Cranial trauma following birth in term infants.

The purpose of this pictorial review is to demonstrate the imaging features of a range of cranial injuries associated with birth at term. Scalp and skull injuries include simple cephalhaematoma, osteomyelitis of the skull vault from infected cephalhaematoma, subgaleal haemorrhage and skull fracture. Intracranial injuries include extradural, subdural and subarachnoid haemorrhage, leptomeningeal cyst and brain infarct. Radiologists need to be aware of the range of cranial injuries following birth and their differentiating features.

Asymmetrical muscle hypertrophy simulating a localised soft tissue mass.

Three children with a soft tissue mass presented to the Department of Radiology for investigation. Two children had a mass in the right axilla and the third had a mass overlying the right scapula. Cross-sectional imaging in each case revealed muscle hypertrophy rather than a discrete mass. The radiological diagnosis was later confirmed by histology. Minor asymmetry of muscles is quite common as a normal finding, but gross asymmetry of normal muscle is rare. Localised hypertrophy of muscle may result from exercise in children, but a history of excessive gymnastic exercise was apparent in only one child. The cause of the hypertrophy in the other two children is unknown.

Endotracheal suctioning causes right upper lobe collapse in intubated children.

OBJECTIVE: Right upper lobe collapse is a common radiographic finding in intubated children. We hypothesized that deep suctioning and uncontrolled negative pressures during endotracheal tube suctioning were significant contributory factors. METHODS: The incidence of right upper lobe (RUL) collapse in intubated, ventilated children on a paediatric cardiac intensive care unit was determined over a 3-month period (n = 102). Graduated suction catheters and suction vacuums of < 165 cm H2O were then introduced. Another prospective audit was carried out 3 months later (n = 60). RESULTS: We found that 24% developed RUL collapse and 4 developed an apical pneumothorax. Following the introduction of graduated catheters and controlled vacuums pressures; a significant reduction in the incidence of RUL collapse, to 7%, was observed (p < 0.05). CONCLUSIONS: We conclude that high negative pressure and deep-suctioning causes RUL collapse in children. Any lobar collapse not only prolongs the child's stay in intensive care, but can be associated with further morbidity which may have a serious implication. By improving suctioning technique this morbidity can be significantly reduced.

Ultrasound of the discharging umbilicus.

Ultrasound of a patent urachus has been well described. However, ultrasound of the other congenital abnormalities affecting the umbilicus has not. Two cases are described, one of a vitelline (omphalomesenteric) duct and one of an umbilical granuloma, in which the ultrasound findings guided the child's management, preventing a minilaparotomy.

Lung perfusion scintigraphy in patients with congenital heart disease: sensitivity and important pitfalls.

The lung perfusion scans requested over a 5-year period for children with known congenital heart disease were reviewed retrospectively. Altogether, 102 lung perfusion scans were performed and comparable pulmonary arteriograms were available in 63 cases. There was agreement between scintigraphy and angiography in 50 (79%) cases and discrepancy in 13 (21%) cases. Scintigraphy was more sensitive in detecting small perfusion defects, particularly those seen only on oblique views. Pulmonary arteriography was more specific in identifying the cause of the perfusion abnormalities. The two techniques yield complementary information about lung perfusion. Perfusion scintigraphy is safe in children with congenital heart disease even with known pulmonary to systemic shunting. Many pitfalls could be avoided by careful choice of injection site, by knowledge of previous surgery and comparison with relevant angiograms.

Single catheter approach for occlusion of a patent arterial duct with a Rashkind double umbrella.

OBJECTIVES: To determine the benefits of using a single venous catheter and a single angiogram during catheter occlusion of a patient arterial duct with the Rashkind double umbrella compared with those of venous and arterial catheters and multiple angiograms. DESIGN: Retrospective review of case notes. PATIENTS: 103 consecutive patients. The long sheath could not be advanced adequately in two patients. 101 patients had 104 implantations. Median (range) age was 35 (7-549) months and median (range) weight 13 (7-62) kg. Fifty four implantations were performed using the venous and arterial method and 50 using the venous only method. RESULTS: Median procedure times (70 v 90 min), number of angiograms (one v four), and angiographic dye volume used (2 v 7 ml/kg) were significantly reduced using the venous only method compared with those of the venous and arterial method. There was no significant difference in fluoroscopy time (venous only 9 v venous and arterial 10 min). CONCLUSIONS: Considerable improvements can be made in the technique of catheter closure of patent arterial ducts using the Rashkind double umbrella without compromising outcome using venous cannulation alone and a single angiogram, rather than venous and arterial cannulation and multiple angiograms. reduced risk to arteries from cannulation, The benefits are reduced radiation exposure, reduced risk to arteries from cannulation, shorter procedures, and lower equipment costs.

The expandable metal stent for tracheal obstruction.

A 10 month old boy with stridor persisting from birth was found to have tracheal narrowing secondary to myofibromatosis of the tracheal wall. An expandable metal stent was positioned across the tracheal stenosis with immediate clinical improvement. There were no complications relating to stent insertion. The child remained clinically asymptomatic and repeat bronchoscopy at nine months' follow up showed that the stent had become completely endothelialised with no evidence of granuloma formation.

The painless soft tissue mass in childhood--tumour or not?

