann Ritter 2 , Gary Tye 2 ; 1 Radiology, Virginia Commonwealth University, Richmond, VA, 2 The Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Shunts are near-ubiquitous in the world of pediatric neuroimaging, and it is incumbent on radiologists who interpret pediatric neuroimaging to have a basic understanding of the different shunt types and components. In this educational poster we will review the appearance of a shunt with its three parts. We will correlate this to the imaging appearance of different shunt valves (programmable and nonprogrammable), and appropriate proximal and distal catheter positioning. We will describe the more common complications (i.e. shunt failure, subdural collections, slit ventriclular syndrome, etc.) associated with shunts in pediatric patients. The poster will also briefly highlight some of the relative advantages and disadvantages of computed tomography (CT) and magnetic resonance (MR) imaging in the assessment of hydrocephalus. Purpose or Case Report: The phakomatoses, or neurocutaneous syndromes, are the classically described congenital disorders with involvement of structures derived from the ectoderm. While the cutaneous manifestations of these conditions often establish their diagnosis, imaging characteristics can indicate the extent of disease and signify prognosis and potential complications related to the disorders. This educational poster reviews key multimodality imaging features and examples of infrequently encountered phakomatoses, including Sturge-Weber, von-Hippel Lindau disease, hereditary hemorrhagic telangiectasia, neurocutaneous melanosis, PHACES syndrome, basal cell nevus, and Parry-Romberg in pediatric patients. This case-based review of these syndromes will focus on relevant imaging findings with self-testing. After this electronic exhibit, residents will be able to describe the common imaging features of the less common phakomatoses.

Mimics of hypoxic ischemic encephalopathy: Infectious, metabolic, congenital, Oh My! Anne Misiura, MD 1 , Jaqueline Urbine 1 , Mea Mallon 1 , Archana Malik 1 , Faaiza Kazmi 1 , Erica Poletto, MD 1 ; 1 Radiology, St. Christopher's Hospital for Children, Philadelphia, PA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Hypoxic-ischemic encephalopathy is a potentially devastating neurological diagnosis for which prompt recognition is crucial for patient management. The appearance of HIE on imaging depends on the duration and severity of the hypoperfusion injury, which can range from global to subtle. As such, the differential diagnosis is wide, including infectious, metabolic, and congenital dysmyelination causes. It is also critical for the pediatric radiologist to be aware of possible confounding cases when presented with imaging features seen in HIE which would significantly change management.

A retrospective analysis of multimodality imaging in neonatal patients demonstrating imaging features similar to that of HIE with alternative diagnoses, who presented to an urban children's hospital since 2005 is performed. Imaging and clinical history are correlated with laboratory findings where applicable. A variety of HIE mimics are selected for imaging review. Results: Review of mimics of HIE is provided with imaging examples. Examples include infectious, metabolic, and other disorders, including, but not limited to herpes infection, parechovirus infection, non-ketotic hyperglycemia, neonatal hypoglycemia, and disorders of myelination. Conclusions: While HIE in itself is a crucial diagnosis to make, it is important for the pediatric radiologist to be familiar with the differential diagnoses that can mimic the findings of HIE, many of which require prompt recognition to improve patient outcomes.

Huy Pham 2 , huy.p.pham@gmail.com; Jeffrey Gardner 1 , Zachary Stewart 2 , Allison Thompson, MD 2 ; 1 Mercer University of Medicine, Savannah, GA, 2 Memorial Health University Medical Center, Savannah, GA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Our educational poster will evaluate and present the complications of the Medtronic Intrathecal Baclofen Pump as seen by our institution. Intrathecal Baclofen pumps are indicated as the treatment for intractable spasticity secondary to cerebral palsy and spinal cord injuries. However, it is not without complications and thus, reserved only for those refractory to other medical interventions. After reviewing radiographs available at our institution, we seek to discuss the complications of baclofen pumps using a multi-case illustration. We present some interesting radiographs of complications seen during infusion pump aspiration studies. These complications include the inability to aspirate CSF, catheter disconnection, catheter fracture, and malposition of catheter tip. Other complications of baclofen pumps include CSF leakage, infections, and even death. It is important to understand these complications because rapid intervention decreases morbidity and mortality rates.

T. Shawn Sato, MD 1 , shawn-sato@uiowa.edu; Yutaka Sato, MD 1 ; 1 Diagnostic Radiology, University of Iowa, Iowa City, IA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: The 2016 World Health Organization Classification of Tumors of the Central Nervous System has now incorporated molecular and genetic parameters in addition to histology to define many tumor entities. Significant restructuring has occurred for pediatric CNS tumors. For example, medulloblastomas are classified into four genetic subtypes. Other embryonal tumors such as embryonal tumor with multilayered rosettes (ETMR) and atypical teratoid/rhabdoid tumor (ATRT) are further defined by their molecular features. Also new entities have been added defined by both histology and molecular signatures including H3 K27M-mutant diffuse midline glioma, RELA fusion-positive ependymoma and diffuse leptomeningeal glioneuronal tumor (DLGNT). These more homogeneous and narrowly defined entities are expected to facilitate better classification, prognostication and patient stratification for precision therapy. This also improves the design of clinical trials and experimental models. In this presentation, we will review the new WHO classification scheme and review the imaging and as well as molecular/genetic features of pediatric CNS tumors. Radiologists must keep up to date with updates to the WHO classification scheme to be able to better communicate with clinicians ensure optimal patient care and relevant research collaboration.

Retroclival Hematoma: Significance of the space behind the slope.Atsuhiko Handa 1 , atsuhiko-handa@uiowa.edu; Robert Becker 1 , Yutaka Sato, MD 1 , T. Shawn Sato 1 ; 1 Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity. Purpose or Case Report: Retroclival hematomas most often occur in pediatric patients following high speed motor vehicle accidents. Hematomas may involve the epidural, subdural, or subarachnoid spaces. Of these hematoma patterns, retroclival epidural hematomas are often associated with ligamentous injury to the tectorial membrane, transverse ligament, or alar ligament resulting in instability. Children's relatively large head size in proportion to their bodies, less muscular support and more superior fulcrum point of cranial vertebrae (C2-C3 in young children) relative to adults predispose pediatric patients to ligamentous injury. Retroclival subdural hematomas are the most often to be associated with non-accidental brain injuries. Therefore, when young non-ambulatory children present without significant trauma, it is not only imperative to recognize the radiographic findings of retroclival subdural hematomas, but to be cognizant of its association with child abuse. Radiological evaluation should include reconstructed sagittal CT images in soft tissue window as well as bone window. Special attention should be paid to the soft tissue window since hematomas often show low or intermediate attenuation on CT and can be easily missed on bone window. If only CT of the head is performed, extension to the craniocervical junction should be included. MRI, especially T2 weighted thin cut images are best suited for evaluation of ligamentous injury. STIR sequence can also provide ligamentous details as well as bone marrow edema. Methods & Materials: 1. Review craniovertebral junction anatomy as it pertains to retroclival hematomas. 2. Illustrate the retroclival hematoma injury patterns including epidural, subdural and subarachnoid bleeds. 3. Demonstrate the CT and MRI findings of retroclival hematoma and the significance of scrutiny of the soft tissue windows of the craniovertebral junction. Results: Demonstration of multiple cases involving retroclival hematomas with review of pertinent anatomical landmarks to help establish the diagnosis. Conclusions: It is important for pediatric radiologists to be familiar with this disease entity as findings can be subtle and therefore easily overlooked. Each of the hematoma patterns described is associated with certain traumatic injury to the spine or brain that requires different management. Retroclival hematomas among non-ambulatory children without significant trauma history should be considered as abusive injury until proven otherwise. Purpose or Case Report: Precocious puberty is defined as development of secondary sex characteristics before the age of 8 years in girls and 9 years in boys. Two types of precocious puberty have been recognized: central (CPP) and peripheral (PPP). The central precocious puberty is further divided into idiopathic or organic types. CNS imaging is indicated if CPP is diagnosed in boys at any age or in girls younger than 6 years. Different structural abnormalities are associated with CPP such as Hypothalamic hamartoma, Hypothalamic astrocytoma, germ cell tumors or suprasellar arachnoid cysts. The goals and objectives of the current presentation are as follow: 1-To briefly review the pathophysiology, clinical presentation and different types of CPP 2-To review the indications for CNS imaging work-up in children with CPP and to discuss the appropriate imaging modality and imaging protocol 3-To review different brain pathologies that are associated with CPP followed by discussion of main imaging characteristics through an interactive case series Methods & Materials: Review of the current literature and retrospectively research in our PACS database for patients scanned with clinical concern for central precocious puberty. Illustrative cases will be chosen and anonymized. Results: The exhibit will provide a brief review of the causes of central precocious puberty. Then, suggestions for dedicated imaging protocols will be provided, followed by an interactive series of illustrative cases of CPP. Finally, a summary will be available for the viewer in quiz format.Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: The goal of this educational exhibit is to explore the utility of interictal FDG PET brain imaging in the evaluation of intractable, drug-resistant cases of pediatric epilepsy and to clarify its role in pre-surgical seizure focus localization. We will also explore the salient pearls and pitfalls of FDG PET brain imaging.

