Incidental mastoid opacification in children on MRI.

BACKGROUND: The opacification the mastoid cavity is frequently reported by radiologists on cross-sectional imaging done for non-otological indications. It is well known that presence of fluid the mastoid does not amount to mastoiditis. This study seeks to provide an evidence-based confirmation of this known finding. OBJECTIVE: The purpose of our study was to determine the prevalence of mastoid opacification in children undergoing outpatient brain MRI examination. MATERIALS AND METHODS: Our study included 515 outpatient children who had brain MRI for indications other than mastoiditis or otitis media from January 2014 to March 2014. Children with history of skull base trauma or radiation were excluded. The age range was 15 days to 18 years. The overall prevalence of mastoid opacification was determined using one sample proportion and exact 95% Clopper-Pearson confidence intervals. The prevalence of mastoid opacification was analyzed based on gender, age and presenting symptoms using chi-square test of association. RESULTS: One hundred ten children (21.4%) had mastoid opacification. Younger patients tended to have higher opacification rates with the prevalence in children younger than 1 year of age and between 1 and 2 years of age as high as 41.7% (20/48) and 47.5% (38/80), respectively. CONCLUSION: The diagnosis of mastoiditis in children should not be based upon a radiologist's report of finding fluid or mucosal thickening in the mastoid air cells as incidental opacification the mastoid is seen frequently.

Compression of the posterior fossa venous sinuses by epidural hemorrhage simulating venous sinus thrombosis: CT and MR findings.

BACKGROUND: Posterior fossa dural venous sinus thrombus is a well-described complication of head trauma, especially when fracture crosses the dural sinus grooves or in association with epidural hemorrhage. We have found that post-traumatic posterior fossa epidural hematoma compressing a dural venous sinus can mimic dural venous thrombus. OBJECTIVE: To discuss the CT and MRI findings of posterior fossa epidural hemorrhages simulating sinus thrombosis, to make radiologists aware of this important imaging pitfall. MATERIALS AND METHODS: We describe radiologic findings in four children in whom a posterior fossa epidural hemorrhage mimicked dural venous sinus thrombus. Routine CT head and CT venography were obtained on Toshiba volume and helical CT scanners. MRI and MR venography were performed on a Philips scanner. RESULTS: In all cases there was medial displacement and compression of the posterior fossa dural venous sinuses without intraluminal thrombosis. The epidural hemorrhage was seen tracking along sinus grooves in the occipital bone, peeling the dura containing the sinuses from the calvarium and compressing the sinus, simulating thrombosis on axial CT views. CONCLUSION: Both venous sinus thrombosis and posterior fossa epidural hemorrhages in children are well-described complications of head trauma. Posterior fossa epidural hemorrhage can mimic a sinus thrombus by compressing and displacing the sinuses. It is important to recognize this pitfall because treatment of a suspected thrombus with anticoagulation can worsen epidural hemorrhage.

Determining the normal aorta size in children.

PURPOSE: To establish effective aorta diameter standards at multiple levels of the thoracic aorta, abdominal aorta, and common iliac arteries by using computed tomographic (CT) data in healthy children (infants, children, adolescents) through young adults (hereafter referred to collectively as "children") of a wide range of sizes so that z scores may be calculated. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board. The effective diameter, the average of aortic anteroposterior and lateral diameters, was independently measured at multiple levels of the aorta and common iliac arteries by two radiologists using 1-mm-collimation double-oblique reconstructions. Ordinary least squares regression methods were used to investigate models with various functional forms that related effective diameters at each level to patient body surface area (BSA) and sex. The best model was selected by using R(2), and formulas for deriving the expected diameter and estimates of the mean squared error (MSE) were generated. RESULTS: Results from 88 thoracic and 110 abdominal contrast material-enhanced CT examinations were analyzed in children without known cardiovascular disease who ranged in age from 0 to 20 years (mean, 9.9 years; standard deviation, 5.7), with BSA ranging from 0.19 to 2.52 m(2). Excellent interrater reliability was present (correlation coefficients ranged from 0.95 to 0.98). The best model was a polynomial regression model of the natural log transformation of the effective diameter that included linear, quadratic, and cubic BSA terms and a sex main effect as independent variables. The z scores were calculated by using the observed and expected effective diameters and the MSE. CONCLUSION: The range of normal effective diameters of the aorta at multiple levels and the common iliac arteries was determined for children of different sizes and both sexes. Measurements outside of the normal ranges are consistent with aneurysm or hypoplasia.

The incidental pulmonary nodule in a child. Part 2: Commentary and suggestions for clinical management, risk communication and prevention.

