Radiology

Martine and Mr. Monkey

Who knew there was a spaceship in the basement of Children's Hospital Boston at Waltham? It clangs and bangs, so travelers have to wear funky headgear. And the interstellar passengers include a Mr. Froggy and a Mr. Monkey.

Naturally, it's endlessly fascinating to four- to six-year-olds, and that's exactly the point. "Some of the kids are so funny," said Arnie Cyr, an MR technologist at Waltham. "One of them said, 'Ready for takeoff!'"

Researchers at Children’s Hospital Boston built the "spaceship" to prepare young subjects for functional MRI (fMRI) studies of their brain. Kids get a chance to crawl inside the MR simulator, where they play a video game starring cartoon aliens named Mi and Mo and become comfortable with the loud noises they'll hear in the real MR upstairs.

The simulator makes all the difference during the actual MR study, when it is essential that children lie motionless for five to seven minutes at a time while performing a mental task. As they play around with a digital camera and stuffed animals before the exam, kids can see for themselves why it's so important not to move.

Five-year-old Martine learned that recently as she and neuropsychologist Nora Raschle, MS, experimented with Mr. Froggy and a point-and-shoot camera. Martine snapped a blurry shot as Raschle jiggled the stuffed animal and a crisp one as she held him motionless.

"If we are going to play with our spaceship here, I need you to be super, super still," said Raschle, a visiting scholar in the hospital's Gaab Laboratory. Martine then slid into the bore of the mock scanner and pushed buttons in response to the sounds she heard in the computer game – a dry run for the actual experiment upstairs.

Raschle is using fMRI, along with behavioral assessments, to record how pre-readers with and without family histories of dyslexia process different sounds. A year later, after the children have had a year of kindergarten, they undergo the behavioral and imaging studies again. The goal is to identify subtle differences in brain structure and function between children at risk for dyslexia and those who are not so that more effective screening and interventions can begin well before problems with reading develop.

To watch Raschle prepare a child for one of the experiments, see "Making MR Imaging Child's Play."

See how the MR Division helps young patients avoid sedation for their MRIs: Read "Lili and the Big Doughnut" below.

Lili, age 5

Lili, age 5, was ready for her MRI. She had everything she needed: Mom, Dad, her stuffed bear Teddy, and a Barbie DVD. So she was quite happy to put on funny looking video goggles recently and slide into the hole of a big "doughnut" that would clang and bang for 30 minutes while taking pictures of her brain.

What Lili didn't know was that she was part of a pilot program at Children's Hospital Boston to see if kids like her could lie still enough to undergo an MRI without sedation. When Lili's mother, Maria, learned that her daughter would be a good candidate for the MRI Division's "Try Without" protocol, she enthusiastically agreed.

"When the nurse called and gave us this option, we were thrilled," Maria said. "We really didn't want to sedate her unless it was an emergency."

So Lili was booked into a special Tuesday evening time slot reserved for "Try Without" children and their parents. Technologist Reid Nichols explained in child-friendly terms what would happen, and Lili eagerly clambered onto the table for her exam. She was such a pro that her only complaint afterward was about the movie: "It's not done yet!" she exclaimed.

"Try Without" was implemented in January 2009 in an effort to reduce the use of sedation. Patients 5-7 years old who needed neurological studies for indications like seizures or headaches were the target candidates, although the program has since been expanded to include 4-year-olds and different medical indications. Sharon Silk, director of radiology operations improvement, MRI technologist Stephanie DeHart, and MRI assessment nurse Margo Coakley were instrumental in creating the program.

Sixty-two children with a mean age of 5.7 years participated in "Try Without" from January through August. Eighty-five percent of them (52) were able to stay still enough for diagnostic quality images; the others came back for a study under sedation. As a result, most 7-year-olds are now routinely booked into non-sedation time slots.

"Giving the children the information they need to prepare for the exam and distracting them with activities such as our video goggles makes a huge difference," said Amy Danehy, MD, one of the radiologists affiliated with the pilot program. "We are so pleased with these outcomes."

As for Lili, the visit to the hospital was a success all the way around. Her parents received good news when the scans were read and she received a piece of cake at Au Bon Pain downstairs.

Eighteen faculty members from the Department of Radiology will participate in the upcoming Radiological Society of North America (RSNA) meeting.

The meeting is the world's largest gathering of radiologists, attracting about 65,000 participants from around the globe to courses, lectures, and presentations by leaders in the field. It will be held this year in Chicago from Nov. 29-Dec. 4.

The RSNA, which was founded in 1916, works "to promote and develop the highest standards of radiology and related sciences through education and research."