Retrospective review of key cases of interictal FDG PET brain imaging in pediatric epilepsy: Normal brain FDG PET uptake in children: -Normal distribution at different ages -Normal variance in temporal lobes Indications for FDG PET in epilepsy: -When initial MRI is negative, interictal FDG PET can spotlight an area of concern and second-look MRI may uncover an inconspicuous seizure focus. (Figure 1 . Initial MRI was negative except for hippocampal inversion. Hypometabolic activity was seen on FDG PET throughout the left temporal lobe, and on second look MRI, corresponding FLAIR abnormality was seen in the temporal lobe.-Evaluation of post-operative areas difficult to assess with EEG (Figure 2 . Hypometabolic activity was seen in the occipital lobe, which extended beyond the resection cavity and corresponded to areas of abnormal EEG activity).-Isolating a target lesion when there is more than one area of abnormality (i.e. focal nodular heterotopia or tuberous sclerosis) -Differentiate inflammation/limbic encephalitis from other seizure etiologies (i.e. focal cortical dysplasia or low grade glioma) Utility of fusion techniques, comparison with ictal SPECT, and other hybrid imaging: -Fusing PET with MRI enhances detection of subtle structural abnormalities -Comparison of sensitivity with ictal SPECT -Other hybrid imaging such as fusion with EEG or stereo grids can help localize seizure focus Major artifacts and pitfalls in interpretation: -metallic and motion artifact -areas of ictal activity -calculated attenuation difference due to skull thickness -hyperglycemia -drug related hypo-or hypermetabolism The future: -New tracers -Utility of quantitative evaluation to confirm areas of hypometabolism Results: This exhibit will review indications for interictal FDG-PET brain imaging and its utility in the multimodal work-up of pediatric epilepsy. Pearls and pitfalls in imaging will be discussed, including review of the normal distribution of FDG PET and major artifacts. Conclusions: Recognizing the utility of FDG PET of the brain, as well as its shortcomings and potential pitfalls, will help radiologists and clinicians better utilize this modality in the evaluation of pediatric epilepsy. Purpose or Case Report: Neuroblastoma is recognized as having a broad spectrum of clinical behavior in children diagnosed with the disease. Some tumors exhibit aggressive characteristics and portend a poor prognosis, while others that appear aggressive spontaneously regress. Accurately identifying high risk neuroblastoma is important in determining which patients will benefit most from intense chemotherapy, which unfortunately carries a risk of significant adverse effects later in life. Historically this has been difficult, as the classification schemes vary in different parts of the world, limiting the ability to pool data and improve prognostication. In recent years, efforts among experts around the globe have led to a consensus on the most evidenced based approach to staging. The aim of this educational exhibit is to describe the new standardized language for radiology reports, which will contribute to accurate staging and improve treatment for patients with neuroblastoma. Additionally, key imaging features highlighting image defined risk factors will be presented. Purpose or Case Report: Conventional cardiac MRI (CMR) acquisitions in children are limited by long acquisition time, need for sedation, and an inefficient workflow. A conventional cine SSFP short-axis stack typically takes 5-7 minutes to complete and is ineffective for subjects with arrhythmias. Available alternatives like free-breathing, real-time cine (RTcine) SSFP have suboptimal temporal and spatial resolution. Recent advances in compressed sensing (CS) MRI techniques may overcome this limitation. We hypothesize that a CS-based approach will allow the scan time for a short axis RT-cine stack to be shortened to less than a minute without compromising spatial or temporal resolution.

Five patients (Age: 14-44 years; 4 males) underwent CMR study with both conventional breathheld cine SSFP (BH-cine) as well as CS-based free-breathing, cardiac-triggered RT-cine acquisitions (Ahmad and Schniter, DOI: 10.1109/TCI.2015.2485078). The short-axis of the ventricles was covered with 14 slices in each patient. The spatial resolution for both acquisitions was 1.8x1.8x8 mm 3 ; temporal resolution was 32 ms (BH-cine) and 32 ms (RT-cine) per cardiac phase. End-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), and scan duration were computed using established methods, and compared between BH-cine and RTcine acquisitions using paired Student's t-test. Results: Both BH-cine and RT-cine images were deemed of diagnostic quality by two expert readers. The EDV, ESV and EF showed good agreement (Mean EDV (BH-cine first): 144 ± 27 vs 137 ± 27 ml, p = 0.03; mean ESV: 58.8 ± 10.4 ml vs. 54.9 ± 6.4, p = 0.29; and mean EF = 58.8 ± 5% vs 54.9 ± 6.4 % ;p = 0.03 ); see figure 1. The scan times were significantly shorter for RT-cine (2 heart beats/slice; ~45 seconds for entire 14 slice acquisition) compared with BH-cine acquisition (6-8 beats/slice; ~5:38 minutes for 14-slice acquisition, p< 0.01). Figure 2 shows representative images acquired. Conclusions: CS-based free-breathing RT-cine technique is feasible and provides images of comparable quality and diagnostic value when compared to conventional BH-cine SSFP, while significantly reducing scan time. It offers a potential solution to avoid the need for sedation for functional evaluation, improve diagnostic utility of MRI in arrhythmia, and improve CMR efficiency and workflow. Future reduction in reconstruction times, is needed prior to implementation of CSbased RT techniques into clinical practice.

