Ultrasound imaging of bowel obstruction in infants and children.

We review the etiologies of bowel obstruction in infants and children that can be identified on ultrasound (US) including perforated appendicitis, intussusception, foreign body ingestion, colonic volvulus, intra-abdominal mass lesions, internal hernia, and stricturing inflammatory bowel disease. US can potentially identify the cause of bowel obstruction in these age groups, without the need for additional cross-sectional imaging, and can aid in patient management including interventional and surgical planning. Hence, it is important to be familiar with the sonographic imaging findings of bowel obstruction in infants and children.

MR imaging spectrum of adolescent pubic symphyseal injuries/athletic pubalgia.

BACKGROUND: Magnetic resonance imaging (MRI) findings associated with athletic pubalgia are well documented in the adult literature. OBJECTIVE: To describe the spectrum of MRI findings in adolescents with pubic symphyseal injuries/athletic pubalgia. MATERIALS AND METHODS: This is an institutional review board approved, retrospective study of all patients < 18 years who were referred for MRI, over the last 10 years. Two pediatric musculoskeletal radiologists evaluated the MRI in consensus for the following findings: Chronic Salter-Harris (SH)-I equivalent fracture or asymmetric parasymphyseal ossific fraying, non-retractile muscular tear or retraction, and edema of the aponeurosis and arcuate ligament. Radiographs were also reviewed for Risser stage. RESULTS: Fifteen patients were identified (100% male, median age 17 years, IQR 16-17.6). Most patients (14/15, 93%) had either asymmetric parasymphyseal ossific fraying (4/15, 27%) or chronic SH-1 equivalent fracture (10/15, 67%) of the pubic symphysis, and all patients (15/15, 100%) had aponeurotic and arcuate ligament edema. Few patients had rectus abdominis muscular retraction (2/15, 13%), non-retractile muscular tear of the rectus abdominis (2/15, 13%), and/or adductor muscle (4/15, 27%). Risser stage was as follows: stages 0 (13%), 3 (7%), 4 (47%), and 5 (33%). The injuries in our limited data set were independent of skeletal maturity with no statistically significant association between any of the MRI findings and Risser stage. CONCLUSION: The MR imaging spectrum of adolescent athletic pubalgia differs from the described findings in adults due to skeletal immaturity. The cleft sign described in adults manifests in adolescents as asymmetric parasymphyseal ossific fraying and chronic SH-1 equivalent fractures.

Ultrasound imaging of bowel obstruction in neonates.

Bowel obstruction (BO) in children has a wide differential diagnosis, ranging from non-urgent conditions to surgical emergencies. Abdominal radiographs are most often used as the first imaging modality for the evaluation of obstruction. However, for some indications, ultrasound can be the primary imaging modality. Therefore, it is incumbent on radiologists to recognize the types of bowel obstruction that can be recognized with US. Key sonographic features of BO include differential dilation of bowel loops, bowel wall thickening, and free fluid. "Do Not Miss" findings that indicate need for emergent treatment include volvulus, pneumoperitoneum, and/or signs of ischemia (bowel wall thinning and/or absent perfusion). The aim of this pictorial essay is to provide guidance on the sonographic technique and findings that enable identification of BO on US. Examples of neonatal BO on US, including common and less frequently encountered etiologies, are illustrated in this pictorial essay.

Medial meniscal posterior horn tears and ramp lesions in pediatric patients: lessons learned.

Meniscal injuries are increasingly reported in pediatric patients due to early sports participation and are commonly encountered during anterior cruciate ligament reconstruction. Preoperative identification of meniscal tears is crucial, particularly when involving the posteromedial meniscocapsular junction (ramp lesion). MRI plays an important role in detecting this particular type of meniscal injury. Consequently, pediatric radiologists should be aware of particular MRI findings related to ramp lesions including the presence of a medial meniscal tear, peripheral meniscal irregularity, meniscocapsular junctional fluid-like signal intensity, and capsular ligament tears. Thus, we illustrate the lessons we have learned from our institutional multidisciplinary arthroscopic-MR correlation conference for retrospectively identified posterior horn medial meniscal tears and ramp lesions.

Diagnostic performance of artificial intelligence for pediatric pulmonary nodule detection on chest computed tomography: comparison of simulated lower radiation doses.

