Feasibility of rapid magnetic resonance imaging (rMRI) for the emergency evaluation of suspected pediatric orbital cellulitis.

PURPOSE: To determine the feasibility of noncontrast rapid magnetic resonance imaging (rMRI), compared with traditional contrast-enhanced computed tomography (CT) in assessing pediatric emergency department patients with suspected orbital cellulitis or orbital abscess. METHODS: All subjects <19 years of age who presented emergently with suspected orbital cellulitis from July 1, 2017, to July 31, 2019, were included. Participants received both the standard contrast orbital CT, if deemed necessary, with the addition of the noncontrast rMRI after informed consent was obtained. No sedation was used for either examination. All clinical decisions were based on CT findings; rMRI was interpreted within 24 hours of the visit. Three pediatric radiologists, with 8-21 years' experience of pediatric neuroradiology, interpreted the rMRI, masked to the CT and clinical results. Results were analyzed for interobserver bias. RESULTS: A total of 14 patients were enrolled during the study period. Mean age was 5.9 years (range, 0.33-13). Of the 14 patients, 13 (93%) were able to complete the rMRI at 1.5 and 3T; 1 patient (1.67 years of age) was unable to complete the rMRI (no images obtained). Of the 26 unilateral orbital units assessed, 3 were positive for retroseptal orbital cellulitis by CT and were diagnosed correctly by rMRI. Interobserver agreement was 100% in detecting presence or absence of retroseptal cellulitis. CT and rMRI findings were concordant in 100% of cases in differentiating preseptal vs orbital cellulitis. Kappa statistics for three-category ratings by three raters for right eye/orbit was 0.921 and for left eye/orbit was 0.9288, suggesting almost perfect agreement. Concordance correlation coefficients were 0.938 for the right eye and 0.955 for the left eye. CONCLUSIONS: Noncontrast rMRI orbits showed findings concordant in all cases with contrast-enhanced CT for differentiating preseptal cellulitis from orbital cellulitis.

Conservative management of urachal anomalies.

PURPOSE: The purpose of this study was to evaluate trends in management of urachal anomalies at our institution and the safety of nonoperative care. METHODS: Based on our experience managing urachal remnants from 2000 to 2010 (reported in 2012), we adopted a more conservative approach, including preoperative antibiotic use, refraining from using voiding cystourethrograms (VCUG), postponing surgery until at least six months of age, and considering nonoperative management. A retrospective analysis of urachal anomaly cases was conducted (2011-2016) to assess trends in practice. Charts indicating anomalies of the urachus were pulled and trends in management (nonoperative versus surgical treatment), VCUG and antibiotic use, and outcomes were reviewed. RESULTS: Data from 2000-2010 and 2013-2016 were compared. Our findings indicate care has shifted towards nonoperative management. A smaller proportion of patients from 2013-2016 was treated surgically compared to 2000-2010. Patients receiving nonoperative treatment exhibited lower rates of complication relative to surgically managed cases. VCUGs were eliminated as a diagnostic tool for evaluating urachal anomalies. Prophylactic preoperative antibiotic use was standardized. No patients with a known urachal remnant presented later with an abscess or sepsis. CONCLUSIONS: We find that a shift towards nonoperative treatment of urachal anomalies did not adversely affect overall outcomes. We recommend observing minimally symptomatic patients, especially those under six months old. STUDY TYPE: Performance improvement. LEVEL OF EVIDENCE: Level IV.

Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma.

PURPOSE: Child abuse is a leading cause of death in infants, which is often associated with abusive head trauma (AHT). The purpose of this retrospective analysis was to identify ocular and systemic findings in confirmed cases of AHT and compare them to a group of non-abusive head trauma (NAHT) patients. PATIENTS AND METHODS: A retrospective chart review of 165 patients with accidental and non-accidental trauma admitted between 2013 and 2015 to Children's Hospital and Medical Center in Omaha, NE, USA, was performed. Diagnosis of AHT was made after the analysis of ocular and systemic findings by various subspecialists. The NAHT group consisted of accidental trauma, abusive trauma without significant apparent head involvement on initial evaluation and unconfirmed AHT cases. RESULTS: Of the 165 presenting cases, 30 patients were diagnosed with AHT and 127 were diagnosed with NAHT. Ocular findings in AHT patients were significant for retinal hemorrhages (63%) and vitreous hemorrhages (37%), while NAHT patients had no ocular findings (p<0.001). Neuroimaging revealed subdural hemorrhages (SDHs) in 29 out of 30 AHT patients (97%) and in 27 out of 127 NAHT patients (21%). Seizures were present in 43% of AHT patients (n=13) and only in 8% of NAHT patients (n=10). CONCLUSION: AHT has statistically significant findings of retinal and vitreous hemorrhages. The absence of diffuse retinal hemorrhages, however, does not preclude the AHT diagnosis as more than one-third of AHT patients lacked retinal hemorrhages. SDHs, loss of consciousness and history of seizures also have high correlation with a diagnosis of AHT.

