Abstracts of the 37th Postgraduate Course and 51st Annual Meeting of the European Society of Paediatric Radiology, June 2-6, 2014, Amsterdam, The Netherlands.

Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 DOI 10.1007/s00247-014-2968-2

ABSTRACTS

Founded in 1963 The European Society of Paediatric Radiology 37th Postgraduate Course and 51st Annual Meeting of the European Society of Paediatric Radiology June 2–6 2014 NH Grand Hotel Krasnapolsky Amsterdam, The Netherlands

Table of contents Welcome address ...................................................................................................................................................................... S257 Congress Organization ............................................................................................................................................................. S258 ESPR General information ....................................................................................................................................................... Officers of the Board ..................................................................................................................................................... Honorary members ........................................................................................................................................................ Gold Medalist ................................................................................................................................................................ Jacques Lefèbvre awards ............................................................................................................................................... Poster awards ................................................................................................................................................................. Young Researcher awards ............................................................................................................................................. President’s awards ......................................................................................................................................................... Past Presidents and meeting sites .................................................................................................................................. Future ESPR, SPR & IPR meetings ............................................................................................................................. European Courses of Paediatric Radiology (ECPR) .................................................................................................... Future ECPR meeting .................................................................................................................................................... European Courses of Paediatric Neuroradiology (ECPNR) ......................................................................................... ESPR Gold Medal Award 2014 .................................................................................................................................... ESPR Honorary Members 2014 ................................................................................................................................... ESPR Jacques Lefèbvre lecturer 2014 ..........................................................................................................................

S260 S260 S260 S261 S261 S261 S262 S262 S263 S263 S263 S263 S263 S264 S265 S266

ESPR 2014, Program at a glance ............................................................................................................................................. S267 ESPR 2014, Floorplan - Meeting area ..................................................................................................................................... S269 Acknowledgements .................................................................................................................................................................. S271 Continuing Medical Education ................................................................................................................................................ S272

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Pediatr Radiol (2014) 44 (Suppl 2):S255–S402

ESPR 2014, 37th Postgraduate course Program ........................................................................................................................................................................ S273 Abstracts ....................................................................................................................................................................... S274 ESPR 2014, 51st Annual meeting Program ........................................................................................................................................................................ Plenary and keynote lectures - abstracts ...................................................................................................................... Oral presentations – abstracts, ordered by session ...................................................................................................... Poster presentations - list, ordered by category ........................................................................................................... Poster presentations - abstracts ....................................................................................................................................

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ESPR 2014, 1st Radiographers symposium Program ........................................................................................................................................................................ S388 Abstracts ....................................................................................................................................................................... S389 Author index for abstracts ........................................................................................................................................................ S395


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Welcome address

Dear colleagues, Dear friends, It is a great pleasure and honor for me to welcome you at the 37th Postgraduate course and 51st Annual scientific meeting of the European Society of Paediatric Radiology (ESPR 2014) in Amsterdam, The Netherlands. The theme of ESPR 2014 is “Back to the future”. With this the local organizing committee wants to emphasize that they recognize the numerous technical innovations that paediatric radiology will benefit from in the near future, without ignoring the roots and basic techniques that are still very valuable for imaging children worldwide. The 37th Postgraduate course on June 2–3, 2014 will include up-to-date lectures on basic to advanced imaging topics in children, given by a world-wide faculty of experts in the field of paediatric radiology. In order to increase the interactivity of the attendees with the faculty, several case-based interactive lectures using an electronic voting system will be given throughout the course. During the 51st Annual meeting, from June 4 to 6, 2014, there will be a special focus on “infectious diseases of the world”, as this diagnosis is an increasing worldwide radiological challenge. This topic lends itself for a global interactive communication where first world paediatric radiologists can learn from the experiences of third world paediatric radiologists and vice-versa. The scientific program will include state-of-the-art plenary and keynote lectures, as well as several (interactive) special focus, taskforce, educational and research sessions. Highlights of this years Annual meeting include the opening lecture by Professor Gabriel Krestin (past-president, ESR) on “Leadership in (paediatric) radiology: the way forward in a changing radiological world”, and the Jacques Lefèbvre lecture by Dr. Robert van Langh (head conservation & restoration, Rijksmuseum, Amsterdam) on “The use of radiographic techniques in the study of art objects”. Furthermore, there will be a special focus on “Molecular/Nuclear medicine” and “Image guided oncological interventions”, as these emerging fields will change our paediatric radiology practice considerably in the near future. The importance of a global perspective on child health is highlighted during a special plenary session entitled “Outreach in paediatric radiology” on Wednesday June 4, and the annual executive committee meeting of the World Federation of Pediatric Imaging (WFPI) on Thursday June 5. Of course, selected oral presentations and electronic poster sessions from submitted abstracts will form an important part of the Annual meeting with ample opportunity for interactive discussion. For the first time in history of the ESPR, a 1-day Radiographers symposium will be organized on Thursday June 5, exclusively for radiographers and technicians. By organizing this dedicated symposium, the local organizing committee aims to create a unique opportunity to bring together expert paediatric radiologists in the field and radiographers with special interest in paediatric radiology. The program includes lectures on imaging technique optimization, new innovations, several disease related topics, and outreach in paediatric radiology. The ESPR 2014 will be held in the 5-star Grand Hotel Krasnapolsky, located on the Dam Square in the middle of Amsterdam. Amsterdam is a beautiful city in which history, art, culture and an open, friendly atmosphere come together. It is ranked the number 2 best in travel city of the world for 2013 by Lonely planet. Several (ludic) historical touches and highlights throughout the meeting and during fascinating social events will help to create the optimal atmosphere to meet with professionals from all over the world that are dedicated to the many aspects of paediatric radiology. We hope that you will enjoy the meeting and beautiful city of Amsterdam! On behalf of the local organizing committee, Rutger A.J. Nievelstein

President ESPR 2014

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Congress Organization

President Rutger A.J. Nievelstein Local Organizing Committee Frederik J.A. Beek Annick Devos Herma C. Holscher Albert Martijn Willemijn Klein Maarten H. Lequin Rick R. van Rijn Simon G.F. Robben Anne M.J.B. Smets Jonathan Verbeke Postgraduate Course Committee Simon G.F. Robben, Chair Rick R. van Rijn Anne M.J.B. Smets Annick Devos Albert Martijn Jonathan Verbeke Scientific Program Committee Maarten H. Lequin, Chair Frederik J.A. Beek Herma C. Holscher Simon G.F. Robben Albert Martijn Willemijn Klein


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Radiographers Symposium Committee Anne M.J.B. Smets, Chair Annick Devos Frederik J.A. Beek Karin Kamphuis-Van Ulzen Marian Starkenburg Social Program committee Annick Devos, Chair Anne M.J.B. Smets Herma C. Holscher Nazanin Ahmadi Congress Secretariat Congress Company PO Box 2428 5202 CK ‘s-Hertogenbosch The Netherlands Tel: +31 73 700 3500 Fax: +31 73 700 3505 [email protected] www.congresscompany.com www.espr2014.org

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General Information—European Society of Paediatric Radiology Officers 2013–2014 President Past President 1st Vice President 2nd Vice President General Secretary Treasurer Counsellor for Northern Europe Counsellor for Southern Europe Pediatric Radiology Managing Editor JESPeR delegate Webmaster Head of Education Committee Secretariat

ESPR Office

Rutger A.J. Nievelstein (Utrecht, The Netherlands) Eva Kis (Budapest, Hungary) Michael Riccabona (Graz, Austria) Karen Rosendahl (Bergen, Norway) Catherine M. Owens (London, United Kingdom) Catherine Adamsbaum (Paris, France) Karen Rosendahl (Bergen, Norway) Maria I. Argyropoulou (Ioannina, Greece) Guy Sebag (Paris, France) Samuel Stafrace (Aberdeen, UK) Rick R. van Rijn (Amsterdam, The Netherlands) Jean-François Chateil (Bordeaux, France) Catherine M. Owens Department of Radiology Great Ormond Street Hospital for Sick Children Great Ormond Street, London, WC1N 3JH, UK E mail: [email protected]

Honorary members of the Society 1964 John Caffey (USA) 1964 Lutz Schall (Germany) 1965 Sven R. Kjelberg (Sweden) 1965 Edward B. D. Neuhauser (USA) 1966 Jacques Lefèbvre (France) 1973 Hardy M. Geffert (Hungary) 1973 Ksawery Rowinsky (Poland) 1974 Frederic Silverman (USA) 1975 Ulf G. Rudhe (Sweden) 1979 John Kirkpatrick (USA) 1979 Arnold Lassrich (Germany) 1979 Jacques Sauvegrain (France) 1982 Clement Fauré (France) 1982 Andes Giedion (Switzerland) 1983 Eberhard Willich (Germany) 1984 Roy Astley (England) 1987 Jean Bennet (France) 1987 Ole Eklof (Sweden) 1987 Charles A. Gooding (USA) 1987 John Holt (USA) 1987 Andrew Poznanski (USA) 1987 D.C. Harwood-Nash (USA) 1987 Hooshang Taybi (USA) 1988 Herbert Kaufmann (Germany) 1989 Bryan Cremin (South Africa) 1989 Klaus D. Ebel (Germany) 1989 Helmut Fendel (Germany) 1989 Elizabeth Sweet (Scotland) 1990 Donald Kirks (USA) 1991 Alan Chrispin (England) 1991 Edmund Franken (USA) 1991 Daniel Nussle (Switzerland) 1991 Beverly Wood (USA) 1992 Walter Berdon (USA) 1993 Javier Lucaya (Spain) 1993 Wilhelm Holthusen (Germany) 1994 Noemie Perlmutter (Belgium) 1994 Hans Ringertz (Sweden) 1994 Donald Shaw (England)

1996 Robert Lebowitz (USA) 1996 Bela Lombay (Hungary) 1997 Yan Briand (France) 1997 Philip Small (England) 1997 N. Thorne Griscom (USA) 1998 Alan Daneman (Canada) 1998 Gabriel Kalifa (France) 1999 Michael Grunebaum (Israel) 2000 Paul Thomas (Ireland) 2000 Noel Blake (Ireland) 2000 Peter Kramer (Netherlands) 2000 Gunnar Stake (Norway) 2001 Janet Strife (USA) 2001 Robert Brasch (USA) 2001 Max Hassan (France) 2001 Yacob Bar-Ziv (Israel) 2002 Sven Laurin (Sweden) 2003 Aldo Pelizza (Italy) 2003 Giampiero Beluffi (Italy) 2003 Helen Carty (England) 2003 Bruce Parker (USA) 2004 Christine Hall (England) 2004 Andrzej Marcinski (Poland) 2005 Ulrich Willi (Switerland) 2005 Jean-Philippe Montagne (France) 2005 Giuseppe Farielo (Italy) 2006 Francis Brunelle (France) 2006 Laurent Garel (Canada) 2006 Morteza Mearadji (Netherlands) 2006 Alan E. Oestreich (USA) 2007 Marianne Spehl (Belgium) 2007 Gabriel Benz-Bohm (Germany) 2007 Pedro Daltro (Brazil) 2007 Richard Fotter (Austria) 2008 Jose Fonseca-Santos (Portugal) 2008 Ingmar Gassner (Austria) 2008 Tom Slovis (USA) 2008 Rita Teele (New Zealand) 2009 Reinhart Schumacher (Germany)


2009 Nicholas Gourtsoyiannis (Greece) 2009 Ines Boechat (USA) 2009 Steve Chapman (United Kingdom) 2009 Jochen Troeger (Germany) 2010 Ernst Richter (Germany) 2010 Veronica Donoghue (Ireland) 2010 Freddy Avni (Belgium) 2010 François Diard (France) 2010 Paola Toma (Italy) 2011 Rose de Bruyn (United Kingdom) 2011 Goya Enriquez (Spain) 2011 Cristian Garcia (Chile) 2011 Paul Kleinman (USA)

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2011 George Tayor (USA) 2012 Corinne Veyrac (France) 2013 Danièle Pariente (France) Gold Medalists 2007 Javier Lucaya (Spain) 2008 Gabriel Kalifa (France) 2010 Ulrich Willi (Switzerland) 2011 Richard Fotter (Austria) 2012 Francis Brunelle (France) 2013 Freddy Avni (Belgium)

Jacques Lefèbvre Awards

1977 Ringertz H. (Sweden) 1978 Garel L. (France) 1979 Brauner M. (France) 1980 Spehl-Robberech M. (Belgium) 1981 Garel L. (France) 1982 Couture A. (France) 1983 Brunelle F. (France) 1984 Veyrac C. (France) 1985 Avni F. (Belgium) 1986 Pariente D. (France) 1987 Sellier N. (France) 1988 Deeg K. H. (Germany) 1989 Winkler P. (Germany) 1990 Garel C. (France) 1991 Pracros J. P. (France) 1992 Hollman A. (UK) 1993 Chami M. (France) 1994 Adamsbaum C. (France) 1995 Sebag G. (France) 1996 Rohrschneider W. (Germany) 1997 Hertz-Pannier L. (France) 1998 Nicaise N. (Belgium) 1999 Rypens F. (Belgium) 2000 Ziereisen F. (Belgium) 2001 Lidegran M.K (Sweden) 2002 Cassart M. (Belgium) 2003 Boddaert N. (France) 2004 Jourdan C. (Germany)

2005 Kellenberger C.J. (Switzerland) 2006 Phalla O. (France) 2007 Sporcq C. (Belgium) 2008 Damasio M. B. (Italy) 2009 McDonald K. (UK) 2010 Ording-Müller L.S. (Norway) 2011 Duran C. (Spain) 2012 Vazquez J. (Spain) 2013 Viehweger A. (Germany)

The width of cranial sutures in neonates: an objective method of assessment Xanthogranulomatous pyelonephritis in children: 19 cases Metrizamide myelography in infants with brain injury to the brachial plexus Ultrasonic study of the pancreas in cystic fibrosis The renal sinus: an important anatomical landmark in children Ultrasonographic exploration of cerebral malformations Percutaneous cholecystography in children Ultrasound of normal and pathologic choroid plexus Ultrasonic demonstration of abnormal and atypical gallbladder content in newborns Biliary tract involvement in children with Langerhans cell Histiocytosis Focal cortical dysplasia: a rare cause of epilepsy Pulsed Doppler sonographic measurement of normal values for the flow velocities in cerebral arteries of healthy infants Major pitfalls in the Doppler examination of cerebral vascular system Laryngeal ultrasonographic study in infants and children. Pathological findings Systemic study of superior mesenteric vessels in abdominal ultrasound Colour Doppler imaging of the acute paediatric scrotum Ultrasound contribution in the analysis of the newborn infant normal foot and club foot: preliminary study Vermian agenesis without posterior fossa cyst Magnetic resonance angiography of paediatric renal transplants with quantification of allograft blood flow US, CT and MR imaging. Characteristics in nephroblastomatosis: evaluation of 23 Patients Non-invasive preoperative motor mapping in children with brain functional MRI Dynamic Gd-DTPA-enhanced T1W turbo field echo imaging: Interest in paediatric renal evaluation Fetal lung volume estimation by MRI: normal values and potential use Doppler assessment of pulsatility index (PI) of the uterine artery in girls around puberty MRI and echocardiography in assessment of ventricular function in atrially corrected transposition of the great arteries The assessment of fetal uronephropathies by MR imaging 18F-Fluoro-L-Dopa PET scan of focal forms of hyerinsulinism of infancy US evaluation of intima-media thickness (IMT) and elastic properties distensibility, stiffness and incremental modulus of elasticity of the common carotid artery as a marker of early vascular damage in children with chronic renal failure and reference values Cardiovascular MRI for investigating Newborns and Infants with Congenital Heart Disease Detection of coronary complications after arterial switch operation for transposition of the great arteries: first experience with 65-slice CT in children Reappraisal of the sonographic characteristics of the fetal and newborn kidney: introducing the corticomedullary ratio Which is the best imaging modality to capture bone erosions in juvenile idiopathic arthritis? DWI to assess chemotherapy response in solid tumors Development of the wrist. Normal standards based on MRI for 6–15 year old Voiding urosonography: normal and abnormal appearance of the urethra External manual reduction with US assistance: a new procedure for pediatricidiopathic ileocolic intussuseption The Gini-coefficient: A new method to assess fetal brain development

Poster Awards

1994 Gomes H. (France) 1995 Schmit P. (France) 1997 Schmit P. (France)

Neonatal hip sonography from anatomy to sonography Imaging of cystic mesenchymal hamartomas of the liver. Review of 13 patients Congenital hepatic vascular malformations in children

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1998 Brisse H. (France) 2000 Valle M. (Italy) 2001 Rohrschneider W. K (Germany) 2002 Owens C.M (UK) 2003 Schumacher R. (Germany) 2004 Mentzel H.-J. (Germany) 2005 Enriquez G (Spain) 2006 de Maupeou F. (France) 2007 Punwani S. (UK) 2008 Chateil J.-F. (France) 2009 Barez MG. (Spain) 2010 Brun M. (France) 2011 Fonda C. (Italy) 2012 Arthurs O. (UK) 2013 Duran C. (Spain)


In utero MRI. Normal gyral development of the human brain High-frequency ultrasound detection of the brachial plexus in newborns and infants Static dynamic MR-urography—simultaneous morphological and functional evaluation of the urinary tract The utility of MRI in the assessment of symptomatic adenoidal hypertrophy and rhinosinusitis in children. pre and post medical therapy Sonographical anatomy of the anal sphincter complex (ASC) and levator ani muscle in neonates and infants Comparison of whole body STIR MRI and 99mTc-methylene diphosphonate scintigraphy in the examination of children with suspected multifocal bone lesions Prenatal assessment of lung hypoplasia in congenital diaphragmatic hernia:correlation between volumetric MRI and biometric ultrasound measurements Whole body imaging in malignant bone tumours in children:preliminary results Effects of reducing radiation dose on lung nodule detection Imaging of acquired spinal cord lesions and spinal canal pathology in children Spectrum of imaging findings in the brachial apparatus anomalies Diffusion tension imaging in attention deficit disorders in children treated for posterior fossa tumours: preliminary results 3T arterial spin labelling (ASL) in pediatric patients Diffusion weighted MRI of the fetal brain in intrauterine growth restriction Voiding urosonography: a pictorial essay of the lower urinary tract pathology

Young Researcher Awards

2003 Brun M. (France) 2004 Barnacle A.B. (UK) 2005 Raissiki M. (Greece) 2006 Sorge I. (Germany) 2007 Alison M. (France) 2008 Herrmann J (Germany) 2010 Arthurs O. (UK) 2011 Gupta N (UK) 2012 Laborie L. B. (Norway) 2013 Lochbühler N. (Switserland)

Phonological Decoding in Dyslexic Children: Activation Pattern of FMRI Image-guided percutaneous biopsy of soft tissue masses in children Eye-lens Bismuth Shielding in Pediatric Head CT Examinations Reduction of radiotherapy in children with early stages of Hodgkin’s lymphoma, influenced by a new imaging and FDG-PET based strategy In vivo targeting of macrophagic activity with MRI contrast agent (USPIO) in an experimental model of neonatal brain lesions Capsular arterial collateralisation after paediatric liver transplantation MR Voiding cystourethrography for vesico-ureteric reflux in unsedated infants Predictors of vesicoureteric reflux in infants with UTI using NICE criteria Associations between femoroacetabular impingement and hip dysplasia as demonstrated radiographically. Preliminary results MRI assessment of inflammatory activity and mandibular growth following intra-articular TMJ steroid injection in children with JIA

President’s Awards

2004 Kilian A.K. (Germany) 2005 Larke A. (Ireland) 2007 Duran C. (Spain) 2008 Calder A. (UK) 2009 Senocak E. (Turkey) 2010 Franchi-Abella S. (France) 2011 Punwani S. (UK) 2012 Xenophontos P. (Greece) 2013 Pasztor G. (Hungary)

Prenatal magnetic resonance (MR) lung volumetry of congenital diaphragmatic hernia (CDH): comparison with the clinical outcome and the necessity of extracorporeal membrane oxygenation (ECMO) MRI findings as an indication of underlying genetic lesions in congenital malformations of the brain Voiding cystosonography for the study of the urethra Computed tomography compared with ultrasound and chest radiography in children with pleural empyema MRI and DWI findings in children with hemophagocytic lymphohistiocytosis: tendency for symmetricity Congenital portosystemic shunt: complications and outcome after closure: about 19 pediatric cases MRI vs. PET/CT for detection of focal splenic lesions in paediatric and adolescent lymphoma at initial staging Detection of primary sclerosing cholangitis (PSC)-type lesions in children with inflammatory bowel disease via MRCP: a relative risk measures analysis The importance of pyelectasis—report of a clinical study in progress


