M-mode ultrasound for assessment of the "tethered fat sign" in children: an easily performed way to certify a dynamic process as a still picture.

Background: Omental infarction is a rare pediatric disease. Ultrasound is a useful modality for a non-invasive pre-operative differential diagnosis between inflammatory conditions (as appendicitis) and omental infarction, especially by detecting immobility of the omentum adhered to the abdominal wall ("tetherd fat sign"). However, this is a dynamic sign that cannot be documented in a static image with B-mode technique. The goal of this work is to incorporate the versatile function of motion mode (M-mode) into omental infarction diagnosis to describe how the M-mode is useful in the evaluation of fat motion in children suspected of having omental infarction. In 2019 we suggested a new Ultrasound sign named "tethered fat sign" for an accurate non-invasive diagnosis of omental infarction in children. This finding was observed in 6 of the 234 seen children of our previous study with 4 laparoscopic confirmed diagnosis. Methods: From January 2019 to July 2021, we evaluated 195 children (91 boys and 104 girls, from 3 to 15 years) admitted to our Santobono-Pausilipon Children Hospital with acute right-sided abdominal pain. Abdominal ultrasound was performed to all the patients and the investigation of "tethered fat sign" was always included. Results: In 7 patients ultrasound showed the presence of a hyperechoic oval mass localized in the right upper abdominal quadrant and in 2 of these M-mode documented a normal subhepatic fat moving during respiratory movements in relation with the abdominal wall. The remaining 5 patients had an omental infarction showed as a subhepatic motionless mass tethered to the abdominal wall on M-mode. In these patients, a sonographic follow-up was performed every 15 d for 2 months showing a progressive reduction in size of the right-sided hyperechoic mass. Conclusions: In the evaluation of all children who showed the presence of the "tethered fat sign" the use of M-mode provide a certified image in diagnostic ultrasound.

Volvulus of a wandering spleen in a pediatric patient.

Wandering spleen is a rare condition in children that is often caused by the loss or weakening of the splenic ligaments. Its clinical presentation is variable; 64% of children with wandering spleen have splenic torsion as a complication. A 13-year-old boy who had been showing abdominal pain in the hypogastric region accompanied by vomit and an enormous tumefaction in the suprapubic region came to our observation. Considering the ovoid morphology at ultrasound exam, the echostructure and the marked reduction of parenchymal vascularization, suspicion for torsion of an ectopic spleen arose. Ultrasound evaluation has a primary role in the diagnosis of a suspected wandering spleen and, to avoid potentially life-threatening complications, immediate surgery is often times required.

Congenital tibial pseudarthrosis: A challenge in pediatric radiology.

Congenital pseudarthrosis of the tibia (CPT) is a rare disorder affecting the skeletal system in pediatric population with an estimated incidence of 1:140,000 to 1:250,000 newborns. It is characterized by deformity of the tibia, including anterolateral bowing of the bone diaphysis and/or narrowing of the medullary canal, leading to instability or fracture. CPT can be either idiopathic or associated with underlying conditions such as type 1 neurofibromatosis (NF1), fibrous dysplasia, or Campanacci's osteofibrous dysplasia. Diagnosis is based on clinical and imaging findings, using conventional radiography and magnetic resonance imaging (MRI). The disorder is characterized by recurrent pathological fractures of the tibia or fibula during childhood, often beginning by the age of 2 years. Treatment options include surgical and nonsurgical management.

Ultrasound findings in early congenital syphilis: Two case reports and literature review.

Syphilis is caused by treponema pallidum. If untreated, or inadequately treated, during pregnancy, it can result in congenital syphilis (CS), which is classified as early and late. Early CS displays before 2 years of age. We herein describe 2 cases of early CS, whose clinical onset included liver failure, edema, organomegaly, and respiratory distress. We focus on liver, intestinal, and brain ultrasound (US) and other peculiar radiological findings. To date, there are no scientific data on intestinal and brain US findings in patients with early CS whereas data on abdominal US are scarce. Increasing knowledge about US findings in early CS could be useful to improve the diagnostic and therapeutic approach to these patients.