Chen Guo 1 , guochen0028@163.com; Qian Wang 1 , Li-Wei Hu 1 , Yu-Min Zhong 1 ; 1 Radiology, Shanghai Children's Medical Center affiliated with Shanghai Jiao Tong University Medical School, Shanghai, China Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: The purpose of this study was to demonstrate manifestations of MSCT in Abernethy malformation and its diagnostic value. Methods & Materials: Twelve pediatric cases of Abernethy malformation were admitted to the center between July 2011 and September 2016. All the 12 patients (seven males and five females) performed MSCT and DSA. The patient ages ranged from 3 and 14 years old (median age 9 years old). The clinical records of the patients were thoroughly analyzed. MSCT angiography was performed on a 16-row CT scanner (Lightspeed 16, General Electric Medical Systems) or 64-row CT scanner (GE Discovery CT 750 HD, Waukesha, WI). CT raw data were transferred to an Advantage Windows 4.2 or 4.6 workstation (General Electric Medical Systems, Waukesha, WI). Maximum intensity projection (MIP) and multiplanar reformation (MPR) were the primary methods of visualization for evaluation. DSA was performed with a digital subtraction angiography machine (LC-LP biplane machine, General Electric Medical Systems) in all patients. Results: Three cases were type Ib Abernethy malformation and nine cases were type II Abernethy malformation．Two cases of type II Abernethy malformation were misdiagnosed to type Ib Abernethy malformation in MSCT. Among the twelve patients, nine presented with single vessel shunt between portal vein and IVC, one with shunt between portal vein and left renal vein, one with shunt between splenic vein and right iliac vein, one with shunt between splenic vein and left iliac vein. Other clinical information of these patients includes congenital heart disease, pulmonary hypertension, diffuse pulmonary arteriovenous Purpose or Case Report: Giant omphaloceles are large in size and contain a significant portion of liver. Giant omphaloceles are often associated with other co-morbidities, such as pulmonary hypoplasia, which can lead to respiratory insufficiency, prolonged intensive care support, assisted ventilation, and death. The purpose of this study is to develop a prognostic model for prediction of post-natal outcomes in patients with giant omphaloceles using fetal MRI calculated observed to expected total lung volumes (O/E TLV).

After IRB approval, a retrospective search was performed to identify patients with giant omphalocele who underwent fetal MRI and received pre-and post-natal care at our institution from 2007 to 2017. Patients with other anterior abdominal wall defects, including OEIS complex, were excluded. After review of the fetal MR images, 3D lung volumes and O/E TLV were calculated. Statistical analysis was performed using Chi-square and Student's t-test. Results: 14 patients met our inclusion criteria. Two of these patients died shortly after birth and two died in utero (one due to termination of pregnancy). 4 were female and 9 were male (1 was non-identified). Mean gestational age at fetal MRI was 26.5 ± 5.49 weeks with a mean O/E TLV of 0.56 ± 0.37. Mean gestational age at birth was 37.2 ± 1.89 weeks. O/E TLV did not significantly correlate with sex (p=0.53), pulmonary hypertension (p=0.69), need for tracheostomy (p=0.92), need for supplemental oxygen at discharge (p=0.16), or incidence of chronic lung disease (p=0.13). O/E TLV approached significance with regard to fetal distress at birth (p=0.06) and number of days intubated (p=0.057). O/E TLV did significantly correlate with the incidence of hypoxia at birth (p=0.005) and in-utero or neonatal death (p=0.004). Infants with hypoxia at birth had a mean O/E TLV of 0.53 ± 0.25. All infants with O/E TLV of less than 0.23 died in utero or around time of birth. Results: Prenatal MRI was performed for heterotaxy 5/9, congenital heart disease 3/9, and skeletal dysplasia 1/9. Indications for postnatal UGI included emesis 3/9, peritonitis 1/9, distended abdomen 1/9, and asymptomatic heterotaxy 4/9. Gestational age at MRI ranged from 23-37 weeks. AFI's were normal and no cases had dilated bowel. Prospectively, malrotation was suspected in 5 cases. Retrospectively on MRI, small bowel position was best assessed on T2 coronal images; colon T1 coronal images. Small bowel was nonrotated in 9/9 cases with small bowel positioned contralateral to stomach situs. Colon was nonrotated in 7/9 cases, contralateral to the small bowel in 6/7 and on the same side as the small bowel in 1/7. Colon position was indeterminate in 1/9; not seen 1/9. Prenatal small bowel position corresponded to the UGI/SBFT or autopsy in all cases with nonrotation in 8/9; partial rotation of the duodenum in 1/9. Colon prenatal position corresponded to the SBFT/KUB or autopsy with nonrotation in 7/7 cases. Of the 2/9 with indeterminate prenatal colon position, postnatal colon was nonrotated. No postnatal cases were obstructed. Surgery confirmed diagnosis in 4/9; autopsy 1/9 cases. The prenatal MRI control group had GA ranging from 21 to 38 weeks and normal bowel rotation seen in all cases. Conclusions: Detection of bowel malrotation on prenatal MRI is possible with careful analysis of the small bowel and colon position. In a fetus with heterotaxy, prenatal analysis of the position of the bowel is useful secondary to the increased incidence of malrotation. If malrotation is suspected prenatally, postnatal evaluation prior to onset of symptoms may minimize potential for subsequent complication. Purpose or Case Report: Gadolinium deposition in normal tissues is an increasingly recognized consequence of intravenous gadolinium contrast agents. Children with inflammatory bowel disease (IBD) undergo frequent surveillance imaging with contrast enhanced MR enterography (MRE). Purpose: To determine the benefit (if any) of IV contrast in evaluation of IBD by MRE.

This was a retrospective, IRB approved study. The radiology information system was searched to identify all children who had undergone MRE and endoscopy within 6 weeks of each other in 2016. Imaging studies were interpreted by 2 radiologists, blinded to all clinical information, in 2 sessions 6 weeks apart (session 1 pre-contrast MRE; session 2 pre/post contrast MRE). The pre-and pre/post contrast assessment of bowel inflammation was assessed with respect to endoscopy. A logistic regression model was evaluated using receiver operating characteristics curves and expressed by c-statistics. The concordance of each assessment with endoscopy was compared by the c-statistics using the DeLong method. Agreement between the raters was evaluated using a Cohen's or the weighted kappa statistics, as appropriate, and 95% confidence interval. A two-sided P-value < 0.05 was considered statistically significant. Descriptive statistics were used for assessment of IBD complications, with pre/post MRE as the reference standard. Results: 52 children (46% female), mean age 13.2 (SD 3.42) years formed the study cohort. 77% (40/52) had evidence of inflammation on endoscopic biopsy. Pre/post contrast MRE showed no significant increase in the c-statistics compared to pre contrast MRE (Table 1) . Intravenous contrast showed no significant change in interobserver agreement for assessment of inflammation in either the small (kappa 0.92 pre MRE, 0.88 pre/post MRE) or large bowel (kappa 0.83 pre MRE, 0.73 pre/post MRE). IV contrast had no significant impact on interobserver agreement for length of small bowel inflamed (kappa 0.90 pre MRE, 0.95 pre/post MRE). Assessment of IBD complications was improved with IV contrast, with 3/5 cases with perianal penetrating disease not recognised on pre MRE. Conclusions: Routine administration of IV gadolinium has no impact on assessment of small or large bowel inflammation. However, there is potential for missing perianal penetrating disease using a non contrast protocol. Purpose or Case Report: Radiographic findings of right diaphragmatic eventration may overlap with true hernia if only liver herniates without bowel. We thus wanted to know the accuracy of ultrasonography (US) in the diagnosis of right diaphragmatic hernia.

We identified all patients (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) who had US of the right diaphragm, and surgery for eventration or hernia. The medical record was reviewed for clinical presentation and surgical or pathologic diagnosis. US studies were reviewed for any diaphragm abnormalities. Surgical or pathology diagnosis was considered the gold standard. Results: 16 children (8 females, age range birth-16 months, mean 5.2 months) had US as well as surgery for eventration (n=7) or hernia (n=9; 6 Bochdalek and 3 Morgagni). The most common presentation was respiratory distress (12/16, 75%). US correctly diagnosed all 9 patients with hernia and misdiagnosed 3 patients with eventration, yielding 100% sensitivity for hernia, 57% specificity, and 81% accuracy. Presence of at least one of the following US findings increased the specificity to 86% with 100% sensitivity, and 94% accuracy: folding of the free diaphragmatic edge (n=8) or liver seen cranial to the diaphragm muscle (n=7).Conclusions: US imaging can be useful in the diagnosis of diaphragmatic hernia, although it is important to recognize presence of folding of free diaphragmatic edge and liver above the diaphragm muscle to improve specificity and overall accuracy.