The combination of low dose CT and AI performance in the pediatric population has not been explored. Understanding this relationship is relevant for pediatric patients given the potential radiation risks. Here, the objective was to determine the diagnostic performance of commercially available Computer Aided Detection (CAD) for pulmonary nodules in pediatric patients at simulated lower radiation doses. Retrospective chart review of 30 sequential patients between 12-18 years old who underwent a chest CT on the Siemens SOMATOM Force from December 20, 2021, to April 12, 2022. Simulated lower doses at 75%, 50%, and 25% were reconstructed in lung kernel at 3 mm slice thickness using ReconCT and imported to Syngo CT Lung CAD software for analysis. Two pediatric radiologists reviewed the full dose CTs to determine the reference read. Two other pediatric radiologists compared the Lung CAD results at 100% dose and each simulated lower dose level to the reference on a nodule by nodule basis. The sensitivity (Sn), positive predictive value (PPV), and McNemar test were used for comparison of Lung CAD performance based on dose. As reference standard, 109 nodules were identified by the two radiologists. At 100%, and simulated 75%, 50%, and 25% doses, lung CAD detected 60, 62, 58, and 62 nodules, respectively; 28, 28, 29, and 26 were true positive (Sn = 26%, 26%, 27%, 24%), 30, 32, 27, and 34 were false positive (PPV = 48%, 47%, 52%, 43%). No statistically significance difference of Lung CAD performance at different doses was found, with p-values of 1.0, 1.0, and 0.7 at simulated 75%, 50%, and 25% doses compared to standard dose. CONCLUSION: The Lung CAD shows low sensitivity at all simulated lower doses for the detection of pulmonary nodules in this pediatric population. However, radiation dose may be reduced from standard without further compromise to the Lung CAD performance. WHAT IS KNOWN: • High diagnostic performance of Lung CAD for detection of pulmonary nodules in adults. • Several imaging techniques are applied to reduce pediatric radiation dose. WHAT IS NEW: • Low sensitivity at all simulated lower doses for the detection of pulmonary nodules in our pediatric population. • Radiation dose may be reduced from standard without further compromise to the Lung CAD performance.

Should isolated superolateral Hoffa's fat pad edema identified by MRI be reported or ignored in adolescent patients?

BACKGROUND AND OBJECTIVE: The presence of superolateral Hoffa's fat pad (SHFP) edema is associated with several morphometric measurements related to patellar alignment and trochlear morphology. Our aim is to evaluate management implications in adolescent patients with isolated superolateral Hoffa's fat pad edema on MRI. MATERIALS AND METHODS: Retrospective review of 117 adolescents with knee MRI (mean 14.8 years old) with isolated superolateral Hoffa's fat pad edema. Patients with edema were separated into two groups based on the number of MRI axial slices involved with edema: group 1 (G1) of 27 patients with 1 slice vs group 2 (G2) of 90 patients with 2 or more slices. A comparison control group was used (45 patients who had normal MRI knees). Data points included % referral for physical therapy (PT) or surgery, Hoffa's fat pad edema, tibial tubercle-trochlear groove (TT-TG) distance and lateral trochlear inclination (LTI) angle. Fisher's exact and independent t-tests, ANOVA and regression models were used for statistical analysis. RESULTS: There is statistically significant difference between Hoffa's fat pad edema patients and control regarding PT referral with G1: 70%, G2: 76%, and control: 53% (p = 0.03). There is statistically significant difference between these groups regarding TT-TG measurements with higher values in edema groups; G1: 11.9 mm±4.1, G2 13 mm ±4.1, and control 8.7 mm±3.6, (p = 0.001). There was a statistically significant association between edema and increased TT-TG distance (p = 0.001) but not LTI angle (p = 0.2). CONCLUSION: MRI identification of isolated superolateral Hoffa's fat pad edema is positively associated with TT-TG distance and its presence is associated with higher referral rates to physical therapy for patella maltracking.

Diagnostic performance of artificial intelligence for pediatric pulmonary nodule detection in computed tomography of the chest.

