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Objective: To characterize clinical, hemodynamic, imaging, and pathologic findings in children with pulmonary arterial hypertension (PAH) and variants in SRY-box transcription factor 17 (SOX17), a novel risk gene linked to heritable and congenital heart disease-associated PAH., Study Design: We assembled a multi-institutional cohort of children with PAH and SOX17 variants enrolled in the Pediatric Pulmonary Hypertension Network (PPHNet) and other registries. Subjects were identified through exome and PAH gene panel sequencing. Data were collected from registries and retrospective chart review., Results: We identified 13 children (8 female, 5 male) aged 1.6-16 years at diagnosis with SOX17 variants and PAH. Seven patients had atrial septal defects and 2 had patent ductus arteriosus. At diagnostic cardiac catheterization, patients had severely elevated mean pulmonary artery (PA) pressure (mean 78, range 47-124 mmHg) and markedly elevated indexed pulmonary vascular resistance (mean 25.9, range 4.9-55 WU∗m 2 ). No patients responded to acute vasodilator testing. Catheter and computed tomography angiography imaging demonstrated atypical PA anatomy including severely dilated main pulmonary arteries, lack of tapering in third and fourth order pulmonary arteries, tortuous 'corkscrewing' pulmonary arteries, and abnormal capillary 'blush.' Several children had PA stenoses and 2 had systemic arterial abnormalities. Histologic examination of explanted lungs from 3 patients disclosed plexiform arteriopathy and extensive aneurysmal dilation of alveolar septal capillaries., Conclusions: SOX17-associated PAH is a distinctive genetic syndrome characterized by early onset severe PAH, extensive pulmonary vascular abnormalities, and high prevalence of congenital heart disease with intracardiac and interarterial shunts, suggesting a role for SOX17 in pulmonary vascular development., Competing Interests: Declaration of Competing Interest The PPHNet Registry was supported by grant U01 HL12118 (Data Fusion: A Sustainable, Open Source Registry Advancing Pediatric Pulmonary Vascular Disease Research; K.D. Mandl and S.H. Abman) from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) Work for this paper was also supported by a philanthropic grant for SOX17 research to the Boston Children's Hospital Pulmonary Hypertension Program, the Jayden de Luca Foundation, the Manton Center for Orphan Disease Research/Manton Foundation, and by NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. Contents are the authors' sole responsibility and do not necessarily represent official NIH or NHLBI views., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mark C. Liszewski reports a relationship with GE Healthcare that includes consulting or advisory. Mark C. Liszewski reports a relationship with Carestream Health Inc that includes board membership. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest The Authors have nothing to disclose.

Competing Interests: Declaration of competing interest Mark C. Liszewski reports a relationship with GE Health-care that includes consulting or advisory. Mark C. Liszewski reports a relationship with Carestream Health Inc that includes board membership.

Pediatric lung infections continue to be a leading cause of pediatric morbidity and mortality. Although both pediatric and general radiologists are familiar with typical lung infections and their imaging findings in children, relatively rare lung infections continue to present a diagnostic challenge. In addition, the advances in radiological imaging and emergence of several new lung infections in recent years facilitated the need for up-to-date knowledge on this topic. In this review article, we discuss the imaging findings of pediatric lung infections caused by unusual/uncommon and new pathogens. We review the epidemiological, clinical, and radiological imaging findings of viral (coronavirus disease 2019, Middle East respiratory syndrome, bird flu), bacterial (Streptococcus anginosus, Francisella tularensis, Chlamydia psittaci), and parasitic lung infections (echinococcosis, paragonimiasis, amoebiasis). Additional disorders whose clinical course and imaging findings may mimic lung infections in children (hypersensitivity pneumonitis, pulmonary hemorrhage, eosinophilic pneumonia) are also presented, to aid in differential diagnosis. As the clinical presentation of children with new and unusual lung infections is often non-specific, imaging evaluation plays an important role in initial detection, follow-up for disease progression, and assessment of potential complications., (© 2023. The Author(s).)

Objectives: To determine the added diagnostic value of contrast-enhanced ultrasound (CEUS) in pediatric chest abnormalities by comparing interpretation of CEUS studies and confidence level to conventional US studies., Methods: CEUS studies in patients with a variety of clinically suspected chest abnormalities performed between 2016 and 2020 were reviewed and compared to same-day conventional US studies. Examinations were independently interpreted by 4 radiologists blinded to clinical and other imaging data. Rater confidence was classified as low, moderate, or high. Diagnostic accuracy was determined by comparing image interpretation to patient outcome as the ground truth. Interobserver agreement was also assessed., Results: Sixteen patients (10 male) with 18 CEUS studies were included. Median rater agreement with ground truth was significantly higher for CEUS (100%) than conventional US (50%; P = .004). Median rater confidence was high (3.0) for CEUS, and low-moderate (1.5) for conventional US (P < .001). CEUS sensitivity (54.6-81.8%) and specificity (63.4-100.0%) were greater than conventional US (45.5-72.7% and 12.5-63.5%, respectively). CEUS false positives (0-4) and false negatives (2-5) were fewer than conventional US (4-7 and 3-6, respectively). Except for one rater pair where agreement was substantial (κ = .78, P < .01), inter-rater agreement for CEUS for all other rater pairs was nonsignificant (κ = .25-0.51, P ≥ .07). Agreement for conventional US was moderate and statistically significant for 3 rater pairs (κ = .55-0.78) and nonsignificant for the remaining 3 rater pairs (P ≥ .06)., Conclusions: CEUS adds diagnostic value to the assessment of a variety of chest abnormalities. The data support further evaluation of the role of CEUS as a non-invasive, problem-solving technique in children., (© 2024 American Institute of Ultrasound in Medicine.)

A multitude of lung disorders ranging from congenital and genetic anomalies to iatrogenic complications can affect the neonate or the infant within the first year of life. Neonatal and infant chest imaging, predominantly by plain radiography and computed tomography, is frequently employed to aid in diagnosis and management; however, these disorders can be challenging to differentiate due to their broad-ranging, and frequently overlapping radiographic features. A systematic and practical approach to imaging interpretation which includes recognition of radiologic patterns, utilization of commonly accepted nomenclature and classification, as well as interpretation of imaging findings in conjunction with clinical history can not only assist radiologists to suggest the diagnosis, but also aid clinicians in management planning. The contents of this article were endorsed by the leadership of both the World Federation of Pediatric Imaging (WFPI), and the International Society of Pediatric Thoracic Imaging (ISPTI)., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Disorders of the lungs and airways are among the most common indications for diagnostic imaging in infants and children. Traditionally, chest radiograph has been the first-line imaging test for detecting these disorders and when cross-sectional imaging is necessary, computed tomography (CT) has typically been the next step. However, due to concerns about the potentially harmful effects of ionizing radiation, pediatric imaging in general has begun to shift away from CT toward magnetic resonance imaging (MRI) as a preferred modality. Several unique technical challenges of chest MRI, including motion artifact from respiratory and cardiac motion as well as low signal-to-noise ratios secondary to relatively low proton density in the lung have slowed this shift in thoracic imaging. However, technical advances in MRI in recent years, including developments in non-Cartesian MRI data sampling methods such as radial, spiral, and PROPELLER imaging and the development of ultrashort TE and zero TE sequences that render CT-like high-quality imaging with minimal motion artifact have allowed for a shift to MRI for evaluation of lung and large airways in centers with specialized expertise. This article presents a practical approach for radiologists in current practice to begin to consider MRI for evaluation of the pediatric lung and large airways and begin to implement it in their practices. The current role for MRI in the evaluation of disorders of the pediatric lung and large airways is reviewed, and example cases are presented. Challenges for MRI of the lung and large airways in children are discussed, practical tips for patient preparation including sedation are described, and imaging techniques suitable for current clinical practice are presented., Competing Interests: Mark C. Liszewski is the recipient of grant funding for unrelated study from Carestream Health Inc., is an unpaid member of Carestream Health Medical Advisory Board, and recipient of travel and meal support and consulting fees from Carestream Health. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system., (© 2023. The Author(s).)