Should non pediatric radiologists use ultrasound as the primary study for evaluation of hypertrophic pyloric stenosis?Daniel Sassoon, PhD 1 , dsassoon@iupui.edu; Matthew Wanner 1 , Megan Marine, MD 1 , Boaz Karmazyn, MD 1 ; 1 Radiology, Indiana University, Indianapolis, IN Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: To evaluate false positive rate of community hospital ultrasound (US) diagnosis of hypertrophic pyloric stenosis (HPS) Methods & Materials: Our institutional review board approved this HIPAA-compliant study; informed consent was waived. We identified all patients (1/2015-12/2016) who performed US for newly diagnosed HPS at an outside hospital (OSH), referred to our children's hospital. Only positive studies were included. Confidence of OSH diagnosis was grouped based on key words as follows: high confidence (compatible, positive, diagnostic of, consistent with, meet criteria for, highly suspicious), low (favor, concern, suspicious, suggesting, may represent), or equivocal (equivocal, non-diagnostic, borderline). OSH imaging and reports for discrepant cases were reviewed by a pediatric radiologist to determine reasons for false diagnosis. Surgical results were used as the gold standard for positive HPS, while the gold standard for negative HPS utilized was successful non operative management with no readmission for surgery on follow-up chart review. Results: 65 cases were referred from OSHs to our children's hospital. 6/65 (9.2%) were equivocal for HPS and 59 (90.8) positively identified HPS. Of the 59 cases that identified HPS, 30 (50.8%) did so with high confidence and 29 (49.2%) with low. 11/59 (18.6%) of cases diagnosed with HPS at OSH were not found to be HPS on further evaluation at our institution. Of discrepant cases 2/11 (18.2%) were diagnosed with high confidence by OSH and 9/11 (81.8%) low confidence. The most common 7/11 (%) reason for false positive results was misinterpretation of pylorospasm as HPS.In 13/59 (22.0%) the US were repeated in our children's hospital as the OSH study was considered technically limited. Conclusions: US for evaluation of HPS performed by nonpediatric radiologist is a limited study. About half of the positive studies were read with low confidence and 18% of the studies were false positives.

Daniel Nahl 1 , dannynahl@gmail.com; Justin Glavis-Bloom 1 , Amit Sura, MD, MBA 1 ; 1 Radiology, Children's Hospital Los Angeles, Santa Monica, CA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Transabdominal ultrasound (TUS) is a fast, safe, and well-established screening modality for identifying pancreas, liver, and biliary tract pathology in the pediatric population. A subset of patients with findings that are incompletely characterized by ultrasound or who have no sonographic evidence of disease but persistent clinical suspicion may receive magnetic resonance cholangiopancreatography (MRCP). Pediatric inpatients who obtain an MRCP often experience longer inpatient stays, higher costs and delays in management. Relying on the sonographic findings or pursuing more advanced imaging as an outpatient may be a better option. To our knowledge, there have been no studies that have assessed whether inpatient MRCP performed following TUS in pediatric patients resulted in significant changes to additional inpatient treatment rendered. Our group ultimately looks to develop interdepartmental guidelines on when pursuit of an inpatient MRCP after TUS is indicated.

Our hospital is a pediatric, tertiary referral, level I trauma center with multiple transplantation services and approximately 80,000 emergency department visits each year. We sought to evaluate imaging data and clinical records for all patients at our hospital who received TUS followed by inpatient MRCP evaluation in 2016. This allowed us to investigate if MRCP studies performed after transabdominal ultrasound changed inpatient clinical management in pediatric patients with suspected pancreatohepatobiliary disease. The change was assessed by either an additional inpatient procedure or new treatment administered based on MRCP findings. Results: There were a total of 101 inpatient MRCPs performed in 2016, of which 84 had a preceding abdominal ultrasound performed. Of these 84 MRCPs, 28 (33.3%) resulted in additional diagnostic information not seen on the ultrasound. Of these 28 studies, there were only eight cases in which the additional information obtained from the MRCP lead to an additional inpatient procedure or new treatment during the course of the patients hospital stay (Figure 1 and Table 1) . Conclusions: Transabdominal ultrasound is the primary screening modality for pediatric pancreatohepatobiliary disease. For some patients, obtaining ultrasound alone, serial ultrasound evaluations, or outpatient MRCP may be sufficient for evaluation. Inpatient MRCP may be over utilized, as only 8 out of 101 (7.9%) of MRCPs performed lead to a significant change in inpatient clinical management. Purpose or Case Report: Inflammatory bowel disease (IBD), including Crohn disease, is a cause of significant morbidity in the pediatric population. Perirectal disease is a Crohn related complication affecting as many as 62% of children. Magnetic resonance enterography (MRE) is being increasingly utilized in characterizing the extent of IBD. Dedicated perirectal disease imaging, such as a T2 SPACE, requires an additional 10-15 minutes of imaging time on an already time constrained modality. The goal of our study was to determine the best imaging protocol for patients without clinically suspicious perirectal disease based on the incidence in this population.

A retrospective chart review on patients up to 22 years of age who underwent an MRE examination between 1/2015 and 9/2017 for IBD were included in our study. A single reviewer evaluated all included patients' electronic medical records looking for documented clinical suspicion or colonoscopy/pathology findings of perirectal disease prior to MRE. Patients with prior history of perirectal disease or who had clinically suspected perirectal disease by the treating gastrointestinal physician were excluded. All patients in our study population received dedicated perirectal sequences in addition to the conventional MRE sequences. The study population was evaluated for presence of perirectal disease on MRE. Local institutional review board was approved for this study. Results: A total of 301 patients had MRE for IBD during our two year time frame. Forty-two patients were excluded due to prior clinical suspicion of perirectal disease, yielding 267 patients in our total population. Fourteen patients (5%) had MRE findings of perirectal disease, five (35%) were found to have perirectal abscess and seven (50%) had a perirectal fistula or fistulous tract. Conclusions: Our study found a 5% incidence rate of perirectal disease in IBD patients without clinical suspicion of perirectal disease. Thus, radiologists need to be aware of this population to add on perirectal sequences where needed to conventional MRE examinations. However, it is an inefficient use of resources to routinely perform perirectal sequences on this group of patients.

Use of MRI in risk stratification, diagnosis, and monitoring of Pediatric Non-alcoholic Fatty Liver Disease Zachary Swenson 1 , zjs4ge@virginia.edu; Lydia Kuo-Bonde, MD, PhD 1 ; 1 Radiology, University of Virginia, Charlottesville, VA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Non-alcoholic fatty liver disease (NAFLD) is now the most common form of pediatric chronic liver disease. This disease can have profound effects on overall health and is associated with diabetes, heart disease, and an Purpose or Case Report: Pelvic ultrasound is commonly used to detect ovarian torsion, but the diagnosis remains challenging as there is no single pathognomonic feature. This retrospective case-controlled study aims to identify an algorithm to detect torsion based on common ultrasound imaging features.

