Elhamy Bekhit

Imaging Assessment of Congenital and Acquired Abnormalities of the Portal Venous System

Abnormalities of the portal venous system are a heterogeneous group of conditions that can cause substantial morbidity and mortality and may lead to complications during surgery or percutaneous interventions involving the portal venous system. High-resolution computed tomography, ultrasonography, and magnetic resonance imaging permit a comprehensive, noninvasive evaluation of the portal venous system, enabling the detection of both structural and functional abnormalities. However, an understanding of the embryologic development of the normal portal venous anatomy and anatomic variants is essential to accurately interpret the imaging findings. Knowledge of the characteristic appearances of abnormalities of the portal venous system allows a more confident diagnosis, permitting timely treatment and more informed guidance of surgical procedures and percutaneous interventions, which may lead to an improved outcome.

Extranodal lymphoma in the thorax: cross-sectional imaging findings

The purpose of this review is to discuss and illustrate the spectrum of appearances of extranodal lymphoma in the thorax, including the lungs, pleura, heart, thymus, chest wall, thoracic spine, and breast, using current cross-sectional imaging techniques, such as multidetector computed tomography, positron-emission tomography/computed tomography, magnetic resonance imaging, and sonography. Extranodal lymphoma can affect any organ or tissue in the thorax, and can be mistaken for other inflammatory or neoplastic conditions. This review should alert the radiologist to consider extranodal lymphoma in the appropriate clinical setting to ensure timely diagnosis, correct staging, and accurate post-treatment evaluation to optimize treatment regimens.

Paediatric MRCP: 10 year experience with 195 patients

PURPOSE Magnetic resonance cholangiopancreatography (MRCP) has now largely substituted endoscopic retrograde cholangiopancreatography (ERCP) in evaluating the biliary tree in adults giving its high sensitivity and specificity. Whilst smaller series published to date suggests this may be extrapolated to the paediatric population, its routine use in children is still debatable. The aim of our study is therefore to review the utility of MRCP in a large series of paediatric patients. METHODS AND MATERIALS All MRCPs performed in our institution were examined for diagnostic quality, spectrum of diagnoses and correlation with direct cholangiography (DC) were available. Correlation with histopathology results and final clinical diagnosis was made in the subset of patients in whom a MRCP had been performed to evaluate the presence of primary sclerosing cholangitis (PSC). RESULTS There were 245 MRCP examinations performed on 195 patients and 219 were diagnostic. There was 100% MRCP and DC concordance in the 16 cases where both had been performed. MRCP yielded a sensitivity of 89% in the subset of patients with PSC. CONCLUSION MRCP was a valuable diagnostic tool in our paediatric population. Image quality is sufficiently diagnostic and shows good correlation with clinical diagnosis in conditions encountered in our population, including primary sclerosing cholangitis, post liver transplant biliary strictures, post surgical complications, dilated common bile ducts, choledochal cysts, cholelithiasis and choledocholithaisis.

Magnetic Resonance Imaging Findings in Children With Tinnitus

Objective: Tinnitus in adults is generally investigated by contrast-enhanced magnetic resonance imaging (MRI) to rule out the diagnosis of acoustic neuroma. Acoustic neuroma is rare in children and, therefore, the role of MRI in children with tinnitus is unclear. This study was undertaken to determine the value of MRI in the investigation of tinnitus in children. Methods: Retrospective study of children younger than 18 years who underwent MRI for the investigation of tinnitus over a 10-year period. Results: Sixty-five patients were identified, but there were only 34 who had also undergone audiologic assessment. Among the 25 patients with normal audiology, MRI abnormalities were present in 9, but these were all thought to be nonspecific. Nine patients had abnormal audiograms and the MRI was abnormal in 4 of these cases, which included 3 children who were found to have multiple sclerosis. Conclusion: Magnetic resonance imaging would appear to be mandatory in the investigation of tinnitus in children who are found to have sensorineural hearing loss, particularly to rule out the diagnosis of multiple sclerosis. Although our study does not support the routine use of MRI in children with normal audiology, the numbers in our series are too small for a conclusive recommendation.