Past Presidents and Meeting Sites 1964 Jacques Lefèbvre, Paris, France 1965 Ulf Rudhe, Stockholm. Sweden 1966 John Sutcliffe, London, England 1967 Herbert Kaufmann, Basel, Switzerland 1968 Arnold Lassrich, Hamburg, Germany 1969 Ksawery Rowinsky, Warsaw, Poland 1970 Guido Lannacone, Rome, Italy 1971 Gregers Rhomsen, Copenhagen, Denmark 1972 Jacques Sauvegrain, Paris, France 1973 Roy Astley, Birmingham, UK 1974 Per-Erik Heikel, Helsinki, Finland 1975 Klaus Knapp, Madrid, Spain 1976 Ole Eklof, Stockholm, Sweden 1977 Andreas Geidion, Lucerne, Switzerland 1978 Noemi Perlemutter-Cremer, Brussels, Belgium 1979 Klaus Dieter Ebel, Koln, Germany 1980 The Dutch Group of Paediatric Radiologists, The Hague, Netherlands 1981 Gunnar Stake, Oslo, Norway 1982 Antonin Rubin, Prague, Czechoslovakia 1983 Clement Fauré, Paris, France 1984 Gianfranco Vichi, Florence, Italy 1985 Elizabeth Sweet, Glasgow, Scotland 1986 Javier Lucaya, Barcelona, Spain 1987 Denis Lallemand (ESPR) and Derek Harwood-Nash (SPR), Toronto, Canada 1988 Daniel Nussle, Montreux, Switzerland 1989 Noel Blake, Dublin, Ireland 1990 Hlemut Fendel, Munich, Germany 1991 Hans Ringertz (ESPR) and Donald Kirks (SPR), Stockholm, Sweden 1992 Bela Lombay, Budapest, Hungary 1993 Donald Shaw, London, UK 1994 Fred Avni, Brussels, Belgium 1995 Peter Kramer, Utrecht, Netherlands 1996 Paul Thomas (ESPR) and Kenneth Fellows (SPR), Boston, USA 1997 Ulrich Willi, Lugano, Switzerland 1998 Basilos Theodoropoulos, Rhodes, Greece 1999 Jacob Bar-Ziv and Gabriel Kalifa, Jerusalem, Israel 2000 Jose Fonseca Santos, Lisbon, Portugal 2001 Francis Brunelle (ESPR) and Janet Strife (SPR), Paris, France 2002 Tore Nordhus, Bergen, Norway 2003 Paolo Tomà, Genoa, Italy 2004 Jochen Troeger, Heidelberg, Germany 2005 Veronica Donoghue, Dublin, Ireland 2006 Richard Fotter (ESPR) and George Taylor (SPR), Montreal, Canada 2007 Goya Enriquez, Barcelona, Spain 2008 Stephen Chapman, Edinburgh, UK 2009 Mithat Haliloglu, Istanbul, Turkey 2010 Jean-François Chateil, Bordeaux, France 2011 Catherine M. Owens (ESPR) and Dorothy Bulas (SPR), London, United Kingdom 2012 Maria I. Argyropoulou, Ioannina, Greece 2013 Eva Kis, Budapest, Hungary

S263 Future ESPR Meeting

2015 Graz, Austria, June 2–6

Future SPR Meeting

2015 Seattle, Washington, April 27–May 1

Future IPR Meeting

2016 Chicago, Illinois, May 16–20

European Courses of Paediatric Radiology (ECPR)

1992 F. Brunelle, Biarritz, France (Abdomen) 1993 P. Tomà, Genoa, Italy (Musculoskeletal) 1994 G. Enriquez, Barcelona, Spain (Thorax) 1995 C. Raybaud, Marseille, France (Neuro) 1996 G. Benz-Bohm, Koln, Germany (Abdomen) 1997 H. Carty, Liverpool, UK (Thorax) 1998 C. Adamsbaun & G. Sebag, Montpellier, France (Musculoskeletal) 1999 P. Tortori-Donati, Genoa, Italy (Neuro) 2000 R. Fotter, Graz, Austria (Abdomen) 2001 S. Laurin, Lund, Sweden (Thorax) 2002 B. Lombay, Budapest, Hungary (Musculoskeletal) 2003 E. Martin-Fiori & T. Huisman, Zurich, Switzerland (Neuro) 2004 T. Berrocal, Madrid, Spain (Abdomen) 2005 M. Spehl & C. Christophe, Brussels, Belgium (Thorax) 2006 J.-N. Dacher, Rouen, France (Emergencies) 2007 R. Schumacher, Mainz, Germany (Musculoskeletal) 2008 K. Chong, London, UK (Neuro) 2009 R. R. van Rijn, A. Smets & E. Deurloo, Netherlands (Abdomen) 2010 C. Fonda, Firenze, Italy (Thorax) 2011 I. Barber, Spain (Musculoskeletal) 2012 H-J. Mentzel, Jena, Germany (Abdomen) 2013 M.H. Lequin, Rotterdam, The Netherlands (Thorax)

Future ECPR Meeting

2014 Sheffield, UK, October 15–17 (Musculoskeletal)

European Courses of Paediatric Neuroradiology (ECPNR)

Course run jointly by the ESPR, the ESNR and the ESMNR 2011 Maria I. Argyropolou (ESPR), Andréa Rossi (ESNR), Nadine Girard (ESMRN) 2013 Andrea Rossi (ESNR), Maria I. Argyropoulou (ESPR), Nadine Girard (ESMRN)

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ESPR Gold Medal Award 2014 It is a great pleasure to announce that Veronica Donoghue is our ESPR Gold Medalist, and this honour will be officially presented to her during the ESPR meeting in Amsterdam, June 2–6, 2014. The ESPR Gold Medal is a very special achievement and an exceptional award acknowledging a lifetime of professional accomplishment and dedication to paediatric radiology as a specialty, and in recognition of an individual’s outstanding contribution to the ESPR.

Dr Veronica Donoghue (Ireland)

Dr Donoghue graduated from the National University of Ireland in Galway in 1970 and obtained her Fellowship of the Royal College of Radiologists, London in 1982 thence obtaining the Fellowship of the Faculty of Radiologists, Royal College of Surgeons, Ireland in 1985. She undertook radiology training at the University of Manchester with Prof. Ian Isherwood from 1978 to 1982 and then undertook Paediatric Neuroradiology and Paediatric General Radiology Fellowships at The Hospital for Sick Children, Toronto from


1983 to 1984. Dr Donoghue returned to Dublin as Consultant Paediatric Radiologist in July 1984 to the Children’s University Hospital, Temple Street, and The National Maternity Hospital, Dublin. Dr Donoghue has had many important leadership roles utilizing her calm erudition wisdom and prudence to take ESPR forwards with regal aplomb. She was co-organiser (as Secretary) of the Dublin ESPR annual meeting early in her career in 1989 with Dr. Noel Blake, and subsequently was President of ESPR when the meeting returned to Dublin in 2005. She was then appointed as Northern European Councilor of the Board of ESPR from 2006 to 2010. She has continued using her considerable diplomacy in paving the way for a very active and successful collaboration between ESPR with ESR, as Scientific Committee Chairman for Paediatric Radiology at ECR in 2001 and 2006, and coordinator of the foundation Course at ECR in 2011, and also ESPR representative on the ESR Education Committee between 2006 and 2010. Despite a very busy clinical workload and important role as mentor to young trainees she has published more than 50 papers in peer reviewed Journals and has written many book chapters and edited “Radiological Imaging of the Neonatal Chest “– Springer-Verlag Publication—1st Ed. in 2002 & 2nd Ed. in 2007. Dr Donoghue has been a member of the Editorial Board of” Pediatric Radiology” since 1996 becoming Assistant Editor from June 2006 to July 2012. Veronica is a very popular invited speaker at ESPR Courses, National and International meetings. She holds Honorary Memberships of the Hungarian Radiological Society, South American Society of Paediatric Radiology and our own European Society of Paediatric Radiology. It goes without saying that Dr Donoghue is a worthy recipient of the ESPR Gold Medal. Those of us who have the privilege of knowing Dr Veronica Donoghue as a teacher mentor and friend will stand testament to the fact that Dr Donoghue is an exceptional human being. She has enormous integrity, wisdom and generosity, and is always ready to advise in complex issues with her considerable knowledge always remaining regal, calm and unruffled. She is passionate about music, art and literature, and frequents opera houses worldwide in her elegant attire. We are fortunate to have Dr Veronica Donoghue as our very special Ambassador and Gold Medalist at ESPR 2014. February 2014 Dr Cathy M. Owens Dr Rutger A.J. Nievelstein


ESPR Honorary members 2014 We have the pleasure and honour to introduce Drs Rosemary Arthur and Dr Mithat Haliloglu as our ESPR Honorary Members for ESPR 2014 in Amsterdam, June 2–6, 2014. ESPR honorary membership is awarded to acknowledge, commend and thank recipients for all of their hard work and dedication in contributing to the care of children within Europe, and for their exceptional dedication and commitment over many years to the ESPR.

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roles at the Royal College of Radiologists in the UK. Dr Arthur was the Secretary of the 2008 ESPR meeting in Edinburgh. Dr Arthur retired in 2012 and now lives in the North West of Scotland with her husband and they are happy indulging in their passion for mountaineering, sea kayaking and rowing.

Dr Mithat Haliloglu (Turkey)

Dr Rosemary Arthur (United Kingdom)

Following radiology training in Leeds and Glasgow, Dr Arthur chose a career in paediatric radiology with the encouragement of Dr Elizabeth Sweet, a former ESPR President. In 1983 Dr Arthur was appointed as the first dedicated paediatric radiologist to Leeds General Infirmary in the North of England, and then spent a further period of training in Paris and used the experience to develop a highly respected department of Paediatric Radiology in Leeds. At the time of her retirement in 2012 she had the great pleasure to see her department flourishing, staffed by an enthusiastic and dedicated team of young radiologists and radiographers. Dr Arthur developed particular expertise in neonatal neuroradiology and early evaluation of MRI in the premature neonatal brain. She also specialised in quality assurance and in computerised digital radiography. Dr Arthur has presented papers at many national and international meetings and has contributed to chapters in brain, thoracic and gastrointestinal imaging with an important list of publications in many journals. She has served on editorial boards in the UK and Europe and has had leadership positions in the British Society of Paediatric Radiologists and examining

Mithat Haliloglu graduated from Hacettepe University School of Medicine in 1988, Ankara, Turkey. He completed his Radiology residency at Hacettepe University Department of Radiology in 1993 and his paediatric radiology fellowship in 1993–1995 at the Department of Radiology of Indiana University School of Medicine, Indianapolis, IN, USA. He undertook a paediatric MR imaging fellowship in 1998–1999 at the Department of Diagnostic Imaging of St. Jude Children’s Research Hospital, Memphis, TN, USA. Since 1995, he has been on staff at Hacettepe University in the Department of Radiology. He now holds the position of Professor of Radiology and Chief of Paediatric Radiology at Hacettepe University. His primary field of research is paediatric body imaging and he has written many peer reviewed articles and chapters. Dr. Haliloglu is very active in both national radiology societies and in the European Society of Paediatric Radiology (ESPR). He was the President of the very successful ESPR 2009 meeting in Istanbul. He has served as a Program Committee Chairman in the Annual National Congress of the Turkish Society of Radiology in 2010. He is a member of the ECR 2015 Programme Planning Committee. He has a seminal role in Paediatric Radiology in Turkey and works tirelessly for the good of children. February 2014 Dr Cathy M. Owens Dr Rutger A.J. Nievelstein

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ESPR Jacques Lefèbvre Lecturer 2014 Robert van Langh, PhD

Robert van Langh (1968) was trained as a gold and silversmith. After his graduation from the National Higher Institute of Fine Arts in Antwerp (Belgium), he started as a metals conservator at the Museum of the Tropics (Amsterdam, The Netherlands) and the Rijksmuseum (Amsterdam, The Netherlands) in 1995. He also acted as senior tutor for Metals conservation at the Netherlands Institute of cultural Heritage, a position he held until 2006. In 1998, he carried out a brief research project on behalf of the Rijksmuseum at the Sherman Fairchild Center for Objects Conservation at the Metropolitan Museum of Art. He was appointed Head of the Department of Metal Restoration of the Rijskmuseum in 2001, and in 2006 he became head of the department of Conservation & Restoration. In September 2006, he started his PhD research in the Department of Materials Engineering of the 3 mE Graduate School (Mechanical, Maritime and Materials Engineering) at Delft University of Technology, where, in 2012, he earned his PhD with his thesis entitled: “Technical Studies of Renaissance Bronzes: The use of neutron imaging


and time-of-flight neutron diffraction in the studies of manufacture and determination of historical copper objects and alloys”. In 2011, he was selected as a museum scholar at the Getty Research Institute in Los Angeles, where he spent 3 months. During his lecture, Robert van Langh will give an overview of the various radiographic techniques that can be used to study art objects, followed by a more in depth insight into the study of bronze sculptures in a (art) historical context. In November 2005 the Rijksmuseum (Amsterdam) showed 13 different neutron tomographs during an exhibition in London. The project was widely perceived as being the newest thing that we could think of. However, after elaborate studying of the technique, it now raises the question what we can actually learn from these newly applied techniques. What is the relevance and how can these data been involved for authentication and conservation of objects of art? In 2010 a continuation of the project took place where 12 bronzes more were studied at the PSI installation for neutron tomography at the beam line NEUTRA located at the spallation neutron source SINQ. The setup consists on a quasi-parallel beam with up to 40 cm annual diameter directed to the object of interest. Behind the object, the transmitted beam is detected with a two-dimensional neutron sensitive device, based on a highly sensitive CCD-camera looking via a mirror onto a scintillation screen. About 300 single projections of the object are needed for one tomography run, where the object is rotated around its vertical axis in steps from 0 to 180°. A reconstruction algorithm calculates from these 2D projection data the 3D volume matrix, which can be forwarded for further analysis to the visualisation tools, where animation, slices and segmentation can be obtained. Using the data from neutron imaging, neutron diffraction was used to analyse the inside of the sculptures based on the difference of attenuation shown in the neutron tomographs. These experiments were executed at Engin-X the neutron diffractor of ISIS, Science and Technologies Facilities Council at the Rutherford Appleton Laboratory in Oxfordshire. The data revealed completely new insights in the manufacturing of Renaissance bronzes. This research project illustrates that collaboration between scientists, curators and conservators is essential for obtaining results that are reliable for the art historical context.


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ESPR 2014, Program at a glance

MONDAY JUNE 2, 2014 POSTGRADUATE COURSE GRAND BALLROOM 08.00 - 08.45

Conference registration

08.45 - 09.00

W elcome

09.00 - 10.30

Session 1 - (Thorax)

10.30 - 11.00

Coffee Break

11.00 - 12.30

Session 2 - (Cardiovascular)

12.30 - 13.00

Session 3 - (Technique - US)

13.00 - 14.00

Lunch

14.00 - 15.00

Session 4 - (Technique - CT)

15.00 - 15.30

Special Lecture: White matter disorders: MRI and beyond

15.30 - 16.00

Tea Break

16.00 - 17.30

Session 5 - (Head/Neck)

TUESDAY JUNE 3, 2014 POSTGRADUATE COURSE GRAND BALLROOM 08.00 - 09.00


09.00 - 10.30

Session 6 - (Perinatal imaging)

10.30 - 11.00

Coffee Break

11.00 - 12.30

Session 7 - (GI/GU)

12.30 - 13.30

Lunch

13.30 - 15.00

Session 8 - (Molecular imaging)

15.00 - 15.30

Tea Break

15.30 - 17.00

Session 9 - (MSK)

17.00 - 17.30

JESPeR Lecture: Imaging child abuse - an update and lessons from an expert

19.30 - 22.30

JESPeR Dinner

19.30 - 22.30

Faculty Dinner

WEDNESDAY JUNE 4, 2014 ANNUAL MEETING 08.15 - 10.15

ESPR Officers Meeting

09.30 - 10.30


10.30 - 11.10

Opening Ceremony

11.10 - 12.30

Plenary session: Outreach in paediatric radiology

12.30 - 13.30

Lunch GRAND BALLROOM

ST. JOHNS ROOM I+II

Scientific Session 1 Cardiac & Chest

Scientific Session 2 Vascular & Interventional

13:30 - 15:00

15.00 - 15:30

Tea break GRAND BALLROOM

ST. JOHNS ROOM I+II

Special focus/Taskforce session CT & Dose

Special focus session Education & Healthcare

15:30 - 17.30

19.00 - 21.00

W elcome Reception

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Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 THURSDAY JUNE 5, 2014 ANNUAL MEETING 08.00- 08.30


08.30 - 10.30 08.30 - 10.30

GRAND BALLROOM

St. Johns Room I+II

Scientific Session 3 Neuro/Head & Neck

Scientific Session 4 Musculoskeletal

10.30 - 11.00

Coffee Break GRAND BALLROOM

ST. JOHNS ROOM I+II

Scientific Session 5 Fetal

Special focus/Taskforce session Musculoskeletal radiology Imaging in Juvenile Idiopathic Arthritis

11.00 - 12.30

12.30 - 13.30

Lunch GRAND BALLROOM

13.30 - 14.15

Jacques Lefèbvre lecture: The use of radiographic techniques in the study of art objects GRAND BALLROOM

ST. JOHNS ROOM I+II

Taskforce session Neuroradiology in paediatrics

Taskforce session Child abuse

14.15 - 15.15

15.15 - 15.45

Tea break GRAND BALLROOM

ST. JOHNS ROOM I+II

Scientific Session 6 Technique & Radiation protection

ESPR Research committee session

15.45 - 17.15

GRAND BALLROOM 17.15 - 18.30

General Assembly & ESPR Awards

19.30 - 24.00

Annual Dinner / Party

THURSDAY JUNE 5, 2014 RADIOGRAPHERS SYMPOSIUM AMSTERDAM ROOM 08.00 - 09.00


09.00 - 09.05

W elcome

09.05 - 10.30

Session 1 - (General)

10.30 - 11.00

Coffee Break

11.00 - 12.30

Session 2 - (Technique & MSK)

12.30 - 13.30

Lunch

13.30 - 15.00

Session 3 - (GU, GI, Oncology)

15.00 - 15.30

Tea Break

15.30 - 17.00

Session 4 - (Trauma & Outreach)

17.00 - 17.10

Closure

FRIDAY JUNE 6, 2014 ANNUAL MEETING 08.00 - 08.30 08.30 - 10.30

Conference registration GRAND BALLROOM

ST. JOHNS ROOM I+II

Scientific Session 7 Genitourinary & Gastrointestinal

Scientific Session 8 Oncology

10.30 - 11.00

Coffee Break GRAND BALLROOM

ST. JOHNS ROOM I+II

Scientific Session 9 Gastrointestinal

Special focus session Molecular imaging/Nuclear medicine

11.00 - 12.30

Lunch

12.30 - 13.30 GRAND BALLROOM 13.30 - 14.00

Plenary Lecture: Image guided oncological interventions - current status and future perspectives GRAND BALLROOM

ST. JOHNS ROOM I+II

Special focus/Taskforce session Uroradiology & Abdominal imaging

Special focus/Taskforce session Oncolocy

14.00 - 15.30

15.30 - 16.00

Closing ceremony (poster/presentation Awards)

official receptions and dinners coffee and tea breaks scientific sessions special focus/taskforce session


ESPR 2014, Floorplan—Meeting area, NH Grand Hotel Krasnapolsky

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Acknowledgements The organizers of the ESPR 2014 gratefully acknowledge the support of the following organizations: Bayer Pharma (Gold sponsor) BioMarin Europe Ltd. (Gold sponsor) Siemens (Gold sponsor) Canon Europe (Silver Sponsor) Carestream Health Netherlands (Silver Sponsor) Exhibitors GE Healthcare Philips Healthcare Sectra Benelux Other Sponsors Stichting Bevordering Kinderradiologie (SBKR) Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands As of April 4, 2014 This supplement was not sponsored by outside commercial interests; it was funded entirely by the publisher.

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Continuing Medical Education

Objectives

As previous years, the 37th Postgraduate Course and 51st Annual Meeting (ESPR 2014), June 2–6, 2014, Amsterdam, The Netherlands, will apply for CME credits by the European Accreditation Council for Continuing Medical Education (EACCME) and the Dutch Society of Radiology (NVvR). The EACCME is an institution of the European Union of Medical Specialists (UEMS), www.uems.net. The EACCME credit system is based on 1 European CME credit (ECMEC) per hour with a maximum of three ECMECs for half a day and six ECMECs for a fullday event. In addition to this application, ESPR 2014 has also applied for accreditation of the 1st Radiographers Symposium by the Nederlandse Vereniging Medische Beeldvorming en Radiotherapie (NVMBR), www. nvmbr.nl, and the European Federation of Radiographer Societies (EFRS), www.efrs.eu. Each medical specialist and radiographer should claim only those hours of credit that he/she actually spent in the educational activity. A Certificate of Attendance (including CME credits) will be available at the registration desk on the last day of the Meeting.

The ESPR 2014 will provide attendees with an opportunity: 1. 2. 3.

4.

To learn about the most current information on state-of-the-art paediatric imaging and image-guided therapy. To learn about new technologies for paediatric imaging. To learn how to optimize imaging techniques and minimize radiation exposure and risks during diagnostic imaging and image-guided therapy in children. To discuss common challenges and possible solutions in paediatric radiology with colleagues and experts in the field from all over the world.

