Strategies to minimize sedation in pediatric body magnetic resonance imaging

Clinical evaluation of scout accelerated motion estimation and reduction (SAMER) for brain MRI in non-sedated children: initial clinical experience

BACKGROUND

The scout accelerated motion estimation and reduction (SAMER) method has been developed to achieve rapid retrospective motion correction and may be advantageous in pediatric imaging to mitigate motion artifacts.

OBJECTIVE

To evaluate the efficacy of SAMER for motion correction of brain imaging in awake pediatric patients.

METHODS

In this institutional review board (IRB) approved and Health Insurance Portability and Accountability Act (HIPAA) compliant prospective study, 33 pediatric patients were scanned on a 3-T MRI system in the outpatient setting. The imaging protocol included an accelerated 3D T1-weighted SAMER MPRAGE research sequence acquired in 2 min 37 s. Retrospective reconstructions of the T1-weighted MPRAGE data were performed with and without SAMER motion correction. Reconstructed image pairs were reviewed side-by-side by two board-certified neuroradiologists in a blinded manner and graded for motion artifacts using a 5-point scale. The improvement in motion score was calculated by subtracting the post-correction score from the pre-correction score.

RESULTS

Without SAMER motion correction, 24 out of 33 cases (73%) showed motion artifact (21% (7/33) minimal, 27%(9/33) mild, 9% (3/33) moderate, and 15% (5/33) severe). SAMER motion correction improved motion artifacts in 79% (19/24) of cases, improving the motion score by median of 3 vs. 2 for motion-corrected examinations using SAMER. After applying SAMER motion correction, 50% (4/8) of cases considered nondiagnostic due to motion were reclassified as diagnostic.

CONCLUSION

SAMER demonstrates potential for reducing motion artifacts in 3D T1-weighted MPRAGE brain MR images, with the most notable improvements occurring in cases of moderate to severe motion.

Development and fundamental psychometric properties of the Magnetic Resonance Imaging Child-Anxiety Questionnaire (MRIC-AQ)

INTRODUCTION

Magnetic Resonance Imaging is known to provoke anxiety among children, and they may need to be examined with the help of anaesthesia, which has risks. An instrument is needed to evaluate children's anxiety related to a procedure with Magnetic Resonance Imaging. The study aims to adapt and evaluate a children's version of the Magnetic Resonance Imaging-Anxiety Questionnaire.

METHODS

The 'Magnetic Resonance Imaging Child-Anxiety Questionnaire' (MRIC-AQ) was drafted by an expert group consisting of a paediatric nurse, a teacher and two radiographers. This version was discussed in focus groups consisting of 10 children between the ages of four and 12 years. The children's suggestions were summarised and analysed using thematic analysis. The revised questionnaire was again discussed with focus groups of children before a paediatric nurse made final readjustments. For a basic psychometric analysis, children undergoing MRI-examinations without anaesthesia were asked to answer the MRIC-AQ.

RESULTS

Responses to the questionnaire were gathered from 77 children (girls = 44, boys = 33) aged five to12 years (M = 9.3, SD = 1.7). Only two missing data points were found. The median of the total scale score was 25 (P25-P75 = 21-29), which is below the midpoint of the scale. The Cronbach's alpha was 0.84 (95 % CI = 0.78-0.89).

CONCLUSION

The MRIC-AQ has been developed with the help of children. It has satisfactory elementary psychometric properties and will be a useful tool for investigating different interventions for children.

IMPLICATIONS FOR PRACTICE

This new instrument (MRIC-AQ) is considered to be of great value when different kinds of interventions are evaluated, all to make MRI examinations as positive an experience as possible. This helps children to undergo examinations without fear.

Innovative 4D FreeBreathing technique in pediatric abdominal MRI improves feasibility and image quality

OBJECTIVES

To compare the feasibility and imaging quality of a golden angle radial stack-of-stars dynamic three-dimensional free-breathing T1w turbo field echo acquisition (4D FreeBreathing) with a conventional dynamic cartesian breath-hold T1w sequence in young children undergoing abdominal magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Fifty consecutive pediatric patients (34 females; 3.4 ± 2.0 years) underwent abdominal MRI: 25 were examined with 4D FreeBreathing and 25 with conventional dynamic T1w sequence. The image quality was evaluated subjectively on a 5-point scale by two radiologists. Interobserver agreement, as well as signal-to-noise ratio for arterial (SNRart) and portal venous (SNRpv) phases, were evaluated separately. Additionally, the image quality of 4D FreeBreathing sequence was compared to a non-dynamic post-contrast radial stack-of-stars free-breathing T1w fast field echo acquisition (3D T1w Vane mDixon). Interobserver agreement of both assessors was calculated using quadratic weighted Cohen's kappa test (ϰ), while independent samples Student's t-test was employed to compare mean SNR values among the two groups.

RESULTS

Using 4D FreeBreathing, SNRart and SNRpv were significantly higher from 500 ± 170 and 550 ± 160 to 900 ± 210 and 820 ± 260 (p < 0.001); the diagnostic image quality increased from 77.6 to 89.6%; respiratory artifacts decreased from 22.4 to 10.4%, with an almost perfect interobserver agreement. Compared to 3D T1w Vane mDixon sequence, SNR and image quality were equal.

CONCLUSION

4D FreeBreathing pediatric abdominal MRI improves the feasibility and image quality compared to conventional dynamic exams while showing an image quality equivalent to post-contrast 3D T1w Vane mDixon.

KEY POINTS

Question During dynamic abdominal MRI in young children, it is important to conduct a brief yet robust examination without respiratory artifacts. Findings 4D FreeBreathing MRI technique for pediatric abdominal imaging enhances both image quality and feasibility when compared to conventional dynamic scans that require breath-holding. Clinical relevance Dynamic abdominal MRI using the 4D FreeBreathing sequence provides significant benefits for pediatric patients. The absence of breath-holding requirements improves patient cooperation, reduces the need for general anesthesia, and results in higher-quality diagnostic images.

Self-Gated Radial Free-Breathing Liver MR Elastography: Assessment of Technical Performance in Children at 3 T

BACKGROUND

Conventional liver magnetic resonance elastography (MRE) requires breath-holding (BH) to avoid motion artifacts, which is challenging for children. While radial free-breathing (FB)-MRE is an alternative for quantifying liver stiffness (LS), previous methods had limitations of long scan times, acquiring two slices in 5 minutes, and not resolving motion during reconstruction.

PURPOSE

To reduce FB-MRE scan time to 4 minutes for four slices and to investigate the impact of self-gated (SG) motion compensation on FB-MRE LS quantification in terms of agreement, intrasession repeatability, and technical quality compared to conventional BH-MRE.

STUDY TYPE

Prospective.

POPULATION

Twenty-six children without fibrosis (median age: 12.9 years, 15 females).

FIELD STRENGTH/SEQUENCE

3 T; Cartesian gradient-echo (GRE) BH-MRE, research application radial GRE FB-MRE.

ASSESSMENT

Participants were scanned twice to measure repeatability, without moving the table or changing the participants' position. LS was measured in areas of the liver with numerical confidence ≥90%. Technical quality was examined using measurable liver area (%).

STATISTICAL TESTS

Agreement of LS between BH-MRE and FB-MRE was evaluated using Bland-Altman analysis for SG acceptance rates of 40%, 60%, 80%, and 100%. LS repeatability was assessed using within-subject coefficient of variation (wCV). The differences in LS and measurable liver area were examined using Kruskal-Wallis and Wilcoxon signed-rank tests. P < 0.05 was considered significant.

RESULTS

FB-MRE with 60% SG achieved the closest agreement with BH-MRE (mean difference 0.00 kPa). The LS ranged from 1.70 to 1.83 kPa with no significant differences between BH-MRE and FB-MRE with varying SG rates (P = 0.52). All tested methods produced repeatable LS with wCV from 4.4% to 6.5%. The median measurable liver area was smaller for FB-MRE (32%-45%) than that for BH-MRE (91%-93%) (P < 0.05).

