Joseph Junewick

Cranial Ultrasound Lesions in the NICU Predict Cerebral Palsy at Age 2 Years in Children Born at Extremely Low Gestational Age

Our prospective cohort study of extremely low gestational age newborns evaluated the association of neonatal head ultrasound abnormalities with cerebral palsy at age 2 years. Cranial ultrasounds in 1053 infants were read with respect to intraventricular hemorrhage, ventriculomegaly, and echolucency, by multiple sonologists. Standardized neurological examinations classified cerebral palsy, and functional impairment was assessed. Forty-four percent with ventriculomegaly and 52% with echolucency developed cerebral palsy. Compared with no ultrasound abnormalities, children with echolucency were 24 times more likely to have quadriparesis and 29 times more likely to have hemiparesis. Children with ventriculomegaly were 17 times more likely to have quadriparesis or hemiparesis. Forty-three percent of children with cerebral palsy had normal head ultrasound. Focal white matter damage (echolucency) and diffuse damage (late ventriculomegaly) are associated with a high probability of cerebral palsy, especially quadriparesis. Nearly half the cerebral palsy identified at 2 years is not preceded by a neonatal brain ultrasound abnormality.

Observer variability assessing US scans of the preterm brain: the ELGAN study

BackgroundNeurosonography can assist clinicians and can provide researchers with documentation of brain lesions. Unfortunately, we know little about the reliability of sonographically derived diagnoses.ObjectiveWe sought to evaluate observer variability among experienced neurosonologists.Materials and methodsWe collected all protocol US scans of 1,450 infants born before the 28th postmenstrual week. Each set of scans was read by two independent sonologists for the presence of intraventricular hemorrhage (IVH) and moderate/severe ventriculomegaly, as well as hyperechoic and hypoechoic lesions in the cerebral white matter. Scans read discordantly for any of these four characteristics were sent to a tie-breaking third sonologist.ResultsVentriculomegaly, hypoechoic lesions and IVH had similar rates of positive agreement (68–76%), negative agreement (92–97%), and kappa values (0.62 to 0.68). Hyperechoic lesions, however, had considerably lower values of positive agreement (48%), negative agreement (84%), and kappa (0.32). No sonologist identified all abnormalities more or less often than his/her peers. Approximately 40% of the time, the tie-breaking reader agreed with the reader who identified IVH, ventriculomegaly, or a hypoechoic lesion in the white matter. Only about 25% of the time did the third party agree with the reader who reported a white matter hyperechoic lesion.ConclusionObtaining concordance seems to be an acceptable way to assure reasonably high-quality of images needed for clinical research.

Ossification Patterns of the Atlas Vertebra

OBJECTIVE The objective of this study was to characterize ossification patterns of the C1 (atlas) vertebra in children, to better differentiate normal variants from traumatic injury. MATERIALS AND METHODS A retrospective review of all sinus and temporal bone CT examinations was performed for the period of 2002-2009. Patients 96 months old or younger for whom C1 level was at least partially imaged were included. Patients with a history of trauma or genetic disorder-associated spinal abnormalities were excluded. RESULTS A total of 1270 CT examinations were reviewed. The anterior arch of C1 was completely imaged in 841 patients (66%), and the posterior arch was completely imaged in 378 patients (30%). Multiple anterior arch ossification centers were observed in 179 of 841 patients (21%), and posterior arch variants were present in nine of 378 patients (2%). At least partial ossification of the anterior arch was seen in 113 of 147 children (77%) younger than 25 months, whereas only 14 of the remaining 694 children (2%) older than 24 months failed to show any ossification. Incomplete ossification of the anterior arch was noted in 47 of 103 patients (46%) in the 85-96-month-old category. The posterior arches were at least partially ossified in all children. Incomplete fusion of the posterior synchondrosis was seen in 17 of 108 patients (16%) older than 60 months. CONCLUSION C1 ossification patterns and timing of synchondrosis fusion are variable. Knowledge of these patterns is important to better differentiate a normal variant from traumatic injury.

Pediatric Craniocervical Junction Injuries

OBJECTIVE The purpose of this article is to review pediatric craniocervical junction injuries in the context of embryology, developmental anatomy, and biomechanics. CONCLUSION The craniocervical junction is functionally and developmentally distinct from the rest of the spine, and mechanistic models often fail to explain these injuries. Various developmental features and complex anatomy likely contribute to injury in this region in children. Some of the injury patterns at the craniocervical junction in children are similar to adults, but many are unique.

