Espr 2015.

Pediatr Radiol (2015) 45 (Suppl 2):S247–S368 DOI 10.1007/s00247-015-3337-5

ABSTRACTS

Founded in 1963 The European Society of Paediatric Radiology 52nd Annual Meeting and 38th Post Graduate Course of the European Society of Paediatric Radiology June 2 - 6, 2015 Congress Graz Graz, Austria

Table of contents Welcome Words ............................................................................................................................................................................................................... S249 ESPR 2015 Congress organisation .................................................................................................................................................................................. S251 General Information - European Society of Paediatric Radiology ................................................................................................................................. S252 Officers 2014–2015 ............................................................................................................................................................................................ S252 Honorary members ............................................................................................................................................................................................. S252 Gold medalist ..................................................................................................................................................................................................... S253 Jacques Lefèbvre awards ................................................................................................................................................................................... S253 Poster awards ...................................................................................................................................................................................................... S253 Young researcher awards .................................................................................................................................................................................... S254 President’s awards .............................................................................................................................................................................................. S254 Past presidents and meeting sites ....................................................................................................................................................................... S255 Future ESPR meeting ......................................................................................................................................................................................... S255 Future SPR meeting ............................................................................................................................................................................................ S255 Future IPR meeting ............................................................................................................................................................................................ S255 European courses of paediatric radiology (ECPR) ............................................................................................................................................ S255 Future ECPR meeting course ............................................................................................................................................................................ S255 European courses of paediatric neuroradiology (ECPNR) ................................................................................................................................ S255 ESPR Gold Medal Award 2015 ......................................................................................................................................................................... S256 ESPR Jacques Lefèbvre Lecturer 2015 ............................................................................................................................................................. S257 ESPR 2015 Programme at a glance ................................................................................................................................................................................. S258 ESPR 2015 Post graduate course programme ................................................................................................................................................... S258 ESPR 2015 Annual meeting programme ........................................................................................................................................................... S259 Floorplan .......................................................................................................................................................................................................................... S262 Acknowledgements .......................................................................................................................................................................................................... S264 Key messages/Objectives ................................................................................................................................................................................................. S265 CME—Continuing Medical Education ........................................................................................................................................................................... S265

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Pediatr Radiol (2015) 45 (Suppl 2):S247–S368

Programme - 38th Post Graduate Course ........................................................................................................................................................................ S266 Invited Abstracts 38th Post Graduate Course .................................................................................................................................................... S268 Tuesday, June 2, 2015 .................................................................................................................................................................................... S268 Wednesday, June 3, 2015 ............................................................................................................................................................................... S273 Programme 52nd Annual Meeting .................................................................................................................................................................................. S279 Oral Presentations - Abstracts 52nd Annual Meeting ....................................................................................................................................... S288 Thursday, June 4, 2015 .................................................................................................................................................................................. S287 Friday, June 5, 2015 ....................................................................................................................................................................................... S295 Saturday, June 6, 2015 ................................................................................................................................................................................... S307 Poster Abstracts 52nd Annual Meeting and 38th Post Graduate Course ....................................................................................................................... S322 Cardiovascular & Chest - Scientific Poster Presentations ................................................................................................................................. S322 Cardiovascular & Chest - Educational Poster Presentations ............................................................................................................................ S325 Cardiovascular & Chest - Case Report Poster Presentations ............................................................................................................................ S327 Education/Healthcare & Global Perspectives - Scientific Poster Presentations ............................................................................................... S329 Education/Healthcare & Global Perspectives - Educational Poster Presentations ........................................................................................... S330 Fetal - Scientific Poster Presentations ................................................................................................................................................................ S331 Fetal - Educational Poster Presentations ............................................................................................................................................................ S332 Fetal - Case Report Poster Presentations ........................................................................................................................................................... S333 Oncology - Scientific Poster Presentations ........................................................................................................................................................ S333 Oncology - Educational Poster Presentations .................................................................................................................................................... S335 Oncology - Case Report Poster Presentation ..................................................................................................................................................... S336 Basics, Physics & Radiation Protection - Scientific Poster Presentations ........................................................................................................ S337 Basics, Physics & Radiation Protection - Educational Poster Presentations .................................................................................................... S339 Neuroradiology & Head and Neck - Scientific Poster Presentations ............................................................................................................... S339 Neuroradiology & Head and Neck - Educational Poster Presentations ............................................................................................................ S342 Neuroradiology & Head and Neck - Case Report Poster Presentations ........................................................................................................... S345 Musculoskeletal - Scientific Poster Presentations .............................................................................................................................................. S348 Musculoskeletal - Educational Poster Presentations ......................................................................................................................................... S352 Musculoskeletal - Case Report Poster Presentations ......................................................................................................................................... S354 Gastrointestinal and Genitourinary - Scientific Poster Presentations ................................................................................................................ S355 Gastrointestinal and Genitourinary - Educational Poster Presentations ............................................................................................................ S361 Gastrointestinal and Genitourinary - Case Report Poster Presentations............................................................................................................ S363


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Welcome Words Dear colleagues, dear friends, It’s a great pleasure and honour for us to welcome you at this year’s 52nd Annual Meeting and 38th Post Graduate Course of the European Society for Paediatric Radiology (ESPR) in Graz, Austria, from June 2–6, 2015. The theme of the ESPR 2015, “The Basics, the Modern and the Future”, reflects the intentions of the organising and the scientific committees to highlight the huge spectrum of requirements to meet the challenges of today’s paediatric imaging. The program of this largest European meeting of paediatric radiologists and one of the worldwide biggest congresses on imaging children addresses all aspects of Paediatric Radiology - from a thorough review of all basic tools to the most innovative techniques of state-of-the-art and future applications for appropriate imaging of childhood conditions. The congress is not only aimed at (sub)specialists but all radiologists engaged in imaging children. Fostering communication and cooperation with our clinical partner disciplines from paediatrics and paediatric surgery is increasingly important and represents another goal of this congress. Many keynote lectures will therefore address the clinical expectations towards Paediatric Radiology. Consequently, the implications of all the modern options and new approaches for a clinically relevant up-to-date imaging in neonates, infants and children are discussed. Workshops offer the opportunity to be practically engaged in selected topics and for in-depth discussion in smaller groups. In addition to state-of-the-art plenary and keynote lectures, as well as several special focus, taskforce, educational and research sessions, highlights of the ESPR 2015 meeting include: & The opening lecture by Prof. Moser (Leoben, Rector of the Montanuniversität) who will demonstrate imaging applications in non-medical fields, potentially inspiring new perspectives for our profession. & The Jacques LeFèbvre lecture by Prof. Brian Coley (Chair of Paediatric Imaging, Cincinnati Children’s’ Hospital, and SPR president) who will talk on “What US can do - from Dolphins and bats to modern paediatric imaging”. & And the JESPeR lecture, given by Prof. Richard Fotter (em. chair of Paediatric Radiology in Graz), entitled “The Paediatric Radiologist of the Future - Doctor or Photographer?”. In order to spread Paediatric Radiology knowledge and skills, the involvement and networking with young radiologists also from Central and Eastern Europe represents another priority of the ESPR 2015. Thus, besides the scientific sessions and poster exhibits presenting the most novel research in our field, refresher courses and special focus sessions provide information on the state-of-the-art imaging for most areas and modalities that need to be covered in Paediatric Radiology. We also welcome the radiographers, technicians, as well as colleagues from engineering disciplines - our daily partners in the routine work. We want to encourage them to embrace the ESPR 2015 as the opportunity for interdisciplinary discussions and knowledge exchange, thus deepening the radiologists’ understanding of practical needs in performing the various examinations. And we cordially welcome participants from all over the world, and particularly our friends and colleagues from the Society of Pediatric Radiology (SPR) and the World Federation of Pediatric Imaging (WFPI). Two special focus sessions on “Education & Global Challenges” and “The Future of Paediatric Radiology World-wide” are dedicated to the important international perspective highlighting the specific challenges of Paediatric Radiology on the different continents, also addressing the needs in lower resource settings. In the industrial exhibit, our industry partners present their newest equipment and options. We appreciate them as important and essential partners, without whom a successful organisation of this meeting would not have been possible. We thank them in the name of our small patients, with less representation and lobbies in the mainstream medicine who deserve their support. The Post Graduate Course revisits the Paediatric Radiology imaging methods, according to its motto “Basics for the Future”. It is tuned towards the congress theme and content and it aims at providing a thorough educational survey on all relevant imaging modalities applicable to children, focussing on their specific adaptation towards childhood needs. A particular focus is paediatric ultrasonography, with its ever-increasing potential as a non-invasive and non-ionising alternative imaging modality, offering reliable and comprehensive diagnostic information particularly in children. Furthermore, the numerous technical innovations beneficial to Paediatric Radiology in the near future are presented, without ignoring the roots and basic techniques that are still irreplaceable for imaging children worldwide. Thus, the course is this year not primarily intended as an update for experienced paediatric radiologists, but also tries to inform other radiologists (and clinicians) about the specific needs when imaging children. A worldwide faculty of experts in the field of Paediatric

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Radiology will discuss the teaching messages and summarise the main contents in additional case-based interactive lectures. Finally, “Minisymposia” before and after the main meeting (on paediatric neuroradiology on Thursday morning and on paediatric urogenital radiology on Saturday afternoon) offer focused information on selected important areas not only for radiologists, but also providing an overview for our clinical partners. So we are glad to warmly welcome everybody to Graz, in the heart of Europe, and close to Eastern and Southern European countries. We hope that you will find some time to also visit the historical architecture of this World Heritage city, easily accessible from the centrally located congress venue. And we hope that you will enjoy the meeting and the beautiful city of Graz. On behalf of the local organising committee and the international scientific committee,

Michael Riccabona Congress President 2015

Erich Sorantin Co-President


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ESPR 2015 Congress organisation

Congress President 2015 Michael Riccabona Co-President Erich Sorantin Local Organising Committee Alexander Kolli Elisabeth Kranacher Robert Marterer Vera Melcher Birgit Oppelt Michael Riccabona Erich Sorantin Sebastian Tschauner Sabine Weissensteiner Scientific Committee Maria Argyropoulou Fred Avni Csilla Balassy Marie Cassart Jean-Francois Chateil Oystein E. Olsen Lil-Sopie Ording-Müller Catherine Owens Gerald Pärtan Michael Riccabona Rick van Rijn Karen Rosendahl Anne M. Smets Erich Sorantin Samuel Stafrace ESPR 2015 Congress Office Education Congress Research GmbH Neutorgasse 9/2 1010 Vienna/Austria Tel.: +43 1 533 40 64 319 Fax.: +43 1 533 40 64 445 Email: [email protected] www.espr2015.org

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General Information - European Society of Paediatric Radiology Officers 2014–2015 President General Secretary Treasurer Congress President 2015 Congress Past President 2014 IPR 2016 Co-President Council of Trustees

Catherine M. Owens (London, United Kingdom) Maria I. Argyropoulou (Ioannina, Greece) Catherine Adamsbaum (Paris, France) Michael Riccabona (Graz, Austria), Co-President: Erich Sorantin (Graz, Austria) Rutger A.J. Nievelstein (Utrecht, The Netherlands) Karen Rosendahl (Bergen, Norway) Veronica Donoghue (Dublin, Ireland) Fred Avni (Brussels, Belgium) Paolo Toma (Genoa, Italy)