DATA CONCLUSION

FB-MRE with 60% SG can quantify LS with close agreement and comparable repeatability with respect to BH-MRE in children.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

Magnetic resonance imaging of masticatory muscles in patients with duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy in children. Impairment of masticatory function and swallowing disorders, potentially leading to aspiration and gastrostomy, are linked to fatty infiltration in the masticatory muscles, as previously observed in muscle ultrasound. This study aims to quantify muscle volume and fat fraction in muscle magnetic resonance imaging (MRI) in the masticatory muscles in non-ambulant DMD patients compared to healthy controls and evaluate their correlation with maximum bite force (MBF), which has not been previously described. Fifteen patients with DMD and 16 controls were included. MBF was measured with an oral dynamometer and total muscle volume (TMV) and fat signal fraction (FSF) were quantified using MRI with the Dixon technique. Four DMD patients presented with masticatory or swallowing difficulties. DMD patients had a significantly lower median MBF (141.8 N) compared with healthy controls (481.6 N, p < 0.0001). Additionally, median FSF was significantly higher in DMD patients (47.07 %) compared to controls (5.31 %, p < 0.0001). A strong negative correlation between TMV and MBF was observed in DMD patients (ρ = -0.70, p = 0.0048). A significant negative correlation between MBF and normalized FSF was observed in healthy controls (ρ = -0.5487, p = 0.300) and DMD patients (ρ = -0.5893, p = 0.0224). A non-significant positive correlation between age and FSF in DMD was detected (ρ = 0.38, p = 0.17). MBF, TMV and FSF quantified with the Dixon MRI are sensitive measures to evaluate masticatory function in DMD patients and may serve as biomarkers for clinical follow up. Studies in older patients are needed to evaluate the predictive role of MBF, TMV and FSF in the nutritional status of patients and the need for therapeutic interventions such as gastrostomy.

International standardization of pediatric magnetic resonance imaging protocols: creation of the World Federation of Pediatric Imaging MR Protocols Committee

The World Federation of Pediatric Imaging (WFPI) MR Protocols Committee was formed in response to the critical need for standardized magnetic resonance imaging (MRI) protocols tailored specifically for pediatric populations. This initiative addresses the inherent challenges and variabilities in pediatric MRI practices due to the unique physiological and anatomical characteristics of children, which often result in extended scan times, increased costs, and greater need for sedation. The committee, comprising a diverse group of international radiologists, pediatric imaging societies, and major MRI vendors, collaboratively developed a comprehensive set of MRI protocols. These protocols are designed to enhance diagnostic accuracy, reduce sedation use, and streamline workflows, thereby minimizing healthcare disparities across global regions. Protocols cover a wide range of applications, including neuroradiology, abdominal imaging, and musculoskeletal conditions, with specific focus on practical implementation in both high-resource and resource-limited settings. After rigorous development and refinement through global feedback, these protocols have been made accessible through the WFPI website and will be directly integrated into MRI systems via vendor collaborations. These protocols provide a flexible, foundational approach that can be adapted to suit the needs of centers worldwide. This ensures that even basic protocols are accessible across different settings, allowing customization based on available resources and specific clinical demands.

Evaluation of Image Quality and Scan Time Efficiency in Accelerated 3D T1-Weighted Pediatric Brain MRI Using Deep Learning-Based Reconstruction

OBJECTIVE

This study evaluated the effect of an accelerated three-dimensional (3D) T1-weighted pediatric brain MRI protocol using a deep learning (DL)-based reconstruction algorithm on scan time and image quality.

MATERIALS AND METHODS

This retrospective study included 46 pediatric patients who underwent conventional and accelerated, pre- and post-contrast, 3D T1-weighted brain MRI using a 3T scanner (SIGNA Premier; GE HealthCare) at a single tertiary referral center between March 1, 2023, and April 30, 2023. Conventional scans were reconstructed using intensity Filter A (Conv), whereas accelerated scans were reconstructed using intensity Filter A (Fast_A) and a DL-based algorithm (Fast_DL). Image quality was assessed quantitatively based on the coefficient of variation, relative contrast, apparent signal-to-noise ratio (aSNR), and apparent contrast-to-noise ratio (aCNR) and qualitatively according to radiologists' ratings of overall image quality, artifacts, noisiness, gray-white matter differentiation, and lesion conspicuity.

RESULTS

The acquisition times for the pre- and post-contrast scans were 191 and 135 seconds, respectively, for the conventional scan. With the accelerated protocol, these were reduced to 135 and 80 seconds, achieving time reductions of 29.3% and 40.7%, respectively. DL-based reconstruction significantly reduced the coefficient of variation, improved the aSNR, aCNR, and overall image quality, and reduced the number of artifacts compared with the conventional acquisition method (all P < 0.05). However, the lesion conspicuity remained similar between the two protocols.

CONCLUSION

Utilizing a DL-based reconstruction algorithm in accelerated 3D T1-weighted pediatric brain MRI can significantly shorten the acquisition time, enhance image quality, and reduce artifacts, making it a viable option for pediatric imaging.

Rapid and motion-robust pediatric brain imaging: T2-weighted turbo-spin-echo PROPELLER acquisition with compressed sensing

BACKGROUND

In pediatric magnetic resonance imaging (MRI), reducing the rate of non-diagnostic scans due to artifacts and shortening acquisition time are crucial not only for economic reasons but also to minimize sedation or general anesthesia.

OBJECTIVE

Enabling faster and motion-robust MRI of the brain in infants and children using a novel, enhanced compressed sensing (CS) algorithm in combination with a turbo-spin-echo T2-weighted sequence utilizing the PROPELLER-technique (periodically rotated overlapping parallel lines with enhanced reconstruction; T2PROPELLER CS).

MATERIALS AND METHODS

This prospective study included 31 patients (8.0 ± 4.7 years, 15 males) undergoing a clinically indicated MRI examination of the brain on a 3-T scanner. The T2PROPELLER CS sequence was compared to a conventional, CS-accelerated Cartesian turbo-spin-echo T2-weighted sequence (T2Cartesian CS). Apparent contrast-to-noise ratio (aCNR) and signal-to-noise ratio (aSNR) were calculated. Three blinded radiologists independently rated both sequences twice qualitatively on a 5-point Likert-scale from 1-5 (non-diagnostic-excellent) for artifacts, image sharpness, basal ganglia delineation, lesion conspicuity, and overall image quality. Statistical analysis was performed using the Wilcoxon signed-rank test and paired sample t test. Intra- and interrater reliability of qualitative image assessment was evaluated by computing Krippendorff's α reliability estimates.

RESULTS

The average acquisition time of the T2PROPELLER CS (189 ± 27 s) was 31% shorter than that of the T2Cartesian CS sequence (273 ± 21 s; P < 0.001). aCNR (7.7 ± 4.6 vs. 6.2 ± 2.8; P = 0.004) and aSNR (24.8 ± 9.7 vs. 18.8 ± 5.5; P < 0.001) were higher for the T2Cartesian CS compared to the T2PROPELLER CS sequence. The T2PROPELLER CS sequence significantly reduced (motion-)artifacts (P < 0.001) and increased image sharpness (P < 0.001), basal ganglia delineation (P<0.001), lesion conspicuity (raters 1 and 2, P < 0.001; rater 3, P = 0.004), and overall image quality (P < 0.001). Metal artifacts were prominent in both sequences, though slightly more pronounced in the T2PROPELLER CS sequence.

CONCLUSION

The T2PROPELLER CS sequence enables faster and motion-robust imaging of the brain in infants and children, reducing the rate of non-diagnostic scans and potentially allowing sedation or general anesthesia to be minimized in the future.

Body MRI in pediatrics: where we are and what the future holds

Body magnetic resonance imaging (MRI) is increasingly used for disease diagnosis, characterization, and monitoring in children of all ages. MRI has numerous advantages when compared to other imaging modalities, including a lack of ionizing radiation, superior soft tissue image contrast, and ability to provide objective, quantitative assessments. As MRI continues to evolve, pediatric body MRI examinations of the future will certainly be different than our current and past protocols. In this review article, we will discuss the present and likely future states of pediatric body MRI, including the increasing application of quantitative MRI methods, faster imaging techniques and implementation of abbreviated targeted protocols, and the growing use of artificial intelligence methods.

Practical strategies to improve MRI operations and workflow in pediatric radiology

Magnetic resonance imaging (MRI) is an essential tool in pediatric imaging. It offers detailed, high-contrast images without ionizing radiation, making it particularly suitable for children. Creating an efficient MRI service is challenging given the balancing priorities of image quality and scan time and the overlying logistical challenges, including MRI safety protocols, the need for sedation in certain patient populations, and flexibility to accommodate patients at different phases of care. This paper reviews practical strategies to improve MRI operations and workflows in pediatric radiology, emphasizing protocol standardization and customization, scheduling optimization, and identification of key performance indicators (KPIs). Operational data through dashboards and reports enable continuous quality assessment and improvement, while specialized staff training ensures high imaging and patient safety standards. The strategies outlined in this paper highlight the importance of a comprehensive, patient-centered approach to MRI operations. By prioritizing efficiency, quality, and patient care, radiology departments can improve diagnostic outcomes and patient experience.

Child life specialists predict successful MRI scanning in unsedated children 4 to 12 years old

BACKGROUND

It can be challenging for children to cooperate for a magnetic resonance imaging (MRI) exam. General anesthesia is often used to ensure a high-quality image. When determining the need for general anesthesia, many institutions use a simple age cutoff. Decisions on the necessity for anesthesia are often left to schedulers who lack training on determination of patient compliance.

OBJECTIVE

The study aimed to evaluate whether screening questions administered by certified child life specialists (CCLS) could successfully predict which children could complete an MRI without sedation.

