Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Johnson et al.
3-T MRI to Detect Pediatric Appendicitis

Pediatric Imaging
Original Research

Ultrafast 3-T MRI in the Evaluation

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of Children With Acute Lower

Abdominal Pain for the Detection
of Appendicitis
Alisa K. Johnson1,2 OBJECTIVE. The purpose of this study is to evaluate the feasibility of ultrafast 3-T MRI
Christopher G. Filippi1 in the evaluation of children with acute lower abdominal pain for the detection of appendicitis.
Trevor Andrews1 SUBJECTS AND METHODS. Forty-two pediatric patients (30 girls and 12 boys;
Timothy Higgins1 mean age, 11.5 years; age range, 4–17 years) with acute abdominal pain were prospectively
Judy Tam1 studied. Ultrafast 3-T MRI was performed with a three-plane single-shot turbo spin-echo se-
quence and an axial T2-weighted turbo spin-echo sequence with fat suppression. All scans
David Keating1
were performed without sedation or oral or IV contrast agent. Scan times were less than 8
Takamaru Ashikaga3 minutes 45 seconds (median, 5 minutes 40 seconds). Patients underwent CT or ultrasound or
Steven P. Braff 1 both as a comparison study to the MRI examination. The MRI, CT, and ultrasound examina-
Janice Gallant 1 tions were interpreted independently by four board-certified radiologists who were blinded to
patient information, study interpretations, surgical pathologic findings, and final diagnosis.
Johnson AK, Filippi CG, Andrews T, et al.
RESULTS. Twelve of 42 cases of acute appendicitis were detected with 100% sensitiv-
ity, 99% specificity, 100% negative predictive value, and 98% positive predictive value, all
of which were statistically significant (p < 0.01). The pooled and individual receiver operat-
ing characteristic curves for radiologists’ interpretation of the diagnosis of acute appendicitis
were greater than 0.95 in all cases (p < 0.01)
CONCLUSION. Ultrafast 3-T MRI is a feasible alternative imaging modality for the di-
agnosis of acute appendicitis in children, particularly in cases where ultrasound is equivocal
or nondiagnostic, as an alternative to CT. Ultrafast MRI requires no sedation and no oral or
IV contrast agent and has no associated radiation exposure risks.

R
Keywords: acute abdominal pain, appendicitis, apid accurate diagnosis of appen-
MRI, pediatric dicitis is important because it is the
most common acute condition re-
DOI:10.2214/AJR.11.7436
quiring surgical intervention in
Received June 15, 2011; accepted after revision children, with nearly 250,000 cases annually;
November 16, 2011. the highest incidence is among patients 10–19
years old [1–4]. Up to one third of cases have an
This study was performed with support provided to the
University of Vermont MRI Center for Biomedical Imaging
atypical or confusing clinical presentation, and
by the U.S. Department of Energy (DOE contract no. imaging studies may assist in clarifying the di-
0001753). agnosis [1, 5]. Ultrasound is often the first study
1
performed in pediatric patients with acute ab-
Department of Radiology, Fletcher Allen Health Care,
Burlington, VT. 
dominal pain because of its lack of ionizing ra-
diation, lower cost, accessibility, ability to pro-
2
Present address: University of Wisconsin, 2822 Maple vide dynamic information through graded
View Dr, Madison, WI 53719. Address correspondence to compression, and ability to detect gynecologic
A. K. Johnson (AJohnson9@uwhealth.org).
disease [6, 7]. There are disadvantages to ultra-
3
Department of Mathematics & Statistics, University of sound, including that it is highly operator de-
Vermont, Burlington, VT. pendent. Ultrasonic compression in patients
with acute abdominal pain is sometimes poorly
AJR 2012; 198:1424–1430
tolerated, leading to suboptimal image quality.
0361–803X/12/1986–1424 In addition, obesity in younger patients is in-
creasingly a limiting factor in obtaining diag-
© American Roentgen Ray Society nostic ultrasound studies [1, 7, 8]. Ultrasound in
children has a wide range of diagnostic sensitiv-
ity for the diagnosis of acute appendicitis (44–
94%) and a specificity of 47–95% [5, 6, 9–12].
Equivocal results on ultrasound frequent-
ly prompt subsequent imaging with CT using
an IV or oral contrast agent [11, 12]. CT is
a highly accurate and effective cross-section-
al imaging modality that is widely accessible
and not user dependent [13]. CT has a sensi-
tivity for the diagnosis of acute appendicitis
in the pediatric population of 87–100% and
a specificity of 89–98% [13–17]. In at least
one metaanalysis, it has been shown that CT
has improved sensitivity and specificity com-
pared with ultrasound in the diagnosis of ap-
pendicitis in children. It is likely that such re-
sults have formed the impetus for clinicians
to use CT in an increasingly greater number
of cases when investigating possible appen-
dicitis [18, 19]. This development has paral-
leled a general trend in the increased use of
CT as a diagnostic imaging tool when clini-
cians suspect acute appendicitis in children.