JESPeR representatives - Tom A. Watson (London, United Kingdom) - Robert Materer (Graz, Austria) - Burak Ozkan (Ankara, Turkey) - Loukia Tzarouchi (Ioaninna, Greece)

Honorary members 1964 J. Caffey (USA) 1964 L. Schall (Germany) 1965 S.R. Kjelberg (Sweden) 1965 E.B.D. Neuhauser (USA) 1966 J. Lefèbvre (France) 1973 H.M. Gefferth (Hungary) 1973 K. Rowinski (Poland) 1974 F.N. Silverman (USA) 1975 U.G. Rudhe (Sweden) 1979 J.A. Kirkpatrick, Jr (USA) 1979 A. Lassrich (Germany) 1979 J. Sauvegrain (France) 1982 C. Fauré (France) 1982 A. Giedion (Switzerland) 1983 E. Willich (Germany) 1984 R. Astley (United Kingdom) 1987 J. Bennet (France) 1987 O.A. Eklöf (Sweden) 1987 C.A. Gooding (USA) 1987 D.C. Harwood-Nash (USA) 1987 J.F. Holt (USA) 1987 A.K. Poznanski (USA) 1987 H. Taybi (USA) 1988 H.J. Kaufmann (Germany) 1989 B.J. Cremin (South Africa) 1989 K-D. Ebel (Germany) 1989 H. Fendel (Germany) 1989 E.M. Sweet (United Kingdom) 1990 D.R. Kirks (USA) 1991 A. Chrispin (United Kingdom) 1991 E.A. Franken (USA) 1991 D. Nussle (Switzerland) 1991 B.P. Wood (USA) 1992 W.E. Berdon (USA) 1993 W. Holthusen (Germany) 1993 J. Lucaya (Spain) 1994 N.C. Perlmutter (Belgium) 1994 H.G. Ringertz (Sweden) 1994 D.G. Shaw (United Kingdom) 1996 R. Lebowitz (USA) 1996 B. Lombay (Hungary) 1997 Y. Briand (France) 1997 N. T. Griscom (USA)

1997 P. Small (United Kingdom) 1998 A. Daneman (Canada) 1998 G. Kalifa (France) 1999 M. Grunebaum (Israel) 1999 P. Thomas (Ireland) 2000 N. Blake (Ireland) 2000 P. Kramer (The Netherlands) 2000 G. Stake (Norway) 2001 J. Bar-Ziv (Israel) 2001 R.C. Brasch (USA) 2001 M. Hassan (France) 2001 J.L. Strife (USA) 2002 S. Laurin (Sweden) 2003 G. Beluffi (Italy) 2003 H. Carty (United Kingdom) 2003 B. Parker (USA) 2003 A. Pelizza (Italy) 2004 C. Hall (United Kingdom) 2004 A. Marcinski (Poland) 2005 U. Willi (Switzerland) 2005 J.P. Montagne (France) 2005 G. Fariello (Italy) 2006 A.E. Oestreich (USA) 2006 L. Garel (Canada) 2006 M. Mearadji (The Netherlands) 2006 F. Brunelle (France) 2007 R. Fotter (Austria) 2007 P.A.N. Daltro (Brasil) 2007 G. Benz-Bohm (Germany) 2007 M. Spehl-Robberecht (Belgium) 2008 R. Teele (New Zealand) 2008 T. Slovis (USA) 2008 I. Gassner (Austria) 2008 J. Fonseca Santos (Portugal) 2009 R. Schumacher (Germany) 2009 N. Gourtsoyiannis (Greece) 2009 I. Boechat (USA) 2009 S. Chapman (United Kingdom) 2009 J. Troeger (Germany) 2009 E. Richter (Germany) 2010 F. Avni (Belgium) 2010 V. Donoghue (Ireland) 2010 P. Toma (Italy)


2010 F. Diard (France) 2011 R. De Bruyn (United Kingdom) 2011 G. Enriquez (Spain) 2011 C. Garcia (Chile) 2011 P. Kleinman (USA) 2011 G. Taylor (USA) 2012 C. Veyrac (France) 2013 D. Pariente (France) 2014 R. Arthur (Scotland) 2014 M. Haliloglu (Turkey)

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Gold medallists 2007 J. Lucaya (Spain) 2008 G. Kalifa (France) 2010 U. Willi (Switzerland) 2011 R. Fotter (Austria) 2012 F. Brunelle (France) 2013 F. Avni (Belgium) 2014 V. Donoghue (Ireland)

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

2005 C.J. Kellenberger (Switzerland) 2006 P. Ou (France) 2007 C. Sporcq (Belgium) 2008 M.B. Damasio (Italy) 2009 K. McDonald (United Kingdom) 2010 L.S. Ording-Müller (Norway) 2011 C. Duran (Spain) 2012 J. Vazquez (Spain) 2013 A. Viehweger (Germany) 2014 S. Kinner (Germany)

The Width of the Cranial Sutures in the Neonate: An Objectif Xanthogranulomatous Pyelonephritis in Children: 19 cases Metrizamide Myelography in Infants with Brain Injury to the Brachial Plexus Ultrasonic Study of 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 invovement in Children with Histiocytosis X Focal Cortical Dysplasia: A rare Cause of Epilepsy Pulsed Doppler Sonographic Measurement of Normal Values for the Flow Velocities in the Cerebral Arteries of Healthy Infants Major Pitfalls in the Doppler Examination of the Cerebral Vascular System Laryngeal Ultranographic Study in Infants and Children: Pathological Findings Systematic Study of Superior Mesenteric Vessels in Abdominal US Colour Doppler Imaging of the Acute Pediatric Scrotum Ultrasound Contribution in the Analysis of the Newborn and Infant Normal Foot and Club Foot: Preliminary Study Vermian Agenesis without Posterior Fossa Cyst Magnetic Resonance Angiography of Pediatric Rena 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 Pediatric 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 in focal forms of hyperinsulinism 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 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 Magnetic resonance assessment of aortic flow dynamics and aortic arch geometry in patients with successful repair of coarctation of the aorta 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 tumours Development of the wrist. Normal standards based on MRI for 6–15 year-olds Voiding urosonography: normal and abnormal appearance of the urethra External manual reduction with US assistance: a new procedure for pediatric idiopathic ileocolic intussuseption The Gini-coefficient: A new method to assess fetal brain development MR colonographywith diffusion weighted imaging (DWI) in children and adolescents with inflammatory bowel disease (IBD)

Poster awards 1994 H. Gomes (France) 1995 P. Schmit (France)

Neonatal Hip Sonography from Anatomy to Sonography Imaging of Cystic Mesenchymal Hamatomas of the Liver. Review of 13 Patients

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1997 P. Schmit (France) 1998 H. Brisse (France) 2000 M. Valle (Italy) 2001 W.K. Rohrschneider (Germany) 2002 C.M. Owens (United Kingdom) 2003 R. Schumacher (Germany) 2004 H.J. Mentzel (Germany) 2005 G. Enriquez (Spain) 2006 I. Sorge (France) 2007 S. Punwani (United Kingdom) 2008 J-F. Chateil (France) 2009 G.M. Barez (Spain) 2010 M. Brun (France) 2011 C. Fonda (Italy) 2012 O. Arthurs (United Kingdom) 2013 C. Duran (Spain) 2014 A. Tanase (France)


Congenital Hepatic Vascular Malformations in Children In Utero MRI Normal Gyral Development of the Human Brain High-frequency US detection of the brachial plexus in newborns and infants Static Dynamic MR-Urography—Simultaneous Morphological and Fonctional Evaluation of the Urinary Tract The Utility of MRI in the Assessment of Symptomatic Adenoidal Hypertrophy and Rhynosinusitis 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 Reduction of radiotherapy in children with early stages of Hodgkin’s lymphoma, Influenced by a new imaging and FDG- PET based strategy 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 tensor imaging in attention deficits 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 Ultra low dose imaging for the follow up of idiopathic scoliosis: feasibility of spinal 3D reconstructions and reproducibility of 3D parameters reproducibility- a pilot study

Young researcher awards 2003 M. Brun (France) 2004 A.B. Barnacle (United Kingdom) 2005 M. Raissiki (Greece) 2006 I. Sorge (Germany) 2007 M. Alison (France) 2008 J. Herrmann (Germany) 2010 O. Arthurs (United Kingdom) 2011 N. Gupta (United Kingdom) 2012 L.B. Laborie (Norway) 2013 N. Lochbühler (Switzerland) 2014 A. Slaar (The Netherlands)

Phonological decoding in dyslexic children: activation pattern in 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 A clinical decision rule for acute wrist trauma in children

President’s awards 2004 A.K. Kilian (Germany) 2005 A. Larke (Ireland) 2007 C. Duran (Spain) 2008 A. Calder (United Kingdom) 2009 E. Senocak (Turkey) 2010 S. Franchi-Abella (France) 2011 S. Punwani (Greece) 2012 P. Xenophontos (Greece) 2013 G. Pasztor (Hungary) 2014 A.S. Littooij (The Netherlands)

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: tendancy 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 Whole-body MRI for staging of paediatric lymphoma: prospective comparison to an FDG-PET/CT-based reference standard


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Past presidents and meeting sites

Future ESPR meeting

1964 J. Lefèbvre, Paris/France 1965 U.G. Ruhde, Stockholm/Sweden 1966 J. Sutcliff, London/United Kingdom 1967 H.J. Kaufmann, Basel/Switzerland 1968 A. Lassrich, Hamburg/Germany 1969 K. Rowinsky, Warsaw/Poland 1970 G. Iannacone, Rome/Italy 1971 G. Thomsen, Copenhagen/Denmark 1972 J. Sauvegrain, Paris/France 1973 R. Astley, Birmingham/United Kingdom 1974 P.E. Heikel, Helsinki/Finland 1975 K. Knapp, Madrid/Spain 1976 O. Eklöf, Stockholm/Sweden 1977 A. Giedion, Lucern/Switzerland 1978 N. Perlmutter-Cremer, Brussels/Belgium 1979 K.D. Ebel, Cologne/Germany 1980 The Dutch Group of Paediatric Radiologists, The Hague/The Netherlands 1981 G. Stake, Oslo/Norway 1982 A. Rubin, Prague/Czechoslovakia 1983 C. Fauré, Paris/France 1984 G.F. Vicchi, Florence/Italy 1985 E. Sweet, Glasgow/Scotland 1986 J. Lucaya, Barcelona/Spain 1987 D. Lallemand (ESPR) & D. Harwood-Nash (SPR), Toronto/Canada 1988 D. Nusslé, Montreux/Switzerland 1989 N. Blake, Dublin/Ireland 1990 H. Fendel, Munich/Germany 1991 H.G. Ringertz (ESPR) & D. Kirks (SPR), Stockholm/Sweden 1992 B. Bomblay, Budapest/Hungary 1993 D.G. Shaw, London/United Kingdom 1994 F. Avni, Brussels/Belgium 1995 P. Kramer, Utrecht/The Netherlands 1996 P. Thomas, (ESPR) & K. Fellows (SPR) Boston/USA 1997 U. Willi, Lugano/Switzerland 1998 B. Theodoropoulos, Rhodes/Greece 1999 J. Bar-Ziv & G. Kalifa, Jerusalem/Israel 2000 J. Fonseca Santos, Lisbon/Portugal 2001 F. Brunelle (ESPR) & J. Strife (SPR), Paris/France 2002 T. Nordshus, Bergen/Norway 2003 P. Toma, Genoa/Italy 2004 J. Tröger, Heidelberg/Germany 2005 V. Donoghue, Dublin/Ireland 2006 R. Fotter (ESPR) & G. Taylor (SPR), Montreal/Canada 2007 G. Enrìquez, Barcelona/Spain 2008 S. Chapman, Edinburgh/United Kingdom 2009 M. Haliloglu, Istanbul/Turkey 2010 J.F. Chateil, Bordeaux/France 2011 C.M. Owens (ESPR) & Dorothy Bulas (SPR) London/United Kingdom 2012 M.I. Argyropoulou, Athens/Greece 2013 E. Kis, Budapest/Hungary 2014 R.A.J. Nievelstein, Amsterdam/Netherlands 2015 M. Riccabona & E. Sorantin, Graz/Austria