MATERIALS AND METHODS

This is a retrospective, institutional review board approved study. Data was collected as part of a quality improvement program, where a CCLS screened 4- to 12-year-old children scheduled for MRI scanning using a questionnaire. Parent responses to the screening questions, CCLS's recommendation for scheduling the MRI awake, start and end time for the MRI scan, and scan success were recorded. A predictive model for the CCLS's recommendation was developed using the child's age, estimated scan length, scan difficulty, and the parent's responses to the screening questions. The primary outcome measure was a successfully completed MRI not requiring additional imaging under anesthesia.

RESULTS

Of the 403 screened children, 317 (79%) were recommended to attempt the MRI without anesthesia. The median age of participants was 7 (IQR 4-17) years. Overall, 309 of 317 (97.5%) participants, recommended by the CCLS for the program, met the primary outcome of successful MRI completion on their first attempt. The multivariable regression model which included clinical information about the child's age, estimated scan length, scan difficulty, and four of the six parent screening questions had excellent performance (area under the curve = 0.89).

CONCLUSION

Information collected by the CCLS via screening along with the child's age, the estimated scan length, and difficulty can help predict which children are likely to successfully complete a non-sedate MRI.

Emerging technologies in pediatric radiology: current developments and future prospects

Radiological imaging is a crucial diagnostic tool for the pediatric population. However, it is associated with several unique challenges in this age group compared to adults. These challenges mainly come from the fact that children are not small-sized adults and differ in development, anatomy, physiology, and pathology compared to adults. This paper reviews relevant articles published between January 2015 and October 2023 to analyze challenges associated with imaging technologies currently used in pediatric radiology, emerging technologies, and their role in resolving the challenges and future prospects of pediatric radiology. In recent decades, imaging technologies have advanced rapidly, developing advanced ultrasound, computed tomography, magnetic resonance, nuclear imaging, teleradiology, artificial intelligence, machine learning, three-dimensional printing, radiomics, and radiogenomics, among many others. By prioritizing the unique needs of pediatric patients while developing such technologies, we can significantly alleviate the challenges faced in pediatric radiology.

Magnetic resonance imaging of the musculoskeletal system in the diagnosis of rheumatic diseases in the pediatric population

Magnetic resonance imaging (MRI) of the musculoskeletal system is an examination increasingly performed for suspected juvenile idiopathic arthritis, chronic nonbacterial osteomyelitis and juvenile idiopathic inflammatory myopathies, as well as other rheumatic diseases of developmental age. T1-, T2- and PD-weighted with or without fat suppression or short tau inversion recovery/turbo inversion recovery magnitude (STIR/TIRM) sequences and post-contrast sequences are evaluated to diagnose pathological changes in the synovial membrane, subchondral bone marrow and surrounding soft tissues. Magnetic resonance imaging allows detection of synovitis, tenosynovitis, bursitis, and enthesitis as well as bone marrow edema and soft tissue edema. Several pediatric-specific MRI scoring systems have been developed and validated to standardize and facilitate the assessment of the extent of the inflammatory process and disease activity in MRI. Early detection of inflammatory changes allows the inclusion of comprehensive pharmacotherapy giving the possibility of permanent remission and objective measurement of the effectiveness of treatment.

The effect of video-based education program applied before children's pediatric Magnetic Resonance Imaging (MRI) on anxiety in Turkey: A randomized controlled study

OBJECTIVE

This study is a randomized controlled trial conducted to examine the effects of a Turkish video-based education program on scanned image quality and child and parent anxiety during Magnetic Resonance Imaging (MRI).

DESIGN AND METHODS

The study was conducted with 66 children aged between 4 and 15 years at Zonguldak Bulent Ecevit University Health Practice and Research Hospital, between January 2019 and December 2019. A video-based educational program was applied to an intervention group before MRI.

RESULTS

The video-based education program reduced children's anxiety and fear (p < 0.001). The study also showed a significant reduction in parental stress (p < 0.001). The image quality in the intervention group was better than that in the control group (control group: 3.24 ± 1.20; intervention group: 4.18 ± 0.81) (p = 0.001). Significantly fewer children refused to enter the MRI room in the intervention group than in the control group (p < 0.05).

CONCLUSION

Child-friendly and video-based educational programs can be organized for children and parents in diagnostic and treatment procedures for children in hospitals.

PRACTICE IMPLICATIONS

MRI scans can be uncomfortable for children and require transport to a better-equipped hospital for sedation. They can also cause financial loss for children and their parents and disrupt facility workflow. An educational program to adjust the children and their families will improve the scanning process and its success rate.

[Reduction of Motion Artifacts in Liver MRI Using Deep Learning with High-pass Filtering]

PURPOSE

To investigate whether deep learning with high-pass filtering can be used to effectively reduce motion artifacts in magnetic resonance (MR) images of the liver.

METHODS

The subjects were 69 patients who underwent liver MR examination at our hospital. Simulated motion artifact images (SMAIs) were created from non-artifact images (NAIs) and used for deep learning. Structural similarity index measure (SSIM) and contrast ratio (CR) were used to verify the effect of reducing motion artifacts in motion artifact reduction image (MARI) output from the obtained deep learning model. In the visual assessment, reduction of motion artifacts and image sharpness were evaluated between motion artifact images (MAIs) and MARIs.

RESULTS

The SSIM values were 0.882 on the MARIs and 0.869 on the SMAIs. There was no statistically significant difference in CR between NAIs and MARIs. The visual assessment showed that MARIs had reduced motion artifacts and improved sharpness compared to MAIs.

CONCLUSION

The learning model in this study is indicated to be reduced motion artifacts without decreasing the sharpness of liver MR images.

Motion Artifact Reduction Using U-Net Model with Three-Dimensional Simulation-Based Datasets for Brain Magnetic Resonance Images

This study aimed to remove motion artifacts from brain magnetic resonance (MR) images using a U-Net model. In addition, a simulation method was proposed to increase the size of the dataset required to train the U-Net model while avoiding the overfitting problem. The volume data were rotated and translated with random intensity and frequency, in three dimensions, and were iterated as the number of slices in the volume data. Then, for every slice, a portion of the motion-free k-space data was replaced with motion k-space data, respectively. In addition, based on the transposed k-space data, we acquired MR images with motion artifacts and residual maps and constructed datasets. For a quantitative evaluation, the root mean square error (RMSE), peak signal-to-noise ratio (PSNR), coefficient of correlation (CC), and universal image quality index (UQI) were measured. The U-Net models for motion artifact reduction with the residual map-based dataset showed the best performance across all evaluation factors. In particular, the RMSE, PSNR, CC, and UQI improved by approximately 5.35×, 1.51×, 1.12×, and 1.01×, respectively, and the U-Net model with the residual map-based dataset was compared with the direct images. In conclusion, our simulation-based dataset demonstrates that U-Net models can be effectively trained for motion artifact reduction.

A survey of non-sedate practices when acquiring pediatric magnetic resonance imaging examinations

BACKGROUND

Improving access to magnetic resonance imaging (MRI) in childhood can be facilitated by making it faster and cheaper and reducing need for sedation or general anesthesia (GA) to mitigate motion. Some children achieve diagnostic quality MRI without GA through the use of non- practices fostering their cooperation and/or alleviating anxiety. Employed before and during MRI, these variably educate, distract, and/or desensitize patients to this environment.

OBJECTIVE

To assess current utilization of non-sedate practices in pediatric MRI, including variations in practice and outcomes.

MATERIALS AND METHODS

A survey-based study was conducted with 1372 surveys emailed to the Society for Pediatric Radiology members in February 2021, inviting one response per institution.

RESULTS

Responses from 50 unique institutions in nine countries revealed 49/50 (98%) sites used ≥ 1 non-sedate practice, 48/50 (96%) sites in infants < 6 months, and 11/50 (22%) for children aged 6 months to 3 years. Non-sedate practices per site averaged 4.5 (range 0-10), feed and swaddle used at 47/49 (96%) sites, and child life specialists at 35/49 (71%). Average success rates were moderate (> 50-75%) across all sites and high (> 75-100%) for 20% of sites, varying with specific techniques. Commonest barriers to use were scheduling conflicts and limited knowledge.

CONCLUSION

Non-sedate practice utilization in pediatric MRI was near-universal but widely variable across sites, ages, and locales, with room for broader adoption. Although on average non-sedate practice success rates were similar, the range in use and outcomes suggest a need for standardized implementation guidelines, including patient selection and outcome metrics, to optimize utilization and inform educational initiatives.

