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ABSTRACT |
Obaldo R.E.1; Morriss M.C.2,3; Lowe L.H.2,3; 1. Radiology, The University of Kansas, Kansas City, KS; 2. Radiology, Children's Mercy Hospital and Clinics, Kansas City, MO; 3. Radiology, The University of Missouri-Kansas City, Kansas City, MO.
Address correspondence to R.E. Obaldo (robaldo{at}kumc.edu)
Background: Differentiating accidental from abusive head trauma is fraught with pitfalls and controversies. While certain neuroimaging appearances are highly suggestive of abuse, radiological findings are often nonspecific.
Key Issues: This pictorial presentation will review various manifestations of nonaccidental head trauma, including a discussion meant to distinguish findings that are considered characteristic and those that are controversial.
Format: Didactic format organized by pathology.
Teaching Points: After viewing this exhibit, the viewer will (1) Be familiar with the typical neuroimaging findings of child abuse, (2) Understand the difference between typical findings of nonaccidental head injuries and those that are controversial, and (3) Have an increased level of comfort interpreting neuroimaging studies in children who are victims of abuse and those who have suffered accidental injuries.
E329. Pediatric Brain Neoplasms: What We See Everyday
Sajewicz A.M.; Johnson A.A.; Radiology, Long Island Jewish Medical Center, New Hyde Park, NY.
Address correspondence to A.M. Sajewicz (sajewiczmd{at}yahoo.com)
Background: Pediatric brain neoplasms encompass a long laundry list of entities that can be sometimes confusing. Tumors of the central nervous system represent the most common form of solid tumors found in the pediatric population. Thousands of children are affected annually and the incidence seems to be increasing. Our institution, being affiliated with a children's hospital, sees many great and simultaneously unfortunate cases every week. We wish to share these cases in an educational exhibit following a format that makes sense and can easily be remembered.
Key Issues: We propose a simple way of looking at the various types of brain neoplasms that afflict children based on location, cell type and frequency of occurrence. The main form of imaging utilized will be MRI. However, when necessary, some CT images will be used because specific tumors containing high density cells and calcifications can be readily identified with this technique.
Format: The format will be didactic and first broken down based on general location, supratentorial vs. infratentorial. Supratentorial neoplasms are again divided into location subgroups of sellar tumors, para and suprasellar tumors, hypothalamic tumors, optic tumors, hemispheric tumors, ventricular tumors and tumors of the pineal region. The most common tumors of each of these regions will be presented related to their major cell type, focusing on their imaging characteristics. A similar format will follow for the infratentorial neoplasms.
Teaching Points: Emphasis will be placed on tumor location and imaging characteristics to help the reader nail down a common sense differential and definitive diagnosis when possible. We hope medical professionals will feel more comfortable discussing the range of neoplasms that occur in the pediatric population after viewing this exhibit.
E330. Pediatric Bone Cysts and Benign Bone Tumors: A Comprehensive Review
Dave A.M.; Palacio D.A.; Hernandez J.A.; Swischuck L.E.; Department of Radiology, University of Texas Medical Branch, Galveston, TX.
Address correspondence to A.M. Dave (amdave{at}utmb.edu)
Background: Although a common imaging finding, cystic bone lesions and bone tumors in the pediatric patient often present a diagnostic dilemma for the practicing radiologist. The variety of pathologic lesions, broad spectrum of imaging findings, and varied clinical presentations of these entities provide a challenge in determining the correct diagnosis and determining the need for further intervention. Of vital importance is the determination of the benign versus malignant nature of such lesions, which is often challenging with considerable overlap of imaging findings. We have selectively chosen and categorized a comprehensive collection of benign bone cysts and benign tumors in the pediatric patient population from over 30 years of cases from our Children's Hospital, with key plain film, CT and MRI findings.
Key Issues: This educational exhibit will describe the common locations and radiological (plain film, CT and MRI) findings associated with a variety of benign bone cysts, as well as explore cases of benign bone cysts in unusual locations and aggressive radiographic appearance which could be confused with malignancy or infection. Benign bone tumors, including common and rare entities, as well as those associated with specific syndromes, have been categorized into the fibrous group, cartilaginous group and vascular group, with emphasis on plain film diagnosis with CT and MR correlation.
