Bronchoscopy findings in children with congenital lung and lower airway abnormalities.

Congenital lung and lower airway abnormalities are rare, but they are an important differential diagnosis in children with respiratory diseases, especially if the disease is recurrent or does not resolve. The factors determining the time of presentation of congenital airway pathologies include the severity of narrowing, association with other lesions and the presence or absence of congenital heart disease (CHD). Bronchoscopy is required in these cases to assess the airway early after birth or when intubation and ventilation are difficult or not possible. Many of these conditions have associated abnormalities that must be diagnosed early, as this determines surgical interventions. It may be necessary to combine imaging and bronchoscopy findings in these children to determine the correct diagnosis as well as in operative management. Endoscopic interventional procedures may be needed in many of these conditions, ranging from intubation to balloon dilatations and aortopexy. This review will describe the bronchoscopic findings in children with congenital lung and lower airway abnormalities, illustrate how bronchoscopy can be used for diagnosis and highlight the role of interventional bronchoscopy in the management of these conditions.

Respiratory infections in low and middle-income countries.

OBJECTIVES: To investigate the epidemiology, aetiology, diagnostics and management of childhood pneumonia in low and middle income countries (LMICs). DESIGN: Review of published english literature from 2019 to February 2024. RESULTS: Lower respiratory tract infections (LRTIs) still result in significant mortality in children under 5 years of age in LMICs. Important studies have reported a change in the pathogenesis of LRTIs over the last 5 years with respiratory syncytial virus (RSV) resulting in a large burden of disease. SARS-CoV-2 had a significant direct and indirect impact in children in LMICs. Mycobacterium tuberculosis (MTB) remains a priority pathogen in all children. Nucleic acid amplification and rapid antigen tests have improved diagnostic accuracy for MTB and other bacterial pathogens. Point of care diagnostics may overcome some limitations, but there is a need for better cost-effective diagnostics. Access to shorter courses of TB treatment are now recommended for some children, but child friendly formulations are lacking. The role of chest X-ray in TB has been recognized and included in guidelines, and lung ultrasound to diagnose LRTI is showing promise as a lower cost and accessible option. CONCLUSION: Advances in diagnostics and large multi-centre studies have provided increased understanding of the causative pathogens of LRTIs in LMICs. Increased access to preventive strategies such as vaccines, treatment modalities including antivirals, and addressing upstream factors such as poverty are essential if further declines in LRTIs in LMICs are to be realised.

Can Automated 3-Dimensional Dixon-Based Methods Be Used in Patients With Liver Iron Overload?

PURPOSE: Accurate quantification of liver iron concentration (LIC) can be achieved via magnetic resonance imaging (MRI). Maps of liver T2*/R2* are provided by commercially available, vendor-provided, 3-dimensional (3D) multiecho Dixon sequences and allow automated, inline postprocessing, which removes the need for manual curve fitting associated with conventional 2-dimensional (2D) gradient echo (GRE)-based postprocessing. The main goal of our study was to investigate the relationship among LIC estimates generated by 3D multiecho Dixon sequence to values generated by 2D GRE-based R2* relaxometry as the reference standard. METHODS: A retrospective review of patients who had undergone MRI scans for estimation of LIC with conventional T2* relaxometry and 3D multiecho Dixon sequences was performed. A 1.5 T scanner was used to acquire the magnetic resonance studies. Acquisition of standard multislice multiecho T2*-based sequences was performed, and R2* values with corresponding LIC were estimated. The comparison between R2* and corresponding LIC estimates obtained by the 2 methods was analyzed via the correlation coefficients and Bland-Altman difference plots. RESULTS: This study included 104 patients (51 male and 53 female patients) with 158 MRI scans. The mean age of the patients at the time of scan was 15.2 (SD, 8.8) years. There was a very strong correlation between the 2 LIC estimation methods for LIC values up to 3.2 mg/g (LIC quantitative multiecho Dixon [qDixon; from region of interest R2*] vs LIC GRE [in-house]: r = 0.83, P < 0.01; LIC qDixon [from segmentation volume R2*] vs LIC GRE [in-house]: r = 0.92, P < 0.01); and very weak correlation between the 2 methods at liver iron levels >7 mg/g. CONCLUSION: Three-dimensional-based multiecho Dixon technique can accurately measure LIC up to 7 mg/g and has the potential to replace 2D GRE-based relaxometry methods.