Application of intelligent pacifying strategy information system in reducing short-duration MRI sedation rate in children

Exploring and analyzing the effectiveness of an intelligent pacifying strategy information system based on assisted decision-making in reducing the sedation rate of children in short-duration magnetic resonance scans. A total of 125 children aged 3-5 years who underwent MRI scans at a children's hospital from July to December 2021 participated in this study, during which 62 children were assigned to a control group from July to September, and 63 children were assigned to an intervention group from October to December. In the intervention group, the pacifier used the intelligent pacifying strategy information system based on assisted decision-making to assess children's temperament, and utilization of a system-generated pacification plan according to assessment results. In the control group, the pacification plan was formulated by the pacifier based on their own experience and discussion with families of the participating children. The success rate of pacification, duration of pacification, and image quality of the two groups were compare. Compared with the control group, the intervention group had a higher success rate of pacification and lower duration of pacification, with statistically significant differences (P < 0.05). There was no difference in image quality between the two groups (P > 0.05). The intelligent pacifying strategy information system can help reduce the use of the sedative drugs in children aged 3-5 years who underwent a short-duration MRI scan.

A total inverse planning paradigm: Prospective clinical trial evaluating the performance of a novel MR-based 3D-printed head immobilization device

Background and purpose

Brain radiotherapy (cnsRT) requires reproducible positioning and immobilization, attained through redundant dedicated imaging studies and a bespoke moulding session to create a thermoplastic mask (T-mask). Innovative approaches may improve the value of care. We prospectively deployed and assessed the performance of a patient-specific 3D-printed mask (3Dp-mask), generated solely from MR imaging, to replicate a reproducible positioning and tolerable immobilization for patients undergoing cnsRT.

Material and methods

Patients undergoing LINAC-based cnsRT (primary tumors or resected metastases) were enrolled into two arms: control (T-mask) and investigational (3Dp-mask). For the latter, an in-house designed 3Dp-mask was generated from MR images to recreate the head positioning during MR acquisition and allow coupling with the LINAC tabletop. Differences in inter-fraction motion were compared between both arms. Tolerability was assessed using patient-reported questionnaires at various time points.

Results

Between January 2020 - July 2022, forty patients were enrolled (20 per arm). All participants completed the prescribed cnsRT and study evaluations. Average 3Dp-mask design and printing completion time was 36 h:50 min (range 12 h:56 min - 42 h:01 min). Inter-fraction motion analyses showed three-axis displacements comparable to the acceptable tolerance for the current standard-of-care. No differences in patient-reported tolerability were seen at baseline. During the last week of cnsRT, 3Dp-mask resulted in significantly lower facial and cervical discomfort and patients subjectively reported less pressure and confinement sensation when compared to the T-mask. No adverse events were observed.

Conclusion

The proposed total inverse planning paradigm using a 3D-printed immobilization device is feasible and renders comparable inter-fraction performance while offering a better patient experience, potentially improving cnsRT workflows and its cost-effectiveness.

Factors and Labor Cost Savings Associated with Successful Pediatric Imaging without Anesthesia: a Single-Institution Study

RATIONALE AND OBJECTIVES

In pediatric imaging, sedation is often necessary to obtain diagnostic quality imaging. We aim to quantify patient and imaging-specific factors associated with successful pediatric scans without anesthesia and to evaluate labor cost savings associated with our institutional Scan Without Anesthesia Program (SWAP).

MATERIALS AND METHODS

Patients who participated in SWAP between 2019-2022 were identified. Chart review was conducted to obtain sociodemographic and clinical information. Radiology database was used to obtain scan duration, modality/body part of examination, and administration of contrast. Mann-Whitney U and Chi-Square tests were used for univariate analysis of factors associated with success. Multivariate logistic regression was used to evaluate independent contributions to success. Associated hospital labor cost savings were estimated using salary information obtained through publicly available resources.

RESULTS

Of 731 patients, 698 had successful and 33 had unsuccessful scans (95% success rate). In univariate analysis, older age, female sex, absence of developmental delay, and administration of contrast were significantly associated with successful scans. Multivariate analyses revealed that older age, female sex, and absence of developmental delay were significant independent factors lending toward success. Imaging-related factors were not associated with outcome in multivariate analysis. Estimated labor cost savings were $139,367.80 per year for the medical center.

CONCLUSION

SWAP had an overall success rate of 95%. Older age, absence of developmental delay, and female sex were independently significantly associated with successful outcome. Cost analysis reveals substantial labor cost savings to the institution compared with imaging under anesthesia.

Implications of Pediatric Artificial Intelligence Challenges for Artificial Intelligence Education and Curriculum Development

Several radiology artificial intelligence (AI) courses are offered by a variety of institutions and educators. The major radiology societies have developed AI curricula focused on basic AI principles and practices. However, a specific AI curriculum focused on pediatric radiology is needed to offer targeted education material on AI model development and performance evaluation. There are inherent differences between pediatric and adult practice patterns, which may hinder the application of adult AI models in pediatric cohorts. Such differences include the different imaging modality utilization, imaging acquisition parameters, lower radiation doses, the rapid growth of children and changes in their body composition, and the presence of unique pathologies and diseases, which differ in prevalence from adults. Thus, to enhance radiologists' knowledge of the applications of AI models in pediatric patients, curricula should be structured keeping in mind the unique pediatric setting and its challenges, along with methods to overcome these challenges, and pediatric-specific data governance and ethical considerations. In this report, the authors highlight the salient aspects of pediatric radiology that are necessary for AI education in the pediatric setting, including the challenges for research investigation and clinical implementation.

Juvenile idiopathic arthritis of the knee: is contrast needed to score disease activity when using an augmented MRI protocol comprising PD-weighted sequences?

Objective

To compare unenhanced versus enhanced knee joint magnetic resonance imaging (MRI) to assess disease activity of juvenile idiopathic arthritis (JIA).

Methods

Fifty-three knee joint MRI examinations were performed on a 3-Tesla system in 27 patients (age: 11.40 ± 3.61 years; 21 females, 6 males). MRI protocols comprised PD-weighted sequences in addition to the widely used standard protocol. JIA subgroups comprised oligoarticular arthritis (n = 16), extended oligoarthritis (n = 6), rheumatoid factor-negative polyarticular arthritis (n = 3), enthesitis-related arthritis (n = 1), and psoriatic arthritis (n = 1). MR images were retrospectively analyzed by 3 experienced radiologists in two readings, using JAMRIS (juvenile arthritis MRI scoring) system and a modified IPSG (international prophylaxis study group) classification. In the first reading session, only unenhanced MR images were evaluated. In a second reading session, all images before and after contrast medium application were included. In order to avoid bias, an interval of at least 2 weeks was set between the two readings. The clinical JADAS10 (juvenile arthritis disease activity score) was calculated including clinical assessment and laboratory workup and correlated with MRI scores. Statistical analysis comprised Pearson’s correlation for correlating two scoring results of unenhanced and the enhanced MRI, intra-class correlation coefficient (ICC) for inter- and intra-reader agreement. Diagnostic accuracy was calculated using ROC (receiver operating characteristics) curve analysis.

Results

Inter-reader agreement determined by ICC for unenhanced and enhanced MRI scores for IPSG was moderate (0.65, 95% CI 0.51–0.76, and 0.62, 95% CI 0.48–0.75) and high for JAMRIS (0.83, 95% CI 0.75–0.89, and 0.82, 95% CI 0.74–0.89). Intra-reader agreement was good to very good for JAMRIS (0.85 95% CI 0.81–0.88, 0.87 95% CI 0.83–0.89 and 0.96 95% CI 0.92–0.98) and IPSG (0.76 95% CI 0.62–0.86, 0.86 95% CI 0.77–0.92 and 0.92 95% CI 0.86–0.96). Scores of unenhanced MRI correlated with contrast-enhanced MRI: JAMRIS (r = 0.97, R2 = 0.93, p < 0.01), modified IPSG (r = 0.95, R2 = 0.91, p < 0.01). When using JADAS10 as a reference standard, moderate accuracy for both unenhanced and enhanced MRI scores was noted: JAMRIS (AUC = 0.68, 95% CI 0.51–0.85, and AUC = 0.66, 95% 0.49–0.82), IPSG score (AUC = 0.68, 95% 0.50–0.86, and AUC = 0.61, 95% 0.41–0.81).

Conclusions

Our results suggest that contrast agent application could be omitted in JIA patients with an augmented knee MRI protocol comprising PD-weighted sequence.

Key Points

• Unenhanced MRI can detect disease activity of the knee joint in patients with JIA with equally high accuracy compared to contrast-enhanced MRI.

• The intra- and inter-reader agreement was high for unenhanced and enhanced MRI JAMRIS scores, which indicate relatively good applicability of the scoring system, even for less experienced readers.

• When using the clinical JADAS10 as a reference standard for the detection of disease activity, moderate accuracy for both unenhanced and enhanced MRI scores, both JAMRIS and IPSG, was noted, which might be caused by the fact that the majority of patients had either no or minimal clinical disease activity.

Utilization of neonatal sedation and anesthesia: an SPR survey

BACKGROUND

There is little data regarding the use of sedation and anesthesia for neonatal imaging, with practice patterns varying widely across institutions.