MR detection of retinal hemorrhages: correlation with graded ophthalmologic exam.

BACKGROUND: Dilated fundoscopic exam is considered the gold standard for detecting retinal hemorrhage, but expertise in obtaining this exam is not always immediately available. MRI can detect retinal hemorrhages, but correlation of the grade or severity of retinal hemorrhage on dilated fundoscopic exam with retinal hemorrhage visibility on MRI has not been described. OBJECTIVE: To determine the value of standard brain protocol MRI in detecting retinal hemorrhage and to determine whether there is any correlation with MR detection of retinal hemorrhage and the dilated fundoscopic exam grade of hemorrhage. MATERIALS AND METHODS: We conducted a retrospective chart review of 77 children <2 years old who were seen for head trauma from April 2007 to July 2013 and had both brain MRI and dilated fundoscopic exam or retinal camera images. A staff pediatric radiologist and radiology resident reviewed the MR images. Retinal hemorrhages were graded by a chief ophthalmology resident on a 12-point scale based on the retinal hemorrhage type, size, location and extent as seen on review of retinal camera images and detailed reports by ophthalmologists. Higher scores indicated increased severity of retinal hemorrhages. RESULTS: There was a statistically significant difference in the median grade of retinal hemorrhage examination between children who had retinal hemorrhage detected on MRI and children who did not have retinal hemorrhage detected on MRI (P = 0.02). When examination grade was categorized as low-grade (1-4), moderate-grade (5-8) or high-grade (>8) hemorrhage, there was a statistically significant association between exam grade and diagnosis based on MRI (P = 0.008). For example, only 14% of children with low-grade retinal hemorrhages were identified on MRI compared to 76% of children with high-grade hemorrhages. MR detection of retinal hemorrhage demonstrated a sensitivity of 61%, specificity of 100%, positive predictive value of 100% and negative predictive value of 63%. Retinal hemorrhage was best seen on the gradient recalled echo (GRE) sequences. CONCLUSION: MRI using routine brain protocol demonstrated 61% sensitivity and 100% specificity in detecting retinal hemorrhage. High-grade hemorrhage was more often detected on MRI than low-grade hemorrhage, 76% vs. 14%. GRE images were the most sensitive for detection of retinal hemorrhages. A dilated fundoscopic exam can be difficult to obtain in infancy, especially in critically ill or non-sedated children. MRI is a useful modality for added documentation of retinal hemorrhage and can be used as an alternative exam when ophthalmologic expertise or retinal camera images are unavailable. Additionally, identification of retinal hemorrhage on MRI can raise the possibility of abuse in children presenting with nonspecific findings.

Pathologic changes in biliary dyskinesia.

PURPOSE: For children with upper abdominal pain and evaluation for acalculous biliary disease, laparoscopic cholecystectomy is an accepted treatment with inconsistent outcomes. The purpose of this study was to identify predictors of outcomes. METHODS: One hundred sixty-seven children underwent laparoscopic cholecystectomy at a single children's hospital. Radiographic findings, histopathology, family history, and demographics (sex, age, height, weight, body mass index-for-age percentile) were evaluated as predictors of postoperative symptomatic resolution using a binomial probability model. The data for radiologic studies and pathologic specimens were obtained via re-review in a blinded fashion. RESULTS: Of 167 children, 43 (25.7%) had a preoperative diagnosis of biliary dyskinesia and 41 (95.3%) had documented follow-up. Mean follow-up was 8.4 months. Twenty-eight patients (68.3%) had symptom resolution. Ejection fraction less than or equal to 15%, pain upon cholecystokinin injection, and a family history of biliary disease were not predictors of symptomatic resolution. Nonoverweight patients (body mass index-for-age <85th percentile) were more likely to have symptom resolution than their overweight counterparts (odds ratio, 2.13). Most patients (68.3%) had a pathologic gallbladder on blinded review. However, this did not correlate with outcome. CONCLUSIONS: Most gallbladders removed for biliary dyskinesia are pathologic. Being overweight can be considered a relative contraindication to cholecystectomy for biliary dyskinesia.

Pulmonary interstitial glycogenosis.

Although bronchopulmonary dysplasia (BPD) is a common cause of interstitial lung disease in chronically intubated premature neonates, other interstitial lung disease in nonintubated infants is rare. We present a case of pulmonary interstitial glycogenosis that developed in a nonintubated, 31-week gestation infant in whom infectious etiologies had been excluded. The infant was well initially and then developed respiratory distress at 18 days of life. Radiographs at first day of life were normal, but CT and radiographic findings at 18 days of life showed severe interstitial lung disease, mimicking BPD. Lung biopsy showed pulmonary interstitial glycogenosis. This entity is not well described in the pediatric radiology literature and is important to consider, as the condition is responsive to a course of corticosteroids.