After the meeting, attendees should have an improved general knowledge of paediatric radiology, as well as of its role in clinical decision making.


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ESPR 2014, 37th Postgraduate Course—Program Monday June 2 & Tuesday June 3, 2014

Monday, June 2

Tuesday, June 3

08.45–09.00

Welcome

S.G.F. Robben & R.R. van Rijn

09.00–10.30

Session 1 (Thorax)

Moderator: P. Garcia-Peña

09.00–09.30 09.30–10.00

09.00–09.30

Imaging interstitial lung disease in children

P.A. de Jong (Utrecht, NL)

09.30–10.00

G. Balázs (Budapest, HU)

10.00–10.20

Imaging infectious lung disease in children Interactive cases

10.20–10.30

Questions & answers

10.30–11.00

P. Garcia-Peña (Barcelona, ES)

Coffee break Session 2 (Cardiovascular)

Moderator: G. Balázs A. Taylor (London, UK)

12.00–12.20

Imaging of congenital cardiac anomalies: when, what and how Diagnosis and classification of vascular malformations Interactive cases

12.20–12.30

Questions & answers

11.00–12.30 11.00–11.30

11.30–12.00

12.30–13.00

Session 3 (Technique—US)

D. Lord (Sydney, AU) T. Leiner (Utrecht, NL)

09.00–10.30

Session 6 (Perinatal imaging) Fetal MRI (non-CNS)

Moderator: W. Klein D. Prayer (Vienna, AT)

10.30–11.00

Neonatal infectious diseases A. Paterson (Belfast, UK) and its complications O. Arthurs (London, UK) Post-Mortem fetal imaging: An adjunct to conventional autopsy? Coffee break

11.00–12.30

10.00–10.30

Session 7 (GI/GU)

Moderator: A. Devos

11.00–11.30

Small bowel imaging in children

K. Darge (Philadelphia, USA)

11.30–12.00

Renal and adrenal ultrasonography

S.G.F. Robben (Maastricht, NL)

12.00–12.20

Interactive cases

M. Riccabona (Graz, AT)

12.20–12.30

Questions & answers

12.30–13.30

Lunch

13.30–15.00

Session 8 (Molecular imaging) Whole-body DWI: technique

Moderator: F.J.A. Beek

13.30–14.00

R. Ganpat (Eindhoven, NL)

14.00–14.30

Moderator: F.W. Hirsch T.C. Kwee (Utrecht, NL)

13.00–14.00

Lunch

14.00–15.00

Session 4 (Technique—CT) Moderator: P.A. de Jong

15.00–15.30

Abdominal applications of P. Petit (Marseille, FR) DWI PET/MRI: combining the best F.W. Hirsch (Leipzig, DE) of both techniques? Coffee break

E. Sorantin (Graz, AT) New CT techniques: Volume CT with large scan ranges New CT techniques: Iterative K.H. Nieboer reconstruction (Brussels, B)

15.30–17.00

12.30–13.00

14.00–14.30

14.30–15.00 15.00–15.30

15.30–16.00

New techniques in Ultrasonography

Session 9 (MSK)

Moderator: P. Petit

15.30–16.00

Imaging of osteomyelitis

D. Jaramillo (Philadelphia, USA)

16.00–16.30

Inflammatory diseases of the MSK system (JIA)

L.S. Ording Muller (Oslo, NO) L. Tanturri de Horatio (Rome, IT)

Special lecture:

Moderator: R.A.J. Nievelstein

16.30–16.50

Interactive cases

White matter disorders: MRI and beyond

M.S. van der Knaap (Amsterdam, NL)

16.50–17.00

Questions & answers

Coffee break Session 5 (Head/Neck)

Moderator: M.H. Lequin

16.00–16.30

Imaging of neck masses

M. Elmaleh Berges (Paris, FR)

16.30–17.00

Imaging of the temporal bone F.J.A. Beek (Utrecht, NL)

17.00–17.20

Interactive cases

17.20–17.30

Questions & answers

16.00–17.30

14.30–15.00

M.H. Lequin (Rotterdam, NL)

17.00–17.30

JESPeR lecture

Moderator: S. Stafrace R.R. van Rijn (Amsterdam, NL)

19.30

Imaging child abuse—an update and lessons from an expert JESPeR dinner

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ESPR 2014, 37th Postgraduate Course—Abstracts

PG02

PG01

Imaging infectious lung disease in children G. Balázs Semmelweis University Heart and Vascular Center and Heim Pál Children’s Hospital, Budapest, Hungary

Imaging interstitial lung disease in children P.A. de Jong Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands

I assume that most pediatric chest computed tomography exams in Europe are interpreted by general pediatric radiologists. This is important to realize when we think about the radiological diagnosis of rare pulmonary disorders such as interstitial lung disease in children. Exotic signs associated with and subtle differences between interstitial diseases maybe of no use in daily practice, although some experts may recognize specific interstitial diseases. The cornerstones of the diagnosis are age and patient history. Patient history is focused on finding a potential cause such as an infection, immunologic disorder (dermatomyositis, immunodeficiency) or inhalation/aspiration injury. Subsequently computed tomography is the optimal radiological test to confirm or reject the diagnosis of an interstitial lung disease, differentiate it from airways disease, visualize its distribution for possible biopsy and its extent for monitoring progression. Interstitial lung disease in infants In all neonates and infants with diffuse lung disease cystic fibrosis, immunodeficiency, congenital heart disease, chronic lung disease of prematurity, infection, primary ciliary dyskinesia and recurrent aspiration should be excluded. Computed tomography can be used to differentiate between airways disease and interstitial lung disease. The most common interstitial lung diseases are categorized as; 1) diffuse developmental disorders, for example alveolar (capillary) dysplasia; 2) growth abnormalities reflecting deficient alveolarization often related to chromosomal disorders; 3) specific conditions of undefined etiology such as neuroendocrine cell hyperplasia of infancy and pulmonary interstitial glycogenosis; 4) surfactact dysfunction disorders, including surfactant protein C mutations and ABCA3 mutations, often presenting as chronic pneumonitis of infancy; 5) disorders related to systemic disease processes mostly collagen vascular diseases; 6) disorders of the normal host for example hypersensitivity pneumonitis; 7) disorders masquerading as interstitial lung disease such as arterial hypertensive vasculopathy. Interstitial lung disease in children The most common interstitial lung disease in children after infancy are; 1) surfactant dysfunction disorders; 2) non-infectious pneumonias that can be related to collagen vascular disorders; 3) lymphoproliferative diseases; 4) other diffuse lung diseases including hemosiderosis, hypersensitivity pneumonitis, Langerhans cell histiocytosis and granulomatous disease; and 5) vascular disorders. The postgraduate course During the postgraduate course of the ESPR 2014 a strategy to differentiate interstitial lung disease from airways disease on chest computed tomography exams of children will be practiced. Subsequently a few examples of childhood interstitial lung disease will be reviewed based on computed tomography findings. Conclusion A multitude of interstitial lung diseases are encountered in infants and children. They are all rare and radiological manifestations overlap. The role of imagers is to acquire a sufficient quality chest computed tomography exam, differentiate airways disease from interstitial lung disease, monitor the disease and aid open lung biopsy. Sometimes a specific diagnosis maybe suggested.

Respiratory infections are among the most common illnesses in childhood and the most frequent indication on radiology request forms. While upper respiratory tract infections usually do not require special medical treatment, lung infections are accompanied by more serious clinical symptoms and higher risk of significant complications. Therefore, early diagnosis and treatment is substantial. The causative agents of childhood pneumonias are different from those of adults and show some agespecific distribution. In the neonatal period viral pneumonias are uncommon owing to maternal immunity. From infanthood until the age of 2 years most lung infections are of viral background. Later bacterial pneumonias become more frequent, but still under the age of 5 years about 50% of pneumonias are of viral origin. Etiology has significant impact on treatment and the spectrum of potential complications. Physical examination and laboratory findings are often aspecific and do not enable us for early differentiation between viral and bacterial pneumonias. The first and most common task of pediatric radiology is to help specify the microbiologic background e.g. the viral versus bacterial nature of a clinically manifest pulmonary infection. Radiographic appearance of pneumonias with different origin is not quite specific but some characteristic features together with clinical signs are usually sufficient for decision making. For this reason, the indication of chest radiography is generally accepted in cases of respiratory infection with severe clinical symptoms and/or prolonged clinical course for the confirmation of diagnosis, in cases with uncertain clinical signs, and for the detection and follow-up of complications. Routine utilization of chest radiography under the age of 5 years in cases with mild symptoms is debated, though. Viral pneumonias are accompanied by relatively moderate radiographic changes: symmetric perihilar increase of peribroncho-vascular markings, possibly with uncertain perihilar opacities, and linear densities. Signs of hyperinflation caused by small airway obstruction are almost always seen. Peripheral subsegmental atelectasis may be present but the most important clue in differentiating from bacterial pneumonia is the absence of alveolar consolidation with a NPV of 92%. Hilar adenopathy is common, and pleural effusion is rare in viral disease. If radiography supports viral infection unnecessary antibiotic treatment can be avoided and, in regular course of the disease, further imaging is not advised. Most common complication of viral infection is secondary bacterial superinfection, the clinical suspicion of which may justify repeated radiography. Occasionally, severe course of the disease with respiratory failure and higher mortality is encountered in some viral infections such as influenza type A H1N1. In these cases the usual aspecific findings rapidly progress to bilateral consolidations. Furthermore, late complications of viral infections are uncommon, such as post-infectious bronchiolitis obliterans. Bacterial pneumonias are characterised by alveolar infiltrates which manifest as patchy opacities sometimes bilaterally, typically causing peripheral air-space consolidations. Lobar or segmental consolidations are characteristically seen in Streptococcus pneumoniae infections, which are also the most frequent agents in the background of so called round pneumonias: these radiographically mass-like well circumscribed peripheral consolidations occur in patients under the age of 8 years in the early development of the disease with lower lobe and posterior predominance. Although the morphology itself might raise the suspicion of a mass lesion, the age and clinical context help establishing the diagnosis without the need for further cross-sectional imaging. Among the complications of bacterial pneumonias cavitary necrosis, abscess formation and


parapneumonic effusion are seen most frequently. Accurate diagnosis and therapeutic decision making in such complications is usually based on cross-sectional imaging. Contrast-enhanced CT is the standard procedure offering most comprehensive evaluation of the chest, including the differentiation of intrapulmonary and pleural components of complex fluid collections. The same applies when recurring and/or prolonged pneumonias raise the suspicion of predisposing congenital anomalies such as bronchopulmonary sequestration, CPAM, bronchial atresia…etc. Parapneumonic effusion accompanies bacterial pneumonias in 30–50% and only a minority of these evolve to empyema. The early detection of this transformation from the serous to fibrino-purulent stage, however, is crucial in order to prevent the evolution of gross septations and organised fluid collections which cannot be treated by minimally invasive techniques and may require open thoracotomy. Currently ultrasonography (US) is the best technique for the detection of pleural fluid collections with the assessment of possible fibrous strands and septations. Owing to its non-ionising nature it can be applied liberally for follow-up. Furthermore, not only pleural processes but pulmonary consolidations and cavitations are adequately assessed by US too. Thus, as a recent trend an increasing use of US in pediatric chest infections is reflected in the literature, partially replacing conventional X-ray in its classical indications. Likewise, MRI with advanced fast sequences proved its value in the problem solving imaging of pediatric lung infections, although restricted availability in some regions worldwide still hinders its introduction in routine protocols. Atypical pneumonias caused by Legionella, Chlamydia and Mycoplasma can occur in children, their aspecific radiographic appearance resemble those in adults. Tuberculosis (TB) is rare in developed countries, although an increasing incidence is observed worldwide. Most important feature of TB differentiating it from other bacterial infections is the presence of lymphadenopathy. Diagnosis and assessment of therapeutic response often require chest CT. Immunocompromised children pose special tasks on radiologists as lung infections are associated with significant morbidity and mortality both in various congenital and acquired diseases among which iatrogenic immunosupression of patients under chemotherapy and following bone marrow transplantation are seen most often in clinical practice. Viral, bacterial as well as opportunistic infections can occur, sometimes in combination. Fungal pneumonias most often caused by Aspergillus, Candida and Nocardia are the most feared complications of immunosuppression. Multiple nodular lesions with or without cavitation are the classic manifestations of mycotic pneumonias. Angioinvasive aspergillosis presenting with perinodular halos and cavitations showing the so called air-crescent sign is quite characteristic, but differentiation from other granulomatous infections like TB is not possible by imaging alone. Pneumocystis jirovecii is one of the most common opportunistic infection among AIDS patients, characterised by diffuse interstitial reticular and alveolar opacities. Since the performance of conventional radiography in the early detection of interstitial changes, small nodules and cavitations is limited, the routine use of CT in immunocompromised children is warranted with carefully tailored low-dose pediatric protocols.

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referred for imaging. This can create challenges for the pediatric radiologist. Most vascular anomalies are not biopsied, so accurate diagnostic imaging is important to identify those lesions that require biopsy, such as to exclude a malignancy. In general all vascular lesions in children fit into three imaging groups: 1) 2) 3)

masses with high vascular flow; areas of increased vascular flow and blood vessels without a defined mass, and; fluid filled spaces with little or no vascular flow.

This paper will focus on: A)

B)

radiologic techniques to differentiate lesions in the child with increased or high flow vascularity (groups 1 and 2), rather than differentiating slow flow lesions (group 3), and; syndromal associations of vascular anomalies that the pediatric radiologist needs to understand.

Within group 1 and 2 lie the high flow lesions. When a radiologist detects that a lesion has high vascular flow, the clinical question is whether this is a benign vascular tumor, i.e. hemangioma of infancy (which does not require biopsy), a malignancy with high vascularity (requiring biopsy) or an arteriovenous malformation. Arteriovenous shunting may be seen in all of these lesions, although it is the dominant feature in hemangioma and arteriovenous malformation. The answer to the clinical question lies in combining the clinical features with radiologic interpretation of the known histology. For example, hemangioma of infancy is a very well defined lesion with uniform histology in lobules of tissue and the imaging reflects this. As it is a lesion of infants it should not be used as a descriptive term for a lesion that did not appear in infancy. As the lesion undergoes its involution, a process clinically visible in the second 6 months of life (earlier with propranolol therapy), the lobules of tissue disappear to be replaced with a fatty stroma although the abnormal blood vessels persist. A lesion that does not involute may require biopsy as it arouses suspicion of a non benign tumour. Within all classification systems there are atypical and unusual lesions. Within vascular malformations these are more often the syndromal associations, such as PHACES or PELVIS. PHACES is posterior fossa, hemangioma of infancy, arterial, cardiac, eye and sternal anomalies, while PELVIS is perineal hemangioma, external genital malformation, lipomyelomeningocele, vesicorenal anomaly, imperforate anus, and skin tags. The hemangioma in these lesions may be atypical. There are also atypical arteriovenous malformations, particularly those associated with gene anomalies in RASA-1 and PTEN. Summary The best way to differentiate difficult vascular anomalies in children is with good knowledge of the clinical and histologic features of each lesion.

PG04

PG05

Diagnosis and Classification of Vascular Lesions in Children D.J.E. Lord Department of Radiology, The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network, Sydney, Australia

New techniques in Ultrasonography R. Ganpat Philips Healthcare, Eindhoven, The Netherlands

The vascular anomalies classification developed by the International Society for the Study of Vascular Anomalies (ISSVA) is now well established. Practical application of this in the clinic is often straightforward. Lesions that are not easy to diagnose are the ones more frequently

Ultrasound is a cheap diagnostic modality and can be used without radiation. There are ultrasound systems in different price points in the market to be able to use for pediatric ultrasound. In general, the same ultrasound systems which are being used for scanning adults can also be used for pediatric with more dedicated transducers. Ultrasound systems

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have many features which need to be used properly. This lecture will give an overview about which features and technologies to use: when and how, to get a proper understanding of the displayed images: Tissue Harmonic Imaging, use of Multiple beams and others. As ultrasound is operation dependent, some vendors are trying to make from ultrasound a more definitive modality like CT/MR: To be able to make confident diagnosis after the first ultrasound exam. Other highlights in this lecture will be new highlights of developments for the future in ultrasound: High frequency transducers, 3D technology for Ultrasound in radiology, Automation, shear wave imaging, contrast. It’s very important to know how to use your ultrasound system properly. R. Ganpat - Field Marketing Manager of Philips Healthcare Image Systems


the right side depicts, that there is no over-beaming, the grey areas marked with stars represent those being radiated but where there are no image data available (modified after Sorantin, E et al. Experience with volumetric (320 rows) pediatric CT. Eur J Radiol. 2013; 82(7):1091–1097).

PG06 New CT techniques: Volume CT with Large Scan Ranges E. Sorantin1, S. Weissensteiner1, B. Oppelt1, G. Stücklschweiger2, H. Guss2 1 Division of Pediatric Radiology, Department of Radiology Medical University Graz, Graz, Austria 2 Competence Centre for Medical Physics and Radiation Protection, Univ.-Hospital Graz, Graz, Austria

Computed Tomography (CT) is a rapidly evolving imaging technology. Due to the growing microprocessor capabilities more complex algorithms can be implemented. Today CT scanners offer a broad range of different scan types such as helical, superhelix, volume, dual source/dual energy, just to name a few. Additionally, after using filtered back projection during more than 40 years for image reconstruction nowadays, dose saving iterative reconstruction is available. For children, all steps of the “Imaging Chain” has to be adapted and optimized—from the correct indication according Euratom 97/43 guideline, scoutview adaption, exposure settings to image reconstruction. The purpose of this paper is to present the experience for Pediatric Radiology with a volume scanner (AquilionONE™, Toshiba Medical Systems Coop., Japan) at the authors institution. The scanner offers a 16 cm long detector with 320 rows, where 640 images can be reconstructed. The shortest rotation time for this 16 cm scan range is 0.35 s in cardiac mode, more of these 16 cm ranges can be stitched together to “wide volumes”. Moreover other scan modes like helical (including super helix with 8 cm broad detector), and single slice mode are available too. All multislice scanner suffer from over-ranging (excess radiation at the beginning and end of the scan length in order to have enough data for reconstruction of the first and last slice) and over-beaming (radiation delivered by the “penumbra” not used for image date reconstruction), where overranging being more prominent in large detectors and over-beaming in scanners with smaller ones e.g. 4–16 slice scanner (Fig.1). The influence of scan modes on dose is shown in Table 1 and it can be easily recognized, that from a dose perspective the single slice mode is unfavourable. Applications for the 16 cm dose saving volume mode are numerous. Until puberty head scans can be performed e.g. trauma and premature synostosis. 4D head CT Angiography (CTA) represents a further hallmark of the volume mode. Due to low dose native scanning, subtraction of dose data can be done safely in CTA and thus high quality 3D rendering can be performed without further necessary editing. This will save patients with treatead cerebral aneurysms from post-procedural follow-up catheterization. Chest CTA can be done until toddler’s age and the speed of the volume mode can be further exploited for a microbolus technique in cardio-vascular imaging, where only 1.5 cc of intravenous contrast medium is used. Additional musculoskeletal applications exist in almost all ages. During the course appropriate examples will be shown and the scan technique explained. Fig. 1: a CR phosphorous plate was scanned twice with identical settings— left side in helical (64row) mode and on the right side in volume mode. The bright stripes on the left image correspond to the over-beaming effect and the grey areas at top and bottom to over-ranging. Image from volume mode on

Scan mode Scan length DLPc Helical (0.5×32) 4.0 cm 161% Helical (0.5×64) 4.0 cm 182% Volume 4.0 cm 100% Single Slice Mode “Sequence Mode” 40×1.0 mm 541% Table 1: relative dose according to scan type—volume dose was set to 100% (DLPc→dose length product percentage, all data obtained from AquilionONE scanner)


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PG07

PG08

New CT techniques: Iterative reconstruction K. Nieboer, G. Van Gompel, C. Ernst, N. Buls, J. De Mey Department of Radiology, University Hospital Brussels, Brussels, Belgium

White matter disorders: MRI and beyond M.S. van der Knaap Department of Child Neurology, VU University Medical Center, Amsterdam, The Netherlands

