Objectives Robust tools for automated segmentation of paediatric organs in cross-sectional imaging remain limited, particularly compared to well-established models for adult populations such as TotalSegmentator. The objective of this study was to develop a segmentation model and incorporate Global Intensity Non-Linear (GIN) augmentation to determine its potential for robust organ segmentation in paediatric computed tomography (CT) and magnetic resonance imaging (MRI). Methods We trained a 3D U-Net model on the public Pediatric-CT-SEG dataset, incorporating GIN to facilitate transfer from CT to MR images. The model was evaluated on a subset of the public CT dataset (n=70) and fully independent paediatric MRI examinations (n=42). We compared our novel GIN model with a structurally identical baseline model without GIN as well as TotalSegmentator using Dice similarity coefficient (DSC) and normalized surface distance (NSD). Results The baseline and GIN model achieved similar mean DSC and NSD values for CT examinations across all organs: DSC 0.91±0.13 (baseline) and 0.91±0.12 (GIN), NSD 0.77±0.16 (baseline) and 0.78±0.15 (GIN). TotalSegmentator achieved significantly lower overall DSC than the GIN model of 0.88±0.12 and NSD of 0.71±0.19, p<0.001. For MRIs, our GIN model showed significantly higher overall DSC (0.72±0.24) and NSD (0.46±0.17) compared to the baseline model (DSC 0.18±0.26; NSD 0.11±0.16) and to TotalSegmentator (DSC 0.56±0.37; NSD 0.30±0.26), resulting in p<0.001 for all organs except lungs. Conclusion Our findings highlight the potential of deep-learning models with GIN augmentation to enable robust organ segmentation, and consequently reliable organ volumetry, in paediatric CT and MRI examinations within clinical workflows. To our knowledge, the proposed GIN model is the first to enable robust multi-organ segmentation in paediatric MRI and CT examinations.

MRI-based age estimation offers a non-invasive approach for assessing biological maturity in forensic medicine. This study compares CNN-,transformer- and hybrid-based architectures for knee MRI age classification and bone segmentation, evaluating vision transformer, Swin transformer, DINOv2, attention U-Net, transformer U-Net, and a baseline CNN U-Net on 1,000 images for classification and 3,000 for segmentation. Pure transformer models failed to train effectively, while attention U-Net and transformer U-Net achieved good segmentation with a dice coefficient of 0.997 but poor classification with an F1-score of 0.751. These results suggest that CNN locality bias is essential for classification, whereas global attention enhances segmentation. Overall, small datasets and the absence of inductive biases limit transformer performance in knee MRI age estimation.

Portal hypertension in children presents distinct etiologies, clinical manifestations, and management strategies compared with adults, making accurate imaging evaluation essential across the diagnostic and therapeutic pathway. Ultrasound remains the first-line modality, providing real-time assessment of vascular anatomy, haemodynamics, splenic involvement, and portosystemic collaterals. Colour Doppler ultrasound and pulsed-wave Doppler ultrasound, along with systematic scanning protocols, enable early identification of portal vein obstruction, cavernous transformation, and hepatofugal flow patterns. Elastography techniques, particularly spleen stiffness measurement, provide valuable non-invasive biomarkers of clinically significant portal hypertension and variceal risk and complement conventional imaging. When ultrasound findings are inconclusive, contrast-enhanced ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) offer detailed vascular mapping, characterisation of parenchymal changes, and preoperative evaluation. MRI—especially dynamic contrast-enhanced sequences, magnetic resonance cholangiopancreatography (MRCP), and magnetic resonance elastography—provides comprehensive anatomical and functional assessment without ionising radiation. Interventional and surgical procedures, including portal vein recanalisation, Meso-Rex bypass, and transjugular intrahepatic portosystemic shunts, require precise imaging both before and after treatment. Long-term surveillance relies on multimodal imaging to detect stenosis, thrombosis, or flow-related complications and to guide timely reintervention. With continuous advances in elastography, high-resolution CT, and MRI-based haemodynamic techniques, imaging plays an expanding role in the tailored management of paediatric portal hypertension, supporting early diagnosis, therapeutic decision-making, and structured follow-up.