Multimodal imaging approach in hyponatremic hypertensive syndrome. A rare case of pediatric unilateral hypoplasia of the main renal artery combined itself with stenosis and review of literature.

Renal artery stenosis (RAS) accounts for approximately 5%-10% of secondary renovascular hypertension in the pediatric population. It can occur as an isolated entity, or as a hypoplasia combined itself with stenosis. Hypoplasia, or long-segment developmental narrowing, is a rare cause of renovascular hypertension. Hyponatremic hypertensive syndrome (HHS) is a malignant complication of unilateral RAS and/or renal artery hypoplasia. Hyponatremia, hypokalemic hypochloremic metabolic alkalosis, nephrotic range proteinuria, polyuria, polydipsia, and weight loss are the most common findings. In particular, hypertension remains refractory despite aggressive antihypertensive therapy. Laboratory findings of elevated plasma levels of renin in most case suggest that the stimulation of renin release from the ischemic kidney plays an important pathophysiologic role. HHS is a diagnostic and therapeutic challenge in children. We report a case of a unilateral right renal artery hypoplasia, complicated by a segmental narrowing, in a 17-month-old male, clinically symptomatic for hypertension. We emphasize the role of ultrasound, computed tomography, and digital subtraction angiography that should be planned as reliable and non-invasive multimodal imaging approach.

Hepatic hemangiomas in childhood: the spectrum of radiologic findings. A pictorial essay.

Hepatic hemangiomas (HHs) are the most common benign liver tumors in infancy, but despite their frequent occurrence, their radiologic appearance may be particularly challenging to assess, owing to unique anatomical and development features that distinguish their subtypes in the pediatric population. There are 3 main patterns of the lesions recognized in HHs: focal, multifocal and diffuse. Medical care strategies range from simple observation to surgery, and a timely diagnosis is crucial to establish the most appropriated clinical management and therapy. Ultrasound (US) is typically the first level examination of pediatric vascular anomalies, able to meet a satisfactory diagnosis and has proved very helpful to assess for involution through serial imaging. CT and MRI are second-level methods seldom performed, offering an anatomical panoramic view and clarification when US is non-conclusive. Histologic confirmation is rarely required. HHs show a variable sonographic appearance, with hypoechoic (mostly) or hyperechoic solitary\multifocal mass and wide features. Hepatic vessels assessment reveals an abnormal flow, enlarged vasa, decreased resistive index (RI) values, scarce blood supply distally to lesions and hyper vascular regions inside them. In this pictorial essay, we review HHs subtypes in further details, illustrate US, CT and MRI findings and clarify a recurrent dispute over the existing terminology.

Para-oesophageal hernia in 4-month-old girl: possible role of ultrasound-case report and literature review.

Hiatal hernia is the passage of digestive tract portions into the posterior mediastinum through a defect in the esophageal diaphragmatic hiatus. By guidelines, the diagnosis uses first-level radiographic investigations such as chest X-ray and contrastographic methods. As of today, use of ultrasonography in the suspicion/diagnosis of hiatal hernia is not standardized although it shows advantages such as not using ionizing radiation, which is essential in the small pediatric patient. We report the case of a little 4-month-old patient who came to our attention for dysphagia, vomiting and borborygmus to whom Type II hiatal hernia was suspected by ultrasound investigation, later confirmed by guidelines approved methods.

Compressed Sensing Cardiac Cine Imaging Compared with Standard Balanced Steady-State Free Precession Cine Imaging in a Pediatric Population.