Ileocolic intussusception is the most common cause of intestinal obstruction in children under two years of age. Treatment in most cases is radiologically guided reduction. In Slovenia, ultrasound (US)-guided hydrostatic reduction is currently the standard of care. The purpose of this study was to compare the success rate of US-guided hydrostatic reduction when performed by subspecialty-trained pediatric radiologists, non-pediatric radiologists, or radiology residents. We retrospectively analyzed medical records of patients with ileocolic intussusception who underwent US-guided hydrostatic intussusception reduction at University Medical Centre Ljubljana between January 2012 and December 2022 (n = 101). During regular daily working hours, the reduction was performed by pediatric radiologists. After hours (evenings and overnight), pediatric radiologists, non-pediatric radiologists, or radiology residents performed the reduction procedure. Patients were divided into three groups based on the operator performing the procedure. Data was analyzed using the chi-square test. Pediatric radiologists had thirty-seven (75.5%) successful first attempts, non-pediatric radiologists had nineteen (76.0%), and radiology residents had twenty (74.1%). There was no statistically significant difference in the success rate of ileocolic intussusception reduction depending on the operator who performed the procedure (p = 0.98). No perforation was observed in either group during the reduction attempts.  Conclusion: Our results demonstrate that US-guided hydrostatic reduction is a reliable and safe procedure that achieves good results even in the hands of less experienced, however appropriately trained, radiologists. The results should encourage more medical centers to consider the implementation of US-guided hydrostatic reduction of ileocolic intussusception. What is Known: • US-guided hydrostatic reduction is a well-established method of treatment for ileocolic intussusception in children. • The results regarding the influence of operator's experience with the procedure on its success rate are scarce and contradictory. What is New: • US-guided hydrostatic intussusception reduction is a reliable and safe technique that achieves similar success rates when performed by experienced subspecialized pediatric radiologists or less experienced but trained operators such as non-pediatric radiologists and radiology residents. • The implementation of US-guided hydrostatic reduction in general hospitals without subspecialized pediatric radiologists could improve patient care by increasing access to radiologically guided reduction and simultaneously decreasing the time to reduction attempts., (© 2023. The Author(s).)