OBJECTIVE

To understand the current utilization of sedation and anesthesia for neonatal imaging, and review the current literature and recommendations.

MATERIALS AND METHODS

One thousand, two hundred twenty-six questionnaire invitations were emailed to North American physician members of the Society for Pediatric Radiology using the Survey Monkey platform. Descriptive statistical analysis of the responses was performed.

RESULTS

The final results represented 59 institutions from 26 U.S. states, the District of Columbia and three Canadian provinces. Discrepant responses from institutions with multiple respondents (13 out of 59 institutions) were prevalent in multiple categories. Of the 80 total respondents, slightly more than half (56%) were associated with children's hospitals and 44% with the pediatric division of an adult radiology department. Most radiologists (70%) were cognizant of the neonatal sedation policies in their departments. A majority (89%) acknowledged awareness of neurotoxicity concerns in the literature and agreed with the validity of these concerns. In neonates undergoing magnetic resonance imaging (MRI), 46% of respondents reported attempting feed and bundle in all patients and an additional 46% attempt on a case-by-case basis, with most (35%) using a single swaddling attempt before sedation. Sedation was most often used for neonatal interventional procedures (93%) followed by MR (85%), nuclear medicine (48%) and computed tomography (31%). More than half of respondents (63%) reported an average success rate of greater than 50% when using neonatal sedation for MR.

CONCLUSION

Current practice patterns, policies and understanding of the use of sedation and anesthesia for neonatal imaging vary widely across institutions in North America, and even among radiologists from the same institution. Our survey highlights the need for improved awareness, education, and standardization at both the institutional level and the societal level. Awareness of the potential for anesthetic neurotoxicity and success of non-pharmacologic approaches to neonatal imaging is crucial, along with education of health care personnel, systematic approaches to quality control and improvement, and integration of evidence-based protocols into clinical practice.

Inpatient Care Team Views on Child Life Services: A Scoping Review

CONTEXT

The utilization of Child Life Services is influenced by interprofessional collaboration and perceptions of other members of the medical team.

OBJECTIVES

To summarize studies which address pediatric health care team perspectives on Child Life Services and their utilization in the hospital setting.

DATA SOURCES

A comprehensive literature search was conducted with controlled vocabularies and key terms in MEDLINE, Embase, CINAHL, PsycInfo, and Web of Science.

STUDY SELECTION

Primary studies published before November 2021 were screened using a predetermined set of inclusion and exclusion criteria.

DATA CHARTING

Data charting was performed by 2 independent reviewers. Data extracted include baseline study characteristics, common themes, main outcomes, strengths, and limitations. Because this is not a systematic review, data from included studies was not quantitatively analyzed, but carefully summarized in the manner of a standard scoping review.

RESULTS

Nine studies met criteria for inclusion. Common qualitative themes on certified child life specialists include: (1) their broad responsibilities, (2) their positive impact on patients and families, (3) challenges with interprofessional collaboration and integration, and (4) the value of educating others on their roles and responsibilities.

CONCLUSIONS

Medical subject headings, controlled vocabulary, or other standardized subject headings that index literature on Child Life Services is limited. However, the existing body of literature supports the positive impact certified child life specialists have on patients and families, despite challenges with complete integration into the interdisciplinary care team. Additional research is required to fully understand and overcome these challenges in continued efforts to further drive patient and family-centered care.

Pediatric magnetic resonance imaging: faster is better

Magnetic resonance imaging (MRI) has emerged as the preferred imaging modality for evaluating a wide range of pediatric medical conditions. Nevertheless, the long acquisition times associated with this technique can limit its widespread use in young children, resulting in motion-degraded or non-diagnostic studies. As a result, sedation or general anesthesia is often necessary to obtain diagnostic images, which has implications for the safety profile of MRI, the cost of the exam and the radiology department's clinical workflow. Over the last decade, several techniques have been developed to increase the speed of MRI, including parallel imaging, single-shot acquisition, controlled aliasing techniques, compressed sensing and artificial-intelligence-based reconstructions. These are advantageous because shorter examinations decrease the need for sedation and the severity of motion artifacts, increase scanner throughput, and improve system efficiency. In this review we discuss a framework for image acceleration in children that includes the synergistic use of state-of-the-art MRI hardware and optimized pulse sequences. The discussion is framed within the context of pediatric radiology and incorporates the authors' experience in deploying these techniques in routine clinical practice.

Children and neonates anesthesia in magnetic resonance environment in Italy: an active call survey

Background

Pediatric anesthesia care in the Magnetic Resonance Imaging is a challenge for clinicians. The recent debate about the role of anesthetic agent on neural development, encouraged an evaluation of their actual activity in this environment. In this active call survey, the authors sought to delineate the Italian situation regarding national centers, staff involved, monitoring tools available and sedation techniques.

Methods

A complete sample of all national centers performing almost a pediatric discharge in the 2014 was obtained from Health Ministry registers. All Institutions were contacted for a prospective phone investigation and a three-section survey was fill out with the Physician in charge. A descriptive and exploratory analyzes about the organization setting of the Centers were performed.

Results

Among 876 Institution screened, only 106 (37%) met minimal criteria for inclusion. Children are managed by anesthesiologists in the 95% of cases, while neonates in the 54%. A dedicated nurse is present in 74% of centers. While a pulse oximetry is present in 100% of centers, the rate of prevalence of other monitoring is lower. A specific MRI-compatible ventilator is available in the 95% of Centers, but many tools are not equally homogenously distributed. Pharmacological approach is preferred in pediatric age (98%), but its use for newborns is reduced to 43%.

Conclusions

We found significant heterogeneity in the daily clinical practice of sedation in MRI. Our results could be a starting point to evaluate the further evolution of approach to children and neonates in magnetic resonance setting.

Trial registration

ClinicalTrials.gov identifier: NCT04775641.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01821-3.

Free-breathing magnetic resonance imaging with radial k-space sampling for neonates and infants to reduce anesthesia

BACKGROUND

Conventional chest and abdominal MRI require breath-holds to reduce motion artifacts. Neonates and infants require general anesthesia with intubation to enable breath-held acquisitions.

OBJECTIVE

We aimed to validate a free-breathing approach to reduce general anesthesia using a motion-insensitive radial acquisition with respiratory gating.

MATERIALS AND METHODS

We retrospectively enrolled children <3 years old who were referred for MRI of the chest or abdomen. They were divided into two groups according to MRI protocol: (1) breath-held scans under general anesthesia with T2-weighted single-shot fast spin-echo (SSFSE) and contrast-enhanced T1-weighted modified Dixon, and (2) free-breathing scans using radial sequences (T2-W MultiVane XD and contrast-enhanced T1-W three-dimensional [3-D] Vane XD). Two readers graded image quality and motion artifacts.

RESULTS

We included 23 studies in the free-breathing cohort and 22 in the breath-hold cohort. The overall imaging scores for the free-breathing radial T2-W sequence were similar to the scores for the breath-held T2-W SSFSE sequence (chest, 3.6 vs. 3.2, P=0.07; abdomen, 3.9 vs. 3.7, P=0.66). The free-breathing 3-D radial T1-W sequence also had image quality scores that were similar to the breath-held T1-W sequence (chest, 4.0 vs. 3.0, P=0.06; abdomen, 3.7 vs. 3.9, P=0.15). Increased motion was seen in the abdomen on the radial T2-W sequence (P<0.001), but increased motion was not different in the chest (P=0.73) or in contrast-enhanced T1-W sequences (chest, P=0.39; abdomen, P=0.15). The mean total sequence time was longer in free-breathing compared to breath-held exams (P<0.01); however, this did not translate to longer overall exam times (P=0.94).

CONCLUSION

Motion-insensitive radial sequences used for infants and neonates were of similar image quality to breath-held sequences and had decreased sedation and intubation.

Let's Play the fMRI-Advantages of Gamified Paradigm in Examining the Motor Cortex of Young Children

Background: Performing functional magnetic resonance imaging (fMRI) examination is difficult when a child needs to stay awake and cooperate. Many techniques help to prepare them for the study but without modification of the examination protocol. The objective of this research was to prepare a gamified motor paradigm (“computer game”) that will improve the fMRI examination of young children. Methods: After preparing a dedicated application the fMRI examination was performed on 60 healthy children (10 girls and 10 boys in each age group of 4, 5, and 6 years old). Each child performed the gamified and a standard motor paradigm, both based on squeezing a rubber bulb. The effectiveness of squeezing were compared. Results: With the application of the gamified paradigm children completed significantly more active blocks (3.3 ± 1.4) than for the standard paradigm (2.2 ± 1.6) (p < 0.0001). In mixed-effects Poisson regression, age (IRR = 1.9; 95%CI: 1.5−2.5) and application of gamified paradigm (IRR = 5.6; 95%CI: 1.1−28.0) were significantly associated with more completed blocks. Conclusions: The gamified motor paradigm performed better than a standard paradigm in the fMRI examination of children between 4 and 6 years old. It allowed a significant increase in the number of completed active blocks and also better squeezing effectiveness in each block.