1424 AJR:198, June 2012


There is increased awareness of the long-
term risks of radiation exposure associated
with medical imaging that has recently been
published in both the scientific and lay press
[20]. The pediatric population is at greater
risk because they are inherently more radio-
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sensitive and have a longer remaining life ex-
pectancy during which a radiation-induced
cancer may develop [21]. This concern has
prompted a search for alternatives to CT, de-
spite its efficacy as a diagnostic imaging tool,
to minimize the risk of increasing radiation-
induced cancers in pediatric patients. MRI
has recently been investigated in the evalua-
tion of acute abdominal pain in pregnant and
nonpregnant patients and has been found to
be an effective diagnostic modality, with a
reported sensitivity of 97–100% and speci-
ficity of 92–93.6% [22–33]. To date, there
are few data on the efficacy of abdominal
MRI in the setting of acute abdominal pain
in pediatric patients, which is complicated
by long scan duration, required breath-holds
for certain sequences, and the need for seda-
tion in younger pediatric patients to prevent
image degradation due to motion.
Using abdominal MRI for the diagnosis of
acute appendicitis in pediatric patients with
the goal of providing a viable alternative to
CT, particularly in cases where ultrasound is
not possible or nondiagnostic, would reduce
ionizing radiation exposure in the pediatric
population. The introduction of 3-T abdom-
inal MRI in combination with newer body
coils and the use of parallel processing has
significantly reduced scan times, making it
possible to advocate for the use of MRI. The
purpose of this study was to show the fea-
sibility of ultrafast abdominal 3-T MRI se-
quences with free breathing, no IV contrast
agent, and no sedation for the diagnosis of
acute appendicitis in pediatric patients.
Subjects and Methods
This HIPAA-compliant prospective study was
approved by the institutional review board. Af-
ter a thorough explanation of the study, informed
consent was obtained from the participants’ par-
ents or guardian. Over a 23-month period, 42 pa-
tients 4–17 years old with acute abdominal pain
suspicious for acute appendicitis were recruited
in the emergency department setting to undergo
unenhanced abdominal MRI. Pediatric patients
who had been admitted through the emergency
department within 24 hours’ time were also in-
cluded. All patients underwent CT or ultrasound
or both for comparison with MRI results. Ideally,
the MRI study was performed before the CT, but
AJR:198, June 2012 1425
3-T MRI to Detect Pediatric Appendicitis
in our busy academic center, there was flexibility
in performing MRI after CT to facilitate care. To
render the comparisons between different imag-
ing modalities more valid, the time between imag-
ing sessions was minimized, and all studies were
performed within 24 hours, with a mean time of 4
hours. All CT and ultrasound examinations were
conducted at Fletcher Allen Health Care. Clini-
cally unstable patients, patients with a history of
acute trauma, and patients with a positive urine
pregnancy test were excluded from the study. Pa-
tients with chronic medical conditions (e.g., in-
flammatory bowel disease) were excluded.
All MRI examinations were performed at the
University of Vermont MRI Center for Biomedical
Imaging on a 3-T MRI system (Achieva, Philips
Healthcare) using a 16-channel SENSE receive
coil (Torso XL, Invivo). None of the patients was
sedated for the MRI examination. Free breathing
was used to eliminate the need to train these
pediatric patients to perform breath-holds. No
contrast agent was given.
Detailed explanations about how the examina-
tion was going to be conducted were given to all
patients before entering the MRI room. The pe-
diatric care coordinator or a parent was permit-
ted to be in the MRI scanner magnet room (zone
IV) with the patient. The visual analog scale was
used to assess the patient’s pain at two different
points during the process to ensure that the pa-