Pulmonary embolism (PE) is a potentially life-threatening condition that requires immediate medical intervention. Although PE was previously thought to occur infrequently in the pediatric population, recent studies have found a higher-than-expected prevalence of PE in the pediatric population of up to 15.5%. The imaging modality of choice for detecting PE in the pediatric population is multi-detector CT angiography, although MRI is assuming a growing and more important role as a potential alternative modality. Given the recent advances in both computed tomography pulmonary angiography (CTPA) and MRI techniques, a growing population of pediatric patients with complex comorbidities (such as children with a history of surgeries for congenital heart disease repair), and the recent waves of coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C), which are associated with increased risk of PE, there is new and increased need for an up-to-date review of practical CT and MRI protocols for PE evaluation in children. This article provides guidance for up-to-date CT and MR imaging techniques, reviews key recent studies on the imaging of pediatric PE, and discusses relevant pediatric PE imaging pearls and pitfalls, in hopes of providing readers with up-to-date and accurate practice for imaging evaluation of PE in children., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Chest tube placement and subsequent removal is a routine step in patient management after cardiovascular surgery. The purpose of this retrospective study is to determine the necessity of routine chest radiography following chest tube removal in order to detect potential complications in pediatric patients after cardiovascular surgery., Materials and Methods: We retrospectively reviewed the hospital records of all consecutive children up to 5 years of age who had cardiovascular surgery at our hospital between January 2015 and December 2020. Two radiologists independently evaluated routine chest radiographs performed 4 hours following chest tube removal for the presence of potential complications. In all post chest tube removal chest radiographs that demonstrated a complication, the patient's medical record was investigated in order to determine if there was an associated clinical or laboratory test abnormality, and if the radiographically detected complication led to a change in patient management. Inter-rater agreement between the 2 reviewers was evaluated with κ statistics., Results: We identified 147 children (73 [49.7%] male and 74 [50.3%] female; mean age=13.8 mo old; range 0 to 60 mo) who met the inclusion criteria. Complications were detected on routine chest radiograph after chest tube removal in 10 patients (6.8%) including pneumothorax (n=5, 3.4%), pleural effusion (n=3, 2%), pneumomediastinum (n=1, 0.7%), and pneumopericardium (n=1, 0.7%). No clinical or laboratory abnormalities were present in all children affected with radiographically detected complications on routine chest radiograph 4 hours after chest tube removal, and there was no need for intervention in any affected patients. There was high inter-rater κ agreement between the 2 independent reviewers for detecting complications on chest radiographs after chest tube removal (κ=0.94)., Conclusion: Our study shows that routine chest radiograph performed shortly after chest tube removal may not be necessary for the safe management of asymptomatic children after cardiovascular surgery because complications are rare and do not require intervention. In addition, obviating performance of this routine chest radiograph following chest tube removal will lead to a substantial decrease in exposure to unnecessary ionizing radiation in children who undergo frequent radiographs and lower medical costs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Childhood interstitial lung disease (chILD) refers to a diverse group of rare diffuse parenchymal lung diseases affecting infants and children, previously associated with considerable diagnostic confusion due to a lack of information regarding their clinical, imaging, and histopathologic features. Due to improved lung biopsy techniques, established pathologic diagnostic criteria, and a new structured classification system, there has been substantial improvement in the understanding of chILD over the past several years. The main purpose of this article is to review the latest advances in the imaging evaluation of pediatric interstitial lung disease within the framework of the new classification system., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Infants and children often present with respiratory symptoms referable to the airway. For these pediatric patients, airway imaging is frequently performed to evaluate for underlying disorders of the large airway. Various imaging modalities have been used to evaluate the pediatric large airway, and pediatric airway imaging techniques have continued to evolve. Therefore, clear understanding of the status and new advances in pediatric large airway imaging is essential for practicing radiologists to make timely and accurate diagnoses, which can lead to optimal pediatric patient management., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Mediastinal masses are commonly identified in the pediatric population with cross-sectional imaging central to the diagnosis and management of these lesions. With greater anatomical definition afforded by cross-sectional imaging, classification of mediastinal masses into the traditional anterior, middle and posterior mediastinal compartments - as based on the lateral chest radiograph - has diminishing application. In recent years, the International Thymic Malignancy Interest Group (ITMIG) classification system of mediastinal masses, which is cross-sectionally based, has garnered acceptance by multiple thoracic societies and been applied in adults. Therefore, there is a need for pediatric radiologists to clearly understand the ITMIG classification system and how it applies to the pediatric population. The main purpose of this article is to provide an updated review of common pediatric mediastinal masses and mediastinal manifestations of systemic disease processes in the pediatric population based on the new ITMIG classification system., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Disorders of the respiratory system are common in children and imaging plays an important role for initial diagnosis and follow-up evaluation. Radiographs are typically the first-line imaging test for respiratory symptoms in children and, when advanced imaging is required, CT has been the most frequently used imaging modality. However, because of increasing concern about potentially harmful effects of ionizing radiation on children, there has been a shift toward MRI in pediatric imaging. Although MRI of chest in children presents many technical challenges, recent advances in MRI technology are overcoming many of these issues, and MRI is now being used for evaluating the lung and large airway in children at centers with expertise in pediatric chest MRI. In this article we review the state of pediatric lung and large airway imaging, with an emphasis on cross-sectional modalities and the roles of MRI versus CT., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To retrospectively compare the lung and pleural findings in children with pulmonary vein stenosis (PVS) with and without aspiration on multidetector computed tomography (MDCT). Materials and Methods: All consecutive children (≤18 years old) with PVS who underwent thoracic MDCT studies from August 2004 to December 2021 were categorized into two groups: children with PVS with aspiration (Group 1) and children with PVS without aspiration (Group 2). Two independent pediatric radiologists retrospectively evaluated thoracic MDCT studies for the presence of lung and pleural abnormalities as follows: (1) in the lung (ground-glass opacity (GGO), consolidation, nodule, mass, cyst(s), interlobular septal thickening, and fibrosis) and (2) in the pleura (thickening, effusion, and pneumothorax). Interobserver agreement between the two reviewers was evaluated by the proportion of agreement and the Kappa statistic. Results: The final study population consisted of 64 pediatric patients (36 males (56.3%) and 43 females (43.7%); mean age, 1.7 years; range, 1 day−17 years). Among these 64 patients, 19 patients (29.7%) comprised Group 1 and the remaining 45 patients (70.3%) comprised Group 2. In Group 1 (children with PVS with aspiration), the detected lung and pleural MDCT abnormalities were: GGO (17/19; 89.5%), pleural thickening (17/19; 89.5%), consolidation (16/19; 84.5%), and septal thickening (16/19; 84.5%). The lung and pleural MDCT abnormalities observed in Group 2 (children with PVS without aspiration) were: GGO (37/45; 82.2%), pleural thickening (37/45; 82.2%), septal thickening (36/45; 80%), consolidation (3/45; 6.7%), pleural effusion (1/45; 2.2%), pneumothorax (1/45; 2.2%), and cyst(s) (1/45; 2.2%). Consolidation was significantly more common in pediatric patients with both PVS and aspiration (Group 1) (p < 0.001). There was high interobserver agreement between the two independent reviewers for detecting lung and pleural abnormalities on thoracic MDCT studies (Kappa = 0.98; CI = 0.958, 0.992). Conclusion: Aspiration is common in pediatric patients with PVS who undergo MDCT and was present in nearly 30% of all children with PVS during our study period. Consolidation is not a typical radiologic finding of PVS in children without clinical evidence of aspiration. When consolidation is present on thoracic MDCT studies in pediatric patients with PVS, the additional diagnosis of concomitant aspiration should be considered.

Purpose: To retrospectively compare the pleuropulmonary MDCT findings in children with pulmonary vein stenosis (PVS) and prematurity-related lung disease (PLD). Materials and Methods: All consecutive infants and young children (≤18 years old) who underwent thoracic MDCT studies from July 2004 to November 2021 were categorized into two groups—children with PVS (Group 1) and children with PLD without PVS (Group 2). Two pediatric radiologists independently evaluated thoracic MDCT studies for the presence of pleuropulmonary abnormalities as follows—(1) in the lung (ground-glass opacity (GGO), triangular/linear plaque-like opacity (TLO), consolidation, nodule, mass, cyst(s), interlobular septal thickening, and fibrosis); (2) in the airway (bronchial wall thickening and bronchiectasis); and (3) in the pleura (thickening, effusion, and pneumothorax). Interobserver agreement between the two reviewers was evaluated with the Kappa statistic. Results: There were a total of 103 pediatric patients (60 males (58.3%) and 43 females (41.7%); mean age, 1.7 years; range, 2 days−7 years). Among these 103 patients, 49 patients (47.6%) comprised Group 1 and the remaining 54 patients (52.4%) comprised Group 2. In Group 1, the observed pleuropulmonary MDCT abnormalities were—pleural thickening (44/49; 90%), GGO (39/49; 80%), septal thickening (39/49; 80%), consolidation (4/49; 8%), and pleural effusion (1/49; 2%). The pleuropulmonary MDCT abnormalities seen in Group 2 were—GGO (45/54; 83%), TLO (43/54; 80%), bronchial wall thickening (33/54; 61%), bronchiectasis (30/54; 56%), cyst(s) (5/54; 9%), pleural thickening (2/54; 4%), and pleural effusion (2/54; 4%). Septal thickening and pleural thickening were significantly more common in pediatric patients with PVS (Group 1) (p < 0.001). TLO, bronchial wall thickening, and bronchiectasis were significantly more frequent in pediatric patients with PLD without PVS (Group 2) (p < 0.001). There was high interobserver kappa agreement between the two independent reviewers for detecting pleuropulmonary abnormalities on thoracic MDCT angiography studies (k = 0.99). Conclusion: Pleuropulmonary abnormalities seen on thoracic MDCT can be helpful for distinguishing PVS from PLD in children. Specifically, the presence of septal thickening and pleural thickening raises the possibility of PVS, whereas the presence of TLO, bronchial wall thickening and bronchiectasis suggests PLD in the pediatric population.