Evaluation of highly accelerated wave controlled aliasing in parallel imaging (Wave-CAIPI) susceptibility-weighted imaging in the non-sedated pediatric setting: a pilot study

BACKGROUND

Susceptibility-weighted imaging (SWI) is highly sensitive for intracranial hemorrhagic and mineralized lesions but is associated with long scan times. Wave controlled aliasing in parallel imaging (Wave-CAIPI) enables greater acceleration factors and might facilitate broader application of SWI, especially in motion-prone populations.

OBJECTIVE

To compare highly accelerated Wave-CAIPI SWI to standard SWI in the non-sedated pediatric outpatient setting, with respect to the following variables: estimated scan time, image noise, artifacts, visualization of normal anatomy and visualization of pathology.

MATERIALS AND METHODS

Twenty-eight children (11 girls, 17 boys; mean age ± standard deviation [SD] = 128.3±62 months) underwent 3-tesla (T) brain MRI, including standard three-dimensional (3-D) SWI sequence followed by a highly accelerated Wave-CAIPI SWI sequence for each subject. We rated all studies using a predefined 5-point scale and used the Wilcoxon signed rank test to assess the difference for each variable between sequences.

RESULTS

Wave-CAIPI SWI provided a 78% and 67% reduction in estimated scan time using the 32- and 20-channel coils, respectively, corresponding to estimated scan time reductions of 3.5 min and 3 min, respectively. All 28 children were imaged without anesthesia. Inter-reader agreement ranged from fair to substantial (k=0.67 for evaluation of pathology, 0.55 for anatomical contrast, 0.3 for central noise, and 0.71 for artifacts). Image noise was rated higher in the central brain with wave SWI (P<0.01), but not in the peripheral brain. There was no significant difference in the visualization of normal anatomical structures and visualization of pathology between the standard and wave SWI sequences (P=0.77 and P=0.79, respectively).

CONCLUSION

Highly accelerated Wave-CAIPI SWI of the brain can provide similar image quality to standard SWI, with estimated scan time reduction of 3-3.5 min depending on the radiofrequency coil used, with fewer motion artifacts, at a cost of mild but perceptibly increased noise in the central brain.

ACR Appropriateness Criteria® Crohn Disease-Child

Crohn disease is an inflammatory condition of the gastrointestinal tract with episodes of exacerbation and remission occurring in children, adolescents, and adults. Crohn disease diagnosis and treatment depend upon a combination of clinical, laboratory, endoscopic, histological, and imaging findings. Appropriate use of imaging provides critical information in the settings of diagnosis, assessment of acute symptoms, disease surveillance, and therapy monitoring. Four variants are discussed. The first variant discusses the initial imaging for suspected Crohn disease before established diagnosis. The second variant pertains to appropriateness of imaging modalities during suspected acute exacerbation. The third variant is a substantial discussion of recommendations related to disease surveillance and monitoring of Crohn disease. Finally, panel recommendations and discussion of perianal fistulizing disease imaging completes the document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Strategies to optimize a pediatric magnetic resonance imaging service

A pediatric MRI service is a vital component of a successful radiology department. Building an efficient and effective pediatric MRI service is a multifaceted process that requires detailed planning for considerations related to finance, operations, quality and safety, and process improvement. These are compounded by the unique challenges of caring for pediatric patients, particularly in the setting of the recent coronavirus disease 2019 (COVID-19) pandemic. In addition to material resources, a successful pediatric MRI service depends on a collaborative team consisting of radiologists, physicists, technologists, nurses and vendor specialists, among others, to identify and resolve challenges and to strive for continued improvement. This article provides an overview of the factors involved in both starting and optimizing a pediatric MRI service, including commonly encountered obstacles and some proposed solutions to address them.

Strategies to perform magnetic resonance imaging in infants and young children without sedation

Given the increasing use of MRI in the pediatric population, the need for sedation in MRI performed in young children is a topic of growing importance. Although sedation is generally tolerated well by children, the financial and operational impacts of anesthesia on MRI workflow, as well as potential adverse effects of anesthetic medications, highlight the need to perform MRI in children without sedation whenever possible. This review focuses on current techniques to facilitate non-sedation MRI in children, including exam preparation with MRI simulation; asleep but not sedated techniques; awake and relaxed techniques using certified child life specialists, animal-assisted therapy, a child-friendly environment and in-scan entertainment; and non-sedated MRI protocol modifications such as shorter scan time, prioritizing sequences, reducing motion artifact, noise reduction, limiting use of gadolinium, employing an open MRI and modifying protocols.

Radial sequences and compressed sensing in pediatric body magnetic resonance imaging

Magnetic resonance imaging (MRI) is often an ideal imaging modality for children of any age for any anatomy and for many pathologies. MRI sequences can be prescribed to produce high-resolution images of anatomical structures, characterize tissue composition, and detect physiological states and organ function. Shortening imaging sequences in any manner possible has been a topic of research and development in MRI since its emergence. Selection of imaging sequence parameters influences more than just the appearance and signal qualities of the imaged tissues; these details along with spatial encoding and data readout steps determine the time it takes to acquire an image. As each piece of image data is acquired and encoded with spatial and temporal information it is stored in k-space. As k-space is filled, either completely or partially, a diagnostic image or physiological data can be reconstructed. Shortening the length of time required for the readout step by efficiently filling k-space using compressed sensing and radial techniques is the subject of this manuscript.

Three-dimensional printing in paediatric orthopaedic surgery

Three-dimensional (3D) printing is a rapidly evolving and promising field to improve outcomes of orthopaedic surgery. The use of patient-specific 3D-printed models is specifically interesting in paediatric orthopaedic surgery, as limb deformity corrections often require an individual 3D treatment. In this editorial, various operative applications of 3D printing in paediatric orthopaedic surgery are discussed. The technical aspects and the imaging acquisition with computed tomography and magnetic resonance imaging are outlined. Next, there is a focus on the intraoperative applications of 3D printing during paediatric orthopaedic surgical procedures. An overview of various upper and lower limb deformities in paediatrics is given, in which 3D printing is already implemented, including post-traumatic forearm corrections and proximal femoral osteotomies. The use of patient-specific instrumentation (PSI) or guiding templates during the surgical procedure shows to be promising in reducing operation time, intraoperative haemorrhage and radiation exposure. Moreover, 3D-printed models for the use of PSI or patient-specific navigation templates are promising in improving the accuracy of complex limb deformity surgery in children. Lastly, the future of 3D printing in paediatric orthopaedics extends beyond the intraoperative applications; various other medical applications include 3D casting and prosthetic limb replacement. In conclusion, 3D printing opportunities are numerous, and the fast developments are exciting, but more evidence is required to prove its superiority over conventional paediatric orthopaedic surgery.

Should I irradiate with computed tomography or sedate for magnetic resonance imaging?

In the context of pediatric cross-sectional imaging, the risk of ionizing radiation for CT and the potential adverse effects associated with sedation/anesthesia for MRI continue to provoke lively discussions in the pediatric literature and lay press. This is particularly true for issues relating to the risks of ionizing radiation for CT, which has been a topic of discussion for nearly two decades. In addition to understanding these potential risks and the importance of minimizing individual pediatric patient exposure to ionizing radiation, it is equally important for radiologists to be able to frame these risks with respect to the potential for adverse outcomes associated with the use of anesthesia for cross-sectional imaging in the pediatric population. Notably, before such risks can be estimated and compared, one should always consider the potential utility of each imaging modality for a given diagnosis. If one cross-sectional imaging modality is likely to be far superior to the other for a specific clinical question, every effort must be made to safely image the child, even if sedation/anesthesia is required.

Free-breathing radial magnetic resonance elastography of the liver in children at 3 T: a pilot study

BACKGROUND

Magnetic resonance (MR) elastography of the liver measures hepatic stiffness, which correlates with the histopathological staging of liver fibrosis. Conventional Cartesian gradient-echo (GRE) MR elastography requires breath-holding, which is challenging for children. Non-Cartesian radial free-breathing MR elastography is a potential solution to this problem.

OBJECTIVE

To investigate radial free-breathing MR elastography for measuring hepatic stiffness in children.

MATERIALS AND METHODS

In this prospective pilot study, 14 healthy children and 9 children with liver disease were scanned at 3 T using 2-D Cartesian GRE breath-hold MR elastography (22 s/slice) and 2-D radial GRE free-breathing MR elastography (163 s/slice). Each sequence was acquired twice. Agreement in the stiffness measurements was evaluated using Lin's concordance correlation coefficient (CCC) and within-subject mean difference. The repeatability was assessed using the within-subject coefficient of variation and intraclass correlation coefficient (ICC).