Retropharyngeal Abscess Complicated by Mediastinitis in Infants.

INTRODUCTION: Most paediatric upper respiratory infections are virally mediated and result in self-limiting reactive lymphadenopathy. In children younger than 5 years, retropharyngeal lymph nodes may give rise to deep neck space infections in this potential space. Retropharyngeal infections are rare after 5 years because lymph nodes undergo atrophy. METHODS: We present a series of 6 cases of paediatric retropharyngeal abscesses (RPA) complicated by mediastinitis, managed at a tertiary hospital over a 4-year period. RESULTS: All our cases presented with fever, difficulty feeding, and neck swelling. The age range was 11 weeks-11 months, and all tested negative for human immunodeficiency virus. The diagnosis and complications were confirmed on computed tomography (CT) scan. The CT scans consistently revealed RPA with varying degrees of deep neck space and mediastinal extension. All children were promptly taken to theatre for source control. Two were extubated successfully immediately after surgery, and the other 4 were extubated in the paediatric intensive care unit, with the longest duration of intubation being 3 days. Methicillin-sensitive Staphylococcus aureus (MSSA) was cultured in all 6 cases. CONCLUSION: Management of these cases may be challenging, and young children with RPA require close care and airway monitoring. CT or magnetic resonance imaging is essential to delineate the extent of infection. Surgical drainage should be performed when there is a large abscess, a complication occurs, or an inadequate response in 24-48 h to medical management.

Cryoprobe for Endoscopic Enucleation in Children with Pulmonary Tuberculosis: Effective but Not Without Danger - Case Report and Review of Literature.

INTRODUCTION: Tuberculosis (TB) in children under 15 years often results in airway compression, with bronchus intermedius (BI) being the most common site. Endoscopic enucleations can be used to remove lymph nodes and establish an airway in severe cases. Both rigid and flexible bronchoscopy are suitable, with alligator forceps being preferred for its ability to extract tissue. Recent studies have also explored cryoprobe enucleation. CASE PRESENTATION: An HIV-positive boy with persistent symptoms after 9 months of TB treatment was diagnosed based on his mother's and sister's Xpert MTB/RIF positive status. He was started on 4-drug TB treatment, but the child remained clinically symptomatic with abnormal chest X-ray and unconfirmed TB. Bronchoscopy was performed, revealing complete obstruction of BI due to caseating granulomas causing collapse of the right middle and lower lobes. Cryotherapy was used to recanalize the airway, and follow-up bronchoscopy confirmed patent BI. CONCLUSION: While cryotherapy was effective in the restoration of airway patency in this case, there is a lack of knowledge about its use in children.

Radio-pathologic correlation: no pial angioma-subarachnoid varicose network drainage pathway in Sturge-Weber syndrome.

