13 can't-miss findings on pediatric imaging 2015-12-2

8/19/2019 13 Can'T-Miss Findings on Pediatric Imaging 2015-12-2

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13 Can't-Miss Findings on Pediatric Imaging Studies

Jose Luiz de Oliveira Schiavon M! | December 2, 2015

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When interpreting pediatric imaging studies, it is critical to be familiar with normal variations,anatomic deviations, normal bone appearance, growth plate maturation, as well as pitfalls relatedto different imaging artifacts, in order to identify abnormal findings !ee if you can correctlydetermine any findings on the following pediatric images

"he computed tomography #$"% scan shown reveals an acute subdural hematoma with midlineshift in a child who suffered physical abuse

&mage courtesy of 'awrence ( (icci, )D

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/n unresponsive preschooler was brought to the emergency department with an unclear traumahistory luid attenuated inversion recovery # '/&(% magnetic resonance imaging #)(&% of the

brain was performed #shown%

What are the )(& findings and their possible causes

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Findings * &ntrahemispheric subarachnoid bleeding # red arrows % with bilateral subduralhematomas # blue arrows % are present

$hild abuse should be suspected in trauma cases with a missing or unclear history, particularlywith high ris children "hose considered to be at high ris include infants and preschoolers, aswell as children with behavioral problems, developmental delays, physical and+or mentalabnormalities, or other medical conditions / s eletal survey should be re3uested whenever childabuse is suspected 41



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/ child presented with a slap mar on the face, raising the concern for possible abuse / s eletalsurvey was re3uested (adiographs showed old radius and ulna fractures # yellow arrows %

6very year, more than 7 million reports of child abuse and neglect are made in the 8nited !tates,involving more than million children 42 / study estimated that the lifetime cost of one year ofconfirmed cases of child maltreatment in the 8nited !tates was :12; billion 47,;



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"he s eletal survey of the same child in the previous slide also revealed multiple rib fractures# yellow arrows % ractures that are highly specific for abuse include posterior rib fractures,scapular, and spinous process fractures ractures with different healing stages also have highspecificity for abuse "hese findings should mandate reporting to child protective services

/n average of four children per day die as a result of child abuse or neglect in the 8nited !tates45 &n 2017, an estimated 1520 children died as a conse3uence of child abuse or neglect 45



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/nswer* "ethered cord syndrome

"he )(& reveals a low lying conus below the level of '2 # red arrow %, which is associated withanatomic abnormalities such as an intradural sacral lipoma+tethered cord # blue arrow % &n thesetypes of cases, )(& may aid in surgical decision ma ing 4



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!hown, is an abdominal $" scan of a child with blunt abdominal trauma history What is themost common diagnosis based on the $" scan and its history



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/nswer* =ancreatic pseudocyst

"he $" scan in the region of the pancreas demonstrates a large, well marginated cystic structurethat is a pancreatic pseudocyst "he differential diagnosis includes a large choledochal cyst "he

pseudocyst, a fibrous walled cavity filled with pancreatic en>ymes that complicates pancreatitis,is primarily locali>ed in the lesser sac behind the stomach "he incidence of pancreatic

pseudocysts is greater than 50? when associated with traumatic in@ury to the abdomen /s aresult of limited case reporting and underdiagnosis by clinicians, the fre3uency and trueincidence of pancreatitis in children is un nown "rauma is responsible for an estimated 10?;0? of pediatric cases of acute pancreatitis 4 ,A



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"his $" scan shows a large type & choledochal cyst and the ad@acent gallbladder Bote that thecyst is typically filled with bile, which produces waterli e attenuation &f any 3uestionconcerning the diagnosis remains after a $" scan, endoscopic retrogradecholangiopancreatography #6($=% can be performed



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"his technetium 99m pertechnetate scan was performed on a 12 year old boy with right lowerabdominal pain and rectal bleeding Beither appendicitis nor intussusception was found onultrasonography What is the diagnosis



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/nswer* )ec el diverticulum

"he delayed image shows focal activity in the right lower 3uadrant /n inflamed )ec eldiverticulum containing ectopic gastric mucosa was removed during surgery



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"his $" scan was obtained on a child with right lower abdominal pain "here were no abnormalultrasonographic findings due to intestinal interposition What does the $" scan reveal

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/nswer* / distended, ovoid structure descending into the pelvis and containing a central, roundcalcification #appendicolith% #arrow %

/cute appendicitis is one of the most common causes of abdominal pain, and it is the mostfre3uent condition leading to emergency abdominal surgery in children / delay in the diagnosisis associated with rupture and other complications, especially in young children8ltrasonography is often the first imaging modality used in pregnant and pediatric patients withabdominal pain &ts advantages include lac of radiation e posure and short ac3uisition time, aswell as the potential to identify and diagnose other causes of abdominal pain / significantdisadvantage of ultrasonography is that it is operator dependent, and its diagnostic potentialrelies on the s ill of the operator