PURPOSE: To test the performance of a commercially available adult pulmonary nodule detection artificial intelligence (AI) tool in pediatric CT chests. METHODS: 30 consecutive chest CTs with or without contrast of patients ages 12-18 were included. Images were retrospectively reconstructed at 3 mm and 1 mm slice thickness. AI for detection of lung nodules in adults (Syngo CT Lung Computer Aided Detection (CAD)) was evaluated. 3 mm axial images were retrospectively reviewed by two pediatric radiologists (reference read) who determined the location, type, and size of nodules. Lung CAD results at 3 mm and 1 mm slice thickness were compared to reference read by two other pediatric radiologists. Sensitivity (Sn) and positive predictive value (PPV) were analyzed. RESULTS: The radiologists identified 109 nodules. At 1 mm, CAD detected 70 nodules; 43 true positive (Sn = 39 %), 26 false positive (PPV = 62 %), and 1 nodule which had not been identified by radiologists. At 3 mm, CAD detected 60 nodules; 28 true positive (Sn = 26 %), 30 false positive (PPV = 48 %) and 2 nodules which had not been identified by radiologists. There were 103 solid nodules (47 measuring < 3 mm) and 6 subsolid nodules (5 measuring < 5 mm). When excluding 52 nodules (solid < 3 mm and subsolid < 5 mm) based on algorithm conditions, the Sn increased to 68 % at 1 mm and 49 % at 3 mm but there was no significant change in the PPV measuring 60 % at 1 mm and 48 % at 3 mm. CONCLUSION: The adult Lung CAD showed low sensitivity in pediatric patients, but better performance at thinner slice thickness and when smaller nodules were excluded.

Cardiac Computed Tomographic Angiography Evaluation of Right Ventricle-Pulmonary Artery Conduits with Surgical Correlation.

Right ventricle-pulmonary artery (RV-PA) conduits are used in the treatment of certain congenital heart disease (CHD). RV-PA conduit complications might develop over time and require intervention. To evaluate how well cardiac computed tomographic angiography (CCTA) performs compared to transthoracic echocardiography (TTE) in evaluating RV-PA conduit complications by using surgical findings as the reference standard. A retrospective chart review of all patients over a 5-year period who underwent CCTA for RV-PA conduit evaluation was performed. Patient demographics and clinical data were recorded. Preoperative CCTA and TTE findings were compared to the operative findings for concordance or discordance. Forty-one patients were included, 51% females. The complications were conduit stenosis (28.68%), infection (7.17%) and aneurysm/pseudoaneurysm (6.15%). TTE and CCTA were consistently able to visualize focal conduit stenosis (96%). The greatest discrepancy between TTE and CCTA was in evaluating for aneurysm/pseudoaneurysm, where TTE detected only 2/6 (33%) compared to CCTA which detected 6/6 (100%) of the cases. However, TTE was slightly better at detecting conduit infection (3/7, 43%) compared to CCTA (2/7, 29%). Note that 5 out of 7 patients with endocarditis had bovine jugular graft. CCTA and TTE provide similar diagnostic accuracy evaluating certain types of RV-PA conduit complications. However, certain complications were only visualized on CCTA or TTE making both modalities complementary to each other during diagnostic evaluation.

Imaging findings of COPA Syndrome.

BACKGROUND: Autosomal dominant mutations in the coatomer-associated protein alpha (COPA) gene cause an immune dysregulation disorder associated with pulmonary hemorrhage, lymphoid hyperplasia, arthritis, and glomerulonephritis. OBJECTIVE: To describe the thoracic, musculoskeletal, and renal imaging findings of COPA syndrome with a focus on the evolution of the pulmonary findings. MATERIALS AND METHODS: With approval of the Institutional Review Board, consensus retrospective review of findings on chest radiography and computed tomography (CT), musculoskeletal radiography and magnetic resonance imaging (MRI), and renal ultrasound (US) was performed for pediatric COPA syndrome patients. COPA syndrome patients < 18 years of age presenting between 1992 and 2019 were identified from an institutional rheumatology registry. RESULTS: Twelve pediatric COPA syndrome patients (mean age of 6.5 years at first imaging exam; 6 females) were identified. Imaging exams available for review included 45 chest CT exams on 12 patients, 37 musculoskeletal exams on 4 patients, and 10 renal US exams on 5 patients. All 12 had abnormal chest CT exams, with findings including ground-glass opacities (12/12), cysts (8/12), septal thickening (9/12), nodules (8/12), fibrosis (7/12), crazy-paving (2/12), consolidation (1/12), hilar/mediastinal lymphadenopathy (11/12), and chest wall deformity (5/12). Nine had at least one follow-up chest CT, which showed improvement in nodules (7/9), ground-glass opacities (4/9), and lymphadenopathy (9/9), but worsening of septal thickening (3/9), cyst formation (3/9), and fibrosis (3/9). Four had musculoskeletal imaging revealing synovitis (2/4), bone erosions (1/4), tenosynovitis (1/4), enthesitis (1/4), and subcutaneous nodules (1/4). Five had at least one renal US, revealing renal size abnormalities (4/5) and cortical hyperechogenicity (3/5). CONCLUSION: The most prevalent imaging finding of COPA syndrome is diffuse lung disease related to early childhood-onset recurrent pulmonary hemorrhage and lymphoid hyperplasia that may progress to pulmonary fibrosis. Other imaging findings manifesting later in childhood or adolescence relate to arthritis and glomerulonephritis.