PURPOSE: The traditional imaging findings reported in Sturge-Weber syndrome (SWS) include endpoints of cortical injury-cortical atrophy and cortical calcifications-but also what has been termed a "leptomeningeal angiomatosis," the latter recognized and reported as a leptomeningeal enhancement on magnetic resonance imaging (MRI). The objective of this study is to demonstrate through neuropathological correlation that the "leptomeningeal angiomatosis" in patients with Sturge-Weber syndrome (SWS), represents a re-opened primitive venous network in the subarachnoid space that likely acts as an alternative venous drainage pathway, seen separately to abnormal pial enhancement. MATERIALS AND METHODS: Retrospective review of MR imaging and surgical pathology of patients that underwent surgery for epilepsy at a tertiary, children's hospital. A pediatric radiologist with more than 20 years of experience reviewed the MR imaging. Surgically resected brain specimens that had been sectioned and fixed in 10% paraformaldehyde for histologic processing, following processing and paraffin embedding, were cut into 5-µm unstained slides which were subsequently stained with hematoxylin and eosin (H&E). Slides were re-examined by a board-certified pediatric neuropathologist, and histologic features specifically relating to cerebral surface and vascularity were documented for correlation with MR imaging of the resected region performed prior to resection. RESULTS: Five patients were reviewed (3 boys and 2 girls; the median age at the onset of seizures was 12 months (IQR, 7 to 45 months); the median age at surgery was 33 months (IQR, 23.5 to 56.5 months)). Surgical procedures included the following: 4, hemispherotomy (right: 2, left: 2) and 1, hemispherectomy (right). A subarachnoid space varicose network was present on both MRI and histology in 4 patients. Calcifications were seen on both MRI and histology in 3 patients. Abnormal leptomeningeal enhancement was present in 5 patients and seen separately from the subarachnoid vascular network in 4 patients. CONCLUSION: Histopathology confirmed the MRI findings of a subarachnoid space varicose network seen separately from leptomeningeal enhancement and presumed to represent an alternative venous drainage pathway to compensate for maldevelopment of cortical veins, the primary abnormality in SWS. No pial-based angioma was identified.

Miliary meningeal tuberculosis - an unusual imaging presentation for an early definitive diagnosis.

PURPOSE: Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with magnetic resonance (MR) imaging diagnosis. We present MR-detectable miliary meningeal TB in two patients. CASE 1: A 9-year-old girl developed fevers, cough, lethargy, and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. CSF showed pleocytosis, low glucose, and high protein. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules, and a splenic hypo enhancing lesion. Serial bronchoalveolar lavage studies were Xpert MTB/RIF and acid-fast negative. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR. She was started on a 4-drug treatment for TBM and dexamethasone. Contact tracing revealed a remote positive contact with pulmonary tuberculosis. CASE 2: A 17-year-old female with Crohn's disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics. She underwent myringotomy, with negative aerobic ear fluid culture. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were normal. CT chest, abdomen, and pelvis to assess for disseminated disease showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT-guided aspiration of the obturator muscle collection, bronchoscopy with bronchoalveolar lavage, biopsy of two preexisting chronic skin lesions, and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. Cultures from the ear fluid, skin tissue, muscle tissue, and alveolar lavage showed growth of acid-fast bacilli. She was started on 4-drug therapy and prednisone. CONCLUSION: Our cases highlight that TBM in many cases remains a diagnostic dilemma - both our patients presented in a prolonged atypical manner. The term miliary TB not only refers to a pattern of interstitial nodules on chest radiographs but also indicates the hematogenous spread of the disease and concurrent pulmonary and extrapulmonary involvement with high risk of TB meningitis. We promote the use of the term miliary meningeal TB - in both cases, the neuroimaging diagnosis of TB preceded both chest imaging and laboratory confirmation of the disease. Miliary meningeal nodules on MRI may have characteristic T2 low signal and may be more conspicuous in children and immunocompromised individuals where background basal meningeal enhancement is less prominent.

Fast magnetic resonance imaging for diagnosing pulmonary tuberculosis in children: the sub-10-min unenhanced scan.

PURPOSE: In this study, we aimed to report the feasibility and quality of fast (unenhanced < 10-min duration) magnetic resonance imaging (MRI) for the detection of lymphadenopathy in non-sedated children with suspected tuberculosis (TB). MATERIAL AND METHODS: This was a prospective study that involved children (< 13 years of age) hospitalised at Red Cross Children's Hospital with suspected pulmonary TB who were referred for a fast MRI of the chest. The limited short-duration MRI protocol included coronal short tau inversion recovery (STIR) and axial diffusion-weighted imaging (DWI) sequences with additional axial STIR and axial and coronal T2 sequences if the patient was compliant. The scan time was capped at 10 min and a study was considered successfully completed when DWI and STIR images were obtained in axial planes. MRI quality was recorded as 'acceptable quality'; 'poor quality, but readable'; and 'non-diagnostic'. RESULTS: Of the 192 fast MRI protocol scans, 166 (86%) were successfully completed within the 10-min allotted scan period. There was no age or sex difference between successful and unsuccessful studies. The mean duration of successful scans was 6.5 min (standard deviation = 1.5 min, range = 4-10 min). CONCLUSION: Fast (sub-10-min scan) MRI is feasible for diagnosis of lymphadenopathy in non-sedated children in the setting of suspected TB, including those below 6 years of age.