Purpose: To compare real-time compressed sensing (CS) and standard balanced steady-state free precession (bSSFP) cardiac cine imaging in children. Materials and Methods: Twenty children (mean age, 15 years ± 5 [SD], range, 7-21 years; 10 male participants) with biventricular congenital heart disease (n = 11) or cardiomyopathy (n = 9) were prospectively included. Examinations were performed with 1.5-T imagers by using both bSSFP and CS sequences in all participants. Quantification of ventricular volumes and function was performed for all images by two readers blinded to patient diagnosis and type of sequence. Values were correlated with phase-contrast flow measurements by one reader. Intra- and interreader agreement were analyzed. Results: There were no significant differences between ventricular parameters measured on CS compared with those of bSSFP (P > .05) for reader 1. Only ejection fraction showed a significant difference (P = .02) for reader 2. Intrareader agreement was considerable for both sequences (bSSFP: mean difference range, +1 to -2.6; maximum CI, +7.9, -13; bias range, 0.1%-4.1%; intraclass correlation coefficient [ICC] range, 0.931-0.997. CS: mean difference range, +7.4 to -5.6; maximum CI, +37.2, -48.8; bias range, 0.5%-7.5%; ICC range, 0.717-0.997). Interreader agreement was acceptable but less robust, especially for CS (bSSFP: mean difference range, +2.6 to -5.6; maximum CI, +60.7, -65.3; bias range, 1.6%-6.2%; ICC range, 0.726-0.951. CS: mean difference range, +10.7 to -9.1; maximum CI, +87.5, -84.6; bias range, 1.1%-17.3%; ICC range, 0.509-0.849). The mean acquisition time was shorter for CS (20 seconds; range, 17-25 seconds) compared with that for bSSFP (160 seconds; range, 130-190 seconds) (P < .001). Conclusion: CS cardiac cine imaging provided equivalent ventricular volume and function measurements with shorter acquisition times compared with those of bSSFP and may prove suitable for the pediatric population.Keywords: Compressed Sensing, Balanced Steady-State Free Precession, Cine Imaging, Cardiovascular MRI, Pediatrics, Cardiac, Heart, Cardiomyopathies, Congenital, Segmentation© RSNA, 2022.

Value of intestinal ultrasound in pediatric magnet ingestion: a case report.

Ingestion of magnetic foreign bodies in pediatric settings has become more common in the last years due to the marketing of various toys containing small magnetic parts. Most magnets, especially if a single element is ingested, usually pass through the gastrointestinal tract without complications. However, ingestion of multiple magnets or magnets and small metallic components may require a prompt intervention due to the risk of attraction across bowel layers, leading to pressure necrosis, perforation, and even death. Routinely, serial radiological evaluations are needed to follow the progression of magnets through the intestine, while the role of small bowel ultrasound is regarded as marginal. Here we report a case of a 5-years old boy who ingested 8 magnets and in which small bowel ultrasound was pivotal for the correct assessment of magnets location to correct address the surgical approach.

Osteofibrous dysplasia: A rare case in 3-day-old female.

Osteofibrous dysplasia (OFD) is a nonneoplastic tumor-like lesion, made up of fibrous matrix with immature bone tissue surrounded by osteoblasts, occurring usually in the cortex of tibial diaphysis. OFD is usually seen in the first decade of life and, according to literature, it is rarely seen in the newborn period. Diagnosis of congenital OFD in the newborn is challenging because it is uncommon in this age group and can be confused with other bone benign or malignant lesions. Imaging plays an important role in diagnosis, although histological confirmation is often required. Our report presents a rare case of pathologically confirmed congenital OFD in 3-day-old female which presented with a swelling of her right leg. We will focus on imaging findings of OFD and main differential diagnosis of this lesion in neonatal age.

Early diagnosis of Meigs syndrome in children A case report and a review of the literature.

