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Magnetic resonance imaging for the evaluation of appendicitis in children has rapidly increased recently. This change has been primarily driven by the desire to avoid CT radiation dose. This meta-analysis reviews the diagnostic performance of MRI for pediatric appendicitis and discusses current knowledge of cost-effectiveness. We used a conservative Haldane correction statistical method and found pooled diagnostic parameters including a sensitivity of 96.5% (95% confidence interval [CI]: 94.3-97.8%), specificity of 96.1% (95% CI: 93.5-97.7%), positive predictive value of 92.0% (95% CI: 89.3-94.0%) and negative predictive value of 98.3% (95% CI: 97.3-99.0%), based on 11 studies. Assessment of patient outcomes associated with MRI use at two institutions indicates that time to antibiotics was 4.7 h and 8.2 h, time to appendectomy was 9.1 h and 13.9 h, and negative appendectomy rate was 3.1% and 1.4%, respectively. Alternative diagnoses were present in ~20% of cases, most commonly adnexal cysts and enteritis/colitis. Regarding technique, half-acquisition single-shot fast spin-echo (SSFSE) pulse sequences are crucial. While gadolinium-enhanced T1-weighted pulse sequences might be helpful, any benefit beyond non-contrast MRI has not been confirmed. Balanced steady-state free precession (SSFP) sequences are generally noncontributory. Protocols do not need to exceed five sequences; four-sequence protocols are commonly utilized. Sedation generally is not indicated; patients younger than 5 years might be attempted based on the child's ability to cooperate. A comprehensive pediatric cost-effectiveness analysis that includes both direct and indirect costs is needed.

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