Accuracy of non-medical and medical individuals in identifying cerebral cortical abnormality from three-dimensional printed models of magnetic resonance images in children with hypoxic ischemic injury.

Effective communication of imaging findings in term hypoxic ischemic injury to family members, non-radiologist colleagues and members of the legal profession can be extremely challenging through text-based radiology reports. Utilization of three-dimensional (D) printed models, where the actual findings of the brain can be communicated via tactile perception, is a potential solution which has not yet been tested in practice. We aimed to determine the sensitivity and specificity of different groups, comprising trained radiologists, non-radiologist physicians and non-physicians, in the detection of gross disease of the cerebral cortex from 3-D printed brain models derived from magnetic resonance imaging (MRI) scans of children. Ten MRI scans in children of varying ages with either watershed pattern hypoxic ischemic injury (cortical injury) or basal-ganglia-thalamus hypoxic ischemic injury pattern with limited perirolandic cortical abnormalities and 2 normal MRI scans were post processed and 3-D printed. In total, 71 participants reviewed the 12 models and were required to indicate only the brain models that they felt were abnormal (with a moderate to high degree of degree of confidence). The 71 participants included in the study were 38 laypeople (54%), 17 radiographic technologists (24%), 6 nurses (8%), 5 general radiologists (7%), 4 non-radiologist physicians- 3 pediatricians and 1 neurologist (6%) and 1 emergency medical services staff (1%). The sensitivity and specificity for detecting the abnormal brains of the 71 participants were calculated. Radiologists showed the highest sensitivity (72%) and specificity (70%). Non-radiologist physicians had a sensitivity of 67.5% and a specificity of 75%. Nurses had a sensitivity of 70% and a specificity of 41.7%. Laypeople (non-medical trained) had a sensitivity of 56.1% and a specificity of 55.3%. Radiologists' high sensitivity and specificity of 72% and 70%, respectively, validates the accuracy of the 3-D-printed models in reproducing abnormalities from MRI scans. The non-radiologist physicians also had a high sensitivity and specificity. Laypeople, without any prior training or guidance in looking at the models, had a sensitivity of 56.1% and a specificity of 55.3%. These results show the potential for use of the 3-D printed brains as an alternate form of communication for conveying the pathological findings of hypoxic ischemic injury of the brain to laypeople.

Evaluation of the diagnostic performance of physician lung ultrasound versus chest radiography for pneumonia diagnosis in a peri-urban South African cohort.

BACKGROUND: Lung ultrasound (US), which is radiation-free and cheaper than chest radiography (CXR), may be a useful modality for the diagnosis of pediatric pneumonia, but there are limited data from low- and middle-income countries. OBJECTIVES: The aim of this study was to evaluate the diagnostic performance of non-radiologist, physician-performed lung US compared to CXR for pneumonia in children in a resource-constrained, African setting. MATERIALS AND METHODS: Children under 5 years of age enrolled in a South African birth cohort study, the Drakenstein Child Health Study, who presented with clinically defined pneumonia and had a CXR performed also had a  lung US performed by a study doctor. Each modality was reported by two readers, using standardized methodology. Agreement between modalities, accuracy (sensitivity and specificity) of lung US and inter-rater agreement were assessed. Either consolidation or any abnormality (consolidation or interstitial picture) was considered as endpoints. In the 98 included cases (median age: 7.2 months; 53% male; 69% hospitalized), prevalence was 37% vs. 39% for consolidation and 52% vs. 76% for any abnormality on lung US and CXR, respectively. Agreement between modalities was poor for consolidation (observed agreement=61%, Kappa=0.18, 95% confidence interval [95% CI]: - 0.02 to 0.37) and for any abnormality (observed agreement=56%, Kappa=0.10, 95% CI: - 0.07 to 0.28). Using CXR as the reference standard, sensitivity of lung US was low for consolidation (47%, 95% CI: 31-64%) or any abnormality (5%, 95% CI: 43-67%), while specificity was moderate for consolidation (70%, 95% CI: 57-81%), but lower for any abnormality (58%, 95% CI: 37-78%). Overall inter-observer agreement of CXR was poor (Kappa=0.25, 95% CI: 0.11-0.37) and was significantly lower than the substantial agreement of lung US (Kappa=0.61, 95% CI: 0.50-0.75). Lung US demonstrated better agreement than CXR for all categories of findings, showing a significant difference for consolidation (Kappa=0.72, 95% CI: 0.58-0.86 vs. 0.32, 95% CI: 0.13-0.51). CONCLUSION: Lung US identified consolidation with similar frequency to CXR, but there was poor agreement between modalities. The significantly higher inter-observer agreement of LUS compared to CXR supports the utilization of lung US by clinicians in a low-resource setting.