Detection of anomalous aortic origin of a coronary artery (AAOCA) by echocardiogram: When does computed tomographic angiography add value?

BACKGROUND AND OBJECTIVE: There is limited literature comparing TTE and CCTA in children with suspected AAOCA. To determine the distribution of various coronary anomalies comparing TTE and CCTA data, and define the added value advanced imaging brings in clinical decision-making. MATERIALS AND METHODS: Retrospective review of data was obtained in patients aged 0-18 years who underwent TTE and CCTA for suspected AAOCA. Patient demographics, CCTA and TTE findings, and interventions performed were recorded. RESULTS: 100 consecutive patients were included (60% male), mean age 11 years (7 days-18 years old). In 93 patients, CCTA detected 94 anomalous coronaries. Definitive coronary abnormality was reported on TTE in 77 patients; 76 of which were confirmed by CCTA, 1 patient was found to have a normal variant. Suspected anomalous origin was reported in 16 patients on TTE, 13 of which were abnormal on CCTA. The coronary origin was not seen on TTE in 6 patients; of these, 3 had AAOCA on CCTA and 3 had hypoplastic RCA with left dominant system. Only 1 patient who had a normal TTE was found to have AAOCA on CCTA. CCTA was better than TTE in defining ostial characteristics and the course of the anomalous coronary artery, and detecting myocardial bridge. CONCLUSIONS: CCTA adds value in diagnosing AAOCA when the coronary origins are not well assessed or suspected anomalous origin is suggested on TTE. In addition, when a confident definitive diagnosis of AAOCA is reported on TTE, CCTA demonstrates better performance in determining additional features of AAOCA.

Brain magnetic resonance imaging findings and brain volumetric differences in a large series of benign rolandic epilepsy.

BACKGROUND: Several studies with a small sample size have investigated the relationship between structural and functional changes on MRI and the clinical and natural history of BRE. We aim to assess the frequency of incidental epileptogenic lesions on brain MRI in a large cohort of patients diagnosed with BRE and to assess the difference in volumetric brain measurements in BRE patients compared to healthy controls. METHODS: The case-control study includes 214 typical BRE cases and 197 control children with non-epileptic spells. Brain MRIs were evaluated for abnormalities which were classified into normal and abnormal with or without epileptogenic lesions with categorization of epileptogenic lesions. Brain segmentation was also performed for a smaller group of BRE patients and another healthy control group. Pearson's chi-squared test and two-tailed independent samples t-test were used. RESULTS: In patients with BRE, 7% had an epileptogenic lesion on their MRI. The frequency of epileptogenic lesion in the control group was 10.2% and not significantly different from those with BRE (p= 0.2). Significantly higher intracranial and white matter volumes were found in BRE patients compared to the healthy group while lower gray matter volume was found in BRE patients. Cortical and subcortical regions showed either higher or lower volumes with BRE. Interestingly, altered subcallosal cortex development which has a known association with depression was also found in BRE. CONCLUSIONS: Our findings confirm the absence of any association between specific brain MRI abnormalities and BRE. However, the altered cortical and subcortical development in BRE patients suggests a microstructural-functional correlation.

Pediatric tinnitus: The role of neuroimaging.