Background:Aortic coarctation (CoA) necessitates long-term monitoring to identify late complications, including re-stenosis, aneurysms, arrhythmias and heart failure. Nonetheless, there remain gaps in understanding the effects of adverse left-ventricular (LV) remodeling at the myocardial tissue level, which may contribute to incipient heart failure. The aim of this study is to evaluate myocardial tissue characteristics in patients with CoA using advanced cardiac magnetic resonance (CMR) imaging techniques to identify markers of adverse tissue remodeling and their association with disease severity, bicuspid aortic valve (BAV), and clinical management strategies such as blood pressure (BP) medication. Methods:CMR imaging at 3 Tesla was used to determine the myocardial extracellular volume fraction (ECV), native T1, and intracellular water lifetime (τic) by pre- and post-gadolinium contrast T1 mapping in 46 patients (21 male; mean age 20 years) with CoA and 14 age-matched controls. LV volumes, mass, and ejection fraction were obtained from cine CMR. CoA was classified as low grade ["LG" = the maximum flow velocity (Vmax) ≤3 m/s and no re-stenosis, nor arterial hypertension or medication], severe CoA ("sCoA" = Vmax >3 m/s or one of LG's other variables applies), and "CoA with BAV". Results:ECV was significantly higher in sCoA group (0.31±0.04) compared to LG group (0.26±0.02, P=0.002) and healthy controls (0.26±0.02, P=0.001). ECV with BAV (0.31±0.05) was higher than in LG group (P=0.03) and healthy controls (P=0.03). Native T1 values were significantly elevated in sCoA group (T1 =1,391±162 ms) compared to LG group (T1 =1,213±47 ms, P=0.002) and in CoA with BAV (T1 =1,390±127 ms) versus LG group (P=0.002). τic was lower in LG group (0.24±0.03 s), indicative of a smaller cardiomyocyte diameter, compared to sCoA (0.28±0.04 s; P=0.01) and LG CoA with concomitant BAV (0.31±0.05 s; P=0.04). The LV end-systolic volume (ESV) was significantly higher in group with BAV than in LG CoA (P<0.001) and sCoA (P=0.001) groups. Patients who took BP medication had significantly lower values in native T1 (P=0.02) and τic (P=0.03). Conclusions:sCoA is associated with an elevated myocardial ECV and native T1 compared to LG CoAs and healthy controls, reflecting adverse tissue remodeling. Patients with LG CoA and concomitant BAV showed significantly greater diffuse myocardial fibrosis than those with isolated LG CoA. CoA patients, especially those with sCoA and those with concomitant BAV, could be at increased long-term risk for complications related to diffuse myocardial fibrosis, such as diastolic dysfunction and arrhythmias. Patients taking antihypertensive medication may benefit from reduced cardiomyocyte hypertrophy and less interstitial fibrosis.

Background Congenital abnormalities occur in about 3 in 100 fetuses. Prenatal ultrasound is the standard technique to detect these fetal abnormalities. In Germany, three ultrasound examinations are provided in the first, second, and third trimesters, respectively. Fetal magnetic resonance imaging (MRI) can be used as an adjunct technique to provide further information in cases of congenital abnormalities. Method A literature search was performed on PubMed focusing on publications that used fetal MRI as a secondary approach after prenatal ultrasound. Results MRI is a safe imaging method that does not harm the fetus when used during pregnancy. Some publications with experts in radiology show a very clear diagnostic advantage with respect to performing MRI on fetuses with brain abnormalities, while other publications with experts in neurosonography do not find the advantage to be that evident. Both techniques are clearly user-dependent. Conclusion Fetal MRI can supplement the information obtained by fetal ultrasound and can provide additional information or exclude others. Diagnosis made by an interdisciplinary cooperation based on all available ultrasound and MRI findings is the key to optimal imaging and advice for expectant parents.

The Kasabach-Merrit syndrome is characterized as the association of a vascular tumor, typically a caposiform hemangioendothelioma and rarely a tufted hemangioma, and a severe consumptive coagulopathy with potentially life-threatening thrombocytopenia. The severe coagulopathy with increased bleeding tendency must be considered before invasive procedures and often requires repeated platelet concentrate substitutions. We present a case of a mature male neonate with Kasabach-Merritt- Syndrome as well as VACTERL association. The VACTERL association describes a group of malformations. Our patient presented with anal atresia combined with tethered cord, and left renal agenesis. The VACTERL association as well as Kasabach-Merritt syndrome were found to be independent pathologies within this patient. A common occurrence or an association with each other has not been described in the literature so far. The challenging coagulation setting due to severe thrombocytopenia complicated the surgical management so far. Finally, mTOR-inhibitor sirolimus was successful in terms of tumor reduction and especially reduction of platelet consumption.