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/ child presented with recurrent urinary tract infections "he ultrasound was performed asrecommended "he first study demonstrated bilateral hydronephrosis with thinning of the renal

parenchyma # shown % What diagnoses should be considered



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/nswer* (enal cysts and+or hydronephrosis

"his longitudinal sonogram of the right idney shows that the hypoechoic areas interconnect#arrow %, a finding that is consistent with hydronephrosis rather than with multiple distinct renalcysts, which do not interconnect What imaging study is indicated ne t



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/nswer* Coiding cystourethrogram

"he ultrasound findings may be due to complications of a posterior urethral valve Coidingcystourethrographic evaluation of the abdomen, bladder, and urethra confirmed the presence ofthe posterior urethral valve # left % as well as demonstrated a trabeculated bladder, diverticula, and

bilateral massive reflu # right %

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"his angiogram was performed on a 10 year old girl with headaches What are the indications,findings, and diagnosis suggested by this image

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Indication" )ore than 50? of patients who present with headache, blood pressure differences inthe e tremities, claudication, arthralgia, and+or bruit #most commonly at the carotid artery% havearteritis of the great vessels 4E

Findings" Barrowing of the pro imal descending aorta # blue arrow % and right brachiocephalicartery #red arrow % are present

!iagnosis" "a ayasu arteritis is the only form of aortitis that causes stenosis and occlusion of theaorta ibromuscular dysplasia is a differential diagnosis for "a ayasu arteritis 49 Fowever,fibromuscular dysplasia usually does not affect the aorta, as evidenced by this angiography, andit is rare in the subclavian artery Binety percent of patients with "a ayasu arteritis are youngerthan 70 years, 49 and most of them are female 410

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"his frontal chest radiograph is from a newborn presenting early respiratory distress What arethe findings and diagnosis suggested by this image



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Findings * Ferniation of the liver # white arrow % and bowel loops into the right hemithora# yellow arrow % as well as a shift of the heart and mediastinum to the left side # green arrow % can

be seen on the radiograph

!iagnosis" "his is a right sided congenital diaphragmatic hernia 'oss of the normal welldelineated right superior curvilinear diaphragmatic contour # black arrow % and the shiftedmediastinum help to distinguish this condition from others in the differential diagnosis, such ascongenital cystic adenomatoid malformation



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"his chest radiograph is from another newborn presenting early respiratory distress What are thefindings that would lead to the correct diagnosis



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Findings * =hysiologic fluid was reabsorbed from an area of congenital cystic adenomatoidmalformation and replaced with an air containing cystic area that occupies the right upper lung# yellow arrow % Bote the well defined right diaphragmatic line that helps to distinguish thisfinding from herniation # black arrow %

!iagnosis" $ongenital cystic adenomatoid malformation is a developmental hamartomatousabnormality of the lung, with adenomatoid proliferation of cysts resembling bronchioles 411



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/ child was presented with a 2 month history of whee>ing What is the main finding on thisradiograph

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"his radiograph obtained during an e hale is from the same child as in the previous slide Botethe continued hyperlucency and hypere pansion of the right hemithora that was also present inslide 2; / greater mediastinal shift is noted toward the left lung field What is the most li elydiagnosis based on these findings

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/nswer* oreign body aspiration

"his radiograph is from another child with the same clinical condition as the child in the previoustwo slides &t shows a radiopa3ue earring bac ing # arrow % lodged in the right mainstem

bronchus /spirated foreign bodies are most often found in pediatric patients, and they accountfor thousands of 8! emergency department visits annually 411 $linicians must therefore maintaina high inde of suspicion for airway foreign body aspiration in young patients to allow prompttreatment as well as to avoid its complications 6stimates of deaths from foreign body aspirationrange from hundreds to thousands, 411 17 with most deaths occurring before hospital evaluation andtreatment 417

"he most common site of airway foreign bodies is the right mainstem bronchus due to its posterior location, shallow angle to the trachea, and wide diameter "he density of the aspirateditem will determine whether or not it can be directly identified on radiographs &ndirect signs ofairway foreign body used to confirm the diagnosis include ipsilateral focal overinflation if there

is partial obstruction or ipsilateral atelectasis if a more complete obstruction is present417

"he patient in slides 2; and 25 had a corn ernel removed from their right mainstem bronchus during bronchoscopy



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"his radiograph is from an infant with abdominal pain and vomiting What should be suspected

&mage courtesy of )edscape+ Jelly )arshall, )D, !cottish (ite Fospital, $hildrenKs Fealthcareof /tlanta


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Bote the small bowel obstruction pattern, with crescent sign to the left upper 3uadrantL thesefindings should always indicate the diagnosis of intussusception 8nfortunately, in plainabdominal radiography, up to ;0? of cases have no signs that suggest this diagnosis, which canalso be evaluated by the ultrasound 41;

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"his ultrasound reveals the classic target sign of an intussusception case "he ultrasound hasalmost 9E? of sensitivity and specificity for this important diagnosis that should be treatedimmediately by therapeutic enema or surgical reduction 415,1

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13 can't-miss findings on pediatric imaging 2015-12-2

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