The incidental detection of small lung nodules in children is a vexing consequence of an increased reliance on CT. We present an algorithm for the management of lung nodules detected on CT in children, based on the presence or absence of symptoms, the presence or absence of elements in the clinical history that might explain these nodules, and the imaging characteristics of the nodules (such as attenuation measurements within the nodule). We provide suggestions on how to perform a thoughtfully directed and focused search for clinically occult extrathoracic disease processes (including malignant disease) that may present as an incidentally detected lung nodule on CT. This algorithm emphasizes that because of the lack of definitive information on the natural history of small solid nodules that are truly detected incidentally, their clinical management is highly dependent on the caregivers' individual risk tolerance. In addition, we present strategies to reduce the prevalence of these incidental findings, by preventing unnecessary chest CT scans or inadvertent inclusion of portions of the lungs in scans of adjacent body parts. Application of these guidelines provides pediatric radiologists with an important opportunity to practice patient-centered and evidence-based medicine.

The incidental pulmonary nodule in a child. Part 1: recommendations from the SPR Thoracic Imaging Committee regarding characterization, significance and follow-up.

No guidelines are in place for the follow-up and management of pulmonary nodules that are incidentally detected on CT in the pediatric population. The Fleischner guidelines, which were developed for the older adult population, do not apply to children. This review summarizes the evidence collected by the Society for Pediatric Radiology (SPR) Thoracic Imaging Committee in its attempt to develop pediatric-specific guidelines.Small pulmonary opacities can be characterized as linear or as ground-glass or solid nodules. Linear opacities and ground-glass nodules are extremely unlikely to represent an early primary or metastatic malignancy in a child. In our review, we found a virtual absence of reported cases of a primary pulmonary malignancy presenting as an incidentally detected small lung nodule on CT in a healthy immune-competent child.Because of the lack of definitive information on the clinical significance of small lung nodules that are incidentally detected on CT in children, the management of those that do not have the typical characteristics of an intrapulmonary lymph node should be dictated by the clinical history as to possible exposure to infectious agents, the presence of an occult immunodeficiency, the much higher likelihood that the nodule represents a metastasis than a primary lung tumor, and ultimately the individual preference of the child's caregiver. Nodules appearing in children with a history of immune deficiency, malignancy or congenital pulmonary airway malformation should not be considered incidental, and their workup should be dictated by the natural history of these underlying conditions.

Risk factors and outcomes in patients with cochlear nerve deficiency.

INTRODUCTION: Cochlear nerve deficiency (CND) is a cause of sensorineural hearing loss made by radiologic criteria. There is sparse literature involving audiological outcomes and cochlear implantation (CI) success in patients with CND. METHODS: A retrospective chart review of all patients with sensorineural hearing loss at a tertiary children's hospital from 2000 to 2020 was conducted. Patients with CND on radiographic imaging were included and categorized as hypoplastic, aplastic, or indeterminate. RESULTS: In this study, 53 patients were identified with CND, totaling 70 ears. Of the 53 patients, 30 (56.6 %) were male, 8 (16.0 %) had a family history of childhood hearing loss, 6 (11.3 %) were born preterm, and 11 (23.4 %) required neonatal intensive care admission. The median maternal age was 29 years old [IQR: 27, 35], and 8 (15 %) patients were born to mothers with diabetes. Of the 70 ears, 49 (70 %) utilized conventional hearing aids, 12 (17.1 %) utilized a bone-anchored hearing aid, and 10 (14.3 %) underwent CI. Of the 10 ears implanted, 4 (40 %) ears had nerves classified as hypoplastic, 3 (30 %) as aplastic, and 3 (30 %) as indeterminate. Improvement in pure tone averages compared to preoperative testing was demonstrated in 8 (80 %), and 6 (60 %) displayed improved speech awareness thresholds. CONCLUSION: This study demonstrates that there may be an association between CND and maternal diabetes and NICU admission. There are variable results with hearing amplification options in patients with CND, and further research is needed to better describe the role of CI, bone-anchored hearing aids and conventional hearing aids in patients with CND.

CT findings in pediatric blunt intestinal injury.

Trauma is the leading cause of morbidity and mortality in children. Computed tomography examinations play an important role in the management of patients with major trauma. Though abdominal trauma is less common compared to head injuries, the associated morbidity and mortality are substantial. It is easier to diagnose solid abdominal injuries than intestinal or mesenteric injuries on CT examinations. However, recognition of bowel injury is very important as a delay in diagnosis increases the morbidity and mortality. Hence, with every CT of the abdomen and pelvis, the radiologist must look for signs of bowel and mesenteric injury. This pictorial review presents various CT findings of blunt intestinal injury in children.