2017 Basel, Switzerland, May 29–June 3 Future SPR meeting 2017 Vancouver, Canada, May 16–20 Future IPR meeting 2016 Chicago, Illinois, May 15–20 European courses of paediatric radiology (ECPR) 1992 F. Brunelle, Biarritz/France (Abdomen) 1993 P. Toma, Genoa/Italy (Musculoskeletal) 1994 G. Enrìquez, Barcelona, Spain (Thorax) 1995 C. Raybaud, Marseille/France (Neuroradiology) 1996 G. Benz-Bohm, Cologne/Germany (Abdomen) 1997 H. Carty, Liverpool/United Kingdom (Thorax) 1998 C. Adamsbaum & G. Sebag, Montpellier/France (Musculoskeletal) 1999 P. Tortori-Donati, Genoa/Italy (Neuroradiology) 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 (Neuroradiology) 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/United Kingdom (Neuroradiology) 2009 R. van Rijn, A. Smets & E. Deurloo, Amsterdam/The Netherlands (Abdomen) 2010 C. Fonda, Firenze/Italy (Thorax) 2011 I. Barber, Barcelona/Spain (Musculoskeletal) 2012 H.J. Mentzel, Jena/Germany (Abdomen) 2013 M.H. Lequin, Rotterdam/ The Netherlands (Thorax) 2014 D.C. Hughes, Sheffield/United Kingdom (Musculoskeletal)

Future ECPR course 2015 Rome, Italy, September 23–25, 2015 (Chest & Cardiac)

European courses of paediatric neuroradiology (ECPNR) Courses run jointly by ESPR, the ESNR and the ESMNR 2011 M. I. Argyropoulou (ESPR), A. Rossi (ESNR) & N. Girard (ESMNR), Marseille/France 2013 M. I. Argyropoulou (ESPR), A. Rossi (ESNR) & N. Girard (ESMNR), Genoa/Italy 2015 M. I. Argyropoulou (ESPR), A. Rossi (ESNR) & N. Girard (ESMNR), Ioannina/Greece

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ESPR Gold Medal Award 2015 The ESPR gold medal is an exceptional award instituted to recognise a lifetime’s work and outstanding achievements in Paediatric Radiology. Exceptionally, this year’s award will be presented posthumously to Professor Guy Sebag (France), who unexpectedly passed away on November 28th, 2014, in his 55th year of life. Guy Sebag was born in Egypt and went to France with his family, where he attended the medical school at the Faculté de Médecine - Pitié Salpétrière, University Paris VI. After his residency, Guy completed two fellowships in Paediatric Radiology, one at Stanford University in Palo Alto, California, and the other one at Hôpital Necker-Enfants Malades in Paris. Guy Sebag got very involved in a research unit and, at the same time, with his clinical imaging unit. Since 1998, he was at the Head of the Research Unit on Developmental Imaging in the laboratory Inserm U 676, Institut Claude Bernard. He became chairman of the department of Paediatric Radiology of the Hopital Robert Debré, Paris, in 2003; then he became Director of Physiology, Imaging & computer-assisted medical information Departments of this hospital, and - at the same time - Director of the University Department of Radiological Sciences at Diderot University, Paris. He also chaired the board of the academic group of radiologists of Paris University Hospitals during the last 3 years of his life. On the scientific part, Guy published 86 peer-reviewed papers, 23 book chapters and contributed to 190 scientific presentations. His main interests were focused on paediatric musculoskeletal and neuroimaging. He was also an outstanding teacher and he gave more than 100 international and national lectures. Guy Sebag was involved in the life of several professional societies: the French Society of Radiology (SFR), the French Speaking Society of Pediatric & Fetal Imaging (SFIPP), with the charge of General Secretary from 1996 to 2002, the European Society of Radiology (ESR) and its annual congress in Vienna, the European Institute of Biomedical Imaging Research (EIBIR), and finally the European Society of Paediatric Radiology (ESPR): he was an active member of our society since decades, coorganized the European course of Paediatric Radiology in 1998, acted as treasurer from 2007 to 2009, and participated to the board of officers till his death. He also dedicated a lot of time to the editing work and life of scientific journals. Guy acted as Assistant Managing Editor for the journal de Radiologie (1996-2001), then for our journal, Pediatric Radiology (2003-2009), of which he became the Editor-in-Chief of the European office for this journal since 2009 to his death. His contribution to the success of the journal is invaluable, and all colleagues who submitted


and published scientific articles are grateful for his advice, his scientific approach, and his conviction to always elevate the level of the publications. The perfect cooperation with his American counterparts of the Journal was also fully recognized. Guy’s professional qualities were not the only facet of his character; along with those talents, his gaiety and humour were legendary. He never attended a meeting without injecting a pertinent remark as a joke; drawing caricatures was one of his hobbies. Guy will stay as a model, but also as a very faithful friend and gentleman for all the members of the Pediatric Radiology community. Above all, we know how Guy cherished his dear family. His wife Christina and his children, Alexandra, Paul and Angélique, of whom he was so proud, have now to face the realty without Guy. Nobody can ignore their sadness and how much they miss Guy. This gold medal must stay for his family and for ESPR members as the best honour, the greatest acknowledgement and gratitude the ESPR Society could offer for his work and his entire life dedicated to children care. March 2015 Guy Sebag (France)


ESPR Jacques Lefèbvre Lecturer 2015 What Ultrasonography can do - from dolphins and bats to modern paediatric imaging

Brian Coley MD. Professor of Paediatrics and Radiology Chair of Paediatric Imaging, Cincinnati Children’s’ Hospital, USA; SPR President I am honoured and excited that Brian Coley, a dear friend for more than a decade, has agreed to hold this year’s Jacques Lefèbvre lecture—focusing on probably the most commonly used and increasingly recognised and valued paediatric imaging modality, ultrasonography (US). To me, this is extremely important, as with the need to reduce invasiveness, to reduce radiation burden and to avoid anaesthesia, together with the growing economic pressure, US offers the ideal alternative and sometimes even superior imaging solution for many paediatric queries. And thus this method has to be maximally exploited and new options and capabilities are becoming even more important for achieving this goal. To fulfil the task, however, high level US performed with child-adapted equipment and by skilled and knowledgeable investigators must be made available 24/7/365. Brian has always been convinced of these US options and has enthusiastically engaged in developing and introducing US to many paediatric queries; additionally, he has started and used US for guiding many interventions—another aspect that helps to significantly reduce radiation burden to children. So I am very glad that Brian, ideally suited to deliver

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this lecture, has accepted to cross the ocean to share with us his views and visions about US, its roots and its future. Brian, who studied at Yale University and at the University of California in San Diego, started his clinical career in San Diego Medical Centre as a surgeon and then turned to radiology. He completed his fellowship in Paediatric Radiology at the Children’s Hospital Medical Centre, Cincinnati/ Ohio, in 1994/95. He is happily married and has three lovely “children”. During his professional career he worked at various institutions before he returned to Cincinnati in 2011 when he became Radiologist-in-Chief and the Frederic Silverman Chair for Pediatric Radiology at the Cincinnati Children’s Hospital Medical Centre. He has authored more than 100 publications, numerous abstracts and scientific presentations, as well as 15 book chapters. Many of those reflect his special interest in paediatric US, among them particularly vascular sonography and interventional US. Thus, Brian always has been inspiring for many of us, leading the way to new approaches and horizons - as most recently during RSNA 2014 when he addressed “point of care US” and the related aspects and challenges. He was invited all over the world to present, he gave numerous (invited) lectures and courses / conferences and he often has travelled to Europe to share his knowledge and foster communication and cooperation between the continents. He is editor of one of the most renowned text books in Paediatric Radiology - Caffey’s Pediatric Diagnostic Imaging, and is co-editor of the book The Core Curriculum: Pediatric Radiology. He is a member in and partially fellow of many societies and associations such as SPR, AIUM, RSNA, ACR, or SRU. As such he has served on multiple committees and taken on multiple tasks and offices / positions (such as secretary, treasurer, or president) in conjunction with these memberships and the respective obligations, all aimed at promoting Paediatric Radiology in the light of improving patient care and safety. At present, he is acting president of the SPR and president-elect of the AIUM. And he has been working for many journals as reviewer, guest or co-/assistant editor or editorial board member. No wonder that he received many honours and awards - among which two nominations particularly highlight his engaged and sensitive care for (sick) children and their families and his deep understanding towards their daily needs: the Golden Stethoscope Award (awarded by medical staff to a select group of its most highly respected peers “to extraordinary, caring physicians who exhibit excellence in patient care, mentoring and communication”) in 2008, and being selected for “The Best Doctors in America” from 2009 to 2013. Regardless of all his admirable achievements, he has managed to remain as I originally got to know and deeply appreciate him: a lovely, warm, calm, humorous, humble and understanding person you always want to have around and as a friend. And besides all his activities he always has an open ear and tries to help when and wherever he can, e.g., when asked to help with English editing of my US textbook he just said: just send me, we’ll get it done. This answer characterises Brian: oriented towards problem solving, with significant personal involvement when deemed necessary, working reliably and profoundly. His personality, his CV and his integrity, as well as his impact on paediatric radiology and his engagement for our subspecialty not only in the USA, but across the continents, with a deep understanding of the different settings and environments that one encounters worldwide, truly rate Brian worthy to give this year’s Jacques Lefèbvre lecture. Michael Riccabona, February 2015

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ESPR 2015 Programme at a Glance ESPR 2015 Post graduate course programme

NOTE different entrance than the Annual Meeting - not the main Congress Graz entrance; Please use the entrance “SCHMIEDGASSE 2”



ESPR 2015 Annual meeting programme

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Floorplan

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WD 2

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Acknowledgements The organisers of ESPR 2015 gratefully acknowledge the support of the following organisations: Siemens (Platinum Sponsor) GE Healthcare (Gold Sponsor) Guerbet (Silver Sponsor) Biomarin (Silver Sponsor) Zonare (Silver Sponsor) Hitachi Bracco LMT Medical Menges Medical Philips SuperSonic Imagine Planmed Oy Toshiba Mides Kyoto Kagaku Ltd. Agfa As of April 20, 2015 This supplement was not sponsored by outside commercial interests; it was funded entirely by the publisher.