Soft tissue malignancies are uncommon in adults and even rarer in children. Twelve children presented to the radiology department over a three-year period with a clinical diagnosis of a malignant lower limb mass. This diagnosis was usually based on the presence of a firm, painless mass. However, imaging revealed a heterogeneous group of benign pathologies: haemangioma (two cases), haematoma (two cases), aneurysm (two cases), and one case each of infection, myositis ossificans, Baker's cyst, lipoma, muscle rupture, and venous malformation. During the same period there was only one malignant soft tissue neoplasm. A variety of imaging techniques were used but ultrasound combined with colour flow Doppler was the single most helpful modality. The radiological diagnosis were confirmed by biopsy, surgery or clinical follow-up.

Shoe, scimitar or sequestration: a shifting spectrum.

Congenital abnormalities of the tracheobronchial tree are rare causes of recurrent chest infections in childhood. A case is described which shows some typical features of horseshoe lung. More detailed imaging revealed complete separation of the right and left pleural cavities and the malformation represents part of the sequestration spectrum. The case emphasises the need for careful evaluation of the pulmonary arteries, veins, bronchi and oesophagus, particularly prior to surgery.

Adrenal cortical tumours in children.

Adrenal cortical tumours are uncommon in children. For many years it was thought that the majority were malignant with a poor prognosis. Pathological criteria for malignancy are unreliable for these tumours in childhood. The radiological findings in seven children are presented. Large tumour size (> 6 cm diameter) and radiological appearances such as a complex echo pattern were considered to provide useful indicators of malignancy.

The magnetic resonance appearances of the normal thymus in children.

The normal thymus in children is highly variable in size and shape. In some cases this has led to the misdiagnosis of mediastinal pathology and an unnecessary thoracotomy. Twenty-five children without suspicion of mediastinal pathology and five children with suspected mediastinal pathology were imaged using magnetic resonance imaging (MRI). MRI is recommended to distinguish between the normal and abnormal thymus in difficult cases where other imaging techniques are inconclusive.

The role of computed tomography (CT) in the investigation of unexplained haemoptysis.

Forty patients with a history of haemoptysis, normal chest radiographs apart from evidence of chronic airflow limitation, and normal fibreoptic bronchoscopy (or blood alone in the bronchial tree) were investigated by computed tomography (CT). Abnormalities were seen in 20 (50%) of the CT scans. Seven of the patients had evidence of bronchiectasis (18%), one of whom also had a mass. In four (10%) cases a mass alone was detected (two tuberculous, two malignant). In a further four (10%) scans alveolar consolidation was present and in three cases abnormal vessels were detected (7.5%). One patient had cystic changes shown in their scan and multiple nodules were shown in the final patient. The contralateral lungs of 93 patients undergoing CT for pre-operative assessment of bronchogenic carcinoma were used as controls. In six (6%) of these patients abnormalities were detected by CT. Pleural nodules were observed in two patients, fat in the transverse fissure in another, atelectasis in two patients and an apical bulla in the other abnormal scan. The relative risk for patients with unexplained haemoptysis having abnormal CT scans compared to the control group of patients was 7.75. We conclude that computed tomography is of value in the investigation of patients with unexplained haemoptysis.

MR appearances of bone marrow in children following bone marrow transplantation.

Two cases are presented of children who demonstrated complete absence of bone marrow signal on MR imaging of the spine following bone marrow transplantation. The possible causes for these appearances are discussed.

McBurney's point--fact or fiction?

Anthropometric measurements were performed on 51 normal, supine, barium enema examinations to determine the position of the lower pole of the caecum and the base of the appendix relative to palpable bony landmarks (the anterior superior iliac spine and the symphysis pubis). Four quadrants were defined (iliac, umbilical, inguinal and pelvic) by the intersection of the right lateral line and the interspinous line (the line joining the left and right anterior superior iliac spines). The position of the lower pole of the caecum was iliac in 12%, inguinal in 37%, and pelvic in 51%. The appendix or appendix stump was visualised on 53% of the barium examinations. The position of the appendix was iliac in 15%, umbilical in 15%, inguinal in 11%, and pelvic in 59%. The positions of the lower pole of the caecum and base of the appendix are lower and more medial than previously described. 70% of appendices were found to lie inferior to the interspinous line, contrary to established surgical teaching, which assumes McBurney's point to be the surface landmark for the appendix.

The ultrasound cystodynamogram--a new radiological technique.

Voiding dysfunction may be assessed using the intravenous urodynamogram (IVUD) or combined with pressure studies in the videocystometrogram (VCMG). However, VCMG requires bladder catheterization and voiding in public which often leads to inhibition of sphincter relaxation. For this reason the urinary flow rate measurement performed in private is more representative of the true voiding pattern. The ultrasound cystodynamogram (USCD) evaluates the bladder capacity, mean and maximum flow rates, flow pattern and post-micturition residual. The diagnostic capability of USCD was studied in 116 consecutive cases 46 of whom had also had VCMG. Comparison of the data obtained using both techniques revealed no significant difference. USCD has proved to be accurate, safe and reproducible and is of particular value in patient follow-up.

Rectal duplications in children: a presentation of four cases.

Four cases with histologically proven duplication cysts of the rectum are presented. Two of these had communicating and two had closed rectal duplications.

Puzzling intrauterine insults.

Two male infants were noted at birth to have open wounds involving a forearm. These have been associated with abnormal bone modelling and growth. The cause of these appearances remains unclear and no similar cases have been reported.