tients were not in undue discomfort. All patients
enrolled in the study were able to complete the ex-
amination such that there was no failure rate. Di-
agnostic quality examinations were successfully
performed in all cases.
With the patient in the supine position, a
29-second coronal localizer was obtained to help
plan the subsequent scans. A reference scan was
then acquired in approximately 29 seconds; this
scan is required for the SENSE parallel imaging
acceleration used in the later sequences. To re-
duce the length of the scanning session, two au-
tomated calibrations were suspended (automatic
shimming and receiver optimization) for all sub-
sequent sequences; this reduced the total scan ses-
sion duration by a factor of two. The patients were
then imaged using single-shot T2-weighted turbo
spin-echo (TSE) sequences acquired in all three
planes, with fat suppression used on an addition-
al axial acquisition. To keep the scan duration as
short as possible for a large range of patient sizes,
the FOV varied among patients. TR values also
varied among patients and were kept short to min-
imize motion and overall session duration. Sag-
ittal acquisition parameters were as follows: me-
dian TR/TE, 2138/80; slice thickness, 2–4 mm;
gap, 0.5 mm; in-plane resolution, 0.9 mm; FOV,
240–330 mm; and number of slices, 26–70. Coro-
nal acquisition parameters were as follows: me-
dian TR/TE, 2516/80; slice thickness, 2–4 mm;
gap, 0.5 mm; in-plane resolution, 0.9 mm; FOV,
230–380 mm; number of slices, 25–44; and me-
dian scan duration, 81 seconds. Axial acquisi-
tion parameters were as follows: median TR/TE,
1721/50–80; slice thickness, 3–4 mm; gap, 1 mm;
in-plane resolution 0.8 mm, FOV, 230–300 mm;
number of slices, 32–55; and median scan dura-
tion, 77 seconds. A T2-weighted axial sequence
without fat saturation was also acquired with the
following parameters: median TR/TE, 1832/50–
80; slice thickness, 3 mm; gap, 1 mm; in-plane
resolution, 0.8 mm; FOV, 210–330 mm; and num-
ber of slices, 45–63. The total scan duration for
these sessions varied according to patient size,
from 2 minutes 29 seconds to 8 minutes 45 sec-
onds (median, 5 minutes 40 seconds).
The MRI interpretations were performed by
four board-certified attending radiologists, in-
cluding two body radiologists and two pediatric
radiologists, both of whom had the certificate of
added qualification for pediatric radiology. Each
radiologist independently evaluated the MRI stud-
ies at a separate time from the ultrasound or CT
studies blinded to the patient history, age, sex, sur-
gical pathologic findings, and clinical follow-up.
The reviewers were aware that the study was be-
ing performed for acute abdominal pain. For both
the MRI examination and the comparative stud-
ies, the reviewers recorded their diagnosis along
with a confidence level, from 1 to 5 (with 5 being
the equivalent of 100% confidence in the diagno-
sis). Pertinent positives, pertinent negatives, and
whether a normal appendix was visible were also
recorded. Each pathologic condition was evaluat-
ed in accordance to the standard imaging criteria.
Clinical follow-up was obtained for all patients
for at least 6 months. Pathology results were ob-
tained for all patients who underwent surgery. For
the few patients with differing CT interpretations,
a consensus was reached among the four radiolo-
gists to determine the final diagnosis. Clinical fol-
low-up, ultrasound, or CT combined with surgical
pathologic examination were considered the ref-
erence standard by which to judge the MRI. On
the single-shot T2-weighted TSE sequence, a di-
agnosis of acute appendicitis was made when the
following features were present: markedly hyper-
intense thickened wall, markedly hyperintense
periappendiceal tissue, and dilated appendix (6
mm), which can often be accompanied by free flu-
id in the pelvis, all of which are consistent with
current clinical standard diagnostic criteria [17].
Statistical Analysis
A multiple-study multiple-reader experiment as-
sessment design was used in evaluating the images.