Congenital lung malformations are a spectrum of developmental anomalies comprised of malformations of the lung parenchyma, airways, and vasculature. Imaging assessment plays a pivotal role in the initial diagnosis, management, and follow-up evaluation of congenital lung malformations in the pediatric population. However, there is currently a lack of practical imaging guidelines and recommendations for the diagnostic imaging assessment of congenital lung malformations in infants and children. This article reviews the current evidence regarding the imaging evaluation of congenital lung malformations and provides up-to-date imaging recommendations for pediatric congenital lung malformations., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Childhood interstitial lung disease (ChILD) is an umbrella term encompassing a diverse group of diffuse lung diseases affecting infants and children. Although the timely and accurate diagnosis of ChILD is often challenging, it is optimally achieved through the multidisciplinary integration of imaging findings with clinical data, genetics, and potentially lung biopsy. This article reviews the definition and classification of ChILD; the role of imaging, pathology, and genetics in ChILD diagnosis; treatment options; and future goals. In addition, a practical approach to ChILD imaging based on the latest available research and the characteristic imaging appearance of ChILD entities are presented., Competing Interests: Disclosure For T. Semple: Consultancy: Parexel, Boehringer Ingelheim. Educational fees: Vertex Phamaceuticals. Research grants: Chiesi Pharmaceuticals. (This article does not influence any of the aforementioned projects). No other disclosure or conflict of interest for other 2 authors (E.Y. Lee and A.J. Winant)., (Copyright © 2021 Elsevier Inc. All rights reserved.)

In contrast with the algorithms and screening criteria available for adults with suspected pulmonary embolism, there is a paucity of guidance on the diagnostic approach for children. The incidence of pulmonary embolism in the pediatric population and young adults is higher than thought, and there is an urgent need for updated guidelines for the imaging approach to diagnosis in the pediatric population. This article presents an up-to-date review of imaging techniques, characteristic radiologic findings, and an evidence-based algorithm for the detection of pediatric pulmonary embolism to improve the care of pediatric patients with suspected pulmonary embolism., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To investigate the characteristic thoracic multidetector computed tomography (MDCT) findings of pathologically proven combined congenital lung lesion consisting of bronchial atresia (BA) and congenital pulmonary airway malformation (CPAM) in children., Materials and Methods: All pediatric patients (age ≤ 18 years) with a known pathological diagnosis of a combined BA-CPAM congenital lung lesion, who underwent thoracic MDCT studies from January 2011 to January 2021 were included. Two pediatric radiologists independently evaluated thoracic MDCT studies for the presence of abnormalities in the lung, including nodule, mass, cyst, ground-glass opacity, and consolidation. When a lung abnormality was present, the number, size, composition (solid, cystic, or combination of both), borders (well-circumscribed vs. ill-defined), contrast enhancement pattern (nonenhancement vs. enhancement), and location (laterality, and lobar distribution) were also evaluated. Interobserver agreement between two independent reviewers was evaluated with κ statistics., Results: Eighteen contrast-enhanced thoracic MDCT studies from 18 individual pediatric patients (8 males (44%) and 10 females (56%); mean age: 4.9 months; SD: 2.6; range: 1-10 months) with a pathological diagnosis of combined BA-CPAM congenital lung lesion comprised the final study population. The most frequent MDCT finding of combined BA-CPAM congenital lung lesion in children was a solitary (18/18; 100%), well-circumscribed (18/18; 100%), both solid and cystic (17/18; 94%) lesion with nonenhancing (17/17; 100%) nodule, reflecting the underlying BA component, adjacent to a well-circumscribed multicystic mass (18/18; 100%), representing the underlying CPAM component. This combined congenital lung lesion occurred in all lobes with similar frequency. There was almost perfect interobserver κ agreement between the two independent reviewers for detecting abnormalities on thoracic MDCT studies (k = 0.98)., Conclusion: The characteristic thoracic MDCT findings of a combined BA-CPAM congenital lung lesion are a solitary, well-circumscribed solid and multicystic mass, with a nonenhancing nodule, reflecting the BA component, adjacent to a cystic mass, representing the CPAM component. Accurate recognition of these characteristic MDCT findings of combined BA-CPAM congenital lung lesion has great potential to help differentiate this combined congenital lung lesion from other thoracic pathology in children., (© 2021 Wiley Periodicals LLC.)

