Arabinda K. Choudhary

Diseases Associated with Childhood Obesity

OBJECTIVE Radiologists can play an active role in childrens health by increasing awareness of diseases associated with obesity. This article reviews key imaging findings in obesity-related diseases, current issues in imaging obese children, and treatment strategies. CONCLUSION There has been a well-documented pediatric obesity epidemic and a dramatic increase in clinical diseases associated with it. These serious health consequences affect nearly every organ system. Despite the increasing prevalence of obesity and the associated health hazards, pediatric obesity as a diagnosis is often overlooked by health care providers.

Spinal Subdural Hemorrhage in Abusive Head Trauma: A Retrospective Study

PURPOSE To compare the relative incidence, distribution, and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma versus that after accidental trauma in children. MATERIALS AND METHODS This study received prior approval from the Human Subjects Protection Office. Informed consent was waived. This study was HIPAA compliant. Two hundred fifty-two children aged 0-2 years treated for abusive head trauma at our institute between 1997 and 2009 were identified through retrospective chart review. A second group of 70 children aged 0-2 years treated at our institute for well-documented accidental trauma between 2003 and 2010 were also identified through retrospective chart review. All clinical data and cross-sectional imaging results, including computed tomographic and magnetic resonance imaging of the brain, spine, chest, abdomen, and pelvis, were reviewed for both of these groups. A Fisher exact test was performed to assess the statistical significance of the proportion of the spinal canal subdural hemorrhage in abusive head trauma versus that in accidental trauma. RESULTS In the abusive head trauma cohort, 67 (26.5%) of 252 children had evaluable spinal imaging results. Of these, 38 (56%) of 67 children had undergone thoracolumbar imaging, and 24 (63%) of 38 had thoracolumbar subdural hemorrhage. Spinal imaging was performed in this cohort 0.3-141 hours after injury (mean, 23 hours ± 27 [standard deviation]), with 65 (97%) of 67 cases having undergone imaging within 52 hours of injury. In the second cohort with accidental injury, only one (1%) of 70 children had spinal subdural hemorrhage at presentation; this patient had displaced occipital fracture. The comparison of incidences of spinal subdural hemorrhage in abusive head trauma versus those in accidental trauma was statistically significant (P < .001). CONCLUSION Spinal canal subdural hemorrhage was present in more than 60% of children with abusive head trauma who underwent thoracolumbar imaging in this series but was rare in those with accidental trauma.

Accuracy of Apparent Diffusion Coefficient Value Measurement on PACS Workstation: A Comparative Analysis

OBJECTIVE The purpose of this article is to evaluate the accuracy of apparent diffusion coefficient (ADC) measurements made with a PACS workstation compared with measurements made with a dedicated workstation, which is currently considered the reference standard. MATERIALS AND METHODS A retrospective review was performed in liver lesions from 79 patients using three MRI platforms. The final diagnosis was established by liver biopsy in 31 patients and by dynamic MRI and follow-up, both clinical and radiologic as indicated, in 48 patients. Each lesion that was clearly demonstrable on the ADC map was measured with a commercial dedicated postprocessing workstation and again with a PACS system. A two-sample t test was used to determine the statistically significant differences between the two ADC measurements. RESULTS A total of 79 patients with 120 liver lesions were included. ADC values measured on the workstation were 0.4-4.38 × 10(-3) mm(2)/s. The ADC values measured on the PACS were 0.42-4.35 × 10(-3) mm(2)/s. The T value was -1.113, with 119 degrees of freedom, and the significance level was 0.268, which implies no significant difference between the two different measuring systems for all pathologic abnormalities and MRI scanners used. CONCLUSION ADC values measured on a routine PACS workstation are as accurate as the values obtained on a dedicated specialized workstation. ADC value measurement on the routine PACS will save time and lead to increased utilization, which, in turn, will lead to an improved understanding of the different disease processes and their clinical management.

Occipital sutures and its variations: the value of 3D-CT and how to differentiate it from fractures using 3D-CT?