Key messages/Objectives & To learn about and update your knowledge on state of the art paediatric imaging approaches, and to get inspired by new scientific results and endeavours. & To revisit basic imaging rules and methods, and to hear about new technologies for paediatric imaging. & To discuss how to optimally adapt the various imaging techniques minimising radiation exposure and risks during diagnostic imaging in children. & To consider common restrictions, challenges, and possible solutions in Paediatric Radiology within the different settings in different countries, regions, continents and clinical scenarios— discussing all these aspects with colleagues, and to mingle with experts from all over the world learning from each other and fostering networking in Paediatric Radiology to try to grant optimal imaging for all children.

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CME—Continuing Medical Education The ESPR 52nd Annual Meeting and 38th Post Graduate Course, June 2– 6, 2015, Graz/AT has been submitted for accreditation to the “Akademie der Ärzte” to provide certification of CME activity for medical specialists. The number of credits approved by “Akademie der Ärzte” will be announced as soon as the approvals have been sent to the ESPR 2015 Congress Office. Each medical specialist should only claim those hours of credit that he/she actually spent in the educational activity. Certificates of attendance will be available in the ESPR MyUserArea after the meeting.

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Programme - 38th Post Graduate Course



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Invited Abstracts 38th Post Graduate Course

PGC 02

Tuesday, June 2, 2015

Plain film & digital radiography: challenges in paediatric imaging E. Sorantin, Graz/AT

PCG - Radiography PGC 01

General remarks on imaging neonates, infants & children M. Sinzig, Klagenfurt/AT

Objectives & To point out specific challenges in children based on their different anatomy and physiology. & To revisit how these aspects impact imaging modalities and techniques. & To discuss some general and more specific aspects in the various age groups and conditions Abstract In 1897 Escherich established a roentgen laboratory especially for children at Graz/ Austria and it seems that this was the first of this kind worldwide. Since that time diagnostic imaging has evolved from the single technique (x-ray) to a field in which we have a choice of many modalities. Medical imaging has revolutionized how we care for children and is one of the fastest growing areas of health care today. The corresponding medical literature has also exploded in volume and mostly focus on how to interpret imaging and on the potential benefits of the newest imaging technologies. Less attention has been given to determining when it is appropriate to image, with what modality, how and how often it is used and by whom, and how to apply the results of imaging to clinical care. As we all know sometimes it can be quite difficult to distinguish beneficial from unnecessary or harmful care. The biologic effects of radiation result primarily from damage to DNA and are greatest on the faster growing organisms, the fetus, infant and young child. Additionally individuals with certain diseases are uniquely sensitive to radiation induced cancers, although the exact mechanism remains unclear. As the existence of a threshold dose is unknown, it has been assumed that even the smallest dose involves a proportionately small risk of induction of malignancies and it has further been assumed that the dose acts cumulatively. The modality that delivers the largest dose of ionizing radiation is CT. Use of this examination in children has been increasing at a rapid rate. It is estimated that since the 1980s when CT was beginning its ascendancy there has been up to an 800% increase. Two major advances have lowered the radiation dose of plain films and fluoroscopy: digital imaging and pulsed fluoroscopy. Nevertheless, radiation time and therewith resultant radiation dose reflect the patient’s complexity at the one hand and the radiologists experience on the other hand. Ultrasound and MRI—non-radiation-producing modalities—represent the safest imaging tools. As US has a wide range of applications in children it is of special importance in the paediatric age group. The paediatric radiologist plays a central role in making the decision on what test is best. Therefore communication with the referring physician is indispensable.

Objectives & To address needs, specifically important in paediatric radiology, in conventional radiology. & To revisit the basic techniques, particularly focusing on challenges from digital radiography. & To illustrate how knowledge about post-processing, filtering, and other (electronic) image optimization techniques have to be adapted for optimal quality at lowest reasonable dose in neonates, infants and children. Abstract Plain films are the most frequent examinations in Radiology including Paediatric Radiology. In adults the body weight changes from 40.0 kg to about 160.0 kg representing a mass factor of 4, whereas in Paediatric Radiology the ranges starts at premature babies with 400 g to more than 120 kg in obese adolescents— thus representing a mass factor of 300. Therefore one of the challenges is to convert changes of parameters like body mass and composition, calcifying skeleton, and increasing lung air content due to alveolar maturation into exposure settings and post processing. Over the years Paediatric Radiology units developed algorithms for exposure settings, e.g., adjusting them by body weight (representing mass) for body trunk examinations and by age for extremities (representing skeletal calcification). But considerable differences can be found if one takes a close look at the digital radiography signals obtained by different units and comparing those to the corresponding adult ones. Therefore, post processing must be optimized for children. Unfortunately, usually this is left to the vendors since changing those parameters appears rather difficult and requires the appropriate privileges to change the settings—most often not available locally. Another challenge in children is correct positioning and exposure field size. The purpose of this presentation is to describe the radiological relevant differences between adults and children and how exposure settings and post processing can be adapted to different age groups. Additionally examples for assessing image quality using simple phantoms and applicable to daily routine will be given as well as a quality control tool for positioning and field size. PGC 03

Cone beam radiography & other new techniques in paediatric patients D. Jaramillo, Philadelphia/US

Objectives & To briefly present the basic idea and technique of cone beam radiography and similar new techniques (e.g., EOS …). & To discuss its potential application and use in children. & To illustrate the potential benefit of these new techniques in specific paediatric applications in terms of radiation efficacy. Abstract Cone beam CT (CBCT, also referred as C-arm CT or flat panel CT or cone beam radiography) is a technology that has gained


increasing applications. Its name comes from the cone shape of a divergent X-ray beam that reaches several centimetres of the detector. Unlike conventional CT, an entire 3D volume data is acquired during a single sweep of the detector. The beam captures a cylindrical or spherical volume data. In conventional CT, the beam is tightly collimated; in cone beam CT the beam is not, and therefore it has more scatter, less contrast, and greater noise. Another disadvantage of CBCT is that the greyscale values are not only dependent on the density but on the position of the object and therefore density measurements in Hounsfield units are not accurate. The single sweep takes more than 10 s and is thus much more susceptible to motion. Spatial resolution, however, is very high (100 μ), and 2-D and 3-D reconstructions are of excellent quality. Cone beam CT allows flexible geometry. It is used in the angiography suites, in the operating room (the “O-arm”), in dental applications, and increasingly in orthopaedic applications. In orthopaedics, the use of a small bore and a small unit (with a maximal diameter under 2 m) provides flexibility to image joints distant to the trunk, in both horizontal and standing positions. A Cone-beam unit dedicated to joint applications typically uses a detector of 10 cm. That means that for a greater length of bone, there have to be several sweeps that have to be stitched or analysed separately. The unit design allows for a substantial decrease in radiation exposure (at least one third of the dose). Given that most wrist, elbow and ankle doses with conventional CT are less than 10 mSv, the radiation exposure of one cone-beam CT is not too far that of a series of radiographs. In addition, when exposing the elbow or the wrist, the joint is exposed at a distance from the head, thus eliminating the exposure to the eyes and thyroid that occur during conventional CT imaging. Another geometrical advantage is the capability of imaging the foot, ankle and knee during weight bearing. The geometrical versatility, the low radiation dose, the ease of housing of the unit make it a promising technology for evaluating multiple congenital anomalies (such as club foot or tarsal coalition), trauma (such as complex elbow, wrist and ankle fractures) and benign tumours.

PGC - Fluoroscopy & general issues

PGC 04

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Radiation protection: Children are more radiosensitive to the induction of some (but not all) important malignancies than adults; they have a longer lifespan for the manifestation of radiation induced malignancies, and they will probably undergo an increasing number of radiologic examinations with accumulation of dose. Therefore adherence to the ALARA (As Low As Reasonably Achievable) principle remains a keystone of Paediatric Radiology. However, image quality has to be maintained at a level sufficient for answering the relevant diagnostic questions. For intravasal CA, the use of iso-osmolality CAs is recommended in childhood; they should be warmed in order to lower viscosity. For CT the injection rate usually is slower compared to adults, not only to avoid extravasation but also for a better match of the very short scanning times with the very short injection times of the small CA volumes applied in smaller children. Consider splitbolus (i.e., double or triple bolus peak) injection instead of multiphasic protocols in order to limit the number of CT series and to spare radiation dose. To prevent contrast-induced nephropathy age-based normal serum creatinine levels combined with childspecific GFR calculation methods (eg. Schwartz Equation) should be applied. During pregnancy iodine based CA should only be administered exceptionally, and in the neonate thyroid function should be checked - at least during the first week. After maternal application of Gadolinium (Gd) based CA breast feeding should be avoided for 24 h. Also in the first months of life these Gd-based CAs should only be used exceptionally administering the smallest possible dose of one of the most stable (cyclic) CAs, to reduce the risk of nephrogenic systemic fibrosis throughout childhood. However, only a few of them are approved for use in neonates and infants in Europe. For opacifying the gastrointestinal tract, Barium based CAs are cheaper and provide better contrast than iodinated CAs. They may be applied rectally or orally by drinking or via catheters and tubes, but they may not be used when the integrity of the intestinal wall is compromised or high grade obstruction is suspected. Also consider avoiding aspiration of massive amounts of Barium. Hyperosmolar iodinated CAs (eg. Gastrografin®) should only reluctantly be used in children, as they may cause fluid shifts between extravascular compartments and blood vessels, especially in neonates and in children with cardiac and renal impairment. And aspirated hyperosmolar CA may cause pneumonitis and pulmonary oedema. Ultrasound CAs (i.v. and intravesically) are not approved for paediatric use to date, despite their excellent safety profile.

Radiation protection & use of contrast agents in children G. Pärtan, Vienna/AT PGC 05

Objectives & To revisit basic facts about radiation sensitivity and the various options for radiation protection in childhood imaging. & To discuss use, pharmacodynamics, interactions, potential adverse reactions and other risks, restrictions and challenges of the various contrast agent applications in Paediatric Radiology. & To illustrate challenges associated with radiation protection as well as how and when contrast agents are used in Paediatric Radiology (safety, approval, dose, concentration, indications….). Abstract Besides of diagnostic errors, main risks of radiologic examinations are side effects of ionizing radiation and of contrast agent (CA) application.

How to report using standardised terminology P.H. Vivier, Rouen/FR

Objectives & To revisit basic needs for a specific imaging report format particularly addressing need for standardized terminology. & To discuss the content of a report in terms of legal necessity as well as usefulness for the referring clinician. & To illustrate how reporting and nomenclature can be standardized and optimized in paediatric radiology. Abstract Reports in Radiology should be well structured - with a systematic description of normal findings and potential pathology.

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Reports have to be understandable by all physicians who may have to manage children with the respective disorders. To achieve this goal, terms have to be standardized and accepted by the medical community in general. As an example, the ESPR uroradiology taskforce is currently working on harmonising and standardizing uroradiologic terminology in cooperation with European urologists and nephrologists. Whatever the imaging modality, a classical report should include a description and eventually an interpretation; the description should address the following items (if applicable): - number, location, size, contour etc.… of all organs or structures assessed, as well as the adjacent area and tissue with its respective relation and behaviour, - parenchymal morphology, destructive processes, vasculature and vessels or perfusion / enhancement (if applicable), - potential dilatation of cavities or additional cavities, - all other relevant features, e.g., in the urinary bladder the ostia, the distal ureters, (if applicable) the urethra, as well as the perivesical space. A conclusion must be drawn at the end of every report. It should not repeat the previously reported findings but should provide a comprehensive diagnosis deducted from the findings described above. Ideally, the primary abnormality should be mentioned at first with its consequences thereafter. The conclusion may include other data from the clinical history or from other imaging. For example, if a unilateral uretero-pelvi-caliceal dilatation is depicted sonographically and a previous cystography did not show vesicoureteric reflux, the conclusion should suggest a primary megaureter, but cannot comment on the degree of impairment of urinary drainage without additional functional imaging. Finally, any limitations of the study (e.g., some parts not visible, artifacts …) need to be mentioned. And a recommendation on further complementing imaging (or follow-up) should be stated if deemed necessary. The consequent use of a rigorous imaging technique, systematic reporting, standardized terminology and a comprehensive conclusion improves the quality and avoids potential misunderstandings.