The following faculty members from Children's Hospital Boston will be participating:

• Sarah D. Bixby, MD: Hip Impingement Syndromes in Children (course, 12/3)
• Stephen D. Brown, MD: Beyond Substance Abuse (course, 12/1); Physician-Patient Difficulties (course, 12/1)
• Michael J. Callahan, MD: Pancreatic Disorders in Children (case-based review 12/2); The Pediatric Pancreas (course, 12/03)
• Kirsten Ecklund, MD: Advanced MR Imaging Techniques in Children (course, 12/3)
• Frederic H. Fahey, DSc: Therapy Shielding and Physics and Applications of PET/CT (course, 11/30)
• P. Ellen Grant, MD: Update in Neonatal Brain Imaging (course, 11/29)
• Edward Y. Lee, MD: CT of Congenital Lung Lesions (course, 12/1); Lung Masses and Mass-Like Conditions in Children (case-based review, 12/2); moderator, Pediatric Scientific Session (12/2)
• Horacio M. Padua, Jr., MD: Techniques of Freehand Invasive Ultrasound with Thermal Ablation (course, 11/29)
• Tina Young Poussaint, MD: Pediatric Spine (course, 12/3)
• Caroline B. Robson, MB, ChB,: Congenital Ear Problems (course, 12/3)
• Diana P. Rodriguez, MD: Imaging of Head and Neck Emergencies in Children (course, 11/29)
• Jeannette Perez-Rossello, MD: Pediatric Gastrointestinal Imaging (course, 12/3)
• Keith J. Strauss, MSc: Pediatric CT Physics Workgroup: Image Gently (presentation, 11/30), Correction of Displayed CT Doses (presentation, 12/1)
• George A. Taylor, MD: Panelist, image interpretation session (11/29); Cranial Ultrasound (course, 12/2); Imaging of Acute Hepatic Disease (course, 12/3); Controversies in Setting Up a Fetal Imaging Program: Who, Why, and How? (special focus session, 12/2)
• Andy Tsai MD, Simon K. Warfield PhD et al: Micro CT and High-Resolution Flat Panel CT with 3D Modeling to define the morphology of the classic metaphyseal lesion (educational exhibit)
• Stephan Voss MD: Complications of Oncologic Disease (course, 12/04)
• Valerie L. Ward, MD, MPH: Statistics in Clinical Radiology Research (course, 12/1)

Radiologist Ellen Grant, MD, talks to the Boston Globe about the mysteries of the cerebral cortex. Dr. Grant directs the hospital's new Fetal-Neonatal Neuroimaging & Developmental Science Center.

Kids with Crohn's Disease, an inflammatory bowel condition, sometimes come to the hospital with painful flare-ups that require medical imaging. Is there an abscess? Has the intestine become dangerously narrow?

In many cases, those questions can now be answered effectively with magnetic resonance imaging (MR or MRI). Pediatric radiologists Laureen Sena, MD, Jeannette Perez-Rossello, MD, and Michael J. Callahan, MD, have perfected the use of fast imaging sequences in MR to "freeze" the movement of the bowel, allowing physicians to minimize the use of computed tomography (CT) in the treatment of chronic conditions like Crohn's.

CTs deliver significantly more radiation dose than normal X-rays, so it's desirable to reduce the number of exams patients receive in the course of long-term treatment for a chronic disease. MR produces two- and three-dimensional images of tissues and organs with a powerful magnet, radio-frequency waves, and computers. It does not use ionizing radiation.

"We're reducing the number of CTs that we're doing," says Athos Bousvaros, MD, a gastroenterologist and associate director of the hospital's Inflammatory Bowel Disease Center. "In cases where I can use MRI, I love to do it. Our radiologists are not technicians, they're colleagues. They’re professionals who are specialists in what test to do.

"Rather than just saying, 'I've got a patient with Crohn's, I want a CT scan,' he says, "I will talk with Jeannette or another radiologist and say, 'Here are the symptoms, here's what I'm worried about, what do you think is the best test to do?' What the radiologist brings to the table is expertise in imaging, radiation, and complications."

The National Institutes of Health (NIH) have awarded $1.9 million in stimulus funds to the hospital for a state-of-the-art 7-Tesla magnet for its Small Animal Imaging Laboratory (SAIL).

The research MR will be used by Children's Hospital physicians and scientists to diagnose, localize and investigate a wide range of disorders, as well to evaluate potential new treatments.

"We are most excited by the possibilities for multidisciplinary research that this new instrument will facilitate," said S. Ted Treves, MD, Chief of the Division of Nuclear Medicine/PET and principal investigator for the grant. "The discoveries we make in the lab may lead to important advances in clinical care."

Magnetic resonance imaging (MRI) uses powerful magnets and radio waves to create computerized 2- and 3-dimensional views of organs and structures inside the body. When the 7-T magnet comes online, it will complement the other micro-imaging modalities already in the research laboratory: computed tomography (CT), positron emission tomography (PET), ultrasound (US) and radiography.

The lab's goals are to leverage experimental findings into new research and to translate what is learned about the mechanisms of disease into clinical practice.

Learn more about the lab