Tinnitus is defined as the perception of sound without an external source and can be categorized as either pulsatile or nonpulsatile (ie, continuous). A variety of etiologies have been reported to cause pediatric tinnitus, many with long-lasting implications due to hearing and concentration impairments. Therefore, imaging can be an essential part of the accurate and timely diagnosis of treatable etiologies. We describe neuroimaging findings in different etiologies of pediatric tinnitus. Etiologies of pulsatile tinnitus are frequently vascular in nature and include vascular loops, congenital vascular anomalies or variants, high riding jugular bulbs with or without a jugular bulb diverticulum, idiopathic intracranial hypertension, aneurysms, internal auditory canal hemangiomas, and petrous apex cephaloceles. Etiologies of continuous tinnitus frequently affect the middle/inner ear structures and include vestibular schwannomas, cholesteatomas, trauma, Chiari malformations, and labyrinthitis ossificans. CT and MR are often complementary modalities: CT is better suited to evaluate the integrity of the temporal osseous structures and MR is better suited to evaluate the vestibulocochlear nerve and to assess for the presence of any masses or malformations. Prompt diagnosis of the etiology of tinnitus in pediatric patients is important to avoid any potential long-term developmental impairments. In the approach to pediatric tinnitus, categorizing the symptoms as either pulsatile versus nonpulsatile and then being aware of the possible causes and imaging findings of either can assist both the clinician and the radiologist in making an expeditious diagnosis.

Radiologic and clinical outcome of isolated fourth ventricle following post-hemorrhagic hydrocephalus in children.

PURPOSE: Few studies report radiologic and clinical outcome of post-hemorrhagic isolated fourth ventricle (IFV) with focus on surgical versus conservative management in neonates and children. Our aim is to investigate differences in radiological and clinical findings of IFV between patients who had surgical intervention versus patients who were treated conservatively. METHODS: A retrospective analysis of patients diagnosed with IFV was performed. Data included demographics, clinical exam findings, surgical history, and imaging findings (dilated FV extent, supratentorial ventricle dilation, brainstem and cerebellar deformity, tectal plate elevation, basal cistern and cerebellar hemisphere effacement, posterior fossa upward/downward herniation). RESULTS: Sixty-four (30 females) patients were included. Prematurity was 94% with 90% being < 28 weeks of gestation. Mean age at first ventricular shunt was 3.6 (range 1-19); at diagnosis of IFV, post-lateral ventricular shunting was 26.2 (1-173) months. Conservatively treated patients were 87.5% versus 12.5% treated with FV shunt/endoscopic fenestration. Severe FV dilation (41%), severe deformity of brainstem (39%) and cerebellum (47%) were noted at initial diagnosis and stable findings (34%, 47%, and 52%, respectively) were seen at last follow-up imaging. FV dilation (p = 0.0001) and upward herniation (p = 0.01) showed significant differences between surgery versus conservative management. No other radiologic or clinical outcome parameters were different between two groups. CONCLUSION: Only radiologic outcome results showed stable or normal FV dilation and stable or decreased upward herniation in the surgically treated group.

Lower skeletal muscle mass on CT body composition analysis is associated with adverse clinical course and outcome in children with COVID-19.

OBJECTIVES: To assess the association between body composition measures in children with COVID-19 and severity of the disease course and clinical outcome. METHODS: A retrospective study of children (< 19 years) with COVID-19 admitted to the hospital who underwent CT of the chest and/or abdomen was conducted. Data compiled from electronic medical records included demographics, body mass index (BMI), length of stay, ICU admission, invasive mechanical ventilation and death. Waist circumference and perimeters for skeletal muscle mass (abdominal, psoas and paraspinal muscles) were measured on an axial CT image at the level of the twelfth thoracic vertebra or first lumbar vertebra using FIJI software. RESULTS: Fifty-seven subjects were identified (54% male, median age 15.6 years, 61% Hispanic, 23% African-American). 25% (14/57) were admitted to the ICU and 21% (12/57) needed intubation. 9% (5/57) died. Waist circumference ranged between 53.2 and 138.4 cm (mean 86.58 ± 18.74 cm) and skeletal muscle mass ranged between 0.6 and 6.8 cm2 (mean 3.5 ± 1.19 cm2). Lower skeletal muscle mass had a univariate association with ICU admission (odds ratio (OR) 0.4; 95%CI 0.17-0.76; p = 0.01) and mortality (OR 0.22; 95%CI 0.04-0.69; p = 0.01). Multivariate analysis showed similar association after controlling for comorbidities (adjusted OR 0.46; 95%CI 0.19-0.95; p = 0.04 and adjusted OR 0.31; 95%CI 0.06-0.95; p = 0.04, respectively). There was no association between BMI or waist circumference with ICU stay, mechanical ventilation or mortality. CONCLUSION: Lower skeletal muscle mass is associated with an adverse clinical course and outcome in children with COVID-19.