Rate and Associations of Epididymal Cysts on Pediatric Scrotal Ultrasound

PURPOSE We established the baseline occurrence of epididymal cysts, and the correlation between epididymal cysts and testicular size. MATERIALS AND METHODS We retrospectively reviewed all pediatric scrotal ultrasounds done at our institution in 8 years. We analyzed the proportion of cysts by patient age and compared testicular size in boys with vs without epididymal cysts. RESULTS Of all patients 14.4% had epididymal cysts. The cyst incidence increased with age, ie 35.3% of boys older than 15 years had cysts. Boys with epididymal cysts had larger testes than boys without cysts regardless of side or age (p <0.001). CONCLUSIONS Epididymal cysts are more common in older boys. Boys with epididymal cysts had larger testes than boys without cysts.

Cervical spine injuries in pediatrics: are children small adults or not?

Diagnosis of cervical spine injuries is crucial whether in children or adults. It is necessary to understand the injuries unique to the developing spine. Equally important is an insight to similarities in injury patterns between adults and children.

Mechanisms of injury to white matter adjacent to a large intraventricular hemorrhage in the preterm brain.

The purpose of this article is to investigate the hyperechoic lesion seen adjacent to a lateral ventricle that contains blood but is not distended. The literature on ependymal barrier dysfunction was reviewed in search of mechanisms of injury to the white matter adjacent to an intraventricular hemorrhage. The clinical literature on the clinical diagnosis of periventricular hemorrhagic infarction was also reviewed to find out how frequently this diagnosis was made. Support was found for the possibility that the ventricular wall does not always function as an efficient barrier, allowing ventricular contents to gain access to the white matter where they cause damage. Hemorrhagic infarction may not be the only or the most frequent mechanism of white matter damage adjacent to a large intraventricular hemorrhage.

Focal nodular hyperplasia in oncology patients

Sir, A case of multiple focal nodular hyperplasia (FNH) in a patient treated for stage III neuroblastoma was presented at the Midwest Society for Pediatric Radiology Meeting in September 2005 at Madison, Wisconsin. The patient received carboplatin, cyclophosphamide, Adriamycin, vincristine, cisplatin, and etoposide chemotherapy, right paraspinal thoracic irradiation, and stem cell bone marrow transplantation. Two years after initiation of retinoic acid therapy and 3 years after the diagnosis of neuroblastoma, numerous hepatic lesions (hyperdense on portal venous phase and isodense on delayed phase) were noted on surveillance CT imaging. Several new lesions were found on a short-term follow-up CT examination. This case complements the article by Joyner et al. [1] in Pediatric Radiology and allows some additional points: (1) other drugs may be implicated in the development of FNH, (2) chemotherapy-induced FNH may not necessarily be a late complication, and (3) knowledge of this complication may not necessarily obviate the need for biopsy. While many of the drugs used to treat this patient are associated with the development of FNH, retinoic acid should also be considered. The chemotherapeutic effect of retinoic acid is related to its promotion of cytodifferentiation and apoptosis. However, retinoic acid also has prothrombotic effects by inducing endothelial coupling of coagulation factors. Retinoic acid has been implicated in various thrombotic events including myocardial infarction, pulmonary embolism, venous thrombosis and stroke [2]. The time to development of FNH noted by Bouyn et al. [3] is 8.5 years for cytoreductive chemotherapy and 12.3 years for other chemotherapy. One of three cases presented by Joyner et al. occurred 3 years after diagnosis. The case presented here also occurred 3 years after diagnosis. While development of FNH is typically late, lesions can occur early and could be confused with metastatic disease. FNH can have many imaging appearances, and there is overlap with hepatic adenoma, hypervascular metastasis, and other hepatic malignancies [4]. While the diagnosis of FNH was suggested in the current patient, the lack of a central scar and the number of lesions resulted in a shortterm follow-up examination. The increase in the number of lesions on the follow-up examination was unsettling and resulted in confirmation of the diagnosis with biopsy. In conclusion, retinoic acid may be another drug implicated in development of FNH, chemotherapy-induced FNH may occur early, and biopsy may be necessary to confirm the diagnosis in atypical cases.

Arachnoiditis ossificans in a pediatric patient

A 14-year-old girl with spastic quadriplegic cerebral palsy and progressive neuromuscular scoliosis presented with back pain 6 months after posterior spinal fixation. CT of the lumbar spine revealed numerous ossified dural plaques (Fig. 1, arrows). Semitransparent volume-rendered CT reconstruction shows the distribution of intraspinal ossifications (gray amorphous regions with white stippling) in

Reader Variability in the Use of Diagnostic Terms to Describe White Matter Lesions Seen on Cranial Scans of Severely Premature Infants: The ELGAN Study

To evaluate reader variability of white matter lesions seen on cranial sonographic scans of extreme low gestational age neonates (ELGANs).