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Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis

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Abstract

Background

Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated.

Objective

To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis.

Materials and methods

We included patients ages 4–18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy.

Results

Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative.

Conclusion

Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall thickness demonstrate high sensitivities but relatively low specificities. Nonvisualization of the appendix favors a negative diagnosis.

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Acknowledgments

The authors thank Kyle Hart, MS, Department of Surgery, Oregon Health & Sciences University, for statistical analysis and support. This study was supported by The National Institute of Biomedical Imaging and Bioengineering (#1R25EB016671) and the Society for Pediatric Radiology (#GDRAD0012A). Preliminary data were presented at the Radiologic Society of North America meeting Dec. 4, 2014.

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Authors and Affiliations

  1. Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA

    Ryne A. Didier, Katharine L. Hopkins, Fergus V. Coakley & Bryan R. Foster

  2. Department of Surgery, Oregon Health & Science University, Portland, OR, USA

    Sanjay Krishnaswami

  3. Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA

    Sanjay Krishnaswami & David M. Spiro

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  1. Ryne A. Didier
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  2. Katharine L. Hopkins
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Correspondence to Ryne A. Didier.

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Didier, R.A., Hopkins, K.L., Coakley, F.V. et al. Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis. Pediatr Radiol 47, 1312–1320 (2017). https://doi.org/10.1007/s00247-017-3897-7

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  • DOI: https://doi.org/10.1007/s00247-017-3897-7

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