In case of a CT scan request in children, the (pediatric) radiologist should consider alternatives for CT first. Can the diagnostic question be answered using ultrasound or MRI? If not, the ALARA principle must be kept in mind. Children should be scanned on the CT system providing the best options to reduce radiation dose. Reduce the scan length as much as possible or desirable to answer the diagnostic questions. Choose (automatically) the correct tube voltage. In general, for children, the tube voltage should be reduced to 100 kVp or even down to 80 or 70 kVp, depending on the age (size) and diagnostic question. Adjust the estimated tube current (mA) by choosing a reference mA or noise index in combination with an iterative denoising technique to obtain an acceptable diagnostic image quality or a quality for comparison, depending on the request. Denoising or iterative reconstruction techniques Standard Filtered Back Projection (FBP) computes the image from the acquired CT projection data using an analytical formula. This formula assumes a perfect system (no noise, no dead pixel zones, point source, etc.), which is in reality not the case such that noise (and artifacts) appear in the images. Iterative algorithms use an imaging model that describes the imaging system and its imperfections. Such an imaging model is used to estimate virtual projection data from a reconstructed image. The difference between this virtual projection data and the real projection data from the CT scanner is then used to improve the image. This process is iterated (repeated) multiple times. Using an accurate model in this iterative approach significantly reduces noise and artifacts. Three generations of imaging iterative models are currently commercially in use. The first generation is a denoising model applied only in image space after FBP reconstruction without feedback to the projection data. The second generation iteratively models the statistical noise in the projection domain in combination with FBP reconstruction, therefore often referred to as ‘hybrid algorithms’. The third generation models include the complete imaging system (noise, focal spot, detector size, geometry, etc.). The corresponding iterative methods do not need an initial FBP image and are referred to as ‘model based iterative reconstruction’ (VEO™, GE Healthcare) or ‘knowledge based iterative reconstruction’ (IMR™, Philips Healthcare) algorithms. The more accurate (and complex) the imaging model, the better image quality (and noise reduction) can be obtained. The complexity of the imaging model has a major impact on reconstruction time. Algorithms of the first and second generation can, with adaptations of the hardware, be considered to deliver (almost) real-time reconstructions. The third generation reconstruction methods, using an extended and complex imaging model, require prolonged reconstruction times in combination with dedicated reconstruction hardware. Although all these techniques remain black-boxes to radiologists, we have to acknowledge that since they can compensate for the increased image noise, these reconstruction techniques can reduce the radiation dose dramatically. For diagnostic CT scans, a reduction of radiation dose between 50 and 90% compared to standard FBP reconstructions is feasible. In the setting of CT scans for comparison, radiation dose levels can even be further reduced for the same region of interest. A lot of effort has to be done to optimize and validate scan protocols and applications for these new techniques. For example, in our institute, all our non-emerging pediatric CT scan requests are obtained by low dose protocols reconstructed by VEO™. Furthermore, chest X-rays in cystic fibrosis follow up are replaced by an ultralow dose CT scan at a level of ~0.06 mSv to compare with the low dose CT scan at a radiation dose of ~0.5 mSv which is performed every other year. Multiple examples of images from these scan protocols and correlating radiation doses will be presented during this lecture. K. Nieboer - Medical advisory board, GE Healthcare Medical Diagnosticss

The brain is an organ with a highly complex functional topography. Different areas have different functions and connectivity. They have specialized cellular composition and organisation and use specific neurotransmitters. There are differences in metabolism and in energy demands. Chemical composition and antigenic make-up differ. Similar cells in different areas are not necessarily identical. Cortical astrocytes are different from white matter astrocytes and most likely are astrocytes in different white matter areas not identical. Myelin in the deep cerebral white matter is not necessarily exactly the same as myelin in the U-fibers or myelin in the brain stem or cerebellum. The complex topography of the brain is reflected in complex patterns of selective vulnerability of brain structures to various adverse influences. These patterns of selective vulnerability can be visualized by MRI and form the basis of the MRI interpretation process called MRI pattern recognition. It is striking that both acquired disorders and genetic defects are often associated with highly consistent patterns of MRI abnormalities or “MRI phenotypes”. The consistent differences concern both large and small structures and substructures. Apparently, specific structures and parts of structures have an individual vulnerability for specific dysregulations and defects. There is at most a superficial understanding of some of the basic mechanisms underlying the selective vulnerability to different adverse influences. Yet, “patterns of selective vulnerability” or “MRI phenotypes” can be used in the diagnostic process to recognize different disorders. In the early nineties, we developed an MRI pattern recognition system for white matter disorders. Over the years, the system evolved and became more complete, including information on many details. At present, the MRI patterns related to the many known white matter disorders have been defined and the variability of these patterns has been studied. In addition, novel disorders can be detected by their MRI phenotype. Despite the fact that there are many known etiologies for white matter disorders, both acquired and genetic, the cause of the white matter disease remains unknown in substantial numbers of patients. MRI pattern recognition has been applied to large groups of patients with a leukoencephalopathy of unknown origin and multiple novel MRI phenotypes have been defined, including

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megalencephalic leukoencephalopathy with subcortical cysts (MLC) vanishing white matter disease (VWM), also called childhood ataxia with central hypomyelination (CACH) hypomyelination with atrophy of the basal ganglia and cerebellum (HABC) leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation (LBSL) hypomyelination with brainstem and spinal cord involvement and leg spasticity (HBSL) leukoencephalopathy with thalamus and brainstem involvement and lactate elevation (LTBL) hypomyelination of early myelinating structures (HEMS) congenital cytomegalovirus (CMV) infection

We have used the MRI phenotypes to select patients and families eligible for genetic linkage studies and have found the genes for multiple disorders. The MRI phenotypes associated with these genetic defects have proven to be consistent and homogeneous so that these diseases can often be recognized by their MRI phenotype.

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The basis of the selective vulnerability of individual structures and parts of structures for specific adverse influences is not understood. Insight into the mechanisms behind the MRI phenotypes would greatly enhance our understanding of the pathophysiology of diseases. Similarities in MRI phenotypes may reflect similarities in basic defects or pathophysiological mechanisms. Studies on the pathophysiology of the newly defined leukoencephalopathies are ongoing.


lesions, if no haemorrhagic or infectious episode occurred. MRI allows for a better delineation of these lesions, which infiltrate multiple neck spaces and can extend into the thorax or to the infratemporal fossa. MRI can also display characteristic fluid-fluid levels and hypersignal on T1weighted sequence occurring after haemorrhagic episodes. Lymph nodes are ubiquitous, power doppler may be useful to differenciate a necrotic lymph node from a cervical cyst. Additional chest X-ray is mandatory in the work-up of large cervical lymph nodes.

PG09 PG10 Imaging of neck masses M. Elmaleh-Bergès Hôpital Robert Debre, Paris, France

The most common aetiologies of cervical masses in children include: 1) congenital lesions that could be present at birth or even detected antenatally but also revealed later in childhood by an infection, 2) inflammatory/ infectious lesions, mainly lymphadenitis but secondary inflammation of a pre-existing congenital lesion must be kept in mind, 3) vascular lesions, and 4) neoplastic lesions. Clinical history, physical examination findings, and age of onset are important to reduce the spectrum of differential diagnosis, but localization and imaging appearance are key features to determine the nature of a cervical mass. The goal of imaging is to achieve the diagnosis within the shortest time, with non-ionizing modalities when possible, while evaluating the risks of sedation when required. Ultrasound (US) is a non-invasive, non-ionizing, and easily reproducible procedure, requiring no sedation. US is the first technique to be used in the evaluation of neck lesions in children and is often sufficient because these lesions are most often benign, small, well-delineated and have characteristic US findings. It specifies the location and extension of the mass and its content: homogeneous or heterogeneous mass, fluid, solid, mixed or pseudo-solid aspect, the presence of septae or calcifications. Vascularization is assessed with colour Doppler imaging. CT or MRI are required when US fails to delineate the mass because of its volume, its deep situation, or air or bone interposition. Advantages of CT are the short imaging time of spiral CT, with most often no need for sedation. It is the modality of choice in emergency. It allows a good evaluation of air, calcification, and fat but contrast injection is needed more often than in MRI and of course, it is an ionizing technique. MRI allows for a good delineation of the lesion due to a better spontaneous contrast of tissues. In addition to T1- and T2-weighted sequences, the use of specific sequences and/or techniques such as fat-saturation, diffusion, dynamic-contrast-enhanced sequences, MR angiography helps to characterize the lesions. Because MRI is also a non-ionizing technique, it will be preferred over CT if no additional information is expected from CT and if the clinical status of the child allows it, because sedation is most of the time needed for children under 5 years of age. This lecture will review the main aetiologies of neck masses, according to their localization. If situated on the midline, diagnosis is more likely a thyreoglossal duct cyst, a dermoid cyst or a lymph node, and assessment of a normal thyroid gland, in its usual site is mandatory, before any surgical procedure. Lateral lesions must be localized within anatomical landmarks such as sternocleïdomastoid muscle (SCM), carotid artery and jugular vein. A mass in the SCM is most likely a fibromatosis colli in a young infant with torticollis. In older children, it may be a desmoid fibromatosis. A cystic lesion anterior to the SCM is consistent with a second branchial cleft cyst. Behind the carotid artery and jugular vein, a neurogenic tumour such as neuroblastoma must be suspected. Anterior and medial to the vessels, a teratoma or a thyroid mass resulting from a fourth branchial pouch fistula are possible diagnoses. In case of a diffuse enlargement of the submandibular or the parotid space, US helps to differentiate a lymphangioma from an hemangioma. Lymphangiomas are ubiquitous masses; they are more frequent in the posterior triangular space. Typically they appear as multicystic anechoic

Imaging of the temporal bone F.J.A. Beek Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands Wilhelmina Children’s Hospital, Utrecht, Utrecht, The Netherlands

The indications for imaging of the temporal bone vary with age. In newborns and infants congenital anomalies are most frequent. Infections, cholesteatoma and trauma are the most common indications in older children and adolescents. Multislice CT of the temporal bone is done with slices of 1 mm or less. The primary acquisition should avoid the orbits. From the primary data set axial and coronal slices can be reformatted. Additional planes can also be reconstructed. A bone reconstruction algorithm is used. The spatial resolution is excellent but the contrast resolution is insufficient to distinguish soft tissue differences in masses and so on. One should always inspect the source images for serendipitous findings which are outside the field of view of the detailed reformatted images of the temporal bones itself. MR Imaging should include a series of the whole brain, thin T2weighted images of the cerebellopontine angle, T1-weighted images with and without intravenous contrast material and diffusion-weighted images. With CT the bony contours of the inner ear are visible, whereas with thin T2-weighted images the fluid filled structures of the inner ear itself are imaged. Congenital anomalies Atresia of the external ear canal occurs in approximately 1 :15,000 live births. It is more often unilateral than bilateral. The severity of the abnormality varies from a deformed auricle with a stenotic external ear canal to an absent auricle, external ear canal and middle ear. CT is the preferred imaging modality and can show the state of the ossicular chain. Often the malleus and incus are fused together and adherent to the lateral tympanic wall. The stapes is often normal. The mastoidal part of the facial nerve canal often has a more anterior course than normal and it is worthwhile to look for this anomaly. Inner ear anomalies vary from a minor deformation of the cochlea to complete absence of the inner ear. CT can show the malformations of the bony outline of the inner ear. MRI can show the malformations of the membranous inner ear structures and can depict the 7th (facial) and 8th (cochleovestibular) nerve. T2-weighted images perpendicular to the inner auditory canal are very useful to assess the presence of the facial nerve and the three parts of the cochleovestibular nerve. The most common inner ear anomaly is a large vestibular aqueduct, often in combination with an incomplete partition of the middle and apical turn of the cochlea. Infections An acute otomastoiditis requires no imaging. If complications are suspected, CT will show completely opacified air cells. A breakdown of the bony septa in the mastoid and erosion of the cortex can be present. An abscess can form in the soft tissue lateral to the temporal bone, at the mastoid tip, and in the middle or posterior fossa. Sigmoid sinus thrombosis can be seen. CT of the temporal bone will demonstrate the bony erosions and the opacification of the air cells and tympanic cavity. CT with thicker slices after intravenous contrast will demonstrate (intracranial) abscesses and sinus thrombosis. MRI is more sensitive than CT for intracranial complications.


Cholesteatoma ENT surgeons often say that cholesteatoma is a clinical diagnosis. However, quite a number of the requests for a CT of the temporal bone include the question: cholesteatoma? Some things are apparently not as easy as they seem. The etiology of cholesteatoma is largely unknown. It starts as a small mass between the lateral tympanic wall and the malleus. As it grows it can erode the scutum, the ossicular chain, the wall of the lateral semicircular canal and the tegmen tympani. Erosion of the canal of the facial nerve is also possible. On MRI a cholesteatoma is of low signal intensity on T1and of high intensity on T2-weighted images. After intravenous contrast material some rim enhancement can be seen. It typically shows signs of restricted diffusion on diffusion-weighted imaging. Trauma The posttraumatic findings in children are identical to adults. CT is well suited to demonstrate fractures. The usual imaging chain of events is a posttraumatic brain CT for intracranial bleeding which shows a skull base fracture or opacification of the temporal bone. On thin bone algorithm slices the temporal bone can be inspected and the course of the fracture(s) can be assessed. If clinically indicated, for instance in patients with 7th nerve palsy, sensorineural hearing loss, or persistent CSF leakage or conductive hearing loss, a dedicated temporal bone CT can be made. The most important task of the radiologist is to describe which structures of the temporal bone are affected by the fracture. Knowledge of normal sutures and canals helps to distinguish a true fracture from a pseudofracture. Examples of pseudofractures are: the petromastoid channel, the cochlear aqueduct, and the canal for the singular nerve. During the lecture imaging of cochlear implants, tumors and syndromes will also be discussed briefly.

PG11 Fetal MRI (non-CNS) D. Prayer Division of Neuroradiology and Muskuloskeletal Radiology, Medical University Vienna, Vienna, Austria

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displacement or lack of normal parts of the bowel, and pathological meconium signals may be associated with pathologies such as stenoses, atresias, and cloacal malformations. Dynamic studies of peristalsis may support the localization of the stenoses/atresias. The liver is examined looking at its position, size, shape and signals. Changes thereof may be detected with malformations, abnormalities of blood cell formation, and metabolic diseases. The gall bladder is identified, and its age related MR appearance is known. Consequently, pathologies, such as sludge or malformations will be identified. Adrenals are seen and can be checked for size and associated space occupying lesions. Impairment of kidney development often leads to a lack of amniotic fluid, inhibiting ultrasound assessment of the fetus and having an impact on lung development. The use of diffusion-weighted sequences has been shown to be beneficial in examination of the kidneys, as they normally present with restricted diffusion, enabling their detection even in case of misplacement or pathological shape. Fluid –filled structures are easily detected on T2-weighted images, thus cystic kidney disease, dilated renal pelvis, ureters and urinary bladder pathologies are readily depicted. The same is true for pathologies of the uterus or ovarian cysts. The content of the latter may also be hemorrhagic which points towards torsion. Descensus of the testicles can be readily assessed, as well as malformations of the male and female genitals. Fetal bones are seen on echoplanar sequences, allowing the detection of skeletal anomalies. Signals and shape of the skeletal muscles are also assessed. Neuromuscular diseases may be already detectable in utero. 3D MRCP sequences give an overview over the fetal proportions and sometimes reveal fetal shapes that are characteristic for certain diseases. Every fetal MRI should include the assessment of the whole fetus and the extrafetal organs, such as the umbilical cord, the placenta, amount of fluid, and membranes. Otherwise complex syndromes with genetic background, or situations, such as placenta related intrauterine growth restriction, will not be recognized. This approach requires a profound knowledge of normal and pathological intrauterine development and its presentation on imaging studies.

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With the availability of ultrafast sequences that allowed acquiring MRI images of good quality without maternal or fetal sedation, MRI started to become an important adjunct to prenatal ultrasound about 30 years ago. However, for some time only T2contrast could be used, making indications apart from the fetal brain less important as structures, such as for instance the bowels could not be imaged more accurately than it was possible using ultrasound. In the meantime indications that are related to the fetal head, face, neck, lungs, gastrointestinal system, urogenital system, the bones, and extrafetal structures are among the routinely asked clinical questions nowadays. Regarding the fetal head and face, extracranial lesions and clefts have been shown to can be imaged in more detail, especially isolated clefts of the soft palate that may be overlooked by ultrasound. The fetal profile is usually assessed by ultrasound, but MRI may help in situations when the face lies adjacent to the placenta or the uterine wall. In case of neck masses the position and course of the trachea can be determined, helping with the planning of ex-utero-intra-partum (EXIT) procedures. Lung maturity can be determined based on volumetry and assessment of signal intensities that change correlating to the gestational age. In addition, lung- (or complex) pathologies, such as congenital diaphragmatic hernia, congenital cystic adenomatoid malformations, and sequestrations can be described in detail, and prognosis can be estimated more accurately than using ultrasound alone. Bowel pathologies, including atresias, stenosis, gastroschisis, and malrotations are visualized by assessment of the morphology and content of bowel loops, their position, and the signals at the respective sequences. There, the T1-hyperintensity of normal meconium is used to detect

Neonatal sepsis and its complications A. Paterson Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland, United Kingdom

Neonatal sepsis is a significant cause of both morbidity and mortality in preterm and term infants. Early onset neonatal sepsis (EONS) is variably defined as having an onset within the first 3–7 days of life, with late onset neonatal sepsis (LONS) referring to infections acquired after this time. The incidence and microbiology of neonatal sepsis show geographical diversity. EONS groups the transplacental haematogenous spread of infection alongside agents transmitted (in the main) via inhalation or aspiration during the perinatal period. LONS is comprised of postnatal and nosocomial infections. Aetiology Transplacental spread of infection is rare, with the risk to the developing fetus dependent upon the organism involved and the gestational age when the mother was infected. Disease in the affected fetus is systemic, and during the first trimester, fetal death and miscarriage, or profound damage to developing organ systems may result. The extended acronym ‘TORCHES’ is used as an aide-memoire to recall those organisms, which may be transmitted via this route: Toxoplasma gondii, “Other” (includes: Varicella Zoster virus/VZV, Parvovirus B19, HIV, Listeria monocytogenes and TB), Rubella virus, Cytomegalovirus/CMV, Herpes Simplex virus/HSV, Enteroviruses and Syphilis/Treponema pallidum. Perinatal infections encompass those occurring secondary to ascending infection from the mother’s genitourinary tract, and transvaginal

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acquisition during labour. Documented risk factors include: maternal group B Streptococcal (GBS) colonisation, premature rupture of membranes (especially if prolonged), the development of chorioamnionitis, maternal urinary tract infection, fetal intrapartum hypoxia, fetal instrumentation and repeated vaginal examinations during labour. The major organisms responsible for perinatally acquired EONS are GBS and E. Coli, which together account for around 70% cases. E. Coli is of particular concern in very low birth weight (VLBW) infants. Other Streptococcal sp., Listeria monocytogenes, Enterococci, N. Gonorrhoeae and Chlamydia sp. may also cause EONS. LONS is chiefly caused by coagulase-negative Staphylococci (VLBW premature infants are most at risk), Staph. aureus, Gram negative Enterobacteria, Candida sp., and HSV types I and II. Prolonged stays in the neonatal unit, invasive support apparatus and procedures, prolonged and repeated prescription of broad spectrum antibiotics, episodes of necrotizing enterocolitis (NEC), gastric acid suppression (via H2 blockers or H+-pump inhibitors), and damage to skin and mucosal surfaces, all increase the risk of LONS. Such problems are compounded by the immaturity of the neonatal immune system and in premature infants, the reduced transplacental passage of maternal immunoglobulins. Clinical manifestations Unfortunately, the clinical symptoms and signs of both EONS and LONS are generally non-specific. The infant may develop pyrexia or hypothermia, feeding intolerance, listlessness, pallor, apnoea or tachypnoea. Rashes, thick respiratory secretions, abdominal distension, refusal to move a limb or seizures may be observed with more focal sources of sepsis. Hepatosplenomegaly, jaundice and ptechiae can be seen soon after birth in growth retarded infants who may have ‘TORCHES’-type infections. CNS involvement may be heralded by microcephaly, hypotonia and seizures (CMV). Limb defects (VZV) and cardiac anomalies (Rubella) may be apparent. Diagnosis Prompt diagnosis and treatment are imperative to decrease the mortality rates from neonatal sepsis; a high index of clinical suspicion is vital. Blood cultures (obtaining adequate sample volumes can be an issue) from central and peripheral sites, surface culture when clinically indicated and lumbar puncture when meningitis/encephalitis is suspected, are necessary. Other laboratory investigations are less reliable and need to be cautiously interpreted. Full blood count—an increased immature-tototal neutrophil ratio may be present. Serial CRP levels over 24–48 h; if normal, this has a high negative predictive value, but elevated levels are present physiologically in the first days of life, and also in association with other complications of prematurity. Currently, the measurement of serum procalcitonin levels, mannose-binding lectin, cytokine profile and neutrophil/monocyte surface protein marker assay remain predominantly research tools to evaluate septic neonates. Herpes DNA polymerase chain reaction (PCR) from blood and CSF is required to confirm a diagnosis of suspected HSV encephalitis. Management and treatment Vaccination programmes to prevent maternal disease and serological screening in the antenatal clinic are important. New vaccines, for example against GBS, are in development. Infected mothers should be treated with appropriate antibiotic/viral therapy and immunoglobulins, per local policies. Fetal wellbeing needs to be monitored by the obstetricians, and delivery may need to be planned. GBS screening remains controversial and in the UK is currently only performed in high risk cases, such as women with (prolonged) premature rupture of membranes. In culture positive cases, intra-partum antibiotics are administered to the mother. Scrupulous attention to hygiene in the neonatal unit is vital to prevent nosocomial infection and cross contamination. Hand washing protocols, the use of gloves and aprons, and regular testing of water supplies are required. Strict asepsis is necessary during line/catheter insertion, with local policies to determine how lines should be managed and for how long they must remain in situ. The administration of probiotics has been shown to prevent the development of NEC. Lactoferrin is suggested as


helpful to reduce both bacterial and fungal infections in VLBW babies. Antifungal prophylaxis with oral nystatin or fluconazole is of benefit to LBW infants who are at high risk of fungal sepsis. Antibiotics, whilst absolutely necessary to treat sepsis, must be utilised judiciously, to prevent multi-drug resistant organisms developing, and complications such as NEC and disseminated fungal infections. Local prescribing policies must be drawn up and adhered to. Definitive therapy is based upon sensitivity per culture results. Complications of neonatal sepsis Complications may be generic to all organism, and occur early on in the course of the disease, such as chronic lung disease as a consequence of prolonged ventilation. Septic infants are at risk of intracerebral haemorrhage and periventricular leukomalacia, which may manifest later in childhood with varying degrees of neurodisability and cognitive impairment. Disease specific complications are also recognised; congenital CMV infection is one of the commonest causes of sensory neural hearing loss, which may likewise be the result of Rubella infection. Whilst EONS is far less common than LONS, its mortality rates are far greater. Despite early diagnosis and optimal management strategies, up to 40% or infants succumb to the former, whilst less than 5% die from LONS. Radiology involvement Imaging investigation will be instigated by the neonatologists in an attempt to confirm a diagnosis of sepsis and so guide therapeutic options. The algorithm will be individualized and obviously depend upon clinical findings. A chest radiograph may suggest a diagnosis of pneumonia in the appropriate scenario, but is not specific for any particular organism, and the findings—isolated or combined interstitial and air space disease— often overlap with other respiratory conditions of the neonatal period. However, the presence of a pleural effusion, cardiomegaly or hyperinflation are reported more likely to represent pneumonia. For suspected focal infection, abdominal radiographs and ultrasound (US), extremity films and MR each have a role. Cranial US may add diagnostic weight in suspected ‘TORCHES’ cases, and is invaluable to assess for intracranial complications of sepsis such as haemorrhage and later PVL. Neuroimaging is necessary for suspected meningitis/encephalitis.