In this IRB approved retrospective study, patients who underwent pelvic ultrasound because of abdominal or pelvic pain between 2005 and 2015 were identified and classified as either torsion-absent or torsion-confirmed, based on final radiologic and surgical evidence. Of patients with torsion, patients less than 1 year of age were excluded as infants with torsion have different presentation and imaging features than older patients. In total, 99 torsion-confirmed and 331 sequential torsion-absent cases from 2015 were included. Radiologic features extracted from the ultrasound images included binary variables of presence of Doppler flow, free fluid, peripheral follicles, as well as ovary medialization and the continuous variables of right and left ovarian size. These features were fed into supervised learning systems to find viable decision algorithms. Data was divided into 60% training and 40% validation data sets and performance was assessed using sub-sets of the validation set. Results: All variables had statistically significant differences between the torsion-confirmed and torsion-absent groups with pvalues < 0.005 (Table 1 ). Using single variables to identify torsion provided only modest detection performance with areas under the curve (AUC) for medialization, peripheral follicles, and absence of flow of 0.76+/-.16, 0.66+/-0.14, and 0.82 +/-.14 respectively. The best decision tree (Fig. 1) using a combination of variables yielded an AUC of 0.96 +/-0.07 and required knowledge of the presence of flow, peripheral follicles, the volume of both ovaries, and presence of cysts. Conclusions: An algorithm combining multiple ultrasound imaging features associated with ovarian torsion performs better than simple approaches relying on singular features. While complex combinations using multiple interaction models provide slightly better performance, a clinically pragmatic decision tree can be employed to detect torsion and provide sensitivity levels of 95+/-14% with a specificity of 92 +/-2%. Purpose or Case Report: Ultrasound has long been a readily available, noninvasive, and accurate means of evaluating the female pelvis and is widely used in the emergency setting for girls with abdominal and pelvic pain. One key element in evaluating for pathology is to measure ovarian size and compare left and right ovaries. Normative volume data stratified by age are available; however, these studies suffer from lack of numbers, and frequently older equipment. Technological advances in ultrasonic hardware and software have increased the resolution of both gray-scale and Doppler imaging. Increases in Purpose or Case Report: To describe the fluoroscopic practice patterns during pregnancy in pediatric radiologists and potential impact on professional relationships and career. Methods & Materials: An anonymous online survey was sent to SPR members via email. Results: Of 398 responses (65% female, 35% male), most females (78%) reported being pregnant while practicing radiology. The majority (72%) announced their pregnancy during the first trimester. Factors affecting the timing and decision to announce pregnancy included fear of miscarriage (43%), impact of co-workers having to perform extra work during maternity leave (42%), impact of co-workers having to perform extra fluoroscopy during pregnancy (32%), negative reaction from co-workers (22%), and fear of negative impact on career (21%). The majority (85%) performed fluoroscopy during pregnancy. Forty percent felt they had a choice whether to perform fluoroscopy; 28% said it depended on the pregnancy; and 32% felt they had no choice. Most performed fluoroscopy during all 3 trimesters (1st 78%, 2nd 90%, 3rd 87%). The majority (81%) double leaded; 45% asked a coworker to cover fluoroscopy; 38% observed trainees performing fluoroscopy; 37% used a lead shield. Forty-six percent felt their fluoroscopic responsibilities during pregnancy were stressful. Physical demands included lead aprons being too heavy (42%) or not fitting (29%), and back pain (38%), and 26% described no extra physical demands. Of all male and female survey respondents, 56% have had to cover fluoroscopy for a pregnant co-worker; a majority (76%) did not consider this burdensome. Twenty percent of women Purpose or Case Report: Treatment pathways for isolated distal radius fractures in children are evolving and becoming more tailored to specific fracture types, including different management plans for stable buckle fractures (BFs) versus unstable distal radius fractures (DRFs). We propose a measurement rule to aid differentiation of stable BFs from unstable DRFs in children. Methods & Materials: IRB approval was waived for this retrospective QI project. Medical record search identified children with closed radius fractures during a 14month period. Demographic and other study data were collected and recorded using REDCap. Original radiology reports were compared to consensus diagnosis of two senior readers, which was used as the reference standard. Agreement was calculated using Cohen's Kappa statistic. Fracture to distal radial physis distance was measured in mm on PA and Lateral (LAT) views. Diagnostic accuracy using fracture distance as a predictor for buckle fractures was analyzed on both views. An ROC curve was used to determine the cutoff values tested. Results: There were 148 BFs (73%), 55 isolated DRFs (27%). Agreement between the original report and final diagnosis was 'slight' (κ=0.120, SE=0.058, n=203). The BF to physis distance was < 1cm in only 1 of 106 (0.9%) children 7-16y on PA view. No older children had a BF to physis distance <1 cm on LAT view and the sensitivity, specificity and accuracy for BF diagnosis were all above 82% using a cut off of 14mm (PA) and 13 mm (LAT). The BF to physis distance was < 1cm in 1 (2.4%) of 42 children 3-6y on PA view and another 1(2.4%) on LAT view. Diagnostic accuracy was low for children <7 years old for all tested distances. The areas under the ROC curve increased after excluding patients <7y: 0.822 to 0.867 (PA) and 0.819 to 0.874 (LAT). Diagnostic odds ratios also increased when excluding patients < 7y: from 11.375 to 24.612 (>14mm PA) and from 10.095 to 22.815 (>13mm LAT). Conclusions: An isolated distal radius fracture in a child is not likely to be a BF if the fracture to physis distance is < 1 cm. We propose measurement cut offs to increase diagnostic accuracy in children ≥ 7y. Using measurements to differentiate stable BFs and unstable DRFs is less reliable in younger children.

Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Whole body (WB) MRI is a valuable method for surveying the overall burden of systemic diseases such as juvenile idiopathic arthritis (JIA), directing further diagnostic and treatment approaches. Consensus-driven development and validation of a standardized WB-MRI scoring system for JIA has important clinical utility in timely detection and monitoring of disease activity, and serves as an outcome measure in research. We describe our experience utilizing a formal consensus approach amongst imaging and/or clinical JIA experts towards developing a novel WB MRI scoring system to assess disease activity in JIA.

Three rounds of anonymous, iterative Delphi surveys were used to determine the relevant anatomic joints for assessment, diagnostic item selection, definition and grading, and selection of appropriate imaging planes and sequences. These surveys were completed independently by an international expert group consisting of pediatric musculoskeletal radiologists and rheumatologists. The rates of agreement for potential choices, and additional suggestions were discussed amongst the group after each survey, ultimately yielding to a structured WB-MRI scoring system for JIA. Results: Eighteen to 22 experts participated in three rounds of Delphi surveys and a concluding consensus meeting. A first iteration scoring system was developed that ultimately included assessment of 40 joints, representation of both axial and peripheral joints, 2-5 diagnostic items graded in each, and inclusion of levels from binary (presence/absence) to 4-level ordinal scoring. Recommendations specific to the imaging of each joint, consisting of anatomical planes and MRI sequences were constructed as a preliminary, minimally necessary imaging protocol to supplement the scoring system. Conclusions: A novel WB-MRI scoring system for JIA was developed by consensus. Further iterative refinements, feasibility, reliability and responsiveness testing are warranted in upcoming studies. Purpose or Case Report: SPICA MRI with gadolinium contrast administration is routinely performed after closed reduction for the treatment of developmental dysplasia of the hip (DDH). Quantifying the degree of femoral head enhancement and abduction angles are routinely performed to identify and stratify those patients who may be at risk for epiphyseal osteonecrosis. The purpose of our study is to evaluate predictors for epiphyseal osteonecrosis based on percentage enhancement and abduction angles evaluated based on SPICA MRI.

Retrospective descriptive study for all patients identified through text word query through our electronic medical record who underwent closed hip reduction for the treatment of DDH followed by gadolinium enhanced MRI between 7/11 and 11/14. Patient demographics were recorded and follow-up data inclusive of development of epiphyseal osteonecrosis and need for re-intervention after the initial reduction. MRI data recorded included hip abduction angles after the initial closed reduction and percentage of femoral head enhancement.

