Pituitary sellar spine in a pediatric patient with diabetes insipidus.

A sellar spine is a midline bony spur arising from the ventral aspect of the dorsum sellae. Representing a remnant of the anterior notochord, it is often an incidental finding and thought to be of no clinical significance. However, it has recently been suggested that a potential association may exist between sellar spine and pediatric pituitary endocrinopathies, possibly caused by deformation of the developing pituitary gland by the sellar spine. To our knowledge, this is the first case report demonstrating an association between sellar spine and clinical diabetes insipidus.

Unilateral absence of the pulmonary veins: an unusual diagnosis with characteristic imaging findings.

BACKGROUND: Congenital unilateral absence of the pulmonary vein (UCAPV) is a rare entity with characteristic clinical and imaging findings. Despite its congenital nature, the radiographic findings and symptoms of UCAPV may not be recognized at birth and patients may present in childhood or early adulthood with findings that may mimic other diagnoses. METHODS: The evolution of imaging findings in UCAPV is presented through two cases, one of which demonstrates the progression of findings over several years. The embryologic basis of this entity is reviewed and the clinical presentation and characteristic imaging findings including radiographs, nuclear scintigraphy, computed tomography, magnetic resonance imaging and cardiac catheterization are demonstrated. RESULTS: Characteristically, normal at birth, radiographs demonstrate the gradual development of a small lung and ipsilateral pulmonary artery over time. In addition to unilateral absence of the pulmonary veins on CT or MRI, a mediastinal "soft tissue mass" reflecting the development of mediastinal collaterals is a common finding and should be recognized as secondary to the absent ipsilateral pulmonary veins rather than as a primary process causing occlusion of the pulmonary veins. Scintigraphy will show absent perfusion to the affected lung. CONCLUSION: Awareness of the distinctive imaging findings in this unusual condition is critical to avoid misdiagnosis and to prevent the consequences of UCAPV which include pulmonary hypertension and extensive venous collaterals with or without hemoptysis, both of which may prevent definitive repair.

Acute appendicitis in childhood: oral contrast does not improve CT diagnosis.

INTRODUCTION: We compared the diagnostic accuracy of CT performed without and with oral contrast for suspected appendicitis in children. METHODS: In this retrospective cohort study, we reviewed abdomen/pelvis CT scans with IV contrast performed between 2011 and 2015 for suspected appendicitis. Oral contrast was used routinely before August 2013 and eliminated from the CT protocol thereafter. Diagnostic accuracy of CT was compared with operative/pathology reports, and included a 30-day follow-up period for non-surgical patients. For a secondary analysis, the oral contrast group was subdivided into "complete" (contrast extending into the cecum) or "partial" contrast. We also compared groups for CT turnaround time, the frequency of appendiceal perforation and abscess, and the potential influence of a prior appendix ultrasound. RESULTS: Five hundred fifty-eight patients were included: 51.6% (n = 288) without oral contrast and 48.4% (n = 270) with oral contrast (of which 52% (n = 140/270) had "complete" contrast). There was no difference in diagnostic accuracy between the oral contrast and non-contrast groups (p = 0.903), with sensitivity/specificity of 93.8% (95% CI 84.8-98.3)/98.5% (CI 95.8-99.7) and 94.6% (CI 84.9-98.9)/98.3% (CI 95.7-99.5), respectively. Similarly, there was no difference in accuracy when comparing only "complete" contrast vs. non-contrast groups (p = 0.755). CT turnaround time for the non-contrast group was significantly faster (43.8 ± 37.6 min), on average, than the oral contrast group (137.4 ± 47.5 min). CONCLUSION: For children evaluated by CT with IV contrast for suspected appendicitis, administering oral contrast increased wait time by > 90 min, did not reach the cecum in 48% of cases, and did not improve diagnostic accuracy. Oral contrast for pediatric CT appendicitis evaluation is not warranted.

Therapeutic enema for pediatric ileocolic intussusception: using a balloon catheter improves efficacy.

A therapeutic enema for pediatric intussusception may benefit by using a rectal catheter with an inflated balloon. We compared the efficacy of rectal catheters without and with an inflated balloon for air and liquid enemas. We retrospectively reviewed PACS images and hospital records of children who had a therapeutic enema for intussusception at our institution between January 2006 and May 2011. Sixty-two enemas in 60 children were included. Physician assistants with training in pediatric fluoroscopy and pediatric radiologists were more likely to use air enema (37/41 or 90 %), and general radiologists were more likely to use liquid enema (18/21 or 86 %). However, the reduction rate for air enema overall was only slightly higher than for liquid enema using an inflated balloon catheter (36/40 or 90 % versus 14/17 or 82 %) (P=0.653). For air enema, mean procedure time for successful reductions was shorter with an inflated balloon catheter than with a plastic catheter (7.6 versus 28.2 min) (P<0.009), but the reduction rate was not affected. For liquid enema, the reduction rate was higher with an inflated balloon catheter than without inflation (14/17 or 82 % versus 1/5 or 20 %; P=0.021), but the procedure time was not shortened. No procedural complications were directly attributed to using a rectal catheter with an inflated balloon. Using a rectal catheter with an inflated balloon appears to safely shorten the procedure time of a successful air enema and improve the reduction rate of liquid enema.