PG13 Post-Mortem fetal imaging: an adjunct to conventional autopsy? O.J. Arthurs Great Ormond Street Hospital, London, United Kingdom

Perinatal and paediatric autopsy rates are at a historic low level, mostly because bereaved parents are reluctant to agree to a full traditional autopsy as it is perceived to be unacceptably invasive. Declining parental acceptance of an invasive post mortem (PM) assessment means that significant information which could be used to counsel parents about future pregnancies is lacking, as well as data for epidemiological studies regarding fetal deaths and stillbirths. This has led to the evolution of a miniminally invasive autopsy (MIA) which involves a fully non-invasive assessment (including detailed external examination of the body, photographs and radiological investigations which may include conventional radiographs, PM CT and PM MRI) with modern targeted or endoscopic tissue sampling of the organs, as necessary. Skeletal radiography can be crucial in evaluating paediatric deaths, particularly cases where non-accidental or inflicted injury is considered, and is used to classify characteristic fetal skeletal dysplasias. However, several publications have demonstrated that routine skeletal radiography adds very little new information to the conventional fetal post mortem examination. By contrast, whilst PM CT and other imaging techniques have yet to be evaluated in a systematic fashion, recent data from a large prospective validation study of PM imaging in fetuses and children found a greater than 90% concordance rate between MIA (including PM MRI) and conventional full autopsy findings in 400 paediatric cases, including 277 fetuses (Thayyil S et al., 2013). Diagnostic accuracy was greatest for


fetuses (24 weeks 96%), and less good for newborns and children, with accuracy decreasing with increasing age. PM MRI is particularly good at diagnosing neurological abnormalities (sensitivity 93%), cardiac (sensitivity 73%) and abdominal abnormalities (sensitivity 72%), but poorer at detecting musculoskeletal (sensitivity 51%) and lung (sensitivity 39%) abnormalities. PM MRI is particularly useful for intracranial pathology in fetuses, because the inherent fragility of the fetal brain leads to difficulties with fixation for traditional neuropathological examination, and in whom adequate pathological examination of the brain is frequently difficult due to artifacts. PM MRI was particularly poor at accurately detecting intestinal (sensitivity 50%) and infectious lung pathology (sensitivity 13%), which have imaging features similar to normal post mortem changes. However, as a significant number of fetal deaths are related to systemic sepsis, myocardial disease and other pathology which are not currently identifiable on conventional PM MRI, PM MRI alone in the absence of other ancillary PM investigations (such as microbiology and placental analysis) currently has a poor diagnostic yield (around 50%). Parents should be informed that a MIA, performed jointly by a perinatal pathologist and paediatric radiologist has a similar accuracy to that of conventional autopsy for detection of cause of death and/or major pathology in the majority of cases. If PM MRI is to be offered alone, then the limitations must be appreciated and adequately explained to parents, and novel imaging strategies are required to improve the diagnostic accuracy in areas where PM MRI is currently weak. The step-wise approach to undertaking external examinations and noninvasive examination of the body, together with post mortem imaging, can therefore form a triage process in which a decision can be made to allow full, limited or non-invasive sampling to be performed. This would reduce the need for full autopsies in around 40% of cases, with a proven 99% concordance using this MIA approach. A stepwise approach is likely to be most useful in improving the uptake of PM evaluation for parents to whom current approaches are unacceptable, and is likely to increase the number of overall post mortem referrals without significantly adding to the pathologist’s workload. The corner stone of the step-wise approach is perinatal and paediatric PM imaging, with which very few medical practitioners are adequately familiar. Practitioners need to have expertise in several aspects of radiology, including plain radiographs and cross-sectional imaging modalities, knowledge of specialist techniques, and be familiar with the unique range of pathologies in this patient population, including rare perinatal pathology. The skill base for correctly interpreting post mortem imaging is currently distributed between paediatric radiologists, fetal medicine specialists, perinatal pathologists and forensic physicians. In order to offer the best clinical service for the parents of a fetus or child following death, a paediatric PM service requires a sensitive and ethically sound approach, with a multi-disciplinary team approach across specialities, acknowledging the skill base of individual practitioners, interpreted within each country’s specific medicolegal framework.

PG14 Small bowel imaging in children K. Darge Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA

One of the main indications for imaging the small bowel is inflammatory bowel disease (IBD) i.e. Crohn’s disease, ulcerative colitis and others. The conventional methods of imaging have been fluoroscopic small bowel follow-through and small bowel enteroclysis. After oral contrast administration the negative footprint of the small bowel is used to look for pathologic changes. The replacement of the fluoroscopic part by CT and performing CT enterography or enteroclysis converted the imaging to a direct visualization of the bowel loops, a step ahead compared to the

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fluoroscopic studies. However, there was and still is a major concern about the above described modalities, namely, the radiation exposure to the patients. Patients with IBD are inherently at higher risk for cancer due to their primary disease itself. The current potent medications further contribute to this risk. The fact that these patients have many recurrences requiring a multitude of imaging studies coupled with the cumulative effects of radiation, decreasing age of first manifestation of the disease and the longer life expectancy due to improved medical care make radiation exposure a major issue. Thus studies that are without any radiation exposure have become very important. Ultrasonography (US) and MR enterography (MRE) not only eliminate the radiation exposure to the IBD patients, but have the added advantage of direct and improved depiction of the mural and extramural pathological changes. US is widely available, costs less, is non-invasive and does not require any preparation. US provides comparable images to fluoroscopy and CT and has been shown to have high diagnostic value. In particular, the combination of sonographic depiction of bowel wall thickening in the presence of positive lab findings for IBD (Crohn’s disease) has a 99.5% positive predictive value. US is used for initial screening including as a same-day-study, for follow-up after conservative treatment or surgery and for evaluation of complications. An optimal examination of the bowel requires high-frequency linear transducers and the use of graded compression technique. Color Doppler is necessary for evaluation for possible hyperemia. With the use of harmonic imaging the conspicuity of the bowel depiction can be significantly improved. Panorama imaging allows the scan of long segments of diseased bowel and curved length measurement. Using short clips the presence or absence of peristalsis can be documented. There are additional advanced emerging US modalities that are used to further improve the imaging of the bowel: hydrosonography, contrast enhanced US, elastography and 3D US. MRE has been shown to have high sensitivity and specificity in depiction of inflamed bowel in Crohn’s disease in children. MRE can be combined with MR colonography and/or MR fistulography. However, MRE is not like US a screening modality, but reserved to be carried out for surgical planning, for evaluation of major complications, large field visualization prior to the start of some new potent medications and in combination with MR fistulography. It is important to note that the main limitations for the use of MRE are not really medical, but ancillary issues like availability and cost. MRE requires some preparation that includes that the patients have nothing per os for few hours and about an hour before the study drink an oral contrast. There are different oral contrasts in use e.g. Volumen®, a diluted Barium solution. Having the patient lie down on in the right decubitus position for some time prior to entering the scanner helps to empty the stomach. Antispasmolytic agents like N-butylbromide (Buscopan®) or Glucagon are used to offset the bowel peristalsis and reduce motion artifact. Positioning the patient prone increases the separation of the bowel loops, reduces the motion artifacts and the susceptibility artifacts from bowel gas in the anterior abdomen. It may also contribute to reducing the number of coronal slices needed. The core sequences for the bowel imaging pre-contrast are carried out in both axial and coronal planes and include a single shot technique T2-weighted, a balanced sequence T2-weighted in 2D/3D and post IV contrast a gradient spoiled sequence T1-weighted with fat suppression. Additional sequences that can be performed are the balanced sequence T2weighted coronal for evaluation of peristalsis and axial diffusion weighted sequences for improved depiction of the pathological changes. There are a range of mural and extramural pathological findings that one has to look for in US and MRE. The mural changes include bowel wall thickening (3 mm or more), increased echogenicity/signal intensity, loss of bowel stratification, hyperemia, stiffness or tethering, ulceration, bowel disruption, phlegmon, stenosis with or without pre-stenotic dilatation and fecalization, and bowel wall fibrosis. The extramural findings involve the mesentery which can be thickened, increased in echogenicity or signal intensity with fibrofatty proliferation, creeping fat and hyperemia (comb sign); fistulas can be internal (enteroenteric, enteromesenteric), external (enterocutaneous, enterovesical,

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enterovaginal) or perineal. Abscess, inflammatory bowel conglomerate and lymphadenopathy are the additional possible findings. There are still many open questions regarding the bowel imaging in IBD. One of the most important ones is how to definitely separate inflammatory from fibrotic bowel stenosis. The former involves conservative management and the latter a surgical one. An early and definite management would be important to reduce unnecessary delay and morbidity. The implementation of some of the advanced US imaging modalities described above may potentially have a role in the future in helping differentiate the above two conditions. Diffusion-weighted imaging is promising not only in increasing the conspicuity of the pathological findings, but also because it may play a role in potentially helping to forgo the administration of intravenous contrast. In summary, the use of US and MRE in children is not only radiation-free but has high diagnostic values and also many more potentials for future advancements that can further significantly enhance the overall diagnostic capability of the modalities.

PG15 Renal and adrenal ultrasonography S.G.F. Robben Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands Ultrasonography (US) is the imaging modality of choice for initial evaluation of renal and adrenal diseases in children for many reasons: it is relatively inexpensive, it is patient friendly, it lacks radiation and motion artifacts, the small size of the child compensates for the limited penetration of sound waves, the small size of the child facilitates the use of high frequency transducers, US involves direct contact with the patient offering a unique opportunity to ask specific questions and to perform additional physical examination, emphasizing the role of the radiologist as a clinician, flow studies are possible using the Doppler mode, and realtime imaging allows visualization of movements e.g. peristalsis in the ureter. Actually, US has become the most important imaging technique in children and can be considered as the workhorse of pediatric radiology. Within a decade it completely replaced the intravenous urography (IVU). This abstract will give an brief overview of the diagnostic potential of pediatric renal and adrenal US. Kidneys Renal diseases can be classified in many different ways. For instance according to pathology (congenital, acquired, metabolic, neoplastic, traumatic, vascular, infectious/inflammatory and auto-immune diseases), according to anatomy (medullary and cortical diseases and diseases of the collecting system), according to US features (cysts, masses, calcifications, echogenicity, edema, abnormalities in size and shape, dilatation and vascularization). Considering a) the US perspective, and b) the limited amount of text granted by the organizing committee, I will focus on some the US features in this abstract. Renal masses The most common pediatric abdominal tumor is Wilms’ tumor (nephroblastoma) with a peak incidence at 3–4 years of age. It contains blastemal, stromal and epithelial elements. Patients typically present with a painless unilateral abdominal mass. The contralateral kidney needs close inspection because in 4–13% of children have bilateral Wilms’ tumor, particularly in some syndromes that are known to be associated with the risk of developing Wilms’ tumor: Beckwith Wiedemann syndrome and hemihypertrophy syndrome (both 5% risk), sporadic aniridia (30–40% risk), Drash syndrome, Perlman syndrome, WARG syndrome (Wilms’ tumor, Aniridia, Genitourinary anomalies and Retardation) and Fanconi anemia. In these patients screening is performed from 6 months till 7 years every 3 months with US. Nephroblastomatosis is defined as the presence of foci of persistent embryological metanephric blastema (nephrogenic rests) which have the potential (1–5%) to develop into nephroblastomas (Wilms’tumor).


Nephroblastomatosis presents as multinodular, peripheral cortical lesions or as a subcapsular rind-like renal mass. They are best appreciated on contrast enhanced CT or T1-weighted MR images. Other nephrogenic tumors are less frequent, such as: Mesoblastic Nephroma commonly presents in the neonatal period (90% within first year of life) and is sometimes referred to as infantile Wilms’ tumor although histology (spindle cells) does not resemble Wilms’tumor. Multilocular cystic renal tumor (multilocular cystic nephroma) is a predominantly cystic tumor. If the cyst walls contains blastemic elements it is called a cystic partially differentiated nephroblastoma, if the cyst wall is well differentiated it is called cystic nephroma. Rhabdoid tumor was formerly considered as a sarcomatous variant of Wilms’ tumor, occurring in a slightly younger age group. Imaging findings resemble Wilms’ tumor. It has the worst prognosis of all childhood nephrogenic tumors and it is often associated with primary or metastatic central nervous system lesions. Clear cell sarcoma also was formerly considered as a sarcomatous variant of Wilms’tumor. Mean age is 1–4 years and it has the same imaging characteristics as Wilms’ tumor. The tumor is characterized by its aggressive behaviour. It is also referred to as “bone metastizing tumor of infancy”. Renal cell carcinoma (RCC) is rare in the first decade of life (as most carcinomas). In the second decade of life a nephrogenic tumor is equally likely to be a Wilms’tumor or renal cell tumor. RCC is associated with von Hippel-Lindau disease, especially multiple and bilateral RCC’s. Medullary carcinoma of the kidney has been recently described a separate entity that occurs almost exclusively in patients with African descent with sickle cell trait. Renal lymphoma is usually a regional metastatic deposit because the renal tissue does not contain lymphoid tissue and primary renal lymphoma is rare. Angiomyolipomas are the hamartomatous renal manifestations of tuberous sclerosis (TS). Usually at birth no abnormalities are seen but at the age of 10 years the majority of children with tuberous sclerosis have angiomyolipomas. They contain a variable amount of fat and therefore may mimick Wilms’tumor on imaging. Cysts Cysts are usually readily recognized with US however cystic renal disease should also be suspected in patients with enlarged hyperechoic kidneys on pre- or perinatal US. Cysts can be genetic or non-genetic (acquired or congenital). Genetic cystic renal disease includes autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), glomerulocystic kidney diseases (incl. TCF2 anomalies, nephronophtisis/medullary sponge kidney complex), cystic dysplasia, medullary cystic dysplasia associated with syndromes. Nongenetic cystic renal disease includes renal obstructive dysplasia, multicystic dysplastic kidney, simple cysts, cystic tumor, cysts associated with chronic dialysis. Syndromes that are associated with cystic dysplasia include (amongst others) Ivemark syndrome, Zellweger syndrome, Meckel Gruber syndrome, Bardet Biedl syndrome, tuberous sclerosis complex. Calcifications Calcifications can manifest as urolithiasis or (cortical and medullary) nephrocalcinosis. Urolithiasis in children is less frequent than in adults and further investigation of its cause is justified e.g. hyperparathyroidism and urinary tract infection. Nephrocalcinosis has many causes, e.g. renal tubular acidosis, furosemide induced nephrocalcinosis, idiopathic hypercalciuria, Barrter syndrome, cystinosis, glycogen storage disease, Williams syndrome, hyperoxaluria, and many more. Adrenal glands Adrenal lesions include hemorrhage, cysts, neoplasms, abscesses and hyperplasia. Neoplasms may arise from the adrenal medulla or cortex. Those arising from the medulla are of neural crest origin and may therefore also arise in sympathetic nerve chains (neuroblastoma, ganglioneuroma and pheochromocytoma). Tumors arising from the cortex include adrenocortical carcinoma and adenoma which may cause secondary symptoms such as Cushing syndrome, precocious puberty and virilisation. Adrenal hyperplasia occurs in Adrenogenital syndome


(AGS), adrenal Cushing (primary hyperplasia) and in patients with increased ACTH levels (secondary hyperplasia as in Cushing’s disease and ectopic ACTH production). Adrenal hemorrhage occurs in the neonatal period and is caused by birth trauma, perinatal asphyxia, renal vein thrombosis, septic shock or dehydration and may resemble neuroblastoma, whereas adrenal cysts may be found in older children. Conclusion US is a reliable initial imaging technique to evaluate a variety of renal and adrenal pediatric diseases. A solid knowledge of the pathophysiology of diseases is necessary to understand the ultrasonographic manifestations of renal and adrenal disease and this lecture is intended to create awareness of the diagnostic possibilities of pediatric renal and adrenal US. PG16 Whole-body DWI: technique T.C. Kwee Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

The purpose of this lecture is to introduce the technique of whole-body diffusion-weighted imaging (DWI), to briefly demonstrate its clinical applications, and to discuss acquisition and post-processing methods for image optimization. DWI is an MRI technique that is sensitive to the random (Brownian) motion of water molecules. This technique does no use any ionizing radiation, is completely non-invasive, and does not require any patient preparation. Clinical advantages of DWI are its high lesion-tobackground contrast that may facilitate lesion detection, and the opportunity to acquire functional tissue information (quantification of diffusion) that may help in the characterization and follow-up of lesions. Diffusion-weighted images are usually acquired using a Stejskal-Tanner sequence, which includes the use of symmetric motion-probing gradients that are applied around the 180° refocusing pulse. Thanks to the development of high performance gradients and parallel imaging techniques (among others), the application of DWI has been extended from the brain to the entire body. Whole-body DWI can be used for several clinical applications, cancer imaging being the most important field so far. In order to obtain a high-quality, time-efficient whole-body DWI examination, it is important to determine the purpose of the examination (i.e. lesion detection, lesion characterization, and/or follow-up), to instruct the patient before the examination, to know the strengths and limitations of the available hardware (coil technology and field strength), to use adequate fat suppression techniques for each body region, to apply b-values that are in line with the purpose of the examination, and to pay attention to breathing/respiratory motion compensation techniques (a free breathing approach is regarded as being most effective for all body regions). Once the whole-body diffusion-weighted images have been acquired, they can be further optimized with computed DWI, a post-processing method that allows for the computation of very high b-value images (which improves background suppression and potentially facilitates lesion detection), without requiring any additional scan time. An optimized whole-body DWI examination can be a valuable complementary method or even alternative to other MRI sequences and/or other whole-body imaging modalities such as CT and PET/CT. PG17 Abdominal applications of DWI P. Petit Department of Pediatric Radiology, Hôpital Timone Enfants, Marseille, France

Only scarce information regarding this topic is present in the pediatric literature. In this contribution, based on our experience, we will give an