Purpose: The purpose of this study was to investigate the characteristic thoracic multidetector computed tomography (MDCT) findings of pathologically proven inflammatory myofibroblastic tumor (IMT) of the lung in children in the era of modern understanding based on refined pathologic diagnosis., Materials and Methods: All pediatric patients (age 18 y and above) with a known pathologic diagnosis of IMT of the lung who underwent thoracic MDCT studies from May 2008 to December 2020 were included. Two pediatric radiologists independently evaluated thoracic MDCT studies for the presence of abnormalities in the lung (nodule, mass, cyst, ground-glass opacity, consolidation), pleura (pleural effusion, pneumothorax), and mediastinum and hilum (lymphadenopathy). When a lung abnormality was present, the number, size, composition (solid, cystic, or combination of both), location (laterality, lobar distribution, and intraparenchymal vs. pleural-based), borders (well-circumscribed vs. ill-defined), the presence and type of associated calcification (punctate, dense, curvilinear, or flocculent), the presence of associated cavitation, contrast enhancement pattern (homogeneous, heterogenous, central, or peripheral), and other associated findings (neural foramen involvement, anomalous vessels, mass effect, and invasion of adjacent thoracic structures) were also evaluated. Interobserver agreement between 2 independent reviewers was evaluated with κ statistics., Results: In all, 12 thoracic MDCT studies from 12 individual pediatric patients (5 males [42%] and 7 females [58%]; mean age: 9.9 y; SD: 4.4 y; range: 2 to 16 y) comprised the final study population. All 12 thoracic MDCT studies (100%) were performed with intravenous contrast. The most frequent MDCT finding of IMT of the lung in children is a solitary (92%), pleural-based (83%), well-circumscribed (100%), solid (92%) mass with heterogenous contrast enhancement (100%), often with dense calcification (50%), which occurred in both lungs and all lobes with similar frequency. No pleural abnormality (pleural effusion, pneumothorax) or mediastinal abnormality (lymphadenopathy) was detected. In addition, although mass effect on adjacent thoracic structures was frequently seen (42%), no invasion, neural foramen involvement, or associated anomalous vessels was identified. There was excellent interobserver κ agreement between 2 independent reviewers for detecting abnormalities on thoracic MDCT studies (κ>0.95)., Conclusions: IMT of the lung in children typically presents as a solitary, pleural-based, well-circumscribed, solid mass with heterogenous contrast enhancement, often with dense calcification, without significant laterality or lobar preference. In addition, pleural or mediastinal abnormalities are characteristically absent. These notable MDCT attributes of IMT of the lung are an important and novel finding, with great potential to help differentiate pediatric IMT of the lung from other thoracic masses in children., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to investigate the extravascular thoracic multidetector computed tomography (MDCT) angiography findings of pediatric primary pulmonary vein stenosis (PVS) by comparing extravascular thoracic MDCT angiography findings in children with and without PVS., Materials and Methods: All pediatric patients (age 18 y and below) with a known diagnosis of primary PVS, confirmed by echocardiogram and/or conventional angiography, who underwent thoracic MDCT angiography studies from July 2006 to December 2020 were included. A comparison group, comprised of age-matched and sex-matched pediatric patients without PVS who underwent thoracic MDCT angiography studies during the same study period, was also generated. Two pediatric radiologists independently evaluated thoracic MDCT angiography studies for the presence of extravascular thoracic abnormalities in the lung (ground-glass opacity [GGO], consolidation, pulmonary nodule, mass, cyst, septal thickening, fibrosis, and bronchiectasis), pleura (pleural thickening, pleural effusion and pneumothorax), and mediastinum (lymphadenopathy and mass). When a thoracic abnormality was identified, the location and distribution of the abnormality (in relation to the location of PVS) were also evaluated. Extravascular thoracic MDCT angiography findings of pediatric patients with and without primary PVS were compared. Interobserver agreement between the 2 independent reviewers was evaluated with κ statistics., Results: The study group consisted of 15 thoracic MDCT angiography studies from 15 individual pediatric patients with primary PVS (8 males [53%] and 7 females [47%]; mean age: 10.9 mo; SD: 11.7 mo; range: 1 to 48 mo). The comparison group consisted of 15 thoracic MDCT angiography studies from 15 individual pediatric patients without PVS (8 males [53%] and 7 females [47%]; mean age: 10.2 mo; SD: 11.5 mo; range: 1 to 48 mo). In children with primary PVS, the characteristic extravascular thoracic MDCT angiography findings were GGO (14/15; 93%), septal thickening (5/15; 33%), pleural thickening (14/15; 93%), and ill-defined, mildly heterogeneously enhancing, noncalcified soft tissue mass (14/15; 93%) following the contours of PVS in the mediastinum. There was excellent interobserver κ agreement between 2 independent reviewers for detecting extravascular abnormalities on thoracic MDCT angiography studies (κ=0.99 for the study group and κ=0.98 for the comparison group)., Conclusions: Children with primary PVS have characteristic extravascular thoracic MDCT angiography findings. In the lungs and pleura, GGO, septal thickening, and pleural thickening are common findings. Importantly, in the mediastinum, the presence of a mildly heterogeneously enhancing, noncalcified soft tissue mass in the distribution of PVS is a novel characteristic thoracic MDCT angiography finding unique to pediatric primary PVS. When this constellation of extravascular thoracic MDCT angiography findings is detected, although rare, primary PVS should be considered as a possible underlying diagnosis, especially in symptomatic children., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate the characteristic thoracic multidetector computed tomography (MDCT) findings of dedicator of cytokinesis 8 (DOCK8) deficiency, a rare autosomal recessive form of hyperimmunoglobulin E syndrome, in children., Materials and Methods: All pediatric patients (age 18 y and below) with a known diagnosis of DOCK8 deficiency based on genetic testing who underwent thoracic MDCT studies from November 2004 to November 2020 were included. Two pediatric radiologists independently evaluated MDCT studies for the presence of thoracic abnormalities in the lung [ground-glass opacity (GGO), consolidation, pulmonary nodule, mass, cyst, and bronchiectasis], pleura (pleural effusion and pneumothorax), and mediastinum (lymphadenopathy). When a lung abnormality was present, laterality, distribution (upper, middle, and lower lung zone), and extent were also evaluated. When a pleural abnormality was identified, laterality and size of the abnormality were also assessed. When mediastinal lymphadenopathy was present, its location and size were also evaluated. Interobserver agreement between two independent reviewers was evaluated with κ statistics., Results: In all, 17 thoracic MDCT studies from 17 individual pediatric patients [5 males (29%) and 12 females (71%); mean age: 7.4 y; SD: 3.7; range: 1 to 13 y] comprised the final study population. Among 17 thoracic MDCT studies, 11 studies (65%) were performed with intravenous contrast (IV) and the remaining 6 MDCT studies (35%) were obtained without IV contrast. Bilateral bronchiectasis (11/17; 65%) with a middle lung zone predominance (8/11; 73%) was the most frequently detected lung abnormality, followed by GGO in 9/17 patients (53%). Among 11 contrast-enhanced MDCT studies, the majority (9 patients, 82%) had mediastinal lymphadenopathy. There was excellent interobserver κ agreement between 2 independent reviewers for detecting abnormalities on thoracic MDCT studies (κ>0.90)., Conclusion: Children with DOCK8 deficiency have characteristic thoracic MDCT findings, including bilateral bronchiectasis with a middle lung zone predominance, GGO, and mediastinal lymphadenopathy. When these characteristic thoracic MDCT findings are detected, although rare, DOCK8 deficiency should be considered as a possible underlying diagnosis in the pediatric population., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate extravascular findings on thoracic MDCT angiography in secondary pulmonary vein stenosis (PVS) due to total anomalous pulmonary venous connection (TAPVC) repair in children., Materials and Methods: All patients aged ≤18 years with a known diagnosis of secondary PVS after TAPVC repair, confirmed by echocardiography, conventional angiography, and/or surgery, who underwent thoracic MDCT angiography studies between July 2008 and April 2021 were included. Two pediatric radiologists independently examined MDCT angiography studies for the presence of extravascular thoracic abnormalities in the lung, pleura, and mediastinum. The location and distribution of each abnormality (in relation to the location of PVS) were also evaluated. Interobserver agreement between the two independent pediatric radiology reviewers was studied using kappa statistics., Results: The study group consisted of 20 consecutive pediatric patients (17 males, 3 females) with secondary PVS due to TAPVC repair. Age ranged from 2 months to 8 years (mean, 16.1 months). In children with secondary PVS due to TAPVC repair, the characteristic extravascular thoracic MDCT angiography findings were ground-glass opacity (19/20; 95%), septal thickening (7/20; 35%), pleural thickening (17/20; 85%), and a poorly defined, mildly heterogeneously enhancing, non-calcified soft tissue mass (17/20; 85%) which followed the contours of affected pulmonary veins outside the lung. There was excellent interobserver kappa agreement between two independent reviewers for detecting extravascular abnormalities on thoracic MDCT angiography studies (k = 0.99)., Conclusion: Our study characterizes the extravascular thoracic MDCT angiography findings in secondary pediatric PVS due to TAPVC repair. In the lungs and pleura, ground-glass opacity, interlobular septal thickening, and pleural thickening are common findings. Importantly, the presence of a mildly heterogeneously enhancing, non-calcified mediastinal soft tissue mass in the distribution of the PVS is a novel characteristic thoracic MDCT angiography finding seen in pediatric secondary PVS due to TAPVC repair.