Comparison of chest radiographs against minimum intensity projection reconstruction computed tomography scans for detection of airway stenosis in children with lymphobronchial tuberculosis.

BACKGROUND: Ideally, suspected airway compression in symptomatic children with lymphobronchial tuberculosis (TB) would be diagnosed using modern computed tomography (CT) assisted by coronal minimum intensity projection (MinIP) reconstructions. However, in TB-endemic regions with limited resources, practitioners rely on conventional radiography for diagnosing TB and its complications. Furthermore, airway compression detected on conventional radiographs would upgrade a patient into the severe category according to the new World Health Organization guidelines, precluding the patient from shorter treatment protocols. The accuracy of conventional radiographs in the context of detecting airway compression in children with TB has not been specifically evaluated against an imaging gold standard. OBJECTIVE: We aimed to compare frontal chest radiographs against thick-slab angled coronal CT MinIP in identifying airway stenosis at ten specific sites and to determine observer agreement between the modalities regarding the degree of stenosis. MATERIALS AND METHODS: This retrospective cross-sectional study compared chest radiographs with standardized angled coronal CT MinIP in children with symptomatic lymphobronchial TB at ten predetermined airway locations. Chest radiographs were evaluated by one pediatric radiologist and CT MinIP reconstructions were independently interpreted by three readers. Sensitivity and specificity were calculated using CT MinIP as the gold standard. Stenosis was graded as 1 for mild (1-50%), 2 for moderate (51-75%), 3a for severe (76-99%), and 3b for total occlusion (100%). Agreement between the two modalities regarding severity of stenosis was calculated using the kappa coefficient for each affected site. RESULTS: A total of 37 patients were included in the study. The median age of patients was 14.3 months (interquartile range 8.0-23.2). Three hundred and seventy individual bronchi (10 from each of the 37 patients) were evaluated for stenosis. Chest radiographs showed that 31 out of 37 (84%) patients had stenosis in at least one of ten evaluated sites, most commonly the left main bronchus and bronchus intermedius, and this was confirmed via CT MinIP. The gold standard (CT MinIP) demonstrated stenosis in at least one of ten sites in all 37 patients (100%). Left main bronchus stenosis was detected by chest radiography with a 92.9% sensitivity and 100% specificity. Sensitivity and specificity for bronchus intermedius stenosis were 80% and 75%, respectively. There was substantial agreement for grade of stenosis between chest radiographs and CT (kappa=0.67) for the left main bronchus and moderate agreement (kappa=0.58) for the bronchus intermedius. Severe stenosis was found in 78 bronchi on CT compared to 32 bronchi (Grade 3a: 9, Grade 3b: 23) on chest radiographs. CONCLUSION: The diagnosis of pulmonary TB in children continues to rely heavily on imaging, and we have shown that in young children, chest radiographs had a high sensitivity and specificity for detecting airway stenosis at certain anatomical sites, when adequately visualized, resulting from tuberculous lymph node compression at left main bronchus and bronchus intermedius. For most sites, the interobserver agreement was poor. Stenosis of the left main bronchus and bronchus intermedius should be the focus of chest radiograph interpretation and can assist both diagnosis and classification of patients for treatment.

Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology.

Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short- and long-term outcomes in many cases. Because of a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describes advantages and disadvantages of different imaging modalities, highlights disorders that predispose children to infarct or hemorrhage, and presents an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.

Intrathoracic tuberculosis: Role of interventional bronchoscopy in diagnosis.

Tuberculosis (TB) is the leading cause of death from a single infectious agent globally. Mortality is related to the delay in diagnosis and starting treatment. According to new guidelines it is very important to classify pulmonary tuberculosis (PTB) as severe or not severe disease due to the difference in treatment duration. Bronchoscopy is the gold standard for assessing the degree of airway compression and obstruction in paediatric PTB. Paediatric bronchoscopy has evolved from a primarily diagnostic procedure to include interventional bronchoscopy for diagnostic purposes. Endobronchial ultrasound (EBUS) has increased the potential of sampling mediastinal lymph nodes both for histological diagnosis and microbiological confirmation.

Complicated intrathoracic tuberculosis: Role of therapeutic interventional bronchoscopy.

In recent years bronchoscopy equipment has been improved with smaller instruments and larger size working channels. This has ensured that bronchoscopy offers both therapeutic and interventional options. As the experience of paediatric interventional pulmonologists continues to grow, more interventions are being performed. There is a scarcity of published evidence in the field of interventional bronchoscopy in paediatrics. This is even more relevant for complicated pulmonary tuberculosis (PTB). Therapeutic interventional bronchoscopy procedures can be used in the management of complicated tuberculosis, including for endoscopic enucleations, closure of fistulas, dilatations of bronchial stenosis and severe haemoptysis. Endoscopic therapeutic procedures in children with complicated TB may prevent thoracotomy. If done carefully these interventional procedures have a low complication rate.

Patient rotation chest X-rays and the consequences of misinterpretation in paediatric radiology.

PURPOSE: We aimed to demonstrate the consequences of rotation on neonatal chest radiographs and how it affects diagnosis. In addition, we demonstrate methods for determining the presence and direction of rotation. BACKGROUND: Patient rotation is common in chest X-rays of neonates. Rotation is present in over half of chest X-rays from the ICU, contributed to by unwillingness of technologists to reposition new-borns for fear of dislodging lines and tubes. There are six main effects of rotation on supine paediatric chest X-rays: 1) unilateral hyperlucency of the side that the patient is rotated towards; 2) the side 'up' appears larger; 3) apparent deviation of the cardiomediastinal shadow in the direction that the chest is rotated towards; 4) apparent cardiomegaly; 5) distorted cardio-mediastinal configuration; and 6) reversed position of the tips of the umbilical artery and vein catheters with rotation to the left. These effects can cause diagnostic errors due to misinterpretation, including air-trapping, atelectasis, cardiomegaly, and pleural effusions, or disease may be masked. We demonstrate the methods of evaluating rotation with examples, including a 3D model of the bony thorax as a guide. In addition, multiple examples of the effects of rotation are provided including examples where disease was misinterpreted, underestimated or masked. CONCLUSION: Rotation is often unavoidable in neonatal chest X-rays, especially in the ICU. It is therefore important for physicians to recognise rotation and its effects, and to be aware that it can mimic or mask disease.

Unequal Cerebral Magnetic Resonance Imaging Changes in Perinatal Hypoxic Ischemic Injury of Term Neonates.