PGC 06


programme, to ensure the ALARA principle may be adhered to at all times. It is recommended that pulsed fluoroscopic units with adjustable frame rate speeds and removable grids are used for paediatric examinations. The lowest pulse rate should be used whenever possible and the grid should be removed for all but the largest of children. The kVp and mAs must be altered depending upon the size of the patient, and all doses—including screening time— should be recorded; fluoroscopy should be intermittent rather than continuous. “Image grab” and “last image hold” features can be used during anatomic fluoroscopic studies, with x-ray exposures being reserved for occasions when greater detail is required. Positioning the patient using not only the light beam diaphragm but also virtual collimation will further reduce dose, and the radiologist may store fluoroscopic loop relays during the examination. Time taken to both ready the fluoroscopy room and talk with the patient/parents prior to the examination is important. The selection and preparation of appropriate contrast media: using 5% dextrose rather than water to make up barium, adding preferred flavoured syrups for older children and letting the child use their favourite bottle or cup are simple but valuable techniques for paediatric patients. Ensuring the room is warm, the lights are low, the patient comfortable on the table and having a selection of distraction toys available also help. Babies may benefit from being given oral sucrose to soothe them immediately prior to their examination. Fluoroscopy is an essential imaging modality in paediatric radiology, despite on-going advances in both ultrasound and MRI. It remains crucial for the evaluation of the GI and GU tracts both pre- and post-operatively, particularly in neonates and young infants. Depending upon local resources and expertise, a department may still rely upon fluoroscopy to investigate the small bowel or to guide air reduction of intussusception. This talk will review available fluoroscopic techniques and study optimisation for paediatric patients, illustrated by clinical examples of how the modality is still used today.

PGC - Nuclear medicine, interventional radiology and hybrid imaging

Fluoroscopy in paediatric radiology A. Paterson, Belfast/IR PGC 07

Objectives & To revisit the presently available fluoroscopic techniques recommended for imaging neonates, infants and children. & To discuss procedural optimization towards imaging paediatric patients, additionally reflecting indications and examinations that have changed over the last decade. & To illustrate how and when fluoroscopy is performed today, and where it remains the standard imaging approach in childhood conditions. Abstract As with all imaging modalities that utilise ionising radiation, fluoroscopic studies require the radiologist to balance optimal image quality with the lowest possible radiation dose to the patient. Dedicated paediatric fluoroscopy equipment does not exist. It is the responsibility of each individual radiology department to work with their local medical physics team following the installation of new equipment and regularly thereafter, as part of a QA

Basics of nuclear medicine - what paediatric radiologists need to know M. Easty, London/UK

Objectives & To revisit basics of nuclear medicine, as far as it is important to understand their application throughout childhood. & To discuss typical paediatric applications - also addressing potential (future) challenges and risks, physiological limitations and radiation issues. & To illustrate typical findings - also enhancing the perception of the complementary nature of sectional imaging and nuclear medicine techniques. Abstract Diagnostic Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose and determine the


severity of a variety of diseases, including many types of cancers. Nuclear medicine procedures are able to pinpoint molecular activity within the body, and offer the potential to identify disease in its earliest stages as well as a patient’s immediate response to therapeutic interventions. Depending on the type of nuclear medicine examination, the radiotracer is either injected into the body, swallowed, or inhaled as a gas and eventually accumulates in the organ or area of the body being examined. Radioactive emissions from the radiotracer are detected by a Gamma camera or PET imaging device that produces pictures and provides molecular information. These low resolution images have often been termed ‘unclear medicine’ by radiologists. In many centres, nuclear medicine images can be superimposed with computed tomography (CT) or magnetic resonance imaging (MRI) to produce special views, a practice known as image fusion or co-registration. These views allow the information from two different diagnostic examinations to be correlated and interpreted on one image, leading to more precise anatomical information and accurate diagnoses. By combining the functional study with a cross sectional data set, the images become more familiar to the paediatric radiologist. Combined dedicated single photon emission computed tomography (SPECT/CT) and positron emission tomography/computed tomography (PET/CT) units are now commonplace and fused images are obtained in one imaging episode. An emerging imaging technology, but not readily available at this time is PET/MRI. The lecture will present the common paediatric nuclear medicine studies available in most departments and then briefly mention hybrid imaging with some key points on image fusion and SPECT/CT, as well as a brief review of paediatric PET/CT and PET/MRI. References Hirsch W F,Sattler B et al. (2013) PET/MR in children. Initial clinical experience in paediatric oncology using an integrated PET/MR scanner. Pediatr Radiol 43:860–875 Biermann M,Schwarzlmüller T(2013) Is there a role for PET-CT and SPECT-CT in pediatric oncology? Acta Radiolvol. 54 no. 9 1037–1045

PGC 08

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To discuss the potential diagnostic benefit and application of these new techniques for specific paediatric queries. To illustrate findings and presently existing limitations as well as future perspectives of these new methods.

Introduction: Paediatric diagnostic imaging has largely been based on a principle of applied anatomy, either through indirect visualisation, for example the contours observed on plain film, or via reconstruction methods using either ionising radiation (CT), sound waves (US) or proton imaging (MRI). The use of radio-isotopes in paediatric imaging has been long established in functional renal imaging, cancer imaging and infection, using gamma camera data acquisition. There is a growing array of newer imaging techniques that enable physiological, biological and metabolic assessment of tissues, elevating diagnostic imaging beyond applied anatomy. Co-registered anatomical and functional data (“hybrid imaging”) enables multiparametric assessment, with recent commercially available platforms improving ease of co-acquisition. Some of these techniques are described for use in paediatrics, whilst others are more a research tool at present. Aims: & To provide an overview of the variety of advanced imaging techniques available & To outline current advanced techniques with available evidence for use in paediatrics & To consider current research techniques that may be translatable to paediatric use in the mid to long term Materials and Methods: The current literature will be discussed and personal experience of some advanced techniques described. Outcome: At the end of this session the participants will have an overview of the current state of new advanced and hybrid techniques as they pertain to paediatric practise and be aware of current research techniques that may be translatable to paediatrics in the mid-long term.

Interventional radiology in childhood A. Robinson, Doha/QA (new speaker to be announced)

Objectives & To revisit basic technical aspects and needs for performing catheter angiography and interventional radiology in childhood. & To discuss various approaches, options, techniques and requirements as well as limits of interventional radiology in childhood & To illustrate typical common conditions, where interventional radiology has become an excepted or even preferable diagnostic or therapeutic option for typical paediatric conditions, or where diagnostic catheter angiography should better be replaced by other modalities in children.

PGC 09

Modern & new (hybrid) imaging methods applicable in children P. Humphries, London/UK

Objectives & To list modern and new (particularly hybrid) imaging methods applicable to children.

PGC - Paediatric CT PGC 10

Paediatric CT: basics revisited E. Stranzinger, Bern/CH

Objectives & To revisit basic physical aspects necessary for understanding the modality and how CT can / must be adapted for paediatric use. & To discuss how the various (new) techniques and approaches impact image quality, radiation dose and sedation needs. To illustrate how of all these factors may impact practical application of diagnostic CT in children Abstract The aim of this presentation is to revisit basic physical aspects necessary for understanding the CT imaging modality of and how CT must be adapted for paediatric use. The basic principles of CT have not changed since the introduction of the first commercially

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available CT in 1972. Since then scanning time, radiation dose, and image quality have significantly improved. As newer CTscanners are able to scan a large area of the body within a few seconds, cardiac motion and breathing artefacts are no longer a major drawback. Therefore sedation needs and intubation are far less often necessary compared to MRI-studies. Fast scanning time, good availability of CT in many institutions, and robust image quality have an effect on the numbers of CT-studies especially in younger children. CT is a powerful diagnostic tool even in children—mainly for chest imaging, heart and vascular imaging, and for trauma patients. New CT-scanners are able to reveal new applications (e.g., dual energy metal artefact reduction, post processing for vascular imaging, automatic volume measurements etc.). There are still technical limitations, radiation risks, as well as physiological restrictions when imaging children. For example limitation of the rotation time of multiple row detector scanners together with the high heart rates in smaller children may be challenging to image the coronaries and sometimes even without with ECG-triggering. Radiation is recognized as carcinogen particularly in children as they have a higher sensitivity for radiation-induced cancer and a longer life expectancy. The seven rules, described by Vock in 2005, are valid for all CT-scanners: i.e., Justify, Prepare, Accept noise, Optimize scan parameters (kVp, mAs), Optimize volume coverage, Scan minimal length, and Minimize repeat scanning. Although new scanners allow automatic selection of optimal kVp and mAs by automatic exposure control, every study must be reviewed for the diagnostic task and given dose. Size specific dose estimates may offer a user friendly tool to estimate radiation dose during paediatric CT examinations. The important role of the paediatric radiologist is to teach, supervise and improve the performance of paediatric CT-scans but also to consult the clinicians for the best imaging approach for a given clinical question at the respective institution.


shown that even small amounts of radiation can increase this risk substantially. This explains the increasing interest of international scientific organizations and literature in MDCT dose reduction and optimization strategies. Reducing the radiation dose in children starts with “justification of scan” or performing MDCT in children only when properly indicated. This requires adequate communication between referring physician and radiologist, as only with a complete clinical picture a well-considered decision can be made which imaging modality is best to answer the clinical question. Common indications for MDCT in children include (severe) trauma, acute neurological deterioration, craniosynostosis, chest pathology (lung, cardiac), and bone diseases. Rarely abdominal (acute) conditions require MDCT, as most of the time these can be solved by ultrasound or MRI. If MDCT is indicated, “optimization of scan” for children is essential to reduce the dose as much as possible. This starts with an adequate patient preparation, including age- and intellectadapted information to child and parents, inviting one or both parents to stay with the child, and adaptation of the scanner environment to children. This will help to reduce the anxiety of the child and increase the success rate of the CT examination, reducing the need for sedation or anaesthesia. The next step will be optimization of the scan and technical parameters to the size of the child, body region of interest and clinical question. This includes the settings of several factors such as scout view, scan length, exposure settings including automated exposure control, type of scanning (single slice, helical, volume mode), slice thickness, pitch values as well as image reconstruction techniques. Furthermore, the technique of intravenous contrast media administration should be optimized for age and size of the child. This lecture will focus on all these technical and non-technical aspects relevant for paediatric MDCT optimization.