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overview of classical up to unusual applications of diffusion weighted imaging (DWI) in the abdomen and pelvis. Technical approach Most of the authors use the spin-echo single-shot echoplanar imaging sequence acquisitions during free breathing. The axial plane is mostly preferred but we currently add a coronal acquisition when bowel is explored. The slice thickness can vary from 4 to 8 mm. The selection of a reduced echo time allows for an increased signal to noise ratio and reduction of susceptibility. B-values: qualitative lecture Most published papers have chosen an initial b-value at 0, accepting the fact that the apparent diffusion coefficient calculation (ADC) includes a perfusion effect. To suppress this noise and to electively work with a more reproducible ADC an initial b-value up to 50 s/mm2 is strongly recommended. In current practice, even if it increases time of acquisition, it is better to use multiple b-values (up to 5, usually b100, 200, 400, 600, 800) when exploring solids organs. We even select b-values over 1,000 when dealing with bowel in order to clearly suppress water signal present in the bowel lumen. In certain circumstances (acute pyelonephritis, inflammatory bowel disease) the advantage of this sequence is to decrease the need for gadolinium injection. Apparent diffusion coefficient: qualitative and quantitative lecture This quantitative parameter combines the effects of capillary perfusion and water diffusion in the extracellular extravascular space. Among other factors, it strongly depends of the b-values initially chosen. The absence of parameter homogeneity between the different publications on the clinical use of this quantitative parameter partially explaines the discrepancies noted in the results. ADC images must be read with all the other conventional sequences, in particular the T1-weighted sequence, as the T1 signal intensity has proved to influence the ADC values. An increased signal on T1-weighted images results in a decrease in ADC value. When signs of hemorrhage are present within the lesion, appearance and value of ADC must be used with great caution since products of degradation of hemoglobin and delay of hemorrhage have a non single direction influence on this value. Injection of gadolinium will also result in decreased diffusion-weighted signal intensity, and therefore, injection of gadolinium is usually done after acquisition of the diffusion-weighted sequence. Normal imaging findings One must be aware of the high b signal and low ADC signal of some normal tissues in the abdomen, such as the spleen, testis, and ovaries during peri-ovulation. Histopathology A link has been made between the restriction of diffusion (low value of the ADC) and the cellularity of tissue. Cinical applications Tissues localization: Detection of a high signal with a high b-value is of interest in multiple situations. One must be aware to exclude a T2 shine through effect before considering this signal as pathological. Actual applications in pediatric practice include chronic inflammatory bowel disease, liver lesions, acute pyelonephritis, nephrogenic rests, testis and tumor location. Tumor characterization: Two pediatric articles report the existence of a cut off value to differentiate malignant from benign lesions in the abdomen. These reported values were respectively 1.29×10−3 s/mm2 (sensitivity 77%, specificity 82%) and 1.11×10−3 s/mm2 (sensitivity 100%, specificity 78.6%). The first study used different b-values at 2 different field strengths (b0– b500 at 1.5 T and b0–b500–b800 at 3 T), and the second study only used two b-values at 1.5 T (b0–b800). However, in another study (using respectively b-values of b0, b500, b1000 at 1.5 T) differentiation between malignant and benign lesion was not possible. Furthermore, the lack of ADC reproducibility from one to the other magnet has been reported. Therefore, the reported cut-off values cannot be used in current practice and their added value compared to other imaging findings have not been established yet. Similar to other organs (bone, brain), ADC changes have been demonstrated during chemotherapy in abdominal tumors. An increase in the ADC during chemotherapy is in favor of response to treatment. It is, therefore, concluded that

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DWI could be a promising noninvasive biomarker for therapy response, especially in renal tumors. Tissue Stiffness: Detection and quantification of liver fibrosis with low bvalues (b0–b500) have been reported in the pediatric literature but the accuracy of this technique has not been confirmed in larger adult populations. In these adult studies, only a good correlation between the ADCvalue and liver fibrosis grade F1 to F4 has been demonstrated. Comparison with transient elastography (FibroScan) or with Shear Wave Ultrasonography, easy and cheap techniques, has not been investigated yet. Conclusion Diffusion-weighted imaging (DWI) is increasingly being used in the abdomen over the past few years and numerous clinical applications in pediatric practice will probably emerge in the near future. However, absence of standardization for both the terminology and the methodology strongly limits comparison between publications. Consequently, in particular for the use of ADC values, if we do not resolve these issues its exact place in the imaging strategy will remain uncertain.

PG18 PET/MRI: combining the best of both techniques? F.W. Hirsch Department of Paediatric Radiology University of Leipzig, Leipzig, Germany The first CE-certified device of an integrated whole-body Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI) system for regular clinical use was installed in 2011 at the University Hospital of Leipzig/Germany. Since November 2011, all examinations conducted on children with oncological problems requiring whole-body hybrid imaging have been performed exclusively using PET/MRI. Our experiences with children suffering from multifocal oncological diseases show that a complete PET/MRI examination, finished within 45–60 min, contains all relevant information for paediatric surgeons and paediatric oncologists. The speeding up of the diagnostic procedure in the initial staging is relevant. Technique The PET/MRI which we are working with is a fully integrated wholebody PET/MRI with field strength of 3.0 T (mMR, Siemens, Germany). For young children, the 3.0 T MRI devices have been very successful because the smaller body diameter in children in the abdominal and thoracic areas means that the typical 3.0 T signal loss artefacts seen in adults are less problematic, and the high field strength leads to a higher speed of the investigation. The new developed PET detector ring is integrated between the patient-oriented RF body coil and the gradient coil. A lot of radiotracers are produced for PET imaging. In paediatric PET/MR we use mainly 18F-fluorodeoxyglucose (18F-FDG) and 11Cmethionine (11C-MET); however other tracers are also available, e.g. 18 F-fluorodehydroxyphenylalanine (18F-DOPA) for neuroendocrine tumours. The radiation exposure in PET/MRI equals 3–4 mSv in 3D-mode. In contrast to this a typical effective dose for a child in a PET/CT is about 25 mSv (range: 6.2 to 60.7 mSv). Therefore, it is likely that through the establishment of PET/MRI 80% of radiation exposure can be prevented compared to PET/CT. Our paediatric PET/MRI protocol is performed as a complementary combination of whole-body MR imaging (WB-MRI) to determine the spread of the cancer, of a whole body PET and an additional regional MR imaging—if is necessary—to give more detailed visualization for surgical procedures. Clinical applications Lymphomas in children: 18F-FDG-PET and PET/CT is recognized as a valuable staging procedure for most lymphoma subtypes, with a very high sensitivity in patients with classical Hodgkin Lymphoma (HL) and high-grade or aggressive Non-Hodgkin Lymphoma (NHL). The PET component proved itself to be appropriate and helpful for the detection of involved, but morphologically borderline-sized lymph nodes, which in


PET have an increased glucose metabolism. In contrast, the MRI examination demonstrated an advantage in cases with symmetrical involvement of organs as testes and kidneys. Because of the bilateral characteristics, the PET scan produced differential diagnostic uncertainties in the interpretation of these findings. MRI provides options for whole-body diffusion imaging with B-values from 800 to 1,000, offering an additional aid if the PET and MRI findings produce differing interpretations. A restricted diffusivity suggests an increased cellularity and also a change in the nuclear-cytoplasmic ratio, and therefore suggests a tendency for metabolically active tumour tissue. A recent study demonstrated the use of DWI sequences to be highly complementary to 18F-FDG-PET supporting its incorporation into integrated PET/MRI scanner lymphoma protocols. Solid child-like tumours and bone tumours: Local staging is still the domain of dedicated MR imaging, because of the required higher spatial resolution. Using our WB-MRI protocols we were able to reach a compromise, which, in particular, offers sufficient anatomic orientation for the paediatric surgeon, but nevertheless doesn’t forsake the concept of a onestop-shop examination. FDG uptake may vary in solid tumours, especially in neuroblastoma, and may diverge from more specific metaiodobenzylguanidine (MIBG) uptake labelling chromaffine tissues. Since the intensity of FDG uptake in neuroblastoma is an adverse prognostic marker, FDG-PET could be used in addition to MRI and MIBG scintigraphy for the initial evaluation of high-risk neuroblastomas. In bone tumours MRI is the preferred imaging modality for primary diagnosis and local tumour (T)-staging whereas nodal (N)-staging may benefit more from the 18F-FDG-PET component. Bain Tumours: In paediatric brain tumours, PET/MRI offers a useful option to obtain more precise information on tumour metabolism in correlation to its morphologic shape. Radiolabeled amino acids like 11 C-methionine (11C-MET) are markers of tumour proliferation. PET/ MRI scans employing such [11C]methionine—PET and contrastenhanced 3D-MR-sequences provide information about lesions for improved target volume delineation in preoperative biopsy planning and navigation. Our paediatric neurosurgeons use these additional data nowadays not only to obtain tissue from an optimal biopsy site -hot spot biopsy-, but also for tailoring resection. Epilepsy: MRI is the regular imaging tool in epilepsy. In temporal lobe epilepsy (TLE) it has a high sensitivity and specificity (97 and 83%) for hippocampal sclerosis (HS), the most common pathologic substrate of TLE. However about 16–55% of patients with TLE do not show any suspicious lesion on MRI (nonlesional epilepsy). Especially for this group of patients, other non-invasive functional imaging modalities like interictal or ictal FDG-PET are of value for preoperative assessment. Interictal 18F-FDG-PET can detect epileptogenic foci by hypometabolism with a sensitivity of 70–85% in patients with temporal lobe epilepsy. Limitations and pitfalls in PET/MR The main limitation for PET/MRI, however, is the duration of the WBMRI protocol. Due to the respiratory triggering of thorax and upper abdomen an ordinary WB-MRI measurement lasts up to 45 min. Additional sequences for dedicated local diagnostics require another 15– 30 min. The typical limitations of WB-MRI persist even in PET/MRI, e.g. signal inhomogeneity was sometimes found in overlapping regions of the MRI sections. A critical factor is the calculation of the μ-map by means of the Dixon sequence for attenuation correction. Another limitation of PET/MRI is the huge amount of data produced by the Dixon sequence, the WB-MR images and the PET data (approximately 2,800 images and more). Therefore, it is not possible to demonstrate a PET/MRI study on a normal PACS workstation, even if only the composite series are transferred into the PACS. Conclusion PET/MRI produces additive information, including whole-body diffusion weighting. These results were elucidated in a joint findings discussion between radiologists and nuclear physicians and then communicated in a joint


findings report to clinical colleagues. The visually impressive fusion of high-resolution anatomy, pathology and metabolic activity demonstrates a new quality in imaging and functional diagnostics for children with oncological diseases.

PG19 Imaging of Osteomyelitis D. Jaramillo Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA

Osteomyelitis is an infection of the growing ends of the bone, affecting primarily young children under the age of 7 years. In 70% of the cases, the metaphyses of the lower extremities are involved. In flat bones such as those of the pelvis, and in round bones such as the talus and calcaneus, the infection begins at the metaphyseal equivalents, which are areas adjacent to the junction between bone and cartilage, and which have a similar vascular supply to the metaphyses of the long bones. Imaging plays a significant role in the diagnosis and therapy of these infections. The role of imaging, however, has evolved dramatically over the last 10 years, primarily due to drastic changes in the epidemiology and clinical presentation of this disorder. Less than half of the patients have positive blood cultures and therefore, culture of the infected bone or soft tissue has a higher yield. Imaging is important to detect the location of disease and to determine whether it is uni- or multifocal. The therapy has increasingly become dependent on surgical debridement and drainage of abscesses. The second role of imaging is to determine whether there are drainable collections. The bacteria responsible for the disease have changed in the last few years. Community acquired Staphylococcus Aureus has become almost three times more prevalent, regardless of whether the bacteria are sensitive or resistant to methicillin. Regardless of the response to antibiotics, community acquired S. Aureus infections now have the PVL gene, which results in a higher incidence of multifocality and more frequent subperiosteal collections, myositis, piomyositis and, in more than 10% of the cases, deep venous thrombosis. In children under 4 years of age, Kingella Kingae has become one of the most frequent organisms, particularly in Europe and the Middle East. Kingella produces milder infections, is responsive to antibiotics, and tends to affect more the cartilaginous epiphyses. Osteomyelitis, therefore, is no longer just an infection of the bones, and consequently it is important to be able to image the subperiosteal space, soft tissue, veins and epiphyseal cartilage. The value of bone scintigraphy, which for a long time was the main diagnostic modality in the evaluation of bone infections, has decreased markedly. Plain radiographs remain fundamental for the exclusion of other pathologies. They are relatively insensitive to destructive changes in the bone, which only become apparent after a week. Ultrasonography (US) is useful in the detection of subperiosteal collections, soft tissue edema and abscesses, and deep venous thrombosis. It is limited in its depiction of intraosseous pathology. MR imaging has become the most important modality in the evaluation of bone infections. Gadolinium enhancement is useful in increasing the confidence about the presence of an abscess, but does not affect the sensitivity or specificity of the diagnosis. The only exception is in very young children with infections that affect primarily the epiphyseal cartilage, in which the unenhanced images can fail to diagnose the abnormality. In older children, however, if the precontrast imaging is negative, the administration of gadolinium does not contribute significantly to the diagnosis. PET/CT is useful in determining whether a focus of chronic infection is active. On MR imaging, the initial focus of infection is of low signal intensity on T1-weighted images, high signal intensity on water-sensitive images, and enhances after gadolinium administration. A purulent collection has a

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non-enhancing center surrounded by a halo of marked enhancement. A subperiosteal collection is non-enhancing, separates the hypointense periosteum from the cortex, and stops at the perichondrium, where the periosteum becomes tightly attached to the cartilage. Infections affecting primarily the epiphyseal cartilage are more infectious chondritis than osteomyelitis, and are of increasing prevalence. Chronic osteomyelitis is characterized by the presence of a fragment of dead bone, the sequestrum, surrounded by a walled-off halo of pus, the involucrum. The pus tends to drain through an elongated track called draining sinus or cloaca. Brodie’s abscess, another common manifestation of chronic osteomyelitis, is characterized by a necrotic (non-enhancing) center, surrounded by a well-defined wall of bone, which in turn is surrounded by a poorly defined halo of inflammation. The evaluation of osteomyelitis should begin with whole body coronal STIR images in infants and young children. In children from 5 to 10 years of age with symptoms in the lower extremity, it is reasonable to limit the coronal STIR imaging to the lower extremities. A focused evaluation of the site of infection follows, including longitudinal T1 and STIR, and axial fat suppressed T2 weighted-images. If the unenhanced images are abnormal, fat suppressed gadolinium enhanced T1-weighted images should complete the evaluation. In summary, osteomyelitis in children is a changing disease with increasing involvement of non-osseous structures. MR imaging is the modality of choice for evaluation of these disorders. Gadolinium enhancement helps in the detection of purulent collections.

PG20 Inflammatory diseases of the MSK system (JIA) L.S. Ording Müller Unit for Paediatric Radiology, Oslo University Hospital, Oslo, Norway

Juvenile idiopathic arthritis (JIA) is defined as arthritis of unknown cause occurring in children under 16 years and is the most common rheumatic entity in childhood with a prevalence of 0.6–1.9 in 1,000 children. The exact cause and pathogenesis of JIA are not fully understood but seem to include both genetic and environmental components. The International League of Associations for Rheumatology, ILAR, provides the most recent diagnostic criteria and classification with six different disease subtypes. The diagnosis is made from clinical and laboratory presentation the first 6 months of the disease. The outcome varies with the clinical subtype of JIA. Despite the heterogeneity of juvenile idiopathic arthritis it is likely that there is some genetic overlap because all subtypes share joint inflammation as the most prominent disease feature. Joint pathogenesis involves inflammation of the synovial lining, with the potential to cause joint destruction. The peripheral joints are predominantly affected and wrist synovitis is associated with a severe course. There have been major advances in the treatment of JIA in the last decade. The development of new therapeutic agents and new, individually tailored, treatment strategies has lead to significant improvement in functional outcome in children with JIA. The paramount goal of current treatment in JIA is to achieve inactive disease and remission with or without medication. The role of imaging of joint pathology in Juvenile Idiopathic Arthritis (JIA) The diagnosis of JIA is based on clinical and laboratory criteria. Imaging is crucial for assessing the extent and activity of the disease, treatment response and potential complications. In some cases, imaging can also help define the subtype of JIA. In order to evaluate therapeutic response, sensitive tools for assessment of early inflammation and bony destruction have become crucial. Subtle changes can be difficult to assess clinically hence imaging is an important additional tool. The radiological investigations in JIA should ideally be able to determine the presence and degree of 1) active inflammation 2) precursors of bony destructions 3) established erosions.

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Radiography. Joint misalignment and joint damage evaluation in JIA has traditionally been performed by X-ray scoring methods. Radiographs are quick and easy to obtain, cost effective and give low radiation exposure to the child. Radiographs can show bone erosions and it may depict cartilage loss indirectly through joint space narrowing. Joint space narrowing, misalignment and focal concavities or lytic lesions of the bones are perceived as signs of joint destruction. Radiographic scoring systems specific for juvenile idiopathic arthritis have been devised. However, plain radiographs cannot visualize synovium, joint effusion, articular cartilage, bone marrow, ligaments or tendons directly, and are not sensitive for bony destruction. The sensitivity is particularly low for disease in early stages. Ultrasonography (US). US is a non-invasive, non-ionizing and childfriendly technique that allows for dynamic evaluation of several joints. The periarticular soft tissue, joint fluid, cartilage and the articular surface of a joint can be assessed by US. US with power Doppler examination has shown higher sensitivity than clinical examination for detecting synovitis. US is superior to MRI in the assessment of tenosynovitis, particularly in younger children. Erosions and cartilage destruction may also be depicted by US, but the whole articular surface can be assessed only in small joints hence the sensitivity may be low. The major problem, however, is the lack of standardised imaging techniques and scoring systems for inflammation and the lack of normal standards of anatomy on US in children. Computer Tomography (CT). CT can show the skeletal structures in great detail and CT imaging with 3D reformatted images may be useful in complex joint misalignment and in preoperative planning. However, few data addressing the modality’s ability to determine erosions are available and CT has a relatively high radiation burden and should not be used in the routine imaging of JIA. Positron Emission Tomography (PET). There are a few studies on the use of 18-F FDG-PET in the assessment of synovitis in adults where the degree of 18-fluorodeoxyglucose (FDG) uptake is reported to correlate with physical examination and laboratory tests for evaluating disease activity in patients with rheumatoid arthritis. Similar findings have been reported in a study by Tateish et al. on children with JIA. FDG PET may be used to quantify the degree of synovitis and could potentially be useful in the therapeutic management of JIA. Further evaluation of this technique is needed before it may be applied in clinical practice. MRI. MRI is the only diagnostic tool that can assess all relevant anatomical structures in joint inflammation. Erosions are difficult to assess clinically and MRI is thought to have greater sensitivity than radiography in early detection of destructive disease. MRI is able to depict synovial thickening and enhancement, joint fluid, bone marrow oedema as well as damage to cartilage and bone and is therefore a potential powerful imaging tool in the assessment of joint inflammation and the progression of joint-damage. The Outcome Measures in Rheumatoid Arthritis (OMERACT)-group has over the last decade created an MRI scoring system for these features for adult patients with Rheumatoid Arthritis (RA), based on a set of standard MR-sequences (T1, T2 f. or STIR and T1fs pre and post Gd). The OMERACT-definitions for disease activity and bony destruction on MRI have in part been adapted for use in children with JIA. However, the definitions have not been validated for children. In a recent study we showed that the majority of healthy children have changes at the wrist that, according to the OMERACT- criteria, would be defined as erosions. More than half of the children had bone marrow changes suggestive of bone marrow oedema. Joint fluid seemed to disappear in most of the joints at the wrist when there was active synovitis and more than half of the children had amounts of joint fluid that in adults would be defined as a sign of inflammation. Moreover, children with JIA could show signs of joint destruction (misalignment and deformations) without the presence of erosions. Some studies addressing the normal MRI anatomy and enhancement patterns of the temporomandibular joints are available but there is a general paucity of normal MRI appearances of all other joints in children. Definitions extrapolated from research in the


adult population cannot automatically be used in children and may lead to both overstaging and understaging of disease. Exciting advances in MRI techniques could potentially enhance the diagnostic accuracy in children with JIA but so far there is no scientific data on how to overcome the problem with the differentiation of normal variants from disease. This makes the assessment of bone destruction and the interpretation and grading of inflammatory changes difficult on MRI in children, particularly in early disease. Conclusion Imaging plays a key role in the assessment of children with JIA. Conventional radiographs still play an important role in the diagnostic work up and to monitor the development of chronic change and growth deformities. Both US and MRI are excellent tools for the detection of inflammatory changes, although there is an urge for specific scoring systems for children with JIA taking normal variants into consideration. PG21 JESPeR lecture: Imaging child abuse—an update and lessons from an expert R.R. van Rijn Department of Radiology Academic Medical Center/Emma Children’s Hospital, Amsterdam, The Netherlands

Eleven years after Melanie Hiorns delivered the first JESPeR lecture entitled ‘How do I do it in fluoroscopy?’ at the 2004 ESPR in Heidelberg (Germany) it’s my honour to deliver the 2014 JESPeR lecture. Over the years many renowned paediatric radiologists have given this lecture and it is a strange feeling to have come from a Junior in 2004 to be called an expert in 2014. In this lecture I will discuss imaging of child abuse and neglect, which is a highly prevalent and important medical and social problem. The US Child Abuse Prevention and Treatment Act defines child abuse as ‘Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm’. Studies performed in the US, Canada and the Netherlands, based on either reporting by professionals or on administrative data show a national incidence rate of 1.0–3%. In 2011 676,569 victims of child abuse and neglect were recorded in the USA, which equals a rate of 9.1 victims per 1,000 children in the population [data from the U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau. Child Maltreatment 2011, http://www.acf.hhs.gov. Studies using self-reports of parents or children show tenfold or even higher rates compared to these studies. Child abuse, especially physical abuse, can lead to demise of the victim. In 2011 in the USA 1,570 children died from abuse and neglect, which equals a rate of 2.1 death per 100,000 children. Child abuse and neglect fatality rates for other western countries are in a similar order of magnitude. It is of interest to compare this to other diseases we are confronted with. A good comparison could be childhood cancer which was diagnosed in 10,400 children under age 15 in 2007 in the USA, equalling an incidence of 1 to 2 children for every 10,000 children and which has a death rate of 1,545 children. Radiology can play an important role in the detection of physical abuse and it’s not an unrealistic scenario that a paediatric radiologist is one of the first to recognize a fracture or lesion which is not in keeping with the clinical history. However, more often the radiologists will be called upon to assist the clinician in cases in which child abuse is suspected. Radiology can be used to support the diagnosis of child abuse and also to evaluate long term outcome, especially in case of abusive head trauma. Based on a real-life case the radiological findings, the evidence (or lack thereof) behind these findings and their implications in legal proceedings will be discussed.