MR enterography of perforated acute Meckel diverticulitis.

Meckel diverticulum is the most common congenital anomaly of the small intestine that generally comes to attention due to a variety of complications, such as gastrointestinal tract bleeding, bowel obstruction or acute inflammation. These diverticula frequently are difficult to prospectively diagnose by imaging. Clinically, acute Meckel diverticulitis can be mistaken for acute appendicitis or Crohn disease. We present a 6-year-old boy with perforated acute Meckel diverticulitis that mimicked Crohn disease both clinically and by CT imaging and was definitively diagnosed using MR enterography.

The medicolegal importance of establishing human identity by using dactyloscopy and rugoscopy: A comparative study.

BACKGROUND: Palatal rugae are irregular and asymmetric mesenchymal ridges that extend in a lateral direction away from the incisive papilla and mid-palatine raphe. Their unique characteristics and environmental stableness justify their inclusion in forensic investigations. Dermatoglyphics or fingerprint patterns are epidermal ridges, which are genetically controlled and are specific to an individual. Hence they are used as a forensic tool. OBJECTIVES: The study aimed to assess the reliability of Rugoscopic and Dermatoglyphic patterns for gender identification. MATERIALS AND METHODS: A total of 200 subjects were recruited in this prospective study. All subjects were between the age range of 18 and 55 years. The subjects were categorized into 100 males and 100 females. Fingerprint dermatoglyphic patterns were recorded using stamp pad, ink, and A4 size white sheets. A subject's fingers were pressed onto the stamped ink pad and lightly pressed over a sheet of paper. Obtained patterns were coded and analyzed as per Galton's criteria into arch, loop, and whorl patterns. Palatal rugae patterns were obtained by making alginate impression material and impression trays. Obtained casts were analyzed for rugae pattern analysis using Kapali's classification. An unpaired t test was used as a statistical tool. RESULTS: On analyzing dermatoglyphic patterns, the arch pattern was most common among male subjects, whereas loop pattern was found to be most common among females. On rugoscopic pattern analysis, Straight pattern was most frequent among males, whereas the circular pattern was common among females. CONCLUSION: A statistically significant difference was noted between gender and rugoscopic patterns (P = 0.02) and dermatoglyphic patterns (P = 0.03).

Interprofessional education and practice in an Indian setting.

With current global healthcare trends, there is a growing need for interprofessional education (IPE) and interprofessional practice (IPP) in collaborative care of persons with chronic medical conditions. Tools and models for IPE and IPP are now available, but they are not yet in widespread use. Developmental-behavioural paediatrics is a medical discipline that is characterized by IPP with an encouraging emergence of this speciality in India and other developing countries. This article provides an overview of IPE and IPP, followed by a precise account of an Indian institution, which provides services to children suffering from neurodevelopmental disorders utilizing an IPP approach and implementing IPE to its trainees.

Craniometaphyseal dysplasia in a 14-month old: a case report and review of imaging differential diagnosis.

We report a 14-month-old male with craniometaphyseal dysplasia (CMD). The patient presented with a history of diminishing vision and hearing loss. Cranial computed tomography scan showed diffuse calvarial and skull base hyperostosis with excessive bone narrowing the internal auditory canals and skull base foramina. A subsequent skeletal survey revealed other skeletal abnormalities, which led to the diagnosis of CMD. This was later confirmed by ANKH mutation. CMD is a rare genetic disorder that belongs to the group of craniotubular bone dysplasias. It is important to recognize this condition from other causes of craniotubular bone dysplasias to institute early treatment and explain prognosis.

Tetralogy of Fallot with double aortic arch and discontinuous left pulmonary artery.

We report a case of Tetralogy of Fallot with double aortic arch and discontinuous left pulmonary artery, supplied by the ductus arteriosus, a rare entity.

Newborn respiratory distress: airway abnormalities.

Respiratory distress is a common symptom in the newborn. Surfactant deficiency in the preterm infant and meconium aspiration and transient tachypnea in the term newborn are among the most common causes of respiratory distress, but primary airway abnormalities can also present with respiratory distress in the newborn. Delay in diagnosis of airway abnormality can be life threatening. Radiologists are among the first to be consulted in the evaluation of a neonate with respiratory distress, and knowledge of the spectrum of airway anomalies is essential for making the correct diagnosis. This article describes airway abnormalities that can present as respiratory distress in a neonate.

Tracheobronchial foreign bodies in children: imaging assessment.