Format: The exhibit is designed in a quiz format, with key images followed by correct diagnosis and brief discussion of important features and differential considerations. The quiz is organized by pathology; benign bone cysts followed by benign tumors organized into the fibrous group, cartilaginous group and vascular group. Plain film, CT and MRI findings of the different lesion are included within each pathologic category. Also included are rare entities and unusual radiographic presentations, as well as imaging of specific lesions which are associated with more complex syndromes.
Teaching Points: 1. Comprehensive review in quiz format of pediatric benign bone cysts, including common imaging appearance, unusual locations and those whichmay be confused with malignant lesion or infection. 2. Comprehensive review in quiz format of pediatric benign bone tumors, categorized by the underlying pathology; including fibrous, cartilaginous and vascular tumors. 3. Imaging findings which help distinguish benign versus malignant bone tumors. 4. Characteristic cases which are "aunt minnies".
E331. Interactive Digital CT Atlas of the Pediatric Temporal Bone
Pham H.P.1; Paladin A.M.2; Maycock R.2; Weinberger E.2; 1. Radiology, Virginia Mason Medical Center, Seattle, WA; 2. Radiology, Children's Hospital and Regional Medical Center, Seattle, WA.
Address correspondence to H.P. Pham (hppzz{at}yahoo.com)
Background: The large data sets that now comprise single CT examinations with multiple reformations do not easily lend themselves to static representation in a teaching file. In addition, with the advent of PACS, images are usually viewed in stack mode, where one scrolls through all images in a given series, rather then looking at each image as if printed on a page of film. To simulate this environment, we created a program that easily allows the importing of large data sets and which has many of the linking and scrolling options offered in current PACS systems. Selected non-contrast enhanced CT case of the pediatric temporal bone were used to populate our database in order to demonstrate how the program can be used as an atlas, as a self-taught learning module, or for teaching case presentation.
Key Issues: The temporal bone is an extremely complex, anatomically diverse structure with pathology confined to a very small anatomic region. Mastering the anatomy of the temporal bone is essential to diagnosis of temporal bone pathology. We believe that the learning of normal anatomy and abnormal pathology of the temporal bone is much more efficacious using an interactive digital atlas.
Format: The atlas contains over 2000 CT images of the pediatric temporal bone including both normal anatomy as well as various pathologies. Viewing of the images is controlled by a program written in C# and which runs under Microsoft Windows with the .NET Framework installed. The interactive atlas allows for easy simultaneous scrolling of different examination series for the same patient, as well as for scrolling through the same series for different patients. This allows for both a dedicated evaluation of a single patient, as well as the ability to compare the same region over many different patients. A comment field for each image can be selectively accessed, allowing one to view studies as teaching or test cases. The software design allows the user to further customize the database by easily removing or adding additional images to the provided data set.
Teaching Points: We demonstrate an intuitive interactive digital atlas to facilitate learning about the normal and abnormal CT appearance of the pediatric temporal bone. The program allows for easy modification of the database to create other teaching modules.
E332. Ultrasonography for Children with Hemophilic Arthropathy: How We Do It
Zukotynski K.A.1; Doria A.S.2; Babyn P.S.1,2; Jarrin J.2; Carcao M.2; 1. Diagnostic Radiology, University of Toronto, Toronto, ON, Canada; 2. Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.
Address correspondence to K.A. Zukotynski (katherine.zukotynski{at}utoronto.ca)
Background: Approximately 80% of hemorrhage in patients with hemophilia involves the joints, commonly the ankles, knees and elbows. Breakdown of extravasated blood from synovial vessels ultimately leads to synovitis, cartilage loss and subchondral bone irregularity. Ultrasound is useful in evaluating musculoskeletal involvement of joints in children. It is easily accessible and does not require sedation. We have developed a systematic protocol for ultrasound assessment of the knee and ankle in children with hemophilic arthropathy. Findings on radiography, ultrasound and MRI will be shown and compared for the ankle, knee and elbow. Imaging scoring methods currently used will be reviewed.
Key Issues: X-ray, ultrasound and MRI findings in children with hemophilic arthropathy will be shown with specific focus on the knee and ankle. The ultrasound protocol developed for imaging the knee and ankle in children with hemophilic arthropathy will be illustrated. The MRI protocol, including preparation and sequences used, will be reviewed.