BACKGROUND: Perinatal hypoxic ischemic injury (HII) has a higher prevalence in the developing world. One of the primary concepts for suggesting that an imaging pattern reflects a global insult to the brain is when the injury is noted to be bilateral and symmetric in distribution. In the context of HII in term neonates, this is either bilateral symmetric ( a ) peripheral/watershed (WS) injury or ( b ) bilateral symmetric basal-ganglia-thalamus (BGT) pattern, often with the peri-Rolandic and hippocampal injury. Unilateral, asymmetric, or unequal distribution of injury may therefore be misdiagnosed as perinatal arterial ischemic stroke. OBJECTIVES: We aimed to determine the prevalence of unequal cerebral injury in HII, identify patterns, and determine their relationship with existing classification of HII. MATERIALS AND METHODS: Review of brain magnetic resonance imaging from a database of children with HII. Reports with any unequal pattern of injury were included and further classified as a unilateral, bilateral asymmetric, or symmetric but unequal degree pattern of HII. RESULTS: A total of 1213 MRI scans in patients with a diagnosis of HII revealed 156 (13%) with unequal involvement of the hemispheres: unilateral in 2 of 1213 (0.2%) (involvement only in the WS), asymmetric in 48 of 1213 (4%) (WS in 6 [0.5%], BGT in 4 [0.3%], and combined BGT and WS in 38 [3.1%]), and bilateral symmetric but unequal degree in 106 of 1213 (8.7%) (WS in 20 [1.6%], BGT in 17 [1.4%], and combined BGT and WS in 69 [5.7%]). CONCLUSIONS: The majority of children with cerebral palsy due to HII demonstrate a characteristic bilateral symmetric pattern of injury. In our study, 13% demonstrated an unequal pattern. Differentiation from perinatal arterial ischemic stroke, which is mostly unilateral and distributed typically in the middle cerebral artery territory, should be possible and recognition of the typical BGT or WS magnetic resonance imaging patterns should add confidence to the diagnosis, in such scenarios.

Natural History of Chiari 1 Deformity.

PURPOSE: Chiari type 1 deformity (Ch1) is associated with bony deformity of the skull base and herniation of cerebellar tonsils more than 5 mm below the foramen magnum. Magnetic resonance imaging (MRI) is used for diagnosis and surgery is advised for symptomatic children. We present a case series using MRI including cerebrospinal fluid (CSF) flow, in children with Ch1 to demonstrate a variety of outcomes, both surgical and spontaneous: spontaneous resolution, spontaneous worsening, postsurgical improvement, and postsurgical deterioration. CASE: A 2-week-old female newborn underwent brain MRI demonstrating an ectopic neurohypophysis, under opercularization suggesting brain immaturity and a normal craniocervical junction (CCJ). Follow-up (F/U) MRI at 6 years of age showed interval spontaneous development of Ch1 with decreased CSF spaces at CCJ. CASE: A 6-year-old girl referred for imaging with short stature and growth hormone deficiency demonstrated incidental findings of Ch1 without syringomyelia. There was 15-mm protrusion of pointed cerebellar tonsils through the foramen magnum and a reduced CSF space at the craniocervical junction. No surgery was performed, and F/U MRI at the age of 7 years demonstrated spontaneous resolution of the tonsillar ectopia (cerebellar tonsils now 3 mm right and 6 mm left) and expansion of the CSF spaces at CCJ. CASE: A 7-year-old boy with headaches and staring spells underwent an MRI demonstrating 6-mm protrusion of pointed cerebellar tonsils and CSF space reduction at CCJ. No surgery was performed, and F/U imaging at the age of 9 years demonstrated spontaneous improvement in cerebellar tonsillar position and increased bidirectional CSF flow at CCJ. CASE: A 17-month-old boy underwent brain MRI for unsteady gait and poor vestibular response, which showed Ch1 and narrow CSF spaces at the foramen magnum and with reduced CSF flow. At the age of 3 years, after posterior fossa decompression, F/U MRI showed postsurgical improvement of the position of the cerebellar tonsils and increased CSF space at CCJ. CASE: A 4-month-old male infant with a history of 34-week prematurity, prior germinal matrix hemorrhage, and neonatal subdural hemorrhage was referred for MRI of the cervical and thoracic spine for evaluation of developmental delay and hypotonia with torticollis. Magnetic resonance imaging of the spine demonstrated mild protrusion of inferiorly pointed cerebellar tonsils up to the foramen magnum, with visible CSF and without retroflexion of the dens. Follow-up MRI scans demonstrated progressive worsening of the Chiari 1 deformity, even after multiple surgeries. CONCLUSIONS: It is important to be aware of a variety of different outcomes with Ch1, including spontaneous resolution, spontaneous worsening, improvement with surgery, and even deterioration after surgery. More research is required to determine objective criteria for predicting outcome, which include both anatomic measures and physiologic measures of CSF flow, so that better surgical decisions can be made and for evaluating patients who have undergone surgery.