Liliane Gibbs, MD 1 , Joyce Keyak, PhD 1 ; 1 University of California Irvine, Anaheim, CA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Determining the underlying etiology of bone fracture in children is an essential part of patient care. Very young patients who may be victims of child abuse, but who may not be able to express themselves, must be distinguished from those who have low bone mineralization due to disease. Quantitative computed tomography (QCT) has been used to evaluate volumetric bone mineral density (BMD) in children, but there is little information on BMD in very young subjects. 1,2 The goal of this study was to demonstrate the feasibility of using QCT to evaluate BMD and volume (Vol) of lumbar vertebral bodies in children and to establish the need for a separate comparative database to evaluate these parameters in subjects less than 6 years.

We obtained anonymized QCT scans 977mm pixel size, 2-4mm slice thickness) of lumbar vertebrae of 24 male subjects, 15 less than 6 years old (<6yo) and 9 between 13 and17 years old (13-17 yo), who were imaged for unrelated medical reasons in the ER of our institution (Image Analysis INTable phantom; Philips BrillianceTM iCT 3.2, 256 slice scanner). IRB approval to study anonymous data is not required. BMD and Vol of the vertebral body were evaluated on one image in a region of interest (ROI) through the mid-vertebral body (Figure 1 ). Volume was computed using an assumed 3-mm slice thickness. Student's ttests were performed to determine if BMD and Vol at each level differed between subjects of different groups. Linear regression analysis of the two groups separately was used to determine if BMD and Vol at each level were associated with age. A significance level of p<0.05 was used. Results: BMD was virtually independent of age in the younger group but increased with age at multiple levels in the older group (Tables 1-2, Figure 2 ). In contrast, Vol in 13-17yo was more than twice that in <6yo at all levels (p<0.002). Volume increased 0.09 to 0.29 cm 3 /yr in subjects <6yo (0.33 ≤ R 2 ≤ 0.61, p ≤ 0.04), but was not associated with age in 13-17yo (p>0.7). Conclusions: This study demonstrated a QCT method for evaluating bone mineralization in very young subjects and showed that a separate normative database is needed for subjects less than 6 years. With future work, this method may be helpful for distinguishing very young patients who may be victims of child abuse from those with low bone mineralization due to disease or a metabolic process. 

We performed a retrospective IRB approved review of epilepsy patients that received preoperative language fMRI between 2010 and 2017. We recorded age, FSIQ scores, scan information and the radiologist's reports. We defined success of the fMRI by the radiologist's ability to locate Broca's and Wernicke's areas in their report. Under the old protocol, patient preparation consisted of a 10minute verbal explanation before the MRI consisting of 2 language tasks. Under the new protocol, the practice session lasted 60 minutes using a mock MRI scanner. Tasks were first practiced seated and then supine in the mock scanner. Coaching with real-time feedback was given during the practice and exam. Information from practice was used to select and modify tasks according to patient's ability. We increased the number of language tasks, and an additional specialist was responsible for task practice and coaching during the exam. On average 6 language tasks were administered during the MRI, increasing total length over the old protocol. Results: We identified 33 preoperative language-mapping fMRI scans of children with epilepsy. 13 of 33 were done under the old protocol with a mean age of 16 (range 12 -19 years). FSIQ scores were available for 10 of the 14 patients with a mean score of 84 (range 62 -108). 19 of 33 scans were done after institution of an new protocol with mean age of 14 (range 8 -19 years). FSIQ scores were available for 14 of the 19 patients with a mean score of 75 (range 49 -111). The radiologist could identify Broca's area in 9 of 14 scans (64%) under the old protocol, and 18/19 (95%) with the new protocols. The radiologist could identify Wernicke's area in 9 of 14 scans (64%) under the old protocol, and 19/19 (100%) of scans with the new protocol. Using the z-statistic for two group proportions, the success rate between new and old protocols were significantly different (p<0.05), with p=0.035 for Broca's and p=0.005 for Wernicke's. Conclusions: Higher pediatric fMRI success rates can be achieved with intensive patient preparation in an fMRI practice session using a mock scanner.Poster #: SCI-045The Pediatric Upper Airway: Thoroughfares and Road blocks Mark Whitehead, PA 2 , markallenwhitehead@gmail.com; Matthew Whitehead, MD 1 ; 1 Neuroradiology, Children's National Medical Center, Washington, DC, 2 Just 4 Kids Pediatrics, Hohenwald, TN Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: The human airway is fundamental to respiratory gas transmission and oxygen exchange. The pediatric upper airway is subject to a number of specific age and location related disease processes that can cause alarming morbidity and could be deadly by impairing normal air movement. In this exhibit, we guide the learner on a fantastic journey thorough the pediatric upper airway from nose to cords illustrated thorough neuroimages. Congenital and acquired anatomic and pathologic barriers to airflow will be reviewed.

CT, MRI, ultrasound and radiographic images with didactic value will be procured from the teaching file of a pediatric medical center in order to demonstrate anatomy and pathology of the pediatric upper airway. Purpose or Case Report: Accurate imaging characterization of chronic subdural hemorrhage (cSDH) has clinical and forensic implications, and continues to challenge the radiologist. The MRI characteristics of surgically proven cSDH were retrospectively reviewed in the context of known pathomorphology of the aging SDH.

A search of the pediatric neurosurgical database at a large children's hospital was performed with the terms "chronic subdural hemorrhage" and "subdural drainage". Data was available from 2010-2017. Chart review was performed. Operative findings, pertinent demographic and clinical information was recorded. Preoperative MR imaging of 14 patients with surgically confirmed cSDH was retrospectively reviewed. NECT was reviewed if available. Imaging was surveyed by a senior pediatric neuroradiologist and a senior radiology resident. This retrospective study is pending approval by the Institutional Review Board.Results: 14 patients with 19 drained subdural compartments were identified. The majority of MR imaging was performed within 3 days antecedent to drainage (84%). Most cases were determined to be sequelae of non-accidental trauma (74%). Using gray matter as an internal control, the fluid signal characteristics were recorded (table 1) . All cases showed internal membranes (figure 1). The majority of the membranes demonstrated post contrast enhancement and a minority of cases showed enhancement of the meningeal dura (table 2) . A subjective determination was made as to which axial sequence showed the membranes most conspicuously. Membranes were determined to be most conspicuous on SWI (61%) or T2 (39%) in all cases. All sequences and planes were then evaluated to determine which best demonstrated membranes. Coronal T2 (31%), axial T2 (31%), and axial SWI (37%) were nearly equal. Conclusions: Our data of the signal characteristics of cSDH shares some similarities with current literature. We chronicle the paradoxical signal features of T2* and SWI as well as the confounding variability of T1, T2, and FLAIR imaging. However, analysis of fluid characteristics alone provides an incomplete evaluation of cSDH. Importantly, in our cohort, all patients demonstrated internal membranes within the cSDH and assessment of these structures is critical. Our results showed the most useful sequences for detection of membranes to be T2 and SWI, particularly when obtained in orthogonal planes. The administration of intravenous contrast was of limited utility in the evaluation of cSDH.

Performance of whole-body MRI in evaluation of pediatric oncology patients: a single center experience. Purpose or Case Report: Whole-body magnetic resonance imaging (WB-MRI) is an increasingly important tool in pediatric oncology. Optimized WB-MRI protocols allow for abbreviated imaging of young patients with excellent tissue contrast/resolution and without ionizing radiation exposure. Recent data suggest a role for WB-MRI in pediatric cancer staging, cancer predisposition syndrome (CPS) surveillance and evaluation for chemotherapy-related osteonecrosis. The purpose of this study is to evaluate the performance of WB-MRI in these populations.