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Fig. 1—7-year-old girl with emesis and right lower quadrant pain.
A and B, Axial T2-weighted turbo spin-echo (TSE) MR image (A) and axial T2-weighted TSE fat-saturated MR image (B) show markedly dilated appendix with fluid-fluid
level in mid abdomen. Appendicitis was proven at pathologic examination.
The MRI diagnoses were then compared with the
corresponding CT study results, ultrasound study
results, and pathologic analysis results. A two-way
contingency table approach was used to determine
the sensitivity and specificity of the diagnosis of
acute appendicitis on MRI among the four readers
along with negative and positive predictive values
using SYSTAT software (version 11.0, Systat). A
three-way contingency table analysis that stratified
on the four readers showed that the four readers did
not differ in any statistical fashion relative to the re-
lationship between the MRI-based diagnoses and
the CT-based or ultrasound-based diagnoses, which
allowed the pooling of the data. For the interpreta-
tion of acute appendicitis using ultrasound or CT
as a comparative study, the pooled data of the four
readers were assessed with a Fisher exact test using
SYSTAT software. Exact 95% CIs were calculated
for each MRI performance measure using the Clop-
per-Pearson method as implemented in StatXact
software (version 4, Cytel). A p value of less than
0.05 was considered statistically significant.
Receiver operating characteristic (ROC) curves
and areas under these curves were determined for
each of the four radiologists using the interpreta-
tions from the MRI data as well as combined CT
and ultrasound data. In addition, a pooled ROC
curve was obtained for all four readers for both
MRI interpretations as well as the comparative
CT and ultrasound interpretations. A gaussian
model was implemented using SYSTAT software,
where a response category (−5 to 5) was used to
weigh the certainty of the MRI interpretation,
with a value less than 0 implying a nonappendici-
tis reading and a value greater than 0 implying an
appendicitis reading. The gaussian model refers to
the nonappendicitis cases normalized to a mean
1426 AJR:198, June 2012
Johnson et al.
A B
of zero and unit SD as the “noise,” whereas the
“signal plus noise” portion of the gaussian model
represents the mean and SD for appendicitis cases.
The ROC plot gives the hit rate or sensitivity (y-
axis) versus the false alarm rate or (1 − specifici-
ty) (x-axis) based on the estimated gaussian model
parameters and the certainty levels.
Results
Twelve of 42 patients had acute appendici-
tis, verified in all cases by surgical patholog-
ic findings; five patients also had an associated
abscess consistent with a perforated appendix
(Figs. 1–4). The average age of the 12 patients
(six girls and six boys) was 11.6 years. The
four readers interpreting 42 MRI examinations
yielded 168 interpretations, which indicated a
highly significant statistical association (p <
0.001) (Table 1). These results indicated that
MRI had a specificity of 99% (95% CI, 95–
100%) and sensitivity of 100% (95% CI, 93–
100%). For the MRI diagnosis of acute appen-
dicitis, the negative predictive value was 100%
(95% CI, 97–100%), and the positive predic-
tive value was 98% (95% CI, 89–100%).
Diagnosis of acute appendicitis using the
pooled CT and ultrasound data showed a
highly significant association (p < 0.001).
Sensitivity was 100% (48/48; 95% CI, 93–
100%), specificity was 98% (118/120; 95%
CI, 94–100%), the negative predictive val-
ue was 100% (118/118; 95% CI, 97–100%),
and the positive predictive value was 96%
(48/50; 95% CI, 86–100%).
Table 2 and Figure 5 depict statistics and
calculations used for the pooled ROC curves
for the four readers for the MRI diagnosis of
acute appendicitis. The y-axis shows the hit
rate or true-positive rate or sensitivity, where-
as the x-axis shows the false alarm rate or
false-positive rate (Fig. 5). The gaussian mod-
el parameter mean and SD estimates for the
acute appendicitis cases were 3.98 and 1.37,
respectively. For MRI, this corresponds to an
area under the ROC of 0.991. The goodness
of fit statistic for this model appeared very
reasonable (χ2 = 3.70l; df, 7; p = 0.814). Indi-
vidual ROC areas for each reader were 0.949,
0.952, 0.950, and 0.969, respectively.
Of the remaining 30 patients, one radiolo-
gist questioned the presence of appendicitis in a
17-year-old boy. The other three radiologists in-
terpreted this MRI examination as normal, but
two of the four questioned appendicitis on CT.
For the same patient, a consensus opinion was
reached that appendicitis was not present, and
there was a low clinical suspicion for appendi-
citis. The patient’s clinician opted for clinical
management, and the patient has done well on
follow-up. A second patient had negative MRI
and CT studies but underwent surgery on the
basis of strong clinical suspicion for acute ap-
pendicitis. This patient had a normal appendix.
There were no false-negative interpretations.
Of the 29 patients with no appendicitis, a
normal appendix was visualized 43% of the time.
There was one outlier, a pediatric radiologist
with over a decade of experience, who identified
the normal appendix at a rate of 81%.
In this study, 18 patients had both CT and
ultrasound comparative studies, 13 had only
ultrasound, and 11 only had CT comparative
studies. Eighteen patients had normal scans,
all of which were correctly interpreted by
 3-T MRI to Detect Pediatric Appendicitis