RESULTS

Fourteen healthy children and seven children with liver disease completed the study. Median (±interquartile range) normalized measurable liver areas were 62.6% (±26.4%) and 44.1% (±39.6%) for scan 1, and 60.3% (±21.8%) and 43.9% (±44.2%) for scan 2, for Cartesian and radial techniques, respectively. Hepatic stiffness from the Cartesian and radial techniques had close agreement with CCC of 0.89 and 0.94, and mean difference of 0.03 kPa and -0.01 kPa, for scans 1 and 2. Cartesian and radial techniques achieved similar repeatability with within-subject coefficient of variation=1.9% and 3.4%, and ICC=0.93 and 0.92, respectively.

CONCLUSION

In this pilot study, radial free-breathing MR elastography was repeatable and in agreement with Cartesian breath-hold MR elastography in children.

Comparison of ultrafast wave-controlled aliasing in parallel imaging (CAIPI) magnetization-prepared rapid acquisition gradient echo (MP-RAGE) and standard MP-RAGE in non-sedated children: initial clinical experience

BACKGROUND

Fast magnetic resonance imaging (MRI) sequences are advantageous in pediatric imaging as they can lessen child discomfort, decrease motion artifact and improve scanner availability.

OBJECTIVE

To evaluate the feasibility of an ultrafast wave-CAIPI (controlled aliasing in parallel imaging) MP-RAGE (magnetization-prepared rapid gradient echo) sequence for brain imaging of awake pediatric patients.

MATERIALS AND METHODS

Each MRI included a standard MP-RAGE sequence and an ultrafast wave-MP-RAGE sequence. Two neuroradiologists evaluated both sequences in terms of artifacts, noise, anatomical contrast and pathological contrast. A predefined 5-point scale was used by two independent pediatric neuroradiologists. A Wilcoxon signed-rank test was used to evaluate the difference between sequences for each variable.

RESULTS

Twenty-four patients (14 males; mean age: 11.5±4.5 years, range: 1 month to 17.8 years) were included. Wave-CAIPI MP-RAGE provided a 77% reduction in scan time using a 32-channel coil and a 70% reduction using a 20-channel coil. Visualization of the pathology, artifacts and pathological enhancement (including parenchymal, leptomeningeal and dural enhancement) was not significantly different between standard MP-RAGE and wave-CAIPI MP-RAGE (all P>0.05). For central (P<0.001) and peripheral (P<0.001) noise, and the evaluation of the anatomical structures (P<0.001), the observers favored standard MP-RAGE over wave-CAIPI MP-RAGE.

CONCLUSION

Ultrafast brain imaging with wave-CAIPI MP-RAGE is feasible in awake pediatric patients, providing a substantial reduction in scan time at a cost of subjectively increased image noise.

Surgical Procedures Based on the Arthrographic Findings of the Fifth MTP Joint With Proximal Phalanx Duplication in Postaxial Polydactyly of the Foot

Radiographic findings in several atypical cases of postaxial polydactyly of the foot do not provide sufficient information to assess the cartilaginous structures or duplicated digit connections at the MTP joint. The purpose of this study was to demonstrate the surgical procedures using arthrography for the cartilaginous structures of the MTP joint in postaxial polydactyly of the foot. We performed arthrography in 7 feet of 7 patients with postaxial polydactyly of the foot in which duplication of the proximal phalanx was observed at the fifth MTP joint on the basis of radiographic evaluation. The average age at surgery was 13.5 months and average duration of postsurgical follow-up was 36 months. Individual surgical procedures were confirmed or modified during the operation by reference to the arthrographic findings. Radiographic and arthrographic findings were assessed in relation to the findings from direct observation of the cartilaginous structures at surgery. Postoperative malalignment, functional disturbance and pain in the reconstructed toe were evaluated. The arthrographic findings provided different forms of cartilaginous structures that could be categorized in 4 types, and reflected the cartilaginous connection visualized at surgery that could not be detected on radiographs in each case. No cases revealed any deformities, functional disturbance, or pain in the reconstructed toe after surgery. The parents' evaluation in each case was "very satisfied" or "satisfied." The arthrographic findings provided additional information regarding variations in the cartilaginous structures of the fifth MTP joint and for determining individual surgical procedure for postaxial polydactyly of the foot.

Imaging sedation and anesthesia practice patterns in pediatric radiology departments - a survey of the Society of Chiefs of Radiology at Children's Hospitals (SCORCH)

BACKGROUND

There are few data describing practice patterns related to the use of sedation/anesthesia for diagnostic imaging in pediatric radiology departments.

OBJECTIVE

To understand current practice patterns related to imaging with sedation/anesthesia in pediatric radiology departments based on a survey of the Society of Chiefs of Radiology at Children's Hospitals (SCORCH) in conjunction with the American College of Radiology's Pediatric Imaging Sedation and Anesthesia Committee.

MATERIALS AND METHODS

A multi-question survey related to imaging with sedation/anesthesia in pediatric radiology departments was distributed to SCORCH member institutions in January 2019. A single reminder email was sent. Descriptive statistical analyses were performed.

RESULTS

Of the 84 pediatric radiology departments, 23 (27%) completed the survey. Fifty-seven percent of the respondents self-identified as academic/university-affiliated and 13% as a division/section in an adult radiology department. Imaging sedation (excluding general anesthesia) is commonly performed by pediatric anesthesiologists (76%) and intensive care unit physicians (intensivists, 48%); only 14% of departments expect their pediatric radiologists to supervise imaging sedation. Ninety-six percent of departments use child life specialists for patient preparation. Seventy percent of departments have preparatory resources available on a website, including simulation videos (26%) and audio clips (17%). Nearly half (48%) of the departments have a mock scanner to aid in patient preparation. Imaging sedation/anesthesia is most often scheduled at the request of ordering clinicians (65%), while 57% of departments allow schedulers to place patients into imaging sedation/anesthesia slots based on specified criteria.

CONCLUSION

Imaging sedation/anesthesia practice patterns vary among pediatric radiology departments, and understanding current approaches can help with standardization and practice improvement.

Success of Nonsedated Neuroradiologic MRI in Children 1-7 Years Old

BACKGROUND. MRI use and the need for monitored anesthesia care (MAC) in children have increased. However, MAC is associated with examination delays, increased cost, and safety concerns. OBJECTIVE. The purpose of this study was to evaluate the success rate of nonsedated neuroradiologic MRI studies in children 1-7 years old and to investigate factors associated with success. METHODS. We retrospectively reviewed data from our institutional nonsedated MRI program. Inclusion criteria were outpatient nonsedated MRI referral, age 1-7 years old, and neuroradiologic indication. Exclusion criteria were MRI examinations for ventricular checks and contrast material use. Success was determined by reviewing the clinical MRI report. We recorded patient age and sex, type of MRI examination (brain, spine, craniospinal, head and neck, and brain with MRA), protocol length, presence of child life specialist, video goggle use, and MRI appointment time (routine daytime appointment or evening appointment). We used descriptive statistics to summarize patient demographics and clinical data and logistic regression models to evaluate predictors of success in the entire sample. Subset analyses were performed for children from 1 to < 3 years old and 3 to 7 years old. RESULTS. We analyzed 217 patients who underwent nonsedated MRI examinations (median age, 5.1 years). Overall success rate was 82.0% (n = 178). The success rates were 81.4% (n = 127) for brain, 90.3% (n = 28) for spine, 71.4% (n = 10) for craniospinal, 66.7% (n = 6) for head and neck, and 100% (n = 7) for brain with MRA. Age was significantly associated with success (odds ratio [OR], 1.33; p = .009). In children 1 to < 3 years old, none of the factors analyzed were significant predictors of success (all, p > .48). In children 3-7 years old, protocol duration (OR, 0.96; 95% CI, 0.93-0.99; p = .02) and video goggle use (OR, 6.38; 95% CI, 2.16-18.84; p = .001) were significantly associated with success. CONCLUSION. A multidisciplinary approach with age-appropriate resources enables a high success rate for nonsedated neuroradiologic MRI in children 1-7 years old. CLINICAL IMPACT. Using age as the primary criterion to determine the need for MAC may lead to overuse of these services. Dissemination of information regarding nonsedated MRI practice could reduce the rate of sedated MRI in young children.

Magnetic resonance imaging quality control, quality assurance and quality improvement

Quality in MR imaging is a comprehensive process that encompasses scanner performance, clinical processes for efficient scanning and reporting, as well as data-driven improvement involving measurement of key performance indicators. In this paper, the authors review this entire process. This article provides a framework for establishing a successful MR quality program. The collective experiences of the authors across a spectrum of pediatric hospitals is summarized here.