Purpose: To determine whether diagnostic quality thoracic computed tomography angiography (CTA) studies can be obtained without general anesthesia (GA) in infants and young children using dual-source computed tomography (DSCT) with turbo flash spiral mode (TFSM) and free-breathing technique., Materials and Methods: All consecutive infants and young children (≤ 6 years old) who underwent thoracic CTA studies from January 2018 to October 2020 for suspected congenital thoracic disorders were categorized into two groups: with GA (Group 1) and without GA (Group 2). All thoracic CTA studies were performed on a DSCT scanner using TFSM and free-breathing technique. Two pediatric thoracic radiologists independently evaluated motion artifact in three lung zones (upper, mid, and lower). Degree of motion artifact was graded 0-3 (0, none; 1, mild; 2, moderate; and 3, severe). Logistic models adjusted for age and gender were used to compare the degree of motion artifact between lung zones. Interobserver agreement between reviewers was evaluated with kappa statistics., Results: There were a total of 73 pediatric patients (43 males (59%) and 30 females (41%); mean age, 1.4 years; range, 0-5.9 years). Among these 73 patients, 42 patients (58%) underwent thoracic CTA studies with GA (Group 1) and the remaining 31 patients (42%) underwent thoracic CTA studies without GA (Group 2). Overall, the degree of motion artifact was higher for Group 2 (without GA). However, only a very small minority (1/31, 3%) of Group 2 (without GA) thoracic CTA studies had severe motion artifact. There was no significant difference between the two groups with respect to the presence of severe motion artifact (odds ratio [OR] = 6, p = .222). When two groups were compared with respect to the presence of motion artifact for individual lung zones, motion artifact was significantly higher in the upper lung zone for Group 2 (without GA) (OR = 20, p = .043). Interobserver agreement for motion artifact was high, the average Kappa being 0.81 for Group 1 and 0.95 for Group 2., Conclusion: Although the degree of motion artifact was higher in the group without GA, only a small minority (3%) of thoracic CTA studies performed without GA had severe motion artifact, rendering the study nondiagnostic. Therefore, the results of this study support the use of thoracic CTA without GA using DSCT with TFSM and free-breathing in infants and young children. In addition, given that motion artifact was significantly higher in the upper lung zone without GA, increased stabilization in the upper chest and extremities should be considered., (© 2021 Wiley Periodicals LLC.)

Purpose : To retrospectively investigate the extravascular thoracic MDCT angiography findings of pulmonary vein stenosis (PVS) in children with a cardiac septal defect. Materials and Methods: Pediatric patients (age ≤ 18 years) with cardiac septal defect and PVS, confirmed by echocardiogram and/or conventional angiography, who underwent thoracic MDCT angiography studies from April 2009 to April 2021 were included. Two pediatric radiologists independently evaluated thoracic MDCT angiography studies for the presence of extravascular thoracic abnormalities in: (1) lung and airway (ground-glass opacity (GGO), consolidation, pulmonary nodule, mass, cyst, septal thickening, fibrosis, and bronchiectasis); (2) pleura (pleural thickening, pleural effusion, and pneumothorax); and (3) mediastinum (mass and lymphadenopathy). Interobserver agreement between the two independent pediatric radiology reviewers was evaluated with kappa statistics. Results: The final study group consisted of 20 thoracic MDCT angiography studies from 20 consecutive individual pediatric patients (13 males (65%) and 7 females (35%); mean age: 7.5 months; SD: 12.7; range: 2 days to 7 months) with cardiac septal defect and PVS. The characteristic extravascular thoracic MDCT angiography findings were GGO (18/20; 90%), septal thickening (9/20; 45%), pleural thickening (16/20; 80%), and ill-defined, mildly heterogeneously enhancing, non-calcified soft tissue mass (9/20; 45%) following the contours of PVS in the mediastinum. There was a high interobserver kappa agreement between two independent reviewers for detecting extravascular abnormalities on thoracic MDCT angiography studies (k = 0.99). Conclusion: PVS in children with a cardiac septal defect has a characteristic extravascular thoracic MDCT angiography finding. In the lungs and pleura, GGO, septal thickening, and pleural thickening are frequently seen in children with cardiac septal defect and PVS. In the mediastinum, a mildly heterogeneously enhancing, non-calcified soft tissue mass in the distribution of PVS in the mediastinum is seen in close to half of the pediatric patients with cardiac septal defect and PVS.

Objective: The primary immunodeficiency syndromes of cytotoxic T lymphocyte-associated protein 4 (CTLA-4) haploinsufficiency and lipopolysaccharide-responsive and beige-like anchor protein (LRBA) deficiency present with multisystem immune dysregulation. The aim of this study was to characterize and compare the pulmonary manifestations of these two diseases., Methods: We retrospectively analyzed the pulmonary clinical, radiologic, and histopathologic characteristics of six patients with CTLA-4 haploinsufficiency and four patients with LRBA deficiency with pulmonary involvement followed at a large tertiary care center., Results: Chronic respiratory symptoms were more frequent in patients with LRBA deficiency versus CTLA-4 haploinsufficiency (3/4 vs. 1/6). Cough was the most common respiratory symptom. Abnormalities in pulmonary exam and pulmonary function testing were more frequent in LRBA deficiency (4/4, 2/4) compared to CTLA-4 haploinsufficiency (1/6, 2/6). Chest computed tomography (CT) findings included mediastinal lymphadenopathy (4/4 in LRBA deficiency vs. 1/4 in CTLA-4 haploinsufficiency), pulmonary nodules (4/4, 3/4), ground-glass opacification (4/4, 3/4), and bronchiectasis (3/4, 1/4). Lymphocytic inflammation, concentrated bronchovasculocentrically and paraseptally, was the predominant pathologic finding and was observed in all patients who had lung biopsies (N = 3 with LRBA deficiency; N = 3 with CTLA-4 haploinsufficiency)., Conclusion: Despite phenotypic overlap amongst these diseases, LRBA deficiency demonstrated greater severity of pulmonary disease, indicated by respiratory symptoms, pulmonary exam, and intrathoracic radiologic findings. Chest CT was the most sensitive indicator of pulmonary involvement in both disorders. Lymphocytic inflammation is the key histologic feature of both disorders. Pediatric pulmonologists should consider these disorders of immune dysregulation in the relevant clinical context to provide earlier diagnosis, comprehensive pulmonary evaluation and treatment., (© 2021 Wiley Periodicals LLC.)

Objectives: To assess the diagnostic utility of MDCT in the evaluation of persistent stridor in children for the underlying large airway causes and benefit of additional findings., Methods: All consecutive pediatric patients who underwent MDCT for the evaluation of persistent stridor from December 2018 to February 2020 were included. Two pediatric radiologists independently reviewed MDCT studies for the presence of abnormalities at six large airway levels: (1) nasopharynx, (2) oropharynx, (3) glottis, (4) subglottis, (5) trachea, and (6) mainstem bronchi. In addition, studies were evaluated for the presence of non-airway abnormalities. Interobserver agreement between two reviewers was evaluated with kappa statistics., Results: There were a total of 40 pediatric patients (age range: 1 day-4 years. MDCT detected large airway abnormalities in 20 (50%) out of 40 patients, including 4 (20%) in nasopharynx, 4 (20%) in glottis, 4 (20%) in trachea, 3 (15%) in subglottis, 3 (15%) in mainstem bronchi, and 2 (10%) in oropharynx. Non-airway abnormalities were seen in 13 (32.5%) children, including 9 (69%) in the lungs, 3 (23%) in the soft tissue, and 1 (8%) in the bone. The remaining 7 (17.5%) studies were normal. There was excellent interobserver agreement seen for detecting large airway and non-airway abnormalities (k > 0.90)., Conclusion: MDCT has high diagnostic utility in diagnosing large airway causes of persistent stridor in children. It can also provide additional information regarding non-airway abnormalities. Therefore, MDCT has the potential to be utilized as a noninvasive problem-solving imaging modality in pediatric patients with persistent stridor., (© 2021 Wiley Periodicals LLC.)

