Miliary meningeal tuberculosis - an unusual imaging presentation for an early definitive diagnosis.

PURPOSE: Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with magnetic resonance (MR) imaging diagnosis. We present MR-detectable miliary meningeal TB in two patients. CASE 1: A 9-year-old girl developed fevers, cough, lethargy, and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. CSF showed pleocytosis, low glucose, and high protein. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules, and a splenic hypo enhancing lesion. Serial bronchoalveolar lavage studies were Xpert MTB/RIF and acid-fast negative. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR. She was started on a 4-drug treatment for TBM and dexamethasone. Contact tracing revealed a remote positive contact with pulmonary tuberculosis. CASE 2: A 17-year-old female with Crohn's disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics. She underwent myringotomy, with negative aerobic ear fluid culture. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were normal. CT chest, abdomen, and pelvis to assess for disseminated disease showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT-guided aspiration of the obturator muscle collection, bronchoscopy with bronchoalveolar lavage, biopsy of two preexisting chronic skin lesions, and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. Cultures from the ear fluid, skin tissue, muscle tissue, and alveolar lavage showed growth of acid-fast bacilli. She was started on 4-drug therapy and prednisone. CONCLUSION: Our cases highlight that TBM in many cases remains a diagnostic dilemma - both our patients presented in a prolonged atypical manner. The term miliary TB not only refers to a pattern of interstitial nodules on chest radiographs but also indicates the hematogenous spread of the disease and concurrent pulmonary and extrapulmonary involvement with high risk of TB meningitis. We promote the use of the term miliary meningeal TB - in both cases, the neuroimaging diagnosis of TB preceded both chest imaging and laboratory confirmation of the disease. Miliary meningeal nodules on MRI may have characteristic T2 low signal and may be more conspicuous in children and immunocompromised individuals where background basal meningeal enhancement is less prominent.

State-of-the-art imaging for children with central lymphatic disorders.

Lymphatic imaging plays a crucial role in novel lymphatic interventions, offering valuable insights into central lymphatic drainage. Lymphatic system abnormalities may appear in various pediatric disorders, and accurate imaging is crucial for effective diagnosis and tailored therapeutic interventions. Traditional imaging modalities have offered valuable insights, but the demand for non-invasive, high-resolution techniques has fueled the development of innovative lymphatic imaging methods. In this review, we explore the state of the art in lymphatic imaging specifically within the context of pediatric surgery.

Frequency of MRI Low Signal Intensity in the Buccal Fat of Fetuses and Speculation as to What It May Reflect.

PURPOSE: We aimed to characterize the fetal buccal fat pad (BFP) on magnetic resonance imaging (MRI) to determine the frequency and types of sequences on which the BFP demonstrates low signal intensity and determine any possible correlation with timing of the MRI during fetal development. MATERIALS AND METHODS: A retrospective review of all fetal MR studies was performed, and a pediatric radiologist blinded to the referring and final fetal diagnosis as well as outcome evaluated the included cases. A positive buccal fat pad sign (BFS) was recorded as present if a round, symmetric, and bilateral area was seen in the submalar region of the face with the following signal characteristics: T1 hyperintensity, low signal on echo planar imaging (EPI), low signal on true fast imaging with steady-state free precession (TRUFI), and with restriction on diffusion-weighted imaging (DWI). RESULTS: A total of one hundred sixty-seven (167) fetal MRI studies: one hundred fourteen (114) body (68%) and fifty-three (53) neuro (32%) scans were reviewed during the study period. The BFS was most commonly seen on EPI (63%) and TRUFI (49%) sequences. Substantial agreement between TRUFI and EPI (κ = 0.68; p < 0.01); moderate agreement between TRUFI and T1 (κ = 0.53; p < 0.01) as well as T1 and EPI (κ = 0.53; p < 0.01), and fair agreement between EPI and Diffusion (κ = 0.28; p < 0.01) was observed. The median gestational age (GA) was 24 weeks (IQR 22-30 weeks). The fetuses with a positive BFS were significantly older (mean GA of 27 weeks or higher) than those without, for each sequence. CONCLUSIONS: The focal low signal in the fetal buccal fat pad, termed the fetal BFS, is a commonly encountered normal finding in the majority of fetal MRI scans on TRUFI and EPI sequences. This finding may be related to the presence and development of brown adipose tissue in the buccal fat pad resulting in T2* effects, but further studies are needed in order to confirm this. Further work can incorporate any of the sensitive sequences demonstrating low signal in brown adipose tissue to map its distribution and development in the fetus and beyond.

Percutaneous biopsy for the diagnosis, risk stratification, and molecular profiling of neuroblastoma: A single-center retrospective study.

PURPOSE: To determine whether percutaneous core needle biopsy (PCNB) is adequate for the diagnosis and full molecular characterization of newly diagnosed neuroblastoma. MATERIALS AND METHODS: Patients with newly diagnosed neuroblastoma who underwent PCNB in interventional radiology at a single center over a 5-year period were included. Pre-procedure imaging and procedure details were reviewed. Rates of diagnostic success and sufficiency for International Neuroblastoma Pathology Classification (INPC), risk stratification, and evaluation of genomic markers utilized in the Children's Oncology Group risk stratification, and status of the anaplastic lymphoma kinase (ALK) gene were assessed. RESULTS: Thirty-five patients (13 females, median age 2.4 years [interquartile range, IQR: 0.9-4.4] and median weight 12.4 kg [IQR: 9.6-18]) were included. Most had International Neuroblastoma Risk Group Stage M disease (n = 22, 63%). Median longest axis of tumor target was 8.8 cm [IQR: 6.1-12]. A 16-gauge biopsy instrument was most often used (n = 20, 57%), with a median of 20 cores [IQR: 13-23] obtained. Twenty-five specimens were assessed for adequacy, and 14 procedures utilized contrast-enhanced ultrasound guidance. There were two post-procedure bleeds (5.7%). Thirty-four of 35 procedures (97%) were sufficient for histopathologic diagnosis and risk stratification, 94% (n = 32) were sufficient for INPC, and 85% (n = 29) were sufficient for complete molecular characterization, including ALK testing. Biologic information was otherwise obtained from bone marrow (4/34, 12%) or surgery (1/34, 2.9%). The number of cores did not differ between patients with sufficient versus insufficient biopsies. CONCLUSION: In this study, obtaining multiple cores with PCNB resulted in a high rate of diagnosis and successful molecular profiling for neuroblastoma.