The anatomy and embryology of occipital bone are complex and may present with a varied ossification pattern and masquerade as fractures. There are only a few articles in the literature and none on CT appearance of occiput ossification and sutures. Awareness of the normal and variant anatomy, appearance and position along with age of fusion of sutures will be helpful in confidently differentiating variant suture from fracture. This will be particularly important in children in the field of non-accidental injury with its attendant medicolegal complications. We describe the normal anatomy, embryology, normal and variant sutures of occipital bone as published in the literature so far and present a pictorial review of 15 cases of variant sutures. With CT as the primary modality in assessing for head injury now, it is important to know the CT features of these sutures, their appearance, position and variants and be able to utilize 3D-CT to be able to give a more definitive diagnosis.

Congenital nasal obstruction: clinical and radiologic review.

Congenital nasal obstruction can result in neonatal respiratory distress because neonates are obligate nasal breathers. Therefore, all physicians who deal with infants should be familiar with the structural abnormalities, masses, and syndromes that cause nasal obstruction, so that appropriate work-up and treatment can be promptly initiated. This paper reviews the embryology of the nasal passage and then continues with the different causes of nasal obstruction. Special attention is paid to the presentation, physical exam findings, and imaging modality of choice.

Non‐lethal congenital hypotonia due to glycogen storage disease type IV

Glycogen storage disease type IV (GSD‐IV) is an autosomal recessive genetic disorder due to a deficiency in the activity of the glycogen branching enzyme (GBE). A deficiency in GBE activity results in the accumulation of glycogen with fewer branching points and long, unbranched outer chains. The disorder results in a variable phenotype, including musculoskeletal, cardiac, neurological, and hepatic involvement, alone or in continuum, which can be identified at any stage of life. The classic form of GSD‐IV is a hepatic presentation, which presents in the first 18 months of life with failure to thrive, hepatomegaly, and cirrhosis that progresses to liver failure, resulting in death by age 5 years. A severe congenital musculoskeletal phenotype with death in the neonatal period has also been described. We report an unusual case of congenital musculoskeletal presentation of GSD‐IV with stable congenital hypotonia, gross motor delay, and severe fibro‐fatty replacement of the musculature, but no hepatic or cardiac involvement. Molecular analysis revealed two novel missense mutations with amino acid changes in the GBE gene (Q236H and R262C), which may account for the mild phenotype.

The etiology and significance of fractures in infants and young children: a critical multidisciplinary review.

This paper addresses significant misconceptions regarding the etiology of fractures in infants and young children in cases of suspected child abuse. This consensus statement, supported by the Child Abuse Committee and endorsed by the Board of Directors of the Society for Pediatric Radiology, synthesizes the relevant scientific data distinguishing clinical, radiologic and laboratory findings of metabolic disease from findings in abusive injury. This paper discusses medically established epidemiology and etiologies of childhood fractures in infants and young children. The authors also review the body of evidence on the role of vitamin D in bone health and the relationship between vitamin D and fractures. Finally, the authors discuss how courts should properly assess, use, and limit medical evidence and medical opinion testimony in criminal and civil child abuse cases to accomplish optimal care and protection of the children in these cases.

Macrocephaly in infancy: benign enlargement of the subarachnoid spaces and subdural collections