Tracheobronchial foreign-body aspiration is a relatively frequent pediatric emergency and a cause of substantial morbidity and mortality especially in preschool children. Although foreign-body aspiration may cause sudden airway obstruction and subsequent death, quite often symptoms are mild and nonspecific; therefore, the correct diagnosis may be delayed particularly in the pediatric population. A delay in diagnosis increases the rate of complications and can cause substantial morbidity. Early and accurate diagnosis combined with intervention through foreign-body retrieval is critical for proper patient management. For evaluation of both radiopaque and non-radiopaque airway foreign bodies in pediatric patients, imaging plays an important role in initial detection and follow-up evaluation. In this article, we discuss the currently available imaging modalities and techniques for evaluating tracheobronchial foreign bodies in infants and children. Imaging findings of various tracheobronchial foreign bodies and mimics of foreign bodies are also discussed. In addition, information regarding management of tracheobronchial foreign-body aspiration is included.

MDCT Derived Left Ventricular Function in Relation to Echocardiography: Validation and Revising the Role with the Evolving Technology.

BACKGROUND: Coronary computed tomography angiography (CCTA) is a frequently performed examination for coronary artery disease. When performed with retrospective gating, there is an opportunity to derive functional parameters of left ventricle utilizing automated software. Complementary information, if validated with established standards, will enhance the total value of study. OBJECTIVE: Study evaluates the usefulness of fully automated software for the assessment of left ventricular ejection fraction (LVEF) using 64-slice CCTA data and to correlate CT results with echocardiography (ECHO). Role of CT derived LV function is reviewed in the light of emerging technologies and recent developments in multidetector CT (MDCT). MATERIALS AND METHODS: A total of 113 patients referred for MDCT CCTA for evaluation of coronary artery disease. All patients were scanned on 64 slice GE-Helical CT scanner and had an ECHO done within 1 week of the CT scan. Retrospectively electrocardiogram (ECG)-correlated image reconstruction was performed with the reconstruction at 10% R-R interval increment. Axial image sets were analyzed with advanced workstation using a program-Auto ejection fraction, Circulation: GE Medical Solutions. RESULTS: The mean LVEF calculated by clinical ECHO was 58.6 ± 4.5% and by fully automated software based on CTA data was 58.9 ± 5.4%. The Pearson's regression analysis showed a large correlation, with a correlation coefficient of 0.503 (P < 0.001). Bland-Altman analysis showed a trend towards MDCT resulting in slightly higher values for LVEF when compared with ECHO. CONCLUSION: The fully automated software is simple, reliable, and user-friendly, and can provide rapid assessment of LV functional parameters with good reproducibility. Despite of good correlation, fewer patients are likely to benefit, in future, from this function due to smaller number of patients undergoing CCTA with retrospective gating.

Imaging of multifocal liver lesions in children and adolescents.

Multifocal liver lesions are encountered regularly in children and adolescents. By knowing the specific ultrasonographic, computed tomographic, and magnetic resonance imaging (MRI) features of benign and malignant pediatric liver lesions as well as the particular clinical setting, radiologists can frequently narrow the differential diagnosis and sometimes offer a definitive diagnosis. The purpose of this review article is to illustrate the imaging findings of numerous benign and malignant causes of multifocal liver lesions in the pediatric population.

Calculating the required transfusion volume in children.

BACKGROUND: The traditional method of calculating blood volume for pediatric transfusion in the UK is weight (kg) x aimed increment in hemoglobin concentration (Hb; g/dL) x the transfusion factor, usually quoted at 3 or 4. This equation is without evidence base. The aim was to assess how the volume of red cells (RBCs) affects the increase in serum Hb in children and to devise a formula that allows accurate volume calculation. STUDY DESIGN AND METHODS: All pediatric intensive care charts for 2 years were examined retrospectively. The immediate pre- and posttransfusion Hb estimations and the precise volumes of RBC transfused were recorded. Fluid boluses and hemorrhagic loss during the transfusion were documented. RESULTS: A total of 7679 patient charts were examined with a total of 564 transfusions. All patients who were bleeding, had drain losses, or had concurrent colloid infusions were excluded, giving 379 data points. The correlation gradient between mL per kg blood transfused and increase in Hb was 5.02. There was no significant association between effect and patient weight, age, starting Hb, transfusion time, or sex. No significant difference was found in Hb at 1 and 7 hours posttransfusion. CONCLUSIONS: The following equation should be used to calculate transfusion volumes: weight (kg) x increment in Hb (g/dL) x 3/(hematocrit [Hct] level of RBCs). This predicts that with a UK standard Hct of 0.6, 10 mL/kg gives an increment of 2 g/dL. Care must be taken not to risk hypervolemia, while minimizing donor exposure. Hb estimation 1 hour after transfusion is the same as 7 hours after transfusion.