A study to establish international diagnostic reference levels for paediatric computed tomography.

The article reports results from the largest international dose survey in paediatric computed tomography (CT) in 32 countries and proposes international diagnostic reference levels (DRLs) in terms of computed tomography dose index (CTDI vol) and dose length product (DLP). It also assesses whether mean or median values of individual facilities should be used. A total of 6115 individual patient data were recorded among four age groups: <1 y, >1-5 y, >5-10 y and >10-15 y. CTDIw, CTDI vol and DLP from the CT console were recorded in dedicated forms together with patient data and technical parameters. Statistical analysis was performed, and international DRLs were established at rounded 75th percentile values of distribution of median values from all CT facilities. The study presents evidence in favour of using median rather than mean of patient dose indices as the representative of typical local dose in a facility, and for establishing DRLs as third quartile of median values. International DRLs were established for paediatric CT examinations for routine head, chest and abdomen in the four age groups. DRLs for CTDI vol are similar to the reference values from other published reports, with some differences for chest and abdomen CT. Higher variations were observed between DLP values, based on a survey of whole multi-phase exams. It may be noted that other studies in literature were based on single phase only. DRLs reported in this article can be used in countries without sufficient medical physics support to identify non-optimised practice. Recommendations to improve the accuracy and importance of future surveys are provided.

Computed tomography of blunt abdominal trauma in children.

Computed tomography (CT) plays a major role in diagnosis of blunt abdominal trauma of haemodynamically-stable children. The purpose of this article is to review the CT findings in children with hepatic, splenic, renal, adrenal, pancreatic, bowel, and mesentery injuries and in children with blunt abdominal trauma and active haemorrhage.

Mycotic aneurysm of the left subclavian artery: CT findings.

Mycotic aneurysms caused by aspergillosis are rare. We report a nine-year-old girl with acute lymphoblastic leukaemia who had invasive pulmonary aspergillosis and subsequently developed a left subclavian artery aneurysm. Prior to the aneurysm, computed tomography (CT) of the chest showed a nodule with an air crescent in the left upper lobe, adhering to the mediastinum and the left subclavian artery. The left subclavian artery was ill-defined and had a small lumen, and it was embedded in the wall of the nodule. 37 days after the chest CT, the patient underwent a left thoracotomy because of massive haemoptysis, at which time a false aneurysm in the left subclavian artery was found. Plication of the aneurysm was performed. On a follow-up CT with multiplanar reconstruction six days after surgery, there were the plicated aneurysm and a small amount of pleural effusion in the upper portion of the left hemithorax, adjacent to the plication. In invasive pulmonary aspergillosis, it is important to be aware of the possibility of mycotic aneurysms, particularly in patients with pulmonary lesions adjacent to mediastinal vessels with ill-defined borders and small lumens, since the aneurysms may increase in size and rupture. CT, particularly multidetector CT, helps in visualisation of mycotic aneurysms.

Clinics in diagnostic imaging (103). Dural sinus thrombosis with cerebral venous infarction.

A 13-year-old boy had a history of severe headache for two weeks. He also had seizures and vomited many times. Neurological examination was normal except for bilateral papilloedema. Sagittal T1-weighted magnetic resonance (MR) images showed loss of the normal flow void in the superior sagittal sinus. There was hyperintensity, which came from subacute thrombosis in the posterior half of the superior sagittal sinus. MR venography confirmed loss of flow signal in the superior sagittal sinus. There was also thrombosis of the right transverse, right sigmoid, and left transverse sinuses, and haemorrhagic infarctions in the right frontal and left parietal regions. A diagnosis of dural sinus thrombosis with cerebral venous infarction was made. CT, MR imaging, MR venography, and CT venography findings are discussed in patients with cerebral venous thrombosis.

Chronic inflammatory demyelinating polyneuropathy in a child: clinical-spinal MR imaging correlation.

Spinal magnetic resonance (MR) imaging of a 3-year-old girl with chronic inflammatory demyelinating polyneuropathy (CIDP) showed thickened and marked enhancement of the lumbosacral nerve roots. These abnormalities resolved after steroid treatment. MR imaging of the cauda equina may be helpful in the diagnosis of CIDP.

Clinics in diagnostic imaging (96). Plexiform neurofibromatosis.