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ESPR 2014, 51st Annual Meeting—Program Wednesday June 4–Friday June 6, 2014

Wednesday, June 4 Themes

Wednesday, June 4 Cardiovascular/thorax Interventional Technique

10:30–11:10

Opening Ceremony

10:40–11:10

Opening lecture: Leadership in Radiology: the way forward in a changing radiological world G.P. Krestin (Rotterdam, NL) (ESR) Plenary session: Outreach in paediatric radiology Moderators: M.I. Boechat (SPR), T. Cain (AOSPR) WFPI: Bringing pediatric radiology all over the world, an update M.I. Boechat (Los Angeles, US) (WFPI) HIV and related infections S. Andronikou (Johannesburg, SA) (ASR) Infectious diseases of the hepatic parenchyma and biliary tract E. Nunez Santos (Rio de Janeiro, BR) (SLARP) Lunch 12:40–13:25

Lunch Symposium

13:30–15:00

Scientific session 1: Cardiac & Chest Moderators: R. Dikkers, A. Secinaro

13:30–15:00

Scientific session 2: Vascular & Interventional Moderators: N. de Graaf, D. Roebuck

13:30–13:50

Keynote lecture: Imaging of cardiac infectious and inflammatory diseases A. Secinaro (Rome, IT)

13:30–13:50

Keynote lecture: Therapeutic strategies in vascular malformations A.M. Barnacle (London, UK)

Scientific presentations

13:50–15:00

11:10–12:30 11:10–11:30

11:30–12:00 12:00–12:30

12:30–13:30

13:50–15:00


13:50–13:57 O001 Pediatric chest CT using a 320-row-detector volume CT: a comparison of the wide-volume and helical scans Y. Choi (Seoul, ROK) 13:57–14:04 O002 Ultrafast pediatric chest CT: comparison of free breathing/breath-hold imaging with and without anesthesia A.Y.A. Kino (Palo Alto, USA) O003 Follow-up of paediatric patients with non cystic fibrosis 14:04–14:11 bronchiectasis using lung MRI L. Bonello (Milan, IT)

O013 Radiation exposure from interventional cardiology in childhood: the Coccinelle study H. Baysson (Fontenay aux Roses, F)

14:11–14:18

O004 Thin section lung parenchymal CT findings in children 14:11–14:18 with juvenile dermatomyositis O.C. Carney (London, GB)

O014 Comparison of MR and CT for planning of US-guided intra-abdominal abscess drainage in children P. Caro Dominguez (Ottawa, CDN)

14:18–14:25

O005 MRI of the thorax for preoperative evaluation of chest wall deformities A.L. Lollert (Mainz, D)

14:25–14:32

O006 Stethoscope v. Ultrasound probe—What can we rely on 14:25–14:32 more in children with suspected pneumonia? Dr. Lovrenski (Novi Sad, SE)

O016 The Utility of Image-Guided Biopsy in the Management of Children with Thyroid Nodules S.E. Vatsky (Phoenix, USA)

14:32–14:39

O007 Volumetric chest-CT: Comparison of the dose and scan- 14:32–14:39 time between high pitch iterative reconstruction technique (FLASH-SAPPHIRE) and organ-dose based modulation technique (X- CARE) on a 128-detector row CT A. Magistrelli (Rome, IT) 14:39–14:46 O008 Qualitative assessment of MRI sequences for morphological imaging of the lungs in children with cystic fibrosis R.G. Gnannt (Zurich, CH)

O017 The Necessity for Multidisciplinary Management in Sclerotherapy involving the Airway D.J. Aria (Phoenix, USA)

13:50–13:57

13:57–14:04

14:04–14:11

14:39–14:46

14:18–14:25

O011 Implementation of percutaneous gastro-jejunostomy service: A local review H. Anderson (Brighton, GB) O012 IVC Calibre as an indicator of haemodynamic status in paediatric trauma patients J.L. Barber (London, GB)

O015 Pediatric Internal Carotid artery Psuedoaneurysms : Role of endovascular management A.J.A.Y. Kumar (Chandigarh, IND)

O018 Effectiveness of intra-arterial Verapamil injection in pediatric TBI patients with vasospasm monitored by transcranial Doppler P. Cornejo (Phoenix, USA)

S288 14:46–14:53

14:53–15:00

15:00–15:30 15:30–17:30 15:30–16:00

Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 O009 Chest radiographic abnormalities in HIV-infected South African children—a longitudinal study R.D. Pitcher (Cape Town, ZA) O010 A HRCT- score can differentiate between immunemediated and non-immunemediated lung disease after Hematopoietic Stem Cell Transplantation A.B.. Versluys (Utrecht, NE) Tea Break Special focus/Taskforce session: CT & Dose Moderators: C.M. Owens, E. Sorantin Making CT safer for children: International perspective M. Rehani (Vienna, AT)

14:46–14:53

O019 Outpatient liver biopsies: are they safe? T. Davis (Phoenix, USA)

14:53–15:00

O020 The Use of Hunter Device in Children Z.F. Farhat (Toronto, CDN)

Paediatric CT—Things to consider before scanning S. Weissensteiner (Graz, AT) Effects of special scan features on image quality and dose M. Dijkshoorn (Rotterdam, NL) Cardiovascular and thoracic imaging in babies and toddlers—Tips, Tricks, Traps R. Booij (Rotterdam, NL) Scientific presentations Image Quality and Dose Reduction using Iterative Reconstruction in paediatric head CT: Initial experience in an Emergency Department setting C. Lloyd (London, GB) Pediatric Head CT: axial vs volumetric scan with organdose based modulation (X-CARE) technique on a 128detector row CT A. Magistrelli (Rome, IT) The Relationship between SSDE and diagnostic image quality: How a Dose Index Registry (DIR) can determine the minimum radiation dose needed to achieve acceptable diagnostic image quality in pediatric abdominal CT S.J. Westra (Boston, USA) Quality Improvement Registry of CT Scans in Children (QuIRCC): Diagnostic Reference Levels for Pediatric Chest CT S.J. Westra (Boston, USA)

16:15–16:45

16:00–16:20 16:20–16:40 16:40–17:00

17:00–17:30 17:00–17:07

O021

17:07–17:14

O022

17:14–17:21

O023

17:21–17:28

O024

15:30–17:00 15:30–16:15

16:45–17:30 16:45–16:52

16:52–16:59

16:59–17:06

17:06–17:13

17:13–17:20

17:20–17:27

19:00–21:00

Scientific presentations O025 Introduction of a Pictorial Poster and a ‘Crash Course’ of Radiographic Errors for Improving the Quality of Paediatric Chest Radiographs in an Unsupervised Unit L.T. Hlabangana (Johannesburg, ZA) O026 Can the iPad Be Used in the Diagnosis of Lung disease in Chest x-rays of Neonates and Infants?: Preliminary Results G. Papaioannou (Athens, GR) O027 Third level remote consulting to support FAST echography in pediatric emergency assistance by the use of COTS technology (Commercial Off The Shelf) F. Zennaro (Triest, IT) O028 Digital teleradiology can improve quality of health care and reduce cost: a paediatric experience from a mediumsized hospital in Angola F. Zennaro (Triest, IT) O029 World Federation of Pediatric Imaging (WFPI) Volunteer Outreach through Telereading: A brief history and audit of a teleradiology pilot project in South Africa R.M. Griggs (Santa Monica, USA) O030 Crash Course for Improving Non-radiologists interpretation of Chest Radiographs for suspected TB in Children: a ‘task-shifting’ exercise S. Andronikou (Johannesburg, ZA)

Welcome Reception

Thursday, June 5

Thursday, June 5 Themes

Special focus session: Education & Healthcare Moderators: O. Olsen, S. Stafrace Reviewing manuscripts for scientific journals: how to do? P. Strouse (Ann Arbor, US) & G. Sebag (Paris, FR) Presenting a scientific paper: how to do? S.G.F. Robben & W. de Grave (Maastricht, NL)

Neuro/Head-Neck MSK Technique

08:30–10:30

Scientific session 3: Neuro/Head & Neck Moderators: C. Adamsbaum, Th. Huisman

08:30–10:30

Scientific session 4: Musculoskeletal Moderators: N. Ahmadi, A. Coskun

08:30–08:50

Keynote lecture: Infectious diseases of the CNS Th. Huisman (Baltimore, US)

08:30–08:50

Keynote lecture: Imaging of spondylodiscitis A. Coskun (Kayseri, TR)

08:50–10:30


08:50–10:30


08:50–08:57

O031 Efficacy of Susceptibility Weighted Magnetic Resonance 08:50–08:57 Imaging in Detecting and Discriminating Intracranial Calcification and Hemorrhage in Pediatric Patients K. Gumus (Kayseri, TR)

O045 Normal growth of the paediatric wrist—long term follow-up of a healthy cohort D.F.M. Avenarius (Tromsø, N)


S289 08:57–09:04

08:57–09:04

O032 1.5T pediatric brain perfusion fraction map without contrast medium: initial clinical experience A. Ciccarone (Florance, IT)

09:04–09:11

O033 Association of skull deformity with Chiari 1 anomaly in 09:04–09:11 pediatric patients F.G.M. Menegotto (Montreal, CDN) 09:11–09:18 O034 Grey matter volume, neuropsychology and motor abilities in children born preterm J. Schneider (Basel, CH)

09:11–09:18

09:18–09:25

O035 Is post-mortem magnetic resonance imaging an important 09:18–09:25 adjunct to autopsy in the fetal and neonatal age group? E. H. Whitby (Sheffield, GB)

09:25–09:32

O036 Central tegmental tract hyperintensity in cerebral palsy patients B.D. Derinkuyu (Ankara, TR)

09:25–09:32

09:32–09:39

O037 Subependymal cysts: red flags in prenatal detection on US and MRI E. Blondiaux (Paris, F)

09:32–09:39

09:39–09:46

O038 Incidence of white matter injury and cerebral hemorrhage in early preterm infants: a qualitative magnetic resonance imaging study at term B. Schweiger (Essen, G) O039 The changes of the cytotoxic edema (CE) in asphyxiated newborns during the first week of life G. Rudas (Budapest, H) O040 Application of a low-dose multidetector CT protocol for children with cranial deformity J.L. Vazquez (Vigo, E) O041 International Diffuse Intrinsic Pontine Glioma (DIPG) Registry: Initial Imaging Evaluation and Update A.K. Kanfi (Cincinatti, USA)

09:39–09:46

O042 DTI-tractography in patients with craniosynostosis syndromes B.F.M. Rijken (Rotterdam, NE) O043 Alterations of the regional amplitude low-frequency fluctuation (ALFF) and peculiarities of the brain metabolism in autistic children: fMRI and in-vivo 1H MRS study Z.Z. Rozhkova (Kiev, UA) O044 Value of follow-up brain MR imaging in children with localization-related epilepsy and negative initial MR imaging J.A. Kim (Seoul, ROK) Coffee Break Scientific session 5: Fetal Moderators: F. Avni, A. Rossi

10:07–10:14

09:46–09:53

09:53–10:00

10:00–10:07

10:07–10:14

10:14–10:21

10:21–10:28

10:30–11:00 11:00–12:30

11:00–11:20

11:20–12:30

11:20–11:27

09:46–09:53

09:53–10:00

10:00–10:07

10:14–10:21

10:21–10:28

O058 Kocher criteria revisited in the era of MRI: How often does the Kocher criteria identify underlying osteomyelitis? A.V.N. Nguyen (Houston, USA)

11:00–12:30

Special focus/Taskforce session: Musculoskeletal radiology Imaging in Juvenile Idiopathic Arthritis Moderators: P. Toma, K. Rosendahl Opening, European projects K. Rosendahl (Bergen, NO)

Keynote lecture: A systematic approach to posterior fossa 11:00–11:10 congenital malformations A. Rossi (Genova, IT) 11:10–11:35 Scientific presentations

O059 Diagnostic accuracy of post mortem MRI for thoracoabdominal abnormalities in fetuses and children O.J. Arthurs (London, GB)

O046 Acute musculoskeletal infections in children: how does age of presentation affect when tailored MR imaging of the joint should also be performed? J. Monsalve (Houston, USA) O047 Rapid Two-Point DIXON Turbo Spin Echo (TSE) high resolution 3T MR Imaging of the Pediatric Knee B. Kammen (Oakland, USA) O048 Reliability of CT Scout Views of the Skull for Assessing Basilar Impression and Platybasia in Children A.C. Offiah (Sheffield, GB) O049 Pediatric Postmortem CT Scans: Anatomic and Iatrogenic Skeletal Findings not to be confused with Fractures A.C. Offiah (Sheffield, GB) O050 The “instability angle” generated from 3D ultrasound differentiates between normal and dysplastic infant hips J.L. Jaremko (Edmonton, CDN) O051 Follow up MRI of Chronic Recurrent Multifocal Osteomyelitis (CRMO) in Children after Bisphosphonate (Pamidronate) Therapy K.R. Richard (Toronto, CDN) O052 Metaphyseal osteomyelitis: how often does a joint effusion identified by MRI actually represent coexisting septic arthritis? E.K. Schallert (Houston, USA) O053 A clinical decision rule for acute wrist trauma in children A. Slaar (Amsterdam, NE) O054 Detection of sacroiliitis in children with newly diagnosed Enthesitis-Related Arthritis N. Chauvin (Philadelphia, USA) O055 Bone health assessment of patients with juvenile idiopathic arthritis: a comparison between DXA and BoneXpert C.M. Nusman (Amsterdam, NE) O056 Fetal and Congenital Rickets, Syphilis, and Heavy Metal Bands (back to the future) A.E. Oestreich (Cincinnati, USA) O057 Sonographic assessment of cervical root avulsion in infants with perinatal brachioplexopathy being considered for nerve repair M.A. DiPietro (Ann Arbor Michigan, USA)

11:35–12:00

12:00–12:25

The validity of existing MRI scoring systems M. Maas (Amsterdam, NL) Imminent questions to be answered before proceeding with MRI scoring systems L.S. Ording Müller (Oslo, NO) Imaging of TM-joints in JIA C. Kellenberger (Zurich, CH)

S290 11:27–11:34

11:34–11:41

11:41–11:48

11:48–11:55

11:55–12:02

12:02–12:09 12:09–12:16

12:16–12:23

12:23–12:30

12:30–13:30 13:30–14:15

14:15–15:15 14:15–15:15

Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 O060 The contribution of fetal Imaging to the diagnosis of esophageal atresia: look at the trachea! V. Hochart (Lille, F) O061 The fetal renal artery hemodynamics in third trimester pregnancies with oligohydramnios M. Ozkan (Ankara, TR) O062 Can maternal sedation with low dose diazepam improve image quality of fetal MRI? E. Rubesova (Stanford, USA) O063 Bronchial Mucus Plug: Pre- and Post-natal Recognition and Significance E. Rubesova, Stanford, USA) O064 Initial experiences of a minimally invasive autopsy service E.H. Whitby, Sheffield, GB O065 Real time cine-MRI in prenatal imaging A.B.. Bhatia (Philadelphia, USA) O066 Congenital pulmonary malformations: agreement between prenatal MR imaging and postnatal CT with respect to histology L. Bonello (Milan, IT) O067 Post-mortem magnetic resonance imaging assessment of fetal maceration S. Addison (London, GB) O068 Recognizing the ‘Nutmeg’ Lung on Fetal MRI—a sign of congenital pulmonary lymphangiectasia T. Victoria (Philadelphia, USA) Lunch 12:40–13:25 Jacques Lefèbvre lecture Moderator: V. Donoghue The use of radiographic techniques in the study of art objects R. van Langh (Rijksmuseum, Amsterdam, NL) Taskforce session: Neuroradiology in paediatrics 14:15–15:15 Moderator: M. Argyropoulou Multicenter study in pediatric stroke” 14:15–14:20 M. Argyropoulou (Ioannina, GR) 14:20–14:40 14:40–15:00 15:00–15:10

15:15–15:45 15:45–17:15 15:45–16:15

Tea break Scientific session 6: Technique & Radiation protection 15:45–17:15 Moderators: H.C. Holscher, J.F. Chateil 15:45–16:20 Keynote lecture: Teleradiology—Better care through cooperation and image sharing J. Carlegrim (Linköping, SE) 16:20–17:00

16:15–17:15


16:15–16:22

16:22–16:29

16:29–16:36

16:36–16:43

O069 Imaging in Suspected Non Accidental Injury—Does Dose Matter? K. Chetcuti (Liverpool, GB) O070 The impact of bismuth shielding in dose reduction to the breasts during CT examinations of chest E. Ozmen (Istanbul, TR) O071 Paediatric Trauma: Children are not just small adults—Emergency imaging by the general radiologist. A. Quigley (Aberdeen, GB) O072 Indication based Diagnostic Reference Levels (DRL) for paediatric CT: a feasibility study R.M. Seuri (Helsinki, FIN)

17:00–17:10

Lunch Symposium

Taskforce session: Child abuse Moderators: A.C. Offiah, C. Adamsbaum Opening. A.C. Offiah (Sheffield, UK) Shaken baby syndrome—why both CT and MRI? E. Vazquez (Barcelona, ES) Shaken baby syndrome—the challenge of dating the event. C. Adamsbaum (Paris, FR) Collaborative research. A.C. Offiah (Sheffield, UK) ESPR Research committee session Moderators: K. Rosendahl, O. Arthurs International multicenter collaborative research: What can EIBIR offer? G.P. Krestin (Rotterdam, NL) Biostatistics for radiologists: repeatability studies. G. Di Leo (Milano, IT) Status, ongoing projects. E. Sorantin (Graz, AT)

Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 16:43–16:50

16:50–16:57

16:57–17:04

17:04–17:11

17:15–18:30 19:30–24:00

O073 Age-specific effective dose analysis for pediatric abdominal CT in the United States compared to other countries—how are we doing? S.J. Westra (Boston, USA) O074 Radiation induced cancer after CT scans in pediatrics: first results from a national cohort study in France N.J. Journy (Fontenay aux Roses Cedex, F) O075 Optimisation of image quality and patient dose in radiographs of paediatric extremities using DDR A. Jones (London, GB) O076 Optimize image quality and lower radiation dose in pediatric femur and pelvic fracture H. Precht General assembly & ESPR Awards Annual Dinner/Party

Friday, June 6 Themes

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Friday, June 6 Abdomen Oncology

08:30–10:30

08:30–08:50

08:50–10:30

Scientific session 7: Genitourinary & Gastrointestinal Moderators: J. Verbeke, J. Blickman Keynote lecture: Imaging strategies in urinary tract infections J.G. Blickman (Rochester, US) Scientific presentations

08:30–10:30

Scientific session 8: Oncology Moderators: A.M.J.B. Smets, P. Humphries

08:30–08:50

Keynote lecture: Whole body MR applications in paediatric oncology P. Humphries (London, UK)

08:50–10:30


08:50–08:57

O077 Post Mortem abdominal organ DWI G. Price (London, GB)

08:50–08:57

O091 Soft-tissue masses in children—a 4 year experience in a tertiary referral center, with imaging and histopathological correlation J. Carmichael (London, GB)

08:57–09:04

O078 The Long and Winding Road: Duodenum Inversum, a Controversial Imaging Diagnosis S.E. Ortiz-Romero (Cincinnati, USA)

08:57–09:04

O092 The time has come to abandon routine Tc99m-MDP bone scans in paediatric rhabdomyosarcoma K. McHugh (London, GB)

09:04–09:11

09:04–09:11 O079 Magnetic Resonance Manifestations of Liver in Langerhans Cell Histiocytosis with Emphasis on MR Cholangiopancreatography S.H.I. Yingyan (Shanghai, CN) 09:11–09:18 O080 Does appendix diameter change with age? A sonographic study S.M. Coyne (Cincinnati, USA)

O093 Imaging examinations and trends within the EpSSG study K. McHugh (London, GB)

09:11–09:18

O094 The Efficiency of Share Wave Elastography in Differentiation of Pediatric Malign Hepatic Tumors from Infantile Hepatic Hemangioma E. Ozmen (istanbul, TR)

09:18–09:25

O081 Elastosonographic evaluation of testes with varicocele C. Bruno (Verona, IT)

09:18–09:25

O095 High-pitch abdominal CT in oncologic patients. Comparison of radiation dose and image quality between FLASH vs FLASH-SAFIRE scan protocol on a 128-slice DSCT system S.S. Savelli (Roma, IT)