Purpose: First, to investigate the added diagnostic value of chest computed tomography (CT) for evaluating COVID-19 in symptomatic children by comparing chest CT findings with chest radiographic findings, and second, to identify the imaging signs and patterns on CT associated with COVID-19 pneumonia in children., Materials and Methods: From March 2020 to December 2020, 56 consecutive children (33 males and 23 girls; mean age ± SD, 14.8 ± 5.0 years; range, 9 months-18 years) with mild to moderate symptom and laboratory confirmed COVID-19 (based on Centers for Disease Control criteria) underwent both chest radiography and chest CT on the same day within the first 2 days of initial presentation to the hospital. Two experienced radiologists independently evaluated chest radiographs and chest CT studies for thoracic abnormalities. The findings from chest radiography and chest CT were compared to evaluate the added diagnostic value of chest CT for affecting patient management. Interobserver agreement was measured with Cohen's κ statistics., Results: Eleven (19.6%) of 56 patients had abnormal chest radiographic findings, including ground-glass opacity (GGO) in 5/11 (45.4%) and combined GGO and consolidation in 6/11 (54.5%). On chest CT, 26 (46.4%) of 56 patients had abnormal CT findings, including combined GGO and consolidation in 19/26 (73.1%), GGO in 6/26 (23.1%), and consolidation in 1/26 (3.8%). Chest CT detected all thoracic abnormalities seen on chest radiography in 11/26 (42.3%) cases. In 15/26 (57.7%), chest CT detected lung abnormalities that were not observed on chest radiography, which included GGO and consolidation in 9/15 (60%), GGO in 5/15 (33.3%), and consolidation in 1/15 (6.6%) cases. These additional CT findings did not affect patient management. In addition, chest CT detected radiological signs and patterns, including the halo sign, reversed halo sign, crazy paving pattern, and tree-in-bud pattern. There was almost perfect interobserver agreement between the two reviewers for detecting findings on both chest radiographs (κ, 0.89, p = .001) and chest CT (κ, 0.96, p = .001) studies., Conclusion: Chest CT detected lung abnormalities, including GGO and/or consolidation, that were not observed on chest radiography in more than half of symptomatic pediatric patients with COVID-19 pneumonia. However, these additional CT findings did not affect patient management. Therefore, CT is not clinically indicated for the initial evaluation of mild to moderately symptomatic pediatric patients with COVID-19 pneumonia., (© 2021 Wiley Periodicals LLC.)

OBJECTIVE. The purpose of our study was to determine the CT features of benign intrapulmonary lymph nodes in pediatric patients with known extrapulmonary solid malignancy. MATERIALS AND METHODS. A retrospective review of surgical pathology archives was performed to identify consecutive chest CT studies of pediatric patients (≤ 18 years) with extrapulmonary solid malignancy and histologically confirmed benign intrapulmonary lymph nodes between January 1, 2004, and March 15, 2020. CT features of intrapulmonary lymph nodes-including size, shape, margin, type, associated calcification or fat, and location-were independently evaluated by two pediatric radiologist reviewers. The CT features of benign intrapulmonary lymph nodes in pediatric patients were analyzed using summary statistics. Interobserver agreement was measured with the kappa coefficient. RESULTS. There were 36 pathology-confirmed benign intrapulmonary lymph nodes in 27 pediatric patients (18 boys and nine girls; mean age, 12 years; age range, 1-18.2 years). Twenty-three (63.9%) of the benign intrapulmonary lymph nodes were biopsied from the right lung and 13 (36.1%) from the left lung ( p = .03). The mean size, determined from CT studies, of benign intrapulmonary lymph nodes was 3.6 mm (SD, 1.4 mm; range, 1.3-7.8 mm). Triangular shape (25/36, 69.4%) was the most common shape of the benign intrapulmonary lymph nodes. Less commonly seen shapes of benign intrapulmonary lymph nodes were oval (6/36, 16.7%), round (3/36, 8.3%), and trapezoidal (2/36, 5.6%). All benign intrapulmonary lymph nodes were smoothly marginated and solid without associated calcification or fat. Of the 36 benign intrapulmonary lymph nodes, 15 (41.7%) were pleura-based; 11 (30.6%), perifissural; and 10 (27.8%), parenchymal. The kappa value for interobserver agreement between the two reviewers was 0.917 (95% CI, 0.825-1.000; standard error, 0.047), which corresponds to near-perfect agreement. CONCLUSION. In pediatric patients with known extrapulmonary solid malignancy, benign intrapulmonary lymph nodes are subcentimeter (mean size, 3.6 mm), smoothly marginated, and solid without containing calcification or fat on CT. In particular, triangular shape was the most commonly encountered shape of a benign intrapulmonary lymph node.

Filtering through the plethora of radiologic studies generated in response to the coronavirus disease of 2019 (COVID-19) pandemic can be time consuming and impractical for practicing thoracic radiologists with busy clinical schedules. To further complicate matters, several of the imaging findings in the pediatric patients differ from the adult population. This article is designed to highlight clinically useful information regarding the imaging manifestations of pediatric COVID-19 pneumonia, including findings more unique to pediatric patients, and multisystem inflammatory syndrome in children.

Purpose: To investigate how COVID-19 has impacted pediatric radiology practice around the world at the present time., Materials and Methods: This study was based on a survey conducted by the World Federation of Pediatric Imaging (WFPI) COVID-19 task force. Pediatric radiology representatives from countries around the world were identified and asked to complete an electronic survey consisting of 17 questions related to the impact of, concerns surrounding, and education related to COVID-19 on pediatric radiology. For each outcome variable, a pair of 2-way frequency tables was constructed: one against COVID-19 prevalence, and another against region. Tests of independence of the tables' row and column factors were performed based on Fisher's exact test and odds ratios (OR) were estimated via logistic regression models corresponding to these 2-way tables., Results: The survey (response rate 87%, 72/83) comprised representatives from 71 countries and Hong Kong across 6 continents. 66/72 respondents (92%) indicated that COVID-19 has resulted in moderate (21/72, 29%), significant (36/72, 50%), or complete (9/72, 13%) change in radiology departments/practices in their countries. The two most frequent concerns over the next four months were personal/family health (54/72, 75%) and exposure (48/72, 67%). 79% (57/72) of respondents indicated some level of discomfort in identifying pediatric COVID-19 imaging manifestations. Changes in resident education were reported by 68/72 (94%) respondents, and 22/72 (31%) were concerned that the likelihood of current trainees pursuing a career in pediatric radiology will be impacted., Conclusion: COVID-19 has had a substantial negative impact on pediatric radiology practice around the world., (2020 by the Radiological Society of North America, Inc.)