Format: Didactic poster illustrating the key anatomic, physiologic and imaging findings described above.
Teaching Points: An optimal approach to ultrasound of the knee and ankle will be illustrated. Findings on x-ray, ultrasound and MRI for children with hemophilic arthropathy will be shown. Scoring systems described in the literature for hemophilic arthropathy will be reviewed.
E333. Primary Pulmonary Tuberculosis in Pediatrics in the New Century
John S.D.1; Robinson L.H.1; Mercado-Deane M.G.2; 1. Diagnostic and Interventional Imaging, University of Texas Houston Medical School, Houston, Texas; 2. Radiology, Case Western Reserve University, Cleveland, Ohio.
Address correspondence to S.D. John (Susan.D.John{at}uth.tmc.edu)
Objective: Primary tuberculosis remains an important cause of acute respiratory illness in children despite advances in infection control and treatment. Symptoms are often mild and nonspecific, but more severe disease caused by hematogenous spread is not rare and resistant forms of the disease are increasing. We wondered if the cases of primary tuberculosis in our population showed any differences in radiologic appearance from the classic findings that have been described. This exhibit illustrates our findings during a review of cases of pulmonary tuberculosis at our institution during the last 10 years.
Materials and Methods: We reviewed the clinical and radiologic findings in 102 children and adolescents diagnosed with tuberculosis at our institution over the past 10 years. Clinical data was retrieved from a pediatric tuberculosis database. Chest radiograph and CT findings were documented at initial diagnosis and on follow-up studies.
Results: Slightly over 50% of the children were symptomatic and 16 children had a PPD of less than 5 mm. A wide variety of imaging findings were encountered, including pulmonary consolidation, atelectasis, lymphadenopathy, nodules, pleural effusion, obstructive emphysema, calcifications, cavities, and pneumatoceles. Unilateral hilar adenopathy was the most commonly encountered finding seen in 38 of the 92 patients. Atelectasis and lung consolidation were seen with nearly equal frequency. Pleural effusions were present in 6% of patients. Pneumatoceles developed in 4% of cases. Biliary nodules were present in 10% of patients but were quite variable in size. A rare case of congenital tuberculosis was encountered, and the progression of this disease is illustrated.
Conclusion: The radiologic findings of tuberculosis in infants and children are variable and differ significantly from those seen in adults. Lymphadenopathy remains a valuable clue to the diagnosis but may be difficult to detect. The value of CT in diagnosis is discussed.
E334. The Role of Cardiac CT in Pediatric Congenital Heart Disease: Our Experiences
Jose J.1; Dalmeida M.1; Oneto J.1; Restrepo R.1; 1. Radiology, Miami Children's Hospital, Miami, FL; 2. Radiology, Mount Sinai Medical Center, Miami Beach, FL.
Address correspondence to J. Jose (jeanjose{at}gmail.com)
Background: Most cases of congenital heart disease referred for cardiac CT involve complex malformations, often at differing phases of multistage repair. After reviewing previous radiographic examinations and surgical reports, each cardiac CT protocol should be tailored to the patient's clinical diagnosis. When a specific question is raised by the cardiologist, CT may play an important role in selected patients, particularly the critically ill. Several complications can be depicted taking advantage of the short CT acquisition time that otherwise would not be seen on echocardiogram. In very unstable patients MRI may be more technically difficult to perform, requiring anesthesia or sedation.
Key Issues: The purpose of this presentation is to emphasize the importance of pediatric cardiac CT and its role in the diagnosis and treatment of congenital heart disease. Multiple cases of vascular anomalies and complications will be shown in an interactive format. Even though CT is not done routinely in the evaluation of pediatric congenital heart disease because of excess radiation, it has several valuable indications. CT can provide information that supplements echocardiography and MRI for surgical planning and follow up. Pre-operatively it can evaluate the presence, size and relationship of the aorta, pulmonary vessels and collaterals, vascular rings and type of situs. Post-operatively it can detect recurrence or aneurysm formation following aortic manipulation, pulmonary arterial and venous stenosis pre and post repair, and the status of stents, conduits and shunts which can be difficult to visualize on echocardiograms and MRI. Involvement of other intra-thoracic organs and structures such as lungs and bronchi can be readily evaluated by CT.