CT head in children

The advances in computerized technology (CT) technique over the last few decades have greatly modified imaging protocols in children. The range of pathologies that can now be demonstrated has broadened with the advent of newer techniques such as CT perfusion and the ability to perform complex reconstructions. Increasing speed of scanning and reduction in scan time have influenced the need for sedation and general anaesthetic as well as impacting on motion artefact. Additionally, concerns about radiation safety and avoidance of unnecessary radiation have further impacted on the inclusion of CT in the imaging armamentarium. Justification and image optimisation are essential. It is important to familiarize oneself with the appearances of normal variants or age related developmental changes. CT does however remain an appropriate investigation in a number of conditions.

Voice Matters: Late Presentation of an Iatrogenic Vertebral Arteriovenous Fistula after Liver Transplantation in Early Childhood with Successful Endovascular Treatment

Central venous cannulation is known to be a frequent cause of iatrogenic morbidity. Children are at particular risk for anatomical reasons, especially those who require complex surgical interventions because central venous access is frequently needed before, during, and after the procedure. Immediate complications, such as failure of cannulation, pneumothorax, arterial puncture, and nerve injury, are well documented. Traumatic vertebral artery pseudoaneurysms and arteriovenous fistulas are however uncommon lesions in children. Whilst surgical fistula closure has been traditionally advocated as first-line treatment, endovascular noninvasive techniques are becoming increasingly available in childhood. We report the successful endovascular treatment of a 14-year-old girl with a large vertebro-subclavian fistula 13 years after orthotopic liver transplantation.

Skull base anatomy and surgical safety in isolated and CHARGE-associated bilateral choanal atresia

INTRODUCTION Bilateral choanal atresia (BCA) is associated with a high incidence of congenital abnormalities that include skull base anomalies and defects. Surgical repair of BCA is necessary in the early neonatal period and any altered anatomy of the adjacent skull base will heighten the risk of intracranial injury. This risk may be further increased in patients with CHARGE syndrome. OBJECTIVES To measure surgically relevant nasal and skull base dimensions in neonates with BCA in order to determine whether any difference exists between isolated and CHARGE syndrome associated subgroups, thereby optimizing the safety of surgical repair. METHODS A retrospective review of medical charts and computed tomography was undertaken at a tertiary pediatric hospital of all neonates diagnosed with BCA between 2004 and 2016. Isolated and CHARGE syndrome subgroups of BCA were identified from clinical records and CT data was analyzed and compared between the two. The skull base parameters measured were choanal width, choanal height, mid-nasal skull base height and skull base slope. RESULTS Of the 13 patients included, 3 had CHARGE syndrome and 10 had isolated BCA. Whilst the difference in mid-nasal height approached significance for the two groups, numbers were too small for a statistical difference to be identified. The mean value for choanal width in the isolated BCA group was significantly less the largest series of normative data available in the literature for comparison (p < 0.001). No skull base anomalies were noted in either group. CONCLUSION While this is a small study with limited numbers, it is the first that has attempted to identify and measure the posterior nasal and skull base anatomy most pertinent to avoiding skull base injury in the surgical management of BCA.

Splenic cyst and its management in a 21-month-old boy: a rare complication of invasive meningococcal disease

Splenic complications of invasive meningococcal disease (IMD) are well recognised, though cyst formation is rare, particularly in paediatric populations. The best approach to their management is not yet established. This case outlines the management of a splenic cyst in a 21-month-old boy following severe IMD. The case took place in the context of an acute emergence of serogroup W prompting significant media attention and subsequent change in vaccination practice at a jurisdictional level in Australia. The patient was critically unwell early in the illness, then later a collection in the left upper quadrant was detected, shown on ultrasound to be a 11.6×7.7 cm splenic cyst. In this case, the cyst was managed by ultrasound-guided drainage tube insertion. The residual collection was small and stable on subsequent imaging.