Accuracy of non-medical and medical individuals in identifying cerebral cortical abnormality from three-dimensional printed models of magnetic resonance images in children with hypoxic ischemic injury.

Effective communication of imaging findings in term hypoxic ischemic injury to family members, non-radiologist colleagues and members of the legal profession can be extremely challenging through text-based radiology reports. Utilization of three-dimensional (D) printed models, where the actual findings of the brain can be communicated via tactile perception, is a potential solution which has not yet been tested in practice. We aimed to determine the sensitivity and specificity of different groups, comprising trained radiologists, non-radiologist physicians and non-physicians, in the detection of gross disease of the cerebral cortex from 3-D printed brain models derived from magnetic resonance imaging (MRI) scans of children. Ten MRI scans in children of varying ages with either watershed pattern hypoxic ischemic injury (cortical injury) or basal-ganglia-thalamus hypoxic ischemic injury pattern with limited perirolandic cortical abnormalities and 2 normal MRI scans were post processed and 3-D printed. In total, 71 participants reviewed the 12 models and were required to indicate only the brain models that they felt were abnormal (with a moderate to high degree of degree of confidence). The 71 participants included in the study were 38 laypeople (54%), 17 radiographic technologists (24%), 6 nurses (8%), 5 general radiologists (7%), 4 non-radiologist physicians- 3 pediatricians and 1 neurologist (6%) and 1 emergency medical services staff (1%). The sensitivity and specificity for detecting the abnormal brains of the 71 participants were calculated. Radiologists showed the highest sensitivity (72%) and specificity (70%). Non-radiologist physicians had a sensitivity of 67.5% and a specificity of 75%. Nurses had a sensitivity of 70% and a specificity of 41.7%. Laypeople (non-medical trained) had a sensitivity of 56.1% and a specificity of 55.3%. Radiologists' high sensitivity and specificity of 72% and 70%, respectively, validates the accuracy of the 3-D-printed models in reproducing abnormalities from MRI scans. The non-radiologist physicians also had a high sensitivity and specificity. Laypeople, without any prior training or guidance in looking at the models, had a sensitivity of 56.1% and a specificity of 55.3%. These results show the potential for use of the 3-D printed brains as an alternate form of communication for conveying the pathological findings of hypoxic ischemic injury of the brain to laypeople.

Embolization for pediatric trauma.

BACKGROUND: The management of pediatric trauma with trans-arterial embolization is uncommon, even in level 1 trauma centers; hence, there is a dearth of literature on this subject compared to the adult experience. OBJECTIVE: To describe a single-center, level 1 trauma center experience with arterial embolization for pediatric trauma. MATERIALS AND METHODS: A retrospective review was performed to identify demographics, transfusion requirements, pre-procedure imaging, procedural details, adverse events, and arterial embolization outcomes over a 19-year period. Twenty children (age 4.5 months to 17 years, median 13.5 years; weight 3.6 to 108 kg, median 53 kg) were included. Technical success was defined as angiographic resolution of the bleeding-related abnormality on post-embolization angiography or successful empiric embolization in the absence of an angiographic finding. Clinical success was defined as not requiring additional intervention after embolization. RESULTS: Seventy-five percent (n=15/20) of patients required red blood cell transfusions prior to embolization with a mean volume replacement 64 ml/kg (range 12-166 ml/kg) and the median time from injury to intervention was 3 days (range 0-16 days). Technical success was achieved in 100% (20/20) of children while clinical success was achieved in 80% (n=16/20). For the 4 children (20%) with continued bleeding following initial embolization, 2 underwent repeat embolization, 1 underwent surgery, and 1 underwent repeat embolization and surgery. Mortality prior to discharge was 15% (n=3). A post-embolization mild adverse event included one groin hematoma, while a severe adverse event included one common iliac artery pseudoaneurysm requiring open surgical ligation. CONCLUSIONS: In this single-center experience, arterial embolization for hemorrhage control in children after trauma is feasible but can be challenging and the clinical failure rate of 20% in this series reflects this complexity. Standardization of pre-embolization trauma assessment parameters and embolic techniques may improve outcomes.

Caution: shortcomings of traditional segmentation methods from magnetic resonance imaging brain scans intended for 3-dimensional surface modelling in children with pathology.

This technical innovation assesses the adaptability of some common automated segmentation tools on abnormal pediatric magnetic resonance (MR) brain scans. We categorized 35 MR scans by pathologic features: (1) "normal"; (2) "atrophy"; (3) "cavity"; (4) "other." The following three tools, (1) Computational Anatomy Toolbox version 12 (CAT12); (2) Statistical Parametic Mapping version 12 (SPM12); and (3) MRTool, were tested on each scan-with default and adjusted settings. Success was determined by radiologist consensus on the surface accuracy. Automated segmentation failed in scans demonstrating severe surface brain pathology. Segmentation of the "cavity" group was ineffective, with success rates of 23.1% (CAT12), 69.2% (SPM12) and 46.2% (MRTool), even with refined settings and manual edits. Further investigation is required to improve this workflow and automated segmentation methodology for complex surface pathology.