Chronic Osteomyelitis of Long Bones: Imaging Pearls and Pitfalls in Pediatrics.

Chronic bacterial osteomyelitis is characterized by progressive inflammatory bone destruction and apposition of new bone most often caused by pyogenic bacteria. Clinical findings are nonspecific, and serum inflammatory markers can be normal. Prompt diagnosis and treatment are essential. Left untreated, chronic infection can lead to high morbidity and mortality. Imaging's major role is to suggest the correct diagnosis, exclude other diagnoses that can mimic osteomyelitis, document extent of disease, and guide interventions such as image-guided biopsy or surgical debridement. Several conditions can mimic chronic osteomyelitis clinically and radiographically. The main differential diagnoses include an oncologic process, chronic nonbacterial or chronic recurrent multifocal osteomyelitis, bone infarct in sickle cell disease, osteoid osteoma, and stress reaction/fracture. The oncologic process to consider includes metastatic neuroblastoma and Langerhans cell histiocytosis in a child younger than five years or leukemia, Ewing sarcoma, and osteosarcoma in the older age group. However, these lesions can typically be excluded based on radiographs and magnetic resonance imaging findings. Therefore, radiologist familiarity with imaging findings and mimickers is essential. In this article, we briefly review the epidemiologic, clinical, and histopathologic features of chronic bacterial osteomyelitis and emphasize imaging pearls and pitfalls, with discussion of the most common differential diagnoses.

Ileocolic intussusception in pediatric SARS-CoV-2 patients: experience at a tertiary pediatric center.

PURPOSE: COVID-19 disease can manifest with intussusception in pediatric patients, but prevalence of abnormalities on ultrasounds performed for intussusception is uncertain. We aim to report our experience in children with COVID-19 presenting with suspected intussusception imaged with ultrasound. METHODS: Children under 18 years who had an ultrasound for possible intussusception underwent retrospective analysis and were tested for COVID-19 between April 1 and December 14, 2020. Patients' demographic, clinical, radiological and surgical characteristics were reviewed. RESULTS: Twenty-four COVID-19-positive patients were identified; 19 boys with mean age 3 years (range: 3 months-18 years). Ultrasound was abnormal in 11 patients (11/24, 46%). Sonographic features of enterocolitis were documented in seven children (7/24, 29%). Three boys (3/24, 13%) were found to have ileocolic intussusception on ultrasound and underwent air enema with failed reduction (3/3, 100%), precipitating surgical reductions, all with favorable outcomes. One patient (1/24, 4%) was found to have a long segment of persistent small bowel-small bowel intussusception which was surgically repaired. CONCLUSION: Given the known association between failed reduction at air enema and delayed presentation, heightened awareness for intussusception in the setting of COVID-19 should be maintained, though more often, the etiology was attributed to other GI manifestations of COVID-19.

Imaging Modalities Employed in the TAVR Procedure With a Focus on CTA: What the Radiologist Needs to Know.

RATIONALE AND OBJECTIVES: Aortic stenosis (AS) is one of the most common valvular heart disease. Symptomatic AS is associated with a high mortality rate which prompts fast intervention. The introduction of transcatheter aortic valve replacement (TAVR) has drastically improved the outcome of high surgical risk for mortality patients with severe AS. However, this procedure requires the employment of multimodality imaging in the pre-procedural planning, intra-procedural optimization, and post-procedural follow-up stages. This also requires an accurate understanding of the indications, measurements, strength, and limitations of each imaging modality during the different TAVR stages. CONCLUSION: In this review, we aim to outline to radiologists the evidence-based approach and indications of different imaging modalities through the pre, peri, and post TAVR stages.

Acute appendicitis and SARS-CoV-2 in children: imaging findings at a tertiary children's hospital during the COVID-19 pandemic.