Format: Several pre and post-operative pediatric congenital heart disease CT cases will be presented in a challenging interactive program, followed by a brief discussion of their findings. The participant will be informed as to the advantages and disadvantages of pediatric cardiac CT, familiarized with the protocols used at our institution, and educated as to the adequate indications for this study.
Teaching Points: 1. To emphasize the importance of a tailored cardiac CT study in view of the limitations of echocardiography and MRI in the evaluation of pediatric congenital heart disease. 2. To illustrate characteristic anatomic features of congenital heart disease before and after surgical repair. 3. To depict pre and post-operative complications identified by cardiac CT.
E335. Imaging of the Diaphragmatic Disorder in Childhood
Cho Y.A.1; Kim B.K.2; Yoon H.K.2; 1. Diagnostic Radiology, Bundang CHA general hospital, College of Medicine, Pochon Cha University, Sungnam-si, Kyonggido, South Korea; 2. Diagnostic Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Address correspondence to Y.A. Cho (youngbud27{at}gmail.com)
Background: Diaphragm performs most of the physiologic work of inspiration and forms an anatomic barrier between the thoracic and abdominal cavities. Disorders of the diaphragm can be related to impairment of either of these functions and most have radiologic manifestations.
Key Issues: In this exhibit, we present normal anatomy and embryology of the diaphragm. We review various pathologic processes of the diaphragm including diaphragmatic paralysis, diaphragmatic eventration, various form of congenital and acquired diaphragmatic hernias.
Teaching Points: The pathogenesis, imaging features of these pathologic processes of the diaphragm and role of various imaging studies including plain radiographs, fluoroscopy, ultrasound, computed tomography will be discussed.
E336. Percutaneous Nephrostomy (PN) in Children Under 1 Year of Age: Indications, Risks, and Complications
Brahm G.L.; Amaral J.G.; Connolly B.; John P.; Temple M.; Chait P.G.; Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.
Address correspondence to J.G. Amaral (joao.amaral{at}sickkids.ca)
Objective: To evaluate the indications, risks and complications of PN in children under one year of age.
Materials and Methods: From November 1991 to December 2004, 50 PN were placed in 39 patients under one year of age. Indications included: ureteropelvic junction obstruction (22), posterior urethral valve (PUV) (11), ureterovesicular junction obstruction (4), megaureter (3), vesicularureteral reflux (2), pyonephrosis (1), post pyeloplasty (5), post partial nephrectomy (1), and post bladder extrophy (1).
Results: The procedure was successful in 98% of the cases (49/50). One procedure was not successful due to abnormal anatomy. In 3 procedures, the initial access was unsuccessful, but PN was successfully completed via a different access site during the same procedure. Post-operative complications included urinary tract infection (10), sepsis (6), perirenal collection (2), tube leak (5), and tube dislodgement (2). There were no cases of major hemorrhage or septic shock. Surgery was performed in 26 cases: 11 pyeloplasties, 7 PUV ablations, 5 nephrectomies, and 3 ureterocele resections and ureteral reimplantations.
Conclusion: Percutaneous nephrostomy in children less then one year of age is an effective procedure, with minimal complications and great therapeutic value.
E337. Volumetric Isotropic Magnetic Resonance Cholangiopancreatography: Successful Application in the Pediatric Population
Hussain H.K.1; Khan A.S.1; 1. Radiology, University of Michigan, Ann Arbor, MI;
Address correspondence to A.S. Khan (asrakhan{at}med.umich.edu)
Background: Today, standard MRCP is performed using Single Shot Fast Spin Echo (SSFSE or HASTE) T2-weighted pulse sequences. A novel technique using respiratory triggered 3D Fast Recovery Fast Spin Echo (3D FRFSE) pulse sequence with Array Special Sensitivity Encoding Technique (ASSET) has been developed to provide improved spatial resolution with 4–8 minute aquisition times. This has been successfully implemented at our institution in the pediatric population, where breath held sequences are often not possible and short scan times are essential. High resolution imaging, suitable for multiplanar reformatting without image distortion have allowed excellent visualization of the pancreaticobiliary tree.