A single institution IRB-approved retrospective review of radiology reports identified pediatric patients who underwent WB-MRI in the years [2002] [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] . Electronic records were queried to identify patients undergoing WB-MRI for cancer staging, CPS surveillance or evaluation for osteonecrosis. A single pediatric radiologist reviewed all studies to confirm findings in the report. Electronic medical records of imaging and notes within one year of WB-MRI were reviewed to assess impact on clinical management. Results: A total of 24 patients were included: 12 undergoing cancer staging (5 neuroblastoma, 2 Ewing sarcoma, 5 lymphoma), 5 undergoing CPS surveillance (4 hereditary paraganglioma-pheochromocytoma syndrome (HPPS), 1 Li-Fraumeni syndrome) and 7 undergoing evaluation for osteonecrosis. In the staging group, WB-MRI demonstrated known disease in 12 of 12 (100%) patients when compared to concurrent scintigraphy, PET, SPECT or CT/MR imaging ( fig  1) . In the CPS group, no new lesions were seen on follow-up imaging in 5 of 5 patients (fig 2) . WB-MRI identified known lesions in 1 of 2 (50%) HPPS patients, failing to detect a vertebral lesion seen on PET imaging. In the osteonecrosis group, WB-MRI confirmed osteonecrosis in 6 of 7 patients (86%) and ruled it out in 1 of 7 (14%). Imaging affected the decision to continue, hold or restart steroids in all 6 patients with steroid-based treatment plans (fig 3) . In one patient, WB-MRI identified an area of sub-clinical osteonecrosis in the femoral head.Conclusions: This preliminary single-institution study demonstrates the value of WB-MRI in pediatric cancer staging, surveillance and chemotherapy-related osteonecrosis. Study limitations included population size and retrospective nature of the analysis. We note that WB-MRI was used as an adjunct to other imaging modalities in our population, and further studies will be needed to assess WB-MRI performance in the pediatric oncology population as the sole surveillance imaging modality.

The Landscape of Pediatric Breast Imaging Bonmyong Lee, MD 2 , blee111@jhmi.edu; Matthew Whitehead, MD 1 ; 1 Neuroradiology, Children's National Medical Center, Washington, DC, 2 Johns Hopkins Medical Institute, Baltimore, MD Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Imaging evaluation of the pediatric breast is often necessary to evaluate suspected disease in immature and developing mammary tissue. The initial assessment of these patients commonly occurs at a children's hospital. In this retrospective study, we aim to demonstrate the landscape of pediatric breast imaging by providing the prevalence of various breast-related imaging techniques, diagnoses, and demographics encountered at an academic children's hospital over a 10 year period.

The imaging database at a single academic children's hospital was queried for all reports containing "breast" over 10 consecutive years (11/1/06-11/1/16). Each imaging report and electronic medical records were reviewed for demographics, clinical data, imaging findings, follow-up information, and histopathology when available. Results: 1348 reports (595 inpatient, 124 ER, and 92 outpatient; 1129 ultrasound, 129 CT, and 90 MRI) from 1175 patients (1140 female, 208 male; mean 12 +/-6 years) were identified. The most common diagnoses were infection (abscess, cellulitis, mastitis) (n=244 patients), fibroadenoma (n=231 patients), gynecomastia (n=80 patients), breast buds (n=51 patients), ductal ectasia (n=30 patients), and hematoma (n=27 patients). Neoplastic disease was questioned in 16 patients; histopathology revealed 5 fibroadenomas, 1 hyperplastic lymph node, and 1 lipoma. The remaining 9 patients were either lost to follow-up (n=6) or considered to have benign disease after breast surgery consultation (n=3). There were no proven cases of breast carcinoma, sarcoma, or lymphoma. Conclusions: Pediatric breast imaging encompasses an array of typically benign etiologies. Breast disease in the pediatric population is generally benign; we found no proven cases of neoplastic breast disease in an academic children's hospital setting over 10 consecutive years. Purpose or Case Report: Slipping Rib Syndrome (SRS) is a condition that affects adolescents and young adults. Dynamic Ultrasound imaging has a potential and likely significant role; however, limited data exists describing the protocol and techniques available for evaluating SRS. It is the intent of this study to describe the development of an effective and reproducible protocol for dynamic imaging in patients with SRS.

Retrospective review was performed of suspected SRS patients that presented either to the Radiology or Surgery department from March through October of 2017. 22 patients were evaluated utilizing a high frequency 12-5 linear transducer. Focused history was taken and imaging was performed at the site of pain. Images of the bilateral 7th-11th ribs were obtained in the parasagittal plane at rest and with dynamic maneuvers. Dynamic maneuvers included Valsalva, crunch, focal rib push/compression, and any other provocative movement that elicited pain per the patient. Imaging results were correlated with medical and surgical records generated by the pediatric surgeon specializing in treatment of slipping ribs. (3/3) . Two of the three examinations which did not detect SRS did not utilize dynamic crunch or push maneuvers. In the last patient, crunch was performed, but push maneuver was not. All but one exam utilizing the crunch and push maneuver correctly detected SRS. Conclusions: Dynamic Ultrasound imaging of the ribs, Purpose or Case Report: The purpose of this submission is to educate technologists in performing magnetic resonance (MR) lymphangiography in conjunction with intranodal gadolium contrast injection in the pediatric patient. MR lymphangiography is a new procedure in the pediatric population. The lymphatic system plays the important role of transporting fluid from tissue back into the venous system via lymphovenous connections. Despite this key role, there has been a poor understanding of lymphatic flow physiology. The recent development of dynamic contrast intranodal MR lymphangiography, which provides quick and reliable access to the central lymphatic system, has provided insight into understanding the pathophysiology of several lymphatic flow disorders and provides guidance for interventional procedures. It also makes it possible to see central lymphatic anatomy with high spatial and temporal resolution. This allows clinicians to map the anatomy of the lymphatic system to determine the location of lymphatic leaks. MR lymphangiography may reduce the need for conventional IR lymphangiogram and spare patient's radiation exposure.

Multiplanar multisequence MR is performed with and without the administration of intranodal gadolinium. Precontrast sequences include coronal T2 "Sampling Perfection with Application Optimized Contrasts using Different Flip Angle Evolution" (SPACE), axial coronal and sagittal with "True Fast Imaging with Steady State Free Precession" (TRUFI) and precontrast coronal T1 "Volumetric Interpolated Breathhold Examination" (VIBE). Subsequently, under ultrasound guidance, 22-gauge spinal needles are inserted into bilateral inguinal lymph nodes and gadolinium followed by saline is injected into the lymph nodes timed over a duration of 15 minutes. TWIST sequences are acquired as well as delayed postcontrast sequences. Results: MR lymphangiography was performed in several patients who received conventional IR lymphangiogram contemporaneously. Qualitative evaluation of these cases indicates that MR lymphangiography may be diagnostically adequate for evaluation of lymphatic disorders. Conclusions: MR lymphangiography requires complex coordination between anesthesia, interventional radiology (IR) and the MR divisions. Despite these challenges, our recently developed MR lymphangiography protocol has been successfully performed in several patients and early validation looks promising.