PGC 12 PGC 11

Paediatric CT: indication, protocols & radiation protection R.A.J. Nievelstein, Utrecht/NL

Objectives & To revisit typical applications and protocols for paediatric CT - particularly addressing radiation issues. & To discuss accepted indications and those, where CT still remains a (second) option - including major aspects of how to tailor these protocols. & To illustrate typical imaging findings in terms of radiation burden versus image quality balance, with respect to the clinical query. Abstract: The recent revolutionary developments in multi-detector CT (MDCT) technology have contributed to a substantial increase in its diagnostic applications and accuracy in children. A major drawback of MDCT is the use of ionizing radiation and, consequently, the risk of radiation-induced side effects, particularly the induction of cancer. This is especially true in children, because rapidly dividing cells are more sensitive to ionizing radiation and children will have more years ahead in which cancerous changes might occur. Although the available evidence on the side effects of low-dose ionizing radiation still remains matter of discussion, recent population-based epidemiological studies in children have

Paediatric CT: contrast agent application & modern developments E. Sorantin, Graz/AT

Objectives & Discuss understanding of contrast agent dynamics and how to properly address amount, dose and timing of contrast agent in paediatric CT. & To discuss other modern developments which improve image quality and help to reduce radiation burden. & To illustrate typical applications and pitfalls associated with contrast agent administration and use of modern CT tools such as iterative reconstruction, new detectors, fast circle time Abstract Despite the availability of radiation free imaging modalities like Ultrasound or MRI CT and CT-Angiography (CTA) is unavoidable in many clinical situations. In CT enhancement after intravenous (iv.) contrast agent (CA) injection depends on factors like iodine concentration, amount and speed of injection, vessel configuration (eg., tissue vascularisation, vessel stenosis/hypoplasia, arterio-venous malformations, haemangioma) and cardio-vascular status. Today’s CT scanners offer high spatial and temporal resolution the latter, in combination with the increased heart rate and blood


flow velocity of young children, shortens the time window for correct image acquisition. Therefore in many situations the iv. CA injection approaches a “hit or miss” situation. In CTA bolus tracking improves scan timing. Due to the change in attenuation when using a current less than 120 kV for the bolus tracking thresholds must be adapted, otherwise scans would start inappropriate early. Furthermore achieving, eg., optimal liver enhancement still represents a challenge especially in young children. In addition the amount of injected CA should be as low as possible in order to reduce side effects. And - as multiple phases should be avoided for radiation protection issues - new innovative CA application techniques such as split bolus injection may be an option. Due the lack of radiation in MRI repeated acquisitions are possible after iv. injection of Gadolinium preparations but dose is even more crucial than in CT. Ultrasound CA have only minor side effects but are presently not licensed for paediatric use. At the author’s institution an Excel sheet was developed to support radiologist and radiographers in the task of calculating an iv. CA administration-this sheet is available within an ESPR multicentre study. The purpose of this presentation is to present strategies to overcome the above mentioned limitations and to meet the challenges for CA administration in childhood, with a special focus on CT. Furthermore, a specific “MicroBolus Technique” for iv. CA administration at CTA in infants and small children will be suggested.

Wednesday, June 3, 2015

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Skills: In paediatric radiology it is of utmost importance to choose the most appropriate transducer, depending on the size of the patient and the body part to be examined. Graded compression, different positions of the patient and oral liquids can be extremely beneficial. Technical parameters: Many parameters can be adapted and it is horrifying to observe how novices produce pathetic images, just by ignorance. An ultrasonographer should master basic parameters as gain, time-depth gain, focus, persistence, and log compression. But also knowledge of more advanced adjustable parameters is mandatory such as harmonic imaging, compound imaging and adaptive image analysis. When using colour- and power Doppler, one should be aware of wall-filtering and pulse repetition frequency. Knowledge of 3-dimensional US, elastography and US contrast media is beneficial. The improvement of US image quality by compound imaging and adaptive image analysis is significant and therefore in many machines it is the default setting. Real time colour Doppler US should be used liberally in daily routine for many indications: detection of flow in unknown tubular structures, detection of flow in vessels, detection of necrosis (or abscess formation) in tumours, organs and lymph nodes. Artefact recognition: artefacts include poor gain setting, acoustic shadowing (air, metal, calcification and ossifications), mirror artefacts, comet tails, reverberation, and enhancement artefacts. At the end of the 20th century US lost reputation and importance (particularly in radiology) due to the advent of new CT and MRI techniques. However, the above mentioned emerging US techniques significantly broaden the potential of US. Needless to state that Paediatric Radiology benefits most from these new developments.

PGC - Paediatric ultrasound - the basics PGC 14 PGC 13

Ultrasound basics revisited - with respect to paediatric needs S.G.F. Robben, Maastricht/NL

Objectives & To briefly revisit physical basics of sonography as far as important to understand and perform proper instrumentation of ultrasonography in childhood. & To discuss necessities specific for paediatric ultrasound applications including limitations and other relevant aspects such as standardization, choice of transducer, patient handling and measurements. & To illustrate results of properly applied understanding of ultrasound physics and application needs in children. Abstract Ultrasonography (US) is the initial imaging technique for many diseases in childhood. Often it is also the final imaging technique and no other imaging modalities are necessary to confirm the diagnosis. Therefore paediatric radiologists rely more on US than other subspecialities in radiology, and therefore need to be familiar with technique. First, one needs excellent skills to visualize the specific organs. Second, one needs to master the technical parameters to create a diagnostic image without blurring, a minimum of graininess and sufficient contrast- and spatial resolution. Finally, artefacts need to be recognised.

Doppler sonography in children M.L. Lobo, Lisbon/PT

Objectives & To briefly revisit the technical background of Doppler ultrasound including potential risks and hazards of the different techniques and applications. & To discuss the value of Doppler sonography throughout the body in different paediatric conditions. & To illustrate where Doppler sonography is irreplaceable for establishing a diagnosis in specific queries of neonates, infants and children. Abstract Doppler sonography (DS) should be regarded as an integral part of any ultrasound (US) examination in children. In general, the additional information on blood flow provided by DS can contribute significantly to improve the diagnostic capabilities of US examinations in a wide range of paediatric applications. The Doppler effect, defined as the frequency change of the reflected wave by a moving object (usually blood particles), allows assessment of flow direction and flow velocity. DS includes different techniques (continuous wave or pulsed wave DS, colour DS [CDS], amplitude-coded colour DS), each one with specific applications and restrictions. The combination of real time B-mode US with CDS is essential for proper angle correction, which is a crucial factor that influences accurate quantification of blood flow

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PGC - Special ultrasound applications in neonates, infants & children

be readily performed at the bedside without any need for sedation or specific monitoring. There are a number of neurologic conditions that significantly influence morbidity and mortality in neonates and infants related to the brain and the spinal cord; many of them can be addressed by ultrasonography (US). Thus US is an accepted first line imaging tool, with added potential for specific queries. And US may help to tailor potentially necessary complementing imaging. Increasingly neonatal neurosonography is performed by other subspecialties than Paediatric Radiology; however, the respective knowledge and practical skills are essential for paediatric imaging and thus must be an intrinsic part of training in Paediatric Radiology. This is particularly important as, after the introduction of first CT and then MRI, neonatal neurosonography was increasingly considered just a basic first line technique that offers only orienting and no relevant information, which was partially caused and promoted by suboptimal US performance - either by restricted availability of modern equipment or by lack of specialized expertise in performing and reading neurosonographic scans. The lecture presents the practical basics of US of the brain and spinal cord in neonates and infants (including some applications in the orbit), and will touch on modern approaches exploiting all options US can offer today. It defines technical requirements, and lists typical and common indications for US with illustration of the respective imaging findings—such as brain haemorrhage, hypoxic-ischemic brain damage, malformations, inflammatory conditions, perfusion disturbances and vascular disorders, or trauma as well as tumour and other rare conditions encountered in this age group that can be assessed by US. Additionally, potential restrictions, the indications for complementing imaging, as well as potential hazards are discussed. In conclusion the lecture aims at encouraging paediatric radiologists to reorient the respective imaging algorithms and skills towards the potential of modern neurosonography, particularly in the view of efficacy, considering growing economic pressure, and the low invasiveness, the high diagnostic value and potential in many conditions sufficient for patient management, as well as the good availability of US that can easily be repeated any time, even at the bedside. And the lecture tries to motivate paediatric radiologists to engage in offering competence and quality in Neurosonography, thus ensuring an appropriate imaging service to the affected patient group.

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PGC 17

Brain ultrasound in neonates & infants M. Riccabona, Graz/AT

Musculoskeletal ultrasound in children A. Pilhatsch, Graz/AT

Objectives & To revisit standards of neurosonography in neonates and infants - including technical needs, risks and dangers, as well as requisites. & To list the most important indications where ultrasound is still a valuable and irreplaceable tool including limitations of ultrasound in neonatal brain and spine. & To illustrate typical findings also of rarer applications, such as transcranial ultrasound or ultrasound of the orbit.

Objectives & To revisit techniques and requisites for assessing the paediatric musculoskeletal system. & To discuss specific paediatric applications and conditions where ultrasound is a valuable diagnostic tool, such as for example DDH and hip ultrasound, childhood rheumatoid arthritis, osteomyelitis or trauma. & To illustrate typical findings and pitfalls in paediatric musculoskeletal ultrasound.

Abstract Paediatric and particularly neonatal neurosonography still remains a mainstay of imaging the neonatal brain and spinal cord. It can

Abstract The advantage of ultrasound (US) especially in infants is the absence of radiation. It is also a fact that one usually does not

velocity. Proper setting of technical parameters, recognition of Doppler artifacts, and how to correct and optimize those are basic aspects in any DS examination. Pre-adjustment of the various parameters is required, and the investigation should be kept as short as possible. As a significantly higher sound energy is employed in DS, potential risks from biological effects should not be neglected, particularly when scanning vulnerable areas in very young patients. DS has gained increasing acceptance in paediatric imaging, and its applications are extensive throughout the entire body. However, the interpretation of DS findings is not always straightforward and it should be analysed with caution in respect to a given clinical scenario. Besides its role in echocardiography and in typical vascular conditions (eg., arterial / venous thrombosis / embolism, arterial stenosis, pesudoaneurysm, arteriovenous fistula and malformations, renovascular hypertension, portal hypertension etc. …), DS is essential in the evaluation of organ transplantation. Furthermore, DS is also extremely useful for several inflammatory and ischemic conditions, as well as for characterization of vascular patterns in tumours and mass-like lesions. PGC 15

Modern ultrasound techniques applicable in childhood S. Franchi-Abella, Paris/France