Meigs syndrome is a rare disease defined by the coexistence of benign ovarian neoplasm, ascites and hydrothorax, which mainly affects women over the age of 30. This clinical condition refers only to cases in which the ovarian neoformation is a fibroid, a thecoma, a granulosa cell tumor or a Brenner tumor with disappearance of symptoms and effusions after removal of the neoplasm. Meigs syndrome is most frequently characterized by the presence of an ovarian fibroid, which in childhood is very rare and not commonly associated with the disease. In this article we report the case of an 11- year-old girl who came to our observation for a high fever for five days accompanied by cough and abdominal pain; imaging methods revealed bilateral hydrothorax, ascites, and a voluminous expansive right ovarian formation. On histological examination, the mass showed a cellular fibroid and the diagnosis of Meigs syndrome was made. Furthermore, we present a review of the literature aimed at detecting the state of knowledge on this disease in pediatric age, giving particular emphasis to the condition for which, in the presence of pleural effusion and ascites, an ovarian neoformation is not necessarily malignant. KEY WORDS: CT, Meigs syndrome, Pediatric, Pelvic mass, Ultrasounds.

Midsternal bump: an infrequent localization of dermoid cysts.

A 5-month-old boy was evaluated for an unusually large presternal bump present since birth. The ultrasound examination revealed a well-defined soft tissue mass with an oval shape. The lesion demonstrated a regular and well-demarcated outline, with an upper margin that was thinned and inserted into the upper skin plane; the content was anechoic with a small echogenic formation, mobile with changes in the patient's decubitus. The histologic diagnosis was dermoid cyst. Although dermoid cysts are commonly seen in the midline, the midsternal location, found in our patient, is rare. Dermoid cysts can have ultrasonographic features similar to those of other subcutaneous cystic masses. However, if an anechoic cyst with an internal well-circumscribed echogenic ball-like formation is seen within the presternal subcutaneous fat layer, as in our patient, dermoid cyst should be considered in the differential diagnosis of subcutaneous cystic masses.

Identification of secondary splenic lymphoma with contrast-enhanced ultrasound in the pediatric population. A case report.

Contrast-enhanced ultrasound scan (CEUS) is the application of ultrasound contrast agents (UCAs) to traditional ultrasound. Our aim is to report the use of CEUS for a prompt assessment of a suspected secondary splenic lymphoma in a child, which, in our experience, has allowed an accurate description of the parenchymal perfusion and vascularization pattern, leading to a confident diagnosis. We suggest that CEUS will replace Magnetic resonance imaging (MRI) or Computed tomography (CT) as standard imaging option for differential diagnosis of spleen lesions in pediatric population. As a result this will lead to decreasing the overall use of ionizing radiation and reducing the time interval to a certain diagnosis.

Role of ultrasound in diagnosis of neonatal breast enlargement: a newborn case report.

Neonatal breast enlargement is a hormone-related condition, mostly asymptomatic\physiological, with a well-recognizable sonographic appearance but limited data in the literature. It can be uni-or bilateral. Typically described in the first week of life, the transient lesion disappears spontaneously within 6 months. The main differential diagnosis is neonatal mastitis, a breast tissue infection that requires a specific antibiotic therapy. Knowledge of clinical and imaging findings is crucial, and ultrasound represents a reliable tool which allows a quick identification and an excellent examination of neonatal breast abnormalities. We aim to highlight sonographic classic features of benign neonatal breast enlargement showing how ultrasound rules out real breast masses helping to differentiate between it and mastitis when clinical and laboratory data are inconclusive. We describe a 2-day-old male with bilateral breast swelling more pronounced on the right side.

Type II pleuropulmonary blastoma in a 3-years-old female with dyspnea: a case report and review of literature.

Pleuropulmonary blastoma (PPB) is a rare but aggressive pediatric tumor originates from either lung or pleura. It was recently linked to the DICER I mutation as a part of predisposition syndrome for different type of tumor. It is characterized histologically by a primitive, variably mixed blastomatous and sarcomatous tissue. PPB is classified into four subtypes: cystic (type I and type Ir); cystic and solid (type II); solid (type III). PPB has no characteristic imaging findings. Integrated imaging can help to make a differential diagnosis and to recognize the subtypes in order to set up therapy. An early recognition and differentiation from congenital airway malformations and other benign cysts are very important. The treatment consists in a multimodal therapy including surgery and chemoterapy. We report a case of 3 years old female admitted at our hospital with fever, non productive cough and dyspnea, who was diagnosed with type II PPB.