Fig. 2—5-year-old girl with nausea, vomiting, and right lower quadrant pain.
A and B, Sagittal (A) and coronal (B) T2-weighted turbo spin-echo MR images show large complex fluid
collection with tubular blind-ending structure (appendix) posterior to fluid collection. Patient had clinically and
surgically proven perforated appendicitis.

ment of the MRI examinations for the de-

tection of other abnormalities, not just acute
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appendicitis, which strengthens our study in

A B
all four radiologists. Twelve of 42 patients
had abnormalities other than acute appendi-
citis. One patient had small-bowel obstruc-
tion due to adhesions from prior surgery, one
had terminal ileitis, and one had a mass le-
sion (cavernous lymphangioma), all of which
were correctly interpreted by all four radiol-
ogists on MRI with no false-negative inter-
pretations. Five patients had adnexal cysts
that were detected on MRI. There were four
cases of mesenteric adenitis for which there
were eight false-negative misinterpreta-
tions, of a total of 16 interpretations, given
four different readers; there were three false-
negative CT misinterpretations. Of the five
patients with adnexal cysts, there was one
false-negative CT interpretation.
Discussion
Although ultrasound remains the primary
modality for the diagnosis of acute appendi-
citis in pediatric patients with acute abdom-
inal pain, ultrasound has potential draw-
backs, including poor image quality in obese
adolescents, which is becoming a significant
problem [1, 7, 8]. Given that there may be
cases in which ultrasound is equivocal, non-
diagnostic, or difficult to perform, the devel-
opment of an alternative approach to CT, the
usual next imaging choice, is warranted be-
cause of the growing awareness of the nega-
tive effects of radiation associated with med-
ical imaging in pediatric patients.
Our study investigated the feasibility of
ultrafast abdominal and pelvic MRI at 3 T
in the evaluation of children with acute ab-
dominal pain, with an emphasis on the detec-
tion of acute appendicitis because this is the
most common acute condition of the abdo-
men requiring surgical intervention in chil-
dren [1–4]. Of the 42 prospective cases in
this feasibility study, 12 patients had acute
appendicitis, all of which were correctly di-
agnosed with nearly perfect sensitivity, spec-
ificity, positive predictive value, and negative
predictive value. Sample size is relatively
small, but this is a feasibility study for the
development of an ultrafast MRI protocol.
To our knowledge, this is the first study to
address diagnostic MRI capability in the
evaluation of acute abdominal pain in the pe-
diatric population at 3 T.
A prior study [31] showed the ability of
MRI to detect acute appendicitis in children
7–16 years old, but that study had selection
bias in that only children with the ultrasound
diagnosis of acute appendicitis were included.
The present study differs significantly from
that study because we examined all children
with acute abdominal pain, which allows the
detection of normal examinations (true-neg-
atives) and mandates an independent assess-
that it allows the possibility of false-positive
diagnoses. In the present study, other causes
for acute abdominal pain were readily detect-
ed with nearly perfect sensitivity and specific-
ity. Furthermore, that study acquired images at
0.5 T, which would have a lower contrast-to-
noise ratio, resulting in poorer image quality
or increased scan duration. Of note, total scan
durations were not published. In one study, the
use of fast sequences on MRI to detect acute
appendicitis had an average scan time of 20
minutes [29]. We chose to use 3-T MRI with
parallel processing not only to take advantage
of increased signal-to-noise ratio at 3 T but
also to use parallel processing to allow ultra-
fast MRI sequences for the shortest possible
scan time without sacrificing image quality,
and all scans were under 8 minutes 45 seconds
in total duration, with a median scan time for
the entire examination of 5 minutes 40 sec-
onds. Pediatric patients in acute abdominal
pain will be far less likely to tolerate a scan
duration that averages 20 minutes or longer.
Our individual sequence durations us-
ing single-shot TSE at 3 T ranged from 40
seconds to 2 minutes 38 seconds, which is
more easily tolerated by younger patients
and allowed us to include patients as young
Fig. 3—13-year-old boy with right lower quadrant
pain. Coronal T2-weighted turbo spin-echo MR image
reveals large hyperintense complex fluid collection in
right abdomen, which was perforated appendicitis.