(1) Background: Accurate hepatic artery (HA) depiction following pediatric liver transplantation (LT) is essential for graft surveillance but challenging on ultrasound (US). This study assesses if improved HA delineation can be achieved by recording two-dimensional US volumes in Color Doppler (CD) and B-flow technique. (2) Methods: Of 42 consecutive LT, 37 cases were included, and HA delineation was retrospectively rated using a four-point score (0 = HA not detectable, 3 = HA fully detectable, separable from portal vein) within 48 h post-LT (U1) and before discharge (U2). (3) Results: Adding B-flow compared with CD alone showed superior results at neohilar (U1: 2.2 ± 1.0 vs. 1.1 ± 0.8, p < 0.0001; U2: 2.5 ± 0.8 vs. 1.5 ± 0.9, p < 0.0001) and segmental levels (U1: 2.8 ± 0.6 vs. 0.6 ± 0.8, p < 0.0001; U2: 2.8 ± 0.6 vs. 0.7 ± 0.5, p < 0.0001). (4) Conclusions: Standardized US volume recordings combining B-flow and CD can effectively delineate the HA along its vascular course in pediatric LT. The technique should be further evaluated as a standard monitoring instrument to rule out vascular complications after LT.

Background Liver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of intraoperative and postoperative complications. So far, only limited data regarding the best radiological approach to monitor children during liver transplantation is available. Objective To harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra- and postoperative phase. This paper reports the responses related to intraoperative imaging. Materials and methods An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey. Results Intraoperative ultrasound (US) is used by all sites to assess the quality of the vascular anastomosis in order to ensure optimal perfusion of the liver transplant. Vessel depiction is commonly achieved using color Doppler (95.3%). Additional US-based techniques are employed by fewer centers (power angio mode, 28.6%; B-flow, 19%; contrast-enhanced US, 14.3%). Most centers prefer a collaborative approach, with surgeons responsible for probe handling, while radiologists operate the US machine (47.6%). Less commonly, the intraoperative US is performed by the surgeon alone (28.6%) or by the radiologist alone (23.8%). Timing of US, imaging frequency, and documentation practices vary among centers. Conclusion Intraoperative US is consistently utilized across all sites during pediatric liver transplantation. However, considerable variations were observed in terms of the US setup, technique preferences, timing of controls, and documentation practices. These differences provide valuable insights for future optimization and harmonization studies.

BACKGROUND:Kasai procedure (KPE) is a palliative intervention in infants with biliary atresia (BA) aiming to restore biliary drainage. While the measure of success in BA is the post-Kasai native liver survival (NLS), BA remains the most frequent indication for liver transplantation in children. While a considerable amount of children fail to clear their jaundice following KPE, resulting in early liver failure and transplantation, some children become jaundice-free after "successful" KPE. However, sequelae of chronic liver disease might affect those children, becoming a later risk for NLS. While liver transplantation is inevitable in the majority of children, various salvage procedures have been recently described to maintain NLS. This article provides a comprehensive overview of procedures performed after KPE to prolong NLS in BA patients from early childhood to late adulthood and discusses their indications and limitations. METHODS:A literature-based search for surgical and radiological interventions performed in BA patients after KPE to prolong NLS (salvage procedures) was performed using PubMed. Data from case reports, retrospective studies, and registries were included. RESULTS:Fifteen studies included 794 patients who underwent post-KPE salvage procedures. The Oxford Centre for Evidence-Based Medicine levels were IIc to IV.Interventions included redo-Kasai's (n = 710) for cessation of bile flow post-KPE, surgical and radiological procedures (n = 14) for bile lakes, and recurrent cholangitis, shunt surgery (n = 49), and transjugular intrahepatic portosystemic shunt (n = 21) for portal hypertension in BA patients. Age at the time of salvage interventions varied considerably, including redo-Kasai's at 27 days of life and percutaneous biliary interventions in a 35-year-old. CONCLUSION:Salvage procedures can maintain NLS after KPE in BA patients with disease sequelae. However, indications remain scarce and liver transplantation is ultimately unavoidable in the majority of patients. While redo-Kasai numbers are globally decreasing with the advances in liver transplantation, procedures for bile lakes and portal hypertension can be viable options for patients with complications but otherwise stable liver function. Discussion on those procedures should be held by multidisciplinary expert teams, involving pediatric hepatologists, pediatric surgeons, and transplant surgeons to elaborate on the potential of maintaining NLS or proceeding with transplantation.