A 10-year-old boy presented with a mass on the left side of his face for many years, left ear deafness, and limited vision in the left eye. Enhanced CT of the face and neck showed a multilobulated low attenuation mass in the left parotid space, with nodularity and involvement of branches of the left facial nerve. There was a mass in the left orbital apex that extended into the left cavernous sinus, exopthalmos of the left eye, and erosion of the medial portion of the greater wing of the left sphenoid. Partial removal of the mass in the left parotid space was performed. Histopathological examination revealed plexiform neurofibromas. CT and MR imaging findings in neurofibromatosis type 1 patients with craniofacial abnormalities are discussed.

Clinics in diagnostic imaging (86). Ruptured bronchogenic cyst.

An eight-year-old boy presented with a sudden onset of chest pain. He had been diagnosed to have a left spontaneous pneumothorax. Chest radiographs and computed tomography of the chest showed a thin-walled cyst in the left lower lobe. Thoracotomy and a segmentectomy of the apical segment of the lower lobe was performed, confirming the diagnosis of a ruptured bronchogenic cyst. Imaging findings of various pulmonary cystic lesions in children are discussed.

Clinics in diagnostic imaging (81). Hypothalamic glioma with diencephalic syndrome.

A 15-month-old boy presented with failure to thrive. Physical examination revealed third degree malnutrition. MR imaging showed a large lobulated mass in the suprasellar region. The mass was hypointense on T1-weighted MR images, hyperintense on proton density-weighted and T2-weighted MR images, and enhanced homogeneously. The patient underwent a craniotomy for a subtotal resection of the tumour. Histopathological examination revealed a juvenile pilocytic astrocytoma that caused the diencephalic syndrome. Clinical presentation and imaging findings of the various tumours or diseases that can cause suprasellar masses in children are discussed and illustrated via further examples.

Clinics in diagnostic imaging (75). HIV encephalopathy and cerebral aneurysmal arteriopathy.

A six-year-old girl with vertically-transmitted HIV infection had hyperreflexia. MR imaging showed diffuse prominence of the subarachnoid spaces and ventricles caused by HIV encephalopathy. Fusiform dilatation of the supraclinoid segment of the right internal carotid artery was also noted. MR angiography confirmed cerebral aneurysmal arteriopathy. Imaging findings of the various cerebral manifestations and complications found in children with AIDS coming from the primary effects of HIV, opportunistic infections, tumours, and vascular disease are discussed.

Clinics in diagnostic imaging (78). Cardiac rhabdomyoma in tuberous sclerosis.

A seven-day-old boy with a family history of tuberous sclerosis presented with congestive heart failure. Cardiac-gated magnetic resonance (MR) imaging showed a mass in the right atrium, which was T1-isointense and T2-hyperintense relative to myocardium. Follow-up echocardiographical studies showed a decrease in the number and size of the nodules. Finally, no cardiac nodules were seen when he was two years and eleven months old. The echocardiographical studies, MR imaging findings and the clinical history are consistent with cardiac rhabdomyomas. MR imaging of the brain also showed multiple subependymal nodules, white matter abnormalities, and cortical tubers. The varied imaging appearances of tuberous sclerosis are discussed and illustrated with additional examples.

Digitotalar dysmorphism with craniofacial and other new associated abnormalities.

We report digitotalar dysmorphism in a grandfather, father, and a daughter. All the affected members had clasped thumbs. The father had a short stature, large zygomatic arch and a flat mandibular condyle. The newly recognized findings found in the affected girl were large maxillary deciduous central incisors, a short proximal phalanx of the second finger, and a large subcutaneous hemangioma of the back. Her paternal grandfather had only congenital clasped thumbs. Congenital clasped thumb is a very heterogeneous anomaly and related to many syndromes. The findings in the reported family which are consistent with digitotalar dysmorphism, include congenital clasped thumbs, ulnar deviation of fingers, and a congenital vertical tali.

Cryptophthalmos, dental and oral abnormalities, and brachymesophalangy of second toes: new syndrome or Fraser syndrome?

We report on an 8-year-old Thai girl with bilateral complete cryptophthalmos, facial asymmetry, delayed bone age, brachymesophalangy and medial deviation of the second toes, and dental anomalies. The dental anomalies consist of delayed dental development, congenital absence of the second premolars, microdontia of the deciduous molars. A fibrous band of the buccal mucosa was found. Dental anomalies are rare among patients with Fraser syndrome. They have not been reported in either isolated or other syndromic cryptophthalmos. The oral manifestations and brachymesophalangy of the second toes found in our patient may represent newly recognized findings associated with cryptophthalmos or they may represent a newly recognized syndrome.