AJR:198, June 2012 1427


Table 1:  Acute Appendicitis Diagnosis Using Ultrafast MRI
Final Surgical Pathologic Diagnosis
Negative for acute appendicitis
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Positive for acute appendicitis
Note—For performance measures, sensitivity was 100% (48/48; 95% CI, 93–100%), specificity was 99%
(119/120; 95% CI, 95–100%), positive predictive value was 98% (48/49; 95% CI, 89–100%), and negative
predictive value was 100% (119/119; 95% CI, 97–100%). For the association between the final surgical
pathologic diagnosis and MRI diagnosis of acute appendicitis, p < 0.001 (Fisher exact test).
as 4 years old. Single-shot TSE allows free
breathing because gastrointestinal and respi-
ratory motion is effectively minimized and
each image is acquired in one-third of a sec-
ond. This technique decreases the effects of
voluntary motion that can be seen in longer
acquisitions as well. In our study, we chose to
use single-shot TSE sequences because this
technique has been shown by others to be the
most sensitive for the detection of acute ap-
pendicitis because of its ability to detect in-
flammatory changes [23–26, 29, 31].
In this feasibility study, we are not advo-
cating the use of MRI as a replacement to
ultrasound as the primary imaging modality
for pediatric patients with acute abdominal
pain. Rather, MRI could serve an important
role as an alternative to CT when ultrasound
is not diagnostic to lessen the exposure of pe-
diatric patients to ionizing radiation associ-
ated with medical imaging. This rationale
underlies the use of MRI in the diagnosis
of acute appendicitis in pregnant patients to
avoid radiation exposure to the fetus [26, 27].
Prior studies of adult pregnant and non-
pregnant patients with acute abdominal pain
have shown sensitivities of 97–100% and
specificities of 92–94% for the diagnosis of
acute appendicitis with MRI in the setting of
acute abdominal pain [22, 24–30]. Our fea-
sibility study has a higher rate of specificity
and similar rate of sensitivity for the diagno-
sis of acute appendicitis, which supports the
use of MRI in the evaluation of pediatric pa-
tients with acute abdominal pain.
In the present study, other treatable con-
ditions were also detected with 100% sensi-
tivity and 99% specificity, including terminal
ileitis, small-bowel obstruction, and a mass
lesion (cavernous lymphangioma). Untreat-
able causes of acute abdominal pain were
also detected in our study, including adnexal
cysts and mesenteric adenitis. MRI is known
to be an excellent modality for the evalua-
tion of gynecologic abnormalities, especially
the cystic changes in the adnexa that result in
1428 AJR:198, June 2012
Johnson et al.
diagnosis of appendicitis, and studies have re-
ported a normal appendix 43–63% of the time
MRI Result
[27, 29, 34]. This is similar to the rate at which
Negative for Positive for a normal appendix was visualized in the pres-
Acute Appendicitis Acute Appendicitis ent study, with the exception of one imager
119 1 with a much higher rate of detection. These
0 48
differences in detection of a normal appendix
may be the result of the different patient popu-
lations that were investigated. The amount of
intraperitoneal fat in pediatric patients is usu-