Background Liver transplantation is the state-of-the-art curative treatment in end-stage liver disease. Imaging is a key element for successful organ-transplantation to assist surgical planning. So far, only limited data regarding the best radiological approach to prepare children for liver transplantation is available. Objectives In an attempt to harmonize imaging surrounding pediatric liver transplantation, the European Society of Pediatric Radiology (ESPR) Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phase. This paper reports the responses on preoperative imaging. Material and methods An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted and 22 institutions from 11 countries returned the survey. From 2018 to 2020, the participating centers collectively conducted 1,524 transplantations, with a median of 20 transplantations per center per annum (range, 8–60). Results Most sites (64%) consider ultrasound their preferred modality to define anatomy and to plan surgery in children before liver transplantation, and additional cross-sectional imaging is only used to answer specific questions (computed tomography [CT], 90.9%; magnetic resonance imaging [MRI], 54.5%). One-third of centers (31.8%) rely primarily on CT for pre-transplant evaluation. Imaging protocols differed substantially regarding applied CT scan ranges, number of contrast phases (range 1–4 phases), and applied MRI techniques. Conclusion Diagnostic imaging is generally used in the work-up of children before liver transplantation. Substantial differences were noted regarding choice of modalities and protocols. We have identified starting points for future optimization and harmonization of the imaging approach to multicenter studies.

A neonate was born via cesarean section at 35+4 weeks of gestation weighing 2310 g (13th percentile) and presenting with clinical signs of severe respiratory distress. The X-ray revealed bilateral diaphragmatic hernia, which led to displacement of both liver and stomach into the respective thoracic cavities ([Fig. 1]). Antenatal dysmorphic features such as microcephaly, elongated eyelashes ([Fig. 2a]), and retrognathia had already led to the suspicion of Cornelia de Lange syndrome (CdLS), later confirmed genetically. In addition, based on intrauterine Magnetic Resonance Imaging (MRI), severe lung hypoplasia as a result of bilateral Congenital Diaphragmatic Hernia (CDH) ([Fig. 2b]) was expected.

Background Liver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of postoperative complications. So far, limited data is available regarding the best radiologic approach to monitor children after liver transplantation. Objective To harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phases. This paper reports the responses related to postoperative imaging. Materials and methods An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey. Results All sites commence ultrasound (US) monitoring within 24 h after liver transplantation. Monitoring frequency varies across sites, ranging from every 8 h to 72 h in early, and from daily to sporadic use in late postoperative phases. Predefined US protocols are used by 73% of sites. This commonly includes gray scale, color Doppler, and quantitative flow assessment. Alternative flow imaging techniques, contrast-enhanced US, and elastography are applied at 31.8%, 18.2%, and 63.6% of sites, respectively. Computed tomography is performed at 86.4% of sites when clarification is needed. Magnetic resonance imaging is used for selected cases at 36.4% of sites, mainly for assessment of biliary abnormalities or when blood tests are abnormal. Conclusion Diagnostic imaging is extensively used for postoperative surveillance of children after liver transplantation. While US is generally prioritized, substantial differences were noted in US protocol, timing, and monitoring frequency. The study highlights potential areas for future optimization and standardization of imaging, essential for conducting multicenter studies.