Extra-osseous uptake of Tc 99m -HDP on bone scintigraphy in a paediatric patient with hepatoblastoma Major intracranial cerebral arterial (PSV/RI/PI) values with hypoxic ischemic encephalopathy, hydrocephalus, vascular malformations and brain death; terminal vein flow; dural venous sinus flow, and compression of the fontanelle for intracranial pressure assessment will be described. Results: Typical findings in normal and abnormal infant transcranial Doppler exams will be illustrated. Emphasis on appropriate technique and methodology for serial examinations is described. Tips including utilization of a high frequency linear transducer, choosing optimal window of insonation will be discussed.Conclusions: Through this exhibit, participants will learn to utilize cranial Doppler as an effective adjuvant tool when performing infant neurosonography.

The Impact of One Volume Acquisition Tara Cielma 1 , tcielma@cnmc.org; Kadine Linden 1 ; 1 Children's National Health System, DC Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: Background: Volume acquisition in ultrasound is recognized as a helpful tool in prenatal sonography, but notorious for having a steep learning curve. At times, utilizing this technology may be the only way to visualize anatomy due to factors such as maternal body habitus or fetal position. Our goal is provide the audience with the information and techniques required to take a volume sweep acquisition and obtain numerous rendering modes to evaluate the fetal craniofacial area. Aims: 1. To describe utility and benefit of acquiring volume ultrasound in detection of craniofacial anomalies in prenatal patients. 2. To describe tips, tricks, and current technology to optimize imaging and assist in minimizing equivocal exams.vovulus. This is when the gut twists counterclockwise around the superior mesenteric artery and vein causing a narrowing. This may cause abdominal distention and pain or acute bowel necrosis. It can also be life threatening or lead to a lifelong dependence on total parenteral nutrition, so surgical correction is the dependent treatment. When medical history and physical examination indicate a suspicion of malrotation and vovulus, patients must undergo blood tests and diagnostic imaging studies to evaluate the position of the intestine to determine if there is blockage or twisting. The imaging modality of choice remains the upper GI study. This is a fluoroscopic study using barium contrast to look at the upper and middle sections of the gastrointestinal tract. A radiologist's knowledge of normal anatomy is important in performing and interpreting the upper GI series. From a technical standpoint common pitfalls during this test that can lead to a misdiagnosis would be imaging quality. Improper patient positioning, nonsufficient images taken and the wrong amount of contrast administered during the most crucial part of the study can lead to false findings. The purpose of this abstract is to present case studies and imaging which mimic intestinal rotation but are a normal variant vs. actual cases of malrotation.

Poster #: EDU-008 (T) Purpose or Case Report: To recognize imaging artifacts that are unique to digital radiography (DR) and to learn techniques to reduce the most common image quality issues. DR systems in medical imaging have transformed planar xray, one of the oldest imaging modalities. Computed radiography (CR) and DR share some of the same image quality challenges including poor positioning, inappropriate techniques, and motion. There are image quality issues unique to DR that may be unfamiliar to new operators. Although, artifacts have been a part of imaging since the use of film-screen xray, with DR, the technologists have to be aware of new artifacts related to digital acquisition and processing. At times, pediatric DR imaging can present even bigger challenges. Technologists must learn methods to avoid DR imaging artifacts, and how to identify them before sending the image to the Picture Archiving and Communication System (PACS). This exhibit will review how to identify common DR imaging artifacts, explain the reason they occur, and suggest methods to reduce their interference with image quality.

Common DR artifacts were identified by review of recent literature and a retrospective review of images acquired at our institution. A physicist was consulted regarding the source of these DR image quality issues. A radiologist was consulted to assess how much these artifacts interfere with clinical interpretation. Image quality issues were evaluated for their appearance on both image viewing station and the radiologist viewing station in order to assess differences in conspicuity and appearance. Example cases were identified where DR artifacts are significantly more prominent on high resolution PACS monitors than they appear at the technologists work station. A case-based technologist staff education was developed.Results: A case-based educational module was developed that reviews common artifacts in DR, the physical principles behind these artifacts, and their effect on diagnostic quality. Methods to reduce or eliminate these artifacts were reviewed and summarized. A protocol to communicate with Radiologists regarding digital artifacts was developed including best practices for determining when repeat imaging is required.

Technologists familiar with CR may face challenges when learning DR because image artifacts are different. Case based education on artifacts unique to digital imaging may reduce image quality issues and the need for repeat imaging leading to reduced radiation exposure in children. To identify a decrease in sedations after the installation of the SOMATOM Force, we analyzed sedation percentages before the installation to the sedation percentages after installation. A report was created within our EMR system to identify patients five years and younger that received CT imaging of the thorax and/or abdomen/pelvis. An additional report was generated by the sedation physicians' data regarding the number of sedations for the same time reference. These reports were analyzed and compared to generate the overall percentage of sedations. Results: Four months of data prior to the installation of the Siemens SOMATOM Force revealed sedation percentages on an average of 34.5% of patients aged five years and younger. The first full month after installation of the Siemens SOMATOM Force revealed a decrease in sedations to 15% of patients aged five years and younger. Conclusions: Installation of the Siemens SOMATOM Force at Children's Healthcare of Atlanta at Scottish Rite has resulted in a decrease in the sedation of patients five years and younger receiving CT imaging of the thorax and/or abdomen/pelvis.

Angie Wright 1 , angie.wright@choa.org; Stephen Simoneaux 1 ; 1 Radiology, Children's Healthcare of Atlanta, Atlanta, GA Disclosures: All authors have disclosed no financial interests, arrangements or affiliations in the context of this activity.Purpose or Case Report: During a recent CT renovation, a mobile CT scanner had to be used at a major urban children's hospital which also is a Level 1 trauma center. Performing exams while maintaining patient safety and providing quality diagnostic imaging involved the collaborative efforts of the radiology team, the project manager, the construction team, and the hospital service line leaders. The purpose of this exhibit is highlight the anticipated and unanticipated considerations which had to be addressed prior to the use of the mobile CT scanner. Knowing how these environmental and patient safety issues were identified and addressed may be a help with future radiology equipment replacement projects.

Environmental concerns: As the unit was outside, the construction team had to design and build an adequate overhead awning to protect patients from inclement weather. An approaching hurricane meant the area had to be reassessed for its ability to be used during violent weather. Inpatient imaging: Patient simulations were performed to determine which pieces of medical equipment could fit onto the mobile CT lift when transporting the patient from ground level into the scanner. Earlier communication to pertinent hospital personnel, notably Emergency Department and ICU staff, would have allowed for more education in preparation for transporting patients to the mobile CT. Issues around severe trauma and unstable ICU patients would have been addressed with more time for preparation. With more notice and simulations, staff in these critical areas would have been more prepared for the utilization of the mobile CT scanner. Emergency and Sedation Preparation: Anesthesiology and Sedation Services were involved in the process. Ultimately, Anesthesia decided that patients could not be safely performed at the mobile location, and these patients were performed on a PET/CT scanner. The sedation team was able to provide its services off-site, but again, simulations and early involvement were key. Security and the Code Team were also engaged to ensure that responses to codes were prompt and the site wellknown.

The use of the mobile CT scanner during the removal and installation of a new CT scanner was an educational experience to those involved. This radiology project may have gone more smoothly if many of these concerns were addressed prior to the start of the project. The information contained in this presentation will help other sites who have to use a mobile CT unit for scanning. • Staff demonstrated an improved understanding of our shielding practices post education.• Staff feel more empowered to discuss shielding practices with parents and are aware of their resources for more complex questions.• Image quality and safety has improved in our pediatric patient population. Purpose or Case Report: The purpose of this education is to describe Therapeutic Enema reduction of Intussusception using Hydrostatic and Pneumatic methods. The benefits of Delayed Repeated Enema (DRE) instead of immediate surgical intervention after a failed reduction will be reviewed.

Harreld, Julie H.