ally less than the amount in adults. The pres-
ent of less fat makes it more difficult to detect
high signal on a T2-weighted image. In our a normal appendix. It may be that the addition
study, there was accurate detection of adnex- of T1-weighted imaging may have increased
al cysts, including hemorrhagic cysts with no the detection rate, but total MRI examination
false-negative or false-positive diagnoses. times would have been lengthened.
All of the false-negative misinterpretations in The lack of any contrast agent is another
our study were related to a diagnosis of mes- potential benefit to the MRI protocol used in
enteric adenitis. There are limited data on the our study. At our institution, a 1–2-hour delay
MRI appearance of mesenteric adenitis, but is introduced by the ingestion of an oral con-
presumably it would be similar to that on CT trast agent in routine appendicitis exclusion
with respect to the number, location, and size on CT. Ultrafast MRI abdominal imaging has
of lymph nodes. In a study by Karmazyn et the potential to obviate ingestion of the oral
al. [33], lymph nodes of 5–10 mm are often contrast agent, which can be problematic in
present on CT examinations of children with patients with acute abdominal discomfort.
a low likelihood of mesenteric lymphadenop- Another benefit to this technique is the lack
athy and should be considered nonspecific of sedation, which avoids the risk of compli-
findings. Because of the conservative man- cations from anesthetics and the added delays
agement of mesenteric adenitis, clinicians of- for scheduling and consent.
ten equate a diagnosis of mesenteric adenitis There are several limitations to this study,
to a nonspecific finding. Thus, the false-neg- including the relatively small sample size of
ative rate may not be clinically significant in 42 patients, but the primary purpose was to
this setting. establish the feasibility of this ultrafast MRI
Visualization of a normal appendix en- abdominal imaging protocol for pediatric
sures that acute appendicitis is not present. It patients with acute abdominal pain in the
has been reported that visualization of a nor- emergency department setting. T1-weight-
mal appendix on MRI virtually excludes the ed sequences were not obtained because the
A B
Fig. 4—13-year-old boy with right lower quadrant pain.
A, Coronal contrast-enhanced CT image reveals dilated tubular structure with surrounding fat stranding.
B, Coronal T2-weighted turbo spin-echo MR image shows dilated tubular structure with hyperintense signal in
surround soft tissues. Patient had pathology-proven appendicitis.
 3-T MRI to Detect Pediatric Appendicitis

1.0
ibility in performing the MRI after the CT to
facilitate patient care and not to delay the clin-
ical process. Therefore, seven of 42 MRI ex-
0.8
aminations were performed after CT with a
delay time less than 2.5 hours. This may be
0.6 construed as a potential limitation because
Hit Rate
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implemented is considerably greater than
the cost of the CT.
Finally, the generalizability of the protocol
may be limited because of the requirement of
a 3-T magnet. Compared with our results, the
images performed at 1.5 T would have low-