Fallpräsentation Reifes weibliches Neugeborenes (40+1 SSW), das nach unauffälliger Schwangerschaft per sekundärer Sectio bei pathologischem CTG in einer Geburtsklinik geboren wurde. Geburtsgewicht 3500 g, Nabelarterien-pH 7,28, Apgar 7/8/8. Wegen respiratorischer Adaptationsstörung mit Tachydyspnoe und O2-Bedarf wurde der Neugeborenennotarzt alarmiert. Bis zum Eintreffen supportive Therapie mittels CPAP-Atemhilfe (PEEP 6 mbar) sowie Beginn einer antibiotischen Therapie mit Ampicillin und Tobramycin. Im Verlauf weitere klinische Verschlechterung mit gemischter Azidose in der kapillären Blutgasanalyse (pH 6,93, pCO2 82 mmHg, BE − 14,9 mmol/l, Laktat 10,5 mmol/l). Zunehmende Kreislaufinstabilität mit verlängerter Kapillarfüllungszeit, Tachykardie (180/min) und arterieller Hypotension (MAD 33 mmHg) bei nur leise auskultierbaren Herztönen. Nach Eintreffen des Neugeborenennotarztes endotracheale Intubation und maschinelle Beatmung. Zudem Kreislaufstabilisierung mit Volumen und Dobutamin und zügiger Transport auf die neonatologische Intensivstation des Perinatalzentrums.

Reifes weibliches Neugeborenes (40+1 SSW), das nach unauffalliger Schwangerschaft per sekundarer Sectio bei pathologischem CTG in einer Geburtsklinik geboren wurde. Geburtsgewicht 3500 g, Nabelarterien-pH 7,28, Apgar 7/8/8. Wegen respiratorischer Adaptationsstorung mit Tachydyspnoe und O 2 -Bedarf wurde der Neugeborenennotarzt alarmiert. Bis zum Eintreffen supportive Therapie mittels CPAP-Atemhilfe (PEEP 6 mbar) sowie Beginn einer antibiotischen Therapie mit Ampicillin und Tobramycin. Im Verlauf weitere klinische Verschlechterung mit gemischter Azidose in der kapillaren Blutgasanalyse (pH 6,93, pCO 2 82 mmHg, BE - 14,9 mmol/l, Laktat 10,5 mmol/l). Zunehmende Kreislaufinstabilitat mit verlangerter Kapillarfullungszeit, Tachykardie (180/min) und arterieller Hypotension (MAD 33 mmHg) bei nur leise auskultierbaren Herztonen. Nach Eintreffen des Neugeborenennotarztes endotracheale Intubation und maschinelle Beatmung. Zudem Kreislaufstabilisierung mit Volumen und Dobutamin und zugiger Transport auf die neonatologische Intensivstation des Perinatalzentrums.

Cardiac MRI is a crucial tool for assessing congenital heart disease (CHD). However, its application remains challenging in young children when performed at 3T. The aim of this retrospective single center study was to compare a non-contrast free-breathing 2D CINE T1-weighted TFE-sequence with compressed sensing (FB 2D CINE CS T1-TFE) with 3D imaging for diagnostic accuracy of CHD, image quality, and vessel diameter measurements in sedated young children. FB 2D CINE CS T1-TFE was compared with a 3D non-contrast whole-heart sequence (3D WH) and 3D contrast-enhanced MR angiography (3D CE-MRA) at 3T in 37 CHD patients (20♂, 1.5±1.4 years). Two radiologists independently assessed image quality, type of CHD, and diagnostic confidence. Diameters and measures of contrast and sharpness of the aorta and pulmonary vessels were determined. A non-parametric multi-factorial approach was used to estimate diagnostic accuracy for the diagnosis of CHD. Linear mixed models were calculated to compare contrast and vessel sharpness. Krippendorff's alpha was determined to quantify vessel diameter agreement. FB 2D CINE CS T1-TFE was rated superior regarding image quality, diagnostic confidence, and diagnostic sensitivity for both intra- and extracardiac pathologies compared to 3D WH and 3D CE-MRA (all p<0.05). FB 2D CINE CS T1-TFE showed superior contrast and vessel sharpness (p<0.001) resulting in the highest proportion of measurable vessels (740/740; 100%), compared to 3D WH (530/620; 85.5%) and 3D CE-MRA (540/560; 96.4%). Regarding vessel diameter measurements, FB 2D CINE CS T1-TFE revealed the closest inter-reader agreement (Krippendorff's alpha: 0.94-0.96; 3D WH: 0.78-0.94; 3D CE-MRA: 0.76-0.93). FB 2D CINE CS T1-TFE demonstrates robustness at 3T and delivers high-quality diagnostic results to assess CHD in sedated young children. Its ability to function without contrast injection and respiratory compensation enhances ease of use and could encourage widespread adoption in clinical practice.