Objectives & To revisit modern techniques (potential and artifacts / limitations ...) such as high resolution imaging, harmonic imaging, image compounding etc..., and new approaches such as perineal ultrasound or diagnostic / therapeutic sonographical enema & To discuss the necessity for these new modalities in terms of improving ultrasound potential throughout childhood & To illustrate typical applications and findings—particularly those with the benefit achieved by applying modern modalities in terms of image quality, diagnostic reliability or therapeutic success


have to cope with a wide amount of impairing air—one of the few enemies of US—in the soft tissue. Additionally the younger the child the more of the bone is formed by cartilage, particularly the epiphysis; therefore US can be beneficial particularly in the joint regions—in comparison to conventional radiographs, e.g., after trauma. The ability of real-time-imaging allowing for dynamic examinations may reveal further valuable information. The only persisting black spot for US remains the “unaffected” bone with an intact, well ossified surface. The rest of the musculoskeletal (MSK) system is composed by soft tissue and thus is a perfect target for diagnostic US; the only limitation to such musculoskeletal examinations is a widespread laceration or an open wound. For performing MSK-US one needs appropriate equipment, with a high frequency (up to 17–20 MHz) linear probe that offers high spatial resolution. Secondly particular knowledge of the physiology and pathophysiology of the targeted condition and anatomic area is mandatory. This does not so much concern meanwhile standardized applications like shoulder US, imaging of Bakercysts and Achilles tendon pathology, or a simple ganglion cyst evaluation. Also the instant depiction of the median nerve close to the carpal tunnel may be easy if one knows the exact topography. But this topographic knowledge is particularly important in specifically challenging conditions such as for US of the radial nerve in higher sections, e.g., when the clinician is in doubt whether the nerve is just compressed or torn in case of palsy after a supracondylar humeral fracture. For special locations, MSK-US is preferable to conventional x-rays not only in children to proof a fracture, e.g., of the sternum or the skull. Also US is able to perfectly visualize ligament structures. Finally, US is a ideal tool to search for particularly radiolucent foreign bodies or, after a while, to find the reactive granuloma originating from the foreign body. And in the evaluation of a soft tissue swelling of unknown origin US can help differentiating a tumorous from a cystic or necrotic and abscess-like infectious lesion, although – particularly with contrast administration and DWI—MRI has a higher specificity. So in summary, there is a wide range of capabilities for MSK-US in the field of paediatric radiology. PGC 18

Ultrasonography of the chest & small parts in childhood B.D. Coley, Cincinnati/US

Objectives & To revisit (specific paediatric) applications of small part and chest ultrasound in children (except musculoskeletal ultrasound). & To discuss typical paediatric conditions and the benefit of ultrasonography in relation to other imaging modalities & To illustrate typical findings - also addressing limitations of ultrasound in paediatric small parts and chest imaging Abstract The young child’s thorax offers many acoustic windows for sonographic investigation, making chest ultrasound (US) extremely useful for many paediatric disease queries. And while US of the paediatric chest has been performed for many years, more recent innovations (and greater concern over radiation from CT) have shown an even greater potential for patient diagnosis and management. In evaluating the radio-opaque hemithorax, US can determine whether the cause is from fluid, lung, or tumour, and help

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determine appropriate further imaging or treatment. Ultrasound has always been a sensitive method for diagnosing pleural fluid, but it allows characterization of para-pneumonic collections and assessment of whether they are drainable by percutaneous methods or require surgical intervention. Lung consolidation can be diagnosed, and fluid within the bronchial tree may help to differentiate atelectasis from pneumonia. Changes in gray scale appearance and Doppler evaluation can help detect necrotizing pneumonia, lung infarction, and abscess. Interstitial disease is traditionally evaluated with radiography and CT, but ultrasound US can be useful as well. The evaluation of sonographic artifacts (“B lines” or “lung rockets”) from aerated lung may allow for diagnosing indicates interstitial disease, whether from fibrosis, inflammation, or oedema. In the evaluation of oedema, fluid overload, and septic shock, ultrasound US can help evaluate lung water content and guide therapy. Abnormalities of the mediastinum can often be assessed, and queries about chest wall abnormalities and superficial small parts structures (lymph nodes, breast tissue, soft tissue cysts, rib anomalies ..) are usually best evaluated with US. This potential for small part evaluation applies to all other body areas as well—such as assessment of nodes and lumps, or foreign bodies, or glands and mass lesions. Assessment of the central vasculature is often needed, and while MRI and CT are valuable, direct and indirect Doppler findings can reliably indicate venous and arterial pathology. Like any US examination, there are may be limitations due to a restricted field of view, obscuration from overlying structures, and operator inexperience. However, proper appreciation of what US can achieve in paediatric thoracic queries and the application of a little effort can yield great benefits for our patients.

PGC - Paediatric abdominal ultrasound PGC 19

Abdominal ultrasound in neonates - requisites, how to do & typical examples P. Trinavarat, Bangkok/TH

Objectives & To revisit typical applications of ultrasound in the neonatal abdomen (liver, spleen, pancreas, GI-tract, GU-tract, major vessels …). & To discuss requisites, needs, indications and limitations of neonatal abdominal ultrasonography. & To illustrate typical findings in the neonatal abdomen. Abstract Abdominal ultrasonography (US) in neonates provides high resolution images of abdominal viscera with easy availability and portability, and without exposing neonates to radiation, while its limitations are operator dependency and disturbance from bowel gas. High-frequency (8–18 MHz) transducers are essential in yielding high resolution images. Linear, small convex, or (rarely) sector transducer may be used according to area of interest with adjustment of its frequency and focal zone for different depth. Compression and/or different approaching windows are used to visualize normal anatomy or pathology behind bowel gas. Filling of gastro-intestinal structures (e.g., by drinking / installing tea or

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saline) additionally offers more anatomical and also functional information, also allowing for therapeutic options. Indications for a neonatal abdominal US are assessment of prenatally detected abnormalities, screening for congenital anomalies, evaluation of a palpable abdominal mass, and investigation of neonatal clinical symptoms—particular inflammation or vomiting. The majority of abnormalities found by prenatal and from postnatal US screening arises from the urogenital tract; some of them need prompt action and treatment, for example severe bilateral hydronephrosis or posterior urethral valves. A non-palpable (prenatally diagnosed) or a palpable abdominal mass and organomegaly can be evaluated by US: to confirm the mass, to show its origin, to assess its solid or cystic nature and its vascularity, as well as to define the size and extension. Thus US may diagnose or at least suggest an infantile hepatic haemangioma, a choledochal cyst, a renal tumour or a renal cystic disease, an adrenal haemorrhage, a hydro-/haemato (metro)colpos, an enteric duplication cyst, a cystic hygroma, a retroperitoneal teratoma, an ovarian cyst, and several other mass lesions. There is a variety of clinical symptoms requiring an US study in neonates, for example—cholestatic jaundice, anuria or oliguria, hypertension, vomiting, etc.… . And US can not only be beneficial—sometimes US is irreplaceable or better than other available options, e.g., in necrotizing enterocolitis US can better and earlier depict intestinal pneumatosis and portal vein gas than plain films, and may furthermore enable assessment of bowel wall thickness and vascularity thus also estimating disease activity. In summary, US has become a very useful tool for evaluating many neonatal abdominal conditions.


with acute appendicitis present with perforation at diagnosis due to non-specific symptoms and low clinical suspicion. Intussusception is one of the most common causes of acute surgical queries in young children. The clinical symptoms are not always specific. US has a high sensitivity and specificity for this condition. Vomiting is another common reason for referral, typical conditions such as pyloric stenosis which can easily be diagnosed by US. If the scan does not reveal the suspected pathology, other causes of the symptoms should be sought. E.g., obstructive nephropathy may cause diffuse abdominal pain and or vomiting in a younger child. Pyelonephritis may have non-specific symptoms and should be considered in an infant with non-specific symptoms of infection or malaise without obvious cause. Malrotation can cause acute abdominal pain and/or vomiting, in both infants and older children, and the assessment of duodenum and the DJflexure should be included in the first US scan. Older children are often referred for US due to diffuse abdominal pain. Functional abdominal pain and constipation are frequent causes of abdominal pain in the older age groups, neither of which are diagnosed based on imaging. US is performed to rule out underlying causes like tumours, inflammatory bowel disease, nephropathy or genital pathology. A systematic approach to the abdomen is important in the first abdominal US in children, in the acute setting and in elective examinations, in order not to miss important diagnosis.

PGC 21

Contrast-enhanced ultrasound in children A. Ntoulia, Ioannina/GR PGC 20

Abdominal ultrasound in children: typical queries and findings L.S. Ording-Müller, Oslo/NO

Objectives & To revisit abdominal ultrasound application in children - including GI and GU tract, liver, spleen, pancreas and major vessels. & To discuss necessities, indications and queries, procedural details, and limitations of paediatric abdominal ultrasonography. & To illustrate typical conditions - particularly those that can be assessed by ultrasound, obviating need for other potentially irradiating imaging Abstract Ultrasound (US) is the first modality of choice in almost all abdominal queries in children of all ages. The queries-and findings however, vary with age. US is a readily available, harmless investigation and the threshold for referring a child for abdominal ultrasound is normally low. Therefore, a common ‘finding’ in children in a primary referral centre, is a normal abdomen. Children are not always able to describe their complaints or to localise pain. Therefore the clinical question may sometimes be misleading, particularly in younger children. It is important not only to answer the specific query, but also to get an overview of the whole abdomen when a child with abdominal complaints is referred for US. Referred pain from other organ systems, e.g., pneumonia may be misinterpreted as abdominal pathology and vice versa, e.g., a child with a limp may occasionally have intra-abdominal pathology. Appendectomy is the most common acute surgical procedure in childhood, but more than half of children under 5 years of age

Objectives & To revisit basics and challenges or risks of contrast-enhanced ultrasound in childhood. & To discuss typical queries and applications of intravenous or intracavitary use of ultrasound contrast agents throughout childhood. & To illustrate typical findings - particularly of conditions, where contrast-enhanced ultrasound can help avoiding other particularly irradiating imaging. Abstract Contrast enhanced ultrasound (CEUS) in children includes contrast enhanced voiding urosonography (ce-VUS), with the intravesical use of ultrasound contrast agent (UCA) and CEUS following intravenous (iv.) UCA administration. Ce-VUS is a paediatric specific application for vesicoureteral reflux (VUR) detection and grading as well as for urethral imaging. It is performed in five steps including baseline pre-contrast ultrasound of the urinary tract, bladder catheterization, intravesical UCA administration and post-contrast ultrasound scan of the urinary tract including possibly urethral imaging during voiding. VUR in ce-VUS is graded into five grades in a similar manner to fluoroscopic voiding cystoourethrography (VCUG). IV CEUS is widely practiced in adults and is steadily gaining increased use in the paediatric population as an alternative or problem-solving imaging modality. Common applications include detection, characterization and/or treatment monitoring of neoplastic, traumatic, or inflammatory conditions. Baseline ultrasound examination always precedes iv. CEUS. UCA dosage should be appropriately adjusted according to patient’s weight or age. An iv. line with adequate flow is established and UCA bolus


administration followed by quick saline flush is performed. Scanning protocol should be individually tailored according to clinical indications. General principles include imaging of the organ/body site under clinical suspicion and separate scanning of each body side with specific scanning order on each side i.e., kidneys, liver/ spleen and pancreas. Contrast enhancement dynamics in arterial, venous and delayed phases are similar to contrast enhanced computed tomography or magnetic resonance imaging. Administration of additional UCA dose and repeat studies, if needed, may be performed after the UCA’s clearance. In children all UCAs applications remain off-label. Although UCAs have a favourable safety profile, the possibility of adverse reactions requires undertaking appropriate precautionary measures.

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may have a very heterogeneous signal. A breadth of contrasts is therefore helpful: STIR, non-fat suppressed T2-weighted turbo spin-echo, diffusion-weighted imaging, contrast-enhanced sequences. Final tips We do not need all sequences and weighting in all planes. It is better to get a few sequences spot on rather than ending up with a lot of half-decent images Anatomical planes are really arbitrary. Isotropic non-fat suppressed T2weighted turbo spin-echo provides an excellent dataset for multiplanar post-processing Combine contrasts during post-processing (e.g., very easily done in OsiriX®, available at http://www.osirix-viewer.com/).