0.4
0.2
0.0
0.0 0.2 0.4 0.6
False Alarm Rate
Fig. 5—Receiver operating characteristic (ROC)
curve plot. ROC areas were 0.949 for reader 1, 0.952
for reader 2, 0.950 for reader 3, and 0.969 for reader 4.
Overall ROC area was 0.99.
primary focus was to detect acute appendici-
tis and to keep overall scan duration as short
as possible, although it has been shown that
the use of a T1-weighted sequence may im-
prove visualization of the normal appendix
for some readers [29, 34]. However, the lack
of visualization of the appendix on CT and
a lack of secondary inflammatory chang-
es can be used to exclude acute appendicitis
[35]. In theory, MRI has the potential to be
more sensitive to the secondary signs of ap-
pendicitis because inflammatory changes in-
crease the fluid in surrounding tissues, which
is seen as hyperintense signal on T2-weight-
ed imaging. A larger prospective study will
be needed to more directly evaluate ultrafast
MRI with CT to establish the statistical sig-
nificance and accuracy of diagnosis with re-
liance on secondary signs in the absence of
visualization of a normal appendix.
Another limitation is the potentially re-
duced sensitivity and specificity in detect-
ing some conservatively managed causes of
abdominal pain. To improve the diagnosis of
untreatable causes would require additional
sequences, which would increase scan time,
and that increased scan time would poten-
tially increase the risk of patients in acute
pain not being able to complete the exami-
nation. If the focus is on acute appendicitis,
then ultrafast MRI scanning may be suffi-
cient. If the focus is to find an alternative to
CT for reduced risk associated with ionizing
radiation, then additional MRI sequences,
such as T1-weighted sequences, may be ben-
eficial to check for mesenteric adenopathy.
In our prospective study, ideally MRI
would be performed before CT. In a busy aca-
demic tertiary referral center, there was flex-
later scanning may allow pathologic abnor- er signal-to-noise ratio and may not be of di-
malities to progress, making detection easier, agnostic quality. Potential alterations can be
and there could be an influence on MRI from made to the 1.5-T protocol to recover the sig-
orally administered CT contrast material. nal, such as increasing slice thickness, but this
In a recent study utilizing the Alvarado would reduce spacial resolution and increase
scoring system for assessing symptoms in volume averaging, potentially making the ex-
0.8 1.0 patients with possible appendicitis, 26% of amination nondiagnostic. The increase in the
patients received a score between 8 and 10, number of averages to recover signal loss may
which put them in the category where it was result in increased motion artifacts.
deemed that no imaging study was necessary. In conclusion, our study has a specificity of
None of these patients had a normal 99% and specificity of 100% in the diagnosis
appendix at surgery. For the remainder of of acute appendicitis and supports the feasibil-
patients, a decision would need to be made ity of ultrafast 3-T MRI of pediatric patients in
about the most appropriate study, taking the setting of acute abdomen as an alternative
into consideration such factors as patient to CT when ultrasound results are equivocal
characteristics, operator dependence that or nondiagnostic. Potential advantages to this
might affect ultrasound results, the need technique include no ionizing radiation, fast
for a contrast agent in CT, and the expense examination times, no need for oral or IV con-
of the various studies. At our institution, a trast agent, and avoidance of sedation.
limited ultrasound of the pelvis is clearly
the least expensive technique, costing Acknowledgments
approximately $400, but it is fraught with a We thank Jay Gonyea, Mary Streeter,
number of limiting factors, as have already Scott Hipko, and Aida Arapovic for making
been discussed. A charge of $2000 has been this study possible.
established for limited CT of the pelvis in
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of Acute Appendicitis
Category
Label False Alarm Rate Hit Rate
−5 0.4772 0.9902
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0 0.0207 0.9412
2 0.0124 0.9216
3 0.0083 0.8824
4 0.0041 0.7255

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