Key Issues: Our experience using this MRCP technique in children is presented, demonstrating various pathologies, including choledochocele, pancreatic divisum, common bile duct and pancreatic duct strictures. Technical pitfalls including artifacts from crossing vessels and pseudodefects from air or surgical clips are also presented.
Format: The format will be didactic with explanation of the MRCP using Single Shot Fast Spin Echo T2-weighted pulse sequence. This will be followed by presentation of various pathological entities involving the pediatric pancreaticobiliary tree imaged at our institution using this technique as well as examples of technical imaging pitfalls.
Teaching Points: Understanding the basis of MRCP using the 3D volumetric SSFSE T2-weighted technique. Review of pathologies involving the pediatric biliary tree. Review of technical artifacts that may cause problems in interpretation of this MRCP technique.
E338. Viral Appendicitis (The Pink Appendix) in Mesenteric Adenitis-Enteritis
Swischuk L.E.; Hernandez J.A.; Sullivan R.D.; Chung D.; Angel C.; Hawkins H.K.; Radiology, University of Texas Medical Branch, Galveston, TX.
Address correspondence to L.E. Swischuk (lswischu{at}utmb.edu)
Objective: To present the ultrasound and CT findings of viral appendicitis as it is seen in the complex of mesenteric adenitis-enteritis.
Materials and Methods: We retrospectively reviewed 22 patients diagnosed with viral appendicitis in association with mesenteric adenitis-enteritis. The specific imaging features on ultrasound and CT were documented. Three of the appendices were removed and the pathology evaluated.
Results: Nineteen had ultrasound studies, 4 CT studies and 1 both. The age range was 2–17 years with a mean of 10.4 years. The male to female ratio was 14/8. On ultrasound typical findings of a hypoechoic, thickened appendix with a central linear echogenic streak (dot on cross-section-compressed mucosa) was identified. On CT findings consisted of a swollen, round appendix with an enhancing, thickened wall and some intraluminal fluid. The diameter of the appendix ranged from 4.7 mm to 7.5 mm with a mean of 5.6 mm. Inflamed, periappendiceal mesenteric fat (i.e., stranding) was rare. Pathologic evaluation in one patient with proven adenoviral infection, and two with strongly suspected viral infection demonstrated reactive lymphoid hyperplasia.
Conclusion: Viral appendicitis is a definite entity. It is manifest by hyperplasia of lymphoid tissue within the appendiceal wall, reacting the same way as does lymphoid tissue in lymph nodes. On imaging the findings often are misinterpreted for normal or early acute appendicitis, while pathologically they generally are considered normal (i.e., no evidence of purulent appendicitis). Generally, appendectomy is not required.
E339. The Developing Role for Reformatted Images in Pediatric Trauma
Wile G.E.; Anthony E.Y.; Barnes C.E.; Department of Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, NC.
Address correspondence to G.E. Wile (gwile{at}wfubmc.edu)
Background: Radiographic evaluation of pediatric patients in the setting of trauma tends to follow, by default, established adult protocols at many institutions. These protocols include both radiographs and axial computed tomography studies with limited attention to radiation exposure issues. However, with the introduction of 64-detector computed tomography and a thin client workstation in the ED, re-evaluation of these protocols is in order. Radiologists can now manipulate isotropic data sets for a variety of 2-D, 3-D and MIP renderings for better assessment of subtle injuries. These physician-generated images are easily made and may allow bypass of the numerous plain radiographs that often accompany a trauma series, many of which are of poor quality.
Key Issues: In this exhibit, we will illustrate, with a variety of cases from our level one trauma center, the value of reformatted images in lieu of most plain films and as a complement to routine axial CT images.
Format: Our educational exhibit will be didactic in format, explaining the value and ease of generating 2-D, 3-D, and MIP images from an axial CT data set and illustrating the superiority of these images to standard radiographs and to axial CT images alone. All images are taken from pediatric trauma patient studies and will focus on injuries to the abdomen and pelvis, including those involving the axial skeleton, the viscera, and the vasculature.
Teaching Points: The goal of this exhibit is to provide the viewer with evidence that multiplanar and 3-D CT images are a superior and complete method of evaluating pediatric trauma patients, obviating the need for the majority of radiographs that currently comprise trauma imaging. Moreover, these reformatted images, which are quickly created, increase the efficiency of the radiologist and the accuracy of the interpretations.
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