09:25–09:32

09:25–09:32 O082 Renal involvement in children with Tuberous Sclerosis (TS): can we define the optimal follow-up by Imaging? A. Robert (Lille, F)

O096 The Brain Supporters Project: a system to support diagnosis of brain lesions of suspected infectious origin, in transplanted patients, starting from a database and a set of radiologic image analysis tools F. Zennaro (Trieste, IT)

09:32–09:39

O083 Establishing a reference range for the renal pelvis anterior- 09:32–09:39 posterior diameter in children ages 0–18 years J.S. Chow (Boston, USA)

O097 Thoracic imaging findings in long-term cancer survivors T.R. Mehlman (Cincinnati, USA)

09:39–09:46

O084 “Dynamic” ultrasonography in the assessment of children with urinary tract abnormalities O. Fufezan (Cluj-Napoca, RO)

O098 Comparison of Semi-automated Volumetry with Elliptical Volume in Pediatric Neuroblastoma & Rhabdomyosarcoma: A Pilot Study A. Almuslim (Al-khobar, AS)

09:46–09:53

O085 Role of low-dose techniques in the evaluation of ingested 09:46–09:53 foreign bodies: 1 year experience in a pediatric referral center A. Magistrelli (Rome, IT)

09:39–09:46

O099 Soft Tissue Neuroblastoma Response to I-131 MIBG in the Pediatric Population A.B.. Bhatia (Philadelphia, USA)

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Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 O086 Association of Tuberous Sclerosis Complex with Pancreatic Neuroendocrine Tumors G. Koc (Kayseri, TR) O087 How reliable is ultrasound in detecting vascular complications following liver transplantation in children? T. Humphrey (Leeds, GB) O088 Renal DTI and tractography in pediatric patients K. Darge (Philadelphia, USA)

09:53–10:00

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O089 Reproducibility of functional MR urography (fMRU) analysis results K. Darge (Philadelphia, USA)

10:14–10:21

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O090 Volume-dependency of bladder wall thickness in children: effects on normal cut-off values A. Seehofnerová (Bruno, CZ) Coffee Break Scientific session 9: Gastrointestinal Moderators: A.S. Littooij, M. Raissaki

10:21–10:28

09:53–10:00

10:00–10:07

10:07–10:14

10:30–11:00 11:00–12:30

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Keynote lecture: Ultrasonographic evaluation of the pediatric pancreas: what to look for M. Raissaki (Heraklion, GR)

10:00–10:07

10:07–10:14

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11:30–12:00

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O105 Can Sonoelastography Differentiate the Subgroups of Chronic Liver Diseases? E. Ozmen (Istanbul, TR) O106 Dual Bolus Single Acquisition CT (DBSA-CT) in children: factors affecting technical quality J.M. Stedman (Oxford, GB) O107 Splenic parenchymal heterogeneity and impact on image interpretation at dual-bolus single-acquisition CT (DBSA-CT) in paediatric poly-trauma patients J.M. Stedman (Oxford, GB) O108 CT and MR enterography in pediatric patients with eosinophilic gastrointestinal disorders A.J. Towbin (Cincinanti, USA) O109 Identification of the Duodenojejunal Junction on Magnetic Resonance Enterography in Children A. Almuslim (Al-khobar, AS) O110 Anticlockwise swirl of mesenteric vessels: A normal CT appearance, Retrospective analysis of 200 pediatric patients S. Kushaljit (Chandigarh, IND) O111 MR colonography with diffusion weighted imaging (DWI) in children and adolescents with inflammatory bowel disease (IBD): Is intravenous contrast really needed? S. Kinner (Essen, D) O112 Real-time tissue elastography (RTE) in pediatric liver diseases J.P. Schenk (Heidelberg, D) O113 Significance of Intrahepatic Bile Duct Status in LongTerm Survivors of Biliary Atresia After Portoenterostomy H. J. Lee (Daegu, ROK) O114 High resolution MRI for preoperative work-up in anorectal malformation: a prospective study comparing with fluoroscopic studies using surgical findings as reference standard M.G.J. Thomeer (Rotterdam, NE)

12:00–12:30

O100 Pleural Effusions in Intermediate Risk Hodgkin Lymphoma: Evolution and Significance K.M. McCarten (Providence, USA) O101 Evaluation of metastatic risk factors in children with retinoblastoma: High-resolution MRI using orbit surface coils vs. conventional MRI S. Sirin (Essen, D) O102 Role of diffusion-weighted MRI in diagnosis and monitoring of neuroblastoma in children E. Varga (Budapest, H) O103 Whole-body MRI for staging of paediatric lymphoma: prospective comparison to an FDG-PET/CT-based reference standard A.S. Littooij (Utrecht, NE) O104 MR imaging findings in children with pseudotumor cerebri and comparison with healthy controls S. Gorkem (Kayseri, TR) Special focus session: Molecular imaging/Nuclear medicine Moderator: P. Brader Molecular Imaging—MRI and Optical imaging P. Brader (Graz, AT) Current status and future directions of PET imaging in paediatric oncology R. Kluge (Leipzig, DE) Current status of PET imaging in paediatrics— non-oncological indications A.W.J.M. Glaudemans (Groningen, NL)

Pediatr Radiol (2014) 44 (Suppl 2):S255–S402 12:30–13:30 13:30–14:00

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Lunch Plenary Lecture Moderator R.R. van Rijn Image guided oncological interventions—current status and future perspectives M.A.A.J. van den Bosch (Utrecht, NL) Special focus/Taskforce session: Uroradiology & Abdominal imaging Moderator: M. Riccabona Potential of ultrasound elastography in children: liver and kidney M. Stenzel (Jena, DE) Testicular torsion in infancy and childhood L.S. Ording Müller (Oslo, NO)

12:40–13:25

Lunch Symposium

14:00–15:30

Special focus/Taskforce session: Oncology Moderator: A.M.J.B. Smets

14:00–14:25

Treating childhood cancer: present and future H.N. Caron (Amsterdam, NL)

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The role of imaging in intersex M.L. Lobo (Lisbon, PT)

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15:15–15:30 Retrograde urethrography in infants and children—a procedural recommendation K. Darge (Philadelphia, US) Efforts to standardise terminology in pediatric uroradiology P.H. Vivier (Le Havre/Rouen, FR) The ESPR uroradiology (and GI/abdominal) task force, an update M. Riccabona (Graz, AT) Closing ceremony (poster/presentation Awards)

True and pseudo-progressive disease in osteosarcoma patients H. Brissé (Paris, F) Response of the primary tumour and outcome in neuroblastoma K. McHugh (London, UK) Ongoing projects/Difficult cases A.M.J.B. Smets (Amsterdam, NL)

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ESPR 2014, 51st Annual meeting—Plenary and Keynote lectures

Abstracts AM01 Leadership in Radiology: The Way Forward in a Changing Radiological World G.P. Krestin Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands

Imaging is the key diagnostic tool in many diseases and has an important role in monitoring treatment and predicting outcome. A wide variety of new medical imaging techniques and methods produce important biological information about physiology, organ function, biochemistry, metabolism, molecular biology and functional genomics. These new methods combine the ability to measure and quantify biological processes with the ability to localize the measured entities into a high-quality anatomical image providing a new class of versatile and useful biomarkers. Stratification based on such imaging biomarkers can help identify individuals for preventive intervention and can improve disease staging. In vivo visualization of loco-regional physiological, biochemical, and biological processes using molecular imaging can detect diseases in pre-symptomatic phases or facilitate individualized drug delivery. Furthermore, imaging biomarkers are essential to patient-tailored therapy planning, therapy monitoring, and follow-up of disease progression, as well as targeting non-/minimally-invasive treatments, especially with the rise of theranostics. While medical imaging has always been personalized as it provides individual assessment of the location and extent of an abnormality, in the future it will prove fundamental to almost all aspects of personalized medicine. Thus, for personalized medicine to reach its’ highest potential, medical imaging must be an integral part. Leadership in radiology needs to be prepared for this new paradigm as it will mean changes in training, in research, and in clinical practice. Making medicine more personalized and precise will entail increasing emphasis on, and precision in, diagnostics. Diagnoses however, depend on multiple components that include not only imaging, but also clinical observation, pathology, laboratory, and genomic tests. To date, there is too little coordination between the medical specialities responsible for ordering and performing these tests, nor is there enough consideration as to the optimal order of tests. What is required is a new concept of “integrated diagnostics”: the convergence of imaging, pathology and laboratory tests with advanced information technology (IT). Around the world, pressures are mounting to expand healthcare coverage while reducing its cost. Much of the spending is wasteful—the result of inappropriate or fragmented care, in which diagnostic tests and treatments are under-used, over-used, or delayed. Recent studies suggest that integrated delivery systems, in which specialists share information and work in teams to determine which tests and procedures are necessary, result in less costly, higher-quality care. Integrated diagnostics offers increased operational efficiency and benefits to patients in terms of more rapid and accurate diagnoses. As physicians with the most expertise in IT, radiologists are well placed to take the lead in introducing IT solutions and cloud computing to promote integrated diagnostics. Notwithstanding the continuing need for a broad perspective, further subspecialization of radiologists will become necessary, given the sheer immensity of radiological knowledge and the rate at which it is growing. Benefits of sub-specialization include higher level of expertise, higher quality of patient services, improved efficiency, and improved interaction and common language with other clinicians. Sub-specialization improves


the standing of radiology as a specialty, enriches radiologists’ armamentarium in turf battles, provides a stronger basis for clinical research, and supports recruitment of students into radiology. Such sub-specialization will be most useful when it follows the specializations within the nonradiological disciplines, as this will provide a solid foundation for intensive collaboration between medical specialist and imaging specialist. However, sub-specialization needs to evolve from one-dimensional organ/system based models to three-dimensional patient-centered matrix models in which mastering and further improving imaging technology should remain a substantial component. Performing the appropriate, standardized, high quality exam and delivering a correct, reliable and timely interpretation is usually taken for granted by customers of imaging services. It is the additional ad-hoc advice and expert consultation in formalized multidisciplinary conferences and boards that is most valued by referring physicians. Putting an increased emphasis on super-specialized consultation activities, radiologists could offer highly valued services that would be different from standard commodities. These consultations should be offered to primary care physicians by triaging their patients between general practice and hospital care and by offering full outpatient evaluation (including in vitro diagnostics) with a fast and efficient telecommunication of the results. Integrated diagnostics presents an opportunity for radiology to evolve as a profession and deepen the impact of the radiologist on healthcare.

AM02 WFPI: Bringing pediatric radiology all over the world; an update M.I. Boechat Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, USA

The World Federation of Pediatric Imaging (WFPI) was launched in London at the IPR 2011. Presented as a “committed visionary group with a strategic plan to explore global inequalities […] and address them tactically with a focus on education, training and a partnership across all nations”, WFPI has since evolved into a carefully structured medicopolitico organization governed by an international board (from: Presidents’ welcome address, IPR supplement, May 2011, Pediatric Radiology). Its global mission: to unite pediatric imaging organizations to form one voice, a common message, a unified network in addressing the global challenges of pediatric imaging. Given its roots and history, WFPI’s primary goal must be communication and collaboration between pediatric imaging practitioners via their organizations. From this all other action flows. Our founding four regional societies (AOSPR, ESPR, SLARP and SPR) were soon joined by the African Society for Pediatric Imaging (AfSPI), on WFPI’s Council. The British, French-speaking, German-speaking, Indian, Nigerian, Spanish and South African groups are also WFPI members. We aim to encourage other groups to form and/or join us. How have the original group’s hopes and dreams been translated into action? Education comes in many shapes and sizes. A part of WFPI’s education output is rolled out in multi-partner set-ups: ACR-Haiti (radiology education days), UCLA-Mozambique (pediatricians’ rotations in Los Angeles, onsite training and education), Ethiopia (via Children’s Hospital of Philadelphia and a pediatric radiology fellowship) and South Africa (via African societies). Equally, WFPI focuses on onsite and hands-on training—for Médecins Sans Frontières (MSF) physicians working on AIDS and TB and in health facilities in South Africa, Malawi and Mozambique. WFPI also offers a selection of online links to educational material via its website (www.wfpiweb.org) and plans a major shift in focus to an online video repository; the production of short films has started (f.i., Savvas’ Seven Minute Snippets, TB Corner. Retrieved February 5, 2014 from http://pedrad.org/associations/5364/wfpi/Outreach/TBCorner.aspx.). We


invite our member societies to contribute to this forward-looking medium of multi-discipline appeal, accessible any time, any place, which seems to be the future for us all. Breaking down geographic and economic education barriers still further, SPR run a web streaming trial at its 2014 annual meeting, in association with WFPI. WFPI’s sentinel efforts in outreach and training in lower resource settings rely on a flow of support from modern medical settings to medically underserved areas, led either by people on the ground or with direct links to the facilities, “bolting on” to existing facilities and/or other not-forprofit organizations’ initiatives. In all cases, we add pediatric imaging expertise to existing services, largely based upon tele-radiology but heavily underpinned with (planned or current) training and education support, onsite and online. Among on-going projects, MSF largely sends us TB, while Khayelitsha Hospital (South Africa) now refers straight to Stanford University as part of WFPI’s “buddy” system. A tele-reading/training project in Malawi is under preparation, as is work in Central Europe. An Indian CT project has struggled to start, but our TB work is taking form through training in “HIV hotspots”. At a global level, there are on-going discussions on the best use of a standardized methodology for the interpretation of pediatric chest radiographs in epidemiological studies, including education and safety. WFPI is part of the initial stages of a proposal process to re-establish a global advisory group, in collaboration with the World Health Organization (WHO). Also on the research front, WFPI is looking to become a pediatric partner for Imaging the World (ITW) (Imaging the World. Retrieved February 5, 2014 from http://imagingtheworld.org/.), involving non-radiologists acquiring ultrasound images using anatomical landmarks on the skin and storing US sweeps as cine-loops in a standard format to be tele-read by radiologists. We are developing hydronephrosis, hydrocephalus and mediastinal lymphadenopathy (as a proxy for TB) volume sweep US protocols to be used in rural clinics at the point of care (POC) for management changing decisions. The TB volume sweep protocols were introduced in the Red Cross Memorial Children’s Hospital, Cape Town, in January 2014, nested within a larger HIV-TB project. The development of head and kidney protocols need moving forward, we would like to see them adopted in Europe. We are very fortunate to have our outreach efforts steered by physicians from lower resource settings, in step with field realities and creating vital partnerships on the ground. We have 50+ international volunteers ready to tele-read and many ideas for projects. But the challenges are immense. Outreach work in imaging cannot be addressed in isolation of the larger environment, often harbouring a towering disease burden and a lack of equipment, infrastructure and manpower, among others. Nonetheless, the medicine we seek to provide is an attempt to offer a serious and quality response to the expectations of parents/ caregivers whose children are deprived of access to healthcare. We need to develop techniques and approaches that are better adapted to the living conditions and priorities of these young patients, and publish our results, meeting the highest ethical and scientific standards. However, decision-making at health authority or facility manager level and scientific certitude operate on different time-scales. We need determination and lucidity as WFPI outreach work moves ahead. On the publication side, Drs. Savvas Andronikou and Kieran McHugh will edit a WHO manual on pediatric radiology and ultrasound under the auspices of the ISR with international authors. WFPI has co-published an article on tele-radiology with MSF, edited MSF’s ultrasound manual and produced the WFPI mini-symposium for Pediatric Radiology. Global advocacy for pediatric imaging often dovetails with imaging safety efforts, tied in to the Image Gently campaign in a bid to avoid the duplication of resources. WFPI members have attended global meetings in Geneva and the USA to reinforce these messages. Since 2011, our leaders have worked hard to create a clear mandate to govern and lay WFPI’s institutional foundations. We accepted the challenges of setting up an international organization driven by regional and

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national groups that are highly diverse—internally and in their respective aspirations for WFPI. We have had moments of tangible worldwide collaboration, and wrestled with deep tensions that will need time and empathy to resolve. We aim to accommodate varying viewpoints in so far as our resources allow, but ultimately WFPI calls for the blurring of national and regional boundaries, the re-distribution of traditional stakeholder roles and the acceptance that actions must be louder than words if we wish to accomplish our goals. Europe’s participation is a fundamental part of our future success.

AM03 HIV and related infections S. Andronikou Department of Radiology, Faculty of Health Sciences, University of the Witwatersrand, South Africa

There are over 2 million HIV-infected children in sub-Saharan Africa and about a fifth of these are in South Africa. Imaging in HIV infection and AIDS is often performed with plain radiographs of the chest and with MRI of the central nervous system. Chest imaging presents the radiologist with interpretation difficulties because it predisposes children with HIV infection to both common and unusual super-infections, often simultaneously. Furthermore, imaging findings become less specific as diseases compound each other and when complications of HIV such as aspiration and cardiac failure occur. HIVrelated neoplasms, such as lymphoma and Kaposi sarcoma may be indistinguishable from infections such as TB, particularly when there is lymphadenopathy or a diffuse nodular pattern (Figure 1). Highly active anti-retroviral therapy (HAART) also complicates interpretation. As treatment allows the body to develop an immune response, the phenomenon of immune reconstitution inflammatory syndrome (IRIS) may occur with a worsening imaging picture. Clinical information is paramount for the radiologist to make an adequate interpretation of a chest radiograph: newonset pyrexia allows the radiologist to make the diagnosis of infection; skin lesions allow the suggestion of Kaposi sarcoma in the differential diagnosis; low CD4 counts make some infections or neoplasms more likely. The clinician also depends on radiological identification of lymphadenopathy to start anti-TB treatment prior to initiating HAART. Disease progression, resolution of acute infections, response to treatment and success of interventions for some complications can also be determined using chest radiography. CT has an adjunctive role for diagnosis and for guided biopsy but has limited availability in developing countries in Africa, requires expertise to interpret it, and carries a significant radiation burden. When imaging the central nervous system, the radiologist also needs to distinguish changes resulting from HIV infection itself, such as brain shrinkage and HIV encephalopathy (HIVE) from super-infections and neoplasms. Again, co-infection with TB may complicate the imaging appearances. In particular, HIV immunosuppression has been shown to mask the features of TB meningitis (TBM) because the patient is unable to mount an inflammatory response, which is essential for generating the well-known imaging features of TBM. Basal enhancement is often absent or mild, and when present may be atypical and focal with milliary meningeal nodules (Figure 2). Distinguishing hydrocephalus as a result of TBM from ventriculomegally due to atrophy is also challenging. New advances such as, diffusion tensor imaging, are able to detect whitematter disease before signal changes occur making MRI scanning a possible screening tool for early detection of encephalopathy. Postprocessing techniques allow quantification of atrophy, which also can direct management. HIV infection also predisposes to multiple forms of extra-pulmonary TB and imaging of the abdomen and musculoskeletal system is also part of the radiologist’s duty in these patients.

S296 AM04 Infectious diseases of the hepatic parenchyma and biliary tract E. Nunez1, P. Daltro1, M. Boechat1, E. Just da Costa e Silva2 1 Department of Radiology, Instituto Fernandes Figueira, Rio de Janeiro, Brazil 2 Escola Pernambucana de Medicina e Saúde, FBV-IMIP, Pernambuco, Brazil

Liver infections remain a major public health problem worldwide. This report describes the most common liver diseases and their respective complications/ characteristics affecting children and adolescents in Brazil. Infectious liver and biliary tract diseases can be diagnosed and their severity defined by ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), or cholangiography; however, US is often the first and only imaging exam performed due to its efficiency and affordability. Viral infections Hepatitis A, B and C virus (HAV, HBV, and HCV) infections represent primary causes of viral hepatitis affecting millions in Brazil and many individuals are chronic carriers. HAV is transmitted primarily via the fecal/oral contamination of food and water. Infections are usually benign but

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Abstracts. Seventh annual meeting. The European Society for Paediatric Haematology and Immunology. Oslo, Norway, June 11-13, 1979.

Abstracts of the 54th Annual Teratology Society Meeting, June 28-July 2, 2014, Bellevue, Washington.

Abstracts from the 37th Annual Meeting of the Society of General Internal Medicine, 2014, San Diego, CA, USA.

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Society of Thoracic Radiology ninth annual meeting and postgraduate course, May 1991.

European Society for Paediatric Gastroenterology and Nutrition (ESPGAN) and North American Society for Paediatric Gastroenterology (NASPGN). Abstracts presented at the third joint meeting. Amsterdam, The Netherlands, May 23-26, 1990.

Abstracts of the XXXII Annual Scientific Meeting of the British Blood Transfusion Society, 24-26 September 2014, North Yorkshire, UK.

Abstracts of the 2014 SGI 61st Annual Scientific Meeting, March 26-29, 2014, Florence Italy.

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Selected abstracts of the 19th annual meeting of the European Environmental Mutagen Society. 21-26 October 1989, Rhodes, Greece.

British society of breast radiology annual scientific meeting 2014.

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31st annual meeting of the European Society for Paediatric Endocrinology (ESPE). Zaragoza, September 6-9, 1992. Abstracts.

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