Not only fat: omental infarction and its mimics in children. Clinical and ultrasound findings: a pictorial review.

Acute abdominal pain in children is the most common cause of emergency department admissions. Omental infarction is a rare cause of acute abdominal pain in this age group, accounting for approximately 15% of cases in children and 0.024-0.1% of cases of surgery for suspected appendicitis at the same age. Its clinical presentation may mimic similar diseases such as acute appendicitis, epiploic appendagitis, and mesenteric panniculitis. Ultrasound is the modality of choice for the initial evaluation of acute abdominal pain in pediatric patients and it can be used with confidence in the diagnosis and management of omental infarction in children. In this brief review, we focus on the main ultrasound findings and their diagnostic clue for omental infarction and its mimics.

"Tethered Fat Sign": The Sonographic Sign of Omental Infarction.

Our purpose is to describe the ultrasound sign for a correct non-invasive diagnosis of omental infarction in children. From January 2014 to December 2018, a total of 234 children (109 boys and 125 girls, age range 3-15 y) with acute right-sided abdominal pain, admitted to our hospital with a presumptive diagnosis of acute appendicitis, were prospectively evaluated. In all patients, abdominal ultrasound was performed, and the omental fat was always evaluated. In 228 patients, the omental fat resulted to be normal or hyperechogenic, never tethered, and they results affected by other causes of abdominal pain different from omental infarction (such as appendicitis, pancreatitis, urolithiasis and others). In the remaining 6 children, we found a hyperechoic mass between the anterior abdominal wall and the ascending or transverse colon in the right abdomen quadrant, suggesting the diagnosis of omental infarction. This subhepatic mass was always tethered to the abdominal wall, motionless during respiratory excursions. We named this finding the "tethered fat sign." The diagnosis was confirmed with laparoscopy in 4 children. The other 2 children were treated with conservative therapy. In these 2 patients, a sonographic follow-up was performed, showing a progressive reduction in size of the right-sided hyperechoic mass. In conclusion, our study suggests that the presence of the "tethered fat sign" may be an accurate sonographic sign for non-invasive diagnosis of omental infarction in children.

Up-to-date imaging review of paediatric soft tissue vascular masses, focusing on sonography.

The purpose of this article is to provide an up-to-date overview on imaging of paediatric vascular soft tissue masses, including both neoplastic and non-neoplastic lesions. We describe the-often challenging-imaging diagnosis-mainly performed by ultrasound (and secondarily by MRI) and differential diagnosis of vascular soft tissue lesions in children. We underline how important it is to determine whether a vascular anomaly has a regional vascular origin, or if there are other entities, ranging from benign to malignant lesions, which have flow-signal or blood degradation products. Even though clinical examination and patient's history are the first and indispensable steps in the initial diagnosis, the role of imaging is crucial, not only to determine whether a mass represents a true tumour/pseudo-tumour, but also to achieve a more correct diagnosis and determine the extension of the tumour/pseudo-tumour and its relation with the nearby anatomic structures.

The pediatric gastrointestinal tract: ultrasound findings in acute diseases.

The study of the gastrointestinal tract by imaging, particularly using ultrasound, is a required instrument for diagnosis of acute and chronic gastrointestinal pathologies in pediatric age. Actually, ultrasound plays an increasing role in the evaluation of gastrointestinal tract in neonatal and pediatric patients because of their small body habitus and the presence of less fat tissue in the abdominal wall and peritoneal cavity. Ultrasound has certain advantages, thanks to the new wide-spectrum frequency probes able to assess a detailed study of the morphological aspects and functional characteristics of bowel loops, adding a new dimension to the imaging of this body system. In this paper, we review anatomy, ultrasound technique and sonographic findings of bowel pathology frequently encountered in neonatal and pediatric emergency setting.