Caution: shortcomings of traditional segmentation methods from magnetic resonance imaging brain scans intended for 3-dimensional surface modelling in children with pathology.

This technical innovation assesses the adaptability of some common automated segmentation tools on abnormal pediatric magnetic resonance (MR) brain scans. We categorized 35 MR scans by pathologic features: (1) "normal"; (2) "atrophy"; (3) "cavity"; (4) "other." The following three tools, (1) Computational Anatomy Toolbox version 12 (CAT12); (2) Statistical Parametic Mapping version 12 (SPM12); and (3) MRTool, were tested on each scan-with default and adjusted settings. Success was determined by radiologist consensus on the surface accuracy. Automated segmentation failed in scans demonstrating severe surface brain pathology. Segmentation of the "cavity" group was ineffective, with success rates of 23.1% (CAT12), 69.2% (SPM12) and 46.2% (MRTool), even with refined settings and manual edits. Further investigation is required to improve this workflow and automated segmentation methodology for complex surface pathology.

Frequency of ulegyria on delayed MRI scans in children with term hypoxic-ischemic injury.

BACKGROUND: Ulegyria is an under-recognized and underreported potential sequela of hypoxic-ischemic injury (HII) in full-term neonates. Ulegyria is a unique form of parenchymal scarring that leads to a mushroom-shape of the affected gyri resulting from volume loss at the deep portions of the sulci during HII in this specific period in infantile neurodevelopment. Identifying ulegyria is important for ascribing cause and timing of HII on delayed magnetic resonance imaging (MRI) scans and because of its close association with pharmaco-resistant epilepsy. OBJECTIVE: The purpose of this study was to determine the frequency of ulegyria and characterize the anatomical distribution of watershed injury in a large database of patients who developed cerebral palsy with term HII pattern and underwent delayed MRI. MATERIALS AND METHODS: Patients with term HII patterns on MRI were analyzed for ulegyria. The frequency of ulegyria overall and for each pattern of HII distribution was determined as was the anatomical distribution of watershed injury. RESULTS: Of the 731 children with term HII and cortical injury, 484 (66%) had ulegyria. Ulegyria was most common in those cases with a combined watershed/basal ganglia-thalamic pattern (56%) and isolated watershed pattern (40%). Watershed injury in patients with ulegyria was most common at the posterior watershed (80.6%) and perisylvian watershed (76.7%). CONCLUSION: Ulegyria was present in nearly two-thirds of patients with term HII and cortical injury and should be sought to support the diagnosis of previous perinatal HII, especially in posterior and perisylvian watershed regions. The implications of ulegyria can be significant for clinical decision-making and for ascribing timing of injury to the perinatal period.

Evolving role of chest radiographs for diagnosis of pediatric pulmonary tuberculosis.

Chest radiographs (CXR) have played an important and evolving role in diagnosis, classification and management of pediatric pulmonary tuberculosis (TB). During the pre-chemotherapy era, CXR aided in determining infectiousness, mainly to guide isolation practices, by detecting calcified and non-calcified lymphadenopathy. The availability of TB chemotherapy from the mid-1900s increased the urgency to find accurate diagnostic tools for what had become a treatable disease. Chest radiographs provided the mainstay of diagnosis in children, despite high inter-reader variability limiting its accuracy. The development of cross-sectional imaging modalities, such as computed tomography, provided more accurate intra-thoracic lymph node assessment, but these modalities have major availability, cost and radiation exposure disadvantages. As a consequence, CXR remains the most widely used modality for childhood  pulmonary TB diagnosis, given its relatively low cost and accessibility. Publication of the revised 2022 World Health Organization Consolidated TB guidelines added practical value to CXR interpretation in children, by allowing the selection of children for shorter TB treatment using radiological signs of severity of disease, that have high reliability. This article provides a review of the historical journey and evolving role of CXR in pediatric pulmonary TB.