Magnetic resonance imaging in children with implants

As access to MRI in pediatrics increases, the radiologist needs to become acquainted with the basic principles of MRI safety. As part of the image acquisition, the static magnetic field, gradient system, and the radiofrequency transmit-receive coil interact with medical and non-medical implants and can result in serious injury. The main stage of risk triage is based on the determination of whether the implant is MRI-safe, conditional, unsafe or unknown. Guiding principles include the strict adherence to manufacturer specifications for MRI-conditional implants and the assumption that an unknown implant is MR-unsafe. In this article we review considerations for common medical implants encountered in pediatrics including ventriculoperitoneal shunts, orthopedic hardware, orthodontic hardware, pacemakers, vascular stents, vagal nerve stimulators and cochlear implants. Finally, we review a set of high-yield considerations, including the non-communicative patient (sedated or non-verbal), susceptibility artifacts from unclear source, and the approach to an unknown implant.

Simultaneous assessment of colon motility in children with functional constipation by cine-MRI and colonic manometry: a feasibility study

BACKGROUND

Colonic manometry is the current reference standard for assessing colonic neuromuscular function in children with intractable functional constipation (FC). Recently, cine magnetic resonance imaging (cine-MRI) has been proposed as a non-invasive alternative. We compared colonic motility patterns on cine-MRI with those obtained by manometry in children, by stimulating high-amplitude propagating contractions (HAPCs) with bisacodyl under manometric control while simultaneously acquiring cine-MRI.

METHODS

After Institutional Review Board approval, adolescents with FC scheduled to undergo colonic manometry were included. A water-perfused 8-lumen catheter was used for colonic manometry recordings. After an intraluminal bisacodyl infusion, cine-MRI sequences of the descending colon were acquired for about 30 min simultaneously with colonic manometry. Manometry recordings were analysed for HAPCs. MRI images were processed with spatiotemporal motility MRI techniques. The anonymised motility results of both techniques were visually compared for the identification of HAPCs in the descending colon.

RESULTS

Data regarding six patients (three males) were analysed (median age 14 years, range 12-17). After bisacodyl infusion, three patients showed a total of eleven HAPCs with colonic manometry. Corresponding cine-MRI recorded high colonic activity during two of these HAPCs, minimal activity during seven HAPCs, while two HAPCs were not recorded. In two of three patients with absent HAPCs on manometry, colonic activity was recorded with cine-MRI.

CONCLUSIONS

Simultaneous acquisition of colonic cine-MRI and manometry in children with FC is feasible. Their motility results did not completely overlap in the identification of HAPCs. Research is needed to unravel the role of cine-MRI in this setting.

Predictors of Anesthetic Exposure in Pediatric MRI

BACKGROUND. Anesthetic exposure in children may impact long-term neurocognitive outcomes. Therefore, minimizing pediatric MRI scan time in children under anesthesia and the associated anesthetic exposure is necessary. OBJECTIVE. The purpose of this study was to evaluate pediatric MRI scan time as a predictor of total propofol dose, considering imaging and clinical characteristics as covariates. METHODS. Electronic health records were retrospectively searched to identify MRI examinations performed from 2016 to 2019 in patients 0-18 years old who received propofol anesthetic. Brain; brain and spine; brain and abdomen; and brain, head, and neck MRI examinations were included. Demographic, clinical, and imaging data were extracted for each examination, including anesthesia maintenance phase time, MRI scan time, and normalized propofol dose. MRI scan time and propofol dose were compared between groups using a t test. A multiple linear regression with backward selection (threshold, p < .05) was used to evaluate MRI scan time as a predictor of total propofol dose, adjusting for sex, age, time between scan and study end, body part, American Society of Anesthesiologists (ASA) classification, diagnosis, magnet strength, and IV contrast medium administration as covariates. RESULTS. A total of 501 examinations performed in 426 patients (172 girls, 254 boys; mean age, 6.55 ± 4.59 [SD] years) were included. Single body part examinations were shorter than multiple body part examinations (mean, 52.7 ± 18.4 vs 89.3 ± 26.4 minutes) and required less propofol (mean, 17.7 ± 5.7 vs 26.1 ± 7.7 mg/kg; all p < .001). Among single body part examinations, a higher ASA classification, oncologic diagnosis, 1.5-T magnet, and IV contrast medium administration were associated with longer MRI scan times (all p ≤ .009) and higher propofol exposure (all p ≤ .005). In multivariable analysis, greater propofol exposure was predicted by MRI scan time (mean dose per minute of examination, 0.178 mg/kg; 95% CI, 0.155-0.200; p < .001), multiple body part examination (p = .04), and IV contrast medium administration (p = .048); lower exposure was predicted by 3-T magnet (p = .04). CONCLUSION. Anesthetic exposure during pediatric MRI can be quantified and predicted based on imaging and clinical variables. CLINICAL IMPACT. This study serves as a valuable baseline for future efforts to reduce anesthetic doses and scan times in pediatric MRI.

How are Certified Child Life Specialists perceived by healthcare professionals?: A call for interprofessional collaboration

Certified child life specialists (CCLS) depend on collaboration with healthcare professionals for awareness of patient needs; however, historically other healthcare professionals misunderstand the CCLS role. The purpose of this study was to examine how healthcare professionals perceived the CCLS role and provide implications on the contribution of the CCLS to interprofessional collaboration (IPC). This study was a partial replication of two previous survey studies. Participants (N = 67) consisted of 26 child life and 42 other healthcare professionals who were employed at one freestanding children's hospital in the southern United States. Qualitative analyses revealed CCLS responsibilities could be explained with seven categories. Child life professionals were more likely to report CCLS responsibilities as providing patient support and family support and documenting psychosocial assessment and interventions in the medical record than other healthcare professionals. Child life and other healthcare professionals are mostly aligned in their perception of the CCLS role, specifically patient education, play, and normalization and development. Previous misconceptions about the CCLS role may be diminishing among other healthcare professionals; however, continued education about the CCLS role and communication with CCLSs would likely promote IPC.

Establishing a magnetic resonance safety program

Establishing a magnetic resonance (MR) safety program is crucial to ensuring the safe MR imaging of pediatric patients. The organizational structure includes a core safety council and broader safety committee comprising all key stakeholders. These groups work in synchrony to establish a strong culture of safety; create and maintain policies and procedures; implement device regulations for entry into the MR setting; construct MR safety zones; address intraoperative MR concerns; guarantee safe scanning parameters, including complying with specific absorption rate limitations; adhere to national regulatory body guidelines; and ensure appropriate communication among all parties in the MR environment. Perspectives on the duties of the safety council members provide important insight into the organization of program oversite. Ultimately, the collective dedication and vigilance of all MR staff are crucial to the success of a safety program.

Motion-corrected cardiac MRI is associated with decreased anesthesia exposure in children

BACKGROUND

The benefits of cardiac magnetic resonance imaging (MRI) in the pediatric population must be balanced with the risk and cost of anesthesia. Segmented imaging using multiple averages attempts to avoid breath-holds requiring general anesthesia; however, cardiorespiratory artifacts and prolonged scan times limit its use. Thus, breath-held imaging with general anesthesia is used in many pediatric centers. The advent of free-breathing, motion-corrected (MOCO) cines by real-time re-binned reconstruction offers reduced anesthesia exposure without compromising image quality.

OBJECTIVE

This study evaluates sedation utilization in our pediatric cardiac MR practice before and after clinical introduction of free-breathing MOCO imaging for cine and late gadolinium enhancement.

MATERIALS AND METHODS

In a retrospective study, patients referred for a clinical cardiac MR who would typically be offered sedation for their scan (n=295) were identified and divided into two eras, those scanned before the introduction of MOCO cine and late gadolinium enhancement sequences and those scanned following their introduction. Anesthesia use was compared across eras and disease-specific cohorts.

RESULTS

The incidence of non-sedation studies performed in children nearly tripled following the introduction of MOCO imaging (25% [pre-MOCO] to 69% [post-MOCO], P<0.01), with the greatest effect in patients with simple congenital heart disease. Eleven percent of the post-MOCO cohort comprised infants younger than 3 months of age who could forgo sedation with the combination of MOCO imaging and a "feed-and-bundle" positioning technique.

CONCLUSION

Implementation of cardiac MR with MOCO cine and late gadolinium enhancement imaging in a pediatric population is associated with significantly decreased sedation utilization.

The role of child life in pediatric radiology

Pediatric radiology departments rely heavily on a dedicated, efficient and collaborative multi-disciplinary health care team to provide efficient service and quality care to patients and families. Certified child life specialists are an essential part of this multi-disciplinary team. The main goal of the child life specialists is to improve the overall experience for patients and families. In addition, child life specialists, working in collaboration with the medical care team, help decrease the need for general anesthesia by providing patient pain management, distraction and coping techniques. These interventions result in improved patient safety, increased departmental efficiency and increased revenue. The role of child life specialists extends into the exam room, where their interventions help decrease procedure times and improve imaging quality. In this article, the authors discuss the key role of child life specialists in a pediatric radiology department and provide examples of how child life can impact patient safety, patient and family satisfaction, and operational efficiency.