PGC 23

PGC - MRI in childhood

Specific MR-applications in the child’s abdomen & the paediatric cardiovascular system C. Kellenberger, Zurich/CH

PGC 22

MRI basics revisited - with respect to tailoring paediatric studies O.E. Olsen, London/UK

Objectives & To revisit basic physics of MRI that allows a deeper understanding of the technique and its implications on tailoring paediatric sequences and investigations. & To discuss how to practically approach adaption of sequences for specific paediatric needs in the various age groups based on their different size, physiology and query. & To illustrate how changing of various parameters will affect details of image quality, sequence duration and diagnostic yield. Abstract There are three significant challenges in paediatric body MRI. These are not independent, but it simplifies matters to consider each in turn. 1. Poor signal-to-noise ratio (SNR) The coil is the main determinant. The (active elements of the) coil should cover the area of interest, while over-coverage introduces additional noise. Multi-channel coils are preferable. For a given coil/sequence combination, SNR is proportional to the voxelvolume times the square root of the dwell time (the “active” acquisition time). Therefore, higher resolution imaging requires longer scan times. In general, spin-echo sequences give higher SNR than gradient-echo sequences. 2. Motion artefact Since long acquisition times are usually required (as per above), motion artefact reduction is crucial. A good multi-disciplinary approach is invaluable: training in a mock scanner, in-scanner entertainment and distraction, sedation/anaesthesia, etc. Secondline actions include 1) using motion-gating techniques (diaphragmatic gating, ECG gating), 2) pharmacological attenuation of peristalsis, 3) special k space trajectories (e.g., alternating phase direction), 4) fat suppression (but remember that fat is important for anatomical definition), 5) adjustment of the phase encoding direction. 3. Surprising tissue contrasts (as compared to adult imaging) Examples: childhood tumours often do not have very high signal intensity on water-sensitive sequences; the normal bone marrow

Objectives & To revisit important applications in the paediatric abdomen and cardio-vascular system. & To discuss how to adapt and tailor examinations for the specific needs of the specific age group and individual application. & To illustrate typical findings, also comparing various approaches in terms of image quality and diagnostic value, addressing limitations and risks Abstract Most magnetic resonance (MR) applications of the chest and abdomen rely on the three basic imaging sequences fast spin echo (FSE, TSE), steady state free precession (SSFP, FIESTA, bFFE, trueFISP) and fast spoiled gradient echo (FSPGR, FFE, FLASH). With variation of k-space filling, spatial resolution and temporal resolution the MR sequences can be optimised for imaging the lungs, heart, vessels, parenchymal organs, pancreatico-biliary system or bowel. As a comprehensive MR assessment of the chest or abdomen can be lengthy, preschool aged children need to be immobilised by sedation or anaesthesia with intubation if imaging in breathhold is deemed necessary. Respiratory motion artefacts can be avoided by fast imaging (real time SSFP, single shot FSE), imaging in breathhold or using respiratory gating either with a bellows belt or navigator techniques. With ECG gating cardiac motion can be resolved which permits structural or functional imaging of the heart. Although cardiac and respiratory gated 3D SSFP sequences can be used for contrast medium free MR angiography (MRA) of most thoracic and abdominal vessels, small vessels in small children are still best visualised with contrast enhanced 3D gradient echo sequences. High spatial resolution MR A can be achieved with linear or centric k-space filling schemes, whereas some kind of undersampling of the kspace is needed for dynamic MRA with improved temporal resolution. With the temporal resolution around 1 to 2 s assessment of lung perfusion becomes feasible. Dynamic contrast enhanced imaging of the abdomen using 3D high resolution techniques employing view sharing and interpolation (LAVA, VIBE) coupled with Dixon water-fat separation are well suited for detection and characterisation of hepatic or renal lesions. The same

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kind of 3D gradient echo sequence is also suited for assessing differential renal function and dynamics of renal contrast excretion and drainage. Morphology of the urinary tract and the pancreatico-biliary system is best assessed with respiratory gated, heavily T2-weighted 2D or 3D FSE sequences (long echotrain or single shot). Diffusion weighted imaging (DWI) offers new possibilities for detection and characterisation of hypercellular lesions (e.g., tumours, pyelonephritis, inflammatory bowel disease,…). Every MR examination of the chest or abdomen needs to be adapted to the clinical question, age and size of the child. The relation between diagnostic value and potential risks of an MR examination (e.g., from sedation/anaesthesia or Gadolinium based contrast agents) should be higher than that for any alternative imaging method with radiation exposure.


Most children with cancer will be treated according to a clinical trial. Clinical trials increasingly include imaging recommendations: sometimes specific MRI sequences and/or the injection of intravenous gadolinium are mandatory. At diagnosis, when the origin of a tumour is unknown, it might be appropriate to perform an extensive protocol in order to gain as much diagnostic information as possible. When origin and type of tumour are obvious, the protocol can be tailored to that particular tumour type. In general, questions about size, extension and relationship to surrounding organs and tissues must be answered. Diffusionweighted imaging (DWI) is often added to the standard imaging protocol: it increases sensitivity for tumour detection and depicts areas of high cell density, indicating locations for biopsy. The role of DWI as a biomarker for distinguishing benign from malignant lesions and for evaluating response to therapy in children is being evaluated. Whole-body MR is now frequently used to detect disease remote from the primary tumour, particularly in bones and bone marrow.

PGC 24

MRI- typical paediatric applications in musculoskeletal & oncology imaging A.M Smets, Amsterdam/NL

Objectives & To list modern MRI applications in paediatric musculoskeletal & oncologic queries. & To discuss the potential diagnostic benefit and application of MRI for specific paediatric queries, also in terms of diagnostic / therapeutic thinking efficacy. & To illustrate typical findings, the “do’s and don’ts”, and presently existing limitations as well as future perspectives. Abstract Musculoskeletal MRI With its superb soft tissue contrast and lack of ionizing radiation, MRI is an excellent modality for examining paediatric bone, bone marrow, cartilage, joints, and soft tissues. Nevertheless, x-ray studies and ultrasound should not be omitted as baseline and complementary studies, and CT still adds useful information in certain cases. Age-related anatomy plays a role in the choice of the MRI technique and in the interpretation of the images. Knowledge of the particularities of different sequences allows for tailoring the examination to age and clinical history. I maging protocols typically include a T1-weighted (T1-W) sequence for anatomical detail and detection of bone marrow abnormalities, contusions and fractures. Water-sensitive sequences demonstrate fat (T2-W without fat suppression) and fluid (short tau inversion recovery (STIR) and T2-W with fat suppression); the latter can be used to cover greater field-of-views in coronal or sagittal planes. Proton-density (PD) sequences provide excellent anatomic detail of ligaments, tendons and menisci. Gradient recalled echo sequences (GRE) are sensitive for cartilage and blood products. T1-W fat-suppressed sequences after injection of intravenous gadolinium are useful in tumours, inflammation, infection, avascular necrosis and vascular malformations. MR Imaging in oncology In many institutions, MRI has replaced CT for the imaging of thoracic and abdominal tumours. Chest x-ray and ultrasound still play a role at baseline and during monitoring and follow-up. CT-scans are performed for the detection of lung metastases.

PGC 25

Paediatric neuro-MRI A. Rossi, Genoa/IT

Objectives & To revisit typical paediatric queries different from common adult conditions that can specifically be answered by MRI. & To discuss the specific imaging appearance and findings throughout the various paediatric age groups & To illustrate typical examples - also demonstrating the value of modern approaches such as diffusion weighted imaging, tractography, perfusion imaging or MR-spectroscopy Abstract Modern paediatric neuroimaging is essentially based on MRI; its applications have enormously expanded over the past few years. On the other hand, the role of CT has progressively regressed and is now basically confined to selected indications, most often related to emergency. Ultrasound remains an important (bed-side) and first line imaging technique particularly in neonates and small infants. The lecture will focus on the implementation of MRI in a paediatric neuroimaging practice. The basic standard protocol for brain imaging should include a combination of four sequences (T1wi, T2wi, FLAIR, and DWI) in three planes (axial, sagittal, and coronal). Special additional sequences include T2* gradientecho and SWI, that exquisitely depict paramagnetic artefacts such as those resulting from haemoglobin degradation products or calcification. Indications for contrast material administration should be carefully weighted especially in children below age 1 year, in compliance with existing regulations. The use of DWI, DTI, perfusion methods, and MR spectroscopy will also be highlighted. Familiarity with the evolving appearance of the brain in the first 2 years of life paralleling the evolution of the process of myelination is also required, especially in view of the fact that the indications for neonatal imaging have markedly expanded and now include also the imaging of the premature brain with MRI. The tailoring of basic MR sequences to the physical properties of the unmyelinated neonatal brain will be addressed, with the aim of improving study quality also in this difficult subset of patients.


Programme 52nd Annual Meeting

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Thursday, June 4, 2015

AM 02

Minisymposium: Paediatric neuroradiology - the requisites & beyond

Common queries – how to approach them & how do various conditions look like? A. Rossi, Genoa/IT

AM 01

Standards in paediatric neuroradiology, ultrasonography, CT, MRI how? M. Argyropoulou, Ioannina/GR

Objectives & To revisit procedural standards in ultrasonography, CT, and MRI of the paediatric brain and spine & To discuss practical details and specific modification as necessary for paediatric neuroradiology & To illustrate application of these modalities in workup of paediatric neuroradiologic queries Abstract Ultrasonography (US) is the first line imaging modality to apply for the evaluation of the neonatal and infantile brain. US can be applied at bed side especially in the ICU and offer valuable information provided that we apply state of the art imaging technique. The use of sectorial transducers and high frequency linear transducers is necessary. Imaging should be performed not only through the anterior fontanel but also through accessory windows like the posterior and mastoid fontanel (asterion). Accessory windows offer valuable information regarding the cerebellum and occipital lobes. Colour Doppler is an additional important tool to evaluate not only brain arteries but also venous flow in venous sinuses and the internal veins. Colour Doppler can detect the presence of blood into the aqueduct of Sylvius by depicting alternating red and blue colour echoes. Brain US should be performed during the first 48–72 h after birth in all low birth weight premature babies to check for brain haemorrhagic disease and by the end of the first week of life to check for focal periventricular leukomalacia. Follow up should be adapted to the detected pathology. US imaging patterns of congenital malformations, infection, hypoxia-Ischemia lesions are well known and offer valuable information in the diagnostic work up and decision making in those young patients. Irradiation concerns have limited the use of CT in children. CT is useful for the evaluation of trauma especially for bone fractures. Low dose protocols adapted to the ALARA criteria are necessary in the paediatric population. MRI comes next to US in neonates and infants and comes first in older children. A standard MRI protocol should include conventional sequences (T2, plain and contrast enhanced T1W sequences). Diffusion imaging and preferentially diffusion tensor imaging (DTI) with the very useful information from DTImetrics (ADC, FA, axial and radial diffusivity) and tractography is gaining an important place in MRI protocols. Susceptibility weighted perfusion imaging can be applied for the evaluation of ischemia and brain tumours. MR angiography offers useful information on the arterial and venous vascularization of the brain. The application of MR spectroscopy not only for brain tumours but also for metabolic disorders and ischemia hypoxia can offer valuable information. A safe application of gadolinium chelates necessitates age older than 4 months, GFR

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