OBJECTIVE. The purpose of this article is to review new pediatric lung disorders-including disorders that have occurred in recent years years such as severe acute respiratory syndrome (SARS), swine-origin influenza A (H1N1), Middle East respiratory syndrome (MERS), e-cigarette or vaping product use-associated lung injury (EVALI), and coronavirus disease (COVID-19) pneumonia-to enhance understanding of the characteristic imaging findings. CONCLUSION. Although the clinical symptoms of SARS, H1N1, MERS, EVALI, and COVID-19 pneumonia in pediatric patients may be nonspecific, some characteristic imaging findings have emerged or are currently emerging. It is essential for radiologists to have a clear understanding of the characteristic imaging appearances of these lung disorders in pediatric patients to ensure optimal patient care.

The coronavirus disease 2019 (COVID-19) global pandemic is an ongoing public health emergency, with over 4 million confirmed cases worldwide. Due to the novel nature of this coronavirus and our evolving understanding of its pathophysiology, there is continued uncertainty surrounding diagnosis and management of COVID-19, especially in pediatric patients. In addition, a new febrile hyperinflammatory Kawasaki-like syndrome (also known as multisystem inflammatory syndrome in children, or MIS-C) has emerged in pediatric patients with temporal association to COVID-19 infection. This review article aims to provide an up-to-date review of the clinical and imaging findings of pediatric MIS-C associated with COVID-19, compared with typical acute pediatric COVID-19 infection, with an emphasis on thoracic imaging findings. Supplemental material is available for this article. © RSNA, 2020., Competing Interests: Disclosures of Conflicts of Interest: A.J.W. disclosed no relevant relationships. E.B. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author and spouse own a U.S. patent for segmentation of vertebral bodies from CT scans of the chest and abdomen (Automated Vertebral Body Image Segmentation for Medical Screening US20130077840. Publication date 3/28/2013. Einat Blumfield, Anthony Blumfield. Radnostics LLC); author and spouse are cofounders of Radnostics LLC; product is software for automated segmentation of vertebral bodies in chest and abdomen CT scans and automated calculation of bone mineral density. The company is currently inactive. They did not receive any financial compensation. Other relationships: disclosed no relevant relationships. M.C.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author is member of the medical advisory board of Carestream Health; author is recipient of a grant from Carestream Health for an unrelated study; received travel and meal support from Carestream Health. Other relationships: disclosed no relevant relationships. J.K. disclosed no relevant relationships. A.M.F. disclosed no relevant relationships. E.Y.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: expert testimony for Cambridge Medical Experts; received royalties as editor of textbooks; received travel support and lectureship honorarium from Guerbet. Other relationships: disclosed no relevant relationships., (2021 by the Radiological Society of North America, Inc.)

Background Electronic cigarette or vaping product use-associated lung injury (EVALI) is a serious public health concern with substantial morbidity and mortality, particularly in young individuals. Purpose To evaluate chest radiographic and chest CT findings of EVALI in the pediatric population. Materials and Methods This was a retrospective study of children who presented to a tertiary pediatric hospital from December 2018 to December 2019. Patients fulfilled the Centers for Disease Control and Prevention criteria for EVALI and had chest radiographs and CT images available at initial presentation. Two pediatric radiologists independently reviewed imaging for pattern, distribution, and extent of pulmonary abnormalities, as well as for extrapulmonary abnormalities. Clinical information, management, and outcomes were reviewed. Interobserver agreement was measured with Cohen κ coefficient. Results Seven male patients (50%) and seven female patients (50%) (mean age, 16 years; range, 13-18 years) were evaluated. All patients underwent chest radiography and CT within 4 days of presentation (range, 0-4 days). Chest radiographic findings included ground-glass opacity in 14 of 14 (100%) and consolidation in eight of 14 (57%). CT findings included ground-glass opacity in 14 of 14 (100%), consolidation in nine of 14 (64%), and interlobular septal thickening in two of 14 (14%). At CT, subpleural sparing was seen in 11 of 14 (79%) and a reversed halo sign was seen in five of 14 (36%). Chest radiographic and CT abnormalities were predominately bilateral in 14 of 14 (100%) and symmetric in 13 of 14 (93%), with lower lobe predominance in seven of 14 (50%). Extent of abnormality was predominately diffuse at both chest radiography and CT. There was almost perfect interobserver agreement between two reviewers for detecting abnormalities on chest radiographs (κ = 0.99; 95% confidence interval: 0.97, 1.00) and CT (κ = 0.99; 95% confidence interval: 0.98, 1.00). Conclusion In pediatric patients, electronic cigarette or vaping product use-associated lung injury is characterized by bilateral symmetric ground-glass opacities, consolidation, and a lower lobe predominance at CT. © RSNA, 2020.

Coronavirus disease 2019 (COVID-19) has quickly spread since it was first detected in December 2019 and has evolved into a global pandemic with over 1.7 million confirmed cases in over 200 countries around the world at the time this document is being prepared. Owing to the novel nature of the virus and the rapidly evolving understanding of the disease, there is a great deal of uncertainty surrounding the diagnosis and management of COVID-19 pneumonia in pediatric patients. Chest imaging plays an important role in the evaluation of pediatric patients with COVID-19; however, there is currently little information available describing imaging manifestations of COVID-19 in pediatric patients and even less information discussing the utilization of imaging studies in pediatric patients. To specifically address these concerns, a group of international experts in pediatric thoracic imaging from five continents convened to create a consensus statement describing the imaging manifestations of COVID-19 in the pediatric population, discussing the potential utility of structured reporting during the COVID-19 pandemic, and generating consensus recommendations for utilization of chest radiographs and CT in the evaluation of pediatric patients with COVID-19. The results were compiled into two structured reporting algorithms (one for chest radiographs and one for chest CT) and eight consensus recommendations for the utilization of chest imaging in pediatric COVID-19 infection. © RSNA, 2020., Competing Interests: Disclosures of Conflicts of Interest: A.M.F. disclosed no relevant relationships. G.S.P. disclosed no relevant relationships. W.C.C. disclosed no relevant relationships. P.D. disclosed no relevant relationships. K.M.D. disclosed no relevant relationships. P.G.P. disclosed no relevant relationships. T.K. disclosed no relevant relationships. A.J.W. disclosed no relevant relationships. E.Y.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: Guerbet supported author’s traveling and accommodation to 2019 AOSPR meeting in Seoul, Korea for luncheon lecture of contrast agent for pediatric imaging study; author paid by Michigan Professional Insurance Exchange for medical legal consultation work ($3529.17); author receives royalties for editorial work for textbook publication from Wolters Kluwer Health (book royalty = $1008.55) and Elsevier (book royalty = $1000). Other relationships: disclosed no relevant relationships., (2020 by the Radiological Society of North America, Inc.)

Anatomic variants are common incidental findings in pediatric chest imaging and can be mistaken for true underlying pathology, sometimes resulting in unnecessary additional imaging evaluation or invasive procedures. Clear understanding of the imaging characteristics and clinical significance of anatomic thoracic variants is important for accurate diagnosis and avoidance of unnecessary intervention. This article provides an up-to-date review of anatomic variants in the pediatric chest to increase knowledge and aide in timely, correct diagnosis., (Published by Elsevier Inc.)