BACKGROUND: Evidence suggests severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be associated with appendicitis or clinical symptoms that mimic appendicitis, but it is not clear if the findings or utility of imaging in pediatric patients with suspected appendicitis have changed since the onset of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To evaluate for potential differences in SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients imaged for suspected appendicitis to determine the reliability of the existing medical imaging approach for appendicitis in a population that contains both SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients. MATERIALS AND METHODS: Patients imaged for suspected appendicitis Apr. 1, 2020, to Dec. 31, 2020, were identified via an electronic medical records search. Differences in ultrasound (US) diagnostic performance, use of computed tomography (CT) following US, rates of appendicitis, imaging findings of appendicitis and perforation were compared between SARS-CoV-2 positive and SARS-CoV-2 negative tested patients, using pathology and surgery as reference standards for appendicitis and perforation, respectively. Fisher exact test and Student's t-test were used for statistical analysis. RESULTS: One thousand, six hundred and ninety-three patients < 18 years old met inclusion criteria, with 46% (772/1,693) female, 11 imaged with only CT and 1,682 with US. Comparing SARS-CoV-2 positive and SARS-CoV-2 negative patients, no statistically significant differences in sensitivity or specificity of US (P = 1 and P = 1, respectively), or in the US (P-values ranging from 0.1 to 1.0) or CT imaging findings (P-values ranging from 0.2 to 1.0) in appendicitis were found. Perforation rates were similar between SARS-CoV-2 positive (20/57, 35.1% perforated) and SARS-CoV-2 negative (359/785, 45.7% perforated) patients with appendicitis (P = 0.13). Use of CT following first-line US was similar, with 7/125 (5.6%) of SARS-CoV-2 positive imaged with CT after US and 127/1,557 (8.2%) of SARS-CoV-2 negative imaged with CT after US (P = 0.39). CONCLUSION: In pediatric patients with suspected appendicitis, no significant difference was found in the diagnostic performance of US, CT usage or perforation rates between SARS-CoV-2 positive and SARS-CoV-2 negative patients.

A Novel Large-Vessel Arteritis in SARS-CoV-2-Related Multisystem Inflammatory Syndrome in Children (MIS-C).

Multisystem inflammatory syndrome in children (MIS-C) is a newly defined condition associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The syndrome has been described as a "Kawasaki disease"-like illness and the spectrum of associated abnormalities, including vascular complications, remain to be fully defined. The novel findings of a large-vessel arteritis in this report will add to the understanding of this syndrome and its associated vascular complications.

Role of gated cardiac computed tomographic angiography in the evaluation of postsurgical complications after stage I Norwood procedure and its implications on management: a comparative study with two-dimensional echocardiography.

BACKGROUND: The Norwood procedure is the first part of a three-stage surgical palliation for patients with functionally single ventricle anatomy. Complications after the stage I operation are not uncommon. Transthoracic echocardiography (TTE) is traditionally the mainstay for evaluation. OBJECTIVE: The purpose of our study is to compare gated cardiac computed tomographic angiography (CCTA) with TTE when evaluating for postoperative complications after stage I Norwood procedure and to describe management implications. MATERIALS AND METHODS: A retrospective chart review of all patients over a 4-year period who underwent nonelective urgent CCTA for suspected complications related to stage I Norwood procedure was performed. Elective CCTA studies before stage II palliation were excluded. Patient demographics, CCTA and TTE findings, as well as interventions performed, were recorded. RESULTS: Thirty-four patients were included. The mean age at CCTA was 63 days (range: 4-210 days). All patients had a recent TTE with a mean time interval between TTE and CCTA of 2 days. CCTA detected 56 abnormalities in 30 patients, with 23 directly related to postsurgical complications, including shunt-related complications (10/23, 43%), Damus-Kaye-Stansel anastomotic narrowing (2/23, 9%) and neo-aortic arch/branch vessel abnormalities (11/23, 48%). These complications were managed as follows: surgery (9, 39%), catheter-based intervention (7, 30%), medical (4, 17%) and no change in management (3, 13%). TTE did not detect 8/23 (35%) findings found on CCTA, of which 75% were either managed with surgery (4/8, 50%) or catheter-based intervention (2/8, 25%). CONCLUSION: CCTA plays an important role in detecting surgical complications after stage I Norwood procedure and demonstrates additional findings that have direct management implications.