OBJECTIVE Benign enlargement of the subarachnoid spaces (BESS) is a common finding on imaging studies indicated by macrocephaly in infancy. This finding has been associated with the presence of subdural fluid collections that are sometimes construed as suggestive of abusive head injury. The prevalence of BESS among infants with macrocephaly and the prevalence of subdural collections among infants with BESS are both poorly defined. The goal of this study was to determine the relative frequencies of BESS, hydrocephalus, and subdural collections in a large consecutive series of imaging studies performed for macrocephaly and to determine the prevalence of subdural fluid collections among patients with BESS. METHODS A text search of radiology requisitions identified studies performed for macrocephaly in patients ≤ 2 years of age. Studies of patients with hydrocephalus or acute trauma were excluded. Studies that demonstrated hydrocephalus or chronic subdural hematoma not previously recognized but responsible for macrocephaly were noted but not investigated further. The remaining studies were reviewed for the presence of incidental subdural collections and for measurement of the depth of the subarachnoid space. A 3-point scale was used to grade BESS: Grade 0, < 5 mm; Grade 1, 5-9 mm; and Grade 2, ≥ 10 mm. RESULTS After exclusions, there were 538 studies, including 7 cases of hydrocephalus (1.3%) and 1 large, bilateral chronic subdural hematoma (0.2%). There were incidental subdural collections in 21 cases (3.9%). Two hundred sixty-five studies (49.2%) exhibited Grade 1 BESS, and 46 studies (8.6%) exhibited Grade 2 BESS. The prevalence of incidental subdural collections among studies with BESS was 18 of 311 (5.8%). The presence of BESS was associated with a greater prevalence of subdural collections, and higher grades of BESS were associated with increasing prevalence of subdural collections. After controlling for imaging modality, the odds ratio of the association of BESS with subdural collections was 3.68 (95% CI 1.12-12.1, p = 0.0115). There was no association of race, sex, or insurance status with subdural collections. Patients with BESS had larger head circumference Z-scores, but there was no association of head circumference or age with subdural collections. Interrater reliability in the diagnosis and grading of BESS was only fair. CONCLUSIONS The current study confirms the association of BESS with incidental subdural collections and suggests that greater depth of the subarachnoid space is associated with increased prevalence of such collections. These observations support the theory that infants with BESS have a predisposition to subdural collections on an anatomical basis. Incidental subdural collections in the setting of BESS are not necessarily indicative of abusive head injury.

Morel-Lavallée lesion of the thigh: characteristic findings on US

A 12-year-old boy presented for evaluation 3 weeks after an ATV accident. Although no traumatic injury was initially noted, he developed progressive left thigh swelling and blisters 2 weeks after the injury. US identified a collection in the subcutaneous tissues with hyperechoic material (arrowheads) along the wall (Fig. 1). Serous collections were drained at surgery; cultures were negative. Because of continued drainage of lymphatic-appearing fluid, the child was treated with Sotradechol foam injection and doxycycline twice, with improvement. The Morel-Lavallee lesion is an internal degloving type of injury with separation of the hypodermis from the underlying deep fascia. This results in disruption of the vascular and lymphatic plexus and a cavity is created, filling with blood, lymph, liquefied fat and necrotic debris [1]. US demonstrates a collection in the subcutaneous region with hyperechoic nodules corresponding to remnants of fat. If there is history of shear injury to the soft tissue with chronic recurrent fluid collection and imaging features of subcutaneous collection with fat lobules along the wall, the diagnosis of Morel-Lavallee lesion should be suspected. Treatment options include serial aspiration and, if unsuccessful, sclerodesis. Early identification is important, as delay can increase incidence of infection-related morbidity.

Prevalence of Persistent Falcine Sinus as an Incidental Finding in the Pediatric Population

OBJECTIVE Persistence of the embryologic falcine sinus can be a congenital or acquired phenomenon related to a defect of the straight sinus. Previous studies have stated that it is rare for the falcine sinus to persist without an additional abnormality of the brain such as a vein of Galen malformation or venous sinus thrombosis. The purpose of this article is to show that persistent falcine sinus is not an uncommon isolated finding in the pediatric population. MATERIALS AND METHODS We performed a retrospective review of pediatric brain MRIs to identify patients with a persistent falcine sinus and subsequently recorded whether there were findings in addition to the straight sinus defect. RESULTS Thirty-one patients were identified as having a persistent falcine sinus, five of whom had no other congenital or acquired abnormality of the brain other than a defect in the straight sinus. CONCLUSION Our data support the hypothesis that persistent falcine sinus is not an uncommon isolated finding in the pediatric population.