Use of a dedicated pediatric CT imaging service associated with decreased patient radiation dose.

PURPOSE: The growing use of CT as a diagnostic imaging tool has led to increased concern over radiation dose, particularly in pediatric patients. The ALARA concept has been popularized in dose reduction. ALARA supports the use of low-dose, pediatric-specific protocols. Strict adherence to low-dose protocols can be challenging, particularly in a high-volume radiology department that scans both pediatric and adult patients. The aim of this study was to determine whether the relocation of pediatric radiologic services from a combined high-volume pediatric and adult hospital to a children's hospital improves compliance with adjusted lower CT exposure parameters and thus the estimated effective dose of radiation delivered to pediatric patients. METHODS: A retrospective review of abdominal and pelvic CT console dose and exposure parameter data on 495 patients from a combined pediatric and adult radiology department and subsequently 244 patients from a dedicated pediatric radiology department was performed. The console dose-length product was converted to estimated effective dose. Patients were divided into 1 of 8 weight categories for analysis. RESULTS: A statistically significant decrease in the estimated effective dose for abdominal and pelvic CT studies was observed in all but one of the weight categories at the pediatric radiology department compared with the pediatric and adult radiology department. CONCLUSIONS: Imaging pediatric patients in a dedicated pediatric imaging department with dedicated pediatric CT technologists may result in greater compliance with pediatric protocols and significantly reduced patient dose. Conversely, greater scrutiny of compliance with pediatric dose-adjusted CT protocols may be necessary for departments that scan both children and adults.

Randomized controlled trial for intermittent versus continuous propofol sedation for pediatric brain and spine magnetic resonance imaging studies.

OBJECTIVES: Intermittent bolus propofol is an effective agent for pediatric magnetic resonance imaging sedation but requires constant vigilance and dose titration. Magnetic resonance imaging-compatible infusion pumps may make it possible to continuously infuse propofol, achieving a steady level of sedation at a lower total dose. This study investigates total propofol dose, recovery time, and magnetic resonance image quality in children receiving intermittent vs. continuously infused propofol sedation in children undergoing brain and spine magnetic resonance imaging studies. DESIGN: An open-label, prospective, randomized, controlled study. A single-blinded radiologist rated the quality of magnetic resonance images. SETTING: Children's hospital pediatric radiology sedation center. PATIENTS: One hundred seventy children age 1 month to 18 yrs undergoing deep sedation for brain, spine, or both brain and spine magnetic resonance imaging. INTERVENTIONS: After informed consent, patients were randomly assigned to two groups: group 1 (intermittent) received a propofol bolus of 2-4 mg/kg, followed by repeat boluses of 0.5-2 mg/kg/dose as needed. Group C (continuous) received a bolus of propofol 2-4 mg/kg, followed by a continuous infusion of 100 µg/kg/min with 1-mg/kg/dose boluses with drip titration to effect. MEASUREMENTS AND MAIN RESULTS: Patient demographics, sedation risk assessment, propofol dose, sedation recovery times, incidence of complications, and quality of the magnetic resonance imaging studies were measured. A total of 170 children were enrolled in the study, with 75 in group C and 95 in group I. Both groups were similar with regard to age, weight, gender, and magnetic resonance imaging study type. Group C required a lesser dose of propofol (132 ± 54 µg/kg/min) compared to (162 ± 74 µg/kg/min) in that required in group I (p = .018). There were no differences between the two groups with regard to quality of the imaging study, recovery time, or incidence of complications. CONCLUSIONS: Compared to intermittent bolus dosing, continuous propofol infusion provides lesser dose exposure without impacting recovery time or quality of the magnetic resonance imaging study.

Observer variability assessing US scans of the preterm brain: the ELGAN study.

BACKGROUND: Neurosonography can assist clinicians and can provide researchers with documentation of brain lesions. Unfortunately, we know little about the reliability of sonographically derived diagnoses. OBJECTIVE: We sought to evaluate observer variability among experienced neurosonologists. MATERIALS AND METHODS: We collected all protocol US scans of 1,450 infants born before the 28th postmenstrual week. Each set of scans was read by two independent sonologists for the presence of intraventricular hemorrhage (IVH) and moderate/severe ventriculomegaly, as well as hyperechoic and hypoechoic lesions in the cerebral white matter. Scans read discordantly for any of these four characteristics were sent to a tie-breaking third sonologist. RESULTS: Ventriculomegaly, hypoechoic lesions and IVH had similar rates of positive agreement (68-76%), negative agreement (92-97%), and kappa values (0.62 to 0.68). Hyperechoic lesions, however, had considerably lower values of positive agreement (48%), negative agreement (84%), and kappa (0.32). No sonologist identified all abnormalities more or less often than his/her peers. Approximately 40% of the time, the tie-breaking reader agreed with the reader who identified IVH, ventriculomegaly, or a hypoechoic lesion in the white matter. Only about 25% of the time did the third party agree with the reader who reported a white matter hyperechoic lesion. CONCLUSION: Obtaining concordance seems to be an acceptable way to assure reasonably high-quality of images needed for clinical research.

Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage.

OBJECTIVE: Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage. DESIGN: A prospective, randomized trial was conducted at DeVos Children's Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol. RESULTS: Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group. CONCLUSIONS: The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.